A structured, competency-based framework for aspiring cardiothoracic surgeons

Abstract

Objective

Cardiothoracic surgery requires mastery of a broad knowledge base and advanced skillset to manage critically ill patients. Although competency-based assessment frameworks have been developed in several specialties, there remains a paucity of resources to guide practical progression for early cardiothoracic surgical trainees.

Methods

Members of the Thoracic Surgery Residents Association, Thoracic Surgery Medical Student Association, and attending cardiothoracic surgeons with a strong track record of surgical education were invited to share their insights and experiences. A structured, milestone-driven roadmap was developed on the basis of their contributions.

Results

We developed a structured, competency-based framework for early surgical trainees, with an emphasis on progressive development of clinical knowledge, technical skills, and academic proficiency. Key milestones and applicable resources were curated to help guide independent learning and skill acquisition.

Conclusions

This structured roadmap offers early-stage cardiothoracic surgery trainees a competency-guided path toward proficiency. By providing clear guidance and granular action points, this guide may help facilitate independent learning and prepare residents for advanced cardiothoracic surgical training.

Graphical Abstract

Schematic of structured benchmarks for clinical, technical, and academic development.

Structured, competency-based framework for aspiring cardiothoracic surgeons.

Central Message.

We propose a structured, competency-based framework designed to guide aspiring junior residents and early-career surgical trainees in developing proficiency in clinical knowledge, technical skill, and academic excellence.

Perspective.

The pathway for aspiring cardiothoracic surgeons to match and excel in surgical residency and fellowship is both rigorous and demanding, requiring mastery of clinical knowledge, surgical techniques, and academic proficiency. We propose a structured, competency-based framework outlining clear and progressive milestones to help aspiring trainees develop their competencies and cultivate the skills needed to excel.

Cardiothoracic surgery is among the most demanding specialties in medicine, given its extensive knowledge base, technical complexity, and critically ill patient population.¹ It is further distinguished by its close integration with multiple other medical disciplines, including cardiology, pulmonology, vascular surgery, and oncology for patient evaluation and management.² Intraoperatively, surgeons must perform technically sound operations while interpreting data and maintaining hemodynamic stability along with anesthesiologists and perfusionists. Postoperatively, many patients require strong critical-care management and coordination with intensivists. Furthermore, the field's constant evolution requires routine engagement with contemporary literature and technologies, such as minimally invasive, robotic, and transcatheter approaches.

For junior surgical residents pursuing cardiothoracic surgery, mastering the requisite content and skills may seem overwhelming, especially as nearly one half of trainees do not have home training programs to provide mentorship, structure, and support.³ A home program is vital, because cardiothoracic surgery is excluded from medical school and general surgery curricula, leaving trainees to pursue self-guided learning.⁴ Although previous reports have outlined various paths to residency and mentorship opportunities,^5,6 there remains limited resources highlighting the features of gradual progression through cardiothoracic surgical training. The American Board of Surgery has implemented a milestone-based assessment platform known as Entrustable Professional Activities for general surgery trainees,⁷ with plans to release a similar platform for vascular surgery residents.⁸ The Royal College of Physicians and Surgeons of Canada instituted an analogous model for cardiac surgery trainees in 2019.⁹ The model outlined the expectations across multiple domains and a detailed map of knowledge, procedural skills, and competencies that residents are expected to master in the Canadian setting.⁹ Similarly, the American Board of Thoracic Surgery has developed a thoracic surgery curriculum that identifies expected proficiencies by residency completion. There is no outline, however, for practical progression through the early stages of training in cardiothoracic surgery.

We propose a structured, milestone-based roadmap specifically tailored to aspiring and early-stage trainees in cardiothoracic surgery. This competency-guided approach aims to support the development of clinical expertise, technical skills, and offer a structured path toward robust advanced cardiothoracic surgery training ensuring consistency.^10,11

Objective 1: Develop Your Clinical Armamentarium

Although it is important to learn operative strategies, prioritizing high-level surgical elements too early into training may be premature. Firm understanding of anatomy and physiology should precede the study of disease processes, diagnostics, and surgical techniques (Tables 1 and 2). This approach ensures a strong foundation, which will lead to a deeper and more enduring understanding of specialized operations.

Table 1.

Useful resources and links

Goal	Level 1	Level 2	Level 3
Develop your clinical armamentarium	-ICU Advantage - https://www.icuadvantage.com/- TSDA Resources - https://tsda.org/- TSRA - https://tsraweb.com/- TSMA - https://www.ctmedstudent.org/- Netter's Anatomy Atlas - https://tinyurl.com/ms3wbhbh	-Bojar's Perioperative Manual - https://tinyurl.com/4kzk8kp8 -STS - https://www.sts.org/- AATS - https://www.aats.org/- TSMA Adult Cardiac Primer – https://www.jtcvsopen.org/article/S2666-2736(23)00109-2/fulltext -TSMA General Thoracic Primer – https://www.jtcvsopen.org/article/S2666-2736(23)00109-2/fulltext -TSMA ICU Primer – https://www.jtcvsopen.org/article/S2666-2736(23)00093-1/fulltext -TSRA Review of Cardiothoracic Surgery - https://tinyurl.com/bdd3uht9 -The ICU book - https://tinyurl.com/2h7m6dnn	-TSMA Away Rotation Directory - https://www.ctmedstudent.org/copy-of-resources -TSMA Away Rotation Anki Deck – TO UPDATE -TSRA Decision Algorithms in Cardiothoracic Surgery- https://tinyurl.com/4e29amun -AATS Op Techs - https://www.optechtcs.com/- CTSNet - https://www.ctsnet.org/- MMCTS - https://www.mmcts.org/- Atlas of Endoscopic Major Pulmonary Resections – https://link.springer.com/book/10.1007/978-3-030-74115-0 -Atlas of Cardiac Surgical Techniques - https://www.amazon.com/Atlas-Cardiac-Surgical-Techniques-Sellke/dp/0323462944
Develop your technical armamentarium	-Synthetic Suture Pads - https://tinyurl.com/3zk92wpt -Sutures - https://tinyurl.com/4bffcyup -Mayo Hegar Needle Driver - https://tinyurl.com/4d679eev -DeBakey Forceps - https://tinyurl.com/yck6pvnd -Suture Tying Kit - https://tinyurl.com/yzpevn9u -Laparoscopy Module - https://tinyurl.com/478fkbab -The Modern Surgeon - https://www.themodernsurgeon.org/- Knot Tying Module - https://www.youtube.com/watch?v=EUEh_pf3Ipc	-Penn Box Sternotomy Module - https://mmcts.org/tutorial/1614 -Konsari's Textbook - https://tinyurl.com/3suv8srh -Castroviejo Needle Driver - https://tinyurl.com/nh4kdv55 -Low fidelity simulation, robotic, laparoscopic and VATS - https://www.youtube.com/watch?v=GUheFddh86A	-Stanford Global Surgery Box - https://globalsurgbox.com/ -Penn Box Cannulation Module - https://mmcts.org/tutorial/1649 -Penn Box Coronary Module - https://mmcts.org/tutorial/1672 -Third Hand Alligator Clips – -Vascular Grafts - https://tinyurl.com/52y6ey9x
Develop your academic armamentarium	-List of CT Surgery Journals - https://www.ctsnet.org/journals -TSMA STATS 101 series - https://www.ctmedstudent.org/resources (coming soon) -AATS Summer Intern Scholarship - https://www.aats.org/foundation/summer-intern-scholarship -MGH General Thoracic Surgery Service Summer Scholars Program - https://www.massgeneral.org/surgery/thoracic-surgery/education-and-training/summer-scholars-program	-TSMA CT Resources - https://tinyurl.com/mrxas9cy -STS Looking to the Future Scholarship - https://www.sts.org/looking-future-scholarship-program -AATS Member for a Day - https://www.aats.org/foundation/member-for-a-day -Sarnoff Fellowship - https://www.sarnofffoundation.org/page/Fellowship_Info	-TSMA Conference Survival Guide - https://tinyurl.com/3wumbm5v -Establishing an academic niche in cardiothoracic surgery: The earlier the better - https://www.jtcvs.org/article/S0022-5223(18)33153-2/fulltext

