cardiac surgery and interventional cardiology

[Dr.alfa]

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Quote from CTSnet.org

"How can a cardiac surgeon get training so that he can (and be officially able to) perform balloon angioplasty and stenting in the cath lab while still doing CABG in 3V disease and valve surgery in the OR?

Wouldn't this coupling be the best solution for the referencing problem cardiac surgeons are facing and for the declining workload in CABG (valves are going up, see the STS stats)?

How can someone who finishes a cardiac surgery programm get a fellowship in interventional cardiology and vascular radiology?"


Please share your thoughts
Thank you

 

[ArrogantSurgeon]

Gradually there is becoming a push in some CT surgery training programs to incorporate cath lab training into the CT surgery fellowship. There is no reason why CT surgeons who can perform CABGs, valvular surgery, and other complex corrections of the great vessels could not also perform angioplasty and stenting after adequate training.

Regarding drug coated stents, below is some info I recently read about the issue written by a CT fellow:

The jury is still deliberating on the impact of coated stents on CABG volume. Recent data suggests that the impact has been over-exagerated by as much as 80%. Additionally, non-invasive coronary imaging will likely replace the diagnostic cath within 5-10 years, thereby ending self-referral in the cath lab. Pt's with non-invasive testing that demonstrates 3V disease will be sent for CABG, where currently they may be stented. The SOS (Surgery or Stent) data in the Lancet is conclusive with a 3 fold mortality in the 3V stented group when compared to CABG. Additionally, the slope of the line for mortality in the stent group appears exponential when compared to CABG. It will be interesting to see what the 6 and 9 year f/u's demonstrate in ths study. I would not be surprised if the study were stopped and all pt's with 3V disease were sent for CABG.


Hope this helps. This is an area that I am also interested in, so I'd appreciate if you'd post any info that you come across.

 

[southerndoc]

I think CV surgeons performing cardiac caths and stenting is the way to go. Why? You eliminate one team by doing so. When an interventional cardiologist does a cath, he/she must have a cardiac surgeon on standby in case something goes wrong. By letting the surgeon do it in the first place, you eliminate one team from the process... thus it's more economical.

 

[droliver]

It certainly makes sense for the field to adapt this way. Incorporating it into the curriculum is going to be formidable however. There will be a lot of hard feelings that are engendered with cardiology during the transition if it happens. What you could see develop are sorts of multi-disciplinary specialty groups with both providers in partnership for these things

 

[Skylizard]

Originally posted by Geek Medic
I think CV surgeons performing cardiac caths and stenting is the way to go. Why?...When an interventional cardiologist does a cath, he/she must have a cardiac surgeon on standby in case something goes wrong...

I don't know about it being economical. If the CT surgeon bills for the cath as opposed to the cardiologist, you are just robbing Peter to pay Paul. The surgeon will bill at the very least the same for the cath as the cards doctor.

However, I think there is a more fundamental issue involved in this matter. It is demonstrated with some similar parallels. Interventional radiology is an example. During surgery internship, the rads guys would do stenting. Guess where the patients went post stenting? That's right, the vascular surgery service. The rads guys were just not capable of managing these patients or generally treating any complications so the patients had to be admitted post procedure to Vasc surge service. Colonoscopy is an example. The GI docs can not do anything about their complications from endoscopy. So, it makes a great deal of sense for Gsurgeons to be skilled with the scope. If there is a problem in the colon, they see it first hand and can tatoo it for resection. If there is a perforation secondary to a scoping misadventure they can take the patient to the OR without awaiting a "consult". So to is it with cathing. Gsurgeons place IVC filters. Vascular surgeons place big stents in the Aorta. In Lubbock Texas, I got the impression the entire interventional rads is now under the control of the vascular surgery division do to some serendipidous meltdown of the interventional radiologist. So, why not have CT surgeons cath? Frankly, they are the only ones capable of fixing a lacerated coronary. If they find bad disease requiring CABG, they do not have to await a consultant. They can consult cards after the OR for general cardiac outpatient care🙂

 

[makatak]

More and more, I think the trend will be that radiology tasks will be distributed amongst the respective fields. Many neurologists and now even some rare surgeons are licensed to read and dictate their own xray/ct/mri/mra. (higher malpractice insurance though)

I think it is a sort of "tug-of-war" and not necessarily stealing. Some interventional cards do endovascular work even in the popliteals ( vascular territory ). I hope that surgery hops on the bandwagon in terms of training, so that the fellowships/residencies put out surgeons who are proficient in the latest minimally invasive procedures.

thanks for the data arrogant, I was wondering this same thing myself.

 

[Dr Gupta CNN]

I think this topic may be a little bit of surgical wishful thinking to be honest. As an MS4 going into surgery just because I really like it, I think I do understand why GS has gotten so much less competitive. My father being a GI in private practice has tried hard in the past to sway me towards that field, but has of course been very supportive in my current plans. Nonetheless, in talking to him and his partners and friends who practice invasive cards, it is crystal clear that those boys own the minimally invasive techniques and surgeons are on the outs (one cardiologist told me point blank, don't do CT surgery). The fact is, the comments above are wishful thinking because the guys that do scopes/angios/etc all the time are going to be superior and thus referred to by primary care docs over those who do it part time. If you are a surgeon doing endoscopy/laparoscopy/and laparotomies, sounds like you're gonna be a jack of all trades and master of none... i.e. pretty unsucessful. If you are a surgeon doing PTCA, no PC doc will send a patient to you with good confidence over a guy that does them 6 days a week. The point is, in today's "business" of medicine, the key is to be highly specialized, and if you really want to do PTCA and live well, do cards and not surgery. If you want to do scopes, do GI and not surgery. If you like plastics, transplant, laparoscopy, vascular, or colorectal surgery, then do that. These I believe are the reasons that right now GI and Cards are difficult to get into and surgery is not so tough (which is fine with me!).

