Residents' News

The Training Program Experience

By Mara B. Antonoff, M.D., Resident Medical Editor

The new thoracic surgery curriculum has arrived. Debuting this past summer, the curriculum resulted as a joint endeavor of several key organizations heavily vested in thoracic surgical education, with the aim of providing a web-based, multimedia repository of educational materials, accompanied by a formal structure and schedule of weekly topic coverage. Conceptually, the new curriculum has much to offer, with immense theoretical benefits to both the teacher and the student. But what about in practice? Now several months after its launch, the materials provided via the Moodle site and WebBrain have been accessed by the majority of training programs in this country.

How are these tools being utilized by the various programs, and what feedback do they have based on their experiences? The goal of this article will be to explore the various usage patterns of several institutions and their strategies for implementing the materials and integrating them with on-the-ground educational activities. Both the strengths and drawbacks from a programmatic standpoint will be addressed. As you read this article, perhaps you will be motivated to take another look at the curriculum, with new ideas as to how it might best suit your program’s needs.

At Oregon Health and Science University (OHSU), the new curriculum was officially introduced to the trainees and faculty members in a very formal and organized manner, heavily employing the provided instructional videos to become quickly oriented to the new system ("How-To: Utilizing the Thoracic Surgery Brain WebBrain," by Dr. Craig Baker; "How-To: Navigating Moodle," by Dr. Ara Vaporciyan; and "Overview of Teaching Cardiothoracic Surgery" – all available from the Moodle site, http:// jctse.mrooms.net, under Resources on the right hand column). OHSU Program Coordinator Jill Rose reports that she also received helpful information about accessing the curriculum when she attended the "Educate the Educators" course in June, sponsored by the Joint Council on Thoracic Surgery Education (JCTSE). Ms. Rose states, "Faculty and learners enthusiastically adopted this new curriculum and immediately put it to use at least twice a week." When the weekly emails come out, the relevant articles and videos are sent to the trainees and faculty members in the form of a reminder email, including links to the online videos and all related PDF’s as attachments. The residents and fellows then engage in formal curriculum review sessions with faculty, students, and mid-level practitioners – covering the cardiac topics on Monday mornings and thoracic topics on Friday mornings.

At Loma Linda University Health, the residents meet with a faculty moderator on a weekly basis to cover the materials related to the weekly Thoracic Surgery Curriculum topics. The style of presentation is left to the discretion of the attending surgeon, with the majority of the didactic sessions following an oral-board, case-based scenario format. Rather than directly accessing the Moodle pages and WebBrain site, the majority of the faculty and trainees have found that they prefer to have the materials provided to them as hard copies. Consequently, these materials are downloaded and distributed by the program coordinator on a weekly basis.

As with any new educational program, there may be a need for adjustments in initial plans and utilization based on early experiences. For the first few months following release of the curriculum, the Loma Linda group aimed to cover two topics per week – cardiac on Monday mornings and thoracic on Thursday mornings. However, with a tremendous amount of material available for each topic, they ultimately decided to transition to a single weekly session.

While the Loma Linda program has attempted to adhere to the schedule according to the weekly curriculum emails, other programs have chosen to utilize the available materials within the framework of alternative curricular schedules. Rose Haselden, the program coordinator at the Medical University of South Carolina (MUSC), explains that they created their own timeline for covering the materials, based on their specific needs and objectives.

Dr. John Ikonomidis, program director at MUSC, recalls being quick to adopt the new thoracic surgery curriculum. He states, "We were very impressed with its scope and current referencing. When it became available, we went through its entire corpus and divided it into sections which could be covered in 30 minutes. Then we developed a schedule where two topics (one adult or pediatric cardiac and one thoracic) would be covered in our weekly one-hour didactic sessions." Dr. Ikonomidis continues, "The residents are expected to read the material beforehand and faculty are assigned to quiz the residents during the session." In this way, the MUSC program has found a way to use the full breadth of materials, but tailoring the exact learning objectives for their trainees.

While some programs have taken to re-organizing the materials and producing hard copies of the resources for the residents, others have chosen to use the curriculum in its native structure, as a freestanding means of educational supplementation. At Washington University in St. Louis, the trainees are taught how to access the materials and encouraged to both follow the weekly thoracic surgery curriculum emails for independent reading and to utilize the immense resources available for investigating topics relevant to specific cases, conferences, and research interests. Dr. Marc Moon, program director at Washington University, explains that "we have not utilized the materials in any formal, assigned manner; rather, we choose to use the curriculum as a resource for independent study, encouraging our residents to access the multimedia materials both for at-home study and point-of-care reference." Dr. Moon expresses gratitude for the new curriculum, reporting that the faculty members "are grateful that our trainees are able to access these curricular materials through the WebBrain and Moodle, as they serve as an outstanding educational supplement to a high volume operative experience." Dr. Moon further emphasizes, "We find that the new curriculum functions as an excellent adjunct to our clinical teaching."

There are a number of proposed strengths to the new curriculum – its breadth, its ease of access, its correlation with the educational objectives of the American Board of Thoracic Surgery. But what are the benefits being identified from the level of the training program? Dr. Paul Schipper, program director at OHSU, expresses appreciation for the greater volume of material accessible by the trainees, as compared with the older curriculum previously sponsored by the Thoracic Surgery Directors Association (TSDA). States Dr. Schipper, "We’ve been using the TSDA emailed curriculum for several years. With the release of WebBrain, we’ve switched over and been very pleased. Residents are accessing the material and digging deeper into it than previously. In our teaching sessions, we are spending more time on applying the material and less time on explaining it, and I think this is good." Appreciation for the breadth and depth of the material was also noted by Dr. Moon, who identifies the program’s strengths as its ease of access, its large volume, and its applicability to a wide range of educational needs.

Despite the generally laudatory praise, there have been a few issues identified by the training programs that could benefit from some improvement.

Certainly, this is not surprising, as with any educational program, practice and feedback are necessary to optimize the execution for the users. Further, with a resource collection of such enormity, minor tweaks will likely continue in the background at all times in order to ensure ongoing quality-control.

In considering further revision, Dr. Wallen raises some concerns regarding format. He states that "all the moving around on the links makes people crazy," and, for this reason, at Loma Linda, all of the materials are distributed from the WebBrain to the faculty and trainees by the program coordinator. "Otherwise, we would have a revolt," Dr. Jason Wallen explains, This distaste for accessing the materials via the WebBrain is not shared by all users, but it provides feedback, suggesting that changes could be made to optimize formatting to increase ease of use.

Certainly, the leaders in the TSDA, JCTSE, and Thoracic Surgery Residents Association (TSRA) who contributed to the development of the new curriculum are eager for this kind of feedback, welcoming all users to provide constructive criticism. Dr. Ara Vaporciyan, program director at the University of Texas MD Anderson Cancer Center, co-chair of the TSDA/JCTSE Curriculum Committee, and one of the 4 section editors for the curriculum itself, has been a key player in the development of the new curriculum.

States Dr. Vaporciyan, "I never expected this to be perfect on the first try and this is exactly the feedback we need. If we can start an honest conversation about the flaws in the system we can better allocate resources to fixing the most pervasive issues."

Despite the challenges that have been identified, Dr. Wallen remains positive about the curriculum, stating, "We are excited to have an electronic curriculum that our residents can access from anywhere that includes readings and multimedia content. We anticipate that following the curriculum will enhance our residents’ performance on future inservice exams and pave the path to certification."

Dr. Ikonomidis shares Dr. Wallen’s enthusiasm, summarizing that his "residents are constantly engaged and we believe that their learning efficiency has increased." Notes Dr. Schipper, "I am hopeful that this system will stay current and realize and appreciate the effort this has and will take to do so."

Certainly, the new curriculum has already been heavily utilized and appreciated by a number of training programs. While there will always be minor adjustments to be made, the innovators behind the Thoracic Surgery WebBrain and Moodle site are receptive to feedback and clearly dedicated to its ongoing growth.

Perhaps this article has encouraged those of you that aren’t using the curriculum regularly to incorporate it into your institution’s educational structure. For those of you already heavily engaged, perhaps you’ve been inspired to try some new strategies of implementation. Moreover, for all users of the system – trainees, educators, and coordinators – regardless of your program’s current level of use, the take-home message from the creators of the curriculum is that you are encouraged to provide feedback to allow evolution and improvement of the program.

The Trainee Experience

By Sanford M. Zeigler, M.D., Resident Medical Editor

Dr. Antonoff has detailed how different programs have chosen to implement the new curriculum. Of course, in order for the curriculum to work in any setting, people have to actually sit down, access the material, and learn from it. The modules need to be easily accessible, logically organized, and appropriate for the audience for which they are intended. To that end, the folks behind the new curriculum worked diligently to organize all the material into the WebBrain format, which attempts to organize the content by the logic of the human brain, using mind maps, and Moodle, which compartmentalizes the readings into individual curricular assignments that are served up on each resident’s personal Moodle page.

The overall architecture of the WebBrain is very organic; the "Brain" is split into four main branches, comprised of Foundations of Surgery, Cardiovascular, Thoracic, and Congenital headings. From these, the subject matter continues to divide and subdivide again until you reach a terminal branch, where the reader can open a number of different sources, both primary and secondary, on a given subject. The brains’ power lies in the connections that can be made across these fluid boundaries. An example can be seen with one reference that discusses MRI imaging of pericardial disease and cardiac masses. When this is selected, the thought leads the reader back to both the pericardial disease heading and the cardiac tumors heading. The subject selection feature allows the reader to wander throughout the entire WebBrain in a free-flowing but logical manner. Connections across different subjects are, at this point, still rarely utilized. The cross-referencing feature could be a boon for more junior integrated residents and general surgery residents if more of the basic concepts section were connected to cardiac and thoracic subjects, and could allow more self-directed reading to residents that find the time to do so. The WebBrain has some basic search functionality embedded in it that could be used to help understand specific clinical scenarios as they are encountered. Layered upon all of the subject matter are tags, which correspond to the weekly curricular readings. If trainees search for the tag "CV08," for example, they will be directed to each source with that tag, bringing the weekly source matter right to the front. Thus, the WebBrain can be used as a guide for casual reading, as a reference for a particular question or clinical scenario encountered in practice, and also as the source for material covered in didactic session.

The Moodle interface is the gateway to the WebBrain. While it may sound easier to deliver the contents of the WebBrain to each resident rather than go through Moodle, this interface serves two functions. In order to license the content for the curriculum, publishers of many of the textbooks require tight security to prevent unauthorized duplication of the materials. Moodle, by requiring a unique login to access the single WebBrain, provides that security and also allows the WebBrain to be modified in the Cloud, rather than at the level of the end-user. Moodle also provides other testing and tracking tools that have not been completely rolled out. Over the coming months, its full architecture will be used to incorporate quizzes, collaborative message boards, and personal tracking to help residents and their program directors ensure that the material is being covered adequately.

Nearly every resident and faculty member I asked about the new curriculum agreed that the update in content and delivery was badly needed. As an intern in an integrated cardiothoracic surgery program, I remember feeling very jealous of my general surgery colleagues’ access to the SCORE portal, which gave them an easily navigable curriculum accessible from anywhere, with instruction in everything from basic science and physiology to advanced surgical diagnosis and technique. The rollout of the Moodle interface and Web Brain content is the first step to a similar, comprehensive compendium of the necessary knowledge to master cardiac and thoracic surgery.

Response to the rollout has been generally positive from the residents. Most residents agree that the content provides a great sample of landmark papers, lecture videos, book chapters, and consensus statements. A fellow Stanford resident, George Dimeling, wrote: "I like the weekly focus and the topic organization. The content is good, but tough to access." The articles and chapters are often more up to date than printed textbooks, and, once the reader accesses the Brain, are instantly viewable with no further log ins or downloads.

Of course, for a busy resident, it may not always be possible to cover a long book chapter quickly, and the primary literature sometimes fails to cover an entire topic. Justin Schaffer, another Stanford resident, offered this thought: "There’s either a short paper or a 40-page book chapter – there is no solid review of the subject matter. They need something like the Doty lecture series and the TSRA publications to get you warmed up if you don’t have all that time." In fact, the WebBrain incorporates many chapters of the TSRA Cardiothoracic Review book, and the TSRA Clinical Scenarios were added to Moodle on Dec. 12.

One of the more common complaints had little to do with the content but more to do with delivery. At my own institution, most of our hospital computers run an outdated copy of Internet Explorer and have restricted access to update or install a new browser. The out-of-date or restricted software packages that are pervasive in institutional machines nullify many of the advantages of the WebBrain/Moodle format, as the majority of computers at Stanford Hospital cannot access the WebBrain. Furthermore, the WebBrain interface can be laggy and slow even with compatible software.

Others have complained that it is not always easy to find the readings, especially if a program does not follow one of the standardized curricula included with the rollout. First, one must find which content they are responsible for via departmental website or reference to the curricula. Next, the resident logs into the Moodle room, and the proper WebBrain course is launched, then each article for the week is selected and downloaded. Only after that can the content be read, saved, or printed. Using the tag function is helpful, but each time a tagged article is selected, the resident is taken away from the search and to the specific content area, away from the other material assigned for the week. Though it isn’t very difficult to navigate back to the search, all of the steps above make it a bit more of a process to access the material than is convenient for a resident trying to fit in readings between cases or while waiting to round. The new software is a definite improvement, yet still has not reached its full potential.

As Dr. Antonoff pointed out, one residency program has easily overcome this obstacle by consolidating and emailing the appropriate material every week. While the Moodle portion of the curriculum still sees limited functionality, this is probably the best solution to all of the problems. If the articles are in your mailbox, they are accessible anywhere, without the bother of logging in and navigating the Brain.

I discussed this with Dr. Jim Fann, who has been very involved in developing the curriculum, and he explained that direct delivery of the content to each resident had been part of the original goal. As mentioned before, however, publishers require that the delivery of the material is secure from unauthorized duplication. Within the context of an individual institution, those issues are less confining. While individual programs work to integrate the material into their own traditions, it may be worthwhile to designate a resident or office staff member to be in charge of distributing the week’s reading. One little-recognized feature of Moodle is the ability to upload calendars. Perhaps this area could be used by each program to keep the curricular and departmental calendars adjacent to the WebBrain link for easier access.

The recent changes in cardiothoracic surgical education have been myriad, and the rollout of the new curriculum is one of the most pervasive and visible signs of that change. The new curriculum has been designed and updated to reflect not only updates in medical knowledge and consensus, but also changes in the demographic of the cardiothoracic surgery resident and new paradigms in surgical education. The content and delivery systems, while not perfect, remain an ever improving work in progress, which aims to bring cardiothoracic surgical education into the collaborative, cloud based learning era while broadening its reach to both green cardiothoracic surgery interns and traditional fellows with a full general surgery residency behind them. All things considered, the rollout has been very successful, and as more functionality is added and bugs are worked out, things can only improve.

The Training Program Experience

By Mara B. Antonoff, M.D., Resident Medical Editor

The new thoracic surgery curriculum has arrived. Debuting this past summer, the curriculum resulted as a joint endeavor of several key organizations heavily vested in thoracic surgical education, with the aim of providing a web-based, multimedia repository of educational materials, accompanied by a formal structure and schedule of weekly topic coverage. Conceptually, the new curriculum has much to offer, with immense theoretical benefits to both the teacher and the student. But what about in practice? Now several months after its launch, the materials provided via the Moodle site and WebBrain have been accessed by the majority of training programs in this country.

How are these tools being utilized by the various programs, and what feedback do they have based on their experiences? The goal of this article will be to explore the various usage patterns of several institutions and their strategies for implementing the materials and integrating them with on-the-ground educational activities. Both the strengths and drawbacks from a programmatic standpoint will be addressed. As you read this article, perhaps you will be motivated to take another look at the curriculum, with new ideas as to how it might best suit your program’s needs.

