Thoracic Surgery Fellowship

Program Overview

The Thoracic Surgery Fellowship at Penn State Health Milton S. Hershey Medical Center is a two-year, ACGME-accredited program that admits one fellow per year, with the expectation for certification by the American Board of Thoracic Surgery.

Program Details

The Divisions of Thoracic Surgery, Cardiac Surgery and Pediatric Cardiac Surgery run three busy services: one that covers the gamut of adult cardiac surgery, one that focuses on thoracic surgery procedures, and one that offers broad exposure to congenital cardiac surgery.

The first year of the Thoracic Surgery Fellowship focuses on pediatric cardiothoracic surgery, then general thoracic surgery, including open, minimally invasive (VATS and robotic), and endoscopic interventions for malignant and benign lung, esophageal, mediastinal, tracheal, chest wall, pleural and diaphragmatic disorders.

The second year concentrates on adult cardiac surgery, including heart failure surgery, valvular surgery, aortic surgery, CABG, endovascular interventions and cardiac transplantation.

Trainees can expect to perform at least 350 operations as primary surgeon. They can also participate in an extensive ventricular assist device and artificial heart program if so inclined.

In the Penn State Heart and Vascular Institute, Department of Surgery and Penn State Children’s Hospital, the opportunity to experience other cutting-edge treatment modalities is encouraged.

Our Team

Overall 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 residency program 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 resident 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 resident’s clinical, professional, social, and academic pursuits.
  • Combined resident mentoring with instruction by faculty including both didactic and Socratic education, hands-on experience, simulation, and self-directed learning.

Education Overview

The two-year program 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 resident 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. Residents 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 that he/she participates. The residents 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. Residents 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 residents are mentored by a staff surgeon in this setting and participate actively in the evaluation and care of these patients.

During the first year, residents 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 residents 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 residents are exposed to congenital cardiac surgery during the first year. They participate in surgical cases either as the responsible surgeon or first assistant. Residents 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 resident transitions to the adult cardiac surgery service (see below, Year Two) while the chief resident (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 resident has chosen General Thoracic Pathway he/she 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 resident is assigned to run the service as Chief Resident. It is his/her 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. He/she also will participate actively with the attending staff in operative planning and decision making for post-operative care. The resident will have major responsibilities for operative, intra-operative and post-operative patient care and clinical decision-making. It is expected that the resident 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 Resident) is assigned to attend the outpatient adult cardiac surgery clinics (blocks 4 to 7). In this setting, he/she will be intimately involved in the pre-operative and post-operative evaluation of patients. The resident 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). Residents 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. Residents 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 resident, 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 block 8, the Year 2 Chief Resident has an elective rotation. If the trainee is pursuing the American Board of Thoracic Surgery (ABTS) General Thoracic Pathway, the resident will focus on thoracic surgery. If the trainee is following the ABTS Cardiothoracic Surgery Pathway, the resident will focus on advanced cardiac surgery (mechanical circulatory support and/or minimally invasive cardiac surgery) or congenital cardiac surgery. During this period, while the Year 1 trainee is starting adult cardiac surgery and directing the clinical service, the Year 2 trainee will direct the thoracic surgery service.

Conclusion of Residency Education Program

At the conclusion of this residency education program in Cardiac and Thoracic Surgery, the successful resident 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 thoracic surgery residents.
  • 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.

Our program is designed to provide a sound didactic and clinical education that is structured to optimize educational opportunities for the resident concurrently with balancing concerns for patient safety and resident well being. Service obligations are minimized but not eliminated. Ancillary staff members, including a cadre of nurse practitioners and physician assistants, assist with healthcare service. Didactic and clinical education carries priority for residents’ time and effort. Faculty, trainees, and staff collectively have responsibility for the safety and welfare of the patients. Faculty and residents 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 resident, under the guidance and supervision of qualified teaching staff. With this process, each resident will develop mature surgical judgment and operative skills which will prepare him/her 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 Cardiothoracic Surgery.

Competency-Based Goals

The following competency-based goals apply to the Thoracic Surgery Fellowship.

Year One Overview

In the first year of the program, the resident experiences a concentrated exposure to congenital cardiac surgery (block 1) and general thoracic surgery (blocks 2 and 3). When feasible, early exposure is permitted to adult cardiac cases. In the fourth three-month block the junior fellow will take over direction of the adult cardiac surgery service. The junior fellow is expected to meet the ABTS index case requirements in congenital heart disease and general thoracic surgery during the first year. Residents are charged with the conduct of daily pre-operative and post-operative care, assuring a robust exposure to the in-hospital management of these patients. The residents are expected to communicate with the attending staff about operative planning, pre-operative and post-operative management, and all care decisions for each case that he/she participates. The thoracic surgery residents supervise consults and review them, including associated studies, with the attending. Attendings round daily with house staff on their own patients. Intensivists in the cardiovascular intensive care unit round independently and with the team, collaboratively managing ICU patients.

Residents are assigned to the thoracic surgery 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, and post-operative follow-up of patients are all part of this environment. The residents are mentored by a staff surgeon in this setting and participate actively in the evaluation and care of these patients.

During the first year, residents concentrate their attention on the outpatient work-up, operative procedures, and follow-up of general thoracic surgical patients. This includes the determination and planning of their appropriate operative and non-operative management. Further, the residents participate in the multidisciplinary conferences, which include participation by a core group including thoracic oncologists, radiation oncologists, interventional pulmonologists, and thoracic radiologists.

