Cardiovascular Surgery

Interview #1 Conducted by 2000-01 Division Coordinator, Gilbert Tang (U. of Toronto) William E. Cohn, M.D., Clinical Instructor, Department of Surgery, Harvard, Beth Israel Deaconess Medical Center

Biography: Dr. Cohn attended Oberlin as an undergraduate and majored in Chemistry/Biology. He attended medical school and completed his residency and cardiovascular surgery fellowship at Baylor College of Medicine in Houston, TX. Dr. Cohn's interests in cardiovascular surgery include less invasive approaches to heart surgery-off pump coronary bypass.

What attracted you to cardiovascular surgery? The excitement involved. What kind of residency training would you recommend to prepare someone for a career in cardiovascular surgery? A busy one... lots of hands on. How many cardiothoracic fellowship spots are there in the US? 140, I think. How would you classify the competitiveness of obtaining one of the cardiothoracic surgery fellowship spots? Moderate, but very competitive at the best programs. Of course, it is different every year. What is the average annual salary for a fellowship program? 30-35K...not much. What advice would you give to a resident looking to obtain one of the fellowship spots? The applicants we get now (and we are a very competitive program( generally have done research in cardiovascular surgery and have 4-8 publications already. The more commitment you have demonstrated, the better. Also, it is imperative that you do well on your on-site general surgery training exams. What level of training does it take to become a pediatric cardiac surgeon? Generally 5 years of general surgery residency, followed by 2-3 years of adult cardiothoracic surgery residency, then an additional 1-2 years of pediatric cardiac surgical training. Occasionally, pediatric intensive programs combine the pediatric experience with the adult, so you can go into ped ct after your first 3 years. Of the current practicing cardiovascular surgeons in the US, what percent would you say are situated at academic centers? N o idea... I would guess 15%. Throughout your career and training, what has been the hardest thing to deal with? Budgeting time. There are so many things in life worth doing, and all of them take time. It is easy to get caught up in heart surgery, and not allow time for other things. If you could pick the three most important characteristics for a cardiovascular surgeon, what would they be? Determination Intelligence Integrity Cardiovascular surgeons are busy people. How do you balance between your work and family life? I make that a priority. I have 5 small children, and play in a rock band. When I start getting caught up in the cardiac surgical rat race, I remind myself that, as an old man, I doubt I will lament not having done more operations. What is the average income of a cardiovascular surgeon? Lots! 400K - 1.5M Do you have any suggestions or advice for medical students considering a career in cardiovascular surgery? Carpe diem. It is an absolute blast. The lows are pretty low, but the highs are incredible. The opportunity to save a life is a wonderful thing. What would you say are the three most common types of operations performed by cardiovascular surgeons today? Coronary Artery Bypass Aortic Valve Replacement Mitral Valve Repair/Replacement What would you say is the most challenging problem seen by cardiovascular surgeons today? The effects of prolonged cardio pulmonary bypass, and the older and sicker patients on whom we are asked to operate. Where do you see cardiovascular surgery 10 years from now? Robotics? Maybe gene therapy? Probably some surgically induced angiogenesis. The completely implantable artificial hearts are coming along well.... probably ready for human trials in the next 2 years. What do you see as the three most important advances in cardiovascular surgery over the next 20 years? See response to question above. Throughout your career as a cardiovascular surgeon, is there a particular case that stands out in your mind? If so, please describe. I couldn't single out a case... each one is memorable in its own way - some because they go so well, some because they go so poorly, some because of what you got away with doing, some because of what you didn't get away with. Every patient is different and every operation is unique.

INTERVIEW #2 Conducted by 2000-01 Division Coordinator, Gilbert Tang (U. of Toronto) David F. Torchiana , M.D., Associate Prof, Chief of Cardiac Surgery, Massachusetts General Hospital (MGH), Harvard

Biography: Dr. Torchiana attended Yale University as an undergraduate and majored in Biology. He attended Harvard Medical School and completed his residency and cardiovascular surgery fellowship at Massachusetts General Hospital.Dr. Torchiana also completed a research fellowship.

