Future CT surgery Compensation

[copacetic]

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Does anyone think that the expected dearth in CT surgery physicians will result in an increase in incomes (due to more work)..or anything else for that matter.

 

[ZagDoc]

I think it will make it a more attractive field in the future than it's been the past 5 years or so. My gut tells me that integrated CT programs are going to continue to grow which will remove another hurdle (time) as well. That combined with data starting to trickle out that stents aren't quite as magical as cardiologists believed them to be... I think the declaration of the death of the CABG was quite premature and that CT surgeons will continue to earn a healthy income. Good data coming out about the role of CABG in otherwise healthy septuagenarians and octogenarians also.

 

[ESCrawford]

I'm curious about the basis for "the expected dearth in CT surgery physicians." Irving Kron, a CT leader from the UVA, has been agressively promoting this concept of a looming severe shortage of CT physicians. Frankly though, it comes off as more of a recruiting tool than an objective reality. CT program directors have had a lot of trouble filling their slots with American grads in recent years--to the point where it's a non-competitive fellowship. To the casual observer, it would appear that programs are struggling desperately to remain relevant. Dr. Kron was also pitching the idea of combined CT/Vascular residency at the SVS a couple years ago--to a very hostile audience. Believe such propaganda at your own peril, as physician workforce predictions are notoriously inaccurate and usually politically motivated. Many of the news items about a shortage of CT surgeons also reference an impending shortage of cardiologists--which is frankly laughable.

Perhaps coronary angioplasty and stenting is not all that durable, but point that out to a cardiologist (I have), and they will promptly produce data about the dismal long-term patency of vein grafts (and it's pretty convincing). And lets be honest, cardiology is in total control of this patient population. There isn't going to be a sudden epiphany that we should be doing more CABG.

What if percutaneous valves turn out to be durable? What if the rates of lung cancer drop off dramatically as the rate of smoking drops. Hard to predict what will happen 15 years from now, but the safe bet is to presume a tight job market in the near future. Personally, I think the leadership in CT surgery should be aggressively closing down training programs so that the number of graduates is appropriate for the current job market--not promoting some theoretical future boom in cardiac surgery.

 

[JackADeli]

I'm curious about the basis for "the expected dearth in CT surgery physicians." Irving Kron, a CT leader from the UVA, has been agressively promoting this concept of a looming severe shortage of CT physicians. Frankly though, it comes off as more of a recruiting tool than an objective reality. CT program directors have had a lot of trouble filling their slots with American grads in recent years--to the point where it's a non-competitive fellowship. To the casual observer, it would appear that programs are struggling desperately to remain relevant. Dr. Kron was also pitching the idea of combined CT/Vascular residency at the SVS a couple years ago--to a very hostile audience. Believe such propaganda at your own peril, as physician workforce predictions are notoriously inaccurate and usually politically motivated. Many of the news items about a shortage of CT surgeons also reference an impending shortage of cardiologists--which is frankly laughable.

Perhaps coronary angioplasty and stenting is not all that durable, but point that out to a cardiologist (I have), and they will promptly produce data about the dismal long-term patency of vein grafts (and it's pretty convincing). And lets be honest, cardiology is in total control of this patient population. There isn't going to be a sudden epiphany that we should be doing more CABG.

What if percutaneous valves turn out to be durable? What if the rates of lung cancer drop off dramatically as the rate of smoking drops. Hard to predict what will happen 15 years from now, but the safe bet is to presume a tight job market in the near future...

http://www.theheart.org/article/988839.do

I am not sure (and nobody else is) what sort of future there is for cardiac, cardiothoracic, thoracic surgeons. I will leave it to those guys/girls to figure that out...

However, there has been continuous downturn in fellowship filling over the past half decade or so. I think the last data in the general surgery pubs showed under 100 per year. There is also the latest information on screening CT scans for lung cancer. Then, you add to that the aging population of current CV/CT surgeons, the issue of general surgery residents exposure (or lack of) to CV/CT/Thor. It is reasonable to consider undermet need in these fields in the future.

I guess, the final component to add is the life-style value issue. There is more and more published on surgery residents placing increased emphasis and value on life style. If we presume the same amount of CV/CT disease volume (ignoring increased numbers of elderly population), it may be that future CV/CT surgeons will not kill themselves to do the same volume of previous senior surgeons. Also, with increasing cuts, there may be less incentive at some point for them to kill themselves to do solo practice, high volume, etc.... If that is the case, there would be a need for more surgeons just to provide care for the same volume of disease.