At Oregon Health and Science University (OHSU), the new curriculum was officially introduced to the trainees and faculty members in a very formal and organized manner, heavily employing the provided instructional videos to become quickly oriented to the new system ("How-To: Utilizing the Thoracic Surgery Brain WebBrain," by Dr. Craig Baker; "How-To: Navigating Moodle," by Dr. Ara Vaporciyan; and "Overview of Teaching Cardiothoracic Surgery" – all available from the Moodle site, http:// jctse.mrooms.net, under Resources on the right hand column). OHSU Program Coordinator Jill Rose reports that she also received helpful information about accessing the curriculum when she attended the "Educate the Educators" course in June, sponsored by the Joint Council on Thoracic Surgery Education (JCTSE). Ms. Rose states, "Faculty and learners enthusiastically adopted this new curriculum and immediately put it to use at least twice a week." When the weekly emails come out, the relevant articles and videos are sent to the trainees and faculty members in the form of a reminder email, including links to the online videos and all related PDF’s as attachments. The residents and fellows then engage in formal curriculum review sessions with faculty, students, and mid-level practitioners – covering the cardiac topics on Monday mornings and thoracic topics on Friday mornings.

At Loma Linda University Health, the residents meet with a faculty moderator on a weekly basis to cover the materials related to the weekly Thoracic Surgery Curriculum topics. The style of presentation is left to the discretion of the attending surgeon, with the majority of the didactic sessions following an oral-board, case-based scenario format. Rather than directly accessing the Moodle pages and WebBrain site, the majority of the faculty and trainees have found that they prefer to have the materials provided to them as hard copies. Consequently, these materials are downloaded and distributed by the program coordinator on a weekly basis.

As with any new educational program, there may be a need for adjustments in initial plans and utilization based on early experiences. For the first few months following release of the curriculum, the Loma Linda group aimed to cover two topics per week – cardiac on Monday mornings and thoracic on Thursday mornings. However, with a tremendous amount of material available for each topic, they ultimately decided to transition to a single weekly session.

While the Loma Linda program has attempted to adhere to the schedule according to the weekly curriculum emails, other programs have chosen to utilize the available materials within the framework of alternative curricular schedules. Rose Haselden, the program coordinator at the Medical University of South Carolina (MUSC), explains that they created their own timeline for covering the materials, based on their specific needs and objectives.

Dr. John Ikonomidis, program director at MUSC, recalls being quick to adopt the new thoracic surgery curriculum. He states, "We were very impressed with its scope and current referencing. When it became available, we went through its entire corpus and divided it into sections which could be covered in 30 minutes. Then we developed a schedule where two topics (one adult or pediatric cardiac and one thoracic) would be covered in our weekly one-hour didactic sessions." Dr. Ikonomidis continues, "The residents are expected to read the material beforehand and faculty are assigned to quiz the residents during the session." In this way, the MUSC program has found a way to use the full breadth of materials, but tailoring the exact learning objectives for their trainees.

While some programs have taken to re-organizing the materials and producing hard copies of the resources for the residents, others have chosen to use the curriculum in its native structure, as a freestanding means of educational supplementation. At Washington University in St. Louis, the trainees are taught how to access the materials and encouraged to both follow the weekly thoracic surgery curriculum emails for independent reading and to utilize the immense resources available for investigating topics relevant to specific cases, conferences, and research interests. Dr. Marc Moon, program director at Washington University, explains that "we have not utilized the materials in any formal, assigned manner; rather, we choose to use the curriculum as a resource for independent study, encouraging our residents to access the multimedia materials both for at-home study and point-of-care reference." Dr. Moon expresses gratitude for the new curriculum, reporting that the faculty members "are grateful that our trainees are able to access these curricular materials through the WebBrain and Moodle, as they serve as an outstanding educational supplement to a high volume operative experience." Dr. Moon further emphasizes, "We find that the new curriculum functions as an excellent adjunct to our clinical teaching."

There are a number of proposed strengths to the new curriculum – its breadth, its ease of access, its correlation with the educational objectives of the American Board of Thoracic Surgery. But what are the benefits being identified from the level of the training program? Dr. Paul Schipper, program director at OHSU, expresses appreciation for the greater volume of material accessible by the trainees, as compared with the older curriculum previously sponsored by the Thoracic Surgery Directors Association (TSDA). States Dr. Schipper, "We’ve been using the TSDA emailed curriculum for several years. With the release of WebBrain, we’ve switched over and been very pleased. Residents are accessing the material and digging deeper into it than previously. In our teaching sessions, we are spending more time on applying the material and less time on explaining it, and I think this is good." Appreciation for the breadth and depth of the material was also noted by Dr. Moon, who identifies the program’s strengths as its ease of access, its large volume, and its applicability to a wide range of educational needs.

Despite the generally laudatory praise, there have been a few issues identified by the training programs that could benefit from some improvement.

Certainly, this is not surprising, as with any educational program, practice and feedback are necessary to optimize the execution for the users. Further, with a resource collection of such enormity, minor tweaks will likely continue in the background at all times in order to ensure ongoing quality-control.

In considering further revision, Dr. Wallen raises some concerns regarding format. He states that "all the moving around on the links makes people crazy," and, for this reason, at Loma Linda, all of the materials are distributed from the WebBrain to the faculty and trainees by the program coordinator. "Otherwise, we would have a revolt," Dr. Jason Wallen explains, This distaste for accessing the materials via the WebBrain is not shared by all users, but it provides feedback, suggesting that changes could be made to optimize formatting to increase ease of use.

Certainly, the leaders in the TSDA, JCTSE, and Thoracic Surgery Residents Association (TSRA) who contributed to the development of the new curriculum are eager for this kind of feedback, welcoming all users to provide constructive criticism. Dr. Ara Vaporciyan, program director at the University of Texas MD Anderson Cancer Center, co-chair of the TSDA/JCTSE Curriculum Committee, and one of the 4 section editors for the curriculum itself, has been a key player in the development of the new curriculum.

States Dr. Vaporciyan, "I never expected this to be perfect on the first try and this is exactly the feedback we need. If we can start an honest conversation about the flaws in the system we can better allocate resources to fixing the most pervasive issues."

Despite the challenges that have been identified, Dr. Wallen remains positive about the curriculum, stating, "We are excited to have an electronic curriculum that our residents can access from anywhere that includes readings and multimedia content. We anticipate that following the curriculum will enhance our residents’ performance on future inservice exams and pave the path to certification."

Dr. Ikonomidis shares Dr. Wallen’s enthusiasm, summarizing that his "residents are constantly engaged and we believe that their learning efficiency has increased." Notes Dr. Schipper, "I am hopeful that this system will stay current and realize and appreciate the effort this has and will take to do so."

Certainly, the new curriculum has already been heavily utilized and appreciated by a number of training programs. While there will always be minor adjustments to be made, the innovators behind the Thoracic Surgery WebBrain and Moodle site are receptive to feedback and clearly dedicated to its ongoing growth.

Perhaps this article has encouraged those of you that aren’t using the curriculum regularly to incorporate it into your institution’s educational structure. For those of you already heavily engaged, perhaps you’ve been inspired to try some new strategies of implementation. Moreover, for all users of the system – trainees, educators, and coordinators – regardless of your program’s current level of use, the take-home message from the creators of the curriculum is that you are encouraged to provide feedback to allow evolution and improvement of the program.

The Trainee Experience

By Sanford M. Zeigler, M.D., Resident Medical Editor

Dr. Antonoff has detailed how different programs have chosen to implement the new curriculum. Of course, in order for the curriculum to work in any setting, people have to actually sit down, access the material, and learn from it. The modules need to be easily accessible, logically organized, and appropriate for the audience for which they are intended. To that end, the folks behind the new curriculum worked diligently to organize all the material into the WebBrain format, which attempts to organize the content by the logic of the human brain, using mind maps, and Moodle, which compartmentalizes the readings into individual curricular assignments that are served up on each resident’s personal Moodle page.

The overall architecture of the WebBrain is very organic; the "Brain" is split into four main branches, comprised of Foundations of Surgery, Cardiovascular, Thoracic, and Congenital headings. From these, the subject matter continues to divide and subdivide again until you reach a terminal branch, where the reader can open a number of different sources, both primary and secondary, on a given subject. The brains’ power lies in the connections that can be made across these fluid boundaries. An example can be seen with one reference that discusses MRI imaging of pericardial disease and cardiac masses. When this is selected, the thought leads the reader back to both the pericardial disease heading and the cardiac tumors heading. The subject selection feature allows the reader to wander throughout the entire WebBrain in a free-flowing but logical manner. Connections across different subjects are, at this point, still rarely utilized. The cross-referencing feature could be a boon for more junior integrated residents and general surgery residents if more of the basic concepts section were connected to cardiac and thoracic subjects, and could allow more self-directed reading to residents that find the time to do so. The WebBrain has some basic search functionality embedded in it that could be used to help understand specific clinical scenarios as they are encountered. Layered upon all of the subject matter are tags, which correspond to the weekly curricular readings. If trainees search for the tag "CV08," for example, they will be directed to each source with that tag, bringing the weekly source matter right to the front. Thus, the WebBrain can be used as a guide for casual reading, as a reference for a particular question or clinical scenario encountered in practice, and also as the source for material covered in didactic session.

The Moodle interface is the gateway to the WebBrain. While it may sound easier to deliver the contents of the WebBrain to each resident rather than go through Moodle, this interface serves two functions. In order to license the content for the curriculum, publishers of many of the textbooks require tight security to prevent unauthorized duplication of the materials. Moodle, by requiring a unique login to access the single WebBrain, provides that security and also allows the WebBrain to be modified in the Cloud, rather than at the level of the end-user. Moodle also provides other testing and tracking tools that have not been completely rolled out. Over the coming months, its full architecture will be used to incorporate quizzes, collaborative message boards, and personal tracking to help residents and their program directors ensure that the material is being covered adequately.

Nearly every resident and faculty member I asked about the new curriculum agreed that the update in content and delivery was badly needed. As an intern in an integrated cardiothoracic surgery program, I remember feeling very jealous of my general surgery colleagues’ access to the SCORE portal, which gave them an easily navigable curriculum accessible from anywhere, with instruction in everything from basic science and physiology to advanced surgical diagnosis and technique. The rollout of the Moodle interface and Web Brain content is the first step to a similar, comprehensive compendium of the necessary knowledge to master cardiac and thoracic surgery.

Response to the rollout has been generally positive from the residents. Most residents agree that the content provides a great sample of landmark papers, lecture videos, book chapters, and consensus statements. A fellow Stanford resident, George Dimeling, wrote: "I like the weekly focus and the topic organization. The content is good, but tough to access." The articles and chapters are often more up to date than printed textbooks, and, once the reader accesses the Brain, are instantly viewable with no further log ins or downloads.

Of course, for a busy resident, it may not always be possible to cover a long book chapter quickly, and the primary literature sometimes fails to cover an entire topic. Justin Schaffer, another Stanford resident, offered this thought: "There’s either a short paper or a 40-page book chapter – there is no solid review of the subject matter. They need something like the Doty lecture series and the TSRA publications to get you warmed up if you don’t have all that time." In fact, the WebBrain incorporates many chapters of the TSRA Cardiothoracic Review book, and the TSRA Clinical Scenarios were added to Moodle on Dec. 12.

One of the more common complaints had little to do with the content but more to do with delivery. At my own institution, most of our hospital computers run an outdated copy of Internet Explorer and have restricted access to update or install a new browser. The out-of-date or restricted software packages that are pervasive in institutional machines nullify many of the advantages of the WebBrain/Moodle format, as the majority of computers at Stanford Hospital cannot access the WebBrain. Furthermore, the WebBrain interface can be laggy and slow even with compatible software.

Others have complained that it is not always easy to find the readings, especially if a program does not follow one of the standardized curricula included with the rollout. First, one must find which content they are responsible for via departmental website or reference to the curricula. Next, the resident logs into the Moodle room, and the proper WebBrain course is launched, then each article for the week is selected and downloaded. Only after that can the content be read, saved, or printed. Using the tag function is helpful, but each time a tagged article is selected, the resident is taken away from the search and to the specific content area, away from the other material assigned for the week. Though it isn’t very difficult to navigate back to the search, all of the steps above make it a bit more of a process to access the material than is convenient for a resident trying to fit in readings between cases or while waiting to round. The new software is a definite improvement, yet still has not reached its full potential.

As Dr. Antonoff pointed out, one residency program has easily overcome this obstacle by consolidating and emailing the appropriate material every week. While the Moodle portion of the curriculum still sees limited functionality, this is probably the best solution to all of the problems. If the articles are in your mailbox, they are accessible anywhere, without the bother of logging in and navigating the Brain.

I discussed this with Dr. Jim Fann, who has been very involved in developing the curriculum, and he explained that direct delivery of the content to each resident had been part of the original goal. As mentioned before, however, publishers require that the delivery of the material is secure from unauthorized duplication. Within the context of an individual institution, those issues are less confining. While individual programs work to integrate the material into their own traditions, it may be worthwhile to designate a resident or office staff member to be in charge of distributing the week’s reading. One little-recognized feature of Moodle is the ability to upload calendars. Perhaps this area could be used by each program to keep the curricular and departmental calendars adjacent to the WebBrain link for easier access.

The recent changes in cardiothoracic surgical education have been myriad, and the rollout of the new curriculum is one of the most pervasive and visible signs of that change. The new curriculum has been designed and updated to reflect not only updates in medical knowledge and consensus, but also changes in the demographic of the cardiothoracic surgery resident and new paradigms in surgical education. The content and delivery systems, while not perfect, remain an ever improving work in progress, which aims to bring cardiothoracic surgical education into the collaborative, cloud based learning era while broadening its reach to both green cardiothoracic surgery interns and traditional fellows with a full general surgery residency behind them. All things considered, the rollout has been very successful, and as more functionality is added and bugs are worked out, things can only improve.

The Training Program Experience

By Mara B. Antonoff, M.D., Resident Medical Editor

The new thoracic surgery curriculum has arrived. Debuting this past summer, the curriculum resulted as a joint endeavor of several key organizations heavily vested in thoracic surgical education, with the aim of providing a web-based, multimedia repository of educational materials, accompanied by a formal structure and schedule of weekly topic coverage. Conceptually, the new curriculum has much to offer, with immense theoretical benefits to both the teacher and the student. But what about in practice? Now several months after its launch, the materials provided via the Moodle site and WebBrain have been accessed by the majority of training programs in this country.

How are these tools being utilized by the various programs, and what feedback do they have based on their experiences? The goal of this article will be to explore the various usage patterns of several institutions and their strategies for implementing the materials and integrating them with on-the-ground educational activities. Both the strengths and drawbacks from a programmatic standpoint will be addressed. As you read this article, perhaps you will be motivated to take another look at the curriculum, with new ideas as to how it might best suit your program’s needs.

At Oregon Health and Science University (OHSU), the new curriculum was officially introduced to the trainees and faculty members in a very formal and organized manner, heavily employing the provided instructional videos to become quickly oriented to the new system ("How-To: Utilizing the Thoracic Surgery Brain WebBrain," by Dr. Craig Baker; "How-To: Navigating Moodle," by Dr. Ara Vaporciyan; and "Overview of Teaching Cardiothoracic Surgery" – all available from the Moodle site, http:// jctse.mrooms.net, under Resources on the right hand column). OHSU Program Coordinator Jill Rose reports that she also received helpful information about accessing the curriculum when she attended the "Educate the Educators" course in June, sponsored by the Joint Council on Thoracic Surgery Education (JCTSE). Ms. Rose states, "Faculty and learners enthusiastically adopted this new curriculum and immediately put it to use at least twice a week." When the weekly emails come out, the relevant articles and videos are sent to the trainees and faculty members in the form of a reminder email, including links to the online videos and all related PDF’s as attachments. The residents and fellows then engage in formal curriculum review sessions with faculty, students, and mid-level practitioners – covering the cardiac topics on Monday mornings and thoracic topics on Friday mornings.

