Cardiac Surgery

[Handsome88]

Is that pretty much a guaranteed match even for IMGs as long as you show some interest in your application? For me it's between Cardoilogy and Cardiac Surgery, but I see so many positions left for Cardiac surgery and was wondering if it is actually that easy to match in to?

 

Also, while I understand that the job market is really bad for Cardiac Surgery, isn't there always the option of practicing in the US? So why is it so "unwanted"?

[rmorelan]

Is that pretty much a guaranteed match even for IMGs as long as you show some interest in your application? For me it's between Cardoilogy and Cardiac Surgery, but I see so many positions left for Cardiac surgery and was wondering if it is actually that easy to match in to?

 

Also, while I understand that the job market is really bad for Cardiac Surgery, isn't there always the option of practicing in the US? So why is it so "unwanted"?

 

I will add one caveat to that - C.S. are the sort of people that would rather leave a spot unfilled than admit the wrong sort of person. This is why there are left over spots every year in that field.

[jock2doc]

In terms of surgical subspecialties, are there any with good job markets? It would seem from this forum that they are all oversupplied.

[rmorelan]

In terms of surgical subspecialties, are there any with good job markets? It would seem from this forum that they are all oversupplied.

 

None jump off the page as being great job market wise but there are jobs in gen surg from what I hear.

[NLengr]

Gen Surg is probably your best bet, as long as you are willing to go to more rural areas. Don't expect an academic job without residency, fellowship, MSc and possibly PhD.

 

But if you don't mind taking a job in Pembrooke, Kamloops or Edmunston (etc.), you should be ok.

 

Cardiac surg is probably the worst for any specialty. I'm pretty sure even the US is brutal. The jobs that are there are very low pay salary type positions from what I have heard.

[thebouque]

Keep in mind that there's an oversupply of surgical subspecialists because they use a lot of equipment and staff (they need ERs, nurses etc), not because of the population's needs.

There's an global oversupply of cardiac surgery because of the nature of the specialty itself. It's not a dying specialty, but its bread and butter procedure (CABG) has been largely replaced by interventional cardiology. Of course there's room for CABG but it's not what it used to be. Cardiologists are also starting to perform some endovascular valve replacements.

[jock2doc]

In terms of possibilities in the states, are there any more for the other surgical specialties? I read somewhere that Canadian trained Neurosurgeons could no longer go south of the border. That article was about 8 years old though.

[cdnmaple]

In terms of possibilities in the states, are there any more for the other surgical specialties? I read somewhere that Canadian trained Neurosurgeons could no longer go south of the border. That article was about 8 years old though.

 

The Canadian Neurosurgery program, as dictated by the Royal College, no longer meets the training requirements for American certification. I think it's something to do with the amount of pediatric exposure or something like that.

 

In any case, it is fixable. If a Canadian-trained NSx wants to write their American boards, they need to find a training position in the US to pick up the missing components, usually along with subspecialty fellowship training of some kind.

[Handsome88]

I will add one caveat to that - C.S. are the sort of people that would rather leave a spot unfilled than admit the wrong sort of person. This is why there are left over spots every year in that field.

 

That may be true but looking at the stats it shows that every single one who applied for C.S. as first choice matched into it.

[rmorelan]

That may be true but looking at the stats it shows that every single one who applied for C.S. as first choice matched into it.

 

Oh sure, there is a lot of self selection going on there as well though and early pruning - when I stated I was interested in cardiac surgery - and I still love that field - they told me aside put me through the wringer for a month to really see things. I know others my class that were basically told to rethink they options by the cardiac teams due to their skill set going in.

 

It is not hard to believe that the 4-5 people that actually applied really are top rate people

[canucks_14]

 

The Canadian Neurosurgery program, as dictated by the Royal College, no longer meets the training requirements for American certification. I think it's something to do with the amount of pediatric exposure or something like that.

 

In any case, it is fixable. If a Canadian-trained NSx wants to write their American boards, they need to find a training position in the US to pick up the missing components, usually along with subspecialty fellowship training of some kind.

What about the other way around? Can an American trained neurosurgeon practice in Canada?

