Minimizing and Maximizing: The Future of Cardiothoracic Surgery Training and Practice
Health care in the U.S. is rapidly changing, and cardiothoracic surgery is at the forefront of these changes. Cardiothoracic surgeons were not always so well positioned for the future, however. In 2003, Fred A. Crawford, Jr., MD used his presidential address to the American Association for Thoracic Surgery (AATS) as a call to rejuvenate the specialty. At the time, interest in cardiothoracic surgery training had reached its nadir, and the specialty was grappling with high numbers of unfilled fellowship positions, declining surgical volume, and the uncertainty of new bureaucratic limits on trainee work hours. In the address, Dr. Crawford summarized that in order for our specialty to remain successful, cardiothoracic surgeons must rekindle interest in the specialty by engaging students and surgical residents, injecting efficiency into training programs, and adapting to a changing surgical skill set. Doing so would require innovation in simulation based training, new models for resident training, and streamlining of educational curriculum.1
After many years of planning and hard work, momentum is again with us, and the specialty is thriving. The future holds many changes for the young cardiothoracic surgeon, and the forces in play are complex and myriad. Changes in the structure and tools for cardiothoracic education will adapt training to a changing milieu of surgical techniques that, in turn, will help fulfill an increasing demand for cardiothoracic surgeons. Finally, global political and technological changes will alter the structure of the workforce and the daily practice of the cardiothoracic surgeon over the next 20 years. The new educational and clinical tools at cardiothoracic surgeons' disposal, coupled with an increasing need for cardiothoracic surgery and innovative techniques, make this an incredibly exciting time to enter the field.
It is impossible to separate one force from another into a coherent and logical progression of cause and effect. There has been no stepwise progression to an inevitable conclusion. Rather, the work of many dedicated surgeons and educators has spread from the ground up, creating a network of positive feedback loops.
Looking back to 2003, changes in education are the very reason that the cardiothoracic surgery specialty remains successful. In many ways, the difficult work in changing how cardiothoracic surgeons are educated is well underway and currently in a phase of implementation and improvement. In the coming decades, training programs may be split among traditional and new models, the number of trainees will continue to increase, and a more rigorous educational curriculum – including reading assignments, tests, and simulation goals – will be a mandatory portion of cardiothoracic surgery training. In order to keep the profession sustainable, it will be important to recognize and reward the important contributions faculty make to education.
While the six-year integrated cardiothoracic training model is still quite young, the experiment has seen success so far.2 Implementation can be difficult and requires commitment from all involved faculty, including those outside of the division of cardiothoracic surgery.3 To date, five residents have finished from two programs. Three have joined competitive private groups, one is in practice in an academic cardiac surgery program, and another is pursuing fellowship training in congenital cardiac surgery.4,5 Furthermore, the model continues to spread to new programs and attract very talented candidates. All 33 six-year positions were filled this year, 26 by U.S. medical graduates.6 As workforce surveys indicate that half of practicing cardiothoracic surgeons selected their specialty in medical school,7,8 future training allocations will likely split close to 50/50 between integrated and traditional pathways.
The rapid egress of senior cardiothoracic surgeons during the current decade was first predicted in 2002,7 and a major shortage was predicted most powerfully in 2009.9 In this particular report, the supply of surgeons was extrapolated based on retirement and attrition rates combined with an assumed certification of 150 new surgeons per year. This was plotted against calculated demand for surgeons based on demographic changes to the U.S. population. The authors considered changes to medical management under the assumption that CABG would no longer be performed. For reference, 118 trainees were accepted to cardiothoracic surgery programs in 2014,6,10 the highest number since 2005.11 Based on these extremely conservative assumptions, there was an expected shortage of 1,500 surgeons by 2020, compared with the current estimate of about 4,000 practicing surgeons.12 In the interim, universal health insurance has been mandated, and the Centers for Medicare & Medicaid Services (CMS) has approved computed tomography screening for lung cancer. With 42 million uninsured Americans in 2013 now entering managed health care, the deficit is likely to be even worse.13
Most would agree that during training, there was an overabundance of training programs and too few jobs for graduates. Cardiothoracic surgeons have now passed the nadir in residency applications but need to continue attracting smart, hardworking people to the field. The long training pipeline, compounded by a growing lack of access to thoracic surgery during medical school and general surgery training, makes urgent action imperative.14 Integrated programs should help by decreasing the time it takes to train a new surgeon, but we need to ensure that bright minds are still attracted to medicine and cardiothoracic surgery in particular. Mentorship is critical for the undecided undergraduate and medical student. Current successful efforts to attract talented applicants earlier, including existing medical student scholarships sponsored by the AATS and The Society of Thoracic Surgeons (STS),15 should be augmented and embraced in order to meet the rising demand. Furthermore, it is imperative that we continue to increase the availability of training positions as interest and demand grows.
