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The Bias Against Integrated Thoracic Surgery Residency Applicants During General Surgery Interviews James M. Meza, MD, John E. Rectenwald, MD, and Rishindra M. Reddy, MD Department of Surgery, Duke University Medical Center, Durham, North Carolina; and Sections of Vascular Surgery and Thoracic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
Background. New paradigms for training cardiothoracic surgeons have been introduced, including the integrated thoracic surgery residency. Currently, a limited number of these programs exist, and all candidates apply to both integrated thoracic and general surgery residencies. We sought to investigate the applicants’ experiences applying for both types of positions. Methods. An online survey was distributed to applicants to three integrated thoracic surgery programs during a 2-year period. Results. The response rate was 50% (90 of 180). Most respondents were fourth-year medical students (81%; 72 of 89) and were interested in adult cardiac surgery (81%; 73 of 90). Sixty-one percent (55 of 90) had an interest in cardiothoracic surgery before clinical clerkships, and 93% (84 of 90) tailored their clinical education to this interest. Fifty-seven percent (49 of 86) scored above 230 on the USMLE Step 1 examination. Ninety-two percent (80 of 87) performed research during medical school, and 78% (62 of 80), specifically within cardiothoracic surgery; 76%
(61 of 80) published their work. The number of general surgery interviews varied widely, but 46% (36 of 79) interviewed at one to five integrated thoracic surgery programs, and 39% (31 of 79) interviewed at six to ten integrated thoracic surgery programs. During general surgery interviews, 36% (24 of 66) received negative comments regarding applying to integrated thoracic residencies. Fifty-two percent (38 of 73) thought that their application to integrated thoracic programs diminished their chances to match at a general surgery program. Conclusions. The applicants to the integrated thoracic surgery residencies become interested in cardiothoracic surgery early and tailor their clinical education to this interest. Although they are academically successful, they report significant negativity regarding their applications to both general surgery and integrated thoracic residencies.
he field of cardiothoracic (CT) surgery is predicted to face a shortage of up to 1,500 to 2,000 surgeons during the next decade in the United States. Greater than 51% of CT surgeons are older than 55 years, and waves of retirements are expected as this decade ends [1, 2]. This exodus from the field is occurring just as millions of new patients will become insured under the Affordable Care Act and as the baby boom generation reaches 65 years of age and becomes eligible for Medicare. Concurrently, despite the fact that CT surgery had been historically viewed as among the most competitive fields to enter, the number of surgeons deciding to pursue a career in CT surgery has decreased dramatically. Post– general surgery CT surgery residency, ie, fellowship, positions in the United States have not been filling, a trend that began during the mid-1990s and continues today [3]. The subspecialty reached its lowest fellowship
match rate in the mid-2000s, with as many as 55% of positions going unfilled during this period [4]. Decreased interest in CT surgery as a career has been attributed to multiple reasons, including but not limited to the length of training, a demanding lifestyle, inability to find a job after training, and the rise of percutaneous interventions [3]. According to survey data of general surgery residents, the duration of training represents a serious barrier to many who may consider a career in CT surgery [3]. Traditionally, a minimum of 7 years of training was required to complete a 5-year general surgery residency plus a 2-year CT surgery residency or fellowship. Residents training at academic institutions who pursue dedicated research time may have added 1 to 3 more years. Also, many traditional CT residencies are 3 years instead of 2. Therefore, the training of a CT surgeon often stretched past 10 years, with one study reporting 9.3 years as the average length of training for traditional residents [5]. To address these issues, several new paradigms for training aspiring CT surgeons have emerged. Several programs now use a “4þ3” or “fast-track” model in which a resident completes 4 clinical years of general surgery
T
Accepted for publication Nov 24, 2014. Presented at the Sixtieth Annual Meeting of the Southern Thoracic Surgical Association, Scottsdale, AZ, Oct 30–Nov 2, 2013. Address correspondence to Dr Reddy, University of Michigan, Section of Thoracic Surgery, 1500 E Medical Center Dr, 2120 Taubman Center, Ann Arbor, MI 48109-5344; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
(Ann Thorac Surg 2015;99:1206–12) Ó 2015 by The Society of Thoracic Surgeons
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.11.053
and continues on into CT surgery training at the same institution for 3 years. This program enables residents to become board-certified in both general and thoracic surgery. Medical students may be slotted for this position during the match process or may have to match into the general surgery residency and subsequently compete for these positions during their first years of general surgery residency. The integrated thoracic surgery program was also developed, recognizing that CT surgery has evolved into its own field and that more time focused on CT surgery may be optimal. Concerns have been raised that current general surgery residents, working within the 80hour workweek, may not be able to develop the skills or confidence during only 2 to 3 years of postgraduate training [6]. These residencies incorporate a varied amount of general surgery experience with earlier exposure to and training in CT surgery, with most requiring 6 years of training. Graduates are only eligible for board certification in thoracic surgery. Medical students must apply for these positions during their fourth year, and there is limited availability of these positions. Twenty-five integrated thoracic programs exist as of October 2013, with each accepting one or two applicants per year [7]. In 2011, the applicant: position ratio for Mount Sinai Medical Center’s integrated residency was 131:1 [8]. Given the limited number of integrated programs, and the large number of applicants, most medical students have applied to both general surgery and integrated thoracic residencies. There has been anecdotal evidence of bias against integrated thoracic applicants during their nonthoracic surgery interviews. We sought to determine the academic background and quantify the experiences of those students during the application process.
Material and Methods A survey of 42 questions was created using the online Qualtrics software suite (Qualtrics, Provo, UT) to assess the demographic and educational backgrounds of the integrated thoracic surgery residency applicants. Additional questions were focused on the experience of the integrated thoracic applicants during the general surgery residency interviews. The survey was validated using a small cohort of applicants to three programs. Minor modifications were made to improve the flow and clarity of the survey. The survey was then distributed to applicants to three integrated thoracic programs after completion of the interview period but before the match, at the University of Washington, the University of Virginia, and the University of Michigan, during a 2-year period (2012 and 2013). We specifically chose to survey applicants after their interviews and after rank lists were submitted, but before the match, in an attempt to obtain an unbiased response, which would not be confounded in any direction by the final match results. Applicants were contact directly by e-mail with an electronic survey invitation and a link to the survey. Applicants were notified that their responses were anonymous and did not affect their chances of matriculation. It is estimated that 180 unique students received an invitation, with some
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students receiving multiple invitations. Participation was voluntary and anonymous, and respondents were asked to complete the survey only once. Of the 180 invitations sent, 104 responses were received. Minimally completed surveys were removed, yielding a final sample of 90 completed responses. Respondents were analyzed as a single population (n ¼ 90). The data were analyzed using Microsoft Excel (Microsoft Office 2008; Microsoft Corp, Redmond, WA). Frequency distributions for categorical variables and descriptive statistics for continuous variables were examined to identify basic distribution patterns among valid response and to summarize the responses to all survey questions.
