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Introduction: Innovation education programs can help guide and empower surgeons and surgical trainees through the many steps to analyze and de-risk novel ideas to impact healthcare or care delivery. Providing quality programming that is conducive to a surgeon's busy schedule is an ongoing challenge, but even more so for a surgical trainees' schedule. Through a needs assessment and applying lean principles, the "Surgical Trainee Agile Innovation and empoweRment" (STAIR) framework was created to encourage surgical trainees to participate in innovation programming., Objective: Numerous works have explored the design and development of learning experiences to support physician innovators. However, there is a lack of evidence supporting frameworks that contribute to innovation empowerment for surgical trainees as a complement to the demands of clinical practice. The following catalogs the systematic design and development of a novel innovation and discovery agile framework tailored to surgical residents with original innovation ideas., Design and Setting: The course designed to implement the "Surgical Trainee Agile Innovation and empoweRment" (STAIR) is funded through the Department of Surgery at the University of Michigan. It is an 8-week team-based innovation course designed for surgical residents to learn and apply fundamental innovation concepts to clinical problems., Participants and Results: Surgical trainees in all programs at the host institution are all eligible to participate. A total of four innovation teams were selected to participate in inaugural course., Conclusions: The novel instructional design and development of this course encouraged participation in surgical innovation programming. The course aided the development of innovative ideas and inspired interest in innovation among surgical trainees. The STAIR framework is exemplary for inspiring and facilitating innovation among surgical trainees, enhancing the professional experience., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: It has been postulated that a possible barrier to pursuing cardiothoracic surgery is a lack of exposure and mentorship during training. In 2006, The Society of Thoracic Surgeons began the Looking to the Future Scholarship to expand interest in the field. Undecided trainees with limited exposure were prioritized in the selection process. This report summarizes the career outcomes of general surgery resident and medical student recipients., Methods: Scholarship recipients and nonrecipients (control) were queried in a Google search. The percentage of those who were cardiothoracic surgeons or in cardiothoracic training (%CTS) was calculated, as well as the percentage of female surgeons in cardiothoracic surgery., Results: From 2006 to 2021, there were 669 awardees. The %CTS was 63.7% for resident recipients and 31.4% for students, respectively. There was no significant difference in %CTS between resident and student recipients compared to nonrecipients. Notably, the percentage of female cardiothoracic surgeons was significantly greater for both resident and student recipients., Conclusions: The majority of resident recipients are now in cardiothoracic surgery, comparable to nonrecipients. While there was no significant difference between the percentage of recipients and non-recipients in cardiothoracic surgery, these groups differed substantially as nonrecipients had greater exposure and commitment to the field at the time of application., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: Timely and high-quality feedback is important in cardiothoracic (CT) surgery education. Feedback on operative proficiency is an area for improvement in CT surgery programs. Traditional evaluations significantly lag behind operative interactions. We hypothesized that use of the System for Improving and Measuring Procedural Learning (SIMPL) app would improve operative feedback for trainees., Methods: Use of SIMPL was evaluated from December 2018 to January, 2021 within an academic CT surgery training program. Ratings include level of supervision, complexity of the operation, and trainee performance. Completion was limited to 72 h after the operation. Descriptive statistics of the users and ratings are presented., Results: Over 28 months, 816 evaluations were completed, and of these, 495 had a rating from both the faculty and trainee. There were 19 trainees representing post-graduate years 1-8 and 19 faculty members who received or submitted at least one evaluation over the study period. The number of evaluations for each trainee ranged from 1 to 166 and from 1 to 81 for each of the faculty. The response rate for faculty ranged from 0% to 100%. "Active help" was the most common type of supervision (50.7% by the faculty, 60.4% from the trainees)., Conclusions: Use of SIMPL within a CT surgery training program was feasible and engagement was observed from both trainees and faculty. SIMPL provided trainees with timely, concise feedback on operative performance. Further work will focus on correlating SIMPL ratings with pre-existing assessments of performance., (© 2021 Wiley Periodicals LLC.)

