Comparing Graduating Plastic Surgery Residents' Case Logs With Accreditation Council for Graduate Medical Education Requirements, Content at National Meetings, and In-Service Examination Test Items.

BACKGROUND: The importance of adaptable and up-to-date plastic surgery graduate medical education (GME) has taken on new meaning amidst accelerating surgical innovation and increasing calls for competency-based training standards. We aimed to examine the extent to which the procedures plastic surgery residents perform, as represented in case log data, align with 2 core standardized components of plastic surgery GME: ACGME (Accreditation Council for Graduate Medical Education) minimum procedure count requirements and the PSITE (Plastic Surgery In-Service Training Examination). We also examined their alignment with procedural representation at 2 major plastic surgery meetings. METHODS: Nine categories of reconstructive and aesthetic procedures were identified. Three-year averages for the number of procedures completed in each category by residents graduating in 2019-2021 were calculated from ACGME national case log data reports. The ACGME procedure count minimum requirements were also ascertained. The titles and durations of medical programming sessions scheduled for Plastic Surgery The Meeting (PSTM) 2022 and the Plastic Surgery Research Council (PSRC) Annual Meeting 2022 were retrieved from online data. Finally, test items from the 2020 to 2022 administrations of the PSITE were retrieved. Conference sessions and test items were assigned to a single procedure category when possible. Percent differences were calculated for comparison. RESULTS: The distribution of procedures on plastic surgery resident case logs differs from those of the major mechanisms of standardization in plastic surgery GME, in-service examination content more so than ACGME requirements. Meeting content at PSTM and PSRC had the largest percent differences with case log data, with PSTM being skewed toward aesthetics and PSRC toward reconstructive head and neck surgery. DISCUSSION: The criteria and standards by which plastic surgery residents are evaluated and content at national meetings differ from the procedures they actually complete during their training. Although largely reflecting heterogeneity of the specialty, following these comparisons will likely prove useful in the continual evaluation of plastic surgery residency training, especially in the preparation of residents for the variety of training and practice settings they pursue.

Trends in minimally invasive and open inguinal hernia repair: an analysis of ACGME general surgery case logs.

BACKGROUND: Groin hernia repair is one of the most commonly performed surgical procedures and is often performed by surgical interns and junior residents. While traditionally performed open, minimally invasive (MIS) groin hernia repair has become an increasingly popular approach. The purpose of this study was to determine the trends in MIS and open inguinal and femoral hernia repair in general surgery residency training over the past two decades. METHODS: Accreditation Council for Graduate Medical Education (ACGME) national case log data of general surgery residents from 1999 through 2022 were reviewed. We collected means and standard deviations of open and MIS inguinal and femoral hernia repairs. Linear regression and ANOVA were used to identify trends in the average annual number of open and MIS hernia repairs logged by residents. Cases were distinguished between level of resident trainees: surgeon-chief (SC) and surgeon-junior (SJ). RESULTS: From July 1999 to June 2022, the average annual MIS inguinal and femoral hernia repairs logged by general surgery residents significantly increased, from 7.6 to 47.9 cases (p < 0.001), and the average annual open inguinal and femoral hernia repairs logged by general surgery residents significantly decreased, from 51.9 to 39.7 cases (p < 0.001). SJ resident results were consistent with this overall trend. For SC residents, the volume of both MIS and open hernia repairs significantly increased (p < 0.001). CONCLUSIONS: ACGME case log data indicates a trend of general surgery residents logging overall fewer numbers of open inguinal and femoral hernia repairs, and a larger proportion of open repairs by chief residents. This trend warrants attention and further study as it may represent a skill or knowledge gap with significant impact of surgical training.

National Profile of the ACGME Milestones 1.0 and 2.0 within General Surgery: A Seven-Year National Study from 2014 to 2021.

