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kocker

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ok there has been some chatter on this issue before, all of which I have found and read before but i found this googling today:

http://www.acgme.org/acWebsite/RRC_sharedDocs/sh_jointSurgThorSurg.pdf

it makes it sound like you can just ask you program if you can do this with no predesigned pathway.

Also, if this is what I'm interested in, should it change my approach to my application and interviews?.... (obviously other than which schools)

Blade.... i know you're pretty busy right now.... but I could use some guidance from someone up on the field.
 

JackADeli

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...I have found and read before but i found this googling today:

http://www.acgme.org/acWebsite/RRC_sharedDocs/sh_jointSurgThorSurg.pdf

it makes it sound like you can just ask you program if you can do this with no predesigned pathway...
I can not speak to exactly what is or what is not in the field of Thoracic. I will just tell you what I have heard talking with some residents, attendings, and fellows.... This is not gospel.

1. I have been told the originally envisioned dual board integrated style program is not what will occur. Apparently, talks fell through when trying to integrate the demands of the ABS with the needs of the ABTS.

2. As a result of a failure in meeting of the minds.... ABTS decided GenSurge boarding (i.e. ABS certified) will no longer be a requirement to sit for thoracic boards.

3. All residents by year 2007 must declare a "pathway" in their thoracic residency training. This is either a Cardiac or GenThor pathway with different case number requirements. [URL]http://www.abts.org/sections/Certification/certification-articles/article.html[/URL]

4. I believe that ABTS has set down a mandate that all future grads that sit for ABTS boards on 2019 or later will have to have completed a six year straight out of medical school integrated program. Such programs are to be RRC/ACGME pre-approved and will not be "...ask you program if you can do this with no predesigned pathway..."

so, I found this with a google search:
ABTS said:
http://www.abts.org/doc/4018
[FONT=Times New Roman, Times, serif][SIZE=+1]GENERAL REQUIREMENTS[/SIZE].
Certification by the ABTS may be achieved by completing one of the following two pathways and fulfillment of the other requirements:1.Pathway One is the successful completion of a full residency in General Surgery approved by the ACGME or the Royal College of Physicians and Surgeons of Canada, followed by the successful completion of an ACGME-approved Thoracic Surgery residency.
Pathway Two is the successful completion of a six-year categorical-integrated Thoracic Surgery residency developed along guidelines established by the TSDA and having the approval of the ACGME (RRC-TS).
These pathways must provide adequate education and operative experience in cardiovascular and general thoracic surgery.
2.For residents who begin their thoracic surgery residency in July 2003 and after, certification by the American Board of Surgery (ABS) will be optional rather than mandatory.
3.......morality/ethics
4.A satisfactory performance on the American Board of Thoracic Surgery examinations.
5.....full and unrestricted license ....
MUSC said:
http://academicdepartments.musc.edu/surgery/divisions/cardiothoracic/residency/program.htm
In 2007, the MUSC faculty developed a six-year integrated CT residency program matching directly out of medical school. This was submitted to the Thoracic Surgery Residency Review Committee and approved in July 2008, and the program will match its first resident in the spring 2009 match. Only three such programs have been approved at this time (MUSC, Stanford, and the University of Pennsylvania), and this division is proud to be one of these programs which could completely change cardiothoracic surgery education.
Institution of this program will require a transition period of three years during which time residents will be matched to both the traditional program and the new integrated program. This is necessary in order that there be no "gaps" in the program as the new curriculum is phased in. In other words, if the traditional program were to be abandoned completely as the six-year program is started, after three years the existing senior residents in the program would have all finished and yet there would only be three residents left (one each at the PG-1, 2 and 3 level)...
ABTS said:
...Future Directions for Cardiothoracic Surgery Education
The debate over the future of cardiothoracic surgery education continues....The ABTS recently passed a proposal that comprehensive integrated cardiothoracic surgery training, beginning directly after medical school graduation, become the sole pathway leading to ABTS certification starting in 2020. ... it would require cardiothoracic surgery programs to institute such an integrated program by 2013...
http://ctsurgery.stanford.edu/about/news/ct_reinvention.html

I am no expert on this but a curious sideline spectator. Thus I leave it to others to clarify or correct what I have found via google search. If Blade or a thoracic surgeon or somebody has some information, please provide.
 