The major upside of a surgeon shortage, of course, is that the job market should continue to be more open for the next decade. In the 2010 update of the STS/AATS Workforce Snapshot, 1,467 active U.S. surgeons responded, indicating intent to retire in a mean of 12.6 years. Sixty percent of surveyed physicians intended to hire a new surgeon within the next two years.8 Furthermore, there will be a vacuum of expertise, creating vast opportunity for early career advancement. The increasing demand for skilled surgeons from a politically active population of baby boomers presents an incredible platform to restore physician leadership to federal and state governments. Despite, or even because of, cardiothoracic surgeons' rising professional star, it is important now more than ever to maintain ethical and professional standards and consistently focus on advocating for the health and safety of our patients.
As training programs are restructured to produce surgeons more efficiently, surgeons can look forward to further refinement of the educational curriculum. In response to limitations due to the 80-hour work week, heterogeneity of teaching experiences amongst programs, and a real risk of "curriculomegally" stunting clinical education,14 the Joint Council on Thoracic Surgery Education (JCTSE) has undertaken a total revamp of the curriculum. The new curriculum was designed with a web-based format in order to be modular, dynamic, consistent across programs, and convenient. Its first iteration has already been rolled out via the Moodle and WebBrain platforms. As more feedback is generated, bugs will be fixed, readings will be streamlined, and more self-assessment tools will be available. As surgical knowledge advances, so too will the content. The modular format leaves room for experiments in different training program styles and lengths, standardizing curriculum without excessive rigidity.
Aside from the new content delivery, the JCTSE has just rolled out the Milestones program, which is built from the concept of the Accreditation Council for Graduate Medical Education (ACGME) milestones.16 This model addresses some of the inherent problems with a time-based apprenticeship program. Namely, these include heterogeneous exposures to different techniques and pathologies across different programs, and the inflexibility of time- and service-based programs when significant life events occur. The Milestone curriculum incorporates frequent assessments from both the program director and the individuals. The frequent, two-way feedback keeps the resident aware of his progress, and allows the program director to proactively alter each resident's experience to ensure all milestones are met prior to finishing training.3,14
Carried farther ahead, the author of this article anticipates seeing a much more modular, custom-built educational arc for each trainee in terms of both academic reading and hands-on patient care experience. For example, if one senior resident needs time off for a family emergency, another resident who is just returning from maternity or paternity leave takes his or her spot to fulfill some of the experiential milestones missed while starting his or her family. While the residents are away, they could still make significant progress completing the electronic curriculum in order to focus on service more when they return to work. In a decade, after the curriculum has been fully integrated into each residency, and the assessment tools are verified, that the medical knowledge portion of residency may more closely resemble a Masters degree or PhD program to be completed alongside the hands-on training.
The technical demands and high risks of cardiothoracic surgery put our specialty in a unique position to benefit from simulation training. As hospitals continue to focus on outcomes and work hour limitations reduce opportunities for trainees to gain operative experience, the author of this article expects the role of simulation will continue to increase. Hopefully, this will help us train surgeons more efficiently with equal or improved efficacy.17 While many cardiothoracic trainees report that they have used simulation in their training, variability among labs is high, and there is no standard simulation curriculum. By the end of this decade, we can anticipate the full integration of an upcoming 92-page simulation training guide, along with a 42-week syllabus.14 The already popular Thoracic Surgery Directors Association Boot Camp has introduced a number of faculty and residents to some new techniques of simulation, but major inroads need to be made in order to find time and resources to maintain such programs nationwide.
As surgeons continue to diversify a repertoire of open and minimally invasive techniques, patients will increasingly expect that trainees are competent in these newer procedures. A discussion of the relative merits of current open, endovascular, and minimally invasive techniques in general thoracic and cardiovascular surgery is far beyond the scope of this editorial, but the march of progress is towards miniaturization in nearly all things surgical. This includes the advent of video-assisted thoracic surgery, transcatheter aortic valve replacement, thoracic endovascular aortic repair, endobronchial ultrasound, minimally invasive cardiac surgery, and whatever other minimally invasive procedures the future holds. A streamlined educational curriculum and a robust simulation infrastructure will allow educators to train practicing surgeons and residents alike as new techniques are developed.
