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Cardiothoracic Residency Gains Professional Pinnacle

   Portland, Ore.

An OHSU program that was close to being shut down five years ago has been rebuilt under Dr. Ross Ungerleider's leadership into a model of the residency education of the future

Kai E. Engstad, M.D. -who has just started his residency in cardiothoracic surgery at Oregon Health & Science University - is engaged in a training regimen that has vaulted in five years from near extinction to a pinnacle of professional respect nationally.

Over the next two years Engstad will follow an exacting program that recently earned a rare "perfect" accreditation rating from the Thoracic Residency Review Committee of the American Council for Graduate Medical Education (ACGME). Five years ago the OHSU program was on probation and at risk of being shut down.

Engstad, who looked at 25 different cardiothoracic residencies across the country, was one of 31 applicants for OHSU's single slot. "I was lucky enough to match here," said the 31-year-old native of Victoria, British Columbia. The number of applications for the OHSU residency itself is a measure of the program's growing reputation. Residency spots in cardiothoracic surgery nationwide are going begging because of a paucity of applicants, but the applicant pool has been rising steadily for OHSU's program, which at any one time will have two residents - one starting and one completing the two-year program - about the same number as are trained in programs elsewhere in the country.

The ACGME review committee's seal of approval constituted formal recognition of a remarkable turnaround led by the program's director Ross Ungerleider, M.D., OHSU professor of surgery; head, Division of Cardiothoracic Surgery, OHSU School of Medicine; and John C. Hursh Chair in Pediatric Cardiac Surgery at Doernbecher Children's Hospital. When Ungerleider took charge of the residency in 2001 he undertook - with the assistance of Jamie Dickey, Ph.D., OHSU professor of nursing education - a radical overhaul of a program that he said had been neglected for years. He instituted a new curriculum, a new evaluation process, an online competencies training course and a wide range of other innovations. Dickey, whose doctorate is in educational psychology, also is Ungerleider's wife.

Ungerleider set out not just to rescue the program but to build a new template "to show," he said, "what the residency education of the future would look like." And the review committee, after its site visit earlier this year, agreed that he and the OHSU faculty had succeeded. In an unusual commendation, they cited the program as a best-practice example for the entire graduate medical education community."

The program Ungerleider has built emphasizes, as he puts it, "skills and knowledge that extend beyond the boundaries of medical knowledge and surgical studies, and include things like emotional intelligence, leadership, professionalism, interpersonal and communication skills, and efficient, timely, equitable, unprejudiced and patient-centered care."

"We basically added into our curriculum a way to teach these elements and then created an evaluation tool that consists of day-to-day coaching that is exploratory rather than critical or judgmental. We're trying to integrate a mindset to help residents understand where the ever-moving edges of their competency are, something that no place else in the country has yet."

 "I think what the ACGME was most taken by was the understanding reflected in our program that our mission was not only to offer structured education that was well managed but also to teach residents to be learners," said Ungerleider. "It's unrealistic to think that after two years of training you can do everything. I've been practicing now for 30 years and I'm still learning, because the field keeps changing. I'm doing operations now that we weren't doing back then; I'm using equipment that wasn't invented back then. If I weren't able to learn I would have gotten stuck.

"We don't want residents who train here to get stuck. In fact, we defined a competent surgeon as one who knows his or her limitations and knows that it's not a sign of weakness to ask for help, with the proviso that your limitations are understood to be 'at this time.' At this time I need help and maybe in three years, when I'm better at this, I won't."

Engstad is no neophyte. He has four years of medical school (St. George's University, Grenada) and five years of general surgery training (Brooklyn Hospital Center in New York and Saint Barnabas Medical Center in New Jersey) under his belt. In his first rotation, which runs through September, he is managing patients undergoing thoracic surgical procedures at both OHSU and at the Portland Veterans Affairs Medical Center and delivering case presentations at Monday morning teaching conferences.

He also is deep into a structured program of reading that will continue throughout his residency, absorbing the core information all cardiothoracic surgeons need to master. In subsequent three-month rotations through 2007, he will be exposed to the gamut of cardiothoracic cases from pediatric surgery to coronary artery disease, from valvular heart disease, routine coronary artery bypass grafts and aortic and mitral valve repair and replacements to the evaluation of hearts and other organs for transplantation. His final year as a resident will culminate with a research project for publication.

"It's apparent," Ungerleider concluded, "that the reputation this program has now as a place to go to train is among the best in the country, and that's what we set out to do."

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