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Ann Thorac Surg 2004;78:1523-1527
© 2004 The Society of Thoracic Surgeons
a University of California, San Francisco, Pediatric Cardiothoracic Surgery, San Francisco, California, USA
b St. Louis University, St. Louis, Missouri, USA
c University of Texas Southwestern Medical Center, Dallas, Texas, USA
d LDS Hospital, Salt Lake City, Utah, USA
Accepted for publication May 17, 2004.
* Address reprint requests to Dr Salazar, The University of Texas Health Science Center at San Antonio, Division of Thoracic Surgery, 7703 Floyd Curl Drive, Mail Code 7841, San Antonio, TX78229-3900 (E-mail: salazarj2{at}uthscsa.edu).
Presented at the Fortieth Annual Meeting of The Society of Thoracic Surgeons, San Antonio, TX, Jan 26–28, 2004.
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Abstract |
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METHODS: In June 2003, the Thoracic Surgery Residents Association surveyed residents completing accredited cardiothoracic training or additional subspecialization, utilizing a web-based survey hosted by CTSNet. Resident participation was voluntary and anonymous.
RESULTS: Of the estimated 140 graduates, 89 responded. The majority were male (91.0%, n = 81), married (80.0%, n = 71), and had children (61.0%, n = 54). Average age was 36.2 years old, and mean educational debt was less than $50K. Of the 89 respondents, 77 initially sought jobs and 12 sought additional training. For residents seeking jobs, 19.5% (n = 15) received no offers and 13 of these ultimately pursued additional training. Acquired jobs were in private (53.0%, n = 34) or academic practice (47.0%, n = 30), with 73.4% (n = 47) involving general thoracic surgery. Most would again choose cardiothoracic surgery as a career (75.5%, n = 67), and 62.0% (n = 55) would again submit the same match list. However, 87.0% (n = 77) believed that the number of trainees should be decreased, 81.0% (n = 72) believed that reimbursement for cardiothoracic surgery is inadequate, and 77.5% (n = 69) believed that excessively low reimbursement will result in restricted access or decreased quality for patients.
CONCLUSIONS: Most cardiothoracic residents were successful in finding employment after training. A substantial percentage, however, pursued additional training due to lack of job opportunities. Although most finishing residents were satisfied with training and career choice, significant concerns exist regarding job opportunities and compensation. These conditions may lead to difficulty in recruitment to the specialty.
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Introduction |
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Figure 1 depicts the National Residency Matching Program data for cardiothoracic surgery from 1993 to 2004. The data demonstrate that the total number of training positions available has remained relatively constant at 140. Applications peaked in 1995 at 200 and then steadily decreased to the point that the number of applicants in 2003 equaled the positions available. The total number of applicants to cardiothoracic surgery who graduated from US medical schools has similarly declined such that there are fewer US applicants than training positions. Qualified foreign graduates have filled many positions, although some have remained unfilled [1].
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Material and Methods |
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TopAbstractIntroductionMaterial and MethodsResultsCommentDiscussionAcknowledgmentsReferences |
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Results |
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TopAbstractIntroductionMaterial and MethodsResultsCommentDiscussionAcknowledgmentsReferences |
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Graduates Seeking Jobs (n = 77)
Focusing now on graduating residents seeking jobs, 80.5% received at least one job offer, whereas nearly 20% received none. Residents began their job search 12 months or less before graduation in 80.5% of cases. Approximately half of residents had 3 or more interviews (52.0%), although 36.5% had zero or one. Graduates were equally distributed between those pursuing private and academic positions. For those that found jobs, this distribution was similar, but 17% of those seeking jobs resorted to pursuing additional training.
Most residents sought jobs in purely cardiac (32.5%) or mixed cardiac and general thoracic (52.0%) practices. Relatively few pursued purely general thoracic (13.0%) or congenital (2.5%) jobs. The reported distribution of clinical practice for jobs actually obtained was similar, with mixed jobs predominating. A majority of graduates reported that finding a job was difficult or extremely difficult (71.5%). Only 44.0% were satisfied with available job opportunities.