ICU, Intensive care unit; TSDA, Thoracic Surgery Directors Association; TSRA, Thoracic Surgery Residents Association; TSMA, Thoracic Surgery Medical Student Association; STS, Society of Thoracic Surgeons; AATS, American Association for Thoracic Surgery; CTSNet, Cardiothoracic Surgery Network; MMCTS, The Multimedia Manual of Cardio-Thoracic Surgery; VATS, video-assisted thoracoscopic surgery; CT, cardiothoracic surgery; MGH, Massachusetts General Hospital.

Table 2.

Sample timelines to achieve benchmarks

A. Timeline for medical student who decides on CT surgery in MS1
	MS1	Summer break	MS2	MS3	MS4
Objective 1: Develop your clinical armamentarium	Level 1 (physiology, anatomy, and diagnostics) The focus of preclinical years first and foremost needs to be course content. True understanding of pre-clinical material will facilitate clinical mastery in later years.	Level 1 (physiology, anatomy, and diagnostics) Take time to reinforce any weak concepts from MS1	Level 2 (pathology, hemodynamics, and critical care) Again, your primary focus during this time should be course content! A good foundation in pathophysiology will set you up for success.	Level 3 (surgical approaches, and operative decision-making) Surgical approaches and decision making are quite complex. Allow your third year to focus on the bread and butter, as you still need to make time to dive into all the other specialties required in clerkships.	Level 3 (surgical approaches and operative decision-making) Continue to expand your surgical knowledge during advanced electives and away rotations.
Objective 2: Develop your technical armamentarium	Level 1: The Fundamentals Although this phase should be more focused on Objective 1, a gradual introduction to basic surgical skills can provide an enjoyable break to studying. Start shadowing in the OR on occasion. You may have the opportunity to scrub in.	Level 1: The Fundamentals Without the time constraints of lectures, summer break provides a great opportunity to do some shadowing in the OR. After a case, ask a surgical fellow if they would be willing to give you a few pointers on closing skin.	Level 1 – Level 2 Depending on how comfortable you feel with the fundamentals, you may start to learn more level 2 skills. Again, during this time your primary focus should be Objective 1.	Level 2: Ergonomics and needle angles Clerkship year is often a student's first experience sewing, cutting, and tying in the OR. Because you mastered the fundamentals over the first 2 years, you should be prepared to demonstrate these skills when given the opportunity.	Level 3: Simulations Surgical trainees and students may sometimes find themselves with an unexpected opportunity to do an advanced skill in the OR. If you are diligent about simulating these skills beforehand, you will excel when given the chance. The more competency you demonstrate, the more opportunities you will be given.
Objective 3: Develop your academic armamentarium	Level 1: Reading and understanding literature A mistake students often make is getting involved in research too early. Allow yourself time at the beginning of medical school to first establish good study habits. Once you have a good study routine, start to delve into the literature.	Level 1 AND Level 2 The summer break is an important opportunity to spend dedicated time doing research. Find an established research group where you can work on 1-2 projects to complete over the summer. This will give you a foundation to build upon throughout the rest of your time in medical school.	Level 2: Join a research team Stay connected with your summer research team. See if there are any other projects you can work on with the group. Reach out to the surgical faculty to ask if there is a case report you can write up. You should be able to handle more work in MS2 than MS1.	Level 3: Lead your own projects Come up with research questions based on your clinical experience. Propose new projects to your existing research team, recruit younger students to help you with new ideas, find another student off of whom to bounce ideas.	Level 3: Lead your own projects Continue your work from MS3. Offer to write up an interesting case on your away rotation. Start to involve more younger students in your work to pass off the baton when you graduate.

