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Ann Thorac Surg 2002;74:1741-1746
© 2002 The Society of Thoracic Surgeons
a Department of Cardiovascular and Thoracic Surgery, The Albert Einstein College of Medicine-Montefiore Medical Center, Bronx, New York, USA
* Address reprint requests to Dr Gold, Department of Cardiovascular and Thoracic Surgery, The Albert Einstein College of Medicine-Montefiore Medical Center, 3400 Bainbridge Ave, Bronx, NY10467, USA.
e-mail: jgold{at}montefiore.org
Presented at the Thirty-eighth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2002.
During the last decade thoracic surgical resident education has undergone considerable change [1–9]. These changes have occurred in three closely related areas: the content of the educational process (what we teach), the structure of the educational process (how we teach), and the duration of the educational process (when we teach) [10–16]. Although our formal thoracic surgical education spans a period of 2 or 3 years we continue to rely on a significant amount of information to have been mastered by the resident before initiating the formal thoracic surgery residency process. We also continue to anticipate ongoing maturation of technical and clinical skills as well as didactic knowledge after the completion of a residency during postgraduate practice. The rapid growth of fact-based information pertaining to our field has resulted in a dramatic expansion of the amount of material we must successfully transmit to our residents without any change in the amount of time available to do so [17, 18]. There is an increasing reliance on a solid background in fundamental surgical skills and knowledge that has been imparted to our residents before the first day of their thoracic surgery residency.
Purpose
It is the goal of the Prerequisite Curriculum Project of the Thoracic Surgery Directors Association (TSDA) to develop and maintain a catalog of factual knowledge that would be optimally required for residents before initiation of the thoracic surgical residency and then to develop an innovative methodology to impart that knowledge in such a way that it is useful and serves as a permanent reference before, during, and after the residency.
To do so, it was necessary to analyze the current structure of thoracic surgical education. Our educational process involves subject material that can be categorized into the surgical and nonsurgical components of education. The nonsurgical educational areas encompass many of the subjects that have not been traditionally taught within either a general surgery or thoracic surgery residency program. They include many of the core curricular subject areas including bioethics, research methodology, literature review, surgical leadership, and many other important but not traditionally "surgical" areas. Within the field of traditional surgical education we have taught the technical aspects, clinical aspects, and didactic aspects of the thoracic surgery curriculum in a synchronized fashion.
The third component, the didactic aspects of the education, includes the core of facts that support the technical and clinical aspects but are traditionally taught in a library or classroom-like venue. This can either be a lecture, a series of conferences, a textbook, journal, or other traditional methods and materials. The TSDA has provided a requisite curriculum outline for the technical, clinical, and didactic material that is to be taught during the thoracic surgery residency [16, 19]. It is the intent of the Prerequisite Curriculum Project to focus on the didactic aspects of that information that we believe should be brought to the beginning of the thoracic surgery residency. The residents will then be well positioned to begin to build on this and acquire new knowledge taught during the thoracic surgery residency period.
The time interval dedicated to the thoracic surgery residency is well defined. It was the hope that the prerequisite project could address a portion of the didactic component and be initiated before the completion of the general surgery prerequisite residency program. It would run from the time that a resident was successfully matched into a thoracic surgery residency until they matriculate, approximately 12 months later. It was anticipated that during this period the residents would be motivated to increase their fund of knowledge related to thoracic surgery. It is hoped that this didactic curriculum would provide an organized and coordinated method for learning with a standardized core of information to be studied.
Development
To accomplish this goal, the TSDA created a Prerequisite Curriculum Committee that began its work in September 1998. It was the goal of this committee to develop the content of prerequisite curriculum, to develop an implementation plan, and to develop a methodology to evaluate the effectiveness of the content and implementation of prerequisite curriculum during the course of several cycles of residents for a minimum of 5 years. It was the secondary goal to develop a CD-ROM Internet Hybrid educational product that would allow the resident to study this curriculum with the most modern techniques of electronic-based education.
The curriculum project now spans a total of 75 topics, which are divided into 13 textbook-like sections and also into 12 case-based sections (Appendix). It is possible to navigate through this curriculum by numerous means. The 13 textbook sections were divided in responsibility by the 6 editors of the Prerequisite Curriculum Committee coordinating the efforts of 60 participating authors. These authors include not only thoracic surgeons but adult and pediatric cardiologists, anesthesiologists, bioethicists, pulmonologists, intensivists, statisticians, and radiologists, as well as many other disciplines who not only are extremely knowledgeable in their field but are articulate in their ability to transmit didactic subject material in an audiovisual format. Each of the 75 segments of the 13 sections was divided so that each would be built around a 12-minute to 24-minute audiovisual presentation narrated by the individual author. Relevant media including video photography, roentgenogram scans, and so forth were included. Each segment also contains a two- to six-page summary document as well as a set of frequently asked questions, (FAQs), a dynamic bibliography, relevant Internet linkages, and a multiple choice or true–false self-assessment for the resident to complete before considering that segment "done." In addition, each segment would have a number of evaluation questions that would be fed back directly to the Prerequisite Curriculum Committee to assess the content, format, and quality of each of the individual segments of the curriculum. It became the responsibility of the Prerequisite Curriculum Committee to assemble these 75 segments including each of the eight portions that would constitute each of the completed segments.
