TGH - Thoracic Anesthesia

(3-4 positions annually)

Clinical Curriculum

Surgical oncology procedures make up the bulk of thoracic surgery at the Toronto General Hospital. Interventions for lung cancer vary from diagnostic procedures to minimally invasive resection (video-assisted and robotic thoracic surgery) to major incision and resection. There is an active caseload of esophageal surgery, both resection and reconstruction for cancer and functional surgery for benign disease (anti-reflux surgery, etc.). It’s a referral centre for major airway surgery; airway stenting, resection, and reconstruction are frequent. Thymectomy is also routinely performed, both for malignancy and for the treatment of myasthenia gravis. A comprehensive approach to acute perioperative pain practice in thoracic surgery patients includes multimodal systemic analgesia, the use of truncal blocks, and epidural placement.

There is emphasis for fellows to become proficient at the care of patients with end-stage lung disease undergoing high-risk surgery: lung transplantation (approximately 200 cases per year), pulmonary endarterectomy (60–70 cases annually), and lung volume reduction (10–15 cases per year). The anesthesia department plays an active role in the assessment, selection, and perioperative management of these cases. Thoracic anesthesia fellows gain extensive experience in a number of extracorporeal life-supporting technologies. ECMO, both veno-venous and veno-arterial, is used as a treatment for acute lung injury and hemodynamic failure, respectively. Intra-operative ECMO support is common during lung transplant surgery and less commonly used for bridge-to-transplant or bridge-to-recovery scenarios.

The fellowship aims to offer two thoracic days per week, factoring in on-call duties and case availability.

Call duties

At this time, calls are made from home for lung transplants and pulmonary endarterectomies in a one-in-three to four-week rotation, including approximately two weekends per month.

Potential applicants from countries with limits on working hours should note that no such legislation exists in Canada. It would be impossible to gain the level of experience for which we are known if there were. However, we aim to make sure no one works >24 hours unless they have had sufficient rest and wish to finish their overnight cases.

Education Curriculum

Weekly teaching sessions are held Tuesdays at 17:00, covering various TGH practice-specific topics. Echocardiography lectures and case discussion rounds are done Wednesdays and Thursdays at 17:00, and attendance and participation are encouraged. Monthly professor rounds are organized on Mondays at 17:00. Departmental rounds are scheduled for Friday mornings at 07:30.

A fellow-lead journal club/topic discussion round focusing specifically on thoracic topics has recently been initiated, running every 4-6 weeks.

Multidisciplinary meetings for discussion and selection of patients for lung transplant listing and pulmonary endarterectomy surgery are also weekly, and thoracic anesthesia fellows are welcome to participate.

Research

Participation in research and education is encouraged. Research opportunities can be integrated into the fellowship, with academic time provided to those involved in projects, with a goal of one non-clinical day per week up to a maximum of 40 days over a 12-month fellowship period. Frequently, there are ongoing trials in which fellows may participate, or they may embark on their own individual research projects. Recent study opportunities include transfusion management during ECMO-supported lung transplantation and coagulation profiles in pulmonary endarterectomy patients. Quality improvement and assurance projects are also an area of interest.

Participation and presentation at academic conferences are encouraged. Travel grants are available for research presentations at eligible North American meetings.

Applications and Inquiries

The fellowship is aimed at anesthesiologists in their early professional careers. Interested applicants need to have successfully completed all the required anesthesia examinations, be registered with the official regulatory authorities, and have at least 5 years of anesthesia training and experience at an academic centre. (1 of the 5 years may include a rotational year, also known as an internship, houseman year, or medical officer year).

Experience as a staff anesthesiologist based in the operating room in an academic setting for 1-2 years is strongly advised. Your clinical anesthesia practice should be current, and exposure during the preceding three years of a fellowship should have a strong operating room component.

You will need to have significant experience managing life-threatening situations such as massive transfusions, cardiac failure, critical vasoplegia, hemodynamically unstable arrythmias, and profound fluid shifts before you start this fellowship. This is not the opportunity to acquire this experience; you will need to feel comfortable independently in such situations when you arrive. We are here to teach you the technically demanding subspecialty of thoracic anesthesia, preferably so that you go on to do thoracic anesthesia in your consultant life, not give you an opportunity to gain “big case experience.”

It is very hard to come to a new country with a completely different medical system and culture, possibly in a second language, and jump straight into doing some of the most complex anesthesia there is. We often offer people a 6- to 12-month placement in our Advanced Clinical Practice (ACP) fellowship, which offers excellent experience in non-thoracic anesthesia cases in its own right, as a way into our program with a “softer landing." It’s an opportunity to get used to our department and Canadian practice without the intensity of the thoracic fellowship and for us to get to know you with a view to offering you a thoracic fellowship if all goes well.

A current and valid ACLS certification is a requirement.

Shortlisted candidates will be contacted 12–18 months before the tentative start date for reference letters and to further the application. Please do not send any reference letters until requested to do so.

Successful candidates will be notified about 9–15 months ahead of a potential start date. An interview may be required.

Begin Your Application

Applicants can apply using the online platform:

• The January 2025 application process has closed.
• If you are interested in applying for July 2025, please complete this online application form.
• If you are interested in applying for January 2026, please complete this online application form.

Send direct inquiries to:

Dr. Adam Snyman
Coordinator, Fellowship Program
Toronto General Hospital
200 Elizabeth Street, EN3-438
Toronto, ON, Canada M5G 2C4
adam.snyman@uhn.ca