Is CT surgery dying out/worth going into?

[Med16484]

I’m a medical student and have always been interested in both the cardiovascular system and surgery. Hence, I’ve been leaning towards a career in CT surgery and soon beginning research in it to build on my resume. A few people have told me I shouldn’t go into CT because it’s a dying speciality and it’s hard to find jobs (is this true?). I know it’s a competitive speciality, but what is the general consensus on CT surgery’s potential in the future?

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[LucidSplash]

Short answer: It isn’t.

Medium answer: Previously asked and answered in this forum.

Long answer: Why is CT Surgery considered dying even though it has the thoracic (lung) domain?

 

[deleted50541]

We've discussed this before in other threads, but no CT surgery is not a dying field.

Transcatheter therapies likes stents, valves, and ablations have definitely been a game changer in cardiac surgery. But they can't fix everything and there's plenty of work to be had. Many CT surgeons are on the older side (last average age I saw was 55) and retirements are happening everywhere. Anecdotally, I've seen four CT surgeons retire in my early career so far.

 

[cardsperson]

Not a surgeon, but cards fellow strongly considering IC here so I think I have something to contribute. People have been predicting the death of CT surgery since the early 2000s and it hasn't gone anywhere yet. Yes, overall CABG volume has gone down (and no, this is not primarily because of stents, it's mostly because medical therapy has gotten so good) - but as long as people have left main or three vessel disease, there will always be a need for it. The other indications for cardiac surgery are still going strong and in some cases expanding (VAD being a big one). TAVR has increased the overall size of the valve pie given the valve-in-valve procedures and patients who were considered inoperable getting TAVRs (although at some point in the future, once CTS is no longer needed to be on standby for these cases, their slice of the pie will decrease considerably). Plus, as long as there's IVDU, there are valves that need to be surgically replaced.

If you like surgery and want to be in a unique field where you routinely regularly stop a patient's heart then restart it (or give them a brand new one), then go for it. Plus, as other posters here have pointed out, prior to the integrated pathway, CT surgery fellowships had a lot of difficulty finding candidates, so there are basically a few years in the 2000s where the number of surgeons trained was well below how many would actually be needed to replace all the people who are retiring in the next decade, so between this and the boomers hitting their peak MI and AS years, there won't be any shortage of jobs even if the overall number of indications for surgery drops.

 

[CTFellowMD]

Not dying. General thoracic is booming more than ever. Cardiac has certainly changed and cases tend to be more complex, but plenty of cases and job opportunities.

 

[SpliceOfLife]

Stents were invented in the 1970s and began being used throughout 80s and 90s. In short, there is an entire generation of cardiac surgeons who have come and gone and the field is still here. In fact, many of the recent trials comparing CABG vs stents have actually continued to prove the enduring benefits of CABG. Salaries have gone up and more job opportunities are available. Additionally there have been recent innovations in both technology and education and surgeons are getting wiser to the benefits of interventional/transcutaneous approaches and so we are learning these sooner and in more depth.

In general you should never really take the advice of people who just go around saying "that field is dying." Nay-sayers said the same thing about vascular surgery and radiology and these fields have also reinvented themselves.

 

[oldman]

I know so many who have been going into CT surgery fellowship recently. It's become a hot fellowship to go after. Much different than about 15 years ago when I was starting training.

 

[deleted50541]

I know so many who have been going into CT surgery fellowship recently. It's become a hot fellowship to go after. Much different than about 15 years ago when I was starting training.

Yeah, it's crazy how much this has changed in the last decade. When I applied for the 2015 match, it was the first year nearly every spot filled in a very long time. I had no idea going in that it was getting so competitive and was surprised by the number of people who didn't match.

There didn't seem to be a lot of interest in my residency for CTS, as I was the first one to do it in over 5 years. But since then, there's been at least 3 residents from my program who matched into CTS and I helped guide them as best I could through the process.

 

[droliver]

A few people have told me I shouldn’t go into CT because it’s a dying specialty and it’s hard to find jobs (is this true?). I know it’s a competitive specialty, but what is the general consensus on CT surgery’s potential in the future?

It's more of a mixed bag I think, talking to colleagues at the 5 hospitals I work at in a medium metro area (> 1.2M popl) .

Cardiac surgery as it once was, where they were the highly compensated rock stars of most departments of surgery, isn't dying.... it died 25 years ago. There are an awful lot of discouraged cardiac surgeons in mid-late career, as the field is kind of unstable to their POV. They're working harder, often in smaller groups (with more call as a result), on worse operative candidates, for much (MUCH) less money then what was commonly earned a generation ago. The volumes of operative cases has shrunk to where the ability to support larger groups is challenged at many community CV programs. I've seen several private practice groups over the last 15 years I've been around that were once 4-5 surgeon practices contract to groups of 1-2 and had to become employees of hospitals to stabilize their situation

 

[Dave1980]

I’m a medical student and have always been interested in both the cardiovascular system and surgery. Hence, I’ve been leaning towards a career in CT surgery and soon beginning research in it to build on my resume. A few people have told me I shouldn’t go into CT because it’s a dying speciality and it’s hard to find jobs (is this true?). I know it’s a competitive speciality, but what is the general consensus on CT surgery’s potential in the future?

not at all. my friend graduated recently and had his choice of amazing jobs all of which paid over 650 starting and partners in the 7 figures

 

[Medstart108]

It's all cyclical, I wouldn't necessarily job into any one thing, but as a field CT is not dying. CABG is here to stay, surgeons will lose some of the valve work but there will be a gradual shift towards surgeons obtaining wire skills.

 

[plukfelder2017]

I am primarily posting this for OP and any other folks interested in CT in the future. It took me a while to truly understand what people meant when they said that CT wasn't going away.

After spending 6 months as a med student on the service, here are the subsectors of CT where my mentors are optimistic:
1. HF and Transplantation (VADs, Pumps-Impella, solid-organ etc)
2. Peds (particularly with regards to hybrid pediatric cardiac surgery and fetal cardiac surgery)
3. Complex Redo Coronary Surgery (No chipshot CABGs anymore, expect 3 vessels or 3-4 vessels and a valve at minimum)
4. Complex Structural Work (valve in valve in valve explantation. the cardiologists, much like their role in peripheral intervention, are undoubtedly going to need help and you will be rectifying those issues)
5. Robotic Cardiac Surgery
6. Administration (there's no better CEO/hospital leader than a CT surgeon. Work ethic is unparalleled)

Pessimistic on:
1. Aortic Surgery (Zone 0 devices are in play and vascular has captured the arch, they will have difficulty attacking the proximal ascending aorta where the coronary ostia lie but there are cases of Endo-Bentall reported out of Brazil. Zone 2 single branch devices are in clinical trials. Expect open cervical debranching and cases like great vessel bypass to be captured by vascular. Several integrated programs have months on cardiac surgery where they are doing midline sterns to get appropriate exposure)
2. Chipshot CABGs and such


Decision Tree:
1. If interested in complex aortic surgery and endo-stuff do vascular before an advanced aortic/cardiac fellowship (Cleveland Clinic, Penn, UTH etc have these).
2. If interested in the others expect to do a super-fellowship at most institutions after a primary cardiac focused fellowship.
3. If heading to the community/privademic environment expect to sit there in a hybrid suite watching cardiology and vascular doing TAVR, TEVAR respectively.

