Cardiothoracic or trauma surgery?

[trkd]

Hi everyone, I am a med student who originally wanted to do ER but then fell in love with surgery. I still like the idea of treating the critically ill patient however, but am also very enthralled by cardiothoracic surg......So the first part to my question is how much trauma surg do the cardiothoracic surgeons get to do? Are they called for critical pts who have suffered cardiothoracic trauma, or are the trauma surgeons taking care of all of that?

Also, is anyone else having this debate, and what are their pros and cons of each specialty?

Also, how much are the surgeons in each specialty involved in the patients care post op? Do they manage their care in the ICU?

Thanks for any input/help you may have.....

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[ggx12]

Hi everyone, I am a med student who originally wanted to do ER but then fell in love with surgery. I still like the idea of treating the critically ill patient however, but am also very enthralled by cardiothoracic surg......So the first part to my question is how much trauma surg do the cardiothoracic surgeons get to do? Are they called for critical pts who have suffered cardiothoracic trauma, or are the trauma surgeons taking care of all of that?

Also, is anyone else having this debate, and what are their pros and cons of each specialty?

Also, how much are the surgeons in each specialty involved in the patients care post op? Do they manage their care in the ICU?

Thanks for any input/help you may have.....

Trauma is definitely not in the daily menu of a cardiothoracic surgeon (unlike neurosurgery), but it happens. Chest trauma is treated solely by cts surgeons (at least in all institutions i know of). The reason is that (especially with cardiac trauma suspicion) you really don't know what you'll find after opening the patient. You might need from a simple stitch, to initiation extra corporeal circulation, so one has to be prepared.

 

[chemamr]

Both fellowships take care of patients in ICU, definitively, in their different settings but yes.

If you liked ER, I think it´s more similar trauma surgery.

 

[fourthyear]

Trauma surgeons DO operate on chest trauma in many centers - it really depends on what hospital you're at and what doctors in each specialty want to cover this and have the experience to feel comfortable with it.

Either way whether you do trauma or CT surgery, you need to do a 5 year general surgery residency first. Do your residency at a place that has both strong trauma and strong CT surgery if you can...then you will get to see both fields over your first few years of residency and decide from there what appeals to you more.

 

[Lemont]

From what I have heard about trauma surgery is that they do not operate as much as you may think. I have heard of them referred to as "glorified ER physicians" who "babysit" the patient until the appropriate surgical specialist arrives (neurosurgeon for head trauma, orthopod for fractures, cardiothoracic surgeon for chest trauma, etc.). And when trauma surgeons do operate it is mostly for abdominal injuries and other procedures limited to the general surgeon. Afterall, they are primarily general surgeons with or without an additional fellowship in critical care (depending on the hospital).

 

[flashman]

One thing to keep in mind is that while many cardiothoracic patients may be in ICU, increasingly the CT surgeon will not direct their care. There is the result of a huge national movement known as the leapfrog initiative which directs that ICU care be directed by a critical care specialist--people have been shown to have better outcomes in ICU with this standard. Trauma surgeons generally don't even complete a strict trauma fellowship-they do surgical critical care with a rotation in trauma. The point is not that CT surgeons don't take care of people in ICU, they obviously do--they point is that trauma critical care surgeons are the primary ICU guys. To me this is the compensation for the fact that trauma is increaingly nonoperative.
Another consideration is that there is a shortage of surgeons in critical care/trauma, and a horrible market for CT. Also critical care/trauma is trending towards being a shiftwork specialty and hence offers a far better lifestyle, e.g one of my attendings at a previous private practice job worked seven 24 hour shifts a month, and per him made more than the average numbers for GS.

flashman

 

[trkd]

Hey, thanks for all of your answers.....Flashman, why do you say that there is a horrible market for CT surgeons?

Thanx

 

[flashman]

Hey, thanks for all of your answers.....Flashman, why do you say that there is a horrible market for CT surgeons?

Thanx

There is a crisis in CT surg because their number of cases have drasticaslly declined--many saw themselves as coronary surgeons and within the past 5 years have had the number of CABGs they perform fall by ~75%. They have poorly responded to this by failing to decrease the number of seats in their fellowships. On this forum there have been quoted discussions where fellows say theat there are NO jobs out there. Take a look at the resident discussion forum at CTS-very discouraging. They also note that CT trainees are increasingly becoming "super-fellows" doing further specialized fellowships and still being unable to land a spot--which is downright sad. To be fair however some people predict a brighter fututre for the field, but not many.

