Thoracic Surgery Fellowship

Program Goals

This residency education program encompasses the operative, perioperative and critical care of patients with pathologic conditions within the chest. This includes the surgical care of coronary artery disease; cancers of the lung, esophagus, and chest wall; abnormalities of the great vessels and heart valves; congenital anomalies of the chest and heart; tumors of the mediastinum; diseases of the diaphragm; and management of chest injuries.

Program Philosophy

The philosophy of this fellowship is to:

• Provide a robust, appropriately supervised setting in which advanced, highly skilled education in adult cardiac surgery, pediatric cardiac surgery, and thoracic surgery will take place.
• Seek opportunities for the fellow to acquire an in-depth knowledge and advanced skill in cardiac and thoracic surgical techniques.
• Develop academically and professionally. Skills to be acquired include those of medical knowledge, patient care, practice-based learning and improvement, communication and interpersonal skills, professionalism, and systems-based practice.
• Provide an excellent clinical education and graduated clinical advancement accomplished by directed expert clinical, academic, and social instruction promoting self-directed education, and fostering the refinement of the individual fellow’s clinical, professional, social and academic pursuits.
• Combine fellow mentoring with instruction by faculty, including didactic and Socratic education, hands-on experience, simulation and self-directed learning.

The Thoracic Surgery Fellowship program is a two-year traditional program that is accredited for a total of two positions, one per year.

All applicants are required to apply through the Electronic Residency Matching Service and to participate in the interview process and the National Resident Matching Program (NRMP).

Virtual Tour

Penn State Health

Penn State Health is an integrated academic health system serving patients and communities across 25 counties in central Pennsylvania. It employs more than 20,900 people systemwide.

The system includes Penn State Health Milton S. Hershey Medical Center, Penn State Health Children’s Hospital and Penn State Cancer Institute based in Hershey, Pa.; Penn State Health Hampden Medical Center in Enola, Pa.; Penn State Health Holy Spirit Medical Center in Camp Hill, Pa.; Penn State Health Lancaster Medical Center in Lancaster, Pa.; Penn State Health St. Joseph Medical Center in Reading, Pa.; Pennsylvania Psychiatric Institute, a specialty provider of inpatient and outpatient behavioral health services, in Harrisburg, Pa.; and 2,417 physicians and direct care providers at 225 outpatient practices. Additionally, the system jointly operates various healthcare providers, including Penn State Health Rehabilitation Hospital, Hershey Outpatient Surgery Center and Hershey Endoscopy Center.

In 2017, Penn State Health partnered with Highmark Health to facilitate creation of a value-based, community care network in the region.

Penn State Health shares an integrated strategic plan and operations with Penn State College of Medicine, the University’s medical school. With campuses in State College and Hershey, Pa., the College of Medicine boasts a portfolio of more than $150 million in funded research and more than 1,700 students and trainees in medicine, nursing, other health professions and biomedical research.

Learn more about Penn State Health

Penn State Health Children’s Hospital (left), Penn State Health Milton S. Hershey Medical Center (center) and Penn State Cancer Institute (right)

Penn State Health Milton S. Hershey Medical Center

500 University Dr., Hershey, Pa., 17033 (Derry Township, Dauphin County)

• The health system’s 611-bed flagship teaching and research hospital
• The only medical facility in Pennsylvania accredited as both an adult and a pediatric Level I (highest-level) trauma center
• Dedicated surgical, neuroscience, cardiovascular, trauma and medical intensive care units
• Accredited Life Lion critical-care transport providing more than 1,100 helicopter and approximately 750 ground ambulance transports per year
• More than 1,300 faculty members and more than 650 residents and fellows
• Approximately 29,000 admissions, 73,000 emergency department visits, 1.1 million outpatient visits and 33,000 surgical procedures annually
• Designated as a Magnet hospital since 2007

Learn more about Milton S. Hershey Medical Center

Penn State Health Children’s Hospital

600 University Dr., Hershey, Pa. 17033 (Derry Township, Dauphin County)

• An eight-story, 263,000-square-foot-facility built in 2013 and expanded in 2020
• 160 licensed pediatric beds, 26-bed pediatric intensive care unit and a 56-bed neonatal intensive care unit
• Level IV (highest-level) neonatal intensive care unit
• Level I quaternary (highest-level) pediatric intensive care unit
• Level I (highest-level) pediatric trauma center designation
• Intermediate care unit
• Dedicated pediatric operating rooms
• More than 150,000 pediatric outpatient visits, 20,000 pediatric emergency room visits, and approximately 5,000 pediatric patient discharges annually

Learn more about Penn State Health Children’s Hospital

Welcome to Hershey

More About Hershey

Interested in learning more about living and working in Hershey, Pa.? See details here:

• Benefit and stipend information
• Virtual tour
• GME policies
• Wellness resources
• More about Penn State Health and its locations
• Application and visa requirements

Wellness, including emotional, spiritual, social and physical health, is a crucial component to training and to becoming a professional, compassionate and resilient physician. Self-care is a skill which must be continually practiced and reinforced. Penn State College of Medicine and Penn State Health are committed to addressing wellness among residents and fellows, with multiple resources readily available.

Institutional resources

• Visit BeWell – a health program designed to support Penn State Health employees
• See Penn State College of Medicine wellness resources here
• Employee Health Care Concierge and Case Management Service
• Partners in Medicine
  Moving to a new city with your family does not have to be stressful. Residency programs have assisted many significant others with finding employment. There is also a GME-Wide Partners in Medicine (PIM) group that offers networking opportunities as well as various social and community oriented activities.
• The Doctors Kienle Center for Humanistic Medicine
• Active and easily accessed Office of Professional Mental Health

Graduate medical education resources

• See resident and fellow wellness resources here

Institutional Resources

Penn State Health and Penn State College of Medicine celebrate, embrace and support the diversity of all patients, faculty, staff, students and trainees.

Office for Diversity, Equity and Inclusion

In keeping with this, Penn State Health has an active Office for Diversity, Equity and Inclusion with various programs, networks and resource groups, including:

• Talks and lectures on diversity, equity and inclusion through the Inclusion Academy
• Regular events on topics such as eradicating racism and creating a culture of inclusiveness
• Many Business Employee Resource Groups (BERGs), including:
  • Disability Business Employee Resource Group
  • Interfaith Business Employee Resource Group
  • LGBTQ+ Business Employee Resource Group
  • Military and Veterans Business Employee Resource Group
  • Multicultural Business Employee Resource Group
  • NextGen Business Employee Resource Group
• Black Physician Professional Staff Association – Resource Group
• Hispanic Professional Association
• Asian Physician and Professional Staff Association
• International Workforce Inclusion
• Inclusion Academy

Learn more about the Penn State Health Office for Diversity, Equity and Inclusion

Learn more about the College of Medicine’s Office for Diversity, Equity and Belonging

Office for Culturally Responsive Health Care Education

The vision at Penn State College of Medicine and Penn State Health is to equip learners with the knowledge, skills and attitudes they will need to provide culturally excellent health care and research for an increasingly diverse U.S. population. The Office for Culturally Responsive Health Care Education was formed to help meet that goal.

Learn more about the Office for Culturally Responsive Health Care Education

Office for a Respectful Learning Environment

In addition, the institution does not tolerate discrimination, biases, microaggression, harassment or learner mistreatment of any kind, and any concerns are immediately addressed by the Office for a Respectful Learning Environment.

Learn more about the Office for a Respectful Learning Environment

Network of Under-represented Residents and Fellows
The Network of Under-represented Residents and Fellows (NURF) is a group of diverse residents and fellows representing all specialties. NURF’s goal is to promote cultural diversity in the residency programs through community involvement, mentorship with diverse faculty, professional networking and support for the recruitment of diverse medical students into the residency programs.

NURF is sponsored by the Penn State College of Medicine Graduate Medical Education Office and the Penn State Health Office for Diversity, Equity and Inclusion.

Learn more information about NURF

Mailing Address

Thoracic Surgery Fellowship
Penn State Health Milton S. Hershey Medical Center
P.O. Box 850, MC H159
500 University Dr.
Hershey, PA  17033

General Contact Information

Phone: 717-531-4451

Fax: 717-531-0395

The two-year Thoracic Surgery Fellowship is divided into three-month rotations with seven blocks assigned and the eighth block offering a choice of elective rotations.

