General Thoracic Surgery vs. EP vs. IP

[listenupnow]

MS3 here. I've been spending a ton of time (probably too much time) thinking about specialty and essentially have come down to choosing between IM (cardiology-EP, or pulm/cc) vs. Surgery (general thoracic). My priority is finding a specialty that has curative outcomes & with pathology of the heart and lungs.

I definitely loved the work of surgery/being in the OR tons more than I ever enjoyed my rotation on medicine. However, when I got home from my GS days I was always so exhausted (physically destroyed) -- coming back from medicine was a little more physically tolerable (though everyday was a mental blur that felt like nothing was accomplished). Don't know if I could function as well as the surgeons can with minimal sleep. For me, going into medicine would really be my fallback if I realized I couldn't handle enduring a surgical lifestyle for the rest of my life. About me:

• MS3 from US school in the northeast, competitive applicant in both fields
  
  
• Like treating acute, life-threatening issues, want to be able to "fix" the problem and not manage
  
  
• Enjoy understanding physio/pathophysio of disease, explaining things to patients/a moderate amount of patient interaction, don't care much for long-term continuity
  
  
• Like hands-on approach; however, I'm not totally enthralled by the interventional approach (visualizing the anatomy in an open or VATS procedure and manipulating it is so much more gratifying than seeing fluoroscope images and wearing lead/behind the glass. Additonally IP procedures are mostly diagnostic or palliative at this time)
  
  
• Disliked rounding on medicine, but anticipate it going a bit faster during residency (?) when you are in responsible for half of the team's patients and not just responding to attending questions
  
  
• Found it hard to really tell how I'd feel doing the actual surgery since we just retract/cut sutures/hold cameras as students

I am not considering any other residencies asides from IM and GS for reasons above (no EM, anesthesia, DR/IR, OBGYN, surgical subspecialties). I prefer to have more autonomy with all of my patients and would like to complete the work-up/treatment for the patient (I know the ED does end up treating a lot of things other specialties don't end up seeing, but I prefer being an expert at something). Don't want to deal with a lot of things that rolls through the ED as well. I'd be frustrated doing anesthesia since I'd prefer to be on the other side. I don't find the pathology of ortho/ENT/Uro/ophtho as interesting.

Another critical point is that I dislike a decent amount of abdominal GS pathology. Not a huge fan of bowel and poop. Sounds dangerous for me to be considering GS if at the end decide I can't continue forwards with CTS to pursue gen thoracic. If I decide on surgery, will apply to thoracic track i6s, but doubt I'd make the cut given my lack of pubs/research.

Basically I like surgery more, but don't know if I can survive GS->CTS and the attrition rate scares me. Life as an attending is still wild and getting late-night callbacks may frustrate me down the line. I think I could tolerate a medicine residency + fellowship (though be less satisfied with my work) and if I become completely jaded about medicine in general, at least my work-life balance will be more controllable (e.g falling back on outpatient cards/pulm, which will be 'just a job' for me). I guess the ultimate decision is job satisfaction vs. having time away from work, which I don't really have much insight about this point in my life. I've read many great comments on this forum that range from "30 years from now you'll wish you had more time with your family" to "I'd rather do what I love for 70+ hrs a week than round and write notes for 40" though I can't tell which side fits more with me. Thoughts or advice?

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[yoyoni]

This is a hella good question, I hope someone on here is able to give you some good advice

 

[marstonne]

A few thoughts, all of these are anecdotes picked up from this site and talking to surgeons/residents:

1. Anecdotes I've come across suggest the traditional GS + CT fellowship tend to produce more technically adept thoracic surgeons due to the extensive laparoscopic training in GS residency and experience with operating in the foregut and around the diaphragm. Not to say that being a great thoracic surgeon from an I6 program is out of the question, and honestly after a few years of practice it would likely be a wash.

2. CT fellowship has become more competitive but should still be well within your reach as a hard working resident. It isn't surgical oncology or pediatric surgery competitive.

3. General thoracic seems to be a more niche/academic specialty from what I can tell. In the community, most CT folks are doing cardiac + thoracic from what I can tell. Something to think about if being a thoracic surgeon is your goal.

4. You are correct that EP and IP are not "curing" too many folks at this time. Both do great things, but they definitely seem to work more with long-term, chronic illnesses (especially EP).

5. EP is a long path (3 + 3 + 1/2, some programs let you enfold your first year of EP fellowship). Cardiologists are also super busy. I worked as an ED scribe for 2 years before med school, and can count on one had the number of shifts where we didn't consult cards at least once. We usually consulted them multiple times. And in the community, EP and interventional folks are taking general cardiology call as well as EP/IC call. Outpatient general cardiologists are still taking inpatient and ED call in addition to their office schedule. It was my impression that they were often slightly busier than the surgeons in the two hospitals I worked in.

6. Cardiologists and pulm/CC folks are going to follow patients for quite a while. Cardiology is essentially primary care for many patients.

Sounds like you enjoy surgery but fear the lifestyle. I definitely understand and empathize. I'm applying to GS, and am head over heels excited for it, but the demands seem daunting to me as well. It's a tough road that requires sacrifices. However many surgeons I've talked to have told me that while this is true, you can shape your practice as you like and still accomplish things outside of medicine. If you want to be a good spouse/parent/friend/marathon runner/etc as well as a good surgeon, you can, it will just take work and organization. Talk to some surgeon's and residents who's judgment you trust, as well as some cardiologists and pulm/CC folks. No real bad decision here, all of those are excellent specialties that will significantly impact patient's lives and give you a lot of satisfaction I feel. Hope this helps, good luck.

 

[Levo]

• Like treating acute, life-threatening issues, want to be able to "fix" the problem and not manage

Much of what you do in the medical ICU is managing acute complications of chronic illness. For instance, you could get a medical ICU patient with metastatic cancer who gets a massive PE, a cirrhotic with SBP, a COPD-er who was intubated for a bad exacerbation, or a non-compliant diabetic coming in for DKA. The event that puts someone in a medical ICU is usually acute and curable, but after you pull them through whatever the event is, the patient usually doesn't become a normal healthy person, they go back to being a chronically ill patient with a potentially life-limiting condition. Previously perfectly healthy people do end up in a medical ICU sometimes, but there's definitely fewer of them. It's very important to come to terms with that fact before considering a career in IM-based critical care, and understand that it would mean for you to be able to "fix the problem."