Selective Digestive Decontamination (SDD) – The ICU Book

Lately I’ve been reading The ICU Book by Paul L. Marino.  Everyone in crticial care recommmends this book as standard reading for interns and junior residents, and I have to say it has been quite the read so far.

One of the articles in Marino’s book that has really stuck out to me has to do with selective digestive decontamination (SDD). Marino explains that in the presence of severe chronic illness, the G.I. tract becomes populated with more pathogenic organisms capable of causing invasive infections. He quotes one study that showed that hospitalized patients are often colonized with pathogenic organisms in the G.I. tract most notably aerobic gram-negative bacilli like Pseudomonas. This paper noted that the change in microflora is not environmentally driven, however it is directly related to the severity of illness in ICU patients. Marino recommends selective digestive decontamination for all ICU patients.

One example of this regimen includes a three-step decontamination process.

1. Oral cavity: a paste containing 2% polymyxin, 2% tobramycin, and 2% amphotericin to be applied inside the mouth with a gloved finger every 6 hours.

2. G.I. tract: 10 ml solution containing 100 mg polymyxin, 80 mg tobramycin, and 500 mg amphotericin and given via nasogastric tube every 6 hours.

3. Systemic: intravenous cefuroxime, 1.5 g given every 8 hours for the 1st 4 days of this therapy

Multiple years of randomized controlled trials have shown that ICU acquired infections are dramatically reduced with this kind of regimen. In one study that Marino quotes all 3 types of infections common in ICUs–pneumonia, urinary tract infections, and septicemia septicemia from vascular catheters–were significantly less frequent in patients who received selective digestive decontamination. Many clinical trials are showing a combined 40% relative reduction in the frequency of acquired infections in the ICU.

Marino mentions that over 20 years of experience with selective digestive decontamination and numerous reports of its efficacy clearly show the benefits related to selective digestive decontamination. However there continues to be a debate over the merits of this practice. Marino states two concerns that feed this debate. First the impact of SDD on mortality and also the possibility of the emergence of antibiotic resistant organisms. Marino points out that studies that support the relative reduction in mortality in ICU patients that have received selective digestive decontamination and also he points to studies that show no evidence of antibiotic resistance with use of a standard selective digestive decontamination regimen.

So the question is why don’t hospitals use this regimen in the ICU? I cannot speak for all hospitals, however I can speak for the UC Health. In our ICU we do not use a selective digestive decontamination regimen. I’ve questioned the fellows about this practice, and I usually receive an answer dealing with the concern of the emergence of antibiotic resistant organisms. When I explained that this was a huge part of Dr. Marino’s ICU book the fellows question the studies stating that most of these are over 10 years old. This prompted me to look again at the current data to see if SDD is still the huge benefit that Dr. Marino felt that it once was.

I found an article in the Expert Opinion of Pharmacotherapy, a metanalysis from this year which included 65 randomized controlled trials with over 15,000 enrolled patients, over a 25 year period.  This article concluded:

From an objective, and strictly evidence-based, perspective we conclude that SDD is recommended because there is level 1 evidence to support its use. Moreover, intensivists should be aware that SDD is a life-saving strategy: only 18 patients need to receive the full protocol of SDD to save one life. This makes the ethics of withholding SDD highly questionable.

This was incredibly shocking to me, because I felt that I have stumbled upon something in medicine with evidence so clear and for such a long term period that there seems to be absolutely no debate in the clinical literature.  With evidence this clear and strong, why isn’t SDD a routine in ICUs across the country? Are physicians really that set in their ways?

 

References:

Marino, Paul L. The ICU Book. 2007. Third Ed. Chapter 4 pg 63-80.

Silvestri L, van Saene HK, Petros AJ. Selective digestive tract decontamination in critically ill patients. Expert Opin Pharmacother. 2012 Jun;13(8):1113-29. Epub 2012 Apr 25.

Trust in the White Coat

Medical culture is a weird yet powerful force that bonds together those who practice medicine.  From the SOB in bed 2 to the frequent-flyer out in the waiting room, the connection that we get by speaking our medical lingo brings out a special bond  of the medical culture.  Its a large, sub-culture, and like many sub-cultures we have our different rules and lingo.  I would even argue that within our large medical sub-culture we have many many different smaller ones inside that.  Nurses, techs, doctors, etc.  And even among the doctors their tends to be this imaginary dividing line between specialties.