Duty-hour restrictions have implications on trainee operative exposure necessary to meet minimum case-volume requirements. We utilized a previously validated simulation model to evaluate the effect of program volume, trainee numbers and complement, and rotation schedule on the probability of achieving adequate esophagectomy case numbers for cardiothoracic surgery trainees. A ProModel simulator centered on probabilistic distributions of operative cases was utilized. Historical data from five 2-year cardiothoracic surgery training programs were obtained from 2016-2018 and used as inputs to the simulator that generated 10,000 "trainee 2-year periods" per program. Programs varied in annual average esophagectomy volume (12-91 per year), with 2-4 trainees graduating over a 2-year training period. If esophagectomy cases were distributed solely based on scheduling and institutional volume, only 60% of evaluated programs could adequately expose all trainees in esophagectomy to meet case requirements. The 3 programs with adequate esophagectomy volumes had averaged 3.3 times (range 3.0-3.6) the minimum number of board-required cases for their programs' trainees. The ability of programs to provide trainees with adequate esophagectomy volume is challenging based on institutional volume and scheduling. Through simulation, we demonstrate that programs need >2 times the expected minimum number of esophagectomies to ensure that >90% of trainees meet case-volume requirements. Programs may consider strategies such as allowing trainees to select cases based on personal need, train fewer fellows, or enable trainees to seek subspecialty exposure externally to achieve minimum esophagectomy case-load requirements., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: We examined the impact of video editing and rater expertise in surgical resident evaluation on operative performance ratings of surgical trainees., Design: Randomized independent review of intraoperative video., Setting: Operative video was captured at a single, tertiary hospital in Boston, MA., Participants: Six common general surgery procedures were video recorded of 6 attending-trainee dyads. Full-length and condensed versions (n = 12 videos) were then reviewed by 13 independent surgeon raters (5 evaluation experts, 8 nonexperts) using a crossed design. Trainee performance was rated using the Operative Performance Rating Scale, System for Improving and Measuring Procedural Learning (SIMPL) Performance scale, the Zwisch scale, and ten Cate scale. These ratings were then standardized before being compared using Bayesian mixed models with raters and videos treated as random effects., Results: Editing had no effect on the Operative Performance Rating Scale Overall Performance (-0.10, p = 0.30), SIMPL Performance (0.13, p = 0.71), Zwisch (-0.12, p = 0.27), and ten Cate scale (-0.13, p = 0.29). Additionally, rater expertise (evaluation expert vs. nonexpert) had no effect on the same scales (-0.16 (p = 0.32), 0.18 (p = 0.74), 0.25 (p = 0.81), and 0.25 (p = 0.17)., Conclusions: There is little difference in operative performance assessment scores when raters use condensed videos or when raters who are not experts in surgical resident evaluation are used. Future validation studies of operative performance assessment scales may be facilitated by using nonexpert surgeon raters viewing videos condensed using a standardized protocol., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

The first integrated cardiothoracic surgery residents (I-6) graduated in 2013. Predominantly, there is still the option to pursue a traditional training pathway via general surgery residency followed by 2-3 years of specialized cardiothoracic surgery training. Our aim was to understand the perspectives of academic cardiothoracic faculty on the various training models. An anonymous web-based survey was distributed to all academic cardiothoracic surgeons in the United States. Respondents were asked about their perceptions of the 2 training models (I-6 and traditional). Descriptive statistics and Fisher exact test were used to analyze the data. A total of 15.4% (111/719) of faculty completed responses. When comparing training models, 23.4% of faculty believe the I-6 is a superior structure, 31.5% believe they are about the same, and 45.0% believe the traditional model is better. Also, 51.4% of the faculty said they would still apply into a traditional fellowship, with 27.9% picking an I-6 program and 20.7% picking a 4 + 3 model. A total of 40.5% believe the I-6 is good for the specialty and 55.0% think the I-6 attracts higher achieving applicants, but 26.1% and 19.8% believe it is improving training or increasing the scholarly activity of residents, respectively. When asked about resident experience, 56.4% of I-6 faculty feel there is a bias against their residents on the general surgery service, which some believe leads to poor educational outcomes for I-6 residents. The integrated residency represents a major shift in cardiothoracic surgery training. Faculty opinions vary regarding the quality and effectiveness of this model with many preferring the traditional model., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Teaching and mentorship have a long history in surgical education, but with a growing focus on safety, quality improvement, and continuous