Training in cardiothoracic surgery: The role for simulation.

Adequate cardiothoracic surgical training is essential for provision of quality care to patients. In recent years, simulation-based training has been advocated as an adjunct to traditional surgical training. Advances in simulation technology has resulted in many low- and highfidelity simulators being employed in cardiothoracic surgical training. Such models allow trainees to practice an array of realistic full-length procedures in a safe and controlled environment, with the window to make mistakes and consider them learning points. There is significant evidence to demonstrate the effectiveness of cardiothoracic surgery simulation in improving surgical skills and operating room performances in addition to building confidence among trainees. However, owing to the high financial cost of arranging it, simulation-based training is not widespread in low- and middle-income countries, including Pakistan. More work is warranted on the cost effectiveness of implementing simulation-based learning, which, in turn, would increase the uptake of simulation to enhance cardiothoracic surgical training in Pakistan.

Cardiothoracic surgery leadership and learning are indispensable to each other.

Cardiothoracic surgery is facing a multitude of challenges in leadership and training on the global scale, these being a complex and aging patient population, shortage of cardiac surgeons, diminishing student interest and trainee enthusiasm, increasingly challenging training obstacles and work-life imbalances, suboptimal job prospects, reports of discrimination and bullying and lack of diversity as well as gap between innovation and technology, clinical application, and training of future surgeons. The survival of cardiac surgery hinges on the leadership attracting and retaining young surgeons into the specialty. Mentoring, leading through example, recognizing the work-life imbalances, adapting to diverse and modern training models and embracing diversity with respect to gender and race, will ultimately be required to create and cultivate a nurturing environment of training and preparing future leaders. The vision for training future generations of cardiothoracic surgeons must rely heavily on strengthening the unity of the heart team. In doing so we can provide the best possible care for our patients and a most fulfilling career for the future generation of cardiac surgeons.

The White Coat Ceremony: Welcome to the Medical Profession.

We have written about a number of the transitions, or 'lurches,' that most of us in medicine encounter as we move through the various stages of education and training in our profession. Some of our prior musings have addressed the transition into a Surgery Clerkship or a Surgery externship in the third or fourth years of medical school, respectively, as well as transitions into internship, the senior years of a Surgery residency, and a new job after completing Thoracic Surgery training. [Tribble: 2019, 2021, 2018, 2021, 2022].

Characterization of Cardiothoracic Surgeons Actively Leading Basic Science Research.

BACKGROUND: There is increasing concern regarding the attrition of surgeon-scientists in cardiothoracic (CT) surgery. However, the characteristics of CT surgeons who are actively leading basic science research (BSR) have not been examined. We hypothesized that early exposure to BSR during training and active grant funding are important factors that facilitate the pursuit of BSR among practicing CT surgeons. MATERIALS AND METHODS: We created a database of 992 CT surgeons listed as faculty at accredited United States CT surgery teaching hospitals in 2018. Data regarding each surgeon's training/professional history, publication record, and National Institutes of Health funding were acquired from publicly available online sources. Surgeons who published at least one first- or last-author paper in 2017-2018 were considered to be active, lead researchers. RESULTS: Of the 992 CT surgeons, 73 (7.4%) were actively leading BSR, and 599 (60.4%) were actively leading only non-BSR. Only 2 women were actively leading BSR. Surgeons actively leading BSR were more likely to have earned a PhD degree (20.5% versus 9.7%, P = 0.0049), and more likely to have published a first-author BSR paper during training (76.7% versus 40.9%, P< 0.0001). Surgeons actively leading BSR were also more likely to have an active National Institutes of Health grant (34.2% versus 5.8%, P< 0.0001), especially an R01 grant (21.9% versus 2.5%, P< 0.0001). CONCLUSIONS: A small minority of CT surgeons at academic training hospitals are actively leading BSR. In order to facilitate the development of surgeon-scientists, additional support must be given to trainees and junior faculty, especially women, to enable early engagement in BSR.