Year One

In the first year of the program, the fellow begins concentrated exposure to congenital cardiac (block 1) and thoracic (blocks 2 and 3) pathology; however, early exposure time is permitted to acquired cardiac and thoracic great vessel disease cases. The junior fellow is expected to meet the ABTS index case requirements in congenital heart disease and general thoracic disease for the cardiothoracic pathway during the first year. Fellows are charged with the conduct of daily pre- and post-operative rounds of peri-operative patients, assuring a robust exposure to the in-hospital management of these patients. The trainees are expected to communicate with the attending staff about operative planning, pre- and post-operative management, and all clinical care decisions for each case in which they participate. The fellows additionally will see a portion of daily consults and review these evaluations and associated studies with the attending on-call that day. Attendings round daily with house staff on their own patients; intensivists in the cardiovascular intensive care unit round independently with the cardiothoracic surgery team, concurrently managing ICU patients.

There are outpatient congenital cardiac and thoracic surgical clinics weekly. Fellows are assigned to these outpatient venues with documentation of this experience. The outpatient setting allows for an enriching exposure to congenital cardiac and thoracic pathology. Pre-operative assessment, non-operative management of thoracic pathology, post-operative care, and long-term follow-up of our patients are all part of this environment. The fellows are mentored by a staff surgeon in this setting and participate actively in the evaluation and care of these patients.

During the first year, fellows concentrate their attention on the outpatient work-up, operative procedures, and follow-up of thoracic surgical patients. This includes the determination and planning of appropriate operative intervention for these patients. Further, the fellows participate in the weekly multi-discipline thoracic case conference, which includes participation by a core group including thoracic oncologists and radiation oncologists, interventional pulmonologists, and thoracic radiologists.

The fellows are exposed to congenital cardiac surgery during the first year. They participate in surgical cases either as the responsible surgeon or first assistant. Fellows are expected to follow patients post-operatively and to work in concert with the attending Pediatric Cardiac Surgeons, the Pediatric Cardiology Service, and the Pediatric Cardiac Intensivists. There is a pediatric cardiac surgery outpatient clinic once weekly, and the junior fellow is expected to include this setting in the core of outpatient clinics, which are to be attended regularly.

During the fourth block, the fellow transitions to the adult cardiac surgery service (see below, Year Two) while the chief fellow (eighth block) has an elective rotation.

The learning objectives of the first year include planning, implementation and mastering of the clinical skills that are listed in the Competency-Based Goals and Objectives. Additionally, a core curriculum follows the Thoracic Surgery Curriculum established by the Thoracic Surgery Directors Association, covering thoracic, pediatric and adult cardiac surgery annually.

Year Two

The emphasis in the second year is placed on completing index cases to meet the operative numbers entirely from one pathway. Therefore, if the fellow has chosen the general thoracic pathway, they will complete the index adult cardiac cases for that pathway and then focus on increasing general thoracic cases to meet required operative experience (eighth-block elective). On the other hand, if the cardiothoracic pathway is chosen, emphasis will be on adult cardiac index cases with the general thoracic surgery cases already completed for the pathway in the previous year (eighth-block elective).

The second-year cardiothoracic surgery fellow is assigned to run the service as chief fellow. It is the chief fellow’s responsibility to conduct daily pre-operative and post-operative rounds for the purpose of both providing patient care and for education of the house staff. The fellow also will participate actively with the attending staff in operative planning and decision making for post-operative care. The fellow will have major responsibilities for operative, intra-operative and post-operative patient care and clinical decision-making. It is expected that the fellow will be able to perform most cases as the operative surgeon with graded responsibility in the operating room as the year progresses. The attending staff directly supervises intra-operative care. Post-operative care is coordinated with the attending staff, and additionally includes the Heart and Vascular Institute Intensive Care Unit staff.

The senior fellow (chief fellow) is assigned to attend the outpatient adult cardiac surgery clinics (blocks 4 to 7). In this setting, they will be intimately involved in the pre-operative and post-operative evaluation of patients. The fellow is also expected to become intimately involved with the cardiac transplantation team. Responsibilities include familiarity with peri-operative management of patients undergoing cardiac transplant, as well as techniques of mechanical circulatory support, including the total artificial heart, extracorporeal membrane oxygenation (ECMO) and a cadre of ventricular assist devices (VADs). Fellows are exposed to the pre-operative care of cardiac transplantation patients via the cardiac transplantation conference. The transplant program has a close relationship with the congestive heart failure cardiology team, who render concurrent daily care of all transplant and assist device patients, providing an example of strong interdisciplinary support. Fellows participate in the performance of transplant and circulatory assistance procedures, as well as donor organ procurements.

Administrative responsibilities include coordination of the junior thoracic surgery fellow, general surgery residents, medical students, nurse practitioners, and physician assistants that comprise the services, including assignment of daily responsibilities and coordination of the call schedule.

As in the first year, the learning objectives of the second year include planning, implementation and mastering of the clinical skills that are listed in the Competency-Based Goals and Objectives. The core curriculum continues to follow the Thoracic Surgery Curriculum established by the Thoracic Surgery Directors Association, covering thoracic, pediatric and adult cardiac surgery.

During the eighth block, the second-year chief fellow has an elective rotation. If the trainee is pursuing the American Board of Thoracic Surgery (ABTS) general thoracic pathway, the fellow will focus on thoracic surgery. If the trainee is following the ABTS cardiothoracic surgery pathway, the fellow will focus on advanced cardiac surgery (mechanical circulatory support and/or minimally invasive cardiac surgery) or congenital cardiac surgery. During this period, while the first-year trainee is starting adult cardiac surgery and directing the clinical service, the second-year trainee will direct the thoracic surgery service.

There are two adult clinical teams, cardiac and thoracic. Rotations are divided into three-month blocks. For each rotation, the primary operative experience, secondary operative experience (if no operative cases of significant educational benefit are available for the primary experience) and clinical service are defined.

The first-year thoracic surgery fellow directs the thoracic service for nine months (first through third blocks) to gain clinical leadership experience. At that time, the second-year chief fellow (fifth through seventh blocks) runs the cardiac service. The first-year fellow takes over direction of the cardiac service at the fourth block, while the second-year chief fellow (on elective rotation, eighth block) directs the thoracic service.

During the eighth block, the second-year chief fellow has an elective rotation. If the trainee is pursuing the American Board of Thoracic Surgery (ABTS) general thoracic pathway, the fellow will focus on thoracic surgery. If the trainee is following the ABTS cardiothoracic surgery pathway, the fellow will focus on advanced cardiac surgery (mechanical circulatory support and/or minimally invasive cardiac surgery) or congenital cardiac surgery.

The two teams work collaboratively, with cross-coverage between the two thoracic surgery fellows on nights, weekends and holidays. There is signout between the two teams twice daily. When serving an educational purpose, the thoracic surgery fellows are encouraged to participate in cases on the secondary service. The chief fellow has primary responsibility for administrative duties, including operative case assignments.

Independent Program Format, Year 1

Independent Program Format, Year 2

General Thoracic Surgery

The general thoracic surgery first-year experience will serve as the introduction to general thoracic surgery, including pre-operative workup and post-operative care. Fellows will learn how to recognize and care for critically ill patients, including placement of chest tubes and obtaining central venous access. Finally, this rotation will teach surgical and endoscopic techniques.

(1) Medical knowledge

1. Know the anatomy, embryology, physiology, and pathology of the trachea, lungs, esophagus, pleura, diaphragm, chest wall, and mediastinum.
2. Understand the pharmacology, indications, and complications of drugs commonly used in the specialty, including anti-arrhythmics, diuretics, anticoagulants, bronchodilators, and analgesics.
3. Describe the general principles of preoperative assessment and postoperative management of thoracic surgical patients.
4. Learn the natural history of treated and untreated diseases of the specialty, including benign and malignant tumors, pulmonary infectious disease, emphysema/COPD, interstitial lung disease, benign and malignant esophageal disease, esophageal dysmotility disorders, and Barrett’s esophagus.
5. Understand the principles of thoracic surgery including hemostasis, wound healing, wound complications, electrolyte and fluid replacement, surgical nutrition, and oncology.
6. Understand common postoperative care issues in the thoracic surgery patient, including pain management, exercise expectations/limitations, need for home oxygen, indications for a skilled nursing/rehabilitation facility.
7. Understand pulmonary function tests, arterial blood gases, ventilation-perfusion tests, PET scans, MVO2 studies, and esophageal motility and manometry studies.