PURPOSE: The Accreditation Council for Graduate Medical Education (ACGME) introduced General Surgery Milestones 1.0 in 2014 and Milestones 2.0 in 2020 as steps toward competency-based training. Analysis will inform residency programs on curriculum development, assessment, feedback, and faculty development. This study describes the distributions and trends for Milestones 1.0 and 2.0 ratings and proportion of residents not achieving the level 4.0 graduation target. METHODS: A deidentified dataset of milestone ratings for all ACGME-accredited General Surgery residency programs in the United States was used. Medians and interquartile ranges (IQR) were reported for milestone ratings at each PGY level. Percentages of PGY-5s receiving final year ratings of less than 4.0 were calculated. Wilcoxon rank sum tests were used to compare 1.0 and 2.0 median ratings. Kruskal-Wallis and Bonferroni post-hoc tests were used to compare median ratings across time periods and PGY levels. Chi-squared tests were used to compare the proportion of level 4.0 nonachievement under both systems. RESULTS: Milestones 1.0 data consisted of 13,866 residents and Milestones 2.0 data consisted of 7,633 residents. For 1.0 and 2.0, all competency domain median ratings were higher for subsequent years of training. Milestones 2.0 had significantly higher median ratings at all PGY levels for all competency domains except Medical Knowledge. Percentages of PGY-5 residents not achieving the graduation target in Milestones 1.0 ranged from 27% to 42% and in 2.0 from 5% to 13%. For Milestones 1.0, all subcompetencies showed an increased number of residents achieving the graduation target from 2014 to 2019. CONCLUSIONS: This study of General Surgery Milestones 1.0 and 2.0 data uncovered significant increases in average ratings and significantly fewer residents not achieving the graduation target under the 2.0 system. We hypothesize that these findings may be related more to rating bias given the change in rating scales, rather than a true increase in resident ability.

Operative Experience of Esophageal Surgery among General Surgery Residents in the United States: An Analysis of ACGME Operative Case Logs.

INTRODUCTION: Esophageal surgery is an essential component of general surgery training and encompasses several types of cases that are logged by general surgery residents. There is a scarcity of data on the quality and volume of esophageal surgery experience during surgical residency in the United States. We analyzed trends for 9 different esophageal procedure categories logged by residents in the United States, with the aim to identify areas for improvement in training. METHODS: We conducted a retrospective analysis of operative case logs of all general surgery residents graduating from programs accredited by the ACGME over a fourteen-year period from 2009 to 2023. Data on mean esophageal cases reported by graduates, including mean in each procedure subcategory were retrieved. Cases were categorized as either surgeon chief or surgeon junior for each procedure category. Mann-Kendall trend test was used to obtain tau statistics and p-value for trends in mean operative surgical volume for the total number of cases in each operative category over the study period. Trends in surgeon chief and surgeon junior cases were also investigated for each operative category. RESULTS: The mean number of all esophageal procedures performed per resident during their training increased significantly from 10.5 in 2009 to 16 in 2022 (τ = 0.833, p < 0.001). This trend observed among all esophageal procedures during this 14-year study can be largely attributed to the steady increase in the number and proportion of laparoscopic esophageal antireflux procedures performed (τ = 0.950, p < 0.001). Additionally, esophagectomy procedures had a statistically significant, but modest, increase during the study period (τ = 0.505, p = 0.023), from a mean of 1 case during training in 2009 to a peak of 1.3 in 2020. Although the general trend of esophagus procedures increased during the study period, most categories (7 out of 9) either decreased or did not significantly change. Esophagogastrectomy volume decreased significantly by 30%, from 1 per resident during their training in 2009 to 0.7 in 2022 (τ = -0.510, p = 0.018), esophageal diverticulectomy procedures decreased by 50% from 0.2 to 0.1 (τ = -0.609, p = 0.009), and operations for esophageal stenosis decreased by 75% from 0.4 to 0.1 (τ = -0.734, p = 0.001). Mean number of esophageal bypasses (τ = -0.128, p = 0.584), repair of perforated esophageal disease (τ = -0.333, p = 0.156), and other major esophagus procedures (τ = 0.416, p = 0.063) did not significantly change. CONCLUSION: The operative volume of esophageal surgery that general surgery residents in the United States are exposed to has significantly risen over the past 14 years, largely driven by the increase in laparoscopic antireflux procedures. However, given the recent advances and the resultant heterogeneity in both esophageal surgery, the increase in resident operative volume is still inadequate to ensure the training of safe and adept esophageal surgeons, necessitating postresidency specialized training for trainees interested in esophageal surgery.

The Accreditation Council for Graduate Medical Education 20-Year Trends in Diversity, Equity, and Inclusion in the United States: How Does Neurological Surgery Compare?

