Cardiologist versus Cardiac Surgery?

[heartfelt]

I am applying for a residency match this year and I am undecided whether to go the IM/IC way or the GS/CTVS way. I love everything about the heart. Almost all my research throughout medical school has focussed on cardiac-biochemistry, cardiac-physiology etc.
I know this is a pretty major debate 🙂 and though I loved my surgery rotations over IM rotations (hated the 4+ hours rounds!), interventional cardiology has some pretty cool procedures and a better lifestyle (maybe!).
I read up "Want to be a Chest Surgeon?". Brilliantly written, but I am not sure I want to spend 10 hours in the OR everyday. Moreover, I certainly do not want to depend on cardiologists to pass on the cases to me.
I am posting in a surgery forum, because all my life all I have wanted to be is a surgeon and now I am confused.

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[filter07]

With cardiology you can do a lot of different things involving the heart. Interventional cardiology is the obvious example, but that is only a subset. You can do general cardiology, heart failure, transplant cardiology, electrophysiology, imaging (nucmed/echo), and so on.

Cardiothoracic surgery will also provide variety, but (probably?) less variety than cardiology. CT surgery will allow you to do CABG, AVR, MVR, cardiac transplant, aortic replacements, maybe some endovascular grafts, and ablations for afib.

The medicine folks out in practice do not round for 4+ hours. The 4+ hours is for didactic purposes. You're not going to sit alone for 4 hours debating with yourself everyday. Similarly, in surgery, you will not be "pre-rounding". Remember that your experience in medical school and residency can be different than when you are an attending.

The CT surgeons I know in academics don't spend 10 hours in the OR daily. They have 1 or 2 days in the OR per week, plus whatever cases they get on call for transplant or other emergencies. Whether or not you get patients from cardiologists, there is plenty of work for cardiac surgeons once you get a job. And getting a job seems to be getting easier.

 

[blue2000]

Also, my husband's a cardiologist and from what I've seen in private practice, STEMI call for interventional cardiologists can be very busy. I think the cardiac surgeons work hard, but I don't think interventional cardiology call is a cakewalk. Depending on the situation, an interventionalist may be on call 1 in 5, and may be coming in most of those nights to cath. Something to think about.

 

[ESU_MD]

cardiologists are alot more busy on call than surgeons.
think about how the er docs call the general surgeons for every abdominal pain.... well, they call the cardiologists for every 25yr old with chest pain too.

it is unusual to operate in the cardiac OR at nite, but not unusual for the cath lab to be going at all hours. the difference is that a dx cath takes less than 30 minutes, while a "standard" emergent cabg is gonna cost you 3-4hours if you are lucky.

that being said- the training aint that much shorter or easier.
the vast majority of interventional guys are not doing aortic stents, valves andf other exotic stuff in the cath labs- the ones that are virtually live in the hospital taking care of these patients.

theres no shortcuts if you want to do big league interventions: cathlab or OR

 

[Black Surgeon]

I am applying for a residency match this year and I am undecided whether to go the IM/IC way or the GS/CTVS way. I love everything about the heart. Almost all my research throughout medical school has focussed on cardiac-biochemistry, cardiac-physiology etc.
I know this is a pretty major debate 🙂 and though I loved my surgery rotations over IM rotations (hated the 4+ hours rounds!), interventional cardiology has some pretty cool procedures and a better lifestyle (maybe!).
I read up "Want to be a Chest Surgeon?". Brilliantly written, but I am not sure I want to spend 10 hours in the OR everyday. Moreover, I certainly do not want to depend on cardiologists to pass on the cases to me.
I am posting in a surgery forum, because all my life all I have wanted to be is a surgeon and now I am confused.

As a cardiologist you would still depend on PCPs to "pass on the cases to you". Go with what makes you happier.

The CT surgeons I know in academics don't spend 10 hours in the OR daily. They have 1 or 2 days in the OR per week, plus whatever cases they get on call for transplant or other emergencies. Whether or not you get patients from cardiologists, there is plenty of work for cardiac surgeons once you get a job. And getting a job seems to be getting easier.

