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Cardiothoracic Surgery, How tough is it to land a spot?
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Not very hard.
Its frequently mentioned to be a dying specialty and that in and of itself (not mentioning the tedious surgeries done by CT surgeons), has kept people away from CT fellowships.
Its frequently mentioned to be a dying specialty and that in and of itself (not mentioning the tedious surgeries done by CT surgeons), has kept people away from CT fellowships.
The top programs are still very competative, but the lowest tiers of programs are having trouble filling. As an aside, I have heard that Washington University has just started a pilot program for fast-tracking (abbreviated general surgery training before the subspecialization) people into CTVS,Vascular, Trauma/critical care, and Pediatric Surgery from the incoming intern class. This is the first program that I know of that has officially made the leap in this direction yet
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Could you elaborate? Why is it a dying specialty and what procedures are you referring to as tedious?
I recently read an article (off a link from the AMA website) about the alarming decline in applications for CT fellowship spots. According to the article 10 yrs ago there were approx 500 applications for the 140+ positions but in the last few years they have received fewer applications than there are positions to fill.
That suggests it is currently a buyer's market. However, I am sure you are well aware that trends in medicine tend to shift rather quickly and CT may yet become very competitive again
That suggests it is currently a buyer's market. However, I am sure you are well aware that trends in medicine tend to shift rather quickly and CT may yet become very competitive again
I have to agree with afmsboy on the changing trends in medicine. It seemed to me like the majority of applicants on the general surgery interview trail were interested in CT fellowships, including myself.
I'll be curious to see how WashU's fast track program works. I don't think that's the future of surgical education, but I can't say that I know what is.
Not that I know too much about it but seeing as nobody answered your questions I figure I'd try to answer it. I think the "dying specialty" aspect of CT surgery is that there are more and more less invasive procedures to fix CT problems that may not involve CT surgery (cracking open the chest is a big deal). I think the tedious aspect of CT surgery is that a majority of the surgeries performed are bypass and valve replacement...both long and tedious things to do.
Gonna shed some optimism on CT surg here...
Interesting observations I was reading lately about patients w/ LVAD's who, after some time to allow their LV to rest and relax 🙂, showed some LV remodeling heading back toward a pre-pathologic state.
Also, no matter who is saving the myocardium (Medicine vs. Surgery), these patients in another couple of decades are probably going to start heading on to CHF. What with the AbioCor coming along (or perhaps caming along would be a better phrase?), maybe some hope along those lines as well.
Remember, a few years ago there was a huge push for us all to become generalist; hence, the present (relative) subspecialist shortage...
Interesting observations I was reading lately about patients w/ LVAD's who, after some time to allow their LV to rest and relax 🙂, showed some LV remodeling heading back toward a pre-pathologic state.
Also, no matter who is saving the myocardium (Medicine vs. Surgery), these patients in another couple of decades are probably going to start heading on to CHF. What with the AbioCor coming along (or perhaps caming along would be a better phrase?), maybe some hope along those lines as well.
Remember, a few years ago there was a huge push for us all to become generalist; hence, the present (relative) subspecialist shortage...
Thanks for the response. Is it correct to assume that cardiologists are performing the less invasive procedures you refer to?
My understanding is that when one does a CVTS fellowship, one develops expertise in relevant cardiac, pulmonary, and even some upper GI tract surgery. So if you go into academia, you tend to focus on certain procedures with which you have developed expertise in technique -- e.g. you do valves, or you do bypass, or you do LVADs, or some mix of the above, +/- transplant. Or, you become more of a lung surgeon and spend most of your time on pulmonary stuff. If you go into private practice, I guess you become a jack-of-all trades. But, what pays the bills in private practice for CVTS guys is heart stuff -- CABG and valves, to a lesser degree.
Surgical treatment of coronary disease is rapidly becoming a thing of the past. There are big volume operators (what Medicine people call interventional cardiologists) at some of the big Interventional programs intervening on unprotected LMs, and people routinely intervene on 3vd now. However, until good trials showing outcomes with PCI on 3vd being comparable to CABG, bypass is still the way to go. But those trials are forthcoming. And there will always be lesions that we can't get a wire past.