What attracted you to cardiovascular surgery? Technical challenge / interplay of anatomy / physiology What kind of residency training would you recommend to prepare someone for a career in cardiovascular surgery? The best you can get How many cardiothoracic fellowship spots are there in the US? about 140 How would you classify the competitiveness of obtaining one of the cardiothoracic surgery fellowship spots? Less than in the past, the top programs are still very competitive What is the average annual salary for a fellowship program? Not sure, about 50K What advice would you give to a resident looking to obtain one of the fellowship spots? Need strong recommendations, evidence of academic productivity to match at one of the top programs What level of training does it take to become a pediatric cardiac surgeon? Added training beyond the standard is usually needed Of the current practicing cardiovascular surgeons in the US, what percent would you say are situated at academic centers? 20% (a guess) Throughout your career and training, what has been the hardest thing to deal with? The hours, the complications If you could pick the three most important characteristics for a cardiovascular surgeon, what would they be? The need to continually learn, judgment, tenacity Cardiovascular surgeons are busy people. How do you balance between your work and family life? Absence makes the heart grow fonder What is the average income of a cardiovascular surgeon? I don't know, less than it used to be Do you have any suggestions or advice for medical students considering a career in cardiovascular surgery? It's a great field, challenging and rewarding. You have to like it to do it, it takes a long time to train and the reward is in the practice of cardiac surgery, not in prestige or money What would you say are the three most common types of operations performed by cardiovascular surgeons today? CABG, AVR, mitral repair/replacement What would you say is the most challenging problem seen by cardiovascular surgeons today? older sicker patients Where do you see cardiovascular surgery 10 years from now? more options for surgery for CHF, continued push towards less invasive therapies What do you see as the three most important advances in cardiovascular surgery over the past 20 years? mitral repair, arterial grafts, immobilizers for beating heart surgery, cyclosporin What do you see as the three most important advances in cardiovascular surgery over the next 20 years? I'll be interested to see - possibly mechanical pumps (vads/tah's), refined robotics, hopefully some new valves Throughout your career as a cardiovascular surgeon, is there a particular case that stands out in your mind? If so, please describe. A transplant I did about five years ago on an old friend's mother. She was in extremis, we got a marginal donor and transplanted her just before she was about to fall apart. She did great, left the unit in five days and on the sixth day developed mental status changes & then abruptly died. It's a cruel world. Do you have any suggestions for specific areas for me to focus on as I develop education materials for the other students? videos Do you have any suggestions for educational references for students to use? CTS net

INTERVIEW #3 Conducted by 2000-01 Division Coordinator, Gilbert Tang (U. of Toronto) Bruce A. Reitz, M.D., Professor and Chairman, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford University Hospitals and Clinics, Lucile Salter Packard Children's Hospital at Stanford

Biography: Dr. Reitz attended Stanford University as an undergraduate and majored in Physiology. He went to medical school at Yale University School of Medicine. Dr. Reitz completed his residency and cardiovascular surgery fellowship at Stanford University School of Medicine. He received additional training at National Institutes of Health, Clinic of Surgery, National Heart and Lung Institute. Dr. Reitz interests in cardiovascular surgery include heart and lung transplantation and adult congenital and complex valvular disease.