professional development, it is clear that the current training system is inadequate. Challenges from changes in residency training, financial constraints, rapidly increasing knowledge, and limited faculty time due to increasing clinical, academic, and research demands require that new approaches are developed, including simulation and online resources. Although coaching is used effectively in other disciplines, surgical coaching remains relatively uncommon. Coaching encourages self-reflection using facilitated feedback individualized to each surgeon's needs and goals and can benefit surgeons at all levels., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: Evaluate the relationship between medical school factors (including preclinical mentorship, order of clerkships, and clerkship grades) and matching into surgical specialties., Design: Clerkship information, match data, and data on structured preclinical research obtained from 2010 to 2015 for a single institution was obtained and analyzed using multivariate analysis., Setting: University of Michigan Medical School., Participants: Seven hundred and forty-six students who took both the Internal Medicine and Surgery clerkships between 2010 and 2015 and have since participated in the match., Results: Among 740 students studied, 243 matched into a surgical field. Higher Shelf scores were associated with higher clerkship grades in Surgery and Internal Medicine. Honors or High Pass in Surgery were associated with matching into a surgical field. Structured preclinical research in Surgery and order of clerkship were not associated with matching into a surgical field., Conclusions: Students who went into surgery were more likely to receive Honors or High Pass. Preclinical choices geared toward a surgical specialty (e.g., order of clerkship and structured research) were not associated with matching into a surgical field. These data may help guide school specific advice for students., (Copyright © 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The impact of fellowship training on general surgery residency has remained challenging to assess. Surgical resident perceptions of fellow-led and resident-led surgical services have not been well described., Methods: Retrospective cross-sectional data were collected from residents' service evaluations from 7/2014 through 7/2017. Surgical services were categorized as resident-led or fellow-led. 31 variables were evaluated and collapsed into 7 factors including clinical experience, educational experiences, clinical staff, workload, feedback, treatment of residents, and overall rotation., Results: Among all PGY levels, fellow-led surgical services were rated significantly higher (p < 0.05) regarding clinical experience, clinical staff, treatment of residents, and overall rotation. PGY1-2 residents rated resident-led services significantly higher in the area of educational experiences, while PGY 3 residents rated resident-led services higher in the area of workload. However, PGY4-5 residents rated fellow-led services significantly higher in all 7 categories. Individual fellow-led services were rated significantly higher for various categories at different PGY levels., Conclusions: Surgical residents appear to value the educational experiences of fellow-led services. Each fellow-led service may ultimately provide unique educational opportunities and resources for different PGY levels., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Attrition in surgical programs remains a significant problem resulting in trainee dissatisfaction and wasted time and educational dollars. Attrition rates in general surgery training programs approximate 5% per year (30% cumulative). Attrition rates in cardiovascular surgery training for the traditional vascular surgery fellowship (VSF), the vascular surgery residency (VSR), and the corresponding programs in cardiothoracic surgery have yet to be described, although they are assumed to be similar to those associated with general surgery training., Methods: A retrospective review of the Association of American Medical Colleges Annual Physician Specialty Data Book was performed. Data from consecutive academic years 2007-2008 to 2013-2014 were analyzed. The number of total residents, the number who did not complete their training, and those who successfully completed the program were recorded. Attrition rates were then calculated for VSF, VSR, general surgery residency (GSR), cardiothoracic surgery fellowship (CTF), and cardiothoracic surgery integrated residency (CTR)., Results: Annually, between 2007-2008 and 2013-2014, there were zero to two vascular surgery residents who failed to complete the program (0%-5.9%). In the last 4 years of the study, whereas the absolute number of residents who failed to complete the program remained constant at 1 or 2 per year, the attrition rate decreased to 1 of 171 trainees (0.6%) in 2013-2014 as the total number of programs (and numbers of vascular surgery residents) significantly increased. During the same 7-year period, the number of vascular surgery fellows who did not complete their training ranged from one to six annually (0.4%-2.5%). Compared with the VSF, the VSR data show a relatively low and constant rate of attrition. In contrast, the number of general surgery residents who did not complete their program