Can a cardiothoracic surgeon have a good work/life balance?

[dienekes88]

Good post, not disagreeing with you. I know the data and I know that CABG is superior to stenting, but the public doesn't know that. Plus the cardiologists don't necessarily disclose that information. When you have one doctor telling you he's gonna run a wire through your groin (or even your arm) and you'll get to go home that same day or next day, and you have a surgeon on the other side telling you he's gonna crack your chest and throw some stiches in your heart, which do you think most people are gonna go with? I don't see that changing, even if the data supports it. Stenting is a much easier sell than CABG.

When the government starts cracking down on healthcare utilization and looks at cost effectiveness, we'll see a change in referral patterns. The fee for service model doesn't seem to be sustainable in the current healthcare climate. Whether that means it'll be capitated, pay-for-performance, or something different is unclear to me. At places where there is less incentive to place stents (i.e. outside of private practice), the cardiac surgeons are getting plenty of cath lab consults for 3V and Left Main disease for two reasons: 1) it's the right thing to do and 2) in the long run, the Cost/QALY will likely favor CABG (Magnuson et al. Cost-effectiveness of PCI/DES vs. CABG from the FREEDOM trial, Circulation 2013).

I agree with you about all the other stuff. CT guys absolutely need wire skills, and finding a program that integrates all that is definitely the way to go. Not disagreeing with you at all.

The problem is, as of today, the job market sucks and a lot of the CT guys are hustling and trying to find jobs. I've met a couple of vascular fellows who were previously CT trained who are doing fellowship because they couldn't find jobs. Go look at the job listings in NY, LA, SF or any other big city on a coast. The job market is horrible for CT, and most guys who get jobs in these areas are junior partners for a couple years, then get tossed aside when it's time to make partner. Plus the pay is about the same as a general surgeon, sometimes less. Will it be better in the future? I hope so. Even with all this, CT is still on my list for possible future fellowship, but location is more important to me than pay, so it's falling farther down the list.

This is partly true. The job market has suffered on account of PCI. You have to be sure to get really good training, and you have to be lucky enough to know the right people. I don't know what the job market is like in other fields, so I can't really comment on that. The best jobs also aren't always on the coasts, and you may have to be a little more flexible with your location requirements than say... an internist or a general surgeon. Location is not always what defines a good job, though. You need support from your senior partners, the opportunity to find your niche, ability to build your practice, etc.

Regarding reimbursement... again, that's true. However, I would rather be doing a root/ascending/total arch than a Whipple; prefer the Type A dissection to the appy or ex-lap for free-air; etc. To each his own. At the end of the day, it's nice to like what you do. Heck, I liked doing gallbladders and hernias, but I just happen to like doing coronaries more.

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[Nivens]

Why not tag me if you are talking about me? I'm pretty sure there is a lot of people out there who always dreamed of becoming a surgeon and they ended up doing it.

Never occurred to me- don't know how to tag

Seriously though, I meant no offense. If I was addressing anyone in particular it was my aforementioned best friend and my wife, as well as all the preclinical students who look all bug-eyed at me when I tell them I'm going into anesthesiology despite a Step score that makes me a shoe-in for Ortho or Uro. I was one of those people who was totally turned off by all of the would-be surgeons jumping over each other to cut 5 cm (sonometer? ; P) incisions in our cadavers' legs so they could practice suturing on day 1 of med school. I was raised never to buy anything sight-unseen, and these people would have traded a kidney on the spot for a career and a life they'd barely scratched the surface of. My surgery rotation took me completely by surprise- I really liked it, and was left with the impression that general surgeons are the strongest all-around doctors in the hospital. But everything in life has a cost, and for me the price of the privilege to wield the scalpel was just too high. I was far from alone.

I don't disagree with your statement that there are people out there who always dreamed of being a surgeon and made it happen, but you have to ask yourself WHY they always dreamed of being a surgeon and whether or not the reality lived up to their expectations. Society worships surgeons, and before they experience surgery on any meaningful level, chances are their "dreams of becoming a surgeon" have a lot more to do with what other people think of them than anything grounded in reality. The same could be said of college students hoping to become doctors, which is why adcoms put such a premium on shadowing when considering applicants, but it isn't enough. Showing up and watching a surgery, following a doctor around for an afternoon, or even a third year rotation where you update a sign-out, scrub in to a few cases and retreat to the library to cram for the shelf is nothing compared to hours, paperwork and other bull**** actual practicing surgeons are subjected to. I don't know if you are in medical school yet, but either you have or will have many classmates who will admit they liked the idea of medicine a whole helluva lot more than they do the reality.