Career Research Productivity Correlates With Medical School Ranking Among Cardiothoracic Surgeons.

BACKGROUND: The foundation for a successful academic surgical career begins in medical school. We examined whether attending a top-ranked medical school is correlated with enhanced research productivity and faster career advancement among academic cardiothoracic (CT) surgeons. MATERIALS AND METHODS: Research profiles and professional histories were obtained from publicly available sources for all CT surgery faculty at accredited US CT surgery teaching hospitals in 2018 (n = 992). We focused on surgeons who completed medical school in the United States during or after 1990, the first-year US News & World Report released its annual medical school research rankings (n = 451). Subanalyses focused on surgeons who completed a research fellowship (n = 299) and those who did not (n = 152). RESULTS: A total of 124 surgeons (27.5%) attended a US News & World Report top 10 medical school, whereas 327 (72.5%) did not. Surgeons who studied at a top 10 medical school published more articles per year as an attending surgeon (3.2 versus 1.9; P < 0.0001), leading to more total publications (51.5 versus 27.0; P < 0.0001) and a higher H-index (16.0 versus 11.0; P < 0.0001) over a similar career duration (11.0 versus 10.0 y; P = 0.1294). These differences in career-long research productivity were statistically significant regardless of whether the surgeons completed a research fellowship or not. The surgeons in both groups, however, required a similar number of years to reach associate professor rank (P = 0.6993) and full professor rank (P = 0.7811) after starting their first attending job. CONCLUSIONS: Attending a top-ranked medical school is associated with enhanced future research productivity but not with faster career advancement in academic CT surgery.

We Were Residents Once And Young.

Each transition in the trajectory of a career comes with changes, some good, some challenging, and some changes are both. As you prepare to enter a Thoracic and Cardiovascular Surgery Residency (TCV Surgery), or the last few years of an Integrated Six Residency, you are well aware that you are likely embarking on one of the most demanding and challenging eras of your professional life. And, you are likely also aware that, as a TCV Surgery resident, you will have a limited amount of time to approximately double what you know about medicine and surgery. In fact, in these last few years of your formal training you will likely have fewer than 700 days to accumulate this necessary medical and surgical knowledge.

Learning Curve from 100 Cases of Totally Thoracoscopic Mitral Valve Replacement.

BACKGROUND: To investigate and analyze the learning curve of totally thoracoscopic mitral valve replacement and provide a quantitative reference for cardiac surgeons to carry out the operation step by step. METHODS: The clinical data were retrospectively analyzed of 100 consecutive patients with totally thoracoscopic mitral valve replacement successively performed by the same surgeon in a single center from May 2019 to June 2020. The learning curve was divided into 2 stages by using cumulative sum analysis, and relevant surgical parameters and perioperative indicators were analyzed. RESULTS: The first stage of the learning curve is the skill acquisition stage, which includes 1 to 40 surgical procedures. The second stage is the proficiency stage, involving 41 to 100 operations. Among the surgical parameters of the patients in the 2 stages, detectable improvements were observed in operative time, cardiopulmonary bypass time, cross-clamp time, and intraoperative injury. After surgery, the amount of drainage, length of hospital stay, blood creatinine levels, and oxygenation index 24 h after surgery were also significantly different between the 2 groups (all P < .05). The age and sex distributions of the patients were balanced, and there was no statistically significant difference in terms of conversion to median sternotomy between the 2 stages (P > .05). CONCLUSIONS: Cumulative sum analysis was used to accurately analyze the learning curve of totally thoracoscopic mitral valve replacement, indicating that 40 cases are needed to master the technique.

Perceptions of Training Pathways from Recent Cardiothoracic Surgery Graduates.