during the study period varied from 255 to 388 residents annually (3.3%-5.2%). During its first 3 years of inception, the CTR program had an attrition rate of 0%, and it was not until 2012-2013 that trainees failed to complete the program, resulting in an annual attrition rate of 1.2% to 3.2% from that point on. The annual attrition rate of CTF training programs ranged from 7 to 15 fellows (2.9%-6.8%) during the study period., Conclusions: The inception of VSR and CTR programs dramatically changed the paradigms for training in these highly specialized surgical fields. Comparisons of attrition rates between these two programs and the traditional VSF and CTR as well as GSR suggests lesser rates of attrition in the integrated programs. These data may prove reassuring to VSR and CTR program directors, whose significantly smaller programs are more vulnerable to the loss of even a single trainee than general surgery training programs are. In addition, the VSF program has stable and lower attrition rates compared with the CTF and GSR programs., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: As resident "index" procedures change in volume due to advances in technology or reliance on simulation, it may be difficult to ensure trainees meet case requirements. Training programs are in need of metrics to determine how many residents their institutional volume can support., Objective: As a case study of how such metrics can be applied, we evaluated a case distribution simulation model to examine program-level mediastinoscopy and endobronchial ultrasound (EBUS) volumes needed to train thoracic surgery residents., Methods: A computer model was created to simulate case distribution based on annual case volume, number of trainees, and rotation length. Single institutional case volume data (2011-2013) were applied, and 10 000 simulation years were run to predict the likelihood (95% confidence interval) of all residents (4 trainees) achieving board requirements for operative volume during a 2-year program., Results: The mean annual mediastinoscopy volume was 43. In a simulation of pre-2012 board requirements (thoracic pathway, 25; cardiac pathway, 10), there was a 6% probability of all 4 residents meeting requirements. Under post-2012 requirements (thoracic, 15; cardiac, 10), however, the likelihood increased to 88%. When EBUS volume (mean 19 cases per year) was concurrently evaluated in the post-2012 era (thoracic, 10; cardiac, 0), the likelihood of all 4 residents meeting case requirements was only 23%., Conclusions: This model provides a metric to predict the probability of residents meeting case requirements in an era of changing volume by accounting for unpredictable and inequitable case distribution. It could be applied across operations, procedures, or disease diagnoses and may be particularly useful in developing resident curricula and schedules., Competing Interests: The authors declare they have no competing interests.

Background: The volume of robot-assisted operations has drastically increased over the past decade. New programs have focused on training surgeons, whereas resident training has lagged behind. The objective of this study was to evaluate our institutional experience with resident participation in thoracic robotic surgery cases since the initiation of our program., Methods: The first 100 robotic thoracic surgery cases at our institution were retrospectively reviewed and categorized into three sequential cohorts. Procedure type, patient and operative characteristics, level of resident participation (primary surgeon [PS] or assistant), and postoperative variables were evaluated., Results: Of the first 100 cases, 38% were lung resections, 23% were esophageal operations, and 20% were sympathectomies. The distribution of cases changed over time with the proportion of pulmonary resections significantly increasing. Patient age (P < 0.05), body mass index (P = not significant [NS]), and comorbidities (P = NS) increased over time. Resident participation as PS increased from 33%-59% between the early and late cohorts (P < 0.05). A subset analysis of the 20 lobectomies (7 attending PS, 13 residents) showed similar patient characteristics (P = NS): age (67 versus 69), body mass index (29.5 versus 26.1), and American Society of Anesthesiologists category (2.8 versus 2.8). Operative and postoperative characteristics were also similar (P = NS) regardless of PS: operative time (260 versus 249 min), estimated blood loss (187 versus 203 mL), and length of stay (4.8 versus 4.7 d)., Conclusions: Residents can participate as the PS in a variety of thoracic operations during the implementation of a robotics program. Operative time, estimated blood loss, and length of stay were similar regardless of level of resident participation., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: General surgery residents' exposure to cardiothoracic (CT) surgery rotations has decreased, which may affect resident satisfaction. We surveyed general surgery graduates to assess the relationships among rotation satisfaction, CT disease exposure, rotation length, mentorship, and mistreatment., Design: A survey assessing CT curriculum, exposure, mentorship, and satisfaction was forwarded to general surgery graduates from 17 residency programs. A Wilcoxon rank-sum test was used to assess statistical