Self-perceived video-assisted thoracic surgery lobectomy proficiency by recent graduates of North American thoracic residencies

Abstract

Minimally invasive surgical techniques offer several advantages over traditional open procedures, yet the pathway to minimally invasive proficiency can be difficult to navigate. As a part of an effort of the Joint Council of Thoracic Surgical Education to increase access to this skill set in the general thoracic community, recent graduates of thoracic residencies were surveyed to determine the self-reported achievement of video-assisted thoracic surgery (VATS) lobectomy proficiency and the merits of various educational opportunities. The objective of this study was to estimate the comfort level of recent graduates with the minimally invasive approach, as this demographic not only reflects the current status of training, but represents the future of the specialty. Surgeons graduating North American thoracic residencies between 2006 and 2008 identifying themselves as practitioners of general thoracic surgery were surveyed. A total of 271 surgeons completed training between 2006 and 2008 and indicated general thoracic to be a part of their practice (84 dedicated thoracic and 187 mixed). One hundred and forty-six surgeons completed the survey (54%) including 74 of 84 (88%) dedicated thoracic surgeons. Overall, 58% of recent graduates who perform general thoracic procedures consider themselves proficient in VATS lobectomies (86% of dedicated thoracic surgeons and 28% of surgeons with a mixed practice, P < 0.0001). Of surgeons considering themselves to be proficient at VATS lobectomies, 66% felt thoracic residency was critical or very important to achieving proficiency. Fellowships after completing board residency, animal labs, and follow-up VATS courses put on by experts were much less consistently beneficial. The vast majority of the 25 dedicated general thoracic surgeons who graduate each year consider themselves proficient in VATS lobectomies, largely due to training in their thoracic residencies. On the other hand, the minority of surgeons performing general thoracic procedures as a part of a mixed practice consider themselves proficient in VATS lobectomies. Further study is warranted to enhance the VATS lobectomy experience of mixed practice surgeons particularly during their thoracic residencies.

INTRODUCTION

Video-assisted thoracic surgery (VATS) lobectomy appears to be a safe alternative to open lobectomy, accomplishing the same oncologic objectives and offering a number of advantages with respect to perioperative recovery and patient satisfaction [1, 2]. Despite these advantages, less than 10% of lobectomies are performed using VATS techniques in the USA [3]. It is uncertain whether the relative infrequency of VATS lobectomies has an impact on the ability of thoracic residents to acquire this skill set.

Many thoracic training programmes participate in the Society of Thoracic Surgeons (STS) General Thoracic Surgical database. The trend in this database has been for a greater proportion of lobectomies to be performed by VATS, increasing from 22% in the 2007 data harvest [4] to almost 40% in the 2010 harvest (personal communication from the STS database). The increase in usage suggests that potential general thoracic educators are themselves in the process of acquiring VATS lobectomy skills. It is unclear whether or not the learning curves would affect the quality of educational experience for the residents [5, 6].

In response to a surge in interest in developing minimally invasive skill sets by thoracic and cardiovascular surgeons, the Joint Council of Thoracic Surgical Education appointed a committee charged with clarifying the current status of minimally invasive skill sets in the thoracic community and identifying pathways to minimally invasive proficiency. As an initial step towards these objectives among early career general thoracic practitioners, the committee compiled data from two surveys designed to communicate subjective impressions of VATS lobectomy proficiency, as a reflection of comfort levels with this approach.

METHODS

Thoracic Surgery Residents Association in training exam survey

Beginning in 2006, the Thoracic Surgery Residents Association (TSRA) began to link a survey to the in-training examination. In 2008, the survey included questions relating to the training of minimally invasive techniques. A total of 256 residents answered the survey (100% response rate). Several of the data elements of this survey have been reported previously [7].

Joint Council survey

Surgeon identification

The profiles of North American Thoracic Training Programmes were screened for graduates between 2006 and 2008 (http://www.ctsnet.org/cfapps/programs/).

A total of 413 surgeons were identified and the profile of each surgeon was examined on CTSnet (http://www.ctsnet.org/sections/members/surgeons/). Surgeons who indicated a general thoracic surgery component to their practice were sent a survey in April 2010. A follow-up posting to encourage participation led to a total of 146 surgeons taking the survey (54%).

Survey instrument

A total of 19 questions concerning VATS lobectomies and minimally invasive oesophageal surgery were compiled and distributed via email. The questions pertaining to this study are available in Appendix A, (Supplementary material). The term ‘proficiency’ was intentionally not defined more specifically than ‘skilled’ to allow surgeons to impose a completely subjective impression.