BACKGROUND: There are three cardiothoracic surgery (CTS) training pathways-general surgery residency followed by a CTS residency of 2-3 years (traditional), 4 years of general surgery and 3 years of CTS residency (4+3), and an integrated 6-year pathway (I-6). The goal of this study was to survey early career cardiothoracic surgeons regarding their training experiences. METHODS: An email-based survey was sent to cardiothoracic surgeons, who graduated between 2012-2017. Data on training pathway specific variables and overall satisfaction were collected. The primary endpoints were career preparation and satisfaction, scored on a scale from 1-100, 100 being the most positive. RESULTS: Four hundred seventy-seven emails were sent, with a response rate of 95/477 (20%). Seventy-six of the respondents (80%) were male; the mean age was 39. Seventy-seven (81.0%) completed a traditional training pathway, 7 (7.4%) completed a 4+3 pathway, and 11 (11.6%) completed an I-6 pathway. Participants felt prepared for practice with a mean response of 79.8 (range 31-100); mean career satisfaction was 87.6.  When asked which pathway respondents would choose in the current era, 52 (54.7%) would choose a traditional pathway, 17 (17.9%) a 4+3 pathway, and 19 (20.0%) an I-6 program; 7 (7.4%) did not respond. Twenty of 72 (27.8%) traditional pathway trained and 18/18(100%) integrated pathway trained surgeons would choose an integrated pathway. CONCLUSIONS: This is the first survey addressing perceptions of training from early-career cardiothoracic surgeons across all training pathways. Data from this study provides insights to better understand how to improve CTS training for the next generation of surgeons.

Impact of the COVID-19 pandemic on interventional cardiology training in the United States.

OBJECTIVES: We sought to determine the effect of COVID-19 related reduction in elective cardiac procedures and acute coronary syndrome presentations on interventional cardiology (IC) training. BACKGROUND: The COVID-19 pandemic has significantly disrupted healthcare in the United States, including cardiovascular services. The impact of COVID-19 on IC fellow training in the United States has not been assessed. METHODS: The Society for Cardiovascular Angiography and Interventions (SCAI) surveyed IC fellows training in both accredited and advanced non-accredited programs, as well as their program directors (PD). RESULTS: Responses were received from 135 IC fellows and 152 PD. All respondents noted reductions in procedural volumes beginning in March 2020. At that time, only 43% of IC fellows had performed >250 PCI. If restrictions were lifted by May 15, 2020 78% of IC fellows believed they would perform >250 PCI, but fell to only 70% if restrictions persisted until the end of the academic year. 49% of IC fellows felt that their procedural competency was impaired by COVID-19, while 97% of PD believed that IC fellows would be procedurally competent at the end of their training. Most IC fellows (65%) noted increased stress at work and at home, and many felt that job searches and/or existing offers were adversely affected by the pandemic. CONCLUSION: The COVID-19 pandemic has substantially affected IC training in the United States, with many fellows at risk of not satisfying current program procedural requirements. These observations support a move to review current IC program requirements and develop mitigation strategies to supplement gaps in education related to reduced procedural volume.

Evaluation of Cardiothoracic Surgery Residency and Fellowship Program Websites.

BACKGROUND: The internet is a valuable resource for residency and fellowship applicants when deciding where to apply or interview, yet program websites have shown critical deficiencies in accessibility and content. No analysis of cardiothoracic surgery program websites has been performed. METHODS: Online databases and Google were used to identify integrated, 4 + 3, and traditional cardiothoracic surgery residency and fellowship programs. The accessibility of websites from each of these sources was assessed and the presence or absence of content that may be relevant to applicants was evaluated by two reviewers. RESULTS: Eighty-nine active programs were identified and 86 had functional websites. Website content and accessibility were overall suboptimal in all 86 of these programs. Google was the most reliable means of accessing a program's website. Fifty percent of integrated program websites and 60% of traditional fellowship websites contained less than half of the content assessed. Information on 4 + 3 programs was extremely limited. CONCLUSIONS: Despite the value that a program's website could provide to applicants when making decisions during the application process, cardiothoracic surgery residency and fellowship websites remain difficult to access and are not uniformly providing information that may be important. Improving cardiothoracic website accessibility and content may have implications for attracting the most competitive applicants while limiting the financial and scheduling demands associated with the interview process. Creation of a current database containing standardized information relevant to applicants may improve applicants' ability to form an impression of a program before scheduling an interview.

