Why is cardiothoracic surgery so unpopular?

[DZT]

I hear all this talk that ortho, ent and neuro are toughest residencies to get but how come CT surgery is pushed to the back of the bus and why is it not the pick of the litter when it comes to residencies? The job satisfaction, pay, intellectual challenge are great; I know that the residency and hours after that are pretty bad, but doesnt that go for other subspecialties as well.

Also, why are 50% of CTs retiring by 2010?

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[GobindSingh]

I've wondered this myself. But there are reasons for why CT surgery is not the most desireable.

First of all, you deal with the most desperate patient population - once they come to you they're essentially in dire straits. CT surgery takes about 8 years to complete - including both fellowship and residency. Also, many Cardiologists are boning in on CT surgery's territory. This is more a product of a lack of CT surgeons getting out there and doing what they should to bring in business than any skill disparity tween 'logists and surgeons.

I think the future is bright in CT surgery - fewer people are going into it, heart disease is on the rise. If you can do anything an interventional cardiologist can do and also have the skills of a surgeon, you can do quite well. Also, remember that CT surgeons still have the highest average income of all doctors.

 

[Idiopathic]

I am interested in congenital CT, but it is a ridiculous long training period, and very few peds surgery spots are available...i dont want to do a GS residency, and lose the numbers game and have to do chole's the rest of my career...

 

[doc05]

There is a little more to it than that.

First, realize that the training is incredibly demanding, and as an attending you still are working 10 times harder than everyone else.

With interventional procedures on the rise, cardiologists are taking a large portion of the patient population away from the CT surgeons. And while a CTS may be able to do cath, they don't want to. It has been a number of years since this was handed over to cards.

Remember: CT surgeons depend on referrals from the cardiologists.

It is also very tedious work. Something like 80% of what they do is CABG.

And yes, average income is very high, but this includes many many surgeons who trained 15 or 20 years ago and are now making close to 1 mil per year. Many new CT grads are earning far less than the commonly quoted "mean salary."

Also, why are 50% of CTs retiring by 2010?

probably because of their age. CT was very hot 15 or 20 years ago. That means there are many surgeons who are now 50-60 years old. By 2010, a lot of them will be ready to retire.

 

[doc05]

Originally posted by Idiopathic
I am interested in congenital CT, but it is a ridiculous long training period, and very few peds surgery spots are available...i dont want to do a GS residency, and lose the numbers game and have to do chole's the rest of my career...

for congenital CT surgery, you don't train in peds surgery. you do GS (5 years) + CTS (2-3 years) + peds CTS (another 2-3 years).

 

[Idiopathic]

I have been told both...either way, arent there several spots to get tripped up on? if someone could guarantee me a 9-10 year track, I might consider it 🙂

 

[Mirror Form]

It looks like the main trend is that most surgerical specialties where there is a medicine field ("-ology") sharing the same name are getting to be worse fields. I read an article in the wallstreet journal about why CTS is getting so unpopular these days. The cardiologists are making life as a CTS much less desirable. It used to be the CTS guys were the big hotshots, but now they're turning into the cardiologist's little whipping boys. I think I heard that groups of cardiologists are demanding around $100,000 / yr from each CTS surgeon for referrals, and if the CTS surgeons don't want to pay, they'll find someone else who will. Maybe as all the CTS surgeons retire though, things will change.

 

[womansurg]

Originally posted by doc05
It is also very tedious work. Something like 80% of what they do is CABG.

VERY tedious work. Many CT surgeons hire PAs to harvest the vein, and open and close the chest, so that the only part they are left with is the graft anastamoses. And as you say, there isn't a lot of variability. It gets frustrating to do the same case over and over again.

I was about 10 days into my CT rotation and I felt like I never wanted to see a CABG again as long as I lived.