(2) Clinical skills

1. Perform an appropriate, relevant history and physical exam in the ward, ambulatory clinic, and emergency department settings.
2. Request appropriate laboratory, radiological and other diagnostic procedures.
3. Demonstrate knowledge in the interpretation of laboratory investigations, CXR, ECG, CT scan, MRI and PET scan.
4. Arrive at an acceptable plan of management for the disease process, including differential diagnosis.
5. Manage the patient throughout as much of the hospital stay as possible demonstrating knowledge and ability to recognize potential complications of the disease process and operative procedures.
6. Demonstrate ability to perform daily fellow work rounds efficiently, including dictation of operative cases performed, daily progress notes, dictation of discharge summary, prescription writing.
7. Provide a plan for patient follow-up.
8. Assess and triage urgent/emergent thoracic surgery patients.

(3) Patient care

1. Obtain graduated responsibility as first assistant and surgeon in the operating room for common thoracic surgery cases, including lobectomy (open and VATS), VATS wedge resection/biopsy, decortication, mediastinoscopy and esophagectomy.
2. Serve as primary surgeon, performing thoracotomies and participating in thoracotomy closure.
3. As primary surgeon, the fellow should perform flexible and rigid bronchoscopy, with understanding of bronchial segmental anatomy.
4. Perform VATS pleurodesis and tunneled pleural catheter placement as primary surgeon.
5. Handle tissues and surgical instruments in an appropriate manner and demonstrate adherence to sterile techniques.
6. Insert and remove chest tubes and perform thoracentesis outside of the operating room.
7. Manage pneumonia, hypoxia, pain, cardiac arrhythmias, and common postoperative conditions (atrial fibrillation/flutter, ventricular tachycardia/fibrillation, sinus bradycardia/tachycardia, wound infections, low urine output, and post-operative bleeding).
8. Insert internal jugular, subclavian, and femoral central venous catheters; insert radial and femoral arterial lines in the ICU with supervision.

(4) Professionalism

1. Demonstrate the ability to be honest, reliable, and respectful of the religious, racial, and gender characteristics of patients, their families, and other members of the health care team.
2. Prove the ability to give and receive advice in a manner that is consistent with the harmonious operation of a health care team.
3. Demonstrate the ability to recognize when to seek assistance from more experienced colleagues.
4. Deliver highest quality care with ethics, integrity, honesty and compassion.
5. Exhibit appropriate personal and interpersonal professional behaviors.
6. Understand the professional, legal, and ethical codes to which physicians are bound.

(5) Interpersonal and communication skills

1. Listen effectively.
2. Establish an effective relationship with patients and families.
3. Obtain and synthesize relevant history from patients and family.
4. Inform patients and families about their condition at an appropriate and understandable level.
5. Prepare clear consultation notes, progress notes, discharge summaries, and clinic notes.
6. Prepare and present ward rounds in an organized manner.
7. Participate actively in scheduled rounds.
8. Communicate effectively with allied health care professionals.

(6) Systems-based practice

1. Utilize resources effectively to balance patient care, learning needs, and outside activities.
2. Allocate finite health care resources wisely.
3. Work effectively and efficiently in a health care organization.
4. Understand the importance of, and mechanisms to, safely utilize resources in a cost-effective manner to benefit all patients.
5. Recommend practices to effectively utilize resources including undertaking studies to assess effectiveness of standard care procedures.

(7) Practice-based learning and improvement

1. Develop effective self-directed learning strategies for continuing education and assessment of knowledge base.
2. Critically appraise sources of medical information and be aware available of resources.
3. Prepare and present scheduled rounds and conferences.
4. Participate actively in scheduled morbidity and mortality conferences.
5. Participate effectively in facilitating learning of patients, teaching house staff, students and other health professionals.

Method of assessment of fellow performance

1. Evaluation by all faculty, as well as ICU staff, nurses, PAs, NPs (360-degree), using New Innovations every six months.
2. Annual TSDA in-training exam.
3. Daily faculty direct observation.
4. Review of case logs monthly using the ACGME Operative Log via Program Director interface.

Congenital Cardiac Surgery

The pediatric cardiac surgery first year (three-month) rotation will serve as the exposure to congenital cardiothoracic surgery including pre-operative work-up and post-operative care.

Fellows will learn how to recognize and care for critically ill children. This rotation will teach surgical and cardiopulmonary bypass techniques.

(1) Medical knowledge

1. Know the anatomy and embryology of the normal heart and of major cardiac anomalies.
2. Understand the physiology of normal fetal circulation, the transition from fetal circulation to the neonatal state, and the physiology of obstructions, intra-cardiac and extra-cardiac shunts, abnormal connections to the heart, and combinations of these anomalies in the fetus, neonate and child.
3. Learn the general principles of pre-operative assessment and post-operative management of pediatric cardiac surgical patients.
4. Understand the arterial and venous cannulation techniques for different intra-cardiac defects, indications for various bypass strategies, techniques of myocardial protection in the neonate and infant, the use of levels of hemodilution and anticoagulation, perfusion flow and pressure control, body temperature manipulation, and deep hypothermic circulatory arrest.
5. Understand the principles of surgery, including hemostasis, wound healing, wound complications, electrolyte and fluid replacement, and surgical nutrition in the congenital cardiac surgery patient.

(2) Clinical skills

1. Perform an appropriate, relevant history and physical exam in the ward, ambulatory clinic and emergency department settings.
2. Order appropriate laboratory, radiological and other diagnostic procedures.
3. Demonstrate knowledge in the interpretation of laboratory investigations, angiography, and echocardiography.
4. Arrive at an acceptable plan of management for the disease process, including differential diagnosis.
5. Manage the patient throughout as much of the hospital stay as possible, demonstrating knowledge and ability to recognize potential complications of the disease process and operative procedures.
6. Contribute to planning for patient follow-up.
7. Assess and triage urgent/emergent congenital cardiac surgery patients.

(3) Patient care

1. Obtain graduated responsibility as first assistant, as well as surgeon when feasible, in the operating room for common congenital cardiac surgery cases including sternotomy, arterial and venous cannulation for bypass, ASD and VSD repair, and other congenital cardiac anomalies.
2. Handle tissues and surgical instruments in an appropriate manner and demonstrate adherence to sterile techniques.
3. Manage hemodynamic disturbances, cardiac arrhythmias, volume status, and post-operative bleeding.

(4) Professionalism

1. Demonstrate the ability to be honest, reliable, and respectful of the religious, racial, and gender characteristics of pediatric patients, their families, and other members of the health care team.
2. Prove the ability to give and receive advice in a manner that is consistent with the harmonious operation of a health care team.
3. Demonstrate the ability to recognize when to seek assistance from more experienced colleagues.
4. Deliver highest quality care with ethics, integrity, honesty, and compassion.
5. Exhibit appropriate personal and interpersonal professional behaviors.
6. Understand the professional, legal, and ethical codes to which physicians are bound, particularly when caring for children.

(5) Interpersonal and communication skills

1. Listen effectively.
2. Establish and effective relationship with young patients and families.
3. Obtain and synthesize relevant history from patients and family.
4. Inform patients and families about their condition at an appropriate and understandable level.
5. Participate actively in scheduled rounds and conferences.
6. Communicate effectively with allied health care professionals.

(6) Systems-based practice

1. Utilize resources effectively to balance patient care, learning needs, and outside activities.
2. Allocate finite health care resources wisely.
3. Work effectively and efficiently in a health care organization.
4. Understand the importance of and mechanisms to safely utilize resources in a cost-effective manner to benefit all patients.
5. Recommend practices to effectively utilize resources including undertaking studies to assess effectiveness of standard care procedures.

(7) Practice-based learning and improvement

1. Develop effective self-directed learning strategies for continuing education and assessment of knowledge base.
2. Critically appraise sources of medical information and be aware of resources available.
3. Prepare and present scheduled rounds and conferences.
4. Participate effectively in facilitate learning of patients, teaching house staff, students and other health professionals.

Method of assessment of fellow academic performance

1. Evaluation by all faculty, as well as ICU staff, nurses, PAs, NPs (360-degree), using New Innovations every six months.
2. Annual TSDA in-training exam.
3. Daily faculty direct observation.
4. Review of case logs monthly using the ACGME Operative Log via Program Director interface.

Adult Cardiac Surgery

The adult cardiac surgery second-year experience will serve as the completion of cardiac surgery training (common and tertiary care patients), including pre-operative work-up and post-operative care. The trainee will serve as the chief fellow, directing the care of critically ill patients. The fellow will work with the cardiac transplantation team and the mechanical circulatory support service. Finally, it is expected that the fellow will be able to perform most adult cardiac surgery cases as the operative surgeon with graded responsibility in the operating room as the year progresses.

