So, you’ve decided to apply into one of the most high-stakes, demanding, and fulfilling specialties? Welcome to the world of cardiothoracic (CT) surgery! Whether you’re an MS1 just getting interested in CT surgery or an MS4 applying into cardiothoracic surgery residency programs, this post will provide some perspective on how to improve your chances of matching into an integrated-cardiothoracic surgery residency.
A Year-by-Year Guide for Medical Students Pursuing Cardiothoracic Surgery Residency
The Early Preclinical Years
Shadowing
The beginning of medical school is a good time to find out if a career in CT surgery is right for you. One of the best ways you can do this is by shadowing CT surgeons and housestaff to get a glimpse into the field. Reach out to one of the attendings or residents at your institution and see if you can come in to follow the team.
The day begins early with team rounds. This will give you a taste of the complex ICU management that’s an inherent part of CT surgery.
Next will come the cases for the day. See if you enjoy longer operations and the added element of cardiopulmonary bypass. If you’re like me, once you see your first sternotomy, you won’t look back!
The cardiac OR room is often packed with the bypass machine, instrument tables, and the echo machine. Oftentimes, the best view is at the head of the bed. Once the bypass machine is humming and lung ventilation has been held, this is a great time to snag a stool and perch up from anesthesia’s side.
Mentorship
As you begin to cultivate your interest in cardiothoracic surgery residency, it’s very important to have strong mentors throughout your journey. Mentors can aid you in identifying goals for professional development and set you on the path for a career in CT surgery.
A good place to start is to reach out to the surgeons at your own medical center. If there’s also a program or geographic location you’re interested in, you can cold email the surgeons there to establish a connection. Doing all of this is also a great way to show early commitment to the field.
During your preclinical years, you can also join the Thoracic Surgery Medical Student Association (TSMA). This is a medical student led organization that holds plenty of online programming and offers a host of resources for learning more about the field.
Medical Knowledge
While you shadow and begin to engage in extracurricular activities, remember that learning the core clinical information should be your top priority. This will serve as the foundation for the rest of your career as a clinician. Believe it or not, many of the core biochemical processes have come up while I was rounding on my ICU rotations. This knowledge will also help you pass Step 1 and excel on Step 2 down the road.
Research
Research is an excellent way to further investigate your interest in cardiothoracic surgery residency and a future career in the field. An important first step as you start out is to find an area you’re interested in, perhaps aortic or lung cancer surgery. Then reach out to the people active in those fields of research. They can provide you with direction on the research process, from project conception to execution and eventual publication.
The toughest part is to come up with a research question that you’re trying to answer, which your mentor can certainly help with. In order to form a research question, familiarize yourself with the literature on a topic within the field to understand what the current gaps in knowledge are. Easier said than done of course! However, it’ll become easier as you build your reservoir of knowledge.
How many publications do I need?
A common question applicants ask is how many publications are required to match I-6. The short of it is that there’s no set number. It’s far more important to focus on projects you’re passionate about and can discuss with interest in an interview down the road. Applicants come from a wide range of research backgrounds. Some have completed research years before medical school and others have earned PhDs. However, these are not mandatory. A research year during medical school for further scholarly pursuits is optional. The important part is to do what interests you.
Are there research conferences to attend in the field?
There are several excellent cardiothoracic-oriented research conferences to attend. Two major national conferences are the American Association for Thoracic Surgery (AATS) and the Society of Thoracic Surgeons (STS) Annual Meetings. They both offer comprehensive scholarships for medical students which cover the full cost of attendance and accommodations: Member for a Day and Looking to the Future, respectively.
Both scholarships provide excellent programming. They’re also a nice way to network and meet other colleagues in the same boat who will be applying with you.
Clinical Years
This is the time to start developing your clinical acumen:
Find cardiothoracic surgery study resources
There are excellent resources out there, many produced by the Thoracic Surgery Resident Association (TSRA), for learning the fundamentals of cardiothoracic surgery. Using them will help you shine on your clinical rotations.
A good starting point is the TSRA Review of Cardiothoracic Surgery. This is divided into cardiac, thoracic, and congenital sections and provides a foundation for many of the core concepts in CT surgery.
For any case you’re about to scrub, it’s a good idea to read the relevant chapter the night before. For example, before a CABG + valve surgery, you can learn in what order the proximal/distal coronary anastomoses and valve placement take place. There’s also the TSRA Clinical Scenarios in Cardiothoracic Surgery, which poses different situations in a question-and-answer format. This text is quite detailed and would be a good second resource to use.
Learn surgical indications
It’s also important to learn the major indications for the different procedures in CT surgery. Guidelines serve as the evidence-driven benchmarks for when surgery is indicated given a certain patient presentation. For example, they inform us which patient is better served by a coronary artery bypass grafting versus stenting based on the degree of their coronary disease.
