Welcome to our next installment in So You Want to Be. In this series, we highlight a specific specialty within medicine, such as cardiothoracic surgery, and help you decide if it’s a good fit for you.
So you want to be a cardiothoracic surgeon. You like the idea of open-heart surgery and the glory that comes with being a CT surgeon. Let’s debunk the public perception myths of what it means to be a cardiothoracic surgeon, and give it to you straight. This is the reality of cardiothoracic surgery.
What is Cardiothoracic Surgery?
Cardiothoracic surgery refers to surgery within the thorax, or the chest cavity. This includes surgery on structures such as the heart, aorta, lungs, mediastinum, esophagus, and diaphragm.
These are the surgeons who do procedures like coronary artery bypass grafts, or CABG for short, to treat plaque buildup in heart vessels. They perform valve replacements to replace poorly functioning heart valves, lung resections to remove lung cancer, and esophageal repairs to remove esophageal cancers. They can also perform heart and lung transplants, usually one or the other, but in rare instances both at the same time.
This specialty is not for the faint of heart. Most CT surgeons are workaholics, as CT surgery is a specialty with a more challenging lifestyle than most. Operations such as CABG or lung resections last from 4 to 8 hours, and when things go wrong, complications can result in a procedure lasting up to 12 hours!
That being said, many CT surgeons make time for their family and hobbies. After all, these are very smart doctors, and they understand the importance of a balanced life for sustainability and longevity.
CT surgery also has a reputation for a malignant culture, which is a term we use to mean you aren’t treated well by your superiors or colleagues. This may have been the norm in the past, but luckily things are changing for the better, and many CT surgeons love teaching residents and medical students.
There are a few ways to categorize CT surgery.
Cardiac vs Thoracic vs Cardiothoracic
First, we can divide the types of surgery based on anatomy. After finishing CT surgery training, surgeons can choose to specialize even further as cardiac or thoracic surgeons. Cardiac surgeons focus on the heart and aorta, performing operations such as CABG and valve replacements.
Thoracic surgeons mainly operate on the lung, such as lung cancer resections, but also work on the esophagus, diaphragm, mediastinum, ribs, and other structures within the thorax.
Alternatively, they can remain generalized and operate in both cardiac and thoracic domains, which is more common at community centers. However, if you work at a larger urban or academic hospital, you’ll probably be specializing in cardiac or thoracic.
Open vs Minimally Invasive Surgery
When you think of CT surgery, especially cardiac surgery, you may imagine an open chest, the heart stopped in the surgeon’s hand, and a giant machine circulating blood to the patient. And that stereotype is mostly true. The majority of cardiac operations, such as aortic valve replacements and CABG involve performing a sternotomy, whereby a saw is used to cut the breast bone in half to access the heart.
The cardiopulmonary bypass machine takes over the function of the heart and lungs while they’re stopped, such that the patient’s blood is drained into the machine, where it’s oxygenated, and then gets pumped back to the rest of the body. This allows the surgeons to operate as needed on the stopped heart.
On the other hand, minimally invasive surgeries include video-assisted thoracoscopic surgeries or robot-assisted, like the Da Vinci robot. Most lung cancer resections are performed in this manner. Four to six small incisions are made in the spaces between the ribs to insert ports for the robot arms or camera. Using long instruments and a camera, surgeons are able to maneuver through the thorax to cut, remove, and suture tissue. Certain cardiac surgeries, such as valve replacements, can also be performed with robot assistance.
How to Become a Cardiothoracic Surgeon
After finishing medical school, there are three pathways to becoming a CT surgeon. This is very similar to the plastic surgery training pathway that we covered in a previous So You Want to Be post.
The most common and traditional, called the independent pathway, is to complete a general surgery residency, lasting 5-7 years depending on the program, and then complete an additional 2-year CT surgery residency afterward. In this situation, the surgeon is board certified in both general surgery and CT surgery and is spending between 7 to 9 years of additional training after medical school.
The second option is the integrated pathway, lasting only 5 or 6 years in total. Residents rotate on general and CT surgery, but spend most of their time on CT. This is a smaller and newer format, but it’s growing each year. Residents in this pathway are only board-certified in CT surgery, not general surgery.
The third option is the combined pathway, also known as the fast track pathway. Rather than 5 years of general surgery residency and then applying separately to another program for a 2 year CT residency, you’ll do 4 years of general surgery and 3 years of CT surgery at a single program. These graduates are certified in both general and CT surgery.
Again similar to plastic surgery, most medical students want to obtain an integrated pathway position. After all, it’s fewer years in training. However, CT surgery integrated programs are new and small in number. Last year, there were only 37 individual positions available, meaning that fewer than 50% of applicants successfully matched. For this reason, most aspiring CT surgeons choose a general surgery residency, which is a less competitive path. Don’t think it’ll be easy however, as it’s still very challenging to match at a top-tier, big-name program.
