General and Thoracic Surgery Joint Pathway

The American Board of Surgery (ABS) and American Board of Thoracic Surgery (ABTS) approved in 2004 a new seven-year joint training pathway leading to certification in both general surgery and thoracic surgery.

This new pathway does not result in a shortening of requirements for surgery certification. Sixty months of residency are still required prior to ABS certification and the requirements of the RC-Surgery continue to apply. The underlying concept is that PGY-4 and PGY-5 are used as transitional or “cross training” years that fulfill the required general surgery curriculum and simultaneously begin thoracic surgical education for the thoracic surgery residency. The only change to surgery residency is an alteration of clinical assignments during the last 24 months to include specific rotations within general surgery that are directly applicable to the practice of thoracic surgery.

Candidate Eligibility

• The resident applicant may apply as early as the fourth year in medical school, but must apply before completion of the PG-3 surgery year.
• Resident applicants must spend all years of general surgery residency and thoracic surgery residency at the same institution.
• Resident applicants must be in good standing and not subject to any current disciplinary actions.
• The general surgery program director must certify that the resident applicant will receive a balanced experience in the Principal Content Areas of surgery (listed farther below) throughout the five years of general surgery education.
• After initial approval of the program format at an institution, the thoracic surgery program director must inform the Review Committee for Thoracic Surgery every time s/he accepts an individual into the thoracic surgery fellowship using this joint program format. The informational correspondence must include the following:
  1. Details about the resident’s eligibility (including all previous GME experience
  2. Details about the resident’s proposed graduation from both the general surgery residency program and the thoracic surgery residency program
  3. Confirmation that the program does not require an increase in complement to include the resident in the program

Eligibility for Certification

Following successful completion the surgery residency portion of this program and meeting ABS requirements, residents may apply for the General Surgery Qualifying Examination (QE). Canddidate who are successful on the QE may then take the General Surgery Certifying Examination (CE). All ABS rules and procedures governing the QE and CE processes for general surgery residents also apply to graduates of the joint training program.

Eligibility for ABTS certification will not occur until the end of the PG-7 year, following successful completion of the thoracic surgery residency program. All ABTS rules and procedures apply.

Oversight

Any general surgery and thoracic surgery programs meeting the requirements outlined below may apply for approval of a joint program. The progress and success of the programs will be continually evaluated to ensure the equivalency or superiority as compared with conventional residencies.

Review and approval of applications is the sole responsibility of the RC-Surgery and RC-TS. Program directors will be asked to report any problems to the applicable RC at and following implementation and also to report the performance of resident participants on the surgery and thoracic surgery in-training, qualifying (written) and certifying (oral) examinations.

Outcome Measures

Specific outcome measures are used to judge a program’s success, including:

1. First-time pass rates on the qualifying and certifying examinations of the ABS and ABTS for graduates of joint training programs compared to their peers in conventional programs.
2. Operative experience records of graduates of these programs as compared with those of other residents in the same institution. All residents in these programs must meet the minimum requirements of both RCs and both certifying boards regarding volume, variety, and breadth of operative experience.
3. Measures of resident satisfaction, including the attrition rate of residents in these programs compared to their peers in conventional residencies.

Program Format Requirements

1. Only institutions that possess both an ACGME-accredited general surgery and an ACGME-accredited thoracic surgery residency programs are eligible to participate. The DIO of the sponsoring institution must submit a letter of commitment and support for the joint program with the application. The application must be co-signed by the DIO, the general surgery program director, and the thoracic surgery program director.
2. The program directors of both the general surgery and thoracic surgery programs must provide documentation of their individual commitment and ability to meet the requirements.
3. Both the general surgery and thoracic surgery residencies and the sponsoring institution must be in substantial compliance with ACGME program and institutional requirements. (The RCs will review the accreditation histories of both programs as well as the institution; this information is routinely appended to an application by ACGME staff members.)
4. Documentation must be submitted to show that both programs’ pass rates for first-time takers for the ABS and ABTS examinations meet or exceed requirements.
5. The submission must include a specific curriculum for all years that has been approved by both program directors. The curriculum must clearly identify the required components as explained below. This curriculum will be reviewed and approved by both RCs.

General Surgery Content Areas

Rotations denoted with an asterisk (*) have been identified by the ABTS as areas of expertise specifically applicable to the education of a thoracic surgeon. It is in these areas that appropriate “cross training” can occur within the last 24 months of general surgery residency. These specific areas are already included within the content of a standard general surgery residency.

a. Principal Content Areas

• Abdomen
• Alimentary tract*
• Head and neck
• Skin, soft tissue and breast
• Endocrine surgery
• Surgical oncology*
• Trauma/burns
• Surgical critical care*
• Vascular surgery*
• Pediatric surgery
• Transplantation*

b. Secondary Content Areas

• Plastic surgery
• Thoracic surgery*
• Endoscopy*

c. Technical Experiences

• Laparoscopy
• Advanced laparoscopy*

d. Other Specialty Areas

• Anesthesia
• Gynecology
• Neurosurgery
• Orthopedic surgery
• Urology

Requirements by PGY Year

a. Thirty-six of the first 48 months of the general surgery program must be documented in areas 6a, b, and c above.

b. Twelve additional months will be spent in the Principal Content Areas in the PG-4 and -5 years (6a above).

c. During the PG-4 and -5 years, a minimum of 12 months must be spent as a chief resident in general surgery in the Principal Content Areas (6 above). Thus, the total Content Area time will be 48 of the 60 general surgery months.

d. The majority of the chief year must be spent in the PG-5 year.

e. No more than six of the 24 months in the PG-4 and -5 years may be devoted exclusively to any one of the Principal Content Areas in general surgery.

f. Those rotations designated as important to the preparation of a thoracic surgeon may comprise a minimum of eight months, but not more than 12 months, of the PG-4 and -5 years. Some of these rotations will be Primary Content Areas (i.e., vascular surgery, surgical critical care), some will be Secondary Components (i.e., thoracic surgery, endoscopy, laparoscopic surgery) and some will be in areas not currently classified in the general surgery curriculum (i.e., cardiac surgery).

It is anticipated that these 8-12 months of thoracic surgery educational preparation will be assigned throughout both the PG-4 and -5 years; however, the majority of these assignments must occur in PG-4 year.

g. All 24 months of the PG-4 and -5 years must be spent in clinical assignments and cannot include research rotations.

Attestations regarding resident classification and supervision

a. During the PG-1-4 years, the general surgery program director will be directly responsible for joint program residents regarding evaluation and supervision.

b. During the PG-5 year, the two program directors will share these responsibilities.

c. The joint program resident will be classified as a categorical general surgery resident on the surgery roster during the PG1-5 years.

d. In the PG-6 and -7 years, the thoracic surgery program director will assume these responsibilities, and the resident will be on the thoracic surgery roster as a thoracic surgery resident.

e. The general surgery program director will be required to sign attesting to these residents’ successful completion of the surgery program.