As a new resident, I’ve found it odd that the same day I’ve earned my long white coat, was also the same day the culture around me changed to the point where it was considered a “newbie” move to wear the long white coat around.  I was quickly made fun of for wanting to flaunt around the fact that now I was actually an MD.  It was a very odd feeling.

However, I have stood my ground, and continued to wear the long white coat despite what my fellow residents say.  While I admit, a large part of wearing the coat is for the extra pockets, I do enjoy the fact that it took me many years to earn it, and I do see it as a sense of pride.  But more-so, it turns out in the literature that the long white coat is actually a non-verbal way of instilling confidence, trust, empathy, and establishing a good doctor patient relationship. For proof please see the references below.

References:

http://www.ncbi.nlm.nih.gov/pubmed/22445730

http://www.ncbi.nlm.nih.gov/pubmed/16546951

http://www.ncbi.nlm.nih.gov/pubmed/18286342

http://www.ncbi.nlm.nih.gov/pubmed/16271913

http://www.ncbi.nlm.nih.gov/pubmed/20095290

http://www.ncbi.nlm.nih.gov/pubmed/2016013

 

Specialty Trends of 2012

According to the NRMP:

 

Match results can be an indicator of career interests among U.S. medical school seniors. Among the
notable trends this year:
• Dermatology, orthopaedic surgery, otolaryngology, plastic surgery, radiation oncology,
thoracic surgery, and vascular surgery were the most competitive fields for applicants.
• Emergency medicine programs offered 61 more positions and filled all 1,668 available
positions.
• Anesthesiology programs offered 78 more positions, and U.S. seniors filled 725 of the
919 positions offered.

 

Reference: http://www.nrmp.org/pressrelease2012.pdf

Most Competitive Specialties of the 2010 Match — for US Seniors

According to the NRMP, here are the most competitive specialties for the 2010 match Table 13 and Table 14 in the Results and Data 2010 Match.

Top Ten Most Competitive Specialties – Based on positions per US Senior 
— Positions per US Senior (aka allopathic graduate), is making the assumption that the specialty is more competitive due to the fact that many more seniors apply for it in relation to the number of actual positions.  
Rank Specialty Name Positions per US Senior
#1 Plastic Surgery (Integrated) 0.6
#2 Vascular Surgery (Integrated) 0.7
#3 Orthopedic Surgery 0.8
#4 Dermatology  0.9
#4 Neurological Surgery 0.9
#4 Otolaryngology 0.9
#7 Radiation Oncology 1.0
#7 General Surgery 1.0
#9 Radiology – Diagnostic 1.1
#10 Emergency Medicine 1.2

***Please note :: Thoracic Surgery (integrated) and urology were left out of this table since they only offer 10 positions and 7 positions respectively in the NRMP main match.

Top Ten Most Competitive Specialties – Based on percent of unmatched US Seniors  
— Percent of unmatched US Seniors is a good barometer of competitiveness.  This calculation takes only those students who ranked one specialty, then figures out the percent of those who did not match into the said specialty.

Rank Specialty Name Percent
Unmatched
#1 Plastic Surgery (Integrated) 26.5%
#2 Dermatology 25.1%
#3 Orthopedic Surgery 19.6%
#4 General Surgery 15.7%
#5 Otolaryngology 15.4%
#6 Neurological Surgery 15.1%
#7 Radiation Oncology 14.5%
#8 Physical Medicine & Rehabilitation (PM&R) 10.2%
#9 Obstetrics and Gynecology 8.6%
#10 Radiology – Diagnostic 6.5%

For comparison sake, Family practice and Pediatrics have a 2.5% unmatched rate for US seniors

USMLE Step 1 – 2010 Percentile Score

Hello everyone.  I received a phone call from a fellow medical student about determining a percentile score, and I told this person that it could be possible to figure out the percentile score this year from the information that the NBME gave us.

According to my score report (and others based on the information I’ve gathered), the NBME states:

“This score is determined by your overall performance on Step 1.  For recent administrations, the mean and standard deviation for first-time examinees from U.S. and Canadian medical schools are approximately 221 and 24, respectively, with most scores falling between 140 and 260.  A score of 188 is set by USMLE to pass Step 1.  The sandar error of measurement for this scale is six points.”

Making the assumption that USMLE scores follow a “normal (Gaussian) distribution” we can figure out the percentile grade.  Of course I do not know how big of an assumption I am making by saying that USMLE scores follow the normal bell curve.  Please note I am not a statistician.

