Is ‘Supersubspecialization’ the Future of Cardiothoracic Surgery Training?

STS News, Summer 2018 -- While a comprehensive knowledge of cardiothoracic diseases will undoubtedly remain essential in training the next generation of cardiothoracic surgeons, developing a focus on a particular area within the specialty is becoming more and more important—for both a surgeon’s career and optimal patient outcomes.

During a roundtable discussion filmed at the STS Annual Meeting in Fort Lauderdale, Florida, earlier this year, John V. Conte, MD, Thomas E. MacGillivray, MD, Michael J. Mack, MD, and Wilson Y. Szeto, MD discussed how training programs could stay current and ensure that residents are prepared for the future.

“The day of the generalist cardiac surgeon cannot continue,” said Dr. Mack, an STS Past President from the Heart Hospital Baylor Plano. “We need to be supersubspecialized—in heart failure surgery, in structural heart disease, and in coronary revascularization.”

Transcatheter aortic valve replacement is one growing area of “supersubspecialization.”

Dr. Conte, from Penn State University in Hershey, said that his institution would be modifying its residency program to address future manpower issues. The planned changes include adding a third year to its traditional residency program, which would function as a “mini fellowship” for those who wanted to gain specialized knowledge in areas such as aortic disease, transplant and mechanical circulatory support, structural heart disease, minimally invasive surgery, coronary revascularization, and robotic surgery.

The updated program would allow residents to focus on just one area or several, depending on their interests. They also could travel to other institutions for part of the time.

“With this dedicated experience, our residents will have clear pathways set up for them as they go forward in their careers,” Dr. Conte said. “It’s incumbent upon us to adapt our training programs and make sure that we’re training the residents for 2030 and beyond.”

Supersubspecialization doesn’t mean that residents should concentrate on just one particular procedure. Dr. MacGillivray, STS Treasurer from Houston Methodist Hospital, stressed that focusing on the entire disease process is the best strategy.

“If someone wants to focus on valvular heart disease, they’ll need to know about not just the surgical interventions, but also the transcatheter solutions and medical treatments,” he said. “If you focus only on one operation, and then one day it’s not the preferred therapy anymore, you won’t have any skills.”

Dr. Conte concurred and added that cardiothoracic surgeons “need to own a disease,” which would help them as they look for jobs.

“As I’m focusing my recruitment, I’m identifying people who can do regular cases, but we also want to hire people who can cover these subspecialty areas,” Dr. Conte added.

“It’s incumbent upon us to adapt our training programs and make sure that we’re training the residents for 2030 and beyond.”

John V. Conte, MD

Patient Benefits

“Data have shown that patients often have better outcomes when undergoing coronary artery surgery with a surgeon who has a lot of experience in that particular area,” Dr. MacGillivray said. “I think the same thing is true with valvular heart disease. Transcatheter therapies are a different skillset. In order to be good at them, you need to spend a lot of time learning and mastering them.”

The trend for cardiothoracic surgeons to have specific areas of focus may lead to a transition in the way that medical care is made available to patients.

“When you’re having subspecialization such as this, much of it is going to happen at larger centers,” Dr. Conte said. "So I do think that there is going to be more regionalization of health care in the future. The end goal, of course, is to ensure that patients get the maximum benefit from the technology and knowledge that’s out there.”

Emphasis on the Heart Team

During the roundtable, the cardiothoracic surgeons also emphasized the need to expose residents to the heart team approach. 

“Integrate residents into the heart team culture at your current institution,” Dr. Szeto advised. “Our surgical residents at the University of Pennsylvania spend a significant part of their training with our cardiology colleagues, rotating through imaging, the cath lab, and the cardiac care unit.”

Two cardiothoracic surgery residents in Dr. Szeto’s program recently published an article in the Journal of the American College of Cardiology about their experience in the I-6 residency program.

Chase R. Brown, MD and Jason J. Han, MD noted that the program gave them a broad knowledge base in cardiovascular medicine and also enabled them to develop relationships with physicians across the medical spectrum—connections they may not have acquired had they not been immersed in the heart team approach from the beginning.

“By coming to understand how both cardiologists and surgeons evaluate certain pathology and assess risks and benefits of their approach, we cultivate an intuition for shared decision-making and collaboration, which will undoubtedly benefit patients in the long run,” they wrote. “We learn to appreciate how they think, and they learn how we think.”

"Residents need to learn the heart team approach from the start."

Thomas E. MacGillivray, MD

Dr. MacGillivray suggested that regular heart team conferences be a mandatory part of residency training.

“When I was in training, the decisions were made more in silos,” he said. “Now, we know that the appropriate way to manage patients is by heart team evaluation. Residents need to learn this approach from the start.”

Above all, those who lead training programs need to embrace change and frequently evaluate whether they’re adequately preparing their residents for the evolving demands of cardiothoracic surgery, Dr. Conte said.

“One of the key things is to remain flexible in how you’re training the next generation,” he added. “The people who are tasked with that responsibility have to be committed to that, or your program is not going to be very successful.”