Integrated CT surgery residency

[Origin]

Hello,

I am actually barely going into medical school, but for a very long time now I have been extremely interested in CT surgery. I have also somewhat recently learned about these 6 year integrated programs that allow you to become a CT surgeon without completing the tradition 5 year general surgery residency.

Although I have researched these programs quite a bit, I just wanted input from you guys about the program. Is it a good program? How competitive are the positions? What should I do during my medical school years to become competitive for these positions? Would you recommend the traditional process instead? Etc.

Thank you for any input.

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[JackADeli]

Hello,

I am actually barely going into medical school, but for a very long time now I have been extremely interested in CT surgery. I have also somewhat recently learned about these 6 year integrated programs that allow you to become a CT surgeon without completing the tradition 5 year general surgery residency.

Although I have researched these programs quite a bit, I just wanted input from you guys about the program. Is it a good program? How competitive are the positions? What should I do during my medical school years to become competitive for these positions? Would you recommend the traditional process instead? Etc.

Thank you for any input.

I can't speak to you on this from any point of experience or authority... but, based on the multiple discussions throughout, this is what I have read:

1. nobody knows if these programs are "good" and I don't think everyone has agreed upon how you would define it as "good" or "bad". The programs are new and geared, from what has been put on the web, towards a somewhat different philosophy from "traditional". Web search suggests a lot of "old school" surgeons think they are "bad". Having said all that, looking on the web, it appears the integrated programs are running at traditionally well respected institutions. I think some programs may have been running about a year or two by now so when you graduate from med-school some may have graduated a few classes.

2. competitive issues, again, will leave towards those that know.... but not an issue for you this early, unless your lazy.

3. as far as what to do in med-school, that answer is universal and not specialty dependent. If you want to be successful, have the most opportunities available to you, you need to work! Just work hard, be disciplined, maximize your time in med-school, get the best board scores you can, highest grades you can.... hard work. There is no other secret trick to give you a leg up on any specialty.

4. Again, doing a web search and looking at previous discussions on these forums, I am not sure future med-students will have an option for the hold pathways.

 

[ESU_MD]

The only thing certain is that things will changes significantly by the time you are ready to apply.

 

[Origin]

Thank you guys very much for replying. I will make sure I utilize all of my time in medical to the utmost potential.

 

[guadsquad]

From personal experience:

Hard work! Hard Work! Hard work! That is what is needed. The field is full of hard workers and they only want hard workers. You have to show you really want to do this. It's not an easy field; it's a difficult lifestyle and a lot of commitment. Days begin early and end late--everyday. They want to make sure you really are dedicated. Each program's worst nightmare is giving that one spot to someone who's going to decide that CT surgery isn't for them--after the fact. So, other than the obvious, studying hard and doing well on boards, you have to stand out. How? Take a year off and do research, get published. During third year, attend AATS or STS meeting and go find the program directors, introduce yourself and express your interest. They may not remember you weeks later, but if you have the credentials and you get that interview, THEY WILL REMEMBER YOU THEN! During your fourth year take Step 2 early before applying, i.e. at the end of July. In August or July do a sub-I where you can get great letters before ERAS opens--it's a tight circle, everyone knows everyone so go work with a mover-and-shaker in the field and try to get a great letter. After that sub-I, I would do some more sub-I's in CT surgery! Do these where you intend to apply. All of these sub-Is will show 2 things: 1) your commitment and 2) that you understand the lifestyle and what you're getting yourself into. Personality is so critical! Being and a-hole is not going to get you anywhere int CT surgery or in life, no matter how high your marks are--there's always someone better. People want to work with nice people. Be the appropriate gunner type; don't be the gunner that shoots people down--be the gunner that helps everyone, reads, and does all duties without complaining or stepping on toes, and thinks sleep is for the weak! Finally, even if you have flaws in your record, you'll be amazed how much the committee is willing to overlook, if dedication and commitment to CT surgery oozes out of your pores!

 

[copacetic]

whats the word on these new integrated and fast track programs teaching their residents wires skills. I mean the vast majority of CT surgeons procedures ares till CABG (making them essentially still a one trick pony). Valves have increased over the last couple of years, but I see percutaneous valve repair biting into those volumes long term. There has to be continued innovation, and programs need to make their trainees competent in wire skills. I really think that the supposed coming shortage in cardiac services (both in interventional and CT surg) is an oppurtunity for CT surg in particular to diversify their skillset and gain a foothold doing interventional procedures. The old cats in the field probably arent much interested in all that, but the younger trainees need to be energetic and ambitous in their vision for the field with the goal of making it versatile and dynamic. Granted I feel that we're starting to see this happening...ala minimally invasive procedures, smaller LVADS, off pump procedures, and the growing use of robotics. There is such a burst in innovation right now, and i hope it continues. Ultimately I feel that its the innovation in field as in any other are what will make it attractive long term.

 

[ESU_MD]

Copacetic, if you are a student, then YOU are the future of ct surg. The one who will be able to reformulate the future of the specialty.

As someone starting my first job as a cv surgeon in a few weeks, i can tell you the field is not quite ready for the next generation yet.... Meaning i cant go out and do crazy minimally invasive stuff, etc... But i can break the ice and be willing to accept the next generation of surgeons. Unlike te dinosaurs who i trained with

 

[copacetic]

the worrisome thing is ending up at a program that has an excellent reputation carried mainly by 2 or 3 faculty members who did amazing things...like 15 years ago and who are not eager to try the latest and greatest. There are alot of those programs out there...excellent reputations and faculty...but no innovation. Those programs are not the programs of tomorrow. They are they programs of yesteryear, and they must reinvent themselves along with the field.

 

[JackADeli]

whats the word on these new integrated and fast track programs teaching their residents wires skills...

I would defer to others (i.e. ESU_Med).

However, if I was looking for a thoracic residency that was ahead of the curve in "wire skills" or similar newer technologies, the first thing I would look for are appropriate baseline facilities. That is, a CV program that supposedly teaches wire skills, IMHO should probably have one of those hybrid rooms that keeps getting advertised in all the surgery pages.

