Future of Surgical Subspecialties

[DO_Surgeon]

I am beginning my general surgery residency in July and have always thought that I wanted to go into cardiothoracic surgery, but after reading and hearing how it is slowly becoming a dying field with few jobs I am having second thoughts. So my question is what other areas of surgery have the brightest future in terms of jobs, pay, not being overtaken by a medical subspecialty, etc? I know this topic has been discussed several times and yes, I have done a search before posting but I was wondering if anyone has any new thoughts on CT surgery following the recent NEJM article?

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[Celiac Plexus]

I am beginning my general surgery residency in July and have always thought that I wanted to go into cardiothoracic surgery, but after reading and hearing how it is slowly becoming a dying field with few jobs I am having second thoughts. So my question is what other areas of surgery have the brightest future in terms of jobs, pay, not being overtaken by a medical subspecialty, etc? I know this topic has been discussed several times and yes, I have done a search before posting but I was wondering if anyone has any new thoughts on CT surgery following the recent NEJM article?

no one really knows what the future holds for any surgical field... the trend seems to always be people looking for/ developing alternatives to operating. ct surgery has lost ground to cath based treatments, which are done by other specialists. there is also a relative oversupply of new ct surgeons, as there are currently too many ct training programs. many newly minted ct surgeons have great difficulty securing a job after graduation. i have even heard of guys finishing ct fellowship, only to apply for another fellowship in a different field.

the future is anyone's guess. things are always changing, and new studies/technologies may come out that will change the ct landscape. but the trend over the last decade or so, has been unfavorable for ct surgeons. that said, if you are dead set on ct, then do your best to secure training at a top, name program that has a rep for letting the fellows actually do operations, and has a solid track record for placing its graduates in good jobs.

as far as other fields... again it's hard to say what the future holds. some general thoughts... the smaller fields will have more leverage from a supply v demand standpoint. fields driven by innovation, and new technology/studies have the best chances of adapting in a constantly changing medical environment.

unfortunately every surgical specialty that depends on insurance and/or medicare reimbursements are at risk for flat or declining reimbursements now and in the future. in our us model, even the smaller fields supply v demand leverage is negated if there is a heavy dependance on medicare, or insurance for reimbursement.

 

[Dire Straits]

So my question is what other areas of surgery have the brightest future in terms of jobs, pay, not being overtaken by a medical subspecialty, etc?

PLASTIC SURGERY

although "cosmetic" surgeons, dermatologists, and ENTs have been known to encroach on their turf. but even so it's still one of the best subspecialties around (no wonder it's so popular). and regarding ct surgery, the advice i've gotten from every single surgeon has been to stay away because it is going to get even worse in the future.

 

[DO_Surgeon]

What about vascular surgery? I know that IR was taking a run at this specialty a couple years ago and it seems that the surgeons held their ground. How common is it for a CT trained surgeon to perform peripheral vascular procedures? I have rotated at a few places where the CT surgeons were performing CEA's, Fem-Pops, AAA, etc. Is it possible to go through CT fellowship and market yourself as Chest and peripheral vascular surgeon? I would think that would open a lot more doors than sticking strictly with chest cases.

 

[UTSouthwestern]

What about vascular surgery? I know that IR was taking a run at this specialty a couple years ago and it seems that the surgeons held their ground. How common is it for a CT trained surgeon to perform peripheral vascular procedures? I have rotated at a few places where the CT surgeons were performing CEA's, Fem-Pops, AAA, etc. Is it possible to go through CT fellowship and market yourself as Chest and peripheral vascular surgeon? I would think that would open a lot more doors than sticking strictly with chest cases.

Correct me if I'm mistaken, but isn't there a special CT/vascular fellowship for those who finish CT and want to spend another year on vascular?

Also, while the impact of IR is now being felt on the major vascular territory, especially with regards to stenting of TAA's and AAA's, some preliminary outcomes from these groups have shown that the stents are migrating. If something more definitive isn't created by the IR guys, vascular will continue to be a surgical stronghold.