 

[trkd]

Wow, thanks for your answer. That seems to be an awfully depressing outlook for CT, which is sad because it is such an interesting field.

 

[Blade28]

There is a crisis in CT surg because their number of cases have drasticaslly declined--many saw themselves as coronary surgeons and within the past 5 years have had the number of CABGs they perform fall by ~75%. They have poorly responded to this by failing to decrease the number of seats in their fellowships.

But many of the fellowship spots don't fill each year. I don't see how this is contributing to the problem.

 

[ggx12]

But many of the fellowship spots don't fill each year. I don't see how this is contributing to the problem.

still, some say there are too many spots out there

 

[flashman]

But many of the fellowship spots don't fill each year. I don't see how this is contributing to the problem.

The point is that there are too many fellowship seats, they never declined the number of seats as their field became increasingly crowded. This is a frustrating point- if the field had themselves acted by training fewer fellows then it wouldn't matter that their procedures were declining. There is current talk about reducing the number of fellows trained by as much as 50%.

I agree that this is all sad. CT surgery does seem like one of the coolest areas of surgery. It would be hard to enter the field though with fellows giving such dire outlooks as to their prospects.


flashman

 

[CTSballer11]

The point is that there are too many fellowship seats, they never declined the number of seats as their field became increasingly crowded. This is a frustrating point- if the field had themselves acted by training fewer fellows then it wouldn't matter that their procedures were declining. There is current talk about reducing the number of fellows trained by as much as 50%.

I agree that this is all sad. CT surgery does seem like one of the coolest areas of surgery. It would be hard to enter the field though with fellows giving such dire outlooks as to their prospects.


flashman

I have an uncle who is a CT surgeon and he is angry with the leaders in the field who have failed to drastically cut the number of fellowship spots. In his opinion, the academic CT surgeons are not willing to drop their fellowship programs. He thinks that the majority of academic programs are only interested in a body to take call not the surgical education/job prospects of their fellows. One mans opinion.

 

[trkd]

To play devils advocate for a moment, I've heard that there will be a huge number of CT surgeons retiring in the next 10-15 years. Has anyone else heard this, and do you think it might possibly help with the above mentioned problems CT surg is having?

 

[Blade28]

That's what I'm hoping for - a mass exodus of attendings retiring, combined with the aging of the baby boomer generation. 🙂

 

[Docgeorge]

That's what I'm hoping for - a mass exodus of attendings retiring, combined with the aging of the baby boomer generation. 🙂

That will alleviate the problem somewhat, but you still have the prob of sicker and sicker patients who are older and have much more co-morbidities and require extensive post op care, coupled with the fact that you get paid less to do a CABG and manage its complications then to drop a stent in (or so it was mentioned somewhere on this site). I think that CT will continue to get the ****ty end of the stick untill they start learning how to do interventional techniques.

But of course I'm just a MSIII and this is pure speculation on my part.

 

[CTSballer11]

That's what I'm hoping for - a mass exodus of attendings retiring, combined with the aging of the baby boomer generation. 🙂

This is what my uncle and his partners think will happen.

 

[Energon]

I get the fact that interventional cardiologists are cutting down the CABG cases with stent placements. Also provided the problems with effusive stents are sorted out, CABG's may possibly be a thing of the past.
I am speaking from a recent experience where my father had a stent placed:
What I dont get is, whenever an interventional cardiac procedure has to be done, a CT surgeon has to be handy, then how come the CT surgeons are not the ones doing the procedure in the first place? I know vascular surgeons do a lot of procedures with caths, aren't CT surgeons trained in the vascular aspects of the system too?

I dont mean to downplay the knowledge interventional cardiologists have, I just wonder, why not cut out the middle man?

 

[Lemont]

I am speaking from a recent experience where my father had a stent placed:
What I dont get is, whenever an interventional cardiac procedure has to be done, a CT surgeon has to be handy, then how come the CT surgeons are not the ones doing the procedure in the first place?