The most effective technique reported for finding a job was through personal contacts (79.0%), while few graduates found benefit from recruiters, letter mailing, journal ads, and Internet job boards. Program directors played an important role in the graduates' job search in nearly two-thirds of cases, although 37.5% perceived the director's role as not important or inconsequential. The most common reasons given by practices to explain the lack of jobs were decreased caseload (41.5%) and decreased reimbursement (25.0%). Graduates accepted their job because it was the best overall job (44.0%) and for reasons of family (25.0%), but nearly one-third said that it was the only reasonable job they could find (30.0%).
Finishing residents reported that the starting salary they accepted or would accept was between $150,000 and $250,000 in 72% of cases. Average starting salaries for private and academic practice were similar at approximately $205,000. Only 58.0% believed this to be adequate compensation. While exploring job opportunities, residents reported that highly sought-after areas of experience included off-pump coronary revascularization (69.0% agree), valve repair (78.0%), and general thoracic surgery (87.0%). Areas of experience that were moderately sought-after included minimally invasive techniques (50.5%), aortic and aortic root surgery (62.5%), and vascular surgery (57.0%). Areas that were less sought after included assist devices (39.0%), heart and lung transplantation (31.0%), and general surgery (18.0%). Most graduates remained in their region of training for their first job.
All Graduating Residents (n = 89)
Now focusing on all survey respondents, there was an equal distribution between those graduating after 2 years and 3 or more years of training. The average number of cases performed as surgeon during training was 405 for 2-year graduates and 462 for 3+-year graduates. In 2-year programs, 13.0% performed less than the Residency Review Committee and American Board of Thoracic Surgery requirement of 125 cases per year [6, 7]. Over one-third (36.5%) of those graduating from 3+-year programs performed less than the minimum requirement. Having said this, nearly all graduates believed that their training was adequate or excellent preparation for independent operating. Similarly, 89.0% believed they had adequate or excellent preparation for board examination. Nearly two-thirds of graduates performed 1 year or more of research after medical school (64.0%)
When asked if most colleagues that they know personally are having difficulty finding a desirable job, 86% of all graduating residents agreed or strongly agreed.
When asked if their match list for cardiothoracic surgery programs would be the same today as it was before training, less than two-thirds responded in the affirmative (62.0%). Most graduating residents responded that they would again choose to become a cardiothoracic surgeon (75.5%), although almost one-quarter would not (24.5%).
When asked if the number of cardiothoracic surgeons being trained should be decreased to reflect the changing market, 87% agreed or strongly agreed. Only 19% of finishing residents believed that reimbursement for cardiothoracic surgery is adequate. Furthermore, 77% believed that excessively low reimbursement for cardiothoracic surgery will result in restricted access or decreased quality of care for patients.
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Comment |
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Not addressed by this survey, but present in the resident comments included in the online Appendix (http://ats.ctsnetjournals.org), is the concern that many groups are hiring new graduates with no intention of bestowing partnership, with its privileges and higher compensation. The perception exists that some groups would rather maintain a steady stream of inexpensive, junior associates than share the decreasing income of the group.
A disturbing number of cardiothoracic graduates are dissatisfied with their choice of specialty. This dissatisfaction appears to be rooted in the diminishing rewards and job security after long years of arduous training. Traditionally, cardiothoracic surgery has recruited the best and the brightest. These exceptional individuals recognize their own abilities and potential, which leads to further dismay when they observe the successes of those of similar caliber who pursued other specialties or professions.
Residents and recent graduates of cardiothoracic surgery training programs are probably the most important ambassadors to those considering careers in our specialty. The downward trend in resident applicants and medical students planning on pursuing cardiothoracic surgery is clear. This decline may be related to the changing lifestyle priorities of potential trainees and changing demographics of medical students. Approximately half of medical students are women, whereas more than 90% of cardiothoracic trainees are men. The decline in interest can only be potentiated by poor job opportunities and compensation, as experienced by recent graduates. Dissatisfaction with training programs is of further concern and is likely communicated to potential trainees. Many residents express concern about the service-related role of training and lack of adequate operative experience, which stands to be further threatened by the 80-hour work week.