 

[Docgeorge]

Correct me if I'm mistaken, but isn't there a special CT/vascular fellowship for those who finish CT and want to spend another year on vascular?

Also, while the impact of IR is now being felt on the major vascular territory, especially with regards to stenting of TAA's and AAA's, some preliminary outcomes from these groups have shown that the stents are migrating. If something more definitive isn't created by the IR guys, vascular will continue to be a surgical stronghold.

The only CTV fellowships that I know of where you get boarded in CT and a certificate in vascular is at Carolinas. It's a 3 yr progarm though. Any body know of anyothers?

Just out of curriosity can the CTV guys (assuming they had a very good relationship with reffering non-intervential cardiologists) stent coranary arteries? It seems like these guys would be a great position to do that.

 

[doc05]

Just out of curriosity can the CTV guys (assuming they had a very good relationship with reffering non-intervential cardiologists) stent coranary arteries? It seems like these guys would be a great position to do that.

no they wouldn't. the cardiologist will just refer to an interventional cardiologist, especially if they are partners in the same private practice.

and why would anyone who's gone through 10 years of surgical training want to put in stents?

 

[navysurgeon]

a lot of vascular programs are requiring their trainees to do a stint with the IR guys...i think vascuakr has done an excellent job at retaining its turf...unfortunately, the specialty is plagued with low-income, medicare types...so reimbursement will always be an issue...

i think plastics is the last bastion of fee-for-service surgery..

TNS

 

[droliver]

i think plastics is the last bastion of fee-for-service surgery..

Actually there is a lot of fee for service with the varicose vein work and to a lesser degree, the bariatric field as more insurers quit paying for it. I also know there are some breast oncologic surgeons, hernia specialists, Reconstructive Plastic Surgeons, and Gynecologists who have managed to carve out narrow niches & do no insurance practices.

 

[pedsid]

Our vascular sugeons also stint ...

 

[JudoKing01]

I think he meant do a stint, as in spend some time with the IR guys, lol.

I don't know how many endovascular AAAs the IR guys are doing, but - and no offense to them - I would sure as hell not have anything other than a vascular surgeon do one of them on me. I wouldn't want to be sitting on the table downstairs waiting for a surgeon to agree to bring me up and cut me open.

 

[hans19]

I don't know how many endovascular AAAs the IR guys are doing, but - and no offense to them - I would sure as hell not have anything other than a vascular surgeon do one of them on me. I wouldn't want to be sitting on the table downstairs waiting for a surgeon to agree to bring me up and cut me open.

No offense to you, but as an MS1, I don't think you know what the hell your talking about . Coronary angiography, peripheral arteriography, angioplasty and stenting (including AAAs) are procedures pioneered and developed by vascular interventional radiologists. These must be pretty effective procedures because vascular surgeons have recently incorporated them into their fellowship training. You will see that in private practice, both vascular surgeons AND interventionalists are very proficient in the endovascular treatment of AAA's. Hell, some interventional cardiologists do them too.

 

[JudoKing01]

Actually, I've been a scrub nurse in the or for a little while before I went to med school, and I've helped on plenty of those, including ones that went bad. All I'm saying is if they go bad, you don't want to be waiting for the surgeon on stand-by.

But, just MHO.

 

[The_Id]

PLASTIC SURGERY

although "cosmetic" surgeons, dermatologists, and ENTs have been known to encroach on their turf. but even so it's still one of the best subspecialties around (no wonder it's so popular). and regarding ct surgery, the advice i've gotten from every single surgeon has been to stay away because it is going to get even worse in the future.

