A Career in Cardiothoracic Surgery: A Passionate Choice

Cardiac surgery is just over half a century old, and cardiac surgeons have always adapted to change rapidly. Innovation has been their hallmark, and it is awe inspiring to think of the innovative procedures developed by cardiac surgeons over the decades. The ingenuity and complexity of cardiac surgical procedures claims superiority over most other specialties.

In spite of strong specialty leadership, rapid progress in the field, and the brilliant academic and technical skills of its practitioners, cardiac surgery is still at a cross roads. Where are we to go? What direction to follow? What skills do we need to acquire? These dilemmas makes practicing surgeons all over the world feel overwhelmed. This feeling has percolated down, and interest in taking up cardiac surgery as a career option has waned.

An ideal cardiothoracic resident, as Prof. Kouchoukos proposed, has “intelligence, drive, and stamina, … loves challenges, hard work and positive outcomes, … is results-oriented, loves working with their hands as well as their brain, and enjoys caring for others and interacting with highly competent physicians and other health care professionals.” To the discerning eye, this ideal resident qualification manifesto encompasses the entire gamut of human occupational skills. No wonder cardiac surgeons are said to be one of a kind!

Cardiothoracic surgical residents are an endangered species, as the statistics from all over the world indicate. In the U.S., applicants for cardiothoracic surgical residency have shown a 24% decline, whereas there has been progressive increase in the takers for other specialties. The statistics from India, where the authors operate, are no different. The quoted reasons often include: “too much hard work,” (confusion between work and life’s passion), “late settlement in life,” (but it is about winning the war and not the battle), “can’t work under someone or with a team,” (man is still a social animal, despite willful denials). But jokes aside, there are challenges that cannot be overlooked, such as: the technical nature of the surgery, fine motor skill requirements, and an associated long learning curve. For example, an aortic valve replacement (AVR) has 122 steps, which a trained surgeon is expected to carry out in a precisely coordinated sequence. (As Dwight McGoon said, “write twice down, learn them and you will do well.”) These challenges should be given due respect, but should not kill the aspirations of budding surgeons.

India, along with China, has more heart disease than the whole of the developed Western world put together (1). An estimated 200,000 babies are born with congenital cardiac defects each year. Over two million await valve surgery (2). Hypertension, diabetes, dyslipidemia, and smoking continue to be major public health problems, adding to the burden of coronary artery disease. The annual figures of 140,000 cardiac surgical procedures amounts to only a paltry 130 cases per million of the population in India. This is in stark contrast to the 850 cases per million of the population in the developed world. At present, the cardiovascular health scenario faces a huge backlog of surgeon deficit, along with dwindling resident enrollment (3, 4).

The advent of minimally invasive and robotic techniques has furthered the expectations of residency programs. The current 3+3 training model in India is probably not suited to contemporary requirements (2). Adopting the 6-year thoracic surgery residency program, based on the U.S. model, although in its preliminary stages, has increased the enrollment of late. A focused perspective on any cardiothoracic residency program should ensure that it is replete with adequate hands-on experience for the resident, with a large portion of the surgery being done by the resident (understanding that the critical steps should be done by a mentor until the resident acquires the necessary level of skill). Improving the efficiency of performance by being organized and the non-repetition of steps, rather than fast hand movements, should receive emphasis. The level of responsibility assigned should increase with preparedness and seniority. The training program should be based on surgical heuristics-learning, through trial and error, under effective mentorship whether it be the motor, perceptual, or the cognitive elements involved. 

Finding the right mentor, acquiring perfection of the skill sets, and gaining enough operating experience to earn the stamp of quality may consume long years, often extending beyond the timeframe of residency. Thus from a resident’s point of view, the road to a career in cardiothoracic surgery is apparently a long, bumpy ride with lots of uncertainties on the way. But as practitioners of this art, the authors would urge any aspirant to concentrate on the “rose” rather the “thorns.”

The aspirants should realize that the perceived future of cardiothoracic surgery is now. As already discussed, at present there is a huge demand versus supply in this field. The cardiothoracic surgical community needs more competent and erudite professionals to serve. The technological boom in the field provides ample opportunities for a cutting-edge career path. Minimally invasive techniques and robotics offer exciting prospects in the field with limitless possibilities for innovation. Lots of unchartered territory awaits the in the field of tele-surgery and tele-mentoring.(5) The advancements in cardiology and catheter-based interventions should not be perceived as an obituary to open procedures, but the birth of a new breed of evolved “hybrid surgeons.”

Above all, the unique privilege to handle the heart, the most dynamic organ of the human body, is unparalleled. The altruistic heights that the profession demands allows the practitioner to find his own alter-self, by losing himself in the care of the seat of the soul. Thus, beyond all rationalizations and logistics, it would still be a right brain choice to walk this difficult yet fulfilling path.

Now what is it that is missing? It is only the passion, the white heat of focused desire to practice this noble art, which should drive the aspirant to succeed to serve in its fullest sense. As Dewitt Jones said, “don’t be the best in the world. But be the best for the world.”

References

1. Joshi R, Jan S, Wu Y, et al. Global inequalities in access to cardiovascular health care. J Am Coll Cardiol. 2008; 52(23):1817-1825.
2. Vaithianathan R, Panneerselvam S. Emerging alternative model for cardiothoracic surgery training in India.  Med Educ Online 2013, 18: 20961.
3. Cox JL. Presidential address: changing boundaries. J Thorac Cardiovasc Surg 2001; 122:413–418.
4. Grover A, Gorman K, Dall TM, et al. Shortage of cardiothoracic surgeons is likely by 2020. Circulation 2009; 120:488-494.
5. Xavier B. The future of cardiac surgery: Find opportunity in change! Eur J Cardiothorac Surg 2013; 43 (1): 253-254.