A Critical Decision

When a student completes medical school and reflects on his or her future, that student must make a critical decision about whether to pursue a career as a primary care physician or a specialist. This decision may not necessarily be permanent, for career changes are often made later. But an early decision may be preferable in order to establish a clear direction and a workable plan for the future. In recalling my own decision to become a cardiothoracic surgeon, I feel that I made the perfect choice. The cardiothoracic specialty has offered me an abundance of rewards, not only economic incentives but also personal satisfactions, including an enjoyable professional life and the opportunity to alleviate human suffering.

Since the early history of mankind, the heart and its function have been equated with the mystery of life. Until the past century, surgeons were warned not to attempt to operate on this essential organ. Eventually, experience in cardiothoracic surgery, acquired largely on the battlefield, disproved the wisdom of this advice. The dawn of modern heart surgery, made possible by the advent of open heart techniques in the 1950s, was an exciting period in which many breakthroughs occurred within a few short years. Heart surgeons acquired a glamorous aura, especially during the early days of heart transplants and the artificial heart. Many young physicians were attracted to the cardiothoracic field and eventually became its leaders.

In the late 1970s, however, things began to change. With the advent of interventional cardiology techniques, numerous cardiac disorders became amenable to nonsurgical therapy. Myocardial revascularization began to be accomplished with balloon angioplasty and stenting. Implantation of pacemakers and implantable cardiac defibrillators became the province of cardiologists. Ventricular arrhythmias became treatable with catheter ablation. Likewise, bronchoscopy was increasingly performed by pulmonologists rather than surgeons. At the same time, the cost of cardiothoracic training began to increase while subsequent reimbursement was cut back. Applications to this specialty began to decrease. Today, there are fewer than 4000 cardiothoracic surgeons in the United States. Most of the operations that they perform are fairly routine—coronary artery bypasses and valve procedures for heart disease, pneumonectomies and lobectomies for lung cancer.

At first glance, it might seem that cardiothoracic surgery has little new ground to cover. However, a deeper look will show the tremendous clinical and research opportunities that await physicians entering this field. In the cardiac arena alone, we are already seeing minimally invasive valve and coronary artery operations; transmyocardial laser revascularization; left ventricular reduction and other surgical procedures for the treatment of dilated cardiomyopathy; stem cell therapy for chronic ischemic heart failure; and totally implantable assist devices, including partial and total artificial hearts. The use of robotic surgical equipment and telepresence surgery has only begun to be explored. In the future, cardiothoracic surgery may be revolutionized by developments in gene therapy, xenotransplantation, molecular biology, bioengineering, and nanotechnology. These breakthroughs will be supported by the steady advent of new diagnostic and treatment technology based on computers, radiology, magnetics, ultrasound, optics, and other methodologies. Therefore, much ground remains for cardiothoracic pioneers to cover, and many unsuspected breakthroughs no doubt lie ahead.

During the 20th century, the average life expectancy in Western nations was increased by almost 30 years because of advances in medicine, surgery, and public health. Long-time scourges including typhus, cholera, smallpox, polio, tuberculosis, and the contagious diseases of childhood were brought under control. Today, chronic, lifestyle-related conditions such as heart failure, stroke, cancer, and chronic obstructive pulmonary disease are the greatest challenges. The goal of 21st-century physicians is to increase not only the length of life but also the quality of life, particularly in the elderly. Cardiothoracic surgeons will play an important role in meeting this goal, especially as the Western population continues to age.

The future is full of opportunities for our specialty if we will recognize and seize them. I strongly encourage new medical school graduates to consider entering cardiothoracic surgery. Some may harbor concerns about the demanding lifestyle traditionally endured by most surgeons in this field. But the constant challenges and life-saving opportunities make this profession especially gratifying. Also, I have always found that cardiothoracic surgeons are afforded special respect. They are almost uniformly considered leaders or even elite among other surgical specialists. Heading a team of other specialists—skilled healthcare providers of many types—is satisfying and stimulating.

Never do I regret having chosen cardiothoracic surgery. Today, I would select it even more readily if given a chance to start over. Having enjoyed a long, satisfying career in this specialty, I look forward to helping the current generation take cardiothoracic surgery to new heights.