Cardiac Surgery: Differing views on its future

[Misterioso]

There seems to be two schools of thought about the future of cardiac surgery. The prevailing attitude is that there will be less need for cardiac surgeons in the future because continued improvements in cardiology will take over more of the procedures traditionally done by cardiac surgeons. This along with the oversupply of cardiothoracic surgeons will mean the job market will continue to get worse than it already is.

The other camp says that because more people are being turned off from a career in cardiac surgery because of lack of jobs, decreasing pay, and "take over" by cardiology, the specialty is self-limiting itself because less people are choosing CT fellowships and thus there will be less output of new CT surgeons in the future. So the job market will balance itself out.

I'd be interested in hearing your thoughts on what you think is the most likely future of cardiac surgery*.


*cardiac surgery and not so much thoracic surgery although most every CT fellowship trains surgeons in both, and in fact more CT fellows are now concentrating on the thoracic part since the job market is better for thoracic surgeons.

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[cardsurgguy]

I've been paying attention to this debate every chance I get

There are alternatives that provide the best of both worlds...

Heart Transplantation
and
Pediatric CT


The cardiac surgery element is there, but neither can be done interventionally, so one would be safe from "cardiology takeover".

An interventional heart transplant would be kinda tough obviously...

On the Peds CT side of things, I've researched that some of the simpler defects, like some septal defects for example, can be done interventionally. But things like Tetralogy of the Fallot or Hypoplastic Left Heart, etc need to be done open and can't be done interventionally.
Surgeries like Fontan and Ross procedures, Blalock Taussig shunting, and transannular patch use probably will remain open for a long while.

Also, CT is undergoing a change right now that will make the process one year shorter than it currently is now. The American Board of Thoracic surgery is rolling out a 3+3 residency where one would become boarded in CT as compared to the 5+2 (ie full general surgery residency) path now. It would cut one year out of the process.

A Peds CT or Heart Transplant fellowship is an extra year. Right now, these would be 8 years, but with the change, they'd be 7 in the future, what a regular CT residency is now. That's another positive for these two fields.

I love pediatric CT. The defects are so amazing. Plus, I really like kids and would much rather take care of kids with their whole future ahead of them as compared to the people I took care of on the Heart Transplant Unit I use to work on who were all smokers who didn't take care of themselves for their whole lives (in some cases didn't take care of themselves even after transplant, ie not taking their anti-rejection meds).

Ever consider these two fields? Just a thought...

 

[Misterioso]

I should have been more specific and specified adult cardiac surgery.

True, pediatric cardiac surgery and transplantation jobs won't be affected as much, but those two fields are very small. Definetly too small to accomodate most new CT surgeons finishing their fellowships.

As for the 3+3 plan, I don't think that would increase the interest much in cardiac surgery if jobs continue to be scarce and reimbursement continues to drop. What's the point of finishing a year early if you're not going to have an attending job once you're done and have to take up additional "superfellowships" for another year or more until you land a job?

Also the 3+3 plan only allows board eligibility/certification in CT Surgery, not General Surgery. So basically all you could do is CT surgery if you went through the 3+3 residency. At least with having done a full general surgery residency you can be board certified in general surgery too and have something to fall back on if you don't get a CT job, which many current grads are finding they need to do since they can't get a job as a CT surgeon.

 

[Joel Fleischman]

I think CT will end up more like like Neurosurg interms of the numbers of those practicing it as well as the scheme of training, but this transformation will probably take the next 10 years.
what I mean by that is that CT surgery will probably have a 3+3/3+4/ 5+2 type training perriod (not exaclty like neuro surg but close), with a relatively smaller number of people in the field, doing procedures which are intense, life saving, but less common than your good old CABG, or gall bladder for that matter.
CT's in the 80's were making a ton of cash on CABG, and doing a lot. It is true that the drugs are better, and that stents have made this obselete.
Folks say that the Cards guys are driving CT out of buisness for this this reason. This is terribly myopic. This argument sees things as CT=CABG. CABG will go down and move to only treat pt who have no myocardium to loose.
Valves are still in the game. There are cath-lab attempts at these, not verry well studied yet, still just a band-aid.
Dont forget, Maze, LVAD (perhaps as a permanent tx now), as well as Transplant.

 

[droliver]

This isn't primarily a "no jobs" issue with CTVS, although talking to friends there really are VERY few desirable positions available for most grads.

Rather the phenomena has to do with the "triad" of job-satisfaction factors influencing students/residents identified by J. David Richardson MD a few years ago in an ariticle in either Journal of the ACS or the Amer Journal of Surgery. In a nut shell, the desirablity is influenced by an interplay between money, prestige, and lifestyle. Dr. Richardson speculated that people will tolerate medical specialties lacking one of the 3 qualities, but one that lacked 2 or more are easy to identify as unpopular.

Currently CTVS is suffering in all 3 areas & there's really not much going to change.
1 - Salaries will never approach a fraction of the golden era (~1960-1990) in any specialty that isn't fee for service.
2 - The aura & prestige of being a heart surgeon is pretty non-existant anymore.
3- The lifestyle has always sucked