Thoracic Surgery Residency Program

First Year

Overview

The Allegheny Thoracic Surgery program provides a flexible training system, which allows the resident to elect concentration in cardiac surgery or general thoracic surgery. Candidates who elect a concentration must meet all American Board of Thoracic Surgeryrequirements for Board certification in cardiothoracic surgery and conform to ACGME/RRC guidelines for thoracic surgery training. This flexible approach was developed in response to the changing career goals of prospective residents and has been very well received by candidates for the Allegheny program.

The resident is either the operating surgeon or the first assistant on every operation in which he or she participates, with the exception of a few very complex procedures for which a second faculty member will act as the assistant. The resident is expected to evaluate and discuss all patients with the attending surgeon prior to surgery and review all relevant diagnostic tests. The resident is expected to see each patient on his or her rotation service in the ICU on a daily basis and to participate in the majority of direct care. Residents are required to write progress notes in the medical record for all patient contacts. Their work on the patient floors is fully supported by 5 dedicated cardiothoracic physician assistants.

The first-year thoracic surgery resident is on call no more than every fourth night and is the first person to be called for management decisions on all critical issues in the ICU, the step-down unit or the regular nursing floor. Residents are encouraged to seek advice and supervision from faculty, consulting physicians and support staff as needed. Year one residents are expected to consult with the chief resident as the first line of support, if feasible.

CORE COMPETENCY TRAINING FOR THORACIC SURGERY RESIDENTS

Core Competency Training in a subspecialty residency is a continuation and reinforcement of training tha teach resident has received in their prior, qualifying residencies. The core competency training approach of the Allegheny Program begins with assessment or prior learning in each area and identification of any necessary remedial educational. This is done as part of the program=s formal evaluation process as described below. Formal training in the core competencies will focus on specific applications of each competency to the practice of thoracic surgery, as described below.
In the AGH Department of Cardiothoracic Surgery, general competencies will be formally assessed by the program faculty using the Thoracic Surgery Director=s Association Comprehensive Evaluation Tool (v1.1) twice each year. The Department's Basic Evaluation Tools will also be used to evaluate clinical incorporation of these skills 5-6 times each year. Additional assessment methods are described below.

PATIENT CARE
Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents are expected to:

Communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families
Counsel and educate patients and their families
Approach patients and their families in a manner free of bias and informed by an understanding of the psychological and social responses to serious illness.
Demonstrate the ability to ensure that patients and families achieve a level of understanding sufficient for informed consent and decision-making.
These skills will be demonstrated by the faculty as role models, and the ethical and health-promoting value of these traits will be discussed. Thoracic surgery residents will be expected to demonstrate and teach these skills to subordinate residents and medical students on the service.
Gather essential and accurate information about their patients
Make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment
Develop and carry out patient management plans
Use information technology to support patient care decisions and patient education
Demonstrate proficiency in patient assessment for diagnosis, selection of appropriate treatment modalities, pre-operative preparation, and post-operative and post-discharge care. These skills will be evaluated using out-patient clinic observations, reviews of written pre-operative assessment documents, clinical discussions and medical chart documentation.
Perform competently all medical and invasive procedures considered essential for the area of practice
Demonstrate increasing competency in performance of essential medical and surgical procedures as described in the AGH/TSDA Thoracic Surgery educational goals and clinical curriculum. Each will be ready for the process of Board certification at the conclusion of training.

It is not presumed that each resident will learn at the same rate. Forty plus years of training experience in the AGH thoracic surgery program has produced useful guidelines for assessing resident progress in technical skills, which is summarized by this diagram:

This diagram is used as a tool to reinforce the concept of different paths to competency among the faculty, and to more accurately inform each resident of his/her progress toward completion of the program training goals.

Provide health care services aimed at preventing health problems or maintaining health
AGH thoracic surgery residents will demonstrate the ability to practice preventative medicine and wellness during pre and post-operative outpatient clinic experience.
Work with health care professionals, including those from other disciplines, to provide patient-focused care

AGH thoracic surgery residents will demonstrate respect for fellow healthcare workers and an ability to learn from others on the healthcare team. The faculty will assess thoracic surgery resident interactions with consulting physicians, nursing staff and support staff by direct observation and discussions with staff members. Interactions will be evaluated on the basis of professionalism and effect on patient outcomes.