***Net-net CT surgery is not dying. It is only becoming more complex requiring super-specialization. If you're a work horse carve out a niche in one of the fields mentioned above. With regards to the job market, I have 2 friends who are graduating CT primary fellowships and superfellowships w/ 6-8 offers each. Cheers.

 

[deleted50541]

Excellent assessment.

TAVR and other endovascular therapies seem like they're exponentially growing in use and availability. My fellowship year was the last to not require endovascular cases for the cardiac track, which I did. But as I started looking at the job market, it was clear TAVR skills were very much expected of new grads.

Complex aortic work has definitely become highly specialized and being focused at high-volume center, which I agree with. Where I trained, we did most of our own aortic work including TEVAR. But at my current hospital, there is a strong collaboration between cardiac and vascular with those cases.

There's still plenty of relatively straight forward CABGs, but I agree that's coupled with more complex patients including the re-dos. It was always a relief to get an easy CABG with good veins and targets since some days they felt few and far between.

Talking with our current and recent fellows doing cardiac, the job market seems relatively robust with multiple offers. They all seem pretty happy with their choices.

 

[ChordaEpiphany]

Cardiac surgery as it once was, where they were the highly compensated rock stars of most departments of surgery, isn't dying.... it died 25 years ago. There are an awful lot of discouraged cardiac surgeons in mid-late career, as the field is kind of unstable to their POV. They're working harder, often in smaller groups (with more call as a result), on worse operative candidates, for much (MUCH) less money then what was commonly earned a generation ago. The volumes of operative cases has shrunk to where the ability to support larger groups is challenged at many community CV programs. I've seen several private practice groups over the last 15 years I've been around that were once 4-5 surgeon practices contract to groups of 1-2 and had to become employees of hospitals to stabilize their situation

Happiness is reality minus expectations. I think the equivalent would be someone dead set on private practice Mohs surgery ("surgery") in the midwest today, expecting $800K+ on 40-45 hour/week, and then watching CMS slash reimbursements while FM docs developed some super easy in-office procedure that covered the bases on a big chunk of typical Mohs patients. Suddenly that dermatologist is only making $450K and working 50 hours/week to get there. Every day they'd probably sulk in their Porsche 718 Cayman wishing it were a 911 Turbo.

I think it's safe to say that most aspiring cardiac surgeons have readjusted their expectations. Anyone expecting to go into cardiac surgery and make $1M/year as a partner in a big practice while strutting around as the king of the hospital is going to be disappointed. Something closer to $600K/year and tons of call as a hospital employee is the most likely scenario. Some people are still interested in that, but the competitiveness has obviously dropped and that speaks for itself. For a lot of people, it's not enough money or prestige to make it worthwhile, especially when you can make good money in other specialties that have a lot more elective work and a more certain future. People inquiring about the specialty are probably aware of where it's at, given most of them were barely alive 25 years ago.

The question is really how bad could it get? Because personally I wouldn't want to find myself in 20 years taking frequent call as an attending while my surg onc colleagues take mostly elective cases and get paid just as much.

 

[Lem0nz]

Happiness is reality minus expectations. I think the equivalent would be someone dead set on private practice Mohs surgery ("surgery") in the midwest today, expecting $800K+ on 40-45 hour/week, and then watching CMS slash reimbursements while FM docs developed some super easy in-office procedure that covered the bases on a big chunk of typical Mohs patients. Suddenly that dermatologist is only making $450K and working 50 hours/week to get there. Every day they'd probably sulk in their Porsche 718 Cayman wishing it were a 911 Turbo.

I think it's safe to say that most aspiring cardiac surgeons have readjusted their expectations. Anyone expecting to go into cardiac surgery and make $1M/year as a partner in a big practice while strutting around as the king of the hospital is going to be disappointed. Something closer to $600K/year and tons of call as a hospital employee is the most likely scenario. Some people are still interested in that, but the competitiveness has obviously dropped and that speaks for itself. For a lot of people, it's not enough money or prestige to make it worthwhile, especially when you can make good money in other specialties that have a lot more elective work and a more certain future. People inquiring about the specialty are probably aware of where it's at, given most of them were barely alive 25 years ago.

The question is really how bad could it get? Because personally I wouldn't want to find myself in 20 years taking frequent call as an attending while my surg onc colleagues take mostly elective cases and get paid just as much.

cries while doing his weekly emergent overnight case and doesn't get paid anywhere close to CT for 24/7 perpetual community call

 

[deleted941485]

Happiness is reality minus expectations. I think the equivalent would be someone dead set on private practice Mohs surgery ("surgery") in the midwest today, expecting $800K+ on 40-45 hour/week, and then watching CMS slash reimbursements while FM docs developed some super easy in-office procedure that covered the bases on a big chunk of typical Mohs patients. Suddenly that dermatologist is only making $450K and working 50 hours/week to get there. Every day they'd probably sulk in their Porsche 718 Cayman wishing it were a 911 Turbo.

I think it's safe to say that most aspiring cardiac surgeons have readjusted their expectations. Anyone expecting to go into cardiac surgery and make $1M/year as a partner in a big practice while strutting around as the king of the hospital is going to be disappointed. Something closer to $600K/year and tons of call as a hospital employee is the most likely scenario. Some people are still interested in that, but the competitiveness has obviously dropped and that speaks for itself. For a lot of people, it's not enough money or prestige to make it worthwhile, especially when you can make good money in other specialties that have a lot more elective work and a more certain future. People inquiring about the specialty are probably aware of where it's at, given most of them were barely alive 25 years ago.

The question is really how bad could it get? Because personally I wouldn't want to find myself in 20 years taking frequent call as an attending while my surg onc colleagues take mostly elective cases and get paid just as much.

I’m of the opinion that the vast majority of surg and med subs are simply not worth doing from a reward/effort perspective. Tacking on workforce uncertainties and risk of obsolescence makes it even worse.

CT surg answer to declining indications is to go after riskier and sicker patients. While at the same time making less.

I guess you can limp along as a specialty but honestly if I were a discerning med student the numbers just don’t add up.

 

[ChordaEpiphany]

I’m of the opinion that the vast majority of surg and med subs are simply not worth doing from a reward/effort perspective. Tacking on workforce uncertainties and risk of obsolescence makes it even worse.

CT surg answer to declining indications is to go after riskier and sicker patients. While at the same time making less.

I guess you can limp along as a specialty but honestly if I were a discerning med student the numbers just don’t add up.

At least a lifetime of data shows that even as surg and med subs get eaten by lower bar-to-entry procedures the compensation of specialists remains higher than general practitioners.

Every facet of medicine has risks, uncertainties, and a pathway to complete obsolescence. Primary care and EM could be completely drowned by APPs. Derm could get hosed by primary care and APPs with great AI that allows them to treat more skin lesions than ever before. Rads could be snuffed out by AI that empowers radiologists to work twice as fast, halving the number of necessary radiologists, and it could be outsourced. Med onc could be devastated by a new era of cancer therapeutics that reimburse the specialist poorly, like mRNA cancer vaccines. Any subspecialty of surgery could be threatened by minimally invasive techniques performed by medical specialists, who own the patient. All of our incomes could be threatened by a shift to a socialized healthcare system in a time when national debt is skyrocketing and our ability to collect taxes from those who should be paying for it is absolutely laughable.