Results Applicant Demographics and Characteristics The response rate was 50% (90 of 180). Table 1 demonstrates the applicants’ demographic characteristics. Most respondents were fourth-year medical students (81%; 72 of 89). One was an attending surgeon abroad (1%; 1 of 90). The average age was 29 years old. The majority received honorsor scored higher than 230 on the United States Medical Licensing Exam (USMLE) Step 1 examination. The applicants were very academically productive as medical students, with 92% (81 of 89) performing research during medical school. Seventy-eight percent (63 of 81) of those who engaged in research specifically worked on projects within the field of CT surgery. Seventy-five percent (61 of 81) published their work, with 59% (36 of 61) applying to residency having published one to three papers. A significant number (38%; 23 of 61) were remarkably productive, publishing four or more times before application to residency. Seventy percent (62 of 88) of all applicants presented their work at a professional society meeting or conference. The number of presentations varied, with 40% (25 of 62) presenting once, whereas 37% (23 of 62) presented four or more times.
Table 1. Applicant Demographics and Characteristics n ¼ 90
Variable Average age (y) Fourth-year medical students Resident Married Have children USMLE Step 1 score > 230 Received an “A” or honors for third-year surgical clerkship Performed research Performed research on a topic within CT surgery Presented research at a conference Published research manuscript Interest in academic surgical career Interest in private practice CT ¼ cardiothoracic;
29 4.5 81% (72/90) 19% (17/90) 26% (21/80) 14% (11/80) 56% (55/90) 61% (52/85) 92% 78% 71% 76% 85% 1%
(80/87) (62/80) (62/87) (61/80) (74/87) (1/87)
USMLE ¼ United States Medical Licensing Exam.
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Development of Applicants’ Interest in Cardiothoracic surgery Sixty-one percent (55 of 90) developed interest in CT surgery before their clinical clerkships in medical school (Fig 1). More than one third (37%; 34 of 90) became interested before medical school, and more than a quarter (27%; 24 of 90), during the preclinical years of medical school. Nearly one quarter (24%; 22 of 90) developed their interest during the third year of medical school. Given the early development of interest in the subspecialty, 93% (84 of 90) attempted to specifically tailor their clinical education to this interest (Fig 2). Of those who responded yes, 90% (75 of 84) requested a rotation on a CT surgery service during their surgical rotations. Eighty percent (66 of 84) acted as sub-interns on a CT surgery service. Sixty-six percent (55 of 84) chose certain nonsurgical services, such as cardiology, with their interest in CT surgery in mind. Seventy-two percent (60 of 84) enrolled in electives such as CT intensive care or echocardiography. Eighty-two percent (68 of 84) spent time outside of required medical school on activities within CT surgery, such as scrubbing into operations during their own free time.
Applicants’ Professional Goals The majority of applicants were interested in pursuing a career in cardiac surgery, with 81% (73 of 90) interested in adult and 56% (50 of 90) interested in congenital surgery, compared with only 34% (31 of 90) interested in general thoracic surgery. Twenty-six percent (23 of 90) noted interest in CT intensive care. Eighty-five percent (74 of 87) of respondents state that they will pursue a career in academic surgery, with only 1 person interested in private practice (1%; 1 of 87), and the remaining respondents (14%) unsure. Ninety-three percent (80 of 86) plan on being involved in research during residency, with 48% of those (38 of 80) interested in clinical research, 29% (23 of 80) interested in translational research, and 10% (8 of 80) interested in basic science.
Application Experience Seventy-four percent of applicants (64 of 86) preferred to apply to integrated thoracic programs over 4þ3 fast track (15%; 13 of 86) or traditional general surgery residencies (10%; 9 of 86). Ninety-five percent (81 of 85) believe they
Fig 1. When applicants become interested in cardiothoracic (CT) surgery. The majority become interested before the clinical years during medical school.
Fig 2. Activities applicants participated in to customize their education. The clinical years are customized with a career in cardiothoracic (CT) surgery in mind. Students tailor their third-year rotations to cardiac or cardiology rotations. Most spend their own free time outside of clinical duties participating in activities related to cardiothoracic surgery.
will still pursue a career in CT surgery even if they did not match into an integrated residency. Mentors were most commonly cited (40%; 36 of 90) for creating awareness of the integrated programs. Seventy-nine percent (72 of 90) rotated on a CT surgery service at an institution other than their own medical school, and 65% (47 of 72) of those who rotated elsewhere believed that this experience helped them in gaining an interview at that institution. The majority (58%; 49 of 86) applied to 21 or more general surgery residencies, whereas 31% (27 of 86) applied to all available integrated programs (Fig 3). Eighty-six percent (56 of 65) applied to more than five integrated residency programs. The number of general surgery interviews received varied, as 23% (19 of 81) were invited to interview at 1 to 5, 22% (18 of 81) at 6 to 10, 21% (17 of 81) at 11 to 15, and 19% (15 of 81) at 16 to 20 programs. Forty-six percent (36 of 79) interviewed at one to five integrated programs, and 39% (31 of 79) interviewed at six to ten integrated programs.
Applicants’ Interview Experience and Perceptions of the Interview Process Applicants were asked about the overall impression on their application strategy during their surgery interviews and on the variety of comments heard during their interviews (checking more than one answer). During general surgery residency interviews, 36% (24 of 66) received an overall negative impression during general surgery interviews regarding their decision to apply to both integrated thoracic and standard general surgery programs (Table 2). Seventy-three percent (61 of 84) reported direct comments about their decision to apply to both programs, with 66% (37 of 57) receiving negative or very negative comments. It is notable that 32% (18 of 57) did experience positive comments also, but concerning that only 22% (14 of 66) had a positive or very positive overall impression during the interview process. Fifty-two percent (38 of 73) thought that their application to integrated programs diminished their chances to match at a general surgery program. Some applicants
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not match to an integrated program (Table 3). Multiple candidates reported that general surgery faculty required explanations of why it was necessary to apply to both types of programs, and were unaware of the very limited number of integrated thoracic positions. Several remarked that they perceived skepticism regarding their commitment to general surgical training or were even directly asked why a general surgery program should train a resident who is not interested in pursuing a career in general surgery. A few applicants responded that they received more-positive comments, such as that applying to both programs was an intelligent and practical strategy. Most observed that they did not receive invitations to interview at both the integrated thoracic and general surgery programs at the same institutions, if both were available.
Comment
Fig 3. Applications and interviews at general surgery and integrated thoracic surgery residencies. (A) Most applicants applied to at least 21 general surgery programs. The number of interviews was relatively evenly distributed across the intervals of programs. (B) Candidates typically applied to more than 6 integrated thoracic programs, but almost half of respondents interviewed at 5 or fewer programs.
responded that during their general surgery interviews, some interviewers questioned the viability of CT surgery as a career in the future. Many applicants mentioned that general surgery faculty were unconvinced that the integrated residency paradigm would be successful, stating that it was not yet a proven training model. Overall, two major themes emerged in the comments: (1) a perceived lack of commitment to general surgery, and (2) the view of general surgery as a backup plan for applicants who do Table 2. Integrated Thoracic Surgery Applicants’ Experience During General Surgery Interviewsa Applicants’ Experience Very positive Positive Indifferent Negative Very negative a
Applicants’ Overall Impression From General Surgery Faculty 5% 17% 42% 30% 6%
(3/66) (11/66) (28/66) (20/66) (4/66)
Comments From General Surgery Faculty 5% 32% 49% 54% 11%
(3/57) (18/57) (28/57) (31/57) (6/57)
Applicants were surveyed regarding the overall impression that they received (one response permitted) and the range of comments (multiple responses permitted) from general surgery program directors and faculty during interviews regarding their application to the integrated thoracic residencies.
