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a Department of Thoracic and Cardiovascular Surgery, University of Texas M. D. Anderson Cancer Center, Houston, Texas
b Department of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina
c Center for Workforce Studies, Association of American Medical Colleges, Washington, DC
d Division of Thoracic Surgery, University of Texas Health Science Center at San Antonio, San Antonio
e Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Children's Medical Center Dallas, Dallas, Texas
f Division of Cardiothoracic Surgery, University of Cincinnati, Cincinnati, Ohio
Accepted for publication February 26, 2009.
* Address correspondence to Dr Vaporciyan, 1515 Holcombe Blvd, Unit 445, Houston, TX 77030-4009 (Email: avaporci{at}mdanderson.org).
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Abstract |
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 Top Abstract IntroductionMaterial and MethodsResultsCommentFootnotesAcknowledgmentsReferences |
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Methods: An initial survey instrument was content-validated, and the final instrument was distributed electronically between March 24 and May 2, 2008 through 251 general surgery program directors to all Accreditation Council for Graduate Medical Education-accredited general surgery residents (7,508).
Results: The response rate was 29% (2153 residents; 89% programs). Respondent's demographics matched existing data; 6% were committed to CTS, and 26% reported prior or current interest in CTS. Interest waned after postgraduate year 3. Interest correlated with CTS rotation duration. Of the respondents committed to CTS, 76% had mentors (71% were cardiothoracic surgeons). CTS had the most shortcomings among 9 subspecialties. Job security and availability accounted for 46% of reported shortcomings (3 to 14 times higher than other subspecialties). Work schedule accounted for 25%. Length of training was not a very important factor, although it was identified as an option to increase interest in CTS. Residents who were undecided or uninterested in CTS were twice as likely to cite the ability to balance work and personal life as important than residents who chose CTS.
Conclusions: The dominant concern documented in the survey is job security and availability. The importance of mentorship and exposure to CTS faculty in promoting interest was also evident. Decision makers should consider these findings when planning changes in education and the specialty.
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Introduction |
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TopAbstractIntroductionMaterial and MethodsResultsCommentFootnotesAcknowledgmentsReferences |
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Considerable speculation surrounding the cause of this trend has been offered [3–6]. Surveys of senior-level CTS trainees as well as recent graduates have been conducted to understand the perceptions of current trainees [7, 8]. In addition, changes are already being initiated to address the most likely deficiencies that are believed to drive applicants away from CTS. These changes have focused on a reduction in the length of training (mostly through reduction in the general surgery training requirements), debt forgiveness, and redefining and expanding the specialty, with the most common example being the inclusion of catheter-based technology [8–11]. Although well founded and likely appropriate, these changes are based on merely educated speculation.
Data from the actual applicant pool, general surgery resident trainees, have been conspicuously absent. Similar data on specialty choice have been collected in other specialties, and these studies have suggested some common themes. These include (1) the demographic characteristics and individual background of matriculating medical students, (2) exposure and experiences during medical school and residency training, (3) the perceived characteristics of training, and (4) perceived characteristics of a career in a given specialty [12–18].
To understand the factors influencing interest in cardiothoracic surgery, the authors, in conjunction with the Association of American Medical Colleges (AAMC) Center for Workforce Studies, developed an instrument and conducted a survey of general surgery residents on behalf of the Society of Thoracic Surgeons (STS) and the American Association for Thoracic Surgery (AATS). In addition, by targeting all general surgery residents in general surgery residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME), we could gain a clearer picture of the factors influencing resident interest in CTS and the changes in perception that occur as residents mature through their 5 years of training. The data from this survey could then potentially be used to guide further modification of cardiothoracic training to attract the best candidates.
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Material and Methods |
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TopAbstractIntroductionMaterial and MethodsResultsCommentFootnotesAcknowledgmentsReferences |
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Participation in the survey was voluntary and anonymous, with assurances that all responses would only be reported in the aggregate. A completed response was considered as consent to participate. As an incentive to participate, residents were informed that they would be entered into a drawing to win a Nintendo Wii (Nintendo, Tokyo, Japan) or a Sabiston Textbook of Surgery 18th Edition (Expert Online Consult E-dition) if they provided an e-mail address when they completed the survey. This methodology was approved by the AAMC's Investigational Review Board.