I'm not claiming to be an expert by any stretch on this stuff, but at the same time I've been counseled over and over again by many highly specialized docs on what I'm getting myself into. You better love surgery if you are going to do it these days! Again, this is why ortho, plastics, uro and optho are so competitive compared to GS; it's no fluke.

 

[Skylizard]

Originally posted by Dr Gupta CNN
...Nonetheless, in talking to him and his partners and friends who practice invasive cards, it is crystal clear that those boys own the minimally invasive techniques and surgeons are on the outs (one cardiologist told me point blank, don't do CT surgery). The fact is, the comments above are wishful thinking because the guys that do scopes/angios/etc all the time are going to be superior...

You have the right to your opinion. However, I beg to differ. You should first look at who is counseling you...IM Docs. Second, EGD & Colonsocpy are not extremely difficult skills...thus FPs actually do them and get privileges and mal-prac insurance to do them. Also, Gsurgeons do perform EGD all the time for PEG placement. I will grant you that ERCP is quite a bit more tricky. Numerous colorectal surgeons perform colonoscopy on a regular basis. I will move now to vascular intervention. At some vascular fellowship programs, graduates do an additional year of training just in the interventional Rads. Vascular surgeons already have to be able to read cath studies and some are even getting certified in vasc u/s. Like I said, Texas Tech to my knowledge now has the Vasc Surgery Dept running the interventional stuff. It is the Vasc surgeons that predominantly do the AAA stenting. I have participated in numerous cardiac caths and I dare say with some practice it would not be so difficult to learn this technical skill. Remember, CT surgeons need to be able to read cath films already. learning to perform the cath is not so arduous a thing.

This is more of a turf war and not an issue of competency. You are right that changing the PCP's viewpoint may take some time. However, coming from the FP perspective, I suspect it will not be too difficult over time. Why? Well, FP docs have been the bastard practitioners of medicine for a long time. They are routinely attacked by IM subspecialists for trying to provide services for which they have not been "boarded in". They are always trying to prove they are qualified and I dare say they will likely not have too much difficulty seeing that a CT surgeon with traing is qualified even if not "boarded in" interventional cards. The other issue that I hear FP doctors always saying is that they learned scoping because it took 2 months to get the GI doctor to see their patient. Think about it...one stop shopping.

Oh, to give you a first hand example, I am currently in an FP residency (can't wait till this internship ends). All the residents, me included preferentially consult two surgeons for PEG placement and IVC filter placement. We do not go through GI medicine or interventional Rads. Why? It is our experience that there is a quicker response time and better patient care via the surgeon route as opposed to the IR or GI path. That means you will have over 20 FP docs graduating in the next 2-3 years with this approach to patient care and consulting.

 

[womansurg]

At our VA the surgeons do all of the endoscopy, short of ERCP which gets farmed out to GI. I've done in excess of 150 endoscopy cases during my training - far more than I cared to, I assure you. But if I have a patient who is having GI bleeding, retained esophageal foreign body, or colonic obstructive symptoms, I can readily perform my own endoscopy without waiting for monday morning to roll around for the GI guys to make their way into the hospital.

Same thing for interventional rads. Our vascular surgeons here do their own angiography, stenting, and angioplasty on a regular basis. The motivation is the same: the need to bypass the overworked IR guys and get the work done in a timely manner.

It's not that surgeons want to do this stuff; compared to surgery most endoscopy and IR is fairly tedious. We just do it to keep the ball of patient care rolling.

 

[droliver]

Gupta,

while I think there is some merit to your post, I'd consider the sources re. some of the procedural things. A gastroenterologist or cardiologist is prob. not the most neutral voice in that debate. The fact is that many of these diagnostic modalities will be obsolete in the not too far distant future for many parts of the country. Emerging technology for non-invasive imaging of the vascular tree & GI tract has the real prospect of dramatically reducing the amount of procedures being done ina similar way that PTCA did for CABG. The timetable for this is still up in the air, but everyone sees the writing on the wall.

Cardiothoracic surgery will clearly have too evolve to stay relavent , & that will involve the move into the vascular lab similar to the vascular surgeons. I think you overestimate how diffucult it is to develop competent endovascular techniques & I do not imagine that it will be that hard to incorporate it into the curriculum for CTVS once there is some momentum to do that & reorganize the training model as a whole (as is in the early stages for all the surgical specialties)

As for diagnostic endoscopy and simple therapeutic techniques (polypectomy, stent placement, variceal/ulcer sclerosising, biopsy, etc...), its a pretty easy skill to learn. If you watch a surgeon who does it with any regularity, you would unlikely be able to tell a skill difference with a gastroenterologist for this. Some of the more specialized procedures like ERCP do take some specialized training, but a number of surgeons are spectacular at it (we actually have a fellowship in it here for surgeons run by one of the recognized leaders in the country)

With the remark about competition, I see that as purely a issue of $$$ to workload ratio. Prior to the dramatic reimbursement cuts to everyone in the late 1980's/early 90's (of which general surgery was recognized as being hit the most dispropotionately) this discussion wasn't really taking place. When you take a pay cut for the most diffucult jobs of all specialties (General Surgery, CTVS,Vascular) while you work load increases & your overhead goes up, its no surprise that students have voted with their feet about which specialties are popular. I guarentee that if routine salaries for heart surgeons still approached 7 figures & mid 6 figures for general surgery, you'd have a much different figures about what specialties were popular again.

