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Ann Thorac Surg 2006;82:1160-1165
© 2006 The Society of Thoracic Surgeons

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Special report

Cardiothoracic Surgery Resident Education: Update on Resident Recruitment and Job Placement

^a University of Texas Health Science Center, San Antonio, San Antonio, Texas
^b Palmetto Cardiovascular and Thoracic Associates, Charleston, South Carolina
^c Department of Cardiothoracic Surgery, St. Louis University, St. Louis, Missouri
^d Arizona Heart Institute, Phoenix, Arizona

^_* Address correspondence to Dr Salazar, University of Texas Health Science Center, San Antonio, 7703 Floyd Curl Dr, MC 7841, San Antonio, TX 78229 (Email: salazarj2{at}uthscsa.edu).

	Abstract

Top Abstract Introduction Material and Methods Results Comment References

 
BACKGROUND: Applications to cardiothoracic surgery training programs have steadily declined. The application cycle for 2004 marked the first time the number of applicants was lower than the positions offered. This survey reflects on this trend in applications and the perspectives of current and graduating residents.

METHODS: In June 2004, the Thoracic Surgery Residents Association, in conjunction with CTSNet, surveyed residents completing accredited cardiothoracic training or additional subspecialization. Participation was anonymous and voluntary.

RESULTS: Of the 140 graduates, 88 responded. Most were male (92%) and married (72%). Their average age was 35.7 years, and 56% had children. The mean educational debt was less than $50,000. Of the 88 respondents, 69 (78%) had plans to seek jobs whereas 15 (17%) sought additional training. Among job-seeking residents, 12% received no offers. Also, 59% of graduates initially sought a position in academics and 41% in private practice. Nearly one quarter (23%) reported that they would not choose a career in cardiothoracic surgery again, and more than half (52%) would not strongly recommend cardiothoracic surgery to potential trainees. Almost all (90%) of the graduates believed that the number of cardiothoracic training spots should be decreased, and 92% believed that a reduction in training positions should be achieved by closing marginal training programs. Additionally, 91% believed reimbursement for cardiothoracic surgery was inadequate, and 88% thought low reimbursement resulted in restricted patient access and decreased quality of care.

CONCLUSIONS: Cardiothoracic training programs are having difficulty in both applicant recruitment and in suitable job placement. This frustration in the job search coupled with reimbursement and lifestyle issues most likely contributes to the general dissatisfaction conveyed by the graduates. If these trends continue, the field will be faced with a crisis of unfilled residency programs and unemployed graduates.

	Introduction

Top Abstract Introduction Material and Methods Results Comment References

 
National Residency Matching Program data from the past decade shows a decrease in the number of applicants to cardiothoracic surgery training programs.

Figure 1 depicts the NRMP data from 1993 to 2005 for the approximately 140 positions available annually. From 1994 to 2002, total applicants decreased an average of 4.4% per year. During this period, the number of US medical graduates applying to the field decreased an average of 5.3% per year. This downward trend in the ratio of applicants to active positions appeared to rise in 2003, but in 2004 continued declining, marking the first time there were fewer applicants than available positions. The 2005 application cycle continued this trend with 104 total active applicants (of which were 78 US medical graduates), filling 100 (72%) of 139 available positions. This cycle left 29 (28%) of the cardiothoracic surgery fellowship positions unfilled. Despite the falling number of applicants, the number of training positions has not markedly decreased [1.

View larger version (13K): [in this window] [in a new window]   Fig 1. National residency matching program applications to cardiothoracic surgery training programs, 1993 to 2005 [1]. (Diamonds = total applicants; boxes = active positions; triangles = US medical school graduate applicants.)

View larger version (38K): [in this window] [in a new window]   Fig 2. Percent of graduating United States medical students planning on a thoracic surgery career, 1980 to 2004 [7].

View larger version (21K): [in this window] [in a new window]   Fig 3. Percent of graduating United States medical students planning on a career in selected surgical subspecialties, 1996 to 2004 [12]. (solid circles = opthalmology; boxes = otolaryngology; triangles = urology; X = plastic surgery; diamonds = neurosurgery; open circles = cardiothoracic surgery.)

