Open Access
Open Peer Review

This article has Open Peer Review reports available.

How does Open Peer Review work?

Comparison of cardiothoracic surgery training in usa and germany

  • Vakhtang Tchantchaleishvili1,
  • Suyog A Mokashi1,
  • Taufiek K Rajab1,
  • R Morton BolmanIII1,
  • Frederick Y Chen1 and
  • Jan D Schmitto1, 2Email author
Journal of Cardiothoracic Surgery20105:118

DOI: 10.1186/1749-8090-5-118

Received: 8 September 2010

Accepted: 26 November 2010

Published: 26 November 2010

Abstract

Background

Training of cardiothoracic surgeons in Europe and the United States has expanded to incorporate new operative techniques and requirements. The purpose of this study was to compare the current structure of training programs in the United States and Germany.

Methods

We thoroughly reviewed the existing literature with particular focus on the curriculum, salary, board certification and quality of life for cardiothoracic trainees.

Results

The United States of America and the Federal Republic of Germany each have different cardiothoracic surgery training programs with specific strengths and weaknesses which are compared and presented in this publication.

Conclusions

The future of cardiothoracic surgery training will become affected by technological, demographic, economic and supply factors. Given current trends in training programs, creating an efficient training system would allow trainees to compete and grow in this constantly changing environment.

Introduction

Cardiothoracic surgeons must possess a wide variety of technical and professional competencies. With time, cardiac operations are becoming increasingly difficult given aging patient population with more co-morbidities and increasingly severe coronary artery disease. On the other hand, training in cardiothoracic surgery is increasingly being restricted by work hour limitations. There are recent trends to reshape cardiothoracic surgery training to make it more efficient and productive. In this regard, it is very intersting and useful to examine various training systems globally. We decided to compare cardiothoracic surgery training system in the United States with the training system in Germany. Germany has one of the best developed cardiothoracic surgery training systems in the world and at the same time differs enough from U.S. training system to be considered for such a comparison.

Methods

Available literature regarding cardiothoracic surgery training in the United States and Germany was reviewed by cardiothoracic surgeons in training and trained cardiothoracic surgeons from U.S. and Germany. Up-to-date publications by American Board of Thoracic Surgery (ABTS) and Accreditation Council for Graduate Medical Education (ACGME) were reviewed. Information about cardiothoracic surgery training in U.S.A. and Germany were divided in different aspects and qualitatively compared. Number of required cases and financial compensation in two countries were compared quantitatively. The term "cardiothoracic surgery" used in this manuscript refers to both cardiac and general thoracic surgery.

Results

Work hours restriction

Accredited residency programs in United States are restricted by 80 hours/week. German resident work-hours are restricted to 42 hours/week with additional hours on call, averaging 4-8 on call nights per month.

Structure of Training

At this time there are four different pathways to become a board certified cardiothoracic surgeon in United States (Table 1).
Table 1

Training pathways leading to board certification in cardiothoracic surgery in United States

Pathway

Total length of training*

Components

Duration of each component

Board certification

Classical

7-8 years

General surgery residency

5 years

General surgery (optional)

  

Thoracic surgery fellowship

2-3 years

Thoracic surgery

Fast-track (4+3)

7 years

General surgery residency

4 years

General surgery (optional)

  

Thoracic surgery fellowship

3 years

Thoracic surgery

Integrated

6 years

Integrated cardiothoracic surgery residency

6 years

Thoracic surgery

Vascular + Thoracic

7-8 years

Integrated vascular surgery residency

5 years

Vascular surgery

  

Thoracic surgery fellowship

2-3 years

Thoracic surgery

* not considering time off for dedicated research or other academic enrichment

  • Most common pathway requires successful completion of five-year long general surgery residency, followed by additional two to three years of cardiothoracic surgery fellowship. Board certification in general surgery is not required [1].

  • 4/3 joint training pathway requires 4 years of general surgery residency training followed by 2 years of cardiothoracic surgery fellowship, both part of the training has to be completed at the same institution. Board certification in general surgery is allowed after completing 4½ years of general surgery residency, but is not required. Despite the name, total duration of the training is not shortened, it only provides somewhat increased exposure to cardiothoracic surgery compared to the most common pathway.

  • Integrated pathway includes six years of dedicated training in cardiothoracic surgery, as well as related surgical and non-surgical specialties. It does include 24 months of core general surgery training, however board certification in general surgery is not allowed.

  • Yet another pathway to become a cardiothoracic surgeon is to complete integrated vascular surgery residency (5 years) followed by regular 2-3 year cardiothoracic surgery fellowship [1]. Board certification in vascular surgery is required to enter cardiothoracic surgery fellowship.

Surgical training programs in United States have strictly determined number of categorical positions which ensures that each trainee accepted on a position has enough exposure to all the aspects of the training, including operative experience. Additional work is being taken over by non-categorical trainees and Physician Assistants.