That being said, it's nice to have another student around interested in surgery. Its a very rewarding specialty & your training can be some of the happiest times for you (mine certainly have been)

cheers,

Rob

 

[Dr Gupta CNN]

Lizard,
I hope you're right, and I'm not disagreeing with you one bit about vascular... that's the one surgical field where the surgeons learned the lessons from errors made in the pastby other specialties.
Your points about EGD and colonoscopy by colorectal surgeons I think are misleading though. In my dad's practice, albeit in a blue collar city (not NYC or LA), the 4 GIs there are super busy all making around a mil a year. There are a few other GI groups there that do the same. In the last 5 years, their perf rates are extraordinarily low, and although he admits there are colorectal surgeons out there who do it, they claim those guys don't get respect in their ability to do them and they get no volume and are busy doing other things (the most successful ones making no more than 300000 per year). Don't be fooled, a colonoscopy IS indeed an art of its own... the ability to remove large polyps, etc, which 'amateurs' struggle with masters will perform well. It goes beyond a perf rate. Besides, when do you have time to pratice and do 150 EGDs and colonoscopies when you are doing hernias and choles? How about the 4 hour lap case eating up the entire afternoon? The proof is in the GS residency (and even colorectal fellowship, compared to GI IM fellowship), which spends comparably little time training in endoscopic technique. And you never answered my first question... how many PC docs are gonna refer to a surgeon for a screening colonoscopy? (I'll answer for you, very few). As a surgeon, where are you gonna get your PTCAs from, the moon? No cardiologist will refer to you, and PC docs refer patients with cardiac problems to CARDIOLOGISTS, that's the way it always has been and probably always will be (how freaked would you be if your neighborhood doc referred you to a CT surgeon for a history of uncontrolled HTN??) The standards have been set. It's more likely that the number of CT fellowships will just fall (as many surgeons at a top 10 university have actually told me). Maybe that will increase the CT surgeon's workload, as the numbers of guys doing CABG fall.

Hey man, I love surgery, the OR, and making that big difference. But if you think you are gonna be a jack of all trades, I think you may be biting off more than you can chew. It probably can be done, but it's unorthodox and unfortunately probably unlikely. My main point was, if you want to do the minimally invasive technique, go that route. If you want to be a surgeon, do general surgery. Don't be a pretender no matter what.

Specialized fields are tougher to get into these days because the smart, competitive people envision these fields being the money-makers of the future. GI is now the most competitive IM fellowship to get now, with programs getting hundreds of apps for 2 spots. Invasive cards is also very tough. Luckily (or unluckily I suppose), general surgery/colorectal/CT have gotten much easier compared to 10 years ago. They can't pay people to take those fellowships anymore. A sign of the times and likely of the future.

 

[Dr Gupta CNN]

PS let me also say that even though after all I've been told your guys views will be looked upon by me as optimistic to say the least... I HOPE YOU ARE RIGHT!!

I'm just not gonna set myself up for financial letdown, LOL.

 

[Dr Gupta CNN]

Also, the point about all of these modalities being obselete in the near future is also very well taken. Those damn rads guys...

Hey guys, when are we gonna get to operate?? Gotta work on the lap technique 😉 the poor old guys!!!

Finally, I guess so long as you are good at what you do, whatever you do, things work out. This really is a great forum for this kind of discussion though, I thank all you, and hopefully I'll be a little more optimistic, too...

 

[Voxel]

I can see how the general surgeon with "enough training" might do their own endoscopy, but more likely than not it will be limited to rural areas without a high enough amount of MD/patients ratio. To think this can happen in crowded urban areas is unrealistic, unless patient demand overwhelms the current supply of subspecialty trained IM docs. There are a lot of political and medico-legal obsticles to over come.

The only way this will happen is there will be more work than they can handle. I suspect that this may happen at some point in the near future within 5-10 years, when the people aged 60 and older skyrockets (and continues to do so).

And I suspect that this may push some of the traditional endoscopy procedures done by subspecialized IM docs to surgeons, FPs, or anyone else under the sky that is willing to take the medico-legal risk performing these procedures. It's not that the GI or Cards guys are unwilling to perform these procedures. Especially GI, it's more likely they are being worked to the limit and there is not enough supply.

 

[Eidolon6]

I think if a CT surgeon wants to do a 3 year cards fellowship and an interventional fellowship...sure, let em do high risk stenting procedures. And hey, let them manage their cardiology problems in a clinic, manage their ischemic cardiomyopathy, arrhythmias, HTN, angina, etc.

Anyways, CT surgeon will have plenty of business in the future without worrying about endovascular techniques...which frankly is quite a bit different than cardiac surgery. Stent reocclusion rates are going down. Many people are being kept from going under the knife, yet the CABG candidates keep coming. Cardiology nor CT surgery will be becoming obsolete any time soon. If CT surgeons wanna be cardiologists...then let them train like cardiologists...its not the same.

 

[womansurg]

Originally posted by Voxel
I can see how the general surgeon with "enough training" might do their own endoscopy, but more likely than not it will be limited to rural areas without a high enough amount of MD/patients ratio. To think this can happen in crowded urban areas is unrealistic, unless patient demand overwhelms the current supply of subspecialty trained IM docs.

Interesting. I don't think most people would consider Des Moines as 'rural'. And this is a major medical center: a 550+ bed hospital, Level I trauma center, so forth, yet several of our surgeons do all of their own endoscopy. It's quick, easy, pays well, and it's nice to do your own pre-op stuff when doing operative planning.

In fact, our general surgeons are the ones who proctor the IM residents for their flexible sigmoidoscopy training.

I'm sure that things vary by region quite a bit.

 

[droliver]

Voxel,

I think you have some misconceptions about how much endoscopy is done in metropolitan areas by surgeons. Depending on you practice some people might do 20+ a week as a general surgeon, while others might do zero (pretty rare) in a practice just several miles away. Practice patterns dictate this to a large extent rather then the presence of GI docs. Many people also do endoscopy on their patients prior to any colonic procedure even if they've been scoped before - eveyone has their horror story about getting bad information from a gastroenterologist in re. to where exactly the pathology is.