At Loma Linda University Health, the residents meet with a faculty moderator on a weekly basis to cover the materials related to the weekly Thoracic Surgery Curriculum topics. The style of presentation is left to the discretion of the attending surgeon, with the majority of the didactic sessions following an oral-board, case-based scenario format. Rather than directly accessing the Moodle pages and WebBrain site, the majority of the faculty and trainees have found that they prefer to have the materials provided to them as hard copies. Consequently, these materials are downloaded and distributed by the program coordinator on a weekly basis.

As with any new educational program, there may be a need for adjustments in initial plans and utilization based on early experiences. For the first few months following release of the curriculum, the Loma Linda group aimed to cover two topics per week – cardiac on Monday mornings and thoracic on Thursday mornings. However, with a tremendous amount of material available for each topic, they ultimately decided to transition to a single weekly session.

While the Loma Linda program has attempted to adhere to the schedule according to the weekly curriculum emails, other programs have chosen to utilize the available materials within the framework of alternative curricular schedules. Rose Haselden, the program coordinator at the Medical University of South Carolina (MUSC), explains that they created their own timeline for covering the materials, based on their specific needs and objectives.

Dr. John Ikonomidis, program director at MUSC, recalls being quick to adopt the new thoracic surgery curriculum. He states, "We were very impressed with its scope and current referencing. When it became available, we went through its entire corpus and divided it into sections which could be covered in 30 minutes. Then we developed a schedule where two topics (one adult or pediatric cardiac and one thoracic) would be covered in our weekly one-hour didactic sessions." Dr. Ikonomidis continues, "The residents are expected to read the material beforehand and faculty are assigned to quiz the residents during the session." In this way, the MUSC program has found a way to use the full breadth of materials, but tailoring the exact learning objectives for their trainees.

While some programs have taken to re-organizing the materials and producing hard copies of the resources for the residents, others have chosen to use the curriculum in its native structure, as a freestanding means of educational supplementation. At Washington University in St. Louis, the trainees are taught how to access the materials and encouraged to both follow the weekly thoracic surgery curriculum emails for independent reading and to utilize the immense resources available for investigating topics relevant to specific cases, conferences, and research interests. Dr. Marc Moon, program director at Washington University, explains that "we have not utilized the materials in any formal, assigned manner; rather, we choose to use the curriculum as a resource for independent study, encouraging our residents to access the multimedia materials both for at-home study and point-of-care reference." Dr. Moon expresses gratitude for the new curriculum, reporting that the faculty members "are grateful that our trainees are able to access these curricular materials through the WebBrain and Moodle, as they serve as an outstanding educational supplement to a high volume operative experience." Dr. Moon further emphasizes, "We find that the new curriculum functions as an excellent adjunct to our clinical teaching."

There are a number of proposed strengths to the new curriculum – its breadth, its ease of access, its correlation with the educational objectives of the American Board of Thoracic Surgery. But what are the benefits being identified from the level of the training program? Dr. Paul Schipper, program director at OHSU, expresses appreciation for the greater volume of material accessible by the trainees, as compared with the older curriculum previously sponsored by the Thoracic Surgery Directors Association (TSDA). States Dr. Schipper, "We’ve been using the TSDA emailed curriculum for several years. With the release of WebBrain, we’ve switched over and been very pleased. Residents are accessing the material and digging deeper into it than previously. In our teaching sessions, we are spending more time on applying the material and less time on explaining it, and I think this is good." Appreciation for the breadth and depth of the material was also noted by Dr. Moon, who identifies the program’s strengths as its ease of access, its large volume, and its applicability to a wide range of educational needs.

Despite the generally laudatory praise, there have been a few issues identified by the training programs that could benefit from some improvement.

Certainly, this is not surprising, as with any educational program, practice and feedback are necessary to optimize the execution for the users. Further, with a resource collection of such enormity, minor tweaks will likely continue in the background at all times in order to ensure ongoing quality-control.

In considering further revision, Dr. Wallen raises some concerns regarding format. He states that "all the moving around on the links makes people crazy," and, for this reason, at Loma Linda, all of the materials are distributed from the WebBrain to the faculty and trainees by the program coordinator. "Otherwise, we would have a revolt," Dr. Jason Wallen explains, This distaste for accessing the materials via the WebBrain is not shared by all users, but it provides feedback, suggesting that changes could be made to optimize formatting to increase ease of use.

Certainly, the leaders in the TSDA, JCTSE, and Thoracic Surgery Residents Association (TSRA) who contributed to the development of the new curriculum are eager for this kind of feedback, welcoming all users to provide constructive criticism. Dr. Ara Vaporciyan, program director at the University of Texas MD Anderson Cancer Center, co-chair of the TSDA/JCTSE Curriculum Committee, and one of the 4 section editors for the curriculum itself, has been a key player in the development of the new curriculum.

States Dr. Vaporciyan, "I never expected this to be perfect on the first try and this is exactly the feedback we need. If we can start an honest conversation about the flaws in the system we can better allocate resources to fixing the most pervasive issues."

Despite the challenges that have been identified, Dr. Wallen remains positive about the curriculum, stating, "We are excited to have an electronic curriculum that our residents can access from anywhere that includes readings and multimedia content. We anticipate that following the curriculum will enhance our residents’ performance on future inservice exams and pave the path to certification."

Dr. Ikonomidis shares Dr. Wallen’s enthusiasm, summarizing that his "residents are constantly engaged and we believe that their learning efficiency has increased." Notes Dr. Schipper, "I am hopeful that this system will stay current and realize and appreciate the effort this has and will take to do so."

Certainly, the new curriculum has already been heavily utilized and appreciated by a number of training programs. While there will always be minor adjustments to be made, the innovators behind the Thoracic Surgery WebBrain and Moodle site are receptive to feedback and clearly dedicated to its ongoing growth.

Perhaps this article has encouraged those of you that aren’t using the curriculum regularly to incorporate it into your institution’s educational structure. For those of you already heavily engaged, perhaps you’ve been inspired to try some new strategies of implementation. Moreover, for all users of the system – trainees, educators, and coordinators – regardless of your program’s current level of use, the take-home message from the creators of the curriculum is that you are encouraged to provide feedback to allow evolution and improvement of the program.

The Trainee Experience

By Sanford M. Zeigler, M.D., Resident Medical Editor

Dr. Antonoff has detailed how different programs have chosen to implement the new curriculum. Of course, in order for the curriculum to work in any setting, people have to actually sit down, access the material, and learn from it. The modules need to be easily accessible, logically organized, and appropriate for the audience for which they are intended. To that end, the folks behind the new curriculum worked diligently to organize all the material into the WebBrain format, which attempts to organize the content by the logic of the human brain, using mind maps, and Moodle, which compartmentalizes the readings into individual curricular assignments that are served up on each resident’s personal Moodle page.

The overall architecture of the WebBrain is very organic; the "Brain" is split into four main branches, comprised of Foundations of Surgery, Cardiovascular, Thoracic, and Congenital headings. From these, the subject matter continues to divide and subdivide again until you reach a terminal branch, where the reader can open a number of different sources, both primary and secondary, on a given subject. The brains’ power lies in the connections that can be made across these fluid boundaries. An example can be seen with one reference that discusses MRI imaging of pericardial disease and cardiac masses. When this is selected, the thought leads the reader back to both the pericardial disease heading and the cardiac tumors heading. The subject selection feature allows the reader to wander throughout the entire WebBrain in a free-flowing but logical manner. Connections across different subjects are, at this point, still rarely utilized. The cross-referencing feature could be a boon for more junior integrated residents and general surgery residents if more of the basic concepts section were connected to cardiac and thoracic subjects, and could allow more self-directed reading to residents that find the time to do so. The WebBrain has some basic search functionality embedded in it that could be used to help understand specific clinical scenarios as they are encountered. Layered upon all of the subject matter are tags, which correspond to the weekly curricular readings. If trainees search for the tag "CV08," for example, they will be directed to each source with that tag, bringing the weekly source matter right to the front. Thus, the WebBrain can be used as a guide for casual reading, as a reference for a particular question or clinical scenario encountered in practice, and also as the source for material covered in didactic session.

The Moodle interface is the gateway to the WebBrain. While it may sound easier to deliver the contents of the WebBrain to each resident rather than go through Moodle, this interface serves two functions. In order to license the content for the curriculum, publishers of many of the textbooks require tight security to prevent unauthorized duplication of the materials. Moodle, by requiring a unique login to access the single WebBrain, provides that security and also allows the WebBrain to be modified in the Cloud, rather than at the level of the end-user. Moodle also provides other testing and tracking tools that have not been completely rolled out. Over the coming months, its full architecture will be used to incorporate quizzes, collaborative message boards, and personal tracking to help residents and their program directors ensure that the material is being covered adequately.

Nearly every resident and faculty member I asked about the new curriculum agreed that the update in content and delivery was badly needed. As an intern in an integrated cardiothoracic surgery program, I remember feeling very jealous of my general surgery colleagues’ access to the SCORE portal, which gave them an easily navigable curriculum accessible from anywhere, with instruction in everything from basic science and physiology to advanced surgical diagnosis and technique. The rollout of the Moodle interface and Web Brain content is the first step to a similar, comprehensive compendium of the necessary knowledge to master cardiac and thoracic surgery.

Response to the rollout has been generally positive from the residents. Most residents agree that the content provides a great sample of landmark papers, lecture videos, book chapters, and consensus statements. A fellow Stanford resident, George Dimeling, wrote: "I like the weekly focus and the topic organization. The content is good, but tough to access." The articles and chapters are often more up to date than printed textbooks, and, once the reader accesses the Brain, are instantly viewable with no further log ins or downloads.

Of course, for a busy resident, it may not always be possible to cover a long book chapter quickly, and the primary literature sometimes fails to cover an entire topic. Justin Schaffer, another Stanford resident, offered this thought: "There’s either a short paper or a 40-page book chapter – there is no solid review of the subject matter. They need something like the Doty lecture series and the TSRA publications to get you warmed up if you don’t have all that time." In fact, the WebBrain incorporates many chapters of the TSRA Cardiothoracic Review book, and the TSRA Clinical Scenarios were added to Moodle on Dec. 12.

One of the more common complaints had little to do with the content but more to do with delivery. At my own institution, most of our hospital computers run an outdated copy of Internet Explorer and have restricted access to update or install a new browser. The out-of-date or restricted software packages that are pervasive in institutional machines nullify many of the advantages of the WebBrain/Moodle format, as the majority of computers at Stanford Hospital cannot access the WebBrain. Furthermore, the WebBrain interface can be laggy and slow even with compatible software.

Others have complained that it is not always easy to find the readings, especially if a program does not follow one of the standardized curricula included with the rollout. First, one must find which content they are responsible for via departmental website or reference to the curricula. Next, the resident logs into the Moodle room, and the proper WebBrain course is launched, then each article for the week is selected and downloaded. Only after that can the content be read, saved, or printed. Using the tag function is helpful, but each time a tagged article is selected, the resident is taken away from the search and to the specific content area, away from the other material assigned for the week. Though it isn’t very difficult to navigate back to the search, all of the steps above make it a bit more of a process to access the material than is convenient for a resident trying to fit in readings between cases or while waiting to round. The new software is a definite improvement, yet still has not reached its full potential.

As Dr. Antonoff pointed out, one residency program has easily overcome this obstacle by consolidating and emailing the appropriate material every week. While the Moodle portion of the curriculum still sees limited functionality, this is probably the best solution to all of the problems. If the articles are in your mailbox, they are accessible anywhere, without the bother of logging in and navigating the Brain.

I discussed this with Dr. Jim Fann, who has been very involved in developing the curriculum, and he explained that direct delivery of the content to each resident had been part of the original goal. As mentioned before, however, publishers require that the delivery of the material is secure from unauthorized duplication. Within the context of an individual institution, those issues are less confining. While individual programs work to integrate the material into their own traditions, it may be worthwhile to designate a resident or office staff member to be in charge of distributing the week’s reading. One little-recognized feature of Moodle is the ability to upload calendars. Perhaps this area could be used by each program to keep the curricular and departmental calendars adjacent to the WebBrain link for easier access.

The recent changes in cardiothoracic surgical education have been myriad, and the rollout of the new curriculum is one of the most pervasive and visible signs of that change. The new curriculum has been designed and updated to reflect not only updates in medical knowledge and consensus, but also changes in the demographic of the cardiothoracic surgery resident and new paradigms in surgical education. The content and delivery systems, while not perfect, remain an ever improving work in progress, which aims to bring cardiothoracic surgical education into the collaborative, cloud based learning era while broadening its reach to both green cardiothoracic surgery interns and traditional fellows with a full general surgery residency behind them. All things considered, the rollout has been very successful, and as more functionality is added and bugs are worked out, things can only improve.

We are pleased to have Dr. Sapan S. Desai come on board as our Resident/Fellow Editor for the next year. Dr. Desai was selected from an excellent candidate pool who submitted their credentials as well as samples of their writings.

Dr. Desai is currently a vascular fellow at University of Texas at Houston/Memorial Hermann Hospital Houston, Tex. He did his surgical residency at Duke University where he still holds the rank of adjunct assistant professor of surgery.

He also has a PhD from the University of Illinois at Chicago, College of Medicine and an MBA in Health Care Management from Western Governors University, Salt Lake City. He is the founder and Executive Editor of the Journal of Surgical Radiology.

We look forward to his contributions and insight into issues that pertain to residents and fellows.

Dr. Russell Samson, Medical Editor, Vascular Specialist

We are pleased to have Dr. Sapan S. Desai come on board as our Resident/Fellow Editor for the next year. Dr. Desai was selected from an excellent candidate pool who submitted their credentials as well as samples of their writings.

Dr. Desai is currently a vascular fellow at University of Texas at Houston/Memorial Hermann Hospital Houston, Tex. He did his surgical residency at Duke University where he still holds the rank of adjunct assistant professor of surgery.

He also has a PhD from the University of Illinois at Chicago, College of Medicine and an MBA in Health Care Management from Western Governors University, Salt Lake City. He is the founder and Executive Editor of the Journal of Surgical Radiology.

We look forward to his contributions and insight into issues that pertain to residents and fellows.

Dr. Russell Samson, Medical Editor, Vascular Specialist

We are pleased to have Dr. Sapan S. Desai come on board as our Resident/Fellow Editor for the next year. Dr. Desai was selected from an excellent candidate pool who submitted their credentials as well as samples of their writings.

Dr. Desai is currently a vascular fellow at University of Texas at Houston/Memorial Hermann Hospital Houston, Tex. He did his surgical residency at Duke University where he still holds the rank of adjunct assistant professor of surgery.

He also has a PhD from the University of Illinois at Chicago, College of Medicine and an MBA in Health Care Management from Western Governors University, Salt Lake City. He is the founder and Executive Editor of the Journal of Surgical Radiology.

We look forward to his contributions and insight into issues that pertain to residents and fellows.

Dr. Russell Samson, Medical Editor, Vascular Specialist

A resident’s ability to balance work and personal life is dependent on multiple factors, with spousal or partner approval likely comprising one of the most important, according to a report published in the Journal of Surgical Education. The report details the results of an electronic survey sent to thoracic surgery spouses via contact with all thoracic surgery residents over 2 years at two training programs and all current thoracic surgery residents in 2010.

A total of 66 surveys were completed and returned (a response rate of 19%), with 86% of the respondents being women, and 82% being married for a mean of 4.3 years; 59% had children, and 64% were planning on having more children within 3 years.

Nearly 90%of the spouses responding reported that they want to travel to more of the interviews, and that they had some to complete influence on which training program to attend, according to Mr. Michael Bohl and Dr. Rishindra M. Reddy of the Section of Thoracic Surgery at the University of Michigan, Ann Arbor (J. Surg. Education 2013;70:640-6).