What attracted you to cardiovascular surgery? I was very interested in cardiac physiology. Cardiac structure and mechanics made a lot of sense to me. I enjoyed working with my hands and enjoyed a technical challenge. It became apparent to me early that cardiac surgeons could do very dramatic things to help patients who would otherwise surely die. I liked being part of the therapy instead of simply prescribing drugs and other treatments. What kind of residency training would you recommend to prepare someone for a career in cardiovascular surgery? I am in favor of an integrated program in which general surgery and cardiothoracic surgery are combined in a single program. These types of programs are not yet established in the United States, but with changes in the American Board of Thoracic Surgery which are anticipated, (namely, not requiring American Board of Surgery certification), these types of programs may be developing in the near future. How many cardiothoracic fellowship spots are there in the US? Approximately 140. How would you classify the competitiveness of obtaining one of the Cardiothoracic surgery fellowship spots? Competitiveness is present, but not as difficult as you might think. The overall length of these training programs and the emphasis in many medical schools in primary care have both contributed to a decline in the number of graduates of medical school who are applying for cardiothoracic surgery fellowships. What is the average annual salary for a fellowship program? $45,000 to $55,000 per year. What advice would you give to a resident looking to obtain one of the fellowship spots? If someone is interested in a fellowship position, demonstrating a commitment to cardiothoracic surgery during early years, primarily by participating in research directed towards some problem relevant to cardiothoracic surgery, would be a great advantage. What level of training does it take to become a pediatric cardiac surgeon? To become a pediatric cardiac surgeon, one has to complete all of the usual surgery and cardiothoracic surgery training, and then seek an additional one- to two-year fellowship in pediatric cardiac surgery. Thus, an individual pursuing this field will have overall perhaps the longest training program of any other specialty. Of the current practicing cardiovascular surgeons in the US, what percent would you say are situated at academic centers? Of the current practicing cardiovascular surgeons, between 15% and 18% are practicing at academic centers. Throughout your career and training, what has been the hardest thing to deal with? Probably the pressure to always perform at peak levels. Of course, there are tremendous demands in terms of hours per week, but you simply have to continually push yourself to look at every detail and do everything you can to maximize your patient's chances of having a good result. If you could pick the three most important characteristics for a cardiovascular surgeon, what would they be? Important characteristics are equanimity, perseverance, and the ability to think clearly at times when there are great distractions around you. Cardiovascular surgeons are busy people. How do you balance between your work and family life? One has to have a good partner in life to balance work and family life, someone who does not always require your presence and yet is dedicated to the family's well-being. What is the average income of a cardiovascular surgeon? The average income can vary from $300,000 per year up to $800,000 per year and above. Do you have any suggestions or advice for medical students considering a career in cardiovascular surgery? Make sure you really are interested and that it becomes a passion for you. Like anything else, any other career choice, you should really love what you do, regardless of what anyone will pay you for it. What would you say are the three most common types of operations performed by cardiovascular surgeons today? Coronary artery bypass surgery, aortic or mitral valve replacement, and combination of the two above. What would you say is the most challenging problem seen by cardiovascular surgeons today? End-stage heart disease with either myopathy or ischemic disease. Multiple options have been developed, including assist devices and transplantation, and both of these will be more available in the future. Where do you see cardiovascular surgery 10 years from now? I think that we will have less bypass surgery as interventional procedures improve. On the other hand, xenografts as sources of organ donors will make heart and lung transplantation more common, and better mechanical devices will also greatly expand the implantation of these devices. There will be a significant amount of bypass surgery performed without cardiopulmonary bypass, and there will be continuing pressure on us to perform more less invasive operations. What do you see as the three most important advances in cardiovascular surgery over the past 20 years? The wider introduction of arteriografts in coronary bypass surgery, continued improvement of tissue valve technology, safer cardiopulmonary bypass, and other supporting technologies in anesthesia and intensive care. What do you see as the three most important advances in cardiovascular surgery over the next 20 years? The perfection of xenograft organs for transplantation, extremely small and very durable mechanical assist devices, and genetically-engineered tissue valve replacements. Throughout your career as a cardiovascular surgeon, is there a particular case that stands out in your mind? If so, please describe. Perhaps for me, the most memorable case was the first heart-lung transplantation that we performed in 1981. This was the culmination of a number of years of laboratory research and seemed like such a tremendously difficult thing at that time. To have this patient survive and be benefited by her heart and lung transplant was extremely memorable. Do you have any suggestions for educational references for students to use? The Kirklin/Barratt-Boyes text entitled "Cardiac Surgery", published by Wiley Medical.

INTERVIEW #4 Conducted by 2000-01 Division Coordinator, Gilbert Tang (U. of Toronto) Dr. Stephen Fremes, Academic title: Associate Professor, University of Toronto, Sunnybrook and Women's College Health Sciences Centre

Biography: Dr. Fremes attended University of Toronto as an undergraduate, majoring in Arts and Science. He also attended medical school, completed his residency and CV surgery fellowship at Toronto. Dr. Fremes interests in cardiovascular surgery include clinical research in CABG and myocardial protection.

What attracted you to cardiovascular surgery? technical challenge and the generally good results What kind of residency training would you recommend to prepare someone for a career in cardiovascular surgery? Either general surgery followed by cardiac surgery or straight cardiac surgery (as in Canada) How many CV surgery residency spots are there in the Canada? 6 How would you classify the competitiveness of obtaining one of the CV surgery residency spots? Very difficult. How about fellowship spots? Likely easy What is the average annual salary in a CVS fellowship program in Canada following residency training? This varies depending whether the fellow can bill for services or not. If not, then usually at the resident level. What advice would you give to a resident looking to obtain one of the fellowship spots? Apply more than 1 year early in writing followed by an interview What level of training does it take to become a pediatric cardiac surgeon? 1-2 years post residency Of the current practicing cardiovascular surgeons in Canada, what percent would you say are situated at academic centers? 95% Throughout your career and training, what has been the hardest thing to deal with? Time If you could pick the 3 most important characteristics of a cardiovascular surgeon, what would they be? Organized Tenacious Bright Cardiovascular surgeons are busy people. How do you balance between your work and family life? Difficult. Usually family comes second What is the average income of a cardiovascular surgeon? Varies. 400-500k Do you have any suggestions or advice for medical students considering a career in cardiovascular surgery? In Canada, need to decide very early (year 1 or 2 of medical school) What would you say are the three most common types of operations performed by cardiovascular surgeons today? CABG valve replacement congenital repair What would you say is the most challenging problem seen by cardiovascular surgeons today? Advanced age of the patient What do you see as the 3 most important advances in cardiovascular surgery over the past 20 years? Improved myocardial protection, improved membrane oxygenators, recognition of the long term IMA results What do you see as the 3 most important advances in cardiovascular surgery over the next 20 years? Likely will be cellular or genetic strategies, greater use of robotics

INTERVIEW #5 Conducted by 2000-01 Division Coordinator, Gilbert Tang (U. of Toronto) David Latter, Associate Professor University of Toronto, Attending Cardiac Surgeon, St. Michael's Hospital

Biography: Dr. Latter, attended Queen's University as an undergraduate and majored in Biology. He went to medical school completed his residency and a cardiovascular surgery fellowship at McGill University. additional training was acquired at Stanford University, Fellowship in Cardio-Thoracic Transplantation. Dr. Latter's interests in cardiovascular surgery include end stage coronary artery disease, mitral valve repair, and aortic surgery.