BACKGROUND: Within the current medical workforce, diversity is limited among surgical specialties. However, diversity allows physicians to provide culturally competent care. This paper discusses the trends in racial, ethnic, and gender representation within different surgical subspecialties with an emphasis on neurosurgery over a 20-year time frame. METHODS: A retrospective review of data collected by the Accreditation Council for Graduate Medical Education over the past twenty years, as reported in Journal of the American Medical Association, was conducted. Residents from 5 surgical specialties were evaluated based on gender, race, and ethnic identifications from 2002 to 2022. One-way analysis of variance was performed to compare the levels and retention rates of racial, ethnic, and gender diversity within these specialties. RESULTS: Analysis of resident demographics of the 5 surgical specialties reveals an overall trend of increasing diversity over the study period. Over the past 20 years, neurosurgery had an overall increase in Asian (+5.1%), Hispanic (+3.0%), and female (+11.4%) residents, with a decrease in White residents by 2.1% and Black residents by 1.1%. Among the surgical specialties analyzed, otolaryngology had the greatest overall increase in minority residents. Notably, there has been an overall increase in female residents across all 5 surgical specialties, with the highest in otolaryngology (+20.3%) which was significantly more than neurosurgery (P < 0.001). CONCLUSIONS: This chronological analysis spanning 20 years demonstrates that neurosurgery, like other specialties, has seen a growth in several racial and ethnic categories. Relative differences are notable in neurosurgery, including Black, Asian, Hispanic, and White ethnic categories, with growth in females, but at a significantly lesser pace than seen in otolaryngology and plastic surgery.

ACR benchmark testing of a novel high-speed ring-gantry linac kV-CBCT system.

A new generation cone-beam computed tomography (CBCT) system with new hardware design and advanced image reconstruction algorithms is available for radiation treatment simulation or adaptive radiotherapy (HyperSight CBCT imaging solution, Varian Medical Systems-a Siemens Healthineers company). This study assesses the CBCT image quality metrics using the criteria routinely used for diagnostic CT scanner accreditation as a first step towards the future use of HyperSight CBCT images for treatment planning and target/organ delineations. Image performance was evaluated using American College of Radiology (ACR) Program accreditation phantom tests for diagnostic computed tomography systems (CTs) and compared HyperSight images with a standard treatment planning diagnostic CT scanner (Siemens SOMATOM Edge) and with existing CBCT systems (Varian TrueBeam version 2.7 and Varian Halcyon version 2.0).  Image quality performance for all Varian HyperSight CBCT vendor-provided imaging protocols were assessed using ACR head and body ring CT phantoms, then compared to existing imaging modalities. Image quality analysis metrics included contrast-to-noise (CNR), spatial resolution, Hounsfield number (HU) accuracy, image scaling, and uniformity. All image quality assessments were made following the recommendations and passing criteria provided by the ACR. The Varian HyperSight CBCT imaging system demonstrated excellent image quality, with the majority of vendor-provided imaging protocols capable of passing all ACR CT accreditation standards. Nearly all (8/11) vendor-provided protocols passed ACR criteria using the ACR head phantom, with the Abdomen Large, Pelvis Large, and H&N vendor-provided protocols produced HU uniformity values slightly exceeding passing criteria but remained within the allowable minor deviation levels (5-7 HU maximum differences). Compared to other existing CT and CBCT imaging modalities, both HyperSight Head and Pelvis imaging protocols matched the performance of the SOMATOM CT scanner, and both the HyperSight and SOMATOM CT substantially surpassed the performance of the Halcyon 2.0 and TrueBeam version 2.7 systems. Varian HyperSight CBCT imaging system could pass almost all tests for all vendor-provided protocols using ACR accreditation criteria, with image quality similar to those produced by diagnostic CT scanners and significantly better than existing linac-based CBCT imaging systems.

