Is the outlook for cardiothoracic surgery really that bad to where IM->Cards is better?

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LebronManning

LebronManning

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Before anyone says to look at other posts similar to this, none have been recent enough to re evaluate the future of a formerly dying speciality.

If a student is set on surgery and specifically CT Surg, should that student consider IM then Cards then Intvnl Cards instead of pursuing CT surg?

Everyone hears the horror stories about CT Surgeons not finding a job, though that seems a stretch.

With continuing evidence of the poor effectiveness of stents are there other areas in which CT Surgery can make a comeback or will? Or is the career doomed as the interventional guys continue improving.
 
LebronManning said:
Before anyone says to look at other posts similar to this, none have been recent enough to re evaluate the future of a formerly dying speciality.

If a student is set on surgery and specifically CT Surg, should that student consider IM then Cards then Intvnl Cards instead of pursuing CT surg?

Everyone hears the horror stories about CT Surgeons not finding a job, though that seems a stretch.

With continuing evidence of the poor effectiveness of stents are there other areas in which CT Surgery can make a comeback or will? Or is the career doomed as the interventional guys continue improving.
Click to expand...

Especially considering all the new I-6 programs. That locks you into CTsurgery for like very young in your medical career. This could prove risky if the outlook is truly that bad.
 
Both CT surgeons I shadowed told me not to go into CT surgery. But thats n=2. For the disease burden, many desirable locations already have the CT surgeons they need.
 
Anti-PD1 said:
Both CT surgeons I shadowed told me not to go into CT surgery. But thats n=2. For the disease burden, many desirable locations already have the CT surgeons they need.
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How unfortunate. The CTSurgeons failed their future generations by allowing such a tragic overtaking by the cardiologists.
 
LebronManning said:
How unfortunate. The CTSurgeons failed their future generations by allowing such a tragic overtaking by the cardiologists.
Click to expand...

On the other hand look at neurosurgery. Half of Neuro IR is run by neurosurgery, and there are dedicated fellowships to learn endovascular techniques. Hell of a subspecialty, would never do it lol.
 
TL;DR: CT Fellows & young attendings have a bright perspective on the future of CT surgery.

Spoke to a few CT guys recently. According to them CT has had a resurgence of sorts. They admit that they hit rock bottom in the late 90's and early 2000's but in the past 5-6 years there has been more and more competition both for I6 and fellowship programs. I think that the field learned from their mistake of thinking that interventional procedures are "beneath" them. Many of them are at the forefront of mastering this tech and pushing it forward. Education for CT is changing dramatically as a result. A lot of the older guys who can't keep up with the new techniques are falling by the wayside. There is a need for younger surgeons who are trained in the modern era to step up into leadership roles in order to direct the future direction of CT surgery. Demand is also growing clinically. I am not informed of the details, but they mentioned that Interv. Cards has really overdone a lot of the procedures. There is now a backlash, and fewer of them are being done. IIRC they also said that there are more open surgeries today than 10 years ago as a result. Lastly, there will always be a need for open heart surgeries and thoracic work in general. They had a few strong opinions about I6 programs (in terms of being prepared to handle bad situations in the abdomen) but ultimately conceded that it is better for the future of the field. All in all they tried to convince me that doing an I6 program is not a bad idea if you want to work with the heart and do surgery. Interventional cards is a long and grueling path too (although not as bad as a surgical residency at the end of the day). 3 years of IM, +/- 1 chief year, 3 years of cards fellowship, 1-2 years of interventional fellowship. Might as well do 6 years and be a full fledged surgeon (according to the..surgeons). They said now is the best time to consider this specialty. The field is becoming more respected and competitive, but it is not so super competitive that it is impossible to get in.
 
Do you want to be a surgeon or do you want to do procedures?

There is a huge difference.

The poster above is correct; when I was in training (and probably most of your faculty), CT surgery was dead and dying. Only 1/3 of fellowships filled. Anyone could get one. The backlash against Cards is real and furthermore, the data to show better outcomes for surgery over catheter based interventions is robust.

But at the end of the day, CT surgery is not going anywhere. Kids are still born with bad hearts that only a surgeon can fix, people still need transplants and we're still eating French fries and smoking.

You have to decide: surgery or medicine.
 
Anti-PD1 said:
On the other hand look at neurosurgery. Half of Neuro IR is run by neurosurgery, and there are dedicated fellowships to learn endovascular techniques. Hell of a subspecialty, would never do it lol.
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Exactly! Neuroradiologists and actually neurologists as well have both been trying to get into those fellowships for years but many of the programs are NSGY only, which protects the field. Too bad the heart surgeons didn't do this.
 
