Cardiothoracic alive and well?

[feenix]

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Hello all,

I know this question is a little pre-mature for someone now applying to get into medical school, but as I prepare I like to think about the future, it helps motivate me.

I have heard from multiple sources (including trauma teams from the hospitals I work/volunteer for and cardiologists I know) that cardiothoracic surgery is a dying field.

Is that true?

I would love to read your thoughts. Thank you for your time.

 

[Winged Scapula]

Hello all,

I know this question is a little pre-mature for someone now applying to get into medical school, but as I prepare I like to think about the future, it helps motivate me.

I have heard from multiple sources (including trauma teams from the hospitals I work/volunteer for and cardiologists I know) that cardiothoracic surgery is a dying field.

Is that true?

I would love to read your thoughts. Thank you for your time.

Well, cardiologists are hardly innocent or uninterested parties to this issue! 😉 A dying field would imply that there is a death knell being tolled for the field in the next few years; while CT isn't seeing the heyday it did a decade or more ago, there will always be certain clinical situations which require opening the chest and cardiologists will be of little help.

Anyway, there are about a million threads in here about this, here are some to start with:

http://forums.studentdoctor.net/showthread.php?t=402320&highlight=cardiothoracic

http://forums.studentdoctor.net/showthread.php?t=44459&highlight=cardiothoracic

http://forums.studentdoctor.net/showthread.php?t=364777&highlight=cardiothoracic

http://forums.studentdoctor.net/showthread.php?t=51631&highlight=cardiothoracic

http://forums.studentdoctor.net/showthread.php?t=354218&highlight=cardiothoracic

http://forums.studentdoctor.net/showthread.php?t=336315&highlight=cardiothoracic

http://forums.studentdoctor.net/showthread.php?t=323046&highlight=cardiothoracic

 

[Skylizard]

The field is great for those that can change with it and those stuck in the past will depart. New technologies and techniques continue to be developed and it is a field for individuals able to change and move into the future with the new. It is a field in dynamic flux but very much alive!


"Mini-mitrals"
VATs/MIS thoracic surgery
Robotics
Earlier interventions for lung cancers....
etc....

Not necessarily in any special order.

 

[TheMightyAngus]

Question: Are most CT surgeons expected to perform heart transplants, or do these go to the sub-subspecialists?

 

[BlackSails]

I heard from a cardiac anaethesiologist that at the last meeting of the american college of CT surgeons, they discussed the following

1) Changing the training from a post gen surg fellowship to a 6 or so year residency.
2) Training the new CT surgeons to do stenting and angioplasty, etc.

 

[johnny_blaze]

Question: Are most CT surgeons expected to perform heart transplants, or do these go to the sub-subspecialists?

These go to the subspecialist. Most surgeons who perform heart/lung transplants are also involved with VADs for heart failure. The fellowship exam for CTS is greatly focused on adult cardiac/thoracic surgery. There are a few questions in subspecialist areas like transplant or paeds but usually these fields require further training following completion of the fellowship exam.

 

[johnny_blaze]

I heard from a cardiac anaethesiologist that at the last meeting of the american college of CT surgeons, they discussed the following

1) Changing the training from a post gen surg fellowship to a 6 or so year residency.
2) Training the new CT surgeons to do stenting and angioplasty, etc.

1) I don't see why this hasn't already been done. CT surgeons in Canada and the U.K are trained separately to general surgeons and they are perfectly competent. Both programs require sometime spent in general surgery (usually a year) to develop operative technique. I think the field is very specialised and spending too much time in general surgery is a waste (in some respects).

2) Why? Is there a shortage of cardiologists? They control the majority of referrals to CT. Why send a patient to another specialist when you can do the procedure yourself?

 

[Winged Scapula]

1) 2) Why? Is there a shortage of cardiologists? They control the majority of referrals to CT. Why send a patient to another specialist when you can do the procedure yourself?

I think that is the thought process of CTS. Why send the patient back to the Cardiologist when you can do the stents and plastys yourself?

 

[johnny_blaze]

I think that is the thought process of CTS. Why send the patient back to the Cardiologist when you can do the stents and plastys yourself?