Do You See What I See? A Comparison of CCC and Self-Assigned Milestones Across Military Medical Specialties.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) requires residency programs to complete competency-based assessments of medical trainees based on nationally established Milestones. Previous research demonstrates a strong correlation between CCC and resident scores on the Milestones in surgery, but little is known if this is true between specialties. In this study, we investigated a variety of specialties and sought to determine what factors affect self-assessment of milestones. In addition, a post-hoc analysis was completed on the COVID-19 pandemic effects on self-evaluation. METHODS: This is an IRB approved observational study on prospectively collected self-evaluation milestone data that is used within each ACGME program's Clinical Competency Committees. Medical trainees within the San Antonio Uniformed Services Health Education Consortium were approached for possible participation in this study with permission from program directors. RESULTS: There was no significant difference between self-assessments and CCC-assessments based on self-identified gender or residency type (surgical versus nonsurgical) for any milestone domain. Within the postgraduate year (PGY) groups, the PGY5 and PGY6 tended to rate themselves higher than CCC. Chiefs (Internal Medicine PGY2/3, and General Surgery PGY5/6) tended to be more accurate in scoring themselves than the interns (PGY1) within the milestone of Interpersonal Skills and Communication (chiefs 0.5 vs. interns 0.62, p = 0.03). On post hoc analysis of self-rating, during the first wave of the COVID 19 pandemic, Post-Covid residents were more likely to underrate themselves in Systems-Based Practice compared to the Pre-Covid cohort (-0.49 vs 0.10; p = 0.007) and more likely to rate themselves higher in Professionalism (-0.54 vs. -0.10, p = 0.012). CONCLUSION: Unique to this study and our institution, there was no gender difference found in self vs CCC evaluations. With the change in learning environment from COVID, there was also a change in ability for some learners to self-assess accurately. As medical educators, we should understand the importance of both encouraging learners to practice self-assessment as well as give feedback to trainees on their progress. We also need to educate our faculty on the use of milestones for assessment to create a true gold standard in the CCC.

Accreditation Council for Graduate Medical Education Milestone Training Ratings and Surgeons' Early Outcomes.

Importance: National data on the development of competence during training have been reported using the Accreditation Council for Graduate Medical Education (ACGME) Milestones system. It is now possible to consider longitudinal analyses that link Milestone ratings during training to patient outcomes data of recent graduates. Objective: To evaluate the association of in-training ACGME Milestone ratings in a surgical specialty with subsequent complication rates following a commonly performed operation, endovascular aortic aneurysm repair (EVAR). Design, Setting, and Participants: This study of patient outcomes followed EVAR in the Vascular Quality Initiative (VQI) registry (4213 admissions from 208 hospitals treated by 327 surgeons). All surgeons included in this study graduated from ACGME-accredited training programs from 2015 through 2019 and had Milestone ratings 6 months prior to graduation. Data were analyzed from December 1, 2021, through September 15, 2023. Because Milestone ratings can vary with program, they were corrected for program effect using a deviation score from the program mean. Exposure: Milestone ratings assigned to individual trainees 6 months prior to graduation, based on judgments of surgical competence. Main Outcomes and Measures: Surgical complications following EVAR for patients treated by recent graduates during the index hospitalization, obtained using the nationwide Society for Vascular Surgery Patient Safety Organization's VQI registry, which includes 929 participating centers in 49 US states. Results: The study included outcomes for 4213 patients (mean [SD] age, 73.25 [8.74] years; 3379 male participants [80.2%]). Postoperative complications included 9.5% major (400 of 4213 cases) and 30.2% minor (1274 of 4213 cases) complications. After adjusting for patient risk factors and site of training, a significant association was identified between individual Milestone ratings of surgical trainees and major complications in early surgical practice in programs with lower mean Milestone ratings (odds ratio, 0.50; 95% CI; 0.27-0.95). Conclusions and Relevance: In this study, Milestone assessments of surgical trainees were associated with subsequent clinical outcomes in their early career. Although these findings represent one surgical specialty, they suggest Milestone ratings can be used in any specialty to identify trainees at risk for future adverse patient outcomes when applying the same theory and methodology. Milestones data should inform data-driven educational interventions and trainee remediation to optimize future patient outcomes.

Accreditation Standards-An Untapped Lever for Cancer Equity.

This Viewpoint describes how the Commission on Cancer and the National Cancer Institute can incorporate health equity benchmarks into existing standards to improve care and outcomes for all patients with cancer.

American Society for Transplantation and Cellular Therapy International Affairs Committee: Report of the 4th Workshop on Quality as a Development Tool for Hematopoietic Cell Transplantation Programs at the 2023 Tandem BMT Meetings.

We provide a summary of the 4th ASTCT International Workshop with presentations from experts from Chile ("Setting Up a Transplantation Program in Chile," by Dr Pablo Ramirez), Saudi Arabia ("Developing Quality Programs in North Africa," by Dr Amal Alseraihy), and Japan ("The Japanese Transplant Registry Unified Management Program [TRUMP]: Current Issues and the Future," by Dr Yoshiko Atsuta). Workshop objectives included: (1) recognizing the benefits and importance for low- and middle-income countries of developing quality criteria and programs beyond existing accreditation programs, such as the Foundation for the Accreditation of Cellular Therapy (FACT) and the Joint Accreditation Committee ISCT-Europe and EBMT (JACIE); (2) describing the relationships among monitoring outcomes, including mortality, improvement of care, data reporting, and associated costs; and (3) reviewing how quality structures have been implemented and are improving care worldwide.