Owing to decreased exposure to and interest in CT surgery by general surgery residents, the thoracic surgery leadership has increasingly targeted medical students for recruitment [9]. Students have also been shown to demonstrate greater interest in CT surgery early in medical school [5]. We have sought to highlight potential gaps in the recruitment of highly qualified candidates, and demonstrate that the current application and interview process for integrated thoracic programs may be hurting strong candidates. We hope to educate the thoracic surgical community regarding this issue and help all surgeons appropriately counsel students interested in a career in CT surgery. Many of the integrated thoracic programs are still in their infancy, and unfortunately there are not enough programs available for interested, highly qualified medical student applicants. Previous studies have examined the qualifications of applicants to a single institution and have compared the academic backgrounds of applicants to the integrated program and to the traditional 2-year residency, and have suggested that medical student applicants are academically stronger [8, 10]. Here we document the backgrounds and experiences for a wider group of integrated thoracic residency applicants. Our respondents represent a distinct group of highly motivated students, and our demographic results are consistent with other published data. The integrated applicants become interested in CT surgery before clinical rotations during medical school. Many even found their interest before medical school, confirming a prior study of preclinical medical student interest in CT surgery [5]. These data are consistent with a previous investigation, which demonstrated that applicants to the Medical College of Wisconsin’s integrated residency scored higher on USMLE examinations and published more manuscripts than applicants to the traditional fellowships [10]. In addition, the integrated thoracic applicants who responded are at least comparable to American senior medical students who matched successfully into general surgery and scored a mean of 227 on the USMLE Step 1 [11]. These applicants have strong research qualifications, as
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Table 3. Comments From General Surgery Faculty During Residency Interviews A Perceived Lack of Commitment to General Surgery
General Surgery Residency Was a Backup Plan
“They seemed skeptical of my commitment to a general surgery program, perhaps believing I may leave during my training.” “We don’t necessarily want to babysit someone who is not planning to be a general surgeon for 5 years.”
“Asked if I consider general surgery to be a backup.”
“Asked why they should bother training someone in general surgery who clearly has no interest in being a general surgeon.” “Most faculty seemed to assume that I would prefer the integrated programs and rank them more highly; they were somewhat defensive, and also seemed to take me somewhat less seriously as a general surgery applicant despite what I perceived to be an honest and convincing explanation for why I thought gen surg might be a better fit for me anyway.”
“Was felt that general surgery was a backup to I6 [integrated thoracic surgery residency], when in fact it was the opposite.” “They were convinced general surgery was a backup plan and not a pure pursuit.” “Faculty often didn’t feel that we had same interest in general surgery.”
Applicants were asked to provide examples of the comments from general surgery faculty during interviews regarding their application to both general surgery and integrated thoracic surgery programs.
most report applying to residency with multiple publications and having presented at multiple professional meetings. A select group of thoracic applicants have been especially academically productive, as greater than one third published at least four manuscripts and made four oral presentations. Interestingly, the majority of applicants hope to perform research during residency and to become academic cardiac surgeons. As integrated programs continue to evolve, it may be necessary to add dedicated research years to continue to attract the brightest students. Given the small number of integrated thoracic programs, most applicants have been encouraged to apply to both general surgery and integrated thoracic residencies. Most reported a negative experience regarding their interest in CT surgery when interviewing for general surgery residencies. Despite their strong academic qualifications, many encountered skeptical attitudes and even direct challenges to their application strategies and career goals during general surgery interviews. The vast majority also thought that their application to both programs imperiled their ability to interview at certain programs. This threatened reaction by general surgery programs could prove very detrimental in the recruitment of high-quality applicants into surgical residencies. High-quality applicants could fail to match at academic general surgery programs, impacting their future career options. Unless matched into an integrated thoracic program, others may be dissuaded from pursuing CT surgery, and instead seek alternative fellowship training after general surgery, where there is a paucity of CT mentorship. To combat these findings, we have developed a number of recommendations for students applying for both surgery and thoracic programs. Cardiothoracic mentors should consider these issues when counseling interested medical students during their third and fourth years about their career and training options. If the student opts to apply to both general and integrated thoracic surgery residencies, we strongly recommend that students should create two separate Electronic Residency Application System (ERAS) applications, with two distinct personal
statements and two sets of letters of recommendation. The general surgery application may highlight their interest in CT surgery, but should include the student’s interests in other, possibly related, fields of general surgery, such as vascular or transplant surgery. The students should be encouraged to be honest about their application strategy to both programs, but should be told to educate the general surgery audience on the paucity of integrated thoracic surgery positions, as most general surgeons are unaware that only 25 integrated thoracic programs are available in 2013 (with one or two positions) compared with the 253 (with most offering more than four positions) available for general surgery [7]. Students must understand that some institutions will not interview them for both general surgery and integrated thoracic surgery residencies, and that they may need to contact the integrated thoracic program to determine this before submitting their applications. Individual mentorship by CT surgeons will continue to be of paramount importance to secure the interest of and properly advise the best and brightest surgical residency applicants. Given the projected retirement of a large subset of surgeons by 2025, the field must recruit the next generation, and should ensure that the field’s best days remain in the future by training the most-promising surgical residents. However, the current application environment risks unnecessarily alienating a talented subset of applicants. An alternative strategy to help at the national level could be to move the integrated thoracic match to an earlier date, similar to urology, which may allow applicants to have a better feel for the likelihood to match for the integrated programs, and better tailor or limit their general surgery applications. There are several important limitations to this analysis. Applicants to only three integrated thoracic programs were surveyed. However, the programs are geographically separate, and all have strong cardiac and general thoracic surgery training programs. We are confident that we surveyed the majority of thoracic surgery applicants during a 2-year period. In addition, a small sample size and response rate of 50% must be noted. There is also the potential for bias in the survey results, as those who
perceived negative experiences were more likely to report negative experiences. We specifically tried to limit the questions on bias until the end of the survey, and tried to focus the overall survey on “navigating the application process” in this time of transition toward an integrated thoracic residency. We did limit the potential bias in responses caused by match results by only surveying applicants after their rank lists were submitted and before the match results were known.
References 1. Grover A, Gorman K, Dall TM, et al. Shortage of cardiothoracic surgeons is likely by 2020. Circulation 2009;120:488–94. 2. Center for Workforce Studies. 2012 Physician Specialty Data Book. Washington, DC: Association of American Medical Colleges; 2012. 3. Vaporciyan AA, Reed CE, Erikson C, et al. Factors affecting interest in cardiothoracic surgery: survey of North American general surgery residents. J Thorac Cardiovasc Surg 2009;137:1054–62.