The second thing I would look for is some sort of structured practice/usage of the new technology. I would think, this often goes hand in hand with younger faculty.

So, in short, if wires, I would look for hybrid room and hybrid room utilization and participation in "wire skill" trials, i.e. valvus/stents, etc...

If interests in robotics, I would look for program with current teaching model robot, track record of regular usage and participation in studies/promotion of this tech. Same for MIS in general, etc...

Keep in mind, in the private sector, plenty of robotic systems underutilized or not utilized by Uro, Gyn, GSurg, etc... Hospitals purchased systems more as advertising gimmic to be able and say, "we have the laser/robot/life-scanner/etc...". I don't put it past residencies/fellowships, i.e. MIS general, Gyn, Uro, Thoracic, ENT, etc... to have underutilized/unused systems and still market how much their residents will "use" them....

the worrisome thing is ending up at a program that has an excellent reputation carried mainly by 2 or 3 faculty members who did amazing things...like 15 years ago and who are not eager to try the latest and greatest. There are alot of those programs out there...excellent reputations and faculty...but no innovation...

Yeh, I have heard the same, sort of hinted/referenced that/similar issue in other CT thread:

...everyone has said, avoid integrated programs that have rep of "old school" track record of observe as opposed to actually operate. These programs, per report, are just milking the system for their senior guys to drag on into the next 5-10yrs without having to do anything...

 

[Guile]

the worrisome thing is ending up at a program that has an excellent reputation carried mainly by 2 or 3 faculty members who did amazing things...like 15 years ago and who are not eager to try the latest and greatest. There are alot of those programs out there...excellent reputations and faculty...but no innovation. Those programs are not the programs of tomorrow. They are they programs of yesteryear, and they must reinvent themselves along with the field.

Examples?

 

[ESU_MD]

I dont know too much about the nuts and bolts of integrated programs, but suspect they at the very least are committed to cutting edge education.

Wires, perc valves, vats and robots are all cool but remember you still need to be able to cut and sew. Do not underestimate the importance of getting exposed to the fundamentals of traditional pump cases.. Cabg, avr etc. It takes more time than you think to be comfortable. You may be better off doing a simple cabg than being the resident changing the instruments on a robot case.

My plan is not to do any minimally invasive surgeries until i have significant good results in traditional cases. Then maybe start making smaller incisions, off pump, etc,, in my mind you cant even think about doing a robot case if you arent rock solid with open surgery.

Although, that paradigm has shifted in general surgery. I think there may be new grads soon that may only know minimally invasive approaches. Ie lap chole is the gold standard. Im not sure if i even did a common duct exploration in training... But thats another thread

 

[JackADeli]

...You may be better off doing a simple cabg than being the resident changing the instruments on a robot case...

I would agree... but the premise is a little off. General surgery/ObGyn/Uro/ENT/CV/etc..., it doesn't matter, you are either doing the case to some significant degree or you are not.

If you are at bedside acting the role of surgical nurse FA, you are not doing the case. IMHO, it goes without saying, if you are doing a cases (preferably many cases) it is far better then assuming the roll of RNSFA... hesitate to say, ~medical student holding the lap scope camera!

It is the same for general surgery MIS fellowships. If you go to such a program, you need to be doing the Lap adrenals, colons, gastric bypass, etc... It is ridiculous to go and just hold a camera for a NOTES procedure or change robot instruments at bedside. All, while, your main operative experience is covering the trauma room.....

Yes, there is something to be said about first assist experience. But, you are not going to graduate and get credentialed to go out and be a first assist. So, your fellowship, in whatever specialty should not be about the excitement of being in the room while some other, world famous, yahoo does something cool.... better they video tape the procedure, you go and actually do a different operation (that they will allow you to do) and watch the yahoo spectacular on video with popcorn at home.

 

[Ellie321]

Apologies for the long-winded post. Main questions are at the end of the post. Everything else is more or less my attempt at sorting through my thoughts.

MS3 here, and pretty certain that CT is the field for me (some days I still get cold feet about the decision, something I'll have to sort out very soon). I am "one of those" that loves cardiac physiology, working with my hands, immediate gratification, time in the OR; and dislike time spent on rounding, hours of discussing what feels like detailed minutia that ultimately doesn't alter patient care, writing extensive notes, clinics more than 1/week. I haven't been able to rule out anesthesiology just yet (and think I might also enjoy cardiac anesthesiology), but ultimately I find that I just don't have the same level of enthusiasm for other fields as I do for CT. (I don't have the opportunity to explore anesthesiology formally this year, but will do so early 4th year)

Instances when I 2nd-guess going into CT:
- attendings I respect from other fields staring at me in horror and disbelief when they ask my specialty interests (people outside of cardiac surg. seem to have nothing positive to say about the field: "dead-end"/"dying" field, poor hours/lifestyle, poor job prospects, poor job stability, decreasing/poor compensation, "difficult characters" in field).
- sleep-deprived at the end of a long day of working with attendings that are less-than-enthusiastic about teaching and use medical students as punching bags (verbally, not literally) when stressed (one particular attending I "get to" work with is notorious for this type of behavior); people say this type of encounter only gets worse and more frequent in residency.
- working with clinically depressed surgery residents (especially since most people I've talked with consider CT more of a life sacrifice than gen surg)

Even though I wake up each morning with renewed enthusiasm for CT, I can't help but wonder that if I'm not 100% all the time this early on...maybe this field isn't for me, as the sacrifices are not insignificant. But when I start thinking about pursuing another specialty, I feel like I'm settling for 2nd best. For those of you that went into CT, did you ever have doubts along the way?