B. Timeline for medical student who decides on CT surgery in MS3, and opts to take a research year∗
	MS1	Summer break	MS2	MS3	Research year	MS4
Objective 1:Develop your clinical armamentarium The timeline will likely not change for this objective	Level 1: Physiology, anatomy, and diagnostics The focus of pre-clinical years first and foremost needs to be course content. True understanding of pre-clinical material will facilitate clinical mastery in later years.	Level 1: Physiology, anatomy, and diagnostics Take time to reinforce any weak concepts from MS1	Level 2: Pathology, hemodynamics, and critical care Again, your primary focus during this time should be course content! A good foundation in pathophysiology will set you up for success.	Level 3: Surgical approaches and operative decision-making Surgical approaches and decision making are quite complex. Allow your third year to focus on the bread and butter, as you still need to make time to dive into all the other specialties required in clerkships.	If deciding on CT surgery late into medical school, take this time to review cardiovascular pathophysiology, and take a deep dive into the Level 3 knowledge you may have been briefly introduced to during clerkships.	Level 3: Surgical approaches and operative decision-making Continue to expand your surgical knowledge during advanced electives and away rotations.
Objective 2:Develop your technical armamentarium	Level 1: The Fundamentals It is possible at this phase that the student may not be interested in surgery at all (as was the case for some of the authors on this paper). Nevertheless, it is good to remain undifferentiated as an early career medical student, and brief exposure into surgical skills, whether in the anatomy lab or on Youtube, may be beneficial.	Level 1: The Fundamentals Summer break is still a good time to do some shadowing in the OR. Even if not initially interested in surgery, shadowing different subspecialities is advantageous for evaluating your own career.	Level 1: The Fundamentals Continue with light exposure, if for no other reason to prepare for the surgical clerkship.	Level 1 – Level 2 Clerkship year is often a student's first experience sewing, cutting, and tying in the OR. If this first exposure ignites a fire, start leaning into mastery of Level 1 skills. As clerkship year progresses, Level 2 concepts can start to be introduced.	Level 2: Ergonomics and needle angles Delve further into surgical skills by focusing on Level 2 mastery. Having dedicated time to get ahead on these skills will help immensely for away rotations.	Level 3: Simulations Surgical trainees and students may sometimes find themselves with an unexpected opportunity to do an advanced skill in the OR. If you are diligent about simulating these skills beforehand, you will excel when given the chance. The more competency you demonstrate, the more opportunities you will be given.
Objective 3:Develop your academic armamentarium	Level 1: Reading and understanding literature A mistake students often make is getting involved in research too early. Allow yourself time at the beginning of medical school to first establish good study habits. Once you have a good study routine, start to delve into the literature. Any literature is helpful, even if it is not cardiothoracic related.	Level 1 AND Level 2 The summer break is an important opportunity to spend dedicated time doing research, regardless of the topic. Find an established research group where you can work on 1-2 projects to complete over the summer. This will give you a foundation to build upon throughout the rest of your time in medical school.	Level 2: Join a research team Stay connected with your summer research team. See whether there are any other projects you can work on with the group. Continuing to develop research skills will be beneficial regardless of the field the research is focused on.	Level 2: Join a research team A clinical exposure to cardiothoracic surgery has lit a fire? Reach out to faculty to help write a case report. Aim to have one CT case report published by the end of clerkship year.	Level 3: Lead your own projects Research years can be through established programs or through personal connections. Take this time to dive into the literature specific to the cardiothoracic field and come up with clinically relevant project ideas. Good mentorship is key for a successful research year, and students should aim to have 5-10 combined manuscripts and presentations by the end of the year.	Level 3: Lead your own projects Continue your work from your research year. Offer to write up an interesting case on your away rotation. Start to involve more younger students in your work to pass off the baton when you graduate.

C. Timeline for surgical residents who decide on cardiothoracic surgery early in training
	PGY-1	PGY-2	PGY-3	PGY-4	PGY-5
Objective 1: Develop your clinical armamentarium	Level 1 (Physiology, anatomy, and diagnostics) Focus on cardiopulmonary physiology, radiology interpretation (CXR, CT, echo), and understanding pre/post-op care for thoracic patients. Join CT rounds or consults if possible.	Level 2 (Pathology, hemodynamics, and critical care) Refine knowledge of cardiothoracic pathologies (valvular disease, lung cancer, aortic dissection). Take ownership of ICU management and perioperative care. Seek rotations involving CT ICU.	Level 3 (Surgical approaches and operative decision-making) Actively assist on CT cases if available. Learn CT-specific decision-making (sternotomy vs thoracotomy, bypass selection). Consider elective time in CT surgery.	Level 3 (Surgical approaches and operative decision-making) Understand indications in CABG, valve repair/replacement, LVAD, and thoracic resections. Review advanced intraoperative strategies and complications. Function as first assist on CT cases.	Level 3 (Surgical approaches and operative decision-making) Manage complex CT patients, pre-/post-op. Master CT consults. Prepare for CT fellowship by refining judgment and intraoperative skills. Prioritize autonomy and leadership.
Objective 2: Develop your technical armamentarium	Level 1: The Fundamentals Refine hand-tying, suturing, and basic assisting. Practice median sternotomy techniques in simulation, if available, Explore perfusion basics and suture techniques used in CT surgery.	Level 2: Ergonomics and needle angles Develop precision with long instruments, needle angles for delicate structures (vessels, bronchi). Participate in CT wet labs or simulation sessions.	Level 2 and Level 3 Practice sternotomy opening/closure, and vessel anastomosis. Continue simulation for valve surgery, cannulation, and thoracic stapling.	Level 3: Simulations Develop comfort with complex simulations, including small coronary anastomoses. Seek opportunities to first-assist or complete partial case steps in cardiothoracic ORs.	Level 3: Simulations Demonstrate readiness to independently handle segments of CT cases. Focus on motion, operative flow, and preparing for CT fellowship technical demands.
Objective 3: Develop your academic armamentarium	Level 1: Reading and understanding literature Read CT journals and join journal clubs. Study landmark trials	Level 1 and Level 2 Join a CT research group or mentor. Start a retrospective or quality-improvement project. Present at local surgery or CT meeting.	Level 2 and Level 3 Publish clinical projects. Attend and network national meetings. Define your research niche.	Level 3: Lead your own projects Lead CT-focused research. Mentor medical students interested in CT. Collaborate across disciplines (cardiology, pulmonology). Build a publication track record.	Level 3: Lead your own projects Finalize research portfolio. Aim for first-author publications and oral presentations. Prepare for fellowship and submit to CT-specific scholarships or awards.

CT, Cardiothoracic surgery; MS1, medical student year 1; MS2, medical student year 2; MS3, medical student year 3; MS4, medical student year 4; OR, operating room; CXR, radiograph of the chest; ICU, intensive care unit; CABG, coronary artery bypass grafting; LVAD, left ventricular assist device.

^∗We do not intend to imply that a research year is necessary for students who decide on cardiothoracic surgery late into medical school.

Level 1: Anatomy, Physiology, and Diagnostics

A thorough understanding of cardiothoracic anatomy, physiology, end-organ perfusion, and hemodynamic compensation is fundamental to the specialty. Trainees should first focus on thoracic anatomy, including the mediastinal compartments, major structures and their arterial supply, venous drainage, innervation, and lymphatics.¹² In cardiovascular anatomy, important structures include cardiac chambers, great vessels, and aortic zones.¹³ Pertinent general thoracic anatomy includes pulmonary segments, mediastinal nodal stations, and esophageal anatomy.¹⁴ In addition, cadaver laboratories help trainees learn surgical anatomy, including 3-dimensional relationships and adjacent danger zones, essential for safe planes in limited visual fields. Supplementing basic anatomy textbooks with 3-dimensional anatomy apps can also help trainees visualize anatomic orientation from the surgeon's point of view.