(1) Medical knowledge

1. Know the anatomy, embryology, physiology and pathology of the heart and great vessels.
2. Understand the pharmacology, indications, and complications of drugs commonly used in the specialty, including anti-arrhythmics, diuretics, anticoagulants, vasopressors and inotropes.
3. Describe the general principles of pre-operative assessment and post-operative management of adult cardiac surgical patients.
4. Learn the natural history of treated and untreated diseases of the specialty, including coronary artery disease, myocarditis, cardiomyopathy, hypertrophic obstructive cardiomyopathy, cardiac tumors, aortic abnormalities, cardiac arrhythmias and valvular heart disease.
5. Understand the principles of cardiac surgery, including hemostasis, wound healing, wound complications, electrolyte and fluid replacement, surgical nutrition, and cardiology.
6. Understand common postoperative care issues in the adult cardiac surgery patient, including anticoagulation, cardiac rehabilitation, and indications for skilled nursing/rehabilitation facility.
7. Understand coronary angiography, echocardiography, ECG, and chest radiography.
8. Know the indications for cardiac transplantation, recognize the signs and symptoms of cardiac rejection and know the appropriate management, understand the evaluation and management of organ donors, and know the methods of organ harvest and preservation.
9. Learn the physiology of extracorporeal bypass, techniques for extracorporeal bypass, and indications for mechanical circulatory support.

(2) Clinical skills

1. Perform an appropriate, relevant history and physical exam in the ward, ambulatory clinic and emergency department settings.
2. Order appropriate laboratory, radiological and other diagnostic procedures.
3. Demonstrate knowledge in the interpretation of laboratory investigations, CXR, ECG, angiography and echocardiography.
4. Arrive at an acceptable plan of management for the disease process, including differential diagnosis.
5. Manage the patient throughout as much of the hospital stay as possible demonstrating knowledge and ability to recognize potential complications of the disease process and operative procedures.
6. Demonstrate ability to direct daily fellow work rounds efficiently, including dictation of operative cases performed, daily progress notes, dictation of discharge summary, prescription writing.
7. Provide a plan for patient follow-up.
8. Assess and triage urgent/emergent adult cardiac surgery patients.

(3) Patient care

1. Obtain graduated responsibility as first assistant and surgeon in the operating room for common adult cardiac surgery cases including coronary artery bypass grafting, valvular repair and replacement and aortic interventions.
2. Serve as primary surgeon, performing sternotomy, cannulation for bypass and conduit procurement.
3. Perform heart procurement and cardiac transplantation.
4. Handle tissues and surgical instruments in an appropriate manner and demonstrate adherence to sterile techniques.
5. Insert and remove ECMO cannulas.
6. Manage hemodynamics, inotropic support, cardiac arrhythmias, and common postoperative conditions (atrial fibrillation/flutter, ventricular tachycardia/fibrillation, sinus bradycardia/tachycardia, wound infections, low urine output, and post-operative bleeding).
7. Insert intra-aortic balloon pumps.

(4) Professionalism

1. Demonstrate the ability to be honest, reliable, and respectful of the religious, racial, and gender characteristics of patients, their families, and other members of the health care team.
2. Prove the ability to give and receive advice in a manner that is consistent with the harmonious operation of a health care team.
3. Demonstrate the ability to recognize when to seek assistance from more experienced colleagues.
4. Deliver highest quality care with ethics, integrity, honesty and compassion.
5. Exhibit appropriate personal and interpersonal professional behaviors.
6. Understand the professional, legal and ethical codes to which physicians are bound.

(5) Interpersonal and communication skills

1. Listen effectively.
2. Establish an effective relationship with patients and families.
3. Obtain and synthesize relevant history from patients and family.
4. Inform patients and families about their condition at an appropriate and understandable level.
5. Write clear consultation notes, progress notes, discharge summaries, and clinic notes.
6. Prepare and present ward rounds in an organized manner.
7. Direct scheduled rounds.
8. Communicate effectively with allied health care professionals.

(6) Systems-based practice

1. Utilize resources effectively to balance patient care, learning needs and outside activities.
2. Allocate finite health care resources wisely.
3. Work effectively and efficiently in a health care organization.
4. Understand the importance of and mechanisms to safely utilize resources in a cost-effective manner to benefit all patients.
5. Recommend practices to effectively utilize resources including undertaking studies to assess effectiveness of standard care procedures.

(7) Practice-based learning and improvement

1. Develop effective self-directed learning strategies for continuing education and assessment of knowledge base.
2. Critically appraise sources of medical information and be aware of resources available.
3. Prepare and present scheduled rounds and conferences.
4. Participate actively in scheduled morbidity and mortality conferences.
5. Participate effectively in facilitating learning of patients, teaching house staff, students, and other health professionals.

Method of assessment of fellow academic performance

1. Evaluation by all faculty, as well as ICU staff, nurses, PAs, NPs (360-degree), using New Innovations every 6 months.
2. Annual TSDA in-training exam.
3. Daily faculty direct observation.
4. Review of case logs monthly using the ACGME Operative Log via Program Director interface.

I. Chest Wall

A. Anatomy, Physiology, and Embryology

Learner Objectives: Understands the anatomy and physiology of the cutaneous, muscular, and bony components of the chest wall and their anatomic and physiologic relationships to adjacent structures; understands the anatomy of the vascular, neural, muscular, and bony components of the thoracic outlet; knows the surgical anatomy, neural, vascular, and skeletal components of the chest wall, as well as the major musculocutaneous flaps; knows all operative approaches to the chest wall.

Clinical Skills: During the training program the fellow: recognizes the normal and abnormal anatomy of the chest wall; reads and interprets tests to diagnose chest wall abnormalities.

B. Acquired Abnormalities and Neoplasms

Learner Objectives: Evaluates primary and metastatic chest wall tumors, knows their histologic appearance, and understands the indications for incisional versus excisional biopsy; knows the radiologic characteristics of tumors; understands the diagnosis and management of various chest wall infections; Knows the types of chemotherapy and radiotherapy of chest wall tumors and the indications for pre-operative and post-operative therapy.

Clinical Skills: During the training program the fellow: performs a variety of surgical incisions to expose components of the chest wall and internal thoracic organs; performs surgical resections of primary and secondary chest wall tumors; identifies the need for major flaps of the chest wall.

C. Congenital Abnormalities and Thoracic Outlet Syndrome

Learner Objectives: Recognizes pectus excavatum and pectus carinatum, understands possible physiologic disturbances, and interprets diagnostic tests to identify such physiologic disturbances; understands the indications for the operative treatment of congenital chest wall abnormalities; knows the complications of reconstruction of congenital chest wall abnormalities and their management; understands the etiology, evaluation, differential diagnosis and diagnostic criteria for thoracic outlet syndrome; knows the operative and non-operative management of thoracic outlet syndrome; recognizes various congenital lung abnormalities and understands their anatomy and indications for treatment.

Clinical Skills: During the training program the fellow: recognizes the varied presentations of thoracic outlet syndrome and interprets diagnostic tests; reads and interprets diagnostic X-ray and performs physiologic examinations for congenital chest wall defects and thoracic outlet syndromes; evaluates and treats patients with congenital chest wall malformations; performs the operative reconstruction of selected chest wall defects; performs first rib and cervical rib resection and repairs or releases vascular and neural abnormalities associated with thoracic outlet syndrome; evaluates patients with congenital lung abnormalities; performs operations for congenital lung abnormalities and their complications.

II. Lungs and Pleura

A. Anatomy, Physiology, Embryology and Testing

Learner Objectives: Understands the arterial, venous, and bronchial anatomy of the lungs and their interrelationships; understands the lymphatic anatomy of the lungs, the major lymphatic nodal stations, and lymphatic drainage routes of the lobes; knows the indications for various thoracic incisions, the surgical anatomy encountered, and the physiological impact; knows the indications for plain radiography, CT scan, MRI, and PET scanning for staging of lung cancer; Knows the indications, interpretation, and use of nuclear medicine perfusion scanning to determine the operability of candidates for pulmonary resection; understands the methods of invasive staging (e.g. endobronchial ultrasound [EBUS], mediastinoscopy, Chamberlain procedure, video-assisted thoracoscopic surgery [VATS]); knows how to interpret pulmonary function tests and cardiopulmonary exercise testing (CPET); knows how pulmonary function tests are performed; understands the segmental anatomy of the bronchial tree.

