Hofstra Northwell School of Medicine Integrated Thoracic Surgery Residency Program
The Integrated Thoracic Surgery Training program at Long Island Jewish Medical Center, North Shore University Hospital and Southside is a six year comprehensive experience in general surgery, medical subspecialties, clinical cardiothoracic surgery (including pediatric cardiothoracic surgery, general thoracic surgery and adult cardiac surgery). Clinical decision-making in preoperative and postoperative care is increased during the six-year training period. The educational program is designed to achieve the following goals for each block of training.
- Mastery of the core curriculum as developed by the Thoracic Surgery Directors Association
- Successful preparation for standardized testing in thoracic surgery (board examination and in-service training examinations)
- Appropriate preparation for the preoperative evaluation and postoperative management of patients undergoing adult and pediatric cardiothoracic surgical procedures
- Appropriate preparation in the clinical and analytical skills required to perform cardio thoracic surgery independently
- Demonstrated development of the core competencies as described by the ACGME
- Evidence of judgment to call for consultation with senior surgical assistance to avoid practice outside of the individual's current level of competency
- Documented achievement in the technical performance of operative procedures and attainment of sufficient operative experience as surgeon to qualify for entry to the thoracic surgery board examinations at the conclusion of the residency program.
The first year of residency is the beginning of a process to produce a thoughtful, knowledgeable and competent surgeon. The first-year resident physician is at the beginning of six years of education that will call upon the doctor to once again become a student. These resident physicians are introduced to surgical thinking, traditions, and limitations. We want the resident physician to become a keen observer and expert at history-taking and physical examination. Throughout residency, the mantra, "Do what's right," is stressed.
The first year resident physician begins to understand the art and science of coordinating judgment and a sick patient. They place the patient along the natural course of disease and evaluate different treatment algorithms. The emphasis is on learning the fundamentals of patient care: fluid and electrolyte balance, nutritional care, wound care and healing, aseptic technique, universal precautions, treatment of infection and shock, and the principles of transfusion and hemostasis. The PGY-1 resident physician will have a wide exposure to general surgery and cardiothoracic surgery, building on knowledge of anatomy, physiology, and pathology gained in medical school. The majority of this year will be spent in the area surgery including acute care and trauma surgery, trauma, cardiac surgery, thoracic surgery and vascular surgery. In addition, time is spent in caring for patients with disease states cared for by associated subspecialties of radiology, and pulmonology.
Resident physicians at this level learn the basics of assessment and management of clinical problems. The resident physician will be responsible for documenting admission history and physical exams, assisting at surgery, writing progress notes and orders, monitoring lab values, radiologic and diagnostic studies, and attending conferences. The resident physician at this level will learn to communicate among team members. Additionally basic surgical skills are learned in the operating room during the PGY-1 year including surgical assisting and the performance of basic surgical procedures such as hernia repairs, excision of soft tissue masses, and appendectomy. The resident will learn to work within a team and to understand the importance of competencies such as self assessment, professionalism and system based practice and starting this year, resident physicians will begin seeing patients preoperatively and postoperatively in clinics and physician offices. Outpatient skills begin to be developed in the clinic setting. Supervision is by senior resident physicians and the teaching faculty.
This year is spent on rotations involving general surgery, vascular surgery, trauma surgery, cardiothoracic surgery, and critical care. During this year, resident physicians manage patients in the critical care unit and are teachers of PGY-1 resident physicians and medical students. The PGY-2 resident physicians often provide initial surgical consultation to patients in the emergency department or for whom a surgical consultation has been requested. The resident physicians initiate treatment, make diagnoses and decisions under direct supervision from senior resident physicians and the attending surgeons. Medical and surgical skills continue to expand and resident physicians begin to develop endoscopic, laparoscopic and thoracic skills as well as more advanced surgical skills such as sentinel node mapping. Outpatient skills continue to be developed in the clinic setting.
During this year the resident physician should be dedicated to the development of coordinated skills and judgment in patient care skills, operative technique, and the core competencies. The resident is expected to transition into a qualified house officer. The resident will perform as first assistant and primary surgeon in cardiothoracic surgical operative procedures under the supervision of an attending surgeon at all times. Although the primary technical performance of each case is determined by the responsible attending surgeon and is progressively graduated according to resident ability, the resident should begin to make choices of preferred style or approach. The resident physician will perform cases such as suturing and closed tube thoracostomy and will be provided with chances to be the operating surgeon (with assistance from the chief resident physician or attending surgeon), for entry level cases in general thoracic, cardiac, and general surgery.
