Thoracic Surgical Training

Objectives of Training
and Training Requirements in Thoracic Surgery (RCPSC)

Contents

• General objectives
• Specific objectives
• Requirements
• Specialty training requirements

General Objectives Thoracic Surgery is concerned with congenital and acquired diseases of the chest wall, mediastinum, lungs, trachea, pleura, esophagus and diaphragm.

Residents must demonstrate the knowledge, skills and attitudes relating to gender, culture and ethnicity pertinent to Thoracic Surgery. In addition, all residents must demonstrate an ability to incorporate gender, cultural and ethnic perspectives in research methodology, data presentation and analysis.

On successful completion of the residency training program, the resident shall be prepared to embark on a career as a consultant thoracic surgeon. Some surgeons will join teams in major centres with facilities for major thoracic surgery, and often practise in conjunction or close association with teams in cardiac and vascular surgery. Other surgeons will practice in community centres where thoracic and general surgery responsibilities may be combined.

The thoracic surgeon should be dedicated to enhancing the quality of life of the patient with surgical diseases of the thoracic, non-cardiac, organs of the chest.

During the course of training, candidates must acquire a satisfactory knowledge of the principles and practice of surgery, including the pathophysiology of shock, nutrition and metabolism, infection, coagulation, immunity, genetics and statistics. The general surgery training should have facilitated experience and proficiency in the care of surgical emergencies, including trauma, the management of problems in pre- and post-operative care, shock, fluid balance and nutritional support, system support and surgical intensive care.

The thoracic surgery resident must acquire a detailed knowledge of and competence in surgery related to diseases of the chest wall, mediastinum, lungs, trachea, pleura, esophagus and diaphragm, as well as chest trauma, respiratory and esophageal physiology, ventilatory support and management of related cardiac diseases. In addition, the resident must acquire competence in related diagnostic procedures, including endoscopy, esophageal physiological studies, and respiratory function tests. The thoracic surgery resident must acquire a comprehensive knowledge of the diseases of the heart and great vessels, as well as the physiology, technology, indications and complications of extracorporeal perfusion. The thoracic surgery resident must acquire a comprehensive knowledge of the technical components of extracorporeal perfusion (including extracorporeal membrane oxygenation) and of surgical management of traumatic injuries of the heart and great vessels.

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Specific Objectives On completion of the training program, each resident will demonstrate, with respect to patients of all age groups:

1. Knowledge

   A comprehensive knowledge of:

   1. the anatomy, including embryology of the lungs, trachea and esophagus, ultrastructure of the human lung, lymphatics of the lung, anatomy of the thorax and pleura, and surgical anatomy of the lungs, the trachea and the esophagus, the anatomy of the heart and great vessels including the blood supply of the spinal cord;
   2. the physiology of the lung including pulmonary gas exchange and mechanics of breathing, and the physiology of the esophagus;
   3. the roentgenographic evaluation of the chest and esophagus and radionuclide studies of the lung;
   4. wound healing, normal and abnormal;
   5. the laboratory procedures in the diagnosis of thoracic diseases, including endoscopic examinations and function studies of the lungs and esophagus;
   6. the pharmacology, including the principles of metabolism, action and toxicity of drugs commonly used in the management of thoracic and cardiac disease, as well as neoplasia;
   7. the pathology and treatment of neoplasia of the lung, trachea, esophagus, mediastinum and chest wall;
   8. sepsis as it especially applies to the operative care of thoracic and esophageal diseases including the management of sternal wound infections;
   9. the principles and practice of medical oncology, radiotherapy and immunotherapy;
   10. the principles of immunology as they relate primarily to tissue transplantation;
   11. the mechanisms of traumatic injury to the chest wall, pleura and thoracic viscera, including heart and great vessels, as well as esophagus; to also include foreign bodies in the esophagus or respiratory tract;
   12. the pathophysiology, investigation and management of clinical syndromes of the thoracic outlet;
   13. the anaesthetic management of the thoracic surgical patient, including the preanaesthetic evaluation and preparation, conduct of anaesthesia, principles of postoperative management, including ventilatory support, and physiotherapy for the thoracic surgical patient;
   14. the surgical management of acquired diseases of the heart, great vessels and pericardium;
   15. the surgical management of the congenital anomalies of the esophagus, trachea, lung, diaphragm and chest wall in the pediatric patient;
   16. the medical-legal and ethical aspects of thoracic surgery;
   17. cardiopulmonary bypass and extracorporeal membrane circulation as well as their attendant complications including bleeding, hemoptysis, and reperfusion injury;
   18. the management of congestive heart failure and cardiac arrhythmia;
2. Clinical Skills

   The capability of independent patient care in all facets of thoracic surgery including the investigation, diagnosis and management design, both acute and long term. This would include all aspects of thoracic trauma (except operative management of aorta and heart); pulmonary, tracheal, esophageal, mediastinal and chest wall neoplasia; and benign diseases of the lung, trachea, esophagus, diaphragm and thoracic outlet. The development of clinical skills should relate to the adult and child.

