A Heart for Pediatric Cardiac Surgery

Session 206

Dr. Thomas Maxey, MD is a pediatric cardiac surgeon who joins me today to share his journey from enlisting in the Air Force to becoming a pediatric heart surgeon. We talk about what led him to pediatric heart surgery, what he loves about his job, what he doesn’t like about his job, and what the toll of having someone’s life in your hand means to a pediatric heart surgeon.

Thomas has been out of training now for 13 years as a pediatric cardiac surgeon taking care of newborns with congenital heart defects. For more information about congenital heart surgery, check out Congenital Heart Surgeons’ Society. For more podcast resources to help you with your medical school journey and beyond, check out Meded Media.

Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:23] Interest in Pediatric Cardiac Surgery

Thomas enlisted in the military right out of high school and got out when he went to college. He began his career wanting to be a physical therapist or anything that had to do with sports medicine or something of that nature.

Then he had an anatomy and physiology professor who was a heart transplant recipient that he got close with. He was introduced to his thoracic surgeon that did his transplant and everything blossomed from there. Thomas’ initial passion was cardiac surgery in general. Then he got attracted to pediatric heart surgery which he thought was a natural fit.

'Pediatric heart surgery is probably the pinnacle of the surgical world from a technical skillset and demand.'Click To Tweet

[03:01] Adult Heart Surgery vs. Pediatric Surgery

Thomas’ cardiothoracic training was on adult hearts so he’s an adult heart surgeon. But he found the variety of pediatric heart surgeries to be intriguing. In adult heart surgery, you’re typically bypassing vessels that are blocked or fixing or replacing valves or maybe an aneurysm. There are subtleties to each of those but you probably have five or six main operations that you do.

Thomas does about 140 operations in pediatric heart surgery, addressing a tremendous variety of congenital heart defects. And he finds it intriguing how the physiology of each is different and the repair of each is different. And as a surgeon, that’s gratifying.

[05:31] The Biggest Myths or Misconceptions

Thomas says that with any surgical specialty, and particularly cardiothoracic surgery, there’s a myth that you can’t have a family or you’re going to be in the hospital 24 hours a day, seven days a week. He clarifies that your availability may be different than someone that works in an emergency room or shift work.

“The myth of heart surgeons working 24 hours a day just needs clarity.”Click To Tweet

You need to be available a lot of times, maybe more so than other people. But the actual times Thomas comes into the hospital to do this at midnight or two o’clock in the morning can probably be counted on one hand throughout the year.

And so, if you’d count his hours, he doesn’t work any more hours than an ER doctor that prides themselves on working shift work and having a great life outside of the hospital.

[07:41] Traits that Lead to Being a Good Pediatric Heart Surgeon

Thomas says it’s a very long journey to get to where he is and you just have to stick to it. He did 12 years of training after medical school, which were not pleasant years. And so, you need to be able to look in the mirror and evaluate yourself.

Just about every problem surgically speaking that he has with children is a technical error on his part. Hence, you need to be able to self-reflect and learn from that. And you need to be able to come back the following day and deliver. And it takes that kind of mindset to do that.

'When you take a child's life due to a technical error, you have to learn and grow from that. It has to be absorbed into your soul.'Click To Tweet

If you do pediatric heart surgery, you will lose a patient, and it’s going to be your fault. That’s a hard thing to swallow. You have to be able to learn from that otherwise, you’d be out of this game in a couple of years.

[11:02] Types of Patients

As a congenital heart surgeon, Thomas operates on people who have what he calls “God-given” heart disease, which means they’re born with that particular heart defect. He operates on all ages but he doesn’t operate on acquired heart disease like heart blockages and those sorts of things.

The vast majority of his practice involves kids and babies, which he finds enjoyable. He likes the other side too, operating on adults that have had previous heart surgery elsewhere.

According to Thomas, it’s a relatively young specialty. And the founding fathers of heart surgery operated on many of the patients that are now adults and that’s rewarding.

[12:25] The Most Technical Challenging Operations They’ve Done

One of the more common heart defects is called a complete AV canal that varies greatly from one child to another. The operation involves dividing the heart equally, closing holes in the upper and lower chambers. It also involves making two functional valves out of one valve. The operation can look completely different from child to child.

You really have to picture what the heart is going to look like when it’s fully inflated with blood and moving and how the valve tissue is going to work. That can be an easy operation or it can be extremely challenging.