...Personally, I think the leadership in CT surgery should be aggressively closing down training programs so that the number of graduates is appropriate for the current job market--not promoting some theoretical future boom in cardiac surgery.

I generally agree with that in most fields. But, I think the other issue is that many surgeons in many fields should also do more to encourage some senior folks to retire! IMHO, many surgical fields have "dinosaurs" that are unwilling to adopt new technologies and/or techniques and stand in the way of innovations. It is unfortunate to see programs staying open because of prestigous names/status but that program is not training residents in modern techniques....

 

[ESCrawford]

Just as an aside, I think it's amusing that every specialty society puts out these ridiculous press releases lamenting the impending severe shortage of their specialty. Seriously, go ahead and Google "Dermatology Shortage." and you get these gems:

www.ncbi.nlm.nih.gov/pubmed/14699364
www.msnbc.msn.com/id/17744996/.../health-skin_and_beauty/


Try Gastroenterology shortage:

www.nytimes.com/2009/01/09/.../09gastro.html

Psychiatry Shortage

www.news-medical.net/.../Psychiatrist-shortage-may-soon-reach-crisis-levels.aspx

and yes, ENT shortage

www.enttoday.org/.../Fill_the_Gap_Strategies_for_addressing_the_otolaryngology_workforce_shortage.html

How many of these are to be believed?

 

[JackADeli]

Just as an aside, I think it's amusing that every specialty society puts out these ridiculous press releases lamenting the impending severe shortage of their specialty. Seriously, go ahead and Google "Dermatology Shortage." and you get these gems:

www.ncbi.nlm.nih.gov/pubmed/14699364
www.msnbc.msn.com/id/17744996/.../health-skin_and_beauty/


Try Gastroenterology shortage:

www.nytimes.com/2009/01/09/.../09gastro.html

Psychiatry Shortage

www.news-medical.net/.../Psychiatrist-shortage-may-soon-reach-crisis-levels.aspx

and yes, ENT shortage

www.enttoday.org/.../Fill_the_Gap_Strategies_for_addressing_the_otolaryngology_workforce_shortage.html

How many of these are to be believed?

I am just not sure what your point or intent is....

Great, other fields project or have projected future shortages. They base this usually in large part on predicted increase in need. Or, more simply increased population/volume of disease. However, while I am not an expert. My read on CV/CT/Thoracic projected shortage is based on some real tangibles. Let us presume current population disease burden/volume goes unchanged:

1. It is published fact in every general surgery news rag I have seen that the numbers of surgery grads going into CV/CT fellowship has dropped. It has dropped to the point where there are more spots then applicants. As noted previously, I think it has been under 100 new first year trainees a year for some time now (have to look at match data). I don't believe the same is said of ENT, Derm, or etc....

2. Published work force data reports the average age of current practicing attendings is on the higher end. I haven't looked at it recently but they are not generally your spring chickens. I will let folks look that stuff up.

3. ABS published information shows the average number of anatomic lobectomies being "done" by graduating surgery residents is I believe less then 5. Many general surgery residencies no longer rotate on CV or they do a minimal exposure of <4wks on CV.

4. The vast majority of graduating surgery residents are citing life-style as important factors in job choice and this does equate to how much volume/work they are willing to do. If new grads, replacing retiring surgeons (i.e. #2) are not willing to put the hours and live in the hospital as previous generations, you don't need increased disease burden to have a shortage of physicians.

All of that is real even if you presume the population need for this type of healthcare does not increase. However, I do not see a flatline in disease burden with the marked number of "baby boomers", obesity, and impending screening CT scans.

 

[dienekes88]

Vein grafts aren't perfect. That's why The Lord gave us the LIMA and RIMA.

All of that is real even if you presume the population need for this type of healthcare does not increase. However, I do not see a flatline in disease burden with the marked number of "baby boomers", obesity, and impending screening CT scans.

Get real, JAD! With the elimination of smoking, downtrend in diabetes, and the development of cholesterol-free McDonald's/Burger King right around the corner, it's obvious that the United States as a whole is getting (or soon will be getting) healthier! In a few short years, "triple vessel disease" will be like neurosyphilis - halfway to being a historic curiosity. Beyond that, there'll be The Perfect Stent (TM), which will be the panacea for all 8 diabetics with left main disease in the entire country.

