Anybody who likes CT surg thinking about pediatric CT surg instead?

[medguy25]

I'm an M1 this year, but would like input on this issue out of sheer curiousity.

So CT surgery is obviously not doing well as everybody knows. Anybody thinking congenital CT surg instead?

The congenital heart defects are fascinating.
I would suspect anybody who has an interest in cardiac anatomy/physiology enough to be interested in adult CT would probably agree with that statement about pediatric CT.

Also, when I look at the survival potential (ie actually have work to do...), it would seem to me that congenital heart surgery has no vulnerability to cardiology takeover as has happened in adult.

I know that some simple ASD's (and PDA's?) are done interventionally.

However, when I think of the majority of the defects, it would seem to me that there's no possibility of cardiology fixing the following...

Aortic switch operation for transposition of the great vessels
A tetralogy of fallot repair
Medium-Large VSD's
Norwood, HemiFontan/Glenn, Fontan for HLHS
Aortic Coarc repair
Truncus arteriosus
Valvular atresias
and so on....


It would seem to me that this means patients to operate on and therefore job security due to these and others only being able to be done surgically.

In terms of training, it's a 1 year long extra fellowship on top of adult CT.

Also, in terms of lifestyle, since it was found that prostaglandins leave the ductus open, many defects that 20-30 years ago would be emergency middle of the night procedures are now scheduled ahead and done during normal business hours.

From my knowledge, the only defect that is an absolutely immediate do it now repair is for total anomalous pulmonary venous return.

I worked night shift at my hospital on the PICU before med school and with my N=1 sample set, I saw him in after 10 PM 1 time when I was in working (in ~7 months). I worked around 30 hours a week since I was also a grad student.

The PICU attending usually managed post op complications since they were in house for the night after the surgery.

(also, this guy was our only surgeon at the hospital, unlike many centers which have multiple peds CT surgeons (Boston has 5 total, CHOP has 3 for example))


So is anybody else who really likes CT thinking along the same lines??

Also, it would be great to hear any criticisms/additional points to my analysis.

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[dry dre]

While I've ended up in ortho I gave pediatric CT much serious thought. In med school I rotated with a private adult CT group...for what it's worth, they were not hurting for cases, only that reimbursement continues to drop. The senior partner makes, in real dollars, maybe a quarter of what he was making 20 years ago for the same amount of work. Pediatric CT interested me as I liked cardiovascular mechanics and I liked the idea of 'fixing' something to improve quality of life and lifespan in the younger folk. I still have the same interests (pediatric surgery), just in the ortho category.

Regarding lifestyle, I would imagine that most peds CT people work in academic/peds hospitals...meaning pay will be less than for private adult CT. While the PICU doc may be able to babysit, I would have to imagine that the little ticker will be going through your mind even when you leave the building (and for years to come).

As an alternative, consider pediatric ortho. Shorter path and easy to get into, complicated in terms of mechanics to satisfy the hyperanalytical mind, and you can help kids walk who otherwise would be confined to a wheelchair. Patients are usually medically very healthy and a general pediatrician can manage periop care. Pay is about the same as a general surgeon, which is enough for me. In short, very satisfying work and an order of magnitude less stressful lifestyle. Just my 2 cents.

 

[naegleria brain]

agreed; the future of CT lies within pediatric cardiothoracic surgery. this is because congenital malformations, especially the severe ones, cannot be fixed via IR or cardiology. they need surgery.

also there are so few out there, that there are so few to train under, and the numbers will be kept low (after all, the actual malformations are quite rare)

surgical success i remember learning goes from 60-80%. not too bad, but something to think about if you can't handle 4 dead babies out of 10 each week.

for what it's worth, i left CT out of my mind because i found out that ppl in these fields don't fall in love with the pediatric heart - that's very specific. they love the challenge, the thinking, the physical abstracts, like the previous poster stated. you can get this with many other surgical fields that get much higher volume and pay as well, if not better. i too loved the abstract challenge, but have realized that many different surgical fields offer this too; once you see more, you'll understand the diversity out there.

also...i don't think i'm one of those who can handle 6 out of 10 dead babies a week. i still shudder when i see slides of dissected stillborns and fetuses.