Gupta,

I certainly agree that there's going to be some tension in the CTVS/Cardiology relationship, but again CTVS HAS to change for the field to survive. As for referals, many of these could potentially done thru 3rd parties as non-invasive imaging of CAD becomes the norm (potentially removing cardiologists from the loop). I would guess you'd get some programs (of surgeons doing PTCA)going in pockets around the country with a slow release of them into the communities. There's also the adversarial option of refusing to provide backup for PTCA procedures, this has already happened with vascular surgeons in some places I understand (although CTVS relationship is much more dependent then vascular). I just can't imagine the cardiac surgeon of tommorow will not have vastly different training & skill sets then in the past

 

[Voxel]

Oliver,

I have no doubt that surgeons are doing endoscopy. I have seen it at major tertiary centers in large academic and and community metropolitan centers. I never denied that they do them. However, if you look at the overall percentage of GI endoscopies, they are performed mainly by GI docs (IM) (I'd wager over ~90% of them). It not that it's that surgeons performing endoscopies are rare, but to simply by pass the GI doc, is unrealistic at places where I trained or where I have friends/colleagues training. I doubt general or colorectal surgeons will be the ones doing screening colonoscopies or endoscopies. Again there is more at play than just being able to perform them. Politics, money, and medicolegal risk, as well as patient care are all at play.

Womansurg,

I've never been to Des Moines, IA. I can mostly comment on what I have seen in the northeast part of the USA. Again I don't deny that it endoscopy is performed by general and especially colorectal surgeons. I just think that by passing the GI docs, unless there are none in your town, is unrealistic.

Best regards,
-Vox.

 

[maxheadroom]

I think that the point about surgeons doing endoscopy needs to be clarified. It should say, "Surgeons doing THEIR OWN endoscopy." There are tons of surgical patients that need EGD/Colonoscopy for their surgical work up. Getting to see GI Med can take quite a while (several months, in some cases). There's no reason why the operating surgeon can't do an EGD or Colonoscopy on the patient on whom they're going to operate.

On an SICU month, we placed several PEGs and did a couple of colonoscopies for dropping HCTs. If a surgeon can do laparoscopy, the skills to do endoscopy should be there, also.

 

[maxheadroom]

Forgot to add, I doubt you'll see many surgeons lining up to do the "majority" of endoscopy, which is screening colonoscopy or EGD for GERD.

 

[Skylizard]

Originally posted by Dr Gupta CNN
...Your points about EGD and colonoscopy by colorectal surgeons I think are misleading though......

Originally posted by Skylizard
...The GI docs can not do anything about their complications from endoscopy. So, it makes a great deal of sense for Gsurgeons to be skilled with the scope. If there is a problem in the colon, they see it first hand and can tatoo it for resection. If there is a perforation secondary to a scoping misadventure they can take the patient to the OR without awaiting a "consult"...

...However, I beg to differ. You should first look at who is counseling you...IM Docs. Second, EGD & Colonsocpy are not extremely difficult skills...thus FPs actually do them and get privileges and mal-prac insurance to do them. Also, Gsurgeons do perform EGD all the time for PEG placement. I will grant you that ERCP is quite a bit more tricky. Numerous colorectal surgeons perform colonoscopy on a regular basis....The other issue that I hear FP doctors always saying is that they learned scoping because it took 2 months to get the GI doctor to see their patient...I am currently in an FP residency (can't wait till this internship ends). All the residents, me included preferentially consult two surgeons for PEG placement and IVC filter placement. We do not go through GI medicine or interventional Rads...

I definately do NOT see how this is "misleading". I do not think I quoted any perf complication rate in my reply. If I somehow have lead some to infer a "perf rate" , I apologize. As per the remainder of issues, I think DrO & WS have replied with a similar and arguably concurring point of view/experience. I do not think Gsurgeons will perform the majority of upper & lower scoping. However, it will not be difficult for surgeons to routinely perform scoping if they choose. They only have to post a few adds with grandma saying, "I went to my surgeon and had my colonoscopy. He found something and was able to take me to surgery immediately. He was so kind and gentle. 🙂" Such an add would get alot of attention. However, I am not going into surgery to predominately scope. The point is that the argument of competency is fairly shallow IMHO and a reflection of turf protection...again, FPs perform scopes. In my FP program, quite a few residents choose to spend a one month away rotation to simply get their numbers (>150) on EGD and colonoscopy!

Originally posted by maxheadroom
...It should say, "Surgeons doing THEIR OWN endoscopy." There are tons of surgical patients that need EGD/Colonoscopy for their surgical work up. Getting to see GI Med can take quite a while (several months, in some cases). There's no reason why the operating surgeon can't do an EGD or Colonoscopy on the patient on whom they're going to operate.

On an SICU month, we placed several PEGs and did a couple of colonoscopies for dropping HCTs. If a surgeon can do laparoscopy, the skills to do endoscopy should be there, also.

Originally posted by droliver
...I think you have some misconceptions about how much endoscopy is done in metropolitan areas by surgeons...Many people also do endoscopy on their patients prior to any colonic procedure even if they've been scoped before - eveyone has their horror story about getting bad information from a gastroenterologist in re. to where exactly the pathology is...

How about that, patient gets TWO scopes in a short period of time. Double the pleasure/double the fun vs double the RISK! The rates of complications may be low. However, no matter how low they are, you expose a patient to said risk twice. This circumstance/practice further supports the argument for one stop shopping😉

 

[Skylizard]

Just another possible commercial:

Intro, picture clean cut, plump, rosy cheeked grampa. Hear the soft friendly music.

