Dr. George Tolis, Jr.

I was alerted on a Sunday morning by a cardiology colleague that he was transferring directly to the cath lab via Med Flight a patient with a presumed acute myocardial infarction from a hospital about 40 miles away from Boston. The patient was intubated due to florid congestive heart failure, had diffuse EKG changes and would most likely require emergent revascularization if opening up the "culprit vessel" would not suffice.

It turned out that this man had a coronary angiogram at age 78 which would make any 20 year old jealous. He had a dominant right coronary artery which looked more like an external iliac vessel and a left system which could take over the mesenteric circulation any day of the week and then some. The interventionalist, however, had a very hard time crossing the aortic valve, and after some skillful manipulations was able to obtain left ventricular hemodynamic measurements. The peak systolic gradient was in excess of 90mmHg.

I personally reviewed the history and physical from the outside hospital's emergency department. The template was a beautifully laid out document, with multiple entry boxes which needed to be checked out by the emergency department staff. There was a check right next to the "normal S1 and S2" box, another check next to the "no murmurs, gallops or rubs" box, with the "comments" lines left blank.

Aortic stenosis was diagnosed via femoral access in the cath lab, utlizing the latest interventional cardiology techniques, including a Perclose device for control of the femoral puncture site.

With such advanced technology available in the year 2007, who needs a stethoscope?

Merry Christmas and Happy New Year!

Posted by George Tolis, Jr., M.D. at 11:16 PM | Permalink | Comments (1) | TrackBacks (0)

As I was perusing through some nicely laid out flyers which I received over the past week, I was impressed by the eloquent titles : "Reinventing the cardiac surgeon", "Catheter skills all cardiac surgeons should master", "Mastering Atrial Fibrillation Surgery" etc. One brochure even included the word "Renaissance".

All this stuff is completely misleading. Yes, it is great to master these skills. But what is even more important is to be able to do bread and butter cardiac surgery and to do it well. If it takes you all day to do a simple AVR and the patient ends up in the unit at 5 in the afternoon on five drips and an intra-aortic balloon pump, knowing how to exchange a glidewire for a Rosen wire through a vertebral sheath will not make you a cardiac surgeon, nor will it provide you with any job security. Along the same lines, you can call yourself an atrial fibrillation specialist if you canclamp the left atrium next to the pulmonary veins and press a foot pedal, but you can't call yourself a heart surgeon if you can't fix a mitral valve.

I think it is admirable that some programs are providing their residents with catheter skills. At the same time, I think it is abhorrent that many programs graduate residents who are unable to independently do a standard open heart case.

Posted by George Tolis, Jr., M.D. at 10:47 PM | Permalink | Comments (1) | TrackBacks (0)

It is very interesting to note the recent surge of "Junior Attending" positions that are offered on the ctsnet job blog. This is in stark contrast to the paucity of "Real Attending" positions offered. One has to wonder what is the origin of this phenomenon. The argument offered by the employers is that just like any other surgical field, cardiac surgery has branched off to several sub-subspecialties (mitral valve repair, off pump CABG, complex aortic surgery, atrial fibrillation surgery, robotic surgery etc) that the standard two or three year fellowship is just not enough to get graduates out in the real world. If there is an advanced laparoscopic surgery or a hepatobiliary surgery fellowship surgery, why shouldn't there be an advanced adult cardiac surgery fellowship?

The argument certainly seems to be solid. However, it does not appear to work that well in practice. Although many candidates who accept these "junior attending" positions find them very helpful in their pursuit for further experience in cardiothoracic surgery, a large number of recent graduates find themselves trapped in an unpleasant situation where they operate less than they did in their chief year of their formal training and spend most of time improving their LIMA harvesting technique, become experts in chest tube and central line placement after 5PM and perfect their wire twisting and subcuticular closure technique.

When looking for further training opportunities, the astute candidate should make sure that "Junior Attending " means :

1) Admitting privileges for all patients, not only for readmissions with wound infections
2) Independent operating for all cases, not only for mediastinal re-exploration for bleeding
3) First assisting for all cases, not only for the ones done by the disgruntled attending that no one else wants to scrub with
4) Your "Junior Attending" predecessors have benefited from this experience

Remember that the 80 hour rule does not apply when your status changes from "resident" to "attending". When everyone else is going home after an all nighter in the hospital, your recent promotion may not end up serving you that well...

Posted by George Tolis, Jr., M.D. at 09:10 AM | Permalink | Comments (1) | TrackBacks (0)