Cardiac and Thoracic Practice vs Pure Thoracic Practice?

[Enantiomer96]

Hello,

I'm having trouble deciding between entering a practice that does both cardiac and thoracic vs doing a thoracic only practice.

The CT practice is a small community hospital that comes with an academic title bc there are gen surg residents. They have simple and straightforward heart cases and not too many emergencies (no transplant, lvads, ecmo, etc.). There are two cardiac surgeons, and one is retiring. There is no thoracic surgeon and I would take on those robotic cases (mentored by a surg onc attending who's doing everything open) - so a lot of volume but would be a struggle out of training. Also its close my family (currently trying to raise small kids). Also pays ~40% more, but is kind of in the middle of nowhere (worried if I get stuck the schools are not as good as the other job).

The pure thoracic practice is in a larger academic place with a medical school. Bigger complex cases, etc. further from family but better schools (eventually kids will need). Seem like a simple straightforward option that would leave options open if I change jobs later because it's more academic. Both are q2 for now.

My issue is that I enjoy doing cardiac cases but not cardiac emergencies so much, and I generally want to protect my time with my family and prioritize my kids education/success. Do I go with the community hybrid job that pays more and is closer to family but has worse schools and possibly difficult to change jobs, or go with the larger academic pure thoracic job and honing my skills with complex cases for the long run and secure better schools all for lower pay and further from family?

How difficult is it to change jobs from a community hospital into an academic practice later?
I enjoy cardiac but how taxing on my family will community hearts be compared to academic thoracic? What's the pay difference here?

Any advice would help, thank you.

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[LucidSplash]

I have bias here in that I took a more community oriented job out of fellowship and wish I’d taken a job with more complexity now. So take what I say here with a grain of salt.

It’s not impossible to switch back to academics from community. But I think that’s less of an issue as many community jobs have far more complexity than people expect plus you have to learn how to handle what complexity you can in the community with fewer resources overall and that has a benefit. But I strongly feel that you’re better off in a 1st job which cements the skills from your training. You will be amazed and how quickly your comfort with some of the complex procedures you feel reasonably comfortable with now will wane without early and frequent exposure as an attending.

These 2 jobs aren’t totally opposites though. I think the first decision you need to make is if you’re willing to give up cardiac entirely. I suspect it would be difficult to spend 5 years in a job doing only thoracic and then switch to a community job that requires both cardiac and thoracic. I will defer to those in your field like @ThoracicGuy for confirmation on that. Every time you apply for privileges somewhere they will want to see your recent case logs to show you can handle the cases you’re being hired to do. I imagine with a 3-5 year gap without cardiac cases you might have difficulty with credentialing for a cardiac job.

Once you figure out if you’re willing to give up cardiac, then you can better choose between these 2 jobs. And if you’re not willing to give up cardiac entirely, maybe you should be looking for a 3rd option that gives you the ability to do that at least some and meets the rest of your goals. No job is perfect. But I wouldn’t chase the community job just for the money. Money will come. Experience and mentoring are worth more early in your career than people give credit.

Also the kids will appreciate you being around more when they are older. Your spouse is the one who will miss your help if the kids are really young now. That’s who needs to be on board. The kids won’t remember at 2 or 4 if you’re working late, but they will know if you miss the soccer game at age 10. So if you have to choose between working a little more now to cement your skills and put your career on good footing, I’d choose that as long as I felt I could pull back later. But you have to know how to set boundaries with work when that time comes. Another grain of salt here as I’m the fun aunt and not a parent, but just from my personal experience as a kid but also as the fun aunt as I watch my friends navigate these same issues.

 

[ThoracicGuy]

I agree with a bunch of what @LucidSplash wrote. The first question is absolutely if you are willing to do only thoracic or if you want to do only cardiac or a combination of the two. Once you go only thoracic, I think you have a pretty small window of maybe a year, two at best, to go back to doing hearts. You will just lose some of the skillset to do them. I haven't done any hearts since training, though I did scrub in as an assist to some local guys for a few years out of training. There is no way I would ever do a job that required any hearts. It would not be fair to the patient at all.

So after you've decided what type of job you're willing to do, then we get to the two jobs you mention here. So in the first one you'd be doing a mix of cardiac and thoracic. As to the percentages, every place will be a bit different, but my experience has been that these jobs you are doing mostly cardiac with some thoracic thrown in. Now if your partner wants to do more cardiac and less thoracic and you are ok with taking more of those, it could be different for you. As for emergencies, yes you wouldn't have VADs or transplants to do or ECMO if your facility doesn't even support it, but emergencies will still happen for you. If an ascending dissection comes in the middle of the night, you will have to go in and do that case. I'm not sure there are many places out there that would accept a dissection in transfer when the original facility has cardiac surgeons on staff. It's not safe for the patient. So you have to be ready for that sort of thing. Location does matter, but why it matters is different for all. You have to decide between you and your wife if that location is ok to raise your family. The other question is how much of a mentor do you feel the partner will be with you. That is absolutely key for you at this stage in your career. It can be the difference between getting through a case that goes bad safely or not. Having someone experienced that is willing to help you is necessary when you start out. Can it be done without it? Sure, but I wouldn't recommend it.