Granpa says, "My stress test said I had a problem with my heart. My family doctor sent me to see a heart surgeon. I was so scared I would need bypass surgery. My heart surgeon did a catheterization and placed a stent. He/she said I would probably not need surgery yet. I was so scared, but it was nice knowing whatever happened my surgeon could take care of it. If there was any problem with the catheterization, I knew my surgeon was right there with me the entire time."

I think it could seLL. I feel the "heart strings" a tuggin. you won't convince me or any educated/knowledgeable individual that a CT surgeon could not be sufficiently trained to be competent in cardiac caths and most lay people in my experience often view surgeons as high end providers. I do not think it will take much to sell the public. Remember, Laparoscopy was in large part a patient driven expansion of service. If patients want a surgeon to do their cath....CT surgeons will learn. Patients can also be convinced that they want a surgeon as aopposed to a non-surgeon interventionalist. Just as I have seen patients come in asking & sometimes demanding a percutaneous stenting for their AAA. I have also had an occasional patient ask me why the heart surgeon doesn't do the cath instead of the "medicine man". Some patients have actually expressed surprise to know their cath doctor wasn't a surgeon...just as patients are surprised to learn the PA wasn't a doctor. It is not that far of a stretch and I dare say numerous patients will not require much of a nudge to start demanding a surgeon.

 

[womansurg]

Originally posted by Voxel
Womansurg,

I just think that by passing the GI docs, unless there are none in your town, is unrealistic.

I guess we're just not being realistic then 😉 .

No, seriously, no one is bypassing GI docs. They do plenty of business. It's not unlike your choices when you need a tracheostomy done. Virtually every general surgeon does them, as well as virtually every ENT surgeon, and most critical care pulmonologists perform percutaneous trachs. So it depends on the referral patterns and who the primary care team is on that patient. If a general surgery patient needs a trach, we do it. If the patient is admitted to pulmonary service and we are just one of the consulting teams, then pulm will usually do it.

Similar to thyroid surgery. It is done by general surgeons, surgical oncologists, endocrine surgeons, and ENT surgeons. In my community, nearly all are done by the general surgeons; ENT gets very few. I imagine that pattern is very different at some other institutions.

In my community, general surgeons do a great deal of endoscopy.

 

[Dr.alfa]

Granpa says, "My stress test said I had a problem with my heart. My family doctor sent me to see a heart surgeon. I was so scared I would need bypass surgery. My heart surgeon did a catheterization and placed a stent. He/she said I would probably not need surgery yet. I was so scared, but it was nice knowing whatever happened my surgeon could take care of it. If there was any problem with the catheterization, I knew my surgeon was right there with me the entire time."
[/B]

Scenario 2
Grandpa had a heart attack, went to the ER, cardiologist say it's a "myocardial infarction". Grandpa is candidate for primary PTCA so the cardiac surgeon (who was actually there and spends time in the ER not only in the OR) took grandpa to the cath lab. The CT surgeon told grandpa that he will be there with him the entire time and he will choose the best treatment for him.

Scenario 3
Grandma has something called aneurism. The CT surgeon took her to the cath lab and told her he will put a stent to fix the problem. Grandma it happy because CT is in charge and she has nothing to fear. It's not like the old days anymore when, she had to beg for a vasc. surgeon to "accept" her in order to fix her damaged, cold, numb leg that the interv radiologist screwed. CT is a properly trained doctor, he can handle it whether in the cath lab or in the OR


and so on....

 

[task]

This is by far one of the most amazing threads I've read in a long time.

Dr. Gupta CNN posts reflect reality.

First -- Anyone who likes and has an aptitude for procedures could learn a procedure. Done. There are PAs doing diagnostic cardiac cath and who are first assists on a variety of surgical procedures and who do flex sigs and colons. You don't need an MD to learn how to do a procedure.

As droliver has stated in other threads (and I'm paraphrasing) it's the judgement and experience that med school and residency and fellowship give us that distinguish MDs -- not HOW to do a procedure, but when to do one, vs when not to do one.

Second -- do any of you think subspecialties just popped out of nowhere? "Hmm, we need another subspecialty to add to the mix, just to make things more interesting". Subspecialties develop because there isn't enough time in the day or enough brain cells in one "uber-MD" to be the jack of all trades AND master of all trades.

Radiologists have one thing working against them -- they are not clinicians in the sense that they have an office practice where they see and follow patients and self-refer them for procedures. They are dependent on other MDs for referrals. You might say the same thing about surgeons or GI docs or cardiologists, but MDs in these fields see and evaluate patients and self-refer for procedures. This is a big difference.

IR procedures take time and expertise. Personally, I'd rather have the MD that does a bunch of a particular procedure every day do a procedure than one who does a certain # a week or whatever. So if the IR doc does the most, then that's who I'll refer the pt. too.

The biggest misconception in the previous posts about interventional cardiac procedures is that some Cardiologist is standing in the cath lab and says "ooh, a blockage, must balloon and stent". That is the farthest thing from the truth. There is an entire science and industry (read theheart.org) based on appropriately selecting, deploying stents and managing pt. who are candidates for PCI. You don't just stent and send the pt. home. How do you select diabetics for PCI and manage their particularly more rabid form of CAD that makes PCI strategies in them more difficult? Do most CVT surgeons even care about managing a patient's diabetes as an outpatient? A cardiologist sure as hell does. Is the cardiac surgeon up to date on the latest use of statins in pt. with normal LDL but HIGH CRP, and the resultant impact of statins in PCI? Do they even care? What CVTS MD can quote me restenosis rates for various caliber lesions in different coronary arteries, and the best management approach for each -- because believe me, they differ. And before you go blasting me for citing the data like most of us flea-IM types are prone to do, remember that this data allows for better outcomes for these patients in the end. Focusing on that annoying lab value has real prognostic and management significance. Better morbidity, and an impact on mortality. And the data I refer to above directly impacts the treatment plan and procedure done, as well as appropriate follow-up.