Given the recent consumer "plastic surgery fever" and the resulting increased desire for surgeons and other specialties to get in on the action, the INTENSE competition should not be discounted. ENT and oral surgeons are doing facial plastics, ophthalmologists are doing oculoplastics, dermatologists are doing lipo/facelifts/injections, general surgeons doing an assortment of things, vascular surgeons/I.R. are doing varicose vein treatments, and even primary care and any other specialty are doing laser rx, botox, etc. Whereas PRS will always have work to do in reconstructive, competition for cosmetic procedures will be cutthroat, which results in decreasing compensation for cosmetic procedures. So, although PRS is full of interesting surgeries, lower stress, and relatively better lifestyle, I wouldn't necessarily count on raking in the dough. People I know who are entering practice aren't finding it so easy to find a job, especially in desirable cities. I also know some people trying to start practices, and not doing very well due to the competition. Of course, you won't starve, but it is becoming less and less of a lucrative surgical specialty.

 

[johnny_blaze]

I’ve attended MDT meetings with vascular surgeons, IR, and vascular lab technicians and I have experience in the vascular field. From what I’ve seen, most cases of PVD are handled in a very diplomatic way; there is no “turf war”. The best care for the patients is always the primary issue… not if “I do the work I get the money” attitude that many people think. Angioplasty and stenting is not 100% reliable, is not commonly used in a variety of situations, and there are a lot of factors that can effect its outcomes. Radiologists are not taking over; they are just lending a helping hand.

the specialty is plagued with low-income

Is this true? I always thought vascular surgery was a fairly high paying field.

 

[Celiac Plexus]

I’ve attended MDT meetings with vascular surgeons, IR, and vascular lab technicians and I have experience in the vascular field. From what I’ve seen, most cases of PVD are handled in a very diplomatic way; there is no “turf war”. The best care for the patients is always the primary issue… not if “I do the work I get the money” attitude that many people think. Angioplasty and stenting is not 100% reliable, is not commonly used in a variety of situations, and there are a lot of factors that can effect its outcomes. Radiologists are not taking over; they are just lending a helping hand.



Is this true? I always thought vascular surgery was a fairly high paying field.

it is but there are a lot of old medicaid types with diabetes who need fem-pops, amputations, foot care, etc... if it weren't for this sector, the compensation would be higher than it is... still it's one of the higher paying specialties.

 

[pedsid]

The vascular surgeons I know do VERY well for themselves.

 

[traumasurgeon]

Vascular surgeons don't rely on IR for referrals. That is the main difference between them and the CT surgeon who depend on cardiologists for referrals. So if vascular surgeon starts doing endovascular stents he gets fatter without reprisal. A CT surgeon who does stents will soon find his referral base dried up. As mentioned above, all specialties are getting tougher including plastic surgery but if you are still early and not absolutely set on one path is look at all the subspecialites for yourself. Look at the lifestyle, the variety of cases, and imagine what you want to be doing every day for t rest of your life 15 years from now when you have a family and kids. Heart surgery is awesome, but it does get old, believe me. It also takes an awesome amount of dedication to your patient at the expense of your personal life. But if that is what you want to do, and your willing to make those sacrifices go ahead. Look at plastic surgery. Lots of variety of case and options, looks like it has a great future now. But what if 20 years from now there is one on every corner and your making 10 bucks a case? Will you be happy? Remember not very long ago anesthesia was looking bad and any FMG could get a residency. Now it one of the most lucrative specialities. I think that the best thing about heart surgery is saying that you are a heart surgeon. I got over it but if thats what you really like and you know what youre getting into, go for it. You'll get a job, whatever you choose as long as your flexible (like you might have to work in Iowa), and if you like it you will be good at it and be happy at the same time.