Because interventional cardiologists have cornered the market on stents for ischemic heart disease. They are not going to give up any of their turf ($) to CT surgeons unless the ischemia is too complex for angio. But they are more than happy to have a CT surgeon stand-by to bail them out if something goes wrong.

I know vascular surgeons do a lot of procedures with caths, aren't CT surgeons trained in the vascular aspects of the system too?

Not really. CT surgeons are too busy arguing for the millionth time about the pros vs. cons of off-pump vs. on-pump CABG without realizing that in due time that won't matter since cardiologists will take over all but the most complex caths for IHD.

I dont mean to downplay the knowledge interventional cardiologists have, I just wonder, why not cut out the middle man?

Again, cardiologists are not going to give up the sweet market they have built in angioplasty. They ("middle men") will only refer their patients on to a CT surgeon for CABG if the ischemia is too complex for angio.

 

[MD2b06]

What I dont get is, whenever an interventional cardiac procedure has to be done, a CT surgeon has to be handy, then how come the CT surgeons are not the ones doing the procedure in the first place? I know vascular surgeons do a lot of procedures with caths, aren't CT surgeons trained in the vascular aspects of the system too?

I dont mean to downplay the knowledge interventional cardiologists have, I just wonder, why not cut out the middle man?

Actually, more and more centers are allowing their experienced interventional cardiologists to do PCI w/o Cardiothoracic backup.

Also, cardiologists are slowly starting to use PCI in patients w/ 3V disease, DM, and left main disease, cases which previously used to be referred for CABG.

As for whether there will be massive exodus of CT surgeons in the next 10-15 years, only time will tell. CT surgeons generally work well into their 60's and sometimes even 70's. Medicine is all about adapting, and that's something CT surgery has not done. As a previous poster mentioned, it's clear that the most important thing @ most CT programs is that there be a body to take call. I always laugh when I read about complaints from program directors regarding the lack of quality fellowship applicants in CT these days.

The market will correct itself. I believe approximately 30% of CT spots went unfilled this past year. How long it will take for the supply/demand imbalance to sort itself out, no one really knows.

 

[Blade28]

That will alleviate the problem somewhat, but you still have the prob of sicker and sicker patients who are older and have much more co-morbidities and require extensive post op care, coupled with the fact that you get paid less to do a CABG and manage its complications then to drop a stent in (or so it was mentioned somewhere on this site). I think that CT will continue to get the ****ty end of the stick untill they start learning how to do interventional techniques.

But of course I'm just a MSIII and this is pure speculation on my part.

As MD2b06 said, CT surgeons still own the 3+ vessel disease and left main diseases...though cardiologists are starting to take over there too. Don't forget, you can't stent everything - sometimes due to poor anatomy or extensive disease, CABG is the only way to go.

 

[Docgeorge]

As MD2b06 said, CT surgeons still own the 3+ vessel disease and left main diseases...though cardiologists are starting to take over there too. Don't forget, you can't stent everything - sometimes due to poor anatomy or extensive disease, CABG is the only way to go.

Learning how to stent alone is not going to fix the problems of CTS. But by learning stents, they could stent the 1 or 2 vessel cases, in the relatively young person with insurance, get paid a decent amount. This would mitigate the older more complex poorly paid Medicare cases. The other thought was that if you have to cordon off your time to be back up for Cardio, you might as well go ahead and do the case. My thinking is that if the CT guys can drop stents, then it would increase the income stream, alleviate some of the dismal starting salaries for the new grads, and increase leverage when negotiating with interventional cards. The CTS organizations have obviously failed to adapt when they should have, but to not change now is asking for the nails to be placed in the coffin.

I was thinking about what another poster said about access to patients, most of these patients don't originally belong to the interventional cards guy any way. They belong to FP, IM, and Cards (non interventional). Whats preventing the surgeons from kissing a little FP, internist, and the non interventional cardiologists a$$ to get cases thrown their way? Obviously, you wont get patients from a cardiologist who belongs to a group with the interventionalist, but you've got the rest. Couple this with some sort of ad-campaign where you extol the safety benefits of a CT Surgeon doing the stents.

I don’t think this will work if it's just a few guys scattered across the country, but if the Society of Thoracic Surgery or some other national body spear headed this, in an organized and coordinated fashion it might work.