The CD-ROM Internet Hybrid product itself represents an extremely high technology marriage between the Internet and CD-based technology. All of the test material, references, Internet linkages, frequently asked questions, and so forth are stored on the Web servers maintained by the TSDA. The high bandwidth video and audio material is, for the most part, stored on a set of serialized CD-ROMs. The examination and critique responses are also stored on the TSDA server. For individual residents to interact with the curriculum, the CD-ROM must be installed on their computer and the computer must be connected to the Internet (at least periodically) to update the material and to be able to access the Web-based portion of the curriculum. The program also tracks the amount of time that residents spend on each of the segments of the curriculum, their performance on the self-evaluation examinations, and, of course, their responses to the critiques. Updates are automatically distributed through the Internet, and any technical questions are addressed in a similar fashion.
One of the key features of this curriculum is that there are four basic ways to navigate through the curriculum. The textbook-based system is similar to a table of contents of a classic textbook of cardiovascular and thoracic surgery. It includes a table of contents with numerous sections and subsections related to the breadth and depth of a prerequisite curriculum (Appendix). In addition to the table of contents there is an index that can be searched in a similar fashion. One of the unique methods of navigation is the case-based methodology in which 12 clinical thoracic surgery cases make up the 75 segments. Managing the 12 patients under consideration, the residents would be able to acquire a similar amount of knowledge as if they had worked through the textbook-based section in a sequential fashion. There is also a media-based navigation system that allows for the user to specifically select a video clip, audio segment, roentgenogram, pathology slide, and so forth based on a specific disease state or organ system. Finally there is a free search methodology in which educational materials are available, including the textbook portions, case-based portions, and media portions by simply searching for a single or multiple keywords.
Implementation
In June of 2001 the thoracic surgery match results for residents matriculating in 2002 was released. A letter describing the Prerequisite Curriculum Project was mailed to all of the matched residents, to their thoracic surgery program directors, and to their general surgery program directors. Great care was taken to inform all of the thoracic residency and general surgery program directors of their residents’ participation but not of their randomization status. This process followed a series of progress reports and rollout schedules previously shared with the TSDA membership and Association of Program Directors in Surgery leadership. It included a description of the project and requested the resident to sign an informed consent allowing them to be randomized into one of two groups, those receiving the full CD-ROM Internet Hybrid curriculum and those receiving only an outline of the content of the curriculum but no educational content materials. In August the residents agreeing to participate (signing the informed consent) were randomized such that 50% received the CD-ROM Internet Hybrid curriculum and the other 50% received the outline. They were instructed to proceed at a pace of approximately one section per month, allowing all of the sections to be completed in the course of the upcoming year. They were informed that their time investment in each of the sections would be tracked as well as their critiques of each of the individual segments. They were told that their performance on the self-assessment examinations contained within each segment would not be recorded or made available to their program directors.
During the ensuing months since the curriculum was distributed, the time investment patterns of the residents have been tracked on a weekly basis. There have been follow-up phone calls and written questionnaires for all of the randomized residents on a 3-month basis requesting specific information regarding ease of use, overall evaluation, and in particular any technical problems they have.
The evaluation of these two resident groups is extensive. All of the residents matriculating in July 2002 will take the American Board of Thoracic Surgery in-training examination in August of 2002 reflecting their didactic base of knowledge at the time they initiate a residency program. In addition, follow-up information concerning the transition from the prerequisite to the core curriculum as well as performance on subsequent in-training examinations and American Board of Thoracic Surgery examinations has been structured. Evaluation techniques have been developed to assess other areas of impact of the prerequisite curriculum on the thoracic surgery residency and thereafter. In particular, the psychological and comfort levels of the residents as their thoracic surgery matriculation approaches and their overall ability to participate actively in core curricular activities will be assessed. Specific psychometric evaluation of the randomized residents will provide an additional basis for comparing the two groups. A standing committee of the TSDA on curricular evaluation has been put into place to facilitate this evaluation process. In July 2002 the CD-ROM curriculum will be made available to those residents randomized to the written outline who are matriculating in July 2002 and to those who are going to matriculate in July 2003.
It is anticipated that a considerable amount of critique and feedback information will be available from those residents who have had a year of experience with the prerequisite curriculum material. It is hoped that the content, format, and some of the features of the curriculum will be improved such that a second-generation CD-ROM Internet Hybrid product, which will be mailed in 2003 to the 2004 matriculating residents, is improved both in content and format.