How extensive if at all are endovascular techniques taught in I-6 programs or CT fellowships? Sure, there will always be a need for open heart procedures and some procedures may come back to the surgeons. However, I think for CT Surgeons to truly get back in the game they have to be trained endovascularly. All interventions of cardiac disease should be consulted by the CT surgery service, and then Cards if the surgeon deems it appropriate. Furthermore, so many of the interventional procedures require CT surgery presence that it would also be economically better for CT surgeons to do them, themselves. I agree with PS2020 in that perhaps the surgeons didn't involve themselves in the endovascular revolution because they thought it was beneath them, surely they can't still believe this.

How about opening Interv. Cards fellowships to CT surgeons? Sounds kinda dumb but perhaps that's the way they can get the endovascular training. This might not sound appealing to the Cards guys who run these programs though.
 
LebronManning said:
Exactly! Neuroradiologists and actually neurologists as well have both been trying to get into those fellowships for years but many of the programs are NSGY only, which protects the field. Too bad the heart surgeons didn't do this.
Click to expand...

Did you just say that neuroradiologists have been trying to get into neurointerventional radiology fellowships?
 
Cognovi said:
Did you just say that neuroradiologists have been trying to get into neurointerventional radiology fellowships?
Click to expand...

Is that surprising? Interventional radiology was/is a fellowship under the radiology umbrella, and non-interventional radiologists still do plenty of procedures.
 
sovereign0 said:
Is that surprising? Interventional radiology was/is a fellowship under the radiology umbrella, and non-interventional radiologists still do plenty of procedures.
Click to expand...

It's not surprising, it's an obvious statement that shouldn't need to be said. The R in neuroIR is radiology. Of course radiologists are trying to get into neuroIR fellowships. Neurosurgery is not "protecting" it, it's taking it away, rebranded as endovascular neurosurgery.
 
CT surgery isn't going anywhere, they will be needed for the foreseeable future. Cards can't do everything, and neither can CT surgery, they complement each other. However, I'm not entirely sure what the market is like, but one area I can see expanding are LVADs, I hear chatter regularly from hospitals that want to start their own lvad programs.
 
Cognovi said:
It's not surprising, it's an obvious statement that shouldn't need to be said. The R in neuroIR is radiology. Of course radiologists are trying to get into neuroIR fellowships. Neurosurgery is not "protecting" it, it's taking it away, rebranded as endovascular neurosurgery.
Click to expand...

Not all neuroradiologists are interventionalists. That's why I said both they and neurologists are applying for the interventional neurology procedural fellowships. NSGY is protecting it by doing it themselves as opposed to letting the other guys take it over.
 
Winged Scapula said:
Do you want to be a surgeon or do you want to do procedures?

There is a huge difference.

The poster above is correct; when I was in training (and probably most of your faculty), CT surgery was dead and dying. Only 1/3 of fellowships filled. Anyone could get one. The backlash against Cards is real and furthermore, the data to show better outcomes for surgery over catheter based interventions is robust.

But at the end of the day, CT surgery is not going anywhere. Kids are still born with bad hearts that only a surgeon can fix, people still need transplants and we're still eating French fries and smoking.

You have to decide: surgery or medicine.
Click to expand...

This is essentially it. The pathway to cards vs CTS is so different on a macro and micro level that it really isn't like choosing between M&Ms and Skittles. There isn't a single bone in my body that is geared to handle IM -> Cards -> IC. That's not how I am wired and it's not how I want to spend my days. Even if I had a guaranteed track to become an IC I wouldn't do it, because you're either medicine or surgery.
 
TypeADissection said:
This is essentially it. The pathway to cards vs CTS is so different on a macro and micro level that it really isn't like choosing between M&Ms and Skittles. There isn't a single bone in my body that is geared to handle IM -> Cards -> IC. That's not how I am wired and it's not how I want to spend my days. Even if I had a guaranteed track to become an IC I wouldn't do it, because you're either medicine or surgery.
Click to expand...
This is so true.

While there are always exceptions, you either want to be a surgeon or you don't and I think that usually becomes pretty clear by 3rd year.

There are some proceduralists who fancy themselves as Surgeons but that's because they don't know the difference.
 
LebronManning said:
Not all neuroradiologists are interventionalists. That's why I said both they and neurologists are applying for the interventional neurology procedural fellowships. NSGY is protecting it by doing it themselves as opposed to letting the other guys take it over.
Click to expand...

I'm saying neurosurgery is the other guy taking it from radiology, not the other way around.
 
Winged Scapula said:
This is so true.

While there are always exceptions, you either want to be a surgeon or you don't and I think that usually becomes pretty clear by 3rd year.

There are some proceduralists who fancy themselves as Surgeons but that's because they don't know the difference.
Click to expand...
They're really not that dissimilar. I get why you would have that false dichotomy in your head, I probably would too if I was a surgeon. Yes, the procedures aren't "surgery," but surgery itself isn't really that much different from a procedure. It's all on a spectrum, and it's all human-derived semantics.
 
