CT surg procedure variety?

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rigid

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Hoping to get some insight from those in the know.

I'm wondering what the variety of work is like in CT surg? It seems whenever i look at operating lists at my hospitals all i see are CABG/AVR/MVR/lobectomy. Is this what their lives are like constantly doing those same 5 procedures over and over?

If so then doesn't it become boring or is there something I'm missing out on? I really want to be in a field where i can operate/deal with blood vessels mainly.

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Hoping to get some insight from those in the know.

I'm wondering what the variety of work is like in CT surg? It seems whenever i look at operating lists at my hospitals all i see are CABG/AVR/MVR/lobectomy. Is this what their lives are like constantly doing those same 5 procedures over and over?

If so then doesn't it become boring or is there something I'm missing out on? I really want to be in a field where i can operate/deal with blood vessels mainly.

Hmmm....I seem to remember there being some surgical specialty that does this......I want to say.....Vascular?
 
Yeah i know and that is my current #1 on the list however i am just wondering about CT as an option
 
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I'm wondering what the variety of work is like in CT surg? It seems whenever i look at operating lists at my hospitals all i see are CABG/AVR/MVR/lobectomy. Is this what their lives are like constantly doing those same 5 procedures over and over?

Esophagectomies?
Thymectomies?
Nissens?
Heller myotomies?
Hiatal hernia repairs?
Chest wall reconstructions?
Lung transplants?
Aortic roots or hemiarches?
Descending thoracic aortic aneurysms?
Type A aortic dissections?
Heart transplants?
LVADs?
Percutaneous valves?
Robotics?
 
Esophagectomies?
Thymectomies?
Nissens?
Heller myotomies?
Hiatal hernia repairs?
Chest wall reconstructions?
Lung transplants?
Aortic roots or hemiarches?
Descending thoracic aortic aneurysms?
Type A aortic dissections?
Heart transplants?
LVADs?
Percutaneous valves?
Robotics?

I thought this would fall under upper gi surgery?
 
Most CTS guys do esophagectomies AFAIK. Where I trained, they may do an occasional Heller, but the referral pattern for HH and Nissens were to gen surg.
 
If you look at gen surgery schedule you will likely see. Hernia/gallbladder/bowel resection/breast biopsy. Over and over too. I guess vascular schedule would be av fistula/ av graft/ fem pop/ amputation over and over too. I think all specialties tend to have their bread and butter
 
Gen Surg doing esophagectomies? That would be unusual...surely they're not doing Ivor Lewises (with the R thoracotomy) or transhiatals on their own?
Really?? The GS guys did transhiatals without CTS involvement where I trained (this was 2 different hospitals too). I can't imagine them asking the CTS guys for help. I never got the feeling that we were "different" in that respect than other training programs, but I guess it depends more on referral patterns. They got more of them than the CTS guys, actually. I did a few in training....all were with (specific) GS attendings. Never did/cared for an Ivor Lewis patient.
 
Hoping to get some insight from those in the know.

I'm wondering what the variety of work is like in CT surg? It seems whenever i look at operating lists at my hospitals all i see are CABG/AVR/MVR/lobectomy. Is this what their lives are like constantly doing those same 5 procedures over and over?

If so then doesn't it become boring or is there something I'm missing out on? I really want to be in a field where i can operate/deal with blood vessels mainly.

Good luck finding "variety" in CT surg, which is really cardiac or thoracic (meaning you usually have to do one or the other) in most arenas unless you know of some atypical rural private practice settings.

If you can't see yourself doing CABG X 200 a year then think twice about cardiac. The "AVR/MVR" you speak of and aortic work some have mentioned is rare. I would say a reasonable ratio would 8:1 CABG to AVR/MVR etc.

I have a hard time imagining a cardiac surgeon doing lobectomies on a regular basis (although I know there are exceptions). Thoracic surgery is in many ways, a completely different beast that requires a specialized oncologic team. Cardiac and Thoracic most definitely do not mix in the academic world.

However, you would probably find more variety in thoracic surg, thats assuming you'll be successful at fighting the GS off your nissens and the like.
 