Concerns and perceived obstacles for females with regards to cardiac surgery residency-A survey.

BACKGROUND: A major difference exists between the rate of females and males entering cardiac surgery (CSx) residency in Canada. The objective of this study was to investigate the concerns and perceived obstacles of medical students with regards to CSx residency training to identify potential modifiable factors. METHODS: A 15-question web-based survey was designed to compare male to female medical students' perceptions with regards to CSx training. The survey was distributed to all 682 medical students at Western University (London, ON, Canada) enrolled during 2018 to 2019 academic year. A total of 153 students (63 males vs 90 females) completed the survey. RESULTS: More females perceived significant levels of difficulties to getting accepted in CSx residency programs (44/63 [63.8%] males vs 77/90 [85.6%] females, P = .03). As for their perception of the most difficult aspect about a career in CSx, more males expressed significant concerns about finding a job after completing the residency training (16/63 [25.3%] males vs 10/90 [11.0%] females, P = .02). A similar proportion of students expressed a strong interest in applying to a CSx residency (12/63 [19.0%] males vs 15/90 [16.7%] females, P = .83). Of these, more males expressed concerns about maintaining a work-life balance (6/12 [50%] males vs 1/15 [6.67%] female, P = .02), and more females expressed fears of not getting matched to CSx residency (3/12 [25%] males vs 11/15 [73.3%] females, P = .02). CONCLUSION: Despite showing a strong interest in completing a residency in CSx, female medical students perceive a significant fear of not getting matched to the speciality, which limits them from applying.

Enhancement in virtual learning cannot substitute for hands-on training in cardiothoracic surgery.

This program director survey attempts to determine how coronavirus 2019 pandemic is impacting current training in cardiothoracic surgery. A transition to virtual didactic sessions may prove beneficial with increasing attendance. On the other hand, decreasing live simulation and case volumes may jeopardize achieving competency in surgical skills.

The impact of COVID-19 on thoracic surgery residency programs in the US: A program director survey.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) has altered how the current generation of thoracic surgery residents are being trained. The aim of this survey was to determine how thoracic surgery program directors (PDs) are adapting to educating residents during the COVID-19 pandemic. METHODS: Thoracic surgery PDs of integrated, traditional (2 or 3 year), and combined 4 + 3 general/thoracic surgery training programs in the United States were surveyed between 17th April and 1st May 2020 during the peak of the COVID-19 pandemic in much of the United States. The 15-question electronic survey queried program status, changes to the baseline surgical practice, changes to didactic education, deployment/scheduling of residents, and effect of the pandemic on case logs and preparedness for resident graduation. RESULTS: All 23 institutions responding had ceased elective procedures, and most had switched to telemedicine clinic visits. Online virtual didactic sessions were implemented by 91% of programs, with most (69.6%) observing same or increased attendance. PDs reported that 82.7% of residents were on a non-standard schedule, with most being deployed in a 1 to 2 week on, 1 to 2 week off block schedule. Case volumes were affected for both junior and graduating trainees, but a majority of PDs report that graduating residents will graduate on time without perceived negative effect on first career/fellowship position. CONCLUSIONS: The COVID-19 pandemic has radically changed the educational approach of thoracic surgery programs. PDs are adapting educational delivery to optimize training and safety during the pandemic. Long-term effects remain uncertain and require additional study.

Training in cardiac surgery using human cadavers: Effectiveness of "Silent Teachers".