The second location would require giving up cardiac entirely, so that's the first big question. As for the thoracic part, are you ready for the tougher cases that come to you from outside hospitals (like the first job). You can't pick and choose your cases at the university service. You'll likely have some backup help from other attendings, but they may also be busy in their practices with the heavier case loads.

Call every other night can be done, but it can also doesn't leave much breathing room there. It really depends on your specific job and how busy it is. I am q2 call at my job and I don't get a ton of calls/consults in the evenings, so it doesn't bother me too much. Some days can be bad though. For a fairly small hospital, we do see a good variety of pathology. We have the ability to transfer patients that are too complex for our hospital to one of the local large community or university hospitals. Now would I feel real comfortable going to a high powered academic job now that I'm 10+ years out from training? Not really. If I had a great mentor at that academic job that would be willing to help out in those complex cases that are 'university cases', that would help, but there is a big difference in what I would be willing to tackle now compared to what I would be willing to tackle the first few years out of training. I'm ok with that, but you have to think about that for yourself. I think with hearts it is probably a bit different. If you're doing bypasses/valves primarily, that's not going to be all that much different in an academic setting. Sure you'll have more exotic stuff, but many academic places have people that specialize in some of the exotic stuff more than others and will tend to get those patients. So I think job #1 wouldn't limit you being able to go to an academic job in 5 or 10 years if you would want to.

Now it is pretty common that the first job out of residency won't be your last job. People do move around and you may get into one of these jobs and decide it really isn't the right fit for you. That's ok. Don't be afraid to look for other opportunities that are out there.

In the end, I think job #1 gives you cardiac/thoracic combined experience and still keeps you marketable for academic jobs if you would like. Job #2 would likely end your cardiac job track pretty quickly if you stayed in it. Location is important, talk with your wife about it. If public schools at job #1 aren't the best, are there private ones that are better? What degree of mentorship is available at either job. If one job has a great amount and the other has none, that would make me heavily biased towards the mentorship spot.

Feel free to ask anything else that I might have overlooked or comes up.

 

[WinslowPringle]

I think the questions to ask yourself are really:

1. Do you want to do hearts or not? If you want to do cardiac at all at some level now or in the future, you have to go to a job that has it. Cardiac isn’t something you can let go for awhile at the beginning of your career and then come back as an attending without doing some significant retraining. The community job probably gives you more options down the road. With the exception of lung transplant and maybe proximal tracheal resections, complex thoracic cases should be well within the wheelhouse of a community program: lobectomy, segmentectomy, LVRS, sleeves, esophagectomy, foregut, complex chest wall recon are done at community places all over.

2. Which place gives you better mentorship? The first year (and really the first three probably) are the most critical in a CT surgeons career. You need some guidance, mentorship but not too much. You need to be able to make some mistakes but not too much. Your colleagues will make or break you. I know you outlined some of the differences, but what does your gut say about the people and their characters? Are there people who will go to bat for you - or just compete with you?

3. What can you do and do well? Be realistic with yourself; you truly have to be able to go out and do the heart as the attending and be able to do that robot lobe solo. Can you do it? Likely your surg onc guy will be happy to be around but an open vs robot case is pretty different and you'll have to already have the basics down pretty well. Similarly, 1:2 call for cardiac doesn’t give the other person a ton of time for scrubbing all your cases if they have their own. And if you went to a cardiac heavy program, are you ready to be the university guy for thoracic?

4. What is programmatic support? A place with lower pay but fellows/midlevels who will do the notes/orders and deal with lower level stuff may be better than a community program with minimal midlevel/institutional support.


Also, there is no such thing as a simple and straightforward heart. Yes, normal EF 3v Cabg w/ good targets is the dream and is like the lap chole of CT, but one wrong needle angle on your aortic cannulation and it’s a dissection and a bad day.
You can go from community to academic in the future; there are a lot of “lower level” academic jobs and academic affiliated programs that can be stepping stones if that’s what you want and needed. Also depends on who you know. It is entirely possible that a good community CT practice with good program support can be much more chill than a big academic thoracic practice where you do transplant and are at each others throats; similarly, a flailing community program with high volume and low support will be miserable long hours compared to a niche in a well endowed academic program.

Good luck!

 

[Enantiomer96]

Thank you all for your insights.

- Deciding to do cardiac or not is difficult to say. I haven't been a cardiac attending so I don't truly know what it's like (cardiac fellowship at a big university very tiring). I like doing the operations, and find them more exciting at times than thoracic cases. I don't like doing dissections from 11pm to 8am though- I would be willing to put up with them sometimes for the higher pay - just not sure when I'm older if I would want to. Again tough to say because I don't know what it's like being an attending - it seems like they come after the chest is open, do the important stuff, then leave, cutting away the hours of set-up, closure, and transport which gets tiring as a trainee. On the other hand they have a lot more stress owning their outcomes. I feel like I am trading time/energy with my family for doing something I like more and pays better?