Gen Surg doing esophagectomies? That would be unusual...surely they're not doing Ivor Lewises (with the R thoracotomy) or transhiatals on their own?

In Australia the CT guys has no gen surg training so they don't touch oesophagus or stomach and the Upper GI guys do it on their own

EDIT:

Black Surgeon you sure the CABG:Other ratio is that big? We take on about 3 CT Surg residents a year and as such there is a very small number of CT surgeons currently practicing and they tend to do all the thoracic stuff as well.
 
Good luck finding "variety" in CT surg, which is really cardiac or thoracic (meaning you usually have to do one or the other) in most arenas unless you know of some atypical rural private practice settings.

If you can't see yourself doing CABG X 200 a year then think twice about cardiac. The "AVR/MVR" you speak of and aortic work some have mentioned is rare. I would say a reasonable ratio would 8:1 CABG to AVR/MVR etc.

I have a hard time imagining a cardiac surgeon doing lobectomies on a regular basis (although I know there are exceptions). Thoracic surgery is in many ways, a completely different beast that requires a specialized oncologic team. Cardiac and Thoracic most definitely do not mix in the academic world.

However, you would probably find more variety in thoracic surg, thats assuming you'll be successful at fighting the GS off your nissens and the like.

This was exactly my impression as well back when I was considering CT surg. You better love bypasses.

To echo what ESU said, every speciality has their bread and butter surgeries that they will do day in and day out. When picking your specialty, you need to strongly consider how much you enjoy the bread and butter because that will be most of what you do. I think picking a specialty based on a few random procedures that they do would be a mistake.

Also, more rural = more variety in pretty much all specialities.
 
Really?? The GS guys did transhiatals without CTS involvement where I trained (this was 2 different hospitals too). I can't imagine them asking the CTS guys for help. I never got the feeling that we were "different" in that respect than other training programs, but I guess it depends more on referral patterns. They got more of them than the CTS guys, actually. I did a few in training....all were with (specific) GS attendings. Never did/cared for an Ivor Lewis patient.

Probably different situation here since we have (CT) people that trained with Mark Orringer, the guy who popularized the transhiatal esophagectomy!

Ivor Lewises here always involve Thoracic since it involves a R thoracotomy.
 
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Probably different situation here since we have (CT) people that trained with Mark Orringer, the guy who popularized the transhiatal esophagectomy!

Ivor Lewises here always involve Thoracic since it involves a R thoracotomy.

At my med school there were gen surg faculty who would do THEs and a couple of thoracic guys who would do Ivor-Lewis

At my residency it is 100% the thoracic guys.
 
Gen Surg doing esophagectomies? That would be unusual...surely they're not doing Ivor Lewises (with the R thoracotomy) or transhiatals on their own?

Not unusual where I'm from. The general surgeons in Wichita did the vast majority of the esophagectomies, both Ivor-Lewis and trans-hiatals. Some of them even did them laparoscopically/thoracoscopically.

Good luck finding "variety" in CT surg, which is really cardiac or thoracic (meaning you usually have to do one or the other) in most arenas unless you know of some atypical rural private practice settings.

Not true at all. It's naive to assume that these situations only exist in rural settings....truly rural settings would have a hard time even supporting a cardiothoracic surgeon from a volume standpoint.

I've experienced private practice CT surgeons in Wichita with a good mix of cardiac, thoracic, and even upper GI cases. There are others that choose to do only hearts, and there's one older surgeon who has "retired" into a purely thoracic and vascular practice. I've seen similar things in Omaha.

The Omaha metropolitan area has around 900,000 people, and Wichita metropolitan area has 631,000.....I'm not sure we can categorize them as "rural." I would love to hear the SDN definition of rural, because the more time I spend on here, the more I think people use it synonymously with "midwest."

"Unusual" and "atypical" have both been used here to describe situations that seem very normal and routine to me. I'm confident that I didn't train is some bizarre rural anomaly, so I think you guys need to open your minds a little bit...
 