So I would say that CAD is primarily the domain of the Cardiologist.
Management of arrhythmia/dysrrhythmia has always been the domain of the EP Cardiologists -- not just with pharmacotherapy, but also with the implantation of pacemakers and AICDs. With trials like MADIT-2 saying that everyone with an EF of 30% deserves an ICD, the demand for EP trained Cardiologists who can implant and manage the devices has ramped up tremendously.
Treatment of valvular disease is still primarily surgical. There are PCIs (angioplasty) done on AS and MS with good results, but the expertise is still at major centers only. Also, there are European interventionalists who are publishing data on their experience with catheter deployable prosthetic valves. I think this will be an area of rapid expansion and development, but is still years away from becoming a therapeutic option or standard of care. But I do think we will get there.
I have heard from many of my surgical colleagues that CV/T surgery is much more about technique than thought. This is a subject that I am sure is up for MUCH debate. But I do think it will have an effect in terms of people who do and don't choose the field.
But as I have said on this forum before, the idea of CVTS being a dying specialty is completely lost on me. However, like other fields in medicine, CVTS is changing, and people who want to train in the field have to realize and accept this change.
First, and foremost, is the simple fact that we won't need as many CVT surgeons in the future. So there is the basic idea of reducing the number trained each year. Second, I think that CVT surgeons will have to be at secondary or tertiary referral centers because of the reduced need, and also because of the types of cases and procedures they will be doing in the future (you need volume, and specialized centers generate volume). To that end, in the future, I think a CV surgeon will primarily be doing the following cardiac stuff:
1. LVAD -- this is huge. Medical therapy for CHF has gotten pretty sophisticated, but many of these patients will eventually exhaust all their options and need transplant. I think you will see the use of LVAD going beyond a "bridge to transplant" but in many ways a surrogate (not as good or as durable as transplant, but there aren't enough hearts to go around anyway).
2. Transplant -- from donors and with artifical hearts as well
3. Valves -- as good as percutaneous valve techniques become people will still need a knife for many valvular disorders (e.g. endocarditis, among others)
4. Coronary disease not amenable to PCI -- there is still disease (not much) out there we can't get a wire past but that has good distal targets for bypass. This kind of disease will always still be there.
and farther off
5. The new stem cell data showing myocardial regeneration -- who knows what the best way to get these cells into the heart will be -- a Cardiologist injecting into myocardium via catheter under fluoro, or a surgeon exposing certain parts of the myocardium with a knife and then injecting under direct visualization
I won't address the lung stuff because it's an area I don't know much about, and from what I understand there are many CVT surgeons who only do lung and stay away from the heart anyway, so I figure that trend will continue.
The bottom line is there will always be a need for well trained, motivated and talented CVT surgeons. Just be aware that we probably won't need as many as we will in the future, and that to have a viable practice as a CVT surgeon, you'll more than likely have to be affiliated with a tertiary referral center that can generate the cases and the volume.
Surgical treatment of coronary disease is rapidly becoming a thing of the past. There are big volume operators (what Medicine people call interventional cardiologists) at some of the big Interventional programs intervening on unprotected LMs, and people routinely intervene on 3vd now. However, until good trials showing outcomes with PCI on 3vd being comparable to CABG, bypass is still the way to go. But those trials are forthcoming. And there will always be lesions that we can't get a wire past.
So I would say that CAD is primarily the domain of the Cardiologist.
Management of arrhythmia/dysrrhythmia has always been the domain of the EP Cardiologists -- not just with pharmacotherapy, but also with the implantation of pacemakers and AICDs. With trials like MADIT-2 saying that everyone with an EF of 30% deserves an ICD, the demand for EP trained Cardiologists who can implant and manage the devices has ramped up tremendously.
Treatment of valvular disease is still primarily surgical. There are PCIs (angioplasty) done on AS and MS with good results, but the expertise is still at major centers only. Also, there are European interventionalists who are publishing data on their experience with catheter deployable prosthetic valves. I think this will be an area of rapid expansion and development, but is still years away from becoming a therapeutic option or standard of care. But I do think we will get there.