BACKGROUND: Surgical skills acquisition in cardiac surgery requires consistent and hard practice. Furthermore, training using cadaver is advocated as a means of transferring learned skills to the operating room and recreate surgical situations for trainees to practice and hone their skills. We expose our experience in training for cardiac surgical procedures using human cadavers. METHODS: From June 2013 to November 2016, we performed 302 cardiac surgical procedures on 50 human cadavers obtained according to the Ivorian laws in force. Cadavers were preserved in 10% formaldehyde and by cryopreservation. RESULTS: In open heart, cardiac surgical techniques were achieved via sternotomy (n = 24) or via "lid-anterolateral thoracotomy" (n = 2). Pericardotomy (n = 26) and/or pericardiectomy (n = 26) were systematic. Aortic and caval canulations and pulmonary artery control (n = 30) were performed. After cardiotomy and arterial incisions (n = 34), 18 atrial and ventricular septal defects repair, 1 Fontan operation, 1 arterial switch, 11 enlargement procedures of the whole right ventricular outlet and 15 acquired valve heart diseases corrections were performed. In closed-heart surgery, procedures were achieved via sternotomy (n = 7), posterolateral thoracotomy (n = 12), or Marfan retroxiphoid approach (n = 3). Pericardotomy (n = 7) or pericardiectomy (n = 7) were performed. Great vessels dissections and expositions (n = 21) were achieved to perform 4 pulmonary artery bandings, 12 patent ductus arteriosus closures, 3 Waldhausen procedures, 7 Brock Operations, and 2 Blalock-Taussig shunts. In both situations, 29 direct pulmonary arterial, auricular, and ventricular sutures were achieved. CONCLUSION: Surgical simulation in cadaver models offer an opportunity for trainees to practice their surgical skills before entering operating room.

Evaluation of a simulation-based mini-elective on medical student interest in cardiac surgery.

BACKGROUND: Integrated cardiothoracic (CT) surgery training programs are an increasingly popular pathway to train CT surgeons. Identifying and engaging medical students early is important to generate interest and ensure highly qualified applicants are aware of opportunities provided by a career in CT surgery. METHODS: An optional CT surgery "mini-elective" was developed for preclinical medical students consisting of five 2-hour sessions covering major procedures in cardiac surgery. Each session had an inital 1 hour lecture immediatly followed by a hands on simulation component. Sessions were taught by CT surgery faculty and residents. A precourse and postcourse survey was administered to identify interest in and awareness of the field of CT surgery. RESULTS: There were 22 students enrolled in the course who provided precourse surveys, while 21 provided postcourse surveys. CT surgery was a career consideration for 95.4% of students who took the mini-elective. nine percent of the students who had either scrubbed or observed a CT case precourse, increased to 33.3% postcourse (P = .11). With regards to mentorship, 23.8% felt they could easily find a mentor in CT surgery precourse, increasing to 66.7% postcourse (P = .01). Eighty-one percent of students reported that the mini-elective significantly increased their CT knowledge over the standard cardiovascular curriculum, and 100% of those completing the course were "extremely satisfied" with the experience. CONCLUSIONS: A CT surgery mini-elective increased awareness and interest in the field among preclinical medical students. Longitudinal exposure and mentorship provided in programs such as this will be key to the continued recruitment of high-quality medical students to the field.

Is there a national variation in cardiothoracic trainees' satisfaction? Evaluation of the United Kingdom General Medical Council national training surveys.

BACKGROUND: The national training surveys was first started in 2006, with an aim to determine the quality of the national training standard. All trainees working in a General Medical Council approved training post are required to complete the survey. We aimed to evaluate cardiothoracic trainees' satisfaction and determine whether there is variation in the United Kingdom. METHOD: The national training survey report in cardiothoracic surgery from 2012 to 2019 was obtained from the General Medical Council website. The cardiothoracic centers were divided based on their geographic locations. Comparisons in all 18 indicators in the national training surveys report were made between the four counties (national) and four local education training boards (LETBs) in England (Regional). Centers with less than 4 years of data were excluded from this study. RESULTS: Thirty-three cardiothoracic centers are included in this study The top three areas that trainees are most satisfied are clinical supervision (out of hours) (91.65), clinical supervision (90.65), and educational supervision (88.27). On the other hand, trainees are less satisfying with the handover (62.63), rota design (61.91), and workload (45.07). It is worth noting that workload is the only area of less than 60%. In addition, there is no national variation in all 18 indicators CONCLUSION: Our data suggested that there is no difference in overall trainee satisfaction in the United Kingdom. However, there are differences in various indicators between England and the three other nations. Individual hospital should reflect on trainees' evaluation on the national training surveys report and improve on specific areas if deemed unsatisfactory.