Statistics

Differences between the groups of practitioners were calculated using the Fisher exact test with a two-tailed P-value using GraphPad software (GraphPad, Inc.).

RESULTS

2007 Thoracic Surgery Residents Association survey

Thoracic residents were asked whether or not they felt adequately trained in VATS lobectomy. Overall, 45% of residents indicated that they did not feel adequately trained in VATS lobectomy (Table 1). This pattern was not dependent on the year of training as 50% of residents in their second year were similarly concerned.

Table 1:

TSRA 2008 survey: Do you feel your CT residency provided appropriate training in the following areas?

	Year 1a	Year 2	Year 3	Fellow	Total
Open lobectomy
Yes (%)	86	97	23	29	235 (92%)
No (%)	6	6	0	9	21 (8%)
VATS lobectomy
Yes	59	50	12	19	140 (55%)
No	33	53	11	19	116 (45%)

^aYear of training at time of survey

2010 Joint Council survey: respondents

A total of 271 surgeons of the 413 (66%) completing thoracic residencies between 2006 and 2008 indicated general thoracic surgery to be part of their practice on their CTSnet home page. Eighty-four surgeons were exclusively general thoracic (dedicated thoracic surgeons), while the other surgeons have a mixed practice. Among mixed practice surgeons, 67% indicated general thoracic to represent between 10 and 25% of their practice, while 15% indicated general thoracic was ≥75% of practice.

The overall survey response rate was 54% (146 of 271) and among dedicated thoracic surgeons, the response rate was 88% (74 of 84).

Lobectomy volumes and technique

Surgeons were asked to estimate their yearly lobectomy volumes for their first 3 years of practice. 30% of the respondents indicated that the data came from a database (personal or STS), while 70% simply estimated from recollection. Among all respondents, most surgeons performed between 1 and 10 open lobectomies in the first year, increasing such that by the third year of practice 62% of surgeons were doing 11 or more a year (Table 2). For VATS lobectomies, numbers in the first year of practice were similar to open, but also seemed to increase in the second and the third year of practice. There were no dramatic differences in the numbers between dedicated thoracic surgeons and mixed practice surgeons (data not shown).

Table 2:

Lobectomy volume estimates by year of practice (% of respondents)

	1–10	11–20	21–30	31–40	41–50	51–75	>75
Open lobes
Year 1	54	21	15	2	4	2	2
Year 2	45	22	19	7	1	4	2
Year 3	38	23	18	11	3	3	4
VATS lobes
Year 1	59	22	8	4	6	0	1
Year 2	39	28	13	9	5	4	2
Year 3	47	15	12	9	7	5	5

VATS proficiency

Overall, 58% of early career thoracic surgeons considered themselves proficient (skilled) in VATS lobectomies (all thoracoscopic, no rib spreading). Dedicated thoracic surgeons were more likely to consider themselves proficient (86%) compared with surgeons who indicated a mixed practice (29%; P < 0.0001).

Value of educational activities

Surgeons were asked to indicate the educational importance of 10 different educational opportunities towards the acquisition of VATS lobectomy skill sets. The responses of the surgeons who considered themselves to be proficient are listed in Table 3.

Table 3:

Perceived importance of various education opportunities in developing proficiency as determined by respondents who consider themselves to be proficient

	Criticala (%)	Very importantb (%)	Important (%)	Not helpful (%)	Number of respondents
CT residency (used to fulfil board requirements)	38	28	24	10	71
Post-graduate fellowship	28	15	21	36	47
Mini fellowship (< year)	6	11	33	50	36
VATS course (1–7 days by experts)	4	13	50	33	46
Follow-up VATS course	0	6	43	51	35
Animal Lab	0	6	42	53	36
Observership (shadowing a proficient surgeon)	8	23	33	36	39
Mentoring (where you are on staff)	11	35	26	28	46
Technical literature	7	18	54	20	54
Trial and error	24	22	44	11	55

^aNot possible without.

^bA major factor in the current technique.

Seventy per cent of surgeons indicated that the thoracic residency used to fulfil board requirements was critical or very important to their technique. Less consistent credit was given towards post-graduate fellowships, mini-fellowships and VATS courses.

DISCUSSION

These data indicate that each year an average of 25 graduates of North American thoracic training programmes adopt an exclusively general thoracic surgery practice. In addition, at least 20–25 graduates per year perform general thoracic surgical procedures as a part of a mixed practice. Given the response rate, the true number of mixed practice surgeons is likely higher, but it is also likely that many of the non-responders do not perform general thoracic procedures. What is clear is that a significant number of North American Graduates who are less likely to ‘track’ into a dedicated general thoracic curriculum will ultimately care for general thoracic surgical patients. This fact must be kept in mind as training is streamlined between the various pathways.