 

[dienekes88]

Perhaps coronary angioplasty and stenting is not all that durable, but point that out to a cardiologist (I have), and they will promptly produce data about the dismal long-term patency of vein grafts (and it's pretty convincing). And lets be honest, cardiology is in total control of this patient population. There isn't going to be a sudden epiphany that we should be doing more CABG.

All very good points.

Indeed. Cardiology definitely has the reins. As far as I know, the COURAGE trial has done nothing to change practice.

Even with poor long-term SVG patency at 10 years, it's still better than DES in terms of need for target lesion revascularization and myocardial infarction according to the SYNTAX trial and DES vs. CABG in Multivessel Coronary Disease (NEJM, 2008).

What if percutaneous valves turn out to be durable? What if the rates of lung cancer drop off dramatically as the rate of smoking drops. Hard to predict what will happen 15 years from now, but the safe bet is to presume a tight job market in the near future. Personally, I think the leadership in CT surgery should be aggressively closing down training programs so that the number of graduates is appropriate for the current job market--not promoting some theoretical future boom in cardiac surgery.

They might be decreasing the number of programs. ABTS has already passed a proposal that integrated CT be the only pathway to ABTS certification starting in 2020. According to the TSDA website, there are only 11 integrated programs in the country. At 6 years longs, unless a lot of programs open up in the next couple years, there will be a precipitous decline in the number of CT surgeons being trained.

http://www.ctsnet.org/sections/residents/residenteduc/article-.html

 

[maxheadroom]

I don't see how compensation for CTVS will go up. The CPT codes are not going to suddenly double the associated RVUs. Unless the hosptial starts kicking big dollars from "medical directorships", you still won't really make more.

 

[ESCrawford]

I am just not sure what your point or intent is....

Great, other fields project or have projected future shortages. They base this usually in large part on predicted increase in need. Or, more simply increased population/volume of disease.

I completely agree with your enumerated reasons why the need for CT surg might increase in the future, and obviously the supply-and-demand balance will likely work itself out one way or another.

But my point is that every single specialty in America (with the possible exception of plastics) puts out projections showing that there will be a future severe shortage. They can't all be right, and usually there is a political agenda driving the analysis. Irving Kron, whose work you referenced, has a very clear agenda--to increase recruitment for CT fellowships and maintain the competitiveness of his specialty. Nothing wrong with that, but a medical student trying to decide on a specialty can't simply take those predictions at face value.

My advice to the OP, who is presumably considering CT as a career, would be this: if you absolutely love CT then go for it, but be sure you have a good back-up plan if the job market turns out to be less robust than Irving Kron predicts.

 

[JackADeli]

I completely agree with your enumerated reasons why the need for CT surg might increase...

But my point is that every single specialty in America ...puts out projections showing that there will be a future severe shortage. They can't all be right...

I appreciate your point. Yes, they could be right, all of them. Why can't they? I see no evidence or reason why there can not be multiple specialties underserved in the future. A shortage in one specialty does not necessarily preclude shortages in other specialties. So, your comparison or collateral examples are really irrelavent to the specific question of possible future need for CV/CT/Thoracic or specifically the possible degree at which the associated diseased population is underserved.

Again to the issue of CV/CT/Thoracic, I would suggest a key difference is that these projections are based not only on projected population and disease volume growth but also the very real fact of dramatic decrease in trainees coupled with the aging population of current surgeons. The comparisons to Derm, ENT, GI, & Psych are a red herring. I suspect you know that.

...Irving Kron, a CT leader from the UVA, has been agressively promoting this concept of a looming severe shortage of CT physicians...

...Irving Kron, whose work you referenced...

I actually google searched that based on you providing the name😀

...Irving Kron ...has a very clear agenda--to increase recruitment for CT fellowships and maintain the competitiveness of his specialty. Nothing wrong with that, but...

Recruiting grads to enter additional [excess] fellowships followed by unemployment....I am not sure how promoting these concerns keeps CT/CV or any other specialty competitive???😕

...My advice to the OP, who is presumably considering CT as a career, would be this: if you absolutely love CT then go for it, but be sure you have a good back-up plan if the job market turns out to be less robust than Irving Kron predicts.

I guess by your distractionary examples, the same advice should go out to Derm, ENT, GI, Psych, etc....

Again, I am not really sure of your point. Derm, ENT, GI, Psych, CV/CT predict a shortage. Don't believe it, have a back up plan (aka career) just in case. Did you forget FM or do you believe that one. I am finding this somewhat silly and am awaiting an unrelated parable next.