I've spun around this a million times and the only reasonable answer I can come to is this: always have useful skills, pursue what you love, and be the best at what you do. You might make millions without ever considering your career path. Just get lucky and wind up in a specialty that reimburses well and stays that way for 30 years. You might also get absolutely boned. If you love what you do, you'll take the hit and keep running. If you're the best, you'll be the last one standing. If you diversify your skillset, you can make a strategic exit or play to whatever the conditions allow for.

 

[deleted941485]

At least a lifetime of data shows that even as surg and med subs get eaten by lower bar-to-entry procedures the compensation of specialists remains higher than general practitioners.

Every facet of medicine has risks, uncertainties, and a pathway to complete obsolescence. Primary care and EM could be completely drowned by APPs. Derm could get hosed by primary care and APPs with great AI that allows them to treat more skin lesions than ever before. Rads could be snuffed out by AI that empowers radiologists to work twice as fast, halving the number of necessary radiologists, and it could be outsourced. Med onc could be devastated by a new era of cancer therapeutics that reimburse the specialist poorly, like mRNA cancer vaccines. Any subspecialty of surgery could be threatened by minimally invasive techniques performed by medical specialists, who own the patient. All of our incomes could be threatened by a shift to a socialized healthcare system in a time when national debt is skyrocketing and our ability to collect taxes from those who should be paying for it is absolutely laughable.

I've spun around this a million times and the only reasonable answer I can come to is this: always have useful skills, pursue what you love, and be the best at what you do. You might make millions without ever considering your career path. Just get lucky and wind up in a specialty that reimburses well and stays that way for 30 years. You might also get absolutely boned. If you love what you do, you'll take the hit and keep running. If you're the best, you'll be the last one standing. If you diversify your skillset, you can make a strategic exit or play to whatever the conditions allow for.

Just get lucky pretty much sums it up…I guess the effort just ain’t worth the risk.

 

[cardsperson]

Happiness is reality minus expectations. I think the equivalent would be someone dead set on private practice Mohs surgery ("surgery") in the midwest today, expecting $800K+ on 40-45 hour/week, and then watching CMS slash reimbursements while FM docs developed some super easy in-office procedure that covered the bases on a big chunk of typical Mohs patients. Suddenly that dermatologist is only making $450K and working 50 hours/week to get there. Every day they'd probably sulk in their Porsche 718 Cayman wishing it were a 911 Turbo.

I think it's safe to say that most aspiring cardiac surgeons have readjusted their expectations. Anyone expecting to go into cardiac surgery and make $1M/year as a partner in a big practice while strutting around as the king of the hospital is going to be disappointed. Something closer to $600K/year and tons of call as a hospital employee is the most likely scenario. Some people are still interested in that, but the competitiveness has obviously dropped and that speaks for itself. For a lot of people, it's not enough money or prestige to make it worthwhile, especially when you can make good money in other specialties that have a lot more elective work and a more certain future. People inquiring about the specialty are probably aware of where it's at, given most of them were barely alive 25 years ago.

The question is really how bad could it get? Because personally I wouldn't want to find myself in 20 years taking frequent call as an attending while my surg onc colleagues take mostly elective cases and get paid just as much.

Lol the idea that a cardiologist performing stents/TAVRs is similar to an FM physician stealing work from Mohs specialists shows the level of delusion a lot of CT surgeons have about their role in treating cardiac pathology. In your analogy, the Mohs specialist the expert in skin conditions, while the FM physician is a generalist. The cardiologist is not a generalist - they are the expert in cardiac pathology, much more so than the cardiac surgeon. And not just in the eyes of the public, but referring physicians too - which is why cardiologists have had so much ease taking over 90% of ACS work, 100% of EP work, half of AV work, and an increasing share of MV/ASD/VSD closure work.

There is virtually no patient that a cardiac surgeon sees that hasn't gone through at least one, if not more, cardiologists. That's why the training pathway to become a cardiologist is as long or longer than the one for cardiac surgeons. Most cardiac surgeons can barely read a coronary angiogram, let alone a TTE or TEE. Could you imagine if neurosurgeons couldn't understand MRIs, or general surgeons couldn't read CTs?

 

[deleted941485]

Lol the idea that a cardiologist performing stents/TAVRs is similar to an FM physician stealing work from Mohs specialists shows the level of delusion a lot of CT surgeons have about their role in treating cardiac pathology. In your analogy, the Mohs specialist the expert in skin conditions, while the FM physician is a generalist. The cardiologist is not a generalist - they are the expert in cardiac pathology, much more so than the cardiac surgeon. And not just in the eyes of the public, but referring physicians too - which is why cardiologists have had so much ease taking over 90% of ACS work, 100% of EP work, half of AV work, and an increasing share of MV/ASD/VSD closure work.

There is virtually no patient that a cardiac surgeon sees that hasn't gone through at least one, if not more, cardiologists. That's why the training pathway to become a cardiologist is as long or longer than the one for cardiac surgeons. Most cardiac surgeons can barely read a coronary angiogram, let alone a TTE or TEE. Could you imagine if neurosurgeons couldn't understand MRIs, or general surgeons couldn't read CTs?

Wait seriously? CT surgeons cant read images? I find this difficult to believe. How are they supposed to operate without knowing what they are looking at?

 

[cardsperson]

Wait seriously? CT surgeons cant read images? I find this difficult to believe. How are they supposed to operate without knowing what they are looking at?

Surgeons have been operating for decades without the use of any kind of imaging. Plus, the nature of imaging in cardiology is such that all imaging is read by a cardiologist (except cardiac CTs, which are read by radiologists at many institutions). If a cardiologist has read an echo and writes that the patient has severe aortic stenosis, it's not like the surgeon is going to go into the echo software, perform their own measurements, and say "nah, I disagree".

Again, the relationship between cardiology and cardiac surgery is pretty unique in medicine. A general surgeon can look at a CT and say "hey, this gallbladder wall thickening that the radiologist thinks might be cholecystitis is really just ascites based on my clinical exam of the patient" and they'd generally be correct because they're the expert in gallbladder pathology, not the radiologist. A cardiac surgeon can't look at a TEE report and say "hey, I disagree with the person who is an expert in cardiac pathology", at most all they'll say is "this person is a poor operative candidate".

 

[dienekes88]

Lol the idea that a cardiologist performing stents/TAVRs is similar to an FM physician stealing work from Mohs specialists shows the level of delusion a lot of CT surgeons have about their role in treating cardiac pathology. In your analogy, the Mohs specialist the expert in skin conditions, while the FM physician is a generalist. The cardiologist is not a generalist - they are the expert in cardiac pathology, much more so than the cardiac surgeon. And not just in the eyes of the public, but referring physicians too - which is why cardiologists have had so much ease taking over 90% of ACS work, 100% of EP work, half of AV work, and an increasing share of MV/ASD/VSD closure work.

There is virtually no patient that a cardiac surgeon sees that hasn't gone through at least one, if not more, cardiologists. That's why the training pathway to become a cardiologist is as long or longer than the one for cardiac surgeons. Most cardiac surgeons can barely read a coronary angiogram, let alone a TTE or TEE. Could you imagine if neurosurgeons couldn't understand MRIs, or general surgeons couldn't read CTs?

