Cardiothoracic Surgeon Talks Heart Surgery & A Day in His Life

Session 159

Dr. Brian Lima talks about what daily life looks like for a cardiothoracic surgeon, the types of patients he sees, technology changes, and what that leads to for the future of cardiac surgery. Brian is also the author of Heart to Beat. He talks about jet setting around the country going and procuring organs and coming back and helping with heart transplants.

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[02:08] Interest in Cardiac Surgery

In college, Brian did a summer research program at NYU between his junior and senior years and he thought being a doctor sounded cool. His older sister was an X-ray tech so she always talked about radiology. She mentioned how radiologists have such a great lifestyle. He got to shadow surgeons at NYU and got to watch. It was a colon operation and they let him scrub in. And he thought it was the greatest thing ever.

Then it evolved from there. When he got to medical school, he got to see the hierarchy of residency and surgery, the longest training being heart surgery. To him, heart surgery seemed to the meanest and baddest. They knew everything because they trained for 10 years. They were the rockstars. He simply looked up to it and wanted to be that guy.

'Heart failure is growing exponentially. So we're going to be dealing with this and all facets of medicine, regardless of what area you go into.'Click To Tweet

The need for some form of heart replacement therapy is increasing, whether that’s heart transplant or the devices that are evolving to do that artificial heart pumps.

Other parts of cardiac surgery are evolving too. That being said, you cannot easily give coronary work up to the cardiologist. For instance, a heart surgeon and a cardiologist are working in tandem for all of those procedures. Brian also sees a critical shortage of heart surgeons in the future.

As Brian went through the process of being a premed student going to medical school, and applying to residency, he was dead set on cardiac surgery. But it was hard. 10 years of training is a long time – seven years of general surgery with two years of research stuffed in there.

They started to see that fewer and fewer people out there were crazy enough to delve into such a long period of residency. Now, you no longer have to do the full general surgery, and then two three-year fellowships in cardiac. You could now match straight out of medical school into cardiac surgery. England and South America have done it forever and that’s kind of how things have changed in the U.S.

[07:12] Biggest Myths or Misconceptions Around Cardiac Surgery

Brian personally believes heart surgery is the most humbling field. One common misconception is the “Oh God!” complex where doctors feel like they’ve got it. Because one mistake in heart surgery means somebody dies. Whereas the stakes aren’t as high if you make mistakes in other kinds of surgery.

“Everyone has a voice and everyone is empowered.“Click To Tweet

But as Brian has gone through it, he finds the field to be humbling. And people won’t put up with that anymore. Everyone has been empowered from the lower tier all the way to the top rung of the team.

[09:35] Types of Patients

It runs the gamut. You can take coronaries such as coronary artery blockages. Many of those patients require bypass surgery as much as the stent technology has evolved. Artery bypass is still the gold standard. So there’s a lot of that. There’s all the structural heart stuff, so all the valves, aortic valve, mitral valve, tricuspid valve, stenosis or regurgitation, endocarditis, all those require surgical intervention.

If you can do it with the transcatheter approach, great. But that’s not often the case. A lot of that is still open surgery. All the aortic pathology, aortic aneurisms, aortic dissections often require open surgery. So there’s still a great deal of stuff that’s within their wheelhouse of things that run the gamut.

Brian’s main niche is in heart failure. He is seeing patients often that are already hospitalized for decompensated heart failure. So they’re already hospitalized. Their team is involved in determining if the patient is a candidate for advanced therapies, a heart transplant, or a left ventricular assist device.

Of all the patients they’re evaluating, about a quarter to half of them end up meeting the criteria or going on towards needing a transplant. That’s whether it’s outpatient or inpatient for advanced therapies. They get one big screening process as the patients eventually make their way to them. In short, they’re the end of the line.

“There's a lot of screening that already goes into it. So a good chunk of the patients that we are called about is surgical candidates for something.”Click To Tweet

[12:21] The Opt-Out System

In this country, we have an opt-in system. Usually at the DMV, when you go get your license here, you’re asked if you want to be an organ donor. And in a lot of countries, it’s an opt-out system, where it’s assumed you’re an organ donor. They ask if you don’t want to be one and human psychology tells us we kind of stick with the default.

Brian thinks we should switch to an opt-out system here in this country. There’s such a huge disparity across the board of some states that have really good rates of people signing up in the opt-in system. They just do it in other states, like New York, which is the worst state for that. And this hampers their ability to get donors.

'If anything, we're more guilty of really sticking it out. We're very reticent to throw in the towel.'Click To Tweet

[14:06] Typical Day

Brian gets called frequently at night for heart organ offers. And without fail, they tend to happen between one and three. So he goes to bed early and then gets nailed in the middle of the night with the calls. Then he goes back to sleep. He gets up around four and he’s usually at the hospital before six. Then O.R. is at 730.