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CaptainSSO said:
They're really not that dissimilar. I get why you would have that false dichotomy in your head, I probably would too if I was a surgeon. Yes, the procedures aren't "surgery," but surgery itself isn't really that much different from a procedure. It's all on a spectrum, and it's all human-derived semantics.
Click to expand...

I disagree entirely. Open surgery really is very different than catheter based procedures, and it is a question at its core of internist vs. surgeon? Training is very different and the practice is very different. Even interventional cards will likely still have a lot of outpatient clinic and in patient medical consults, while a surgeon wants to spend every working moment in the OR.

And I'm looking to pursue interventional cards, not surgery.
 
PS2020 said:
TL;DR: CT Fellows & young attendings have a bright perspective on the future of CT surgery.

Spoke to a few CT guys recently. According to them CT has had a resurgence of sorts. They admit that they hit rock bottom in the late 90's and early 2000's but in the past 5-6 years there has been more and more competition both for I6 and fellowship programs. I think that the field learned from their mistake of thinking that interventional procedures are "beneath" them. Many of them are at the forefront of mastering this tech and pushing it forward. Education for CT is changing dramatically as a result. A lot of the older guys who can't keep up with the new techniques are falling by the wayside. There is a need for younger surgeons who are trained in the modern era to step up into leadership roles in order to direct the future direction of CT surgery. Demand is also growing clinically. I am not informed of the details, but they mentioned that Interv. Cards has really overdone a lot of the procedures. There is now a backlash, and fewer of them are being done. IIRC they also said that there are more open surgeries today than 10 years ago as a result. Lastly, there will always be a need for open heart surgeries and thoracic work in general. They had a few strong opinions about I6 programs (in terms of being prepared to handle bad situations in the abdomen) but ultimately conceded that it is better for the future of the field. All in all they tried to convince me that doing an I6 program is not a bad idea if you want to work with the heart and do surgery. Interventional cards is a long and grueling path too (although not as bad as a surgical residency at the end of the day). 3 years of IM, +/- 1 chief year, 3 years of cards fellowship, 1-2 years of interventional fellowship. Might as well do 6 years and be a full fledged surgeon (according to the..surgeons). They said now is the best time to consider this specialty. The field is becoming more respected and competitive, but it is not so super competitive that it is impossible to get in.
Click to expand...
This take over was due to a lot of new non-invasive techniques like TAVR that IR Cardio introduced.....but NOW they are not being used as much as studies are now showing TAVR and other similar interventions to not be as effective to open heart surgery in terms of reducing mortality and morbidity.
 
LebronManning said:
Before anyone says to look at other posts similar to this, none have been recent enough to re evaluate the future of a formerly dying speciality.

If a student is set on surgery and specifically CT Surg, should that student consider IM then Cards then Intvnl Cards instead of pursuing CT surg?

Everyone hears the horror stories about CT Surgeons not finding a job, though that seems a stretch.

With continuing evidence of the poor effectiveness of stents are there other areas in which CT Surgery can make a comeback or will? Or is the career doomed as the interventional guys continue improving.
Click to expand...

No. Did a month of vascular surgery and watched IV Cards/Rads consult Vascular Surgery so I'm somewhat aware of this whole surgery (CT/Vasc.) v. invasive cardiology (IV Cards, etc.) issue. Surgery is far more equipped to handle things when stuff hits the fan and I'm saying this as someone applying to IM. I think it's very critical to give credit to surgeons where credit is due. It's not like surgeons are fighting to take away the stenting/other interventional techniques from the Cardiologists either... At this point, Endovascular technology (even those done by surgeons) is not as effective as open surgery.
 
Last edited:
imtheman25 said:
This take over was due to a lot of new non-invasive techniques like TAVR that IR Cardio introduced.....but NOW they are not being used as much as studies are now showing TAVR and other similar interventions to not be as effective to open heart surgery in terms of reducing mortality and morbidity.
Click to expand...

Thanks. Yeah, that is pretty much what they told me as well. I am curious how this swing will affect IR Cards over the next 10 years. I personally suspect that this bounce that CT is experiencing will be short lived. Interventional techniques will be refined, and the dip cards is experiencing will reverse. CT downtrend will continue afterwards until it plateaus (since there will always be a need for open surgery). Maybe CT programs will all be integrated by that point and would have diversified their skill set enough to compete with IR Cards and stay relevant for bread & butter cases. Idk. What are your thoughts on this guys?
 
