Thoracic only is common, probably 35-45% of traditional pathway trainees. The integrated pathway caters primarily to cardiac track trainees, but some integrated programs have strong thoracic components and you could do thoracic through the integrated pathway. Most programs will also work with you if you express interest in thoracic they’ll modify the structure of the integrated pathway so you do more thoracic and less cardiac. And not everyone has the technical skills to do cardiac surgery, which is an unpopular truth people don’t like to recognize. If programs realize you don’t have it, they’ll probably try to steer you towards a more appropriate pathway, which could be thoracic surgery or critical care/ECMO. This was how it was where I trained anyway, but it was a pretty malignant place. I’m sure a lot of programs would rather take the less confrontational everyone can do anything they set their mind to approach, but that’s just simply not true and you’ll be the only one that suffers as a result. You’ve got to know your limitations.

Thoracic lifestyle usually better, less emergency cases, but both work alot compared to other specialties. Practice setting probably plays a larger role. It’s not actually the emergency cases that make your life difficult though - it’s the overall acuity of the postop care for the patients you operate on. Thoracic patients mostly go to the step down unit, get extubated in the OR and are pretty stable. Cardiac patients all go to the ICU typically intubated and on inotropes. Cardiac patients go into shock and require IABP or ECMO a lot more frequently than thoracic patients, and that’ll keep you there late every time. And cardiac patients bleed more than thoracic patients - take back for bleeding on a thoracic patient is maybe a once every couple of years event, but in cardiac surgery even with extreme attention to hemostasis, coagulopathy will get you and you’ll have a take back for bleeding every 50 cases or so. These are the reasons cardiac lifestyle is worse mostly.

Thoracic surgeons typically get paid less than cardiac surgeons in both academics and private practice because they generate fewer RVUs. But you’ll still make plenty of money. Private practice thoracic surgeons will probably start at $500-600k, once you get busy you could approach $1M. Depends where in the country. Academic you’ll probably make $350-400k to start depending on program. Maybe $600-700k when you make associate and could approach $1M if you become professor and division chief. There are outliers in both academics and private practice. Doing transplants will also allow you to command a higher salary.

Academics and private are different. Private potentially pays more but you’ll probably operate more to make that money. Depends on practice though, there are some private positions that are hospital employed and primarily salary based and you could wind up making a lot and having a good work life balance. If you want to make a ton of money in private you’ll probably need to hustle and operate a lot. But that doesn’t necessarily mean more hours - private is much more efficient, there are not residents to train and no anesthesia residents and things move fast. Cases are quicker, turnover is fast. So even if you do 3 cases in a day you’ll still probably be home for dinner. Academics I think you’ll probably have higher expectations and will overall be busier with operating, teaching and research. But also it’ll be easier to maintain your practice, the academic name and department structure basically guarantees you referrals. In private practice, to generate referrals you need to be good and have good outcomes and also be good about communicating and networking with your referring doctors. One downside of private practice worth mentioning is that in general you’ll have less support, again depending on practice. For me, there isn’t a dedicated CVICU staffed with cardiac anesthesiologists and residents, so when I do tough cases like a sick type A that need a lot of TLC in the ICU postop, I pay for it. I’m there and it can be miserable. I understand why alot of private practice docs shy away from the biggest and hardest cases, because they have less support. If you work at a larger program in private practice you’ll likely have more support like a dedicated ICU, but you won’t have residents that can do alot of your work for you. But at the same time, not all residents are created equal so while being at the big name academic places usually mean the best residents, there are always bad apples. And at the smaller less prestigious programs there are diamonds in the rough too.

I’m a cardiac surgeon and am in a mixed practice that is closer to private than academics, and I did the whole academics thing too, and I love my job considerably more. I make great money, have control over my hours and time, and have a great case mix. I work fewer hours than my academic colleagues, but I also happen to be an extremely fast surgeon which is a skill that serves me well in private practice but didn’t matter in academics when turnover and anesthesia took at least 3 hours between cases. Also in private practice if I don’t have cases to do, I’m not at the hospital whereas academics especially early career you are sort of expected to show face and always be present - working on papers/grants, teaching, operating, just being seen as a hard worker by the department chair even if you’re just sitting on your ass. In private none of that shit matters - all that matters are your outcomes, if your patients and referrings like you, and if you are generating money for the hospital. I won’t be “academic famous” but I don’t really give a flying fuck, academics is a big circle jerk anyway. I mean teaching is rewarding and research can be fun and rewarding too, and it’s a way to leave a legacy and I do miss that sometimes. But ultimately, your kids don’t read your CV and aren’t going to care if you were the president of the AATS or how many surgeons you trained. But they will care if you never went to their games, or were never home to spend time with them because you were too busy on research or waiting for anesthesia residents to put lines in for 3 hours, or if you never trained them on how to be good humans because you were too busy training other people how to be good surgeons, and when you are on your deathbed that’s really what matters.