To everyone who has seen general surgeons doing transhiatals...what if you get into bleeding while blinding sticking your hands up in the chest? Try to hold pressure and call Thoracic?
 
re the future of CT:

Are robotic cabg and robotic or endo valves going to dominate the field or do you think there will be always be room for a guy who just wants to open cabg, maybe some transplant type stuff (lung and cardiac), oh and maybe a ross?
 
To everyone who has seen general surgeons doing transhiatals...what if you get into bleeding while blinding sticking your hands up in the chest? Try to hold pressure and call Thoracic?

I think the smart thing to do is get a thoracic surgeon involved, but a former co-resident of mine would most likely try to manage his own complication....he does lots of thoracic approaches for spine work, and still does occasional VATS, plus he's aggressive, but I don't think he's the norm.

Significant bleeding during that portion of the procedure is always the main worry, but I've only seen it once, and it was with a general surgeon in town we don't work with....he held pressure and called thoracic....then he cleaned his scrub pants and swore off esophagectomies, IIRC.
 
I think the smart thing to do is get a thoracic surgeon involved, .

The smart thing to do is to avoid these cases.

2011 Medicare reimbursement in Kansas for an Ivor-Lewis esophagectomy: $2417.06.

Think about it:

-4 to 6 hours of OR time.
-post-op ICU for a few days
-all the attendant intra-op and post-op risks not limited to leak/sepsis/death
-90 day global period during which you can add a few gray hairs' worth of stress.

Thankfully as a plastic surgeon I have nothing to do with esophagectomies of any kind. Fortunately I have the opportunity to do a fair amount of hand surgery. For example the Medicare reimbursement in Kansas for a zone II flexor tendon repair without graft is $1014.36. This case takes about 45 minutes to an hour to complete, is done as an outpatient, and has none of the morbidity of an esophagectomy. There is no ICU rounding, no takeback stress, and I can do many more cases and still be home by 4 or 5 pm if I choose.

I guess when I see pissing matches brewing between general surgery and (fill in the blank) specialty about who is doing this case or that, I realize how great my life is. Then again, it is a pick-your-poison world in surgery. Some guys just love to be stressed out in the hospital all day, and some guys like to be home by 5 in time to watch some college hoops. Enjoy those esophagectomies guys and gals.

(Edit: Not trying to be inflammatory by this post, but reimbursement/stress/morbidity are factors that should be considered, although as trainees no one tells you about this stuff. In fact, most academic physicians take whatever deal they get and don't ever look underneath the hood and understand the true economics of what they are involved in. General surgery is typically the most poorly reimbursed field for the amount of work and stress involved. God forbid I ever need an esophagectomy, but if I do I pray that there will be a passionate and skilled surgeon to do it. However, it is worth asking yourself as a trainee if you are up for a lifetime of hospital dwelling, and stress, in order to become great at doing the big operations.)

One more thing: Neither of the reimbursement scenarios above is very good. In either case it will be very difficult, nigh impossible, to cover overhead if all one does is Medicare cases.
 
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However, it is worth asking yourself as a trainee if you are up for a lifetime of hospital dwelling, and stress, in order to become great at doing the big operations.)

Yes. :thumbup:

It's actually the fact that so many of the cardiothoracic surgery patients go to the ICU post-op sick as hell that attracts me to the field. (One of many reasons.)
 
re the future of CT:

Are robotic cabg and robotic or endo valves going to dominate the field or do you think there will be always be room for a guy who just wants to open cabg, maybe some transplant type stuff (lung and cardiac), oh and maybe a ross?

Answer to your first question is No. CT surg in the community setting will still be primarily CABG and simple valves, maybe with some vascular and a little thoracic. Volumes in small hospital communities (or where there is a separate dominant group) may only be 200-400 pump cases/year divided among several surgeons. Outside of this setting--for example in larger cities (like SLUser mentioned), big metropolitan areas, academic medical centers--the future of CT surg is definately mechanical circulatory support, percutaneous valves, "minimally invasive" valves, but not necessarily robotics. There is an exponential increase in the number of VADs coming in the near future.

