General Session

TSDA General Session in Conjunction with the Annual ACS Meeting
October 5-7, 2002
San Francisco Hilton
San Francisco, CA

SUMMARY:

Work Hour Issues Facing Cardiothoracic Surgery
An interesting program was presented discussing the real or imagined impact of work hour restrictions on our residency programs. The overall consensus was that these restrictions are real, we must comply by July 2003, and we must develop new solutions. A more comprehensive set of program notes is included later in this Newsletter.

Curricular Reform:
Introduction
Ed Verrier gave a very brief introduction of a topic which will be the focus of our next meeting in San Diego: “How Do We Implement Curricular Reform in Thoracic Surgery?” This topic has floated around the various educational organizations in surgery (TSDA, JCTSE, TSRRC, ABTS, ABS, APDS, ABMS, JCSS) for the last several years, and we are now close to being ready for significant new options and implementation. The Thoracic Surgery RRC has addressed this issue recently and developed a draft “white paper” by Doris Stoll (our ACGME representative) which was included in the distributed binder. All program directors are encouraged to read this draft proposal and send in comments to TS representatives to the RRC (Mathisen, Fullerton, Verrier) or to Doris Stoll at the ACGME offices, as the TS-RRC will formalize this document at their next meeting in January.

Evaluation Tool
Following the Baltimore meeting, the Executive Committee approved development of a CD-ROM disc, a 360 degree evaluation programmed by Bill Begg which would help Program Directors improve their resident, faculty, rotation, and program evaluations consistent with the ACGME imperatives based on “competency.” This disc was then evaluated by the TS-RRC and beta tested in a few programs. Our RRC felt that if programs used this format, they would easily meet the “competency” requirements of the RRC, and those that beta tested the product had some suggestions which will be included in the next version. Overall, those who did the testing felt that the format was solid and usable. Bill presented this disc to the Program Directors in attendance in some detail, and we distributed the disc and an instruction manual to everyone present. The overall impression is that this tool will be of value to both established and new Program Directors in meeting the new guidelines required by all programs in July 2003. If you are interested in receiving this product and were not at the meeting, please call or e-mail Tom Fise in our administrative offices (tsda@mindspring.com) or Bill Begg (bbegg@tsda.org).

Prerequisite Curriculum Report (Jeff Gold, MD)
As you know, the TSDA, under the leadership of the Prerequisite Curriculum Committee chaired by Jeff, created a CD-ROM/Internet hybrid educational took for incoming residents. Using a clinical trial format under IRB approval, we distributed these discs to half of the July 2002 incoming residents and asked them to use this in preparation for their CT Residency. We then used the “in training service exam” in August to assess whether this tool had any impact on their knowledge of thoracic surgery. Jeff gave an excellent presentation of the preliminary data. I am including at the end of this Newsletter a report that Jeff has submitted to the ABTS because I believe it gives preliminary insight into the potentials of this educational technology. Additionally, an abstract based on these results is being prepared for submission to the AATS Program Committee. A second generation of the CD-ROM curriculum tool has been prepared for distribution to the half of the trial group who did not receive the original disc, to the second or third year residents already in training who might find this useful, and to all program directors who might want to include this in their armamentarium of educational tools. This product was distributed to all Program Directors at the meeting and is available to the remaining Program Directors by communicating to our administrative offices.

Navigation Tool (Jeff Gold, MD)
Jeff perceived a need to develop a navigation tool to coordinate all of Thoracic Surgical educational material (curriculum, post graduate courses, society meetings, textbooks, journals, databases, etc.). Such a navigation tool would be more topic oriented than meeting or resource oriented. On a broader scale, such a tool might have implications for “continuing new education” which we will be responsible for documenting for the rest of our professional lives. Jeff presented this tool to all of us, and the topic was warmly received. The implications for developing such an important tool are huge, particularly politically and financially. Every surgical society or journal that has educational content will have a vested interest, and the financial/personnel resources to bring such a system to life are significant. The TSDA Executive Committee will grapple with these strategic and operational issues over the next few months… very impressive and exciting to say the least!

Executive Committee Meeting (October 7, 2002)
The TSDA Executive Committee met for three hours on Monday morning and basically critiqued the just completed ACS stand-alone meeting. It also defined the emphasis of the next meeting in January.

