The Cardiac Surgeon's Plight

NO JOBS IN CARDIAC SURGERY:   Is this just a fallacy or is there any truth to it? Well, just look around and talk to your colleagues, read over the CTSNet section for “Issues in training” and  you will see that people are looking for jobs which are just not there at all, regardless of your training, years of research, graduating institution, etc. Thoracic Surgeons who even have additional degrees, such as MBA and PhD are jobless, as well. There is something wrong with the whole picture when a senior cardiac surgeon from a major training program mentions that one of his graduating fellows, after 3 years of intense thoracic training, is going to spend another year in vascular surgery.

Obviously either the training was not adequate or the requirements of the market have changed.  After an average of 10 years of cardiothoracic training, surgeons are opting to go for a second specialty training in anesthesia, vascular surgery and plastic surgery. This is no surprise, since the starting salary for thoracic surgeons is somewhere between $120,000 and $250,000, whereas an anesthesia graduate with a pain fellowship starts in the $400,000 range. The jobs which are even out there are so absurd that many are not even worth considering; you are better off working at one of the larger institutions as a super-fellow/adjunct surgeon/instructor or even work as a physician assistant! By the way, the last option only requires two years training after undergraduate school. To further elaborate, a recently advertised job in South Florida offered a handsome compensation of $80,000/year for fully trained cardiac surgeons. One might say it is not all about money, but then economics is the driving force in the world.

I am in private practice myself, and continue to follow the job trends in our market very closely.  It certainly is not a surprise to anyone that the market has shrunk over the past few years, has shown no signs of improvement in the interim, and has exhibited little hope for the future.  Recently, I had the opportunity to talk to one of the legends of our specialty and he expressed his appreciation of my concerns and suggested that I should write a detailed commentary on this very burning issue of “No Jobs,” and thus prompted my writer-self to do so.

The case volume countrywide has dwindled, along with ever decreasing reimbursements. It is just appalling to note that today a CABG can fetch you somewhere between $1800 and $2200 (as a 90-day Universal Fee), whereas almost the same amount can be obtained by  performing an outpatient 20 minute, laser/radiofrequency saphenous vein ablation.  Surgeons who usually would have retired at 60 are turning 70+, with no signs of retirement, for various reasons: declining stock market, less savings over the past few years, etc.  What has all this resulted in?  Certainly, jobless graduating cardiac surgeons, graduates who are looking for super-fellowships in major centers, and the lucky ones who have jobs are paid less then any other specialty surgeon and at times equivalent to a primary care physician.  I personally feel this is not what one should expect after + ten years of grueling surgical training.

Over the past few years there has been a great hue and cry about the declining quality of applicants to the various cardiac programs, with the slots going empty and fewer US graduates applying for cardiac surgical fellowships.  There could be various reasons for this dramatic change, including long training programs, the attitude of faculty, laborious fellowships, etc.  However, I am sure most of us will be ready to undergo long and difficult training programs, as long as there is light at the end of the tunnel.  As we all know, almost everything in this world is economy driven and when you do not see any financial gain at the end, interest can rapidly disappear.

In all honesty, we (the cardiac surgeons) missed the boat when Gruntzig came to this country and the surgeons paid little heed to his catheter work.  It is certainly amazing to notice that a neurosurgeon, a neurologist and an interventional radiologist are all eligible for a neuroradiology fellowship, and thus any of the above can function as a neuroradiologist.  Similarly, peripheral vascular intervention can be the forte of an interventional radiologist, vascular surgeon, general surgeon, cardiac surgeon or a vascular medicine specialist.   On the other hand, interventions of the coronary system are solely restricted to interventional cardiologists.

Alan Greenspan once said, “There is always anxiety about the jobs of the future, because in the long run most of them will involve goods and services that have yet not been invented.”  Keeping that in mind, one could be optimistic in thinking about the future of, say, robotic surgery, or pessimistic in thinking about percutaneous valves, percutaneously applied gene therapy and percutaneously implanted Impella Systems for Heart Failure.

It is very easy to point out problems, but finding solutions is always difficult.  Talking to various leaders of our community at different meetings and research on my own, I have come up with the following suggestions:

1. We must change from coronary surgeons to cardiothoracic surgeons, meaning specializing not only in coronary surgery, but also in valvular and thoracic surgery.  Most of us are trained in valve replacement, but the current emphasis certainly is on valve repair, especially the mitral valve. Thus we ought to attend courses and be proficient in valve repair in addition to replacement. Lung and mediastinal surgery should be a major portion of our practices, as well.
2. Most programs have limited exposure for aortic surgery, but as long as you have decent training as a cardiac surgeon, proficiency in aortic surgery certainly can be obtained.  Similarly, heart failure surgery is another open option, with increasing demand in the future.
3. The diversification into valvular, aortic and heart failure surgery are certainly very attractive options, but the reality is that a community cardiac surgeon (which includes most of us) does not come across a huge number of these cases, and thus making a living on these groups alone will be difficult.  Probably, the most important diversification is to learn peripheral vascular interventional procedures, including Abdominal Aortic Aneurysm Endostent Grafts.  Once you have done them, you can understand why the interventional cardiologists want to stent everybody (besides the financial gains). Our training programs ought to incorporate endovascular techniques for at least 4-6 months. In this way you could graduate as endovascular trained cardiovascular surgeons. This is a field which simply is going to make open vacular surgery obsolete for most elective cases, as it is happening to coronary surgery. As we can see, carotid endarterectomy is soon going to be a thing of the past, as well, except in certain particular conditions.
4. What can we do about the decreasing reimbursement?  Although Medicare for 2004 is up by 1.5%, it is interesting that this slight increase makes us happy; one because it is 5.5% higher than the previously proposed 4% cut in Medicare this year, and secondly we are here today and not in the ‘70s or ‘80s (thus it is all about relativity) and so it seems as a substantial increase in the compensation by Medicare.  One possible solution is to cut the fellowship slots by at least a 50%. There are a few issues with this: Once I discussed this proposition with a program director and his answer was that if he brings it up at any national meeting, he will be the first one asked to decrease his program’s fellowship slots, and the rest may never follow.  I can agree with him.  In addition, if a unanimous decision is made by the American Board of Thoracic Surgery and the Residency Review Committee, it could be a violation of Antitrust Laws, as mentioned in one of the recent STS Presidential Addresses.  I was not well convinced of that notion and so I called  the office of US Assistant Attorney General, Anti Trust Division, where I was rerouted to the Chief of Litigation I (the Antitrust Division’s sector dealing with Healthcare issues in the USA).  I left a message with his assistant, and he was nice enough to call me that very evening. We discussed the issue at hand and the ultimate crux was as follows:
   