The third resident year is spent primarily on rotations involving cardiac, thoracic, vascular surgery and trauma surgery. The resident physician will be the first assistant on more complex cases and will eventually be the surgeon on these cases with the attending surgeon being the first assistant. Supervision is by senior resident physicians, the chief resident physician, and the teaching faculty. Resident physicians will begin to learn endosonographic techniques. This year will mark the transition of the resident to a leader of the surgical team in the day to day activities on the wards. He is expected to transition from the skills of an early learner in the competencies to that of approaching competency.
The PGY-4 year is dedicated to general surgery, vascular surgery, thoracic surgery, and cardiac surgery. The resident physician will function as the first assistant or the operating surgeon on all operative cases and will be directly involved in the management of the patient in the office or clinic and in the hospital. The resident will demonstrate coordination of knowledge and skills in smooth continuity of preoperative, postoperative and perioperative patient care. The resident physician serves as the senior resident physician on the thoracic surgery service and the vascular surgery service with supervision by the chief resident and teaching faculty assigned to the respective service. The resident physician will continue to improve their endo-sonographic and laparoscopic techniques. In accordance with the progressive level of responsibilities, the resident will be expected to build on the medical knowledge foundation of the previous three years and to demonstrate skills such as becoming a leader to the junior resident physicians, physician assistants, and students, and use techniques assimilated to become a more effective teacher and a team leader.
The PGY-5 year is designed to allow the resident to function as an assistant chief resident demonstrating competence in the care of most patients with straightforward cardiothoracic pathology. The resident will demonstrate the ability to be a team leader and resource for the PGY1-4 residents. The resident will understand the importance of and teach professional behaviors such as establishing total continuity of care. The resident at this level will accept responsibility for the patients on the service when on call or covering other services. By exhibiting appropriate communication skills, the resident will show that being a leader requires delicacy, skills of diplomacy, and profound respect for the patients and all members of the healthcare team. Using knowledge of the system and its available resources, the resident will formulate plans and demonstrate responsibility to improve the quality and outcome of patients under care of the service.
The PGY-6 resident is a chief resident and will act as a junior attending. A key element to success should be demonstrating reflective behaviors and the ability to evaluate personal strength and weaknesses. The end goal of this educational year will be a concerted focus on personal and professional improvement that will demonstrate competency to perform as an independent cardiothoracic surgeon upon completion of the residency program.
The program requires each resident to maintain a current log of operative and clinic activities in preparation for evaluation, departmental and system record keeping, and as a record of their professional experiences. The web-based (CTSNET) database is used for operative logging. Each resident will update their case list frequently to assure accuracy and in preparation for review with the program director quarterly. At that time, the resident is made aware of any deficiencies in operative experience so that they may be corrected in a timely fashion.
Additionally, the cardiothoracic surgery office employs a full time data collection nurse whose job it is to maintain records for New York state and for hospitalwide quality assurance. These databases provide a backup source of information for residents since each case is logged with surgeon and assistant as well as patient identification, operative procedure, outcome and perioperative morbidity.
The didactic sessions consist of weekly conferences on Tuesdays and Thursday mornings.
Tuesday morning lectures are based on the 88-week core curriculum developed by the Thoracic Surgery Director’s Association (the resident will participate in the General Surgery core conferences when on service). These hourly sessions are attended by the residents, attending faculty, medical students, physician assistants, nurse practitioners, and nurses. They consist of a 40 minute presentation followed by a 20 minute discussion. We have changed to this format based on the feedback from our yearly program evaluation meetings because the residents and attendings felt this was more conducive to learning. Critical feedback and insights by the attending physicians during these sessions has enhanced the learning environment, and allowed us to incorporate quality assurance, lifelong learning skills, system based practice and professionalism into a traditionally medical knowledge endeavor. The conferences are held in our conference room which has a large screen monitor with internet access. With this format, it is easy to access tools such as Pub Med, Up To Date, CTSNET, TSDA.org, as well as our online library and clinical resources during the lectures.
Thursday mornings are generally allocated to Journal Club, Mortality and Morbidity Conferences, and Grand Rounds. Journal Club articles are usually selected by the program director and Residents. Articles are chosen based upon new or controversial topics, well-designed studies, and the clinical relevance to our practice or topics presented at our Mortality and Morbidity Conferences. The Journal Clubs are attended by the residents, attendings and ancillary staff. This activity focuses on medical knowledge, lifelong learning, scholarly activity and system based practice. Mortality and Morbidity Conferences are designed to promote critical thinking, lifelong learning, personal development, system based practice and professionalism. We have a monthly pre-M&M meeting where the complications of the previous month are reviewed and where specific cases with educational benefit are identified for presentation. The residents are assigned the case to be presented. At the M&M conference, the resident is expected to give a precise presentation, identify potential areas for improvement of the complication, cite recent literature regarding the case, and to provide a self assessment of how he/ she could have managed the case better. Feedback is given to the resident informally during the conferences, and formally every three months by the attendings.