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SouthernSurgeon

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ok there has been some chatter on this issue before, all of which I have found and read before but i found this googling today:

http://www.acgme.org/acWebsite/RRC_sharedDocs/sh_jointSurgThorSurg.pdf

it makes it sound like you can just ask you program if you can do this with no predesigned pathway.

Also, if this is what I'm interested in, should it change my approach to my application and interviews?.... (obviously other than which schools)

Blade.... i know you're pretty busy right now.... but I could use some guidance from someone up on the field.

If I'm reading it right (1) programs would have to develop a structured program and apply for approval (see the sections on oversight and program requirements) and (2) even if you asked your PD would probably say "no" - they would have to totally change the structure of your residency to ensure you met the case requirements, and the document itself talks about the fact that only a limited number of institutions are interested in developing programs like this.

But I don't really have much knowledge about it other than my attempt at interpreting that document...
 

JackADeli

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...talks about the fact that only a limited number of institutions are interested in developing programs like this...
The gist of what I found with google is that many programs have been resistent to integrated programs.... Thus ABTS set down some sort of timed mandate i.e. 2019/2020 requirement that all programs be integrated six year programs....
ABTS said:
...The ABTS recently passed a proposal that comprehensive integrated cardiothoracic surgery training, beginning directly after medical school graduation, become the sole pathway leading to ABTS certification... it would require cardiothoracic surgery programs to institute such an integrated program by 2013...
 
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Winged Scapula

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Seems to me that programs would be loathe to do something like this if only for the question about who's gonna cover the services you aren't doing as a senior and Chief resident? Most faculty aren't very interested in adjusting the call and rotation schedule for the entire residency, let alone a single person.

But who knows? Maybe one day residency can be "design your own".
 

kocker

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JAD, WS and others
thank you very much for your interpretation of things... those are also some really helpful google finds.

I agree that it seems like programs have been resistant to change. Compared to the vascular programs, thoracic surgeons have been really slow to implement the suggested changes in training. With vascular it seems like the idea was accepted and 10 programs popped up in a year.

I feel like I am really on the bubble here. I'm applying this year to residency and it seems like I will be about the last class to do the old route, and probably people who start training behind me will finish before me.

I am planning to put in apps to the musc, stanford, and penn programs but am not that optimistic. My stats are solid, but I don't consider myself a rock star and I have the feeling that with these few positions, outstanding stats will be the mean.

but then again, I suppose going the old route, I could change my mind in a few years.... maybe what I feel right now is lust.

I guess then that I have to do two applications for residency, one for the big three integrated and one for the straight gs programs. agree?

will it be frowned upon by the gs guys writing my letters and interviewing me if I reveal my interest in ct or the fact that I am applying to integrated programs?

thanks again.
kock
 

Winged Scapula

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I agree that it seems like programs have been resistant to change. Compared to the vascular programs, thoracic surgeons have been really slow to implement the suggested changes in training. With vascular it seems like the idea was accepted and 10 programs popped up in a year.

It may seem that way, but the idea of an Integrated Vascular training program was more than 10 years in the making. As a matter of fact, at the recent SSO annual meeting, someone intimately involved in the process spoke (as Surg Onc is interested in getting its own Board and perhaps integrated training). So it might seem like the programs sprung up overnight, but it was a decade or more in the making.

Medicine is slow to change in almost every case.

I guess then that I have to do two applications for residency, one for the big three integrated and one for the straight gs programs. agree?

Yes, if the Integrated Programs aren't using the NRMP. Otherwise, apply through the NRMP, just submit two personal statements and if needed, specifically tailored letters.

will it be frowned upon by the gs guys writing my letters and interviewing me if I reveal my interest in ct or the fact that I am applying to integrated programs?

thanks again.
kock

Probably. Why should someone write you a letter touting what a great general surgery resident you'll be when they know you don't really want to do it? I would play this close to the vest except with those whom you are asking to write letters tailored to the Integrated programs. When interviewing for gen surg, do not tell them you are also applying to integrated programs and give the old, "I have an interest in CTS but really want to spend my residency experiencing as much of general surgery as I can before making any decisions" line.
 