The potential result of these conditions is that residents of insufficient caliber will populate cardiothoracic training programs and subsequently our profession. Cardiothoracic surgery is arguably the most challenging and technically demanding specialty in Medicine. Our specialty has always demanded and maintained the highest standards and long claimed that successful care of our patients required the best and the brightest.
Analysis of previous data [8] has suggested that the arrival of the baby boomers, the retirement of those delayed by the recent market downturn, and the re-presentation of patients temporized by stents may bring the supply and demand for cardiothoracic surgeons back into balance. This may occur, but may not, or may take 10 to 15 years to manifest. Meanwhile, the word is on the street with potential trainees that cardiothoracic surgery cannot guarantee employment, let alone higher compensation. Potential trainees are voting with their feet and looking to other specialties in Medicine. Since the institution of the 80-hour work week, significant difficulty and expense have been experienced in attempts to adequately cover clinical services while maintaining educational priorities. If the applicant pool further declines and many positions go unfilled, the results could be disastrous.
Graduating residents responding to this survey believe that the number of training positions should be decreased in response to the job market. There are many potential problems associated with this course of action, including the perception of noncompetitive practice by our specialty and the financial implications to training programs that rely on residents for patient care. The economic and logistic effects of decreased resident presence have already been experienced after the implementation of the 80-hour work week. Although not addressed by this survey, potential approaches to training slot reduction include programs voluntarily relinquishing spots and strict enforcement of Residency Review Committee requirements to remove marginal programs. But these may be simplistic approaches that are untenable in reality and would take many years to see results. Whatever measures are taken, the first priority is to maintain excellence in caring for our patients. It follows that the highest quality of trainees in cardiothoracic surgery must be preserved.
The limitations of this study must be acknowledged. In particular, the approximately 64% response rate for graduating residents tempers the conclusions to be drawn. A selection bias may be present in those responding, with disgruntled residents unable to find jobs being more likely to fill out such a survey. Although the absolute numbers of those unable to find jobs is still concerning, the only way to definitively address this issue is to increase the number of respondents. A redoubling of efforts will be carried out for the survey of 2004 graduates to attain a response rate more than 90%. Additionally, the actual denominator for this study, estimated at 140, is unclear and needs to be better defined. Respondents need to be categorized as completing standard training versus subspecialization to enable better understanding of the job market. Future surveys also will need to address the possibility that difficulty in job placement is more reflective of inadequate resident preparation/readiness than job availability.
This study explores a sensitive and very important subject for trainees, faculty mentors, and all practicing cardiothoracic surgeons. Its purpose is not to be inflammatory or adversarial. Rather, the motivation behind this survey is that of new and future colleagues wishing to preserve a great specialty and tackle these difficult problems in union with our mentors.
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Discussion |
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TopAbstractIntroductionMaterial and MethodsResultsCommentDiscussionAcknowledgmentsReferences |
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I have plotted the results of the National Thoracic Surgery Residents Match since its inception in 1992, and the number of US medical school graduates pursuing thoracic surgical training has declined. When the match began in 1992–1993, roughly 160 US medical graduates applied for our 140 available positions. That number has decreased steadily, from the 167 applicants that we had in '93 in the early days of the match, sequentially beginning in 1997: 123, 118, 116, 114, 112, 107, and last year, a possible aberration, when it went to 124. International medical school graduates have filled the remaining positions.
Our popularity decline is multifactorial. Ninety-six percent of surveyed medical students regard medical liability as a major crisis which for 48% in their third and fourth years influences their specialty choice. They are steering away from the high-risk specialties. Reimbursement has plummeted. The starting salary for an invasive cardiologist now often exceeds that of a new thoracic surgeon.
This year for the first time women outnumbered men in applications to medical school, 51% of the 35,000 applicants. As a strongly male-dominated specialty, we continue to miss out on their potential talent.
The mandated 80-hour work week duty hour limit for residents is challenging us, to say the least. Shortened work hours mean less time for clinical experience. We must now find ways to provide residents sufficient experience without giving them excessive experience. So do we increase the length of training when our specialty has been struggling to decrease the length of training?