Beyond anatomy, early exposure to physiology and diagnostic metrics is vital for disease grading and risk stratification. Trainees should understand key principles, such as the cardiac cycle, chamber pressures, preload/afterload relationships, electrocardiogram interpretation, right atrial pressure tracings, and Frank-Starling curves. They should also review pulmonary function testing; tumor, node, and metastasis staging; tumor histology; and biomarkers to inform patient selection and operative approach. Early familiarity with imaging, such as echocardiogram, cardiac catheterization, and cardiac computed tomography/magnetic resonance imaging is valuable, and trainees should aim to recognize normal structures across these various imaging modalities.

Although operating room (OR) experience is invaluable, the often-overlooked outpatient clinics provide critical insights into patient evaluation, risk assessment, and longitudinal care. Reviewing laboratory tests and imaging with mentors builds the trainee's understanding of “normal” versus “abnormal.” Clinic experience also reveals often-overlooked aspects of practice, such as developing a referral base, multidisciplinary collaboration, and building rapport with patients. It also highlights differences in follow-up, because coronary surgeons often defer postoperative care to referring cardiologists, whereas aortic and thoracic oncology surgeons may follow patients for life.

Level 2: Pathology, Hemodynamics, and Critical Care

As trainees progress, focus should shift from studying native physiology to understanding how disease disrupts these processes. Trainees should develop a systematic approach to analyzing and understanding pathophysiology, hemodynamics, and disease progression rather than relying on memorization. A strong foundation in core pathologies like coronary artery disease, valvular heart disease, heart failure, aortic aneurysms and dissections, obstructive and restrictive pulmonary disease, lung and esophageal malignancies, and foregut hernias is essential. Trainees should also begin learning cardiopulmonary bypass¹⁵ fundamentals, including basic circuit components, including venous/arterial cannulas, cardiotomy/suction lines, oxygenators, heat exchangers, along with cannulation techniques, pump designs, and associated risks.¹⁵

Critical care exposure is also important for learning postoperative management. Intensive care unit rounds teach common milestones and patient care algorithms, whereas active engagement deepens understanding of postoperative arrythmias, indications for OR “takebacks,” chest-tube removal, ventilator weaning, and the use of specific vasopressors and inotropes. Trainees should also recognize how tools such as Swan-Ganz catheter (Edwards Lifesciences) pressure tracings, lactate trends, mixed venous oxygen saturation, and urine output guide decisions. Intensive care unit experience provides insight into care of critically ill patients, including prolonged ventilation, mechanical circulatory support, and multisystem organ failure. Although early exposure can be emotionally challenging, it competes in managing critically ill patients.¹⁶

Level 3: Surgical Approaches and Operative Decision-Making

With a sound foundation in anatomy, physiology, pathology, and critical care, trainees can now focus on studying surgical steps and approaches. This involves reading about and scrubbing into essential cases, such as coronary artery bypass grafting (CABG), valve replacements, aortic surgeries, lobar and sublobar resections, esophagectomies, and hiatal hernia repairs.^5,17 Preparation involves understanding surgical indications and contraindications with supporting societal guidelines,18, 19, 20 relevant anatomy, major operative steps, and complications,. Trainees should grasp exactly why patients are undergoing surgery, their risk factors, and why a specific approach is chosen. For example, while scrubbing into a CABG, one should read up on conduit options,²¹ benefits of multiarterial grafting,²² off-pump approaches if applicable, and methods for assessing graft function. In aortic cases, one should study peripheral cannulation strategies, cerebral protection and pH management during deep hypothermic circulatory arrest.²³ For lung resections, one can consider why lobar versus sublobar resection is chosen, extent of lymph node evaluation, and how these impact staging and treatment. In addition, understanding driver mutations and evolving neoadjuvant and adjuvant therapies in thoracic oncology is increasingly important for trainees, as well as familiarity with novel therapeutic agents on the horizon.²⁴ Many of these decisions are made well before the OR, in the form of multidisciplinary discussions (heart team, tumor board, etc), further emphasizing the importance of a foundation of knowledge in the clinic and team care setting.

Anticipating surgical steps and major intraoperative decisions are hallmarks of successful trainees. Instead of passively observing, one should attempt to predict the next steps and compare it to what the surgeon actually does,²⁵ paying attention to nuances, such as purse string widths during cannulation or port-site placement in minimally invasive thoracic surgery. Also, observe how the first assistant optimizes exposure and facilitates next steps.²⁶ Keeping a detailed case log with updated lessons, feedback and reflections can foster continuous growth. If unable to scrub, online narrated cases, especially robotic videos, can help provide valuable surgical education.²⁷

Objective 2: Develop Your Technical Armamentarium

Although clinical expertise is foundational to all medical specialties, surgeons are also defined by their technical skills in the OR. Cardiothoracic surgery demands precision, efficiency, and confidence to lead a team through long, high-stakes operations. Aspiring trainees must recognize that, like any craft, mastering surgery requires years of deliberate practice and iterative feedback.²⁸ Too often, students are eager to practice dermal closures or experiment with Castroviejo needle drivers and 6-0 sutures. Instead, trainees should commit to mastering the fundamentals first. The acquisition of technical skills should progress systematically, beginning with basic instrument handling and knot tying and gradually advancing to surgical simulations replicating a deep thoracic operative field (Tables 1 and 2).

Level 1: The Fundamentals: Instrument Handling and Knot-Tying

Technical proficiency begins with understanding the various instruments used in the OR (Table 3). Learn to identify specialized instruments like Mayo-Hegar needle drivers, Metzenbaum scissors, and the various forceps and clamps. Practice opening and closing the needle driver with fingers in the rings, before progressing to “palming” it for greater wrist mobility. Use forceps to load needle drivers both forehand and backhand, practicing perpendicular entry, following the needle's curvature, and taking bites at different angles. Master transitioning seamlessly between forehand and backhand bites is essential to later maximize efficiency when operating in confined spaces.²⁹ To practice, use a suture with a very short tail and a low-friction medium like cloth or sponge, or create a simple module with a wooden board, nails, and rubber bands or hair ties.³⁰ One should familiarize themselves with suture patterns, such as interrupted, continuous, subcuticular, and mattress sutures.

