Cardiothoracic Surgery interest?

[ThorSurg]

I'm curious to know what the current interest level is in CT surgery. There have been numerous recent reports about the upcoming shortage of pepople in the filed and teh job market has improved significantly in the last few years.

any thoughts?

---

Members don't see this ad.

 

[JackADeli]

I'm curious to know what the current interest level is in CT surgery. There have been numerous recent reports about the upcoming shortage of people in the field and teh job market has improved significantly in the last few years...

http://ctsurgery.stanford.edu/about/news/ct_reinvention.html
http://www.aats.org/multimedia/files/Thoracic-Surgery-News/Thoracic-Surgery-News-June-2009.pdf
This is conjecture and opinion. I will leave it to those with some first hand experience and/or knowledge on the subject to correct and or reply...but, IMHO, there are a few things going on in the field:

One, You still have numerous "old school" attendings in the field. Numerous have had trouble (if not outright failed/refused) adapting to the 80 hr/wk and such. When I have spoken with fellows and residents, the attendings are still trying to hold onto 20+ year old surgical training techniques/theories. The concept of advanced technologies and simulation as a component is very much lost on many of them. This means, shortage or not, the training offered still leaves much to be desired.

"Less than 75 percent of CT residency slots have been filled in the last four years, and in 2007 the ABTS examination failure rate was the highest on record," explained D. Craig Miller, M.D...

Two, I googled the topic for another thread recently. It would appear that the ABTS examination (boards) fail rate is at an all time high in recent years. See number one....
http://jtcs.ctsnetjournals.org/cgi/content/abstract/137/6/1317

Three, a good number of senior attendings lost their shorts in 401Ks. Their long anticipated departure may be delayed some years.

Four, there may be a slow motion revolution of sorts.... Some younger new attendings are more inclined to consider modernized teaching techniques and modernized operative approaches. But, it is slow. See number three.

Five, numerous GSurge residents are attracted to minimally invassive GenThor. Thus, more and more considering "thoracic surgical oncology (i.e. genthor)". But, there are not necessarily a multitude of modified (accredited) GenThor training pathway/tracks. Instead, numerous programs have just moved to a three year plan heavy in cardiac but meeting the basic GenThor requirements if you want. Also, while interest is heavy in the MIS Thor, numerous "old school" attendings are NOT adept and poopoo the idea. Unfortunately, see numbers one, two, three, & four...

Six, there is increasing confusion with the highly anticipated conversion to an integrated six year system. Numerous med-students are dubious of being the guinea pigs on this plan. See numbers one & two...
http://forums.studentdoctor.net/showthread.php?t=639101

Seven, income per work ratio is reported to be increasingly poor in the field.

...The problem is finding a job... story of ...the fellows ...who couldn't find a job. Ended up staying ...on faculty with a pity job at $100,000 per year - only $10K per year more than the CTS PA! ...heard of others getting jobs in the low 100s as well...

Eight, considering all of the above, you still see decreasing applicants. There are marked less applicants then training slots.

Ultimately, I think the above will all contribute to continued increase in demand without a mad rush to become trained in that field. A shortage does not necessarily equate a desirable residency. I think a shortage may indicate a need for analysis and rebuild. A shortage without a plan for change just grows and can mean significant demise.

JAD

 

[acridknight]

good points JAD.

I'd also like to add that there's a large movement towards minimally invasive interventional cardiology. The advancements in bioengineering and similar new tools allow many procedures to be done laproscopically.

Granted, some procedures requiring full thoracotomies (such as organ transplants) will remain, but I see the demand in cardiologists increasing relative to CTSurg.

 

[JackADeli]

...a large movement towards minimally invasive interventional cardiology. The advancements in bioengineering and similar new tools allow many procedures to be done laproscopically.

Granted, some procedures requiring full thoracotomies (such as organ transplants) ...

The field is loaded with obstructionists to new technologies and advancements. The attendings hold to doing things the same way as was done for decades. The universities hold attendings hostage to volume as opposed to innovation. A university wants the income that comes from a fast, down and dirty aortic valve or CABG. They do not want a volume productive attending to cut their volume into a third in order to add numerous hours onto a procedure.

Think about it. A straight forward lobectomy done open in 45 minutes or less vs a VATS lobectomy (true anatomic deissxn with nodes) done in twice the time, more equipment, etc??? How about robotic mitrals? or LIMA to LAD? Universities are not conducive to innovation and senior/full professor attendings are often not conducive to innovation.

I think patient disease will maintain the existance of the field of CT surgery. Unfortunately, existance does not equate high quality.

"Less than 75 percent of CT residency slots have been filled in the last four years, and in 2007 the ABTS examination failure rate was the highest on record," explained D. Craig Miller, M.D..."A large part of the problem is negative perceptions... it takes too long, the job market is saturated, reimbursement is low, and the scope of practice is limited mostly to open surgical procedures, not the exciting high-tech interventional procedures being performed by other specialties."