Not entirely true. If the training program is adequate (and many are not), then the surgeon should be able to read a coronary angiogram... though not in the way that the cardiologist reads it. The cardiologist looks for stenoses, the surgeon looks for targets.

With respect to mitral valve repair, which admittedly is a distinct subset, the ability to look at echo and understand the pathology at play is absolutely critical to being able to achieve a high repair rate. This may in part be why some surgeons are so much better than others at mitral repair, but it is a bit of a stretch to say that all cardiac surgeons don't know what they are looking at when presented with a TEE. This is how the surgeon decides between a resectional technique, neochords, flexible band vs. rigid annuloplasty ring.

But... having had a lot of cardiothoracic residents and fellows come through my service... there are many who are pretty clueless, which speaks to the value of an integrated training paradigm.

Wait seriously? CT surgeons cant read images? I find this difficult to believe. How are they supposed to operate without knowing what they are looking at?

The short answer is that the comment is a bit of an exaggeration.

The long answer is that different subfields require different degrees of imaging interpretation, and the kinds of interpretation are fundamentally different. If the surgeon can't read the CTA, then how does anybody make a decision about how much of the aorta to replace. Do the cardiologist and radiologist just put in an order for a root/ascending/total arch replacement and the surgeon does it? Or can it just be an ascending hemiarch? I can tell you that the mortality difference between those operations is substantial, so any aortic surgeon who can't read CTA will be in a lot of trouble. Similarly, being able to interpret (surgically) TEE is actually critical to mitral valve repair and aortic valve repair. Finally, congenital heart surgery probably is the best example of surgeons needing to understand a variety imaging modalities since the pathology is so complex.

 

[cardsperson]

Not entirely true. If the training program is adequate (and many are not), then the surgeon should be able to read a coronary angiogram... though not in the way that the cardiologist reads it. The cardiologist looks for stenoses, the surgeon looks for targets.

With respect to mitral valve repair, which admittedly is a distinct subset, the ability to look at echo and understand the pathology at play is absolutely critical to being able to achieve a high repair rate. This may in part be why some surgeons are so much better than others at mitral repair, but it is a bit of a stretch to say that all cardiac surgeons don't know what they are looking at when presented with a TEE. This is how the surgeon decides between a resectional technique, neochords, flexible band vs. rigid annuloplasty ring.

But... having had a lot of cardiothoracic residents and fellows come through my service... there are many who are pretty clueless, which speaks to the value of an integrated training paradigm.


The short answer is that the comment is a bit of an exaggeration.

The long answer is that different subfields require different degrees of imaging interpretation, and the kinds of interpretation are fundamentally different. If the surgeon can't read the CTA, then how does anybody make a decision about how much of the aorta to replace. Do the cardiologist and radiologist just put in an order for a root/ascending/total arch replacement and the surgeon does it? Or can it just be an ascending hemiarch? I can tell you that the mortality difference between those operations is substantial, so any aortic surgeon who can't read CTA will be in a lot of trouble. Similarly, being able to interpret (surgically) TEE is actually critical to mitral valve repair and aortic valve repair. Finally, congenital heart surgery probably is the best example of surgeons needing to understand a variety imaging modalities since the pathology is so complex.

We are fundamentally in agreement and obviously I'm exaggerating somewhat. I have nothing but respect for CT surgeons, see my comments in other threads. I was more responding to people like ChordaEpiphany who think cardiologists are generalists taking away cases from the experts.

On a completely unrelated note, I was in a conference today about TEVARs and how IC and vascular surgery can collaborate on these cases. On a day to day basis, these two fields already collaborate far more with each other than either does with CT surgery - we cause pseudoaneurysms that vascular has to fix, and they cause STEMIs that we have to fix. I wonder what Chorda thinks about vascular stealing his turf with the help of us lowly generalists

 

[ChordaEpiphany]

We are fundamentally in agreement and obviously I'm exaggerating somewhat. I have nothing but respect for CT surgeons, see my comments in other threads. I was more responding to people like ChordaEpiphany who think cardiologists are generalists taking away cases from the experts.

This is a creative interpretation of what I wrote. I made an analogy in terms of clinical volumes and patient ownership. You made it about expertise.

As far as I know there has never been a world where cardiac surgeons were referred to for their cardiac expertise, and once surgery was performed it was right back to the cardiologist. The person who performs the procedure is the person who is trained to do so and has greatest "ownership" of the patient. Cardiologists control the patient and can do the newest/best procedures, so they absorbed that volume. You don't need pathological expertise to perform a procedure, as you've specifically exemplified in the case of cardiac surgeons.

This is exactly like my hypothetical scenario. FM is upstream of derm in terms of patient ownership. When an upstream physician can do something, they will, especially if it pays well. If it's suddenly appropriate to treat Moh's patients (or any number of derm cases) in the outpatient primary care setting with some new, easy procedure, it will happen. They can always perform the procedure and then refer to the specialist for follow up or complications with regard to the pathology and medical management, just like cardiac surgeons do with cardiologists, just like dermatologists often do with oncologists.

And before you say, "but that would never happen because FM/IM couldn't do it because they aren't skin experts," remember that I made the analogy contingent on technology making this possible.

So it's got nothing to do with generalist or specialist. It's about procedures. It's about suddenly not having volume anymore due to technological advances and lack of patient ownership. This can happen in any direction, be it a generalist creeping on a specialist's procedures, a specialist taking patients away from a surgeon, or a surgeon taking away patients from a specialist. Cardiologists are specialists. Surgeons are surgeons.

I wonder what Chorda thinks about vascular stealing his turf with the help of us lowly generalists

Also, I'm not a cardiac surgeon... I have zero interest in being a cardiac surgeon, but I'm thinking about general thoracic in an academic setting, which is how I wound up in this thread. If you somehow thought I was denigrating your specialty, that's probably projection

 

[Medstart108]

Surgeons have been operating for decades without the use of any kind of imaging. Plus, the nature of imaging in cardiology is such that all imaging is read by a cardiologist (except cardiac CTs, which are read by radiologists at many institutions). If a cardiologist has read an echo and writes that the patient has severe aortic stenosis, it's not like the surgeon is going to go into the echo software, perform their own measurements, and say "nah, I disagree".

Again, the relationship between cardiology and cardiac surgery is pretty unique in medicine. A general surgeon can look at a CT and say "hey, this gallbladder wall thickening that the radiologist thinks might be cholecystitis is really just ascites based on my clinical exam of the patient" and they'd generally be correct because they're the expert in gallbladder pathology, not the radiologist. A cardiac surgeon can't look at a TEE report and say "hey, I disagree with the person who is an expert in cardiac pathology", at most all they'll say is "this person is a poor operative candidate".

I both agree and disagree. If you are dealing with some cardiac surgeons, particularly the traditional 5+2 or 5+3 folk, then yes, they probably can read angios and CTs but many may not read echos. However, many cardiac surgeons can read angios/CTs and echos to the level of a senior cardiology fellow at least.