CVTS MDs can read cath films, but do they have background and experience to determine which lesions are amenable to PCI and which need bypassing? Not realistically. This is not something that three years of fellowship plus another year or two of intervention makes you an expert in. It takes years of experience and of following patients to make these types of decisions. Again, this is why new fields and subspecialties develop. Most, if not all the Cardiologists I know in practice tell CVTS MDs what they want operated on, and the CVTS guy does it -- that is the reality of the game now.

Cardiology fellowship is not just a few years in the cath lab -- between clinic, CCU, consults, ECHO, stress testing, imaging and nuclear cardiology, cardiologists develop expertise in managing the heart as a whole. Just because you can operate on the heart doesn't mean you somehow miraculously acquire this same expertise. Interventional techniques pioneered in Cardiology are a natural outgrowth of years of experience in managing these types of patients. The indications and rationale for the array of cardiac interventional procedures is not something one can just tack onto a resume. The training and background of folks doing CVTS just doesn't encompass this type of training and expertise. They learn how and when to operate on patients. Frankly, the thought and depth behind the interventional or many EP procedures (not putting in boxes, that's pretty brainless) is what keeps other fields from just picking up and doing them themselves.

With regards to drug-eluting stents, I think the biggest problem you will find is patient selection. Everyone and their uncle undergoing PCI is clamoring for a drug-eluting stent. Most of the data on drug eluting stents is focusing on their use in difficult lesions more prone to restenosis or in diabetics. Only 25% of the lesions that have been stented until this point have problems with restenosis. That means in 75% of those lesions in the era before drug-eluting stents, these patients did fine. They didn't need the fanciest stent on the block.

As for complications for PCI, 97% of primary coronary artery perforations are managed with ballooning and stenting off the area affected. The ACC/AHA are changing guidelines for recs for CVTS backup for PCI centers saying because complication rates are so low now (<1% nationally) that CVTS backup has to be 30 minutes flying distance at a minimum, not even in house.

Most people go into GI because they like endoscopy. Some do it for liver, and others do it for the advanced endoscopy like ERCP and EUS. Others because they want to do consultative GI and do EGDs and colons. The more advanced stuff takes time and experience to learn and keep doing, so only people who have the time and experience and expertise to do so will tend to do those procedures. There are surgeons who do ERCP, but those surgeons probably operate less than those who do not. ERCPs can be long cases. EUS takes a lot more time to develop expertise and stay good at. There are other interventional endoscopic techniques which will also require time and expertise to stay proficient at. GI docs do most of the basic endoscopy in this country, and surgeons also do basic endoscopy, but not as much as GI docs. Complication rates are extremely low. Again, send me to the person who does a procedure all day every day rather than someone who does a few a week. No big revelations here. What's the big deal anyway?

Medicare "Granma" and "Granpa" usually aren't in the position to pick and choose and typically don't give a crap about who does their procedure as long as they are good at it. Sure, some patients know the difference between a Cardiologist and a CVTS MD, but the vast majority don't. And when patient's refer to their "heart doctor" they refer to their Cardiologist, because that's who they'll see in followup. In 2 years of internal medicine training and multiple stints as CCU resident and Cardiology consult resident, I've never had any Vet or anyone else ask me "why is the Cardiologist doing my procedure and not the heart surgeon?". They don't make the distinction, they just want someone who is experienced and who can take care of them before, during, and after the procedure. Also, I hate to break it to you, but internists will refer to internal medicine subspecialists first if they can. Why? Because in general, one internist knows another one (even a subspecialist) was trained to think and assess patients in the same way -- there's a commonality of thinking and clinically assessing a patient that differs between Medicine and Surgery types.

One is not better than the other, just different.

Bottom line -- Cardiologists control heart patients. And while surgeons do endoscopy, more GI docs do endoscopy and more primary care people refer to GI docs for endoscopy than to surgeons. There are regional variations of course, but that's true on the whole. And surgeons therefore obtain a good chunk of their cases from referring Gastroenterologists.

Again, what's the big deal?

 

[eddieberetta]

Skylizard, those ads are lame. There's enough business to go around, and there is way too much "business" to send every one with a heart "problem" to a CVTS as you seem to propose. I am not saying that surgeons cannot learn endo/angio ; however volume and common sense dictates that everyone doing these procedures will not be fully trained as a surgeon -- that's a waste of training which is already too slow and onerous. Moreover, the experts in these procedures will have to devote most of their time to it, and hence will often not be surgeons.

However, separate from this is what will happen to CVTS. Given the current job market problems, they will probably just train fewer of them. I am sure they will learn some endovascular skills as well, as this will be needed for complex cases. And then there is always the "T" (and the GS). No one is going to starve.

The massive public groundswelling to be immediately evaluated by a surgeon ("any surgeon, just a surgeon, pleeeeease") at the slightest hint something may be wrong is not going to happen. I am amazed at how many people don't even know that cardiologists are different from cardiac surgeons. People want procedure done on them by someone who has lots of experience in doing that specific procedure. It is not necessary that the same person be able to personally handle every possible complication. (Imagine that -- every OB-GYN would also have to be a urologist!!!!!!)

 

[droliver]

Task,

Loved your post, great stuff! Howevere, methinks you're overstating how difficult it is to come up with the proper strategies for doing stents or other lesions for cardiac lesions. This represents no real major roadblock for training future programs of surgeons to incorporate that into their training.
Along your line of thinking I hear the same arguments from vascular surgeons who think Radiologist & Cardiologists have no business doing non-cardiac vascular stenting because they (these other providers) have no experience with following or tx. thoses lesions or knowing when to intervene on them - food for thought

 

[Skylizard]

Originally posted by task
#1 Radiologists have one thing working against them -- they are not clinicians in the sense that they have an office practice where they see and follow patients and self-refer them for procedures. They are dependent on other MDs for referrals.