 

[maxheadroom]

Doctor comes to you and says, "You have a couple of bad spots in your coronaries. We can send you to a surgeon to have a long procedure with a rough recovery, requiring you to be on a heart/lung machine. Or, we can send you to a cardiologist who can put a couple of stents in with some sedation. You'll stay in the hospital overnight and go home the next day." Which would you choose? I know my answer.

 

[edinOH]

I think I heard that groups of cardiologists are demanding around $100,000 / yr from each CTS surgeon for referrals, and if the CTS surgeons don't want to pay, they'll find someone else who will. [/B]

That is illegal as hell. Kick-backs for referral are a no-no!

 

[Mirror Form]

Originally posted by edinOH
That is illegal as hell. Kick-backs for referral are a no-no!

It's not technically a kickback if 100k is for "joining their group," in which case they'll get referrals from them.

 

[Winged Scapula]

Originally posted by GobindSingh


I think the future is bright in CT surgery - fewer people are going into it, heart disease is on the rise. If you can do anything an interventional cardiologist can do and also have the skills of a surgeon, you can do quite well. Also, remember that CT surgeons still have the highest average income of all doctors.

Actually, surgically-treated heart disease is falling - we eat healthier, exercise more and live longer than our parents and grandparents. As mentioned above, Interventionalists are taking more and more of the pie and its only a small percentage of what used to come to the OR that are treated by CTS.

The average income is not so impressive anymore - I've seen recent grads have trouble finding positions at all, let alone ones that paid anymore than a General Surgeon.

I predict hazy future for CTS.

 

[Mirror Form]

Originally posted by Kimberli Cox
Actually, surgically-treated heart disease is falling - we eat healthier, exercise more and live longer than our parents and grandparents. As mentioned above, Interventionalists are taking more and more of the pie and its only a small percentage of what used to come to the OR that are treated by CTS.

Hmmm, it's true that we're eating healthier then before, but Americans are still far from eating healthy and it's hard to predict the future. Back when my father graduated medical school, he chose not to go into cardiology because everyone thought cardiologists would all be out of work.

Keep in mind that just as this huge CTS retirement thing happens in 2010, the baby boomers will all be hitting their mid to upper 60's. Heart surgeons may have more business then they could handle! I guess only time will tell though.

 

[doc05]

Originally posted by Kimberli Cox
Actually, surgically-treated heart disease is falling - we eat healthier, exercise more and live longer than our parents and grandparents. As mentioned above, Interventionalists are taking more and more of the pie and its only a small percentage of what used to come to the OR that are treated by CTS.

The average income is not so impressive anymore - I've seen recent grads have trouble finding positions at all, let alone ones that paid anymore than a General Surgeon.

I predict hazy future for CTS.

I have to disagree with you on this. As a whole, the U.S. is getting very very fat. We all know that overweight and obesity are strongly related to DM and CAD.

Not that many people are exercising. Look at today's kids. They are mostly a bunch of fat little slobs who eat ring dings and spend all their free time in front of the tv/xbox/computer.

I have also read (don't remember where) that while the percentage of patients being treated by CTS is falling, total number of patients is on the rise, so the future may not be so bleak for CTS.

Obviously, long-term predictions about something so specialized, particularly when unproven technology is in the mix, would be foolish.

 

[Winged Scapula]

Originally posted by Sledge2005
Hmmm, it's true that we're eating healthier then before, but Americans are still far from eating healthy and it's hard to predict the future. Back when my father graduated medical school, he chose not to go into cardiology because everyone thought cardiologists would all be out of work.

Keep in mind that just as this huge CTS retirement thing happens in 2010, the baby boomers will all be hitting their mid to upper 60's. Heart surgeons may have more business then they could handle! I guess only time will tell though.

Never said we were eating healthy. My point is that SURGICAL management of cardiac disease is on the wane - more and more procedures are done in the interventionalist's hands, not in the OR. There will always be a need for CTS, I agree, but I'm not sure that they will have the business that they once had. But as you note, predicting the future is risky business.