In integrated training programs, we do a lot more cardiology, cath blocks/echo blocks etc so we are more comfortable with these imaging modalities. Many of these imaging modalities are entering the OR, TEE pre and post-op, TTE for pre-op planning, CTs for redo, angios for CABG. As a 3, I could read an angio better than most cardiology fellows, we have to review our angios before every case and we get pimped every week at rounds.

I would also say, part of the reason that general surgeons own a disease while cardiac surgeons don't is because traditionally, general surgery is the first thing a surgeon learns and something like a chole is nowhere near as complex as heart surgery. Becoming a competent heart surgeon takes more hours out of your day, leaving less time to also own the workup of cardiac diseases (which means more clinic), see consults (tough when you spend 10 hours in the OR a day). I do agree, there should be more of a role of cardiac surgery in the workup of diseases, the integrated programs are very helpful in achieving those goals. It sometimes surprises me how few consults we get on cardiac, in my opinion we should be seeing massive PEs, cardiac trauma so that these cases get an appropriate surgical opinion. Many times, these are handled by cardiology or general/trauma surgery and we never even get involved and that is unfortunate.

 

[cardsperson]

I both agree and disagree. If you are dealing with some cardiac surgeons, particularly the traditional 5+2 or 5+3 folk, then yes, they probably can read angios and CTs but many may not read echos. However, many cardiac surgeons can read angios/CTs and echos to the level of a senior cardiology fellow at least.

In integrated training programs, we do a lot more cardiology, cath blocks/echo blocks etc so we are more comfortable with these imaging modalities. Many of these imaging modalities are entering the OR, TEE pre and post-op, TTE for pre-op planning, CTs for redo, angios for CABG. As a 3, I could read an angio better than most cardiology fellows, we have to review our angios before every case and we get pimped every week at rounds.

I would also say, part of the reason that general surgeons own a disease while cardiac surgeons don't is because traditionally, general surgery is the first thing a surgeon learns and something like a chole is nowhere near as complex as heart surgery. Becoming a competent heart surgeon takes more hours out of your day, leaving less time to also own the workup of cardiac diseases (which means more clinic), see consults (tough when you spend 10 hours in the OR a day). I do agree, there should be more of a role of cardiac surgery in the workup of diseases, the integrated programs are very helpful in achieving those goals. It sometimes surprises me how few consults we get on cardiac, in my opinion we should be seeing massive PEs, cardiac trauma so that these cases get an appropriate surgical opinion. Many times, these are handled by cardiology or general/trauma surgery and we never even get involved and that is unfortunate.

I find it hard to believe that you're reading angios better than "most" cardiology fellows as a third year I-6 resident. The average cardiology fellow does several hundred diagnostic caths over the course of fellowship. Even at a high volume center, there's no way you're doing several hundred CABGs over the course of 3 years (as a resident). Plus, the cards fellows are seeing a lot more broad coronary pathology than strictly atherosclerosis, which I imagine is 99.9% of what you guys see that requires surgical intervention.

Also, my cards fellowship is in an institution with an I6 program. While we interact with the CT surgery residents here and there and know many on a first name basis due to consults in both directions, they do not rotate with us on echo (I wish they did, then maybe we'd stop getting so many 2 AM stat echo requests for "rule out tamponade" on their post-op patients), nor do they rotate with us on cath unless they are specifically interested in structural heart. Even if they did, you'd be talking about 2-4 weeks of exposure compared to ~6 months (obviously much longer for fellows interested in imaging or IC).

 

[CTFellowMD]

I find it hard to believe that you're reading angios better than "most" cardiology fellows as a third year I-6 resident. The average cardiology fellow does several hundred diagnostic caths over the course of fellowship. Even at a high volume center, there's no way you're doing several hundred CABGs over the course of 3 years (as a resident). Plus, the cards fellows are seeing a lot more broad coronary pathology than strictly atherosclerosis, which I imagine is 99.9% of what you guys see that requires surgical intervention.

Also, my cards fellowship is in an institution with an I6 program. While we interact with the CT surgery residents here and there and know many on a first name basis due to consults in both directions, they do not rotate with us on echo (I wish they did, then maybe we'd stop getting so many 2 AM stat echo requests for "rule out tamponade" on their post-op patients), nor do they rotate with us on cath unless they are specifically interested in structural heart. Even if they did, you'd be talking about 2-4 weeks of exposure compared to ~6 months (obviously much longer for fellows interested in imaging or IC).

When in training, CT fellow was responsible for reviewing every pre-op cath and presenting to the attendings/team. This equated to 8-10 caths/week, as every valve and HF patient also got a diagnostic cath.

Also find it hard to believe your I6 are not rotating on echo and only rotate on cath 'if interested' - those rotations were a major part of the reason I6 was started, and are fairly standard across the 36-ish programs.

 

[cardsperson]

When in training, CT fellow was responsible for reviewing every pre-op cath and presenting to the attendings/team. This equated to 8-10 caths/week, as every valve and HF patient also got a diagnostic cath.

Also find it hard to believe your I6 are not rotating on echo and only rotate on cath 'if interested' - those rotations were a major part of the reason I6 was started, and are fairly standard across the 36-ish programs.

If you're going to count every cath you review in front of your attendings as part of an argument to how trained we are in reading caths, my fellowship has two hours of conference time per week dedicated strictly to reading caths, and we go over at least that many per week. I don't really count those, though, because it's kind of ridiculous to claim that reading a study prepared by someone else is in any way analogous to doing the study yourself and making on-the-spot decisions on what to image, how to image it, how to identify anomalous structures, how to spot abnormalities that aren't obvious until you find just the right view, when to inject various intracoronary medications, etc ... not to mention the growing number of tools we use in the cath lab to augment our understanding of coronary pathology (things like IVUS, OCT, FFR/IFR). Again, the idea that a junior I6 resident is better at reading angios than a senior cardiology fellow is Dunning-Kruger on steroids.

Anyway, on the off chance that the I6 program here is an aberration, I looked up a couple other programs for comparison:

Stanford has a grand total of one month for echo/CT/MRI in their program: Rotations

Yale has no dedicated imaging months:

Integrated Six-Year Cardiothoracic Surgery Residency

The Yale School of Medicine offers an ACGME-accredited integrated six-year cardiothoracic surgery residency program. This program is designed to train future

medicine.yale.edu

My understanding was that the I6 programs were created because the field of cardiac surgery was dying and it was hard to convince med students to do 5 years of gen surg and a minimum of 3 years of CTS fellowship just so they could enter a field in decline, so by lowering the time commitment they hoped to attract more candidates - not because cardiac surgeons were clamoring to spend more time reading echos and caths with the cardiologists lol.

 

[Medstart108]

I find it hard to believe that you're reading angios better than "most" cardiology fellows as a third year I-6 resident. The average cardiology fellow does several hundred diagnostic caths over the course of fellowship. Even at a high volume center, there's no way you're doing several hundred CABGs over the course of 3 years (as a resident). Plus, the cards fellows are seeing a lot more broad coronary pathology than strictly atherosclerosis, which I imagine is 99.9% of what you guys see that requires surgical intervention.

Also, my cards fellowship is in an institution with an I6 program. While we interact with the CT surgery residents here and there and know many on a first name basis due to consults in both directions, they do not rotate with us on echo (I wish they did, then maybe we'd stop getting so many 2 AM stat echo requests for "rule out tamponade" on their post-op patients), nor do they rotate with us on cath unless they are specifically interested in structural heart. Even if they did, you'd be talking about 2-4 weeks of exposure compared to ~6 months (obviously much longer for fellows interested in imaging or IC).

