lifestyle of a vascular surgeon

[q1108]

whats the lifestyle of a vascular surgeon like ? much call?

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[Winged Scapula]

Depends on the size of the group. If you have several partners, your call will be less frequent, although expect as the junior member to take more.

Vascular call is painful...the patients are sick, you have to come in, the operations can be long and are often emergencies (so they can't be put off until the am).

Vascular lifestyle is one of the least friendly (up there with CT, Trauma and Txp). However, if you just do veins and the like (as many do before retiring) you can avoid the drawbacks above.

 

[-Goose-]

Vascular lifestyle is one of the least friendly (up there with CT, Trauma and Txp).

Really? CT I expected, but transplant and trauma? Yikes.

 

[Winged Scapula]

Really? CT I expected, but transplant and trauma? Yikes.

Really? Yes. I suggest you do a search on lifestyle and you'll find several threads here because these are definitely lifestyle unfriendly specialties.

Transplant is particularly unfriendly because of the unpredictability of the work. You never know when an organ will be available and most of the time when it is, its the middle of the night for cadaveric transplants. Obviously living related and unrelated donor transplants are scheduled procedures but there are still a lot of cadaverics which are transplanted. These organs become available, often after a trauma, usually in the late evening or middle of the night. There is a time pressure for limiting ischemia so you must obtain the organ and transplant it in a relatively short period of time...no waiting until the morning. Transplant surgeons often do other emergent procedures on their patients..."once a transplant patient, always a transplant patient" seems to be the motto. In my experience and that of others, EDs and other physicians will not touch a transplant patient, even if their problem is not transplant related. Expect to be in the ED readmitting your patients and dealing with their hernias, appendixes, etc.

You could decide only to do living transplants, but then you remove a decent size category of available organs and in some patients, these are the only possible organs for them. Thus, you must make a decision whether or not to work hard for your patients.

While in some places Trauma is shift work, I must remind those considering it, that as an attending, shift work doesn't necessarily mean you go home at the end of your shift. For example, my ex is a trauma surgeon...he is on call for Trauma 0700-0700, but he doesn't go home at 0700, he either has a day full in his office, or with scheduled OR cases, or finishing cases from the night on trauma. And of course, he still has to round on patients. In places which get enough Trauma to have a staff surgeon, you take in house call or must live within a very short distance. When you are on call you are busy and as I noted above, you don't go home after your call is over and sign out to the next guy...you finish the work, whatever it is.

Trauma, like Transplant is unpredictable, and the patients, just like Transplant patients, can be difficult and have a lot of social problems. You spend a lot of time babysitting Ortho and Neurosurg patients that you don't even get to operate on. When the social worker can't find placement for your homeless man or transportation back to Mexico for the visiting alien, they sit on your service and you round on them everyday.

At any rate, there are many threads here which will regale you with stories of the lack of lifestyle in CT, Transplant, Trauma and Vascular. Sorry...

 

[dpms]

Not to hijack the thread...

But can a transplant surgeon split his/her time up between an Immuno lab and patient care?

Is it possible to do both without sacrificing aptitude? I would think that this would be quite a concern...

Thanks in advance.

 

[Winged Scapula]

Not to hijack the thread...

But can a transplant surgeon split his/her time up between an Immuno lab and patient care?

Is it possible to do both without sacrificing aptitude? I would think that this would be quite a concern...

Thanks in advance.

What you're asking is the same old question: can I find a job as a part-time surgeon (albeit for a different reason)?

The most likely scenario you paint would be a transplant surgeon at an academic medical center with an active research lab. This is definitely doable, although some centers want you to come with your own funding. And it is a pretty common scenario in the academic world; in community settings, much less so if only because of the resources needed to run a good lab.

Transplant does have a fair bit of free time during the day, etc. when you aren't in the OR or dealing with clinical issues (they tend to operate less except in the cases of very busy transplant services), so it would be feasible to have an active lab. Depends on what your hospital is looking for.

 

[Pilot Doc]

But can a transplant surgeon split his/her time up between an Immuno lab and patient care?

Is it possible to do both without sacrificing aptitude? I would think that this would be quite a concern...

That's a large and longstanding philosophical question - should you put 100% effort into research or patient care or do both, typically not excel at either, but provide an important blending of perspectives. Lots of opinions.

But in practice, transplant practices (somewhat excepting kidney) are based in university hospitals and lots of txplant surgeons have labs. It's common and well-regarded.

 

[-Goose-]

Really? Yes. I suggest you do a search on lifestyle and you'll find several threads here because these are definitely lifestyle unfriendly specialties.

Transplant is particularly unfriendly because of the unpredictability of the work. You never know when an organ will be available and most of the time when it is, its the middle of the night for cadaveric transplants. Obviously living related and unrelated donor transplants are scheduled procedures but there are still a lot of cadaverics which are transplanted. These organs become available, often after a trauma, usually in the late evening or middle of the night. There is a time pressure for limiting ischemia so you must obtain the organ and transplant it in a relatively short period of time...no waiting until the morning. Transplant surgeons often do other emergent procedures on their patients..."once a transplant patient, always a transplant patient" seems to be the motto. In my experience and that of others, EDs and other physicians will not touch a transplant patient, even if their problem is not transplant related. Expect to be in the ED readmitting your patients and dealing with their hernias, appendixes, etc.

You could decide only to do living transplants, but then you remove a decent size category of available organs and in some patients, these are the only possible organs for them. Thus, you must make a decision whether or not to work hard for your patients.

