David S. Shersher, MD

At the 62nd annual Southern Thoracic Surgical Association meeting in Orlando, Fla., there were several pervasive themes, including measurement of quality metrics in pulmonary, esophageal, and cardiac surgery. Piggybacking on the topic of quality, Dr. Asad A. Shah of Duke University, Durham, N.C., and colleagues identified something inherent to improving a surgical product: the quality of resident training.

In the presentation titled Characterizing the Operative Experience of Cardiothoracic Surgery Residents in the United States: What are Residents Really Doing in the Operating Room?, Dr. Shah and his group utilized data from the 2015 Thoracic Surgery Directors Association Survey (to which 356 trainees responded) in order to analyze specific critical steps that are being performed by each PGY level in both traditional (2- and 3- year) and I-6 integrated programs.

In I-6 programs, trainees routinely performed sternotomy by PGY1; harvested LIMA, cannulated, and performed proximal anastomoses by PGY3; and performed all aspects of CABG by PGY4. Fully 100% of I-6 residents reported being the operative surgeon for both coronary artery bypass grafting (CABG) and aortic valve replacement (AVR) compared to 94% and 86% for CABG in 2-year and 3-year programs (respectively), and 89% and 83% for AVR in 2-year and 3-year programs (respectively).

Few trainees reported experience with other cardiac surgeries as an operative surgeon. Likely because of this lack of experience, 42% of trainees reported the need for further fellowship training to become facile with most standard cardiac procedures.

When we discuss quality metrics, qualifying an educational experience is critical. I commend Dr. Shah and colleagues for a well-analyzed, thoughtful study using the results of a survey that we all take at the end of our annual in-service training exam.

Graded operative responsibility is shown to work well in I-6 training programs where ALL residents reported experience as operative surgeon for CABG and AVR. Interestingly, traditional residents did not have the same experience: It is possible that a truncated training program makes graded learning more difficult in this population group, despite superior surgical skill at entry into cardiothoracic training. Or is this a matter of poor reporting? The definition of “operating surgeon” is not used or interpreted in a standard way and may be incorrectly used by I-6 trainees who have no basis of comparison to relative operative experience in a general surgery program.

Conversely, traditional cardiothoracic residents may have a different barometer of what it means to be an operating surgeon, potentially under-qualifying their experience. Either way, it is difficult to truly objectify a survey, as all individuals will interpret their experience based on their personal learning environment. Dr. Shah’s team is accurate in alluding to the heterogeneity of this experience.

If the operative experience is perceived to be so different amongst trainees across programs, how do we as a society standardize education in order to graduate more competent and capable cardiothoracic surgeons? Sending trainees to boot camps and increasing utilization of simulation labs is one step. Additionally, 360-degree Accreditation Council for Graduate Medical Education–mandated evaluations may open communication avenues that didn’t exist before between mentor and mentee in the operating room and encourage more stepwise teaching. And how do we augment operating surgeon experience across the other cardiac categories (i.e. mitral valve repair, aorta, TAVR, etc)?

In order for the composite body of new graduates to report better national outcomes, we must standardize quality teaching between programs. It is simply not acceptable that half of trainees feel that advanced fellowships are necessary to reach comfort in standard cardiac cases.

The aforementioned study is a great first start, and the analysis should be extended to thoracic experience. Specifically, it would be interesting to perform the same analysis for thoracoscopic cases, as these also include steps that can be learned and mastered prior to doing a case skin to skin on the operating-surgeon side of the table. Standardizing education is difficult in cardiothoracic surgery, but Dr. Shah and colleagues begin an excellent conversation about the heterogeneous training experience that prepares some but fails others.

Dr. Shersher is a cardiothoracic surgeon at Rush University Medical Center, Chicago, and a resident medical editor for Thoracic Surgery News.

At the 62nd annual Southern Thoracic Surgical Association meeting in Orlando, Fla., there were several pervasive themes, including measurement of quality metrics in pulmonary, esophageal, and cardiac surgery. Piggybacking on the topic of quality, Dr. Asad A. Shah of Duke University, Durham, N.C., and colleagues identified something inherent to improving a surgical product: the quality of resident training.

In the presentation titled Characterizing the Operative Experience of Cardiothoracic Surgery Residents in the United States: What are Residents Really Doing in the Operating Room?, Dr. Shah and his group utilized data from the 2015 Thoracic Surgery Directors Association Survey (to which 356 trainees responded) in order to analyze specific critical steps that are being performed by each PGY level in both traditional (2- and 3- year) and I-6 integrated programs.

In I-6 programs, trainees routinely performed sternotomy by PGY1; harvested LIMA, cannulated, and performed proximal anastomoses by PGY3; and performed all aspects of CABG by PGY4. Fully 100% of I-6 residents reported being the operative surgeon for both coronary artery bypass grafting (CABG) and aortic valve replacement (AVR) compared to 94% and 86% for CABG in 2-year and 3-year programs (respectively), and 89% and 83% for AVR in 2-year and 3-year programs (respectively).

Few trainees reported experience with other cardiac surgeries as an operative surgeon. Likely because of this lack of experience, 42% of trainees reported the need for further fellowship training to become facile with most standard cardiac procedures.

When we discuss quality metrics, qualifying an educational experience is critical. I commend Dr. Shah and colleagues for a well-analyzed, thoughtful study using the results of a survey that we all take at the end of our annual in-service training exam.