All of that being said, I'm not going to convince you of much on a message board. You are going to go on thinking you will be the exception, and that's fine. When people were telling me all of this, I thought the same thing. I was wrong. But if I can convince you just to approach specialty selection with one question in mind "What makes me truly happy?", then the 10 minutes I spent not doing UWORLD questions to type this would be worth it. If that's surgery, fantastic. If not, that's ok too.

 

[The Buff OP]

Never occurred to me- don't know how to tag

Seriously though, I meant no offense. If I was addressing anyone in particular it was my aforementioned best friend and my wife, as well as all the preclinical students who look all bug-eyed at me when I tell them I'm going into anesthesiology despite a Step score that makes me a shoe-in for Ortho or Uro. I was one of those people who was totally turned off by all of the would-be surgeons jumping over each other to cut 5 cm (sonometer? ; P) incisions in our cadavers' legs so they could practice suturing on day 1 of med school. I was raised never to buy anything sight-unseen, and these people would have traded a kidney on the spot for a career and a life they'd barely scratched the surface of. My surgery rotation took me completely by surprise- I really liked it, and was left with the impression that general surgeons are the strongest all-around doctors in the hospital. But everything in life has a cost, and for me the price of the privilege to wield the scalpel was just too high. I was far from alone.

I don't disagree with your statement that there are people out there who always dreamed of being a surgeon and made it happen, but you have to ask yourself WHY they always dreamed of being a surgeon and whether or not the reality lived up to their expectations. Society worships surgeons, and before they experience surgery on any meaningful level, chances are their "dreams of becoming a surgeon" have a lot more to do with what other people think of them than anything grounded in reality. The same could be said of college students hoping to become doctors, which is why adcoms put such a premium on shadowing when considering applicants, but it isn't enough. Showing up and watching a surgery, following a doctor around for an afternoon, or even a third year rotation where you update a sign-out, scrub in to a few cases and retreat to the library to cram for the shelf is nothing compared to hours, paperwork and other bull**** actual practicing surgeons are subjected to. I don't know if you are in medical school yet, but either you have or will have many classmates who will admit they liked the idea of medicine a whole helluva lot more than they do the reality.

All of that being said, I'm not going to convince you of much on a message board. You are going to go on thinking you will be the exception, and that's fine. When people were telling me all of this, I thought the same thing. I was wrong. But if I can convince you just to approach specialty selection with one question in mind "What makes me truly happy?", then the 10 minutes I spent not doing UWORLD questions to type this would be worth it. If that's surgery, fantastic. If not, that's ok too.

Don't sweat it, I will keep my mind open. I have mainly focus on surgical specialties and I have looked into medical specialties, but surgery has always caught my eye. I want to help people with my hands, not by prescribing a medication (no hate, please lol).

Oh BTW to mention someone on your future post just do @ and type their name.

 

[womp]

If I was addressing anyone in particular it was my aforementioned best friend and my wife, as well as all the preclinical students who look all bug-eyed at me when I tell them I'm going into anesthesiology despite a Step score that makes me a shoe-in for Ortho or Uro. I was one of those people who was totally turned off by all of the would-be surgeons jumping over each other to cut 5 cm (sonometer? ; P) incisions in our cadavers' legs so they could practice suturing on day 1 of med school. I was raised never to buy anything sight-unseen, and these people would have traded a kidney on the spot for a career and a life they'd barely scratched the surface of. My surgery rotation took me completely by surprise- I really liked it, and was left with the impression that general surgeons are the strongest all-around doctors in the hospital. But everything in life has a cost, and for me the price of the privilege to wield the scalpel was just too high. I was far from alone.