3. Technical Skills

   Competence in all technical aspects of thoracic surgery (non-cardiac) procedures, competence in pre- and post-operative care, the ability to select the appropriate procedure and to recognize his/her limitations. In particular, competence in pulmonary and esophageal endoscopy; mediastinal nodal biopsy; closed and open lung biopsy; traumatic repair of chest wall, lung, major airways, diaphragm and esophagus; pulmonary resections including lobectomy, segmental and wedge resection, bronchoplasty and pneumonectomy; thoracoplasty; decortication of lung; tracheal resection and approaches; resection of the esophagus including replacement with stomach, colon or small bowel; correction of chest wall deformities; surgical procedures for chest wall and pulmonary infections; chest wall resection for neoplasia; surgical therapy of thoracic outlet syndrome; surgical therapy of pleural effusions and infections, and primary metastatic pleural tumours; surgical procedures for benign and malignant disease of the trachea; correction of benign esophageal disorders including diverticula, cysts, duplications, motor disorders and esophageal hiatal hernia and gastroesophageal reflux; surgery for superior vena caval syndrome; primary tumours and cysts of the mediastinum and thymus gland; pulmonary transplantation (if applicable to anticipated centre of practice); laser therapy (if applicable to anticipated pattern of practice); video-assisted thoracic surgery (if applicable to anticipated pattern of practice); and surgical management of complications of thoracic and esophageal procedures.

4. Attitudes

   The ability to communicate effectively with the patient and the family; a compassionate interest and overall understanding of the patient; the ability to recognize the psychological needs of the patient requiring general thoracic surgery; the ability to function as a member of a multidisciplinary health care team; an understanding and acceptance of the obligation of continuing self-education and teaching of others; an appreciation of the important role that basic and clinical research plays in the critical analysis of current scientific developments related to the specialty; and an awareness of the acceptable and expected result as well as the unacceptable and unexpected clinical result.

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Requirements Training must incorporate the principle of graded increasing responsibility. The term "approved" throughout means "approved by the candidate's program director and the Credentials Committee".

Senior residency is defined as a year in which the resident is regularly entrusted with responsibility for pre-operative, operative and post-operative care, including the most difficult problems in thoracic surgery. The senior resident shall be in charge of a surgical unit. No other resident shall intervene between the senior resident and the attending staff surgeon.

The six year program outlined below is to be regarded as the minimum training requirement. Additional year(s) of training may be required by the program director to ensure that clinical competence has been achieved.

It must be recognized that the usual duration of residency training may not permit the resident to achieve competence in all areas of technical skills. Therefore, to achieve additional expertise in highly specialized areas of thoracic surgery, (i.e. pulmonary transplantation or laser therapy), the resident may require additional training.

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Specialty Training Requirements

1. Six years of approved residency. This period must include:
   1. Twenty-four (24) months of Core Training in Surgery. (See Objectives of Core Training in Surgery.)
   2. Twelve (12) months of Thoracic Surgery and Cardiac Surgery.
      1. six months non-senior thoracic surgery
      2. six months non-senior/senior cardiac surgery
   3. Twelve (12) months of senior general surgery
   4. Twelve (12) months of academic enrichment. Such a period should provide focused training in:
      1. basic science related to Thoracic Surgery, or
      2. highly focused clinical training in one of transplantation, oncology, critical care medicine, airway disease, or oesophageal disease, or
      3. clinical epidemiology, or
      4. surgical education in a specialized program approved for postgraduate qualification in education.
   5. Twelve (12) months of senior thoracic surgery

   OR

2. 1. Full residency in General Surgery in an approved program
   2. 18 months thoracic surgery - six months junior and twelve months senior
   3. 6 months cardiac surgery
   4. twelve months academic enrichment as under 1(d), if not completed during general surgery training

   OR

3. 1. Full training in Cardiac Surgery in a Royal College accredited program plus:
   2. 18 months thoracic surgery - 6 months junior and twelve months senior
   3. twelve months academic enrichment as under 1(d), if not completed during cardiac surgery training