The decline of coronary artery bypass grafting, like the disappearance of thoracoplasty for pulmonary tuberculosis after streptomycin and isoniazid, has resulted in falling case numbers that are affecting recruitment in both academic and private practice. And the country's most recent recession and poor stock market performance altered the retirement plans of many senior thoracic surgeons who have opted "to work just a few more years."
So the word is out. Dr Salazar says that nearly 72% of graduating residents report difficulty or extreme difficulty in finding a good job, and only 44% are satisfied with available job opportunities. Twenty-five percent would not choose a cardiothoracic career again without ever having experienced the exhilaration of what we do in our practices. Medical students and general surgery residents talk to thoracic surgery residents. I predict a dramatic drop in our resident applicants this year across the country and next year. Steps should be taken to address this job market problem, which as a thoracic surgery residency program director I assure you is very real.
The RRC should reject all new requests for residency programs or increases in the complement of residents in existing programs, and marginal programs, whether they are 2 years or 3 years, if they are not meeting the minimal ABTS/RRC index case numbers, should be aggressively closed down. It is wrong to have 20 pediatric cardiac surgery fellowship programs in this country when no more than two to three pediatric cardiac surgeons coming out of training are needed a year.
Residency training emphasizing either cardiac or general thoracic surgery, that is, tracking, should be facilitated, not only encouraged, by the RRCs and the ABTS to better meet market forces, and the Thoracic Surgery Directors Association's office should become an accepted and widely acknowledged clearing-house and facilitator for jobs.
Dr Salazar, I have a few questions that I have shown on this slide. Your job survey data are weakened since only 64% of graduating residents responded. How many of these were fellows completing subspecialty training after residency? The job hunting experience of new pediatric cardiac surgeons, for example, may be quite different from that of residents just finishing training.
Second, would you favor a mandatory graduating resident demographic/job opportunity survey to provide the speciality current data? Finally, most thoracic surgery residents in the past entered this speciality to become cardiac surgeons. Now, 52% seek combined jobs, combining cardiac and general thoracic surgery. As our graduating residents struggle to keep all options open, do you think that many will opt for the chance they now have to forego ABS certification?
You, your colleagues, and the TSRA are to be commended for airing this issue, which is a most serious challenge before us and which warrants careful deliberation and action by thoracic surgical leadership.
DR SALAZAR: Thank you Dr Orringer for your support of this work and your comments.
Your first question addresses the survey's 64% response rate and the characteristics of respondents that could potentially limit the interpretation of these data. Although a 64% response rate is reasonable for a voluntary survey, a higher number is preferred. It is possible that resident responses were biased toward those that did not get jobs, although the reverse may also be true. Without more data, which we plan to collect for next year's graduates, neither assumption can be tested. Even if a bias did exist toward those that did not find jobs, a concerning number of residents had difficulty finding employment and expressed low morale about the profession.
Very few respondents did more that 3 years of training (< 10%), and most were looking for adult cardiac and general thoracic jobs. Future surveys will look more closely at job placement after subspecialty training.
A mandatory graduation survey would be of great utility for monitoring of trends in cardiothoracic surgery and enabling courses of action based on hard data. Continued strong encouragement of graduating residents to fill out the survey by their respective program directors will also be of great assistance.
With regard to American Board of Surgery certification, I was not within the group that could opt out, although many of my colleagues and I have discussed the issue. I believe that most residents, if they have completed the full training in general surgery, will still get ABS certification. In the future it may be possible for some residents to forego full general surgery training and therefore decrease training length. Based on our survey data for the residents that were looking for jobs, relatively few programs were looking for someone to practice general surgery. Given a lack of market impetus, residents may choose not to get ABS certification if they don't need to. How this potential development would affect general thoracic preparation is unclear. Streamlined cardiothoracic surgery training programs without full general surgery training would need to address this issue. Thank you.
The Appendix is available only online. To access it, please visit: http://ats.ctsnetjournals.org and search for the article by Salazar, Vol. 78, pages 1523–1527.
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Appendix |
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Acknowledgments |
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TopAbstractIntroductionMaterial and MethodsResultsCommentDiscussionAcknowledgmentsReferences |
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References |
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