THORACIC SURGERY

DEFINITION:

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

GENERAL OBJECTIVES:

Upon successful completion of the thoracic surgery residency program, the graduate residents should be fully trained and prepared to embark on a career as consultant thoracic surgeons.

The graduate thoracic surgeons are dedicated to enhancing the quality of life of the patient with surgical diseases of the chest.

SPECIFIC OBJECTIVES:

At the completion of training, the resident will have acquired the following competencies and will function effectively as:

Medical Expert/Clinical Decision-maker

General Requirements

    • Demonstrate diagnostic and therapeutic skills for ethical and effective patient care.
    • Access and apply relevant information to clinical practice.
    • Demonstrate effective consultation services with respect to patient care, education and legal opinions.

Specific Requirements

The Thoracic Surgeons must be familiar with and able to describe or discuss the:

                             iv.            principles and practice of surgery to include, pathophysiology of shock, nutrition, metabolism, infection, coagulation, immune system, genetics, pulmonary function, biostatistics, bioethics, transplantation, chemotherapy and radiation oncology

                               v.            anatomy, embryology and diseases of chest wall, mediastinum, lung, trachea, pleura, esophagus, stomach, and diaphragm

                             vi.            respiratory physiology, pulmonary function tests, ventilatory support

                            vii.            esophageal physiology, esophageal motility tests

                          viii.            diseases of the heart, and great vessels

                             ix.            physiology and complications of extracorporeal perfusion

1.Technical Skills

The Thoracic Surgeons must demonstrate competence and proficiency in the surgical technical skills required to:

      1. Perform bronchoscopy and upper gastrointestinal endoscopy.
      2. Treat diseases of the chest wall, mediastinum, lungs, trachea, pleura, esophagus, stomach and diaphragm.

                 2.Clinical Skills

The following clinical skills are to be applied to the adult and pediatric patient, with consideration given to racial, ethnic, gender and religious differences.

The residents must:

      1. Obtain an accurate patient history and perform an appropriate physical examination.
      2. Develop a weighted differential diagnosis.
      3. Outline an appropriate plan of laboratory and radiological investigations.
      4. Recommend an appropriate therapeutic plan taking into account such matters as age, general health, risk/benefit ratio, and prognosis.
      5. Manage with proficiency and expertise, thoracic surgical emergencies including trauma.
      6. Manage pre and post-operative care including intensive care unit (ICU) management.

Communicator

General Requirements

    • Establish therapeutic relationships with patients/families.
    • Obtain and synthesize relevant history from patients/families/communities.
    • Listen effectively.
    • Discuss appropriate information with patients/families and the health care team.

Specific Requirements

The residents must:

    • Be effective communicators and good listeners.
    • At all times, communicate with medical colleagues, health team personnel, patients, and families in a professional, timely, accurate, informative and when appropriate, compassionate manner.

1.Knowledge

The residents must:

      • Understand and empathize with the emotion surrounding illness.
      • Appreciate the dynamics of the traumatized family.
      • Understand the concerns patients have of loss of control, self worth, and personal dignity.
      • Recognize the need for effective use of language.
      • Understand the need to explain medical matters in simple terms.
      • Appreciate the fact that interpreters will be required for ethnic groups.

                   2.Clinical Skills

The residents must:

      • Address patients concerns with empathy and respect.
      • Explain details of medical condition and therapy in understandable terms.
      • Include all members of the health care team in discussions of therapeutic plan when appropriate.

Collaborator

General Requirements

    • Consult effectively with other physicians and health care professionals.
    • Contribute effectively to other interdisciplinary team activities.

Specific Requirements

The residents must:

    • Be team players, contributing to and utilizing the knowledge and skills of other physicians and health care professionals, in a manner that benefits patient care and enhances overall knowledge.

1.Knowledge

The residents must:

      • Understand the roles of health care professionals.
      • Appreciate the unique aspects of care provided by nursing, physiotherapy, and health care technologists.

2.Clinical Skills

The residents must:

      • Seek the advice of other members of the health care team.
      • Organize team meetings to discuss problems in investigation and therapy when appropriate.
      • Consult regularly with other physicians.
      • Share knowledge in education forums.

Manager

General Requirements

    • Utilize resources effectively to balance patient care, learning needs, and outside activities.
    • Allocate finite health care resources wisely.
    • Work effectively and efficiently in a health care organization.
    • Utilize information technology to optimize patient care, life-long learning and other activities.

Specific Requirements

1.Knowledge

The residents must understand the basics of health care funding and the different models of health care delivery.

2.Clinical Skills

The residents must:

      • Undertake quality assurance and quality delivery analyses.
      • Develop plans for more effective use of resources.
      • Apply technology effectively to patient care.