The surgical volumes provide nothing more than a rough estimate of early career practices in this era, and we strongly caution against placing any weight on the actual numbers. We say this not only because of the inherent error rates in surgical volume estimates (less than one-third were from databases) but 22 surgeons (14%) skipped the question (of note, the volume of ‘0’ was actually not given as an option).

VATS lobectomy proficiency is likely comprised of variables that range in their accessibility from the clearly defined (case volumes, operative times, morbidity and mortality), more difficult to measure (conversion rates, completeness of resection and costs) to areas that are more vague and subjective (adequacy of lymph node evaluation, local control, perioperative pain control and overall patient satisfaction). Even if the culmination of such data was done, the results would be subject to a number of confounding patient and surgeon variables. The most likely realization would be that proficiency, while a universally enviable endpoint, is not uniformly defined.

We do propose, however, that there is an intrinsic value in one's own perception of his or her proficiency, as this reflects a surgeon's comfort with the procedure. Although not a surrogate for safe and effective surgery (on occasion the incompetent claim proficiency and the skilled express uncertainty), we postulate that self-assessment provides a window into the overall capabilities of this group of surgeons. The data suggest that the impression given from the 2008 TSRA survey (that almost half of thoracic residents were concerned about the adequacy of their VATS lobectomy training) to some degree persists in the same group of surgeons 2 years into their practice (because both surveys were anonymous, there is no way to link the respondents between the two surveys directly).

The Joint Council survey illustrated a split between dedicated thoracic surgeons and surgeons with a mixed practice. While to some degree this may not be surprising, as the current time constraints of thoracic training and the frequency of VATS lobectomies in North America pose barriers to developing the VATS skill sets in many training institutions. One would anticipate the greatest motivation to overcome these barriers would be in those whose entire practice will be thoracic surgery. Perhaps a bigger issue is whether North American Thoracic residencies are providing the same opportunities to develop VATS skill sets to all practitioners of general thoracic surgery (dedicated and mixed practice), something to keep in mind as competing ablative and radiation-based technologies gain traction among patients (irrespective of efficacy).

The relative utility of educational opportunities, much like the case volumes, should be taken as a rough estimate. By concentrating on those surgeons who consider themselves proficient, we hoped to identify the extremes within these categories (highly likely or highly unlikely to be helpful). These data are clearly dominated by individuals who gained significant VATS instruction during their residencies. It must also be kept in mind that this really only applies to early career surgeons, as individuals at different stages may report a completely different valuation (therefore, no activity should be discounted). Perhaps the most valuable observation is that no opportunity stands out as a uniformly critical resource, which is encouraging that the pathway to proficiency has multiple avenues. That being said, early career thoracic surgeons are advised to research the listed opportunities carefully, as the lack of consistent support may reflect a spectrum of quality in these educational opportunities.

Major limitations are intrinsic to all survey studies, namely whether the study accurately represents the true status of the population. First the target surgeon pool was identified by CTSnet profile, which may not capture all general thoracic practitioners. Although we would assume that in the current era of internet based physician searches surgeons would be motivated to maintain accurate profiles, it is quite possible that the surgical volumes of early career surgeons would paint a very different picture. Next, although the response rate was greater than 50, only 38% of surgeons who indicated a mixed practice on their CTSnet page responded (which may in fact reflect an inaccuracy of the CTSnet profile or a true lack of participation in this subset). A third limitation relates to whether or not the instrument used to survey the surgeons captured our objective sentiment. We had hoped to estimate the comfort level with the minimally invasive approach and self reported proficiency, while undeniably vague, is hard to misconstrue as being anything other than comfortable with the procedure. Finally, one could argue the relevance of surgeon comfort level. We feel that surgeon comfort is a reasonable interim metric to inform decisions that direct limited Joint Council resources towards the expansion of post graduate training opportunities.

In summary within their first 3 years of practice, just over half of the graduates of North American Thoracic Residencies that perform general thoracic procedures consider themselves to be proficient in VATS lobectomies. It appears that the vast majority of dedicated thoracic surgeons are comfortable performing VATS lobectomies, while this is less common among mixed practice surgeons. As training programs continue to evolve more specialized pathways, it is worth considering the impact of the cardiac and thoracic ‘tracked’ curriculum on the VATS experience, particularly among surgeons likely to adopt a mixed practice.

SUPPLEMENTARY MATERIAL

Supplementary material is available at ICVTS online.

Conflict of interest: none declared.