General Thoracic Surgery

[ThorSv]

I've had a lot of experience with cardiac surgery over the past year or two, but less so on the thoracic side. Of the thoracic procedures I have seen, they have been enjoyable. A few questions to those in the know:

How common is it to practice only general thoracic, is that mostly done in academic settings? Is it usual for them to take cardiac call? ie: what can be the expected lifestyle of a thoracic surgeon who practices mostly or all thoracic (academic and non-academic)?

It seems from my experience that a lot of the esophageal stuff is often handled by Gen Surg, including intra-thoracic esophageal procedures and esophageal stenting, as well as all the fundoplications and hiatal hernia repairs. Is this common at most institutions/is this a trend that will continue? Do most general thoracic surgeons focus primarily on the lungs/cancer as their bread&butter cases? Has interventional pulmonology affected the thoracic surgeons scope?

Most CT programs and fellowships seem to have split CV/Thoracic tracks. While I know both are required to sit for the boards, how well does thoracic-track prepare one for cardiac surgery, and visa-versa?

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[idiot07]

Just finished a Thoracic track fellowship last year. To answer your questions:

1) In academics, it is the standard practice to do either general thoracic or cardiac surgery exclusively. With the rise of minimally invasive surgery in thoracic, and the increasing complexity of cardiac cases along with the introduction of wire skills, I think it would be very difficult to stay abreast of the state of the art in both fields. In the community, there's more of a mix with people doing both, but I think the general trend is for the practices to diverge there as well, particularly at larger community hospitals in cities. Smaller rural hospitals probably won't have enough volume to support a full time general thoracic surgeon, and it's a bit of a niche job, so you're going to be limited in general to mid sized cities ~50-,000-100,000) or larger if that's the kind of practice you want. There are still jobs particularly in smaller towns that re looking for surgeons to do cardiac, thoracic, and often some vascular surgery.

2) Your ability to do cardiac surgery after graduating from a thoracic track fellowship would be program dependent. Some have real cardiac experiences, other's not so much. I would have felt ok doing most very very straight forward cardiac operations, but anything more complicated forget about it. Technically cardiac surgery is much more difficult than thoracic, so I also really don't think it's appropriate for someone who doesn't do much cardiac surgery to take cardiac call and be put in a position where you're doing a dissection or an emergency cabg in the middle of the night. I think, it's much easier for a cardiac surgeon to dabble in thoracic surgery and do a perf'ed esophagus or decort or lobe as needed.

3) As you hit on, it is institution dependent on who handles a lot of the esophagus cases. I think the trend is for more and more of it to go to thoracic surgery, particularly the malignant or very complex redo redo benign stuff, but this varies. Your practice as a general thoracic surgeon will invariably involve lung cancer to a large degree, but depending on you want and the needs of your location people often do: anything involving the esophagus, airway surgery, chest wall surgery, thoracic outlet syndrome, hyperhidrosis, lung transplant, and ecmo.

4) Your lifestyle is consequently related to your practice, if you're primarily a surgical oncologist of the chest your almost never back at the hospital in the middle of the night or on the weekends, as there are very very few emergencies, perf'd goose or airway issues is about it, both are relatively uncommon. If you do a lot of transplant or get drafted to do ecmo, this can can really throw a wrench in things. Your pay will probably also be less than a cardiac surgeon, but you'll sleep at night and see your kids.

5) Interventional pulmonology-For the most part, I don't think think this has affected us. Anything IP does, ebus, enbs, bronchoscopic airway interventions, chest tubes, is in the scope of practice of a general thoracic surgeon. Additionally, most of what they do is diagnostic in nature, so it comes to us for definitive treatment. Finally, from what I understand IP doesn't bill particularly well, so there's not the same general drive to go into it as say interventional cardiology. Every place I've worked at IP and general thoracic surgery has had a good working relationship.

 

[ThorSv]

Just finished a Thoracic track fellowship last year. To answer your questions:

1) In academics, it is the standard practice to do either general thoracic or cardiac surgery exclusively. With the rise of minimally invasive surgery in thoracic, and the increasing complexity of cardiac cases along with the introduction of wire skills, I think it would be very difficult to stay abreast of the state of the art in both fields. In the community, there's more of a mix with people doing both, but I think the general trend is for the practices to diverge there as well, particularly at larger community hospitals in cities. Smaller rural hospitals probably won't have enough volume to support a full time general thoracic surgeon, and it's a bit of a niche job, so you're going to be limited in general to mid sized cities ~50-,000-100,000) or larger if that's the kind of practice you want. There are still jobs particularly in smaller towns that re looking for surgeons to do cardiac, thoracic, and often some vascular surgery.

2) Your ability to do cardiac surgery after graduating from a thoracic track fellowship would be program dependent. Some have real cardiac experiences, other's not so much. I would have felt ok doing most very very straight forward cardiac operations, but anything more complicated forget about it. Technically cardiac surgery is much more difficult than thoracic, so I also really don't think it's appropriate for someone who doesn't do much cardiac surgery to take cardiac call and be put in a position where you're doing a dissection or an emergency cabg in the middle of the night. I think, it's much easier for a cardiac surgeon to dabble in thoracic surgery and do a perf'ed esophagus or decort or lobe as needed.

3) As you hit on, it is institution dependent on who handles a lot of the esophagus cases. I think the trend is for more and more of it to go to thoracic surgery, particularly the malignant or very complex redo redo benign stuff, but this varies. Your practice as a general thoracic surgeon will invariably involve lung cancer to a large degree, but depending on you want and the needs of your location people often do: anything involving the esophagus, airway surgery, chest wall surgery, thoracic outlet syndrome, hyperhidrosis, lung transplant, and ecmo.

4) Your lifestyle is consequently related to your practice, if you're primarily a surgical oncologist of the chest your almost never back at the hospital in the middle of the night or on the weekends, as there are very very few emergencies, perf'd goose or airway issues is about it, both are relatively uncommon. If you do a lot of transplant or get drafted to do ecmo, this can can really throw a wrench in things. Your pay will probably also be less than a cardiac surgeon, but you'll sleep at night and see your kids.

5) Interventional pulmonology-For the most part, I don't think think this has affected us. Anything IP does, ebus, enbs, bronchoscopic airway interventions, chest tubes, is in the scope of practice of a general thoracic surgeon. Additionally, most of what they do is diagnostic in nature, so it comes to us for definitive treatment. Finally, from what I understand IP doesn't bill particularly well, so there's not the same general drive to go into it as say interventional cardiology. Every place I've worked at IP and general thoracic surgery has had a good working relationship.

This is great! Thanks for your input!