For any of these educational initiatives to truly take hold and remain relevant, education of residents and trainees needs to reclaim equivalency to patient care and research in academic settings. Education needs its champions. Educational outcomes should be tracked and rewarded, and faculty commitment to resident education needs to be adequately compensated like any other facet of practice. On a national level, it is the responsibility of cardiothoracic surgeons and hospitals to create administrative positions to ensure that the content and assessment tools remain up-to-date and effective.14
Unfortunately, this is a difficult problem to tackle without financial incentives for hospitals and surgeons to be proficient educators, and it may be one of the defining problems of our generation of physicians. While some of our professional bodies can bring some visibility to our cause, ultimately this is a symptom of a national education crisis that impacts the entire country. While the future of this particular facet of our specialty is unclear, one thing is certain. When the predicted surgeon shortage occurs, clinical demands will make very difficult for practicing surgeons to focus on education over patient care. The combination of these two factors is a crisis that needs to be urgently addressed. The increasing pressure hospitals are exerting on surgeons to be efficient with both time and money raises the danger to sustaining educational initiatives.
The impact of health care reform, and most notably the Affordable Care Act (ACA), will resist definition as entirely good or bad. If the community of surgeons embraces the positive developments in reform and plays an active and thoughtful role in changing the negative, then the net effect will benefit surgeons. The ACA offers incentives for efficient, quality performance that minimizes complications and rewards groups that self-regulate through novel models of cost sharing and quality improvement. The Virginia Cardiac Surgery Quality Initiative, founded long before the ACA was passed, serves as a great example for how the specialty is already shaping the future of safer, leaner, more effective health care delivery in the U.S.18
Hospital reimbursement will be increasingly tied to performance in single- and multi-specialty outcomes, with lung cancer and coronary disease among the first diseases to be tracked.19 This means that our bottom line depends on working effectively with cardiologists and pulmonologists, and their bottom line depends on us. This affords a unique opportunity to build bridges to other specialties, channel more patients into appropriate surgical treatment, and develop a higher degree of collegiality with out medical counterparts. Database utilization will be increasingly rewarded, and the need for each specialty to set outcomes standards will force us to shape the STS database into an even more robust tool than it is today. With luck, the federal government will allow the database to be used to track long-term outcomes by reopening access to the Social Security Death Index. Whatever the case, the successful cardiothoracic surgeon of the future will depend heavily on evidence-based decisions, careful attainment of quality and efficiency, and, above all, collaboration.
The law's impact on the organization of practices across the country is unclear. The reimbursement cuts for inefficient and low-quality care will push small practices to consolidate quietly into larger groups and contract with hospitals, where they will continue to subspecialize and silo. General surgeons, who presumably will not have outcomes on par with board-certified thoracic surgeons,20 will have a real incentive not to perform thoracic operations. However, the increased demand for valve replacements, lobectomies, and coronary bypasses will likely make it possible for lower volume and non-board-certified surgeons to keep the doors open on the basis of volume alone. One likely outcome of these competing carrots and sticks, however, will be that complex procedures, such as minimally invasive esophagectomy, mitral valve repair, and complex aortic reconstructions will be further consolidated to high volume centers of expertise. As these forces are felt in practices, it will be important for health care providers to balance the need for high surgical outcomes standards with fair and democratic access to surgical care throughout the country.
We can also expect rapid advances in information technology, medical devices, and biotechnology to change our daily practice. The financial and emotional burden of heart failure to our population is vast and growing, though we are closer than ever to finding a way to cure it. Whether through novel organ preservation techniques, induction of allograft tolerance, or novel stem cell therapies, the landscape for heart failure therapy may be incredibly different in the next 20 years. The trend of miniaturization of ventricular assist and cardiac rhythm devices is changing, and it is this author's hope that inductive powering of ventricular assist devices (VADs) will finally allow surgeons to "cut the cord" for VAD patients. Wearable health care devices are poised to change the delivery of health care, while some very well funded ventures are exploring nanotechnology for disease detection and prevention. We already have the tools to make rounding, clinical documentation, and data collection almost effortless processes, if only there were a bold enough group of engineers to take on the red tape and legal risk in disrupting the current state of health care information technology.