 

[medguy25]

While I've ended up in ortho I gave pediatric CT much serious thought. In med school I rotated with a private adult CT group...for what it's worth, they were not hurting for cases, only that reimbursement continues to drop. The senior partner makes, in real dollars, maybe a quarter of what he was making 20 years ago for the same amount of work. Pediatric CT interested me as I liked cardiovascular mechanics and I liked the idea of 'fixing' something to improve quality of life and lifespan in the younger folk. I still have the same interests (pediatric surgery), just in the ortho category.

Regarding lifestyle, I would imagine that most peds CT people work in academic/peds hospitals...meaning pay will be less than for private adult CT. While the PICU doc may be able to babysit, I would have to imagine that the little ticker will be going through your mind even when you leave the building (and for years to come).

As an alternative, consider pediatric ortho. Shorter path and easy to get into, complicated in terms of mechanics to satisfy the hyperanalytical mind, and you can help kids walk who otherwise would be confined to a wheelchair. Patients are usually medically very healthy and a general pediatrician can manage periop care. Pay is about the same as a general surgeon, which is enough for me. In short, very satisfying work and an order of magnitude less stressful lifestyle. Just my 2 cents.

Yeah, I remember some pediatric ortho stuff from the PICU. I would agree it's definitely complicated mechanics and I do like the "fixing" aspect you mentioned. Walking is one of the most, if not the most, basic functions of a person.

Wasn't too interested in it though. I never bothered asking any of the doctors or nurses about what the patients had since I really wasn't that curious.
Studying musculoskeletal anatomy was like pulling teeth for me. No offense, but I couldn't stand it (hey, we all have our interests)... Head and neck was the only section of anatomy I thought was worse.
Also, I'd like more physiology mixed into my job than what ortho has (from what I've observed and have been told by physicians too)

Haha, it's funny you mention the ticker. Our surgeon use to call in on the evening to check in on pts who there was nothing wrong with (ie no nurse or resident paged him), he just was curious. He was a control freak who obsessed over all details, which is probably why he was good at what he does. Don't think this would bother me. I'm also a control freak and detail obsessed and will probably be this way no matter if I go into pediatric CT surgery or pediatric psychiatry.

As of now, I really would like to work in an academic medical center. I absolutely love teaching and hope some teaching experiences I had prior to med school won't be the last ones I have. I could not imagine my career life without having a teaching function of some sort, therefore would love to work in an academic medical center. Lower salary is a small price to pay in exchange to being much happier having multiple functions instead of only clinical (not just teaching, but perhaps administrative too)

 

[medguy25]

agreed; the future of CT lies within pediatric cardiothoracic surgery. this is because congenital malformations, especially the severe ones, cannot be fixed via IR or cardiology. they need surgery.

also there are so few out there, that there are so few to train under, and the numbers will be kept low (after all, the actual malformations are quite rare)

surgical success i remember learning goes from 60-80%. not too bad, but something to think about if you can't handle 4 dead babies out of 10 each week.

for what it's worth, i left CT out of my mind because i found out that ppl in these fields don't fall in love with the pediatric heart - that's very specific. they love the challenge, the thinking, the physical abstracts, like the previous poster stated. you can get this with many other surgical fields that get much higher volume and pay as well, if not better. i too loved the abstract challenge, but have realized that many different surgical fields offer this too; once you see more, you'll understand the diversity out there.

also...i don't think i'm one of those who can handle 6 out of 10 dead babies a week. i still shudder when i see slides of dissected stillborns and fetuses.

The death is issue is something that is not exactly a great part of the field. However, I don't think I'd let it detract me from pursuing that or any other field.
There were many kids who died on the PICU (and adults on other ICUs I worked on before med school) while I worked there and it's definitely not something I would wish to happen when I went to work on any given day.

