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a Division of Cardiac Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
b Division of Cardiac Surgery, Saint John Regional Hospital, Saint John, New Brunswick, Canada
c Division of Cardiac Surgery, St. Michael's Hospital, Toronto, Ontario, Canada
d Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
e Division of Cardiac Surgery, Royal Columbian Hospital, New Westminster, British Columbia, Canada
f Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
g Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
Accepted for publication April 12, 2010.
* Address correspondence to Dr Feindel, University Health Network, 200 Elizabeth St, 4N-480, Toronto, Ontario, M5G 2C4, Canada (Email: chris.feindel{at}uhn.on.ca).
| For related articles, see pages 365 and 467
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Abstract |
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Methods: A 45-question, web-based survey was distributed to all graduates of Canadian cardiac surgery training programs who completed their training between 2002 and 2008.
Results: Of the 62 estimated recent graduates, 50 completed the survey (81%). Mean age was 36 ± 3 years and 90% were male. The mean number of years of training after medical school was 9.4 ± 1.6 years; 78% completed a graduate degree; and 27% extended their training because of a lack of jobs. When asked about employment, 74% mostly or definitely got the job they wanted, although 34% considered themselves underemployed. Most respondents (98%) considered finding employment for a new graduate in cardiac surgery today difficult or extremely difficult, and 64% believed that there is currently an excess of cardiac surgeons in Canada. Only 54% of participants would strongly recommend cardiac surgery to potential trainees.
Conclusions: The majority of recent graduates from Canadian cardiac surgery training programs were successful in finding secure employment. A substantial proportion, however, extended their training because of a lack of jobs and reported feeling underemployed. Survey respondents agreed that a new graduate might have difficulty finding a job in cardiac surgery today. These concerns may contribute to the challenges of recruiting to the specialty.
The number of applicants to cardiac surgery residency training programs in North America has declined steadily in recent years. In the United States, there have been vacant cardiothoracic (CT) residency positions each year since 2004, and 28% of available positions remained unfilled in 2009 [1]. It has been suggested that the waning interest of this surgical specialty is partly because of anecdotal reports of a difficult job market for graduates [2–6]. In a recent survey of general surgery residents in the United States, job availability and long-term job security were the dominant perceived shortcomings of pursuing a career in CT surgery [7]. Furthermore, assurance that the job market was stable was identified as the most important factor that would make respondents or their peers apply for a CT fellowship program. These misgivings exist despite the results of a workforce projections model predicting an impending shortage of CT surgeons in the United States [8, 9].
In the United States, cardiac and thoracic surgery training are combined and generally consist of 2- or 3-year CT programs with a common certification after general surgery training. In Canada, the specialties have separated, with thoracic surgery necessitating 2 years of training after general surgery and cardiac surgery constituting a 6-year residency program that matches directly out of medical school. The workforce trends in CT surgery in the United States parallel those in cardiac surgery in Canada. In 2009, for the first time ever, the number of vacant cardiac surgery positions in Canada exceeded the number of positions filled after the first residency matching iteration (Fig 1) [10]. In addition, the percentage of Canadian medical school graduates choosing cardiac surgery as their first-choice discipline in the match has declined since 2002 (Fig 2) [10].
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Material and Methods |
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Each individual who graduated from a Canadian cardiac surgery training program between 2002 and 2008 was sent an electronic invitation to participate in the survey. Three electronic reminders were sent at 3-week intervals after the initial invitation. The 45-question web-based survey was administered online from January 25, 2009, to March 31, 2009. Participation was voluntary and anonymous. Ethics approval was obtained from the Research Ethics Board of University Health Network. Descriptive statistics were used to summarize quantitative data. A copy of the complete survey is available in the Appendix.
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Results |
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Training
The mean number of years of training after medical school was 9.4 ± 1.6 years, with 38% of recent graduates completing 10 or more years of training (Fig 3). Almost all respondents (94%) completed the direct entry 6-year cardiac surgery residency program, whereas the other 6% completed a 2-year cardiac surgery fellowship after general surgery training. The vast majority of respondents (96%) completed at least 1 year of fellowship training after cardiac surgery residency, and 52% completed 2 or more years. Of the recent graduates, 56% obtained a master's degree and 22% completed a doctoral degree during their residency training. In the final 12 months of training, the respondents reported performing a mean of 238 ± 108 major cardiac cases as the operating surgeon. The majority of graduates (88%) felt they were ready to operate independently on routine cardiac cases after completing residency. Despite this, a substantial proportion (27%) extended their training owing to a lack of employment.