Syncrohnize said:
No. Did a month of vascular surgery and watched IV Cards/Rads consult Vascular Surgery so I'm somewhat aware of this whole surgery (CT/Vasc.) v. invasive cardiology (IV Cards, etc.) issue. Surgery is far more equipped to handle things when stuff hits the fan and I'm saying this as someone applying to IM. I think it's very critical to give credit to surgeons where credit is due. It's not like surgeons are fighting to take away the stenting/other interventional techniques from the Cardiologists either... At this point, Endovascular technology (even those done by surgeons) is not as effective as open surgery.
Click to expand...
I mean, why fight to take away something that's already struggling?
Stents Show No Extra Benefits for Coronary Artery Disease
‘Unbelievable’: Heart Stents Fail to Ease Chest Pain

(Note: yes, I know it's more complex than that and I don't think the NYT is a good source for medical lit, but it's a concise illustration that there exists controversy over what used to be the golden goose.)
 
mehc012 said:
I mean, why fight to take away something that's already struggling?
Stents Show No Extra Benefits for Coronary Artery Disease
‘Unbelievable’: Heart Stents Fail to Ease Chest Pain

(Note: yes, I know it's more complex than that and I don't think the NYT is a good source for medical lit, but it's a concise illustration that there exists controversy over what used to be the golden goose.)
Click to expand...
Correct me if I'm wrong, but this is only looking at stable angina, so it's not that surprising that ACEi's, beta blockers and aspirin would do a decent enough job in managing it.

Where's the data comparing stents vs "conservative medical management" when dealing with unstable angina?
 
LebronManning said:
Not all neuroradiologists are interventionalists. That's why I said both they and neurologists are applying for the interventional neurology procedural fellowships. NSGY is protecting it by doing it themselves as opposed to letting the other guys take it over.
Click to expand...

Interventional neuroradiology created the field, neurosurgery is trying to gain control over it from them. It's exactly what happened with interventional cardiology taking over procedures that IR created.
 
NYCdude said:
Correct me if I'm wrong, but this is only looking at stable angina, so it's not that surprising that ACEi's, beta blockers and aspirin would do a decent enough job in managing it.

Where's the data comparing stents vs "conservative medical management" when dealing with unstable angina?
Click to expand...
Dunno if it's there; haven't looked at it. I'm not in any way trying to say that stents have no use or anything, just pointing out early signs of a possible shift away from 'stents fix everything'.
 
I think three years of IM just to apply to cardiology would be more hellacious than six years of integrated CT surgery. IM blows something absolutely fierce.
 
Winged Scapula said:
This is so true.

While there are always exceptions, you either want to be a surgeon or you don't and I think that usually becomes pretty clear by 3rd year.

There are some proceduralists who fancy themselves as Surgeons but that's because they don't know the difference.
Click to expand...

Gynecologists?
 
Winged Scapula said:
No.

I'm talking about IR, interventional Cards, etc. not people who actually do surgery.
Click to expand...

I’ve never heard an IC person call themselves a surgeon. I’m starting IC fellowship in a year. We do endovascular procedures. Sometimes advanced procedures (TAVR, TMVR, Watchman, etc) and mechanical support too. But we are cardiologists. Y’all surgeons can keep the “surgeon” name.
 
IMreshopeful said:
I’ve never heard an IC person call themselves a surgeon. I’m starting IC fellowship in a year. We do endovascular procedures. Sometimes advanced procedures (TAVR, TMVR, Watchman, etc) and mechanical support too. But we are cardiologists. Y’all surgeons can keep the “surgeon” name.
Click to expand...

I’m a lot more experienced than you and I have (seen a cardiologist refer to themselves as a cardiac surgeon, more than once) so we are even.

nimbus said:
How long has it been since you’ve seen a gynecologist operate? Ever scrub in with one?
Click to expand...

Yeah, yeah...we can argue about their skills but the fact is that Gyn is a surgical speciality.
 
IMreshopeful said:
Mkay
Click to expand...
I wasn't trying to be rude.

I've been an attending surgeon for over a decade and my point was that I've probably seen and interacted with a lot more other physicians than someone still in training. I don't think that should come as a surprise to anyone.
 
Winged Scapula said:
I wasn't trying to be rude.

I've been an attending surgeon for over a decade and my point was that I've probably seen and interacted with a lot more other physicians than someone still in training. I don't think that should come as a surprise to anyone.
Click to expand...

Yeah I still find it hard to believe you ran into a lot of cardiologists who refer to themselves as cardiac surgeons. There might be the occasional rare egotist out there who’s doing IC and fancies himself a surgeon but I have never, ever met a cardiologist - IC or otherwise - who has made that claim. Neither have any of the fellows, attendings, one medical residents/attendings I’ve ever worked with.
 
IMreshopeful said:
Yeah I still find it hard to believe you ran into a lot of cardiologists who refer to themselves as cardiac surgeons. There might be the occasional rare egotist out there who’s doing IC and fancies himself a surgeon but I have never, ever met a cardiologist - IC or otherwise - who has made that claim. Neither have any of the fellows, attendings, one medical residents/attendings I’ve ever worked with.
Click to expand...
I never said "a lot". I said more than one.

We can agree to disagree about my experiences.
 
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