Thomas calls this operation a true definer of a congenital heart surgeon. Now, there are other technically demanding operations but they’re essentially the same operation over and over again. But for an AV canal, every single child looks different and so, you need to make two functioning atrioventricular valves out of one.

[15:21] Typical Week

Thomas is in a fairly large practice in a children’s hospital where he has two other surgeon partners. One person is on call, one person is on backup call, and then one person will be off. They operate Monday through Friday, so each of them works four days a week. They usually come in the morning at about 6:30 am. His immediate stop after getting a coffee is the intensive care unit. They check on the kids they operated on from the previous day.

They don’t go through every single detail of every single patient, but just the highlight of what has happened overnight with the critical care patients.

From there, they go to the operating room, usually at about 7:15 am. They do two pediatric heart cases a day, almost every day, Monday through Friday. He’s either involved with helping or doing how one of those cases. Most of his day is spent in the operating room.

Thomas spends his clinic days on Thursdays. Thomas sees patients either before their surgery or after their surgery. Not everything he does is a newborn that’s been in the hospital. Many kids can actually go home. Then he gets his meetings done as well as the admin side of things, for which he has a lot as the chairman of cardiothoracic surgery in their situation.

[17:20] Taking Calls

Thomas is in a center where they do heart transplant, that’s why they have someone on call and someone on backup call. To do a heart transplant, it takes two surgeons, someone has to go get it, someone has to be here with the child that’s awaiting the heart. But that doesn’t happen that often, Thomas says.

Technically speaking, Thomas is on call a third of the time. His particular group is responsible for their own kids. So if the child he operated on misbehaves in the middle of the night, he will be the one called for that.

Then they divide the weekends into thirds, so he’s on call for a weekend. He comes in the morning and does a quick highlight through the ICU. They have tremendous support staff from cardiologists and ICU doctors that do the grunt work after the operating room. And this is one of the benefits of his job, which he finds rewarding.

All that being said, he’s on call every third weekend. But call for him is more of a social visit in the hospital.

'Pediatric heart surgery has to have a tremendous support staff or it just doesn't work.'Click To Tweet

[19:44] Less Long-Term Follow-Up with Patients

Thomas explains the preoperative workup is predominantly done by a cardiologist. For instance, if it’s a newborn referred to him, he would go see the family and tell them about surgery and get them through the operation. And it’s successful most of the time. Hence, most long-term follow-up care is performed by a cardiologist, not the pediatric cardiac surgeon.

Thomas adds that if someone is really interested in long-term follow-up where you’re watching a kid from two days old and following them to their 20, you’d probably be better off in the medical world as a cardiologist as opposed to a heart surgeon. It’s not to say that he has tremendous relationships with most of the families, however, they’re better served by a cardiologist.

Therefore, students need to do some self-reflection. Understand who you are as a person and what you want out of your career to make sure that you end up in a specialty that gives you that.

Do you want to sit in the clinic five days a week, seeing 40 patients a day? Well, that’s one career path that you need to think about. Would you like to be in the operating room and then be responsible for all of the things that are involved in that? Then that’s a different mindset.

[21:52] Life Outside of the Hospital

Thomas has raised two young boys. There may be a very rare exception, but he has made it in every football game and baseball game and everything possible. It does take a little bit of juggling sometimes to pull that off.

'The ability to adjust is key in any aspect of medicine, whether it's heart surgery or not.'Click To Tweet

Thomas explains that although his priority is his career and taking care of his patients, that doesn’t mean he loves it more than he loves his family.

If he operates on your child, and your child needs him at two o’clock in the morning, your child’s going to get him at two o’clock in the morning. And if he has to miss a dinner party because your kid is sick and needs surgical intervention, he’s going to miss the dinner party. Fortunately, it doesn’t happen often. But his priority is such that it takes top priority.

[23:48] The Training Path

Thomas spent 12 years of post-graduate training. Right after medical school, he did General Surgery for five clinical years. The general surgery program Thomas was in had two years of research built into that. So after his third year of general surgery residency, he did two years of research. He had cardiothoracic research available in a transplant lab, looking at rejection models with heart and lung transplants.

Then he did a cardiothoracic fellowship. The fellowships can range between two and three years, and Thomas picked the three years of adult cardiothoracic training. And then he did another super fellowship of congenital heart surgery, which was two years long.