	Material and Methods

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The Thoracic Surgery Residents Association, in conjunction with CTSNet (www.ctsnet.org), surveyed the 2004 graduating cardiothoracic residents. Residents surveyed were either completing an accredited US training program or completing an extra year of subspecialization after completing standard training. Participation was solicited by electronic mail and by encouragement from program directors. The survey was administered online June 15 to 30, 2004. Participation was anonymous and voluntary.

	Results

Top Abstract Introduction Material and Methods Results Comment References

 
Eighty-eight of the estimated 140 graduates responded. Their average age was 35.7 years, 92% were male, 72% were married, and 56% had children. The mean educational debt was less than $55,000. Three quarters of the graduates had graduated from US medical schools. Sixty-nine (78%) of the graduates had initial plans to seek jobs whereas 15 (17%) initially sought additional training. Four of the respondents were seeking neither a job nor additional training. The data from these four respondents, however, were still used in the analysis of all graduating residents.

Graduates Initially Seeking Jobs
Looking at those graduates initially seeking jobs (n = 69), 88% received at least one job offer and 12% received no offers. More than half of the graduates (59%) received three or more interviews, but 16% received zero or one. Almost half (42%) started the job search more than 12 months before graduation. More graduates initially sought a position in academics (59%) than in private practice (41%). Looking at the jobs that were obtained, this was reversed with 46% (n = 32) in private practice and 36% (n = 25) in academics. Of those initially seeking jobs, a large majority obtained jobs (85%), but a substantial number of graduates (15%) opted for additional training. Of those graduates initially seeking jobs, but later opting for additional training, 80% did so because of difficulty finding a suitable job.

The majority of graduates sought positions in mixed cardiac and general thoracic (48%) or purely cardiac (26%) practices. The remaining graduates sought either congenital (7%) or general thoracic (19%) positions. The distribution of jobs obtained was similar, with mixed jobs predominating (39%). A large majority of graduates (82%) reported that finding a job was either difficult or extremely difficult. Only 43% of the graduates stated they were satisfied with their job opportunities.

For those graduates initially seeking jobs, most (86%) reported that personal contacts were the most effective tool in getting a job. A slight majority (54%) stated that their program director played an important role in the job search, but almost half (45%) reported that the role of their program director was not important or inconsequential. The predominant explanations given to the graduates for the reason for no available jobs were decreased numbers of cases (38%) and decreased reimbursement (30%). Almost half (46%) reported that many of the jobs did not appear to be partner-tract. Most of the graduates stated the reason for choosing a job was that it was the best job available (54%) or because of their family (19%). Almost one quarter (23%) of the graduates reported choosing a job because it was their only reasonable job offer.

Graduates initially seeking jobs reported the salary they accepted or would accept was between $150,000 and $250,000 in 70% of the cases, with the average salary being approximately $194,000. The average salary actually obtained by those residents gaining a job was $202,500. A slight majority (51%) reported this salary as being adequate. The graduates reported that off-pump coronary revascularization (70%), valve repair (77%), and general thoracic (87%) were highly sought areas of experience. Surgery of the aorta or its root (58%) and vascular surgery (57%) were moderately sought. Experiences with assist devices (43%), heart or lung transplant (43%), minimally invasive cardiac surgery (45%), general surgery (25%), and robotic surgery (12%) were less often sought. Most (54%) graduates accepted positions in their region of training.

Graduates Initially Seeking Additional Training
Almost all (93%, n = 14 of 15) graduates initially seeking additional training had completed only standard cardiothoracic surgery training. A small majority (53%, n = 8) wished to complete additional training in order to pursue personal interests, but 7 (47%) graduates additionally believed further training would make them more marketable. In the end, 3 (20%) of the graduates initially seeking additional training obtained a job. Of the 12 (80%) who ultimately chose additional training, most (58%) pursued congenital/pediatric cardiothoracic surgery. The others pursued: valve repair (n = 2), VAD/transplant (n = 1), aortic (n = 1), and general thoracic (n = 1).

