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Interest and core training in congenital heart surgery (CHS) has not been characterized among current cardiothoracic surgical trainees. This study aimed to evaluate perceptions, interest, exposure, and experience among current trainees. A 22 question survey was distributed to all cardiothoracic surgical trainees in ACGME-accredited thoracic surgery residencies. Questions included demographics, exposure to CHS during, perceptions of, participation in and quality assessment of CHS training. There were 106 responses (20.1% response rate) of which 31 (29.0%) were female and 87 (81.3%) were cardiothoracic track. While 69 (64.5%) reported having an interest in CHS at some point during training, only 24 (22.4%) were actively pursuing CHS. All but 7 (6.5%) residents reported having easy access to congenital mentorship, with 35 (32.7%) actively participating in CHS research. Three months was the median duration of congenital rotations. Residents reported less operative participation on CHS compared to adult cardiac surgery. Several residents noted the need for earlier exposure and increased technical/operative experience as areas in need of improvement. The most cited primary influences to pursue CHS included: mentorship, breadth of pathology, and technical nature of the specialty. Lack of consistent job availability and length of additional training were reported as negative influences. Cardiothoracic residents report adequate exposure to obtain case requirements and knowledge for board examinations in CHS but highly variable operative involvement. Mentorship and early exposure remain important for those interested in CHS, while additional training time and limited job availability remain hurdles to CHS.
Core congenital cardiothoracic training received during ACGME-accredited cardiothoracic residency is heterogeneous yet currently meets the perceived educational goals of most residents.
Perspective Statement
Congenital exposure remains an educational requirement for ABTS certification. However, there is tremendous variability in resident experience during core training. This cross-sectional survey indicates both experience and exposure to congenital surgery were highly inconsistent among programs. Nevertheless, most residents acquire requisite cases and adequate preparation needed for ABTS certification.
INTRODUCTION
The American Board of Thoracic Surgery (ABTS) stipulates that all cardiothoracic surgery residents completing an Accreditation Council for Graduate Medical Education (ACGME) accredited cardiothoracic surgery training program meet minimum case requirements for congenital heart surgery (CHS).
In addition, CHS topics in the Thoracic Surgery Curriculum are routinely included in both the ABTS qualifying (written) and certifying (oral) examinations.
In response to these requirements, cardiothoracic surgery residencies are required to provide both didactic and clinical exposure to CHS within the core residency program. However, there is sparse literature and guidance on how best to implement these educational requirements and little information regarding how residents perceive, participate with and benefit from CHS experiences.
CHS, as a specialty, relies upon the recruitment of interested and qualified candidates from ACGME-accredited cardiothoracic residency program for subspecialty training.
There are approximately 9–11 ACGME-accredited CHS training positions annually, so only a minority of residents initially interested in CHS will have the opportunity to train in the specialty. Although previous studies demonstrate that early exposure and mentorship are important to those pursuing a career in CHS, it remains unclear when this early exposure first occurs and to what level current trainees in cardiothoracic surgery are drawn to pursue CHS.
It is also unknown how training program characteristics and pathways encourage a career in CHS. Yet there are potentially modifiable program related factors which can enhance the recruitment of residents to CHS. The purpose of this study was to evaluate perceptions, interest, and clinical exposure to CHS among current cardiothoracic surgery residents.
METHODS
Ethics
This study was reviewed by the Institutional Review Board of the University of Pittsburgh and found to be exempt from informed consent (IRB: STUDY19010026, approved 1/23/2019). Survey results were collected and analyzed anonymously by study investigators. This survey was designed and reported with consideration to previous recommendations and best practices identified for survey study design in health professions education.
Cardiothoracic surgery residents in ACGME-accredited programs in North America were included in the survey solicitation. The survey was distributed via 2 direct e-mail messages to all 527 current trainees (clinical and research phase) between May 1, 2020 and June 30, 2020 and social media accounts of the Thoracic Surgery Residents Association (TSRA) over the same time period. Residents participating in integrated (6-year) programs, traditional 2- or 3-year fellowship programs, or combined 4+3 general surgery/cardiothoracic surgery programs were included and categorized for the purposes of the survey. Only surveys with complete responses were analyzed.