However, overall, as weird as this may sound, it doesn't bother me. I definitely don't mean this in the context of the individual patient, I mean it in the overall context of my job as a whole.
Almost like a net postive/negative kind of thing. I felt that we were doing and having outcomes that were much more positive than negative. For every baby/kid that died, there were 3-4 who would or who probably should have died due to their conditions/trauma who we saved and gave them back their life.
It's this very positive ratio that makes the deaths easier for me to handle.

Now, there's one confouding variable to the above argument (a really really big one to say the least). This is that I wasn't the one who was actually doing the surgery or managing the patients care. I was merely a patient care tech/nursing assistant.
I'm going to take a wild guess that if you were the one who actually did the surgery or the CCM attending who managed a pt. with ARDS, or whatever, that you'd be feeling a hell of a lot worse than somebody like me felt when a patient died.



As far as the heart comment (about people not loving the heart), that's absolutely not true with me. For most of my life, the heart has amazed me. I have no idea why this is, but I'm drawn to the heart much much more than anything else. There's a curiousity and a passion for the heart that I don't have for anything else.
On the other hand, the hyperanalytical aspects you cite do describe me...


I'm surprised I only got 2 responses. For the last couple months I signed up, it seemed that there were many CT threads always around.

 

[medguy25]

Nobody else thinking of pediatric CT surg?

Sounds good!! Like someone else said, very few training spots, so that leaves a higher shot for a good fellowship for me!

 

[Hoooba]

Your experience is very similar to mine. I'm really interested in ped CTS. You should realize though that even though the career is relatively stable compared to adult CTS, the job market is much smaller. A doc told me once that there are about 4 attending positions that open up every year. It is not uncommon for fellows to spend an extra 1-2 years as fellows waiting for an attending positiion to open up.
Another point to consider is that ped CTS is more technically demanding and the stakes are much higher. A pediatric cardiologists told me once that when a baby doesn't make it through a surgery it's almost always surgeon error compared to adult surgery where you might be dealing with an 80 year old patient with other complicating factors.

Having said all that, I can't help but still be drawn towards this field

 

[Bitsy3221]

Your experience is very similar to mine. I'm really interested in ped CTS. You should realize though that even though the career is relatively stable compared to adult CTS, the job market is much smaller. A doc told me once that there are about 4 attending positions that open up every year. It is not uncommon for fellows to spend an extra 1-2 years as fellows waiting for an attending positiion to open up.
Another point to consider is that ped CTS is more technically demanding and the stakes are much higher. A pediatric cardiologists told me once that when a baby doesn't make it through a surgery it's almost always surgeon error compared to adult surgery where you might be dealing with an 80 year old patient with other complicating factors.

Having said all that, I can't help but still be drawn towards this field

Completely agree. I have a friend who is finishing up his peds CT surgery fellowship, and another who is getting ready to start, and they both echo these thought over and over, particularly the dusty job market.

After all the years (and years!) you have put into training, having to be a benchwarmer for at least 1-2 more years could be immensely frustrating.

As also previously stated, pretty good lifestyle though (for surgery)

 

[LaCirujana]

Nobody else thinking of pediatric CT surg?

Sounds good!! Like someone else said, very few training spots, so that leaves a higher shot for a good fellowship for me!

Jeez! Are you kidding?--it seems like 2/3 of the people we interviewed this year for residency positions were interested in peds CT! The CT surg folks here thought it was hilarious--they know what a complete long shot it is for even one of these wannabes to make it in the field.

 

[medguy25]

Your experience is very similar to mine. I'm really interested in ped CTS. You should realize though that even though the career is relatively stable compared to adult CTS, the job market is much smaller. A doc told me once that there are about 4 attending positions that open up every year. It is not uncommon for fellows to spend an extra 1-2 years as fellows waiting for an attending positiion to open up.
Another point to consider is that ped CTS is more technically demanding and the stakes are much higher. A pediatric cardiologists told me once that when a baby doesn't make it through a surgery it's almost always surgeon error compared to adult surgery where you might be dealing with an 80 year old patient with other complicating factors.