So lets assume you have a three digit score of 245 on the Step 1 and would like to know percentile you fall into (I picked 245 for easy math – I was not fortunate enough to score this high).  As we know from our Step 1 studying, 68% of the population falls into the area of one standard deviation on both sides of the mean.  That means that 34% of the population falls on the upper half of this mean.  The mean on a percentile graph is of course 50%.

So we can say that if you received 24 points away from the mean in either direction (because that is one standard deviation according to the NBME) then you are 34% away from the mean in the same direction.  In this case if you scored a 245 then you are exactly 24 points above the mean.  We can also say then that you are 34% above the 50th percentile putting you into the 84th percentile.  Any score can be figured out using ratios of this.  Of course I realize my math is probably wrong, but this will give a person an estimate.

Keep in mind, my math could be TOTALLY wrong, but it seems to work out in my brain.  Here is a table with my calculated percentile scores.  Any corrections on my math would be appreciated.

Score Percentile (Estimate)
149 <1%
173 2.3%
197 16%
209 30%
221 50th Percentile 
233 70%
245 84%
269 97.7%
293 99.9%

[Similar Post – Check Out Real Board Scores for Step 1]

Sanford School of Medicine – Match Statistics

One thing that I learned sometime during my Pre-Med days was to look at match statistics of schools to determine how well they do at training their students.  I thought that was good advice.  Obviously, how well a school does training their students should correlate to a better match rate.  I mean it’s exactly like looking at how well certain colleges place their students into careers.

So, I took that to heart.  Now, I’ll be the first to admit, I wasn’t exactly afforded a large choice between medical schools.  What I mean to say is, I didn’t get into a ton of medical schools.  But hey, that doesn’t matter now does it?

So, before I even started medical school, I took an interest in the matching statistics of the schools I was applying to.  And after I was accepted at the Sanford School of Medicine (SSOM), I really concentrated on their matching stats, and to be honest we do pretty well.

I have compiled the matching statistics from SSOM since the year 2000 in a spread sheet, and I have found some interesting trends.

Match Stats


Since the year 2000 (including the 2010 match) – we have graduated and matched 545 students from SSOM with 93 going into Family practice which is 17.1% .   Compared to the US match rate of 7.4% matching into Family Practice (and only a 3% behind the leader), I would say that SSOM is doing pretty well meeting it’s mission.  And out of all the students who graduated since 2000 almost 45% of them have entered a primary care specialty (which would include Family Practice, Internal Medicine, Pediatrics, and Psychiatry).

Our medical school has also done a great job matching students into very competitive specialties as well. Dermatology has long been known as one of the most difficult specialties to match into.  Yet, three students from a class of 50, matched in both the 2007 and 2008 match.  Or to put it another way, 6% of our class those two consecutive years matched into a specialty in with only 1.8% of medical students are able to match (according to the 2009 match statistics).

While most of our students match in the midwest, some have matched into some of the most well known universities in the country including Baylor, Cleveland Clinic, Dartmouth, Emory, Massachusetts General, Mayo, UCSF, Rochester, Vanderbilt, Yale, and others.

So, if you’re a Pre-Med student, don’t worry if you don’t get into the Ivy league schools.  State schools, even little South Dakota, can help their students match into competitive specialties in well known programs.

——————
Top Ten SSOM Specialty Choices

  1. Family Practice
  2. Internal Medicine
  3. OB/GYN
  4. Anesthesia
  5. Pediatrics
  6. Psychiatry
  7. Emergency Medicine
  8. Radiology (Diagnostic)
  9. Pathology
  10. Orthopedic Surgery

Top Ten SSOM Match Locations

  1. South Dakota
  2. Minnesota
  3. Iowa
  4. Nebraska
  5. Wisconsin
  6. Kansas
  7. Michigan
  8. Missouri
  9. Texas
  10. Illinois 

The Perfect Medical Career

What are the characteristics of the perfect career?

This is a crucial question I’ve been trying to answer all of my adult life.  Sure, it’s true that I know I am going to become a physician, but what specialty will I pursue?  I’ve heard the same advice picking out my specialty that I had when I was trying to figure out which career I wanted to pursue.

It usually starts with something like ‘you need to figure out what your personality is.’  Then once you know yourself, you can assess your passions, likes and dislikes, and main interests.  Figure out your talents they say.  Find your passion.  Which specialty suits your interests?

The truth is I won’t find happiness using these methods.  Science (I personally haven’t read the literature on this but I have taken people’s word for it) has figured out what people truly want in their dream job.  And I was surprised to find out that it’s only three things…

  1. Autonomy
  2. Mastery 
  3. Purpose 

This is a huge revelation for me as I am trying to choose my future specialty.  And I think this is an incredible piece of knowledge for anyone trying to choose a future career.