significance of ordinal level data. Statistical significance was defined as p < 0.05., Setting: This study was conducted at the University of Michigan Health System in Ann Arbor, MI, a tertiary care center., Participants: The survey was sent to approximately 1300 graduates of general surgery residency programs who graduated between the years of 1999 to 2014. A total of 94 responses were completed and received., Results: Receiving adequate exposure to CT procedures and disease management was significantly associated with higher satisfaction ratings for all procedures, particularly thoracotomy incisions (p < 0.001), empyemas and pleural effusions (p < 0.001), and lung cancer care (p < 0.001). The absence of mistreatment and good/very good mentorship were both positively associated with higher reported satisfaction (p = 0.018 and p < 0.001, respectively). Increased length of time on CT rotation was neither associated with improved levels of satisfaction nor with an improvement in the quality of mentorship., Conclusion: Rotation satisfaction is positively associated with procedure exposure, better mentorship, and the absence of mistreatment. Longer rotation length was not associated with satisfaction. Shorter rotations are not detrimental to training if they have focused clinical exposure and invested mentors to maximize resident satisfaction. These specific markers of rotation quality are useful in curricular design., (Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: New paradigms for training cardiothoracic surgeons have been introduced, including the integrated thoracic surgery residency. Currently, a limited number of these programs exist, and all candidates apply to both integrated thoracic and general surgery residencies. We sought to investigate the applicants' experiences applying for both types of positions., Methods: An online survey was distributed to applicants to three integrated thoracic surgery programs during a 2-year period., Results: The response rate was 50% (90 of 180). Most respondents were fourth-year medical students (81%; 72 of 89) and were interested in adult cardiac surgery (81%; 73 of 90). Sixty-one percent (55 of 90) had an interest in cardiothoracic surgery before clinical clerkships, and 93% (84 of 90) tailored their clinical education to this interest. Fifty-seven percent (49 of 86) scored above 230 on the USMLE Step 1 examination. Ninety-two percent (80 of 87) performed research during medical school, and 78% (62 of 80), specifically within cardiothoracic surgery; 76% (61 of 80) published their work. The number of general surgery interviews varied widely, but 46% (36 of 79) interviewed at one to five integrated thoracic surgery programs, and 39% (31 of 79) interviewed at six to ten integrated thoracic surgery programs. During general surgery interviews, 36% (24 of 66) received negative comments regarding applying to integrated thoracic residencies. Fifty-two percent (38 of 73) thought that their application to integrated thoracic programs diminished their chances to match at a general surgery program., Conclusions: The applicants to the integrated thoracic surgery residencies become interested in cardiothoracic surgery early and tailor their clinical education to this interest. Although they are academically successful, they report significant negativity regarding their applications to both general surgery and integrated thoracic residencies., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: Work-hour restrictions have decreased flexibility in scheduling and reduced exposure to certain operative cases. These restrictions may affect a resident's ability to meet certification requirements, particularly for rare, unscheduled cases (e.g., cardiothoracic transplants). We developed a computer-based simulation model using variables such as case volume and program size to demonstrate the influence of these factors on the likelihood of certifying a set of residents on rare cases., Methods: We built a simulator to predict the probability of attaining certification for surgical residents, using cardiothoracic transplants as a test case. Inputs to the model included operating times, call schedules, and procurement travel times, as well as information on the distribution of times between transplants., Results: We simulated 100 years of schedules using our current system parameters of an average of 33 heart and 31 lung transplants per year, and assuming an Accreditation Council for Graduate Medical Education-compliant daily-rotating call schedule. Despite having enough transplants to certify all residents for lungs if all opportunities were distributed equally among residents, the certification rate achieved when constrained by arrival time (and call schedules) and work restrictions was only 55%. Our calculations show that meeting minimum transplant-certification requirements for all residents would require at least 1.5 times the expected number of annual transplants., Conclusions: Our model enables analysis of a given program's ability to certify its residents based on program size and volume. These results could be used to design alternative scheduling paradigms to improve certification rates, without requiring reductions in certification requirements or program size., (Copyright © 2014 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)