Maximising the FY2 Cardiothoracic

Maximising the FY2 Cardiothoracic Surgical Placement

Jeremy Chan, ST1 Cardiothoracic Surgery, Wales Deanery Najeeba Lallmahomed, Foundation Year 2, Wales Deanery Harry Smith, Foundation Year 2, Wales Deanery Amer Harky, ST5 Cardiothoracic Surgery, North West Deanery

The cardiothoracic surgical workforce has been transformed significantly in the last 10 years due to the impact of the European work time directive, difficulties in recruiting junior doctors and reduction in training and teaching opportunities secondary to service provision.

Several hospitals adapted the impact of such changes into their training structure, including the introduction of advanced clinical/nurse practitioners (ACPs/ANPs), Surgical Care Practitioners (SCPs) and Advanced Critical Care Practitioners (ACCPs) has been proven to be a successful move. The use of ACPs/SCPs/ACCPs has largely replaced the need for Senior House Officers (SHOs), allowing junior doctors to maximise the training opportunities without the need for service provision. Despite such reductions; several deaneries do offer a small number of rotations for Foundation Year 2 (FY2) doctors to experience the speciality. Currently, there are three FY2 posts in Wales offering a 4-month rotation in Cardiothoracic Surgery; while limited rotation within the North-West deanery. We aim to share some tips for upcoming FY2s, who have interest in becoming a cardiothoracic surgeon, to maximise the training opportunities within the rotation.

Clinics and pre-operative assessment

Pre-operative outpatient clinics are mainly led by speciality registrars and Consultants. We recommend reading about the indication on surgical interventions prior attending the pre-operative clinic. It would be useful to apply the indications into the specific case and discuss with the seniors. Attending the cardiac/thoracic surgical multidisciplinary team (MDT) and reviewing in-hospital referrals with the speciality registrars would also be beneficial. Understanding the basics of the core investigations will be an important part of this process as well.

Operative experience

Saphenous vein graft (SVG) harvesting is one of the first cardiac surgical procedures FY2s will learn. SVG harvest involves a number of basic surgical skills including incision, tissue handling, dissection, and precise knot-tying. All of which needs to be performed within a particular time frame. SVG harvesting allows junior surgeons to acquire and develop a number of basic surgical skills regardless of future speciality of choice. FY2 should aim to harvest one length of vein under supervision within the rotation. Under supervision, one may have the opportunity to perform a number of median sternotomies. More importantly, one should aim to be an effective 2nd assistant and help the “flow” of the operation. Recognising the steps of the operation and acting in advance would certainly benefit your future career in cardiac surgery. While in thoracic surgery, assisting video assisted thoracoscopic surgery (VATs) perfectly will be highly appreciated by the operator and chances to perform basic VATs procedures will certainly arise.

Post-operative experience

One of the main duties for FY2s is to manage cardiothoracic surgical patients in the ward. Most patients would be stable by the time they are discharged back to the ward. However, it would be extremely useful to learn about the acute/ late complications after cardiothoracic surgery and identify patients that is/ has the potential to deteriorate. Escalate and discuss your concerns to the seniors promptly would be highly appreciated by your seniors! Experience in cardiothoracic surgery intensive care unit is also extremely valuable. FY2s are not expected to manage patients independently in the ITU, instead, one should aim to understand the principles of post operative management of cardiothoracic surgical patients. During the 4-month rotation, one should aim to manage common conditions post-operatively such as arrhythmias, chest drain and wound management under supervision. One of the best ways of understanding this pathway is by following a patient that you attended his surgery and understand the journey till he is discharged from the hospital.

Academic achievements

We recommend FY2s to complete 1-2 audit(s)/projects during their rotation, with an aim to present at the SCTS Annual Meeting. The annual meeting is one of the best places to meet other junior doctors and consultants to share some tips and experience in cardiothoracic surgery. Publications in cardiothoracic surgery is not easy but not impossible. Be enthusiastic and speak to the consultants for opportunities in advance.

Lastly ...

We encourage to FY2s to follow-up the patients peri-operatively. Seeing the patients in advance if you are allocated to theatre the next day. It would also be highly useful to review all the patients you have been involved in. In short, the cardiothoracic surgery rotation during FY2 is rare but highly educational. Not all FY2s will enter the speciality, but the skills are highly interchangeable and will benefit most in their future career regardless of their choice of speciality. n