Lets look at my situation.  Becoming a physician allows me to knock out two out of these three career characteristics automatically.  First, I’ll be a master at something.  Whether it be the brain, radiology, or taking care of the family’s medical problems, I’ll be a “master” no matter what my specialty.  Second, my career will serve a purpose.  Doctors, whether directly or indirectly, effect peoples’ lives and their health, which can obviously be very rewarding.  But the last one is the most tricky, autonomy.

I believe it is this last trait that many physicians feel like they are now missing in their practice, and may possibly be the main reason for physician burn-out.  Here are some immediate examples of this that I can think of right off the bat…

  •  – Surgeons at the beck and call of the ER.  Surgeon numbers are always much smaller than their medical counter-parts.  Thus, they usually take call much more often then their medical colleagues.  And by the very nature of their job, they have to take care of traumas and emergencies at all times of the day and night. So, surgeons are usually tied to their hospital.
  • – The doctor that I am shadowing mentioned that he’d love to go on mission trips around the world to help those in need.  But he feels like he cannot, because his nurse, the employees in his clinic, and his patients depend on him to be around.  So, he feels like he cannot leave.  I bet many physicians feel this way.  
  • – Student loans.  Physicians are graduating with some of the most atrocious student loan debt in the world.  When exactly are they suppose to take time off or pursue other interests?  

These are just three examples of the lack of autonomy in medicine.  I suspect there are probably way more.  I also suspect these are huge contributors to burn-out.

Now that I’ve learned this, I am definitely going to be looking into how my specialty choice will effect my autonomy.  Because honestly, that may be the one big factor that is keeping many physicians from being happy in their career.

[Via Study Hacks and TED – Daniel Pink]

What Do Doctors Make?

Great question.  While it’s easy to just google and find something, here is some American Medical Group Association referenced data compiled after a compensation survey in 2009.  This information seems legit because I got it from the U.S. Dept. of Human & Health Services.