MEDICAL KNOWLEDGE
Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. Residents are expected to:

Demonstrate an investigatory and analytic thinking approach to clinical situations
Know and apply the basic and clinically supportive sciences which are appropriate to their discipline
Residents will demonstrate their ability to acquire and use medical knowledge by:
Demonstrating the ability to self-assess strengths and weaknesses
Asking appropriate questions and requesting supervision when needed
Demonstrating well-informed decision-making in clinical settings
Teaching assigned curriculum topics at didactic conferences
Cogent sharing of relevant clinical experiences and comments during didactic conferences
Effective clinical teaching of subordinate residents and medical students

AGH thoracic surgery residents will demonstrate a knowledge base relevant to the practice of Thoracic Surgery via achievement on the annual ABTS In-service examination.
At the beginning of training, each resident will complete a standardized course in the use of the medical library, including computer and web-based search strategies, and the use of standard medical information databases.

PRACTICE-BASED LEARNING AND IMPROVEMENT
Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents are expected to:

Analyze practice experience and perform practice-based improvement activities using a systematic methodology.
Locate, appraise, and assimilate evidence from scientific studies related to their patients health problems
Obtain and use information about their own population of patients and the larger population from which their patients are drawn
Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness
Use information technology to manage information, access on-line medical information; and support their own education
Facilitate the learning of students and other health care professionals
Understand and apply relevant patient confidentiality practices (including HIPAA regulations) in the use of patient data for practice analysis.
Maintain a database of their patients which allows them to relate preoperative acuity to mortality and morbidity outcomes. Each resident will discuss these outcomes at regular intervals with a faculty member or the program director.
Recognize and incorporate industry standard regional and national outcomes benchmarks, such as the Pennsylvania HC4 and the Society of Thoracic Surgeons database, to evaluate their outcomes.
Demonstrate their learning in this area in the monthly department Morbidity and Mortality conference. The Chief residents will be responsible for presenting the aggregate monthly department outcomes and identifying areas of concern. Cases selected for discussion will be prepared and presented by the resident who participated in the key operative procedure. The resident will be expected to cite relevant risk factors, benchmarks and findings from the medical literature.
Prepare and discuss personal case reports relevant to curriculum topics presented in the weekly didactic conferences.
Present a critical analysis of an article from the thoracic surgery literature at the monthly journal club meeting and summarize the key learning points for clinical practice.

INTERPERSONAL AND COMMUNICATION SKILLS
Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients families, and professional associates. Residents are expected to:

Create and sustain a therapeutic and ethically sound relationship with patients
Use effective listening skills and elicit and provide information using effective nonverbal, explanatory, questioning, and writing skills
Work effectively with others as a member or leader of a health care team or other professional group
The resident will demonstrate the ability to:
Effectively gather all of the information needed for diagnosis and treatment selection
Create an environment of trust and respect with the patient and his/her significant others
Maintain prompt and effective lines of communication with all members of the healthcare team. Clearly and completely document all aspects of patient care in a timely manner.
Lead or support the healthcare team as directed by the needs of the patient
Relate the value of effective communication with patients and the healthcare team to improvement in patient outcomes

PROFESSIONALISM
Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.
Residents are expected to:

Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development
Demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices
Demonstrate sensitivity and responsiveness to patients culture, age, gender, and disabilities

SYSTEMS-BASED PRACTICE
Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Residents are expected to:

• Understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society and how these elements of the system affect their own practice
• Know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources
• Practice cost-effective health care and resource allocation that does not compromise quality of care
• Advocate for quality patient care and assist patients in dealing with system complexities
• Understand the process of partnering with health care managers and health care providers to assess, coordinate, and improve the delivery of high quality, cost-effective healthcare
•

Residents are expected to demonstrate their competency in this area by:
• Taking part in discussions during the monthly department/academic meetings on the financial and political aspects of healthcare and learning to make responsible choices for his/her patients and profession.
• Incorporating resource conservation in their clinical practice and citing these concerns appropriately when presenting patient outcomes.
• Participating in regularly scheduled didactic conferences on these topics and using this knowledge

THORACIC SURGERY CLINICAL TRAINING: FIRST YEAR

Narrative Description of Year One Training: Adult Cardiac Surgery

The resident is expected to develop increasing knowledge in the management of preoperative, perioperative, and postoperative problems in cardiac surgical patients. The first year resident's patient management skills are expected to be sufficiently developed to allow him or her to fulfill call responsibilities every fourth night, with ready availability of appropriate back-up and supervision. The resident should develop increasing proficiency in myocardial revascularization procedures including the performance of proximal and distal anastomoses and the performance of internal mammary artery anastomoses. The resident should develop a knowledge of indications, preoperative management, perioperative management and postoperative management of problems in cardiac valvular disease and should begin to develop operative skills in this area.