I don't disagree with your statement that there are people out there who always dreamed of being a surgeon and made it happen, but you have to ask yourself WHY they always dreamed of being a surgeon and whether or not the reality lived up to their expectations. Society worships surgeons, and before they experience surgery on any meaningful level, chances are their "dreams of becoming a surgeon" have a lot more to do with what other people think of them than anything grounded in reality. The same could be said of college students hoping to become doctors, which is why adcoms put such a premium on shadowing when considering applicants, but it isn't enough. Showing up and watching a surgery, following a doctor around for an afternoon, or even a third year rotation where you update a sign-out, scrub in to a few cases and retreat to the library to cram for the shelf is nothing compared to hours, paperwork and other bull**** actual practicing surgeons are subjected to. I don't know if you are in medical school yet, but either you have or will have many classmates who will admit they liked the idea of medicine a whole helluva lot more than they do the reality.

All of that being said, I'm not going to convince you of much on a message board. You are going to go on thinking you will be the exception, and that's fine. When people were telling me all of this, I thought the same thing. I was wrong. But if I can convince you just to approach specialty selection with one question in mind "What makes me truly happy?", then the 10 minutes I spent not doing UWORLD questions to type this would be worth it. If that's surgery, fantastic. If not, that's ok too.

Surgical lifestyle is tough, but so are a lot of other medical specialties. It's not like the other docs are all working 9-5 with 2 year residencies. Paperwork abounds in all of medicine. With surgery at least you have a plethora of PAs/NPs to do the bulk of it.

In terms of lifestyle, there is a world of difference between the joints guy at a private hospital in the burbs and the trauma surgeon at a safety net level 1 trauma center with daily GSWs.

In medicine, you buy everything sight-unseen, including in anesthesiology. Make the best of your decision and know that there are always forks you can take to make your chosen path a little bit more of what you had envisioned.

 

[Nivens]

In medicine, you buy everything sight-unseen, including in anesthesiology. Make the best of your decision and know that there are always forks you can take to make your chosen path a little bit more of what you had envisioned.

Absolutely true. I of course didn't tell my *entire* story- I really liked surgery, but I liked anesthesia even more. There are undoubtedly uncertainties in everything. I personally believe the better we can keep our egos out of our decision making, the greater chance we have at happiness. It's not easy. I've learned the importance of surrounding myself with people that will call me out on my bull**** the hard way.

 

[heybeyond]

Good post, not disagreeing with you. I know the data and I know that CABG is superior to stenting, but the public doesn't know that. Plus the cardiologists don't necessarily disclose that information. When you have one doctor telling you he's gonna run a wire through your groin (or even your arm) and you'll get to go home that same day or next day, and you have a surgeon on the other side telling you he's gonna crack your chest and throw some stiches in your heart, which do you think most people are gonna go with? I don't see that changing, even if the data supports it. Stenting is a much easier sell than CABG.

I agree with you about all the other stuff. CT guys absolutely need wire skills, and finding a program that integrates all that is definitely the way to go. Not disagreeing with you at all.

The problem is, as of today, the job market sucks and a lot of the CT guys are hustling and trying to find jobs. I've met a couple of vascular fellows who were previously CT trained who are doing fellowship because they couldn't find jobs. Go look at the job listings in NY, LA, SF or any other big city on a coast. The job market is horrible for CT, and most guys who get jobs in these areas are junior partners for a couple years, then get tossed aside when it's time to make partner. Plus the pay is about the same as a general surgeon, sometimes less. Will it be better in the future? I hope so. Even with all this, CT is still on my list for possible future fellowship, but location is more important to me than pay, so it's falling farther down the list.

bumping this thread

Why are CT surgeons having a hard time finding jobs? Just curious- what surgery specialities are high in demand and good if you are considering surgery but believe location is important as well?
Thanks!

 

[vhawk]

Pedsurg

 

[Winged Scapula]

bumping this thread

Why are CT surgeons having a hard time finding jobs? Just curious- what surgery specialities are high in demand and good if you are considering surgery but believe location is important as well?
Thanks!

While not as "sexy" as some specialties there is high demand for a simple general surgeon, especially if you'll do trauma and/or vascular.

 

[heybeyond]

While not as "sexy" as some specialties there is high demand for a simple general surgeon, especially if you'll do trauma and/or vascular.

Thanks for your answer! But why is CT surgery not in demand? I'm curious to know.

 

[Winged Scapula]

Thanks for your answer! But why is CT surgery not in demand? I'm curious to know.

I never said CT surgery wasn't in demand you just asked what other surgical specialties were.