Oddly, lifestyle sacrifices do not phase me too much. It's the fear of sacrificing 6-10 years of my life in residency without becoming a competent surgeon, due to factors outside my control (ie attendings that aren't interested in teaching, or those that just can't get over letting someone else take the reins for a bit). I guess this is where "knowing the program" becomes important. Any advice/insight on the various integrated programs? Any I should stay away from? Any inside news on how residents are progressing at the various instutions?

Ultimately, if I'm applying for a spot in one of the integrated CT programs, what should I be aware of?
- take step II early?
- away rotations? (if yes, best time?)
- Stanford seems to have the most well-organized program. Anyone know details about the program other than what's on their website?
- Institutions to avoid?
- advice on scheduling 4th year electives? (can take up to 6 electives)
- would it decrease my chance of acceptance to apply to another specialty along with CT? I'd like to have a backup given the small number of integrated programs and high level of applicants (example: if I think I could also be happy doing anesthesiology, but CT's still my 1st choice...apply to both?). My stats aren't good enough for me to be comfortable with these odds (150-ish applicants for 10-ish spots?)

Thanks for taking the time to read through this post. Looking forward to any advice/insight/suggestions/comments.

 

[Hemiarch]

For good experience acquisition with the newer techniques, it seems like it's important to pick a residency program which has a collaborative rather than adversarial relationship with interventional cardiology and the vascular/endovascular surgeons. Perhaps even interventional radiology.
I'm not sure one can effectively evaluate this from the vantage point of an applicant though.
Any thoughts on this?

 

[Hemiarch]

I have been wondering many of the same things myself.

 

[Buzz Me]

Will you have time to rotate through any Cardiac or Thoracic rotations prior to beginning the ERAS application process?

 

[copacetic]

For good experience acquisition with the newer techniques, it seems like it's important to pick a residency program which has a collaborative rather than adversarial relationship with interventional cardiology and the vascular/endovascular surgeons. Perhaps even interventional radiology.
I'm not sure one can effectively evaluate this from the vantage point of an applicant though.
Any thoughts on this?

my guess is you would have to talk to the residents there. their usually the only ones that will give it to you straight.

 

[Hemiarch]

I can't speak for Ellie, but I know away rotations are a major part of my fourth year plan.
With these programs being relatively new/experimental and having so few positions, it seems to me there will be a tendency towards ranking known entities rather than stellar paper applicants sight unseen.

 

[gensurgapp]

As someone who matched into Integrated CT surg, here are my replies:

Take Step II early?
I would do it before September so that it goes on your application. Integrated CT is competitive, most people having > 240 on Step 1 and probably > 250.

Away rotations?
Penn - felt like this was critical to securing an interview and matching
Columbia - ditto
UVA & Northwestern - will be new this upcoming year; probably ditto
UW - not critical for the interview, but probably for the match
Stanford - would probably help, but not all their current residents did aways

Stanford seems to have the most well-organized program.

I think the key here is that not all of these are created equal. Some programs had fantastic traditional CT routes and decided to go the integrated route to enhance the programs. Others were weaker and not fairing well in the traditional route. So I would approach everywhere with an open mind, but be selective. Going integrated at a weak program is no substitute for foregoing gensurg at a strong program and then doing a fellowship:

Solid programs (in my opinion): UW (both C&T), Penn (both C&T), UVA (both C&T), Columbia, Stanford (C > T), Northwestern

Maryland and MUSC are good.

UNC has good thoracic; has had a lot of turnover in cardiac. If you're thinking academics or cardiac, might be a tough starting point...but if thinking thoracic, not a bad starting point.

Not sure about others (Wisconsin, UT, etc.)

Institutions to avoid?
Read between the lines on my above comment.

Advice on scheduling 4th year electives?
Do general surgery sub-I's in addition to CT sub-I's. Would suggest an away at your top choice.

Would it decrease my chance of acceptance to apply to another specialty along with CT? I'd like to have a backup given the small number of integrated programs and high level of applicants.
All of the programs expect you to also be applying to general surgery programs as well. You definitely need to approach it from the standpoint "I would love to do integrated CT, but would also be happy in general surgery."

If you're thinking anesthesia, I wouldn't admit that on the interview trail and would suggest avoiding applying to both anesthesia and CT surg at the same school.

 

[copacetic]

I feel that irregardless of this reorganization of the specialty to become integrated, non of it will mean much if the core of what residents are taught doesnt increase. The specialty needs to redefine and reorganize itself as a one stop shop such that specialty training will incorporate all aspects of cardiac disease management including diagnosis, interventional radiology, interventional cardiology, electrophysiology, and cardiac surgery proper. Now granted surgeons dont need to be perfectly fluent in all these areas, but the oppurtunity should exist after residency to do fellowships in these areas if one were interested.

Cardiac surgeons lost the first mover advantage with PCI because they saw it as below them, and problematic. I believe that that attitude has changed significantly with new technologies on the horizon, and it heartens me that CT surgeons are taking an active role in developing these new procedures. One area in particular that CT surgeons ought to jump upon is TAVI. TAVI i believe will undoubtedly be the future of valves once the technology is perfected. It is well and good that the development of TAVI was a cooperative event involving both CT and interventionalists, but CT surgeons out to be careful that interventionalists dont run away with the technology and further develop it on their own. Hence a close relationship must be maintained, and expansive training must be incorporated to include wire skills and other burgeoning technologies.

 

[EquipartHeart]

Just for background purposes I recently matched into an I6 CT program and am starting in two weeks. Below is my advice for anyone looking to know a bit more about the programs and what my thoughts are on how to secure a spot. Keep in mind there are many ways to get into these programs and also there are many ways to become a CT surgeon (not just the I6 programs). Also the more input you get from more people the better so that you can conclude whats best for you.

