Opinion: Despite empty seats CTVS still retains its glory - Dr HS Bedi

Why are so many seats vacant in a once-glamorous super speciality of Cardio Vascular & Thoracic  Surgery (CTVS)? 

Recently 130 of 185 seats for MCh CTVS went empty. This is indeed shocking and a reason to worry. There is no single reason, but a multitude of factors.

Let us see the perceived demerits of CTVS and its apparent lack of popularity

Long Training: CTVS is a skill that takes time to master and the more one practices, the better he gets at it. After a grueling MBBS, and an MS  General Surgery - one needs to train long and hard to become a competent CTV surgeon. There is an almost mandatory loss of at least a year in between MBBS and MS entry and then between MS and MCh entry due to stiff competition.Even after MCh CTVS, one needs to work further for 4-5 years to reach some semblance of competence

Setup: Consider you had gone through all hardship and struggle and became a confident CTV surgeon yet you need a team and a setup. The setup is costly and you need a good team of junior doctors and trained cardiac anesthesiologists to perform cardiac surgery. Surgical setups are costly and need high maintenance compared to their medical counterparts. It is almost impossible for a CTV surgeon to build and own his setup.

Also read:- Vacant MCh seats: Gujarat now offers waiver of Rs 50 lakh bond, MCC issues notice

• Competition with Interventional Cardiologist: The Interventional Cardiologist is the gatekeeper as he does all the preoperative angiograms. He is the one who gives the first advice re the therapy. I have seen cardiologists persuading a patient on the Cath Table by giving him the option of multivessel stenting even in diabetics (which is NOT the recommended procedure of choice in the majority of cases as per ALL cardiological society guidelines) vs 'sawing' open your chest. This word sawing is told dramatically and vividly without informing the excellent long term results. They never tell him about the guideline recommendations nor do they consult the CTV surgeon as they should in the scientific Heart Team concept.

• Work Hours: They are much higher and tougher for CTV trainees. Working hours for a surgery resident in India are much more than the US. While shifts in the US are rarely more than 24 hours, they could easily extend to 36 hours in India. Some residents have worked 130 hours a week, even more.  Due to a lack of guidelines, there are no fixed working hours for doctors in India (unlike the EU and US). If the working hours are regulated, the trend might shift towards CTV surgery in India.

• Too much paper Work: Just because you made it to CTVS residency doesn't mean your seniors will give you the scalpel and ask you to perform surgery. Initial years are spent doing lot of labour work like pushing patient's trolley, writing discharge documents, taking blood samples, arranging blood, sending and making sure patient's all reports came, going to anesthesiologist and taking fitness, holding retractors for hours, and  handing over the instruments majority of which do not  require any deep knowledge of medical science.

CTVS is not the speciality of choice, it has a long incubation period. While a urologist may be ready to practice on his own at age  30 years, for CTVS where the training is long and hard, it could be at age 35- 45 years. The average workday for a resident could be 18-20 hours. There are very few well-equipped centers because it is both expensive and manpower-intensive to run a CTVS Centre. What is more, after such a long and arduous training, a CTVS surgeon would probably get Rs 20,000 per surgery while a gastrointestinal surgeon would make Rs 50,000 from a gall bladder surgery

• Work Environment: Suppose you are S3 ( surgeon no 3) whose major job during operation is harvesting the vein but yet you will get a maximum scolding if the surgery is not going smoothly. It is very common inside OT to get scolding for no fault of yours. One needs to have a thick skin to survive.


• Pay: Even after all this, the Pay for CTVS is less compared to the effort they put in. In a teaching hospital, the pay scale is the same whether one is operating long hours or just doing rounds as in some specialties.


• Need for multiple fellowships even after finishing training.


• Lesser job opportunities.


• Higher risk of medico-legal issues.


• A lot of physical strain


• Long hours of work


• The new culture of aiming for quick monetary returns

Also read:- DM, MCh, DNB SS Admissions 2019: MCC issues notice on Surrender of Round 1 seats

The paucity of good Faculty and role models: The senior CTV surgeons need to be role models. Mentorship is critical for the undecided undergraduate and medical student.  I remember when I left private practice and joined a large teaching hospital and restarted the CTV program there – we had 2-3 MS students every year who got motivated to take up CTVS.

Taking up CTVS  just because a seat is empty or the Govt has relaxed entrance criteria is a dangerous decision. CTV Surgery is meant for those who are wildly in love with the idea of being a CTV surgeon and are the brightest and hardworking

An update on the cardiovascular disease incidence of India, published in the journal Circulation in 2016, said: "The Global Burden of Disease study estimate of age-standardized CVD death rate of 272 per 100,000 population in India is higher than the global average of 235 per 100,000 population… Premature mortality in terms of years of life lost because of CVD in India increased by 59%, from 23.2 million (1990) to 37 million (2010)." So the need for more CTV surgeons is bound to increase.

SO IS CTVS A DEAD SUBJECT ??

NOT AT ALL.

CTVS  is still one of the best super specialties to go for.   It gives the benefit of seeing the results immediately  – one can see a doomed ECG get better after CABG or a totally blue child become nice and pink after surgery. The immense satisfaction at seeing a patient get well after a complex surgery is priceless. At the end of the day, CTVS does retain its mystique and glamour. There is still an obvious difference between a CTV surgeon and his peers in other branches. CTV branch is both skill-intensive and technology-intensive – a number of advances have taken place recently. Beating heart surgery has reduced the morbidity and mortality of CABG. The author is one of the pioneers in beating heart surgery having the world's first series of multivessel beating heart surgery published in reputed journals and also in the Limca Book of World Records.

There is no need to panic. CTV surgeons are by their genes innovative and hardy. New subfields have opened up – surgery for heart failure, minimally invasive surgery, video-assisted surgery, endovascular surgery, teamwork in TAVI (Transcatheter Aortic Valve Implant), artificial hearts, ventricular assist devices (VAD)  and heart transplant. It will just take some time for the field to attain its lost glory again. A similar thing happened in the USA in 2003 – the field has bounced back there. In view of the expected increase in CV disease at present - there will be a vacuum of CTV expertise, creating vast opportunities for early career advancement. Then we will need good people who will have taken up CTVS in 2019 at the helm. The future is bright.

Dr. Harinder Singh Bedi, the author is MCh, FIACS (Gold Medalist) and is Director, Cardio Vascular Endovascular & Thoracic Sciences, at the Ivy  Hospital, Mohali, Punjab. He was earlier at the Escorts Heart Institute, New Delhi and the St Vincent's Hospital, Australia. Dr Bedi is also the Vice President  of the Venous Association of India and the Patron & Founder President of the Association of the North Zone Cardio Thoracic & Vascular Surgeons. He is a member Editorial Board, Cardiac Sciences at Specialty Medical Dialogues