Survey Instrument Development
A 22-question survey instrument was designed de novo by the study authors with questions focusing on the following key areas: participant demographics, exposure to CHS, perception of CHS training, quality assessment of CHS training experience, and participation in CHS cases during ACGME cardiothoracic surgery training (Supplemental Fig. 1). These topics were deemed of interest in consultation with the study authors, the TSRA, and the Thoracic Surgery Director's Association (TSDA). Question construction and survey design were carried out in an iterative process as previously recommended for educational study design.
Validation and testing of the survey instrument were performed with the 13 member TSRA executive committee with further refinement and feedback being incorporated by the study authors. The final survey was distributed using the TSRA Google Forms distribution instrument with only anonymous data provided to the study team for analysis after final approval from both the TSRA and TSDA.
Outcomes Analysis
Categorical variables are reported as number (%), with discrete numerical variables reported as medians. Chi-square and Fischer's exact analysis were used as appropriate to compare differences between resident demographics, congenital CT interest, and clinical experience as indicated. Linear correlation analyses were performed using the Pearson's correlation test. A 2-tailed P-value of < 0.05 is defined as a significant finding throughout the study. Data analysis was completed in SAS 9.4 (SAS Institute, Inc, Cary, NC).
RESULTS
Demographics and Baseline Congenital Interest
The survey was completed by 106 current CT surgery residents (20.1% overall survey response rate). Of the respondents 75 (70.8%) were male and 31 (29.2%) were female, with 86 (81.1%) reporting being in the cardiothoracic track and 20 (18.9%) in the thoracic track (Table 1). This distribution is representative of the overall ACGME training cohort reported to be 24% female during the 2019–2020 training year.
Response rates nationally in the United States by program type were 53/193 (27.5%) for clinical integrated residents and 53/236 (22.4%) for clinical traditional track residents for the training period surveyed.
Complete survey results were also stratified by integrated vs traditional residents (Supplementary Table 1, Supplementary Fig. 2) and by thoracic vs cardiothoracic track (Supplementary Table 2, Supplementary Fig. 3) to identify interesting differences throughout. Sixty-eight residents (64.2%) had interest in CHS at some point in their training but only 23 residents (21.7%) were currently planning on pursuing the specialty at the time of the survey. Integrated residents were more likely to be interested in congenital at some point in their training (84.9% vs 43.4%, P < 0.01) and more likely to be currently planning on pursuing CHS than traditional or 4 + 3 residents (35.8% vs 7.5%, P < 0.001). Senior trainees (PGY4-6 Integrated or year 2 or 3 traditional/4+3 thoracic phase trainees) and more junior trainees indicated similar overall current interest in CHS (21.7% vs 16.1%, P = 0.08).
Table 1Demographics of Survey Respondents and Interest in Congenital Heart Surgery
Total Survey Responses: 106 (20.1% survey response rate)
Male
70.8% (75)
Post-graduate y
PGY1
6.6% (7)
PGY2
8.5% (9)
PGY3
11.3% (12)
PGY4
13.2% (14)
PGY5
5.7% (6)
PGY6
17.9% (19)
PGY7
17.9% (19)
PGY8
11.3% (12)
PGY9+
7.5% (8)
Program Type
4+3
2.8% (3)
I-6
50% (53)
Traditional 2-y
27.4% (29)
Traditional 3-y
19.8% (21)
Program Track
Cardiothoracic
81.1% (86)
Thoracic
18.9% (20)
Do you currently intend to pursue congenital?
Yes
21.7% (23)
No
78.3% (83)
Have you ever been interested in a career in congenital cardiothoracic surgery at any time?
Fifty-one residents (48.1%) were first exposed to congenital during medical school, while 11 (10.8%) were exposed during college, and 3 (2.8%) were exposed prior to college (Fig. 1). The remaining 41 residents (38.7%) were exposed during CT surgery residency/fellowship or general surgery residency. Those with earlier exposure were significantly more likely to have had interest in CHS at some point in comparison to those exposed during residency (84.6% vs 31.7 P < 0.001) and be actively pursuing CHS (32.3% vs 5.1% P < 0.001). Thirty-four (32.1%) of residents reported performing research in the field of CHS, while the remaining 72 residents (67.9%) did not. Regarding mentorship, 85 (80.2%) of residents felt they could easily access a mentor in CHS (Supplementary Table 3); there were no differences between program types in their reported ability to find mentors (P = 0.393).