Should you apply for an I6 program? I only recommend applying if you are absolutely, 100% sure that you want to do CT surgery and are willing to make the sacrifices to do it. If you are even wavering a bit, I would suggest that you do either a 4+3 year program or a regular general surgery program followed by a fellowship. These programs allow you the opportunity to still pursue CT surgery while having the flexibility to change if you decide to do so. The last thing you want to do is regret going into a field you may not fully be committed to. In addition (and there are many schools of thought on the following comment), I am skeptical about going into an I6 program if you are primarily focused on wanting to do thoracic as a career instead of cardiac. My personal belief is you need more experience in the abdomen to become a thoracic surgeon and thus either need to go to an I6 program that is thoracic heavy (U of Washington) or do a 4+3 or gensurg training program. My experience on the interview trail was that most (not all) programs were looking for applicants who wanted to do cardiac over thoracic, however, I suspect this will definitely change with time.

So I6 is a definite how do I prepare? Again, there are many ways to become a competitive applicant but there are some consistently important things that will give you the best chance of procuring a spot.

- Board scores: numbers are tossed around all the time but as long as you have a very competitive score (most likely above a 240 you should make the cut), I was never once asked about my step II scores during the interview but I did have them available and they were competitive as well.

- Grades: you will need to be one of the top students in your class to be competitive, there is no standardized grading system for schools but as long as you excel at your school you should be competitive, its important to not only excel in surgery and cardiology but also all the subjects and rotations you don't have as much of an interest in, remember every little bit counts.

- Research: most of the I6 programs are looking for someone with a dedicated interest in research or who has done some significant amount with publications. I took a year off before medical school and did bench research that had nothing to do with CT surgery and then came and did mostly clinical research in my four years at medical school (mostly CT or ICU related). Productivity and the ability to complete a project from beginning to end are impressive qualities to these programs and they would prefer applicants who are going to have the same academic drive during residency. Lots of people take a year off if they feel like they lack research so this is always an option.

- Interest in CT Surgery: I can't recommend this enough. Start early in medical school by getting involved with the CT department at your school. Scrub in, attend grand rounds, transplant runs, do research with attendings, make friends with fellows, really anything you can to become known to the department. I started getting involved with the CT department as a first year medical student and consistently showed up to be noticed throughout my four years. This will help with the small world network that CT surgery is that others had alluded to in earlier posts. Remember even if your medical school doesn't have an I6 program, most likely the CT surgeons know chiefs, chairs or surgeons at programs that do and will not only put in a good word but write you your letters if you prove yourself.

- Subis: Some programs only like offering interviews to candidates they saw in person. Penn seemed to be the most geared towards this as they only interviewed 9 people and I was one of only a couple that hadn't done a subi there. To be competitive I would recommend doing a rotation in CT surgery at your own institution (regardless of if they have an I6 program), a couple CT surgery subis at outside institutions with I6 programs in addition to one general surgery subi (at your own institution). Depending on how hard you want your fourth year to be this can be a lot but its definitely worth it as you get to know the programs first hand and that experience is incredibly valuable. Stanford, Penn, and Mount Sinai really get you involved on your subis and exposed you nicely to the field (all three allow you to do donor runs for transplants in addition to your normal surgical schedule). The rest of the institutions I can't speak to as I didn't do aways there. Columbia has a reputation to sticking with their own medical students as I6 candidates so be cautious about doing a month there if they already have slotted in their own. However, this may change with time

- Letters: Need to be from the most important CT surgeons at your institution and therefore you need to get to know them well so that they can write outstanding ones for you.

- Extracurriculars: Being involved with teaching and other things to boost your resume is always important but in my interview experience seemed to be the least important out of all of the above.

What are the programs like? I repeatedly said throughout the interview process that if I didn't get a top notch I6 spot that I would rather do a 4+3 year program or a gensurg at a great institution like MGH, Hopkins, UCSF, Duke, etc. In my opinion, there is a clear level of top I6 programs and another level of I6 programs that are not as good. The top level ones include Stanford, Penn, Columbia, and Mount Sinai. Maryland is right below that in my opinion but has an absolutely fantastic program as well under their chief. I think Northwestern has a chance to join the top level once they become more established and the same goes for Mayo, UVA, and Rochester but this will require more time. I thought U of Washington was too geared towards thoracic and was geographically undesirable for me so I didn't apply there. Some of the other programs are still solid programs but lack the same pedigree. I ended up canceling interviews at these other I6 programs after learning more about what I wanted while on the interview trail.

Important aspects at an I6 program to know of?
- Big names at the institution (chief, chairman, etc...) as it will be their phone calls and involvement in cutting edge changes that will allow you to flourish/secure a position after the program is over.
- Would you fit in there? If you are going to be miserable at an institution then I would recommend you going someplace else.
- Willingness for the program to change to make your education as great as possible. Besides Stanford most of these programs are still test piloting their training so if something doesn't work they have to be willing to change and change quickly for you (Sinai, Maryland, and Stanford seemed great with this but I don't have as good of an insight into the other programs).
- Operative volume and range of operations. Columbia and Penn have two of the busiest programs. Sinai is behind them but not too far. Unfortunately this is one of the few downsides to Stanford as their volume has suffered recently.
- Opportunity to operate and not just be a first assist. CT surgery is a hands on sport so unless you get to do it yourself you won't progress. They throw you in early and get you involved greatly at Columbia, Stanford, Maryland, Sinai, and Penn.
- Research opportunities. Penn, Columbia, and Stanford are involved with trials, clinical research, and have amazing lab opportunities. Sinai is involved with new trials, clinical research, and offers interesting opportunities to get a PhD in a shortened time period (also has a large animal lab). Maryland has fantastic lab experience and is involved with a lot of the STS database work.
- Surgical skills lab and wet labs that allow you to become competent in your surgical skills out of the OR before doing the real thing. Stanford has the best lab set up for this. The surgical simulation program at UNC is supposed to be amazing as well.
- Exposure during residency to cardiology, critical care, endovascular techniques, radiology, cardiac anesthesia and perfusion, etc. CT surgery is not just about being an open surgeon. Stanford is great at this and pioneered it all the way back during the teachings of Shumway. Penn and Sinai have followed in their footsteps. Collaborative institutions are definitely gearing up for the future as the days of CT surgery being in its own world have ended.