Yes, but this can vary significantly. Most academics CT guys I know average 2 cases a day (8 to 10 hours), one day of clinic per week, and the research/ administrative stuff whenever they find time, with the exceptions lying with the guys who are more heavily involved in basic science research labs. I must however add that this is a medium to high volume cardiac center.

I'd imagine most lower volume cardiac center CT surgeons have less OR time, but from what I've seen of the present prevalent lower volume private hospital setting, the non-operative CT surgeon's time is usually filled in with endovascular work.

 

[Buzz Me]

Maybe I'm looking at this too simplistically, or too "black-or-white" (I am, after all, in surgery)...but do you love operating? Or doing catheter-based procedures?

HUGE difference between CT Surg and Cardiology - the fact that they both involve the heart is like saying that Gen Surg and Gastroenterology are similar fields.

 

[JackADeli]

Maybe I'm looking at this too simplistically, or too "black-or-white" (I am, after all, in surgery)...but do you love operating? Or doing catheter-based procedures?

HUGE difference between CT Surg and Cardiology - the fact that they both involve the heart is like saying that Gen Surg and Gastroenterology are similar fields.

I think you are looking at it correctly. The question is up to the OP... he/she needs to decide what the want to do. Not, what organ they like or want to be involved with. Anesthesia is involved with the heart too....

As someone else commented, there is no short-cut and no guarantee at the end of training. You decide what you want to do and then endure the rigors of training. You can go IM and not get into an intervent cards program. You can go surgery and not get into a CV/CT training etc... Either case, you could find yourself burnt out and practicing straight IM or straight general surgery.

But, all that aside, you need to see an advisor and figure out if you want to be a surgeon or not. Do not choose a specialty cause it's ~"kinda like surgery".
I have seen applicants go FM cause ~"it's kinda like surgery" or ~"it's kinda like OB/Gyn".
I have seen folks do IR or Intervent cards cause ~"it's kinda like surgery".
I have seen folks do GI cause ~"it's kinda like surgery".

You, OP, need to figure out what you want to do, what you would be happy doing if your perfect world plan did not pan out, etc....

PS: every field depends on some referral base. cardiologist depend on a referral base, general surgery depends on a referral base, GI, IM, CV/CT, vascular, etc, etc.....

 

[njbmd]

Maybe I'm looking at this too simplistically, or too "black-or-white" (I am, after all, in surgery)...but do you love operating? Or doing catheter-based procedures?

HUGE difference between CT Surg and Cardiology - the fact that they both involve the heart is like saying that Gen Surg and Gastroenterology are similar fields.

I think you are looking at it correctly. The question is up to the OP... he/she needs to decide what the want to do. Not, what organ they like or want to be involved with. Anesthesia is involved with the heart too....

As someone else commented, there is no short-cut and no guarantee at the end of training. You decide what you want to do and then endure the rigors of training. You can go IM and not get into an intervent cards program. You can go surgery and not get into a CV/CT training etc... Either case, you could find yourself burnt out and practicing straight IM or straight general surgery.

But, all that aside, you need to see an advisor and figure out if you want to be a surgeon or not. Do not choose a specialty cause it's ~"kinda like surgery".
I have seen applicants go FM cause ~"it's kinda like surgery" or ~"it's kinda like OB/Gyn".
I have seen folks do IR or Intervent cards cause ~"it's kinda like surgery".
I have seen folks do GI cause ~"it's kinda like surgery".

You, OP, need to figure out what you want to do, what you would be happy doing if your perfect world plan did not pan out, etc....

PS: every field depends on some referral base. cardiologist depend on a referral base, general surgery depends on a referral base, GI, IM, CV/CT, vascular, etc, etc.....

Agree with the above. Either you are a surgeon or you are not a surgeon. As someone who "plays with catheters" and performs surgery, I can tell you that cardiology is definitely not surgery. Once the OP decides whether or not they want to be a surgeon, the organ is secondary. There is no field in medicine or surgery that doesn't involve the heart to some degree.

 

[filter07]

I humbly disagree with the surgeon or not distinction. I just like to fix people. I enjoy putting in ports and lines as much as I like fixing hernias. I like scoping and I like laparoscopy. As long as there is some hands-on aspect, and some element of skill, it's good enough for me. I would probably be content being an interventional radiologist.

