Between the Cracks

In 1993 I finished my cardiothoracic residency and an additional year as the chief resident at the "number one cardiac surgery hospital in the country." I felt like Leonardo Dicaprio in Titanic: " I was on top of the world." So how is it that nine years later I've been unemployed for 3 months and actively looking for a job for 9 months without success? For nine years I've trained residents, had an active clinical practice with good results, so how could this happen? How could I spend 4 years in medical school, 8 years in residency and 9 years in clinical practice, only to find at a time when I should be catching my stride, that I cannot find a job?

Over the last several months I have received numerous phone calls from friends, colleagues and former residents who find themselves in a similar situation, totally unanticipated. The specialty which attracted the best of the best, can no longer provide them with an opportunity to do what they were trained to do. I can only hope that my opinion is that of one angry and frustrated surgeon, and not the reflection of a steadily increasing silent minority.

For those of you who attended the May 2002 AATS meeting, I'm sure you felt as I did, that the mood of our specialty is depressed and disenchanted. Many fine surgeons were talking about retiring early, some younger members talking about leaving medicine altogether. Recently, I considered what I was qualified to do, other then cardiothoracic surgery, and the reality is, despite our many years of training, few of us have other marketable skills. Even staying within medicine, but changing specialty, requires 2-4 years to retool. So now the choice becomes something I never thought I would have to consider: do I stay in medicine or find another career? I faced this question recently when I was informed that my contract was not going to be renewed at the University for fiscal reasons. As I sat there listening to these words, for the first time since residency I wondered whether I could find work as a cardiac surgeon, or would I fall between the cracks? For many years I have worried about finding my residents jobs, now I find myself calling and asking them whether they know of any opportunities.

Despite what has happened, if I had to choose my specialty again, without hesitation I would choose cardiac surgery. They say a difference between success and failure is in the choices. So now, at 49 years of age, what are the choices today in cardiac surgery? I think anyone who is counting on the future success of their practice being in coronary bypass surgery, whether on pump or off, cannot be looking at the same market as I am. The choices as I see them are: thoracic surgery, vascular surgery including endovascular techniques, some valvular surgery, and coronary surgery on patients who have run out of other options. We are currently finishing about 100 new cardiothoracic surgeons every year; are we really preparing them for the current marketplace? I think not. When I talk to my program director friends around the country, they seem to be experiencing difficulty in getting jobs for their residents. So I ask, where are the jobs in cardiothoracic surgery? Have we reached the saturation point? The demographic "experts" tell us no. But the academic centers have been loosing cases to the private hospitals for years, and now the private hospitals are claiming their case volume is way down. Is it possible that coronary stenting is affecting our practice to this degree and if so, how will we prepare ourselves for the widespread application of drug-eluding stents? I think we are standing on the precipice, with slippery sides all around.

The majority of hospitals in this country are not going to have robotic technology or the sophisticated endovascular skills to manage complex aortic problems. As a specialty we have given away pacemakers, defibrillators, most of peripheral vascular surgery, and to some extent coronary intervention, all in the name of the mighty CABG. Well, I am afraid that this golden goose may be close to its final period of egg laying. I don't pretend to have the answers, but I do know that burying our heads in the operating room and pretending it's not happening will not serve our specialty or its future members well. The old adage says that there will always be work for a skilled and dedicated surgeon. Well excuse me, but I don't remember meeting large numbers of unskilled, lazy heart surgeons. We recently were advertising for a cardiac surgeon for a small community hospital in a very small town, but with affiliation to the University. The program does less then 200 cases a year. I was in charge of looking over the CVs that came in. I was not expecting much, but within 2 weeks I had over 100 CVs for this one-man shop.

In summary, I hope these words are those of a single frustrated cardiac surgeon who sees the choices before him as disappointing, compared to the enthusiasm he had in 1993. I have always and will always be proud to be a member of The Society of Thoracic Surgeons, and have many friends, colleagues and mentors within the specialty. We are members of an elite group, the best of the best, but we must put this attitude aside and look carefully at what cardiac surgery needs right now, and 5 years from now, in order to survive. Do we provide our new graduates, and older graduates, with the opportunity and the skills to practice the specialty as it must be practiced in 2002? Or is the future of cardiac surgery to be determined by a few powerhouses that have access to all the new technology, and who continue to amass cases while the rest of us look on in amazement? And then the next day it falls our lot to explain to Mrs. Johnson why her family member is not a candidate for the new technology she saw on the health channel last night.

It is said that those who do not study history are bound to repeat the same mistakes. The general surgeons learned this the hard way with laproscopic gallbladders, and laproscopy in general. We need to stop worrying about whether the CABG is off-pump or on-pump and start worrying whether we are going to have cases to do at all. We need to acquire interventional and endovascular skills, and take control of all aortic disease. We need to get involved with heart failure patients, the group we used to run away from when we were 'just' coronary surgeons. We need to get reacquainted with the esophagus and start getting comfortable with laproscopic Nissens.

My message is don't get stuck between the cracks. Complaining in the doctor's lounge will not increase your surgical volume. Learn what skills you need to compete in this profession. Heart surgery is a contact sport, with a scoreboard and a time clock.