JackADeli

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...I am planning to put in apps to the musc, stanford, and penn programs but am not that optimistic...I guess then that I have to do two applications for residency, one for the big three integrated and one for the straight gs programs. agree?...will it be frowned upon by the gs guys writing my letters and interviewing me if I reveal my interest in ct or the fact that I am applying to integrated programs?...
Agree with WS. It seems lots of folks feel they should tell everyone about every detail of their life and planned future. You don't. If you interview at GSurge programs, you can be honest and say, "I want to train at an excellent place that will make me an excellent surgeon... I am considering/not opposed to subsequent fellowship but it's early in my training and I should probably focus on my primary/initial training program to start with..."
...My stats are solid, but I don't consider myself a rock star...
I don't think anyone knows what the norm is with these applicants. Play yourself up not down and be positive and be yourself.... Do not go in there trying to give them answers you may think they want at whatever type program you may interview.
...but then again, I suppose going the old route, I could change my mind in a few years.... maybe what I feel right now is lust....
Yep. Via old route you may be one of the last "dual boarded". This can have some potential advantages. Integrated sounds (to me) kind of cool. It looks like there will be a significant broad variety at the beginning. But, if your not sure, months of ER, EP, cardiology rotations will not translate into an advanced GSurgery position should you change your mind. You would likely be starting over as an intern. But, there appear to be pros & cons on both sides.

Just my opinions. I may be completely off base and a resident/thoracic fellow/attending might be able to clear things up or provide a little more accurate information.

JAD
 
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7abiby

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For the combined programs do you guys think you should submit a mix of General surgery and CT LORs or should you get them all from CT attendings? I'd imagine the general surgery program has a say in who gets accepted into these combined programs.

I'm interested in applying to the combined programs but I don't think Ill be able to do a CT rotation by the time I apply to get a LOR. I do have two research LORs from CT attendings that I can use. What do you guys think
 

dynx

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What do you guys think

I don't know...and I think that's the answer. the safe bet is the best in the short run...you don't want to be the first to try an experimental therapy right? you don't want to be the first to try an experimental route (even though it is the way of the future). especially in a field as tradition strict as surgery and with few jobs available in CT. my guess...and my path based upon it....I went to a traditional program. you don't want to be the only guy NOT GS board eligable/certified to be going for a job. With a plethora of CT fellows (in the short run) would you choose a guy that's gone through a 5 year residency and 2 year fellowship or a 6 year combined track?..What if they they cost the same. yeah. I'd love to do a short tract....I'm sure it trains just as good a CT surgeon. But I also know that the "thats how I did it that's how it should be done" era folks are still in charge of picking the new hires.
 

JackADeli

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...a short tract....I'm sure it trains just as good a CT surgeon...
I doubt anyone is sure of that...

What I am sure about is that the integrated programs curriculum and implementation is being watched far more closely then the "old programs". I believe in the last several years, business as usual has resulted in the highest board fail rates in Thoracic surgery. With an integrated program, you at least know it is being analyzed more then the programs that "just done it that way for years". Will you be just as good? worse? or better? I don't know.... don't think anyone can know as of yet.
 

dynx

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I doubt anyone is sure of that...

What I am sure about is that the integrated programs curriculum and implementation is being watched far more closely then the "old programs". I believe in the last several years, business as usual has resulted in the highest board fail rates in Thoracic surgery. With an integrated program, you at least know it is being analyzed more then the programs that "just done it that way for years". Will you be just as good? worse? or better? I don't know.... don't think anyone can know as of yet.

Let me go with my first line "I don't know". The second "I'm sure" was a rhetorical way of blowing off the sig of the difference that one year might make and to show that I don't really THINK it makes a big deal. Thats the substance of my response...

here's the hook:
Look at the gist of the post slick...what does jumping on a single line clarify?
 

PostCall

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one of the ct surgeons here is from canada and he said they've been training ct surgeons in canada with a 6 year residency for a while now and it's been working out fine.
 
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johnny_blaze

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one of the ct surgeons here is from canada and he said they've been training ct surgeons in canada with a 6 year residency for a while now and it's been working out fine.

that is a residency for cardiac surgery only, not cardiothoracic. thoracic is a two year fellowship after general surgery or cardiac surgery (total 8 years to do CT).

I'm a british surgeon in england training in CT. Our program is 6-8 years as well (no GS fellowship exam needed) but combined (including sub-specialty, longer for paeds CT, less cardiac if you want to be pure thoracic). It is possible to do train a CT surgeon without a full GS residency.
 

