Early experience with alternative training pathways: a view from the trenches.

In the United States, alternative training paradigms have been approved for vascular surgery and cardiothoracic surgery. The rate of adoption of these programs has been somewhat slower than was initially predicted. This article will summarize the collective experience of both authors with these programs, describe how they have integrated these new pathways into their university-based training programs, and illustrate the advantages and disadvantages of participation. The alternative training paradigms in vascular and cardiac surgery are similar in that they both allow training in general surgery and the respective subspecialty in 1 less year compared with the traditional pathways. It should be stressed that neither program is associated with a shortening of requirements for generalsurgerycertification;instead,12monthsoftrainingina specialty area (vascular surgery or thoracic surgery) counts toward both general surgery and specialty certification. In vascular surgery, the early specialization program (ESP) allows candidates to convert the “5 2” training paradigm (5 years of general surgery followed by 2 years of vascular fellowship) into “4 2” with board eligibility preserved in both general and vascular surgery. In cardiothoracic surgery, the joint surgery/ thoracic surgery program (JSP) allows trainees a “4 3” experience instead of a “5 2 or 3”. The 2 programs differ in that ESP participants complete all or most of their general surgery training by the end of the R4 year, whereas JSP residents have a blended thoracic and general surgery experience during R4 and R5. In the ESP, the chief resident experience in general surgery occurs during the R4; in the JSP, the chief residency year in general surgery is shared between the R4 and R5 clinical years, and it is intermixed with additional months of cardiothoracic training. Essentially, the ESP resident completes the general surgery experience before matriculating into vascular training, whereas the JSP participant gains an additional 12 months of cardiothoracic surgery training before completion of the combinedprogram.Boardeligibilityinbothgeneralsurgeryandthe respective subspecialty are achieved in these pathways. The authors have had the largest experiences in the country with the early specialization program (ESP) and the joint surgery/thoracic surgery program (JSP) pathways. The purpose of this article is to describe the combined experience of both authors with these 2 training pathways at Barnes Hospital/ Washington University (Barnes/WU) and University if Texas Southwestern (UTSW), where both authors serve as general surgery program directors. Both programs were early adopters of these alternative pathways, and they currently have trainees in both tracks. The authors acknowledge that the combined experience is too early and the number of participants too few to reportmeaningfuldatathatmightbeusedtocompareeducational outcomes with the traditional pathways. Likewise, the impact of shortened training pathways on patient safety, medical training costs, and benefit to society as a whole will need to await the analysis of a larger experience. Nevertheless, the authors have learnedseveralpracticallessonsfromadoptingthesenewprograms