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Comment |
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Employment Opportunities and General Satisfaction
Although the majority of survey respondents were satisfied with their training and felt their current job is secure, a considerable proportion extended their training owing to lack of employment. This survey further confirms the opinion that finding a job for new graduates today is difficult or extremely difficult and documents the existence of a substantial number of underemployed or unemployed cardiac surgery graduates. Given the utmost importance of job stability to potential surgical applicants, it is likely that recent difficulties in recruitment are linked to these observations. The general level of dissatisfaction in this survey is similar to that in the United States, where a recent survey reported that 23% of graduates would not choose a career in CT surgery again and less than half (48%) would strongly recommend CT surgery to potential trainees [12]. This dissatisfaction may exacerbate the decline in interest among potential applicants for whom mentorship and encouragement from surgeons in the workforce are vital.
Despite the current difficulties in the job market, several authors have predicted a shortage of CT surgeons in the United States in coming years [2, 8, 9, 14]. Similarly, in 2001, the Canadian Cardiovascular Society reported a pending shortage of cardiac surgeons, based on an analysis of workload and an aging workforce [15]. Predictions of eventual shortages, although reassuring, may have less immediate impact on recruitment than the negative perception created by the existence of even a small number of unemployed graduates. Furthermore, the exact timing of the inevitable shortages is unpredictable and appears to be later than initially anticipated by the 2000 Cardiothoracic Manpower Study [8, 9, 16]. In Canada, the wave of expected retirements of cardiac surgeons anticipated in 2001 was not seen by 2004 [15, 17].
Balancing Supply and Demand of Cardiothoracic Surgeons
In the United States, 90% of graduating residents believed that the number of CT residency positions should be decreased [12]. Similarly, in this survey, limiting the number of training programs and trainees were ranked as the top two strategies for addressing potential manpower issues. Several participants noted no effort to connect the number of training positions offered with employment opportunities and encouraged greater engagement of national specialty organizations through position statements. Recommendations included creating national databases of current and projected cardiac surgery needs from each center and linking these to the number of residency positions offered. A coordinated effort at workforce management may reduce the likelihood of programs training marginal applicants to satisfy short-term and local service needs.
Participants suggested fewer fee-for-service remuneration models as a possible means of improving the current employment situation for new graduates. The density of cardiac surgeons per 100,000 of population in Canada varies by mode of remuneration at the time of the census, for example from 0.65 in Alberta (fee-for-service) to 0.93 in Nova Scotia (salary) [15]. One could envisage flexible funding arrangements that shift in times of surgeon excess toward salary-based remuneration to encourage more hiring and nonclinical activities such as research and education, and in times of surgeon shortage to fee-for-service compensation to encourage productivity.
Addressing the Current Surgeon Excess
Some members of the surgical community may feel that not every graduate is entitled to a job and that market forces should prevail. However, the authors believe that if Canadian training programs are producing competent and capable surgeons, those individuals should be given a chance to work; furthermore, their employment would serve to alleviate a projected long-term shortage. Some degree of unemployment may evoke a healthy competition among graduates and be therefore in the best interest of the public. The optimal percentage of unemployment is difficult to determine, but one may argue that it would be low enough to continue to attract the best and the brightest to the specialty and high enough to spur excellence among graduates competing for the best positions.
The predicted long-term shortage of cardiac surgeons may be addressed in part by offering employment to those recent graduates who remain unemployed. Although their contribution from a case-volume standpoint would not be immediately felt, by continuing to train these surgeons to perform the increasing number of complex cardiac surgical cases found in current clinical practices and offering them greater autonomy as a function of time, one would have in place experienced surgeons who could eventually fill a void left behind by retiring senior colleagues while absorbing greater volumes brought on by an aging population. Furthermore, the gainful employment of recent graduates would serve to reassure potential applicants of job stability at the end of their training, preserve the significant educational and financial investment already made in each fully trained cardiac surgeon, and improve the satisfaction of graduating residents. Some proposals from this survey to achieve this goal include structured and graded integration of new graduates as junior partners then senior partners, particularly by divisions with surgeons planning to retire within the next 5 years; commitment by training programs to find employment for their graduates or to employ them temporarily; and short-term contracts to maintain skills, enabling new graduates to operate independently and reenter the workforce when the inevitable shortages manifest themselves.