The residents are exposed to congenital cardiac surgery during the initial three months of the first year (block 1). They participate in surgical cases either as the responsible surgeon or first assistant. Residents 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 thoracic surgery resident is expected to attend regularly.

The learning objectives of the first year include planning, implementation, and mastering of the clinical skills that are listed below. Additionally, a core curriculum that follows the TSDA Thoracic Surgery Curriculum has been established to cover topics of general thoracic, pediatric cardiac, and adult cardiac surgery over a one-year period.

Goals and Objectives for First-Year Thoracic Surgery Resident

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. Residents 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 resident 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 resident 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 resident 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.

Residents 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 resident 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.

Year Two Overview

The emphasis of the second year is placed on completing index cases to meet the operative requirements entirely from one of the two pathways defined by the American Board of Thoracic Surgery. The resident will have started directing the adult cardiac surgery service during the final rotation of the first year (block 4). If the resident has chosen the General Thoracic Pathway he/she will complete the index adult cardiac cases for that pathway and then focus on increasing general thoracic cases to meet required operative numbers (elective block 8). On the other hand, if the Cardiothoracic Pathway is chosen, emphasis will be on adult cardiac index cases and advanced cardiac surgery (elective block 8) with the general thoracic case requirements already completed in the previous year.

The second-year thoracic surgery resident is assigned to direct the cardiac surgery service as Chief Resident (blocks 4 to 7). It is his/her 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 Chief Resident also collaborates actively with the attending staff in operative planning and decision-making for post-operative care. It is expected that the resident 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, in collaboration with the Heart and Vascular Institute Intensive Care Unit staff. The Chief Resident is expected to attend one of the adult outpatient cardiac surgery clinics every week, with opportunities every day of the week. In this clinic, he/she will be intimately involved in the pre-operative and post-operative evaluation of patients. The resident is also expected to become intimately involved with the cardiac transplantation team. Responsibilities include familiarity with peri-operative management of patients undergoing cardiac transplant and techniques of mechanical circulatory support, including the total artificial heart and a cadre of ventricular assist devices. Residents are exposed to the pre-operative care of cardiac transplantation patients via weekly attendance at the cardiac transplantation conference. The transplant program has a close relationship with the heart failure team, which renders concurrent daily care of all transplant and assist device patients, providing an example of strong interdisciplinary collaboration. Residents participate in the performance of transplant and circulatory assistance procedures, as well as donor organ procurements.

Administrative responsibilities include coordination of the junior residents and mid-level providers that comprise the service, including assignment of daily responsibilities and coordination of the call schedule. The Educational Goals and Clinical Skills of the second year include expansion of the thoracic surgery experience gained during the first year, and the broad scope of adult cardiac surgery.

Goals and Objectives for Second-Year Thoracic Surgery Resident

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 Resident, directing the care of critically ill patients. The resident will work with the cardiac transplantation team and the mechanical circulatory support service. Finally, it is expected that the resident 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 resident 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.
  6. (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 resident 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.

    Specific Medical Knowledge Subjects: General Thoracic Surgery

    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 resident: 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 resident: 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 resident: 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 resident: 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 resident: 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 resident: 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 resident: 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 resident: 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 resident: 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 resident: 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 resident: 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 resident: 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 resident: 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 resident: 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 resident: 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 resident: 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 resident: 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 resident: 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 resident: 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 resident: 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 resident: 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 resident: 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 resident: 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 resident: 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 resident: 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 resident: 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 resident: 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 resident: 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 resident: 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 resident: 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.

    Specific Medical Knowledge Subjects: Congenital Cardiac Surgery

    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 resident: 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 resident: 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 resident: 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 resident: 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 resident: 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 resident: 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 resident: 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:Specific Medical Knowledge Subjects: Adult Cardiac Surgery

    I. Acquired Heart Disease

    A. Coronary Artery Disease

    Learner Objectives:Clinical Skills: During the training program the resident: 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 resident: 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 resident: 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 resident: 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 resident: 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 Trauam

    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 resident: 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 resident: 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 resident: 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 resident: 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 resident: 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 resident: 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 resident: 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.

Block Diagram

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 Year 1 thoracic surgery resident directs the thoracic service for nine months (blocks 1 to 3) to gain clinical leadership experience. At that time the Year 2 Chief Resident (blocks 5 to 7) runs the cardiac service. The Year 1 resident takes over direction of the cardiac service at block 4, while the Year 2 Chief Resident (on Elective rotation, block 8) directs the thoracic service.

During block 8, the Year 2 Chief Resident has an elective rotation. If the trainee is pursuing the American Board of Thoracic Surgery (ABTS) General Thoracic Pathway, the resident will focus on thoracic surgery. If the trainee is following the ABTS Cardiothoracic Surgery Pathway, the resident 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 residents on nights, weekends, and holidays. There is sign-out between the two teams twice daily. When serving an educational purpose, the thoracic surgery residents are encouraged to participate in cases on the secondary service. The Chief Resident has primary responsibility for administrative duties, including operative case assignments.

Independent Program Format, Year 1

Independent Program Format, Year 2

Conferences

Duty Hours

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

See more information on duty hours policy here.

To Apply

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, participate in the interview process and the National Resident Matching Program (NRMP).

Faculty

Current Fellows

Past Fellows

Contact Us

Mailing Address

Thoracic Surgery Fellowship
Penn State Health Milton S. Hershey Medical Center
H149 Box 850
500 University Drive
Hershey, PA  17033

General Contact Information

Phone: 717-531-5429

Fax: 717-531-0395