The residents must have an understanding of how to:

      • Priorize capital and operational components of care within institution or clinic.
      • Participate effectively and constructively in strategic planning.
      • Seek alternative funding mechanisms to enhance patient care and research.

Health Advocate

General Requirements

    • Identify the important determinants of health affecting patients.
    • Contribute effectively to improved health of patients and communities.
    • Recognize and respond to those issues where advocacy is appropriate.

Specific Requirements

1.Knowledge

The residents must:

      • Demonstrate knowledge of the epidemiology of thoracic disease.
      • Recognize the importance of preventive medicine.
      • Understand the means available for constructive support of patient education and preventive medicine intervention.

2.Clinical Skills

The residents must:

      • Participate in patient education.
      • Promote prevention of thoracic disease.
      • Examine the role of environmental toxins in the genesis of particular patient complaints.
      • Assist patients in the acquisition and interpretation of health care information.
      • Advise families of the role of genetics in the genesis of disease.

Scholar

General Requirements

    • Develop, implement and monitor a personal continuing education strategy.
    • Critically appraise sources of medical information.
    • Facilitate learning of patients, housestaff/students and other health professionals.
    • Contribute to development of new knowledge.

Specific Requirements

The residents must:

    • Be able to critically assess the thoracic surgery literature as it relates to patient diagnoses, investigations and treatment.
    • Appreciate the important role of clinical and basic research.
    • Acquire the skills to participate in collaborative research projects, quality assurance, and guideline development as it applies to thoracic surgery.

1.Knowledge

The residents must:

      • Have an understanding of the scientific method and of outcome based research.
      • Appreciate statistical significance.
      • Understand the importance of continuing medical education (CME).
      • Appreciate where information on medical matters is reliably obtained.

2.Clinical Skills

The residents must:

      • Question current practice.
      • Apply outcome-based methodology to interpretation of clinical information.
      • Critically appraise the thoracic surgical literature.
      • Develop a method of self education.
      • Attend regular CME.
      • Provide knowledge to other health care professionals.
      • Read relevant medical literature on a regular basis.

Professional

General Requirements

    • Deliver highest quality care with integrity, honesty and compassion.
    • Exhibit appropriate personal and interpersonal professional behaviours.
    • Practise medicine ethically consistent with the obligations of a physician.

Specific Requirements

The residents must:

    • Maintain personal and professional attitudes consistent with a consulting surgeon role.
    • Maintain clinical skills and knowledge base through ongoing continuing medical education.

1.Knowledge

The residents must:

      • Have knowledge of ethical responsibilities.
      • Appreciate how differences in race, gender and ethnicity affect patient/families responses to therapeutic suggestions and diagnosis.
      • Understand the independence of patients.
      • Recognize the requirement of patient confidentiality.

2.Clinical Skills

The residents will:

      • Be sensitive to the needs of the patient even when they conflict with best medical care.
      • Maintain confidentiality.
      • Practice in an ethical, honest, and forthright manner.
      • Respond to conflict and abuse constructively and with compassion.

CONTENT AND ORGANIZATION OF THE RESIDENCY PROGRAM

There must be an organized program of rotations and other educational experiences, both mandatory and elective, designed to provide each resident with the opportunity to fulfill the educational requirements and achieve competence in the specialty.

The content and organization of every accredited program in thoracic surgery must be consistent with the specialty training requirements.

All residents must have the opportunity to serve as the senior resident. Senior residency is defined as a year in which the resident is regularly entrusted with the responsibility for pre-operative, operative and post-operative care. The senior resident shall be in charge of a surgical service and be responsible for some or all of the quality assurance specific to that service. There shall be no other person capable of intervention between the resident and the staff surgeon.

RESOURCES:

There must be sufficient resources including teaching faculty, the number and variety of patients, physical and technical resources, as well as the supporting facilities and services necessary to provide the opportunity for all residents in the program to achieve the educational objectives and receive full training as defined by the specialty training requirements in thoracic surgery.

In those cases where a university has sufficient resources to provide most of the training in thoracic surgery but lacks one or more essential elements, the program may still be accredited provided that formal arrangements have been made to send residents to another accredited residency program for periods of appropriate prescribed training.

  1. Teaching Faculty

There must be a team that includes two or more dedicated thoracic surgeons (that is - they spend all or nearly all of their clinical activity in thoracic surgery) who will assume the responsibility for both teaching and patient care. There must be a sufficient number of qualified teaching staff to supervise residents at all levels and in all aspects of the specialty and to provide teaching in the basic and clinical sciences of the specialty. Where appropriate, a programmatic approach to clinical care involving the participation of related disciplines is encouraged.