Nearly 80% of the respondents also reported that they wanted more information on salary and on housing, as well as access to faculty spouses. The top 3 factors in chosing a program they reported were: quality of fellowship, geographic location, and proximity to family.

Knowledge of the extent of influence and the desires of spouses with regard to CTStraining positions might allow targeting these needs at a point early enough in the process to help capture general surgery residents interested in but not committed to CTS residency, the researchers suggested.

"The results show numerous demographic and characteristic trends which, if further validated by definitive studies, would be applicable to all post-surgery residency training programs and may help CTS programs to be more competitive in attracting applicants and their families.

The authors had no relevant disclosures.

A resident’s ability to balance work and personal life is dependent on multiple factors, with spousal or partner approval likely comprising one of the most important, according to a report published in the Journal of Surgical Education. The report details the results of an electronic survey sent to thoracic surgery spouses via contact with all thoracic surgery residents over 2 years at two training programs and all current thoracic surgery residents in 2010.

A total of 66 surveys were completed and returned (a response rate of 19%), with 86% of the respondents being women, and 82% being married for a mean of 4.3 years; 59% had children, and 64% were planning on having more children within 3 years.

Nearly 90%of the spouses responding reported that they want to travel to more of the interviews, and that they had some to complete influence on which training program to attend, according to Mr. Michael Bohl and Dr. Rishindra M. Reddy of the Section of Thoracic Surgery at the University of Michigan, Ann Arbor (J. Surg. Education 2013;70:640-6).

Nearly 80% of the respondents also reported that they wanted more information on salary and on housing, as well as access to faculty spouses. The top 3 factors in chosing a program they reported were: quality of fellowship, geographic location, and proximity to family.

Knowledge of the extent of influence and the desires of spouses with regard to CTStraining positions might allow targeting these needs at a point early enough in the process to help capture general surgery residents interested in but not committed to CTS residency, the researchers suggested.

"The results show numerous demographic and characteristic trends which, if further validated by definitive studies, would be applicable to all post-surgery residency training programs and may help CTS programs to be more competitive in attracting applicants and their families.

The authors had no relevant disclosures.

A resident’s ability to balance work and personal life is dependent on multiple factors, with spousal or partner approval likely comprising one of the most important, according to a report published in the Journal of Surgical Education. The report details the results of an electronic survey sent to thoracic surgery spouses via contact with all thoracic surgery residents over 2 years at two training programs and all current thoracic surgery residents in 2010.

A total of 66 surveys were completed and returned (a response rate of 19%), with 86% of the respondents being women, and 82% being married for a mean of 4.3 years; 59% had children, and 64% were planning on having more children within 3 years.

Nearly 90%of the spouses responding reported that they want to travel to more of the interviews, and that they had some to complete influence on which training program to attend, according to Mr. Michael Bohl and Dr. Rishindra M. Reddy of the Section of Thoracic Surgery at the University of Michigan, Ann Arbor (J. Surg. Education 2013;70:640-6).

Nearly 80% of the respondents also reported that they wanted more information on salary and on housing, as well as access to faculty spouses. The top 3 factors in chosing a program they reported were: quality of fellowship, geographic location, and proximity to family.

Knowledge of the extent of influence and the desires of spouses with regard to CTStraining positions might allow targeting these needs at a point early enough in the process to help capture general surgery residents interested in but not committed to CTS residency, the researchers suggested.

"The results show numerous demographic and characteristic trends which, if further validated by definitive studies, would be applicable to all post-surgery residency training programs and may help CTS programs to be more competitive in attracting applicants and their families.

The authors had no relevant disclosures.

Dear Colleague,

This is to officially announce the launch of the Thoracic Surgery Foundation for Research and Education (TSFRE) 2014 Awards Program. Please view the TSFRE Summer Newsletter with information about the 2014 Awards Program, including award descriptions, a timeline, links to download award applications, and a list of 2014 Research and Education Committee members (http://tinyurl.com/kfzdjz9).

Inside the issue you’ll find a special tribute to Dr. Carolyn E. Reed, a timely essay concerning the need to support cardiothoracic surgery research in today’s climate, and information about TSFRE’s mission and history of supporting cardiothoracic surgery research and education initiatives. You’ll also see the faces of many TSFRE supporters and friends.

I’d also like to mention that 2013 marks the 25th Anniversary of TSFRE. Since 1988, we have supported over $11 million toward cardiothoracic surgery research projects. We could not have accomplished this without the partnership of our society friends, the American Association for Thoracic Surgery (AATS), The Society of Thoracic Surgeons (STS), the Southern Thoracic Surgical Association (STSA), and the Western Thoracic Surgical Association (WTSA). And, we especially could not have achieved this without your support.

The quality and quantity of TSFRE-funded projects over the past 25 years have been phenomenal. Please join me today in making a contribution to the TSFRE 25th Anniversary Campaign by clicking on the link in the newsletter. Your donation will help ensure that TSFRE can continue funding important cardiothoracic surgery research and education for the next 25 years.

Thank you for your generosity as we head into our 25th year!

G. Alexander Patterson, M.D.

TSFRE President

Dear Colleague,

This is to officially announce the launch of the Thoracic Surgery Foundation for Research and Education (TSFRE) 2014 Awards Program. Please view the TSFRE Summer Newsletter with information about the 2014 Awards Program, including award descriptions, a timeline, links to download award applications, and a list of 2014 Research and Education Committee members (http://tinyurl.com/kfzdjz9).

Inside the issue you’ll find a special tribute to Dr. Carolyn E. Reed, a timely essay concerning the need to support cardiothoracic surgery research in today’s climate, and information about TSFRE’s mission and history of supporting cardiothoracic surgery research and education initiatives. You’ll also see the faces of many TSFRE supporters and friends.

I’d also like to mention that 2013 marks the 25th Anniversary of TSFRE. Since 1988, we have supported over $11 million toward cardiothoracic surgery research projects. We could not have accomplished this without the partnership of our society friends, the American Association for Thoracic Surgery (AATS), The Society of Thoracic Surgeons (STS), the Southern Thoracic Surgical Association (STSA), and the Western Thoracic Surgical Association (WTSA). And, we especially could not have achieved this without your support.

The quality and quantity of TSFRE-funded projects over the past 25 years have been phenomenal. Please join me today in making a contribution to the TSFRE 25th Anniversary Campaign by clicking on the link in the newsletter. Your donation will help ensure that TSFRE can continue funding important cardiothoracic surgery research and education for the next 25 years.

Thank you for your generosity as we head into our 25th year!

G. Alexander Patterson, M.D.

TSFRE President

Dear Colleague,

This is to officially announce the launch of the Thoracic Surgery Foundation for Research and Education (TSFRE) 2014 Awards Program. Please view the TSFRE Summer Newsletter with information about the 2014 Awards Program, including award descriptions, a timeline, links to download award applications, and a list of 2014 Research and Education Committee members (http://tinyurl.com/kfzdjz9).

Inside the issue you’ll find a special tribute to Dr. Carolyn E. Reed, a timely essay concerning the need to support cardiothoracic surgery research in today’s climate, and information about TSFRE’s mission and history of supporting cardiothoracic surgery research and education initiatives. You’ll also see the faces of many TSFRE supporters and friends.

I’d also like to mention that 2013 marks the 25th Anniversary of TSFRE. Since 1988, we have supported over $11 million toward cardiothoracic surgery research projects. We could not have accomplished this without the partnership of our society friends, the American Association for Thoracic Surgery (AATS), The Society of Thoracic Surgeons (STS), the Southern Thoracic Surgical Association (STSA), and the Western Thoracic Surgical Association (WTSA). And, we especially could not have achieved this without your support.

The quality and quantity of TSFRE-funded projects over the past 25 years have been phenomenal. Please join me today in making a contribution to the TSFRE 25th Anniversary Campaign by clicking on the link in the newsletter. Your donation will help ensure that TSFRE can continue funding important cardiothoracic surgery research and education for the next 25 years.

Thank you for your generosity as we head into our 25th year!

G. Alexander Patterson, M.D.

TSFRE President

Much anticipated by many, exciting to the tech-savvy among us, and unbeknownst to others, yet equally relevant to all: The new curriculum is here. Whether you are a trainee, an educator, or a thoracic surgeon interested in the future of our specialty, the unveiling of the new curriculum is of key significance.

In 1992, at the Joint Conference on Graduate Education in Thoracic Surgery, significant emphasis was placed upon curricular change for thoracic surgical education. In response, the Thoracic Surgery Directors Association (TSDA) initiated the comprehensive thoracic surgery curriculum project in order to develop a consensus as to the content that ought to be learned during thoracic surgical training. Published in 1994, and available online, the TSDA Curriculum was intended to serve as a study guide to individual trainees and a useful resource for Program Directors. While of enormous utility over the last 2 decades, the curriculum is getting a makeover.

Being released this July is a brand-new curriculum, with updated topics and an excitingly novel platform, as a collaborative project from several organizations committed to thoracic surgical education. The Joint Council on Thoracic Surgery Education (JCTSE) has been working closely with the TSDA, with significant input from the American Board of Thoracic Surgery (ABTS), the Society of Thoracic Surgeons (STS), and the Residency Review Committee (RRC) for Thoracic Surgery. Dr. Ara Vaporciyan, Program Director at the University of Texas MD Anderson Cancer Center and 2013 Secretary/Treasurer of the TSDA, has been a key player in the development of the new curriculum.

When asked about the impetus for developing a new curriculum, Dr. Vaporciyan acknowledges that the old curriculum was an enormous advantage when first introduced, but that, now, it is somewhat outdated, and, further, new technology allows us to deliver the content better and more efficiently. Further, Dr. Vaporciyan highlights the valuable aspect of the new curriculum that links its content to expectations of the ABTS for board certification and the requirements of the Accreditation Council for Graduate Medical Education (ACGME) Milestones project.

Similar to the old curriculum, the basic architecture of the new curriculum contains 88-90 separate topics. However, within the new curriculum, the topics have been selected to cover each element of the published learning objectives provided by the ABTS.

Specific topics were identified by appointed section editors (Cardiac: Drs. James Fann and Craig Baker, Thoracic: DRs. Stephen Yang and Ara Vaporciyan, Congenital: Drs. Ram Subramanyan and Winfield Wells). Approximately 20 topic editors from all over the country have helped populate the new curriculum with content, and have additionally provided some input toward the division of topics.

For many, the most exciting feature of the new curriculum relates to the way that the educational materials will be delivered. Using WebBrain software (TheBrain, Los Angeles) for content management, all topics are organized like a mind map. For example, on the main tree, one can click on Thoracic Surgery, then neoplasm of the lung, which then explodes into three related topics: medical knowledge, patient care, and technical skills, which each branch out further. As explained by Dr. Vaporciyan, "the learning objectives of the ABTS provide the structure of the tree – its trunk and main branches – while the content components, provided by the topic editors, serve as the leaves on the ends of the branches."

So what exactly makes up those leaves at the end of the branches? The multi-media material is 100% pre-existing, coming from six different textbooks, up-to-date literature, online presentations created by the TSDA, and societal guidelines. In addition to the WebBrain content management system, the new curriculum utilizes a Moodle-based (Moodle Pty. Ltd., Perth, Australia) platform for organizing specific lessons plans and weekly curricular goals. Moodle (modular object-oriented dynamic learning environment) is an e-learning software platform, also known as a virtual learning environment.

With features such as assignment submission, quiz completion, discussion forums, file download capabilities, and opportunities for instructors to track individual trainee use, the potential opportunities for future growth are enormous. Within the new TSDA curriculum, trainees will receive a weekly email (as they have with the previous version of the curriculum). This email will direct them to a Moodle course for that week, such as "cardiac disease 1," which will provide to direct links within the WebBrain to all of the topics expected to be covered that week, ultimately providing access to the relevant multi-media materials. Once one has accessed the WebBrain, he or she can surf anywhere within the content tree.

The curriculum will be released in two phases. Phase I entails releasing the content which has been populated onto the WebBrain, utilizing Moodle as the access point. Phase II, which is expected to occur over the coming year, will include a more robust Moodle site. These courses will be fleshed out to each include a multiple-choice quiz with feedback, a wiki page, opportunities for commentary, and a means of gathering feedback from end-users regarding the curriculum. Access to these courses will be free of charge to thoracic surgical residents in the United States and Canada, as well as to program coordinators and faculty. Graduating residents will have access for 1 additional year in order to use the curriculum as a tool to prepare for Boards.

Dr. Edward Verrier, JCTSE Surgical Director of Education, explains that "the curriculum revision is a number of years in conception, preparation, organization, and now implementation. It is the combined effort of a number of dedicated educators and societies with some financial support from industry."

Referencing Salman Kahn in The One World Schoolhouse: Education Reimagined, Dr. Verrier continues: "We believe that this educational tool, using both a learning management and content management electronic based platform, has the potential to ‘flip the classroom.’ With work hour restrictions for residents, a constantly increasing body of knowledge, and the challenges of teaching in the operating room, we believe the new Thoracic Surgery Curriculum has the potential to transform our current approach to surgical education."

So what does this mean for trainees? As stated by Dr. Vaporciyan, "the biggest benefit to the trainees is that, with this content and related quizzes, individuals will have the ability to assess their own needs, have immediate access to relevant content that is free of charge, and, importantly, it is the ABTS intent to ultimately derive the examination material from this new electronic curriculum." Yes, it’s true. The board has agreed that the new curriculum will serve as a template of the content for both the written and oral examinations, making this curriculum the ideal study source for trainees. Dr. John Calhoon, chair of the ABTS, reports that "it is our goal to make sure that we draw questions in the future from the content that is called for in our outline and encompassed by the efforts of this new curriculum’s editors." (And did I mention that it’s free and immediately accessible on the Internet?)

And what about for the educators out there – what does this mean for you? Vaporciyan highlights three key advantages for the teachers: 1) the curriculum is completely malleable, so you can take whatever topic you want your learners to focus upon, and you can add to it or separate topics in any way, such as rotation preparation or linear knowledge acquisition; 2) through learner management aspects of Moodle, you can track all of your learners’ progress; 3) the curriculum is linked to Milestones, which should dramatically assist with meeting this requirement of the ACGME.

As mentioned by Dr. Vaporciyan, the Milestones Project is an important recent endeavor of the ACGME, mandating that all specialty groups develop outcome-based goals for resident performance within the six domains of clinical competence. The milestones will be used by the ACGME to demonstrate accountability of effectiveness of education within ACGME-accredited programs, and, looking ahead, resident performance on milestones will become a source of normative data for the RRC to use in assessing residency programs and facilitating improvements. Linking the new curriculum to milestones will render it a great tool to program directors in ACGME-accredited programs. As explained by Dr. Calhoon, "the RRC is working with the Milestones effort to align the individual curricular modules so that residency training programs will find further synergy and utility in adapting or frankly using the curriculum ‘right off the shelf.’"

When asked about the new curriculum, President of the TSDA Dr. David Fullerton shares with us that "along with the other organizations within our specialty, the TSDA is committed to the education of our residents. The TSDA feels that the consolidation of our specialty’s curricular efforts in this way is a significant advance in thoracic surgical education." Further, Dr. Fullerton acknowledges that the new curriculum "will afford our residents immediate electronic access to important educational materials and will be flexible enough for adaption in individual programs." With gratitude on behalf of the TSDA, Dr. Fullerton congratulates all of the individuals who have contributed to making the Thoracic Surgery Curriculum a reality.

Clearly, this new curriculum has much to offer, for both the teacher and the student. It will be of significant interest to track use and observe associated relationships with subsequent board examination success.

In anticipation of an Aug. 1 launch, notifications regarding accessing the site were provided to residents and program directors via email throughout the month of July. More information on the new curriculum, as well as an introductory video, is found at www.tsda.org/education/thoracic-surgery-curricula.