All Graduating Residents
Of all graduating residents (n = 88), more than two thirds of the graduates (68%) had finished a 2-year standard training program while the rest completed a 3-year program. The average number of cases performed as surgeon during the 2-year training program was 418, whereas the average number in the 3-year training program was 543. Comparing these numbers with those required by the Residency Review Committee (RRC) and American Board of Thoracic Surgery (ABTS [125 cases per year]), 7% of those in a 2-year program and almost one quarter (21%) of those in a 3-year program did not perform the number of required cases [9, 10]. Despite this, 95% of the graduates reported having received adequate or excellent preparation for independent operating. Three quarters reported having received adequate or excellent preparation for the Boards. A majority of these graduates (60%) had performed at least 1 year of research at some point after graduating from medical school. Most of the graduates (84%) reported having personal colleagues who were having difficulty finding a job.

More than three quarters (78%) would submit the same match list for cardiothoracic surgery programs that they had submitted prior to their training. Almost a full one quarter of the graduates (23%) reported that they would not choose a career in cardiothoracic surgery again. More than half (52%) would not strongly recommend cardiothoracic surgery to potential trainees.

When asked about how to change training, almost all (90%) of the graduates believed that the number of cardiothoracic training spots should be decreased. Of these graduates, 92% believed that this reduction in training positions should be achieved by closing marginal training program whereas 6% believed it should be done by taking one spot from each program. Almost all of the graduates (91%) reported believing that reimbursement for cardiothoracic surgery was inadequate, and a similar number of graduates (88%) believed that low reimbursement would result in restricted patient access and decreased care.

Graduates With Additional Training
Of graduate with additional training (n = 11), the majority (82%) finished an additional 1 year of training with most (91%) having had completed a 2-year standard program. The majority of the training was obtained in congenital heart surgery (45%) and general thoracic surgery (36%). Most of these graduates had completed additional training owing to personal interest (45%) or to make themselves more marketable (45%) whereas 18% did so because they could not find a suitable job. In the end, 91% of the graduates with additional training found jobs, and a single graduate chose to pursue further training because no suitable job was available. Interestingly, only 60% of the graduates who had received additional training in congenital heart surgery were able to find a job in this area. Overall, the salaries and satisfaction with the job search process was comparable between those with additional training and those with only standard training.

	Comment

Top Abstract Introduction Material and Methods Results Comment References

 
The data obtained from this survey help to reinforce the concerns set forth in the 2004 article [8]. Training programs are having difficulty in both applicant recruitment and in suitable job placement. If present trends continue, the field will be faced with a crisis of unfilled residency programs and unemployed graduates. The lengths of resident training programs, residency faculty director involvement, and women as an untapped applicant pool seem to be areas of importance to increase interest in cardiothoracic surgery.

Cardiothoracic Surgery Supply and Demand
The surveyed cardiothoracic surgery residents give troubling results on the job outlook for trained cardiothoracic surgery residents. Despite completion of 7 to 10 years of residency (mean, 8.6), fully trained Thoracic surgeons are presently being forced to gain additional training due to the inability to obtain a suitable job. It is important to note that even graduates with additional training shared similar job search experiences as those with only standard training.

The large number of residents having troubles in the job search coupled with reimbursement and lifestyle issues most likely contributes to the general dissatisfaction conveyed by the graduates. Logically, the job search difficulty must be due to training too many residents or that current training provides inadequate preparation for the present needs of the marketplace. Almost all graduating residents believe the training is adequate and also report that the number of cardiothoracic surgeons being trained should be decreased by closing marginal programs.