JackADeli

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...you don't want to be the only guy NOT GS board eligable/certified to be going for a job...
Fortunately or unfortunately, there are an increasing number of GS Non-board "traditional" Thoracic surgeons. The ABTS no longer requires board cert in GSurge to be eligible for board cert by ABTS. I have come accross numerous young/junior academic thoracic surgeons that chose not to recert in GSurge. I have also heard numerous "traditional" track thoracic residents and recent grads choose to not take ABS exam/s or after failing decide just not worth it or important as no longer required... Those not taking it will loose elibility.

Thus there is an increasing number of "traditional" trained thoracic surgeons that lack board certification in GSurge. As the integrated becomes the required path, in the next 5-10 years, their competition will largely be a matter of experienced or not experienced and/or boarded by the ABTS; decreasingly, if at all, an issue of dual boarded by ABS & ABTS.

Just my opinion,
JAD

PS: I don't know what is out there, but I did a google search on thoracic jobs. I found quite a few already "seeking dedicated thoracic track grad", etc.... So, I suspect an integrated and "tracked" grad may provide some degree of marketing in years to come. Again an opinion based on no experience.
 
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ESU_MD

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Recently listened to a talk by one of the thoracic RRC members and there is considerable resistance to the proposal by the ABTS to mandate integrated training. I dont think its gonna be a slam dunk. There are just too many political and manpower issues that are involved for such a radical change to occur.

Integrated programs will adequately train candidates that are good protoplasm/ work ethic to begin with- a good resident will succeed no matter what type of program they complete. However, there exists a substantial amount of residents who will only succeed in the "right" environment, and its this category that I think will fail miserably in an integrated program that can push someone into a specialty they arent ready for. Its hard enough to get some staff to train an R-7 to do a mitral valve, how do you think they would feel training someone at the R3/4 level?

Might be better to have a handful of integrated programs, with staff who is dedicated to the integrated model and willing to spend the extra time necessary to develop residents with less experience than the traditional model.
 

ESU_MD

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I really havent heard of any current (traditonal) thoracic residents who havent taken the gen surg boards.
We all talk about what a waste of time, money it is to get gen surg boards, but we all do it. In a competitive job market, no one wants to take a chance.

I think it proves that you are not a screwball. Anyone with a pulse can get into and probably finish a thoracic surgery residency these days. But if you can sit in a hotel room with the ABS examiners and come out on top, that proves something (at least to me)

At the end of the day- it is a nice certificate to have for junior CV staff who may find themselves having to DO general surgery on the side or cover it on call.

Although I have to admit, personally I may not recertify in 10 years if I am lucky enough to evolve into a pure cardiac practice.
 

droliver

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I just don't think CTVS, pediatric surgery, and transplant lend themselves to abbreviated programs well. There's just too many skill sets you need to acquire before you start applying them in the more demanding technical operations.

With CTVS, the skills for cardiac are vascular surgery/general surgery based. If you haven't done operations like carotids, aortic aneuryems, peripheral vascular, dialysis access, etc... to learn how to do vascular procedures on large static vessels, how are you expected suddenly to do 2-3mm bypasses on moving targets? You can't and it takes a lot of remedial work to get you back to where people traditionally were starting cardiac surgery. (You see this to a lesser degree in Plastic Surgery with integrated residents or ENT/OMFS background residents trying to learn microsurgery with no background in simple vascular procedures BTW) .Many thoracic cases are now scope based as well, and the building blocks for those skills are the basic laparocopic and endoscopy cases that you acquire during general surgery.

At the end of the day, the infrastructure to allow an integrated model for CTVS just doesn't exist and there isn't a plausble way to create it at most institutions. There are also financial obligations that would suddenly get dumped on CTVS divisions or departments that they do not want. This has already been a big issue for traditional plastic surgery programs who are having to fund parts of additional salary lines when they were told they had to change from 2 to 3 years duration to remain accredited.
 

maxheadroom

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(You see this to a lesser degree in Plastic Surgery with integrated residents or ENT/OMFS background residents trying to learn microsurgery with no background in simple vascular procedures BTW)

As always, Ollie & I disagree on this. While I can't speak for CT programs, at my (past) place, our junior residents did more Vascular & Pedi Surg in the 2nd and 3rd years than the Gen Surg residents. Couple that with the research time in the lab and most of our residents have been ready for micro as a 4th year, especially compared to the fully-trained General Surgeon who filled an open spot at our place. There was simply no comparison.
 

