Residency Training for the Future, Not the Past

The Thoracic Surgery Residents Association (TSRA) conducted its second annual survey of residents finishing United States thoracic surgery programs in June 2003. The article, “Are There Enough Jobs in Cardiothoracic Surgery?” by Salazar and colleagues [1] that appears in this issue reports the findings from this survey. Of approximately 140 residents who completed training in 2003, 89 individuals (64%) participated in the survey, which the authors refer to as the “Thoracic Residents Job Placement Survey.” This response exceeds that of the first survey of residents who completed their training in June 2002 (40%), the results of which were published in The Annals of Thoracic Surgery editorial titled, “Help Wanted” by Lee [2] in December 2003.See page 1523

Where are the Jobs?

Eleven percent of the respondents in the 2002 residents group and 19% in 2003 received no job offers. Many others described limited or even undesirable job options. Both surveys affirm the widely held perception that job opportunities for current thoracic surgeon residents are poor. Salazar and coauthors [1] infer that declining applications for thoracic surgery resident positions, especially from graduates of United States medical schools are a result, at least in part, of poor career placement opportunities at the completion of residency training. Other factors mentioned are dissatisfaction with diminishing compensation levels and a perception of reduced job security.

Both surveys confirmed that most residents are finished in their mid-30s, married with children, and have manageable or little residual educational debt. Approximately 10% of the residents who are currently completing training are women, compared with only 2% of women respondents to the Work Force Survey of practicing and retired thoracic surgeons reported by Shemin and associates [3] in 2002. Most residents without a suitable job option chose to take additional training or subspecialty fellowships. Some expressed concern that this will create a rolling backlog that will increase the number of job-seeking residents each year.

The residents who completed these surveys fault a number of factors for this current morass facing themselves and many thoracic surgery residents in the United States. There are “more resident positionsthan available career positions,” or “program directors have been ineffective in promoting their residents.” Declining reimbursement for professional services is already the cause of general dissatisfaction among thoracic surgeons and may have caused practicing surgeons to increase the volume of their work, deferring retirement from active practice, which produces further declines in the need for graduating residents. Many respondents in both surveys expressed dissatisfaction with their career choice, with their own training program, and specifically with their program director. However, very few respondents believed that they were not ready to operate independently at the completion of their residency [1].

Professionalism Endures

Despite the present challenges that our residents are facing at the outset of their independent careers, it is gratifying to see clear evidence of the professionalism of our young colleagues. “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” [1]. Another similar sentiment in the article is: “Whatever measures are taken (to deal with the current job challenge for residents), the first priority is to maintain excellence in caring for our patients” [1]. Such idealism makes their current disappointments and frustrations even more distressing.

Current Characteristics of Thoracic Surgery Practice

In June 2002, Shemin and colleagues on the American Association for Thoracic Surgery/The Society of Thoracic Surgeons (AATS/STS) workforce committee published its analysis of the member survey conducted in late 1999. Data from nearly 2000 surgeons in active practice in the United States were available. This was a 63% response rate from STS members. An important and somewhat unexpected finding was a predominance of surgeons with “mixed” rather than single subspecialty practices. Despite the common practice patterns in academic centers, many practicing thoracic surgeons perform both adult cardiac and general thoracic surgery. A substantial minority of respondents also performs peripheral vascular surgery, but few re-certify with the American Board of Surgery. In 2003, a similar survey was conducted by the new successor STS/AATS Task Force on the Thoracic Surgery Practice and Access, directed by Shemin and colleagues (personal communication). There was a slightly lower response rate from active United States-based thoracic surgeons (49%), but a similar number of surgeons characterized their practice as including both general thoracic and adult cardiac surgery (55%). Nineteen percent of the respondents reported that they perform exclusively general thoracic surgery, whereas 18% designated themselves as exclusive adult cardiac surgeons, and 4% reported exclusive congenital heart surgery practice.

It is notable that in both resident surveys, proficiency in general thoracic surgery was described as “highly sought after” as well as a “marketable skill” for prospective associates. Other desirable competencies sought for among job applicants were experience with off-pump coronary revascularization, valve repair surgery, aortic surgery, and to a slightly lesser extent, vascular surgery.

Are We Preparing Residents for Jobs That Do Exist?

