Cardiothoracic Surgery: Is it worth it?

Originally posted by MrGreed
In other words, would going through a minimum of 8 years of training after medical school be worth it?

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With a name like Mr. Greed, I think you should concentrate on becoming a hospital administrator. $250-500,000 per year without the 8 years of post-graduate training.

Originally posted by MrGreed
The numbers of surgeons who are applying to cardiothoracic surgery fellowships has dropped off significantly. This will obviously translate into a shortage and increase demand in the future.

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Not necessarily. Just because there are fewer applicants doesn't mean there will be a shortage - remember you have to maintain or increase supply as well.

The reason applications to CT fellowships have fallen off is that it is widely considered a dying field. With the advent of stenting procedures, a healthier population and the encroachment of interventional cardiologists, many are finding that the lengthy training, repetitive procedures and falling reimbursement are NOT worth it.

Hey, if you want to become an orthopedic surgeon, but radiology offers same compensation, yet 12+wks of vacation as opposed to 3 wks vacation in surgery, what should you do?

I understand that any kind of surgery is more rewarding, but i feel financially it is a rip off. So should i forget it?

Please tell me that there is something cool about radiology, or that ortho surgeons can have more vacation!

Originally posted by MrGreed
The numbers of surgeons who are applying to cardiothoracic surgery fellowships has dropped off significantly. This will obviously translate into a shortage and increase demand in the future. Will this also mean significantly higher compensation? In other words, would going through a minimum of 8 years of training after medical school be worth it?

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Actually, workforce estimates for cardiothoracic surgery are all over board. The effect of better stent techniques could well reduce the number of traditional bypasses being done. Mind you, simultaneous to this is the development of minimally invasive bypass techniques off bypass that may be a better long term tx. for many patients. In point of fact the usual training length is currently 7 years if you do not do lab time, and will very shortly be down to 6 years as the pilot 4+2 programs spring up in the next year or two.

Could you please give more information about these 4+2 programs? Definately sound interesting, and have several friends interested in CT surg.

I understand there is a dropoff, but are all the slots still being filled? Shortage wouldn't seem imminent unless they're unable fill all training slots (and demand stays the same).

The American Board of Surgery has given the OK for the 4+2 model to be started, which would also make you board-elgible in gen. surgery as well. A lot of Program Directors are discussing it (pro & con). I don't know who will be the first programs to try it, I would bet some people try it with in-house candidates first to see if the model works @ their institution. You'd need to talk to your CTVS division to see if they're contemplating it.

And No, all the training positions have not been filled for the last several years. I'm not sure where they were, but they were not any of the more desirable ones.

Apparently Vascular Surgery & Peds Surgery are much closer (especially Vascular) to coming up with their own 4/2 programs as well then I was aware of until recently. CTVS had a head start in the organizational process which is why they'll have some prototypes first

ljube_02,

If you are so worried about vacation time, radiology is definitely the right choice for you. Anyone that would even consider looking at pictures over nailing the fracture doesn't belong in ortho.

True -

If you love ortho, you will never be satisfied with meerly describing the fracture - The thrill comes in making it look like new!

A reply to the original post: why cardiothoracic surgery? Here's a rationale:

I am applying for GS currently, and am considering CVT surgery following (though who could say, so far ahead.) First, my argument for does not concern money. Second, I think that one possible argument against GS is the viewpoint that while academic centers are interesting, private practice offers a lot of appendectomies and gall bladders with the occasional bowel resection or breast biopsy, which is a pretty narrow scope in comparison with the training. In contrast, with an additional 2-3 years one might train for CT, which seems like one of the broadest scopes of surgery. There are many programs offering CVT these days (cardiothoracic vascular) where you can do CT AND VASCULAR work, possibly learning IR techniques with the vascular. Thus a CVT surgeon might do general thoracic, valves, CABG, interventional radiology vascular, regular vascular, all in a week's work--widely varied stuff. Third, CVT surgery offers the chance to work on sicker, ie more interesting patients. Fourth, technically interesting cases. Thus, CVT offers, just what I want: a wide variety of intricate surgeries on very sick patients.