For my rank, I ended up listing my top four picks to be I6 programs followed by one general surgery program, and then another I6 program, followed by other general surgery/4+3 year programs. You can probably tell from the email above which programs were in my top four.

 

[Buzz Me]

That's a great post above. I would add that strong LORs from CT attendings and publications will be tough as a med student, but are potentially attainable goals if you set your sights early and identify a mentor.

I agree that if you're not totally sure you want to do Cardiac you should probably consider going through a Gen Surg residency first.

 

[droliver]

Not to be too curmudgeonly, but

1) I think integrated CTVS is going to be a train wreck at a lot of programs. The infrastructure to incorporate new/old & open/catheter based is formidable and there are going to be a lot of frustrated residents who get caught up in institutional political battles b/w CTVS, vascular surgeons, Cardiology, & IR.

2) A lot of programs (some at traditional cardiac surgery powerhouses) are not going to be able to train you competently starting from a medical student level skills. They're just not set up to incorporate having to hand-hold someone with no preliminary training. Cardiac surgeons in academia more closely resemble private practice groups then before, and efficiency and churning cases to earn a living is more and more an issue. I can remember being told as a surgery resident on CTVS that we were not wanted in the OR unless asked (too hold the heart usually) because we slowed them down and got in the way of the PA's harvesting veins or closing the chest.

3) While I encourage people to follow their interests, it's not for nothing that a lot of physicians (including CTVS guys) are very pessimistic about their field. The workforce issues are hard to plan for as the number of surgeons and their ideal distribution is such a gordian knot. To have a cardiology program you need surgeons for back up, but there may not be enough surgeries to keep them busy. I think you're going to see fewer surgeons concentrated in fewer programs and loss of a lot of the smaller community hospital open heart programs.

4) What sucks about CTVS (long and unpredictable hours, uneven relationship with cardiologists, declining pay, sicker patients) is not going to be changed by these integrated programs. Once the novelty of (maybe) shaving 1 year off your training length is through, some of our best and brightest students looking at this are going to be regretful.

 

[plauto]

Not to be too curmudgeonly, but

1) I think integrated CTVS is going to be a train wreck at a lot of programs. The infrastructure to incorporate new/old & open/catheter based is formidable and there are going to be a lot of frustrated residents who get caught up in institutional political battles b/w CTVS, vascular surgeons, Cardiology, & IR.

2) A lot of programs (some at traditional cardiac surgery powerhouses) are not going to be able to train you competently starting from a medical student level skills. They're just not set up to incorporate having to hand-hold someone with no preliminary training. Cardiac surgeons in academia more closely resemble private practice groups then before, and efficiency and churning cases to earn a living is more and more an issue. I can remember being told as a surgery resident on CTVS that we were not wanted in the OR unless asked (too hold the heart usually) because we slowed them down and got in the way of the PA's harvesting veins or closing the chest.

3) While I encourage people to follow their interests, it's not for nothing that a lot of physicians (including CTVS guys) are very pessimistic about their field. The workforce issues are hard to plan for as the number of surgeons and their ideal distribution is such a gordian knot. To have a cardiology program you need surgeons for back up, but there may not be enough surgeries to keep them busy. I think you're going to see fewer surgeons concentrated in fewer programs and loss of a lot of the smaller community hospital open heart programs.

4) What sucks about CTVS (long and unpredictable hours, uneven relationship with cardiologists, declining pay, sicker patients) is not going to be changed by these integrated programs. Once the novelty of (maybe) shaving 1 year off your training length is through, some of our best and brightest students looking at this are going to be regretful.

You make some excellent points. I have struggled with this same decision myself and ultimately decided to go for a different surgical specialty.
It was a very very hard decision. Having experienced first person many of the things you wrote about, unfortunately I agree 100% with your post. I wish I was born 40-50 years earlier....

 

[Skraps]

Hey guys,

Its really interesting to see the changes that are occurring throughout the US in relation to integrated CTS programs..I'm an Australian med student and we are yet to see any of these changes anywhere in the country (apparently not even on the horizon for me when I plan to start training in CTS in the next few years)..

Perhaps this question has been directed to the wrong thread (and is better placed in the cardiology thread) but here goes: what is the likliehood, seeing that cardiothoracic surgical training is now being significantly integrated with other subspecialties of medicine (interventional card/radiol, endoscopy, etc.), that interventional cardiology fellowships/training in the US would/could be available for cardiothoracic surgery fellows from overseas or those who have completed a non-integrated CTS program in the US. Has anyone heard of anything like this occurring (ie. Qualified surgeon completes interventional cards fellowship)? Apologies in advance for the long-winded question. As a FMG I've got buckley's chance of getting in to one of these integrated programs, which is why I'm posting this question I suppose.

Regards,

Skraps

 

[Buzz Me]

what is the likliehood...that interventional cardiology fellowships/training in the US would/could be available for cardiothoracic surgery fellows from oversea

Honestly? Close to 0%.

Cardiology is a very competitive Internal Medicine fellowship. No way they're going to open up their turf to a CT surgeon (from overseas, without US training, no less)!

 

[ESU_MD]

Actually, I think you may be able to find some kind of un-accreditited position working in interventional cardiology as a foreigner.
It will be largely doing H&Ps, taking first call, pulling sheaths and holding pressure and if you are lucky--- maybe doing some cath lab stuff.
There is always a place for these workhorses.

the problem is it wont get you anywhere in the US system, but I know people who have done these types of "fellowships" and then go back to their countries and probably embellish the training they got in the US. Some may even attempt to practice.. who knows.

 

[Skraps]

Apparently its been done before (not by a FMG though), not too long ago (2006) - although this guy might be the only one in the US(?).

http://asp.cumc.columbia.edu/facdb/profile_list.asp?uni=mw365&DepAffil=Surgery

Regardless, I understand the issue here. Why train a CT surgeon in interventional cards when you can train a cardiologist for his own specialty fellowship program (especially if the CT surgeon is trained overseas)? Ah well, all I can do is hope things change over the next 10 or so years - not necessarily for the US, but for Australia.