The valve guidelines are also foundational and explain the criteria for classifying valve disease as mild vs. moderate vs. severe. They also indicate when to repair/replace the valve. There are also guidelines available on thoracic surgery such as when a cancer is resectable and when to consider chemotherapy.
Discover the art of surgery
A challenge for anyone new to the OR is learning the flow of a procedure. It’s hard to read about the steps of a procedure and fully comprehend all the nuances. After all, that’s why surgical training takes so long.
Nonetheless, in the modern age, YouTube has great videos about everything from the basics to novel, advanced minimally invasive approaches. CTSnet.org is another resource that has vetted videos, especially those featuring cutting-edge techniques.
These can help you create a mental map of the different steps of a procedure so that you can be more prepared in the OR. I highly recommend checking out surgeries on there before you scrub.
Understand ICU management and care
Finally, a big part of being a cardiothoracic surgeon is understanding ICU management. Post-cardiotomy patients are some of the sickest in the hospital and their clinical status can acutely change in the scale of an hour.
To prepare yourself for this, check out The ICU Book by Dr. Marino. It’s one of the most popular for learning critical care. More specific to cardiac surgery is the “Manual of Perioperative Care in Adult Cardiac Surgery” by Dr. Bojar. This provides more nuance on different cardiac pathologies and how that affects the postoperative management.
To qualify, all of this is quite advanced material that would not be expected to be within a medical student’s scope of knowledge, but it wouldn’t hurt to get an early start if you have the bandwidth!
Home and Away Rotations
This is when you get to show off all the skills and knowledge you’ve acquired! Ideally, your first CT surgery rotation of MS4 year will be at your home institution. This is your time to work as hard as you can. Try and learn everything you can about all the patients on your service. If the workflow of your institution allows it, present patients on rounds and try to suggest plans. Show up to cases prepared about the general steps of the procedure and the indication for why that patient is being operated on.
There’s only so much you’ll be able to do in the OR given the highly technical nature of cardiac surgery, but being able to assist with the Rummel tourniquets during cannulation or intuitively placing chest tube stitches when appropriate will make you appear well-prepared.
Keep a pair of scissors in your hand and be ready to cut suture. You might have the opportunity to do a sternotomy—if so, make sure to stay midline! Many people start to veer towards themselves with the saw as they go down on the sternum, but be sure to keep your elbow aligned with the patient’s midline.
Most importantly, the key to a successful rotation is to be present. If there’s a late aortic dissection coming in through the door, ultimately it’s up to you if you want to stay. However, it’ll give you a taste of the life of a CT surgeon and demonstrate that you’re up for the task at hand. Overall, having a can-do attitude and assisting where you’re able will set you up for success.
When and where should I apply to away rotations?
Be sure to apply to your away rotations as soon as VSLO opens up, as they’re often granted on a first come, first served basis. Be strategic in how you apply. Find a program that offers what you value. Sample criteria include training environment, research opportunities, and location.
It’s hard to get a flavor of a program from just a website, and this is your opportunity to live and breathe a program for a month. You might also find out a place isn’t what you thought it was! Side note, be nice to your future self and be sure to coordinate your living accommodations well in advance.
Tips for Crafting Your Cardiothoracic Residency Application
The cardiothoracic surgery residency application is administered via ERAS by the AAMC. Your medical school should give you guidance on completing the application and writing your personal statement.
Here’s some things to keep in mind when you’re applying for a cardiothoracic surgery residency program:
Be your authentic self
When completing your application, make sure that it authentically represents your story. Try to convey a cohesive message about how your passion for cardiothoracic surgery began and ultimately culminated in applying for a spot in the specialty. If you feel comfortable, share any challenges you’ve overcome as a testament to your resilience.
Choose your programs wisely
When applying, be strategic about how you pick programs. Be aware of those that are integrated-6 years (I-6), 4 years general surgery + 3 years cardiothoracic (4+3), and 5 years traditional general surgery + 2-3 years cardiothoracic fellowship. One attribute to consider is the training length. Keep in mind that some programs require research years during training and that you may have to add up to 2 years to any of these training paradigms.
Evaluate your interest in cardiac or thoracic surgery
Another point to evaluate is your interest in cardiac or thoracic surgery. Many I-6 programs tend to be geared towards cardiac surgery, though there are some that are designed with an emphasis on thoracic surgery. Be sure to talk to your mentors about which training pathway they think will be best for your goals.
Be honest with yourself about how serious you are about CT. If there is some degree of doubt in your mind about CT, or the possibility that you might be interested in another surgical subspecialty, then consider general surgery first.
If you decide to apply to I-6, it’s also a good idea to talk to your advisor about dual applying to general surgery. The market for integrated CT-surgery is quite competitive, with less than 50 spots available nationally each year and a significantly greater multitude of applicants. It’s best to try and maximize your chances of matching.