Cardiothoracic Residency Training Program Length and Faculty Director Involvement
The belief of adequate cardiothoracic surgery resident training, however, should be viewed within in its context. Doctor Timothy Gardner states that despite this sentiment "there are relatively few thoracic residents who are fully prepared for current thoracic surgery careers" [11]. Too many residents are failing to achieve the minimum operating case requirements set forth by the RRC and ABTS. The content of training also is called into question when so few jobs state a need for general surgery despite all residents having 5 years of general surgery training. This problem could only be made worse with the recent enactment of the 80-hour work week requirement. If training is not adequate without this requirement, how could one expect to achieve proper training now without increasing the length of training? The questions must be explored of whether current graduates gain the cardiothoracic experience needed and whether adequate exposure is obtained in highly sought after areas such as off-pump coronary revascularization, valve repair, and general thoracic. A potential step toward improvement by ABTS and RRC include the development of two new routes for cardiothoracic surgery training starting in July 2007. The Board will establish two primary pathways to certification, a cardiothoracic surgery pathway and a general thoracic surgery pathway. An additional special certificate pathway will be established for candidates who complete the cardiothoracic surgery track and plan to perform congenital heart surgery [13].

Another frustration among the graduates is their feeling of disenfranchisement within the cardiothoracic field. Some graduates convey a feeling that the relation between the senior surgeons and newly graduated ones can be acrimonious. While these may be isolated comments made by "disgruntled" graduates, the number of graduates who feel that their program director was not important or inconsequential in the job search is troubling. The feeling conveyed by many of the graduates is a lack of care among many program directors about graduate job placement. These concerns are of importance considering such a large number of graduates would not have entered the same match list during the cardiothoracic surgery application process nor would strongly recommend cardiothoracic surgery to potential trainees. These results may have resulted in the attitude of negativity that has become pervasive in the general surgery residency community. Whether this generational divide exists in reality may be questionable, but the mere perception may drive many medical students and general surgery residents away from choosing cardiothoracic surgery as a career.

Cardiothoracic Residency Program Recruitment
Doctor Mark Orringer conveyed this concern when he said that "the lifeblood of every profession is the infusion to its ranks of youth" [8]. That is presently not the case in cardiothoracic surgery where recently total applicants were less than total positions for the first time. With this being the case, the field is losing the "lifeblood" that Dr Orringer described.

The possibility exists that much is related to the problems already discussed—difficulty with job placement and growing frustration among graduates. The decreasing levels of reimbursement aggravate the current situation. In the past, residents would endure the length and stress of training in exchange for high salaries once in practice. The security of that future earning no longer exists. Additionally, the decrease in applicants to cardiothoracic surgery has been attributed to the underlying changes in demographics and lifestyle priorities of US medical graduates. Many of the best graduates are choosing specialties that require fewer training years and less time commitments during residency and in practice.

Women in Cardiothoracic Surgery
The growing number of women graduating from US medical schools is not reflected in the cardiothoracic surgery applicant pool. Currently, more than 90% of the cardiothoracic graduates are male whereas 46% of the 2004 US medical graduates were female. While 50% of medical school acceptances and more than 20% of general surgery residents are female, less than 8% of cardiothoracic surgery residents are female [12]. Because of this untapped population, the pool of applicants to the cardiothoracic surgery positions is already limited before the process even begins.

Forward Outlook for Cardiothoracic Surgery Resident Training
Problems exist, and changes, although difficult, must be undertaken before the field suffers irreparable harm. Even if no voluntary change occurs, change will still take place. Instead of cardiothoracic leaders deciding on how changes are made, free market forces will take control possibly in a volatile way. Having more positions then applicants will inevitably force inadequate or marginal programs to close while also bringing in weaker candidates into a profession that has always demanded, and in the past been able to choose from, the best and the brightest. After residency, graduates will continue to have difficulty in job placement and many will choose to seek additional training. This "backlog" will further increase the pool of job seekers and possibly make additional training a de facto requirement. Graduating residents are the ambassadors of every field playing a vital role in recruiting new members. Their frustration will serve to further decrease the applicant pool. Thus, a vicious cycle may eventually alleviate these supply/demand problems, but in ways far beyond any group's control.