Table 3.

Common cardiovascular instruments

Scissors
Metzenbaum scissors∗	Fine dissection of soft tissue; preferred for delicate tissue handling.
Mayo scissors†	Cutting tough tissue, sutures, and heavy fascia.
Potts scissors‡	Arteriotomy and venotomy; angled blades ideal for vessel opening.
Forceps
DeBakey forceps§	Atraumatic tissue handling; used for grasping vessels and delicate structures.
Coronary pickups||	Fine forceps used for needle and vessel handling during coronary surgery.
Needle holders
Castroviejo needle holder¶	Fine suturing under magnification; commonly used for vascular anastomoses.
Mayo-Hegar needle holder#	General purpose needle holder for suturing.
Clamps
Satinsky clamp∗∗	Partial occlusion of large vessels such as the vena cava or aorta.
Aortic crossclamp††	Temporarily occludes the aorta during cardiopulmonary bypass.
Bulldog clamp‡‡	Small vascular clamp used to temporarily occlude vessels.
Hemostats (Kelly, Mosquito)§§	Clamp used to control bleeding vessels and occasionally for blunt dissection.
Tubing clamp‖‖	Clamp used to occlude the lumen of cardiopulmonary bypass tubing.
Retractors
Vein retractor¶¶	Retracts vessels or soft tissue; useful in exposure of the saphenous vein.
Sternal Retractor##	Opens sternotomy site for exposure of the mediastinum.
Mammary Retractor∗∗∗	Elevates sternal margin for exposure of the internal mammary artery.

^∗https://vernacare.com/products/general-instrumentation/instrapac-metzenbaum-scissors-curved-14cm

^†https://www.anthonyproducts.com/mayo-operating-scissors

^‡https://www.wexlersurgical.com/potts-scissors-90deg-angled-sharp-fine-blades-round-handle-stainless-steel-675quot-17cm-p-2902.html?type=search-instrument-type

^§https://www.anthonyproducts.com/adson-forceps-13

^‖https://monarchmedicalproducts.com/products/debakey-tissue-forceps

^¶https://gulmahersurgico.com/diamond-dust-micro-forceps-round-handle

^#https://www.anthonyproducts.com/castroviejo-needle-holders

^∗∗https://micrins.com/products/mayo-hegar-needle-holder-stainless-steel/

^††https://www.wexlersurgical.com/satinsky-clamp-35mm-angled-debakey-atraumatic-jaws-curved-shanks-stainless-steel-10quot-25cm-p-120.html?type=search-instrument-type

^‡‡https://amblersurgical.com/17-674-morris-ascending-aorta-clamp-10-angled-7-0cm-long-atraumatic-2x3-teeth-jaws-ring-handle

^§§https://peters-surgical.com/our-products/single-use-bulldog/

^‖‖https://www.wpi-europe.com/products/microdissection/surgical-instruments/hemostatic-forceps/hemostatic-forceps-stainless-steel/kelly-hemostatic-forceps.aspx

^¶¶https://www.teleflexsurgicalcatalog.com/pilling/product/341180-gerbode-sternal-retractor

^##https://www.multigate.com.au/instruments-accessories/06-362/

^∗∗∗https://www.rultract.com/products/4100-52/.

Thoracic trainees should develop laparoscopic and 30° scope proficiency early. Scrub into cases and spend time on laparoscopic simulators and Da Vinci training consoles, or build a homemade basic laparoscopy module.³¹ We also advise beginners to learn the unique laparoscopic instrument grip popularized by Dr Ronald Belsey and surgeons at the Toronto General Hospital—holding extra-long instruments in an inverted fashion, with the thumb and index finger in the finger rings.³²

One should begin knot-tying with instrument ties, progressing to 2-hand and eventually 1-handed ties using the dominant hand. Start with large gauge ropes for visualization and subsequently transition to finer sutures. Focus on efficient handling of long suture tails and proper knot placement while avoiding common errors, such as excessive tension or not fully synching down each knot.

Level 2: Ergonomics, Needle Angles, and Efficiency

As trainees become comfortable with basic instrument handling, they should advance to practicing within confined spaces such as a shoebox to stimulate a conventional sternotomy.³⁰ Repeat Level 1 exercises within this model, again focusing on loading the needle driver and taking forehand/backhand bites. One comfortable, progress to running suture over long distances with evenly spaced bites. Altered depth perception will require adjustments in instrument handling and needle angles. Ergonomic adjustments, such as resting the hypothenar eminence on the patient's chest³³ or tucking elbows to increase hand stability will reduce tremor and improve efficiency by avoiding straining fatigue.³⁴ One should also now implement Castroviejo needle drivers for fine motor practice, appreciating how unlike the Mayo-Hegars, the motion of axis of Castroviejos is between the thumb and index, not the full wrist.³⁵ In addition, trainees can begin mastering gentle tissue handling by closing superficial tissues in the OR, learning how to firmly grasp the tissue while avoiding pressure injury.

Knot-tying should progress to advanced knots such as the slip and surgeon's knot, practicing on lightweight bases such as empty soda cans to avoid unnecessary tension. Develop ambidexterity by practicing 1-handed knot tying with the nondominant hand, allowing the dominant to continue holding instruments. Wear surgical gloves when practicing to simulate OR conditions.

At this stage, trainees can also begin to explore vascular anastomosis fundamentals. Use video tutorials³⁶ to learn the general workflow for end-to-end and end-to-side anastomoses, focusing on set up and avoiding suture entanglement. Entry-level simulation should be performed with large-diameter vessel substitutes, like felt rolls or wide tying balloons.

Level 3: Simulations

Once comfortable working in a confined space, trainees should transition to structured surgical simulations replicating OR conditions—standing, gloved, and maintaining proper ergonomics.³⁷ Online resources³⁸ can guide the construction of learning modules for common operative scenarios, such as cannulation,³⁹ vascular end-to-end anastomoses (aortic),⁴⁰ or end-to-side anastomoses (CABG)^E1 using materials such as simulation grafts or balloons to mimic blood vessels^E2 and “third-hand” clips^E3 to practice without the aid of an assistant. Begin in open workspaces for precision before incorporating modules into sternotomy shoebox simulators. Aspiring general thoracic trainees can practice advanced exercises and anastomosis simulations on hospital robotic practice consoles. Appreciate that the majority of general thoracic operations will have the patient in the left or right lateral decubitus position, which can alter visual orientation. Therefore, supplementing laparoscopic/robotic simulators with atlases of minimally invasive thoracic surgery are essential.^E4 Trainees should also be familiar with different sewing techniques, needle sizes and shapes, and suture materials—understanding the indications and optimal use for each (Table 4).

