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Thoracic Surgery

Cracking chest medicine

The New Physician July-August 2007
The life of a thoracic surgeon is “rigorous, pressure-filled and demanding,” says Dr. Brett Sheridan, assistant professor in the division of cardiothoracic surgery at the University of North Carolina at Chapel Hill. The reward, he says, is the ability to make a positive impact on a life-threatening disease process. “It’s not subtle; you give [patients] a better quality of life, a longer life, and they are immensely grateful.”
That is why many medical students choose surgical subspecialties—so many that experts have long lamented the drain of surgery on the primary care workforce. But the long and strenuous training period, stressful work and concern about future job prospects have meant fewer applicants are vying for entry into this particular discipline.
In 2006, only 84 of 126 available thoracic surgery fellowships were filled, leaving one-third of the positions vacant. This continues a downward trend that began in 1995 when there were 200 applicants.
The reason, believes Sheridan, is that prospective thoracic surgeons are concerned that the work of chest surgery is diminishing, thanks to the recent explosion in nonsurgical cardiac interventions—in a word, stents. These procedures are the purview of the interventional cardiologist, and thoracic surgeons who rely on steady demand for coronary artery bypass grafting (CABG) are finding their volumes decreasing.
Coronary angioplasty was first performed in Zurich in 1977. With further technological evolution, the opportunity to apply catheter-based interventions has increased dramatically. Patients have a considerably less-invasive—and often less-expensive—alternative to CABG. Blocked arteries can be opened by threading a catheter into the artery through the thigh and inserting a balloon and a permanent stent—the latest models coated with clot-busting drugs—with no cracking of the chest required. According to the Agency for Healthcare Research and Quality, the number of CABG procedures declined 28 percent from 1997 to 2004, while percutaneous coronary interventions rose 36 percent in that period.
“This monumental shift in therapy for multivessel coronary artery disease is a great controversy in heart disease, and has been the hottest topic outside of universal health care,” Sheridan says. The public has embraced this procedure because it is seemingly safer, the recovery is extremely swift, and it is perceived as an equal alternative to open-heart surgery.
“But as data have accrued,” Sheridan notes, “we’ve seen that for [disease] involving multiple vessels, [angioplasty] is not as reliable or safe as surgery. [CABG] really is the most life-preserving treatment for many patients. But we have a difficult time convincing cardiologists that surgery on the front end has improved outcomes, especially for sicker patients. It seems counterintuitive that CABG would be safer and more durable in sicker patients [than angioplasty], but the published data are consistent. The reality is that the surgical treatment of heart disease is going to make a strong rebound.”
Meanwhile, there are dozens of other procedures that thoracic surgeons can sink their scalpels into. Sheridan performs heart and lung transplants, implants artificial hearts, corrects arrhythmias, and treats the killer cancers of the lung and esophagus. Many thoracic surgeons choose to specialize in either the heart or the lung; others practice a mixture of both.
Training covers the operative, perioperative and critical care of patients with pathologic conditions within the chest. This requires substantial knowledge of cardiorespiratory physiology, vascular biology and oncology, as well as skills in heart-assist devices, management of abnormal heart rhythms, drainage of the chest cavity, endoscopy, and invasive and noninvasive diagnostic techniques.
Typically, residents complete a full program in general surgery, followed by a two- or three-year thoracic surgery fellowship. A second pathway is under development by the Thoracic Surgery Directors Association involving an integrated six-year thoracic surgery residency that will be available through a small number of schools. During the fellowship years, students can train to practice general thoracic surgery or adult cardiac surgery, or to further subspecialize in pediatric cardiac surgery.
After seven to eight years of postgraduate training, thoracic surgeons can expect to go into the field making more than $300,000 annually. Of course, there is a lifestyle trade-off. Sheridan estimates his colleagues work an average of 50 to 60 hours a week, just slightly less than notoriously overworked neurosurgeons. “And I take call every other night.” Still, Sheridan says, most nights pass without an emergency page.
So what’s the attraction to this specialty? Practitioners “love the challenge,” says Dr. Andrew Chang, assistant professor at the University of Michigan Medical School, who shepherds medical students through thoracic surgery clinical rotations and anatomy labs. At the end of a decade of training, “the reward is that we are getting to do what we trained for.”
One might assume this discipline is a young person’s game, but the fact is, “Practicing thoracic surgeons have stuck around,” says Dr. Atul Grover, associate director of the Association of American Medical Colleges’ Center for Workforce Studies, which is researching the future thoracic surgeon workforce. While about 20 percent of all U.S. physicians are 55 or older, more than half of the 4,800 board-certified thoracic surgeons active today are in this bracket. Approximately 70 percent are expected to retire in the next 13 years, dramatically shrinking the provider pool and leading to what certainly will be a critical workforce shortage hitting just at the time a swell of aging baby boomers will need their services.
Sheridan predicts a major comeback for CABG among these older patients: “Demand will explode, and
the field will become more attractive to medical students,” he believes.
Still, Grover’s research predicts that by 2025, the number of thoracic surgeons will be 1,000 to 2,000 short of what’s needed, even if residency programs add positions. “What’s also going on is that we can’t see how the future looks,” he says. “Stent technology was deployed so rapidly and is changing all the time.”
For its part, the Society of Thoracic Surgeons has lobbied Congress to add a provision to H.R. 609—the College Access Opportunity Act of 2006—that will remove barriers to medical school graduates choosing subspecialties requiring the longest training, including thoracic surgery, by forgiving some of their federal student loans. “They are trying to unencumber people who are thinking about choosing this difficult and challenging career,” says Sheridan.
Chang feels that it is becoming more difficult to introduce medical students to the field, “because surgical rotations tend to be less student-friendly. It’s a vicious cycle—the challenging environment exposes students to more negative feedback, so they pull away from these rotations. We can’t bend over backwards to make learning easier, but we do try to make it more attractive. It is up to us [teachers] to be better mentors and role models for our students.”
Chang’s department is looking into resolving such issues through its training model. Instead of a student having to wait a prescribed period of time before trying a procedure, “we are interested in ‘graded responsibility.’ There is no reason teaching should be driven by how many years one has been in medical school [instead of] competency. We are trying to make that a reality.”
But in the end, you can’t entice someone to go into thoracic surgery. It takes a particular work ethic and enthusiasm for battling the top killers of Americans—heart disease and lung cancer. The one thing aspirants have in common, Sheridan says—and he notes that as many women as men are entering the field—is their determination to change lives for the better.
“Their passion for these diseases is what sets them apart,” he observes. “These are students who are comfortable in acute and intensive care…. Their future opportunities will be wide open.”
Martha J. Frase is editor of The New Physician.