No idea will instantly increase cardiothoracic caseloads or reimbursement. No change can affect the ever-growing lifestyle priorities of new medical graduates. Despite this, there is a definite need to explore options that could be pursued. Many ideas have already been discussed and steps have been taken to work toward a resolution of the looming crisis. The ABTS has removed the requirement for general surgery certification [10]. Additionally, there are new training programs consisting of 3 to 4 years of general surgery followed by 3 to 4 years of cardiothoracic surgery.

Other options also exist that might offer improved cardiothoracic surgery experiences and aid in increasing and improving the applicant pool. One would be to match residents out of medical school in a similar process as other surgical specialties such as urology or otolaryngology. This would allow for the cardiothoracic programs to have greater control on the curriculum that their residents are exposed to and thus could serve to increase cardiothoracic experiences. In addition there would be the ability to offer upper level residents more dedicated primary time in the operating room while junior residents could handle more of the day-to-day patient care. There is also the belief that this could serve to increase the applicant pool because the applicants will not have the rigors and frustrations of residency to dissuade them from contributing more years toward cardiothoracic surgical training; that is, recruit our residents when they still have "the fire in their eyes." Experiences from other surgical subspecialties show an increased demand in those fields that match residents out of medical school.

Final Note
The limitations of this study must be acknowledged. In particular, the approximately 63% response rate for graduating residents (including fellows) tempers the conclusions to be drawn. That is despite a redoubling of efforts in an attempt to improve upon the 64% response from the previous survey. 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. Even with the possible selection bias, these results are disturbing when viewed in the context of surrounding issues.

This study explores an extremely sensitive and very important subject for trainees, faculty mentors, and all practicing cardiothoracic surgeons. The concerns presented are very real and very immediate. In no way is its purpose meant to be inflammatory of adversarial. Instead, the intention is to educate and provide motivation in an attempt to preserve a great specialty for both present and future colleagues. Challenges do exist, and recognizing these concerns will provide an opportunity to formulate solutions allowing cardiothoracic surgery to adapt for the modern marketplace. 2–6

	References

Top Abstract Introduction Material and Methods Results Comment References

 

1. Data from National Residency Matching Program for Thoracic Surgery, 1993-2005..
2. Urology match statistics. Available at: http://www.auanet.org/residents/ (accessed Apr 20, 2005)..
3. Otolaryngology match statistics. Available at: http://www.kumc.edu/som/medsos/ (accessed Apr 20, 2005)..
4. Neurological surgery match statistics. Available at: http://www.kumc.edu/som/medsos/ (accessed Apr 20, 2005).
5. Ophthalmology match statistics. Available at: http://www.kumc.edu/som/medsos/ (accessed Apr 20, 2005)..
6. Plastic surgery match statistics. Available at: http://www.kumc.edu/som/medsos/ (accessed Apr 20, 2005)..
7. Data from Association of American Medical Colleges medical school graduation questionnaire, 1980-2004. Available at: http://www.aamc.org/ (accessed Apr 20, 2005)..
8. Salazar JD, Lee R, Wheatley III GH, Doty JR. Are there enough jobs in cardiothoracic surgery? The Thoracic Surgery Residents Association job placement survey for finishing residents Ann Thorac Surg 2004;78:1523-1527.[Abstract/Free Full Text]
9. Accreditation Council for Graduate Medical Education. ACGME/RRC Program requirements for thoracic surgery. Available at: http://www.acgme.org/ (accessed Mar 1, 2005)..
10. American Board of Thoracic Surgery. Certification requirements. Available at: http://www.abts.org/doc/4018 (accessed Mar 1, 2005)..
11. Gardner TJ. Residency training for the future, not the past Ann Thorac Surg 2004;78:1519-1521.[Free Full Text]
12. American Association of Medical Colleges. FACTS—applicants, matriculants, and graduates. Available at: http://www.aamc.org/data/facts/2004/factsgrads2.htm (accessed Apr 20, 2005)..
13. American Board of Thoracic Surgery. New certification pathways and operative requirements. Available at: http://www.abts.org/ (accessed Mar 12, 2006)..

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