He sees all his patients in the unit and on the floor. They do their formal rounds and then get to the O.R. Because of transplants, sometimes it’s unpredictable. Sometimes, he has a free day or two. And other times he’s just operating for days on end.

So on any given day, he has a case, and then in-between cases, or after, he sees his patients. He probably has the sickest patients in the whole hospital. They’re on a bunch of machines, different pumps supporting the right side or the left side. And they require a lot of micromanagement.

He usually sees those folks throughout the day, a few times a day. And obviously, make sure nothing’s happening, which is rare. He safely gets out of the hospital by 5 or 6 pm. But often, there’s something else that’s going on so he sticks it out to see how he can help.

[15:59] Life Outside of the Hospital

Because of how the swings are, his life is unpredictable. When you’re on call for the week, or whatever, for transplant, you’re just a sitting duck, in a sense that anything goes.

It also depends on the kind of family life you’ve set up. Brian says it’s manageable. It’s not as hard as residency. At the end of the day, you could have other partners and set up a work schedule. And you could set it up in a way that you have a life. It’s just going to ebb and flow.

[17:33] Jet Setting Adventures

They usually divide up with their partner. So let’s say your partner is going to get the heart and then you are working on the recipient. If it’s a second or third time in the chest, it’s such that when that donor comes in, you’re ready to take the heart out. And the heart sits in the ice for another two hours. So that has to be really tightly orchestrated.

Brian is the director of the program, and some of these patients are pretty complicated, by and large. He has done countless donor runs. And you do them from nine to one in the morning. So you get to sleep on the private jet.

[19:22] The Training Path

Students have three options. The regular or traditional is where you do general surgery residency first. General surgery residency, clinically speaking, is five years. Many upper-tier programs want you to do two years of research within that so that it becomes seven years.

Brian trained at Duke where everybody does the two years of research and it’s typically years three and four. Then you get to moonlight during that time and still engage in the NICU or go on heart procurement.

Then your fellowship for cardiothoracic can be anywhere from two to three years. It depends if you’re going to a cardiac track or a thoracic track. You have to declare a major. You’re either a heart surgeon or you’re doing straight cardiac. Or you’re doing straight thoracic. So that’s where the track concept comes in for the fellowship.

The second option is the I-6 or the integrated six-year where straight out of medical school, you match into an I-6 program. You do a little bit of general surgery, a little bit of vascular and cardiothoracic all within six years. The difference there is you can’t sit for your general surgery boards. So no need to do 100 colon resections.

The third pathway is a hybrid where do maybe four years of general surgery and go into two years of fellowship. And out of those three, the I-6 has become pretty competitive.

[21:42] The Purpose of General Training

For a lot of the surgical subspecialties, the general training comes in handy because as you graduate your residency/fellowship training, and you come out and practice, you have to build up your specialty patient load. And so having that general training is what keeps you busy until you start building up your specialty patient load.

'It's not everybody that knows, out of the gate, that they want to be a heart surgeon. And so having the general surgery backbone is such great training.'Click To Tweet

General surgery training really covers the full spectrum. It exposes you to different and all kinds of subspecialty areas. If you’re not 100% sure you want to do cardiac surgery, it makes sense to do general surgery because you may change your mind. Now, you’re a full-fledged general surgeon and you can do all sorts of things with that.

The other thing is the paradigm shift. You have to be sure if you’re doing an I-6 program that you’re going into a place that’s going to have the patients to teach you these things. You’ve got to make sure that these programs have a good track record for their I-6 trainees.

[24:23] How to Be Competitive for Matching

First, get a lot of deep exposure in those areas. Do subinternships in cardiac surgery elective. In cardiac surgery, you obviously want to have cardiac surgeons that you worked with that can speak on your behalf and get you a good letter of recommendation. That’s key.

If possible, get involved in some research early on in med school. Year one maybe identifying a cardiac surgery mentor. Help with some chart-based clinical outcomes projects to sort of wet the whistle. Get involved. Start to learn the lingo of the field a little bit. Get some abstracts out to present in national meetings or have your name on one of those or research.

“I-6 programs are competitive so do anything that you can to set yourself apart and reinforce it.”Click To Tweet

[25:41] Message to Osteopathic Students

Be really proactive about getting exposure and experience in that environment within cardiac surgery. Get to work with cardiac surgeons so they can see your work ethic and see your clinical performance and research.

Brian stresses that you really need to do pretty well in Step 1, Step 2, and all of those things. Consider doing a year of research during medical school in cardiac surgery-related areas.

