Author's Accepted Manuscript
Integrated Surgical Residency Initiative: Implications for Cardiothoracic Surgery Ara A. Vaporciyan MD, MHPE
www.elsevier.com/locate/buildenv
PII: DOI: Reference:
S1043-0679(14)00036-7 http://dx.doi.org/10.1053/j.semtcvs.2014.02.009 YSTCS685
To appear in:
Semin Thoracic Surg
Cite this article as: Ara A. Vaporciyan MD, MHPE, Integrated Surgical Residency Initiative: Implications for Cardiothoracic Surgery, Semin Thoracic Surg, http://dx.doi.org/10.1053/ j.semtcvs.2014.02.009 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Editorial: Integrated Surgical Residency Initiative: Implications for Cardiothoracic Surgery Ara A. Vaporciyan, MD, MHPE Word Count: 1041 Address for correspondence: Ara A.Vaporciyan, MD, University of Texas M.D. Anderson Cancer Center, Thoracic & Cardiovascular Surgery, FCT19.6008 1515 Hoclombe Blvd, Box 445, Houston, TX 77030 E-mail: [email protected] Telephone: (713) 745-4533 Facsimile: (713) 794-4901 I read with great interest the article authored by Dr Ikonomidis, Dr Crawford and Dr Fann.1 The integrated 6 year format for the training of cardiothoracic surgeons exploded into existence only 5 short years ago. Explode seems a strong descriptor but when one considers the rapid expansion in the number of programs, the initially high and growing number of applicants, and considerable attention devoted to the paradigm at national meetings the description is apt. The authors give a concise history of the changes that brought about the conceptualization of this approach to cardiothoracic surgical training.
They outline a series of events that transpired making an
integrated straight out of medical school approach to training a clear and logical solution. The authors then go on to describe the implementation of the I6 programs highlighting various strengths and also some hurdles that are both in the process or yet to be addressed. In summary I see two major themes introduced by the authors. The first is that the I6 approach requires a high level of commitment and buy-in at a very broad level while the second is that this approach is still a work in progress. The commitment necessary for the I6 is well above that of any existing traditional program and cannot be understated. The lure of suddenly having many applicants to one’s training program will harken many back to the heyday of cardiothoracic surgery and motivate many programs to develop I6 tracks. But any program without the necessary deep commitment will almost certainly fail. The authors detail many of these including
but not limited to a commitment by the faculty to teach a new and very different population of learners, by colleagues in other disciplines to accept and help train our residents, by local leadership to support both the cost (additional trainees, additional resources, lost revenue by faculty now engaged in teaching) and the promotion of faculty whose academic focus will now veer towards teaching and finally by national leadership to create and support novel ways of teaching and assessing our trainees. The second theme is the fact that the I6 approach is a work in progress. By definition a training model is a curriculum. All curricula must undergo regular and vigorous program evaluation. Curricula are not meant to be static but iterative, always changing and adapting.
While surveys are certainly helpful in outlining what
does and doesn’t work it is classically considered the lowest level of programmatic evaluation. Kirkpatrick2 outlined 4 levels of assessment. First are the reactions from learners and faculty, commonly obtained through surveys. Higher levels follow including evidence of learning, followed by learner’s behavior, and finally impact. The authors make it clear that there is a dearth of higher level data on I6 performance. There is limited data on learning as the majority of I6 trainees are still in their first few years. Assessments specific to I6 trainees are also limited so valid data will remain difficult to obtain even as our trainees progress. For example, what is the validity of a general surgery in training exam score on assessing the knowledge our I6 trainees actually need? Learner’s behavior and impact data are even more limited. The Canadians have some history that we should certainly review. They engaged in a similar experiment with integrated training. Data on both learner behavior and impact is available. The experiment was deemed unsuccessful for general thoracic surgical training and the prior system of general surgery training followed by two years of thoracic surgery was reestablished. For cardiac surgery the integrated approach was accepted. Similar to the US, Canadians have seen a decline in applications despite their integrated approach suggesting that US integrated programs may be “robbing Peter to pay Paul” and may soon see a decline as well as saturation is reached.3 In addition, 96% of resident complete an additional year of fellowship and 52% complete two or more. While much of this may be 2
driven by a lack of jobs some concern regarding their preparedness must also be entertained. The RRC and the ABTS should remain vigilant of these issues as I6 programs continue to multiply. Data on the need for fellowship training and ABTS credentialing will certainly need to be monitored. One development that needs to be addressed soon is the difficulty of obtaining protected research time. If this cannot be addressed then there will certainly be an impact on our field as a whole. We need a steady influx of new members who will engage in research to maintain our specialty. If we cannot support research interest then we will see a decline in these applicants diluting the mix of effective researchers and consummate clinicians, a mix that was the envy of every other surgical and medical fields for many decades. Finally, we must still value existing paradigms for cardiothoracic surgical training. In a survey of general surgery resident 26% maintained an interest in CTS and many made the decision to pursue CTS during their 1st, 2nd, or 3rd year of general surgery training.4 The traditional training programs provide an opportunity for these late converts to gain access to cardiothoracic surgery. In conclusion, the authors have provided an excellent review of the value of integrated programs to address a number of limitations inherent in our traditional pathways. However, they have also clearly identified that in its current form it is not a finished product. Further refinement and careful monitoring remain necessary. Furthermore, the traditional pathways, while also far from perfect, are still needed to provide a mechanism of training to the significant number of late converts to our profession.
