Subspecialties

Cardiothoracic Surgery (PDF)

as published in: The American Journal of Surgery (2011) 202, 357-9.

Sara A. Hennessy, MD
Surgery Resident
Department of Surgery
University of Virginia
Charlottesville, Virginia

Christine L. Lau, MD
Associate Professor
Division of Cardiothoracic Surgery
University of Virginia
Charlottesville, Virginia

Keywords: Thoracic surgery, cardiac surgery, residency training

Abstract: Cardiothoracic surgeons provide care to neonates, children, adults and the elderly with a range of disorders of the heart, lungs, esophagus and major blood vessels of the chest. The field of cardiothoracic surgery continues to thrive amongst the transformations in thoracic and cardiovascular medicine. This resource is intended to provide a guide to medical students and physicians on the training, certification, research and funding opportunities as well as societies and journals specific to cardiothoracic surgery.

Introduction
It is an exciting time in the field of cardiothoracic surgery with major advances and changes in thoracic and cardiovascular surgery. Heart and lung disease has been and will likely continue to be one of the major causes of morbidity and mortality in the United States. Cardiothoracic surgeons have the potential to make a significant difference in the lives of these patients. The patient’s increased life expectancy and improved quality of life makes the rewards of cardiothoracic surgery endless.

Cardiothoracic surgeons are specialists in the surgical management of disorders of the heart, lungs, esophagus, and major blood vessels of the chest. Thoracic surgeons treat diseases of the chest including coronary artery disease; cancers of the lung, esophagus, and chest wall; abnormalities of the great vessels and heart valves; birth defects of the chest and heart; tumors in the organs contained in the chest cavity; and transplantation of the heart and lungs. They provide expert, state-of-the-art care that is life-saving, challenging, and complex. Subspecialties include: adult cardiac surgery, congenital cardiac surgery, and general thoracic surgery.

The American Board of Thoracic Surgery will celebrate its 50th anniversary in 2011. During this time the Board will also mark the 200th woman becoming a diplomat of the American Board of Thoracic Surgery. To date Dr. Carolyn Reed was the first and only president of a major cardiothoracic society, the Southern Thoracic Surgical Association. Over time the number of women in cardiothoracic surgery has grown. In 1986 Women in Thoracic Surgery (WTS) was founded with a mission to enhance the quality of medical care, to mentor young women thoracic surgeons, to enhance the education of patients about heart and lung diseases and to enhance educational opportunities for women thoracic surgeons.1
Residency Requirements

The thoracic surgery residency allows residents to experience a broad clinical scope in the perioperative, operative, and the critical care of patients with diseases of the chest. These pathological diseases include pulmonary, esophageal, mediastinal, chest wall, diaphragmatic, and cardiovascular disorders of all age groups. When completed, residents are expected to be clinically proficient in these areas, as well as knowledgeable in use of cardiac and respiratory support devices. Although operative experience constitutes the most important aspect of the program, residents should learn the pathologic and diagnostic aspects of cardiothoracic disorders. The resident learns important skills in diagnostic procedures such as bronchoscopy and esophagoscopy, as well as the interpretation of all appropriate imaging studies (ultrasound, computed tomography, roentgenographic, radionuclide), cardiac catheterization, pulmonary function, and esophageal function studies.2

There are three Residency Review Committee (RRC) approved training programs, with the American Board of Thoracic Surgery (ABTS) approving the following pathways to certification:2

1. Independent Program (traditional format) Pathway:

Medical students apply and complete a full General Surgery residency (5 clinical years) in an ACGME-approved or a Royal College of Physicians and Surgeons of Canada (RCPSC)-approved program. Many academic training programs recommend one to two years of academic research. During the fourth clinical year of general surgery, residents apply for a residency position in cardiothoracic surgery. Cardiothoracic training varies in length from 2 to 3 years depending on the program. Following completion of the training program, residents apply for certification by both the American Board of Surgery and the American Board of Thoracic Surgery. Subsequently, additional experience may be gained from completing further training in congenital heart surgery, thoracic surgery, heart failure or transplantation.3

2. Integrated Pathway:

Medical students apply directly to a six-year integrated cardiothoracic surgery residency program. The integrated program allows for more focused training in cardiothoracic surgery as well as training in cardiovascular and thoracic disease. Training focuses on surgical skills as well as multi-disciplinary approach including rotations in interventional radiology, interventional cardiology, endovascular surgery, oncology and pulmonary disease. Residents also gain training in new technologies such as minimally invasive approaches. After completion of the integrated program residents may certify for the American Board of Thoracic Surgery but not the American Board of Surgery. A current list of approved integrated programs can be found on the ACMGE Website and these continue to grow.3