Figure 1Timing of initial exposure to congenital heart surgery. Over 50% of trainees are exposed to congenital heart surgery prior to starting any type of residency program. (Color version of figure is available online.)
Ninety-one trainees (85.8%) reported their congenital rotation being at their home institution, with 14 (13.2%) having these rotations at an outside institution and 1 (0.8%) having both. Most integrated program residents (31/50, 62.0%) had their first dedicated CHS rotation during their 4th clinical year, while most traditional fellows (36/13, 73.5%) and 4+3 residents (2/3, 67.7%) had theirs during the first year of fellowship (Fig. 2). Three residents (2.9%) reported not having a dedicated CHS rotation in their program.
Figure 2Timing of first dedicated congenital heart surgery rotation for each training program type. Trainees tend to have the initial exposure prior to the final senior years of training. (Color version of figure is available online.)
Congenital Experience Perception and Quality Assessment
Forty-four (41.5%) residents reported completing CHS cases as primary surgeon whereas 67 (63.2%) as an assistant surgeon. The types of cases performed by trainees as primary and assistant surgeon were summarized (Fig. 3). Overall, the median time spent on congenital CT surgery was 3 months (Central Picture). Eighty-seven (82.1%) residents could elect to spend additional time on congenital if desired. Integrated program residents spent a longer amount of time on the CHS service compared to other training pathways (4 vs 2 months, P < 0.001). Integrated residents also reported feeling more prepared for congenital questions on their ABTS examinations (P = 0.011). There was a non-significant signal identified with the association between increasing length of CHS rotations and perceived confidence on congenital topic preparation for ABTS examinations (rs = 0.177, P = 0.070).
Figure 3Congenital cases performed by cardiothoracic surgery residents logged as Primary and Assistant Surgeons. (Color version of figure is available online.)
The most common factors that influenced residents’ decisions to pursue CHS were technical aspects of the specialty (57.0%), broad range of pathology treated (51.0%), patient population (44.9%) and mentorship (44.9%, Fig. 4). The most common factors reported that influenced residents to not pursue CHS were the job market (57.3%) and length of training (43.8%, Fig. 5). Among the 45 respondents that initially reported an interest in pursuing CHS but currently are not interested, job availability (73.2%) and length of additional training (41.5%) were cited as the most frequent reasons for changing career trajectory. Eighty-six trainees (81.1%) believed CHS should continue to be a required part of CT surgery training. Of the 20 (18.9%) trainees that did not believe congenital should continue to be a part of cardiothoracic surgery training, 9 (45.0%) were thoracic track residents. The median ideal length of CHS core exposure reported by residents was 3 months. Trainees identified the following factors that could improve their CHS training experience: increased time spent on CHS (25.5%), increased operative involvement (20.0%), more coaching and mentoring (9.1%), and exposure earlier in training (9.1%). Six residents (10.9%) indicated a preference for less time and exposure to CHS. The desire for earlier exposure to CHS was identified exclusively among integrated PGY4 residents (N=5).
Figure 4Factors influencing residents to pursue congenital cardiac surgery as a specialty. Trainees cite technical aspects of the field, range of pathology treated, patient population, and mentorship as primary reasons for pursuing congenital cardiac surgery.(Color version of figure is available online.)
Figure 5Factors influencing residents not to pursue congenital cardiac surgery as a specialty. Job availability and length of additional training were commonly cited as reasons for not pursuing congenital cardiac surgery. (Color version of figure is available online.)
The current survey demonstrates significant variability in both experiences and perceptions among current cardiothoracic surgery residents regarding CHS in the core training curriculum (Fig. 6). Despite this finding, most residents reported obtaining the required case exposure to submit for the ABTS certification sequence. Furthermore, residents report sufficient exposure to CHS to feel prepared to answer level-appropriate questions on the ABTS qualifying and certifying examinations. Trainees report relatively less clinical involvement during CHS rotations compared to adult cardiac rotations and feel that increased operative experience would improve CHS core rotations. Perceptions of CHS as a field differed among integrated vs traditional trainees, with integrated residents having a higher level of interest in CHS as a career. Finally, job market issues and length of training were identified as major barriers among those not interested in CHS while the technical challenge of CHS and heterogenous patient population and pathologies continue to be a major stimulus for those interested in pursuing CHS following core residency training.