And we will continue to follow and discuss the new curriculum in these pages of the Residents’ Corner.

Much anticipated by many, exciting to the tech-savvy among us, and unbeknownst to others, yet equally relevant to all: The new curriculum is here. Whether you are a trainee, an educator, or a thoracic surgeon interested in the future of our specialty, the unveiling of the new curriculum is of key significance.

In 1992, at the Joint Conference on Graduate Education in Thoracic Surgery, significant emphasis was placed upon curricular change for thoracic surgical education. In response, the Thoracic Surgery Directors Association (TSDA) initiated the comprehensive thoracic surgery curriculum project in order to develop a consensus as to the content that ought to be learned during thoracic surgical training. Published in 1994, and available online, the TSDA Curriculum was intended to serve as a study guide to individual trainees and a useful resource for Program Directors. While of enormous utility over the last 2 decades, the curriculum is getting a makeover.

Being released this July is a brand-new curriculum, with updated topics and an excitingly novel platform, as a collaborative project from several organizations committed to thoracic surgical education. The Joint Council on Thoracic Surgery Education (JCTSE) has been working closely with the TSDA, with significant input from the American Board of Thoracic Surgery (ABTS), the Society of Thoracic Surgeons (STS), and the Residency Review Committee (RRC) for Thoracic Surgery. Dr. Ara Vaporciyan, Program Director at the University of Texas MD Anderson Cancer Center and 2013 Secretary/Treasurer of the TSDA, has been a key player in the development of the new curriculum.

When asked about the impetus for developing a new curriculum, Dr. Vaporciyan acknowledges that the old curriculum was an enormous advantage when first introduced, but that, now, it is somewhat outdated, and, further, new technology allows us to deliver the content better and more efficiently. Further, Dr. Vaporciyan highlights the valuable aspect of the new curriculum that links its content to expectations of the ABTS for board certification and the requirements of the Accreditation Council for Graduate Medical Education (ACGME) Milestones project.

Similar to the old curriculum, the basic architecture of the new curriculum contains 88-90 separate topics. However, within the new curriculum, the topics have been selected to cover each element of the published learning objectives provided by the ABTS.

Specific topics were identified by appointed section editors (Cardiac: Drs. James Fann and Craig Baker, Thoracic: DRs. Stephen Yang and Ara Vaporciyan, Congenital: Drs. Ram Subramanyan and Winfield Wells). Approximately 20 topic editors from all over the country have helped populate the new curriculum with content, and have additionally provided some input toward the division of topics.

For many, the most exciting feature of the new curriculum relates to the way that the educational materials will be delivered. Using WebBrain software (TheBrain, Los Angeles) for content management, all topics are organized like a mind map. For example, on the main tree, one can click on Thoracic Surgery, then neoplasm of the lung, which then explodes into three related topics: medical knowledge, patient care, and technical skills, which each branch out further. As explained by Dr. Vaporciyan, "the learning objectives of the ABTS provide the structure of the tree – its trunk and main branches – while the content components, provided by the topic editors, serve as the leaves on the ends of the branches."

So what exactly makes up those leaves at the end of the branches? The multi-media material is 100% pre-existing, coming from six different textbooks, up-to-date literature, online presentations created by the TSDA, and societal guidelines. In addition to the WebBrain content management system, the new curriculum utilizes a Moodle-based (Moodle Pty. Ltd., Perth, Australia) platform for organizing specific lessons plans and weekly curricular goals. Moodle (modular object-oriented dynamic learning environment) is an e-learning software platform, also known as a virtual learning environment.

With features such as assignment submission, quiz completion, discussion forums, file download capabilities, and opportunities for instructors to track individual trainee use, the potential opportunities for future growth are enormous. Within the new TSDA curriculum, trainees will receive a weekly email (as they have with the previous version of the curriculum). This email will direct them to a Moodle course for that week, such as "cardiac disease 1," which will provide to direct links within the WebBrain to all of the topics expected to be covered that week, ultimately providing access to the relevant multi-media materials. Once one has accessed the WebBrain, he or she can surf anywhere within the content tree.

The curriculum will be released in two phases. Phase I entails releasing the content which has been populated onto the WebBrain, utilizing Moodle as the access point. Phase II, which is expected to occur over the coming year, will include a more robust Moodle site. These courses will be fleshed out to each include a multiple-choice quiz with feedback, a wiki page, opportunities for commentary, and a means of gathering feedback from end-users regarding the curriculum. Access to these courses will be free of charge to thoracic surgical residents in the United States and Canada, as well as to program coordinators and faculty. Graduating residents will have access for 1 additional year in order to use the curriculum as a tool to prepare for Boards.

Dr. Edward Verrier, JCTSE Surgical Director of Education, explains that "the curriculum revision is a number of years in conception, preparation, organization, and now implementation. It is the combined effort of a number of dedicated educators and societies with some financial support from industry."

Referencing Salman Kahn in The One World Schoolhouse: Education Reimagined, Dr. Verrier continues: "We believe that this educational tool, using both a learning management and content management electronic based platform, has the potential to ‘flip the classroom.’ With work hour restrictions for residents, a constantly increasing body of knowledge, and the challenges of teaching in the operating room, we believe the new Thoracic Surgery Curriculum has the potential to transform our current approach to surgical education."

So what does this mean for trainees? As stated by Dr. Vaporciyan, "the biggest benefit to the trainees is that, with this content and related quizzes, individuals will have the ability to assess their own needs, have immediate access to relevant content that is free of charge, and, importantly, it is the ABTS intent to ultimately derive the examination material from this new electronic curriculum." Yes, it’s true. The board has agreed that the new curriculum will serve as a template of the content for both the written and oral examinations, making this curriculum the ideal study source for trainees. Dr. John Calhoon, chair of the ABTS, reports that "it is our goal to make sure that we draw questions in the future from the content that is called for in our outline and encompassed by the efforts of this new curriculum’s editors." (And did I mention that it’s free and immediately accessible on the Internet?)

And what about for the educators out there – what does this mean for you? Vaporciyan highlights three key advantages for the teachers: 1) the curriculum is completely malleable, so you can take whatever topic you want your learners to focus upon, and you can add to it or separate topics in any way, such as rotation preparation or linear knowledge acquisition; 2) through learner management aspects of Moodle, you can track all of your learners’ progress; 3) the curriculum is linked to Milestones, which should dramatically assist with meeting this requirement of the ACGME.

As mentioned by Dr. Vaporciyan, the Milestones Project is an important recent endeavor of the ACGME, mandating that all specialty groups develop outcome-based goals for resident performance within the six domains of clinical competence. The milestones will be used by the ACGME to demonstrate accountability of effectiveness of education within ACGME-accredited programs, and, looking ahead, resident performance on milestones will become a source of normative data for the RRC to use in assessing residency programs and facilitating improvements. Linking the new curriculum to milestones will render it a great tool to program directors in ACGME-accredited programs. As explained by Dr. Calhoon, "the RRC is working with the Milestones effort to align the individual curricular modules so that residency training programs will find further synergy and utility in adapting or frankly using the curriculum ‘right off the shelf.’"

When asked about the new curriculum, President of the TSDA Dr. David Fullerton shares with us that "along with the other organizations within our specialty, the TSDA is committed to the education of our residents. The TSDA feels that the consolidation of our specialty’s curricular efforts in this way is a significant advance in thoracic surgical education." Further, Dr. Fullerton acknowledges that the new curriculum "will afford our residents immediate electronic access to important educational materials and will be flexible enough for adaption in individual programs." With gratitude on behalf of the TSDA, Dr. Fullerton congratulates all of the individuals who have contributed to making the Thoracic Surgery Curriculum a reality.

Clearly, this new curriculum has much to offer, for both the teacher and the student. It will be of significant interest to track use and observe associated relationships with subsequent board examination success.

In anticipation of an Aug. 1 launch, notifications regarding accessing the site were provided to residents and program directors via email throughout the month of July. More information on the new curriculum, as well as an introductory video, is found at www.tsda.org/education/thoracic-surgery-curricula.

And we will continue to follow and discuss the new curriculum in these pages of the Residents’ Corner.

Much anticipated by many, exciting to the tech-savvy among us, and unbeknownst to others, yet equally relevant to all: The new curriculum is here. Whether you are a trainee, an educator, or a thoracic surgeon interested in the future of our specialty, the unveiling of the new curriculum is of key significance.

In 1992, at the Joint Conference on Graduate Education in Thoracic Surgery, significant emphasis was placed upon curricular change for thoracic surgical education. In response, the Thoracic Surgery Directors Association (TSDA) initiated the comprehensive thoracic surgery curriculum project in order to develop a consensus as to the content that ought to be learned during thoracic surgical training. Published in 1994, and available online, the TSDA Curriculum was intended to serve as a study guide to individual trainees and a useful resource for Program Directors. While of enormous utility over the last 2 decades, the curriculum is getting a makeover.

Being released this July is a brand-new curriculum, with updated topics and an excitingly novel platform, as a collaborative project from several organizations committed to thoracic surgical education. The Joint Council on Thoracic Surgery Education (JCTSE) has been working closely with the TSDA, with significant input from the American Board of Thoracic Surgery (ABTS), the Society of Thoracic Surgeons (STS), and the Residency Review Committee (RRC) for Thoracic Surgery. Dr. Ara Vaporciyan, Program Director at the University of Texas MD Anderson Cancer Center and 2013 Secretary/Treasurer of the TSDA, has been a key player in the development of the new curriculum.

When asked about the impetus for developing a new curriculum, Dr. Vaporciyan acknowledges that the old curriculum was an enormous advantage when first introduced, but that, now, it is somewhat outdated, and, further, new technology allows us to deliver the content better and more efficiently. Further, Dr. Vaporciyan highlights the valuable aspect of the new curriculum that links its content to expectations of the ABTS for board certification and the requirements of the Accreditation Council for Graduate Medical Education (ACGME) Milestones project.

Similar to the old curriculum, the basic architecture of the new curriculum contains 88-90 separate topics. However, within the new curriculum, the topics have been selected to cover each element of the published learning objectives provided by the ABTS.

Specific topics were identified by appointed section editors (Cardiac: Drs. James Fann and Craig Baker, Thoracic: DRs. Stephen Yang and Ara Vaporciyan, Congenital: Drs. Ram Subramanyan and Winfield Wells). Approximately 20 topic editors from all over the country have helped populate the new curriculum with content, and have additionally provided some input toward the division of topics.

For many, the most exciting feature of the new curriculum relates to the way that the educational materials will be delivered. Using WebBrain software (TheBrain, Los Angeles) for content management, all topics are organized like a mind map. For example, on the main tree, one can click on Thoracic Surgery, then neoplasm of the lung, which then explodes into three related topics: medical knowledge, patient care, and technical skills, which each branch out further. As explained by Dr. Vaporciyan, "the learning objectives of the ABTS provide the structure of the tree – its trunk and main branches – while the content components, provided by the topic editors, serve as the leaves on the ends of the branches."

So what exactly makes up those leaves at the end of the branches? The multi-media material is 100% pre-existing, coming from six different textbooks, up-to-date literature, online presentations created by the TSDA, and societal guidelines. In addition to the WebBrain content management system, the new curriculum utilizes a Moodle-based (Moodle Pty. Ltd., Perth, Australia) platform for organizing specific lessons plans and weekly curricular goals. Moodle (modular object-oriented dynamic learning environment) is an e-learning software platform, also known as a virtual learning environment.

With features such as assignment submission, quiz completion, discussion forums, file download capabilities, and opportunities for instructors to track individual trainee use, the potential opportunities for future growth are enormous. Within the new TSDA curriculum, trainees will receive a weekly email (as they have with the previous version of the curriculum). This email will direct them to a Moodle course for that week, such as "cardiac disease 1," which will provide to direct links within the WebBrain to all of the topics expected to be covered that week, ultimately providing access to the relevant multi-media materials. Once one has accessed the WebBrain, he or she can surf anywhere within the content tree.

The curriculum will be released in two phases. Phase I entails releasing the content which has been populated onto the WebBrain, utilizing Moodle as the access point. Phase II, which is expected to occur over the coming year, will include a more robust Moodle site. These courses will be fleshed out to each include a multiple-choice quiz with feedback, a wiki page, opportunities for commentary, and a means of gathering feedback from end-users regarding the curriculum. Access to these courses will be free of charge to thoracic surgical residents in the United States and Canada, as well as to program coordinators and faculty. Graduating residents will have access for 1 additional year in order to use the curriculum as a tool to prepare for Boards.

Dr. Edward Verrier, JCTSE Surgical Director of Education, explains that "the curriculum revision is a number of years in conception, preparation, organization, and now implementation. It is the combined effort of a number of dedicated educators and societies with some financial support from industry."

Referencing Salman Kahn in The One World Schoolhouse: Education Reimagined, Dr. Verrier continues: "We believe that this educational tool, using both a learning management and content management electronic based platform, has the potential to ‘flip the classroom.’ With work hour restrictions for residents, a constantly increasing body of knowledge, and the challenges of teaching in the operating room, we believe the new Thoracic Surgery Curriculum has the potential to transform our current approach to surgical education."

So what does this mean for trainees? As stated by Dr. Vaporciyan, "the biggest benefit to the trainees is that, with this content and related quizzes, individuals will have the ability to assess their own needs, have immediate access to relevant content that is free of charge, and, importantly, it is the ABTS intent to ultimately derive the examination material from this new electronic curriculum." Yes, it’s true. The board has agreed that the new curriculum will serve as a template of the content for both the written and oral examinations, making this curriculum the ideal study source for trainees. Dr. John Calhoon, chair of the ABTS, reports that "it is our goal to make sure that we draw questions in the future from the content that is called for in our outline and encompassed by the efforts of this new curriculum’s editors." (And did I mention that it’s free and immediately accessible on the Internet?)

And what about for the educators out there – what does this mean for you? Vaporciyan highlights three key advantages for the teachers: 1) the curriculum is completely malleable, so you can take whatever topic you want your learners to focus upon, and you can add to it or separate topics in any way, such as rotation preparation or linear knowledge acquisition; 2) through learner management aspects of Moodle, you can track all of your learners’ progress; 3) the curriculum is linked to Milestones, which should dramatically assist with meeting this requirement of the ACGME.

As mentioned by Dr. Vaporciyan, the Milestones Project is an important recent endeavor of the ACGME, mandating that all specialty groups develop outcome-based goals for resident performance within the six domains of clinical competence. The milestones will be used by the ACGME to demonstrate accountability of effectiveness of education within ACGME-accredited programs, and, looking ahead, resident performance on milestones will become a source of normative data for the RRC to use in assessing residency programs and facilitating improvements. Linking the new curriculum to milestones will render it a great tool to program directors in ACGME-accredited programs. As explained by Dr. Calhoon, "the RRC is working with the Milestones effort to align the individual curricular modules so that residency training programs will find further synergy and utility in adapting or frankly using the curriculum ‘right off the shelf.’"

When asked about the new curriculum, President of the TSDA Dr. David Fullerton shares with us that "along with the other organizations within our specialty, the TSDA is committed to the education of our residents. The TSDA feels that the consolidation of our specialty’s curricular efforts in this way is a significant advance in thoracic surgical education." Further, Dr. Fullerton acknowledges that the new curriculum "will afford our residents immediate electronic access to important educational materials and will be flexible enough for adaption in individual programs." With gratitude on behalf of the TSDA, Dr. Fullerton congratulates all of the individuals who have contributed to making the Thoracic Surgery Curriculum a reality.

Clearly, this new curriculum has much to offer, for both the teacher and the student. It will be of significant interest to track use and observe associated relationships with subsequent board examination success.

In anticipation of an Aug. 1 launch, notifications regarding accessing the site were provided to residents and program directors via email throughout the month of July. More information on the new curriculum, as well as an introductory video, is found at www.tsda.org/education/thoracic-surgery-curricula.

