Why Become a Chest Surgeon?

The vast majority of medical students love their surgical rotation because they get to see inside the magical world of a living body.  They finally get to walk through forbidding doors that are labelled with signs that read “Surgical Personnel Only” or “Do Not Enter – Restricted Area.”  They see what lies behind this previously restricted area and observe the incredible world of what lies under the human skin. It is a privilege to be allowed to open another human’s thoracic cavity or to saw apart their sternum enroute to removing a cancerous growth in their lung or to repair a leaky heart valve. The miracle of the cardiopulmonary system impresses everyone, especially medical students who, although they may have all the knowledge of how each cell works, have no idea of what it really looks like. Yet most students choose not to be surgeons.  This may be because students also get to see and live the life of a surgeon.  This is not quite so miraculous.  They see the highs and the lows – the long hours, the intraoperative frustrations and the devastating meetings with families about operative mortalities. They hear about the training. Is this what keeps them out of surgery?  I do not think so. 

The world of any surgeon, especially a chest surgeon, is a special place.  Once a medical student starts their surgical rotation, if it is properly structured, most enjoy the whole concept of the “operating room.”  They see that if they become a surgeon they get to do all the things the medical doctor does – form strong relationships with patients and families, make rounds, track down labs, order tests and correct problems.  In addition, we get the joy of operating from 7am to 4pm. Yet, many medical students who acknowledge and even enjoy all of this and enjoy the technical exercise of operating chose NOT to become a surgeon. Why?  Why do only 14% enter a surgical field?  I believe it is multifactorial. 

Some have a preconceived perception that it is just too hard.  They hear or think that the training is too long, the residency is too malignant, and the price of being a surgeon, especially a thoracic surgeon, is too high.  They think that the toll it takes on one’s personal life is too much to pay.  Many, although afraid to verbalize it, wonder if they have the technical skills or the physical endurance to do it.  They doubt themselves. “Can I really stand for that long, not eat for that long” they question.  “Do I really want to challenge myself when I am 40, 50 and 60 years old in this mental and physical way?”  Only surgeons are faced with the one-on-one challenge of an operation: where no-one can come bail you out in the middle of it when you are in trouble. You have to get the vessel dug out; you have to get the bleeding vessel controlled.   Some hear about or personally witness the egomaniacal personalities of some surgeons and this dissuades them from surgery altogether.  “I never want to be like that”.  Many talk themselves out of a surgical career even before they start their rotation.  In fact, if you carefully listen to medical students, many come into the surgical rotation wanting to dislike surgery or already have decided not to go into surgery.  This makes the decision easier.

There is no pressure to try to convince themselves later that their life as a surgeon really will be ok.

How do we respond to these real concerns?  Our message to medical students should be clear.  No matter what specialty you choose, what field you endeavor to go into, your life is what you make it.  One can be an internist or general practitioner and spend 16 hours a day at the hospital, never be home for your family, or be too wrapped up in your work to have a family life.  Likewise one can be a busy, caring and successful cardiothoracic surgeon and still be at all of their kids’ birthday parties, coach their little league teams and spend one night every few weeks alone with their spouse.  Each one of us is ultimately in control of our own lives – so why not choose what you really enjoy doing during the day?  Many surgeons now are in big groups and the call schedule is as gentle as many medical doctors.  Why not do what you find fun?  Why not challenge yourself?  The training is set up so you will be able to sew like that, get that vessel dug out, ligate that bleeding vessel.  You will be able to stand that long and you will be a better person and have done what you really wanted to do.  Do not be swayed by someone else’s impression or opinion of what it would be like to be a surgeon – make the decision for yourself.  Didn’t you already go through that when you told your family you wanted to be a doctor three or four years ago?

Many medical students choose a field because of a particular role model that they have met or come to respect in that field.  They say I want to be like him or her and they thus decide to go into that field.  But we should not.  We should not choose a field because a role model is in it, we should choose a field because we can see ourselves AS a role model for it.  We can see ourselves doing it for the next 30 years - having fun doing it and teaching others how to do it. We see that some surgical fields have many different avenues, and we can change our practice over time. At times, especially at first it is hard, both physically and mentally. The mountain is steep, the rocks are sharp and there are times we will slip and fall.  But isn’t it better to stand on top of a steep, tall mountain?  Doesn’t that bring more joy and satisfaction than standing on top of a small one?  The instant satisfaction of surgery is unparalleled in medicine.

