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future of cardiac surgery

Discussion in 'Surgery and Surgical Subspecialties' started by stimpworth, Sep 1, 2002.

  1. stimpworth

    stimpworth Junior Member
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    I am an MSIII and am looking into GS and subspecialties.

    Can anyone comment on the trends in heart surgery? I have been told that the future of the field is bleak, there are few procedures (bypass mostly). The compensation is not what it used to be, and newer less invasive proecedures are being employed. Can anyone comment whether it is still worth the eight years of residency?
    Also is there a possibility of artificial heart surgery becoming the "future" of this field and the reason to go into it now?
    :rolleyes:
     
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  3. mustang

    mustang Junior Member
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  4. embolicintent

    embolicintent Junior Member
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    Good articles, but andreas gruntzig did not invent angioplasty. He adapted the technique from the "father of interventional radiology" Charles Dotter who introduced it in 1963. Dotter used progressively larger catheters to dilate stenoses called transluminal angioplasty. Gruntzig developed balloon angioplasty. A significant improvement in the technique, but it was invented by a radiologist not a cardiologist or surgeon (as was percutaneous vascular access... swedish interventionalist Sven Seldinger). Moot point, but when I hear all of these physicians debating about who "stole" what from who it bothers me that they don't even know the history. Anyway, we must remember that we are all on the same team and the best procedure is the one that is best for the patient regardless of who gets paid for it. Do what you love and don't concern yourself with the future of the field because people that love what they do define the future of their field.
     
  5. droliver

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    The logical next step for CVS is the cath lab & incorporating endovascular techniques into their training. It would prob. neccessitate extending the training to 3 years & cause some ruffling of feathers with cardiology & some vascular IR's, but clearly the field must adapt or whither
     
  6. njbmd

    njbmd Guest
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    Hi there,
    There are fewer folks going into Cardiothoracic Surgery these days and the numbers will be declining for the same reasons that the numbers in General Surgery have declined. It's a long haul and the compensation at the end is not what it used to be for so many years of sacrifice to learn your craft. That being said, the numbers of folks needing CABGs is not declining, not to mention valve replacements and other acquired heart disease. So far, robotics hasn't gone beyond the folks who have one-vessel disease which seem to be in the minority. Minimally invasive procedures still have a fairly steep learning curve.

    As one of the authors of the articles correctly stated, vascular surgery is it's own specialty and is doing pretty well at present. With the number of smokers and diabetics continuing to rise, I don't see the vascular surgeons or the thoracic surgeons suddenly heading for the unemployment lines. At my program, the Thoracic-Cardiovascular Service continues to be the busiest and showing no signs of decreasing. Of course, the drugs of choice here in Charlottesville are tobacco and alcohol so business should be good here.

    Almost everything in medicine is cyclical and it is impossible to predict the future of any specialty. A few years back, anesthesia was written off as belonging to the CRNAs but anesthesiologists are in short supply and commanding excellent salaries.

    I would not try to use future demand or future technology as a means to select a specialty in any discipline as crystal balls in medicine have proven to be pretty inaccurate. If you love what you do, you are probably going to be good at it and good cardiothoracic surgeons are always in high demand. :cool:
     
  7. droliver

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    njbmd,

    I would submit it is precisely the lack of foresight into future technology & demand that brought CVS to the current state its in (these thoughts are echoed by the article cited) - namely, being "the bag-men for failures in the cath lab" (as one of my attendings described it once). By ignoring the potential of catheter directed procedures many years ago, many of these procedures are now the exclusive domain of cardiologist & some IR physicians. Witness how agressive vascular surgery how become with retooling the fellowship training programs for endovascular tecniques & the reclaiming of diagnostic a-grams. The urgency of their adaptation is a direct result of the lessons learned from CVS.

    There's going to be a dramatically decreased need for traditional CABG and the surgeons who perform them in our lifetime & even students can see the writing on the wall on this one.

    The same attention to the future also must be applied to the other surgical specialties. For instance, I start my Plastic Surgery fellowship in July. Now take breast reconstruction. I can look down the road & see the trend to more & more breast conservation therapies to treat breast CA & tell you with 100% certainty that there will be fewer breast reconstructions 20 years from now. Same thing for facial rejuvenation procedures- more & more ways to get good results from cutaneous treatments (lasers,peels,PDT,botox,etc..) will decrease the demand for traditional cosmetic procedures of the face and neccessitate tomorrrows successful surgeons to be fluent in many of these areas that are now not taught much. Others: Bariatric surgery is one pill away from being obsolete if the lawsuits don't kill it off first. Advanced laparoscopic skill will become neccesssary to practice general surgery (duh). Hepatic resection could become obsolete due to percutaneous & catheter directed therapy. Endoscopic techniques could replace surgical tx. of GERD, Etc....