Grand rounds are organized by the program director. Topics and presenters are usually nationally known speakers or physicians with topics and speakers chosen to address innovation and ideas in their specialty. The topics and speakers are chosen to enhance the curriculum, foster scholarly activity and lifelong learning. An example of this was a recent speaker, William Northrup, MD. Dr. Northrup is a retired surgeon who currently teaches aortic root replacements. We were able to have Dr Northrup give a grand rounds presentation, followed by a three hour wet lab workshop that was attended by our faculty, residents and ancillary staff. This was a segue for the development of our simulation sessions for the residents and staff.
During the 2007-2008 yearly program evaluation, the residents expressed interest in simulator based training. In July 2008, our first year resident attended the TSDA Boot camp, using both wet and dry models, as well as simulators for bronchoscopy. Our program followed this with two wet lab sessions during that year. At our yearly meeting in 2009 based upon the feedback of the residents and staff, we planned these sessions to occur quarterly. The goal of the sessions is to provide the residents time to develop the techniques used by the attendings during the one on one sessions. As well, based upon the feedback of the residents and staff, we have created additional yearly simulation curricula to allow residents focus on surgical technique and to improve skills in areas such as system based practice, self reflection, patient care skills, communication, and interpersonal skills.
The thoracic surgery residents are required to engage in scholarly activities. In addition to the scholarly activities in journal club and M&M, the resident is required prepare a manuscript for either an oral or written presentation yearly. In the beginning of each academic year, the resident meets with the program director and other faculty to discuss research topics. An appropriate area of inquiry is developed with a faculty member. The hypothesis, background literature search, IRB proposal, data collection and analysis, and manuscript preparation are performed by the resident with assistance of ancillary staff and the designated faculty.
The Department of Cardiovascular and Thoracic Surgery is active with its faculty development program. There are quarterly faculty development meetings with the attending physicians. Topics discussed include mentoring students and residents, how to give feedback, and resident reporting of adverse events. The program director regularly attends the Thoracic Surgery Director Associations biannual meetings and educational sessions, and gives an update to the faculty after the meeting. The GME office of Northwell Health has a systemwide initiative for faculty development. Both the program director and the faculty have participated in these sessions and participation will continue in the future.
Morning multidisciplinary rounds
The resident participates in the daily multidisciplinary rounds with the attending physicians, intensivists, PAs, NPs, nurses, social workers and physical therapists after completing the morning work rounds with the medical students and PAs. The senior resident, with the assistance of the junior resident, are responsible for the initial examination of patients and for the development of a daily and overall plan for the patient’s hospital’s course. At the multidisciplinary rounds, the PAs present a summary to the team, and the resident provides feedback and clarification as needed. A multidisciplinary plan is developed for each patient on the service using this team-based approach. The competencies assessed and evaluated during these rounds include medical knowledge, professionalism, system-based practice, practice based learning and improvement, interpersonal skills, and cultural-socioeconomic sensitivity.
Hofstra-Northwell health conforms rigorously to the working hour and resident supervision requirements of New York state and the ACGME (i.e., adherence to both the Bell Commission Regulations and ACGME requirements). These rules include a maximum average 80 hour work week and provision for adequate rest after extended hours. Weekend days are abbreviated since operative procedures are not booked electively on weekends. Residents are scheduled for one day of rest for each 7-day period. New Innovations is used to track the resident work hours. Residents and staff are aware of the requirement to leave the hospital if the work hour limits are approached/exceeded. Formal attending-level intensive care (intensivist) coverage was initiated in 1999 with coverage 24 hours per day, 7 days per week as of July 2001. This administrative change further reduced the night call responsibilities of the cardiothoracic surgery resident.
Each faculty member evaluates each resident quarterly. The resident is required to evaluate each faculty with whom he has had exposure and to separately evaluate the quality of the educational experience on each rotation. During the quarterly meeting with the program director, the resident is allowed to review his evaluations and comments. The program director will advised the resident of any deficiencies and identify areas of strength at that time. A formal letter of the meeting is generated, signed by the resident and entered into his file by the program director. Residents are encouraged to be forthright in their evaluations of faculty and rotations. There is a formal policy for redress if the resident feels his comments have resulted in prejudicial treatment by the faculty. A Clinical Competency Committee will evaluate the residents biannually to determine the progress in the milestones developed by the American Board of Thoracic Surgery, the ACGME and the RRC.