Preliminary outcome
One hundred thirty-two matched residents responded to the initial letter and indicated that they would like to be involved in the prospective trial, understanding that this was a randomized trial and that only 50% of them would obtain the material at this time. They also understood that they would be electronically tracked. Notification of participation in the trial was sent in writing to all of the thoracic surgery program directors and to all of the general surgery program directors who were responsible for the 130 residents randomized in the trial. (Two residents refused to participate in the trial.) They were not informed as to which of the two randomized groups the residents were assigned. The CD-ROM Internet Hybrid curriculum was mailed to 64 residents in late August 2001 with a written outline of the subject covered in the curriculum mailed to the other 64 residents. The residents have been tracked during the initial months of their experience. The number of hours per week invested in the curriculum for the 64 residents as well as the sections and segments they have been working with are electronically followed on a weekly basis. The utilization patterns, the critique comments, and the evaluations are all followed on a weekly basis as well. The utilization by hours and number of residents from week one through the middle of the sixth month of participation is currently available for analysis. The response to the first quarter telephone interview of 32 of the 64 randomized residents indicates that those who have used the curriculum enjoy it and that they have had very few if any technical problems related to the use of the curricular material. A sophisticated Web-based tracking system was developed to follow group statistics as well as the individual resident progress analysis.
Summary
The TSDA Prerequisite Curriculum Committee has successfully developed the content for a didactic curriculum to be mastered by the residents before their matriculation in a thoracic surgical residency program. In addition the committee assembled an innovative electronic format consisting of a CD-ROM Internet Hybrid to teach this curricular material. By use of a serialized CD-ROM Internet Hybrid it is possible to store relatively dense high bandwidth portions of the curriculum including video and audio materials on the CD-ROM and yet allow constant updating and interaction of the other portions of the curriculum. In addition, it is possible to track the performance and utilization by the residents during the entire course of their residency program. By studying the relationship between the utilization of the curriculum, particularly as it relates to certain subject areas, and comparing that to performance or standardized examinations as well as other measurements of resident satisfaction, the efficacy of the prerequisite curriculum will be tracked during the upcoming years. It is anticipated that the process of developing the content of the prerequisite curriculum will allow the residents and program directors to focus on the subject material currently deemed necessary for successful initiation of a thoracic surgery residency, and that by keeping this subject material outline up-to-date, the changing spectrum of what we anticipate our residents will know at the time of their matriculation will continue to mature.
Although electronic-based education has been available for a number of years, a prospective randomized study comparing it with traditional textbook-based learning is novel. Multiple attempts have been made to implement Web-based or CD-ROM–based educational tools in other specialties with variable results [20–34]. It is our anticipation that successful completion of this project will not only allow for the use of an innovative highly technical means of education for our residents but may in turn become broadly applicable to many other types of educational projects within thoracic surgery education. This may also be applicable to other types of educational projects in the postgraduate education industry and other venues as well. The conduct of a scientific study monitoring the impact of this curriculum project as well as the acceptance of the project by the resident is also relatively unique and will be scrutinized by numerous professional medical and educational groups.
Acknowledgments
This project would not be possible without the extensive assistance of numerous individuals. In particular, the efforts of Bill Begg and Alethea Weiland of the Thoracic Surgery Director’s Association (TSDA) and Martha Klapp were critical to the collection and processing of the masses of information required to assemble this program. The 75 segment authors as well as the technical efforts of Amadeus Multimedia were also critical to the completion and the ongoing monitoring of this project. The TSDA Prerequisite Curriculum Committee, including Drs Malcolm M. DeCamp, Jr, Verdi J. DiSesa, Eugene A. Grossi, Thomas L. Spray, Richard I. White, Douglas E. Wood, and Joseph B. Zwischenberger, was essential to the maturation of the content of the curriculum as well as to the collection of all the sections and segments. This project has been supported in part by an unrestricted educational grant from the Ethicon Endosurgery Inc., a division of Johnson and Johnson. Without the generosity of this group this project would not have been possible, maintaining a position of preeminence in the field of postgraduate surgical education for thoracic surgeons.
