The Cardiothoracic Surgeon

What are Cardiothoracic Surgeons?


CT surgeons are experts on everything in the thorax.  They deal with the complex physiology of the heart.  Pretty much everything that includes the heart, lungs, and mediastinum is their domain.


CT surgery is usually reserved for critically ill patients.  Patients who need surgeries for conditions dealing with blocked coronary arteries, thoracic aneurysms, congenital abnormalities, pulmonary resections, mediastinoscopy, bronchoscopy, esophageal cancer, and achalasia.


Training


CT surgeons have traditionally gone through one type of training curriculum.  A person would first get an undergraduate degree then go to medical school.  After medical school, one would apply for a five year general surgery residency.  Upon finishing this and becoming a general surgeon, one would decide to peruse CT surgery and then apply for and complete a CT surgery fellowship which is usually 2-3 years.


In the recent past, alternative methods to obtain training in cardiothoracic surgery have emerged. A new pathway to a residency in cardiothoracic surgery is to first complete a training program in vascular surgery, followed by two or three years of training in cardiothoracic surgery. There are now several training programs that offer, within the same institution, a 4+3 plan, so that during the four years of general surgery training, a resident has the opportunity to spend some time on cardiothoracic surgery rotations. Upon completion of training, the resident is then eligible to become certified by both the American Board of Surgery and the American Board of Thoracic Surgery. In addition, some institutions now offer an integrated six-year clinical program that will match medical students directly into a cardiothoracic pathway. It is anticipated that more six-year integrated programs will emerge in the near future.


The Problem


Seems like a sweet career.  Saving peoples lives by surgical intervention of the heart and lungs.  Also, I hear that CT surgeons make bank.  If you are a surgical type, who doesn’t mind long hours, hard work, and lots of call, why wouldn’t you consider a rewarding career in this specialty?


How about lack of jobs?  Somewhere around 2005 (I just started researching this topic so I’m not exactly sure when this went down)  graduating CT surgeons were not able to find jobs.  Who in their right mind would go through all of that schooling (undergrad + medical school), and all of that training (8-10 years of residency) to get into a career where you couldn’t find a job.  Right away, practicing CT surgeons knew that this was a problem.  You can see this on the professional websites for The Society of Thoracic Surgeons and the American Association for Thoracic Surgery.  I think that those sites have a lot of medical student recruitment information for a specialty that is supposedly so competitive, well paying, and has a bright future.  Somehow, I’m having trouble believing that this is the case.  


No jobs?  How?


You see nobody sums it up better than Charles R. Morris in his book The Surgeons: Life and Death in a Top Heart Center.  

The Plight of the Cardiac Surgeon


Consider the CABG, for the last forty years the bread-and-butter operation for the average heart surgeon.  During the decade 1993-2003, the number of CABGs in the United States declined about 11 percent, from about 340,000 to just over 300,000, even though the prime-age patient population grew by more than a fourth.  Interventional cardiology, in the meanwhile, has been struggling with exploding workloads.  Stents and angioplasties, the main catheter-based CABG substitutes, had more than doubled, to more than a million, by 2006.  By 2000 or so, one- and two-coronary bypass operations were already becoming a rarity.  


Rubbing it in, insurance reimbursement rates for CABGs have been steadily falling as well.  Medicare reimbursement for the standard leg-vein triple-bypass operation is down 20 percent since 1998, or by about a third if inflation is taken into account.  Private insurers pay better rates than Medicare, but the gap is narrowing fast as health plans consolidate and the demand hospital wide price concessions.  Fees for interventional cardiologists have been dropping even faster than for heart surgeons, but soaring volumes more than make up the difference. 


Signs t
hat the wolf is really at the door came in the spring of 2006, when seventeen newly minted cardiothoracic surgeons failed to find jobs – the first time that has ever happened.  The accreditation authorities responded by cutting back on accredited programs and residency slots.  Worse, there is evidence that the best candidates may be drifting towards other specialties.  Cardiothoracic residency slots have always drawn a surplus of candidates.  But in the 2006 national residency match, there were only 102 applications for 126 approved slots.  Eleven of the applicants then dropped out before the match, so 35 slots were not filled.  That is unheard of – like Harvard going begging for undergraduate applications.  The effect on academic program staffing will be profound.  In the academic year 2004-2005, the first-year residency class was 141.  In 2007-2008, when the group from 2006 match begin their residencies, there will be only 91, a drop of 35 percent.