And we will continue to follow and discuss the new curriculum in these pages of the Residents’ Corner.

Dr. Nathan D. Airhart, Washington University School of Medicine, St. Louis, was the recipient of this year’s SVS Foundation Resident Research Prize Paper, which was presented at the Vascular Annual Meeting as part of the William J. von Liebig Forum, which features the best in resident research.

Dr. Airhart, his mentor, Dr. John A. Curci, and his colleagues studied the specific contribution of the vascular smooth muscle cells (SMCs) to the destruction of the elastic proteins that are uniquely absent in the walls of abdominal aortic aneurysms (AAAs). "Although the SMC is the dominant cell type in the aortic wall, our understanding of the role of these cells in aneurysms has been very limited," said Dr. Airhart.

Courtesy Dr. John A. Curci

To directly study the function of these cells, Dr. Airhart and his colleagues embarked on an ambitious project to isolate live SMCs from AAAs, normal abdominal aorta (NAA), and plaque from carotid endarterectomy (CEA) procedures. The group profiled the mRNA produced by these cultured cells by microarray and clearly demonstrated a unique pattern of expression of the AAA-SMC.

"The mRNA profiles confirmed that the AAA cells were likely interacting with the matrix differently than the other SMCs, but it did not necessarily tell us how they were influencing aneurysm development," said Dr. Airhart. To better understand the role of these cells, the investigators evaluated the ability of these cells to break down elastic fibers in culture.

Under standard culture conditions, AAA-SMCs were able to degrade three times more elastin than the NAA-SMCs. "Even more remarkable was the finding that co-culture with activated macrophages – a cell type always found in the wall of aneurysms – resulted in a further doubling of the elastic fiber damage by the AAA-SMCs. Co-culture of macrophages with NAA-SMCs had no effect on the elastin degraded," said Dr. Airhart.

Further experiments suggested that the enzymes principally responsible for the elastolytic activity of these cells are the matrix metalloproteinases (MMPs). Increases in the production and/or activation of MMP-2 and/or MMP-9 were prominently found in cultures of AAA-SMCs.

"These studies present the strongest evidence that AAA-SMCs exhibit a disease-specific gene expression pattern and can very potently damage the elastic fiber matrix in the aortic wall. The unique and remarkable synergy with activated inflammatory cells might help explain the characteristic elastin loss of aortic aneurysms. Future studies will allow us to understand and alter the cellular mechanisms which lead to increased production and activation of elastolytic MMPs by these cells," Dr. Curci concluded.

The prestigious Resident Research Prize is intended to motivate new physicians to pursue vascular research. The prize recipient is invited to present his or her research results at the Society for Vascular Surgery’s Vascular Annual Meeting and the prize includes a 1-year subscription to the Journal of Vascular Surgery.

Dr. Nathan D. Airhart, Washington University School of Medicine, St. Louis, was the recipient of this year’s SVS Foundation Resident Research Prize Paper, which was presented at the Vascular Annual Meeting as part of the William J. von Liebig Forum, which features the best in resident research.

Dr. Airhart, his mentor, Dr. John A. Curci, and his colleagues studied the specific contribution of the vascular smooth muscle cells (SMCs) to the destruction of the elastic proteins that are uniquely absent in the walls of abdominal aortic aneurysms (AAAs). "Although the SMC is the dominant cell type in the aortic wall, our understanding of the role of these cells in aneurysms has been very limited," said Dr. Airhart.

Courtesy Dr. John A. Curci

To directly study the function of these cells, Dr. Airhart and his colleagues embarked on an ambitious project to isolate live SMCs from AAAs, normal abdominal aorta (NAA), and plaque from carotid endarterectomy (CEA) procedures. The group profiled the mRNA produced by these cultured cells by microarray and clearly demonstrated a unique pattern of expression of the AAA-SMC.

"The mRNA profiles confirmed that the AAA cells were likely interacting with the matrix differently than the other SMCs, but it did not necessarily tell us how they were influencing aneurysm development," said Dr. Airhart. To better understand the role of these cells, the investigators evaluated the ability of these cells to break down elastic fibers in culture.

Under standard culture conditions, AAA-SMCs were able to degrade three times more elastin than the NAA-SMCs. "Even more remarkable was the finding that co-culture with activated macrophages – a cell type always found in the wall of aneurysms – resulted in a further doubling of the elastic fiber damage by the AAA-SMCs. Co-culture of macrophages with NAA-SMCs had no effect on the elastin degraded," said Dr. Airhart.

Further experiments suggested that the enzymes principally responsible for the elastolytic activity of these cells are the matrix metalloproteinases (MMPs). Increases in the production and/or activation of MMP-2 and/or MMP-9 were prominently found in cultures of AAA-SMCs.

"These studies present the strongest evidence that AAA-SMCs exhibit a disease-specific gene expression pattern and can very potently damage the elastic fiber matrix in the aortic wall. The unique and remarkable synergy with activated inflammatory cells might help explain the characteristic elastin loss of aortic aneurysms. Future studies will allow us to understand and alter the cellular mechanisms which lead to increased production and activation of elastolytic MMPs by these cells," Dr. Curci concluded.

The prestigious Resident Research Prize is intended to motivate new physicians to pursue vascular research. The prize recipient is invited to present his or her research results at the Society for Vascular Surgery’s Vascular Annual Meeting and the prize includes a 1-year subscription to the Journal of Vascular Surgery.

Dr. Nathan D. Airhart, Washington University School of Medicine, St. Louis, was the recipient of this year’s SVS Foundation Resident Research Prize Paper, which was presented at the Vascular Annual Meeting as part of the William J. von Liebig Forum, which features the best in resident research.

Dr. Airhart, his mentor, Dr. John A. Curci, and his colleagues studied the specific contribution of the vascular smooth muscle cells (SMCs) to the destruction of the elastic proteins that are uniquely absent in the walls of abdominal aortic aneurysms (AAAs). "Although the SMC is the dominant cell type in the aortic wall, our understanding of the role of these cells in aneurysms has been very limited," said Dr. Airhart.

Courtesy Dr. John A. Curci

To directly study the function of these cells, Dr. Airhart and his colleagues embarked on an ambitious project to isolate live SMCs from AAAs, normal abdominal aorta (NAA), and plaque from carotid endarterectomy (CEA) procedures. The group profiled the mRNA produced by these cultured cells by microarray and clearly demonstrated a unique pattern of expression of the AAA-SMC.

"The mRNA profiles confirmed that the AAA cells were likely interacting with the matrix differently than the other SMCs, but it did not necessarily tell us how they were influencing aneurysm development," said Dr. Airhart. To better understand the role of these cells, the investigators evaluated the ability of these cells to break down elastic fibers in culture.

Under standard culture conditions, AAA-SMCs were able to degrade three times more elastin than the NAA-SMCs. "Even more remarkable was the finding that co-culture with activated macrophages – a cell type always found in the wall of aneurysms – resulted in a further doubling of the elastic fiber damage by the AAA-SMCs. Co-culture of macrophages with NAA-SMCs had no effect on the elastin degraded," said Dr. Airhart.

Further experiments suggested that the enzymes principally responsible for the elastolytic activity of these cells are the matrix metalloproteinases (MMPs). Increases in the production and/or activation of MMP-2 and/or MMP-9 were prominently found in cultures of AAA-SMCs.

"These studies present the strongest evidence that AAA-SMCs exhibit a disease-specific gene expression pattern and can very potently damage the elastic fiber matrix in the aortic wall. The unique and remarkable synergy with activated inflammatory cells might help explain the characteristic elastin loss of aortic aneurysms. Future studies will allow us to understand and alter the cellular mechanisms which lead to increased production and activation of elastolytic MMPs by these cells," Dr. Curci concluded.

The prestigious Resident Research Prize is intended to motivate new physicians to pursue vascular research. The prize recipient is invited to present his or her research results at the Society for Vascular Surgery’s Vascular Annual Meeting and the prize includes a 1-year subscription to the Journal of Vascular Surgery.

Surgical residency programs have not kept up with radical changes in the practice of surgery over the past two decades, but innovations ranging from curriculum reform to increasing the length of residency could help to improve the overall performance of recent surgical residency graduates, according to an analysis in Annals of Surgery.

"The changes that have occurred have been disruptive to residency training, and to date there has been minimal compensation for these." The changes include not only the 80-hour workweek for surgical residents, but also clinical areas, according to Dr. Lewis, executive director of the American Board of Surgery, and Dr. Klingensmith, residency program director at Washington University in St. Louis ( Ann. Surg. 2012;256:553-9).

The effect of the 80-hour workweek has been a reduction by 6 months to a year of in-hospital experience during 5 years of residency. Most of that reduced time corresponds to night and weekends, when residents would be more likely to see urgent and emergent conditions, and to have a greater degree of independent functioning, autonomy, and indirect supervision, they said.

The effects of this and various technology changes "will undoubtedly continue, and the directions in which surgery will evolve in the future are not predictable," Dr. Lewis and Dr. Klingensmith wrote. They laid out potential ways in which residency programs can address the changes:

• There should be a continuous process to define and continually update the surgical residency curriculum, which needs to keep pace with the fast-changing surgical practice landscape, and to "prune" information related to diseases that no longer are seen frequently in practice.

"The starting point for making changes in residency is to recognize that much of what is being taught is obsolete, and addresses diseases that are no longer a significant problem, or those for which surgical treatment is rarely needed," they said.

• Residency programs should improve the efficacy of resident learning by reducing clerical functions for residents, using physician extenders where appropriate, and utilizing mobile computing technology to deliver "a more defined and comprehensive curriculum to residents at an individual level."

• Educators could make better use of simulators in certain areas..

• There should be earlier specialty focus in residency training for those residents who already know the specialty they would like to pursue.

• Residency should include expanded laparoscopic surgery training.

• Residency programs could increase in length to make up for the time lost to the 80-hour workweek rule. Four-fifths of surgical residents already elect to take a postresidency fellowship in a specialty or subspecialty area,

• Training should expand to include additional skills, such as the use of ultrasound and the use of interventional catheter techniques.

The authors reported no conflicts.

Surgical residency programs have not kept up with radical changes in the practice of surgery over the past two decades, but innovations ranging from curriculum reform to increasing the length of residency could help to improve the overall performance of recent surgical residency graduates, according to an analysis in Annals of Surgery.

"The changes that have occurred have been disruptive to residency training, and to date there has been minimal compensation for these." The changes include not only the 80-hour workweek for surgical residents, but also clinical areas, according to Dr. Lewis, executive director of the American Board of Surgery, and Dr. Klingensmith, residency program director at Washington University in St. Louis ( Ann. Surg. 2012;256:553-9).

The effect of the 80-hour workweek has been a reduction by 6 months to a year of in-hospital experience during 5 years of residency. Most of that reduced time corresponds to night and weekends, when residents would be more likely to see urgent and emergent conditions, and to have a greater degree of independent functioning, autonomy, and indirect supervision, they said.

The effects of this and various technology changes "will undoubtedly continue, and the directions in which surgery will evolve in the future are not predictable," Dr. Lewis and Dr. Klingensmith wrote. They laid out potential ways in which residency programs can address the changes:

• There should be a continuous process to define and continually update the surgical residency curriculum, which needs to keep pace with the fast-changing surgical practice landscape, and to "prune" information related to diseases that no longer are seen frequently in practice.

"The starting point for making changes in residency is to recognize that much of what is being taught is obsolete, and addresses diseases that are no longer a significant problem, or those for which surgical treatment is rarely needed," they said.

• Residency programs should improve the efficacy of resident learning by reducing clerical functions for residents, using physician extenders where appropriate, and utilizing mobile computing technology to deliver "a more defined and comprehensive curriculum to residents at an individual level."

• Educators could make better use of simulators in certain areas..

• There should be earlier specialty focus in residency training for those residents who already know the specialty they would like to pursue.

• Residency should include expanded laparoscopic surgery training.

• Residency programs could increase in length to make up for the time lost to the 80-hour workweek rule. Four-fifths of surgical residents already elect to take a postresidency fellowship in a specialty or subspecialty area,

• Training should expand to include additional skills, such as the use of ultrasound and the use of interventional catheter techniques.

The authors reported no conflicts.

Surgical residency programs have not kept up with radical changes in the practice of surgery over the past two decades, but innovations ranging from curriculum reform to increasing the length of residency could help to improve the overall performance of recent surgical residency graduates, according to an analysis in Annals of Surgery.

"The changes that have occurred have been disruptive to residency training, and to date there has been minimal compensation for these." The changes include not only the 80-hour workweek for surgical residents, but also clinical areas, according to Dr. Lewis, executive director of the American Board of Surgery, and Dr. Klingensmith, residency program director at Washington University in St. Louis ( Ann. Surg. 2012;256:553-9).

The effect of the 80-hour workweek has been a reduction by 6 months to a year of in-hospital experience during 5 years of residency. Most of that reduced time corresponds to night and weekends, when residents would be more likely to see urgent and emergent conditions, and to have a greater degree of independent functioning, autonomy, and indirect supervision, they said.

The effects of this and various technology changes "will undoubtedly continue, and the directions in which surgery will evolve in the future are not predictable," Dr. Lewis and Dr. Klingensmith wrote. They laid out potential ways in which residency programs can address the changes:

• There should be a continuous process to define and continually update the surgical residency curriculum, which needs to keep pace with the fast-changing surgical practice landscape, and to "prune" information related to diseases that no longer are seen frequently in practice.

"The starting point for making changes in residency is to recognize that much of what is being taught is obsolete, and addresses diseases that are no longer a significant problem, or those for which surgical treatment is rarely needed," they said.

• Residency programs should improve the efficacy of resident learning by reducing clerical functions for residents, using physician extenders where appropriate, and utilizing mobile computing technology to deliver "a more defined and comprehensive curriculum to residents at an individual level."

• Educators could make better use of simulators in certain areas..

• There should be earlier specialty focus in residency training for those residents who already know the specialty they would like to pursue.

• Residency should include expanded laparoscopic surgery training.

• Residency programs could increase in length to make up for the time lost to the 80-hour workweek rule. Four-fifths of surgical residents already elect to take a postresidency fellowship in a specialty or subspecialty area,

• Training should expand to include additional skills, such as the use of ultrasound and the use of interventional catheter techniques.

The authors reported no conflicts.

Surgical residency programs have not kept up with radical changes in the practice of surgery over the past two decades, but innovations ranging from curriculum reform to increasing the length of residency could help to improve the overall performance of recent surgical residency graduates, according to an analysis in Annals of Surgery.

"The changes that have occurred have been disruptive to residency training, and to date there has been minimal compensation for these," Dr. Frank Lewis and Dr. Mary Klingensmith wrote. "Evidence is now emerging of significant issues in the overall performance of recent graduates from at least three sources – the evaluation of external agents who incorporate these graduates into their practice or group, the opinions of the residents themselves, and the performance of graduates on the oral examination of the American Board of Surgery during the last 8 years" (Ann. Surg. 2012;256:553-59).

The changes include not only the 80-hour workweek for surgical residents, but also clinical areas, according to Dr. Lewis, executive director of the American Board of Surgery, and Dr. Klingensmith, residency program director at Washington University in St. Louis.

The effect of the 80-hour workweek has been a reduction by 6 months to a year of in-hospital experience during 5 years of residency. Most of that reduced time corresponds to night and weekend experience, when residents would be more likely to see urgent and emergent conditions, and to have a greater degree of independent functioning, autonomy, and indirect supervision, they said.

The most significant clinical change has been the development of laparoscopic surgery for intra-abdominal surgical management, which is replacing open surgery and the abdominal incision. Because surgeons in academic settings have been slower to adopt laparoscopy, resident training in the use of this technology has proceeded slowly, they explained.

"While the Residency Review Committee (RRC) for Surgery has been steadily increasing the requirements for surgical resident training, it is still the rule that the most complex laparoscopic surgery is reserved for fellows in postresidency fellowships and not for residents during surgical training, although there is no reason this should be the case," they noted.