Maybe I’m a bit confused as to how referrals in the U.S work. In my experiences in CTS, I have observed that cardiologists assess both emergency and elective cardiac cases as they are primarily diagnosticians (aside from the obvious trauma, ect). Following assessment (say with echo or angiography) they determine what the best course of action is (ie. Medical tx, PTA or CABG). If surgical intervention was intended only then would the cardiac surgeon be involved. A case would only be “returned” if an unexpected co-morbidity was identified or if the surgeon/patient refused the procedure. This does not necessarily mean that PTA is suitable in these cases. Therefore, you see Dr. Cox, I find it very hard to believe that cardiac surgeons would have many stentable cases to deal with in the first place. At least not enough to warrant a change in the CTS training scheme.

 

[Winged Scapula]

Maybe I’m a bit confused as to how referrals in the U.S work. In my experiences in CTS, I have observed that cardiologists assess both emergency and elective cardiac cases as they are primarily diagnosticians (aside from the obvious trauma, ect). Following assessment (say with echo or angiography) they determine what the best course of action is (ie. Medical tx, PTA or CABG). If surgical intervention was intended only then would the cardiac surgeon be involved. A case would only be “returned” if an unexpected co-morbidity was identified or if the surgeon/patient refused the procedure. This does not necessarily mean that PTA is suitable in these cases. Therefore, you see Dr. Cox, I find it very hard to believe that cardiac surgeons would have many stentable cases to deal with in the first place. At least not enough to warrant a change in the CTS training scheme.

You are not wrong, the referral system works the same way in the US.

However, it would not be unheard of for a CTS to have a patient who needed a percutaneous procedure in addition to open surgery. Many CTS follow certain patients for years (especially pediatric and txp patients) who could find themselves in need of these non-surgical interventions at some point in time and they would likely prefer the surgeon do it (assuming a good relationship with the surgeon). In addition, if the CTS did learn these procedures and marketed themselves well, they may find that referrals from primary care physicians (who in turn would refer to cardiologists) would pick up.

Referral patterns are quite variable and prone to political turf wars and the marketing of the professionals doing the procedures. For example, in breast surgery radiologists have been very powerful in usurping all image guided percutaneous biopsy procedures. In some markets, mine included, certain radiology groups require that a patient with an abnormal clinical exam or radiographic finding be seen by a surgeon first - the surgeon can then decide whether or not to do the procedure themselves or refer back to the radiologist. In many other markets, the patient's primary care physician simply refers them straight to the radiologist. It all depends on how you market yourself.

 

[johnny_blaze]

You are not wrong, the referral system works the same way in the US.

However, it would not be unheard of for a CTS to have a patient who needed a percutaneous procedure in addition to open surgery. Many CTS follow certain patients for years (especially pediatric and txp patients) who could find themselves in need of these non-surgical interventions at some point in time and they would likely prefer the surgeon do it (assuming a good relationship with the surgeon). In addition, if the CTS did learn these procedures and marketed themselves well, they may find that referrals from primary care physicians (who in turn would refer to cardiologists) would pick up.

Referral patterns are quite variable and prone to political turf wars and the marketing of the professionals doing the procedures. For example, in breast surgery radiologists have been very powerful in usurping all image guided percutaneous biopsy procedures. In some markets, mine included, certain radiology groups require that a patient with an abnormal clinical exam or radiographic finding be seen by a surgeon first - the surgeon can then decide whether or not to do the procedure themselves or refer back to the radiologist. In many other markets, the patient's primary care physician simply refers them straight to the radiologist. It all depends on how you market yourself.

PTA/angio is very complex and cannot just be performed by someone who is not practicing it on a regular basis. Realistically, interventional cardiologist have the upper hand as this is a major subspecialty of the field (radiologists are not going to go hungry if breast surgeons see patients first as they are still needed in the MDT, they are not being cut out like CT). These cardiologists will spend 2-3 days a week in the cath lab. Their skills are sharp and they pump out research. A CT surgeon trying to compete with this will eventually just become a cardiologist. I cant see CTS moving from tertiary to secondary care, it’s just too specialised and their skills would be wasted, however nothing is impossible.


Cardiologists do the long term follow up for patients following CABG/VRs, not cardiac surgeons. Seeing as how paediatric CT and transplant CT surgeons don’t even do lung resections for cancer (which they have been trained to do) due to lack of time/practice, I find it very unlikely that they would be able to fit a cath lab session into their busy week. You cant just do random one off cath lab sessions, who ever thinks this is underestimating how complex this area is.