Table 4.

Suture and needle classifications

Suture type	Material	Common uses
Polypropylene (PROLENE)	Monofilament, nonabsorbable	Vessel anastomosis
Polyethylene (ETHIBOND)	Braided, nonabsorbable	Valve replacement, annuloplasty rings
Silk	Braided, nonabsorbable	Ties around cannulas, exposure
Nylon (ETHILON)	Monofilament, nonabsorbable	Skin closure
Poliglecaprone (MONOCRYL)	Monofilament, absorbable	Soft tissue closure, especially subcuticular skin
Polyglactin 910 (VICRYL)	Braided, absorbable	Soft tissue approximation (eg, deep sternal fascia)
Polydioxanone (PDS)	Monofilament, absorbable	Fascial closure
Stainless steel	Monofilament, nonabsorbable	Sternal closure
Needle abbreviation	Naming convention	Shape
SH	Small half-circle	1/2 circle, taper
MH	Medium half-circle	1/2 circle, taper
CT	Circle taper	1/2 circle, taper
RB	Round body	1/2 circle, taper
BV	Blood vessel	3/8 or 1/2 circle, taper (fine)
FS	For skin	3/8 circle, cutting
PS	Plastic surgery	3/8 circle, precision cutting

In developing technical skills, it is essential for residents to recognize the value of mastering individual components of an operation before expecting to perform a case in its entirety. Too often, junior trainees perceive partial participation as a lesser learning experience, when in fact the opposite is true. Given the complexity of procedures performed in cardiothoracic surgery, proficiency develops most effectively through a stepwise approach. Early focus and practice on tasks such as sternotomies, cannulations, internal mammary artery harvests, proximal anastomoses, and chest closures provides a strong and critical foundation for a surgeon-in-training's operative autonomy.

Another important element of surgical mastery is the use of structured frameworks to monitor progress. A variety of schemas exist to help residents and faculty assess growth in knowledge, judgement, and technical ability, These include competency-based models such as the ACGME milestones and Entrustable Professional Activities, which provides a structured roadmap for progressive responsibility. In addition, procedure-specific tools such as the Zwisch scale and SIMPL (Society for Improving Medical Professional Learning) app allow both residents and faculty to document and evaluate intraoperative performance in real time. Incorporating these tools into training not only fosters objective feedback but also encourages self-reflection, helping residents identify strengths and areas for improvement. By familiarizing themselves with these assessment frameworks, residents can take a proactive role in tracking their development and guiding their educational trajectory.

Objective 3: Develop Your Academic Armamentarium

Most integrated and traditional cardiothoracic surgery training programs aim to cultivate future academic surgeons.^E5 Advancing surgical innovation and research has long been a cornerstone of academic surgery, serving as one of the most impactful ways individuals can contribute to the field. However, developing research skills during training is also beneficial for those going into community or private practice, fostering intellectual curiosity, and enhancing the essential skills of question formulation, data interpretation and evidence-quality evaluation, which ultimately contributes to clinical decision-making.^E6 To support academic growth, all trainees should seek an established research mentor.^E7

Level 1: Reading and Understanding Literature

At minimum, every aspiring cardiothoracic surgeon should be able to comfortably read and interpret peer-reviewed research. Early on, trainees should familiarize themselves with various study designs and their associated quality of evidence. When reading a paper, consider the following.

• -Context: What was the motivation and purpose of the study, and what gap in the field did it fill?
• -Methodology: How was the methodology designed, and from where were the data collected?
• -Data Analysis and Results: How was the data analyzed, and what were the major findings?
• -Quality: What were the strengths and the limitations of the study?
• -Impact: Most importantly, what are the clinical implications of the study, and what further research is needed?

Engaging in department-led or national journal clubs helps sharpen analytical skills and fosters discussion with field experts. In addition, subscribing to academic journals (Table 5) and newsletters can help trainees stay informed about significant publications every month. We recommend reading at least one new manuscript every week to establish a strong foundation of evidence-based knowledge that will be beneficial throughout one's career.

Table 5.

List of cardiothoracic and associated discipline peer-reviewed journals

Journal name	Area of focus
The Annals of Thoracic Surgery	Cardiothoracic surgery patient care, clinical practice, research, education, and policy
Annals of Thoracic Surgery Short Reports	Clinical advances, current surgical methods, controversial topics and techniques, case and image reports, for adult acquired and congenital cardiovascular disease, thoracic surgery, cardiothoracic transplantation, mechanical circulatory support, perioperative medicine, as well as education and training
European Journal of Cardio-Thoracic Surgery	Clinical and experimental advances related to surgery of the heart, the great vessels and the chest
The Journal of Thoracic and Cardiovascular Surgery (JTCVS)	Diseases of the heart, great vessels, lungs, and thorax with emphasis on surgical interventions
Journal of Thoracic and Cardiovascular Surgery Open	Developments in acquired cardiac surgery, congenital cardiac repair, thoracic procedures, esophageal diseases, heart and lung transplantation, mechanical circulatory support, perioperative management, and formative science that drives innovation and advancement in the field.
Journal of Thoracic and Cardiovascular Surgery Techniques	High-quality case reports, innovative techniques and cardiothoracic images in video and multimedia formats
Journal of Heart and Lung Transplantation (JHLT)	Clinical, basic, and translational science in the fields of advanced heart and lung disease, cardio-pulmonary transplantation, mechanical and biological support of the failing heart, pulmonary vascular disease (pulmonary arterial hypertension and CTEPH), extracorporeal support of donor organs, and cell replacement therapy
JHLT Open	Cardiopulmonary transplantation, mechanical and biological support of the failing heart, advanced lung disease (including pulmonary vascular disease) and cell replacement therapy.
Artificial Organs	Transdisciplinary convergence research, development, innovation, clinical translation, and application of artificial organs
American Society for Artificial Internal Organs (ASAIO) Journal	Innovative technology, organ repair, regeneration and development, preclinical testing, as well clinical outcomes
Circulation	Cardiovascular health and disease
Journal of Thoracic Diseases	New findings and practical information on the diagnosis and treatment of conditions related to thoracic disease
Operative Techniques in Thoracic and Cardiovascular Surgery	Technique-based articles in cardiovascular and thoracic surgery
World Journal for Pediatric and Congenital Heart Surgery	Congenital heart anomalies and pediatric heart diseases
Seminars in Thoracic and Cardiovascular Surgery	Reviews and updates on current issues in thoracic and cardiovascular surgery

CTEPH, Chronic thromboembolic pulmonary hypertension.