In addition, operations performed by general surgeons, and the way in which they are done, have changed significantly in the past 20 years, according to the analysis. For example, the advent of better medical management for benign peptic ulcer disease – along with flexible endoscopy and endoscopic retrograde cholangiopancreatography – means that fewer surgical interventions for peptic ulcer complications and biliary tree stone disease are necessary.

Furthermore, technological innovations have allowed vascular surgeons, rather than general surgeons, to perform most abdominal vascular surgery. Finally, the two surgeons reported, abdominal trauma injuries – which require surgical intervention in 80%-90% of cases – have declined dramatically since 1992.

These types of changes "will undoubtedly continue, and the directions in which surgery will evolve in the future are not predictable," Dr. Lewis and Dr. Klingensmith wrote.

They laid out seven potential ways in which surgical residency programs can address the changes:

• There should be a continuous process to define and continually update the surgical residency curriculum, which needs to keep pace with the fast-changing surgical practice landscape, and to "prune" information related to diseases that no longer are seen frequently in practice.

"The starting point for making changes in residency is to recognize that much of what is being taught is obsolete, and addresses diseases that are no longer a significant problem, or those for which surgical treatment is rarely needed," they said.

• Residency programs should improve the efficacy of resident learning by reducing clerical functions for residents, using physician extenders where appropriate, and utilizing mobile computing technology to deliver "a more defined and comprehensive curriculum to residents at an individual level."

• Educators could make better use of simulators in certain areas, such as laparoscopic surgery and endoscopic surgery.

• There should be an earlier specialty focus in residency training for those surgical residents who already know which specialty they would like to pursue.

• Surgical residency should include expanded laparoscopic surgery training.

• Residency programs could increase in length to make up for the time lost to the 80-hour workweek rule. Four-fifths of surgical residents already elect to take a postresidency fellowship in a specialty or subspecialty area, so "any discussion of extending residency only applies to the 20% of residents who currently complete only general surgical residency and do not seek subspecialty training," they said. "Extending residency by 1 year to obtain more extensive training in general surgery per se would not seem to be an insurmountable issue if the benefits clearly warranted it."

• Surgical training should expand to include additional skills, such as the use of ultrasound for better diagnosis of conditions in breast, endocrine, vascular, and trauma diseases and the use of interventional catheter techniques for the diagnosis or treatment of a variety of conditions.

It’s not possible to reverse the changes that have occurred over the past 2 decades, and in fact the workweek could see further shortening, as has happened in Europe, the investigators noted. "The most effective way in which to address the changes is therefore to look at the things which can be changed in resident training, the many areas in which improvements in resident teaching are possible, and the areas in which residents’ capabilities could be productively expanded."

The investigators did not report any conflicts of interest.

Surgical residency programs have not kept up with radical changes in the practice of surgery over the past two decades, but innovations ranging from curriculum reform to increasing the length of residency could help to improve the overall performance of recent surgical residency graduates, according to an analysis in Annals of Surgery.

"The changes that have occurred have been disruptive to residency training, and to date there has been minimal compensation for these," Dr. Frank Lewis and Dr. Mary Klingensmith wrote. "Evidence is now emerging of significant issues in the overall performance of recent graduates from at least three sources – the evaluation of external agents who incorporate these graduates into their practice or group, the opinions of the residents themselves, and the performance of graduates on the oral examination of the American Board of Surgery during the last 8 years" (Ann. Surg. 2012;256:553-59).

The changes include not only the 80-hour workweek for surgical residents, but also clinical areas, according to Dr. Lewis, executive director of the American Board of Surgery, and Dr. Klingensmith, residency program director at Washington University in St. Louis.

The effect of the 80-hour workweek has been a reduction by 6 months to a year of in-hospital experience during 5 years of residency. Most of that reduced time corresponds to night and weekend experience, when residents would be more likely to see urgent and emergent conditions, and to have a greater degree of independent functioning, autonomy, and indirect supervision, they said.

The most significant clinical change has been the development of laparoscopic surgery for intra-abdominal surgical management, which is replacing open surgery and the abdominal incision. Because surgeons in academic settings have been slower to adopt laparoscopy, resident training in the use of this technology has proceeded slowly, they explained.

"While the Residency Review Committee (RRC) for Surgery has been steadily increasing the requirements for surgical resident training, it is still the rule that the most complex laparoscopic surgery is reserved for fellows in postresidency fellowships and not for residents during surgical training, although there is no reason this should be the case," they noted.

In addition, operations performed by general surgeons, and the way in which they are done, have changed significantly in the past 20 years, according to the analysis. For example, the advent of better medical management for benign peptic ulcer disease – along with flexible endoscopy and endoscopic retrograde cholangiopancreatography – means that fewer surgical interventions for peptic ulcer complications and biliary tree stone disease are necessary.

Furthermore, technological innovations have allowed vascular surgeons, rather than general surgeons, to perform most abdominal vascular surgery. Finally, the two surgeons reported, abdominal trauma injuries – which require surgical intervention in 80%-90% of cases – have declined dramatically since 1992.

These types of changes "will undoubtedly continue, and the directions in which surgery will evolve in the future are not predictable," Dr. Lewis and Dr. Klingensmith wrote.

They laid out seven potential ways in which surgical residency programs can address the changes:

• There should be a continuous process to define and continually update the surgical residency curriculum, which needs to keep pace with the fast-changing surgical practice landscape, and to "prune" information related to diseases that no longer are seen frequently in practice.

"The starting point for making changes in residency is to recognize that much of what is being taught is obsolete, and addresses diseases that are no longer a significant problem, or those for which surgical treatment is rarely needed," they said.

• Residency programs should improve the efficacy of resident learning by reducing clerical functions for residents, using physician extenders where appropriate, and utilizing mobile computing technology to deliver "a more defined and comprehensive curriculum to residents at an individual level."

• Educators could make better use of simulators in certain areas, such as laparoscopic surgery and endoscopic surgery.

• There should be an earlier specialty focus in residency training for those surgical residents who already know which specialty they would like to pursue.

• Surgical residency should include expanded laparoscopic surgery training.

• Residency programs could increase in length to make up for the time lost to the 80-hour workweek rule. Four-fifths of surgical residents already elect to take a postresidency fellowship in a specialty or subspecialty area, so "any discussion of extending residency only applies to the 20% of residents who currently complete only general surgical residency and do not seek subspecialty training," they said. "Extending residency by 1 year to obtain more extensive training in general surgery per se would not seem to be an insurmountable issue if the benefits clearly warranted it."

• Surgical training should expand to include additional skills, such as the use of ultrasound for better diagnosis of conditions in breast, endocrine, vascular, and trauma diseases and the use of interventional catheter techniques for the diagnosis or treatment of a variety of conditions.

It’s not possible to reverse the changes that have occurred over the past 2 decades, and in fact the workweek could see further shortening, as has happened in Europe, the investigators noted. "The most effective way in which to address the changes is therefore to look at the things which can be changed in resident training, the many areas in which improvements in resident teaching are possible, and the areas in which residents’ capabilities could be productively expanded."

The investigators did not report any conflicts of interest.

Surgical residency programs have not kept up with radical changes in the practice of surgery over the past two decades, but innovations ranging from curriculum reform to increasing the length of residency could help to improve the overall performance of recent surgical residency graduates, according to an analysis in Annals of Surgery.

"The changes that have occurred have been disruptive to residency training, and to date there has been minimal compensation for these," Dr. Frank Lewis and Dr. Mary Klingensmith wrote. "Evidence is now emerging of significant issues in the overall performance of recent graduates from at least three sources – the evaluation of external agents who incorporate these graduates into their practice or group, the opinions of the residents themselves, and the performance of graduates on the oral examination of the American Board of Surgery during the last 8 years" (Ann. Surg. 2012;256:553-59).

The changes include not only the 80-hour workweek for surgical residents, but also clinical areas, according to Dr. Lewis, executive director of the American Board of Surgery, and Dr. Klingensmith, residency program director at Washington University in St. Louis.

The effect of the 80-hour workweek has been a reduction by 6 months to a year of in-hospital experience during 5 years of residency. Most of that reduced time corresponds to night and weekend experience, when residents would be more likely to see urgent and emergent conditions, and to have a greater degree of independent functioning, autonomy, and indirect supervision, they said.

The most significant clinical change has been the development of laparoscopic surgery for intra-abdominal surgical management, which is replacing open surgery and the abdominal incision. Because surgeons in academic settings have been slower to adopt laparoscopy, resident training in the use of this technology has proceeded slowly, they explained.

"While the Residency Review Committee (RRC) for Surgery has been steadily increasing the requirements for surgical resident training, it is still the rule that the most complex laparoscopic surgery is reserved for fellows in postresidency fellowships and not for residents during surgical training, although there is no reason this should be the case," they noted.

In addition, operations performed by general surgeons, and the way in which they are done, have changed significantly in the past 20 years, according to the analysis. For example, the advent of better medical management for benign peptic ulcer disease – along with flexible endoscopy and endoscopic retrograde cholangiopancreatography – means that fewer surgical interventions for peptic ulcer complications and biliary tree stone disease are necessary.

Furthermore, technological innovations have allowed vascular surgeons, rather than general surgeons, to perform most abdominal vascular surgery. Finally, the two surgeons reported, abdominal trauma injuries – which require surgical intervention in 80%-90% of cases – have declined dramatically since 1992.

These types of changes "will undoubtedly continue, and the directions in which surgery will evolve in the future are not predictable," Dr. Lewis and Dr. Klingensmith wrote.

They laid out seven potential ways in which surgical residency programs can address the changes:

• There should be a continuous process to define and continually update the surgical residency curriculum, which needs to keep pace with the fast-changing surgical practice landscape, and to "prune" information related to diseases that no longer are seen frequently in practice.

"The starting point for making changes in residency is to recognize that much of what is being taught is obsolete, and addresses diseases that are no longer a significant problem, or those for which surgical treatment is rarely needed," they said.

• Residency programs should improve the efficacy of resident learning by reducing clerical functions for residents, using physician extenders where appropriate, and utilizing mobile computing technology to deliver "a more defined and comprehensive curriculum to residents at an individual level."

• Educators could make better use of simulators in certain areas, such as laparoscopic surgery and endoscopic surgery.

• There should be an earlier specialty focus in residency training for those surgical residents who already know which specialty they would like to pursue.

• Surgical residency should include expanded laparoscopic surgery training.

• Residency programs could increase in length to make up for the time lost to the 80-hour workweek rule. Four-fifths of surgical residents already elect to take a postresidency fellowship in a specialty or subspecialty area, so "any discussion of extending residency only applies to the 20% of residents who currently complete only general surgical residency and do not seek subspecialty training," they said. "Extending residency by 1 year to obtain more extensive training in general surgery per se would not seem to be an insurmountable issue if the benefits clearly warranted it."

• Surgical training should expand to include additional skills, such as the use of ultrasound for better diagnosis of conditions in breast, endocrine, vascular, and trauma diseases and the use of interventional catheter techniques for the diagnosis or treatment of a variety of conditions.

It’s not possible to reverse the changes that have occurred over the past 2 decades, and in fact the workweek could see further shortening, as has happened in Europe, the investigators noted. "The most effective way in which to address the changes is therefore to look at the things which can be changed in resident training, the many areas in which improvements in resident teaching are possible, and the areas in which residents’ capabilities could be productively expanded."

The investigators did not report any conflicts of interest.

MILWAUKEE – General surgery residents in a community-based residency program experienced a significant 49% decline in open aortic surgeries over the last decade, an analysis showed.

In 2000-2001, residents were exposed to 20-25 open aortic cases per year, but now get in on 8-15 cases per year, said Dr. Adam Rothermel, a third-year general surgery resident at Mount Carmel Hospital in Columbus, Ohio, where the analysis was conducted.

Patrice Wendling/IMNG Medical Media

"Open aortic cases are difficult to find, and our residents, as a whole, would agree that we're not coming out with good enough experience with these cases," he said at the annual meeting of the Midwestern Vascular Surgical Society.

The results reflect the exponential shift from open vascular surgery to endovascular procedures over the last decade, as well as the more recent implementation of the 80-hour resident work week.

The total number of carotid endarterectomy, infrainguinal bypass, and open aortic cases for the entire hospital decreased by 55%, 30%, and 71%, respectively, over the study period of 2000 to 2011.

Total resident cases over the same period were unchanged for carotid endarterectomy (77 vs. 84 cases), trended downward for infrainguinal bypass (62 vs. 52 cases), and were significantly lower for open aortic cases (43 vs. 8 cases) according to a review of resident case logs, Dr. Rothermel said.

He pointed out that a significant portion of vascular surgery in the United States is still performed by general surgeons, citing surveys showing that general surgeons performed 59% of the vascular procedures in the United States in 1985 (J. Vasc. Surg. 1987;6:611-21) and 49% in 1992 (J. Vasc. Surg. 1996:23:172-81).

Session moderator Dr. Jean E. Starr, medical director of endovascular services at Ohio State University Medical Center in Columbus, said the current results parallel what's found nationally. She went on to ask what the findings imply for general surgery residents when they've finished training, and how this will reflect on patient practice in light of general surgeons performing half of vascular surgeries in the United States.

"When you get out of your general surgery training from a community based program and are expected then, going into say a rural center, to perform these operations, you have to give pause," Dr. Rothermel replied.

"I don't think I have a good way to fix the problem at this point, but I think we need to be aware of the trend."

Audience member Dr. Joseph Giglia, principal investigator for the laparoscopic aortic surgery program at the University of Cincinnati Medical Center, countered by asking whether the findings really matter given that open aortic cases are decreasing significantly across the country.

He pointed out that the latest survey data were 20 years old, and submitted that general surgeons no longer perform 50% of vascular surgeries in the United States.

"I think these cases are important for our primary vascular residents to participate in," Dr. Giglia said.

"I think there has to be a sea change, a real shift in the paradigm about who's doing these cases and what we're going to do in the future."

Dr. Rothermel agreed that another survey should be conducted to better reflect current practice trends.

If vascular surgeons are to pick up the bulk of the caseload, however, efforts to recruit medical students to the specialty may need to be enhanced.

A recent survey of 338 medical students showed that 236 first- and second-year students had no clinical exposure to vascular surgery, while only 38 of the 102 third-year students had been exposed to vascular surgery after completing a general surgery rotation (Ann. Vasc. Surg. 2012 July 25 [doi:10.1016/j.avsg.2012.02.012]).

Nearly half (49%) of first- and second-year students said that they would consider vascular surgery, however, with another 19% willing to do so if the length of training were reduced, according to the survey.

Dr. Rothermel and Dr. Starr reported no conflicts of interest.

MILWAUKEE – General surgery residents in a community-based residency program experienced a significant 49% decline in open aortic surgeries over the last decade, an analysis showed.

In 2000-2001, residents were exposed to 20-25 open aortic cases per year, but now get in on 8-15 cases per year, said Dr. Adam Rothermel, a third-year general surgery resident at Mount Carmel Hospital in Columbus, Ohio, where the analysis was conducted.

Patrice Wendling/IMNG Medical Media

"Open aortic cases are difficult to find, and our residents, as a whole, would agree that we're not coming out with good enough experience with these cases," he said at the annual meeting of the Midwestern Vascular Surgical Society.

The results reflect the exponential shift from open vascular surgery to endovascular procedures over the last decade, as well as the more recent implementation of the 80-hour resident work week.

The total number of carotid endarterectomy, infrainguinal bypass, and open aortic cases for the entire hospital decreased by 55%, 30%, and 71%, respectively, over the study period of 2000 to 2011.

Total resident cases over the same period were unchanged for carotid endarterectomy (77 vs. 84 cases), trended downward for infrainguinal bypass (62 vs. 52 cases), and were significantly lower for open aortic cases (43 vs. 8 cases) according to a review of resident case logs, Dr. Rothermel said.