Regarding reimbursement as was mentioned in another post: a 3 vessel CABG reimburses ~$3500 from medicare, and most cardiac guys can do 2 a day (a few guys can do more). $7000+ isn't bad, and they should be home for college hoops too. Thoracic reimburses well too. $813 for a VATS wedge (single wedge) which should take under an hour. ~$1500 for a VATS lobe, which can take 1-2 hours depending on the lobe. No matter what specialty you go into , if you're a slow surgeon, you will generate fewer $.
 
Regarding reimbursement as was mentioned in another post: a 3 vessel CABG reimburses ~$3500 from medicare, and most cardiac guys can do 2 a day (a few guys can do more). $7000+ isn't bad, and they should be home for college hoops too.

Thoracic reimburses well too. $813 for a VATS wedge (single wedge) which should take under an hour. ~$1500 for a VATS lobe, which can take 1-2 hours depending on the lobe. No matter what specialty you go into , if you're a slow surgeon, you will generate fewer $.

According to the AMA's web site:

(For comparison's sake we'll stick to the 2011 Medicare rate for Kansas)

CABG x 1 - 1945.37
CABG x 2 - 2135.57
CABG x 3 - 2425.59
CABG x 4 - 2491.65
CABG x 5 - 2634.11
CABG x 6 - 2745.84

VATS for wedge - 794.43
VATS for one lobe - 1387.77
VATS for 2 lobes - 1580.37

You can add another 80 dollars if the surgery is open.

Doing two 3 vessel CABGs in a day will net you 4850 dollars. One hour for a wedge, and 2 for a lobe is also not going to help you. Generating less than 1000 dollars an hour in the operating room will sink you in almost all private practice settings. This is why payor mix is so important when evaluating a job. Who cares if you are going to be "very busy from day one" if a majority of your practice is Medicare?
 
The smart thing to do is to avoid these cases.

The numbers that you quote are sure to shock some of the less experienced SDNers, but I'm well aware of the disparity among surgical subspecialty reimbursements. I also agree with you that general surgery has an imbalanced pain to reimbursement ratio.

My personal feeling is that people primarily interested in money should choose a field, either inside or outside of medicine, that will allow them to be happy. While I don't want to starve, I'm somewhat of a purist/idealist in my approach to surgery, and I still plan on doing the tough cases "for the love of the game."

In colorectal surgery, it is much more profitable, and simultaneously less stressful, to have a primarily anorectal practice, and spend most of your time in clinic, the endoscopy suite, and outpatient surgery centers. Taking out cancers and making J-pouches are big headaches with low financial rewards.....but I personally love those cases.

As you know, postop surveillance is big in colorectal cancer, so we see these people frequently in the first few years. Unlike pancreas/liver/lung cancer, many of these people have excellent long-term survival, and it's extremely rewarding to see them in your clinic....even if it takes time away from your bands/proctos/etc that keep the practice afloat.
 
The smart thing to do is to avoid these cases.

I think you're right. Traditionally, most CT surgeons have avoided the esophagus cases since they are just too much work and not very satisfying... like a CABG or AVR
The more junior you are (or the less skills you have) the more of these esophageal and lung cases you "get"

Things have changed abit now with lack of robust volume in cardiac and some of the new guys actually LIKE general thoracic!!

General surgeons wound up doing alot of these cases because they HAD to, or the patients would have to be shipped off.

If I cant avoid getting sucked into an esophageal case, I usually will enlist the help of my general surgery colleagues. It is usually a good experience since the general guys will be very involved in postop care and have more manpower to play with fluids and check electrolytes, etc.. It also diffuses the workload WHEN the patients leak, obstruct, stricture, recur and then die.

Thats why I like the CABG- quick, simple and elegant!
 
Doing two 3 vessel CABGs in a day will net you 4850 dollars. One hour for a wedge, and 2 for a lobe is also not going to help you. Generating less than 1000 dollars an hour in the operating room will sink you in almost all private practice settings. This is why payor mix is so important when evaluating a job. Who cares if you are going to be "very busy from day one" if a majority of your practice is Medicare?

