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Cardiothoracic Surgery Training Pathway

How to become a cardiothoracic surgeon in Australia — direct entry onto the single national RACS program, the scored national selection, the hard logbook and publication prerequisites, and a famously tiny intake.

One bottleneck, but brutal: getting selected. RACS runs a single national merit selection (CV 20% + competency 20% + interview 60%, times a referee score) for a tiny intake — published offers of 6–13 a year. To be eligible you need 12 months of cardiothoracic experience, a logbook hitting hard minimums, a first-author paper and the GSSE; from 2026, a maximum of three attempts.

Why cardiothoracic surgery

You operate inside the chest on patients who are often acutely unwell: coronary bypass grafting, valve repair and replacement, aortic surgery, lung resections for cancer, and management of cardiac and thoracic trauma. Days are long and physically demanding — cases run for hours, you work with cardiopulmonary bypass and perfusionists, and the post-op patient is in ICU on inotropes and a ventilator, not on a ward. Trainees spend years as first assistant before being trusted to do index cases, and on-call is heavy: aortic dissections, tamponade and bleeding chests don't wait. It is one of the highest-acuity, highest-stakes surgical lives there is, and the feedback loop is immediate — what you do on bypass shows up in the next hour, not the next clinic.

✓ Draws

Direct entry — selected straight onto a cardiothoracic program from SET 1, no second Advanced-Training bottleneck
The most dramatic operative surgery in medicine: heart, lungs and great vessels, with immediate physiological feedback
High earning potential at consultant level (private cardiac/thoracic lists), though the ATO does not publish a cardiothoracic-specific income line
Small, tight specialty community with strong mentorship and a clear, published curriculum

⚖ Trade-offs

Tiny national intake (single digits most years) makes selection one of the hardest in the country
Six years of demanding training with heavy on-call, long cases and a respected exit exam
Consultant job market is genuinely tight — fellowships abroad and waiting for posts are common
Lifestyle cost is real: poor predictability, sustained physical demand, and emotionally heavy outcomes

Subspecialties

Adult cardiac surgery (coronary, valve, aortic)Thoracic / general thoracic surgery (lung cancer, oesophageal, mediastinal)Paediatric / congenital cardiac surgery (a distinct sub-track within SET, e.g. RCH Melbourne)Heart and lung transplantation and mechanical circulatory supportAortic and endovascular thoracic surgeryMinimally invasive / robotic cardiac and thoracic surgery

The training pathway

The same fellowship, two very different timelines. The fast route assumes everything goes right; most people land on the realistic one.

Fastest route

~8 years post-MBBS to Fellowship (structural floor)

Internship and residency used efficiently to build the cardiothoracic logbook and research, selected onto SET at the earliest plausible point (PGY3–4), then six years of SET completed without interruption. Almost nobody does it this cleanly — research years, repeat applications and exam attempts add time.

Internship (PGY1)

1 yr

General registration with AHPRA. Get exposure to surgery and critical care; cardiothoracic-relevant terms (ICU, cardiology, surgery) start to matter for eligibility.

Residency / unaccredited cardiothoracic terms (PGY2–3)

1–2 yrs

Work cardiothoracic surgery terms (need 12 months total, ≥6-month blocks at PGY3+), build the logbook (sternotomies, conduits, first-assists, chest drains), pass the GSSE, get a first-author publication and an oral presentation.

SET selection

—

Single national RACS merit selection: CV 20% + UBCA 20% + interview 60%, × referee score. Tiny intake. Eligibility gates must all be met before you can even be scored; max three eligible attempts from 2026.

SET 1–4

4 yrs

Accredited cardiothoracic rotations (six-month terms), allocated by the Committee. Pass the CSSP exam (two MCQ papers + anatomy viva) by end of SET 4; submit thesis within 4 years of starting SET.

SET 5–6 + Fellowship Exam

2 yrs

Senior operating, complete logbook minimums (≥75% before sitting), pass the RACS Fellowship Examination (two written papers + five clinical/viva segments). FRACS (Cardiothoracic Surgery).