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4. Chitwood WR Jr, Spray TL, Feins RH, Mack MJ. Mission critical: thoracic surgery education reform. Ann Thorac Surg 2008;86:1061–2. 5. Sood V, Reddy RM. An analysis of preclinical students’ perceptions of cardiothoracic surgical procedures. Ann Thorac Surg 2012;94:800–5. 6. Mathisen DJ. It is the journey, not the destination. Ann Thorac Surg 2012;93:1404–15. 7. Fellowship and Residency Electronic Interactive Database. American Medical Association. Available at http://www. ama-assn.org/go/freida. Accessed October 9, 2013. 8. Chikwe J, Brewer Z, Goldstone AB, Adams DH. Integrated thoracic residency program applicants: the best and the brightest? Ann Thorac Surg 2011;92:1586–91. 9. Reddy RM, Kim AW, Cooke DT, Yang SC, Vaporciyan A, Higgins RSD. The looking to the future medical student program: recruiting tomorrow’s leaders. Ann Thorac Surg 2014;97:741–3. 10. Gasparri MG, Tisol WB, Masroor S. Impact of a six-year integrated thoracic surgery training program at the Medical College of Wisconsin. Ann Thorac Surg 2012;93:592–5. 11. National Resident Matching Program. Charting outcomes in the match, 2011. Washington, DC: National Resident Matching Program; 2011.
DISCUSSION DR JOHN H. CALHOON (San Antonio, TX): Thank you, President Cerfolio, Dr Jones. Doctor Meza, congratulations on a really nicely presented and well written paper. Doctor Meza, your timely sharing of it in advance and attention to details which you provided me will serve you well in your career. I also noted that you took one of my suggestions and I appreciate that you didn’t refer to these as I6 programs but integrated programs, and I feel that is really an important change that we in thoracic surgery should get away from. To talk about years when we all know that we need to talk about proficiency doesn’t keep us at the vanguard of education. You pointed out nicely in your manuscript that there are trends that show increasing numbers of patients who need surgery and decreasing numbers of CT (cardiothoracic) surgeons. Yet, my notion is we may well have enough CT surgeons to meet the demands in the United States, which is a little contrary to your thoughts. I realize that’s contrary to much of the current thought, but I think as the United States starts to address the financial realities, patient eligibility may change and it may have us poised perfectly as CT surgeons to be one of the few specialties that provide value in the future while avoiding competing with ourselves. One thing I wanted to point out: it continues to amaze me that some of the general surgeons who during resident interviews “felt like they had to babysit us for those 5 years.” Well, it occurs to me that a similar percentage of those surgeons many of us in the room have been babysitting for the rest of our career. I couldn’t resist throwing that in. I wonder if you might comment on the appeal as a resident of being able to progress based on proficiency rather than time in the future. Congratulations again to you and your colleagues on a wellpresented and timely paper. Thank you. DR MEZA: Regarding the time, it is mostly going to be about the program’s overall goals. I think the time required for training a surgeon is going to require the appropriate amount of time that it requires. I know that’s a chronological statement, but I know that it’s going to require a long time to go into a field that is prestigious but also that’s technically demanding.
I think certain times that are going to need to be adjusted are whether programs want to be training academic surgeons, whether they want to be training private practice surgeons, and maybe even adjusted to the applicant’s career goals, whether it’s general thoracic, whether it’s cardiac, whether it’s congenital cardiac. DR MARK J. KRASNA (Neptune, NJ): Congratulations. A very important study. I just want to make a comment. Last month at the American College of Surgeons I had the privilege of sharing a table one evening with Bill Putnam for the medical student dinner. We have done this several years in a row where second-, third-, and fourth-year students get a chance to interact with different subspecialties; you probably did it at one point in your past. And I have to tell you that there was only one big concern that came out of every one of the students at the table, and that was regarding the integrated program. There were two comments—actually, I would like to hear your perspective on these—one was they asked us very specifically which strategy had the best chance to get accepted. Should they apply, as you have suggested, to both general surgery and to integrated or should they only apply to the integrated? And then the second question, which I thought was even more important, is they want to know in which program do we think that they would get the best skills in preparing them to be a cardiothoracic surgeon. Their concern obviously was that if they were in the integrated program, they may not get general surgical skills that may then help them in the future, although they understood that there was an integrated proactive training program in place. So I am curious what your perception of those two are. DR MEZA: Thank you for your comments. Regarding your first question, I would recommend that students apply to both programs. I know that there are only 25 integrated programs right now. Most of these programs only have one to two positions and most only have a single position. Even if the applicants are extremely competitive, I think the numbers are just that much of a factor still that it requires application to the general surgery program just in terms from a practical standpoint.
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And then regarding your second point, that is a tough question to answer given that the integrated programs have only produced their first graduates in the last 1 to 2 years. I think the safe bet is the general surgery program given that it is well established and just about everyone has gone through a similar type of training in this room, I’m guessing. However, I know that there is substantial investment in making these integrated programs work, and I think that there is great opportunity for young residents in these new programs to have substantial input into how these programs develop, and I wouldn’t shy away from that opportunity if I was in their position.
transition when they express their interest in cardiothoracic surgery early in their training. I have found that when they come back to our service as fourth-year residents, many times they are interested in other things, and a lot of that I think is because our general surgery colleagues continue to give these negative comments to the residents, which is unfortunate. But this may actually change, as the general surgery training programs may change as they start tracking very early as well. And so the perception of training general surgeons is changing rapidly, and it will be very interesting to see how these perceptions change over time as their training changes over time.
DR MELANIE EDWARDS (St. Louis, MO): Were you able to find out if this perceived bias translated into real bias based on their match results and did the students alter the way they ranked programs based on negative comments? Are these from rogue interviewers who may or may not have much influence on the actual selection process? Thank you.
DR BILL PUTNAM (Nashville, TN): Doctor Meza, thank you very much for this presentation. I think the information that you presented here today continues to refine and crystallize the types of individuals who are applying for these integrated programs. I was struck that the average age of the applicants was 29 plus or minus 4 1/2 years, which reflects an older group of individuals who are applying and where a 6-year program carries a high degree of interest. A 6-year program would shorten the time until they could embark upon their chosen career. Eighty-five percent of these individuals were interested in an academic career, an unbelievably high number. How many of these individuals had advanced degrees, either masters or doctoral degrees, prior to entering into an integrated training program? I enjoyed your presentation.
DR MEZA: Thank you, Dr Edwards. We were not able to see if this had an actual impact on their match or not. I think that it did impact where they matched in terms of how they ranked, and that is because our respondents responded that 52% of them believe that they had a worse chance of matching at general surgery programs given the fact that they applied to integrated programs. So I think that would definitely affect their rank order list. DR ERIC L. GROGAN (Nashville, TN): I think that we all find that the comments that are made to our junior residents are very similar from our general surgery faculty as they make the
DR MEZA: Thank you very much for your comments, Dr Putnam. The number who had advanced degrees was in the single digits. I don’t remember the exact number off the top of my head, but it was in the single digits.