3
References 1. Ikonomidis JS, Crawford FA, Fann JI.
Integrated surgical residency initiative: implications for
cardiothoracic surgery. Seminars in Thoracic and Cardiovascular Surgery 2014. 2. Kirkpatrick DL, Kirkpatrick JD. Evaluating training programs, third edition. San Francisco: BerrettKoehler Publishers, Inc., 2006. 3. Ouzounian M, Hassan A, Teng CJ, Tang GH, Vanderby SA, Latham TB, Feindel AM. The cardiac surgery workforce: a survey of recent graduates of Canadian training programs. Annals of Thoracic Surgeons 2010;90:460-6. 4. Vaporciyan AA, Reed CE, Erikson C, Dill MJ, Carpenter AJ, Guleserian KJ, Merrill W. Factors affecting interest in cardiothoracic surgery: survey of north American general surgery residents. The Journal fo Thoracic and Cardiovascular Surgery 2009;137:1054-62
4
Integrated Surgical Residency Initiative: Implications for Cardiothoracic Surgery Ara A. Vaporciyan MD, MHPE
www.elsevier.com/locate/buildenv
PII: DOI: Reference:
S1043-0679(14)00036-7 http://dx.doi.org/10.1053/j.semtcvs.2014.02.009 YSTCS685
To appear in:
Semin Thoracic Surg
Cite this article as: Ara A. Vaporciyan MD, MHPE, Integrated Surgical Residency Initiative: Implications for Cardiothoracic Surgery, Semin Thoracic Surg, http://dx.doi.org/10.1053/ j.semtcvs.2014.02.009 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Editorial: Integrated Surgical Residency Initiative: Implications for Cardiothoracic Surgery Ara A. Vaporciyan, MD, MHPE Word Count: 1041 Address for correspondence: Ara A.Vaporciyan, MD, University of Texas M.D. Anderson Cancer Center, Thoracic & Cardiovascular Surgery, FCT19.6008 1515 Hoclombe Blvd, Box 445, Houston, TX 77030 E-mail: [email protected] Telephone: (713) 745-4533 Facsimile: (713) 794-4901 I read with great interest the article authored by Dr Ikonomidis, Dr Crawford and Dr Fann.1 The integrated 6 year format for the training of cardiothoracic surgeons exploded into existence only 5 short years ago. Explode seems a strong descriptor but when one considers the rapid expansion in the number of programs, the initially high and growing number of applicants, and considerable attention devoted to the paradigm at national meetings the description is apt. The authors give a concise history of the changes that brought about the conceptualization of this approach to cardiothoracic surgical training.