Exactly, we rotate on cath and echo, 1 month each, things are changing though each year with jrs doing more. At my institution cards fellows only do 3 months of cath and our training is much more stringent. I've rotated on cardiology and the cardiologists pimp their residents on echo and ECGs in the same way we get pimped on caths. Of course, I don't profess to know more than a budding interventionalist in terms of cath (particularly non-surgical findings), but compared to the average cards fellow, many of whom aren't interested in cath, I definitely feel more confident.

You'll also be surprised I've scrubbed in on over 400 pumps in residency so far and the vast majority are CABG part by reality and part by choice. When we are on service we review easily 8-10 caths a week and our attendings ask us to review caths and accept referrals without ever having seen themselves.

Reading your other posts with your wide-reaching assertions with little evidence, its insane how polite we are towards you. You sound like an egomaniac, i'd be floored if your co-residents like working with you.

 

[Wordead]

If you're going to count every cath you review in front of your attendings as part of an argument to how trained we are in reading caths, my fellowship has two hours of conference time per week dedicated strictly to reading caths, and we go over at least that many per week. I don't really count those, though, because it's kind of ridiculous to claim that reading a study prepared by someone else is in any way analogous to doing the study yourself and making on-the-spot decisions on what to image, how to image it, how to identify anomalous structures, how to spot abnormalities that aren't obvious until you find just the right view, when to inject various intracoronary medications, etc ... not to mention the growing number of tools we use in the cath lab to augment our understanding of coronary pathology (things like IVUS, OCT, FFR/IFR). Again, the idea that a junior I6 resident is better at reading angios than a senior cardiology fellow is Dunning-Kruger on steroids.

Anyway, on the off chance that the I6 program here is an aberration, I looked up a couple other programs for comparison:

Stanford has a grand total of one month for echo/CT/MRI in their program: Rotations

Yale has no dedicated imaging months:

Integrated Six-Year Cardiothoracic Surgery Residency

The Yale School of Medicine offers an ACGME-accredited integrated six-year cardiothoracic surgery residency program. This program is designed to train future

medicine.yale.edu

My understanding was that the I6 programs were created because the field of cardiac surgery was dying and it was hard to convince med students to do 5 years of gen surg and a minimum of 3 years of CTS fellowship just so they could enter a field in decline, so by lowering the time commitment they hoped to attract more candidates - not because cardiac surgeons were clamoring to spend more time reading echos and caths with the cardiologists lol.

That is an enormous chip you have on your shoulder bro

 

[CTFellowMD]

If you're going to count every cath you review in front of your attendings as part of an argument to how trained we are in reading caths, my fellowship has two hours of conference time per week dedicated strictly to reading caths, and we go over at least that many per week. I don't really count those, though, because it's kind of ridiculous to claim that reading a study prepared by someone else is in any way analogous to doing the study yourself and making on-the-spot decisions on what to image, how to image it, how to identify anomalous structures, how to spot abnormalities that aren't obvious until you find just the right view, when to inject various intracoronary medications, etc ... not to mention the growing number of tools we use in the cath lab to augment our understanding of coronary pathology (things like IVUS, OCT, FFR/IFR). Again, the idea that a junior I6 resident is better at reading angios than a senior cardiology fellow is Dunning-Kruger on steroids.

Anyway, on the off chance that the I6 program here is an aberration, I looked up a couple other programs for comparison:

Stanford has a grand total of one month for echo/CT/MRI in their program: Rotations

Yale has no dedicated imaging months:

Integrated Six-Year Cardiothoracic Surgery Residency

The Yale School of Medicine offers an ACGME-accredited integrated six-year cardiothoracic surgery residency program. This program is designed to train future

medicine.yale.edu

My understanding was that the I6 programs were created because the field of cardiac surgery was dying and it was hard to convince med students to do 5 years of gen surg and a minimum of 3 years of CTS fellowship just so they could enter a field in decline, so by lowering the time commitment they hoped to attract more candidates - not because cardiac surgeons were clamoring to spend more time reading echos and caths with the cardiologists lol.

Lol - Love how you keep moving the goalposts.

First of all, cardiac is far from dying. Have been in practice for 5 years, am constantly getting recruitment offers from both academic and private practices.

Secondly - Argument was about number of caths read and experience doing so, not performing them. Would you like me to go into everything involved with bypass or valve surgery and insist that you must know nothing about true cardiac pathology because you aren't seeing it with your own eyes every day?

As a cards fellow, not even an interventional fellow, I'm sure you're making all of those decisions during the angio yourself too. You are just so good at what you do, no one can compare. I bow to your awesomeness.

That is an enormous chip you have on your shoulder bro

Seriously. These are the kind of docs that either get booted out of university programs because they can't play nice with others, or never make it in private practice because they piss off all the referrals and surgeons. Person is in for a rude awakening after training.

 

[dienekes88]

When in training, CT fellow was responsible for reviewing every pre-op cath and presenting to the attendings/team. This equated to 8-10 caths/week, as every valve and HF patient also got a diagnostic cath.

Also find it hard to believe your I6 are not rotating on echo and only rotate on cath 'if interested' - those rotations were a major part of the reason I6 was started, and are fairly standard across the 36-ish programs.

I would also be shocked if Integrated residents are not rotating on echo. That would be appalling.

If you're going to count every cath you review in front of your attendings as part of an argument to how trained we are in reading caths, my fellowship has two hours of conference time per week dedicated strictly to reading caths, and we go over at least that many per week. I don't really count those, though, because it's kind of ridiculous to claim that reading a study prepared by someone else is in any way analogous to doing the study yourself and making on-the-spot decisions on what to image, how to image it, how to identify anomalous structures, how to spot abnormalities that aren't obvious until you find just the right view, when to inject various intracoronary medications, etc ... not to mention the growing number of tools we use in the cath lab to augment our understanding of coronary pathology (things like IVUS, OCT, FFR/IFR). Again, the idea that a junior I6 resident is better at reading angios than a senior cardiology fellow is Dunning-Kruger on steroids.

Anyway, on the off chance that the I6 program here is an aberration, I looked up a couple other programs for comparison:

Stanford has a grand total of one month for echo/CT/MRI in their program: Rotations

Yale has no dedicated imaging months:

Integrated Six-Year Cardiothoracic Surgery Residency

The Yale School of Medicine offers an ACGME-accredited integrated six-year cardiothoracic surgery residency program. This program is designed to train future

medicine.yale.edu

My understanding was that the I6 programs were created because the field of cardiac surgery was dying and it was hard to convince med students to do 5 years of gen surg and a minimum of 3 years of CTS fellowship just so they could enter a field in decline, so by lowering the time commitment they hoped to attract more candidates - not because cardiac surgeons were clamoring to spend more time reading echos and caths with the cardiologists lol.

Well, I think that's the reason some integrated programs cropped up. Other programs (that were already attracting the best fellows: Penn, Columbia, and Stanford come to mind, but I don't know where the integrated programs are now) actually were trying to get their trainees immersed in imaging, wire skills, etc.