Trends in orthoplastic operative exposure for plastic surgery residents in the United States.

BACKGROUND: Recent trials have demonstrated clinical benefits to a combined orthoplastic approach for complex reconstructive surgery of the hand, upper and lower extremity. PURPOSE: We sought to assess recent trends in exposure to orthoplastic-type procedures among plastic surgery residents training in the United States. METHODS: Independent plastic surgery residents' case logs were extracted from the Accreditation Council for Graduate Medical Education (2011-2022). Select reconstructive procedure were taken as proxies for orthoplastic-type cases and analyzed by descriptive statistical analysis. RESULTS: The average number of orthoplastic-type cases completed per resident per year increased from 168.2 to 189.2 (12.5% increase) between 2011-2022. The greatest increase was in exposure to peripheral nerve injury repair of the hand and upper extremity (22.6 to 39.1, 73% increase). As a proportion of total procedures during the study period, orthoplastic-type procedures remained relatively unchanged (range 9.5-10.4%). CONCLUSIONS: Our findings suggest that plastic surgery residents may be increasingly well-prepared to contribute to orthoplastic care during and following their training. The steady proportion of cases that orthoplastic-type procedures represented over the study period suggests the increase in relevant orthoplastic case volume may be incidental and secondary to an overall rise among all procedures. Given evidence of the benefits of an orthoplastic approach, we recommend consideration of explicit benchmarks for orthoplastic training among plastic surgery residents.

The Enneagram as a Tool for Resident Wellness and Correlation With Accreditation Council for Graduate Medical Education Milestone Achievements.

INTRODUCTION: The Enneagram is an ancient personality typing system developed to improve self-knowledge. Broken down into nine personality types, each is driven by a core motivating factor. Other personality assessments have been used to study the personality profile of surgeons. The purpose of this study is to evaluate the variability in Enneagram type among a single institution's general surgery residents. METHODS: All categorical general surgery residents at a single institution completed an online Enneagram assessment as part of a wellness initiative. Accreditation Council for Graduate Medical Education milestone levels for professionalism (PRO) and interpersonal and communication skills were collected for each resident's intern year. Milestone levels were compared between the nine Enneagram types. RESULTS: All nine Enneagram types were represented among surveyed residents. The most frequent Enneagram type was type 3 (20.69%). There was no significant difference between PRO (P = 0.322) and interpersonal and communication skills (P = 0.645) scores among residents distributed by Enneagram type. CONCLUSIONS: Regardless of core Enneagram type, general surgery residents in this study all achieved appropriate Accreditation Council for Graduate Medical Education milestone levels for entry level of training. The Enneagram can provide self-awareness and understanding of resident differences but does not impact initial assessment of competency in PRO and interpersonal communication skills.

Is the h-Index Enough? A Comprehensive Bibliometric Analysis of 871 Academic Plastic Surgeons and Their Departments/Divisions.

