Operative Case Requirements

The operative experience requirements of the American Board of Thoracic Surgery have two parts.  One is concerned with the intensity or volume of cases and the other the distribution of cases (index cases).

1.  Surgical Volume (Intensity)

The Board's operative experience requirements include an annual average of 125 major operations performed by each resident based on the following lengths of training programs:

2-year programs:  125 major operations for each year, for a total of 250 major cases;

3-year programs:  125 major operations for each year, for a total of 375 major cases;

4/3 joint training programs:  125 major operations for the last two years of training, for a total of 250 major cases;

6-year programs:  125 major operations for the last three years of training, for a total of 375 major cases

This guideline on intensity of cases conforms with the Program Requirements in Thoracic Surgery as published by the ACGME and RRC-TS.

The application of any candidate whose supervised operative experience fails to meet the requirement of an annual average of 125 major operations with a minimal number of 100 in any one year will be referred to the Board's Credentials Committee for review.

2.  Index Case (Distribution)-Full Credit Cases Only

Index cases are Full Credit Cases only.  Index cases are defined as the resident being the primary surgeon. They do not include first assistant cases, unless specifically stated.

The application of a candidate whose operative experience does not include the required number of index cases as listed will be sent to the Credentials Committee for review. 

Index Cases

For Residents who started their training on or after July 1, 2007

Residents who start their training on or after July 1, 2007, can choose either the Cardiothoracic Pathway or the General Thoracic Pathway.  Residents must meet the operative numbers entirely from one pathway.

For Residents who started their training before July 1, 2007

Endoscopic procedures may be counted for credit whether they are performed as independent procedures or immediately preceding a thoracic operation.

*Re-operation procedures can be counted twice for any adult cardiac procedure.  For example, a redo coronary artery bypass surgery may be counted as both a myocardial revascularization and a re-operation. 

VATS procedures may be counted twice, once as a major procedure and again as a VATS procedure.  For example, a Lobectomy with VATS can be counted as a Lobectomy and as a VATS.

Major vascular operations outside the thorax, and procedures such as pacemaker implantation and closed EP, should be listed separately.

The Board recognizes that supervised operative experience in a well-organized teaching setting that is approved by the RRC-TS protects the patient, who, in most instances, is the personal and identifiable responsibility of a faculty surgeon. This supervised experience optimally prepares the candidate to begin the independent practice of cardiothoracic surgery after the completion of residency.

The Credentials Committee has been authorized by the Board to reject a candidate if his or her operative experience during the thoracic surgery residency is considered to be inadequate. The candidate, the program director, and the RRC-TS will be notified if such action is taken. If the Credentials Committee finds the applicant's operative experience inadequate and additional training is required, the additional training must be approved by the Board in advance. Should the program director determine that a resident needs additional training beyond the number of years that have been approved by the ACGME and the RRC-TS, before submitting an application for admission to the ABTS certification process, this additional training must also be approved by the Board in advance.

Even though emphasis on one or another facet of thoracic surgery (pulmonary, cardiovascular, esophageal, thoracic trauma, etc.) may have characterized a candidate's residency experience, the candidate is nevertheless held accountable for knowledge concerning all phases of the field, including extracorporeal perfusion (physiological concepts, techniques, and complications), cardiac assist devices, endovascular techniques, management of dysrhythmias, thoracic oncology and VATS. In addition, the candidate should have responsibility for the care of pediatric cardiac patients.  The candidate should also have an in-depth knowledge of the critical care of acutely ill patients in the intensive care unit. This requires an understanding of cardiorespiratory, circulatory assist devices, physiology, respirators, blood gases, metabolic alterations, cardiac output, hyperalimentation, and many other areas.

OPERATIVE EXPERIENCE CREDIT 
Credit will be allowed for supervised operative experience in a well-organized teaching setting only when the following criteria are met:
 
a. The resident participated in the diagnosis, preoperative planning, surgical indications, and selection of the appropriate operation;
 
b. The resident performed under appropriate supervision in a well-organized teaching setting approved by the RRC-TS those technical manipulations that constituted the essential parts of the procedure itself;
 
c. The resident was substantially involved in postoperative care including critical care.
 
 
Supervision and active participation by the thoracic surgery faculty are required in preoperative, intraoperative, and postoperative care.

The Board also emphasizes that first-assisting at operations is an important part of resident experience, particularly in complex or relatively uncommon cases.