[rmorelan]

Keep in mind that there's an oversupply of surgical subspecialists because they use a lot of equipment and staff (they need ERs, nurses etc), not because of the population's needs.

There's an global oversupply of cardiac surgery because of the nature of the specialty itself. It's not a dying specialty, but its bread and butter procedure (CABG) has been largely replaced by interventional cardiology. Of course there's room for CABG but it's not what it used to be. Cardiologists are also starting to perform some endovascular valve replacements.

 

also we are one drug generation likely away from having medical therapies that even further prevented and significantly reducing the need for revascularization procedures - and everyone is trying to make those drugs and throwing money at it by the truck load (who ever creates the next therapy case is going to make a killing). It isn't just the stenting that has reduced the new for cardiac surgery - we have been slowly but very steadily improving on the medical management so it doesn't get that far and in part this is why the patient population is getting older and older for cardiac surgery. Of course the cardiologists do both the interventional AND the medical management so they are cutting into cardiac surgery in two different ways.

 

and yeah cardiologists and actually some radiologists are involved in the in implanted valve replacements as interventionalists - technology with this as well will only improve going forward.

[canucks_14]

also we are one drug generation likely away from having medical therapies that even further prevented and significantly reducing the need for revascularization procedures - and everyone is trying to make those drugs and throwing money at it by the truck load (who ever creates the next therapy case is going to make a killing). It isn't just the stenting that has reduced the new for cardiac surgery - we have been slowly but very steadily improving on the medical management so it doesn't get that far and in part this is why the patient population is getting older and older for cardiac surgery. Of course the cardiologists do both the interventional AND the medical management so they are cutting into cardiac surgery in two different ways.

 

and yeah cardiologists and actually some radiologists are involved in the in implanted valve replacements as interventionalists - technology with this as well will only improve going forward.

I'm not a doctor but I read cabg is better than stents for the sicker patients? Is that going to swing things back towards cardiac surgery?

[NLengr]

I'm not a doctor but I read cabg is better than stents for the sicker patients? Is that going to swing things back towards cardiac surgery?

I think it's for diabetics and or three vessel disease last time I heard. But I'm not a cardiac guy so my memory may not be correct. I certainly don't know the literature in depth.

[A-Stark]

Three vessel disease, left main disease, diabetes, depressed LV function - all situations where CABG is superior. 

 

Some valves can be done through TAVI procedures but only in select patients. I doubt CV surgery is going to grow much but it's not going anywhere anytime soon.

[rmorelan]

I'm not a doctor but I read cabg is better than stents for the sicker patients? Is that going to swing things back towards cardiac surgery?

 

like all new therapies there is an initial  phase of treatment X is the best for all things, followed by a phase of no treatment X is disappointing followed by balance

 

stenting has a major issue - it doesn't fix the "plumbing", ie vessels it just unclogs the them and supports a small area. The issue is that the pipes in general suck in these patients so small repairs only buy you so much time (if you are dying do to an acute blockage though that repair is kind of an amazing thing). Anyway in the long run often CABG, which replaces the pipes, is better but that is only if you expect the patient to live several years forward due to the initial surgical risk and recovery time. Also you avoid some of the post CABG complications (darn micro clots). 

[rmorelan]

Three vessel disease, left main disease, diabetes, depressed LV function - all situations where CABG is superior. 

 

Some valves can be done through TAVI procedures but only in select patients. I doubt CV surgery is going to grow much but it's not going anywhere anytime soon.

 

never go away - if for no other reason simply than trauma and transplant. It is just the needs are so much less than they used to be overall, and the bread and butter procedures are under attack from multiple sources. 

 

Probably would be better if somehow they just acquired at least in part the interventional side - of course the politics there are extreme.

[dh79]

Like all fields, cardiac surgery is evolving. CABG, valve replacement, and valve repair will always be a part of the specialty. TAVR, TEVAR, minimally invasive cardiac, and mechanical support are growth areas. The relative frequencies and patient demographics will continue to change in accordance with clinical demand.

Right now and for the foreseeable future there is no shortage of cardiac patients. The two centers I know best both increased volumes last year.

