3-Year Cardiothoracic Surgery Program (Follows General Surgery Residency)

The traditional three-year cardiothoracic surgery program has continued at the UNC Division of Cardiothoracic Surgery but is being phased out as the division phases in its six-year integrated cardiothoracic surgery residency program.

The final resident in the three-year program will finish in 2014.

About the three-year residency program

The goal of the Cardiothoracic Surgery Training Program at the University of North Carolina School of Medicine is to produce thoughtful surgeons who have become competent clinically by mixing a thorough understanding of the basic science and progressive assumption of clinical responsibility. We expect the graduate to be technically expert in all the common procedures of cardiothoracic surgery and to be familiar with the rare ones. By the time they complete the program, we expect our resident to perform independently the broad bulk of cases, and to know to seek help on the others.

The program is divided into 6-month rotations, each with a specific focus in the primary subspecialties of thoracic surgery. During these rotations, the residents assume senior responsibility for their individual services, thus serving as a chief resident at all times. These three segments are then repeated, allowing the residents an advanced exposure to each subspecialty, with the ability to incorporate the knowledge of the others into the advancement of the main focus, thus being able to better understand and apply the related aspects of the totality of the field of cardiothoracic surgery. In addition, they are able to accept a significantly increased level of responsibility for the patients and the operations, and particularly in the final year to also function as the administrative chief resident learning to run a complex medical practice, including scheduling and assigning responsibilities for the other residents. They are also afforded the time and flexibility during the final six months to delve more deeply into their chosen area on concentration before proceeding into academic or clinical practice or further subspecialty training.

Each resident is expected to review the goals and objectives for each rotation. When a resident does not meet the goals and objectives for a particular rotation, the resident is counseled by that service, offered advice for remediation, and the resident meets with the program director, where a program for remediation will be determined and will be monitored by the residency program director and the resident's adviser.

First year

During the first year, the resident is assigned initially to general thoracic surgery. The resident has primary responsibility for surgical patients admitted with diseases of the lungs, esophagus, diaphragm, chest wall, and pericardium. The resident is expected to make daily rounds on every patient with the attending surgeons and rotating general surgery residents. They are expected to review and discuss each patient’s chest x-ray films and laboratory data and discuss the significance of these data along with the patient’s clinical course. The resident is responsible for the patient’s initial evaluation and their hospital course, including endoscopy and surgery where indicated.

The resident is also in charge of the Thoracic Surgery Clinic and participates in the Multidisciplinary Thoracic Oncology Clinic in order to participate in the care of the patients during all phases of their disease. The resident is responsible for presentations at the Combined Chest Conference attended by the pulmonologists, oncologists, and chest radiologists. The resident is also responsible for the general surgical portion of the weekly Operative Review Conference. The resident is also expected to interact on a regular basis with the pulmonary and gastroenterology staff and to become proficient with the performance an interpretation of appropriate diagnostic procedures including bronchoscopy, pulmonary function testing, esophagogastroduodenoscopy, esophageal manometry, and pH testing. Participation in the surgical care of patients will result in graded responsibility in the performance of diagnostic and therapeutic procedures including mediastinoscopy, pulmonary and esophageal resections, resection of chest wall tumors and thoracic trauma and lung transplantation.

During the second six months of the first year, the resident has primary responsibility for patients on the adult cardiac surgical service. The resident is expected to make daily rounds on every patient and review and discuss the patient’s chest x-ray films, laboratory data, and the patient’s clinical course with the attending. The resident is responsible for the patient’s initial evaluation and hospital course as well as out-patient follow-up in the Cardiac Surgery Clinic.

The resident will participate in the surgical management of adult patients including experience in coronary revascularization, valve repair and replacement, thoracic aortic disease and cardiac trauma. The resident is expected to assume graded responsibility for these procedures, so that by the end of the rotation they are proficient at harvesting saphenous vein and radial artery conduits, performing sternotomies, cannulation for cardiopulmonary bypass and proximal coronary anastomoses. In addition they will be able to perform routine coronary revascularization, valve replacements and thoracic aortic repairs. In addition, the resident is responsible for participating in the weekly adult cardiac conferences and preparing and presenting the cardiac surgical portion of the weekly Operative Review Conference. The resident will be expected to prepare and present at least one topic for the Core Curriculum Conference. The resident also attends the weekly Cardiac Catheterization Conference and Cardiology Grand Rounds.

Second year

The initial six months of the second year is spent on the Pediatric Cardiac Surgery and Cardiac Transplantation Service. The patient has primary responsibility for the congenital heart surgery patients and is expected to make daily rounds on every patient and review and discuss the patient’s chest x-ray films, laboratory data, and the clinical course with the attending. The resident is responsible for the patient’s initial evaluation and hospital course.

The resident will participate in the surgical management of pediatric patients including all aspects of congenital heart surgery. The resident will assume graded responsibility for these procedures so that by the end of the rotation they have experience with pediatric sternotomies and thoracotomies, cannulation for cardiopulmonary bypass, and the performance of selected procedures such as atrial septal defect repair, repair of coarctation of the aorta, ligation of patent ductus arteriosus, performance of modified Blalock-Taussig shunts, thoracic duct ligations, diaphragmatic plications and placement of permanent pacemakers. In addition, the resident attends the combined Pediatric Cardiology/Cardiac Surgery Conference.

