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Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
Accepted for publication November 2, 2011.
* Address correspondence to Dr Gasparri, Division of Cardiothoracic Surgery, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226 (Email: mgasparr{at}mcw.edu).
Presented at the Forty-seventh Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 31–Feb 2, 2011.
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Abstract |
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Methods: The Medical College of Wisconsin established an Accreditation Council for Graduate Medical Education-approved 6-year integrated thoracic training program. The number and characteristics of applicants to the 6-year program were then compared with previous applicants applying to the traditional 2-year program.
Results: Applicants to the 6-year integrated program scored higher on the United States Medical Licensing Examination part 1 and part 2 than previous applicants to the traditional2-year program. The 6-year applicants also were more published and a greater percentage of them held other advanced degrees.
Conclusions: Institution of a 6-year integrated thoracic surgery training program at the Medical College of Wisconsin led to a significant increase in number of applications. Additionally, the 6-year applicants appeared to be more academically accomplished than previous applicants to the traditional 2-year program. While early in the experience, it appears that interest in thoracic surgery is high among medical students and institution of a 6-year program has the potential to once again attract the "best and the brightest" to this specialty.
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Introduction |
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Numerous reasons are cited to explain this phenomenon. Surveys of both general surgery residents as well as cardiothoracic surgery residency program directors cite a poor job market, a lack of job security, and a decreasing reimbursement rate as the most common reasons for these decreasing numbers [1, 5–7]. Although also mentioned, duration of training and training format are felt to be less important [1, 5–7]. These training-related factors should not be discounted however. With the traditional independent training pathway, 5 or 6 years of general surgery training are followed by 2 or 3 years of cardiothoracic surgery training. As the technologic advancements continue to evolve and expand, it is becoming increasingly difficult to fully train cardiothoracic surgery residents in all these areas over a 2-year or 3-year time period and many residents pursue another year or 2 of training [8]. After all is completed, many residents will have trained for 10 or more years prior to entering the workplace, with half of this training focused on general surgery. It is obvious that this format could dissuade even the most interested trainee.
Acknowledging these issues, over the last few years the American Board of Thoracic Surgery has adopted alternative pathways leading to board certification. Currently, there exist the following 3 approved curricula [9, 10].
Based on our belief that a change in training format could reverse this trend, the Medical College of Wisconsin applied to and was granted approval by the ACGME for a 6-year integrated cardiothoracic residency program. The purpose of this paper is to report the experience of our first match process with the new 6-year integrated training format and compare applicants to this program with previous applicants to our traditional 2-year program.
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Material and Methods |
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The assignment of residents to each of these programs was through the National Residency Matching Program and applicants applied through the Electronic Residency Application Service from 2006 forward and prior to this by paper form. Regardless of the manner in which applications arrived, all applications included a common application form in which United States Medical Licensing Examination (USMLE) results are reported, and additionally, USMLE transcripts are forwarded directly from the National Board of Medical Examiners.
All applications to the MCW thoracic surgery training program for match years 2005 to 2010 were reviewed. Application years 2005 to 2009 were for the T-2 program and year 2010 was for the I-6 program. Overall number of applicants and applicant USMLE step 1 and step 2 scores were evaluated.
The USMLE scores were compared between groups using the Student t test and results were considered statistically significant if the p value was less than 0.05. SigmaStat 3.0 for windows software (SPSS Inc, Chicago, IL) was used.
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Results |
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Comment |
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As stated above, our experience suggests that there remains a high level of interest on the part of medical students for a career in thoracic surgery. This is consistent with Association of American Medical Colleges surveys of medical students, which have shown a continuous and relatively stable yearly number of medical students interested in thoracic surgery [11–13]. A question this raises is if there are so many medical students interested in thoracic surgery, why have the T-2 programs seen such a drop in applications? In other words, why does this persistent apparent interest at the medical school level not translate into persistent interest once that student completes general surgery training and is eligible for a T-2 program? While job market and job security may indeed play a role in altering one's initial interests, our findings would suggest that training format may indeed matter more than is currently appreciated. It is clear that many students are graduating medical school and entering general surgery programs fully intending to ultimately complete a thoracic surgery fellowship. The reality, however, is that most of these residents pursue other specialties [6, 7]. Whereas 10 to 15 years ago it was not uncommon for a general surgery resident to spend 8 to 12 months of a 5-year program rotating on cardiothoracic surgery services, in the current era of general surgery training these months continue to decrease as other surgical discipline training becomes a priority. At our own institution, general surgery residents spend only 2 months total on cardiothoracic surgery services. It becomes clear that regardless of how much enthusiasm one may have for cardiothoracic surgery, if one is only exposed to it for 2 months over a 5-year period, while at the same time being continually exposed to other specialties, other interest will be cultivated and pursued.