The Bias Against Integrated Thoracic Surgery Residency Applicants During General Surgery Interviews James M. Meza, MD, John E. Rectenwald, MD, and Rishindra M. Reddy, MD Department of Surgery, Duke University Medical Center, Durham, North Carolina; and Sections of Vascular Surgery and Thoracic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
Background. New paradigms for training cardiothoracic surgeons have been introduced, including the integrated thoracic surgery residency. Currently, a limited number of these programs exist, and all candidates apply to both integrated thoracic and general surgery residencies. We sought to investigate the applicants’ experiences applying for both types of positions. Methods. An online survey was distributed to applicants to three integrated thoracic surgery programs during a 2-year period. Results. The response rate was 50% (90 of 180). Most respondents were fourth-year medical students (81%; 72 of 89) and were interested in adult cardiac surgery (81%; 73 of 90). Sixty-one percent (55 of 90) had an interest in cardiothoracic surgery before clinical clerkships, and 93% (84 of 90) tailored their clinical education to this interest. Fifty-seven percent (49 of 86) scored above 230 on the USMLE Step 1 examination. Ninety-two percent (80 of 87) performed research during medical school, and 78% (62 of 80), specifically within cardiothoracic surgery; 76%
(61 of 80) published their work. The number of general surgery interviews varied widely, but 46% (36 of 79) interviewed at one to five integrated thoracic surgery programs, and 39% (31 of 79) interviewed at six to ten integrated thoracic surgery programs. During general surgery interviews, 36% (24 of 66) received negative comments regarding applying to integrated thoracic residencies. Fifty-two percent (38 of 73) thought that their application to integrated thoracic programs diminished their chances to match at a general surgery program. Conclusions. The applicants to the integrated thoracic surgery residencies become interested in cardiothoracic surgery early and tailor their clinical education to this interest. Although they are academically successful, they report significant negativity regarding their applications to both general surgery and integrated thoracic residencies.
he field of cardiothoracic (CT) surgery is predicted to face a shortage of up to 1,500 to 2,000 surgeons during the next decade in the United States. Greater than 51% of CT surgeons are older than 55 years, and waves of retirements are expected as this decade ends [1, 2]. This exodus from the field is occurring just as millions of new patients will become insured under the Affordable Care Act and as the baby boom generation reaches 65 years of age and becomes eligible for Medicare. Concurrently, despite the fact that CT surgery had been historically viewed as among the most competitive fields to enter, the number of surgeons deciding to pursue a career in CT surgery has decreased dramatically. Post– general surgery CT surgery residency, ie, fellowship, positions in the United States have not been filling, a trend that began during the mid-1990s and continues today [3]. The subspecialty reached its lowest fellowship
match rate in the mid-2000s, with as many as 55% of positions going unfilled during this period [4]. Decreased interest in CT surgery as a career has been attributed to multiple reasons, including but not limited to the length of training, a demanding lifestyle, inability to find a job after training, and the rise of percutaneous interventions [3]. According to survey data of general surgery residents, the duration of training represents a serious barrier to many who may consider a career in CT surgery [3]. Traditionally, a minimum of 7 years of training was required to complete a 5-year general surgery residency plus a 2-year CT surgery residency or fellowship. Residents training at academic institutions who pursue dedicated research time may have added 1 to 3 more years. Also, many traditional CT residencies are 3 years instead of 2. Therefore, the training of a CT surgeon often stretched past 10 years, with one study reporting 9.3 years as the average length of training for traditional residents [5]. To address these issues, several new paradigms for training aspiring CT surgeons have emerged. Several programs now use a “4þ3” or “fast-track” model in which a resident completes 4 clinical years of general surgery
T
Accepted for publication Nov 24, 2014. Presented at the Sixtieth Annual Meeting of the Southern Thoracic Surgical Association, Scottsdale, AZ, Oct 30–Nov 2, 2013. Address correspondence to Dr Reddy, University of Michigan, Section of Thoracic Surgery, 1500 E Medical Center Dr, 2120 Taubman Center, Ann Arbor, MI 48109-5344; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
(Ann Thorac Surg 2015;99:1206–12) Ó 2015 by The Society of Thoracic Surgeons
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.11.053
and continues on into CT surgery training at the same institution for 3 years. This program enables residents to become board-certified in both general and thoracic surgery. Medical students may be slotted for this position during the match process or may have to match into the general surgery residency and subsequently compete for these positions during their first years of general surgery residency. The integrated thoracic surgery program was also developed, recognizing that CT surgery has evolved into its own field and that more time focused on CT surgery may be optimal. Concerns have been raised that current general surgery residents, working within the 80hour workweek, may not be able to develop the skills or confidence during only 2 to 3 years of postgraduate training [6]. These residencies incorporate a varied amount of general surgery experience with earlier exposure to and training in CT surgery, with most requiring 6 years of training. Graduates are only eligible for board certification in thoracic surgery. Medical students must apply for these positions during their fourth year, and there is limited availability of these positions. Twenty-five integrated thoracic programs exist as of October 2013, with each accepting one or two applicants per year [7]. In 2011, the applicant: position ratio for Mount Sinai Medical Center’s integrated residency was 131:1 [8]. Given the limited number of integrated programs, and the large number of applicants, most medical students have applied to both general surgery and integrated thoracic residencies. There has been anecdotal evidence of bias against integrated thoracic applicants during their nonthoracic surgery interviews. We sought to determine the academic background and quantify the experiences of those students during the application process.
Material and Methods A survey of 42 questions was created using the online Qualtrics software suite (Qualtrics, Provo, UT) to assess the demographic and educational backgrounds of the integrated thoracic surgery residency applicants. Additional questions were focused on the experience of the integrated thoracic applicants during the general surgery residency interviews. The survey was validated using a small cohort of applicants to three programs. Minor modifications were made to improve the flow and clarity of the survey. The survey was then distributed to applicants to three integrated thoracic programs after completion of the interview period but before the match, at the University of Washington, the University of Virginia, and the University of Michigan, during a 2-year period (2012 and 2013). We specifically chose to survey applicants after their interviews and after rank lists were submitted, but before the match, in an attempt to obtain an unbiased response, which would not be confounded in any direction by the final match results. Applicants were contact directly by e-mail with an electronic survey invitation and a link to the survey. Applicants were notified that their responses were anonymous and did not affect their chances of matriculation. It is estimated that 180 unique students received an invitation, with some
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students receiving multiple invitations. Participation was voluntary and anonymous, and respondents were asked to complete the survey only once. Of the 180 invitations sent, 104 responses were received. Minimally completed surveys were removed, yielding a final sample of 90 completed responses. Respondents were analyzed as a single population (n ¼ 90). The data were analyzed using Microsoft Excel (Microsoft Office 2008; Microsoft Corp, Redmond, WA). Frequency distributions for categorical variables and descriptive statistics for continuous variables were examined to identify basic distribution patterns among valid response and to summarize the responses to all survey questions.