Appendix
Textbook-based navigation system/table of contents
Introduction and video tour: how to use this CD-ROM (Jeffrey P. Gold)
Section I: normal thoracic anatomy (Editor: Malcolm DeCamp)
Section II: Normal Thoracic Physiology (Editor: Richard I. Whyte)
Section III: adult cardiac diagnostic studies (Editor: Eugene Grossi)
Section IV: pediatric cardiology diagnosis (Editor: Thomas Spray)
Section V: thoracic imaging studies (Editor: Joe Zwischenberger)
Section VI: thoracic functional studies (Editor: Douglas Wood)
Section VII: thoracic anesthesia (Editor: Joe Zwischenberger)
Section VIII: thoracic critical care (Joe Zwischenberger)
Section IX: fundamentals of thoracic endoscopy (Editor: Douglas Wood)
Section X: surgical instrumentation and basic techniques (Editor: Malcolm DeCamp)
Section XI: cardiopulmonary bypass techniques (Editor: Eugene Grossi)
Section XII: research methodology and professional information (Editor: Jeffrey P. Gold)
Section XIII: academic, ethics, and professionalism (Editor: Jeffrey P. Gold)
Discussion
DR IRVING L. KRON (Charlottesville, VA): I am very pleased to comment on Dr Gold’s paper. I need to mention, however, that this project was born during our President’s presidency of the TSDA. He encouraged this project and made it happen. He needs to be congratulated as well.
As Dr Gold has stated, he has developed a CD-ROM prerequisite curriculum for residents entering thoracic surgical residency. There are two unique aspects of this product. First, it is proposed to ensure uniform knowledge for residents entering thoracic surgery. This takes out the variability in prerequisite training for residents entering our specialty. This is an extraordinary contribution in itself.
The thing I like most, however, is that he will test the product. He has randomized incoming residents for whether or not they have received the CD. He will be able to tell by the in-training scores whether or not this has made a difference in their fund of knowledge. Doctor Gold may not be aware, but the American Board of Surgery is also very interested in this project. They will check to see whether the surgical residents who have received the CD do better or worse than their last in-training examination in general surgery. They are fearful that they will do worse. I suspect they will do better.
As Dr Gold has clearly stated, we have changed our method of education from an apprenticeship to a curriculum-based experience. This is a very important contribution and has changed thoracic surgical attendings into teachers and mentors.
I have two questions for Dr Gold. What if his hypothesis is incorrect? That is, the residents who have the CD do not do better than the ones who do not have the CD on their various in-training examinations. Does he believe his concept is flawed or can he improve? Does performance on examinations relate more to the intrinsic ability of the residents to take the test rather than what we teach them on this CD?
A second, probably more important, question relates to future changes in thoracic surgical education. As most of the audience is now aware, the American Board of Thoracic Surgery has proved the concept of certification in thoracic surgery can occur without certification in general surgery. Likely this will result in integrated programs as well as shortened thoracic surgical overall education. When in the thoracic surgical integrated program would these residents get their CD, particularly if they match out of medical school?
Jeff, finally, I cannot tell you how proud I am of this project. You have clearly surpassed all the expectations I believe Mark had and certainly I had when I was involved with the Curriculum Implementation Committee. It is a great job, and congratulations.
DR GOLD: Doctor Kron, thank you for your comments and questions. What if it does not work, or more specifically, what if we do not find out that there is a statistically significant difference between the two groups? I can almost tell you now that from a statistician’s point of view with fewer than 70 residents randomized into each group that it is going to be awfully hard to find a statistically meaningful difference. We will strive in many ways to demonstrate differences as we are looking at issues of quality of life, of presence or absence of depression, of psychometric testing, program director evaluations, and resident evaluations, as well as performance on examinations. We hope to find what we are already beginning to see, namely that the residents who are working through the curriculum are developing a sense of comfort and confidence as they approach their formal thoracic surgery educational process.
Your second question concerning the future of thoracic surgery education as it relates to the division of the components of the didactic curriculum is a very important one. The Thoracic Directors Association in conjunction with the Joint Council of Thoracic Surgery Education has continued to explore multiple alternative residency education scenarios for a considerable period of time. Clearly, what is prerequisite curriculum, what is requisite residency curriculum, and what is postgraduate curriculum is a meld surrounded by predominantly artificial barriers of nomenclature. In our curriculum navigation system it is possible to put all of these curriculum components together into one seamless navigation system. It matters little whether you choose to structure and study these topics before your residency, during your residency, or after your residency as part of a continuing graduate medical education process. It is the concept and therefore the quality of the educational process that really counts.
I thank you again for your comments and ongoing support of this project, and thanks to the Society for the opportunity to share this exciting information with you this morning.
References
This article has been cited by other articles:
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  J. Gold Invited commentary. Ann. Thorac. Surg., May 1, 2006; 81(5): 1766 - 1766. [Full Text] [PDF]
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J. P. Gold, W. B. Begg, D. A. Fullerton, D. J. Mathisen, M. B. Orringer, and E. D. Verrier Evaluation of Web-Based Learning Tools: Lessons Learned from the Thoracic Surgery Directors Association Curriculum Project Three-Year Experience Ann. Thorac. Surg., September 1, 2005; 80(3): 802 - 810. [Abstract] [Full Text] [PDF]
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 F. A. Crawford Jr Presidential address: thoracic surgery education--responding to a changing environment J. Thorac. Cardiovasc. Surg., November 1, 2003; 126(5): 1235 - 1242. [Full Text] [PDF]
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