As of May 2010 approved institutions with an integrated program include:3

1. Medical College of Wisconsin Affiliated Hospital Programs
2. Medical University of South Carolina
3. Mount Sinai School of Medicine
4. Stanford University
5. University of Maryland
6. University of North Carolina-Chapel Hill
7. University of Pennsylvania
8. University of Texas Health Science Center at San Antonio
9. University of Washington

3. Joint Surgery/Thoracic Surgery Program (the 4+3 program):

Medical students apply to a General Surgery residency program and those general surgery residents interested in the joint pathway or fast track program typically apply after their second clinical year. Only general surgery residents at their own institution are eligible to apply for the fast track program. Residents accepted into the fast track program continue to have general surgery training during every year of training and complete a full general surgery chief resident year. Residents completing the fast track program are board eligible for both the American Board of Surgery and the American Board of Thoracic Surgery. A current list of approved fast track or joint programs are located on the ACGME Website.3

As of October 2009 the approved institutions with a joint program include:3

1. Brigham & Women’s Hospital/Children’s Hospital
2. Duke University
3. Massachusetts General Hospital
4. Mayo School of Graduate Medical Education
5. New York University School of Medicine
6. University of Maryland
7. University of Rochester
8. University of Virginia
9. University of Washington
10. Washington University School of Medicine

Every spring all cardiothoracic surgery residents are required to take an annual In-Training Examination given by the Thoracic Surgery Directors Association (www.tsda.org).

4. Congenital Cardiac Subspecialty Certification

Starting in 2009 the American Board of Thoracic Surgery began offering certification in congenital cardiac surgery. The certification may be obtained by completing one of the two following pathways.2

Pathway One: This is for candidates who have successfully completed a full congenital cardiac residency program approved by the ACGME starting on July 1, 2008 or thereafter.

Pathway Two: This is for candidates who trained prior to July 1, 2008. Certification is based on training, current clinical experience and professional accomplishments in the field.

Board Certification

Candidates for certification must complete a minimum of 24 months of residency training in thoracic and cardiovascular surgery in a program accredited by the RRC. This must include 12 months of continuous senior responsibility. Education and adequate operative experience in both general thoracic surgery and cardiovascular surgery are essential parts of any training program, irrespective of the area of cardiothoracic surgery the candidate may choose to practice.2

Minimal operative experience requirements for volume and type of cases are required to qualify to sit for the Board examination. A list of these requirements, as well as additional information, is available on the ABTS Website (http://www.abts.org). The board conducts two types of examinations. The written exam represents uniform coverage of all areas of thoracic surgery testing cognitive skills. After successful completion of the written exam the candidate will be eligible to take the oral examination.2

Research Opportunities and Funding

Medical Students: The American Association for Thoracic Surgery offers a “Summer Intern Scholarship Program” which was established in 2007 to introduce the field of cardiothoracic surgery to first and second year medical students. The program allows medical students to broaden their educational experience by providing scholarships to spend eight weeks during the summer working in an AATS member’s cardiothoracic surgery department.3

Surgery Residents: Recommendations from cardiothoracic surgeons on research opportunities are strongly encouraged for surgery residents interested in a career in cardiothoracic surgery. There are many opportunities for clinical and basic science research in the areas of thoracic, cardiac and congenital which are available at institutions with cardiothoracic research laboratories. CTSNet and AATS Websites have many of these opportunities updated on a regular basis. Individual programs often have their own Websites with opportunities posted and regularly updated (www.healthsystem.virginia.edu/internet/surgery/res-thoracic.cfm).

The Thoracic Surgery Foundation for Research and Education (TSFRE) is dedicated to increasing the knowledge base of cardiothoracic surgery and to enhancing the knowledge of all thoracic surgeons. The Foundation is supported by the four major thoracic surgery professional societies: The American Association for Thoracic Surgery (AATS), The Society of Thoracic Surgeons (STS), Southern Thoracic Surgical Association (STSA), and Western Thoracic Surgical Association (WTSA). The TSFRE provides fellowships and research grants to surgeons and surgical trainees in the fields of cardiothoracic surgery.4

The TSFRE also provides the Nina Starr Braunwald Career Development Award to women cardiac surgeons in their first ten years of academic practice in cardiac surgery unit investigating areas in cardiac surgery, cardiology or allied disciplines. Dr. Nina Braunwald was the first Board certified thoracic surgeon and this fund was established to provide career development awards and research fellowships for women in academic surgery.4