Today, there are tracks where you can do cardiothoracic training right out of medical school and you can match. So it’s six years, where you bypass at least, the majority of general surgery. It was a long journey but Thomas would be willing to do it again if he had the opportunity.

[26:36] Message to Osteopathic Students

Thomas says that if you could get a cardiothoracic fellowship and you excelled there technically speaking, the opportunity would be there. The numbers are small, maybe because osteopathic students gravitate towards the other more primary care type things.

Generally speaking, if you’re good at General Surgery, you’re probably a good candidate to go to cardiothoracic training. And if you are a reasonable adult heart surgeon, you’re probably good at transitions.

'If you have trouble operating on adult hearts, you're probably not going to succeed in the pediatric world.'Click To Tweet

Thomas’ advice to osteopathic students is to not worry about the initials after your name. Keep your head down and stay focused and do the best that you possibly can. Get into a training program and use it for every ounce that you possibly can.

[30:03] What He Knows Now that He Wished He Knew

Thomas admits he spent a lot of time comparing himself to other people. He was focused on all those sorts of things growing up going through this.

“Believe in yourself and work hard. Attack the things that you're able to change and accept the things that you can't.”Click To Tweet

Whether we’re talking about healthcare, or parenting, or creating your own podcast or whatever, you got to be able to do the best that you can. Make the best of every situation and bring others up around you. Ultimately, it warrants maturity or the foresight to be able to see all of those sorts of things.

[32:02] The Most and Least Liked Things

Thomas likes being able to sit down and talk to a family about the intricacy of their child’s heart disease, a language that nobody speaks. They have total faith in you.

He doesn’t get to bond with them for the next 20 years of their life, but that 45-minute bond is impactful. It’s a transparent relationship that he thinks is not shared by any other doctor in the hospital.

Those are difficult conversations. Thomas explains pediatric heart surgery is a relatively new specialty, which began in the ’90s. The children in the 60s and 70s that were born with common heart defects did not make it or they made it through childhood, but then didn’t make it into adulthood. And those numbers have changed dramatically.

Fortunately, the generation of surgeons, ICU doctors, and anesthesiologists before him really changed the scene.

The success they have with surgery is tremendous and phenomenal. And he’s proud to say that nationwide, they have about a two and a half percent mortality for all congenital heart lesions combined. And about 95% of kids that are born with congenital heart disease of any type make it to adulthood.

Thomas says that the loss of a child affects him in some certain way and it lands in some certain part of his brain. But the thing he likes the least is dealing with people who have less commitment than you, which is a difficult hurdle to get through.

[39:08] Major Changes Coming into the Field

Adult cardiac surgery is having lots of changes with interventions being done in the cath lab. You can get your coronaries, treated with stents and those sorts of things. They can now put valves and without opening your chest.

In pediatric heart surgery, they’ve had some advances in the cath lab. But it’s not going to be to the degree that adult heart surgery is.

When your blood vessels come off of the wrong ventricle. There’s nothing they can do in the cath lab to treat that. There’s no pill that’s going to allow them to switch the vessels from one side to the other.

'The evolution of pediatric heart surgery is going to be continually improved outcomes from a team approach.'Click To Tweet

According to Thomas, we need to start viewing success beyond the operating room. Let’s start measuring their success on how the kids do in school, do they have any behavioral problems, and how are they neuro developmentally adapting to the world after being put on a heart-lung machine at two days of life.

The progress they’re going to make in this specialty is to see zero surgical mortality for which they’re close. But the improvements are going to be in the perioperative care, long-term care of these kids, making them successful, thriving adults.

[41:41] Final Words of Wisdom

If he had to do it all over again, Thomas would do it 100% because it’s a rewarding career and it fits perfectly with his lifestyle.

'The journey here is long and vicious and violent, and all the other negative words that you want to put with it. But anything worth doing, you got to pay the price to do it.'Click To Tweet

He gets to go home with a good feeling 99% of the time. And 1% of the time, it’s the worst feeling in the world – and if it were much more than that, it probably wouldn’t be worth it.

Finally, for students or residents looking into pediatric heart surgery, Thomas encourages students to have a “stick-to-it-iveness.”

You’re going to have ups and downs and work with doctors you don’t like. You’re going to work with surgeons that you think are total ass and unfair. But keep your head down, take care of yourself, and do the best that you possibly can every single day. Then you’re going to land where you need to land.

Self-reflection is a unique skill set that takes a long time to get. So the earlier you can catch on to that, the more successful you’re going to be.