He pointed out that a significant portion of vascular surgery in the United States is still performed by general surgeons, citing surveys showing that general surgeons performed 59% of the vascular procedures in the United States in 1985 (J. Vasc. Surg. 1987;6:611-21) and 49% in 1992 (J. Vasc. Surg. 1996:23:172-81).

Session moderator Dr. Jean E. Starr, medical director of endovascular services at Ohio State University Medical Center in Columbus, said the current results parallel what's found nationally. She went on to ask what the findings imply for general surgery residents when they've finished training, and how this will reflect on patient practice in light of general surgeons performing half of vascular surgeries in the United States.

"When you get out of your general surgery training from a community based program and are expected then, going into say a rural center, to perform these operations, you have to give pause," Dr. Rothermel replied.

"I don't think I have a good way to fix the problem at this point, but I think we need to be aware of the trend."

Audience member Dr. Joseph Giglia, principal investigator for the laparoscopic aortic surgery program at the University of Cincinnati Medical Center, countered by asking whether the findings really matter given that open aortic cases are decreasing significantly across the country.

He pointed out that the latest survey data were 20 years old, and submitted that general surgeons no longer perform 50% of vascular surgeries in the United States.

"I think these cases are important for our primary vascular residents to participate in," Dr. Giglia said.

"I think there has to be a sea change, a real shift in the paradigm about who's doing these cases and what we're going to do in the future."

Dr. Rothermel agreed that another survey should be conducted to better reflect current practice trends.

If vascular surgeons are to pick up the bulk of the caseload, however, efforts to recruit medical students to the specialty may need to be enhanced.

A recent survey of 338 medical students showed that 236 first- and second-year students had no clinical exposure to vascular surgery, while only 38 of the 102 third-year students had been exposed to vascular surgery after completing a general surgery rotation (Ann. Vasc. Surg. 2012 July 25 [doi:10.1016/j.avsg.2012.02.012]).

Nearly half (49%) of first- and second-year students said that they would consider vascular surgery, however, with another 19% willing to do so if the length of training were reduced, according to the survey.

Dr. Rothermel and Dr. Starr reported no conflicts of interest.

MILWAUKEE – General surgery residents in a community-based residency program experienced a significant 49% decline in open aortic surgeries over the last decade, an analysis showed.

In 2000-2001, residents were exposed to 20-25 open aortic cases per year, but now get in on 8-15 cases per year, said Dr. Adam Rothermel, a third-year general surgery resident at Mount Carmel Hospital in Columbus, Ohio, where the analysis was conducted.

Patrice Wendling/IMNG Medical Media

"Open aortic cases are difficult to find, and our residents, as a whole, would agree that we're not coming out with good enough experience with these cases," he said at the annual meeting of the Midwestern Vascular Surgical Society.

The results reflect the exponential shift from open vascular surgery to endovascular procedures over the last decade, as well as the more recent implementation of the 80-hour resident work week.

The total number of carotid endarterectomy, infrainguinal bypass, and open aortic cases for the entire hospital decreased by 55%, 30%, and 71%, respectively, over the study period of 2000 to 2011.

Total resident cases over the same period were unchanged for carotid endarterectomy (77 vs. 84 cases), trended downward for infrainguinal bypass (62 vs. 52 cases), and were significantly lower for open aortic cases (43 vs. 8 cases) according to a review of resident case logs, Dr. Rothermel said.

He pointed out that a significant portion of vascular surgery in the United States is still performed by general surgeons, citing surveys showing that general surgeons performed 59% of the vascular procedures in the United States in 1985 (J. Vasc. Surg. 1987;6:611-21) and 49% in 1992 (J. Vasc. Surg. 1996:23:172-81).

Session moderator Dr. Jean E. Starr, medical director of endovascular services at Ohio State University Medical Center in Columbus, said the current results parallel what's found nationally. She went on to ask what the findings imply for general surgery residents when they've finished training, and how this will reflect on patient practice in light of general surgeons performing half of vascular surgeries in the United States.

"When you get out of your general surgery training from a community based program and are expected then, going into say a rural center, to perform these operations, you have to give pause," Dr. Rothermel replied.

"I don't think I have a good way to fix the problem at this point, but I think we need to be aware of the trend."

Audience member Dr. Joseph Giglia, principal investigator for the laparoscopic aortic surgery program at the University of Cincinnati Medical Center, countered by asking whether the findings really matter given that open aortic cases are decreasing significantly across the country.

He pointed out that the latest survey data were 20 years old, and submitted that general surgeons no longer perform 50% of vascular surgeries in the United States.

"I think these cases are important for our primary vascular residents to participate in," Dr. Giglia said.

"I think there has to be a sea change, a real shift in the paradigm about who's doing these cases and what we're going to do in the future."

Dr. Rothermel agreed that another survey should be conducted to better reflect current practice trends.

If vascular surgeons are to pick up the bulk of the caseload, however, efforts to recruit medical students to the specialty may need to be enhanced.

A recent survey of 338 medical students showed that 236 first- and second-year students had no clinical exposure to vascular surgery, while only 38 of the 102 third-year students had been exposed to vascular surgery after completing a general surgery rotation (Ann. Vasc. Surg. 2012 July 25 [doi:10.1016/j.avsg.2012.02.012]).

Nearly half (49%) of first- and second-year students said that they would consider vascular surgery, however, with another 19% willing to do so if the length of training were reduced, according to the survey.

Dr. Rothermel and Dr. Starr reported no conflicts of interest.

Almost one-third of general surgery residents required remediation over an 11-year period, most often because of a deficiency in medical knowledge, judging from findings in a retrospective study of remediation and attrition rates among general surgery residents at six academic surgical residency programs in California.

The high remediation rate identified in this study "begs the question of whether we are falling short in the education of surgical residents," said Dr. Arezou Yaghoubian of the department of surgery, Harbor-UCLA Medical Center, Los Angeles, and associates (Arch. Surg. 2012;147:829-33).

They conducted the study to determine which of the six Accreditation Council for Graduate Medical Education (ACGME) competencies (patient care, medical knowledge, practice-based learning, interpersonal and communication skills, professionalism, and system-based practice), most often require remediation and to identify predictors of remediation. There is a scarcity of data on how well surgical residency programs have been achieving these competencies, and this information may provide insight into how to modify the surgical curriculum more effectively in this new era of limited hours, they said.

In the study of 348 general surgery residents at the six training programs between 1999 and 2010, the most common reason for remediation was medical knowledge in 74%, followed by interpersonal and communication skills in 24%, patient care in 22%, professionalism in 18%, system-based practice in 14%, and practice-based learning in 8%.

Of the 107 residents who required remediation, 27 required remediation more than once. Almost 16% of the residents left their programs, but most (53 of 55 residents) left voluntarily. The other two failed remediation and had to leave the program.

Monthly meetings with faculty was the most common form of remediation, in 79%, followed by specific reading assignments (72%), required attendance at review courses and/or conferences (27%), evaluation by a therapist, psychologist, or psychiatrist (12%), and having to repeat a clinical year (6.5%).

More than half of the remediations were initiated during the first 2 postgraduate years (25% in the first and 35% in the second year), followed by 21% during the third year, 16% during the fourth year, and 4% during the fifth year.

A predictor of remediation was having received honors during the third-year surgery clerkship (58% of those who were subject to remediation vs. 45% of those who were not remediated, a statistically significant difference), which, the authors noted, was counterintuitive.

United States Medical Licensing Examination (USMLE) step 1 and/or step 2 scores and American Board of Surgery In-Training Examination (ABSITE) scores at postgraduate years 1 through 4 were also predictive of remediation. The median USMLE step 1 and step 2 scores were 225 and 223 among the residents subject to remediation, vs. 232 for step 1 and step 2 scores among those who were not remediated, statistically significant differences.

The ABSITE scores during postgraduate years 1 through 4 were significantly lower among those who were subject to remediation, but the differences in median scores in years 5 through 7 were not significantly different.

But remediation was not a predictor of attrition. The only predictor of attrition was the ABSITE score at the third postgraduate year, which was a median of 34 among those who left the program and 62 among those who stayed.

Possible explanations for the high remediation rate is that residents are not well prepared for the demands of a surgical residency, they need to be more efficient with their time because of the 80-hour work week, and they may not necessarily be spending their increased time outside of the hospital studying at home, the authors said. Possible reasons for the attrition rate among the residents, an "ongoing concern" in general surgery, may be marital, family, and personal issues and a need for a less stressful environment, they added.

Acknowledging the study's limitations, including the retrospective design and lack of information on how many residents passed the American Board of Surgery boards, the authors concluded that the high remediation rate "should give surgical educators pause as we should closely examine the potential sources of these deficiencies."

They called on surgical societies to "take the initiative to encourage the restructuring of medical school education, such that future surgeons are better prepared to enter surgical residencies," and for residency programs to "determine whether current educational methods are adequate to prepare future surgeons."

The authors reported they had no financial disclosures.

Almost one-third of general surgery residents required remediation over an 11-year period, most often because of a deficiency in medical knowledge, judging from findings in a retrospective study of remediation and attrition rates among general surgery residents at six academic surgical residency programs in California.

The high remediation rate identified in this study "begs the question of whether we are falling short in the education of surgical residents," said Dr. Arezou Yaghoubian of the department of surgery, Harbor-UCLA Medical Center, Los Angeles, and associates (Arch. Surg. 2012;147:829-33).

They conducted the study to determine which of the six Accreditation Council for Graduate Medical Education (ACGME) competencies (patient care, medical knowledge, practice-based learning, interpersonal and communication skills, professionalism, and system-based practice), most often require remediation and to identify predictors of remediation. There is a scarcity of data on how well surgical residency programs have been achieving these competencies, and this information may provide insight into how to modify the surgical curriculum more effectively in this new era of limited hours, they said.

In the study of 348 general surgery residents at the six training programs between 1999 and 2010, the most common reason for remediation was medical knowledge in 74%, followed by interpersonal and communication skills in 24%, patient care in 22%, professionalism in 18%, system-based practice in 14%, and practice-based learning in 8%.

Of the 107 residents who required remediation, 27 required remediation more than once. Almost 16% of the residents left their programs, but most (53 of 55 residents) left voluntarily. The other two failed remediation and had to leave the program.

Monthly meetings with faculty was the most common form of remediation, in 79%, followed by specific reading assignments (72%), required attendance at review courses and/or conferences (27%), evaluation by a therapist, psychologist, or psychiatrist (12%), and having to repeat a clinical year (6.5%).

More than half of the remediations were initiated during the first 2 postgraduate years (25% in the first and 35% in the second year), followed by 21% during the third year, 16% during the fourth year, and 4% during the fifth year.

A predictor of remediation was having received honors during the third-year surgery clerkship (58% of those who were subject to remediation vs. 45% of those who were not remediated, a statistically significant difference), which, the authors noted, was counterintuitive.

United States Medical Licensing Examination (USMLE) step 1 and/or step 2 scores and American Board of Surgery In-Training Examination (ABSITE) scores at postgraduate years 1 through 4 were also predictive of remediation. The median USMLE step 1 and step 2 scores were 225 and 223 among the residents subject to remediation, vs. 232 for step 1 and step 2 scores among those who were not remediated, statistically significant differences.

The ABSITE scores during postgraduate years 1 through 4 were significantly lower among those who were subject to remediation, but the differences in median scores in years 5 through 7 were not significantly different.

But remediation was not a predictor of attrition. The only predictor of attrition was the ABSITE score at the third postgraduate year, which was a median of 34 among those who left the program and 62 among those who stayed.

Possible explanations for the high remediation rate is that residents are not well prepared for the demands of a surgical residency, they need to be more efficient with their time because of the 80-hour work week, and they may not necessarily be spending their increased time outside of the hospital studying at home, the authors said. Possible reasons for the attrition rate among the residents, an "ongoing concern" in general surgery, may be marital, family, and personal issues and a need for a less stressful environment, they added.

Acknowledging the study's limitations, including the retrospective design and lack of information on how many residents passed the American Board of Surgery boards, the authors concluded that the high remediation rate "should give surgical educators pause as we should closely examine the potential sources of these deficiencies."

They called on surgical societies to "take the initiative to encourage the restructuring of medical school education, such that future surgeons are better prepared to enter surgical residencies," and for residency programs to "determine whether current educational methods are adequate to prepare future surgeons."

The authors reported they had no financial disclosures.

Almost one-third of general surgery residents required remediation over an 11-year period, most often because of a deficiency in medical knowledge, judging from findings in a retrospective study of remediation and attrition rates among general surgery residents at six academic surgical residency programs in California.

The high remediation rate identified in this study "begs the question of whether we are falling short in the education of surgical residents," said Dr. Arezou Yaghoubian of the department of surgery, Harbor-UCLA Medical Center, Los Angeles, and associates (Arch. Surg. 2012;147:829-33).

They conducted the study to determine which of the six Accreditation Council for Graduate Medical Education (ACGME) competencies (patient care, medical knowledge, practice-based learning, interpersonal and communication skills, professionalism, and system-based practice), most often require remediation and to identify predictors of remediation. There is a scarcity of data on how well surgical residency programs have been achieving these competencies, and this information may provide insight into how to modify the surgical curriculum more effectively in this new era of limited hours, they said.

In the study of 348 general surgery residents at the six training programs between 1999 and 2010, the most common reason for remediation was medical knowledge in 74%, followed by interpersonal and communication skills in 24%, patient care in 22%, professionalism in 18%, system-based practice in 14%, and practice-based learning in 8%.

Of the 107 residents who required remediation, 27 required remediation more than once. Almost 16% of the residents left their programs, but most (53 of 55 residents) left voluntarily. The other two failed remediation and had to leave the program.

Monthly meetings with faculty was the most common form of remediation, in 79%, followed by specific reading assignments (72%), required attendance at review courses and/or conferences (27%), evaluation by a therapist, psychologist, or psychiatrist (12%), and having to repeat a clinical year (6.5%).

More than half of the remediations were initiated during the first 2 postgraduate years (25% in the first and 35% in the second year), followed by 21% during the third year, 16% during the fourth year, and 4% during the fifth year.

A predictor of remediation was having received honors during the third-year surgery clerkship (58% of those who were subject to remediation vs. 45% of those who were not remediated, a statistically significant difference), which, the authors noted, was counterintuitive.

United States Medical Licensing Examination (USMLE) step 1 and/or step 2 scores and American Board of Surgery In-Training Examination (ABSITE) scores at postgraduate years 1 through 4 were also predictive of remediation. The median USMLE step 1 and step 2 scores were 225 and 223 among the residents subject to remediation, vs. 232 for step 1 and step 2 scores among those who were not remediated, statistically significant differences.

The ABSITE scores during postgraduate years 1 through 4 were significantly lower among those who were subject to remediation, but the differences in median scores in years 5 through 7 were not significantly different.

But remediation was not a predictor of attrition. The only predictor of attrition was the ABSITE score at the third postgraduate year, which was a median of 34 among those who left the program and 62 among those who stayed.

Possible explanations for the high remediation rate is that residents are not well prepared for the demands of a surgical residency, they need to be more efficient with their time because of the 80-hour work week, and they may not necessarily be spending their increased time outside of the hospital studying at home, the authors said. Possible reasons for the attrition rate among the residents, an "ongoing concern" in general surgery, may be marital, family, and personal issues and a need for a less stressful environment, they added.

Acknowledging the study's limitations, including the retrospective design and lack of information on how many residents passed the American Board of Surgery boards, the authors concluded that the high remediation rate "should give surgical educators pause as we should closely examine the potential sources of these deficiencies."

They called on surgical societies to "take the initiative to encourage the restructuring of medical school education, such that future surgeons are better prepared to enter surgical residencies," and for residency programs to "determine whether current educational methods are adequate to prepare future surgeons."

The authors reported they had no financial disclosures.