Types of Exposure: The cardiac surgical rotation at Allegheny General Hospital is an adult cardiac surgical experience. Approximately 600 cardiac operations are performed each year at Allegheny General Hospital. Residents are exposed to a full range of cardiac surgical pathology and procedures with emphasis on myocardial revascularization, redo procedures, cardiac valve replacement or repair, thoracic aortic repair, arrhythmia surgery and cardiac assist device management.

As described in the formal curriculum, during the perioperative care of the patient the resident has extensive opportunities to learn the indications and interpretation of all standard cardiac testing modalities including transthoracic and transesophageal echocardiography, right and left cardiac catheterization and coronary angiography, peripheral angiography and vascular ultrasound, cardiac MRI, exercise and pharmacologic stress testing, cardiac MRI and pulmonary function testing. As appropriate to the test, residents learn about bedside, operating room and laboratory based applications of these procedures.

Duties: The resident is expected to develop increasing knowledge in the management of preoperative, perioperative, and postoperative problems in cardiac surgical patients as described below. Each resident is assigned to one operating room which is shared by two or three cardiac surgery faculty members who alternate their operative case days. Room assignments are changed every 4 weeks allowing each resident exposure to all faulty members during this rotation. The team assignment process ensures that each junior resident will have the opportunity for early, one-to-one exposure to the full range of cardiothoracic surgery procedures performed at this institution. Year one residents take call no more than every fourth night. Specific information on patient care responsibilities on the cardiac surgery service is found in the cardiac surgery "survivors" manual as described above.

Preoperative evaluation: In general, the year one resident spends the first two months of this rotation learning to properly evaluate patients for cardiac surgery. Many of the adult cardiac surgery patients at Allegheny undergo surgery immediately following admission for diagnostic testing/cardiac catheterization and thus are available for review in-house at least one day prior to surgery. Additional exposure to the preoperative decision process is provided for the resident in the cardiac surgery outpatient clinic. Working with the faculty each resident is involved in all phases of the decision process including evaluation and choice preoperative testing , selection of appropriate surgical candidates, selection of appropriate procedures and timing of the operation. With outpatients and many non-emergent in-patients the resident will have the opportunity to interact with patients, families and consulting physicians.

The department has pioneered the use of a validated risk-stratification model to more completely inform the preoperative evaluation process. This risk stratification system is described in the curriculum manual given to each resident at the beginning of the academic year. This risk score is used to characterize patient risk for post-operative morbidity and mortality and to provide the basis for outcomes analysis. In an abbreviated form it is used by the surgical teams to assign patients to appropriate perioperative management pathways. It is the responsibility of the attending surgeon and resident to review the evaluation process prior to the operation and to develop a surgical plan based on this process. The rational for proceeding with high or extremely high risk cases is discussed in detail with the resident and a surgical plan is formulated.

For in-patients, the resident is required to write a preoperative note in the patient chart which is then reviewed by the attending surgeon. The attending surgeons generally write an additional preoperative note stating their assessment of the patient=s risk for morbidity and mortality. In the case of patients admitted for same-day surgical procedures the resident assigned to the procedure is required to review the outpatient chart and complete a standardized evaluation form at least one day prior to surgery. The implications of this evaluation are reviewed and discussed by the resident and the attending surgeon prior to initiation of the operation.

Operative experience: In the operating room, the first year resident spends the first two months learning to properly prepare and drape the patient, open the chest, and the fundamentals of internal mammary artery harvest.

During the second two months of the cardiac surgical rotation, the resident develops advanced expertise in the management of preoperative, perioperative and postoperative problems in cardiac surgical patients. During this time the resident should begin to cannulate and place patients on cardiopulmonary bypass. Emphasis is placed on thorough understanding of the physiology and mechanics of cardiopulmonary bypass, including flow rates, cooling, re-warming, de-airing, and the fundamentals of myocardial protection. The resident learns the role of the perfusionist and how to direct and coordinate the care of the patient on cardiopulmonary bypass. The resident will begin to perform dissection of the coronary arteries, proximal and distal anastomoses of vein grafts and internal mammary artery anastomosis.

After four months, the resident should be familiar with the fundamentals of performing coronary bypass grafting via sternotomy, including the dissection of the coronary arteries and vein graft anastomoses and will spend the next months refining standard techniques and gaining exposure to more complex problems in coronary bypass surgery. During the second two months of the rotation the resident also begins to learn the indications, preoperative management, perioperative management, and postoperative management of problems in cardiac valvular disease. In the operating room the resident learns the fundamentals of exposure of the aortic and mitral valves for replacement and repair procedures. It is expected that by the end of six months the resident should be able to perform a straight forward double or triple coronary artery bypass as well as a straight forward aortic valve replacement or mitral valve replacement.