Introducing off-the-job training to cardiovascular surgical residency training: a new era of developing competent cardiovascular surgeons.

PURPOSE: This review summarizes the recent progress made in understanding the skill acquisition process of achieving expert status in various fields that require fine motor skills. We discuss the attempts to apply this progress to develop competent surgeons. METHODS: We reviewed the existing literature, using the keywords "surgical training", "skill acquisition", and "simulator-based training", using Medline, as well as recent books and chapters related to these issues. We also summarized the role of simulator-based training in basic skill acquisition through deliberate practice. Other aspects of surgical skills, such as steps taken to improve motor skills, technical skill in the operating room, and competency level from novice to expert, were reviewed. RESULTS: The common element of practice to develop top-ranking experts in various fields is deliberate practice. Long-term repetitive practice is supported by the individual's mental attitude: guts, resilience, initiative, tenancy (GRIT). GRIT can be imparted using a teaching method that supports a "growth mindset". CONCLUSIONS: Recent theoretical advances in skill acquisition can be applied to surgical residency training, while intense efforts are being made to improve the curriculum and training environment.

Preparing for the Lurch into a Surgery Clerkship.

Over our combined nearly 50 years as surgical educators, we have been asked many times by medical students how they should prepare for and function in a Surgery Clerkship. It is still easy for me (C.G.T.) to recall, as a medical student myself, having the same questions. While I had initially thought that the transition from college to medical school would be challenging, I quickly realized that the first few years of medical school were not as much of a transition as I had imagined. However, as the clerkship year approached for my medical school classmates and me, it was quite clear to us that we were about to enter an educational environment for which our prior years in college and medical school had likely not optimally prepared us. And, when the primary advice we were given about how we should function as medical students rotating through the clerkships was that we should "just live the life of the house officer," we realized that we had little to no idea what we were actually supposed to do once we began the clerkship year.

I Call That A Bargain.

To paraphrase the lyrics of a song by Matchbox Twenty ("It's 3AM, I must be lonely"), it's 3 AM, I must be on a Lear jet. We're heading out to get a pair of lungs for a transplant. It's pitch black out tonight, and there's small rain falling. At least it's not ice or snow, which we've heard is falling to the north of us. I am glad that we'll be heading south on this run. These organ procurement runs tend to violate one of the basic safety rules of flying, which is to avoid, whenever possible, being required to fly. The edgy flights tend to stick in one's mind, of course. I've flown, literally, into a hurricane (Isaac), slid around on icy runways in Michigan and New York, and landed at the same mountaintop airport that was featured in the movie 'We Are Marshall' (which recounted the story of the fatal crash of a plane carrying Marshall University's football team back from a game in North Carolina). I have one of my splendid surgery residents with me. We settle in for the ride south.  There'll be time for a nap, if I can get comfortable. But, I'm awake now, and I'm reminded of the overall mission that we are on. Inevitably, I find myself reflecting on my three decades as a transplanter of hearts and lungs and recalling some of my most memorable patients and the lessons I have learned from them and their families. Memories and lessons that will always be with me.

On Becoming a Surgical Intern: Navigating the Lurch from Medical School to Internship.

There are three major transitions in the educational trajectory of those heading into a career in surgery. The first transition is from the first year or two of medical school to the clerkships of the third year.  The second is the transition from medical school into the first postgraduate year of residency training. The third, which is widely held to be the toughest transition of all, is from residency into independent practice.  This review, which could be called 'a rookie's survival guide,' will address the second of those 'lurches,' that of the transition from medical school into a surgical internship.