The resident is also responsible for the cardiac transplantation service. They are expected to make daily rounds on every patient and review and discuss the patient’s chest x-ray films, laboratory data, and the clinical course with the attending, including the immunosuppressant management and the results of cardiac biopsies. The resident is involved in the patient’s initial evaluation and hospital course. The resident will participate in the surgical management of the patients including assisting on the transplant procedures and biopsies. They will also learn about donor management and the performance of organ procurement procedures for both heart and lung transplants. By the end of the rotation they will be proficient in the evaluation and procurement of donor hearts and lungs, performing sternotomies and cannulation for cardiopulmonary bypass and in selected cases the performance of cardiac transplants. They will also demonstrate proficiency in the performance and interpretation of cardiac biopsies and the use and monitoring of immunosuppressive medications. They will interact with the Cardiology Heart Failure and Transplantation Service and participate in the weekly Cardiac Transplant Conference.

The resident will be responsible for preparing and presenting the pediatric/transplant portion of the weekly Operative Review Conference. The resident is also expected to prepare a presentation for the Core Curriculum Conference. As the Pediatric Cardiac Surgery/Heart Transplant Service does not routinely operate every day, the resident has the opportunity to participate in the care of patients on the Adult Cardiac Service in order to gain additional experience. Since the adult service generally operates in two rooms on the days when the pediatric service is not operating, the resident on the pediatric/transplant service will discuss the scheduled cases with the chief resident on the adult service. The chief resident on the adult service has first choice of cases. The resident on the pediatric/transplant service is then able to evaluate and operate on the patients to be operated on in the other room. The resident also participates in his patient’s postoperative care in order to provide appropriate continuity in all phases of the patients care. This arrangement maximizes the educational opportunity for the residents since they are involved in cases which in the past would have been done without the participation of the resident.

During the second six months of the second year, the resident will participate in an advanced reprise of the general thoracic surgical service. Again the resident will be responsible for all aspects of the thoracic surgical patients care in consultation with the attending staff. Their ability to assess patients and their data will be expected to achieve an advanced level. Likewise the quality of their participation and presentation at conferences will be expected to be appropriately advanced. By the end of the rotation they should be able to perform complex procedures including redo mediastinoscopies and VATS procedures, sleeve resections, carinal resections, and complex esophageal procedures and perform lung transplants including the use of cardiopulmonary bypass if needed. By the conclusion of this rotation, the resident should be proficient in all aspects of the evaluation and care of the general thoracic surgical patient.

Third year

The third year is spent as the Administrative Chief Resident. In this role, the resident is responsible for the overall functioning of the Cardiothoracic Surgical Services. This responsibility will include making sure there is appropriate coverage for all three services and all operative cases, and for creating appropriate call schedules to assure coverage of the services, complete weekend coverage, coverage for appropriate vacations and travel to meetings and adherence to the rules of the 80 hour work week.

During the first six months, the resident has primary responsibility for the adult cardiac service in consultation with the attending staff. They will be expected to be proficient at evaluating and planning care for patients with all types of acquired heart disease. Their participation and presentations at conferences will be expected to be at a senior level, involving more in-depth evaluation and presentation of appropriate data. They will receive graded experience in the performance of complex coronary revascularization procedures, including of pump cases, combined coronary/valve procedures, redo sternotomies for revascularization and valve operations, valve repairs, including minimally invasive approaches to the mitral valve, complex aortic reconstructive surgery, and the use of mechanical assist devices as temporary or permanent support. By the end of the rotation, the resident should be proficient in all aspects of the evaluation and care of the routine adult cardiac surgical patient.

The final six months of the program is spent with senior responsibility on the pediatric cardiac and cardiac transplantation service. During this time they have primary responsibility for the patients on the pediatric cardiac service with graduated responsibility as with the advanced rotations through the other two services. They are expected to develop a more in-depth knowledge and understanding of the pathophysiology of congenital heart disease and an understanding of the repairs used for patients with complex congenital heart lesions. In addition, they will achieve graded experience in the repair of additional cardiac lesions such as repair of VSD’s, sinus venosus ASD’s, partial atrioventricular septal defects and tetrology of Fallot. On the cardiac transplant service, they will perform cardiac transplants and be involved in implantation of ventricular assist devices as bridges to transplantation and destination therapy.

As during their first rotation on this service, they will participate in adult cardiac cases which are not covered by the senior resident on the adult cardiac service. The resident is expected to make arrangements for this coverage sufficiently in advance such that they can be involved in the preoperative and postoperative care in addition to the operative procedure itself.

In addition, this rotation will serve as an opportunity for the finishing resident to seek in-depth exposure in areas of thoracic surgery in which they desire additional experience and training. It will be their prerogative to perform selected cases in general thoracic surgery, adult cardiac surgery, pediatric cardiac surgery and transplantation in preparation for specialization in a subspecialty of thoracic surgery in academic or clinical practice after the completion of their training or as a prelude to additional training. This will also provide the potential for brief elective rotations at other institutions to gain exposure to a special area of thoracic surgical knowledge. By the completion of this three year training program, the resident should be proficient in the broad bulk of cardiothoracic surgery and to know when to seek help in the others.

Information

For more information about the three-year residency program, contact residency coordinator Shelby Long by e-mail at sjmitch@med.unc.edu or by telephone at (919) 966-3382.

Benjamin E. Haithcock, M.D., assistant professor of surgery, is director of the UNC Cardiothoracic Surgery Residency Program: benjamin_haithcock@med.unc.edu