Clinical Skills: During the training program the fellow: reads and interprets pulmonary function studies, perfusion scans, pulmonary arteriograms and arterial blood gases, and correlates the results with operability; applies knowledge of thoracic anatomy to the physical examination of the chest, heart, and vascular tree; uses knowledge of chest, pulmonary and cardiac physiology to interpret tests involving the thoracic cavity and to understand and treat diseases of the chest and its contents; reads and interprets plain radiography, CT scans, MRI and PET scanning of the chest; applies knowledge of thoracic anatomy to flexible and rigid endoscopy; understands the performance of cardiopulmonary exercise testing and pulmonary function tests.

B. Non-Neoplastic Lung Disease

Learner Objectives: Understands diagnostic procedures used to evaluate non-neoplastic lung disease; Knows the common pathogens that produce lung infections, including their presentation and pathologic processes, and knows the treatment and indications for operative intervention; understands the natural history, presentation and treatment of chronic obstructive lung disease; understands the pathologic results and alterations of pulmonary function due to bronchospasm; understands the mechanisms by which foreign bodies reach the airways, how they cause pulmonary pathology, and the management of patients with airway foreign bodies; knows the indications for bullectomy, lung reduction, and pulmonary transplantation; Understands the principles of surgical resection for non-neoplastic lung disease; understands the causes, physiology, evaluation and management of hemoptysis.

Clinical Skills: During the training program the fellow: diagnoses and treats patients with bacterial, fungal, tuberculous, and viral lung infections; manages patients with chronic obstructive lung disease, reactive airway disease, foreign bodies of the airways, and hemoptysis; performs thoracentesis, mediastinoscopy, mediastinotomy, flexible and rigid bronchoscopy, EBUS, VATS and open lung biopsy; performs operative and nonoperative management of lung abscess; performs resections of lung and bronchi in patients with non-neoplastic lung disease; performs bronchoalveolar lavage and transbronchial lung biopsy.

C. Neoplastic Lung Disease

Learner Objectives: Understands AJCC staging of lung carcinoma and its application to the diagnosis, therapeutic planning and management of patients with lung cancer; evaluates and diagnoses pulmonary malignancy, using a knowledge of the histologic appearance of the major types; knows the signs of inoperability; understands the complications of pulmonary resection and their management; understands the indications for resection of benign lung lesions; understands the indications for resection of pulmonary metastases; understands the therapeutic options for patients with lung malignancy; understands the role of adjuvant therapy for lung cancer.

Clinical Skills: During the training program the fellow: evaluates patients with lung cancer and recommends therapy based on their functional status, pulmonary function, staging, and tumor type; performs staging procedures (e.g. bronchoscopy, mediastinoscopy, mediastinotomy, EBUS and VATS); performs bedside bronchoscopy and placement of tracheostomies (open or percutaneous); performs operations to extirpate lung cancer (e.g. segmental resection, lobectomy, pneumonectomy, sleeve lobectomy, carinal resection, chest wall resection); recognizes and manages complications of pulmonary resections (e.g. space problem, persistent air leak, bronchopleural fistula, empyema, cardiac arrhythmia).

D. Diseases of the Pleura

Learner Objectives: Is familiar with the clinical presentation of benign and malignant diseases of the pleura; understands the types of pleural effusions, their evaluation and treatment; understands the indications, contraindications and complications of VATS and has a working knowledge of the equipment; understands the management of empyema with and without bronchopleural fistula.

Clinical Skills: During the training program the fellow: evaluates pleural effusions and recommends appropriate therapy; performs invasive diagnostic studies (e.g. needle biopsy, fluid analysis); places tube thoracostomy and performs chemical or mechanical pleurodesis; performs VATS as necessary for the diagnosis and treatment of pleural disease; Places tunneled pleural drainage catheters; performs initial drainage procedures and subsequent procedures for empyema (e.g. decortication, rib resection, Eloesser flap, Claggett procedure, closure of bronchopleural fistula).

III. Trachea and Bronchi

A. Anatomy, Physiology, and Embryology

Learner Objectives: Understands the anatomy and blood supply of the trachea and bronchi; understands the endoscopic anatomy of the nasopharynx, hypopharynx, larynx, trachea, and major bronchi; understands and interprets pulmonary function studies of the trachea and bronchi; understands the radiologic assessment of the trachea and bronchi.

Clinical Skills: During the training program the fellow: interprets plain radiographic analyses, CT scan and pulmonary function studies involving the trachea and bronchi; performs endoscopy of the upper airway, trachea and major bronchi.

B. Congenital and Acquired Abnormalities

Learner Objectives: Understands congenital abnormalities and idiopathic diseases of the trachea; understands the etiology, presentation and management of acquired tracheal strictures and their prevention; understands the radiologic evaluation of tracheal abnormalities; Knows the methods of airway management, anesthesia, and ventilation for tracheal operations; understands the etiology, presentation and principles of airway trauma management.

Clinical Skills: During the training program the fellow: evaluates diagnostic tests of the trachea and bronchi; performs laryngoscopy and bronchoscopy of the trachea and bronchi, including dilation of stenoses; performs tracheostomy; evaluates patients for tracheal resection and plans the operation.

C. Neoplasms

Learner Objectives: Knows the types, histology and clinical presentation of tracheal neoplasms; knows the indications for and the use of radiotherapy and chemotherapy.

Clinical Skills: During the training program the fellow: performs rigid and flexible bronchoscopy for diagnosis and endobronchial resection; uses ablative techniques in the management of endoluminal tumors; Uses stents, tracheal T-tubes, and tracheostomy tubes in the management of tracheal neoplasms; uses adjunctive therapy for the management of tracheal tumors.

IV. Mediastinum and Pericardium

A. Anatomy, Physiology, and Embryology

Learner Objectives: Understands the anatomic boundaries of the mediastinum and the structures found within each region; understands the embryologic development of structures within the mediastinum and the variations and pathologic consequences of abnormally located structures; understands the radiologic assessment of the mediastinum including CT scan, contrast studies and angiography; understands the aberrations caused by pericardial abnormalities and their effects on the heart and circulation; applies knowledge of mediastinal anatomy and physiology to the diagnosis of mediastinal abnormalities; applies knowledge of pericardial physiology to the diagnosis of pericardial abnormalities.

Clinical Skills: During the training program the fellow: reads and interprets mediastinal plain radiographs, CT scans and contrast studies.

B. Congenital Abnormalities of the Mediastinum

Learner Objectives: Is able to diagnose mediastinal cysts.

Clinical Skills: During the training program, the fellow: reads and interprets plain radiographs, CT scans and contrast studies of congenital abnormalities of the mediastinum; diagnoses and manages patients with congenital abnormalities of the mediastinum.

C. Acquired Abnormalities of the Mediastinum

Clinical Skills: During the training program the fellow: performs diagnostic tests and operations on the mediastinum; recognizes the histologic appearance of mediastinal tumors; diagnoses and manages mediastinal infection.

D. Congenital and Acquired Abnormalities of the Pericardium

Learner Objectives: Understands the physiologic consequences of increased pericardial fluid and the techniques for diagnosis and management; is familiar with the symptoms associated with mediastinal abnormalities; understands the operative management of benign and malignant pericardial neoplasms; understands the physiologic consequences of pericardial constriction and the techniques for diagnosis and management.

Clinical Skills: During the training program the fellow: uses an understanding of abnormal physiologic findings to diagnose pericardial pathology; performs diagnostic tests and therapeutic interventions for the treatment of pericardial tamponade, pericardial effusions, and constrictive pericardial disease; evaluates and manages patients with pericardial cysts or tumors.

V. Diaphragm

A. Anatomy, Physiology and Embryology

Learner Objectives: Knows the embryologic origin of the diaphragm; understands the anatomy of the diaphragm and adjacent structures; understands the neural and vascular supply of the diaphragm and the pathologic consequences of injury; understands imaging studies for assessing the diaphragm; understands the consequences of incisions in the diaphragm; understands developmental anomalies of the diaphragm.

Clinical Skills: During the training program the fellow: uses knowledge of the normal anatomy and physiology of the diaphragm to treat primary or contiguous abnormalities; evaluates and interprets radiographic studies of the diaphragm, including fluoroscopy and CT scan.

B. Acquired Abnormalities, Neoplasms

Learner Objectives: Knows evaluation methods for penetrating injuries of the diaphragm; understands the etiology, diagnosis, and treatment of diaphragmatic paralysis; understands the presentation of diaphragmatic rupture and associated injuries; knows management of infections above and below the diaphragm; understands the etiology, presentation, diagnosis and management of acquired diaphragmatic hernias; understands the primary and secondary tumors of the diaphragm and their management.