Anka

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With CTVS, the skills for cardiac are vascular surgery/general surgery based. If you haven't done operations like carotids, aortic aneuryems, peripheral vascular, dialysis access, etc... to learn how to do vascular procedures on large static vessels, how are you expected suddenly to do 2-3mm bypasses on moving targets? You can't and it takes a lot of remedial work to get you back to where people traditionally were starting cardiac surgery.

A couple of points. First, the general surgery residents are getting to do fewer and fewer open vascular procedures at many academic centers. This is the result of both the increasing number of fellows and the decreasing number of open cases seen with the rise of endovascular approaches. Second, the whole point of an integrated program is that you could schedule your residents for more extensive vascular training -- one of the integrated CT programs includes nine months of vascular training. There is also more flexibility as to which general surgery rotations are included at a junior level; if certain months are complete scut, they might not be included in the integrated curriculum. The integrated (by which I mean 0 and 6) programs are incredibly flexible because there are so few actual requirements. Those comments do not apply to the 3 and 4 programs.

As to your comments on VATS being based on laparoscopic surgery, you can learn VATS primarily. It's a somewhat different skill set -- you're more often working against the camera, but at the same time you don't have guts and such trying to worm their way into where you're working. Also, there are plenty of basic VATS cases to learn the basics, like those little VATS wedge biopsies. That said, very few of the people who think the cardiac integrated programs are a good idea for training a cardiac surgeon think it's a great way to train a general thoracic surgeon. There is a lot of overlap between those fields.

To the medical students thinking about these programs, I would strongly recommend getting in touch with the respective program directors very early in the process. More so than established, large residencies, these programs are works in progress. The program director needs to be personally committed to the program (so that you can get the rotations that you want), and available for open discussions about what's working and what isn't. The faculty at your chosen institution has to be patient enough to cope with a more junior resident. You should do one, maybe two away rotations at each institution you're considering. Choosing an integrated program is a higher risk move than going by the traditional route, at least at this point. On the other hand, one would hope the future cardiac surgeons of this country are not so risk adverse they can't take a risk for the rather large potential benefit, if that's what they think it is.

Anka
 
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JackADeli

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...Integrated programs will adequately train candidates that are good protoplasm/ work ethic to begin with- a good resident will succeed no matter what type of program they complete. However, there exists a substantial amount of residents who will only succeed in the "right" environment, and its this category that I think will fail miserably in an integrated program...
I was speaking to some residents & fellows recently and we were asking them just this question. Five years of GSurge is a long time with enumerable experiences that lend themselves to weeding out those that may not be suited for advanced fellowships. In recent years, numerous programs have had difficulty matching. I think I read something in which some attendings actually cited a "decrease in quality" of applicants as part of the problem. I don't know how one can improve the quality of applicants in a pool that has no residency or training experience....
...Its hard enough to get some staff to train an R-7 to do a mitral valve, how do you think they would feel training someone at the R3/4 level?...
They were talking about this too. CT surgery training programs depend heavily on the "crutch" provided by some foundation in general surgery. The residents were telling me numerous CT residencies traditionally have limited actual hands-on and can have a dramatically greater amount of "observation". From the talk, it seems like CT attendings are less then great teachers even with a student fully trained in GSurgery. An integrated program would require the attendings to take a greater direct role in both "real teaching" and also the foundation teaching. I suspect most "full professors" in CTSurg have not had to actually do that.
...staff who is dedicated to the integrated model and willing to spend the extra time necessary to develop residents with less experience than the traditional model.
Yep, that is what it sounds like talking to residents and recent grads. The staff can not be too busy. They will have to roll their sleeves up and become the primary teachers. I think any marginal 2 or 3 year program can not be expected to have the ability to run a six year integrated program. I think I googled it somewhere, the ABTS board pass rate has been the lowest ever in recent years. I heard upwards of 30% fail rate!!! As it stands, that means most of that 30% represents 2-3 year programs under the direct leadership of the current CT attendings.
I really havent heard of any current (traditonal) thoracic residents who havent taken the gen surg boards. ...personally I may not recertify in 10 years...
I actually have heard of that. I spoke with some fellows that actually failed. They said it was expensive, not required, and preparation deterred from their focus on their CT training and ABTS board preparation. They also site numerous attendings allowing their own ABS cert to lapse.
I just don't think CTVS... lend themselves to abbreviated programs well. ...At the end of the day, the infrastructure to allow an integrated model for CTVS just doesn't exist ...
If even half of what the residents/fellows have told me is true, I have to agree. It sounds like at the core is a lack of senior attending capacity for this large challenge. Again, maybe just exageration, but the residents & fellows constantly talk about excessive observation accompanied with the "go home and read (i.e. teach yourself)" ..."old school" approach. If the senior faculty and those newly arrived have been raised on that mentality and structure, I think IMHO it will be hard for them to successfully implement this new pathway.