With medical therapy for CAD and pci for ACS, patients are living longer. Patients going for CABG are older, but it continues to prove itself as a good surgery for the right patient.

[canucks_14]

Like all fields, cardiac surgery is evolving. CABG, valve replacement, and valve repair will always be a part of the specialty. TAVR, TEVAR, minimally invasive cardiac, and mechanical support are growth areas. The relative frequencies and patient demographics will continue to change in accordance with clinical demand.

Right now and for the foreseeable future there is no shortage of cardiac patients. The two centers I know best both increased volumes last year.

With medical therapy for CAD and pci for ACS, patients are living longer. Patients going for CABG are older, but it continues to prove itself as a good surgery for the right patient.

Which two centres are those?

[Edict]

I've heard that TAVIs are done on predominately older patients who are not fit enough for surgery because studies have shown TAVI ourcomes are poorer than the traditional AVR. 

[rmorelan]

I've heard that TAVIs are done on predominately older patients who are not fit enough for surgery because studies have shown TAVI ourcomes are poorer than the traditional AVR. 

 

quite true - the question though is that cardiac surgeries like AVR are pretty much maxed out in terms of the technology - unlikely to be a lot of further improvement in a technique we have been doing for decades with it being honed to perfection as it were. Probably still small things that can be done better but less like there is some revolution in the field about to happen etc.

 

TAVI is just beginning - we don't know exactly where it will eventually lead

[NLengr]

quite true - the question though is that cardiac surgeries like AVR are pretty much maxed out in terms of the technology - unlikely to be a lot of further improvement in a technique we have been doing for decades with it being honed to perfection as it were. Probably still small things that can be done better but less like there is some revolution in the field about to happen etc.

 

TAVI is just beginning - we don't know exactly where it will eventually lead

 

I'd argue there is still a lot of technology that could be applied to the cardiac surgery guys.

 

Minimally invasive and robotic techniques are still quite new in C. Sx. and have the opportunity to revolutionize the field. Much like laparoscopy did for intra-abdominal surgeons 25 years ago. Cardiac surgery without the big, highly morbid, incision could be a huge game changer.

[A-Stark]

Maybe. Dehiscence is more of a problem for weaning and prolonged hospitalization. Reducing it would definitely save resources on post-operative care, but the really bad complications - prosthetic valve leaks, tamponade, uncontrolled hemorrhage, and the usual post-op AKI or stroke - are still going to be around. 

 

We've made a lot of incremental differences, to the point that CV surgery is fairly "safe", but we're only going to get so much better when the patient population is predominantly elderly with multiple comorbidities (or worse, on dialysis). 

[NLengr]

Maybe. Dehiscence is more of a problem for weaning and prolonged hospitalization. Reducing it would definitely save resources on post-operative care, but the really bad complications - prosthetic valve leaks, tamponade, uncontrolled hemorrhage, and the usual post-op AKI or stroke - are still going to be around. 

 

We've made a lot of incremental differences, to the point that CV surgery is fairly "safe", but we're only going to get so much better when the patient population is predominantly elderly with multiple comorbidities (or worse, on dialysis).

 

I agree. The places you'll probably see the most gains, at least initially are things like post op stay, blood loss, dehissence. Same stuff you see with most lap vs. open.

 

Things start getting real interesting when you start talking robotics and integrating imaging intra-op, intra-op markers to aid structure ID etc. but that's all very new and experimental still.

[dh79]

The Canadian society of cardiac surgeons had their annual general meeting last week at CCC. They discuss the job market every year and perform surveys of division chiefs. If you do a pubmed search for canadian cardiac surgery manpower you will find previous publications from recent years. This years data won't be out yet though.

 

This year the mood was overwhelmingly optomistic.

 

All but one center in canada had increased volumes. There are a lot of surgeons expected to retire within 5 years. Training numbers right now are less than expected hiring numbers. Basically, there is reason to believe there will be jobs for all good trainees. This is a very good time to train in cardiac surgery.

 

People in other specialties just don't know the current facts so take their "advice" with a grain of salt.