 

[droliver]

A lot of the apathy has to do with the fact that their reimbursements for a CABG has fallen over 75% from the mid 1980's WITHOUT adjusting for inflation. It was a lot easier to tolerate the hardships of being a cardiac surgeon when you made mid seven figures (in some cases) as compared to the mid six figures you would expect today. Being increasingly dependent upon the whims of referring interventional cardioloists is also a very frustrating and degrading experience that many complain about.

 

[Been there]

CTS- fellowship is no desirable for several reasons:
1) long training period. 5-7+ yrs of G-surg then 2-3 yrs of CTS
(if you want ped-ct, you may have to put in 1 extra yr, and no, you may not do a ped-surg fellowship instead of the CT fellowship. This simple reason is the CT-surg board will not board you for cardiac surgery.)

2) Bad life style, the dissecting aorta and the stent complications never happens during daytime (I think this is just Murphy's Law). They happen on the last stent case of the day , or finally gets diagnosed by the ER at 10pm. So, you start the case at midnight if lucky, and you'll be home no earlier than 4-6 am. Remember, your first case is usually 7:30 am. That is why many don't even go home til the next evening.

3) The number of cases (mainly CABG) is decreasing. This is simply the effect of the non-re-occulsive stents. The number out of Harvard published in the NY times several months ago suggest a possible drop of 25% (this number was given to the NY times by the Cardiothoracic surgery department).

Cardiologist are still not making the same salary as CT-surg in an academic institution.Cardiothoracic surgeons can do what the cardiologist are doing with the stent techonolgy, but they gave up that turf many years ago. It will be a cold day in hell when the cardiologist will share that gold mine with the surgeons.

The referral bit for money sound like a urban legend to me. It is totally illegal either way he was putting it. If any practice are doing that, the surgeons involved should reported the cardiologist/ group to their state medical board, and the FTC for unfair business practice.

But, Urban legends are the reason why I come to get a good laugh.

 

[Mirror Form]

Originally posted by Been there
The referral bit sound for money sound like a urban legend to me. It is totally illegal either way he was putting it. If any practice are doing that, the surgeons involved would of reported the cardiologist/ group to their state medical board, and the FTC for unfair business practice.

But, Urban legends are the reason why I come to get a good laugh.

Apparently you haven't been around as much as you think. There are many loopholes to disguise income transfers so that they aren't "kickbacks" per say. The referral bit that I quoted is happening right in my home town. But if you don't want to take my word for it, just check out the September 10th edition of the Wall Street Journal and you'll see the article for yourself. It's titled:

Transformation of Heart Care
Is Putting Specialists at Odds

When Surgeons Rebuffed Offer to Join
Medical Group, Cardiologists Cut Them Off

By GEETA ANAND and RON WINSLOW
Staff Reporters of THE WALL STREET JOURNAL

 

[Been there]

Most private practice surgeons are already part of a group, but usually a cardiothoracic group. Most groups must have a good reputation inorder to survive. Just because you think disguising funds can fool the goverment, that is another urban legend within itself. If the cardiothoracic practice can show changes in referral pattern just because they chose not joining the cardiology group without gross medical errors and litigations, they can establish extortion. It is very difficult to hide kickbacks.
In the academic arenas, this can't even be an issue.

 

[Mirror Form]

Originally posted by Been there
Most private practice surgeons are already part of a group, but usually a cardiothoracic group. Most groups must have a good reputation inorder to survive. Just because you think disguising funds can fool the goverment, that is another urban legend within itself. If the cardiothoracic practice can show changes in referral pattern just because they chose not joining the cardiology group without gross medical errors and litigations, they can establish extortion. It is very difficult to hide kickbacks.
In the academic arenas, this can't even be an issue.