I have heard from many of my surgical colleagues that CV/T surgery is much more about technique than thought. This is a subject that I am sure is up for MUCH debate. But I do think it will have an effect in terms of people who do and don't choose the field.
But as I have said on this forum before, the idea of CVTS being a dying specialty is completely lost on me. However, like other fields in medicine, CVTS is changing, and people who want to train in the field have to realize and accept this change.
First, and foremost, is the simple fact that we won't need as many CVT surgeons in the future. So there is the basic idea of reducing the number trained each year. Second, I think that CVT surgeons will have to be at secondary or tertiary referral centers because of the reduced need, and also because of the types of cases and procedures they will be doing in the future (you need volume, and specialized centers generate volume). To that end, in the future, I think a CV surgeon will primarily be doing the following cardiac stuff:
1. LVAD -- this is huge. Medical therapy for CHF has gotten pretty sophisticated, but many of these patients will eventually exhaust all their options and need transplant. I think you will see the use of LVAD going beyond a "bridge to transplant" but in many ways a surrogate (not as good or as durable as transplant, but there aren't enough hearts to go around anyway).
2. Transplant -- from donors and with artifical hearts as well
3. Valves -- as good as percutaneous valve techniques become people will still need a knife for many valvular disorders (e.g. endocarditis, among others)
4. Coronary disease not amenable to PCI -- there is still disease (not much) out there we can't get a wire past but that has good distal targets for bypass. This kind of disease will always still be there.
and farther off
5. The new stem cell data showing myocardial regeneration -- who knows what the best way to get these cells into the heart will be -- a Cardiologist injecting into myocardium via catheter under fluoro, or a surgeon exposing certain parts of the myocardium with a knife and then injecting under direct visualization
I won't address the lung stuff because it's an area I don't know much about, and from what I understand there are many CVT surgeons who only do lung and stay away from the heart anyway, so I figure that trend will continue.
The bottom line is there will always be a need for well trained, motivated and talented CVT surgeons. Just be aware that we probably won't need as many as we will in the future, and that to have a viable practice as a CVT surgeon, you'll more than likely have to be affiliated with a tertiary referral center that can generate the cases and the volume.
triathlete411- a lot of peoples' enthusiasm for CTVS has been tamed by the nearly 50% cut in real pay they've taken from the end of the heyday in the 1980's with also an older,sicker population reserved for CABG due to advances in angioplasty & stent techniques. A seven figure income made it easy for many people to overlook the long training, sick patients, the monotony of frequently repetative surgical procedures,unpredictable schedule, and the feeling of being the cardiologists bagman. I think many of your colleagues who are interested in CTVS as students will lose interest during your training for a variety of reasons. The proof is in the #'s for the field's popularity & people have voted with their feet into other other subspecialties
Gator05- there certainly are some interesting advances being made on the cardiac side of things with a # of ventricular remodeling techniques being introduced. However, the # of appropriate candidates for these is going to be pretty small compared to the people who have traditionally required revascularization and are now treated with endovascular techniques. There just won't be the robust business seen for the last 3 generations of surgeons & you'll likely to see clustering of these newer techniques & even CABG into fewer & fewer super-tertiary hospitals. Large groups of industry are already pushing this to achieve economies of scale for their health care costs. This idea is also routinely floated out there in the surgical literature (consolidating certain procedures @ tertiary centers), albeit with lots of controversy & protest from smaller centers.
Gator05- there certainly are some interesting advances being made on the cardiac side of things with a # of ventricular remodeling techniques being introduced. However, the # of appropriate candidates for these is going to be pretty small compared to the people who have traditionally required revascularization and are now treated with endovascular techniques. There just won't be the robust business seen for the last 3 generations of surgeons & you'll likely to see clustering of these newer techniques & even CABG into fewer & fewer super-tertiary hospitals. Large groups of industry are already pushing this to achieve economies of scale for their health care costs. This idea is also routinely floated out there in the surgical literature (consolidating certain procedures @ tertiary centers), albeit with lots of controversy & protest from smaller centers.
At risk of showing my true lack of knowledge....