Postoperative care: As noted, the first year residents take in-house call about every fourth night. With appropriate back-up, they are able to handle postoperative bleeding, low cardiac output, cardiac tamponade, and manage complex atrial and ventricular arrhythmias with about 2 months of experience. It is expected that they will become comfortable with handling multi-system failure following open-heart surgery including pulmonary failure, renal failure, sepsis and stroke.

During the day the cardiac surgery resident is responsible for the care of patients in the surgical intensive care unit in close cooperation with the team of intensive care physicians (normally pulmonologists), pulmonary medicine residents and fellows, and a group of physician assistants. The cardiac surgery resident supervises postoperative care of all patients after discharge from the intensive care unit, assisted by physician assistants, the patient=s cardiologist, and the nurse practitioners. During nights on call the resident is the first line of defense and the first person called to manage a critically ill adult patient in the surgical intensive care unit, the step-down unit, or on the regular nursing floor.

The junior resident is expected to assume initial responsibility for postoperative care of all patients upon which s/he have operated, using the chief resident, attending surgeons, consulting physicians, physician assistants, and nurse practitioners for advice and supervision as needed to provide appropriate and safe care. The first year cardiac surgery resident is subordinate to the cardiac surgery chief resident and normally discusses postoperative care issues with the chief resident prior to calling the attending surgeon. The first year resident makes rounds on all patients in the intensive care unit on a daily basis and then discusses those patients with problems with the chief resident. The attending surgeons maintain oversight and control of patient care by discussing their expectations for communication and actions as appropriate for the status of each patient.

The requirements for supervision of all residents on the cardiothoracic services during emergencies and postoperative care of the patient are summarized on a document provided to all residents and faculty and to the institution.

THORACIC SURGERY CLINICAL TRAINING: FIRST YEAR

Narrative Description of Year One Training: Adult General Thoracic Surgery

The resident is expected to develop increasing knowledge in the management of preoperative, perioperative, and postoperative problems in general thoracic surgical patients. During the initial six month period the resident has a comprehensive exposure to surgical treatment of diseases of the chest wall, lungs and pleura, trachea and bronchi, mediastinum and pericardium, diaphragm, and esophagus. Because the resident is board eligible in general surgery, he or she is expected to learn to perform all but the most complex general thoracic procedures during this rotation.

Types of exposure: The general thoracic surgery rotation is an adult surgical rotation exposing residents to all aspects of surgical therapy for diseases of the lung and pleura, trachea and bronchi, diaphragm and esophagus. More than 800 major surgical procedures are performed each year on this service, including a full range of minimally invasive / video assisted operations and endoscopic procedures.

In the perioperative care of the general thoracic patient the resident has extensive learning opportunities in the indications and interpretation of all types of esophageal and pulmonary tests, as described in the formal curriculum.

Duties: The resident is expected to develop increasing knowledge in the management of preoperative, perioperative, and postoperative problems in general thoracic surgical patients as described below. The resident is assigned to the dedicated general thoracic surgery operating rooms, where Drs. Keenan, Maley and Dean alternate days of surgery. The resident is on call in the hospital no more than every fourth night. Specific information on patient care responsibilities on the general thoracic surgery service is found in the general thoracic surgery "survivors" manual as described above.

Preoperative evaluation: The requirements for patient evaluation and documentation are similar to those on the cardiac surgery rotation.

Operative experience: During this period, the resident has a comprehensive exposure to surgical treatment of diseases of the chest wall, lungs and pleura, trachea and bronchi, mediastinum and pericardium, diaphragm, and esophagus. During the first month, the resident quickly becomes familiar with positioning the patient for thoracoscopic and other minimally invasive approaches to pulmonary and esophageal disease. Because the resident is board eligible in general surgery, he or she is expected to learn to perform all but the most complex general thoracic procedures during this rotation.

Postoperative care: The requirements for postoperative patient care and documentation are similar to those on the cardiac surgery rotation.

Pediatric Cardiac Surgery Rotation

Children's Hospital of Pittsburgh / University of Pittsburgh School of Medicine

In January, 2001 the Allegheny General Thoracic Surgery Residency Program became affiliated with the Children's Hospital of Pittsburgh for pediatric surgery training. The Director of the service is Victor O. Morell, MD, Professor of Surgery. Children's Hospital of Pittsburgh is a full-service children's hospital with an emphasis on tertiary care of critically ill infants and children. Over 500 pediatric cardiac surgical procedures are performed here each year. It is affiliated with the University of Pittsburgh School of Medicine and serves as the medical school's hospital for pediatric training of medical students and pediatric specialty residency and fellowship programs.