We are not just talking about a new 80 hour work week obligation.... anyone remember that? Numerous attendings, especially the subspecialty fellowships/residencies constantly talked about an inability to train a resident under those restrictions. Well, that was with 5 years of general surgery. Looking up some of these integrated programs, they may be talking 9 months of GSurg, with some trauma, cardiology, EP, IR..... all under 80/wk. This is an enormous undertaking. If you consider that numerous attendings did not take the time to consider creative and modern ways to improve education with the work hours restriction, I doubt they can become creative with this dramatic change.

Having said all that, I believe in theory it is possible. There needs to be clear efficiency of teaching. The integrated programs are likely to be watched more closely and hopefully the marginal/weak non-teaching old-school attending staff will step up or step-out.
 
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Nirazila

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Quick and simple opinion from a lowly student.

At U of MD, there is a new integrated 6-year program. While speaking with the Chief of Cardiac Surgery, he talked a little bit about the integrated program there, which he and another CT surgeon were tasked with designing and leading. He loves the idea of the integrated programs because he notes that he essentially doesn't even need to be board certified in General Surgery, though he is, because he never does any General Surgery procedures anymore. Someone will be quick to note that the training he received was instrumental in developing the techniques he will need to succeed as a CT surgeon, but, as was mentioned previously, with an integrated program it seems that directors can design a more targeted approach, implementing surgical procedures relevant to and key in developing the skills that will be necessary in the cases that one will face as a practicing CT surgeon. If the directors of these integrated programs feel strongly that their trainees will be well-prepared for the ABTS boards and a successful life as a CT surgeon, then these integrated programs sound promising.
 

JackADeli

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...If the directors of these integrated programs feel strongly that their trainees will be well-prepared for the ABTS boards and a successful life as a CT surgeon, then these integrated programs sound promising.
In theory, great. But, it takes far more then PDs feeling strongly. CT attendings have strong feelings already about what great teachers they are now... If they think they are good now, what do you think will convince them to change and increase their obligations into a six year program?

The CT PD will not be the ones actually teaching the GSurge foundation. Rather, they will have to have cooperation from the other specialty surgeons to assure CT residents get the hands on training required. Keep in mind that numerous academic programs provide limited hands on surgical training at the PGY1-3 levels. Now, while PGY1-3 GSurge residents do scut, you are expecting the GSurge attendings to give predominantly hands on to PGY1-3 CT residents? Further, are the CT attendings going to actually open textbooks and start teaching the didactic component of surgical education... which they arguably do not at present?

As stated, in theory, it can be a great thing. But, it really will take a strong effort at all levels to change "business as usual". This of course is change in a field where the attendings are NOT revolutionist (look into the history of angioplasty). On the contrary, in my GSurge residency, the mantra of CT was, "we do it the same way everytime".
 

Anka

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The CT PD will not be the ones actually teaching the GSurge foundation. Rather, they will have to have cooperation from the other specialty surgeons to assure CT residents get the hands on training required. Keep in mind that numerous academic programs provide limited hands on surgical training at the PGY1-3 levels.

The primary reason general surgery programs are forced to have three years of scut before teaching their residents to operate is that the program directors need to cover certain services from a labor perspective. The cardiac surgery program director, on the other hand, has no such conflict of interest with regard to their junior residents. Indeed, it is easy to imagine that their best interest is served rather by having their resident operate than by having their resident do scut for someone else.