Having said all that, I can't help but still be drawn towards this field

Yeah, this is definitely supported by an article I found a while ago researching the job market since it's so small.

Anybody interested should check out article in the Annals of Thoracic Surgery....."Report of the 2005 STS Congenital Heart Surgery Practice and Manpower Survey."

It was a survey done by cong. heart surgeons to try to put an idea together of the demographics of the cong. heart surgery workforce.

In addition to several other interesting findings, they found that 65 surgeons were planning to retire within the next 10 years. However, during the year of the survey, 19 fellows who are planning on staying to work in the US were finishing up their fellowship. If you average out the 65/10, that would be 6.5, so there's approximately 3X as many fellows getting out as there are jobs opening up.
However, it's not random, it's skewed toward the later years. Only 3 surgeons were planning on retiring in the next year from the survey, 25 in the next 5 years, and 40 more in the 5 years after that, and 51 in the 5 years after (see attached graph below).
So that means 19 fellows coming out to compete for 3 jobs in the year of the survey.


On the other hand, there's already been a little bit of a self correction in the market already in CT surgey with a large decline in the number of people who have been going into CT fellowships (I heard one statistic put it at around 40-50% of the available fellowships for CT surgery have been going unfilled each year b/c of lack of applicants.
I'm an M1, so I wouldn't even be finishing a fellowship for another 12 years at the very earliest, so I'm hoping that the trend continues and the retirement and in coming supply even out a bit more.
After all, in the 2nd 5 year period from now in the survey, 40 people were planning on retirement. That's ~8 per year, which compares more favorably to the 3 per year the year of the survey.



On the demanding point, yeah, definitely have heard that too. I never had a cong. heart kid die in the 7 months I worked on the PICU before med school, but we didn't do a huge number of kids either (in other words, not like Boston, or CHP for examples). Also, it was only 7 months.

However, reading "Walk on Water" definitely painted a different picture with a couple of the kids dying in that book. And that's with Roger Mee, one of the best in the biz (formerly, I think he's retired now).

Ever read that book? If you're also interested in the field, it's a MUST READ! It was amazing.




Attached is the graph with the retirement stuff in it from the article-

 

[medguy25]

Jeez! Are you kidding?--it seems like 2/3 of the people we interviewed this year for residency positions were interested in peds CT! The CT surg folks here thought it was hilarious--they know what a complete long shot it is for even one of these wannabes to make it in the field.

Uh, yeah, my post was a joke.

Figured you probably assumed that, but just wanted to clarify anyways...

 

[Circumflex]

I had planned on CT Surg (specifically Peds CT) as a career and did 1 month of Peds CT elective, plus "hanging out" in my spare time.

First, at most places it is a 2 year fellowship and then most surgeons go work/scrub with a more experienced surgeon for at least 1-2 years to become more comfortable with the complex procedures. And yes, you will be at some type of academic center because you need a wide referral base to maintain a practice. Some Peds CT surgeons do peds and adults due to low patient volume, but most of these do not do the more complex procedures. To keep mortality rates low, you need practice and enough volume to keep up your skills.

You were right in stating that there are few emergent procedures that have to be done in the middle of the night, but there are many emergencies that have to be dealt with during the night if you deal with very sick babies - they can crash quickly. The month I spent was with 2 surgeons - no fellow and they were constantly working. They did a lot of complex procedures like Norwoods, Fontans, Truncus repairs, etc., so they had a lot of sick babies.

It is probably the most intense, time-intensive training that you can go through. You have to be perfect and unwilling to settle for nothing else to keep a low mortality rate.

Don't count out interventional cardiology altogether. There is a push to do fetal catheterizations to patch holes as well as redirect blood flow. Some think that if you intervene early enough, it could be possible to alter the hypoplatic left hearts and allow them to grow. Fetal intervention is a cool new area open to surgeons as well as cardiologists - and we know how quick cardiologists are to jump on new procedures.