We developed the initial survey instrument, and its content was validated by discussion with leaders of the APDS. Additional input was provided by the members of the STS and the AATS governing bodies. The instrument was then further validated by the AAMC using information from focus groups made up of volunteer general surgery residents or program directors. The final instrument was converted to an electronic form.
A prenotification letter explaining the importance of the survey was sent to every program director, available associate program director, and program coordinator at 251 general surgery residency programs using a mailing list from the APDS. The initial survey mailing with the link went by e-mail to all program directors, associate program directors, and program coordinators on March 24, 2008. The e-mail included a note to the program directors asking them to forward the survey invitation to the residents in their program. Reminder notices were sent on April 2, 3, 10, and 16, 2008. Dr Tarpley, head of the APDS, assisted with an additional reminder on April 8. The survey was closed on May 2, 2008.
Responses were received from 2364 residents attending 199 unique general surgery programs. The data were cleaned to eliminate invalid cases and response sets, yielding a final sample of 2153. The gender and education mix of the survey respondents are comparable with the gender and education demographics of 2006 general surgery residents as reported in the September 2007 medical education issue of the Journal of the American Medical Association (JAMA) [20], and therefore the sample is felt to be representative.
The data were analyzed using SPSS 15.0.1 software (SPSS, Inc., Chicago, IL). Frequency distributions for categoric variables and descriptive statistics for continuous variables (mean, median, range) were examined to identify basic distribution patterns among valid responses and to summarize the responses to all questions. The significance of gender differences in commitment to CTS and among factors in specialty choice decision according to level of interest in CTS was assessed using Pearson 
2 tests. Statistical significance was defined as either p < 0.01 or p < 0.05, as indicated.
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Results |
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TopAbstractIntroductionMaterial and MethodsResultsCommentFootnotesAcknowledgmentsReferences |
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Historically, CTS has held limited appeal for women, despite a rising presence of women in general surgery. When interest was stratified by gender, a significantly higher percentage of men were committed to CTS (7% vs 3%, p < 0.01); however, a large number of women reported interest in the specialty. The overall gender-dependent interest is shown in Figure 1.
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Interest in CTS also diminished as the residents progressed through their training (Fig 2). Between the first and the fifth years of training, the proportion of residents who were undecided but still considering CTS fell from 22% to 1%. Conversely, the proportion of residents who were uninterested in CTS rose from 66% to 78%.
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Work schedule was the dominant reported shortcoming for most of the subspecialties, accounting for 34% to 50% of the items identified; and within CTS, work schedule accounted for 25%. The dominant items that accounted for the excess of reported shortcomings in CTS were job availability and long-term job security, accounting for 46% of the reported shortcomings, and compared with the other specialties, were chosen from 3 to 14 times more frequently.
Additional survey items explored in more detail those aspects of CTS that were attractive or could be modified to improve its appeal. Respondents were asked to identify those areas of CTS with the greatest appeal. Differences were found between respondents already committed to CTS and those who were still contemplating additional training (Fig 3). General thoracic procedures were heavily favored by those still undecided toward additional training, and this was reinforced by the comments of both the residents and the program directors in focus groups.
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Exposure to CTS
General surgery resident exposure to CTS was postulated as a significant factor driving interest in the specialty. For that reason, a number of items in the survey were aimed at delineating not only the breadth of exposure to CTS but also its effect on interest in the specialty. At the time of the survey, 72% of respondents had completed a CTS rotation. The lengths of their rotations were 2 months or less in 70% (1 month or less in 36%, 1 to 2 months in 34%), 2 to 3 months in 16%, 3 to 4 months in 6%, and 4 or more months in 7%. The program directors offered a number of comments during the focus groups concerning the cause and effect of diminished CTS rotation lengths. They commented that the work hour limitations led to decreased training time in the CTS rotation. They also stated that these short rotations diminish the quality of the interactions between the CTS faculty and the residents, making them feel marginalized. Some examples included: "When the rotation only lasts 1 to 2 months, faculty has less incentive to focus on their training or to turn cases over to them" and "I wonder if cardiothoracic faculty even bother to know the names of the residents anymore."