Graded operative responsibility is shown to work well in I-6 training programs where ALL residents reported experience as operative surgeon for CABG and AVR. Interestingly, traditional residents did not have the same experience: It is possible that a truncated training program makes graded learning more difficult in this population group, despite superior surgical skill at entry into cardiothoracic training. Or is this a matter of poor reporting? The definition of “operating surgeon” is not used or interpreted in a standard way and may be incorrectly used by I-6 trainees who have no basis of comparison to relative operative experience in a general surgery program.

Conversely, traditional cardiothoracic residents may have a different barometer of what it means to be an operating surgeon, potentially under-qualifying their experience. Either way, it is difficult to truly objectify a survey, as all individuals will interpret their experience based on their personal learning environment. Dr. Shah’s team is accurate in alluding to the heterogeneity of this experience.

If the operative experience is perceived to be so different amongst trainees across programs, how do we as a society standardize education in order to graduate more competent and capable cardiothoracic surgeons? Sending trainees to boot camps and increasing utilization of simulation labs is one step. Additionally, 360-degree Accreditation Council for Graduate Medical Education–mandated evaluations may open communication avenues that didn’t exist before between mentor and mentee in the operating room and encourage more stepwise teaching. And how do we augment operating surgeon experience across the other cardiac categories (i.e. mitral valve repair, aorta, TAVR, etc)?

In order for the composite body of new graduates to report better national outcomes, we must standardize quality teaching between programs. It is simply not acceptable that half of trainees feel that advanced fellowships are necessary to reach comfort in standard cardiac cases.

The aforementioned study is a great first start, and the analysis should be extended to thoracic experience. Specifically, it would be interesting to perform the same analysis for thoracoscopic cases, as these also include steps that can be learned and mastered prior to doing a case skin to skin on the operating-surgeon side of the table. Standardizing education is difficult in cardiothoracic surgery, but Dr. Shah and colleagues begin an excellent conversation about the heterogeneous training experience that prepares some but fails others.

Dr. Shersher is a cardiothoracic surgeon at Rush University Medical Center, Chicago, and a resident medical editor for Thoracic Surgery News.

At the 62nd annual Southern Thoracic Surgical Association meeting in Orlando, Fla., there were several pervasive themes, including measurement of quality metrics in pulmonary, esophageal, and cardiac surgery. Piggybacking on the topic of quality, Dr. Asad A. Shah of Duke University, Durham, N.C., and colleagues identified something inherent to improving a surgical product: the quality of resident training.

In the presentation titled Characterizing the Operative Experience of Cardiothoracic Surgery Residents in the United States: What are Residents Really Doing in the Operating Room?, Dr. Shah and his group utilized data from the 2015 Thoracic Surgery Directors Association Survey (to which 356 trainees responded) in order to analyze specific critical steps that are being performed by each PGY level in both traditional (2- and 3- year) and I-6 integrated programs.

In I-6 programs, trainees routinely performed sternotomy by PGY1; harvested LIMA, cannulated, and performed proximal anastomoses by PGY3; and performed all aspects of CABG by PGY4. Fully 100% of I-6 residents reported being the operative surgeon for both coronary artery bypass grafting (CABG) and aortic valve replacement (AVR) compared to 94% and 86% for CABG in 2-year and 3-year programs (respectively), and 89% and 83% for AVR in 2-year and 3-year programs (respectively).

Few trainees reported experience with other cardiac surgeries as an operative surgeon. Likely because of this lack of experience, 42% of trainees reported the need for further fellowship training to become facile with most standard cardiac procedures.

When we discuss quality metrics, qualifying an educational experience is critical. I commend Dr. Shah and colleagues for a well-analyzed, thoughtful study using the results of a survey that we all take at the end of our annual in-service training exam.

Graded operative responsibility is shown to work well in I-6 training programs where ALL residents reported experience as operative surgeon for CABG and AVR. Interestingly, traditional residents did not have the same experience: It is possible that a truncated training program makes graded learning more difficult in this population group, despite superior surgical skill at entry into cardiothoracic training. Or is this a matter of poor reporting? The definition of “operating surgeon” is not used or interpreted in a standard way and may be incorrectly used by I-6 trainees who have no basis of comparison to relative operative experience in a general surgery program.

Conversely, traditional cardiothoracic residents may have a different barometer of what it means to be an operating surgeon, potentially under-qualifying their experience. Either way, it is difficult to truly objectify a survey, as all individuals will interpret their experience based on their personal learning environment. Dr. Shah’s team is accurate in alluding to the heterogeneity of this experience.

If the operative experience is perceived to be so different amongst trainees across programs, how do we as a society standardize education in order to graduate more competent and capable cardiothoracic surgeons? Sending trainees to boot camps and increasing utilization of simulation labs is one step. Additionally, 360-degree Accreditation Council for Graduate Medical Education–mandated evaluations may open communication avenues that didn’t exist before between mentor and mentee in the operating room and encourage more stepwise teaching. And how do we augment operating surgeon experience across the other cardiac categories (i.e. mitral valve repair, aorta, TAVR, etc)?

In order for the composite body of new graduates to report better national outcomes, we must standardize quality teaching between programs. It is simply not acceptable that half of trainees feel that advanced fellowships are necessary to reach comfort in standard cardiac cases.

The aforementioned study is a great first start, and the analysis should be extended to thoracic experience. Specifically, it would be interesting to perform the same analysis for thoracoscopic cases, as these also include steps that can be learned and mastered prior to doing a case skin to skin on the operating-surgeon side of the table. Standardizing education is difficult in cardiothoracic surgery, but Dr. Shah and colleagues begin an excellent conversation about the heterogeneous training experience that prepares some but fails others.

Dr. Shersher is a cardiothoracic surgeon at Rush University Medical Center, Chicago, and a resident medical editor for Thoracic Surgery News.