...It was agreed that the current educational paradigm to train cardiothoracic surgeons must be amended to educate CT surgeons more efficiently, in less time, and in more of the newer technologies. Specific needs identified included: standardize training across all programs to produce higher quality CT surgeons; provide training in the latest techniques, integrate with and use features traditionally in the province of other related disciplines

 

[acridknight]

inertia is always an impediment to change. however, with time and the pressures to reduce cost, do you guys think that CTSurg will remain in, say, 20-30yrs from now?

 

[ESU_MD]

As a whole, you have to pursue CT because you love it.

it is a very, very long, thankless road. currently, there are really not many good reasons to go into the field unless you really like it. the money and prestige are long gone.

many days I think of how much easier life would be to do gen surg, trauma, surg onc- even vascular has to be better than CT in terms of lifestyle and length of training!

but then I think of how much I like the complexity of the cardiac cases. to me, its still exciting each time going on pump, giving 50,000 units of heparin and cutting a hole in the aorta. its a great satisfaction to sew a 1.8mm distal and have it hold up and not leak. it is even more gratifying to be able to fix it if it does leak without it falling apart.
cardiac surgery is very fascinating to me since it is repairing the body, rather than a destructive case like cutting out a cancer.

I hope its worth it- if not I guess theres always bariatrics!

 

[JackADeli]

Probably not very new information for most but maybe of interest to some. I found this in a cardiology publication:

Researchers expect shortage of cardiothoracic surgeons by 2025.

HealthDay (7/28, Reinberg) reported that "over the next 15 years, there could be a severe shortage of cardiothoracic surgeons...," a study appearing in the journal Circulation suggests. ...could be a 46 percent increase in the demand for cardiothoracic surgeons...but a drop of at least 21 percent in the number of available surgeons...
Researchers said that the "only combination scenario that could forestall such a shortage would involve a current surplus of surgeons, the elimination of coronary artery bypass grafting entirely, and an increase in the number of thoracic surgery trainees," MedPage Today (7/28, Neale) reported. That scenario is "extremely unlikely," ..."could produce poorer patient outcomes 'if non-board-certified physicians expand their role in cardiothoracic surgery, or patients must delay appropriate care because of a shortage of well-trained surgeons,'" the team wrote.
MedWire (7/28, Czyzewski) noted that "their model assumed the elimination of open revascularization by 2025, which is based on the 28 percent decrease in coronary artery bypass graft surgery seen between 1997 and 2004 and the accompanying 121 percent rise in cardiac stent placement -- a procedure performed by cardiologists, not cardiac surgeons." HeartWire (7/28) also covered the story...

Drug-eluting stent use declined significantly after critical studies, researchers say.
HealthDay (7/28, Preidt) reported...After analyzing patient registries, researchers saw "that between January and September 2006, about 90 percent of people who had a ...non-ST-elevation myocardial infarction and underwent coronary stent implantation received drug-eluting stents." In September, a "number of studies presented at a European Society of Cardiology meeting said that the risk of blood clots was higher among people who received drug-eluting stents than among those who received bare-metal stents." Afterwards, ...the use of drug-eluting stents declined, to 67 percent by March 2007, "and continued to drop to 58 percent by the start of 2008."...

 

[ESU_MD]

Shortage by 2025! i was hoping to be retired by then.

Another interesting angle: With the propects of socialized medicine looming, rationing of resources will likely follow. Exotic drug eluting stents are expensive and have not really panned out to be the magic bullet for coronary disease. Without a big CABG vs PCI discussion, stenting anything still requires alot more followup, re-cathing, re-stenting, plavix etc than CABG. Some of the complex PCI cases can require 5-10 stents.

I think it could become an easy target for the regulators to crack down on quick. Simply, its not cost effective compared with a classic cabg in a normal risk patient.

cardiologists arent gonna stent stuff they cant get paid for.

 

[dienekes88]

Shortage by 2025! i was hoping to be retired by then.

Another interesting angle: With the propects of socialized medicine looming, rationing of resources will likely follow. Exotic drug eluting stents are expensive and have not really panned out to be the magic bullet for coronary disease. Without a big CABG vs PCI discussion, stenting anything still requires alot more followup, re-cathing, re-stenting, plavix etc than CABG. Some of the complex PCI cases can require 5-10 stents.

I think it could become an easy target for the regulators to crack down on quick. Simply, its not cost effective compared with a classic cabg in a normal risk patient.

cardiologists arent gonna stent stuff they cant get paid for.

Peter Singer, a professor at Princeton, wrote an article in the New York Times that is related to this topic. If an intervention is too expensive per quality adjusted life year, then it won't be pursued. However, the National Institute for Health and Clinical Excellence (UK) put that price limit at $49,000 per year of life extended, though. Would that end the DES? $49,000 is quite a lot. I have no idea how much stenting + follow up costs.