I don't have the first idea what the future holds for CV/CT or Derm, ENT, GI, Psych. I am just not finding your warnings or comparisons very informative or of any cohesive logic. Kron's arguments provide more ~evidence the "sky is falling" then your reverse doom-gloom, ~find a second career warnings.

I don't see how compensation for CTVS will go up. The CPT codes are not going to suddenly double the associated RVUs. Unless the hosptial starts kicking big dollars from "medical directorships", you still won't really make more.

Hey Max, you may or may not know this one. But, how is Neurosurgery sometimes paid million plus? Is it directorship, on-call per-diem, or very high CPT/RVU pay? Most high paid neurosurgeons with million plus contracts I have known were not very high volume.

 

[maxheadroom]

.Hey Max, you may or may not know this one. But, how is Neurosurgery sometimes paid million plus? Is it directorship, on-call per-diem, or very high CPT/RVU pay? Most high paid neurosurgeons with million plus contracts I have known were not very high volume.

No direct experience, but I have a few guesses.

1. Spine pays really, really well. I mean, crazy cash.

2. Cranies probably pay fairly well, but I don't know that for a fact.

3. Maybe they get medical directorships? They might also bill "critical care time" for their patients in the Neuro ICU. Don't know that for a fact, though.

 

[maxheadroom]

And they led the way for on-call per diems.

 

[ESU_MD]

Isnt there a trend towards hospital employed nsurg? I can see the hospital paying big bucks and compensating for it with ancillary charges. How about private nsurg though?

As an aside to the original topic, the key to cv surg jobs nowadays is ability to do peripheral vascular

 

[JackADeli]

...As an aside to the original topic, the key to cv surg jobs nowadays is ability to do peripheral vascular

Does CT do more periph now? I know there is a trend for endovasc thoracic aorta.

I would think more and more are looking for fellowship/board cert vascular over CT folks that are then just trying to keep afloat with periph work. I mean, the CT residents don't do lots of periph vasc work in fellowship, so as far as periph work, it would seem like the hospital/etc is effectively hiring a general surgery trained vascular surgeon for the carotids and peripheral work....

 

[SurgApplicant10]

Get real, JAD! With the elimination of smoking, downtrend in diabetes, and the development of cholesterol-free McDonald's/Burger King right around the corner, it's obvious that the United States as a whole is getting (or soon will be getting) healthier! In a few short years, "triple vessel disease" will be like neurosyphilis - halfway to being a historic curiosity. Beyond that, there'll be The Perfect Stent (TM), which will be the panacea for all 8 diabetics with left main disease in the entire country.

just wait until you rotate through harlem. so many cases... sad, but true.

 

[jc7721]

Does CT do more periph now? I know there is a trend for endovasc thoracic aorta.

I would think more and more are looking for fellowship/board cert vascular over CT folks that are then just trying to keep afloat with periph work. I mean, the CT residents don't do lots of periph vasc work in fellowship, so as far as periph work, it would seem like the hospital/etc is effectively hiring a general surgery trained vascular surgeon for the carotids and peripheral work....

I agree with JAD, CT residents do not do a lot (or any) PVS. Some community CT attendings do PVS, based on their gen surg training of course, but academic CT folks rarely, if ever, do PVS. This does not include endo thoracic aortic work which is definately being done by lots of cardiac attendings.

The key to getting a job: marketability. If you plan to do gen thoracic you need to be comfortable with all things open, minimally invasive, EBUS, meds, esophagus, etc, and if you really want to stand out, airway work, navigational bronchs, transplant and robotic work. None of these necessarily require additional training, just the right training program. For cardiac, many residents have realized that the path to a more secure job is through additional fellowships: valves, aortic, transplant, endovascular. They market themselves as a valve/aorta/etc specialist. Bread and butter cardiac jobs are still hard to find, and they usually want you to do some gen thoracic. Of all the CT residents I've spoken with over the last few years, some of which have gone into private practice, none have mentioned the need to do PVS to get a job.

 

[ESU_MD]

Does CT do more periph now? I know there is a trend for endovasc thoracic aorta.

I would think more and more are looking for fellowship/board cert vascular over CT folks that are then just trying to keep afloat with periph work. I mean, the CT residents don't do lots of periph vasc work in fellowship, so as far as periph work, it would seem like the hospital/etc is effectively hiring a general surgery trained vascular surgeon for the carotids and peripheral work....