Specific Goals and Requirements

The primary objective of this rotation is the application of principles of cardiac and pulmonary physiology to the postoperative care of patients undergoing cardiac surgery for congenital cardiac diseases and diseases of the major thoracic vessels with an emphasis on acute intensive care in and out of the intensive care unit-fluid management, pharmacological management, and ventilatory management.

Additionally, the application of the general principles of postoperative surgical care, including incision and pulmonary care, instruction in basic technical skills and operative techniques, and exposure to the operative therapy of patients with congenital diseases of the heart and major thoracic vessels are components of the experience in cardiac surgery.

The educational goals of the specific rotation in Pediatric Cardiothoracic Surgery at Children's Hospital of Pittsburgh are:

To meet the educational objectives of the American Board of Thoracic Surgery regarding pediatric cardiothoracic surgery.

These goals specify hands-on operative experience and patient care experience with children being treated for congenital heart disease and acquired pediatric heart disease.
The educational goals are designed so as to meet the required numbers of patient contacts within a three-month period, to give supervised clinical experience and instruction to the trainee during that period, and to provide didactic education experience's, including clinical review seminars and research seminars, such that the trainee win be able to establish an outline for his self -education in the focused area of pediatric cardiothoracic surgery.

The specific learning objectives of the program are:

To provide the trainee appropriate clinical operative experience in uncomplicated congenital heart disease repairs

The resident can understand both the nature of repairs typically done within the specialty of congenital heart surgery and have this background information as a standby should the resident in the future experience patient care needs representative of congenital heart defects.
The resident understands the field of congenital heart surgery and congenital heart disease as currently diagnosed and practiced.

Includes the management of infants and children presenting with cyanotic heart disease, heart disease with pulmonary overcirculation, inadequate pulmonary blood flow situations such as pulmonary atresia, single ventricle heart disease, and disease of the great vessels within the chest, including coarctation of the aorta, vascular rings, pericardial disease, and mediastinal disease

The resident should open and close sternotomy and thoracic incisions, should cannulate and de-cannulate from cardiopulmonary bypass, and should perform pacemaker implantations and revision in children and infants weighing less than 30 kg.
The resident should become familiar with pediatric cardiac surgical problems

Develop a working knowledge of evaluation, perioperative care and postoperative management.

The resident should become proficient in the correction of simple, pediatric cardiac surgical operations including coarctation, atrial septal defects, and ventricular septal defects.
The resident should be knowledgeable in the correction of the more complex problems to the end that the resident becomes an accomplished first assistant in these procedures.

Resident Clinical Evaluation

The resident will be evaluated by daily observation in terms of patient care management, participation in conferences. and eventually by adequacy of participation in board examinations. The resident on rotation will be given an oral evaluation by the faculty and will be requested to provide information on the quality of the rotation and suggestions for its approval.

Duty Hours

The AGH resident on rotation will not be expected to take call in the hospital. The resident's patient care responsibilities will be shared by one or possibly two residents or fellows on the service at the same time, by Pediatric Critical Care Medicine fellows on rotation on the service and by Pediatric Cardiology fellows on rotation on the service.

Medical Knowledge - Congenital Heart Disease and Pediatric Cardiac Surgery

The program's curriculum is that of the entire subject of Pediatric Cardiac Surgery. A basic understanding will be required from a cardiothoracic surgery textbook standpoint: of the diagnosis and management of congenital heart disease, the nature history of this disease, and the long-term prognosis of patients treated for this type of disease.

The requisite knowledge and skill objectives for this rotation are outlined in Section VII of the formal Thoracic Surgery Director's Association curriculum ("Congenital Heart Disease"). These topics are taught as a component of the program's cardiothoracic teaching conferences.

Duties, Types of Exposure, Responsibilities

Pediatric Cardiac Surgery Rotation

Type of Exposure: Dr. Morell and his team manage the full spectrum of congenital and acquired heart disease in infants and children, including heart and lung transplantation. Due to the large number of operations performed, the resident is exposed to virtually every palliative or corrective operation for congenital heart disease.

Responsibilities in preoperative evaluation: The resident is expected to evaluate each patient preoperatively, discuss the planned operation with the parents or family, and obtain the consent for operation.

Operative experience: Each Allegheny resident typically performs 10-15 operations as the operating surgeon for closed heart operations, palliations, open heart operations or total repairs. The resident typically serves as the first assistant on approximately 30 additional open heart operations, total repairs or closed heart operations. The resident is always expected to first assist on any operation in which he or she is not the operating surgeon.

Postoperative care: The resident is expected to provide all aspects of postoperative care but has available highly qualified individuals (surgeons, cardiologists, pediatric intensive care physicians, physician assistants) for advice and supervision as needed and requested.