Realistic route

~10–13 years post-MBBS to consultant

The honest version. Most do extra unaccredited years to become competitive, many apply two or three times before selection (now capped at three eligible attempts), a dedicated research year (often a higher degree) is common, and a post-Fellowship overseas or sub-specialty fellowship is near-standard before landing a consultant post in a tight market.

Internship + residency (PGY1–2)

2 yrs

General registration, broad terms, first cardiothoracic and critical-care exposure.

Unaccredited cardiothoracic / surgical years (PGY3–5)

2–4 yrs

Service registrar in cardiothoracic units building the logbook and references, sitting and passing the GSSE, and often a research year/higher degree to build the publication and presentation portfolio. This is where most of the 'lost' time goes.

SET selection (often 2nd or 3rd attempt)

—

Single-digit national intake; no published applicant-to-offer ratio, but most strong applicants reapply. UBCA (your home unit's assessment) and referee scores matter enormously. Maximum of three eligible attempts from the 2026 round.

SET 1–6

6 yrs

Six years of accredited training, CSSP by end of SET 4, thesis, then the Fellowship Exam in SET 5/6. Interruptions for research or family extend this (max 10 years allowed to complete).

Post-Fellowship fellowship + first consultant post

1–3 yrs

A sub-specialty or overseas fellowship (transplant, aortic, MIS, paediatric) is near-standard, partly by choice and partly because consultant jobs are scarce. Then the wait for a substantive appointment.

How competitive is it?

Cardiothoracic is one of the hardest specialties in Australia and New Zealand to enter, driven by scarcity rather than by a published cut-off. RACS runs a single national selection and published these SET offer numbers: 13 (2019), no round in 2020, then 6 (2021), 7 (2022), 6 (2023), 9 (2024) and 8 (2025) — figures include deferred offers. RACS does not publish how many people applied, so there is no official applicant-to-offer ratio or success rate — but a single-digit national intake set against a much larger pool of eligible, portfolio-heavy applicants is the whole story. Unlike physician training there is no second Advanced-Training bottleneck; the entire contest is the front door, and the interview (60% of the score) plus your home unit's UBCA and referee scores decide it. Two structural notes: applicants get a maximum of three eligible attempts from the 2026 round, and the RACS Clinical Examination was a selection prerequisite up to the 2026 intake but is being removed from 2027 selection (2028 intake) onward.

Unaccredited time: Effectively yes — although SET is direct-entry with no formal 'unaccredited registrar' requirement, in practice almost everyone does 1–3+ years of service cardiothoracic/surgical terms (often plus a research year) to meet the logbook, publication and experience gates and to be competitive. The eligibility floor alone (12 months cardiothoracic experience, hard logbook minimums, a first-author publication and an oral presentation) usually can't be met straight out of residency.

Sources: RACS — Cardiothoracic Surgery selection page (yearly offer numbers, CE removal), RACS — 2026 Selection Regulations for SET in Cardiothoracic Surgery (2027 intake) (PDF), RACS — Guide to SET: A Comparative Guide of Surgical Specialties (PDF).

Selection criteria & how to apply

Cardiothoracic selection is unusual among RACS specialties in that it DOES publish explicit percentage weightings. The 2026 Selection Regulations set a national score out of 100: Structured CV (with the cardiothoracic logbook) 20%, Unit-Based Competency Assessment (UBCA) 20%, and a semi-structured interview 60% — and the combined score is then multiplied by a structured referee-check score (two referees chosen at random, each answering five questions scored out of 10, giving an adjustment factor out of 100). Before any of that, an application is dismissed outright unless it clears hard eligibility gates: the required cardiothoracic and non-cardiothoracic experience, the signed logbook minimums, and at least one scoring first-author publication and one oral presentation. Interviews are offered to roughly the top 36 ranked applicants on the combined CV+UBCA score, and the highest-ranked 16 are then shortlisted on interview performance for the referee check. The CV sub-score is explicitly capped at 14 points across additional qualifications (max 2), publications (max 5), presentations (max 3), involvement in Te Ao Māori (max 3) and rurality (max 1). From the 2026 round, applicants get a maximum of three eligible attempts.