 

[arrhythmia7]

I have to agree with Johnny's post. PCI/angio is a completely subspecialized field requiring at least a year of full-time committment before it can be safely performed. There is no way that you could do this in addition to CT surgery and be competent. Perhaps diagnostic angios, but that is a different story. Don't forget that there are a ton of other interventional procedures (valvuloplasty, defect closures, alcohol ablation, etc) that also require intensive training.
I struggled with the decision between CT surgery vs. cardiology in medical school. There is no doubt that opening a chest is cool, however, cardiology is *blowing up* and will continue to for at least the near future. With expanding indications for pacers/CRT, new interventional procedures and ablations, and cardiac CT/MRI/3D echo progressing (and being read by cardiologists), there is literally a niche for everyone. Starting salaries pre-partnership are now >$350k even in fairly desirable areas. Why would you want to kill yourself for 10 years when you can spend all day cathing or ablating if procedures are your thing? If you get burnt out, go read some imaging studies or bang out a few consults (which re-imburse about as much as an appy).
One last thing. I have alot of friends in surgical residencies where I work, and they are still getting killed as 4th and 5th years. The fellows seem to work even harder. As a medicine resident, I more than double my salary each year moonlighting. I know several cardiology fellows who are clearing >150k a year covering for practices and moonlighting part-time. You can payback all of your loans and put some money in the bank before you are done training. I don't think there is really time for that in surgery.
No knock on CT-surgery, by the way. There is no doubt that it is an amazing field if you have the dedication and time.

 

[H_Caulfield]

Definitely tempting to make some extra money during fellowship, but is this something a medical student or intern can reliably factor into his/her decision? I've been under the impression that you have to sort of get lucky with regard to moonlighting, i.e. happen to land in a program which doesn't work you too hard and actually allows you to moonlight. Are fellows generally allowed to moonlight whenever they want, unlike residents?

I think the idea of never being able to cut open a chest or abdomen steers a lot of people away from cardiology, since the training for both cardiology and surgery is about the same length...and because surgery is "awesome." I try to remind myself that "awesome" will wear off after a few years, and, if the above post is correct, then the 4th and 5th years as a surgery resident are a hell of a lot different than the 1st and 2nd years as a fellow after IM. I've heard several accounts implying that fellowship can be pretty close to working and living as a full-fledged trained physician, whereas surgeons are still eating **** for a few more years.

Just thinking out loud and wondering whether anyone will either agree or correct me...

 

[Blade28]

At most programs, moonlighting is only allowed during your research years (in General Surgery).

 

[VAspa]

Along the moonlighting lines....
Why should any employer be able to dictate what one of their employees does outside of the workplace on their days off. What's next, are the programs going to dictate what social functions we do on our days off? Take the argument outside the Ivory Towers and the programs don't have much of an argument.

After years of listening, I haven't heard a strong argument from my program as to why I can't moonlight on one of my mandated days off. Does anyone know why, or want to play devil's advocate?

 

[arrhythmia7]

Moonlighting is alive and well in IM...I'm based on the west coast, but my friends in Chicago are also doing it. There are more shifts available than I can schedule for my current job. As an example, I have vacation the second two weeks of August, and outpatient clinics the first two weeks. I'm set up for 148 hours of moonlighting x $70/hr for the month = $$$.
As a fellow in cardiology or any other IM subspecialty, you are a board certified internist (or at least eligible if you decide not to take them), so there are even more opportunities. I think things are a bit more limited in surgery because your options are basically urgent care, some sort of ER/Procedures gig, or possibly covering shifts in a SICU. Also, you tend to stay alot later than medicine people in your residency work, so I'm not sure when you would schedule this except for your one day off a week.

 

[SocialistMD]

Along the moonlighting lines....
Why should any employer be able to dictate what one of their employees does outside of the workplace on their days off. What's next, are the programs going to dictate what social functions we do on our days off? Take the argument outside the Ivory Towers and the programs don't have much of an argument.

After years of listening, I haven't heard a strong argument from my program as to why I can't moonlight on one of my mandated days off. Does anyone know why, or want to play devil's advocate?

1. If you moonlight a 24 hour shift on your day off, you may be sapped and your performance at your program will be impaired.

2. If you are scheduled to work a moonlighting shift and a coresident has an emergency they (the resident and your program) need you to cover, it will be difficult to get you to do it, as your loyalty to your program will be in conflict with your loyalty to yourself and your name (as in, bailing on a shift will reflect poorly on you, make you seem unreliable and make it less likely for you to get another shift). Moonlighting schedules are sometimes made a year in advance and your residency program needs more flexibility in your ability to adjust to the schedule, especially in the times of the 80-hour work week.