Comments such as these heard in the focus groups led us to compare respondents' rotation length with measures of interest in CTS. Figure 4 demonstrates the relationship between these two factors and the clear trends that exist. As the length of the CTS rotation increases, the likelihood that a resident will choose CTS increases. Similarly, the likelihood that residents will agree that the rotation was a positive experience and that the faculty took an interest in them increases as length of the rotation increases.
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Most respondents (59%) had a key mentor or role model, either formal or informal, to whom they turned for career guidance. The likelihood of having a mentor or role model increased with the number of years in training, peaking at 67% in the fourth and fifth years. Respondents who had decided on a specialty were much more likely to have a mentor than those who were still undecided (66% vs 47%, respectively). Not only are residents who have decided on a specialty more likely to have a mentor than those who do not, they are likely to have a mentor in their chosen specialty. This factor was especially prevalent among respondents committed to CTS. Among these respondents, 76% had a mentor, 71% of whom were cardiothoracic surgeons.
Women were more likely to have a female mentor than their male counterparts (29% and 5%, respectively.) Residents in the focus groups expressed concern that few female mentors were available. They noted that female mentors were overburdened with mentoring responsibilities as the growing number of women in general surgery increasingly turns to them for guidance and support.
Additional information was gleaned by asking respondents to relate comments offered by their mentors regarding CTS. Only 8 respondents recorded examples of positive comments from mentors, whereas 37 logged negative comments. The most common negative comments were related to the job market (22 of the 37), but nine of the negative comments were related to advice given by programs directors and various faculty members, even CTS faculty. Some examples are, "most of the attendings and senior residents tried to steer me away from thoracic surgery," "my program director keeps trying to keep me from applying for CT surgery for many reasons," and "a CT attending steered me away from this specialty when I was in medical school." Clearly, residents are being offered a negative image of the specialty more frequently then a positive image by individuals in a position to influence their decisions.
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Comment |
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TopAbstractIntroductionMaterial and MethodsResultsCommentFootnotesAcknowledgmentsReferences |
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A number of conclusions can be drawn from the data, but some important themes were dominant. First, the respondents' perception of the job market clearly affected their interest in CTS. A poor impression of job availability and stability appears to drive most respondents' decision to avoid CTS. The second dominant theme was the role of mentors in influencing career decisions. The window of opportunity for mentorship is confined to the initial years of training, and its impact wanes by the fourth year of training.
The good news is that a considerable number of uncommitted general surgery residents are interested in CTS. Aside from the 6% of general surgery residents who have already committed to a career in CTS, 26% of residents have had or still have some interest in the specialty. This interest is not confined to one gender, as 30% of men and 20% of women demonstrated this level of interest in the specialty. As one would expect, however, the interest is highest in the first through third years of training and wanes as the resident approaches completion of training. It is in these later years that these interested residents make a final decision about specialization in CTS. This has significant implications for our specialty. It is apparent that a significant untapped pool of potential applicants remain "on-the-fence." If appropriate changes in our educational programs and the specialty as a whole were to be implemented, a commitment to CTS by these individuals would easily fill current cardiothoracic training positions. The additional data obtained in this survey provide some broad strokes to guide the required changes.
Most striking was the perception among general surgery residents that our specialty faces significant job shortages and lack of long-term job security. Other negative factors identified included work schedule, ability to balance work and personal life, income potential, and length of training, but these factors were identified at a frequency similar to that seen in other surgical subspecialties, even those specialties that are currently experiencing high volumes of applicants such as plastic surgery and vascular surgery.
Although these other issues certainly are relevant and likely contribute in some degree to the declining interest in CTS, the poor perception of the CTS job market is the most striking difference compared with other surgical subspecialties. The significance of job market issues in influencing resident decision making was reinforced when the residents were asked to point out improvements that would entice them to seek a career in CTS. Assurances that the job market was stable led the list. This is an area that must be addressed. Whether the residents' perception of the job market deficiencies is based on fact or rumor is irrelevant. They are formulating opinions through their information network, and these opinions are influencing their decision to pursue CTS. Data demonstrating impending manpower shortages presented at recent meetings has either not yet come to their attention or has been disputed [20]. These recent workforce data must be disseminated throughout the residents' information network.