Structured Curriculum Vitae + Procedural Skills Logbook20%

Scored out of 14 points (the CV score sheet is explicit: 'Overall Maximum of 14 Points'): additional qualifications (e.g. cardiac ultrasound/echo or anatomy diplomas) max 2; one highest first-author publication max 5 (tiered by journal H-index — Tier 1 >501 = 5 pts, Tier 2 101–500 = 3 pts, Tier 3 <100 = 1 pt, via SCImago); one highest oral presentation max 3 (international 3 / national or bi-national 2 / state 1), plus minor local mini-oral/poster presentations at 0.5 pt each up to 2; involvement in Te Ao Māori max 3; rurality max 1. At least one scoring publication AND one scoring presentation are mandatory to progress to interview.

Unit-Based Competency Assessment (UBCA)20%

An online, confidential consensus assessment completed by the cardiothoracic unit you nominate (you must have worked there ≥12 months) on your clinical/technical aptitude, communication, workplace behaviour and suitability. Your reputation and performance in the unit you work in genuinely move your rank — and being marked 'not suitable' makes you ineligible. This rewards being a strong, known quantity in a real cardiothoracic team.

Semi-structured interview60%

Held in June (RACS Adelaide office for the 2026 round / 2027 intake). At least three panels of at least three interviewers, ~20-minute stations totalling ~60 minutes, one of which may be a computer-based scenario station. Explores clinical experience, judgement, insight, self-motivation, ethics, teamwork and non-technical professional skills. By far the largest single component.

Structured referee check (multiplier)Applied as a %

For the top-16 shortlist, two referees are chosen at random from the 3–5 you nominate; each answers five structured questions marked out of 10 (max 100), giving an adjustment factor. Final score = Total Interview Score × adjustment factor, so weak references drag down an otherwise strong rank.

Eligibility gates (pass/fail, not scored)Eligibility

GSSE passed; (for the 2026 intake) RACS Clinical Examination passed — being removed from the 2027 selection / 2028 intake onward; 12 months cardiothoracic experience (≥6-month blocks at PGY3+, splitting 9 cardiac / 3 thoracic if units are separate); 12 months non-cardiothoracic surgery; logbook minimums (10 sternotomies, 50 conduits incl. ≥10 radial harvests, 10 chest-drain insertions, 50 cardiac first-assists, 20 thoracic first-assists); EMST/ATLS and CCrISP courses; intercultural competency modules.

Key documents: RACS — 2026 Selection Regulations for SET in Cardiothoracic Surgery (2027 intake) (PDF), RACS — Cardiothoracic Surgery CV Selection Score Sheet (2026 / 2027 intake) (PDF), RACS — Cardiothoracic Surgery selection requirements & process, RACS — Generic eligibility requirements for SET selection.

How it works in each state and territory

Cardiothoracic selection is national, not state-based: you apply once to the RACS Cardiothoracic Surgery Training Committee through the RACS online system, and the Committee (not a state health department or a computer match like PMCV) selects trainees and allocates them to accredited posts across Australia and New Zealand. So the thing that varies by state is not the selection process but where the accredited adult and paediatric cardiothoracic units sit — and the units are concentrated in a small number of tertiary centres. (Applicants do indicate a regional preference — NSW, QLD, SA, VIC/TAS, WA or NZ — for their initial SET years.) State health departments still run the day-to-day employment, payroll and junior/unaccredited cardiothoracic registrar jobs that you use to build eligibility. Per-state SET position counts are not published as a quota; the national intake is single digits in total, and RACS publishes the accredited posts (each carrying 1–2 training posts) in its accredited-hospital-posts list.

NSW

Who runs selection: National RACS selection (RACS Cardiothoracic Surgery Training Committee); NSW provides several of the country's largest accredited adult cardiothoracic units. Junior/unaccredited cardiothoracic registrar jobs are advertised through NSW Health (HETI / hospital recruitment).