Looking back to Dr. Crawford's address 12 years ago, cardiothoracic surgery has proven that we are in charge of our own future. The dangers of satisfaction, professional stagnation, and entitlement lurk nearby, but the current era is one of incredible progress. The future is bright for cardiothoracic surgeons – and it is precisely because cardiothoracic surgeons have responded to the call to arms sounded in the last 20 years by so many of our colleagues. Demand for well-trained cardiothoracic surgeons continues to increase, and techniques to tackle chest surgery safely and efficiently continue to evolve. The educational pipeline has been remodeled to meet the demands of a changing marketplace and changing applicant demographics. In the future, cardiothoracic surgeons may rely increasingly on minimally invasive and endovascular surgical techniques, and that complex, high-fidelity simulation will be critical to acquire competence in this diverse skill set. As surgical techniques, biotechnology, and information technology converge, practices will be less burdened by rote paperwork and data entry. This will allow individual surgeons to treat more patients in less time. The era of the ACA and big data will necessitate close inter- and intra-specialty collaboration. The traditional "three A's" (able, affable, and available) of a successful surgeon will add a fourth – affordability.
As this new era unfolds, cardiothoracic surgeons must remain organized and active in political and regulatory realms. National and regional surgical societies need surgeons' involvement. We must build pathways to recognize and reward the true educators and mentors among colleagues and continue to provide top-quality care for all of our patients.
- Crawford FA. Presidential address: thoracic surgery education—responding to a changing environment. J Thorac Cardiovasc Surg 2003;126:1235–42.
- Lebastchi AH, Tackett JJ, Argenziano M, et al. First nationwide survey of US integrated 6-year cardiothoracic surgical residency program directors. J Thorac Cardiovasc Surg 2014;148:408-15.e1.
- Ikonomidis JS, Crawford FA, and Fann JI. Integrated surgical residency initiative: implications for cardiothoracic surgery. Semin Thorac Cardiovasc Surg 2014;26:14-23.
- Ikonomidis J. Personal correspondence. 2014.
- Fischbein M. Personal correspondence. 2014.
- National Resident Matching Program, Results and Data: 2014 Main Residency Match®. National Resident Matching Program, Washington, DC. 2014.
- Shemin RJ, Dziuban SW, Kaiser LR, et al. Thoracic surgery workforce: snapshot at the end of the twentieth century and implications for the new millennium. Ann Thorac Surg 2002;73:2014-32.
- Shemin RJ, J. S. Ikonomidis JS. Thoracic surgery workforce: report of STS/AATS Thoracic Surgery Practice and Access Task Force—Snapshot 2010. Ann Thorac Surg 2012;93:39-46, 46.e1-6.
- Grover A, Gorman K, Dall TM, et al. Shortage of cardiothoracic surgeons is likely by 2020. Circulation 2009;120:488–94.
- National Resident Matching Program, Results and Data: Specialties Matching Service 2014 Appointment Year. National Resident Matching Program, Washington, DC. 2014.
- Pousatis SM, Marshall MB. Trends in applications for thoracic fellowship in comparison with other subspecialties. Ann Thorac Surg 2014;97:624-32; discussion 632-3.
- Williams TE, Sun B, Ross P, Thomas AM. A formidable task: Population analysis predicts a deficit of 2000 cardiothoracic surgeons by 2030. J Thorac Cardiovasc Surg 2010;139:835-40; discussion 840–1.
- Smith JC, Medalia C. U.S. Census Bureau, Current Population Reports, P60-250, Health Insurance Coverage in the United States: 2013, U.S. Government Printing Office, Washington, DC, 2014. Available at: http://www.census.gov/content/dam/Census/library/publications/2014/demo/p60-250.pdf. Accessed on 11/29/2014.
- Vaporciyan AA, Yang SC, Baker CJ, Fann JI, Verrier ED. Cardiothoracic surgery residency training: past, present, and future. J Thorac Cardiovasc Surg 2013;146:759-67.
- Nelson JS. A bright future: cardiothoracic surgery training in transition.," Ann Thorac Surg 2013;96:1535-8.
- The thoracic surgery milestone project. J Grad Med Educ 2014;6:332-54.
- Carpenter AJ, Yang SC, Uhlig PN, Colson YL. Envisioning simulation in the future of thoracic surgical education. J Thorac Cardiovasc Surg 2008;135:477-84.
- Speir AM, Rich JB, Crosby I, Fonner E. Regional collaboration as a model for fostering accountability and transforming health care. Semin Thorac Cardiovasc Surg 2009;21:12-9.
- US Department of Health & Human Services. The Affordable Care Act, Section by Section (HHS website). 2013. Available at: http://www.hhs.gov/healthcare/rights/law/. Accessed on 12/8/2014.
- Freeman RK, Dilts JR, Ascioti AJ, Giannini T, Mahidhara RJ. A comparison of quality and cost indicators by surgical specialty for lobectomy of the lung. J Thorac Cardiovasc Surg 2013;145:68–73; discussion 73-4.
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