J

I dont understand why ortho (and other surgeons) dont like vacation??
i.e. if there are 6 surgeons in a group, why cant they each take 10wks vacation per year? it will cut their salaries a bit, but the patients still get treated by the other surgeons...

Originally posted by Jay Shoaps
A reply to the original post: why cardiothoracic surgery? Here's a rationale:
Iin comparison with the training. In contrast, with an additional 2-3 years one might train for CT, which seems like one of the broadest scopes of surgery. Thus a CVT surgeon might do general thoracic, valves, CABG, interventional radiology vascular, regular vascular, all in a week's work--widely varied stuff. Third, CVT surgery offers the chance to work on sicker, ie more interesting patients. Fourth, technically interesting cases. Thus, CVT offers, just what I want: a wide variety of intricate surgeries on very sick patients.
J

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My son you have so much to learn Cardiac surgery is prob. one of the most repetative & least varied fields around. Due to the workload & referral patterns you tend to the same operation (CABG) over & over again. Valves are fairly rare & tend to cluster among members of your group who specialize in them. Most CTVS surgeons end up doing very little general thoracic traditionally unless they have a special interest. Many that do quit doing cardiac & just do thoracic & +/- vascular. As it stands now there are no real oppurtunities for expanding the field into the cath lab @ any place I've heard of (although it seems to me it's what they'll need to do to survive as a specialty eventually IMO). In addition you just don't have enough time to learn the IR skills with the current setup & the coming ACGME work hour rules (Which will apply to fellow as well ) are another roadblock to some of these proposals for the fellowship training.

While the distal anastamosis of a CABG is somewhat technically challenging, it becomes rote after thousands of them when the thrill is gone with doing the same operation. The prospect of operating on this group of sickly patients tends to really lose its luster as well when you & your partners are getting called on them @ night or having to reoperate emergently

I think cardiac surgeons will survive, even without taking on additional responsibilities like stenting. Why?

1. Not every patient is a candidate for stents,
2. Stents fail eventually, and you can only stent so many times (the newer stents last a lot longer, especially those that are medicated),
3. Patients will always need heart valve replacements,
4. The future of transplant programs has been unrealized.

Granted that the majority of CT surgeons will not do transplants, those that do a sub-fellowship in transplant surgery will have a leg up on their counterparts. Our baby boomers are an aging population, and because of this, one can expect a larger number of valvular procedures and bypass candidates. Notice the keyword: candidates. With advances in stenting, these candidates may go for stents rather than bypasses.

CT surgeons may take on stenting. Personally I think they should. Why? At many hospitals, including my own, the interventional cardiologists cannot stent unless their is a CT surgeon and OR team in the hospital on standby. So it equates to a surgeon getting paid to sit around and watch TV. For some this may be exactly what they want -- getting paid to do nothing. For others, they would rather just do the procedure and get more money and have more fun. Perhaps it makes more sense for the surgeon on standby to do the procedure, too. That way, you save a buck or two. (heh, I couldn't resist! Eva Savalot is proud of me!)

It's not a question of "surviving" really, but rather a potential future where you'll need a lot fewer surgeons doing Coronary bypass. The newer generation of stents and future gene-directed therapy for intimal hyperplasia is really going to dramatically change the field for both CTVS and cardiology. There's even the first generation of endovascular replacement of valves being done in Europe. What all that means for the workforce is open to debate, but clearly the field will have to change or whither. The cath lab is the logical extension for the surgeons (as you've seen with vascular surgeons), but this will run head long into what the cardiologists feel is their exclusive turf and many battles for privledges loom there. If you want to get experience in this now as a heart surgeon, you have to go to Europe. As far as the transplant field....those patients will continue to make up just the tiniest % of patients we're talking about, & those all cluster at tertiary centers (usually University Hospitals). Most practicing surgeons will never do another transplant or pediatric case after their fellowship. The broad-based CTVS surgeon in metropolitan areas is a very rare breed these days, as increasing specialization is the rule. Logistics and practice patterns also get very diffucult when you mix these very different patient groups together, and most of the surgeons will lean towards thoracic or cardiac for that reason

What are your opinions on how ventricular assist devices (VADs) and possibly a total artificial heart will potentially affect CT surgery workload?

