CTSNet New Horizons

These are trying times for the specialty of cardiothoracic surgery. The educational process for completion of training is criticized for being too lengthy. The work loads and work hours during the required general and cardiothoracic surgical residencies are excessive and stressful, leaving too little time for formal didactic teaching, individual study, family responsibilities, and recreation. Cardiothoracic program directors and other attending surgeons have been criticized for devoting too little time to the welfare of their trainees. Some are considered disinterested or abusive. The educational debt accumulated by many residents upon completion of their training is staggering, averaging about $50,000 and exceeding $100,000 to $150,000 in some instances. Jobs are more difficult to find, both in the private and academic settings. Starting salaries have fallen, malpractice insurance rates are becoming prohibitive, and maintaining the current levels of reimbursement for services rendered is a continuing struggle. Many practicing cardiothoracic surgeons are disillusioned, contemplating early retirement or career changes, and voicing their unhappiness to anyone who will listen.

Medical students about to make career specialty choices are keenly aware of all of these difficulties and are justifiably shying away from cardiothoracic surgery and other specialties with long training periods and high malpractice insurance rates. Only a minute fraction (less than half of one percent) of American medical students currently indicate an interest in pursuing training in cardiothoracic surgery. Presently in the United States, fewer graduates of American medical schools apply for residency positions in cardiothoracic surgery each year, than the number of positions available.

Why then, one might ask, would anyone want to become a cardiothoracic surgeon? In the discussion that follows, I will state the reasons why I became a cardiothoracic surgeon, and why I believe it remains a viable, exciting, stimulating, challenging, and rewarding specialty for young physicians. I made the decision to become a physician when I was 9 years old. I underwent an emergency appendectomy and was so impressed with the general surgeon and the others who cared for me that I decided then and there that I wanted to be a physician and a surgeon. My surgeon was a quiet, compassionate, but highly skilled individual who was totally dedicated to his profession. He loved his work and his patients. Another physician, an otolaryngologist and a family friend, knew of my interest in becoming a doctor and would take me on his rounds and permit me to assist him with minor surgical procedures when I was still in high school. These two surgeons were exemplary role models, and they stimulated me to pursue a surgical career.

During my first year in medical school in 1957, down the hall from where the freshman histology course was being taught, several of the faculty thoracic surgeons (there were no “cardiac” surgeons in those days) were assembling and testing the second Gibbon-Mayo heart-lung machine (the first one was located at the Mayo Clinic) in preparation for its use in humans. It had been purchased with funds donated by the citizens of St. Louis through a fund-raising effort by one of the local newspapers, and had been manufactured in St. Louis by a small engineering company. I wandered down the hall from the histology laboratory on many days and watched these surgeons and an anesthesiologist who was serving as the perfusionist, operate on a series of dogs to become familiar with the apparatus and to master the techniques of cannulation and optimal perfusion. It was a fascinating experience and I was hooked! This fascination with cardiopulmonary perfusion and its physiology remains with me to this day, some 47 years later. That a human being can be connected to such an apparatus, have his or her circulatory and respiratory functions totally performed by a machine for up to three or four hours, have a major cardiac condition corrected, and emerge from anesthesia physiologically intact is nothing short of miraculous.

In my junior and senior years in medical school I would watch cardiac surgical procedures from the observation gallery whenever I had time. I also took an elective in pediatric cardiology and was encouraged by my preceptor to pursue a career in cardiac surgery. Other physicians during my years as a general surgical and cardiothoracic surgical resident served as mentors and role models, and encouraged me to stay the course. I have acknowledged these individuals and the impact they had on my career in a previous publication [1].

What, one might ask, does all of this have to do with the specialty of cardiothoracic surgery in 2004 with all of its problems and uncertainties? I entered the specialty of cardiothoracic surgery at a time when cardiac surgery was in its infancy. It was a surgical frontier with seemingly limitless challenges and opportunities. Extraordinary progress and remarkable achievements have occurred in every aspect of the specialty over the past 50 years. Some would argue that it is now a mature specialty, that there are few problems left to conquer, and that the “action” in the field of medicine is elsewhere. I strongly disagree with this assessment. The potential for new discoveries and for methods of treatment for diseases of the chest by surgical means remains unlimited. Many of the recent scientific advances that have been made at the cellular and molecular levels will eventually be applicable to the treatment of patients with thoracic diseases. Advances in technology that are applicable to such patients are occurring faster that they can currently be assimilated into practice. This is where the “action” will be for the cardiothoracic surgeons of the future: learning to apply these new discoveries and technological advances to the diagnosis and management of diseases of the chest that are presently inadequately treated. This is precisely what the pioneering cardiothoracic surgeons and the generations of surgeons who followed them did.

Despite many apparent difficulties facing the specialty of cardiothoracic surgery, it is important to know that they are not unique to this specialty or even to the medical profession as a whole. Surveys have not identified medical specialists who are clearly happier or less happy than others [2]. Professionals in other fields besides medicine are experiencing loss of autonomy, status, and the respect of the public. They too, are struggling with longer work hours, increased regulation and scrutiny, and declining compensation [2]. Although these professionals may share our frustrations, they will never experience the satisfaction that comes with caring for other human beings and relieving and sometimes curing their pain and suffering.

If you are a student or resident with intelligence, drive, and stamina, who loves challenges, hard work and positive outcomes, who is results-oriented, loves working with your hands as well as your brain, and enjoys caring for others and interacting with highly competent physicians and other health care professionals, you should strongly consider becoming a cardiothoracic surgeon. If you are a high school or college student and want to learn about the specialty, contact your family physician and ask him or her to contact a local practicing cardiothoracic surgeon on your behalf. Meet with this surgeon, express your interest, and spend a day or two learning what cardiothoracic surgeons do. If you are a medical student or resident, contact the chief of cardiothoracic surgery in your medical center and ask to spend time on the cardiothoracic surgical service to learn what being a cardiothoracic surgeon entails.

There are important changes occurring in how cardiothoracic surgical residents are being educated that will have important implications for the future. Options are now available to reduce the number of years of residency required to become a cardiothoracic surgeon. Residency work hours have been reduced. A core curriculum has been introduced into training programs that will permit more didactic teaching and independent study. The internet has become a major source of educational information and will play an even greater role in thoracic surgical education in the future. Resolution of the practice liability crisis is on the horizon. Changing demographics and scientific progress will likely lead to more rather than less work for future cardiothoracic surgeons.

After 34 years of practicing cardiothoracic surgery, I still enjoy going to work every day, participating in complex and challenging thoracic surgical procedures, and interacting with patients and their families and with the physicians, perfusionists, nurses, and other medical professionals who share a commitment to provide the best medical care possible to our patients. The joys of being a cardiothoracic surgeon still greatly outweigh the frustrations and irritations. The practice of medicine just doesn’t get any better than this.

I believe this is the perfect time to become a cardiothoracic surgeon. I envy those who will have the privelege of practicing cardiothoracic surgery in the 21st century. They will possess skills and a knowledge base that will differ substantially from those of their predecessors. This is exactly what is needed to assure the preservation and continued success of our specialty. Would I become a cardiothoracic surgeon if I had it to do over again? In a heartbeat!

Kouchoukos NT. Cardiothoracic surgery in the new millennium: Challenges and opportunities in a time of paradox. Ann Thorac Surg 2000;69:1303-11.
Zuger A. Dissatisfaction with medical practice. N Engl J Med 2004;350:69-75.