In any event. The training is clearly different and for the reason I stated above. Cardiologists read cath in a different way from a surgeon, and to be quite honest... being able to tell if there's a target is much easier than what our cardiology colleagues do: being able to say whether it's a 50 or 70% lesion on a non dominant right that gives of a small acute marginal (surgical interpretation: not going to revascularize it anyway) or the finer points of radial access (like what to do if the radial spasms... or whether to use a TIG or something else) or whether to line up the shot as a 20 LAO or 30 LAO... or anything along those lines. That's why you only need a brief period on cath and then do maybe a hundred CABGs and have a pretty good handle on surgical interpretation of cath.

With respect to one month on CT/MRI... you have to recognize that CT is an almost daily necessity in the day to day workings of the CT fellow. So the one month is to develop a system and learn the process. Then its another 3, 4, 5 years of on the job practice.

Exactly, we rotate on cath and echo, 1 month each, things are changing though each year with jrs doing more. At my institution cards fellows only do 3 months of cath and our training is much more stringent. I've rotated on cardiology and the cardiologists pimp their residents on echo and ECGs in the same way we get pimped on caths. Of course, I don't profess to know more than a budding interventionalist in terms of cath (particularly non-surgical findings), but compared to the average cards fellow, many of whom aren't interested in cath, I definitely feel more confident.

You'll also be surprised I've scrubbed in on over 400 pumps in residency so far and the vast majority are CABG part by reality and part by choice. When we are on service we review easily 8-10 caths a week and our attendings ask us to review caths and accept referrals without ever having seen themselves.

Reading your other posts with your wide-reaching assertions with little evidence, its insane how polite we are towards you. You sound like an egomaniac, i'd be floored if your co-residents like working with you.

I'd refrain from name-calling, because I believe its against the terms of service.

In any event. This isn't a competition about whose training is harder. There's no question that surgical training is more grueling. On top of that, I'll refer back to my prior post: you as the surgical resident are just looking at different things than the cardiology fellow. Both valid. But still different.

 

[deleted50541]

In any event. The training is clearly different and for the reason I stated above. Cardiologists read cath in a different way from a surgeon, and to be quite honest... being able to tell if there's a target is much easier than what our cardiology colleagues do: being able to say whether it's a 50 or 70% lesion on a non dominant right that gives of a small acute marginal (surgical interpretation: not going to revascularize it anyway) or the finer points of radial access (like what to do if the radial spasms... or whether to use a TIG or something else) or whether to line up the shot as a 20 LAO or 30 LAO... or anything along those lines. That's why you only need a brief period on cath and then do maybe a hundred CABGs and have a pretty good handle on surgical interpretation of cath.

In any event. This isn't a competition about whose training is harder. There's no question that surgical training is more grueling. On top of that, I'll refer back to my prior post: you as the surgical resident are just looking at different things than the cardiology fellow. Both valid. But still different.

That was essentially my experience in the traditional 5+2 CT path. I was very comfortable reviewing caths and echos for the purposes of surgical planning. But I and my attendings as well definitely relied on the cardiologists and even our cardiac anesthesiologists for more nuanced interpretations of imaging such as with hybrid revascularizations and re-do operations. There was no competition over who was "better" at reading films.

 

[nimbus]

It's more of a mixed bag I think, talking to colleagues at the 5 hospitals I work at in a medium metro area (> 1.2M popl) .

Cardiac surgery as it once was, where they were the highly compensated rock stars of most departments of surgery, isn't dying.... it died 25 years ago. There are an awful lot of discouraged cardiac surgeons in mid-late career, as the field is kind of unstable to their POV. They're working harder, often in smaller groups (with more call as a result), on worse operative candidates, for much (MUCH) less money then what was commonly earned a generation ago. The volumes of operative cases has shrunk to where the ability to support larger groups is challenged at many community CV programs. I've seen several private practice groups over the last 15 years I've been around that were once 4-5 surgeon practices contract to groups of 1-2 and had to become employees of hospitals to stabilize their situation

20 years ago, our hospital had 4 moderately busy cardiac surgeons. That has dwindled now to 1 very busy cardiac surgeon who adapted by learning robotic mitral repair, port access AVRs, aorta work, and BIMA CABGs. He’s also on call every day unless he’s out of town proctoring for Intuitive. The others basically faded away and occasionally do an empyema, a high risk CABG, or IVDU/endocarditis cases.

A couple of other hospitals in town have busy VAD/heart failure/transplant programs.

 

[droliver]

20 years ago, our hospital had 4 moderately busy cardiac surgeons. That has dwindled now to 1 very busy cardiac surgeon who adapted by learning robotic mitral repair, port access AVRs, aorta work, and BIMA CABGs. He’s also on call every day unless he’s out of town proctoring for Intuitive. The others basically faded away and occasionally do an empyema, a high risk CABG, or IVDU/endocarditis cases.

Two of the hospitals I work at have also gone from 4-5 person groups to 1 full time employed surgeon over the last 15/years. The two surgeons are very busy, but essentially on call 24/7 and make 1/2 the money they made in the 1990’s (per the surgeon)

 

[deleted941485]

Two of the hospitals I work at have also gone from 4-5 person groups to 1 full time employed surgeon over the last 15/years. The two surgeons are very busy, but essentially on call 24/7 and make 1/2 the money they made in the 1990’s (per the surgeon)

I remember being a college student in the way early 2000s we had a CT surgeon speak to the overachieving pre med students. Stood in awe of him but honestly even he was dropping hints back then that CTS may not be the path you should consider.

Honestly thoracic alone is probably a better deal than the cardiac work at this point.

 

[nimbus]

I remember being a college student in the way early 2000s we had a CT surgeon speak to the overachieving pre med students. Stood in awe of him but honestly even he was dropping hints back then that CTS may not be the path you should consider.

Honestly thoracic alone is probably a better deal than the cardiac work at this point.

Unless for some odd reason you want to operate on hearts.

 

[deleted941485]

Unless for some odd reason you want to operate on the heart

Wanting to is irrelevant especially when evidence and tech drive practice

 

[dienekes88]

The rumored death of cardiac surgery had been ongoing for quite a long time. There's no doubt that the pain/sweat to reward ratio is not what it used to be. But everyone's tolerance for pain is different. The days of cardiac surgeons doing chip shot cabgs with good targets and making a couple million bucks a year are gone. The folks who haven't been able to innovate are the highest risk for not continuing. Just because these people are being cut out doesn't mean the entire field is dead. Just take a look at general surgery. Ulcer surgery used to be a thing. Now. Not so much. General surgery isn't dead; its just different. It is probably safe to say that the workforce is contracting. As it should be. But the people who can be effective and innovative seem to do alright.

With respect to thoracic surgery, I really enjoyed it, but I just like cardiac surgery more. So I disagree that "want" is irrelevant, because it was totally relevant to me. Technology and evidence drive practice, but the evidence is that surgery is still better than endovascular therapy in many situations. Additionally, there isn't an endovascular alternative yet for many of the lesions.

 

[Clean7795]

Evidence driving practice is the case in oncology and pediatrics, but for other settings it often comes down to workflow & politics.

