By Douglas J. Mathisen, MD
This is a question that gets posed to me on a regular basis. One might surmise that the declining applications to cardiothoracic residency would argue that it is not a good time to be interested in our specialty. However, I take the opposite view. Events of the last couple years have created an opportunity for people interested in a career in cardiothoracic surgery.
What factors created a decline in interest in cardiothoracic surgery?
The most important factor has been a perceived lack of job opportunities. In my opinion, this has been part perception and part reality. It appears that virtually everyone who wanted a job got a job in cardiothoracic surgery, but had fewer opportunities to choose from and led to many disgruntled individuals. There were three factors that affected the job market. The stock market underwent a dramatic decline after 9/11; thereby affecting the retirement plans of many surgeons. This coincided with the continued decline in reimbursement for cardiothoracic procedures over the last ten years and the widespread use of coronary stents which reduced the volume of procedures in surgical practices heavily dependent on CABGs. To counteract these events, surgeons stayed in practice longer, groups were reluctant to take on new hires, and this created a stagnant job market. This was not a market correction, but an aberration that I believe has now run its course. Corroborating statistics for this theory include the increasing average age of our specialty; the last estimation of this was that it had reached the age of 57, up by almost 6 or 7 years over the last 20 years. This aging of the specialty would imply that people are staying in practice longer, possibly because of the economic impact of the events that I have previously mentioned.
What has changed to affect the job market?
Many of these factors have now reversed themselves. The stock market has climbed above the level it has attained prior to 9/11. The efficacy of drug-eluding stents is being called into question. Cardiologists are being held accountable for the outcomes of angioplasty and stenting and their durability. The most recent five-year RUC review has upheld the cardiothoracic community contention that our procedures are undervalued with the possibility of double-digit increases for some procedures expected. One could surmise from the five-year RUC review the government has realized that a specialty exhibiting declining interest, that they have cut reimbursement too far and maybe this represents a change in that trend. In a related area, Representative Charles Boustany, a cardiothoracic surgeon Congressman from Louisiana has put forth a bill to forgive debt for residents in specialties of greater than five years in length, which can demonstrate a decline in interest in their specialty. These initiatives in my mind are an acknowledgement on behalf of the government that they have gone too far in cutting reimbursement in our specialty.
Often cited as a reason for the decline in interest in our specialty is a change in the type of resident that goes into surgery and an increasing emphasis on lifestyle. I find both of these arguments inaccurate. The quality of cardiothoracic residents that I see still is exceptionally high and the equal of residents that were trained in our program over the years. The issue of lifestyle indeed is an important one that we must all recognize and address, but what more important factor in deciding on a lifestyle choice than choosing something that you love to do as your profession. For individuals broadly interested in surgery, what better field than cardiothoracic surgery? All three areas of our specialty are dominated by open surgery. The operations are still major surgical procedures. All three areas are evolving, innovation has never been greater, minimally invasive techniques are evolving and the absolute number of procedures in cardiothoracic surgery is increasing. The increasing number of procedures in cardiothoracic surgery is supported by an analysis of the Medicare claims data showing that from 1999 to 2004 absolute number of cardiothoracic surgical procedures increased by 14%. This information coupled with the evolving status of coronary stenting suggests that there will be ample cardiothoracic surgery for those in our specialty.
There are two other very important factors that will have a direct impact on demand for cardiothoracic surgeons. Everyone is aware of the impact of the baby boomers on the health care system. In 2011 the baby boomer generation will be entering the Medicare years. This impact will be felt by a 50% increase in Medicare eligible individuals in the United States (13 million people). The impact of the baby boomer generation on Medicare-aged patients will last for over 40 years. Cardiothoracic surgery deals with a disproportionate number of Medicare-aged patients who have cardiothoracic disease. This will translate into an increased demand for cardiothoracic services.
It has been estimated by two different analyses, one conducted by the Society of Thoracic Surgeons Workforce Study Group and one by the American Association of Medical Colleges Task Force on Cardiothoracic Surgery that over the next 13 years between 50 and 73% of current cardiothoracic surgeons will retire. The absolute number of CT surgeons declined in 2004 for the first time, suggesting retirement has accelerated. Over one-quarter of current active cardiothoracic surgeons in the United States are 65 years or older. Another quarter of active cardiothoracic surgeons are in the 55 to 65 year age group. At the current rate of 100 cardiothoracic trainees per year, there will be a shortfall of over 2000 cardiothoracic surgeons over the next 15 years.
In the last year, there appears already to be an increased demand for cardiothoracic surgeons. More inquiries about available residents have occurred in the last year than in the previous two years together in my experience. This is a sure sign the job market is loosening up. All of the previous factors that I have mentioned I think have run their coursed and we are now entering a phase where there will be increased demand for individuals trained in cardiothoracic surgery.
I hope that this brings to light why I believe it is a great opportunity for people who are interested in surgery who are looking for a challenging career that still focuses on major surgical procedures. I believe that the next five to ten years will see an increasing demand for cardiothoracic surgeons, a diminished supply of cardiothoracic surgeons to replace those that are retiring, an increase in the surgical volume for cardiothoracic surgery and an acknowledgement by the US Government that they have gone too far in decreasing reimbursement for cardiothoracic surgical procedures. So, indeed, in my opinion it is an outstanding time to be interested in a career in cardiothoracic surgery, a specialty that has long been noted for innovation, challenging surgical procedures and a profession with great personal satisfaction.