What types of medical students apply to CT surgery? Stereotypically, the gunners. After all, CT surgery is far from easy, and it comes with long hours. The bread and butter cases, such as CABG and lung resections, can last a long while. For these reasons, it attracts those who aren’t afraid of hard work. Particularly if you end up at an integrated CT surgery residency program, you’ll need to be at the top of your class with stellar board scores, research, letters of recommendation, and honors in your clinical rotations.
Subspecialties within Cardiothoracic Surgery
After completing CT surgery training, you can subspecialize even further with a 1 year fellowship.
Congenital Cardiac Surgery
Congenital cardiac surgery is for those who love precision and working on tiny objects. Many congenital cardiac operations must be done as soon as the neonate is born, which means working on a heart the size of a golf ball.
Congenital cardiac surgeons also operate on adults with congenital heart defects. If you’d like to work with a wide age range of patients, this may be a good fit.
Transplant surgery is for the workaholics who love a rush. Transplants can occur at any moment, depending on when the donor passes, and this often translates to operations in the middle of the night. The glorious side of transplant surgery is that you’ll be riding in helicopters and private jets to harvest the organs.
Thoracic Aortic & Endovascular Surgery
Thoracic aortic and endovascular surgery includes extra training to master operating on the thoracic aorta, or the part of the aorta that is in the chest. You mostly treat patients with aortic aneurysms, or aortas with expanded and weak walls that are about to erupt! You can either perform open surgeries to replace the diseased segment of the aorta or perform an endovascular operation in which you snake a wire and a stent through the patient’s femoral artery in the leg. Once you work it up to the thoracic aorta, you can deploy the stent by expanding it to address the defect in the wall.
What You’ll Love About Cardiothoracic Surgery
Cardiothoracic surgery is a pretty dope specialty. If you love big, epic operations, this is the field for you. Where else can you feel the heart beating in your hands, stop it, and then bring it back to life? CT surgery is also incredibly exciting with rapid innovation and new robotic and minimally invasive surgeries being developed regularly.
In terms of patients, you’ll be working with the sickest of the sick. Particularly with heart failure and heart attack patients, who are at death’s door, you’ll be saving lives. For this reason, it’s highly rewarding and CT surgeons build a strong bond with their patients. However, you should also be able to stomach when cases occasionally go bad.
If you love complex work with multiple moving parts and teamwork, CT surgery has you covered. Not only are you working with the nurses and anesthesiologists, but you’ll have the perfusionist manning the cardiopulmonary bypass machine and robot assistance for minimally invasive surgery. Additionally, these patients require close post-op monitoring and care, so you’ll be working with several other members of the healthcare team to ensure a safe recovery.
Lastly, money. CT surgeons are highly compensated for their work, with an average annual salary of $480,000.
What You Won’t Love About Cardiothoracic Surgery
While CT surgery is glamorous and exciting, it’s definitely not for everyone. This is a highly demanding specialty with a great deal of hard work. Surgeries are long, and patients are sick, often not having favorable outcomes. You will have more patients die than compared to other specialties.
And you won’t have a predictable schedule. In this line of work, emergency surgeries in the middle of the night are not uncommon. Get ready to pull all-nighters and still operate the next day. The usual “9 to 5”, 40 hours per week does not apply here.
Training is long and it will take a while to become a CT surgeon, and even longer if you want to specialize further. While other specialties have 3 to 5 years of training after medical school, be prepared to spend another decade for CT surgery. That’s 10 years of making $50 to $80k a year as a resident or fellow as well as 10 years of spending intense hours in training.
Should You Become a Cardiothoracic Surgeon?
At the end of the day, how can you decide if CT surgery is a good fit for you? If you’re an adrenaline junkie who loves big cases, a fast-paced lifestyle but isn’t afraid of standing for hours doing longer surgeries in the middle of the night, then CT surgery may be a good fit.
If you also crave innovation and want to be on the cutting edge of surgery, CT seems to always have a new noteworthy technology every year and is one of the leading specialties in robotics utilization.
Finally, CT surgery is incredibly competitive, particularly if you want to get into an integrated residency or get into a strong general surgery residency to position you well for a CT fellowship.
And who better to learn from and be mentored by than CT surgeons themselves. Big shout out to the CT surgeons at Med School Insiders that helped me in the creation of this post. If you need help acing your MCAT, USMLE, or other exams, our tutors can maximize your test day performance. If you’re applying to medical school or cardiothoracic surgery residency, our CT surgeons can share the ins and outs of what it takes and how to navigate the highly competitive process most effectively. We’ve become the fastest growing company in the industry, and it’s no surprise. Our customers love us because we’re committed to delivering results, period.
Much love to you all.