Cardiology has ownership of patients and diagnostics. This is very different from other surgical fields who either do their own diagnostics or can rely on a 3rd party (radiologist) to guide the primary physician towards a surgical referral. Imagine if neurology owned and interpreted all brain CTs and MRs. It would be very easy for them to gain ground on patient ownership & expand their endovascular workforce, resulting in less endovascular work for neurosurgery.

Cardiac surgery will never die off, but it is basically stuck in its current state since new technologies will always flow to the cardiologist first to decide if it is something they can learn or not.

 

[nimbus]

Adult cardiothoracic anesthesia fellowships are more popular than ever. There’s still a great need in the real world. Granted, the skills acquired during the fellowship are transferable to the structural interventional lab. But I think there will still be a significant amount of cardiothoracic surgery going into the future. It’s still an interesting and exciting field. Just don’t expect it to look the same 15 years from now.

 

[ed*26]

Cardiac surgery will never die off, but it is basically stuck in its current state since new technologies will always flow to the cardiologist first to decide if it is something they can learn or not.

This is a bit of an overstatement; there are many technologies that clearly aren't within a cardiologist's scope of practice (ECMO, VADs), and more and more surgeons are embracing interventional techniques and even pioneering true hybrid procedures. We have yet to get robust data on the limitations of interventional procedures, especially in the long term. I do see a future where the benefits of surgery -- or having some interventions performed by someone who can surgically intervene if necessary -- is better defined.

The other day I scrubbed in on a case where a high-risk patient got a TAVR and an off-pump CABG. Two attendings, an interventionalist and CT surgeon; which one is most necessary?

 

[droliver]

This is a bit of an overstatement; there are many technologies that clearly aren't within a cardiologist's scope of practice (ECMO, VADs),

But how many ECMO cases are there really? Not that many. Certainly not enough to support a large workforce of surgeons in the future

Also one of my nurses just took a rep job for some endovascular placed VAD the cardiologists are doing (which blows my mind), so even that isn't a safe harbor for CTVS apparently

 

[deleted941485]

Adult cardiothoracic anesthesia fellowships are more popular than ever. There’s still a great need in the real world. Granted, the skills acquired during the fellowship are transferable to the structural interventional lab. But I think there will still be a significant amount of cardiothoracic surgery going into the future. It’s still an interesting and exciting field. Just don’t expect it to look the same 15 years from now.

Do you also have involvement with the interventional procedures like mitral clip, TAVR etc?

 

[nimbus]

Do you also have involvement with the interventional procedures like mitral clip, TAVR etc?

I stopped doing cardiac anesthesia at the end of last year but yes I did before.

 

[ChordaEpiphany]

The rumored death of cardiac surgery had been ongoing for quite a long time. There's no doubt that the pain/sweat to reward ratio is not what it used to be. But everyone's tolerance for pain is different. The days of cardiac surgeons doing chip shot cabgs with good targets and making a couple million bucks a year are gone. The folks who haven't been able to innovate are the highest risk for not continuing. Just because these people are being cut out doesn't mean the entire field is dead. Just take a look at general surgery. Ulcer surgery used to be a thing. Now. Not so much. General surgery isn't dead; its just different. It is probably safe to say that the workforce is contracting. As it should be. But the people who can be effective and innovative seem to do alright.

With respect to thoracic surgery, I really enjoyed it, but I just like cardiac surgery more. So I disagree that "want" is irrelevant, because it was totally relevant to me. Technology and evidence drive practice, but the evidence is that surgery is still better than endovascular therapy in many situations. Additionally, there isn't an endovascular alternative yet for many of the lesions.

What are your thoughts on the future of general thoracic? I'd be pretty well-positioned for a solid career in this field. I think the cases are fascinating and the lifestyle and compensation are good enough that I probably wouldn't get several divorces and absolutely hate myself in 30 years.

However, I'm wary of this sort of the long commitment if the future is at all shaky. If we suddenly have a glut of cardiac surgeons, will CT surgeons adopt a more thoracic-heavy workload and drown the field, or is this too big a change for most of them? It seems like most CT surgeons are cardiac, so it wouldn't require a huge shift to suddenly have more thoracic than we need. Otherwise, the field seems very safe. No mid-level threats. No interventionalists taking procedures. Seems like a great gig, so I must be missing something.

 

[SociableJimmy]

But how many ECMO cases are there really? Not that many. Certainly not enough to support a large workforce of surgeons in the future

Also one of my nurses just took a rep job for some endovascular placed VAD the cardiologists are doing (which blows my mind), so even that isn't a safe harbor for CTVS apparently

Big centers can have well over 100 ECMO runs per year. As far as the endovascular VAD you’re referring to, it’s probably an Impella CP, which cards can place in the cath lab, but doesn’t provide the same degree of support as the surgically implanted Impella 5.5 or ECMO. They all operate along a spectrum of support provided, one doesn’t necessarily replace the other.

 

[ESU_MD]

Cardiac surgery is alive and well.
CABG is not going anywhere
TAVR has it's role, but is not designed to be a lifelong solution.

 

[Beeftenderloin]

Do you also have involvement with the interventional procedures like mitral clip, TAVR etc?

Current CV anesthesia fellow. We’re doing all echos for lariat, watchman, TAVR (if under general anesthesia, though most get MAC now), split Mitraclip/Triclip with cardiology fellows, do all pre-ablation TEEs to clear appendage, and provide TEE guidance/monitoring for laser lead extractions. This is all in addition to our robust peri-op TEE experience for open cardiac surgery and MCS. As @nimbus said, more popular than ever and as someone who was recently interviewing for jobs, the skill set is in high demand.

 

[dienekes88]

What are your thoughts on the future of general thoracic? I'd be pretty well-positioned for a solid career in this field. I think the cases are fascinating and the lifestyle and compensation are good enough that I probably wouldn't get several divorces and absolutely hate myself in 30 years.

However, I'm wary of this sort of the long commitment if the future is at all shaky. If we suddenly have a glut of cardiac surgeons, will CT surgeons adopt a more thoracic-heavy workload and drown the field, or is this too big a change for most of them? It seems like most CT surgeons are cardiac, so it wouldn't require a huge shift to suddenly have more thoracic than we need. Otherwise, the field seems very safe. No mid-level threats. No interventionalists taking procedures. Seems like a great gig, so I must be missing something.

This is a very interesting thought. To be honest the majority of cardiac track residencies have somewhat limited thoracic experience from what I can tell. While a cardiac surgeon who has been in practice a couple years can do an open lobectomy or open thymectomy, my suspicion is that most won't be facile with VATS or robotic techniques to be competitive with thoracic track fellowship trained surgeons who continue to develop those skills after fellowship.

I agree. The field is quite good. There are interventional pulmonologists doing PleurX catheters, ultrasound guided pigtail catheters, EBUS with TBNA, rigid bronch with stents, etc. There are advanced endoscopists who are doing POEM, botox injections, esophageal stents, etc. However, from what I can tell these are largely complementary with few exceptions, e.g. POEM.

Thoracic surgery is not going anywhere, and the increasing complexity of minimally invasive techniques is making it such that occasional dabblers are significantly disadvantaged in a way that isn't quite as dramatic as the converse, e.g. you would legitimately see a cardiac surgeon take out a lobe or do a wedge biopsy... you wouldn't see a thoracic surgeon do an aortic valve or TEVAR.