German training in cardiothoracic surgery requires two years of general surgical training ("common trunk") followed by specialty training for additional four years of dedicated training in cardiothoracic surgery [2]. Compared to U.S. training pathways, it is most similar to integrated cardiothoracic surgery residency, however, it has a much stronger component of vascular surgery training. Training in Germany does not have a strict timeframe. It is rather flexible in time and allows to remain in the program for longer time if operative or other requirements are not met. German healthcare system does not have Physician Assistants. As a result, significantly more residents are required on lower level of training than on upper level, and only part of them graduates successfully.

Certification

In United States, board certification exam in cardiothoracic surgery is administered in two parts: computer-based multiple-choice test questions and oral exam. Board certified cardiothoracic surgeon in United States is eligible to practice both cardiac as well as general thoracic, but not vascular surgery. For vascular surgery, separate board certification is required. In Germany, after all requirements are met, an oral examination is required for board certification. A board certified cardiothoracic surgeon in Germany can practice not only cardiac and general thoracic, but also vascular surgery.

Operative experience

American Board of Thoracic Surgery requires an average of 125 major operations in each year as a primary surgeon, with a minimal number of 100 in any one year. Based on the length of program, this makes 250 major cases for two-year fellowships and 375 major cases for three-year fellowships. For 4/3 joint training programs the requirement is 250 major cases. For six-year integrated programs, the requirement is 375 major cases (for the last three years of training).

Residents who started training after 07/01/2007 must meet operative requirements for one of two pathways: cardiac or general thoracic surgery. CTSNet is the primary data collection system for case logging. Distribution of cases is outlined in Table 2 for both cardiac as well as general thoracic pathways (255 cases total, corresponding to two-year fellowship).
Table 2

Required types and number of cases for cardiac and general thoracic surgery pathways for board certification in United States

Cardiothoracic

Pathway

Requirements

General Thoracic

Pathway

20

Congenital Heart Disease

10*

10

Primary

 

10

First Assistant

*All cases can be as First Assistant

150

Adult Cardiac

75

50

Acquired Valvular Heart

20

80

Myocardial Revascularization

40

15

Re-Operations

5

5

Aorta

0

15

Other

15

50

Lung, Pluera, Chest Wall

100

30

Pneumonectomy, lobectomy, Segmentectomy

50

20

Other

50

5

Mediastinum (resection)

10

15

Esophagus

30

10

Esophagectomy/Resection

20

0

Benign Esophageal Disease

5

0

Other

5

5

Benign Esophageal Disease/Other

0

15

VATS

30

255

Total

255

40

Endoscopy

90

20

Bronchoscopy

40

10

Esophagoscopy

25

10

Mediastinoscopy

25

100

Consultative Experience

100

50

New Patients

50

50

Follow-up

50

In Germany, number and type of cases are defined by state medical boards. There is, however, no specific number or types of cases defined for each year, which allows training period to be prolonged if needed. Each trainee has a Logbook of Cardiac Surgery which serves as a comprehensive protocol and allows documenting the level of training as well as defines minimum number of operations required for board certification. Required types and numbers of cases for board certification are outlined in Table 3.
Table 3

Required types and number of cases for board certification in Germany

Required procedure

Required number of cases

CABG

150

Mitral valve, including reconstruction

10

Aortic valve and ascending aorta/mitral valve/coronary artery

25

Anastomosis and reconstruction of the thoracic vessels, including aortic aneurysms (off bypass)

50

AICD implantation

25

Thoracic operations related to cardiac surgery procedures, e.g. chest wall resection, thorax stabilisation, extripation of foreign bodies, operations for thoracic injuries

10

Pulmonary operations and the bordering mediastinum in relation to cardiac surgery operations

10

Operations on peripheral vessels in relation to cardiac surgery procedures, e.g. reconstruction of peripheral vessels after application of circulatory assist systems/extracorporal circulation

50

Application and supervision of extracorporal circulation and circulatory assist systems

50

Application of diagnostic procedures, intubation, application of central venous catheters, arterial cannulation, application of thoracic drains, puncture of pleura, pericardium and lungs

150

Quantitative comparison of case requirements by U.S. and German boards (Figure 1) shows that the American Board of Thoracic Surgery requires more general thoracic cases than German State Medical Boards do. On the other hand, German State Medical Boards require more coronary artery bypass grafting and peripheral vascular cases than American Board of Thoracic Surgery does.
https://static-content.springer.com/image/art%3A10.1186%2F1749-8090-5-118/MediaObjects/13019_2010_Article_350_Fig1_HTML.jpg
Figure 1

Quantitative comparison of case requirements by U.S. and German medical boards. To create similar categories, certain case groups have been merged into larger groups.