[27:00] Message to Future Primary Care Physicians

“Heart failure is more deadly than most cancers, yet it doesn't garner the same street cred that cancer does.”Click To Tweet

If a primary care doctor is seeing a patient and feels a breast lump, or an X-ray with a shadow, worried about a lung tumor, it’s an automatic knee-jerk reflex that they’re going to see an oncologist. No questions asked.

For heart failure, though, primary care physicians will try to figure out what medications they can give and see how it goes for a while. And then, heart failure specialists get to the patients too late. Or they get to them in the 11th hour, and the wheels have fallen off and they need transplant. Then they have to do this whole crazy long evaluation.

From a primary care perspective, they have a very low threshold for referring them to heart failure specialists just to be sure that it’s not too early. He advises them to educate the patient. Hopefully, it may encourage more compliance with medications because they don’t want to end up having to get a transplant or something like that.

[29:54] Opportunities for Subspecialties

There’s the minimally invasive valve space, structural heart-based, where you can not only work with cardiologists on catheter-based valve replacement therapies. But also if it calls for an open surgical intervention that you can do in a minimally invasive way, small incisions, robotic, that sort of thing.

Another kind of niche area is aortic stuff. Here, you’re well-versed in open approaches to fixing or replacing any segment of the thoracic aorta, from the root all the way down to the descending. And also with catheter-based and stent-based ways of doing those things.

For regular heart failure, there’s LVAD (left ventricular assist device) transplant, which is still going to grow exponentially.

'In cardiac surgery, there's still going to always be a need for coronary surgeons, as part of that practice.'Click To Tweet

[31:15] Message to Younger Self

If he could go back to tell his younger self something, that would be to learn more about business stuff. Learn about how a hospital functions, capital investments, the flow of the hospital, and the business and administration.

“You have to figure out how to build your brand and get people to refer patients to you.”Click To Tweet

[32:21] Most and Least Liked Things

What Brian likes the most about being a cardiac surgeon is that doing surgery never gets old. And he loses track of time when he’s in the zone. When you love what you do and you’re passionate about it, the impact is massive on your patients. And he finds that immensely rewarding.

What he likes the least, however, is the unpredictable nature of it. And the fact that because of what his niche is, people get to him too late. When there could have been therapies he could have offered. But the window of opportunity can sometimes close on you before you want it to, no matter what you do. And that’s really disheartening.

This speaks to the flaws in the paradigm of health care, specifically of how we manage patients. For instance, the EHR (electronic health record) is not having things protocolized and there’s such a wide spread in how patients are managed and when they’re referred for heart failure. It’s really frustrating.

'We should treat heart failure more like cancer – protocolized, automatic, tumor board, this is what happens, this is what you get, this is the chemo – it's all out there!'Click To Tweet

[35:36] Major Changes Coming for the Future of Cardiac Surgery

Brian explains there are three competing modalities that are going to potentially do away with the need for transplant. One is creating the perfect mechanical substitute. The holy grail right now is a totally implantable wireless pump. Because all the pumps that we have, as great as they are, are still bad. You still need batteries. There’s still a cord coming out that you’re tethered to. So that is going to be a huge boon for the field.

Number two is xenotransplant and figuring out how to crack the immunology code of getting other species’ organs to take in humans. That’s still a lot of active work going on. And actually some pretty good successes are occurring there.

And the third is the stem cell-like ghost heart, where you have a heart, you digest away all the tissue on a scaffold, then you repopulate the scaffold with autologous stem cells. This is in development. And there’s been some progress, although it’s a little further off.

“The heart is a pump so the one that's probably going to win the race is the mechanical substitute. Now, it's just a matter of figuring out the engineering, battery issue.”Click To Tweet

The newest pump, the Heartmate 3, has had the best blood compatibility profile of any of its predecessor pumps. It has the lowest stroke risk, lowest pump, and thrombosis rates. It’s a continuous flow pump. However, they’ve embedded a pulse feature where the pump will ramp up and ramp down as far as speeds every half a second. So it’s like an artificial pulse.

The design of the pump has made a tremendous difference in terms of spaces, less moving parts, and the blood does not beat up as much as it passes through. So the key now is just the battery thing is the power.

[38:31] Final Words of Wisdom

Brian says he has 100%. no regrets getting into heart surgery. Finally, his advice to aspiring heart surgeons is to really expose yourself to the field of surgery.

“Get exposure before you make any decisions about what you want to do with your career in medicine.”Click To Tweet

It could seem daunting in many respects, but anybody could do it. You just have to be willing to put in the time and effort. One step after another leads to the next and it leads to the next. So don’t get discouraged. There will be dark days but there’s always a light at the end of the tunnel. So just power through it.