   a)Antitrust  Laws constitute three subdivisions and as per the Sherman Act, competitors in a market collectively can not decide to decrease or increase the price or production of a commodity, and thus decrease competitiveness in the market;  the recent example for the US government was in the automobile industry, where the US automobile industrialists unofficially collaborated with their counter parts in Japan and thus everyone decreased the production collectively and increased the prices for vehicles by a margin of approximately 10-15%
   
   b) At a national level, if there is an overproduction of a commodity in a certain sector, the competitors themselves can not correct the market on their own by decreasing production and thus decreasing competitiveness; to the contrary the sector will self correct over time when many participants will leave for other sectors.   That was the opinion of the Chief of Litigation I, at the Antitrust Division of the Attorney General’s office; but as with everything else, lawyers usually have a different view of things. So I approached a lawyer friend of mine (who actually is involved with Litigation in the Health Care Sector): My understanding, after discussing the issues with him, is that the slots in cardiac surgery can be decreased, since there is a surplus of cardiac surgeons in the market and the Anti-trust laws will not kick in, unless we were to create an artificial shortage by decreasing the slots.  In the past there are examples of specialties decreasing their residency slots and thus catching up with the surplus of graduates in their respective specialties; examples include anesthesiology, gastroenterology and neurosurgery.  With this in mind, I called the Executive Directors for the RRCs in Anesthesiology and Internal Medicine. They were certainly receptive to my call, but neither would comment on the decrease in their residency slots; I guess understandably so. But one thing is for certain, their graduates are not scrambling for jobs after ten years of training, and not on the verge of financial collapse.
5. The ABTS is in the process of proposing to the RRC and the TSDA to increase substantially the required number of cases and overall clinical experience of the trainees.  I think this is essential.  The basic number of case requirement should be at least three times the numbers required today, e.g. the minimal number of CABGs for graduating trainees should be at least a 100 rather than 35; the number of lobectomies should again be a 100 rather than 30; the valves should be at least 50 instead of 20-30, and so on.  In addition, there should be an onsite evaluation program of the graduating trainees, conducted by RRC itself, in which the evaluating team should observe a graduating trainee perform say a CABG, a valve and a lobectomy in three consecutive cases. All this will have a two-fold effect: The quality of trained thoracic surgeons will improve tremendously, and at the same time many mediocre training programs will have to close.
6. An area where we have certainly lacked an initiative is pursuing leadership roles.  I feel it is in the psyche of surgeons and more so of cardiac surgeons, to work in an introverted fashion, and be egoistic and be happy with the surgical outcomes alone.  However, in reality there is more to life than surgery alone. Certainly, not everyone can be Bill Frist or Charles Boustany but at least strive to be one. Just to give you a small example; I recently attended my local hospital’s Performance Improvement Committee meeting (an important committee at our hospital), and I was amazed to see that out of the 9 physicians present,  surgical representation was limited to an ENT surgeon and I was the new addition.  I think all of us can collectively make a difference. Our voice should certainly be heard at the local hospital level, but we can also influence local legislators, US Congressman and Senators.  As one of the past STS presidents mentioned, that when he would go to Washington he represented 2000 physicians, whereas his cardiology counterpart represented 30,000 physicians, and thus the voice heard was of the obvious one.  But if we stand on the sidelines, we are simply contributing to our demise and not supporting the cause of uplifting the specialty.  It is certainly understandable that morale is down and in these times one is simply striving to survive. However, if we accept the status quo and continue to stay disinterested then we will be victims of another era of poor leadership, which is partly the cause of where we are today.

This is just a point of view, but I am sure that many in our community will share my thoughts.  Some of the suggestions might seem drastic, but kindly look around you, and once you have seen the devastation of this specialty, you will agree that extreme measures are called for. I just feel our specialty is at a crossroad where the invasive cardiologists feel that they are here to make us extinct, and no doubt it seems like that at times. Can you imagine, just being a back-up surgeon for percutaneous valves and failed cath lab coronaries?  Let us all work together and prevent this from becoming a reality.  I think we can still make it happen, but it will require revolutionary vision and drastic changes coming from the leadership, and a participation from each and every working thoracic surgeon.  At this critical juncture of our specialty we should remember what the 16th century English philosopher Francis Bacon once said, “Things alter for the worse spontaneously, if they are not altered for the better designedly”.

Publication Date: 2-Jun-2005
Last Modified: 8-Jun-2005