What it will probably do, though, is at the very least stall, even possibly scuttle, the progression of percutaneous aortic valve replacement given that there's a safe and cost-effective alternative, which any government rationing body would prefer. Perhaps cost-effectiveness would play a role here also as the population going for percutaneous AVR might be older, higher risk, and have fewer QALYs to gain (artificially increasing the price/QALY).

 

[JackADeli]

...an article in the New York Times that is related to this topic. If an intervention is too expensive per Quality Adjusted Life Year ...the ...(UK) put that price limit at $49,000 per year of life extended ...Would that end the DES? $49,000 is quite a lot.

...Perhaps cost-effectiveness would play a role here also as the population ...might be older, higher risk, and have fewer QALYs to gain (artificially increasing the price/QALY).

Interesting. I think with all these therapies there are costs not immediately apparent to the "public". I have seen PCI & stenting done first prior to an open Aotic valve. You also need to factor in the plavix and other meds in addition to follow-up. Currently, "insurance" covers large amount of the medications. Then the issues of renal function....

So, most of us are not aware of what the "insurance" is paying unless you look closely at your co-pay bill. All in all, I think folks are fairly naive if they think "rationing" will not be a part of any "reform". You do have to consider some sort of outcome and benefit. Currently, a 90+ year old can and often times does recieve their aortic valve surgery or hip replacement or xigris or dialysis or cancer therapies.... or all of the above. To improve costs, you need to look at what "we can not afford" any longer. Can we afford expensive therapies for the elderly? The old xigris, trach, PEG, rehab for the elderly abdominal sepsis patient with weeks if not months in the ICU? How about the very young.... expensive heart procedures, transplants, etc... for the Downs Syndrome child? How about reproductive therapies? Can we afford procedures to reverse vasectomies & tubal ligations when someone remarries and now wants kids with their new partner? What about "mandated" selective reductions in multiples during pregnancy? How much will we spend for CF patients? What if patients smoke and/or are "non-compliant" with their health care maintenance? Do we give lung transplants to who? Hrts to who? Kidneys and/or small bowel and/or pancrease... to who? Livers and hepatitis, alcohol, hepatocellular CA? Limited (stoma preventing) cancer resections with possible need for additional/expensive salvage vs aggressive wide resection up front? Breast conservation with xrt & chemo? There would have to be some priorities established. "Expanding coverage" without limits on said "coverage" will actually collapse the system faster.

I would really like to see congress openly discuss these issues of limits instead of the vague/abstract idea of cake & cookies for all without regard for where it comes from or who cooks.... Again, I think we need to see if congress is willing to forego their healthcare coverage for whatever is planned for the masses? I don't know the answer to any of these. I do know that as physicians facing attornies we do not have the authoriy to "deny care"... thus it falls on the "common sense" of the patients and/or families....

JAD

 

[dynx]

I do know that as physicians facing attornies we do not have the authoriy to "deny care"... thus it falls on the "common sense" of the patients and/or families....

JAD

Oh, thats what you think?
Here's how I think it will play out. In the early days of "reform" futile care is no longer covered. Sounds fairly palatable. Easy to say in a press conference..."we won't cover care thats futile". Whats futile? Well, when the old patient dies after days of languishing in the ICU they'll retrospectively call it futile and refuse to pay. If hospitals/physicians try to anticipate this and refuse care based upon "futility" they will be sued and they will lose. The private system bleeds money through its nose, the public "option" saves money the "evil" doctors get further screwed...and the public cheers: "my grandfather died because evil physicians didn't care for him and I sued for millions YAY!" "My grandfather lived and the gov. insurance paid for it all! YAY!
"
This continues for awhile while the public "option" is cemented and becomes essentually indestructable as the public medical insurance companies are run into the ground.
When this has happened malpractice that has been used to drive the private system of insurance, physicans and hospitals to thier knees will be addressed. Finally you say...hold on now. It won't be addressed in terms of caps or reasonable tort reform. Nope. The gov. will look at the insane amount of insurance premiums that companies are charging, see that its "way more" than they pay out...thats what insurance does afterall it collects large pools of money from many groups to help cover the one huge loss...the gov. will declair that "profiteering" is occuring and will take over the malpractice insurance industry (exactly like they've done with homeowners insurance on the storm prone coast of florida). This will be a huge dog and pony show where people get thier "day in court" and the gov. can further punt responsibility but payouts will be effectively lowered. The lawyers will be assisted on both sides by access to the work of the gov. run malpractice lawyers through disclosure laws and payments to lawyers at least on a per hour basis will be protected. Physicians that don't follow gov. "best practice" or attempt to unionize will be dropped essentually prohibiting them from practicing.
All of this will continue to be funded on the back of the taxpayer untill collapse of the entire system is almost unavoidable.