Many of the academically trained surgeons or those with minimal exposure to physicians in the private practice world have very limited exposure to this reality. They come from a world where the "cowboys" of surgery are the most respected. One wouldn't dare mention anything about money or compensation to any of the attendings at my program, but these attendings all love to hear one quote literature and discuss minutia behind every surgical approach.

I'm somewhat of a purist/idealist in my approach to surgery, and I still plan on doing the tough cases "for the love of the game."

I have found this to be a common denominator among a lot of the academic residents at my program. On my ENT rotation, the residents all wanted to tackle the big radical neck dissections, vasc fellows wanting to aorta fem every patient (and their mother), and snuffed their noses at the endovascular/home next day interventions. The 10 hour procedure loving resident who then raves about it as a testament to the word "macho". The podiatry residents yearning to do the big reconstructive ankle trauma cases while choosing to shun their bread and butter bunions.

They all want to be "cowboys", this is great, but I'd venture to say that this "purist/idealist" approach is better served and left in an academic setting where there are residents to cover call, round on these patients, deal with comps, where overhead is covered, etc. In the private practice setting (as Igap has elaborated), this would most likely lead to financial detriment in the form of a negative operational cash flow.

It isn't about wanting to be opulent or being "primarily interested in money" nowadays, it is about maintaining, and with the direction healthcare has and will be taking, it will be about staying afloat and surviving.

If one's goal is academia, then the "purist/idealist" approach is admirable. However, if one dreams of answering to as few people as possible, working for themselves, or as a partner rather than as an employee, then much has to be learned in the way of running a practice once the academic curtain is pulled.
 
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I have found this to be a common denominator among a lot of the academic residents at my program. On my ENT rotation, the residents all wanted to tackle the big radical neck dissections, vasc fellows wanting to aorta fem every patient (and their mother), and snuffed their noses at the endovascular/home next day interventions. The 10 hour procedure loving resident who then raves about it as a testament to the word "macho". The podiatry residents yearning to do the big reconstructive ankle trauma cases while choosing to shun their bread and butter bunions.

They all want to be "cowboys", this is great, but I'd venture to say that this "purist/idealist" approach is better served and left in an academic setting where there are residents to cover call, round on these patients, deal with comps, where overhead is covered, etc. In the private practice setting (as Igap has elaborated), this would most likely lead to financial detriment in the form of a negative operational cash flow.

It isn't about wanting to be opulent or being "primarily interested in money" nowadays, it is about maintaining, and with the direction healthcare has and will be taking, it will be about staying afloat and surviving.

If one's goal is academia, then the "purist/idealist" approach is admirable. However, if one dreams of answering to as few people as possible, working for themselves, or as a partner rather than as an employee, then much has to be learned in the way of running a practice once the academic curtain is pulled.

Part of what you are experiencing is inherent to a doctor-in-training. Obviously residents are going to be more gung-ho about big cases because they're learning, and it doesn't affect their reimbursement/etc. I don't think that's unique to residents in academic programs....and I don't think it necessarily makes them "cowboys." I think of cowboys more as people that are cavalier and routinely push the limits of what they are qualified to do independently.

I agree with you about the purist's role in surgery. It's more fitting for an academic surgeon on salary to spend their time doing things that aren't financially rewarding. A private practice surgeon interested in a good lifestyle and constant stream of money will lose most of his/her ideology soon after residency ends....among other things, this means consulting lots of people to manage your postop patients so you're not bogged down with pages, and referring out some of the bigger cases that you would have tackled yourself when you were a bright-eyed trainee.
 
Agree with SLUser. A "cowboy" is generally a deregotory term for someone who engages in reckless behavior, and needlessly endangers others/patients for their own aggrandizement.

I think that any good resident should be pushing for any and all cases including big and small alike. Residents who do not demonstrate a healthy enthusiasm for any and all cases are doing themselves a disservice. One of the benefits of being a resident is that you do not bear all of the responsibility, and do not need to be able to actually do the case on your own to book it and do it. You have the luxury of having attending backup/instruction so why not leverage that to the fullest.