@ESU_MD: That's a good point, but the cardiology society of australia and new zealand and the RACP wouldn't permit practice of interventional cards without a attainment of a recognised fellowship program. Unfortunately for me, if I was to get loads of 'experience' in such a way without the formal recognition - its essentially useless to me in terms of practicing those types of procedures. Interesting thought though.

 

[Scean]

bump

any more to say about these programs by those applying currently or current trainees?

 

[45408]

Just curious (and I'm really in the dark here, since I've never investigated CT in any depth, haven't rotated on it yet, and I'm not planning on going into it), why are these I6 programs so competitive, when overall, CT fellowships aren't particularly competitive?

Or is it just that places with top programs are the only ones with I6 programs, so they're all top programs?

 

[dynx]

Just curious (and I'm really in the dark here, since I've never investigated CT in any depth, haven't rotated on it yet, and I'm not planning on going into it), why are these I6 programs so competitive, when overall, CT fellowships aren't particularly competitive?

Or is it just that places with top programs are the only ones with I6 programs, so they're all top programs?

1. The reason you stated. Some strong programs started integrating.
2. the same reason medical school is competative. you've got people with an idealistic attitude that don't know what they're getting into.
3. It makes more sense for foreign trained CT surgeons switching countries to do an I6 so they all apply even though their chances are slim.
4. It takes less time obviously so you get the people that will eventually do CT anyway applying on the front end and the back end.

 

[DoctwoB]

1. The reason you stated. Some strong programs started integrating.
2. the same reason medical school is competative. you've got people with an idealistic attitude that don't know what they're getting into.
3. It makes more sense for foreign trained CT surgeons switching countries to do an I6 so they all apply even though their chances are slim.
4. It takes less time obviously so you get the people that will eventually do CT anyway applying on the front end and the back end.

This. As someone considering an integrated CT program, It's definitely about # 4. Its not just that you save a few years (though that is huge, got some loans to pay), its also about not having to uproot your life (and family) for the sake of a 2 year fellowship and then having to move it again once that fellowship is over.

The other main factor is just that there are so few spots. If even 50 people apply both integrated CT and gensurg, you've got a very competitive field.

 

[mitralwiz]

Since this year's cycle is over would anyone care to share their subi experiences at any of the integrated programs? Also can anyone comment on the program structure of programs they may have interviewed at?

 

[Phoenixrising24]

I applied to 10 of the 14 programs that were available at the beginning of last season (several more opened up during the season for internal/sub-i applicants), and accepted 6/9 interview offers (in addition to a...healthy...number of GSurg programs).

I didn't do a sub-I at any of these programs, and this wasn't a problem in terms of getting interview offers. Ultimately I ranked 4+3 programs above all but two I6 programs, and matched to my first choice, so I can't say whether this affected my competitiveness post-interview, but I'm pretty sure it would have. There were between 100-150 applicants to the I-6 programs this year (based on what I heard at the interviews), and most places interviewed about 10-25 folks.

Bottom line: I'd recommend a sub-I if you 1) absolutely have your heart set on one particular program; 2) have your heart absolutely set on doing an I-6; 3) have the flexibility/$ to explore the possibility and have a decent sense of where you'd like to end up.

Although I didn't do a sub-I, obviously I ran into the same group of generally awesome folks on the interview trail and have heard their experiences. If they don't materialize here to share, feel free to PM me and I can pass on the program-specific rumors for whatever that's worth. Regarding program structure, all of them have a block diagram of what the schedule looks like this month, but please realize that all of these programs are so new that this is really just a formality--they are all rearranging the schedule on an almost monthly basis based on the feedback of their current residents (of which there may be only one or two, depending on the program). This can be a good or bad thing, depending on your perspective.

I loved my I-6 interviews and was during every one seduced by the idea of being special and being able to start doing CT right away. However, I decided early on that I needed to choose a program rather than a curriculum, and ultimately that's what I did. I also came to understand over the course of the interview season that for ME and MY career goals, a 4+3 program was a better choice overall. Believe me, I understand how frustrating it is that there's not more concrete information about these programs floating around. That's unlikely to change within the next interview season, so the only thing to do is be patient and go see for yourself. The programs vary considerably in their feel and attitude, and that's something hard to glean from even the most informative website; when you ARE your residency class, these intangibles are huge and not to be minimized in terms of importance.

Sorry for the rambling reply; maybe some of it was helpful. Feel free to PM me for more program-specific info. Best of luck!

 

[MD2b06]

1. The reason you stated. Some strong programs started integrating.
2. the same reason medical school is competative. you've got people with an idealistic attitude that don't know what they're getting into.
3. It makes more sense for foreign trained CT surgeons switching countries to do an I6 so they all apply even though their chances are slim.
4. It takes less time obviously so you get the people that will eventually do CT anyway applying on the front end and the back end.

Still doesn't make much sense as to why it's all of a sudden it's become competitive. At the end of the day, for most people I think it's still about having a job, supporting a family and hopefully some career flexibility in terms of where you can live. Sure these programs may help you shave a year or two off of training, but at the end of it all, if you don't have a job, or have to go live in Arkansas to support your family and pay off your loans, is it really worth it? These integrated programs don't seem to do anything to address the workforce issue or job market in CT. Has it improved dramatically over the last few years? Have all those old CT surgeons that kept delaying retirement because of the financial crisis finally retired, thus creating a much improved job market? PCI volumes are currently down, and not expected to increase significantly in the next 5-6 years. And it's not because more people are being sent for CABG. When you go looking for a job, no one is going to care how long you trained for or even where to a large extent. It's still simple supply and demand economics. Although people might like to think differently, but no one is owed anything just because they spent 10-11 years in med school and residency/fellowship training. Your worth to a group or a hospital will be dependent on whether or not your skillset is in demand and whether or not you bring some added value to the group. I guess I just find it strange that obtaining CT training, which often was not competitive at all in the past decade, is now all of a sudden attracting candidates that previously wouldn't have thought twice about it when the underlying supply/demand issues haven't changed as far as I know. Correct me if I'm wrong.