They outline a series of events that transpired making an
integrated straight out of medical school approach to training a clear and logical solution. The authors then go on to describe the implementation of the I6 programs highlighting various strengths and also some hurdles that are both in the process or yet to be addressed. In summary I see two major themes introduced by the authors. The first is that the I6 approach requires a high level of commitment and buy-in at a very broad level while the second is that this approach is still a work in progress. The commitment necessary for the I6 is well above that of any existing traditional program and cannot be understated. The lure of suddenly having many applicants to one’s training program will harken many back to the heyday of cardiothoracic surgery and motivate many programs to develop I6 tracks. But any program without the necessary deep commitment will almost certainly fail. The authors detail many of these including
but not limited to a commitment by the faculty to teach a new and very different population of learners, by colleagues in other disciplines to accept and help train our residents, by local leadership to support both the cost (additional trainees, additional resources, lost revenue by faculty now engaged in teaching) and the promotion of faculty whose academic focus will now veer towards teaching and finally by national leadership to create and support novel ways of teaching and assessing our trainees. The second theme is the fact that the I6 approach is a work in progress. By definition a training model is a curriculum. All curricula must undergo regular and vigorous program evaluation. Curricula are not meant to be static but iterative, always changing and adapting.
While surveys are certainly helpful in outlining what
does and doesn’t work it is classically considered the lowest level of programmatic evaluation. Kirkpatrick2 outlined 4 levels of assessment. First are the reactions from learners and faculty, commonly obtained through surveys. Higher levels follow including evidence of learning, followed by learner’s behavior, and finally impact. The authors make it clear that there is a dearth of higher level data on I6 performance. There is limited data on learning as the majority of I6 trainees are still in their first few years. Assessments specific to I6 trainees are also limited so valid data will remain difficult to obtain even as our trainees progress. For example, what is the validity of a general surgery in training exam score on assessing the knowledge our I6 trainees actually need? Learner’s behavior and impact data are even more limited. The Canadians have some history that we should certainly review. They engaged in a similar experiment with integrated training. Data on both learner behavior and impact is available. The experiment was deemed unsuccessful for general thoracic surgical training and the prior system of general surgery training followed by two years of thoracic surgery was reestablished. For cardiac surgery the integrated approach was accepted. Similar to the US, Canadians have seen a decline in applications despite their integrated approach suggesting that US integrated programs may be “robbing Peter to pay Paul” and may soon see a decline as well as saturation is reached.3 In addition, 96% of resident complete an additional year of fellowship and 52% complete two or more. While much of this may be 2
driven by a lack of jobs some concern regarding their preparedness must also be entertained. The RRC and the ABTS should remain vigilant of these issues as I6 programs continue to multiply. Data on the need for fellowship training and ABTS credentialing will certainly need to be monitored. One development that needs to be addressed soon is the difficulty of obtaining protected research time. If this cannot be addressed then there will certainly be an impact on our field as a whole. We need a steady influx of new members who will engage in research to maintain our specialty. If we cannot support research interest then we will see a decline in these applicants diluting the mix of effective researchers and consummate clinicians, a mix that was the envy of every other surgical and medical fields for many decades. Finally, we must still value existing paradigms for cardiothoracic surgical training. In a survey of general surgery resident 26% maintained an interest in CTS and many made the decision to pursue CTS during their 1st, 2nd, or 3rd year of general surgery training.4 The traditional training programs provide an opportunity for these late converts to gain access to cardiothoracic surgery. In conclusion, the authors have provided an excellent review of the value of integrated programs to address a number of limitations inherent in our traditional pathways. However, they have also clearly identified that in its current form it is not a finished product. Further refinement and careful monitoring remain necessary. Furthermore, the traditional pathways, while also far from perfect, are still needed to provide a mechanism of training to the significant number of late converts to our profession.
3
References 1. Ikonomidis JS, Crawford FA, Fann JI.
Integrated surgical residency initiative: implications for
cardiothoracic surgery. Seminars in Thoracic and Cardiovascular Surgery 2014. 2. Kirkpatrick DL, Kirkpatrick JD. Evaluating training programs, third edition. San Francisco: BerrettKoehler Publishers, Inc., 2006. 3. Ouzounian M, Hassan A, Teng CJ, Tang GH, Vanderby SA, Latham TB, Feindel AM. The cardiac surgery workforce: a survey of recent graduates of Canadian training programs. Annals of Thoracic Surgeons 2010;90:460-6. 4. Vaporciyan AA, Reed CE, Erikson C, Dill MJ, Carpenter AJ, Guleserian KJ, Merrill W. Factors affecting interest in cardiothoracic surgery: survey of north American general surgery residents. The Journal fo Thoracic and Cardiovascular Surgery 2009;137:1054-62
4