How might this play out? The Penn integrated program has as it's primary site for general surgery training a small community hospital affiliate, where the attendings are interested in teaching junior residents and the operative experience is impressive. The flexibility of an integrated program makes this sort of creative solution possible.

Best,
Anka
 

JackADeli

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The primary reason general surgery programs are forced to have three years of scut before teaching their residents to operate is that the program directors need to cover certain services from a labor perspective.
Without getting excessively bogged down on that. I have to disagree. General surgery programs/PDs/attendings maintain a manpower over education approach not because anyone is forced to have three years of scut. There are programs that actually roll up their sleeves and take responsibility for education. The three years of scut approach is often referred to as "paying dues".... It is a failure to take responsibility and meet one's obligations under RRC/ACGME. Programs/PDs/attendings that accept teaching positions and then fall back on this pattern... I dare say "old school", are choosing to do so. They are NOT forced to do so.
The cardiac surgery program director, on the other hand, has no such conflict of interest with regard to their junior residents. Indeed, it is easy to imagine that their best interest is served rather by having their resident operate than by having their resident do scut for someone else.

...integrated program has as it's primary site for general surgery training a small community hospital affiliate, where the attendings are interested in teaching junior residents and the operative experience is impressive. The flexibility of an integrated program makes this sort of creative solution possible...
One can only hope this will prove to be the case. However, it relies on outside surgeons to provide the fundamental foundation in surgery. That is not necessarily different then the current model. But, in the current model, the foundation is provided over five years in a completely accredited training structure, with an in-service, and board. The new model would rely on a diverse group of attendings (i.e. cards, GSurge, IR, ER, etc...) to lay the foundation in a forshortened period. The question is how involved will the CT attendings be? Will they have the capacity/competence to assure didactic components of education? Will they impose some degree of oversight? As it stands, I hear from residents and fellows often on the limited capacity to teach by CT attendings. Yes, they may say he/she is a "great teacher". But, when probed, they often say, "because he/she took me through an anastamosis". An integrated program is going to require far more then the occassion technical guidance reportedly rampant in the "CT training" programs today.
 

JackADeli

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PS: I don't know anything directly/firsthand about Penn or any other CT training program for that matter. However, when you look at current residents or recent grads, it is quite troublesome to see the number that are doing additional training. I'm not talking about transplant or congenital either.

It seems troubling the number of advanced/super-fellowships in thoracic or "aorta". I may be over simplifying this with my ignorance. Yet, I hear from residents and fellows about a great deal of observation. I read with a simple google search about lowest board pass rate. Then, I quickly look at programs' current residents & fellows and discover a significant number of advanced training "fellows". I have heard of centers of excellence in MIS CT surgery graduating folks that promptly enter a MIS Thor fellowship.... What does that mean? Job market may be poor. But, there are jobs that pay more then the small pittence a "super-fellowship" pays. I spoke with some of these folks. They do report it is something to do to improve marketability.... but they also report not feeling adequately trained yet!!! This all brings me back to the Stanford website I found..... http://ctsurgery.stanford.edu/about/news/ct_reinvention.html
President of AATS said:
"Less than 75 percent of CT residency slots have been filled in the last four years, and in 2007 the ABTS examination failure rate was the highest on record," explained D. Craig Miller, M.D

...It was agreed that the current educational paradigm to train cardiothoracic surgeons must be amended ...Specific needs identified included: standardize training across all programs to produce higher quality CT surgeons; provide training in the latest techniques...
I think an integrated program will be difficult if approached with the same passive "old school" mentality that seems to persist in many corners and sounds very similar to my GSurge residency CT rotations.
 
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droliver

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As always, Ollie & I disagree on this. While I can't speak for CT programs, at my (past) place, our junior residents did more Vascular & Pedi Surg in the 2nd and 3rd years than the Gen Surg residents. Couple that with the research time in the lab and most of our residents have been ready for micro as a 4th year, especially compared to the fully-trained General Surgeon who filled an open spot at our place. There was simply no comparison.

Well, I can relate my experience of doing advanced microsurgical training and rat surgery during my research time as a PGY-2 in surgery and then retaking the course and doing free flaps 4 years later starting plastics now having done several hundred vascular cases of all sorts.