Junior residents should also develop practical research skills. For example, understand the fundamentals of statistics and available software to analyze data. Those with a background in coding or strong interest in statistical analysis may consider working with a trained statistician to see how analyses are conducted to gradually develop and hone this skill further as desired. In addition, one should understand the processes for institutional review boards, Institutional Animal Care and Use Committees, and Institutional Biosafety Committees to initiate clinical or translational research projects. Developing proficiency using citation management tools (such as Endnote or Zotero) will foster efficient manuscript collaboration and reference formatting. Finally, mastering comprehensive literature searches will later help identify existing evidence and impactful areas for contribution.

Level 2: Join a Research Team

After building a foundation in research methodologies and critical paper analysis, active participation in a research team is the next step. Early research involvement provides invaluable mentorship opportunities, fosters collaboration, and provides exposure to the scientific process. One should start by identifying an established research mentor at their institution. Those without a home program or with niche interests, can consider emailing mentors at other programs or joining mentorship programs offered by the Society of Thoracic Surgeons, American Association for Thoracic Surgery, Women in Thoracic Surgery, Thoracic Surgery Medical Student Association, or Thoracic Surgery Residents Association (Table 6).

Table 6.

Professional societies with mentorship programs/student traveling scholarships

Scholarship	Sponsor	Award type	Target	Link
Medical Student Diversity Scholarship	American Association of Thoracic Surgery	Grant	Medical students from an underrepresented group	Medical… | The American Association for Thoracic Surgery | AATS
Summer Internship	American Association of Thoracic Surgery	Mentored research	Medical students doing a summer research project	Summer Intern… | The American Association for Thoracic Surgery | AATS
AHA Scholarship in Cardiovascular Surgery	American Heart Association	Mentored research	Medical students doing a summer research project	Student Scholarships in Cardiovascular Disease and Stroke - Professional Heart Daily | American Heart Association
AHA Student Scholarships in Cardiovascular Disease and Stroke	American Heart Association	Mentored research	Medical students doing research over the summer or in a block of several months	https://professional.heart.org/en/professional-membership/awards-and-lectures/student-scholarships
Sarnoff Fellowship	Sarnoff Cardiovascular Foundation	Mentored research	Medical students with the intention to pursue a research year outside of their home institution	Fellowship Information - Sarnoff Cardiovascular Research Foundation
AHA Predoctoral Fellowship	American Heart Association	Mentored research	Medical students with the intention to pursue 1-2 years of research	2025 AHA Predoctoral Fellowship - Professional Heart Daily | American Heart Association
Carolyn L. Kuckein Student Research Fellowship	AΩA	Mentored research	Medical students pursuing research alongside medical school	Carolyn L. Kuckein Student Research Fellowship - Alpha Omega Alpha
STS You Belong	Society of Thoracic Surgeons	Traveling scholarship	Medical students and residents from an underrepresented group attending the STS annual meeting	STS "You Belong" Equity and Opportunity Scholarship | STS
Looking to The Future	Society of Thoracic Surgeons	Traveling scholarship	Medical students and residents attending the STS annual meeting	Looking to the Future Scholarship Program | STS
WTS Travel Scholarships	Women in Thoracic Surgery	Traveling scholarship	Women medical students and trainees attending the STS, STSA or WTSA	Trainee Awards - Women in Thoracic Surgery - WTS
Member for a day	American Association of Thoracic Surgery	Traveling scholarship	Medical students attending the AATS annual meeting	Member for a… | The American Association for Thoracic Surgery | AATS
CVSA Underrepresented Populations Travel Grant	American Heart Association Council of Surgery and Anesthesia	Traveling scholarship	Underrepresented students and trainees attending the AHA Scientific Sessions	CVSA Underrepresented Populations Travel Grant - Professional Heart Daily | American Heart Association
Brookes	Southern Thoracic Surgical Association	Traveling scholarship	Medical students and general surgery residents attending the STSA annual conference	James W. Brooks Medical Student Scholarship - Southern Thoracic Surgical Association
ABCTS/STS Visiting Clerkship	American Black Cardiothoracic Surgeons	Traveling scholarship	Final year medical students doing an away rotation at a participating site who identify with an underrepresented race/ethnicity	Opportunities | ABCTS - Association of Black Cardiovascular and Thoracic Surgeons
Tara Karamlou Conference Scholarship	Thoracic Surgery Medical Student Association	Traveling scholarship	Medical students presenting at cardiothoracic surgery conference	Tara Karamlou Conf Schol. | Thoracic Surgery Med

AHA, American Heart Association; STS, Society of Thoracic Surgeons; WTS, Women in Thoracic Surgery; CVSA, Council on Cardiovascular Surgery and Anesthesia; STSA, Southern Thoracic Surgical Association, ABCTS, American Black Cardiothoracic Surgeons.

A critical aspect of academic growth during residency is the ability to write and publish a scientific manuscript. Under a mentor's guidance, one will learn how project ideas evolve from conception to peer-reviewed publication. This skill requires deliberate practice and is best developed early in training. High-quality published manuscripts in the surgical literature serve as excellent models, providing examples of how to frame research questions, present methods clearly, and communicate findings with clarity and precision. Junior researchers should be encouraged to read widely, emulate effective writing styles, and seek mentorship from experienced faculty, as discussed above. In addition, breaking the process down into manageable steps—such as drafting the methods first, then results, followed by introduction and discussion– can make the task less overwhelming.