 

[celling]

The CTS field is actually rapidly changing/evolving. A lot of the older surgeons aren't equipped to perform or aren't willing to learn the newer procedures (eg. VATS lobectomies, MIS Ivor-Lewis esophagectomies, MIDCAB, TECAB, Mini sternotomy for AVR, Minimally invasive Mitral valves, TAVI, VAD's, etc.). Therefore, they are being phased out of the market by the newer surgeons. The market for CTS surgeons is getting a lot better. 5 years ago there was 10-15 new positions/year. Now, there are new positions being posted on CTSnet weekly and that doesn't include the positions that are being directly offered to new graduates.

The US population is aging and the supply of pts requiring heart surgery is expected to go up. Since not a lot of people have been going into CTS the last 10-15 years, there is expected to be a severe nationwide shortage of CTS surgeons in the next 10 years. Many of the senior CTS surgeons are expecting the 2nd golden age of CT surgery to begin in the next 5-10 years.

Now, do I expect med students applying for I-6 or 4+3 positions to know this? NO. Most of them think that CTS is a really cool field (I agree). However, like pre-meds applying for med school, they have no real idea of the demands of the job. Because of this, there is a lot of concern in the CTS community about a high drop-out rate that could occur with these programs. Also, there is concern that attending cardiac surgeons, used to teaching PGY-6 residents that graduated from a surgical residency, would be reluctant to allow more junior residents to participate actively in cardiac cases, and therefore limit their exposure. So, we'll have to see about that.

Anyway, it's a great time for people to be considering the field.

 

[pedisurg23]

A cardiac surgery attending at my institution told me that most (if not all) cardiothoracic surgery training will be switching to the 6-year model within the next few years. Is this true? For those of us in medical school now, will regular cardiothoracic fellowships even be offered by the time we finish general surgery residency (~7 years from now)?

Friends at my institution who are planning on applying to the 6 year programs are being advised by our cardiac surgery faculty to take research years and be incredibly gunner throughout med school. (We have a 6yr program and several students have matched into it and other 6yr programs in the past couple years.) If you are going to do a research year, what's the point of doing a 6 year program? Plus, it seems like choosing to go into cardiac surgery residency as a med student could be a fairly limiting career plan; wouldn't you rather go into general surgery and decide if you really want to do cardiac surgery when you are older/wiser? (if this will be an option for our generation...?)

 

[celling]

A cardiac surgery attending at my institution told me that most (if not all) cardiothoracic surgery training will be switching to the 6-year model within the next few years. Is this true?
-This is currently the plan for CTS training. However, the powers that be can change their minds if they find that the training isn't sufficient. So, its denifitely not 100%.

For those of us in medical school now, will regular cardiothoracic fellowships even be offered by the time we finish general surgery residency (~7 years from now)?
-Possibly, but not definitely.

Friends at my institution who are planning on applying to the 6 year programs are being advised by our cardiac surgery faculty to take research years and be incredibly gunner throughout med school. (We have a 6yr program and several students have matched into it and other 6yr programs in the past couple years.) If you are going to do a research year, what's the point of doing a 6 year program?
-The future of CTS is being directed to "centers of excellence" much like Bariatric Surgery. Small hospitals that do 1-2 hearts/month will go by the way side. Many of these centers of excellence will be academic, university hospitals. To practice there, you will need to do research, and you will not have much if any time to do research during your training without taking at least one year dedicated to research.

Plus, it seems like choosing to go into cardiac surgery residency as a med student could be a fairly limiting career plan; wouldn't you rather go into general surgery and decide if you really want to do cardiac surgery when you are older/wiser? (if this will be an option for our generation...?)
-A huge argument among CT surgeons. Most agree that someone who goes through a surgery residency will go into CTS training with their eyes more wide open than a med student. However, most of the surgery residencies these days are limiting exposure to cardiac surgery in their programs, so it might not make that big of a difference.

 

[fishsticks2629]

A cardiac surgery attending at my institution told me that most (if not all) cardiothoracic surgery training will be switching to the 6-year model within the next few years. Is this true?
-This is currently the plan for CTS training. However, the powers that be can change their minds if they find that the training isn't sufficient. So, its denifitely not 100%.

So those going into general surgery soon and then want to apply to CTS will be sol if the change was made after they went into gen surg? If this is something that is suppose to happen, when would it happen?

 

[rigid]

I imagine they would either have both available or would make it such that those in GS residencies at the time of announcement are still able to do fellowships if they so choose?

 

[celling]

So those going into general surgery soon and then want to apply to CTS will be sol if the change was made after they went into gen surg? If this is something that is suppose to happen, when would it happen?

I think you'll be fine. Most CTS programs have the traditional trainign program after surgery residency, currently. If all of these programs were to switch to a 3+3 or a 4+3 model program today (in theory), they would need to keep fellows until the integrated residents had proceeded into their senior clinical years. My guess would be 5-6 years.

However, I think it won't be for another 8-10 years at least until the traditional training programs have been completely phased out.

 

[Buzz Me]

When I was on the interview trail, the word was that all CT Surg programs wanted to switch to 100% integrated before the year 2020.

 

[Skialta]

I am vascular and don't have any experience with the I6 but I have some of the same concerns about the integrated vascular. For all the residents/attendings here how do you think this training program really works? We all know that the guy doing any of these upper end operations i.e. CABG, Valve, Aortas etc are going to be the most senior resident/fellow.. Is there really that much volume that the R2-R3 is really getting to do much of the cases? It makes me wonder about just how competent the integrated program surgeons are going to be.