Improving Recruitment to Cardiothoracic Surgery
Predictions of shortages in CT surgery coupled with the steadily declining number and quality of CT applicants have prompted considerable discussion on how to improve recruitment to the specialty [16, 18, 19]. Emerging themes include the importance of mentorship; increasing the attractiveness of CT residency programs; and early exposure of potential applicants to CT surgery, as exemplified by the structured medical student program at Johns Hopkins [20]. Although these efforts are laudable, a recent survey of 2,153 general surgery residents in the United States was the first to provide data from potential applicants on deterrents and incentives to a career in CT surgery [7]. In this study, CT surgery totaled the highest number of shortcomings of any surgical subspecialty. Job availability and job security were the dominant items and accounted for 46% of the perceived shortcomings. In addition, when asked to identify factors that if addressed would increase interest in CT surgery, assurance of a stable job market was the highest ranked factor.
Factors other than the job market may be affecting recruitment to the specialty. In both Canada and the United States, the proportion of women in medicine has increased, and since the mid-1990s, women have consistently represented more than 50% of the medical student population. Despite this increase, women continue to take less than 10% of all surgical residency positions. In addition, interest in residencies that lead to a more balanced lifestyle career has also increased consistently in the past decade. These trends may be contributing to the application decline seen in CT surgery.
Differences in Training and Practice Between Canada and the United States
Length of training has been cited as a possible deterrent, and integrated residency programs obviating the need to complete general surgery training have been introduced in the United States [21]. Despite the widespread adoption of 6-year direct entry programs since the mid-1990s in Canada, the mean length of training observed was 9.4 years, considerably longer than the average 8.6 years in the United States [12]. Additional training has become a de facto requirement in Canada, where 98% of graduates completed at least 1 year of fellowship after residency and 78% obtained a graduate degree. Despite more focused training and greater exposure to research, length of training is not diminished in the Canadian system, and the disadvantage of relying exclusively on a cardiac surgery license when looking for employment remains. Practice patterns are much more diverse in the United States, where more than 50% of CT surgeons have mixed thoracic and cardiac practices. In Canada, employment opportunities are more limited for graduates who must have board certification in the specialty they practice. This reduced opportunity in the marketplace is one of the detriments of a residency program that separates thoracic and cardiac surgery training.
Limitations
Several limitations of this study deserve mention. The major limitation of the survey method is that it relies on a self-report method of data collection and faces responder bias. As with all surveys, the results are based on opinions and self-assessment, and thus intentional deception, poor memory, or misunderstanding of the question may all contribute to inaccuracies in the data.
Conclusions
The validity of this survey is strengthened by the notably high response rate of 81%. Comprehensive data on the CT workforce may improve the capacity to forecast and adapt preemptively to human resources needs, rather than the current system that reacts to changes in supply and demand in an ad hoc manner. Results of this study are valuable to the CT surgery community when developing strategies to employ the current set of graduates and optimizing recruitment such that the impending shortage of CT surgeons will be planned for well in advance.
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Appendix |
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Part I: Demographics
1. What is your sex?
2. What is your age?
3. Are you married or living with a common law partner?
4. What year did you graduate from medical school?
5. From which medical school did you graduate?
6. What year did you complete your core training in Cardiac Surgery?
7. What year did you obtain your FRCSC in Cardiac Surgery?
8. Did you obtain the CIP (Clinician Investigator Program) certificate?
9. From which cardiac surgery training program did you graduate?
10. Where do you live?
a. Canada
b. USA
c. Other ____
11. In which province or state do you live?
Part II: Training
1. Which training program stream did you complete?
a. 6-year cardiac surgery residency
b. Cardiac surgery fellowship after General Surgery residency
c. Other ____
2. Where was your funding from?
a. Canada
b. Externally funded
3. How many years of training did you complete for each of the following:
a. Undergraduate degree
b. Medical school
c. Residency
d. Graduate school
e. Fellowship(s)
f. Total
4. If you obtained a graduate degree, please specify year and degree(s) obtained (MSc, PhD, etc.)
5. If you completed one or more fellowship(s), please specify year(s) and focus
6. Did you extend your training due to a lack of jobs?
7. How many cardiac cases did you perform as the operating surgeon during residency in your final 12 months of adult cardiac surgery?