Mentorship was also identified as playing a significant role in residents' decision-making processes. The mentor becomes part of the residents' information network. Residents committed to CTS have greater contact with mentors, and this interaction may contribute to their diminished concern about the job market and even other factors, such as the ability to balance work and personal life and the length of training.
It is clear from the survey that mentorship is an area with considerable room for improvement. The pool of potential applicants is limited in its use of or access to appropriate mentors. Certainly some of the limitation may be due to residents whose interest in CTS is so marginal that they do not search for a cardiothoracic mentor. Alternatively, residents' busy clinical workloads and restricted duty hours limit access.
A CTS rotation, however, is clearly an opportunity to excite interest in the specialty and for many residents may be the first exposure to CTS. The data from this survey suggest that not only is this exposure less than 2 months for most residents but that the quality of the residents' experience during these rotations may be an area with considerable room for improvement. A poor impression during a short CTS rotation was a significant factor limiting interest in CTS. When one considers the reduced exposure to all surgical subspecialties during general surgery training secondary to multiple factors, every effort must be made to capture a potential applicant's interest in CTS during his or her rotation [17].
Balancing work with personal life and length of training were also cited as factors that could be addressed to increase interest in CTS. Fears about balancing work and personal life could be addressed through appropriate mentorship. The length of training was frequently cited as an option for improving interest in the field but was nearly last in importance when the residents were asked to list factors that currently influence their decision to pursue CTS. Nevertheless, mechanisms to reduce the length of training should be explored.
Another area that could be addressed to stimulate interest in the field is expansion of the cardiothoracic surgeon's practice, for example, by the addition of catheter-based treatments and inclusion of more general thoracic surgery. The latter was confirmed by the high appeal for general thoracic surgery among respondents not already committed to a career in CTS. Similar views have been expressed by recent CTS graduates [8]. Efforts to incorporate these changes are already underway at a number of training programs around the country.
Although this survey has revealed many of the factors responsible for the decline in applicants to CTS, there are limitations inherent in the design. The validity of the survey is threatened by the low response rate of 29%. A major contributing factor to this was the need to rely on the individual general surgery program directors to forward the survey to the residents. In addition to limiting the response rate, the decision itself of whether or not to forward the survey to the residents could insert a bias into the results. The similar demographics between our respondents and the population of general surgery residents as a whole addresses the low response rate, but it cannot completely address any bias introduced by the decisions of the program directors.
Additional limitations arise from the use of a convenience sample. Residents who chose to respond to the survey might have been motivated to do so and their views may not reflect the views of the population as a whole. Despite these limitations, the large number of respondents still represents the most objective assessment to date of the factors responsible for the declining interest in CTS.
In summary, this survey identified a substantial number of potential applicants to CTS and a number of factors that influence their decision whether to pursue CTS. Some of these factors can be addressed at the individual program level, whereas others require national attention.
At the individual program level, we must increase faculty exposure to general surgery residents early in their training. The quality of these interactions must also be increased. Grass roots efforts would also help, such as initiating a CTS interest group, leading a general surgery journal club meeting on cardiothoracic trauma or esophageal cancer, or requesting that CTS topics be included in general surgery grand rounds. We should expand our presence at the ACS national meetings and expand the existing STS and AATS summer and meeting scholarships to increase mentorship. Program directors in general surgery will likely eagerly accept offers to mentor individual residents. These contacts are the best way to disseminate the accurate information about our specialty. Although data from our workforce surveys could be disseminated in the print and electronic media, discussions with a mentor are more likely to influence residents' decisions.
At a national level, changes will need to be made in our curriculum. More exposure to catheter-based skills and general thoracic surgery appear to attract a wider selection of applicants. Cardiothoracic program leaders must foster and reward faculty mentorship of students and residents. Finally, the length of training may also be an area that may influence some applicants. Integrated residency programs with increased focus on the skills required to practice contemporary CTS will hopefully attract potential candidates.
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Acknowledgments |
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Footnotes |
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TopAbstractIntroductionMaterial and MethodsResultsCommentFootnotesAcknowledgmentsReferences |
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