#2 There is an entire science and industry (read theheart.org) based on appropriately selecting, deploying stents and managing pt. who are candidates for PCI...Do most CVT surgeons even care about managing a patient's diabetes as an outpatient?...Is the cardiac surgeon up to date on the latest use of statins in pt. with normal LDL but HIGH CRP, and the resultant impact of statins in PCI? Do they even care? What CVTS MD can quote me restenosis rates for various caliber lesions in different coronary arteries, and the best management approach for each -- because believe me, they differ...And the data I refer to above directly impacts the treatment plan and procedure done, as well as appropriate follow-up.

#3 CVTS MDs can read cath films, but do they have background and experience to determine which lesions are amenable to PCI and which need bypassing?...Most, if not all the Cardiologists I know in practice tell CVTS MDs what they want operated on, and the CVTS guy does it -- that is the reality of the game now.

The indications and rationale for the array of cardiac interventional procedures is not something one can just tack onto a resume...They learn how and when to operate on patients.

#4 Medicare "Granma" and "Granpa" usually aren't in the position to pick and choose and typically don't give a crap about who does their procedure as long as they are good at it. Sure, some patients know the difference between a Cardiologist and a CVTS MD, but the vast majority don't.

Per #1: IR docs do these interventions as you state and have no clinic thus they do not manage DM, lipids, Htn, CHF etc... which you seem to suggest/imply is a prereq for a surgeon to be doing these procedures.

Per #2 & #3: Maybe I trained with better CT surgeons then you have experience dealing with but...the CT surgeons I have worked with do in fact know what is amenable to stenting and not, they do know what is an indication to surgery verse med-management, they do know about restenosis rates (especially since they are sometimes required to surgically correct the restenosed stent), they do know what is optimal lipid management and DM management (even reasonable FPs know this...this stuff is critical to outcomes too), they do know what is appropriate follow up because follow up is absolutely necessary for their statistics to be good, I have seen CT surgeons plan out the care and revascularization of an ailing heart by meeting with the cardiologists and asking the cardiologist to stent "vessel A" some weeks before "we graft vessels B & C". The Ct surgeons I have seen have a multidisciplinary approach. Because the surgeon or IR doc does not manage the lipids, Htn, DM does not mean they are uninformed of the current data or guidelines.

Per #4: Many patients do not know the difference. However, I think we as physicians have failed at obtaining informed consent if at the end of the day and procedure the patient expresses being confused as to who performed the procedure...i.e. "I thought you were a heart surgeon".

Finally, I think there is a huge misconception as to the training of a surgeon in general. I have seen it on these forums. The medicine community seems to be under the impression that surgeons spend the 5-7 years just in the OR. This is not the case. Surgical residency requires extensive "medical" management. Our patients have Htn, DM, CHF, dyslipidemia, thyroid Dz, Obesity. Most surgical residencies I have seen do NOT simply consult the medicine folks for the management of these and other disorders. The surgical resident and attending must be up to date on the treatment and management of these entities often in the most ill patients in the ICU. When all is said and done at my orientation to intern year, it will be the surgical residents that carry the most "cards", i.e. BLS, PALS, ACLS, ATLS...and some with neonatal as well. I think everyone out there needs to realize surgeons though we love the technical are not simply technicians. You will find that the best surgeons are up to date on the research and do in fact practice in an evidence based manner. They know that if the data shows medical management is the best option for the patient then they will be better served by not operating and then exposing themselves to undefendable suits should there be a poor outcome.

Originally posted by eddieberetta
There's enough business to go around, and there is way too much "business" to send every one with a heart "problem" to a CVTS as you seem to propose.

I agree there is enough business. My point was not to say surgeons should do all, it is simply to point out surgeons can in fact expand the range of services they provide if they choose too.

 

[task]

Skylizard,

Carrying "the most cards", that is BLS, ACLS, PALS, ATLS, etc., does not make one a "complete doctor", which is what you seem to be implying. With all due respect, there is no such thing as the complete doctor. I know general surgeons who are good internists, and I know general surgeons who are terrible internists. I also know they don't spend 5 years in the OR alone. I am aware of what general surgery training involves, and am quite aware that my surgical colleagues have sick patients with multiple medical problems in their ICUs which they are able to manage quite effectively. There are just as many patients, if not more, that we as internists or as Medicine subspecialists are asked to see by surgeons in order to assist with their management. For one doctor to think they are capable of doing everything and being good at it is not only arrogant but dangerous.

We are talking about coronary intervention, so I'll limit my comments to this topic. There are percutaneous valvular techniques already being employed (balloon valvuloplasty) and well as catheter deployable valves, but the latter is still in the nascent stages of development. CAN or COULD cardiothoracic surgeons learn PCI (our term for coronary intervention) techniques?

Absolutely -- like I said before, anybody can be taught how to do a procedure. Do they know enough Cardiology to be the primary physicians managing patients with coronary arterty disease? Absolutely NOT. I've talked ad nauseum about knowledge base and clinical experience and acumen, so that answers that question -- CVTS MDs don't have this acumen or training. And with all due respect, one cannot be operating on patients AND doing intervention. PCI cases can go 6 hours, though most don't take nearly that long. And as you well know, one has to keep doing procedures to stay good at them. So what's it gonna be -- in the OR operating on hearts, or in the cath lab doing PCI? And doing 1, 10, 20 or 250 PCIs does not make you an expert, just as doing 1, 10, 20 or 250 CABGs does not make you an expert. You have to keep doing cases and keep seeing and managing these patients to refine your skills and be better the next case you do. One person cannot simply do enough coronary intervention AND operate on hearts all the time to be good enough at both. It's that simple. And, one can argue, to even conceive of trying to do both is pretty cavalier and dangerous. You really need to spend some time in a cath lab and CCU with an interventional cardiologist to really understand what I'm talking about.

