At least one first-author paper is encouraged before submitting applications, as this demonstrates the important ability to lead a project to completion. To maximize productivity, we recommend students pursue 2 or 3 projects concomitantly. In balancing these, prospective applicants should be able to contribute as the second (or third) author on several additional publications. Supplementing original research with literature reviews, book chapters, and case reports is advised. For the most competitive IP applicants, we recommend that at least 5 original articles be submitted, in press, or preferably published by the time of application submission.
Thinking of projects in categories of basic science, clinical research, reviews/textbook chapters, and case reports can guide students in diversifying their publishing profile. Basic science and translational research might be considered the most impressive tier of publications, as achieving the evidence required for novel cellular, molecular, and/or biomechanical conclusions can take years to develop and bring to publication. Longitudinal experience in these endeavors, even when unpublished, can provide fruitful conversations during interviews.
In contrast to basic science, clinical outcomes research for students often consists of retrospective chart reviews. A vast amount of data exists in patient records that must be extracted and evaluated in light of a preformed question and hypothesis. Clinical research comes in many other forms, and one should strive to learn something new from each project, be it data-mining, statistical analysis, survey writing, or even the process of obtaining institutional review board approval. Although there are no guarantees, the chances of securing a publication is greater than with basic science and translational investigations.
For each project, applicants should attempt to present a poster and/or an oral presentation in pursuit of the ultimate goal—publication in a peer-reviewed journal. Do not hesitate to submit abstracts to school conferences or regional symposiums. Each chance to present is an opportunity to build a record of academic success. When applying to competitive scholarships and grants (described below), having a record of presentation even on smaller stages can add merit to one's application. Presenting research at national meetings provides a unique opportunity to interact with CT community members from across the country.
The benefits of identifying CT surgical mentors early in one's education are multifaceted. Students should introduce themselves to their home institution's faculty as soon as they develop an interest in CT surgery. Prospective applicants should inquire about weekly educational CT conferences, as attendance will reinforce their visibility within their home CT division and foster mentor/mentee relationships. Attempt to shadow at least once per month to reinvigorate one's commitment and dedication to the field, particularly during the isolating preclinical years.
Mentors offer research opportunities and can introduce applicants to faculty across the country at national meetings when presenting. Moreover, student's educational opportunities can be maximized in the operating room if trust has been developed over several years, allowing mentors to more thoroughly evaluate applicants in letters of recommendation (LOR). If an applicant's home program has a CT training program, resident–student mentorships can complement these opportunities.
Personal relationships are vitally important in the small community of CT surgery. Both LORs and a program's previous knowledge of an applicant are among the most important factors for offering interviews and ranking applicants (Table 1). While applicants' mentors will serve as advocates and references when applying to residency, developing a personal relationship with faculty at other institutions, including prospective IPs, can provide an invaluable opportunity. 15 One should aim to attend at least one major CT surgical society conference per year. Even when not presenting research, a number of funded programs, scholarships, and research grants exist. The American Association for Thoracic Surgeons has a Summer Intern Scholarship as well as a Member for a Day program; the Society of Thoracic Surgeons offers the Looking to the Future Scholarship; the American Heart Association offers student scholarships in both cardiovascular surgery and cardiovascular disease; the Southern Thoracic Surgical Association and regional societies offer other commemorative medical student scholarships. At many of these programs, events are specifically held so that trainees can network with faculty and program directors in a relaxed atmosphere. Search for these opportunities early and reapply if unsuccessful in the first attempt.
Before meetings, scan the program and determine which faculty will be in attendance, giving presentations, or leading lunch lectures. Do not hesitate to briefly introduce oneself to IP residency directors and other surgeons at appropriate times. 15 Be professional and personable while respecting their time and keeping conversations short. Follow up with a brief e-mail after the meeting, such that if paths cross again in the future, there is a basis for reintroduction. It is surprising how often faculty remember these brief encounters years later when applicants sit for interviews.
Applicants should complete an elective rotation in cardiac and/or thoracic surgery (preferably both) at their home program before leaving for visiting rotations (described below). The home rotation is essential to develop fundamental skills, such that one is not learning the most basic management and procedures while visiting other programs. In the operating room, watch the first-assistant during cases, as trainees will earn the opportunity to assist long before becoming the primary surgeon. Become familiar with each step of establishing cardiopulmonary bypass. Seek out opportunities to put in sternal wires and close the chest, place chest tubes, and bandage incisions. On the wards, become familiar with postoperative intensive care, anticoagulation, and chest tube management. Improve at reading echocardiograms and coronary catheterizations.