Results Applicant Demographics and Characteristics The response rate was 50% (90 of 180). Table 1 demonstrates the applicants’ demographic characteristics. Most respondents were fourth-year medical students (81%; 72 of 89). One was an attending surgeon abroad (1%; 1 of 90). The average age was 29 years old. The majority received honorsor scored higher than 230 on the United States Medical Licensing Exam (USMLE) Step 1 examination. The applicants were very academically productive as medical students, with 92% (81 of 89) performing research during medical school. Seventy-eight percent (63 of 81) of those who engaged in research specifically worked on projects within the field of CT surgery. Seventy-five percent (61 of 81) published their work, with 59% (36 of 61) applying to residency having published one to three papers. A significant number (38%; 23 of 61) were remarkably productive, publishing four or more times before application to residency. Seventy percent (62 of 88) of all applicants presented their work at a professional society meeting or conference. The number of presentations varied, with 40% (25 of 62) presenting once, whereas 37% (23 of 62) presented four or more times.
Table 1. Applicant Demographics and Characteristics n ¼ 90
Variable Average age (y) Fourth-year medical students Resident Married Have children USMLE Step 1 score > 230 Received an “A” or honors for third-year surgical clerkship Performed research Performed research on a topic within CT surgery Presented research at a conference Published research manuscript Interest in academic surgical career Interest in private practice CT ¼ cardiothoracic;
29 4.5 81% (72/90) 19% (17/90) 26% (21/80) 14% (11/80) 56% (55/90) 61% (52/85) 92% 78% 71% 76% 85% 1%
(80/87) (62/80) (62/87) (61/80) (74/87) (1/87)
USMLE ¼ United States Medical Licensing Exam.
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Development of Applicants’ Interest in Cardiothoracic surgery Sixty-one percent (55 of 90) developed interest in CT surgery before their clinical clerkships in medical school (Fig 1). More than one third (37%; 34 of 90) became interested before medical school, and more than a quarter (27%; 24 of 90), during the preclinical years of medical school. Nearly one quarter (24%; 22 of 90) developed their interest during the third year of medical school. Given the early development of interest in the subspecialty, 93% (84 of 90) attempted to specifically tailor their clinical education to this interest (Fig 2). Of those who responded yes, 90% (75 of 84) requested a rotation on a CT surgery service during their surgical rotations. Eighty percent (66 of 84) acted as sub-interns on a CT surgery service. Sixty-six percent (55 of 84) chose certain nonsurgical services, such as cardiology, with their interest in CT surgery in mind. Seventy-two percent (60 of 84) enrolled in electives such as CT intensive care or echocardiography. Eighty-two percent (68 of 84) spent time outside of required medical school on activities within CT surgery, such as scrubbing into operations during their own free time.
Applicants’ Professional Goals The majority of applicants were interested in pursuing a career in cardiac surgery, with 81% (73 of 90) interested in adult and 56% (50 of 90) interested in congenital surgery, compared with only 34% (31 of 90) interested in general thoracic surgery. Twenty-six percent (23 of 90) noted interest in CT intensive care. Eighty-five percent (74 of 87) of respondents state that they will pursue a career in academic surgery, with only 1 person interested in private practice (1%; 1 of 87), and the remaining respondents (14%) unsure. Ninety-three percent (80 of 86) plan on being involved in research during residency, with 48% of those (38 of 80) interested in clinical research, 29% (23 of 80) interested in translational research, and 10% (8 of 80) interested in basic science.
Application Experience Seventy-four percent of applicants (64 of 86) preferred to apply to integrated thoracic programs over 4þ3 fast track (15%; 13 of 86) or traditional general surgery residencies (10%; 9 of 86). Ninety-five percent (81 of 85) believe they
Fig 1. When applicants become interested in cardiothoracic (CT) surgery. The majority become interested before the clinical years during medical school.
Fig 2. Activities applicants participated in to customize their education. The clinical years are customized with a career in cardiothoracic (CT) surgery in mind. Students tailor their third-year rotations to cardiac or cardiology rotations. Most spend their own free time outside of clinical duties participating in activities related to cardiothoracic surgery.
will still pursue a career in CT surgery even if they did not match into an integrated residency. Mentors were most commonly cited (40%; 36 of 90) for creating awareness of the integrated programs. Seventy-nine percent (72 of 90) rotated on a CT surgery service at an institution other than their own medical school, and 65% (47 of 72) of those who rotated elsewhere believed that this experience helped them in gaining an interview at that institution. The majority (58%; 49 of 86) applied to 21 or more general surgery residencies, whereas 31% (27 of 86) applied to all available integrated programs (Fig 3). Eighty-six percent (56 of 65) applied to more than five integrated residency programs. The number of general surgery interviews received varied, as 23% (19 of 81) were invited to interview at 1 to 5, 22% (18 of 81) at 6 to 10, 21% (17 of 81) at 11 to 15, and 19% (15 of 81) at 16 to 20 programs. Forty-six percent (36 of 79) interviewed at one to five integrated programs, and 39% (31 of 79) interviewed at six to ten integrated programs.
Applicants’ Interview Experience and Perceptions of the Interview Process Applicants were asked about the overall impression on their application strategy during their surgery interviews and on the variety of comments heard during their interviews (checking more than one answer). During general surgery residency interviews, 36% (24 of 66) received an overall negative impression during general surgery interviews regarding their decision to apply to both integrated thoracic and standard general surgery programs (Table 2). Seventy-three percent (61 of 84) reported direct comments about their decision to apply to both programs, with 66% (37 of 57) receiving negative or very negative comments. It is notable that 32% (18 of 57) did experience positive comments also, but concerning that only 22% (14 of 66) had a positive or very positive overall impression during the interview process. Fifty-two percent (38 of 73) thought that their application to integrated programs diminished their chances to match at a general surgery program. Some applicants
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not match to an integrated program (Table 3). Multiple candidates reported that general surgery faculty required explanations of why it was necessary to apply to both types of programs, and were unaware of the very limited number of integrated thoracic positions. Several remarked that they perceived skepticism regarding their commitment to general surgical training or were even directly asked why a general surgery program should train a resident who is not interested in pursuing a career in general surgery. A few applicants responded that they received more-positive comments, such as that applying to both programs was an intelligent and practical strategy. Most observed that they did not receive invitations to interview at both the integrated thoracic and general surgery programs at the same institutions, if both were available.
Comment
Fig 3. Applications and interviews at general surgery and integrated thoracic surgery residencies. (A) Most applicants applied to at least 21 general surgery programs. The number of interviews was relatively evenly distributed across the intervals of programs. (B) Candidates typically applied to more than 6 integrated thoracic programs, but almost half of respondents interviewed at 5 or fewer programs.
responded that during their general surgery interviews, some interviewers questioned the viability of CT surgery as a career in the future. Many applicants mentioned that general surgery faculty were unconvinced that the integrated residency paradigm would be successful, stating that it was not yet a proven training model. Overall, two major themes emerged in the comments: (1) a perceived lack of commitment to general surgery, and (2) the view of general surgery as a backup plan for applicants who do Table 2. Integrated Thoracic Surgery Applicants’ Experience During General Surgery Interviewsa Applicants’ Experience Very positive Positive Indifferent Negative Very negative a
Applicants’ Overall Impression From General Surgery Faculty 5% 17% 42% 30% 6%
(3/66) (11/66) (28/66) (20/66) (4/66)
Comments From General Surgery Faculty 5% 32% 49% 54% 11%
(3/57) (18/57) (28/57) (31/57) (6/57)
Applicants were surveyed regarding the overall impression that they received (one response permitted) and the range of comments (multiple responses permitted) from general surgery program directors and faculty during interviews regarding their application to the integrated thoracic residencies.