Clinical Skills: During the training program the fellow: interprets plain and contrast X-rays, fluoroscopy, CT scans and MRI of the diaphragm; performs diagnostic studies of the diaphragm (e.g. pneumoperitoneum, direct incisional and excisional biopsy, VATS); performs operative repair of acquired diaphragmatic abnormalities and provides pre-operative and post-operative care; reconstructs defects of the diaphragm.

C. Congenital Abnormalities

Learner Objectives: Understands the anatomy of congenital diaphragmatic hernias; understands the physiologic consequences of diaphragmatic hernias; knows the indications for operative repair of diaphragmatic hernias.

Clinical Skills: During the training program the fellow: performs operative treatment of adults with delayed presentation of diaphragmatic hernias; manages eventration of the diaphragm in children and adults; understands diagnosis and management of infants and adults with diaphragmatic hernias.

VI. Esophagus

A. Anatomy, Physiology and Embryology

Learner Objectives: Understands the anatomy, embryology, innervation and vascular supply of the esophagus and adjacent structures; understands the physiologic function of the esophagus and pharynx; understands the radiographic evaluation of the esophagus.

Clinical Skills: During the training program the fellow: interprets esophageal plain radiographs, contrast studies, CT scans, and EUS; requests and interprets manometric and pH studies of the esophagus; performs rigid and flexible endoscopy of the pharynx and esophagus.

B. Congenital Abnormalities

Learner Objectives: Understands the clinical presentations, types, diagnosis and treatment of esophageal atresia and congenital tracheoesophageal fistula; understands the clinical presentation and diagnosis of esophageal duplication cysts.

Clinical Skills: During the training program the fellow: evaluates patients with various types of esophageal atresia and tracheoesophageal fistula and recommends management; interprets diagnostic tests of congenital esophageal diseases; performs or participates in the operative repair of tracheoesophageal fistula; performs the operative management of esophageal duplication cysts.

C. Acquired Abnormalities

Learner Objectives: Understands the pathophysiology, histology, complications and diagnosis of esophageal reflux; understands the indications for and principles of anti-reflux operations; understands the clinical presentation, diagnosis and management of paraesophageal hernias; knows the clinical presentation, causes, diagnosis and treatment of motility disorders of the esophagus; understands the clinical presentation, diagnosis and management of esophageal perforation; understands the clinical presentation, diagnosis and management of chemical injuries and trauma of the esophagus; understands the indications, methods and operative approaches for esophageal replacement; understands the clinical presentation, diagnosis and management of esophageal foreign bodies; understands the etiology, presentation and management of infections after esophageal injuries and operations.

Clinical Skills: During the training program the fellow: interprets esophageal contrast studies, CT scans, manometry, pH studies and EUS; performs esophagoscopy, foreign body removal and biopsy; uses various operative approaches to different parts of the esophagus; performs anti-reflux operations including management of strictures; performs resection and reconstruction using various esophageal substitutes; evaluates and manages patients with esophageal motility disorders, performs myotomy and resection of diverticula; manages the complications of esophageal operations; uses laparoscopy and VATS for esophageal diseases where appropriate; diagnoses, manages and performs operations for esophageal perforation, chemical burns and trauma.

D. Neoplasms

Learner Objectives: Understands the types of benign esophageal neoplasms, their clinical presentation, diagnosis, and treatment; understands the types of malignant esophageal neoplasms, their clinical presentation, diagnosis, histologic appearance and treatment; understands the AJCC staging of esophageal cancer; understands the principles of patient management after esophageal resection; understands the nutritional management of patients with esophageal neoplasms; understands the role of chemotherapy and radiotherapy in esophageal cancer; understands the operative approaches, methods and complications of esophageal resection and reconstruction; understands the indications for operative and nonoperative treatment of esophageal cancer.

Clinical Skills: During the training program the fellow: evaluates malignant and benign esophageal tumors and recommends overall management, including neoadjuvant therapy; performs diagnostic tests for esophageal neoplasms and correlates the results with clinical staging; performs esophagectomy through various approaches; performs reconstruction with various esophageal substitutes; diagnoses and manages complications of esophageal surgery; manages nutritional needs after esophageal surgery; performs palliative intervention for obstructing esophageal lesions; recommends appropriate postoperative or alternate therapy for advanced or recurrent disease.

VII. Thoracic Trauma

A. Trauma of the Chest Wall

Learner Objectives: Evaluates patients with blunt or penetrating chest wall injury; understands the physiology and mechanics of operative drainage of the thoracic cavity; understands the operative and nonoperative management of chest wall injuries; Understands the pathophysiology of flail chest.

Clinical Skills: During the training program the fellow: evaluates and treats chest wall injuries; performs emergency operations to repair chest wall injuries and provides postoperative management.

B. Tracheobronchial and Pulmonary Trauma

Learner Objectives: Understands clinical presentation and radiologic findings of tracheobronchial injury; understands the principles of airway management; understands the bronchoscopic findings of tracheobronchial and pulmonary injury; understands the injuries associated with tracheobronchial and pulmonary injury.

Clinical Skills: During the training program the fellow: evaluates and manages patients with tracheobronchial trauma; manages the airway of patients with tracheobronchial injuries; performs nonoperative management of pulmonary contusion; performs emergency operations to repair peripheral pulmonary and hilar injuries; uses precautions to avoid air embolism in patients with penetrating and blunt injuries.

C. Esophageal Trauma

Learner Objectives: Understands the etiology and presentation of esophageal trauma; understands the methods of assessment and diagnosis of esophageal trauma; understands the management of injuries that disrupt the esophagus.

Clinical Skills: During the training program the fellow: evaluates and interprets diagnostic tests of patients with esophageal trauma; performs the endoscopic and operative evaluation and management of patients with esophageal injuries.

D. Diaphragmatic Trauma

Learner Objectives: Understands the presentation, evaluation and treatment of blunt and penetrating diaphragmatic injuries; understands the evaluation and management of associated injuries.

Clinical Skills: During the training program the fellow: performs emergency evaluation and diagnosis of diaphragmatic and associated injuries; performs operative repair of acute and chronic diaphragmatic and associated injuries.

VIII. Minor Procedures

A. Bronchoscopy

Learner Objectives: Understands the indications, techniques, and complications of rigid and flexible bronchoscopy of the larynx and tracheobronchial tree.

Clinical Skills: During the training program the fellow: evaluates and manages patients requiring bronchoscopy; performs rigid and flexible bronchoscopy using various anesthetic techniques; obtains diagnostic material using various biopsy techniques; uses ablative techniques via bronchoscopy; understands the use of stents via bronchoscopy.

B. Esophagoscopy

Learner Objectives: Understands the indications, techniques and complications of rigid and flexible esophagoscopy.

Clinical Skills: During the training program the fellow: evaluates and manages patients requiring esophagoscopy; performs rigid and flexible esophagoscopy using various anesthetic techniques; uses ablative techniques via esophagoscopy; understands the use of stents via esophagoscopy.

C. Permanent Pacemakers

Clinical Skills: During the training program the fellow: performs transvenous and epicardial lead and ICD/pacemaker/biventricular pacemaker insertion using single and dual chamber methodology.

D. Tube Thoracostomy

Learner Objectives: Understands the indications and contraindications for tube thoracostomy; knows the techniques and complications of tube thoracostomy and their management.

Clinical Skills: During the training program the fellow: evaluates patients for tube thoracostomy; performs tube thoracostomy under local, regional and general anesthesia; treats the complications of tube thoracostomy.

E. Central Venous Lines and Arterial Lines

Learner Objectives: Understands the indications, contraindications, management and complications of central venous lines and arterial lines.

Clinical Skills: During the training program the fellow: performs central venous line insertions by appropriate techniques (e.g. internal jugular vein, subclavian vein, femoral vein); performs arterial line insertions by appropriate techniques (e.g. radial, brachial, femoral and pedal arteries); manages complications of central venous and arterial lines.

I. Congenital Heart Disease

A. Embryology, Anatomy, and History

Learner Objectives: Knows the embryology and anatomy of the normal heart; knows the embryology and anatomy of major cardiac anomalies.

Clinical Skills: During the training program the fellow: knows the history of congenital cardiac surgery and the intellectual development of operations used to manage each cardiac anomaly; interprets angiocardiograms, echocardiograms and other images to diagnose congenital heart disease; uses knowledge to select the ideal procedure for individual patients; applies knowledge of the normal and abnormal anatomy of the heart to the planning and performance of operations.

B. Physiology and Physiologic Evaluation

Learner Objectives: Understands normal fetal circulation; understands the transitional nature of circulation as the fetus becomes a neonate; understands the physiology of obstructions, of intracardiac and extracardiac shunts, of abnormal connections to the heart, and of combinations of these anomalies in the fetus, neonate and child.