LOL, welcome to reality! The cardiothoracic surgeons in the article were part of a very well respected group of 8 CTS in Baltimore (Dr. McDonald's group). In 1998 the biggest group of cardiologists in Baltimore, the Midatlantic group, offered to let Dr. McDonald's group join w/ midatlantic. The catch is that it would require each CTS to pay 100,000 per year extra. Basically, the cardiologists were insisting on the CTS cutting them in on the profits of heart surgery. Dr McDonald's group offered to join w/o such a high fee, but MidAtlantic refused. MidAtlantic found CTS surgeons from elsewhere that would join the group for the high price, and basically blacklisted Dr. McDonald's group from referrals. Currently in 2003, Dr. McDonald's group is dwindling in numbers, and the MidAtlantic group is thriving. Still think it's so hard to hide kickbacks?

 

[Been there]

I am sure there are other reason for that. Not just about joining a specific group. If it is only because he refuse to join a specific group and he can establish this with his decrease number of referral without other influence, that is a big law suit waiting to happen. In medical practice, just because it sound legal doesn't mean it really its. Perhaps, you should ask your medical school CT surgeons about this.

 

[Mirror Form]

The idea a cardiologist (or any doctor) can't stop referring patients to another doctor once they've started, unless they can prove in a court of law it was for a "good reason" is pretty silly. Since the Midatlantic cardiologists now have cardiothoracic surgeons in their own group, there's no reason why they can't refer patients to them instead of other groups of cardiothoracic surgeons they used to send patients to. Here's a quote from that WSJ article I mentioned earlier:

"That's typical of other cardiologist-surgeon groups, and other multispecialty physician groups, which have become increasingly common in the past decade. These groups typically are exempt from anti-kickback or self-referral laws, and doctors aren't required to disclose to patients their financial arrangements with colleagues."

There is actually a lawsuit on going, but I don't believe it's about the lack of referrals so much as because the Midatlantic cardiologists were literally lying to patients, telling the patients who wanted to see surgeons from Dr. McDonald's group that those surgeons didn't do that particular operation, or that that surgeon had retired, etc. However, I don't think the lawsuit is going anywhere because these things are hard to prove. Also, Dr. McDonald, was asked by his hospital to step down as the head of cardiothoracic surgery because of the lawsuit against Midatlantic. That's probably b/c the hospital is afraid of losing business from the cardiologists.

 

[Been there]

Actually, they are not exampted. It is illegal according to the bylaws of the american college of surgery to set up self referral practices. The american college of surgery can inforce the law a dis-board those surgeons.

here it is:

"C. A surgeon must refuse to split fees.

Fee splitting as an inducement to refer a patient to another physician is unethical. The premise for referral must be quality of care. Violation of this tenet disqualifies an applicant. If a surgeon who is already a Fellow violates this principle, it is a cause for expulsion from Fellowship.

Many states have laws that forbid any form of fee splitting, and there is no state that sanctions it. Additionally, federal law makes illegal any form of rebate, kickback, or splitting of fees that includes any federal money. Thus, such illegal inducement cannot be considered an item of deductible business expense."

that mean "no no" on medicare patients

http://www.facs.org/fellows_info/statements/stonprin.html#3e

just ask your surgery attendings.

 

[Mirror Form]

Originally posted by Been there
Actually, they are not exampted. It is illegal according to the bylaws of the american college of surgery to set up self referral practices. The american college of surgery can inforce the law a dis-board those surgeons.

Hmm, I guess it's a good thing you didn't go to law school. I'll try and explain this one more time. There is no fee splitting going on in a "strict legal sense." The cardiothoracic surgeons are just contributing portions of their fees to the practice's overhead costs (secretaries' salaries, equipment, etc..). That portion happens to be $100,000 more per year then the cardiothoracic surgeon's expenses would be if they weren't in a group w/ cardiologists. Therefore the cardiologists can pay that much less of their own expenses and pocket the rest. So, even though it amounts to fee splitting in the end, it's still legal and becoming increasingly common. I don't like it anymore then you do!