I have met very few students who do not enjoy learning the rudimentary skills involved in learning how to suture, how to cut and sew, if the environment is made friendly enough.  Most can see themselves getting better each day even over a short 14 day rotation.  They get to see the final product they can deliver.  Students get to see the perfectly closed incision of a subcuticular closure that THEY got to create.  They see the incredible joy that they bring families when we tell them that “the operation went well”, their loved one will be “OK,” the “cancer is all out.”  This may be the greatest part of being a surgeon - the instant gratification of all of your hard work and years of training. An operation has a beginning, middle and end.  You get to create the story, paint the landscape and decide the ending.  You get to do this several times a day.  You created it – you got it done safely with minimal morbidity and pain. You got the patient through it. The gratification and satisfaction can be no higher, no greater than after taking out a lung cancer or bypassing obstructed coronary arteries.  

Medical students today are not just book-smart, they are life-smart. They want to work hard and play hard.  Priorities have changed and the doctors of today are different from those of yesterday.  They should be – hasn’t everything else changed?  The importance placed on being able to do things after the work-day is over is higher now than ever.  We have listened to our parents, we have taken their advice.  We realize and agree that there are more important things in life than just work.  Surgery today allows you to do that.  This should be an important part of our message to medical students.  But medical students also understand that being a surgeon is not “just work.” You are called a professional for a reason.  Fortunately, a career in cardiothoracic surgery blends all of these facets.  One is control of one’s life, maybe not through residency, true, but soon after.  Do you really think you are in much more control of your life during a medicine residency?  Life is what you make it, even during residency.

I have had many students tell me that they would love to be a surgeon except the residency is too hard, too long.  Not any more. The 80 hour work week has addressed and controlled this once potentially hostile environment.  It is a thing of the past.  It is gone. The new generation of attendings that have populated many academic programs now do NOT want to make it as hard for them “like it was for us.”  We really want to make it better.  And we have.  Students used to say “the road is too long.”  Not any more. The number of years it takes to be a cardiologist or critical care specialist is the same as it takes to be a cardiothoracic surgeon.  They used to say “they do not make enough money for what they do.”  Not any more.  Although the older generation cardiothoracic surgeons may say this the younger ones do not.  The median compensation of a cardiothoracic surgeon is in the top 3% of all medical doctors and in the top 1% of all jobs in the United States.  We make a great living doing something we love to do day after day. Yes, we work hard, but so do lots of other people in this country.  They used to say “the financial debt is too high.”   Not any more.  The average debt of those going into a career in cardiothoracic surgery is no higher than in other medical subspecialties.  They used to say that the future of cardiac surgery is questionable.  Not any more.  New robotic procedures and new minimally invasive procedures are not just on the way, they are here. Coronary artery bypass grafting (CABG) is such a safe, time-proven operation, it is here to stay.  The number of CABG’s may be down, but the field is still well protected and well monitored. The American Board of Thoracic Surgery and other professional organizations remain strong. There is no turf battle between a cardiac surgeon and a general surgeon when a patient needs a CABG.  Although many general surgeons do perform pulmonary and esophageal work, that number is falling.  The superior results of the general thoracic surgeon in these areas are well documented and patients know it.  This may influence third party payors.  They used to say the lifestyle is no good.  Not any more.  The lifestyle of a general thoracic surgeon is better than most all surgeons I know and yet our pay is almost double. Your life is what you make it.  Yes, there are emergencies in cardiac surgery, but if one is in a big group or in an  academicsetting these can be limited and controlled.  Finally they used to say the job market is no good.  This certainly is not the case for general thoracic surgery.  Right now there are more openings in general thoracic surgery both in academic and private practice than in any other surgical subspecialty.  This will not change over the next ten years.  These are the reason to go into surgery, especially cardiothoracic surgery.

Too many students tell me they love surgery but are afraid they do not have the technical ability to do it.  Or they love general thoracic surgery but do not want to go through the cardiac training.  Or, they would love to be a surgeon but do not want to go through the residency.  If you really like it, just do it.  Do not be short minded.  Do not make a decision because of the perception that a few years are bad and then deny yourself doing what you really want to do for the next 35.

For these reasons I suggest you listen to your heart.  If you found yourself enjoying holding that needle driver in the operating room, then follow your heart. If you did not get the chance to do this during your third year rotation then take an elective with an attending in your hospital who will allow you to try it.  If you did like surgery, then explore all of the surgical subspecialties and carefully evaluate cardiothoracic. In conclusion, these are the questions students must ask themselves.  We as attendings must ask ourselves why so many medical students love parts of their surgical rotation but have a problem seeing themselves as a surgeon.  It is our job to help them discover this world, to make the OR fun, to allow them to open their hearts to surgery.