Home rotations provide a foundation for auditioning one's abilities at a program of interest during a visiting elective in CT surgery. There is no surrogate for one's performance on a visiting rotation, which can be a serious consideration when programs rank applicants (Table 1). It is no surprise that programs regard candidates more highly if they have favorably interacted with them for an extended period of time. No matter how impressive an applicant appears on paper or during interviews, the risks of matching an unknown candidate are greater for IPs compared with traditional fellowships, where programs would otherwise have feedback from surgeons who have trained residents for years. 5 We believe the best way for applicants to distinguish themselves as candidates is to spend time at the institutions in which they are most interested. For those with less-competitive applications, doing so before interview invitations may increase their chances of securing an interview at that specific program.
As mentioned, differences in IP curriculum may provide trainees varying degrees of exposure to cardiac, thoracic, congenital surgery, and transplantation. 11 Applicants with determined career aspirations should take this into consideration when determining programs of greatest interest. Applicants should access the websites of the programs they are particularly interested in well in advance to determine whether there are specific pre-requisites or qualities that program directors are looking for in candidates. For example, programs requiring 2 years of research during residency may place more weight on an applicant's previous research experience and perceived commitment to a career in academic medicine. Other programs prioritize interviewing applicants who have completed away rotations at their program. In any case, the demand for rotations is often high, so it is important to plan on applying for visiting rotations as soon as applications become available.
Away rotations, while important, can be equally harmful if a student is not able to excel in relation to other students and staff. It can be difficult to develop close relationships in just a 1-month rotation, particularly when applicants are unfamiliar with the institutions at which they are visiting. It is extremely important to demonstrate an ability to seamlessly integrate into the clinical service team. Program directors often speak to their coordinators and other personnel who gain exposure to applicants. Do not underestimate the importance of working well with other thoracic surgery trainees, as well as office staff, and other medical students rotating at the same institution during visiting rotations. The importance of exhibiting professional and courteous behavior at all times, unsurprisingly, is essential.
For financial reasons and scheduling logistics, we suggest completing 2 visiting rotations before interview season (which typically begins in mid-November). These rotations should be regarded as 1-month interviews. This invaluable opportunity can offer programs perspective on an applicant's clinical knowledge, technical skills, and ability to work in teams. In the operating room, demonstrate an understanding of anatomy and physiology, surgical indications and contraindications, major operative steps, and potential complications. Overall, visiting students must exhibit a readiness to perform at a resident level.
Honestly evaluate one's individual performance during a visiting rotation, and only ask for a LOR if one's efforts have truly been exceptional. Faculty recognize the competitive nature of IPs and are usually open to writing LORs. Do not fear that other programs will look down at having spent time at another institution but recognize that these recommendations are also unlikely to significantly influence invitations from other IPs in and of themselves (Table 1). Rather, LORs from visiting rotations should serve as unbiased, outside appraisals of an applicant's clinical performance that provide additional merit to the expectedly favorable recommendations uploaded by home institutions.
Students can submit up to 4 LORs for each IP they apply to. With one visiting rotation as a LOR, we recommend students seek additional letters from the Chair of their home institution's Department of Surgery, as well as their Chief of CT surgery. The final letter should relate to CT surgery and might be a cardiac or thoracic surgeon, or a research mentor. Although only 4 letters can be submitted to any given program, there is no limit to the number of letters one can upload to the Electronic Residency Application Service. As such, for the final letter at each program, it is wise to accrue multiple recommendations and strategically upload them to varying programs. For example, if applicants have 2 close mentors—one who trained at program X, and the other at program Y—consider uploading their respective letters to these programs.
The personal statement provides a unique opportunity to convey one's individuality among a pool of stellar applicants. Along with perceived commitment to the speciality and LORs, the personal statement is the only factor cited by all responding programs as a consideration in offering interview invitations (Table 1). 6 Although a remarkable personal statement is unlikely to secure an interview in the absence of the necessary academic and extracurricular merits, a poorly constructed or unclear statement may be sufficient to preclude further consideration of an applicant for interview. A well-constructed personal statement will succinctly articulate the formative experiences that have led applicants to pursue a career in CT surgery. One should illustrate particularly unique skills and attributes that are applicable to specific career aspirations.
The task is challenging. Begin by asking peers and others who have previously applied to IPs to review drafts as they are rewritten and started anew. Obtain perspectives from a variety of editors, including non-physician CT administrative personnel who may have extensive experience in reading personal statements that range from exceptionally well-written to poor quality. Asking these valued staff to review personal statements can provide honest and reliable feedback from veterans of the process. When a draft nears completion, consider sending it to surgical mentors for final comments and critiques.
In this Young Surgeon's Note, we offer perspective for applicants interested in pursuing IPs while attempting to provide objective benchmarks for developing competitive applications. Exemplary academic performance and extracurricular achievements are undeniable prerequisites. However, perhaps more important is demonstrating an unwavering commitment to CT surgery and ensuring this is articulated throughout one's application and interviews. Although applications will necessarily be customized and illustrate the individuality of each applicant, we hope this Note serves as a guide to early exposure and involvement for applicants interested in pursuing a career in CT surgery via an integrated training pathway.