Mr. Greed-
To answer your second question first - I'm almost halfway through my surgery internship and I have no regrets about my choice of career or program. While difficult, I truly have enjoyed this year and don't see that opinion changing anytime soon. As for other promising surgery subspecialities - think baby boomers. What will the demand be in 10-20 years when the baby boomers start to get sick and need surgery? I think vascular (and endovascular) will be in demand, as will surgical oncology. I also don't agree that CVTS is a dying field. It's scope may change, but I think there will always be a demand for it. If that's what you're interested in, then go for it. Laparoscopic surgery will also be a large force in the market, but I see a day when it will become so incorporated into the general surgery residency that you won't necessarily have to do a fellowship to feel comfortable doing advanced laparoscopic work. Time will tell. Best of luck to you!

I have a couple questions (probably naive, but hey...) on this topic....

First, I've read/heard that vascular surgeons are similarly and perhaps more often griping about lost caseloads and dramatically diminishing pay, etc.--the same old jazz, worrying about the future of their field as a single specialty. Perhaps justification to such concerns, most stats show average salaries for vascular surgeons above only general surgery without specialization among the general surgery-based specialties.

However, thoracic and cardiac surgery still seem to always top the charts in terms of compensation, being up there with neurosurgery and some of the ortho specialties like spine, hand, etc. Granted this is likely a decrease from the 80s and 90s when real pay was seemingly even higher, but it seems the specialty is hardly just scraping by in terms of compensation compared to other specialties. Does this not have any bearing on the opinion as to whether it is truly a "dying" field or not?

In other words, it would seem like an NBA player lamenting whether professional basketball is a dying sport, given they're some of the highest paid pro athletes out there.

Second question....I've only read/heard of two integrated thoracic programs out there--U Washington and Texas at San Antonio. Are there any others that have popped up since those two?

Thanks!

first question, i would think ; although compensation is good, if your case volume is low, it makes it difficult to pay your overhead expenses. unless you work for a hospital, but then you aren't getting that 700K salary that you are talking about

2nd . due to the instability of the field., i don't think there will be too many of those CT integrated fields popping up. i'm not sure if those current programs are open to applicants, but i am aware of their existence, wash u in particular.

OK... then as a followup....why the long hours? One often reads that CT surgeons have some of the longest practice hours as well as residency and fellowship schedules. If there are so few cases, why the long hours?

Or is that just because of the (long) nature of the surgeries? And add to that the fact that those who can demand the cases want to do as much as they can, leaving those less fortunate looking for jobs or picking up gen surgery stuff to pay the bills?

Thanks for the responses, by the way...just curious on this ongoing debate.

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I'm wondering how much of a surgeon's practice is determined by location. For example, if I am the only CT-trained surgeon in a smaller area, it stands to reason I'd do a larger number of procedures. Of course, I may open myself up to the risk of more litigation, but this is why some family doctors/general surgeons locate to small areas. I know an internist in my town who used to pull down 800k a year because he loved being the "town doctor" and didn't care about ever having a life outside medicine.

MDstudent79 said:

OK... then as a followup....why the long hours? One often reads that CT surgeons have some of the longest practice hours as well as residency and fellowship schedules. If there are so few cases, why the long hours?

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While the cases may be long, it is the emergencies and the take-backs which prolong the hours. You may work a full day in the office and the OR, then be on call - either for the group or your patients, and have people crashing in the cath lab or ER to take care of, or your own patients who have a post-op complication which either requires going back to the OR or at least you coming in and seeing them.