I thought there was a policy that where interventional cardio procedures are done, the facility must be able to provide a cardiac OR (bypass) "just in case"...? If this is true, doesn't this (ironically) restrict the interventional cardio guys to a place where CT Surg is practicing?
I thought there was a policy that where interventional cardio procedures are done, the facility must be able to provide a cardiac OR (bypass) "just in case"...? If this is true, doesn't this (ironically) restrict the interventional cardio guys to a place where CT Surg is practicing?
Because the periprocedural complication rate for even complicated interventions is so low, the ACC/AHA are planning to revise their guidelines saying where PCI can be done in terms of the proximity of CVTS backup.
I believe (and don't quote me on this) that the new guidelines will say that surgical backup has to be within a 3 hour driving distance of the facility.
With the formalization of Interventional Cardiology fellowships post General Cards, the days of cath labs being vast killing fields with disasters being taken to the OR are much a thing of the past. The primary therapy for dissection 2/2 a wire or trauma from an intervention is to balloon off the area transiently or to place a stent then watch and wait, then ECHO to see is there is an accumulating pericardial effusion. Only 1-3% of complications from an intervention even go to the OR anymore.
I believe (and don't quote me on this) that the new guidelines will say that surgical backup has to be within a 3 hour driving distance of the facility.
With the formalization of Interventional Cardiology fellowships post General Cards, the days of cath labs being vast killing fields with disasters being taken to the OR are much a thing of the past. The primary therapy for dissection 2/2 a wire or trauma from an intervention is to balloon off the area transiently or to place a stent then watch and wait, then ECHO to see is there is an accumulating pericardial effusion. Only 1-3% of complications from an intervention even go to the OR anymore.
Its been covered here pretty well but CT is among the least popular surgical specialties now. From what I've heard, top tier places like Mass General aren't filling their places. No one applies, at least not that they're willing to accept.
There's a hugh shift at present against ALL of the specialties that go through Gen Surg in fact because, in my opinion, people aren't interested in such a grueling lifestyle anymore. And with regard to CT you can't get much more grueling. When it comes to the chest, thats the exclusive domain of the CT guys, so they're always on call for trauma, and frequently up operating all night. Thats tough, tougher than being a trauma surgeon who then doesn't have an elective schedule the next day as well.
So the general rigor of being a CT surgeon, combined with the drastic drop in salary as someone mentioned, has scared a lot of people off.
Its also true though that the cases for CT surgeons are drying up due to the cardiologists stenting everything left and right. So most CT surgeons are now only doing the really bad 3 vessel redo's with lots of risk, lots of complications. Valve replacements don't really make up much of the caseload. The work has dried up so much in fact that many are switching to just thoracic.
A lot of the problem with CT is their own doing though in giving away all of their procedures. Some things like bronchoscopy used to be CT "territory," but they gave that away to the pulmonologists. That the interventional cardiologists do so much now also stems from the CT surgeons giving up turf. So now they're left with no work. I just rotated through CT at my school and the fellows were all in a funk about their bleak prospects when they finish. After 5-7 years of general surgery, then 2-3 years of fellowship, thats pretty sad to not be able to find a job.
I don't think this one's going to bounce back in popularity, but could be wrong.
There's a hugh shift at present against ALL of the specialties that go through Gen Surg in fact because, in my opinion, people aren't interested in such a grueling lifestyle anymore. And with regard to CT you can't get much more grueling. When it comes to the chest, thats the exclusive domain of the CT guys, so they're always on call for trauma, and frequently up operating all night. Thats tough, tougher than being a trauma surgeon who then doesn't have an elective schedule the next day as well.
So the general rigor of being a CT surgeon, combined with the drastic drop in salary as someone mentioned, has scared a lot of people off.
Its also true though that the cases for CT surgeons are drying up due to the cardiologists stenting everything left and right. So most CT surgeons are now only doing the really bad 3 vessel redo's with lots of risk, lots of complications. Valve replacements don't really make up much of the caseload. The work has dried up so much in fact that many are switching to just thoracic.