I respect agressive residents who look for complex, interesting cases. I used to be one myself. That's not being a cowboy, that's being an appropriately enthusiastic, active, learner.
 
Agree with SLUser. A "cowboy" is generally a deregotory term for someone who engages in reckless behavior, and needlessly endangers others/patients for their own aggrandizement.

I don't think it necessarily makes them "cowboys." I think of cowboys more as people that are cavalier and routinely push the limits of what they are qualified to do independently.

Ok, "cowboys", "cowgirls", its all semantics with subjective meaning. My use of the word wasn't meant to be "derogatory". I've most commonly heard it used as a description of some of the more avant-garde attendings at my institution who are very well respected and well known. Anyway, this is besides the point.

I agree with you about the purist's role in surgery.

Wow! SLUser11 agrees with me on a subject, I could get used to this. :D
 
Wow! SLUser11 agrees with me on a subject, I could get used to this. :D

In general, I love to play devil's advocate....so I don't agree with anyone very often. If you tell me the sky is blue, I will argue to the death that it's really more of a light grey.
 
Personally, I am quite fascinated by the cowboy persona in surgery. It is very easy to be a cowboy as a resident, but much more difficult as a new attending. Someone once warned me that cowboys get shot sometimes.
 
Sorry to bump, but something that is hard to appreciate as a medical student is how much variety there can be even when doing the bread and butter stuff.

Can anyone give insight on this with reference to CT?
 
Sorry to bump, but something that is hard to appreciate as a medical student is how much variety there can be even when doing the bread and butter stuff.

Can anyone give insight on this with reference to CT?

Do you mean in-procedure variety?
 
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At my hospital (large, university) the cardiac guys do a pretty large volume of heart/double lung transplants, 1-3/wk, in addition to the usuals (mvr/avr/cabg). There are also a lot of antiarrhythmia procedures (MAZE, atrial reduction) and bridge to transplant/VAD. Although judging from the amount of "advanced cardiac surgery" superfellows floating around the CTICU, it would probably take a few more years of training after fellowship to get there.

One of the CT surgeons here does a moderate amount of TEVARs and runs our corevalve program along with another of the cards attendings. I don't know if this is the trend but it seems like more and more of the younger guys are picking up on the minimally invasive work (also at places like Columbia, Northwestern).

neb
 
Did you read the rest of the thread? I'm confused as to what else you're asking (that hasn't already been answered).

Sorry for not being clear, what i mean is within the same operation (say you have 2 CABG in a row) how much variety would there be between two of the same procedure due to patient factors, exposure issues, co-morbidities?
 
And I'm guessing that goes for EVERY specialty too (not just the surgical ones), so no sense picking specialties based on that.
 
Gen Surg doing esophagectomies? That would be unusual...surely they're not doing Ivor Lewises (with the R thoracotomy) or transhiatals on their own?
We do them in conjunction with CT surg. Neither service does them alone. I think one of our old school attendings used to do them on his own, but he was from the prior era.
 
In colorectal surgery, it is much more profitable, and simultaneously less stressful, to have a primarily anorectal practice, and spend most of your time in clinic, the endoscopy suite, and outpatient surgery centers. Taking out cancers and making J-pouches are big headaches with low financial rewards.....but I personally love those cases.
Our system has such backwards rewards.
 
I know the answer is no, but are any CT guys doing CEA's anymore? I know in the 70s and 80s the turf battle over the carotid was between CT and Neurosurgery, and then the late 80s vascular showed up as a specialty and sort of hogged the carotid (there was a little thing called a CABG that the CT guys seemed interested in)

It's one of my favorite operations (to watch; 4th year) but I loved everything else about CT. My ideal practice would be CEA, CABG, valve and some odd thoracic work. Now in today's age of super-specialists I know that doesn't exist. Hell, my dad said all the general surgeons back in the early 80s did AAA's, carotids, esophagectomies, whipples, you name it.
 
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