 

[Dire Straits]

I think that the best thing about heart surgery is saying that you are a heart surgeon. I got over it but if thats what you really like and you know what youre getting into, go for it. You'll get a job, whatever you choose as long as your flexible (like you might have to work in Iowa), and if you like it you will be good at it and be happy at the same time.

i wish that were true traumasurgeon. the stories i've heard as far as CT surgeons goes is that many of them are unable to find work currently no matter how flexible they are in terms of location. there are just not enough jobs to go around for new graduates every year in either the private or academic settings. it seems the thoracic guys have it a bit easier than the cardiac guys so now i'm hearing more are doing additional training in thoracic surgery. i've also been told that the viable solution is to close down some of the CT training programs around the country (so you'd have less graduates competing for jobs). but i've heard this is unlikely because med centers will be reluctant to just close shop on their CT training programs...they need the fellows to be in the trenches. it will be interesting to see how things play out in the next few years. for example there was talk about starting integrated 6 yr gsurg+CT surg residencies but that plan has all but been abandoned from what i've heard.

 

[DO_Surgeon]

"if you are dead set on ct, then do your best to secure training at a top, name program that has a rep for letting the fellows actually do operations, and has a solid track record for placing its graduates in good jobs."

What are some of the top name programs? Keep in mind that I am a DO going into an AOA general surgery residency. The only 2 CT fellowships are Deborah Heart and Lung Center in NJ and a new one opening in Ft. Worth Texas at Plaza Medical Center. So I doubt that qualifies as a top name place with a good record at placing fellows into jobs, although one graduate from Deborah is on faculty at U of Virginia. There has been discussion on this board about becoming BC if you complete an ACGME fellowship after an AOA residency, and the response I got from the ACOS was that you could but you have to petition the AOA for approval of your fellowship training. Does anyone know of any "DO friendly" CT fellowships? I have heard in the years past that the Cleveland Clinic was traning quite a number of DOs. Thanks!

 

[CardiacSurgeon]

i wish that were true traumasurgeon. the stories i've heard as far as CT surgeons goes is that many of them are unable to find work currently no matter how flexible they are in terms of location. there are just not enough jobs to go around for new graduates every year in either the private or academic settings. it seems the thoracic guys have it a bit easier than the cardiac guys so now i'm hearing more are doing additional training in thoracic surgery. i've also been told that the viable solution is to close down some of the CT training programs around the country (so you'd have less graduates competing for jobs). but i've heard this is unlikely because med centers will be reluctant to just close shop on their CT training programs...they need the fellows to be in the trenches. it will be interesting to see how things play out in the next few years. for example there was talk about starting integrated 6 yr gsurg+CT surg residencies but that plan has all but been abandoned from what i've heard.

Is that true about anethesia? Has it gone competitive too? Last time i checked one could match top programms in anesthesia with ease.

I dont believe in the solution of 2+4 or 3+3 for CT. I'm more into closing programs. One can always open positions in busy programs than try to "educate" cts fellows in a center that does 100 cases per year. And as for the argue that fellows are needed in programs, well excuse me but if programs need CT fellows(=GS board certified, highly educated people) to carry charts up and down then "houston , we have a problem!". CT is a extremely skill demanding speciality. Now that "easy" CABG's are hard to find, training less is not the answer. I agree that 2 years after GS cant teach you to operate but to eliminate GS , i think, its a mistake. And remember, its not years 1+2+3 in GS that one needs for CTS, its more like years 4+5+6.

On the other hand i dont think that CS (i leave the T out on purpose) is anymore a "sub"speciality of GS. Nowadays CS graduates should be trained more as cardiologists that operate, than general surgeons that do heart operations. I dont know if you get the difference , but believe me there is a lot.

As for the jobs, i agree there is a problem right now but i most strongly believe that better things are yet to come (heart failure surgery pops up in my mind as No 1)

 

[McDizzy]

What about vascular surgery? I know that IR was taking a run at this specialty a couple years ago and it seems that the surgeons held their ground. How common is it for a CT trained surgeon to perform peripheral vascular procedures? I have rotated at a few places where the CT surgeons were performing CEA's, Fem-Pops, AAA, etc. Is it possible to go through CT fellowship and market yourself as Chest and peripheral vascular surgeon? I would think that would open a lot more doors than sticking strictly with chest cases.

