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

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 

Tough Decision – Career and Family

Becoming a physician is no easy task.  The long journey is difficult.  But when discussing my career choice with those who are not physicians I always get the cliché answer – “It’ll all be worth it in the end.”

How do they know?

People act as though, that while the road to becoming a physician is long and difficult, some nirvana exists as soon as training gets over.  What do they think happens?  That I’ll become a god, who saves lives with my healing touch, and the government will come print me money in my basement.  I feel like some people believe that.

Well truthfully, that won’t happen.  In fact, physicians are leaving the practice of medicine all the time due to burning out, long work hours, no respect, no control, and not enough pay.  Yes physicians make more than the average joe, but they also have years of student loans and compiling interest that need to be paid off – the average joe is blessed not to have that burden.

So why become a physician?

The chance to affect someone’s life, in a way that no other career can.  Help bring a life into existence or pull someone from the brink of death.  That is the kind of thing that I am working towards.  Having a career that is meaningful and worthwhile, not something I do just to make money.  But it is these life and death careers that demand the most from physicians.  OB/GYN, neurosurgery, cardiology, cardiothoracic surgery, transplant surgery, trauma and critical care, and others are all intense life and death types of specialties.  Doctors are required to put the patients’ needs ahead of all others.  That means that sometimes even a physicians family or own needs are put aside when taking care of these high acuity patients.  The job is extremely rewarding, but at what costs?  Family and marital problems, or even the physician’s own sanity? I could choose a specialty that affords me much more flexibility for my lifestyle, but then will I be loosing some of the rewarding aspects that go along with the more intense patients?

This is something I’ll be thinking a lot about for the next year, as I attempt to narrow down my specialty choice.  It’s going to be a tough decision.

EDIT:: To see this in action, please watch Hopkins – it’s a great series that touches on this issue an many others.

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]

Handbook of Neurosurgery by Greenberg

Those in the neurosurgery circles are pretty excited about Dr. Mark Greenberg’s new edition of the Handbook of Neurosurgery hitting shelves soon.

Dr. Greenberg, a neurosurgeon and director of neurosurgery in Florida, is most widely known for his work producing this book.  This book has been considered by many in the neurosurgery world as the “bible” of neurosurgery.  Every student who is interested in neurosurgery is advised to get one, every neurosurgery resident has one close, and every neurosurgery attending has at least a couple sitting on his bookshelf.

Just today, Dr. Greenberg on his blog posted a contest with the prize being a free copy of his newest edition.  I threw my name in the hat and I won!

I never won a contest before.  I feel awesome!

How Am I Choosing A Specialty?

After reading the Ultimate Guide to Choosing a Medical Specialty by Brian Freeman, more than three times, scouring the internet for hints and tips, and asking every physician I’ve encountered for advice in picking a specialty, I think I may have figured out a couple things about how I am currently going about picking my favorite specialties.

At one time I had read somewhere that the best way to really chose a specialty is to sit down and think of the real reasons that you went to medical school.  This may sound stupid or naive to some, but I went to medical school to save lives.  Seriously, that was my real over-arching reason for pursuing this career.  Now, I realize that most of what physicians do isn’t saving lives, in fact most physicians just make patients lives better by managing chronic disease.  Other reasons I decided to go to medical school were to help people, have an intellectually challenging career, job security, and a salary where I know I’d be able to easily afford the necessities of life without ever worrying about pinching pennies.  Prestige, respect, reputation, and community status played a far lesser role in my decision to become a doctor.

In this context, I’m going to try to objectively think about which specialties actually do some “life-saving.”  Others could probably add some to this list, but this is the best I can do off the top of my head.

  • Emergency Medicine
  • Cardiology/Cardiothoracic Surgery
  • Neurology/Neurosurgery
  • General Surgery
  • Internal Medicine/Pediatrics
  • Anesthesiology
  • OB/GYN
  • Psychiatry 

Out of this list, there is not one acute life-threatening scenario that I can think of that this group of specialist would not be able to handle.  I am assuming of course that General Surgery can amputate gangrenous limbs and handle all but neurologic and thoracic trauma surgery cases.  One could even argue that this list could be narrowed down even farther.  But I think this is a good representation of specialties that work directly on patients in acute situations, that can and do make life and death decisions and provide life-saving treatments.  (Again, I’m just throwing this up in the 10 minutes it takes me to throw together a blog post and may be missing some – and I my mind is just racing right now so I’m just throwing down what I can).

As you can see at this point, a large portion of these make up my top list of specialties I am regarding as my top choices.

Another tip that many physicians have suggested is to decide whether one is a surgeon or a medical physician.  I’ve sat down and pondered this over and over.  Am I a surgeon or am I medical?

Over the last couple years this question has always been in the back of my mind.  Just in the last couple months or so, I think I am on venturing over to the surgery side of the fence.  After I made what I thought was a huge proclamation about myself and my future, close friends of mine said things like “yeah, I could see you as a surgeon.  I figured that’s what you’d probably do.”  And so, I wondered, where were these all knowing friends earlier?

I enjoy working with my hands.  I enjoy little things like shoveling the driveway, washing the dishes, or putting walmart furniture together.  While these are not things I jump for joy doing, I do enjoy them a lot more than mental exercises of the same type.  For example, I could do without doing bills, balancing my check book, organizing my [anything].  Are these examples enough to completely push me onto the surgery side of the fence?  No I don’t think so, but it does start to build a case towards surgery in my opinion.

There are many other things I think have helped push me in that general direction.  I thrive on a chaotic environment.  I enjoyed the hands on part of my research projects (little animal surgeries).  I like playing musical interments (guitar & violin) but I couldn’t care less about musical theory.  I am a visual individual.  I like pictures, charts, and anatomy.  I enjoy figuring out problems and then doing something about them.  I am a self proclaimed doer and I don’t like to wait around for things to happen.  I like physical puzzles like the rubik’s cube more than riddles.

Is all that enough to put me directly into surgeon land?  Maybe.  Maybe not.  But to me, it does make for a case definitely towards surgery in my opinion.

In medical school, I’ve enjoyed my OR time so much that I have been seeking out surgery shadow time in my limited free time.  But at first I was unsure if this was because anything seemed more interesting that sitting in class all day or because I was genuinely interested in surgery.  But now I’m sure, that some procedural specialty is in my future.

There you have it.  My overall thinking process on how I’ve been trying to narrow down my specialty choices.

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.