Critique of ACS - Stand Alone TSDA meeting
The content and quality of the TSDA-ACS meeting were excellent, but there was a need for more concrete recommendations that Program Directors could take home and use for their own programs. Every Program Director faces unique/local work hour issues and has unique resources (support from GS, ability to negotiate additional physician extenders, ability to implement at home call schedules, ability to recruit non-accredited fellows, etc.). Programs with 3 residents/year for 3 years with 3 residents in the lab are different from a smaller program with 1 resident/ year for 2 years with no one in the lab. It was recommended that we 1) develop a synopsis of this program in a written format, 2) survey various sized programs and ask their Directors to outline their exact proposed 80 hour work week schedules, 3) distribute a draft document to all Program Directors with more concrete examples of solutions within the next 2 months, 4) place the Power Point presentations from this last stand-alone meeting on the TSDA web site, and 5) focus on the work hour issue again at the STS meeting in January. I will try to review all of the presentations and slides and develop a “laundry list” of possible recommendations from our discussants for distribution. I will also ask a few Program Directors to forward us their new on call schedules.

Timing of the STS-TSDA Meeting
As you may be aware, the STS meeting this year is different than in the past because there is a combined AATS/STS Technology conference preceding the scientific STS meeting. The Tech/Con begins on Wednesday, January 29, 2003 and concludes on Thursday (January 30, 2003); the STS scientific meeting then begins on Friday (January 31, 2003) and concludes on Sunday (February 2, 2003). That does not leave much time for the TSDA meeting, which usually occurs on the Saturday prior to the Monday meeting of the STS. We have asked Bill Baumgartner if we could still have our TSDA meeting on Thursday afternoon, recognizing we will be in conflict with a portion of the Technology meeting. The STS has a rule that satellite society meetings cannot conflict with the scientific sessions of the STS, but Bill has given us permission to have the TSDA meeting on Thursday afternoon even though the technology meeting will not be completed. Most likely the meeting will be 1:00 – 5:00 p.m., but we could expand the hours to 12:00 – 6:00 p.m. depending on how the program evolves over the next month or so.

Curriculum Reform Implementation
Last year the Joint Council of Thoracic Surgery Education made nine recommendations to change and hopefully improve thoracic surgery education. Members of the TSDA have had these recommendations presented to them at our meetings previously, so I will not restate them here other than to report that the most critical recommendation was to drop the requirement for American Board of Surgery certification as a prerequisite for ABTS certification. This has opened up a variety of possibilities in TS education including: 1) the present 1/2 or 3 residency leading to dual Boards in GS and TS, 2) 6-year integrated program in TS leading to one Board in TS with residents being matched out of medical school, 3) some sort of a 3 or 4-year core surgical curriculum, then a 3-year TS residency leading to ABTS for cardiothoracic, or 4) some sort of more universally accepted shorter GS core curriculum leading into a subspecialty such as TS or vascular surgery curriculum of 2 or 3 years, but still leading to 2 board certifications. The recommendations of the Joint Council have now been tentatively approved by the ABTS and by the TS-RRC. The concepts have also been discussed by the APDS and the ABS and it looks like an option such as the last may be adopted by the ABS and the APDS.

Report from ABS Retreat (Irv Kron, MD)
Irv Kron (Chairman, UVA) is the TS representative on the American Board of Surgery. He presented the recent deliberations of the ABS retreat held in January 2002. The ABS took the preliminary recommendations of an ad hoc committee of surgical subspecialties and tentatively accepted the proposal of a reduced 4-year GS curriculum followed by a 1-year curriculum in advanced GS, a 2-year curriculum in vascular surgery and probably a 3-year curriculum in CT. Such a curriculum plan would lead to dual certification. The ABS also agreed to change the date of the qualifying exam so that it would not interfere with the first year of subspecialty training…something we have been arguing in favor of for a long time. This plan then went back to ABTS for further discussion (some on the ABTS still argued for a 3-year GS core even though that was strongly opposed by the APDS) because they felt they could not logistically design a reasonable, predictable GS curriculum if every subspecialty demanded their own unique prerequisite curriculum). The ABS approved this plan and is presently awaiting support from the ABTS. The Executive Committee of the TSDA believes this compromise is the best option for TS to work with the APDS for new meaningful curricular options in surgery. By January 2003 we should know the deliberations of a planned ABTS retreat to further discuss this issue.

Plans for STS – TSDA January Meeting
The preliminary plans for the January TSDA Meeting have evolved as follows:

• Continue the discussion of work hours with an emphasis on hard core recommendations (tangible, practical) to achieve compliance by July, 2003 for every TS Program
• Report from the ABS on their perspectives of curricular reform by Irv Kron
• Report from the ABTS on their perspectives of curricular reform by Peter Pairlero or some other member of our board
• Report from the TS-RRC on the requirements necessary to change your present curriculum (expansion of the current “white Paper” under consideration)

The Executive Committee also considered having some breakout sessions dealing with the following type of issues (very preliminary):

• Current 5 / 2: How to make it better?
• Current 5 / 2: Should it go to 5 / 3?
• Integrated 6-year program: How to make transition?
• Integrated 6-year program: What should the curriculum look like?
• Integrated 6-year program: How can you as PD ensure quality?
• Integrated 6-year program: How to negotiate with GS to get the rotations your 6-year resident needs?
• Integrated 6-year program: Logistics of preparing for the RRC request?
• New 4 / 3: How to optimize the 4 prerequisite years, working with APDS?
• New 4 / 3: What should the 3 requisite years look like?
• New 4 / 3: Logistics for preparing for the RRC presentation?
• Contemplating curricular changes: Can or should you have more than one option within your present program? (one resident on 5 / 2, the other integrated)
• Contemplating curricular changes: Can we design this transition prospectively for academic enrichment? How to design a meaningful database or clinical trial?  