  1. Number and Variety of Patients

The program must provide an adequate volume and range of patients to ensure full training in the diagnosis and management of diseases requiring pulmonary resection of all types, esophageal resection and repair, and surgery of the mediastinum, trachea, chest wall, pleura and diaphragm. Although specific numbers of cases are not a requirement for individual residents, the program must demonstrate sufficient operative volume to ensure that each resident will obtain adequate operative experience in each procedure. Experience in thoracic trauma including participation in the initial management of multiple injuries is essential for every resident.

  1. Clinical Services Specific to Thoracic Surgery
    1. Integrated Teaching Program

An integrated teaching service that provides access to pre-operative evaluation, operative and post-operative care, and sustained clinical follow-up is mandatory.

    1. Other Clinical Resources

Core Surgery. The core surgical curriculum must be organized so as to ensure residents a satisfactory knowledge of the principles and practice of surgery, including the pathophysiology of shock, nutrition and metabolism, infection, coagulation, immunity, genetics, and statistics. Experience and proficiency in the management of problems in the pre and post-operative period, fluid balance, diagnosis and management of respiratory failure, airway obstruction, and surgical intensive care are essential.

Consultations. Throughout the program, residents should provide the initial consultation in elective and emergent clinical situations.

  1. Supporting Services — Clinical, Diagnostic, Technical
    1. Intensive Care

Experience in the care of the critically ill is a prerequisite. Residents must assume major responsibility for their patients admitted to intensive care units. Dedicated exposure to critical care is an essential part of core training.

    1. Emergency Facilities

Systematic and graded supervision of residents to ensure expertise in the initial management of all types of emergencies related to the specialty including those presenting in the emergency department must be present.

    1. Ambulatory Services

Organized clinics must provide opportunities for pre-admission investigation and post-discharge follow-up of patients.

    1. Liaison with Other Specialties and Subspecialties
      1. There must be access to general surgical services that are capable of fulfilling the objectives in general surgery.
      2. There must be access to a cardiac surgery service that provides structured teaching, quality assurance/improvement, and is capable of fulfilling the objectives in cardiac surgery. 
      3. Interactions with the following related disciplines must be present: medical and radiation oncology, critical care, radiology, pathology, anesthesia, cardiology and gastroenterology.
    2. Physical and Technical Resources

Facilities must be available for respiratory function studies, esophageal physiology studies, CAT scanning and ultrasonography. An adequate endoscopy area for local endoscopy must be provided and the program must demonstrate that residents receive adequate training in endoscopy.

ACADEMIC AND SCHOLARLY ASPECTS OF THE PROGRAM:

The academic and scholarly aspects of the program must be commensurate with the concept of a university postgraduate education. The quality of scholarship in the program will in part, be demonstrated by a spirit of enquiry during clinical discussions, rounds, and conferences. Scholarship implies an in-depth understanding of basic mechanisms of normal and abnormal states and the application of current knowledge to practice.

  1. Organized Scholarly Activities

There must be an organized system of educational rounds and seminars to review the basic and practical aspects of the discipline. Where appropriate these should be multi-disciplinary especially in the area of oncology. 

  1. Basic and Clinical Sciences Relevant to Thoracic Surgery

A systemic approach to the review and interpretation of the specialty literature must be provided.

  1. Biomedical Ethics

The academic program must provide opportunities for residents to gain an understanding of the basic principles of biomedical ethics as it relates to thoracic surgery. The program must demonstrate that biomedical ethics is a part of the formal educational program.

  1. Communication Skills

The program must provide opportunities for residents to learn and demonstrate the ability to communicate effectively with the patient, the patient's family, colleagues and other members of the health care team.

  1. Teaching Skills

Residents must be encouraged and be provided with the opportunity to teach junior residents and allied health personnel. Their abilities in this area should be appropriately noted in their evaluation.

  1. Quality Assurance/Improvement

Residents must be afforded the opportunity to participate in quality assurance and improvement through participation in morbidity and mortality assessments and review and the development of strategies for the resolution of clinical problems pertinent to the specialty or the delivery of care in the particular institution.

  1. Research Opportunities for Residents

The program must offer the opportunity and encourage residents to participate in either clinical or basic science research. In that regard the program or the supporting institution must provide adequate resources to permit computer searches of the pertinent literature and staff support and supervision of investigative efforts. Then residents must be given the opportunity to interact with the active investigators on the surgical staff. Literature reviews should take place on a regular basis as part of training in the interpretation of the pertinent literature.

  1. Faculty Research

A satisfactory level of research and scholarly activity must be maintained among the faculty identified with the program.

  1. Outside Conferences

The program should provide opportunities for residents to attend conferences outside their own university.

Specialty 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.

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.

Approved residency must include Core Training in Surgery, Thoracic Surgery and Cardiac Surgery.

PROGRAMS AVAILABLE:

~ Specialization 

~ Doctor of Philosophy (Ph.D)