Owing to decreased exposure to and interest in CT surgery by general surgery residents, the thoracic surgery leadership has increasingly targeted medical students for recruitment [9]. Students have also been shown to demonstrate greater interest in CT surgery early in medical school [5]. We have sought to highlight potential gaps in the recruitment of highly qualified candidates, and demonstrate that the current application and interview process for integrated thoracic programs may be hurting strong candidates. We hope to educate the thoracic surgical community regarding this issue and help all surgeons appropriately counsel students interested in a career in CT surgery. Many of the integrated thoracic programs are still in their infancy, and unfortunately there are not enough programs available for interested, highly qualified medical student applicants. Previous studies have examined the qualifications of applicants to a single institution and have compared the academic backgrounds of applicants to the integrated program and to the traditional 2-year residency, and have suggested that medical student applicants are academically stronger [8, 10]. Here we document the backgrounds and experiences for a wider group of integrated thoracic residency applicants. Our respondents represent a distinct group of highly motivated students, and our demographic results are consistent with other published data. The integrated applicants become interested in CT surgery before clinical rotations during medical school. Many even found their interest before medical school, confirming a prior study of preclinical medical student interest in CT surgery [5]. These data are consistent with a previous investigation, which demonstrated that applicants to the Medical College of Wisconsin’s integrated residency scored higher on USMLE examinations and published more manuscripts than applicants to the traditional fellowships [10]. In addition, the integrated thoracic applicants who responded are at least comparable to American senior medical students who matched successfully into general surgery and scored a mean of 227 on the USMLE Step 1 [11]. These applicants have strong research qualifications, as
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Table 3. Comments From General Surgery Faculty During Residency Interviews A Perceived Lack of Commitment to General Surgery
General Surgery Residency Was a Backup Plan
“They seemed skeptical of my commitment to a general surgery program, perhaps believing I may leave during my training.” “We don’t necessarily want to babysit someone who is not planning to be a general surgeon for 5 years.”
“Asked if I consider general surgery to be a backup.”
“Asked why they should bother training someone in general surgery who clearly has no interest in being a general surgeon.” “Most faculty seemed to assume that I would prefer the integrated programs and rank them more highly; they were somewhat defensive, and also seemed to take me somewhat less seriously as a general surgery applicant despite what I perceived to be an honest and convincing explanation for why I thought gen surg might be a better fit for me anyway.”
“Was felt that general surgery was a backup to I6 [integrated thoracic surgery residency], when in fact it was the opposite.” “They were convinced general surgery was a backup plan and not a pure pursuit.” “Faculty often didn’t feel that we had same interest in general surgery.”
Applicants were asked to provide examples of the comments from general surgery faculty during interviews regarding their application to both general surgery and integrated thoracic surgery programs.
most report applying to residency with multiple publications and having presented at multiple professional meetings. A select group of thoracic applicants have been especially academically productive, as greater than one third published at least four manuscripts and made four oral presentations. Interestingly, the majority of applicants hope to perform research during residency and to become academic cardiac surgeons. As integrated programs continue to evolve, it may be necessary to add dedicated research years to continue to attract the brightest students. Given the small number of integrated thoracic programs, most applicants have been encouraged to apply to both general surgery and integrated thoracic residencies. Most reported a negative experience regarding their interest in CT surgery when interviewing for general surgery residencies. Despite their strong academic qualifications, many encountered skeptical attitudes and even direct challenges to their application strategies and career goals during general surgery interviews. The vast majority also thought that their application to both programs imperiled their ability to interview at certain programs. This threatened reaction by general surgery programs could prove very detrimental in the recruitment of high-quality applicants into surgical residencies. High-quality applicants could fail to match at academic general surgery programs, impacting their future career options. Unless matched into an integrated thoracic program, others may be dissuaded from pursuing CT surgery, and instead seek alternative fellowship training after general surgery, where there is a paucity of CT mentorship. To combat these findings, we have developed a number of recommendations for students applying for both surgery and thoracic programs. Cardiothoracic mentors should consider these issues when counseling interested medical students during their third and fourth years about their career and training options. If the student opts to apply to both general and integrated thoracic surgery residencies, we strongly recommend that students should create two separate Electronic Residency Application System (ERAS) applications, with two distinct personal
statements and two sets of letters of recommendation. The general surgery application may highlight their interest in CT surgery, but should include the student’s interests in other, possibly related, fields of general surgery, such as vascular or transplant surgery. The students should be encouraged to be honest about their application strategy to both programs, but should be told to educate the general surgery audience on the paucity of integrated thoracic surgery positions, as most general surgeons are unaware that only 25 integrated thoracic programs are available in 2013 (with one or two positions) compared with the 253 (with most offering more than four positions) available for general surgery [7]. Students must understand that some institutions will not interview them for both general surgery and integrated thoracic surgery residencies, and that they may need to contact the integrated thoracic program to determine this before submitting their applications. Individual mentorship by CT surgeons will continue to be of paramount importance to secure the interest of and properly advise the best and brightest surgical residency applicants. Given the projected retirement of a large subset of surgeons by 2025, the field must recruit the next generation, and should ensure that the field’s best days remain in the future by training the most-promising surgical residents. However, the current application environment risks unnecessarily alienating a talented subset of applicants. An alternative strategy to help at the national level could be to move the integrated thoracic match to an earlier date, similar to urology, which may allow applicants to have a better feel for the likelihood to match for the integrated programs, and better tailor or limit their general surgery applications. There are several important limitations to this analysis. Applicants to only three integrated thoracic programs were surveyed. However, the programs are geographically separate, and all have strong cardiac and general thoracic surgery training programs. We are confident that we surveyed the majority of thoracic surgery applicants during a 2-year period. In addition, a small sample size and response rate of 50% must be noted. There is also the potential for bias in the survey results, as those who
perceived negative experiences were more likely to report negative experiences. We specifically tried to limit the questions on bias until the end of the survey, and tried to focus the overall survey on “navigating the application process” in this time of transition toward an integrated thoracic residency. We did limit the potential bias in responses caused by match results by only surveying applicants after their rank lists were submitted and before the match results were known.
References 1. Grover A, Gorman K, Dall TM, et al. Shortage of cardiothoracic surgeons is likely by 2020. Circulation 2009;120:488–94. 2. Center for Workforce Studies. 2012 Physician Specialty Data Book. Washington, DC: Association of American Medical Colleges; 2012. 3. Vaporciyan AA, Reed CE, Erikson C, et al. Factors affecting interest in cardiothoracic surgery: survey of North American general surgery residents. J Thorac Cardiovasc Surg 2009;137:1054–62.