Clinical Skills: During the training program the fellow: describes the physiologic changes of circulation during neonatal life; diagnoses clinically important congenital heart diseases in the neonate, infant, and child; applies knowledge of anatomic abnormalities and their physiologic consequences to diagnose congenital heart defects; performs calculations of blood flows and resistances from cardiac catheterization data; manages the physiologic aspects of the neonate, infant and child with congenital heart disease preoperatively, intraoperatively and postoperatively; stabilizes patients who are critically ill with congenital heart disease.

C. Cardiopulmonary Bypass for Operations on Congenital Cardiac Anomalies

Learner Objectives: Knows arterial and venous cannulation techniques for different intracardiac defects; knows the indications for the various techniques of bypass; understands the techniques of myocardial protection in the neonate and young infant; understands the use of varying levels of hemodilution and anticoagulation; understands perfusion flow and pressure control; knows the methods of body temperature manipulation, and the indications for, and techniques of, profound hypothermia with and without total circulatory arrest.

Clinical Skills: During the training program the fellow: performs arterial and venous cannulation and initiates cardiopulmonary bypass; directs the perfusionist in the intraoperative management and conduct of cardiopulmonary bypass; performs or participates in the repair of congenital heart defects using cardiopulmonary bypass.

D. Left-To-Right Shunts

Learner Objectives: Knows the anatomy, embryology, and physiology of the most common or important anomalies; knows the operative indications of the most common or important anomalies; knows the technical components of the operative repair of the most common or important anomalies; understands the postoperative care of each anomaly.

Clinical Skills: During the training program the fellow: participates in or performs the operative repair of ventricular septal defects; participates in or performs the repair of more complex cardiac anomalies; performs the preoperative evaluation of patients with each of these anomalies.

E. Cyanotic Anomalies

Learner Objectives: Knows the anatomy and physiology of each anomaly; knows the methods of diagnosis; knows the indications for and timing of operation; understands the technical components of operative repair; knows the postoperative care, expected outcome, long-term results, and complications; understands the role of medical management and interventional cardiology as treatment options.

Clinical Skills: During the training program the fellow: performs preoperative evaluation and preparation; manages postoperative care; participates in or performs the major palliative operations for these congenital cardiac anomalies.

F. Obstructive Anomalies

Learner Objective: Understands the anatomy and physiology of obstructive anomalies of the left and right sides of the heart and aorta, their diagnosis, management and postoperative care, and performs the operative and non-operative treatment; knows the anatomy and physiology of each anomaly; knows the methods of diagnosis; understands the role of medical management and interventional cardiology; understands the principles of postoperative care; knows the technical components of operative repair; knows the expected outcome, long-term results and complications.

Clinical Skills: During the training program the fellow: participates in or performs aortic valvotomy, repair of supravalvular and subvalvular aortic stenosis, pulmonary valvotomy, correction of subvalvular pulmonary stenosis, correction of vascular rings; performs corrections for patent ductus arteriosus and coarctation of the aorta; performs preoperative evaluation and preparation; manages postoperative care; Uses prostaglandins in the management of patients with neonatal coarctation, interrupted aortic arch, critical aortic stenosis.

G. Miscellaneous Anomalies

Learner Objectives: Understands the natural history, evaluation and treatment of coronary anomalies, congenital complete heart block, hypoplastic left heart syndrome, pulmonary atresia (with and without VSD), “corrected transposition,” single ventricle, cor triatriatum and cardiac tumors.

Clinical Skills: During the training program the fellow: performs or assists in pacemaker insertion, systemic-to-pulmonary artery shunting for pulmonary atresia or stenosis (with or without VSD), and pulmonary artery banding for large left-to-right shunts; evaluates angiocardiograms, echocardiograms and cardiac catheterizations of the above anomalies; develops treatment plans for the above anomalies; participates in or performs operative treatment for the above anomalies; manages postoperative care for the above anomalies.

H. Principles of Post-Operative Care

Learner Objectives: Knows the physiologic characteristics of neonates and small infants; understands the management of infants and children who have undergone operative correction of simple and complex congenital cardiac anomalies; understands the post-operative management of patients with systemic to pulmonary artery shunts; understands the management of patients who have had a right heart bypass operation; understands the physiologic pre-operative and post-operative management of patients with hypoplastic left heart syndrome; understands which infants and children are prone to develop pulmonary hypertensive crisis; knows the prevention, recognition and treatment of pulmonary hypertensive crises.

Clinical Skills: During the training program the fellow: manages ventilators for infants and children with and without obligatory intracardiac shunts; assesses the cardiac output and pulmonary and systemic resistance in infants and children; uses physiologic and pharmacologic manipulation of preload, myocardial contractility, heart rate and afterload to optimize cardiac output in critically ill infants and children; evaluates the metabolic reserve of neonates and infants and provides prompt therapeutic intervention as indicated; anticipates problems and complications of post-operative pediatric patients and provides appropriate treatment.

I. Acquired Heart Disease

A. Coronary Artery Disease

Learner Objectives: Understands the physiology of coronary circulation and the physiologic derangements caused by stenosis and obstruction; understands the risks and complications of coronary artery bypass operations, coronary angiography and percutaneous coronary artery interventions; understands the pre-operative and post-operative care of patients undergoing coronary artery bypass grafting; understands the rationale for and techniques of coronary artery bypass operations as well as the use of various conduits.

Clinical Skills: During the training program the fellow: evaluates patients with angina pectoris, unstable angina pectoris, and acute myocardial infarction; reads and interprets invasive and non-invasive tests of patients with ischemic heart disease; performs operative and non-operative management of patients with ischemic heart disease, including coronary artery bypass grafting using the internal mammary and radial arteries; participates in or performs surgery for the complications of myocardial infarction.

B. Myocarditis, Cardiomyopathy, Hypertrophic Obstructive Cardiomyopathy and Cardiac Tumors

Learner Objectives: Understands the types of cardiac tumors and their frequency, anatomic location, physiologic and pathologic derangements, diagnostic methods and surgical management; understands myocarditis and its causes, physiologic changes, treatment, prognosis, and radiographic, EKG and echocardiographic changes; understands hypertrophic cardiomyopathy (HMC) and its genetic linkage, pathologic and anatomic changes, physiologic derangements, clinical features, diagnostic tests, natural history, medical and surgical treatment; knows the types of cardiomyopathies and their causes, natural history, diagnostic methods, operative and nonoperative treatment; understands cardiac transplantation and related immunology/rejection and treatment, physiology, indications, operative techniques, diagnostic techniques in follow-up.

Clinical Skills: During the training program the fellow: participates in or performs operative excision of cardiac tumors; participates in or performs operations for the treatment of HCM when indicated; participates in or performs heart transplants and provides pre-operative and post-operative care.

C. Abnormalities of the Aorta

Learner Objectives: Recognizes the potential morbidity and mortality associated with aortic aneurysms and develops appropriate treatment plans for their management.

Clinical Skills: During the training program the fellow: participates in or performs operative and non-operative management of thoracic aortic disease including aneurysms, dissections, and occlusive disease; plans and directs the use of extracorporeal bypass, hypothermia, and circulatory arrest for aortic diseases; understands the fundamentals of endovascular therapy for the treatment of thoracic aortic disease.

D. Cardiac Arrhythmias

Learner Objectives: Understands operative and non-operative management; knows the indications for and techniques of electrophysiologic studies and the application of this information to patient management.

Clinical Skills: During the training program the fellow: performs the operative and non-operative management of patients with atrial arrhythmias; participates in or performs operative management of patients with ventricular arrhythmias, including placement of automatic implantable cardioverter/defibrillator.

E. Valvular Heart Disease

Learner Objectives: Understands the normal and pathologic anatomy of the atrioventricular and semilunar valves; knows the natural history, pathophysiology, and clinical presentation of each major valvular lesion (mitral stenosis and incompetence, aortic stenosis and incompetence, tricuspid stenosis and incompetence); knows the preoperative and postoperative management of patients with valvular heart disease; understands the operative and non-operative therapeutic options for the treatment of each major valvular lesion; knows the techniques for repair and replacement of cardiac valves.

Clinical Skills: During the training program the fellow: evaluates, diagnoses, and selects management strategies for patients with valvular heart disease, including participation in and interpretation of cardiac catheterizations and echocardiograms; makes use of the therapeutic options and relative risks of operative and non-operative treatment for valvular heart disease in planning interventions; manages pre-operative clinical preparation and early and intermediate post-operative care; performs valve repair and replacement for valvular disease, interprets intraoperative echo.