A lot of the problem with CT is their own doing though in giving away all of their procedures. Some things like bronchoscopy used to be CT "territory," but they gave that away to the pulmonologists. That the interventional cardiologists do so much now also stems from the CT surgeons giving up turf. So now they're left with no work. I just rotated through CT at my school and the fellows were all in a funk about their bleak prospects when they finish. After 5-7 years of general surgery, then 2-3 years of fellowship, thats pretty sad to not be able to find a job.
I don't think this one's going to bounce back in popularity, but could be wrong.
I don't know how things operate where you are, but where I live and where I used to work as a paramedic, the trauma surgeons operated on many chest injuries WITHOUT CT surgeons being present. As a third year medical student, I was involved in several chest surgeries... two of which involved perforations of the heart. The CT surgeons weren't there at those 2 am surgical interventions.
All the trauma surgeons I know had elective surgeries scheduled when they were post-call.
Things must operate differently in your neck of the woods.
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At the Elmhurst Hospital Center, in Queens, the education is provided by Mt. Sinai, so the cardiology fellows there are MSH. The hospital is city. There is a pilot project called C-PORT (sorry, I don't know what the acronym stands for), which is interventional stenting and/or angioplasty without in-house CT. Their protocol is 30 minutes to CTS.
They haven't needed the 30 minutes yet.
Here in NYC, 1VD gets medical, 2VD is up in the air (leaning towards sx.), and 3VD+ goes for CABG. Of course, I was in Brooklyn as a student, and am now in Queens as an intern, with a highline to MSH; things might be different at other foci (here in the city).
They haven't needed the 30 minutes yet.
Here in NYC, 1VD gets medical, 2VD is up in the air (leaning towards sx.), and 3VD+ goes for CABG. Of course, I was in Brooklyn as a student, and am now in Queens as an intern, with a highline to MSH; things might be different at other foci (here in the city).
I think you're right - I always noticed how EMT-P protocols were much more expansive in the south and in Texas, and I figured it was from necessity and convenience - outside of cities, there's not a lot in between, so you, if you are Trauma Sx, do your own CT; it's not your specialty, but you're not completely an amateur in there, so you're very functional.
Is this one of those places where you do the anesthesia, then scrub and do the surgery, then sterilize your instruments afterwards with alcohol for the next one? Meanwhile, you're also the town's FP, Ob/Gyn, and ambulance driver?
You're quite right. Things are different up here. 😀
Seriously though, at our Level I trauma the trauma surgeons stay out of the chest. Thought that was the same everywhere but maybe not.
I found this article pretty interesting since it relates to this discussion:
www.ctsnet.org/doc/7406
www.ctsnet.org/doc/7406
Yes, this subject sounds interesting, indeed.
Ahhh Elmhurst... trauma call with Special Forces medics... smoking with the CT surgeons from Cabrini... good times...
Regardless, I don't understand how anyone can be a trauma surgeon and not be comfortable in the chest. Maybe they were grandfathered in as gen surg guys, with no chest experience. Relying in CT guys for trauma is strange to me.
By the way, be wary of Wash U program. While I think it can be useful most CT/ Trauma fellowships are way leery of taking someone who hasn't even completed 4th year. Better to go the conservative route and not cut corners until a new standard is established.
My understanding of this new route is that it will be open to residents staying for a fellowship within the program they have completed four years in. I also gather that Wash U is not the only one contemplating such a move. So I dont think there is too much to be wary of.
Yup that's true; it was my misunderstanding that people were trying to go to other fellowship programs after 4 years. Don't know why I thought that. Sorry about that. Only thing to be wary about is having to know what fellowship you want right out of medical school, a tough proposition indeed.
I don't think the long-term plan is to limit the 4+2 models for the subspecialties to within the program you do your preliminary general surgery in. It would commit people to some of these specialties that they may not end up choosing to do. The pilot programs for these like Wash U. prob. has candidates they handpicked for guinea pigs in this style program. I imagine that you will in the future interview during your pgy-3 year (vs. pgy 4 or 5 year as is now the case). This is going to be a manpower disaster for program directors as they will have no idea of how many pgy-5 general surgery residents to budget for
I knew there was a reason I was leery...
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