Non-operative clinical requirements

Non-operative clinical requirements are similar in USA and Germany and include pre- and post-operative care, ICU and ward experience, as well as consultations. Physician Assistant as a profession does not exist in Germany which is counterbalanced by higher number of junior residents than senior residenets. This could make it more challenging to balance operative and non-operative experience.

Non-clinical academic enrichment

To perform non-clinical academic work, e.g. high-quality research, time is of great importance in recent days especially for young residents [3]. Therefore, many trainees in U.S. hold their training after 2nd or 3rd year of general surgery residency and perform one to three years of dedicated research during General Surgery residency. According to a recent national survey, 36% of general surgery residents interrupt residency to pursue full-time research, with mean research fellowship length of 1.7 years, and with 72% of research fellows performing basic science research [46].

In Germany there is no dedicated research time taken off during the training. Most trainees at university hospitals perform successful research simultaneously with their clinical training which is easier in Germany given more flexible duration of training.

Salary

The salary in USA is based mainly on post-graduate year and does not depend on the specialty a person is being trained in. Below is a table with nationwide resident/fellow salaries for the 2008-2009 academic year (Table 4) [4]. The annual salary for a U.S. cardiothoracic surgeon ranges from $245.000 to $621.000 [5].
Table 4

Annual resident/fellow salaries for the 2008-2009 academic year, published by the Association of American Medical Colleges (AAMC) 5.

Post-MD Year

N

Mean

25th Percentile

50th Percentile

75th Percentile

1

210

$46,245

$44,055

$45,659

$47,760

2

213

48,092

45,720

47,257

49,764

3

213

50,128

47,290

49,095

51,857

4

212

52,154

48,911

50,987

54,468

5

199

54,164

50,606

52,956

56,451

6

182

56,463

52,746

55,265

59,282

7

152

58,520

54,147

57,027

62,520

8

85

60,278

55,266

59,108

63,825

The salary structure of German cardiac surgery trainees is also based on the number of post-graduate years completed (Table 5). The salary itself is the same for German surgery residents nationwide.
Table 5

Monthly salary of residents in Germany

Post-Graduate Year (not board certified)

Amount in EURO's

1

EUR 3,705

2

3,915

3

4,065

4

4,325

5

4,635

Years after board certification

 

1-3

4,890

4-6

5,300

7 and above

5,660

Years after becoming an attending surgeon

 

1-3

6,125

4-6

6,485

7 and above

7,000

Comparison in financial compensation between USA and Germany would be biased and is not performed intentionally. The bias is multifactorial and most importamtly includes different cost of living, costs of insurancies, different education system (public vs private), and also different currencies in USA and Germany. However, it can be noted that change from a trainee status to an attending status is followed by a bigger jump in financial compensation in USA than in Germany.

Job satisfaction

Overall dissatisfaction among cardiothoracic surgery graduates is similar in USA and Germany. This is most likely attributed to the minimal number of available jobs open, low reimbursements and lifestyle issues [7, 8]. Annual reports of National Resident Matching Program show that the number of applicants in United States interested in cardiothoracic surgery training are steadily declining (Table 6) [9]. In Germany, overall situation is very similar. A special committee of German Society for Cardiac, Thoracic and Vascular Surgery (GSCTS) conducted an inquiry of young trainees wich revealed the following:
Table 6

National Resident Matching Program thoracic surgery match data from 1996 to 2008 8.

 

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

Certified positions

146

143

138

137

139

141

144

144

141

138

139

126

130

Certified applicant

197

176

175

156

156

148

149

145

161

134

104

91

96

Programs filled (%)

93.5

88.0

94.7

91.1

89.1

94.5

88.4

84.0

92.6

81.7

67.4

63.0

60.9

Positions filled (%)

95.9

92.3

96.4

93.4

92.1

95.7

91.0

85.4

93.6

87.7

71.9

66.7

66.9

Matched applicants (%)

71.1

75.0

76.0

82.1

82.1

91.2

87.9

84.8

82.0

90.3

96.2

92.3

90.6

Unmatched applicants (%)

28.9

25.0

24.0

17.9

17.9

8.8

12.1

15.2

18.0

9.7

3.8

7.7

9.4

Certified positions filled with US grads (%)

80.8

76.9

77.5

73.0

69.1

73.8

70.8

65.3

75.9

66.7

49.6

47.6

47.7

  • It is currently impossible to staff all positions in cardiac surgical hospitals. An average of 1.2 positions per hospital is available.

  • The majority of members are not satisfied with their situations.

  • Partial payment for overtime occurs in only 73% of evaluated hospitals.

  • Of particular note, almost 70% of residents in cardiac surgery are not satisfied with current compensation.

  • Despite the introduction of a new theoretical concept for post-graduate training and creation of a logbook, a well structured concept for post-graduate training exists in only 29% of hospitals.