Initial roles under a mentor's guidance may include grant identification, literature searches, data entry, and/or assisting with wet laboratory experiments. With growing experience and trust, trainees may take on data analysis, manuscript drafting, and revision and ultimately generate new research questions. Participating in research meetings and proactively seeking opportunities to expand on responsibilities and skills will help advance trainees' experiences. In addition, building familiarity with national and institutional databases is essential to help facilitate new studies. Key resources include the Society of Thoracic Surgeons National Database for adult cardiac research, United Network for Organ Sharing Database for transplant research, the National Cancer Database for oncology research, and many more. Traveling and presenting at academic conferences contributes to the field and provides valuable networking opportunities.^E8 Many professional societies offer travel grants to offset conference expenses for junior residents.^E9

Level 3: Lead Your Own Projects

After contributing to several research projects, the next stage involves leading projects under a mentor's guidance. Trainees should identify significant gaps in the current understanding of conditions or treatment modalities. For instance, after reading about a novel surgical approach, a trainee may find limited studies comparing it with the conventional standard of care and suggest designing a comparative study with their mentor. Depending on time and resources, they may propose a retrospective cohort study leveraging institutional data, a meta-analysis aggregating published study-level data, or a prospective investigation requiring patient enrollment and follow-up. Once a design is agreed upon, they should initiate the appropriate institutional review board process, delegate roles, and oversee data collection, analysis, and abstract/manuscript preparation. Many societies offer research grants for medical students and junior residents to pursue clinical, basic, or translational research with a mentor, either internally or at an external institution (Table 6). Preparing grant applications by drafting aims and compiling preliminary data is an invaluable experience in progressing research projects and becoming an independent surgeon-scientist.

Beyond leading projects, advanced trainees should also develop the ability to systematically appraise research. This skill will become essential for making informed clinical decisions and peer-reviewing manuscripts. One effective way to get started is to work alongside a mentor involved in peer-review.^E10 Trainees can ask to evaluate a manuscript together, compare their comments and critiques, and see if their proposed acceptance decisions align. Feedback from mentors will help sharpen analytical skills and the ability to distinguish high quality research practices. Ultimately, this final stage aims to teach one how to meaningfully contribute to the field and set the foundation for lifelong scientific inquiry.

Further Considerations: Build the Right Habits Early

Habit 1: Read and Practice Daily

Beyond developing one's clinical, technical, and research armamentarium, it is essential for the aspiring applicant to cultivate the physical, mental, and emotional resilience to thrive in the demanding environments of cardiothoracic surgery. As trainees advance in their careers, the time available for studying, practicing technical skills, and engaging in academics outside of clinical duties continues to diminish. Therefore, building strong organizational and time-management skills early in training is paramount. In fact, we would advise all medical students and surgical trainees to select one core surgical textbook and establish a habit of reading at least 10 minutes daily. Trainees can consider taking notes on the chapters they review and correlate them to the cases they encounter in the hospital. Once daily reading has become ingrained, trainees may also consider incorporating an extra 10 minutes daily for technical practice, such as simulating anastomoses and tying knots. As stated previously, surgery is a craft—just as professional athletes and instrumentalists spend hours outside of work developing their skill, so must surgeons. Just a few minutes a day compounded over weeks and years will create a substantial difference in one's clinical framework and technical skills.

Habit 2: Physical Health

Trainees must also be mindful of the physical demand of cardiothoracic surgery. The negative impact of surgical lifestyles on physical health and posture has been well described.^E11 Cardiothoracic surgery requires several hours of standing, sometimes while wearing heavy surgical loupes, head-mounted cameras, and/or full body lead. In addition, long, unpredictable hours during training make it challenging to maintain a consistent exercise routine or balanced diet unless there is intentionality and creativity.^E12 We strongly encourage trainees to set both daily and weekly goals focused on physical health and building stamina. Having realistic and specific goals will make it easier to incorporate them into a busy schedule and adhere to them. Beyond diet and exercise, we advise all trainees to monitor their health with their healthcare providers and to be mindful of their posture during everyday activities, such as working on the computer or sitting. We also recommend investing in high quality compression socks, ergonomic equipment, meal prep containers and electrolytes.

Habit 3: Emotional Control

In cardiothoracic surgery, one will quickly learn that a steady temperament and emotional control is as equally critical to success as intellectual prowess and technical skill. The specialty is filled with dramatic highs and devastating lows. Many patients present during one of the most vulnerable moments in their lives, and the ability to listen to concerns, empathize, alleviate fears, and instill confidence in a positive outcome are core responsibilities as a surgeon. In addition, it is crucial to maintain a calm and composed demeanor intra-operatively, especially when managing diverse personalities in the OR. Leaning on social support and using stress management techniques like meditation,^E13 box breathing,^E14 and mindfulness sessions^E15 have all been previously described to have both personal and professional benefits. Therapy or physician support groups may also be considered when appropriate. Maintaining good sleep hygiene is also essential for mood regulation, memory consolidation, and cognitive function.^E16

As the mantra goes, a reputation takes years to build and just a split instant to ruin. It is paramount to never let emotions dictate how one speaks to a patient, colleague, trainee, mentor or other team members. Trainees should adopt strategies for managing emotions early on and adhere to them during difficult moments. Finally, aiming to have a healthy work-life balance and pursuing personal hobbies outside of surgery can help reduce burn-out rates and improve long-term career sustainability.^E17

Habit 4: Leadership Development

Leadership is one of the most essential and underestimated skills in cardiothoracic surgery. Although the ability to lead a complex operation or respond decisively in critical moments is vital, the most effective leaders are also those who invest in building trust, communicating with empathy, and elevating the people around them. Fortunately, leadership is a practice that can be cultivated every day.

Trainees can begin by taking steps, such as offering to help organize the team's workflow on rounds, mentoring junior learners, or being intentional about their tone during high-stress situations. Being open to feedback and reflecting on previous actions are important habits that contribute to growth. The next and equally important step in leadership development during residency is the responsibility to teach and mentor junior trainees. The influence of residents on medical students and interns cannot be overstated—an engaged, approachable, and supportive resident often serves as one of the strongest recruitment tools for our specialty. Conversely, a negative or dismissive attitude can dissuade talented students from pursuing a career in cardiothoracic surgery. By modeling professionalism, enthusiasm, and patience in clinical and operative settings, residents not only foster the growth of those around them but also shape the culture of their training program. Cultivating these habits early in residency helps develop the interpersonal skills and collaborative spirit essential to success in academic and clinical practice.

Conclusions

The field of cardiothoracic surgery requires mastery of several clinical disciplines, precise technical skills, and a commitment to academics and lifelong learning. For the junior surgical trainees who have chosen a career in cardiothoracic surgery, this guide provides a structured framework to progressively establish a strong foundation in the 3 central tenets of the specialty. Although the road to becoming a master surgeon is long and rigorous, we believe a proactive approach and commitment to gradual and continuous self-improvement will make a profound difference in one's growth and success. Ultimately, by fostering deliberate preparation early in training, we can cultivate the next generation of cardiothoracic surgeons who are not only technically excellent but also thoughtful, resilient, and purpose-driven leaders.

Conflict of Interest Statement

The authors reported no conflicts of interest.

The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.