I think there is a subset of people who can like both. I wouldn't mind being a gastroenterologist as long as I don't have to do IM first. Same goes for cardiologist. So I can relate to the OP. I'm interested in vascular surgery so there is a chance that this is all rationalization on my part.

 

[nomad138]

On a sort of related note - is cardiac surgery getting in on percutaneous valve repair? I haven't really heard much about it and I wonder whether valves are something for CT surg to worry about losing to cardiologists.

 

[ESU_MD]

I wouldn't mind being a gastroenterologist as long as I don't have to do IM first. Same goes for cardiologist.

who wouldnt!!?

no interventional cardiologist worth his weight in wire wants to do rotations on general medicine service.

Since it is becoming more in vogue to allow streamlined training in surgery.. ie becoming a vascular surgeon without full general, cardiac, plastic integrated

I wonder if there is any movement in the nebulous world of IM to cut down and integrate any of the specialty training. I mean, do you really think you need to do rheum, geriatrics, neuro if you are gonna be a GI or cards guy? I have seen plenty of GI guys that try to distance themselves from their IM training. just curious.

 

[ESU_MD]

On a sort of related note - is cardiac surgery getting in on percutaneous valve repair? I haven't really heard much about it and I wonder whether valves are something for CT surg to worry about losing to cardiologists.

almost all perc valves are done under trial protocol and have multi-disciplanary involvement- at least for now. The morbidity of these procedures is not negligible and most people who get them are not surgical candidates anyway.

i'm sure this will change, but I cant see perc valves approaching the durability of a standard AVR in a low risk patient.

theres plenty of work for surgeons, dont forget about the mitral. there isnt likely gonna be a good percutaneous option for quite some time due to the anatomical limitations.

 

[smq123]

I wonder if there is any movement in the nebulous world of IM to cut down and integrate any of the specialty training. I mean, do you really think you need to do rheum, geriatrics, neuro if you are gonna be a GI or cards guy? I have seen plenty of GI guys that try to distance themselves from their IM training. just curious.

Yes, there are now a few places (mostly at the big name academic centers, like Penn and Duke) that offer "cardiology fast track" IM positions.

 

[JackADeli]

almost all perc valves are done under trial protocol and have multi-disciplanary involvement- at least for now. The morbidity of these procedures is not negligible and most people who get them are not surgical candidates anyway.

i'm sure this will change, but I cant see perc valves approaching the durability of a standard AVR in a low risk patient.

theres plenty of work for surgeons, dont forget about the mitral. there isnt likely gonna be a good percutaneous option for quite some time due to the anatomical limitations.

I don't know all the details. However, I doubt perc valves will proceed without CT/CV surgeons unless CT/CV surgeons allow it in similar fashion as with history of standard caths. During general surgery grand rounds, we had several different visiting speakers on the subject of perc valves.

The first issue under being a trial center, institution was required to have a hybrid OR and qualified SURGEON skilled in both open procedures and angio/wire guided procedures. They mentioned wanting a surgeon skilled in endo AAA repairs/stent grafts.

The second issue is the wire guided component. That part is the easiest part of the entire procedure to pick up. It really is not that difficult. The harder part reported at these grand rounds by both the industry speaker and intervent cardiologist is understanding the actual 3-d anatomy. All parties reported the surgeons as the most skilled and knowledgeable of the 3-d anatomy.

The third issue is that the valve must be in the correct place. If the valve is misplaced or migrates acutely, you need emergent OR. Thus, the requirement for hybrid CV OR. This also implies a requirement for skilled CV surgeon involvement.

Again, CV surgeons will be as involved or uninvolved in this developing technology as they want to be. I think it is dumb of them to give it up and say, "oh well, we still have mitrals...". CV surgeons need to be on the front end of endo stent grafts and other endovascular technologies. But, that's my opinion and CV/CT surgeons can do what they want....

 

[ESU_MD]

The second issue is the wire guided component. That part is the easiest part of the entire procedure to pick up. It really is not that difficult. The harder part reported at these grand rounds by both the industry speaker and intervent cardiologist is understanding the actual 3-d anatomy. All parties reported the surgeons as the most skilled and knowledgeable of the 3-d anatomy.