    Failure to plan without an eye towards the future can make you obsolete. I think the comparison to the CRNA/Anesthesia issue is not the right analogy. That was more of a speculation on market forces rather than an adoption of new technology/techniques. You're right in that a lot of predictions re. medicine have been wrong in the past, but you don't want to be on the wrong side of the fence when some of the major trends as they develop. I think most thoracic surgeons would agree with that & that things would be different if they could do it all over again

    cheers
     
  8. task

    task Senior Member
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    Good thread.

    As someone who plans to pursue training in Cardiology, I have often cited the link above to demonstrate just how blurred the line between medicine and surgery has become.

    However, surgical treatment of heart disease is entering a new era. Sure, with the advent of drug eluting stents (more than intracoronary radiation) to be used in combination with antiplatelet agents, the advantage that CABG has over PCI from the standpoint of fewer revascularization procedures will probably fade away. However, there is plenty to keep the cutters busy:

    1. Left main disease (for the long term)
    2. 3v disease (for now)
    2.5 Disease not amenable to PCI -- not as common now, but still around.
    3. Valves -- percutaneous valve deployment is in its nascent stages but I think there will be significant growing pains for this procedure before it becomes close to a viable alternative (patient selection, type of valve, durability of the valve, anticoagulation, to name a few). Percutaneous valvuloplasty is by no means definitive therapy in the majority of cases either.

    And this is really big:
    4. LVAD -- Left Ventricular Assist Devices. Billed as bridge to transplant, these things are now in the running to be use as more than just bridges, but to actually be used in pts who otherwise can't be transplanted. I've actually seen and talked to a patient whose heart on ECHO looked like a functionless balloon. In one corner of the ECHO you can see the little whirring of the LVAD keeping the patient alive and relatively functional.

    These are just a few areas of CVS that I believe will keep the field vibrant for years to come and demand that competent and dedicated folks enter the field.
     
  9. droliver

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    Task,

    good points about some of the still vital areas for CVS. Fortunately for patients is that there has been a lot of progress on endovascular tx. of left main & valvular dz. Unfortunately for CVS as it stands now, there will be signif. less demand for their skills there just aren't that many VAD's to do to support large #'s of surgeons. These also tend to get clustered into large tertiary centers which does not bode well for long-term viability of the dozens of small cardiac programs scattered among metropolitan & rural areas (if they can't sustain enough volume for the cardiac surgeons, it will affect the Cardiologists too who won't be able to do some of these procedures @ smaller facilities without surgery backup).

    It's just so hard to envision how some of these new technologies will play out (for others its less so). What will the impact be of non-invasive coronary imaging (CT/MRI) be on the field and workforce requirements of cardiology per se & who will interpret the studies (radiology,cardiology,or surgery) is something to think about. Same thing with MRCP,capsule endoscopy, & CT-colon imaging as it relates to traditional GI & surgical endosocpy practices. Sometimes these changes are very rapidly introduced and accepted (say laparoscopic surgery, endovascular surgery, CT/MRI body imaging) while others tend to languish in R&D or never catch on for cost issues (robotic surgery for example)
     
  10. finnyel

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    I think surgery would be a great job - my advisor leads me to believe that balancing the hours is a matter of choosing family over cash. I'm 100% uninterested in leaving my daughter and husband for a hospital staff... even in residency. Do you have the option of demanding a 40-50 hr work week in a surgery residency? ... part time from what has otherwise been mentioned?
     
  11. PreMedDocMD

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    On the other hand, orthopedic surgery will always be in demand because people will always need surgery in those areas...right?
     
  12. Winged Scapula

    Winged Scapula Cougariffic!
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    While there are part-time residencies, they tend to be more commonly found in non surgical fields like FP and Peds. Some require that you "share" the position - ie, find someone else willing to do part-time at the same facility.

    Frankly, if you are uninterested in working more than 40-50 hrs per week, a surgery residency, even in the places without much trauma call or less hour intensive subspeciaties (ie, ENT, Urology), is not likely to be found unless things change drastically. Currently, the American College of Surgeons requires that you complete so many full time weeks per year, which would could not be counted if you were part-time.

    That said, you would be hard-pressed to find many residencies, in lots of fields, with so few hours per week. IM, Rads, Anesthesia, etc. all work more than 50 hrs per week during residency. The fewest hours are purported to be PM&R and Derm. Even these require a fair bit of reading outside of the hours in the hospital.
     
  13. Winged Scapula

    Winged Scapula Cougariffic!
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    You could make the case that people are always going to be breaking bones and needing joint replacements, although the techniques used may change over the years. I don't think droliver was advocating that any field of surgery is going to become obsolete in the near future, but that some procedures or techniques may.
     

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