I agree with the fact that very few programs nowadays offer enough peripheral exposur to feel comfortable, however a few do exist. It is mostly from what i see a southern phenomanae of cardiac guys doing the vascular work, but rarely in academic settings. Not so much in the north.
Vascular is still a relatively new board, and alot of the older heart guys do the vascular and give the lungs and esophagus to the general surgeons. Of course this is gonna be changing as the grandaddies retire and cant get grads who can or want to do vasc!

I think the advantage of cardiac is that you become more comfortable with open procedures. One of my vascular friends now a staff still sweats on carotids and has barely done 10 open AAA in training. Disadvantage is that old time cv guys cant teach you endovasc. Best case is to have a new vascular partner in your group.. Teach him open and he teaches you endo

 

[ESU_MD]

I agree with JAD, CT residents do not do a lot (or any) PVS. Some community CT attendings do PVS, based on their gen surg training of course, but academic CT folks rarely, if ever, do PVS. This does not include endo thoracic aortic work which is definately being done by lots of cardiac attendings.

The key to getting a job: marketability. If you plan to do gen thoracic you need to be comfortable with all things open, minimally invasive, EBUS, meds, esophagus, etc, and if you


into private practice, none have mentioned the need to do PVS to get a job.

I can tell you that in my case, the ability to do vascular has directly got my resume to the top of the pile in a few jobs. A quick look at ctsnet will show alot of jobs where vascular is favored. I agree with the marketability thing, but right now the best skill to have is vascular. Infact, vascular skills may protect you from the dreaded general thoracic!

 

[JackADeli]

...the older heart guys do the vascular and give the lungs and esophagus to the general surgeons. Of course this is gonna be changing as the grandaddies retire and cant get grads who can...

I think this is true on the general surgery side as well. I read somewhere by the ABS that the average graduating general surgery resident has logged "doing" less then 5 anatomic lobectomies during training. With this limited background training and continued publications/reports of "better outcomes" when lobectomies done by board certified thoracic, I think general surgery will do less and less. It will also be impacted by things like "leap frog". It is going to be a numbers issue for both credentialing and over all practice. Similar to whipples to University surge-onc, numbers of esphagectomy and lobectomies will progressively steer away from general surgery towards thoracic.

 

[droliver]

Spine pays really, really well. I mean, crazy cash.

Spine procedures are actually about to get crushed with new RVU assignments according to everyone I've talked to. There will be a big shake out with the "Back Surgery Inc." business model as revenues go down and 3rd party payors and Medicare strictly limit indications (see here)

 

[maxheadroom]

Spine procedures are actually about to get crushed with new RVU assignments according to everyone I've talked to. There will be a big shake out with the "Back Surgery Inc." business model as revenues go down and 3rd party payors and Medicare strictly limit indications (see here)

True, there was a talk at ASRM about the new assignments. Spine and Rads are about to get radically restructured. And that is a lesson for all of the idiots who say, "Hey, I don't like it, but it pays well so I'll do that."

 

[Guile]

I can tell you that in my case, the ability to do vascular has directly got my resume to the top of the pile in a few jobs. A quick look at ctsnet will show alot of jobs where vascular is favored. I agree with the marketability thing, but right now the best skill to have is vascular. Infact, vascular skills may protect you from the dreaded general thoracic!

Where did you learn vascular? Did you do it in fellowship or are you confident enough in your skills from general surgery residency to do it?

Also, "dreaded" general thoracic? I thought those jobs were competitive!

 

[ESU_MD]

Where did you learn vascular? Did you do it in fellowship or are you confident enough in your skills from general surgery residency to do it?

Also, "dreaded" general thoracic? I thought those jobs were competitive!

Did alot of vascular in gen surg training, but not enough to do it in practice. Then combined with vascular cases mixed in with cardiac, I think I have enough to be comfortable as well as get credentialed. Although, In places with established vascular surgeons, I am sure they would be able to block me since my services wouldnt be needed. Fortunately, vascular is always in short supply though, thus higher demand!

Personally, I dont care much for the dreaded general thoracic cases, but there is a niche developing for these surgeons. Most general thoracic training occurs in academic settings and tends to self-select those who want to be academic general thoracic surgeons.

 

[JackADeli]

The general surgery news magazine/throw away had nice little article on workforce age accross the surgical specialties. Check out page #17

http://www.facs.org/surgerynews/2011/sn0111.pdf