  • The average age at the time of board certification is 36.6 years. Overall, there exists considerable discontent regarding post-graduate training (only 27% of responses are satisfactory).

  • Women are a minority in cardiac surgery - only 24% amongst residents.

  • In Germany, cardiac surgery has traditionally been an international specialty. One quarter of all colleagues represents foreign medical graduates - most from countries not part of the European Union. 90% of staff members are salaried whereas 10% are financed by scholarships.

Discussion

Both the United States and German cardiac surgery training programs have their own advantages and disadvantages. It will be useful to consider each other's advantages to attract well-qualified individuals. Building an internationally comparable efficient cardiothoracic surgical program should have the same principles and values as a traditional institutional or single country program: high-quality patient care, training and fostering residents and contributing to basic and clinical research. Lot of questions remain to be answered: For example, is it still necessary to be trained in general surgery before becoming a cardiothoracic surgeon? If so, how many years of general surgery are really necessary prior to starting a cardiothoracic surgery training program? The best decision for now seems to keep open diverse training pathways, leading to thoracic surgery certification, and with time we will determine which way is superior to attract best candidates and train best surgeons in a constantly changing environment.

Conclusions

  1. 1.

    Both, the United States and German Cardiac Surgery Training Programs have their own advantages and disadvantages.

     
  2. 2.

    Training in Germany is similar to a pyramidal system and creates a strong competition inside the program. In USA, most of the competition between applicants takes place before entering the program in USA, rather than inside the program.

     
  3. 3.

    Training in Germany is more flexible and does not have a strict timeframe compared to the training in USA.

     
  4. 4.

    Lack of Physician Assistant profession in Germany could make it more challenging to balance operative and non-operative experience for a trainee.

     
  5. 5.

    Research training in USA is mostly performed as dedicated 1-3 years in a research laboratory. In Germany, research training takes place simultaneously with clinical training. This is facilitated by flexibility of training in Germany.

     
  6. 6.

    Change from a trainee to an attending level is followed by a bigger jump in financial compensation in USA than in Germany.

     
  7. 7.

    Work hour restrictions in Germany exceed work hours restrictions in USA.

     
  8. 8.

    Training in Germany has a much stronger component of vascular surgery training compared to the training programs in USA.

     
  9. 9.

    At this time, there is equal job dissatisfaction among graduates of cardiothoracic surgery training in both USA and Germany.

     

Declarations

Authors’ Affiliations

(1)
Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School
(2)
Division of Cardiac, Thoracic and Vascular Surgery, University Hospital of Goettingen

References

  1. General Reequirements for Certification in Thoracic Surgery. [http://www.abts.org/sections/Certification/General_Requirements/index.html]
  2. Bundesaerztekammer: Weiterbildungsordnung. 2003, [http://www.bundesaerztekammer.de/downloads/MWBO_25062010.pdf]Google Scholar
  3. Sossalla S, Schmitto JD: Scientific teamwork - a particular approach. Kardiol Pol. 2009, 67 (12): 1421-3.PubMedGoogle Scholar
  4. Robertson C, Klingensmith M, Coopersmith C: Prevalence and cost of full-time research fellowships during general surgery residency: a national survey. Ann Surg. 2009, 249 (1): 155-61. 10.1097/SLA.0b013e3181929216.View ArticlePubMedPubMed CentralGoogle Scholar
  5. AAMC: Report on Medical School Faculty Salaries 2007-2008. 2009, [http://www.aamc.org/data/stipend/2009_stipendreport.pdf]Google Scholar
  6. AAMC: Survey of Resident/Fellow Stipends and Benefits. 2008, [http://www.aamc.org/data/stipend/2008_stipendreport.pdf]Google Scholar
  7. Salazar J, Ermis P, Laudito A, Lee R, Wheatley Gr, Paul S: Cardiothoracic surgery resident education: update on resident recruitment and job placement. Ann Thorac Surg. 2006, 82 (3): 1160-5. 10.1016/j.athoracsur.2006.04.070.View ArticlePubMedGoogle Scholar
  8. Salazar J, Lee R, Wheatley Gr, Doty J: Are there enough jobs in cardiothoracic surgery? The thoracic surgery residents association job placement survey for finishing residents. Ann Thorac Surg. 2004, 78 (5): 1523-7. 10.1016/j.athoracsur.2004.05.068.View ArticlePubMedGoogle Scholar
  9. Prasad S, Massad M, Chedrawy E, Snow N, Yeh J, Lele H: Weathering the torm: how can thoracic surgery training programs meet the new challenges in the era of less-invasive technologies?. J Thorac Cardiovasc Surg. 2009, 137 (6): 1317-25. 10.1016/j.jtcvs.2009.02.029. discussion 26View ArticlePubMedGoogle Scholar

Copyright

© Tchantchaleishvili et al; licensee BioMed Central Ltd. 2010

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Advertisement