Commentary: All roads lead to Rome? The many paths to cardiothoracic surgery

Ravi K. Ghanta, MD, and Shawn Groth, MD

Central Message.

Multiple training pathways in cardiothoracic surgery widen the net for recruiting talented cardiothoracic surgical trainees and provide educational diversity, which may foster innovation.

See Article page 297.

Cardiothoracic surgical education has rapidly evolved over the last 2 decades to incorporate numerous training pathways that culminate in certification by the American Board of Thoracic Surgery.¹ Presently, there are 6 training pathways: traditional 5/2, traditional 5/3, joint 4/3, integrated 6-year, vascular surgery/2, and vascular surgery/3. After further combining these pathways with the option of selecting a “cardiothoracic” or a “general thoracic” focus, 12 distinct educational phenotypes exist at the completion of training. With so many paths, program directors and residents often debate the “best” path for our specialty.

In this issue of JTCVS Open, Dr Baker² provides his expert opinion on the optimal path for cardiothoracic training. He succinctly builds a case for the integrated 6-year (“I6”) model based on the I6 experience at the University of Southern California, and he defines the characteristics of an ideal training program. We will highlight a few of his suggestions that are relevant to all training pathways. First, trainees should have early and consistent exposure to cardiac, thoracic, and vascular surgery during the first 3 years of residency. While this is relatively easy to accomplish within an I6 training pathway, it's more challenging for the traditional pathway, given the declining exposure to cardiothoracic and vascular surgery among many general surgery residency programs.³ We believe it is incumbent for cardiothoracic faculty to advocate for medical student and general surgery resident rotations in cardiothoracic surgery and to provide a high-quality, educational experience for students and residents on those rotations. This will likely increase the pool of applicants applying through either pathway and provide valuable technical and critical care management skills for all surgical trainees, regardless of his or her career interests. Second, Dr Baker suggests trainees perform 1 to 2 years of dedicated research in the middle of training. This has been a staple among many academic training programs and has been shown to increase academic productivity.⁴ We believe the option to pursue 1 to 2 years of scholarly activity is important to establish academic focus, career selection, and overall analytical skills. Finally, Dr Baker suggests 8-12 months of “elective” time during the final years of training as well as the flexibility to rotate at other institutions. The length of available elective time will vary between 2, 3, 4/3, and 6-year programs. Although funding can be challenging, reinventing “elective” rotations may become increasingly critical for thoracic surgery education to keep pace with the evolution of cardiothoracic surgery. A rising number of subspecializations in cardiothoracic surgery are emerging, such as heart failure, structural heart, complex aorta, esophageal disorders, and lung transplantation. To accommodate the educational needs of trainees entering increasingly complex subspecialized practices, we believe that these elective specialty rotations are invaluable in the maturation of cardiothoracic surgery trainees and should be incorporated within all training pathways. Naturally, the implementation of these electives will vary depending on the size and practice scope of individual training programs. Importantly, decoupling workforce needs from resident education should enable more “specialization” rotations at the home institution and at other institutions.

Dr Baker suggests that the integrated training program is the optimal training pathway and provides an insightful rationale. We agree that the I6 program will play a fundamental role in the thoracic surgery educational ecosystem. However, multiple training pathways should be preserved. Diversity of educational experience may further foster innovation, which is critical in cardiothoracic surgery. Each pathway brings specific strengths and widens the net to recruit talented, diverse individuals to cardiothoracic surgery. Importantly, a number of immensely talented graduates from general and vascular surgery programs enter cardiothoracic residency each year, highlighting the need to preserve and nurture these training pathways. Furthermore, different practice environments will require different degrees of subspecialization. The optimal residency training model may depend on the ultimate career destination for the resident. At present, the optimal training pathway is not yet defined; however, careful tracking of career readiness should be done and educational paradigms should be modified based on real-world data.