Figure 6Graphical abstract: Congenital cardiac training experiences currently meet trainee goals but have opportunities for improved exposure and earlier mentorship for those interested in the field. (Color version of figure is available online.)
The ABTS currently requires education and exposure to CHS as part of core cardiothoracic residency training. For residents in the cardiothoracic track, 5 cases as primary surgeon and 15 cases as first assistant are required for graduation while general thoracic track residents are required to complete 10 cases as first assistant.
Knowledge and understanding of CHS are directly tested on the ABTS qualifying (written) and certifying (oral) examinations; these content areas are outlined in the Thoracic Surgery Curriculum found on the ABTS website.
It remains challenging to ascertain the functionality of each individual training program. Additionally, little information exists regarding how interest in CHS as a specialty influence the perceptions of training requirements and experience. Our study addresses these concerns in the most comprehensive manner to date and provides an important window into how CHS exposure can be improved for all residents during core ACGME cardiothoracic surgery training.
In our study we found that integrated cardiothoracic surgery residents more commonly expressed past and present interest in CHS compared with traditional 2- and 3-year residents. This trend in increased interest among integrated trainees has been identified in a previous survey by ACGME cardiothoracic surgery residents.
In this particular study by Tchantchaleishvili and colleagues, residents in integrated programs were more likely to identify CHS as a primary career interest, and they tended to commit earlier in their training pathway. Indeed, early mentorship was identified as important to this process. In our study CHS nearly 20% of residents cited inadequate or unavailable mentorship. For those who described availability of mentorship, we were not able to discern the quality thereof.
Additionally, the size and scope of the congenital program at a given institution may influence availability of mentorship and overall exposure; however, we were unable to fully account for these factors in this particular survey but they are certainly worth considering. Given that those interested in CHS as a career cited exposures most commonly during college or medical school, the trend favoring integrated resident interest becomes more clear. Further efforts at increasing early exposure and both mentorship availability and quality for medical students and more junior trainees should be a focus of the field moving forward to continue to attract the best candidates for CHS training.
Actual CHS experiences during core cardiothoracic surgery training were highly variable and were associated with both track (cardiothoracic vs general thoracic surgery) and program (integrated 6-year program, 2- or 3- year traditional program, or 4 + 3 general surgery + cardiothoracic surgery) type. Integrated residents and cardiothoracic track residents tend to spend more time on CHS rotations, and rate them as more important in terms of optimal time on the rotation. It seems that a median of 3 months was felt to be the optimal duration of congenital rotation experience to accomplish the goals of obtaining ABTS case requirements and adequate knowledge exposure for ABTS certification. This may be difficult in certain programs with either limited CHS volume or shorter training duration specifically with general thoracic track residents. Indeed, several thoracic track residents suggested minimizing CHS rotation time in the free text entries on the survey while those interested in congenital and cardiothoracic track residents preferred more time and operative responsibilities. As cardiothoracic surgery becomes more specialized and technically advanced, there may be a role for individualizing educational experiences of each resident. Our survey shows many programs have taken a step in this direction with 82.1% providing a mechanism for more elective time to be spent on CHS for those interested. This has clearly been utilized most commonly for those who already desire to pursue CHS as a specialty given our results, and this practice likely leads to some decrease in the learning curve 1 experiences when starting a CHS training program. Whether increased elective time has been used or would be useful to someone exploring the option of CHS is an important question that our survey was not able to answer specifically. Program directors of ACGME cardiothoracic training programs can also utilize the Thoracic Surgery In-Training Exam to monitor CHS knowledge attainment to some degree during training, and tailor additional training needs in preparation for ABTS certification.
Utilizing these specific concepts, along with promotion of easy to understand resources for mastering the required CHS material, should promote a solid basic education in CHS for all cardiothoracic surgery residents.