Medical Specialties
Allergy $241,138
Cardiology $398,034
Cardiology – Branch ** $446,891
Cardiology – Cath Lab $471,746
Cardiology – Echo Lab/Nuclear $414,500
Cardiology – Electrophysiology Pacemaker $437,000
Critical Care Medicine $268,250
Dermatology $350,627
Dermatology – Branch $334,135
Dermatology – Mohs $516,468
Endocrinology $212,281
Family Medicine $197,655
Family Medicine – Branch $187,727
Family Medicine with Obstetrics $202,047
Family Medicine with Obstetrics – Branch $188,785
Gastroenterology $389,385
Gastroenterology – Branch $447,184
Genetics $193,344
Geriatrics $211,425
Hematology & Medical Oncology $315,133
Hematology & Medical Oncology- Medical Oncology Only $248,623
Hospitalist $211,835
Hypertension and Nephrology $246,049
Infectious Disease $222,094
Intensivist $273,520
Internal Medicine $205,441
Internal Medicine – Branch $189,187
Internal Medicine – Office Only $168,133
Neurology $236,500
Occupational/Environmental Medicine $214,146
Ophthalmology – Medical $231,493
Orthopedic – Medical $265,345
Pain Management – Non-Anesthesiology $260,350
Palliative Care $186,924
Pediatrics & Adolescent – Adolescent Medicine $205,395
Pediatrics & Adolescent – Allergy $195,973
Pediatrics & Adolescent – Branch $183,892
Pediatrics & Adolescent – Cardiology $244,944
Pediatrics & Adolescent – Developmental Behavioral $170,769
Pediatrics & Adolescent – Endocrinology $185,901
Pediatrics & Adolescent – Gastroenterology $236,700
Pediatrics & Adolescent – General $202,832
Pediatrics & Adolescent – Hematology/Oncology $205,999
Pediatrics & Adolescent – Hospitalist $167,953
Pediatrics & Adolescent – Infectious Disease $199,165
Pediatrics & Adolescent – Intensive Care $256,913
Pediatrics & Adolescent – Internal Medicine $208,838
Pediatrics & Adolescent – Neonatology $265,000
Pediatrics & Adolescent – Nephrology $217,767
Pediatrics & Adolescent – Neurology $209,955
Pediatrics & Adolescent – Pulmonary $176,974
Pediatrics & Adolescent – Urgent Care $196,934
Physical Medicine & Rehabilitation $236,500
Psychiatry $208,462
Psychiatry – Child $214,304
Psychiatry – Inpatient $218,472
Psychiatry – Outpatient $184,946
Pulmonary Disease $278,000
Pulmonary Disease – Sleep Lab $259,444
Reproductive Endocrinology $317,943
Rheumatologic Disease $219,411
Sports Medicine $214,249
Urgent Care $215,625
Surgical Specialties
Bariatric Surgery $360,000
Cardiac & Thoracic Surgery $507,143
Cardiovascular Surgery $509,302
Colon & Rectal Surgery $366,895
Emergency Medicin
e
$267,293
Emergency Medicine – Pediatrics $217,551
General Surgery $340,000
General Surgery – Branch $309,750
Maternal/Fetal Medicine $394,121
Neurological Surgery $548,186
Neurological Surgery – Pediatrics $612,851
OBGYN – General $294,190
OBGYN – Branch $280,606
OBGYN – Gynecological Oncology $406,000
OBGYN – Gynecology only $218,607
OBGYN – Obstetrics $301,773
OBGYN – Urogynecology $301,777
Oncology – Surgical $337,475
Ophthalmology $325,384
Ophthalmology – Branch $277,975
Ophthalmology – Pediatrics & Adolescent $283,853
Ophthalmology – Retinal Surgery $443,827
Oral Surgery $380,500
Orthopedic Sports Medicine $484,320
Orthopedic Surgery $476,083
Orthopedic Surgery – Branch $483,400
Orthopedic Surgery – Foot & Ankle $399,445
Orthopedic Surgery – Hand $465,006
Orthopedic Surgery – Joint Replacement $580,711
Orthopedic Surgery – Pediatrics $424,367
Orthopedic Surgery – Spine $641,728
Orthopedic Surgery – Trauma $465,773
Otolaryngology $365,171
Otolaryngology – Branch $343,698
Otolaryngology – Head & Neck Surgery $334,250
Pediatric Surgery $400,591
Plastic & Reconstruction $388,929
Thoracic Surgery $405,842
Transplant Surgery – Kidney $348,000
Transplant Surgery – Liver $433,333
Transplant Surgery – Medical $354,158
Trauma Surgery $399,558
Urology $389,198
Urology – Branch $317,322
Vascular Surgery $403,041
Radiology/Anesthesiology/Pathology Specialties
Anesthesiology $366,640
Anesthesiology – Pain Clinic $379,000
Dermapathology $333,250
Diagnostic Radiology – M.D.s Interventional $478,000
Diagnostic Radiology – M.D.s Neuro-Interventional $458,187
Diagnostic Radiology – M.D.s Non-Interventional $438,115
Diagnostic Radiology – Mammography $513,402
Nuclear Medicine (M.D.s Only) $386,506
Pathology – M.D.s Anatomic $285,173
Pathology – M.D.s Clinical $272,500
Pathology – M.D.s Combined $344,195
Radiation Therapy (M.D.s Only) $413,518
Midlevel Providers
Dentistry $167,389
Podiatry – Medical $190,596
Podiatry – Surgical $232,121
Podiatry – Surgical – Branch $175,565

* This information was obtained from the 2009 Medical Group Compensation and Financial Survey published by the American Medical Group Association® (AMGA). For further information, visit AMGA’s Web site at http://www.amga.org/

** Branch is defined as: A physician who practices at a satellite clinic or office removed from the main campus and may be subject to different practice patterns and productivity standards.

A couple notes about this chart, first I didn’t know that according to the government Emergency Medicine is a surgical specialty and being a dentist makes one a mid-level provider.  I also didn’t find any statistics related to this chart.  So I am unsure if survey responses over/under represent a certain region or demographic.  Also, unsure if survey responses are from a fair number of new, current, and soon-to-be retiring practitioners – as the point of one’s career would make a large difference on current income. Next, I do not know if these compensations take into account any physician owned medical building or property (ie: physician hospitals, physician owned MRIs, etc).  Lastly, I couldn’t find out if this was net-pay or gross pay or before malpractice premiums pay or something other than those.

Average Take Home
Medical Specialties — $252,106
Surgical Specialties — $390,866
Rads/Anesthesia/Path — $389,041
Mid-Level Providers — $191,418

As I looked at this whole table, I was a little surprised.  Not really by the amount physicians made, I had a good idea already, but the fact that just yesterday I posted that physicians are having a hard time keeping their practices open.  This data just by itself strikes me as odd that physicians cannot make enough money to keep practicing in some instances.
This makes me wonder, how much are those student loan payments?  I am figuring that I’ll be close to $200,000 in debt post-med school.  By bringing home a salary of $160,000/year, am I really not going to be able to pay off loans, pay for a family, and pay for a decent mortgage?