Vascular Surgeons (especially if trained in endovascular) are highly sought after these days. The American Board of Surgery only has ~2000 board certified vascular surgeons in the country. I just finished my Vascular Surgery Fellowship. I had 3-5 job offers cross my desk every week in all types of practices in all parts of the country.

CT surgeons who practice vascular are becoming a rare breed. There are only one or two programs which train you in both and they lack endovascular training.

I suspect that CT surgery will survive, but will evolve just like Vascular. The change will come when CT surgeons start doing their own cardiac caths. In addition, there are percutaneous aortic valves headed for the market. These devices may spark the change in CT surg.

 

[McDizzy]

Is that true about anethesia? Has it gone competitive too? Last time i checked one could match top programms in anesthesia with ease.

I dont believe in the solution of 2+4 or 3+3 for CT. I'm more into closing programs. One can always open positions in busy programs than try to "educate" cts fellows in a center that does 100 cases per year. And as for the argue that fellows are needed in programs, well excuse me but if programs need CT fellows(=GS board certified, highly educated people) to carry charts up and down then "houston , we have a problem!". CT is a extremely skill demanding speciality. Now that "easy" CABG's are hard to find, training less is not the answer. I agree that 2 years after GS cant teach you to operate but to eliminate GS , i think, its a mistake. And remember, its not years 1+2+3 in GS that one needs for CTS, its more like years 4+5+6.

On the other hand i dont think that CS (i leave the T out on purpose) is anymore a "sub"speciality of GS. Nowadays CS graduates should be trained more as cardiologists that operate, than general surgeons that do heart operations. I dont know if you get the difference , but believe me there is a lot.

As for the jobs, i agree there is a problem right now but i most strongly believe that better things are yet to come (heart failure surgery pops up in my mind as No 1)

I too agree that shortening the training program for CT surgeons is not the right answer. The difference between a PGY3 and a PGY 6 is astronomical in patient care, maturity and operative skill.

 

[McDizzy]

i wish that were true traumasurgeon. the stories i've heard as far as CT surgeons goes is that many of them are unable to find work currently no matter how flexible they are in terms of location. there are just not enough jobs to go around for new graduates every year in either the private or academic settings. it seems the thoracic guys have it a bit easier than the cardiac guys so now i'm hearing more are doing additional training in thoracic surgery. i've also been told that the viable solution is to close down some of the CT training programs around the country (so you'd have less graduates competing for jobs). but i've heard this is unlikely because med centers will be reluctant to just close shop on their CT training programs...they need the fellows to be in the trenches. it will be interesting to see how things play out in the next few years. for example there was talk about starting integrated 6 yr gsurg+CT surg residencies but that plan has all but been abandoned from what i've heard.

I was just looking at a physican job search website. They currently have 9 CT surg jobs available and 54 Vascular surgery jobs listed.

There are 138 CT surg fellowship positions. 121 filled in the match.

There are 117 Vascular fellowship positions. 93 filled in the match.

Given these numbers, there will most likely be CT surgeons looking for jobs. However, the CT surgeons that I know are doing very well. Some of their houses would make a nice episode of MTV cribs.

 

[Dire Straits]

However, the CT surgeons that I know are doing very well. Some of their houses would make a nice episode of MTV cribs.

i can only presume these are the surgeons who were in the game before the current environment in ct surgery. nowadays i hear offers for recent ct grads are in mid 100K range. so there are new general surgery grads making more. this is a far cry from how it used to be. one old timer ct surgeon told me how he and a few of the guys he did ct training with got offers in the 500K range fresh out of fellowship.

 

[JAMMAN]

i can only presume these are the surgeons who were in the game before the current environment in ct surgery. nowadays i hear offers for recent ct grads are in mid 100K range. so there are new general surgery grads making more. this is a far cry from how it used to be. one old timer ct surgeon told me how he and a few of the guys he did ct training with got offers in the 500K range fresh out of fellowship.

Yep...these are surgeons who have been practicing at least 5+ years. If you have a job, then you are set. If you need one, forget it.