II. Thoracic Trauma

A. Cardiovascular Trauma

Learner Objectives: Evaluates patients who have sustained cardiovascular trauma; understands the physiology of deceleration injuries to the thoracic aorta; understands invasive and non-invasive methods for the diagnosis of cardiovascular traumatic injuries.

Clinical Skills: During the training program the fellow: evaluates and treats cardiac contusion; performs emergency operations and endovascular interventions to repair traumatic transactions of the thoracic aorta and provide post-operative management.

III. Transplantation

A. Cardiac Transplantation

Learner Objectives: Knows the indications for cardiac transplantation; recognizes the signs and symptoms of cardiac rejection and knows the appropriate management; understands the evaluation and management of organ donors; knows the methods of organ harvest and preservation.

Clinical Skills: During the training program the fellow: manages organ donors; performs organ harvest and preservation; evaluates transplant recipients for signs of rejection or infection and initiates appropriate therapy.

IV. Extracorporeal Bypass and Coagulation – Blood Products

A. Physiology of Extracorporeal Bypass

Learner Objectives: Understands the physiology and mechanics of membrane and bubble oxygenators; understands the mechanics and operation of roller and vortex pumps; understands the physiology of various extracorporeal bypass circuits and the derangements caused by their use; knows the coagulation system and alterations of blood elements.

Clinical Skills: During the training program the fellow: uses knowledge of the effects of extracorporeal bypass to ensure its safe use; recognizes the correct and incorrect set-up and operation of an extracorporeal circuit; plans and uses extracorporeal circuits in clinical practice; understands and treats physiologic derangements caused by blood-artificial surface interaction.

B. Techniques of Extracorporeal Bypass

Learner Objectives: Understands the standard techniques for extracorporeal bypass; understands the techniques of cannulation for extracorporeal bypass; oversees the management of patients undergoing extracorporeal bypass.

Clinical Skills: During the training program the fellow: performs cannulation for extracorporeal bypass using appropriate access routes; uses left and right heart bypass.

C. Mechanical Support

Learner Objectives: Understands the indications for cardiac support with mechanical devices or ECMO; Understands alternatives to mechanical support (e.g., intra-aortic and intrapulmonary balloon pumping); understands the principles of weaning patients from these devices; understands federal regulations that apply to the use of these devices.

Clinical Skills: During the training program the fellow: evaluates and participates in the pre-operative and post-operative management of patients requiring mechanical support; manages the complications from the use of mechanical support and ECMO; manages the anticoagulation of patients on mechanical support and ECMO; uses appropriate mechanical cardiac support and ECMO; weans patients from mechanical support and ECMO; manages patients bridging to transplantation.

D. Fundamentals of Coagulation Management and Blood Component Therapy

Learner Objectives: Understands the major blood groups, the clotting cascade and the pathophysiology of clotting; understands the specific hemorrhagic and thrombotic complications of cardiac surgery and their management; understands the methods used in blood component storage and the measures taken to ensure a safe blood supply; understands the use of specific blood components to treat abnormalities of red cell quantity and quality, platelet quantity and quality, and coagulation function; knows the pre-operative risk factors for excessive blood loss and blood utilization; understands the operative and post-operative techniques to ensure blood conservation.

Clinical Skills: During the course of the program, the fellow: evaluates patients requiring component therapy and develops management strategies to correct abnormalities of the coagulation system; uses appropriate tests to ensure the safety of blood and blood components; uses appropriate blood conservation techniques.

V. Non-Clinical Elements of Cardiothoracic Surgical Practice

Learner Objectives: Understand the ethical components of surgical practice; understands and will be able to use clinical database and outcome analysis; Understand organizational structure and mechanics of solo practice, group specialty practice, multi-specialty practice, and academic practice; knows the structure, responsibilities and requirements of managed care, capitation payment, contractual agreements, physician-hospital organizations, and independent practice agreements.

VI. Cardiothoracic Surgery and Research

Learner Objectives: Understands the scientific method as it applies to basic and clinical research; knows how to access the literature including computerized and conventional library searches; is able to interpret published material critically; understands the role of statistics in validating scientific inferences, including the appropriate application of statistical tests commonly used in the thoracic literature, their limitations and deficiencies; understands the role of power, significance, and sample size in interpreting data; knows how to develop and design a research proposal and complete the process of solving a problem scientifically; reads published material and listens to presentations critically; demonstrates understanding of the essential steps of the research process by preparing and submitting a manuscript for publication in a peer-reviewed journal (either an oral or a written presentation is appropriate).

Demonstrates competence by:

• Defining an analyzable problem or scientific question
• Assembling an appropriate literature review
• Synthesizing and analyzing available data
• Formulating an informed and insightful discussion
• Composing a properly constructed, critically reviewed bibliography or list of literature citations

Skills: During the course of the program, the fellow: shows an understanding of the appropriate application of statistical tests to the problem; demonstrates an understanding of the appropriate application of other commonly used statistical tests such as univariate analysis, multivariate analysis, analysis of variance, and the use of T-tests for paired data and multiple comparisons, knowing the limitations, deficiencies and proper applications of these commonly used statistical tests; shows evidence of ability to critically analyze major clinical research papers in the thoracic literature which guide practice; applies knowledge of the scientific method to design and execute at least one formal analysis to solve a problem related to thoracic surgery.

The Division of Thoracic Surgery is committed to the ACGME duty hour guidelines. In addition, no moonlighting is permitted for Thoracic Surgery Fellowship fellows.

See more information on duty hours policy here.

At the conclusion of the Thoracic Surgery Fellowship, the successful fellow will:

• Have a thorough understanding of all components of cardiac and thoracic diseases including diagnostic, therapeutic, and management options.
• Effectively develop a diagnostic and therapeutic plan for a wide spectrum of surgical diseases.
• Have the medical knowledge, operative skills, judgment, and leadership to perform common adult cardiac, pediatric cardiac and thoracic surgical procedures without supervision.
• Be the operating surgeon on complex procedures assisted by the surgical attending.
• Organize staff conferences as well as departmental conferences as assigned.
• Mentor medical students, general surgery residents and junior thoracic surgery fellows.
• Critique personal practice outcomes and demonstrate recognition of the importance of lifelong learning in surgical practice.
• Communicate effectively with other health care professionals, counsel and educate patient and families, and effectively document practice activities.
• Maintain high standards of ethical behavior, demonstrate a commitment to continuity of patient care, and demonstrate sensitivity to age, gender and culture of patients and other health care professionals.
• Practice high quality, cost effective patient care, demonstrate knowledge of risk-benefit analysis, and demonstrate an understanding of the role of different specialists and other health care professionals in overall patient management.

The program is designed to provide a sound didactic and clinical education that is structured to optimize educational opportunities for the fellow concurrently with balancing concerns for patient safety and fellow well-being. Service obligations are minimized but not eliminated.

Ancillary staff members, including a cadre of nurse practitioners and physician assistants, assist with health care service.

Didactic and clinical education carries priority for fellows’ time and effort. Faculty, trainees and staff collectively have responsibility for the safety and welfare of the patients. Faculty and fellows are taught to recognize the signs of fatigue via the ACGME Core Competencies Lecture Series.

Institutional and divisional policies ensure strict duty hour compliance to minimize fatigue and optimize education. Moonlighting is not allowed.

The goals of the training program are fostered within an environment of progressively graded clinical and operative experience and responsibility. Within the limits of variability found in a clinical practice, an equivalent experience will be afforded each fellow, under the guidance and supervision of qualified teaching staff. With this process, each fellow will develop mature surgical judgment and operative skills which will prepare them to provide independent surgical care to patients with a wide range of cardiac and thoracic disorders in a manner appropriate to a specialist in cardiothoracic surgery and a candidate for certification by the American Board of Thoracic Surgery. The final assessment of whether these objectives are being achieved is made by the program director as recommended by the faculty of the Division of Thoracic Surgery.

Penn State College of Medicine and Penn State Health Milton S. Hershey Medical Center accept ongoing nominations for the Exceptional Moments in Teaching award.

The award, given monthly by the Office for a Respectful Learning Environment, accepts nominations from College of Medicine students who are invited to submit narratives about faculty members, residents, fellows, nurses or any other educators who challenge them and provide an exceptional learning experience. See more about the award here.

Previous nominees from the Thoracic Surgery Fellowship are listed here. Click the + next to a nominee name to read their nominator’s comments.