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4. Chitwood WR Jr, Spray TL, Feins RH, Mack MJ. Mission critical: thoracic surgery education reform. Ann Thorac Surg 2008;86:1061–2. 5. Sood V, Reddy RM. An analysis of preclinical students’ perceptions of cardiothoracic surgical procedures. Ann Thorac Surg 2012;94:800–5. 6. Mathisen DJ. It is the journey, not the destination. Ann Thorac Surg 2012;93:1404–15. 7. Fellowship and Residency Electronic Interactive Database. American Medical Association. Available at http://www. ama-assn.org/go/freida. Accessed October 9, 2013. 8. Chikwe J, Brewer Z, Goldstone AB, Adams DH. Integrated thoracic residency program applicants: the best and the brightest? Ann Thorac Surg 2011;92:1586–91. 9. Reddy RM, Kim AW, Cooke DT, Yang SC, Vaporciyan A, Higgins RSD. The looking to the future medical student program: recruiting tomorrow’s leaders. Ann Thorac Surg 2014;97:741–3. 10. Gasparri MG, Tisol WB, Masroor S. Impact of a six-year integrated thoracic surgery training program at the Medical College of Wisconsin. Ann Thorac Surg 2012;93:592–5. 11. National Resident Matching Program. Charting outcomes in the match, 2011. Washington, DC: National Resident Matching Program; 2011.
DISCUSSION DR JOHN H. CALHOON (San Antonio, TX): Thank you, President Cerfolio, Dr Jones. Doctor Meza, congratulations on a really nicely presented and well written paper. Doctor Meza, your timely sharing of it in advance and attention to details which you provided me will serve you well in your career. I also noted that you took one of my suggestions and I appreciate that you didn’t refer to these as I6 programs but integrated programs, and I feel that is really an important change that we in thoracic surgery should get away from. To talk about years when we all know that we need to talk about proficiency doesn’t keep us at the vanguard of education. You pointed out nicely in your manuscript that there are trends that show increasing numbers of patients who need surgery and decreasing numbers of CT (cardiothoracic) surgeons. Yet, my notion is we may well have enough CT surgeons to meet the demands in the United States, which is a little contrary to your thoughts. I realize that’s contrary to much of the current thought, but I think as the United States starts to address the financial realities, patient eligibility may change and it may have us poised perfectly as CT surgeons to be one of the few specialties that provide value in the future while avoiding competing with ourselves. One thing I wanted to point out: it continues to amaze me that some of the general surgeons who during resident interviews “felt like they had to babysit us for those 5 years.” Well, it occurs to me that a similar percentage of those surgeons many of us in the room have been babysitting for the rest of our career. I couldn’t resist throwing that in. I wonder if you might comment on the appeal as a resident of being able to progress based on proficiency rather than time in the future. Congratulations again to you and your colleagues on a wellpresented and timely paper. Thank you. DR MEZA: Regarding the time, it is mostly going to be about the program’s overall goals. I think the time required for training a surgeon is going to require the appropriate amount of time that it requires. I know that’s a chronological statement, but I know that it’s going to require a long time to go into a field that is prestigious but also that’s technically demanding.
I think certain times that are going to need to be adjusted are whether programs want to be training academic surgeons, whether they want to be training private practice surgeons, and maybe even adjusted to the applicant’s career goals, whether it’s general thoracic, whether it’s cardiac, whether it’s congenital cardiac. DR MARK J. KRASNA (Neptune, NJ): Congratulations. A very important study. I just want to make a comment. Last month at the American College of Surgeons I had the privilege of sharing a table one evening with Bill Putnam for the medical student dinner. We have done this several years in a row where second-, third-, and fourth-year students get a chance to interact with different subspecialties; you probably did it at one point in your past. And I have to tell you that there was only one big concern that came out of every one of the students at the table, and that was regarding the integrated program. There were two comments—actually, I would like to hear your perspective on these—one was they asked us very specifically which strategy had the best chance to get accepted. Should they apply, as you have suggested, to both general surgery and to integrated or should they only apply to the integrated? And then the second question, which I thought was even more important, is they want to know in which program do we think that they would get the best skills in preparing them to be a cardiothoracic surgeon. Their concern obviously was that if they were in the integrated program, they may not get general surgical skills that may then help them in the future, although they understood that there was an integrated proactive training program in place. So I am curious what your perception of those two are. DR MEZA: Thank you for your comments. Regarding your first question, I would recommend that students apply to both programs. I know that there are only 25 integrated programs right now. Most of these programs only have one to two positions and most only have a single position. Even if the applicants are extremely competitive, I think the numbers are just that much of a factor still that it requires application to the general surgery program just in terms from a practical standpoint.
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And then regarding your second point, that is a tough question to answer given that the integrated programs have only produced their first graduates in the last 1 to 2 years. I think the safe bet is the general surgery program given that it is well established and just about everyone has gone through a similar type of training in this room, I’m guessing. However, I know that there is substantial investment in making these integrated programs work, and I think that there is great opportunity for young residents in these new programs to have substantial input into how these programs develop, and I wouldn’t shy away from that opportunity if I was in their position.
transition when they express their interest in cardiothoracic surgery early in their training. I have found that when they come back to our service as fourth-year residents, many times they are interested in other things, and a lot of that I think is because our general surgery colleagues continue to give these negative comments to the residents, which is unfortunate. But this may actually change, as the general surgery training programs may change as they start tracking very early as well. And so the perception of training general surgeons is changing rapidly, and it will be very interesting to see how these perceptions change over time as their training changes over time.
DR MELANIE EDWARDS (St. Louis, MO): Were you able to find out if this perceived bias translated into real bias based on their match results and did the students alter the way they ranked programs based on negative comments? Are these from rogue interviewers who may or may not have much influence on the actual selection process? Thank you.
DR BILL PUTNAM (Nashville, TN): Doctor Meza, thank you very much for this presentation. I think the information that you presented here today continues to refine and crystallize the types of individuals who are applying for these integrated programs. I was struck that the average age of the applicants was 29 plus or minus 4 1/2 years, which reflects an older group of individuals who are applying and where a 6-year program carries a high degree of interest. A 6-year program would shorten the time until they could embark upon their chosen career. Eighty-five percent of these individuals were interested in an academic career, an unbelievably high number. How many of these individuals had advanced degrees, either masters or doctoral degrees, prior to entering into an integrated training program? I enjoyed your presentation.
DR MEZA: Thank you, Dr Edwards. We were not able to see if this had an actual impact on their match or not. I think that it did impact where they matched in terms of how they ranked, and that is because our respondents responded that 52% of them believe that they had a worse chance of matching at general surgery programs given the fact that they applied to integrated programs. So I think that would definitely affect their rank order list. DR ERIC L. GROGAN (Nashville, TN): I think that we all find that the comments that are made to our junior residents are very similar from our general surgery faculty as they make the
DR MEZA: Thank you very much for your comments, Dr Putnam. The number who had advanced degrees was in the single digits. I don’t remember the exact number off the top of my head, but it was in the single digits.