Proposed Program for TSDA Meeting
Saturday October 5, 2002
San Francisco Hilton Hotel
San Francisco, California
1:00 – 5:00 PM Room: Continental 5

1. WELCOME
2. Formal TSDA Program: “Work Hour Issues In Thoracic Surgery (1:00PM – 3;00PM)
   
   
   1. Ed Verrier, MD moderator
      
      1. EDV: New ACGME Guidelines, Potential Impact on Cardiothoracic Training
      2. Douglas Mathiesen, MD(Chair, Thoracic Surgery RRC / Doris Stoll, TS RRC ACGME Representative: “Report of September ACGME Retreat”
      3. Susan Moffit-Bruce, MD TSRA perspective: “Results of the Resident Work Hours Survey”
      4. Carlos Pellegrini, MD Chairman University of Washington, “ACGME surgical representative: Implication of Work Hour reform on surgical subspecialties from the Chairman’s perspective”
      5. Paul Friedman, MD Chairman of ACGME Work Hour Task Force Dr Friedman is in SF during this time and will try to be at this meeting to answer other specific questions and participate in the discussion
      6. Thoracic Surgery Program Perspectives:
         
         1. Jeff Gold, MD: “The New York Perspective, How to Become More Efficient in Resident Teaching”
         2. John Elefteriades, MD: “Yale Perspective: What happened to the GS program at Yale to lose accreditation due to work hour excess; impact on CT program at Yale”
         3. Curt Tribble, MD: “Virginia perspective: A larger TS program with a TS surgeon as chair, good or bad?”
         4. Keith Naunheim, MD: “Washington U: Perspective from the Heartland”
         5. Dave Fullerton, MD: “Northwestern: Perspective of a smaller program, ? faculty with in-house call”
         6. David B. Ross, MD: “Ottawa: The Canadian Perspective, more experience over a longer time frame? Are there any positives?
3. Refreshment Break (3;00 – 3:20PM)
4. Curricular Reform: Introductory Presentation Ed Verrier: “What will I have to do if I want to go to a 3 year CT program, or start an Integrated Program, or coordinate a Core(4/3 or 3/3) program with General Surgery”
   
   1. Notebook handout with Preliminary “White Paper draft” from the RRC
   2. Mathiesen / Stoll available for questions
5. Evaluations / Competency:
   
   1. Background on Competency requirements for RRC
      1. Verrier
   2. Development and presentation of new TSDA CD-ROM evaluation tool
      1. Bill Begg
   3. Distribution of Evaluation tool to all program directors
6. Presentation of TSDA Navigation Tool
   
   1. Jeff Gold, MD
   2. Development and Presentation of “new” navigator tool for TS educators
   3. This is an amazing system Jeff has been working on for awhile and will make all of our educational programs different in the near future!!
7. Report of Prerequisite Curriculum Committee
   
   1. Jeff Gold, MD
   2. Preliminary results of educational trial of first generation of CD –ROM
   3. Presentation of Upgraded of prerequisite educational tool
   4. Status of Abstract to be submitted to STS
   5. Distribution of New CD-ROM to all Program Directors present
8. Report of Curriculum Implementation Committee
   
   1. a. Richard Shemin, MD Where we stand and where we are headed with Requisite Curriculum
9. Business meeting
   
   1. Presidential / Secretary / Treasurer reports: There will be no significant reports during this meeting
10. Plans for STS / TSDA meeting January / February 2003
    
    1. Curriculum Reform Update

All Meeting Sessions:

Content (from slide presentations):

New ACGME Guidelines and the Potential Impact on CT training
  Edward Verrier, MD
 
Implication of Work Hour Reform on Surgical Subspecialties from the Chairman's Perspective
  Carlos Pellegrini, MD
 
Results of the Resident Work Hours Survey
  Susan Moffatt-Bruce, MD/PhD
 
Workload Issues: The Canadian Perspective
  David Ross, MD
 
The 80-Hour Resident Week
  David Fullerton, MD
 
Thoracic Residency Work Hours
  Keith Naunheim, MD