In addition to attracting an increased number of candidates, it appears that the I-6 program also attracts a candidate with impressive academic credentials. While it is clear that with every passing year the quality of all students improves, it appears that candidates to our I-6 program are more accomplished than their T-2 counterparts. Twenty-seven percent (8 of 30) of the I-6 candidates had an advanced degree in addition to their MD (3 MS, 2 PhD, 2 MPH, and 1 MBA) and 66% (20 of 30) had already published articles in peer-reviewed journals. This compares with no advanced degrees and only 42% (11 of 30) having publications in the T-2 group.
When one compares USMLE scores among the 2 groups, the I-6 group scored significantly higher than the T-2 group on both step 1 and step 2. While it is controversial whether higher USMLE scores translate to a more clinically successful resident, it has been shown that the better one does on the USMLE the more likely it is that he or she performs successfully on the inservice training exam and ultimately on board certification exams (14–21). This is a consistent finding among many different residency training programs [16–21].
Additionally, when evaluating potential candidates, the USMLE score is the only variable that is standardized among all candidates and allows some grounds for equal comparison. Based on that, the USMLE score is used almost universally across all residency training programs to compare and rank candidates with almost all program directors associating a higher USMLE score with a more attractive candidate [22–25].
There are significant limitations with this study and widespread conclusions cannot be made. The first and most obvious limitation is that the comparison between the 2 groups (T-2 and I-6) is biased as the groups are not equally represented. The T-2 group was selected from a very small percentage of the overall applicant pool while the I-6 group was selected from a near 100% representation of that applicant pool. This obviously biases the results in that given a larger group to choose from, more rigorous criteria can be applied, and therefore the I-6 applicants chosen for interview represented the best of the entire group while the T-2 applicants group represented the best of the small percentage applying to our program. Therefore this paper cannot and does not claim that I-6 applicants are better than T-2 applicants, rather it shows that for an individual program, in this case ours, institution of an I-6 program can lead to an increased number in applications and therefore an increased number of talented applicants from which to choose.
The second limitation is that this study cannot and does not imply that the I-6 program is the best way or should be the only way to train the cardiothoracic resident. In fact, I-6 programs have only been in existence for a few years with no graduates to date and only time will tell how these graduates ultimately fare. Concerns with this pathway, including lack of previous general surgery training, inability of a medical student to make a career decision, and the potential for attrition have been raised and indeed these concerns are valid. Having said this, however, we can look to our colleagues in neurosurgery, plastic surgery, otolaryngology, and urology who have implemented and succeeded with this training format. Additionally, we feel that dedicating 6 years of training to areas that apply to the specialty which the trainees will ultimately be practicing for their entire careers has the potential to produce better trained surgeons and allow a greater sense of satisfaction.
Finally, this report relates only to our initial experience participating in our first match year. In this initial match, however, we were extremely pleased with the quantity and quality of our applicant pool. Since this paper was written, we have completed a second match and are currently progressing through our third, and we have continued to see the same amount of applicants with even more impressive credentials.
In summary, the establishment of an I-6 program at MCW has been an extremely positive experience. We found that there remains a significant interest in cardiothoracic surgery among medical students and the creation of a curriculum that is more tightly focused on and relevant to cardiothoracic surgery yet can be completed in less time than the traditional pathway is attractive to them. Additionally, this pool of applicants is talented and academically accomplished. While it remains early in our experience, we feel that the I-6 program is popular and has the potential to once again attract the "best and the brightest" to this specialty.
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Discussion |
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DR GASPARRI: Well, I'll give you the short answer. We stopped our 2-year program, so I've eliminated that problem. I think every candidate is measured relative to the candidate pool. I'm not sure you can ever change the criteria, but the entire bar gets raised when all the applicants are this talented. I'm not sure if that really answered your question, but I think the criteria remain the same for how we choose.
DR LEE: Just to clarify, for example, do you weight the USMLE [United States Medical Licensing Examination] differently? As you know, many of us in this room interview residents all the time, and I think we personally put more weight into the letters of recommendation now because we know the people sending them. We put less weight into the USMLE and more weight into the ABSITE [American Board of Surgery In-Training Examination] scores.
DR GASPARRI: That's a good question. Now, USMLE scores don't necessarily translate to a more clinically talented physician, but they certainly correlate with success on ABSITE and success on ultimately passing your board-certification exams, and ultimately they are the only thing that one can use with medical students to equally assess a wide pool of applicants because it's the only thing that's universally applicable. We certainly look at letters of recommendation, we certainly look at everything, but we do use that as a screener, and I think it's universally used by all program directors across all specialties, not just ours.