What attracted you to cardiovascular surgery? The dramatic effects that I can have on the health and well being of patients What kind of residency training would you recommend to prepare someone for a career in cardiovascular surgery? A cardiac surgery residency that offers a broad exposure to all types of cardiac surgery. A program that has at least two and preferably three hospitals affiliated with it to offer the residents a broad exposure. How many CV surgery residency spots are there in the Canada? How about fellowship spots? I think there are twelve cardiac surgery residency spots in Canada. The number of Fellowships is unknown but I would estimate it probably is around the same number. How would you classify the competitiveness of obtaining one of the CV surgery residency spots? How about fellowship spots? Obtaining a cardiac surgery residency position can be very competitive, particularly at the premiere institutions it is extremely competitive. It is less so for fellowship positions in Canada. What is the average annual salary in a CVS fellowship program in Canada following residency training? I think about $60,000. What advice would you give to a resident looking to obtain one of the fellowship spots? To network as much as possible with surgeons in the field by attending Canadian Cardiovascular Society meetings and by doing elective rotations at these hospitals whenever possible. What level of training does it take to become a pediatric cardiac surgeon? A pediatric cardiac surgeon requires the basic residency in cardiac surgery and then at least a one, preferably two year Fellowship in a pediatric cardiac surgery program of high repute, such as, The Hospital For Sick Children in Toronto, or Children's Hospital of Philadelphia, or Boston Children's Hospital, or another institution of similar status. Of the current practicing cardiovascular surgeons in Canada, what percent would you say are situated at academic centers? I think approximately 80% of practicing cardiovascular surgeons in Canada or at academic centres Throughout your career and training, what has been the hardest thing to deal with? The death of patients. This is particularly difficult when the patient is a young individual with a family that needs that person. If you could pick the 3 most important characteristics of a cardiovascular surgeon, what would they be? dedication technical motor skills compassion Cardiovascular surgeons are busy people. How do you balance between your work and family life? Balancing my life between work and family is very difficult and requires an understanding wife and children. One must never loose sight of the fact that family life is probably the most important aspect of our lives and needs attention as much, if not more, than our work careers. What is the average income of a cardiovascular surgeon? This is confidential Do you have any suggestions or advice for medical students considering a career in cardiovascular surgery? Any medical students that are considering a career in cardiovascular surgery should definitely do rotations in at least two or three different cardiac surgery centres to see if their expectations really are realistic. This also allows them to meet the people in the field, which is a way of networking and is quite valuable when it comes to applying for residency positions. What would you say are the three most common types of operations performed by cardiovascular surgeons today? Most common types of operations are bypass operations, aortic valve replacements, mitral valve replacements. What would you say is the most challenging problem seen by cardiovascular surgeons today? Old patients with end stage coronary disease Where do you see cardiovascular surgery 10 years from now? CV surgery itself will be quite similar to what it is today but more refined and we will have more ancillary measures to help treat patients with end stage disease. In particular I am thinking of gene therapy. What do you see as the 3 most important advances in cardiovascular surgery over the past 20 years? the refinement of cardiac coronary bypass techniques improvements in the medical treatment of cardiac surgery patients; both in the pre op, peri op post op phases of their recovery. What do you see as the 3 most important advances in cardiovascular surgery over the next 20 years? I think the most important advances will be gene therapy angiogenesis, improvements in anti cholesterol medications, and refined cardiac techniques. Do you have any suggestions for specific areas for me to focus on as I develop education materials for the other students? This is really too broad a questions to answer sufficiently. Anyone who is interested in cardiac surgery should definitely read a book on the history of cardiac surgery, of which there are quite a few that have been recently published. No doubt that the pioneers of this profession are remarkable people and everyone should know about their accomplishments. Do you have any suggestions for educational references for students to use? Cardiac surgery is a highly specialized specialty and to read specific books and journals on this topic at the medical student level would be inappropriate. I think students at the medical school level should try and obtain as broad an education as possible, all the while keeping their interest in cardiac surgery but not at the exclusion of having inadequate exposure to other fields of medicine.