It was so dramatically different in how you acquire and apply those skills as well as the way you think about vascular approaches. It is clearly the best way (if not the quickest) to prepare someone for reconstructive surgery IMO as the disciplines are so complementary. These different POV's from surgery, orthopedics, ENT, & OMFS trained surgeons are the biggest loss long term for our field as we drift towards more homogenized backgrounds.
 

kocker

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This turned into a great thread....
thanks to everyone for all of the info.

As I have mentioned previously, I feel very much on the cusp of these changes and am likely to early to take advantage of most of them.

While I am planning to apply to the 6 and 4 year programs, I need to be realistic and expect to match to a gs program.

That said, what do I need to look for? CT fellowships seem to be somewhat easier to get into, does this mean I don't need to go after some of the high powered academic programs? Would I then be better suited to a community gs program, or some place with high operative numbers and a low 'paying the dues' requirement? Thing is, I also consider myself kind of an academic, I want strong didactics and a good educational program? I was also planning on doing research, but maybe I should be rushing to get to CT and put the research on hold until then?

On the other hand, if a lot of the training will be less than useful in the long run maybe I should just find the best 'lifestyle' gs program :rolleyes:

I know lots of questions... but if I am left with crafting my own route to CT I want to be well prepared.
 

JackADeli

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So, I will give your questions a try.....
First, if you are academic minded, try for some research opportunities during medical school if possible.
Second, if in your position, I would not do research time off during a GSurrge residency. I would not take a two year research block (i.e. total 7 years GSurge). I would try to participate in some clinical trials as a resident and get published on those. I would consider doing a one year critical care fellowship during my GSurge. This gives you certifed extra credentials (were 2 yrs research may or may not get you significant publications). During the one year SICU fellowship, you can do research...

Having said all that.... right now none of that is necessary.
only 68% of programs filled in this last match according to NRMP.
http://www.nrmp.org/fellow/match_name/thoracic/stats.html

As for what programs.... That s hard to say. I have heard from folks at UNC Chapel Hill and MUSC. It seems like a significant or at least reasonable hands-on experience in the general thoracic aspects of the training. This is second hand information though... Unfortunately, I have not spoken to any residents/fellows at university/community/etc... that report "hands on teaching" in cardiac/cardiovasc.... When speaking with new fellows last year, they all felt they were lied to.... during their interviews, apparently the residents/fellows speak about how much they "do". It seems like it is quite different out there then it was during my GSurgery training... So, buyer beware. Again, this is obviously second hand information I am passing along and you will just have to look and see.... maybe new/young attendings will make a difference in programs. If their reports are accurate, you want to make sure your gensurgery training is heavy in HANDS-ON vascular.

JAD

PS: I haven't heard of any program with "strong didactics and a good educational program". Based on what I have heard, your on your own to find a book, read, and figure it out on your own..... maybe that is an "old-school" thing.
 
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kocker

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Thanks JAD,

The heavy vascular experience sounds like a strong call.... I think then I will steer away from places with integrated vascular residencies.

From the sounds of it, I would be just fine at a community program. Thinking it might also be helpful to find a place with strong ct roots, as gs people seem a little unfriendly towards people who want to go ct right off the bat.

Not sure though if I would be better at a place with or without fellows... more hands on experience vs. connections/chance to start a fellowship early. Any thoughts?

These 4+3 programs seem a little tough to figure out, none of them actually admit to this track on their webpages, its all just word of mouth. It makes me wonder if there are more out there that are just unknown...
 

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Dear Colleagues,

I have a question please. We all heard about integrated 6 years CT surgery residency. I have seen in a thread on this web that there is what is called (4+3)
CT surgery. Does that mean 4 years GS then 3 years CT surgery? Can you give me some examples of such programs that might be having 4+3 design of residency.

Thanks in advance.
melsorady
 

Winged Scapula

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Dear Colleagues,

I have a question please. We all heard about integrated 6 years CT surgery residency. I have seen in a thread on this web that there is what is called (4+3)
CT surgery. Does that mean 4 years GS then 3 years CT surgery? Can you give me some examples of such programs that might be having 4+3 design of residency.

Thanks in advance.
melsorady

Please do not ask the same question in multiple threads; this is a violation of the Terms of Service agreemnet. Most of us read all the threads here.
 
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