DR HUMBERTO R. RAVELO (Long Beach, CA): Dr Gasparri, I wish to congratulate you for having chosen an extremely timely topic to discuss.
I am a Medical College of Wisconsin graduate, known as Marquette University School of Medicine, prior to 1972. At that time, Dr Derward Lepley, the chief of thoracic and cardiovascular surgery, had noticed the need for a 6-year integrated thoracic surgery training program at the institution. As a senior medical student, I was interested in participating in the pilot program he had designed and proposed to the American Board of Thoracic Surgery (ABTS).
However, the ABTS did not approve it and Dr Lepley discontinued his efforts not wishing to risk having the residents be denied admission to the Board exams, as it had happened in Dr Shumway's 6-year integrated program at Stanford.
I have two questions: first, could you elaborate on the sequence of steps you had to follow to design your program and to have it approved by the ABTS and, second, what advice would you give an institution wanting to start such a program?
DR GASPARRI: I guess the biggest difference is that the American Board of Thoracic Surgery has approved it as a pathway. The application process is straightforward; one goes to the thoracic surgery RRC [Residency Review Committee] and fills out an application and justifies why one thinks they can provide this sort of training. It does involve a fair amount of cooperation with general surgery as well as other disciplines. We have our residents rotate with cardiology and do some cardiac cath as well as interventional radiology to get wire-based skills. They rotate with pulmonary and spend time in various ICUs [intensive care units]. It does, therefore, require a fair amount of cooperation and support within the institution, but as far as the actual process, you can make it real simple, you've got to fill out an application.
DR WILLIAM L. HOLMAN (Birmingham, AL): Thank you so much for bringing some hard data to this field.
I have one comment and then a question. The comment is, I was talking with the PD [program director] of a radiology program at our institution not too long ago and asked him how many applicants he had for his 10 positions and he said 40, and I said, "I'd like to have 40 applicants for my position in cardiothoracic surgery. So you have 40 applicants for 10 positions?" and he said, "No. I have 40 per position. I had 400 applications." I went home very depressed, but then I thought about it, and, in fact, he's drawing on an entire medical school class, whereas our program is still a 2-year program and we're drawing on a select group of people who have chosen general surgery and have progressed to their third post-graduate year or later. You have to keep in mind that the baseline is different.
I'm interested in the future of I-6 programs and my questions relate to them. Obviously, retention of residents once they are in an I-6 program is terribly important. Have you thought about retention and replacement in the design of your program? Do you have any tips for those of us who are planning an I-6 program? Second, why do you think medical students who might have been very interested in cardiothoracic surgery lost their interest during general surgery residency?
DR GASPARRI: I'll answer the second question first. Ten years ago, 15 years ago, it was not uncommon as you went through 5 years of general surgery to do 8, 10, or 12 months of cardiothoracic surgery during that time, so you kind of maintained some feel with it, you maintained an interest. Nowadays, as general surgery residencies have to really teach their residents other fields of general surgery as that explodes, they just don't get exposed. For example, at our institution, our general surgery residents do 2 months of cardiothoracic surgery over 5 years. I don't care how interested you are in CT [cardiothoracic] surgery; if you only see it for 2 months over 5 years, you probably will lose interest, and, additionally, if you're talented, all these other specialties are going to start pulling at you and really cause you to cultivate other interests. So I think that's why we see less after general surgery. As far as the dropout rate, I think there is potential for that. All these I-6 programs are in their infancy. But I think we are clearly getting residents who are sold on it. Cardiothoracic surgery is what they want to do and they are very excited to enter the field. I also think we have to give them credit. I think that at their level they are mature enough to make a career choice and this is seen in other disciplines which have integrated programs such as ortho or neurosurgery in which the dropout rate is low.
DR VARUN PURI (St. Louis, MO): We are actually in the process at the Washington University of getting into the RRC cycle and getting the position approved for us.
I have 2 questions for you. First, how have you organized funding for this position? Secondly, how many of these applicants are in the pool for a general surgical spot also somewhere in the country?
DR GASPARRI: Funding is always a bit tricky, but I just asked and they said yes. So I was lucky. It's a bit of a negotiation with the dean and all of that, but we already had funding for our 2-year program, so I was able to maneuver some slots, and for a medical school, innovative training formats are very exciting for them, so they will support these things monetarily. As far as do they also go in the general surgery pool, sure. For the current match that we're participating in now, I think there are 14 total positions and I received 134 applications this year, so even more than last year. Clearly they are very competitive, and these people do apply for general surgery mainly as a backup because there's a very limited amount of spots for these I-6 programs right now. That's usually the backup plan. And if they don't get in an I-6, they will go a traditional pathway, but I think as the I-6 numbers increase, that will work itself out.
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