 

[droliver]

The CTS field is actually rapidly changing/evolving. A lot of the older surgeons aren't equipped to perform or aren't willing to learn the newer procedures (eg. VATS lobectomies, MIS Ivor-Lewis esophagectomies, MIDCAB, TECAB, Mini sternotomy for AVR, Minimally invasive Mitral valves, TAVI, VAD's, etc.). Therefore, they are being phased out of the market by the newer surgeons.

Most of those procedures with the exception of percutaneous valves (still in the experimental phase) have been done to varying degrees for coming up on two decades, so I don't think there a whole lot of guys still going who do just traditional CABG that will be "phased out" actually exist. Contrary to what you're suggesting, there is TREMENDOUS anxiety of younger CTVS surgeons as to job prospects now and in the future. The cases just aren't there for bread and butter cardiac surgery, and general thoracic surgery practices have always been very niche oriented.

 

[Phoenixrising24]

When I was on the interview trail, the word was that all CT Surg programs wanted to switch to 100% integrated before the year 2020.

The ABTS has said that it would like for all programs to have the I6 model in place by 2020, but having talked to PDs on the interview trail this year, it's clear that there's still a fair amount of hesitancy within the academic community given the novelty of the programs and the, er, heterogeneous execution thus far.

In terms of logistics, I think what you'll find is that many programs will give one or maybe two of their total graduating slots depending on program size over to the I6 model and will save the remaining slots for traditional or 4+3 applicants such that they maintain flexibility in recruiting both excellent medical students and excellent graduating residents, and also have options if (?when) there is attrition within the I6 program. This is what I heard from several programs who have already made the transition, and also those planning to do so in the next few years. Obviously it isn't really as simple as all that since the timing and equivalency of I6 vs. 4+3 vs. traditional outside applicant is highly variable; however, preserving flexibility in a time of uncertainty appears to be worth the headache at least to some. It makes sense to me in practice, but we'll see how it ends up working in reality in the next few years.

 

[Buzz Me]

In terms of logistics, I think what you'll find is that many programs will give one or maybe two of their total graduating slots depending on program size over to the I6 model and will save the remaining slots for traditional or 4+3 applicants such that they maintain flexibility in recruiting both excellent medical students and excellent graduating residents, and also have options if (?when) there is attrition within the I6 program.

It remains to be seen how well this plan will be executed. I'm about to start fellowship along side an integrated resident so we'll see how our respective curricula differ.

 

[mitralwiz]

Can someone applying list all of the current 4+3 programs available.

 

[powow]

what's the best way to find the most up to date info about job prospects for ct surgery? i don't want to apply for training in a dying field

 

[badasshairday]

what's the best way to find the most up to date info about job prospects for ct surgery? i don't want to apply for training in a dying field

My medical school is one of the first 10 integrated CT surgery residency programs and I can tell you what I think from my experience.

Interventional cardiologist are casting the net wide in terms of percutaneous procedures. They are encroaching on turf of vascular surgery, VIR, CT surgery, and now starting to encroach on endovascular neurosurgery (interventional neuroradiology) for acute stroke intervention. A lot of it has to do with the fact that cardiac cath is no longer paying what it use to pay. The second part is that when you have a hammer (catheterization) everything is a nail... even if you are not well versed in the anatomy beyond the carotids. For CT surgery to survive, they must play an integral role in trans-arterial aortic valve implantiations aka TAVI.

To do this, they must obtain wire and catheter skills.

I know at my former medical schol the CT sugery resident would rotate through interventional cardiology and VIR to obtain these skills. I honestly don't think they got enough hands on experience. But they do get some. I know a group in the Bay Area, California who has a CT surgeon on staff with wire skills.

http://www.endovascularsurgery.com/patients/our-physicians/

The fifth doctor down is a CT surgeon.

As a future inteventional radiologist I welcome with open arms my surgical brethren to the endovascular arena as it is the future of cardiovascular disease.

 

[DoctwoB]

My medical school is one of the first 10 integrated CT surgery residency programs and I can tell you what I think from my experience.

Interventional cardiologist are casting the net wide in terms of percutaneous procedures. They are encroaching on turf of vascular surgery, VIR, CT surgery, and now starting to encroach on endovascular neurosurgery (interventional neuroradiology) for acute stroke intervention. A lot of it has to do with the fact that cardiac cath is no longer paying what it use to pay. The second part is that when you have a hammer (catheterization) everything is a nail... even if you are not well versed in the anatomy beyond the carotids. For CT surgery to survive, they must play an integral role in trans-arterial aortic valve implantiations aka TAVI.

To do this, they must obtain wire and catheter skills.

I know at my former medical schol the CT sugery resident would rotate through interventional cardiology and VIR to obtain these skills. I honestly don't think they got enough hands on experience. But they do get some. I know a group in the Bay Area, California who has a CT surgeon on staff with wire skills.

http://www.endovascularsurgery.com/patients/our-physicians/

The fifth doctor down is a CT surgeon.

As a future inteventional radiologist I welcome with open arms my surgical brethren to the endovascular arena as it is the future of cardiovascular disease.

First off, the data on TAVI right now is quite poor. I'm not saying with refined technique/devices that it can't improve, but for now it remains a niche procedure for those too sick to handle surgery (who probably aren't long for this world anyways, but thats another argument).

Secondly, I've always heard the opposite about IR. I know it is entirely instutition dependent, but at my institution Cards and Vascular are fighting over peripheral endovascular work, with IR being relegated to mostly percutaneous fluoro guided work (biopsys, abscesses, LPs, etc.) and tumor work ( RFA, etc.). As always, the issue is about who controls the patients, and cards and vascular see patients long before an IR doc does in general. FWIW, I think vascular should take them given that they can offer both open and endovascular options to patients, while cards and IR have only one hammer so everyone looks like a nail.

However, this same problem apples to CT surgery. Even if they could gain the necessary cath/wire skills, which I'm sure they could, they would be last in the referral chain. Cardiology controls those patients, and you can bet they won't be referring them to CT for caths. The time for CT surgery to get on the Cath train was many years ago, and by now its already left the station.