Something doesn’t seem like it connects here.  Either student loan repayment is VERY expensive (which I guess I wouldn’t really be too surprised by that – the banks definitely know how to steal everyone’s money) or these surveys aren’t accurate in some way. Or it could be something else entirely.  Who knows?

Real Board Scores for Step 1

The other day in Pathology class we had the lecturer tell us that if you want to get into a competitive specialty then you have to get a 260 on the USMLE Step 1.  I know for a fact he was exaggerating, but others in our class think this is true.  


Maybe those people don’t realize how high a 260 is for a score on the Step 1.  Let me give you a base of comparison, according to the Medfriends Score Estimator, a 260 on the Step 1 is like getting a 42 on the MCAT.  Possible?  Sure.  Probable?  NO. 


Yes it’s true, the match is getting more an more competitive with each passing year.  As medical student enrollment (as thus graduates) as been steadily increasing, slots for residency have not.  Thus creating a situation in which the match has become more competitive than ever.  But what kind of scores does it take on the USMLE Step 1 to match into things anyway?


Well out of 14,958 US graduates who applied to match in 2009, 13,646 of them matched (91.2%) and 1,312 did not match (8.8%)*.  The average score on the Step 1 for matching US grads was 225 across all specialties.  Obviously the score was dependent on specialty.  Which I’ll list here.  The average score for non-matching US grads was an average of 216.


*But what if you don’t match?  You scramble. This is a time where unmatched applicants and programs go in an all out free-for-all of faxing, calling, and emailing to match students to program openings.  From what I understand, it’s a nightmare.  If you’re interested, you can find a lot more about the topic on SDN and other medical student blogs.  


Ok, so what does it take on the Step 1 to get considered in the specialty you want to go into? Well here’s a list of the AVERAGE MATCHING USMLE Step 1 scores for each of the specialties.  

  • Anesthesiology: 224
  • Dermatology: 242
  • Diagnostic Radiology: 238
  • Emergency Medicine: 222
  • Family Practice: 214
  • General Surgery: 224
  • Internal Medicine: 225
  • Internal Med/Pediatrics Combined: 225
  • Neurological Surgery: 239
  • Neurology: 225
  • Obstetrics & Gynecology: 219
  • Orthopedic Surgery: 238
  • Otolaryngology (ENT): 240
  • Pathology: 227
  • Pediatrics: 219
  • Physical Medicine and Rehabilitation (PM&R): 214
  • Plastic Surgery: 245
  • Psychiatry: 216
  • Radiation Oncology: 238
  • Transitional Year: 236
So with some mathematics applied = (13646/14958)*225 + (1312/14958)*216 = we can figure that the average score for all (matching and non-matching) US grads applying to the match in 2009 was around 224.  So, you can look above data and get a good idea how competitive the specialties are based on USMLE Step 1 score.  

I better get studying for that exam.  


[Similar Post – Check Out USMLE Step 1 – 2010 Percentile Score]

CT Surgeon Shadow

Over the break, I had a chance to shadow a cardiothoracic surgeon for a day.  This surgeon was one of the partners at North Central Heart, also known as the Avera Heart Hospital of South Dakota.  


The experience was pretty cool.  The cardiothoracic surgeons and handful of interventional cardiologists that I had a chance to meet were receptive to students, and I learned a lot about cardiac pathologies.  


The visit was also disheartening for those interested in CT surgery.  Out of the group of surgeons, only one (out of four) would recommend this specialty to their son/daughter.  While all of them were attracted to the field based on their interests in cardiac diseases, acute patients, and surgical treatments, they weren’t sure if that was enough reason to pursue the field in today’s environment.  


Of course declining reimbursements was one of their main reasons.  But also, the lack of jobs.  Most of them believed that the thoracic surgeon colleges were training too many CT surgeons.  If they keep it up, the job problem will only worsen.  “How would you feel if you put in 10 years of post medical school training only to find out that you can’t get a job?”  


It was eye opening.  The surgeon that I was shadowing told me that he talked his own son out of becoming a CT surgeon.  Told him to be a neurosurgeon, ENT, urologist, or orthopod.  This field is extremely interesting to me since they deal with very sick patients, interesting pathologies, and surgical treatments.  But it’s scary that even the current cardio-surgeons here in South Dakota think their specialty is losing the “turf battle” to cardiologists, vascular surgeons, and interventional radiologists.