Research funding is available through the National Institutions of Health (NIH), from the National Cancer Institute (NCI) or the National Heart, Lung, Blood Institute (NHLBI) as either participants in already established projects or through a supplemental project to a major grant. Funded projects through the NIH are listed on the NIH Website. The TSFRE has been generous in matching many K08 and K23 awards through the NHLBI or the NCI to aid in providing protected time to young academic cardiothoracic surgeons.5

Professional Societies
Cardiothoracic surgical organizations can be accessed by way of the Cardiothoracic Surgery Network (www.CTSNet.org).5

STS

The Society of Thoracic Surgery (STS) is the largest thoracic surgical organization in the world representing surgeons, researchers, and allied health professionals. The society is devoted to enhance the ability of cardiothoracic surgeons to provide the highest quality patient care through education, research and advocacy. Active members must be certified by the American Board of Thoracic Surgery, American Osteopathic Board of Surgery in Thoracic and Cardiovascular Surgery, or Royal College of Physicians and Surgeons of Canada. Membership is designed to encourage younger surgeons and residents to participate in Society activities. International Membership is designed for thoracic surgeons trained outside the United States and Canada.6

AATS

The American Association for Thoracic Surgery (AATS) was founded in 1917 by pioneers in the field of thoracic surgery. Since then, AATS has progressed to an international organization of more than 1200 members, representing the world’s foremost cardiothoracic surgeons from over 35 countries around the world. Surgeons in the AATS have demonstrated a record of distinction in the field of cardiothoracic surgery and have made meritorious contribution to cardiothoracic knowledge or surgical treatment. The Annual Meeting, research grants and awards, educational symposia and courses, and the AATS official journal, the Journal of Thoracic and Cardiovascular Surgery all strengthen its commitment to science, education and research.3

Regional Societies

The Southern Thoracic Surgical Association (STSA) and Western Thoracic Surgical Association (WTSA) are two important regional societies available for membership. STSA membership is limited to thoracic surgeons practicing in the southern regions of the United States or those who have completed a thoracic residency training program in the STSA region (Alabama; Arkansas; Florida; Georgia; Kentucky; Louisiana; Maryland; Mississippi; Missouri; North Carolina; Oklahoma; South Carolina; Tennessee; Texas; Virginia; West Virginia; District of Columbia; the U.S. territories and commonwealths in the Caribbean).7 WTSA membership is for cardiothoracic surgeons within the geographic limits of the Association (Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming, and the provinces of Alberta and British Columbia).8

Journals

There are dozens of journals that deal with thoracic and cardiovascular surgery and medicine. The two major American journals devoted to cardiothoracic surgery are the Journal of Thoracic and Cardiovascular Surgery and the Annals of Thoracic Surgery. Many important articles also appear in the Asian Cardiovascular and Thoracic Annals and the European Journal of Cardiothoracic Surgery.

Access to these journals, and other valuable information for thoracic surgeons and residents, is available through the Cardiothoracic Surgery Network (CTSNet): www.ctsnet.org. CTSNet, Inc. is a not-for-profit corporation jointly created by the Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), and the European Association for Cardio-thoracic Surgery (EACTS). CTSNet also includes 48 cardiothoracic surgical societies around the world. CTSNet aims to provide a comprehensive, Web-based repository of information for those interested or in the field of cardiothoracic surgery. Thousands of surgeons access this information resource daily to research cases, communicate with colleagues, explore the field’s journals, investigate devices, find out about meetings, engage in lively discussions, and conduct private electronic meetings.5

References

1. Women in Thoracic Surgery. www.wtsnet.org

2. American Board for Thoracic Surgery. 633 North St. Clair Street, Suite 2320, Chicago, IL 60611. www.abts.org

3. American Association for Thoracic Surgery. 900 Cummings Center, Suite 221-U, Beverly, MA 01915. www.aats.org

4. Thoracic Surgery Research Foundation for Education and Research. 900 Cummings Center, Suite 221-U, Beverly, MA 01915. www.tsfre.org

5. The Cardiothoracic Surgery Network. 401 E. Pratt Street, Suite 351 World Trade Center Baltimore, Baltimore, Maryland, 21202. www.ctsnet.org

6. The Society of Thoracic Surgeons. 633 N. Saint Clair Street, Suite 2320, Chicago, IL, 60611. www.sts.org.

7. Southern Thoracic Surgical Association. 633 N. Saint Clair St., Suite 2320, Chicago, IL, 60611-3658. www.stsa.org

8. Western Thoracic Surgical Association. 900 Cummings Center, Suite 221-U, Beverly, MA 01915. www.westernthoracic.org.