How to Prepare for Cardiothoracic Surgery Residency Interviews
This is your time to finally reap the rewards of all your years of hard work and punch your ticket into residency. When I was interviewing, 90-95% of interviews were virtual. This balance has since changed as more programs are going in-person so that applicants can get a better sense of the program.
Typically, interviews consist of a meet-and-greet, which offer a more relaxed environment, followed by the actual interview day. Remember that every second is the interview, not just the formal 5-20 minute sessions. So maintain professional behavior at all times. Getting hammered at the pre-interview social is probably not the best look for a CT surgery job interview.
Common Questions to Expect During Cardiothoracic Surgery Residency Interviews
For the actual interview itself, the experience can range from you being asked questions regarding specific clinical scenarios to more casual situations where you can ask questions. A lot of the questions fall into certain buckets.
1. “When did your passion for CT surgery develop?”
The first one relates to when your passion for CT surgery developed. Prepare an answer that’ll make your interviewer understand your interest in CT surgery is a lifetime commitment instead of a transient affair. After all, there are only 1-3 spots at integrated CT programs and training lasts 6-8 years. As such, attrition can have serious implications for the program, and they want to ensure the applicant has done due diligence to ensure this is the right training pathway for them.
2. “How would you handle [hypothetical situation]?”
You may also be asked about how you would react to different situations. For example, you may be presented with a hypothetical situation in which you’re the intern responding to a patient on the floor with unstable vital signs—what are your next steps?
3. “Tell us about your research experience.”
Your research projects will likely come up at some point in the interview as well. If your name is on a manuscript, be able to explain every single detail. You never know what results you might be asked about.
4. “Explain [CT surgery concept].”
Finally, some questions may involve technical knowledge. Be able to explain fundamental CT surgery concepts like how bypass is initiated, or the principles behind ECMO.
Most importantly, just be yourself during the interview. Programs are trying to get a sense of your overall vibe and grit. While it’s no doubt nerve-racking, being your authentic self is the greatest service you can do for yourself.
Post-Interview
Once you’ve had multiple interviews, they’ll start to blur together. Be sure to take copious notes on how you felt about a program during interview day. This is a good method for remembering your interactions with different programs and later deciding where you ultimately want to end up. Take special note of how residents interact with each other and the attendings. After all, the interview is your opportunity to critically evaluate the program, just as they are evaluating you.
Making Your Cardiothoracic Surgery Residency Rank List
Now that all the dust has settled, it’s time to finally make your rank list. Take a moment to recognize all that you’ve accomplished to reach this stage and then start making a list of the factors that are most important to you.
There’s no secret to creating a rank list for cardiothoracic surgery residency programs, but I’d like to strongly emphasize that it should reflect what YOU want. Put aside the influence of online rankings and go with your gut feeling of where you think you might be most happy and fulfilled.
What should I consider when making my rank list?
Impressions from interview day, training culture, and flexibility to incorporate research or other enrichment years are all considerations to take into account. The different I-6 programs may also offer different strengths, like high heart/lung transplant volume or more robotic surgery exposure. Seek out what peaks your interests. Some people are willing to move anywhere in the country, while others have very strict geographic boundaries.
Whatever it may be, start making a list of all the criteria and triage programs into what criteria they fill. Then, you can begin to number them on a list. Once I had created my initial list, I started at the top and compared my #1 and #2 programs. I asked myself, “Would I rather go here or there?”
I then did this for my #2 and #3 and so on, going through my entire rank list is this manner. Remember, the match algorithm is also applicant-focused, as it prioritizes your ranks over those of the institutions:
The most important part of your rank list: REMEMBER TO HIT SUBMIT BEFORE THE DEADLINE!!
I recall when I was a medical student, people always said “You’ll end up where you’re supposed to.” I never quite understood what this meant. However, based on my medical school friends’ experiences and my own, everything works out in the end. Just keep swimming and enjoy the ride!
Parting Advice
A career in CT surgery is highly rewarding. We work with a critically sick patient population, often with life-threatening illnesses, and have the privilege to play an essential role in their healing. This profession also requires complex decision-making and demands superior technical skills, making it attractive for anyone who enjoys a challenge.
Finally, another unique aspect is just how small the community of CT surgery is in the US, on the scale of a few thousand people. It’s humbling to meet giants of the field on the interview trail and later see them at conferences. The peers you’re applying with will also become close friends.
As I progress in my I-6 residency program, I have thoroughly enjoyed my experiences thus far and cannot imagine doing anything else. The path is not easy, but rarely is anything rewarding in life so. For any medical student interested in cardiothoracic surgery residency, I applaud you and cannot think of a more worthwhile endeavor.