8. Were you ready to operate independently on routine cardiac cases at the end of your residency?
9. Comments or suggestions about training:
Part III: Employment
1. Did you get the job you wanted?
a. Definitely yes
b. Mostly yes
c. Definitely no
d. Not sure
2. Is finding a desirable job for a new graduate in cardiac surgery today
a. Easy
b. Difficult
c. Extremely difficult
3. Please rate the importance of the following factors to your successful employment in cardiac surgery (Ratings: extremely important; important; slightly important; inconsequential)
a. Residency training program
b. Research profile (graduate degree, publications, etc.)
c. CIP certificate
d. Fellowship
e. Efforts by your home program/program director
f. Efforts by your fellowship program
g. Your individual efforts (personal contacts, etc.)
h. Serendipity
i. Other factors contributing to your ability to gain successful employment (please elaborate)
4. Please rate the factors that may be detrimental to your ability to gain successful employment (Ratings: extremely detrimental; detrimental; slightly detrimental; inconsequential)
a. Residency training program
b. Research profile
c. Fellowship
d. Declining surgical volumes
e. Over-saturation of the job market
f. Over-production of trainees
g. Lack of surgeons retiring
h. Fee for service remuneration
i. Other factors detrimental to your ability to gain successful employment (please elaborate)
5. What is your current job title?
a. Attending surgeon—full partner
b. Attending surgeon—junior partner
c. Attending surgeon—on contract
d. Clinical associate
e. Clinical fellow
f. Surgical assist
g. Other ____
6. Do you feel that your current job is secure?
7. In your opinion, are you "underemployed"?
8. In what type of setting do you work?
a. Academic
b. Non academic (ie, community or private practice)
c. Other ____
9. What is the fee structure of your current job?
a. Salary
b. Fee for service
c. Other ____
10. Are you satisfied with your remuneration at this stage of your career?
11. In your current practice, specify the percentage of time spent in the following activities:
a. Clinical ___%
b. Research ___%
c. Administration ___%
d. Other ___%
12. Within your clinical practice, specify the percentage of time spent in the following activities:
a. Cardiac surgery ___%
b. Thoracic surgery ___%
c. Vascular surgery ___%
d. General surgery ___%
e. ICU ___%
f. Research ___%
g. Other ___%
13. How many cardiac cases did you perform independently in the past 12 months?
14. Comments or suggestions about employment:
Part IV: Manpower Issues
1. Is finding a desirable job for a new graduate in cardiac surgery today
a. Extremely difficult
b. Difficult
c. Easy
2. In your opinion, is there currently
a. An excess of cardiac surgeons in Canada?
b. A shortage of cardiac surgeons in Canada?
c. Just the right amount?
3. How would you improve the ability of recent graduates to gain successful employment in cardiac surgery?
4. Which general strategy would you prefer to see implemented to address potential manpower problems?
a. Create more cardiac surgery staff jobs
b. Diversify the training of cardiac surgeons
c. Reduce the number of cardiac surgeons being trained
5. Please rank the following specific strategies in order of their potential effectiveness
a. Cap on number of cases per surgeon per year
b. Fewer fee-for-service remuneration models
c. Limit the number of trainees
d. Limit the number of training programs
e. Multiple certification opportunities during core training (thoracic, vascular etc.)
f. Return to general surgery + cardiac fellowship model
g. Mandatory retirement for surgeons at 65 years of age
h. Other ____
6. Comments and suggestions about workforce issues:
Part V: Final Thoughts
1. Are you living where you want to be living?
2. Are you doing what you want to be doing?
3. If you are not currently working in Canada, would you prefer to if there was an opportunity to do so?
4. If you had to do it all over again, would you choose cardiac surgery?
5. Would you strongly recommend cardiac surgery to potential trainees?
6. Final comments about anything:
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References |
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TopAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Related Article
This article has been cited by other articles:
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  V. Sood and R. M. Reddy An Analysis of Preclinical Students' Perceptions of Cardiothoracic Surgical Procedures Ann. Thorac. Surg., September 1, 2012; 94(3): 800 - 806. [Abstract] [Full Text] [PDF]
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J. E. Mayer Jr Managing the Cardiothoracic Surgical Workforce: A Responsibility of the Profession Ann. Thorac. Surg., August 1, 2010; 90(2): 365 - 367. [Full Text] [PDF]
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