BACKGROUND: In plastic surgery academia, research output is heavily used as a metric of accreditation, from assessing residency applicants to evaluating faculty for promotion. The h index, defined as an author's h papers with at least h citations, is commonly used as a measure of academic success. However, the index itself disfavors junior researchers, favors publication quantity, and discounts highly cited works. Given the importance of bibliometrics within plastic surgery, there is a paramount need to adopt additional metrics to measure research productivity. The authors sought to validate the use of time-independent bibliometrics to complement the h index in measuring citation impact. METHODS: The genders and academic titles of plastic surgeons affiliated with US plastic surgery programs were recorded. Author publications were retrieved from Scopus. Bibliometrics software was used to calculate the following metrics per surgeon: h index, e index, and g index. Time-adjusted versions of these indices were used to correct for the number of years since first publication. Medians and interquartile ranges (IQRs) are reported. Departmental ranks were determined using the cumulative sum of time-corrected indices and compared with Doximity departmental research rankings. P < 0.05 was deemed significant. RESULTS: Indices were calculated for 871 academic plastic surgeons in 85 departments/divisions. Men had statistically greater h index (median, 13.0 [IQR, 7.0-21.0] vs 6.0 [IQR, 3.0-13]; P < 0.001), e index (18.3 [IQR, 10.0-28.7] vs 11.1 [IQR, 5.5-18.4]; P < 0.001), and g index (23.0 [IQR, 11.0-39.0] vs 11.0 [IQR, 5.0-22.0]; P < 0.001) than women. Professors had the highest median time-uncorrected indices. After adjusting for the number of years since an author's first publication, there were no significant differences in m quotient (men: 0.66 [IQR, 0.40-0.98] vs women: 0.57 [IQR, 0.33-0.90]; P = 0.05) and ec index (men: 0.93 [IQR, 0.62-1.3] vs women: 0.87 [IQR, 0.50-1.3]; P = 0.08) between genders. Departmental chairs had significantly higher indices than other faculty after correcting for time. The calculated program rankings were low to moderately correlated with that of Doximity (correlation coefficient τ = 0.49 [95% confidence interval, 0.37-0.59; P < 0.001]). CONCLUSIONS: Men and women have statistically similar citation patterns after correcting for the time. Citation differences between academic levels are less pronounced when controlling for time, suggesting comparable research quality between academic roles.

Characterizing the initial effects of the single accreditation system merge on the ophthalmology residency match.

INTRODUCTION: In 2020, the American Osteopathic Association merged its residency programs into one system under the Accreditation Council for Graduate Medical Education (ACGME). The effects of this transition on the ophthalmology match is not fully understood. The purpose of this study is to assess the early impact of the transition to ACGME accreditation on MD, DO, and IMG representation in ophthalmology residency programs. MATERIALS AND METHODS: Information about resident medical degree and resident medical school was gathered from ophthalmology residency program websites from a resident class before and after the Transition. Additionally, the medical degree of residency program directors (PD) was collected to analyze MD vs DO leadership in ophthalmology residency programs and to further stratify resident data to identify any trends in PD preference for different medical graduates. RESULTS: Data was obtained for 915 ophthalmology residents in 110 residency programs that met the study's inclusion criteria. Of these programs, 102 were allopathic with MD leadership, 1 was allopathic with DO leadership, 3 were osteopathic with MD leadership, and 4 were osteopathic with DO leadership. Overall, MD representation increased while DO and IMG representation decreased although not significantly. For both classes analyzed, DO and IMG representation was disproportionately low. DISCUSSION: The transition to ACGME accreditation seems to have primarily harmed DO and IMG applicants in the ophthalmology match while benefitting MDs. Various factors such as loss of protected residency positions for DO applicants and the closure of osteopathic ophthalmology residency programs are likely reasons to blame for this decrease in osteopathic representation.

Training in interventional pulmonology: a leap into the future.

PURPOSE OF REVIEW: This review holds significant relevance and is timely; as of June 2022, the United States Accreditation Council of Graduate Medical Education (ACGME) formally recognized interventional pulmonary medicine as a novel subspecialty with a unique fellowship training program pathway beyond Pulmonary and Critical Care Medicine. This recognition stands as a culmination of extensive efforts spanning decades, aimed at establishing a specialized training program for interventional pulmonary medicine beyond traditional Pulmonary and Critical Care Fellowship in the United States. Globally, there are apprenticeship models in non-US programs with ongoing efforts to further standardize training in interventional pulmonary medicine. It underscores the progressive evolution and innovative nature inherent to this subspecialty, signifying a distinctive leap forward in medical education and practice, which calls for further inventive development of training tools and standardized educational delivery. RECENT FINDINGS: Newly discovered insights from the recent literature review will highlight methodologies of procedural education and innovative training approaches. These findings will underscore the significance of standardized curriculum development within the field as well as ongoing challenges. SUMMARY: Identifying and addressing future challenges in integrating new technologies into clinical education and broadening the educational scope of trainees in this newly recognized subspecialty is crucial for enhancing competency. The implications of moving toward a more standardized process, creating new clinical pathways with research, and adopting emerging minimally invasive technologies aim to impact patient outcomes in both nonmalignant and malignant thoracic diseases. This progressive shift is redefining the specialty, moving beyond specific procedures, and pivoting towards a more distinct educational pathway. Such a transformation will lead to more diverse, comprehensive, and evidence-based driven patient care delivery.