Clinical case exposure while on CHS rotations remains broad. Examining the profiles of cases logged as assistant surgeon, the entire range and breadth of CHS is experienced by most residents. However, there is a trend towards less direct exposure to high complexity cases. This is likely due to the low operative involvement of cardiothoracic surgery residents in these technically complex operations (expressed in the free text comments on the survey). However, it is also important to note that many of the CHS cases logged as primary surgeon are actually on adults. Given that adults with congenital heart disease are increasingly common and adult cardiac surgeons should be familiar with some of these pathologies, this may be beneficial. But this trend does demonstrate that current ACGME cardiothoracic surgery residents are operating on fewer pediatric patients as primary surgeon, and this may dilute interest and technical training. One of the areas of improvement for CHS rotations noted in our study was in operative teaching and independence. Though it is understood that patient safety and outcomes are of paramount importance, CHS can be conducted by trainees safely in a rigorous mentored environment with appropriate graduated responsibility.
Especially for trainees interested in exploring CHS as a career option, appropriate operative experiences should be tailored to allow the trainee to make an informed decision about entering the field.
For those interested in CHS early mentorship, broad pathology treated, and technical aspects of the specialty were cited as major factors influencing that decision. The relative drop off in interest at some point compared to current interest in CHS on our survey was remarkable. The 2 most commonly cited reasons for not pursuing the field were the job market and length of training. The training of a CHS is surely not short, and there have been several changes in recent years with the accreditation of CHS training programs.
With the advent of these changes, surveys performed of CHS trainees and recent graduates have shown that although standardization of case requirements has made the experience more consistent, there are many who recommend a second year of formal training and/or a structured transition to practice to improve chances of a successful early CHS career.
Additionally, there is now significantly less time in either core cardiothoracic training or even CHS training to pursue traditional training opportunities throughout the world without significant additional time commitment outside of ACGME requirements.
The most pressing concern identified, which is also a well-known issue given the congenital workforce studies, continues to be job availability. There are typically fewer jobs than graduates from CHS fellowships each year; however, it remains a priority to continue to encourage the pipeline of the best and brightest thoracic surgery residents to pursue the specialty over the long-term. Several internal and external forces continue to affect how congenital surgeons are trained and eventually employed, but continuous adaption with current data on the next generation of trainees (such as that provided by this survey) will continue to inform this evolution.
Ongoing evaluation of these changes and patterns by the ABTS, ACGME, and other stakeholders are imperative to determine the best way to both recruit and subsequently train future congenital heart surgeons given the actionable knowledge obtained from the current survey.
This study as several limitations worth noting. The primary limitation is the 20.1% response rate. However, this is a reasonable response rate for voluntary anonymous surveys distributed through the TSRA mechanism in the past, and most importantly the cohort demographics and training levels/programs were representative of the overall ACGME trainee cohort. Given the major indicator of validity of a survey is the representativeness of the population rather than the overall response rate, we are comfortable that our survey has achieved this benchmark.
With that being said, we were unable to account for non-responder bias in a comprehensive way given the survey distribution methods and anonymous reporting. Another possible limitation is that trainees may have been more likely to respond to the solicitation if they were in fact interested in CHS. Though there is no way to be certain, given the overall trends in decreased interest over time and the selected track of the respondents, this likely only played a minor role in any selection bias present. This study concentrated on ACGME accredited residency programs; trends and perceptions of international cardiothoracic surgical trainees regarding CHS may differ. Finally, despite the multiple mediums utilized to promote the survey, it is possible not all eligible ACGME residents were reached with the solicitation methodology.
Conclusions
Cardiothoracic surgery trainees report varied experiences in CHS core training and exposure. Overall residents report adequate clinical exposure to obtain ABTS case requirements in CHS, and importantly report adequate preparation for ABTS qualifying and certifying examinations. Operative experiences in CHS are highly variable among programs and was identified as a point of improvement by many residents. Mentorship and early exposure remain important for those interested in the specialty, while additional training time and limited job availability persist as hurdles to pursuing congenital subspecialty training. Further research is warranted to determine how changing educational paradigms in cardiothoracic surgery residency training will affect trainee perceptions of CHS as a field and the pathway to pursuing training in CHS.
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