However, the reason given runs the gamut from the old guys not retiring, to the influx of catheter-based interventions done by other specialists, to a healthier population not requiring as much surgery. I will leave it to those with intimate knowledge of the field to parse these out.

 

[dienekes88]

Thanks for your answer! But why is CT surgery not in demand? I'm curious to know.

It's not that CT surgery is not in demand. It's that the demand is changing. VAD and transplant surgeons are still sought after. As VAD technology improves, things like minimally invasive VAD implantation, peripherally implanted durable mechanical circulatory support (MCS), and less morbid temporary MCS are going to be more common. With devices like the Avalon cannula and the Protek cannula, you can have a patient on VV ECMO awake, extubated, and talking.

As each field develops, the demands on it will change. Before the proton pump inhibitor, there was a lot of ulcer surgery in general surgery. Before the development of non-operative management strategies and thin-slice multidectector CT scan, there was a lot more operative trauma. For better or worse, things change.

Finally, "Cardiothoracic" surgery is undergoing a variety of meioses. While the private practice surgeon in a smaller community practice is still able to schedule a CABG (usual 3), AVR, and a lobectomy in the same week, the modern surgeon has to differentiate. General thoracic surgery is getting progressively more complicated with its own management subtlety - e.g. neoadjuvant chemoXRT vs chemo for Stage IIIA NSCLC ... or what to do with the surprise positive N2 node at the time of surgery for a clinical Stage 1 or 2 NSCLC... or role and patient selection for LVRS. An increasing need to be well versed in VATS technique makes it difficult to be an all-arounder. Similarly, cardiac surgery is differentiating. There are aortic surgeons, heart failure surgeons, minimally invasive cardiac surgeons, etc. Tomorrow's cardiac surgeon is going to be very different from the "golden age" surgeon, for whom the CABG was king.

I never said CT surgery wasn't in demand you just asked what other surgical specialties were.

However, the reason given runs the gamut from the old guys not retiring, to the influx of catheter-based interventions done by other specialists, to a healthier population not requiring as much surgery. I will leave it to those with intimate knowledge of the field to parse these out.

Mostly agree.

However, the annual number of PCIs is falling too. Statins and declining prevalence of smoking is driving down coronary disease. Additionally, the FAME-2 trial has resulted in a significant decline in PCIs as FFR is proving to be a powerful tool in decision making.

 

[doc05]

Thanks for your answer! But why is CT surgery not in demand? I'm curious to know.

One more thing to keep in mind. For very specialized fields, you need a larger population to support the practice --- that is, there is a need for fewer CT/neuro/peds surgeons per 100 000 population, compared to, say, a general surgeon or internist.

What this means is - when you graduate and start looking for a job, your choice of practice opportunities may be very limited.

 

[el_pistolero]

I wonder how common it is for a CT surgeon to have 'mixed' cardiac and thoracic practice? Is it feasible in academics or is it just limited to community settings?

In some EU countries (e.g., Germany, France), I heard there are CT surgeons who practice thoracic and cardio-(and peripheral) vascular...

 

[Trauma Surgeon]

I wonder how common it is for a CT surgeon to have 'mixed' cardiac and thoracic practice? Is it feasible in academics or is it just limited to community settings?

In some EU countries (e.g., Germany, France), I heard there are CT surgeons who practice thoracic and cardio-(and peripheral) vascular...

I can comment on northern Europe (including Germany) : The cardiac guys do only cardiac cases and the thoracic guys do only thoracic (pulmonary cases). This is because there are far less fewer thoracic cases and they are centralized. None of them do peripheral cases since the vascular guys need the very few cases that does not go for angio for keeping them selfs trained or to train the fellows.

 

[celling]

I wonder how common it is for a CT surgeon to have 'mixed' cardiac and thoracic practice? Is it feasible in academics or is it just limited to community settings?

In some EU countries (e.g., Germany, France), I heard there are CT surgeons who practice thoracic and cardio-(and peripheral) vascular...

Usually, in academics you are focused on cardiac vs thoracic vs vascular. However, there are exceptions. Many private practice jobs require you to do cardiac and thoracic. Some, especially in the southeast and texas, like you to do vascular as well.

 

[heybeyond]

Thank you everyone for clearing up my questions on this matter! It was all very helpful.