In the end, I don't know if I want to shut the door on cardiac, which is why I considered doing both for a few years then deciding later. It just seems a little risky compared to the straightforward academic thoracic place that has a clear 5-year 10-year plan with clear support and schools if we get stuck.

- The community job seems to have less mentorship and less support, but is closer to family. Both places said they would mentor me to get going though. The busy academic surgeon may be busy with their own cases/patients. The quieter community place may actually have more support but really hard to say without being there.

 

[LucidSplash]

I still say look for a 3rd option if anyway possible. I’m not convinced either of these jobs fits you based on what you’ve said you value. While no job is perfect, and there will always be compromises, and it’s not uncommon for new grads to find another job within 2-3 years, I am concerned that these 2 jobs may put a new grad into an undesirable position, either with less mentorship than wanted or pigeonholed into thoracic only.

 

[ThoracicGuy]

Thank you all for your insights.

- Deciding to do cardiac or not is difficult to say. I haven't been a cardiac attending so I don't truly know what it's like (cardiac fellowship at a big university very tiring). I like doing the operations, and find them more exciting at times than thoracic cases. I don't like doing dissections from 11pm to 8am though- I would be willing to put up with them sometimes for the higher pay - just not sure when I'm older if I would want to. Again tough to say because I don't know what it's like being an attending - it seems like they come after the chest is open, do the important stuff, then leave, cutting away the hours of set-up, closure, and transport which gets tiring as a trainee. On the other hand they have a lot more stress owning their outcomes. I feel like I am trading time/energy with my family for doing something I like more and pays better?

In the end, I don't know if I want to shut the door on cardiac, which is why I considered doing both for a few years then deciding later. It just seems a little risky compared to the straightforward academic thoracic place that has a clear 5-year 10-year plan with clear support and schools if we get stuck.

- The community job seems to have less mentorship and less support, but is closer to family. Both places said they would mentor me to get going though. The busy academic surgeon may be busy with their own cases/patients. The quieter community place may actually have more support but really hard to say without being there.

You definitely want to have good mentorship, especially doing hearts. Now you mention that you're not sure you want to be doing the overnight dissections when you're older. That's actually a good problem to have. When you're older, you can have choices. You can choose to go to a job that doesn't have much of that sort of business. You could move to doing more thoracic work at that time, though you might be a bit behind on whatever the current thoracic toys are at that time. You still have options though.

 

[SociableJimmy]

As an incoming fellow starting 8/1 leaning toward community practice, I’ve found this thread very helpful and informative. Thanks to all that have been involved. I’m wrapping up critical care fellowship at a major academic center with a large CT program & we are very busy in the ICU overnight. My experience so far has really impressed upon me the importance of a well-oiled ICU team, especially when the surgeons aren’t in house overnight. I’m wondering how realistic it is to find a community/communiversity job with a well-staffed ICU (ideally at least some dedicated intensivist coverage, +/- residents & fellows). It seems like this is overall much better for patient care/continuity than some of the bare bones ICUs I’ve seen in the community and at the local VA for example. Obviously I expect to & and am happy to be involved in ICU issues at any time of the day/night, but taking calls all night every night about routine postop care (expected inotrope/pressor titration, vent weaning, stable arrhythmia management etc, i.e. the stuff I take care of as a fellow right now and update the surgeons about in the morning) seems like a recipe for things to be missed, early burnout, and job dissatisfaction. Is this possible in the community or should I be looking at more academic positions for this?

 

[ThoracicGuy]

As an incoming fellow starting 8/1 leaning toward community practice, I’ve found this thread very helpful and informative. Thanks to all that have been involved. I’m wrapping up critical care fellowship at a major academic center with a large CT program & we are very busy in the ICU overnight. My experience so far has really impressed upon me the importance of a well-oiled ICU team, especially when the surgeons aren’t in house overnight. I’m wondering how realistic it is to find a community/communiversity job with a well-staffed ICU (ideally at least some dedicated intensivist coverage, +/- residents & fellows). It seems like this is overall much better for patient care/continuity than some of the bare bones ICUs I’ve seen in the community and at the local VA for example. Obviously I expect to & and am happy to be involved in ICU issues at any time of the day/night, but taking calls all night every night about routine postop care (expected inotrope/pressor titration, vent weaning, stable arrhythmia management etc, i.e. the stuff I take care of as a fellow right now and update the surgeons about in the morning) seems like a recipe for things to be missed, early burnout, and job dissatisfaction. Is this possible in the community or should I be looking at more academic positions for this?

I think it's definitely a realistic thing to see credible ICU staffing in a community based system. The larger hospitals will typically have in house coverage, though it may end up being NP/PA coverage if they don't have residents in the system. Smaller hospitals will be hit or miss if there is overnight coverage, but even there you can get some decent ICU staffing.