How should we begin to reconcile the apparent lack of opportunities for residents completing their training with the current and evolving state of thoracic surgery? Because there are specific competencies that are being sought by prospective employers of finishing residents, it is logical to question whether residents who are not finding job options are adequately or appropriately trained for the current job market. Although the residents, as a group, consider themselves adequately trained at the completion of their current residencies, realities of the marketplace may be suggesting otherwise. Additional training, especially in adult cardiac surgery and specifically in off-pump coronary revascularization, valve surgery, and management of high-risk patients, may be a necessary expectation for those seeking adult cardiac surgery positions today. In addition, it is possible that with a greater declared interest and proficiency in general thoracic surgery, job options would be enhanced. Salazar and colleagues [1] acknowledge that this is possible when they wrote: “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.”

The Decision to Change Has Been Made

In October 2001, the American Board of Thoracic Surgery voted to abolish the requirement for pre-certification by the American Board of Surgery. Many have asked: “How can we realistically continue to require 5 years of training in general surgery, but only 2 years in a career specialty of thoracic surgery?” Despite the strong traditions and previous successes with this model, it makes little sense today as a training paradigm for every thoracic surgeon. Despite what our own residents say about themselves, there are relatively few thoracic residents who are fully prepared for current thoracic surgery careers, either in adult cardiac, congenital heart, or general thoracic surgery, after a 5-year general and 2-year specialty residency paradigm. We need to afford our residents the opportunities to acquire those marketable skills that will provide them with solid job prospects in this current and evolving era of thoracic surgery, especially when residency work rules will further reduce operating room experience.

The leadership of thoracic surgery must face the clear evidence that our training models require change. We must reduce the amount of time spent in general surgery training and increase time devoted to thoracic surgery training. In addition, instead of requiring every thoracic surgery trainee to finish with identical experiences and competencies, we should allow for greater subspecialty training by some residents. On the other hand, recognizing that most thoracic surgeons in community practices are expected to do both adult cardiac and general thoracic surgery, we must insure training that is appropriate to a specialty devoted to the surgical care of patients with diseases and conditions involving the entire thorax.

It can be exceedingly challenging, even painful, to modify a residency system that has worked well in the past. On the other hand, the distress of our residents as expressed in this article is compelling. It is incumbent on us to respond to the evolutionary changes in our specialty with appropriate changes in resident education. We must encourage more general thoracic surgery training for many of our residents. There can be less congenital surgery exposure for the majority, but much more for those few who will be congenital heart surgeons. For most other residents, adult cardiac surgery training must be broader and more extensive than is often the case today. If our residents are not finding job opportunities, but there are still unmet marketable skills among applicants, there are clearly deficiencies in our training models.

Let Us Fix What We Can

There are many developments in health care and in medical education that we cannot change. A gradual reduction in patient referrals for surgical coronary revascularization is occurring despite increasingly more effective surgical procedures and care. Reductions in thoracic surgery residency positions, although appropriate in cases of failing and inadequate training programs, will not occur quickly in any substantial numbers, especially when residents themselves express their satisfaction with the adequacy of their surgery training. Reimbursement for our professional work is not likely to increase, despite clear inequities, due to the mounting cost of medical care and the role of our government in health care financing. Thoracic surgery is in a challenging phase of its evolution, but these resident surveys make it painfully clear that substantial changes in our training programs are mandatory.

Using broad strokes of the planning brush to affect such changes in thoracic surgery training, these are some of the things that must happen soon:

1 The thoracic surgery resident must be afforded more training time devoted exclusively to thoracic surgery, and correspondingly less time should be spent in traditional general surgery residency training.

2 Greater attention should be paid to the adequacy of resident training experiences in general thoracic surgery, because more than half of the residents will be expected to practice both general thoracic and adult cardiac surgery in community hospital settings.

3 Subspecialty and tracking during thoracic surgery residency must be facilitated, especially for those planning a career devoted exclusively to areas such as congenital heart surgery, thoracic aortic surgery, and tracheal or esophageal thoracic surgery.

Salazar and colleagues [1] end their article with these words: “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.” Again, such admirable sentiments expressed by our concerned, new colleagues should prompt us to look at our traditional residency model critically and quickly. Despite the inertia of tradition, we need to embrace change to insure the preservation of our great specialty, as Salazar and colleagues wrote. Thank you to the Thoracic Surgery Residents Association and to those who conducted these surveys. Let us get on with these changes that all of us should acknowledge are necessary.