CV surgeons need to be on the front end of endo stent grafts and other endovascular technologies.

I think this is evolving since almost all new general surgery residency grads have been involved in quite a few wire-based procedures: EVAR, IVC filter, peripheral stents to some degree, etc.. You are absolutely right that playing around with wire isnt that hard. doing caths isnt hard either! To take a medicine resident, put them in a cath lab and train them to do a dx cath doesnt take much time. the judkins catheter literally falls right into the coronaries.

I guess I have a hard time buying into these procedures since they are considerably less complex than almost any open cardiac procedure. I guess I assume I already could do them if necessary- not a perc valve per se, but certainly a simple descending thoracic aneursym- hell its easier than an EVAR since its only a simple tube. alot of jobs require cardiac AND vascular so I guess its good. funny because alot of the candidates that interview look for places that DONT have vascular exposure!

In my current shop, the cardiologists routinely do the AAA in the cath lab and some have even been venturing up into the chest for the easy cases.

The kicker for doing the valves as you mentioned is imaging. Even though the surgeon knows what the aortic root is really like, you need a good echo guy to help you get the right views.
the other thing is to place a wire for overdrive pacing to drop the cardiac output at deployment.

it should be interesting to see how things work out. hopefully, I'll hit the powerball and just watch from the sidelines

 

[proman]

The kicker for doing the valves as you mentioned is imaging. Even though the surgeon knows what the aortic root is really like, you need a good echo guy to help you get the right views.
the other thing is to place a wire for overdrive pacing to drop the cardiac output at deployment.

it should be interesting to see how things work out. hopefully, I'll hit the powerball and just watch from the sidelines

You don't need to have a cardiologist for that. And, we'll never try to steal your procedures.

 

[Black Surgeon]

On a sort of related note - is cardiac surgery getting in on percutaneous valve repair? I haven't really heard much about it and I wonder whether valves are something for CT surg to worry about losing to cardiologists.

As mentioned by ESU_MD (reiteration has never hurt a soul), I've heard about this possibly becoming a viable option for some of the would be high risk, well aged, triple re-op surgical patients with renal morbidities that no CT surgeon wants to touch at one of the weekly journal club meetings, but not as a gold standard in treatment anytime soon.

 

[Black Surgeon]

On a sort of related note - is cardiac surgery getting in on percutaneous valve repair? I haven't really heard much about it and I wonder whether valves are something for CT surg to worry about losing to cardiologists.

To provide an opinionated answer to your question, I would say NO just to witness JAD have a fit about Surgeons standing around while interventional IM guys take food from the table. 😀

However, based on the present emphasis on endovascular work in the CT private hospital settings, my guess is that CT surgeons would definitely be at the forefront.

 

[JackADeli]

On a sort of related note - is cardiac surgery getting in on percutaneous valve repair? I haven't really heard much about it and I wonder whether valves are something for CT surg to worry about losing to cardiologists.

...reiteration has never hurt a soul...

I don't know the future or details of this procedure as I am not a CV surgeon.... But, I don't think this issue is as complex as some try to make it out. I am certain cath jockeys will continue to tout their skills as if some great shaolin master taught them in the mystical cave on some high blazing mountain.

As noted, at all the grand rounds and conference in which perc and trans-apical valves have been discussed, protocols required a multidisciplinary team that included CV surgeons. They also included hybrid ORs that again included CV surgeons. If CV surgeons choose to not get involved and/or take the lead, yes they will be on the outside while these procedures are done.

Echo is a little more difficult then cath. However, it too is not rocket science and surgeons intimately aware of the actual, physical 3-d anatomy have no problem learning echoe if they choose. Currently, ICU folks are getting basic echoe certified, anesthesia is getting echo certified, etc, etc.... It is a skill that is very learnable if one is interested. Keep in mind that many of the OR echoes are performed by cards fellows/residents and/or anesthesia residents/fellows.....

 

[Buzz Me]

CT Surg training programs are increasingly integrating non-traditional skills (coronary caths, endovascular work, echo training) into their curricula. I think this is a necessary step towards protecting the turf that has been overtaken by Cards/IR.