Add to that the inherent level of knowledge and other non-procedural issues that affect PCI. Yes, I do differentiate between IR type procedures and intervention in the coronary tree. Interventions in the coronary tree are not a procedure unto themselves. They are not done in a vacuum. All the things I talked about before, statins, CRP, LDL, along with platelet biology and platelet inhibition, are intimately connected with coronary intervention, and influence how a particular lesion is approached and treated. And these are ever evolving, ever changing issues that one needs to stay abreast above in order to provide standard of care. These issues are not in the training guidelines for most CT surgery programs I know of.

Just because the CT surgeons you work with "know what is optimal lipid management and DM management" is doesn't mean they do it or do it well. And knowing how to manage those issues is absolutely basic to things like coronary intervention. As an FP resident, I'm sure you know about switching diabetics undergoing PCI to a glitazone because some studies suggest a decrease in 30 day MACE (major adverse cardiac events) for patients on these agents. Again, hearing these things in the abstract and understanding and applying them to your practice are two different things. I absolutely believe knowing how to best manage DM, HTN, and other risk factors is "is a prereq for a surgeon to be doing these procedures" because of how intimately management of these risk factors is tied to optimal and appropriate intervention, and even sometimes timing the intervention.

I have no reason to exaggerate or fabricate or overstate this fact.
But I do take care of these patients, so I know what's involved more than my surgical colleagues do.

As another small example, I'm sure you know there are a not insigificant # of post-PCI MIs, with all the attendant risk of malignant arrhythmia and all the sequlae of MI that one fears (when you balloon a lesion, you shower emboli distally that can occlude perforators and cause myocardial ischemia or even infarct). I don't know about you, but I wouldn't want anyone BUT a Cardiologist managing me if I had an MI, and certainly not a CVTS MD. Sure, patients peri-CABG have MIs, but Cardiologists are already intimately involved in the care of those patients perioperatively and are the ones who manage the MI. The CT surgeon doesn't manage those. AND, as you well know, the primary mgmt for those pt. having an MI is medical.

Internists are better than surgeons in the management of lipids, DM and HTN. I don't think a single surgeon would argue with that statement, and a lot would respond "thank God"
Cardiologists, as internists, take the management of those risk factors and apply them to daily practice, including being a good interventionalist. It is not merely being aware of "of the current data or guidelines" as you suggest. Again, ou really need to spend some time in a cath lab and CCU with an interventional cardiologist to really understand what I'm talking about.

As for your contention that "I think we as physicians have failed at obtaining informed consent if at the end of the day and procedure the patient expresses being confused as to who performed the procedure", again, in my experience thus far, whenever I'm involved in the consent of my patients for any sort PCI or other catheter based procedure, the patient is told that potential complications might incur a trip to the OR. Not a single one of those patients has asked, or cares, who is doing the intervention and if that is the same person taking them to the OR. Again, patients want doctors who are skilled and experienced at what they do first, who've done the same procedue countless # of times before, and who will provide care before, during, and after the case. I've just not seen patients express this sentiment of "why isn't a surgeon doing all the procedures for me".

Bottom line, being a skilled interventional cardiologist means being a good cardiologist AND becoming skilled at interventional procedures that rely and draw directly upon being a good cardiologist first. Having the hands to do the procedure is secondary, it's the knowledge and the training behind them that impacts M & M. CT surgeons frankly don't have the training or expertise to coronary intervention well. 20 years ago, when it was a simple balloon and catheter, yes, maybe then. But not in this day and age.

 

[Dr Gupta CNN]

Task sounds like the majority of physicians I have talked to about this topic (granted most are internists, but who do you think is doing the majority of referring?)

I think it's a fine line... Cardiologists don't claim to be surgeons, I think it's a little arrogant, to tell you the truth, for a CT surgeon to think he's a cardiologist. No one else will.

Anyhow, surgery electives and fourth year start in a week so it's time to get excited!!

 

[droliver]

Originally posted by task

Just because the CT surgeons you work with "know what is optimal lipid management and DM management" is doesn't mean they do it or do it well. And knowing how to manage those issues is absolutely basic to things like coronary intervention. .


Internists are better than surgeons in the management of lipids, DM and HTN.

Just back from vacation so I missed a few days on this thread....


Task,
these statements are a little ironic in that there was a well-publicized report last week that said that less then 50% of people were treated appropriately by their PCP (IM & FP) or various medical subspecialist (including cardiologists) for just about every chronic medical condition that was indexed (including HTN,hyperlipidemia, post-MI medical tx., etc...)

The point being that these kind of statements (while they do seem somewhat intuitively correct) just are not bourne out when you look @ the health care system as a whole. I'm sure you've seen the same phenomena with your interventional cardiologists as I've seen with some super-specialty surgeons..... they're very good at what they do procedure-wise, but they are poor clinicians outside their focus.

Whether practical in the real world or not, I still submit that the change in focus that would produce CTVS surgeons fluent in the cath lab is not such a giant hurdle. The retooling of vascular surgery in a very brief period of time show that it can be done when the will is there. The dramatic reorganization of all the surgical specialty training currently underway could spin off some programs that attempt this. As you point out, comprehensive mgt. of CAD includes MUCH more background in medical management then currently delivered, but you have a lot of time to do that over training programs which are 6-8 years long & are being abbreviated of their core general surgery curriculum presently