While in some places Trauma is shift work, I must remind those considering it, that as an attending, shift work doesn't necessarily mean you go home at the end of your shift. For example, my ex is a trauma surgeon...he is on call for Trauma 0700-0700, but he doesn't go home at 0700, he either has a day full in his office, or with scheduled OR cases, or finishing cases from the night on trauma. And of course, he still has to round on patients. In places which get enough Trauma to have a staff surgeon, you take in house call or must live within a very short distance. When you are on call you are busy and as I noted above, you don't go home after your call is over and sign out to the next guy...you finish the work, whatever it is.

Trauma, like Transplant is unpredictable, and the patients, just like Transplant patients, can be difficult and have a lot of social problems. You spend a lot of time babysitting Ortho and Neurosurg patients that you don't even get to operate on. When the social worker can't find placement for your homeless man or transportation back to Mexico for the visiting alien, they sit on your service and you round on them everyday.

At any rate, there are many threads here which will regale you with stories of the lack of lifestyle in CT, Transplant, Trauma and Vascular. Sorry...

Thanks for the response KC...

What I meant to say was that I expected the lifestyle of vascular to be as bad as CT (bad), but I didn't think it was as bad as trauma or transplant (very bad).

 

[Winged Scapula]

Thanks for the response KC...

What I meant to say was that I expected the lifestyle of vascular to be as bad as CT (bad), but I didn't think it was as bad as trauma or transplant (very bad).

Ahh..gotcha. From a pure in-house call, coming in most nights, Vascular probably isn't as bad as Trauma and Transplant (unless you are poorly skilled and all your grafts go down!)...but it really depends on the setting. Vascular in a community hospital isn't as bad as Trauma in a Level 1 hospital and Vascular in an academic hospital with bigger cases and case load may be worse than trauma in a Level 2 center.

 

[mitchconnie]

Vascular call is painful...the patients are sick, you have to come in, the operations can be long and are often emergencies (so they can't be put off until the am).

Vascular lifestyle is one of the least friendly (up there with CT, Trauma and Txp). However, if you just do veins and the like (as many do before retiring) you can avoid the drawbacks above.

It's hard to generalize about lifestyle since practice situations vary so much, but I would disagree somewhat with the above.

As a resident or fellow, vascular call seems like hell because all the patients are so sick, creating a million calls from the floor, and the ER is pestering you constantly with those necrotic toe or clotted AV graft consults. But it is often a different world as an attending in most vascular practices. I think you see a skewed vascular population as a resident--way more indigent patients with advanced disease, and complicated, tertiary-referral arterial cases requiring open operations. Plus you are expected to actually manage all of the medical problems, not consult the medicine service.

In the average private-practice, most of the medical issues will be handled by the PMD or hospitalists who are consulted on everyone with medical problems (basically everyone), and there are really very few ER things that you need to come in for--Ruptured AAA and cold leg come to mind, but these are rare in most settings. A large fraction of your practice will probably consist of endovascular intervention, venous work, and dialysis access, all of which are very schedule-friendly with minimal emergencies.

I was a general surgeon before doing vascular fellowship and I thought general surgery attending call was way more painful: midnight butt pus, and 80 year-olds with vague belly pain, and "we can't rule out dead gut," and appendectomies, and "this old lady fell and bumped her head and we need clearance from surgery before medicine will admit her," and on...and on...and on.

 

[Winged Scapula]

The environment does significantly affect the practice; I guess I didn't make that clear.

While Vascular call is painful as a resident/fellow in an academic institution I would venture that its not much better for the attendings there. They still have to be called by the residents for problems and as you note, see a lot more indigent patients with advanced disease. If I thought I was doing all the work and the attendings were relaxing at home, I would have noted that, but I think they have a pretty bad lifestyle.

However, in a community practice where you can and do consult other services for the day to day minutae, etc. the lifestyle can certainly be as you describe it.

The same goes for Trauma or even CTS at a community hospital; the acuity, census and other services which can care for the patient can radically change how busy your nights on call are. The again, being in an academic practice with residents, at least good residents, can somewhat soften the blow of getting the calls yourself.

 

[Castro Viejo]

whats the lifestyle of a vascular surgeon like ? much call?

Lifestyle for any surgeon really depends on your practice situation. Solo vs. group, academic vs. community, residents around vs. residents gone, etc. Vascular Surgery, like General, CTS, Trauma, and Transplant, is peppered with middle of the night issues that (if you have a working conscience) can't really wait until the morning.

But unlike General, CTS, Trauma, and Transplant, Vascular Surgery offers you the opportunity to take yourself out of the picture for those kinds of things relatively early in practice. Like Kim Cox mentioned, becoming a phlebetologist in private practice certainly can allow you to sustain a living without having to deal with the 3AM ruptured aneurysms, cold extremities, and clotted accesses. With those other surgical specialties there's no such thing! This is one of the reasons that makes Vascular Surgery, in my opinion, a great option after General Surgery residency. But then again, I'm a little biased.

(If you decide on giving your conscience the old heave-ho, then you can run IV antibiotics into an acute appendicitis with generalized peritonitis, IV heparin for an acutely cold leg, etc.)

 

[Miami_med]

Kim Cox has had a metamorphasis into a Simpson.

 

[Winged Scapula]

Kim Cox has had a metamorphasis into a Simpson.

Whatcha think? I'm making all the Admins do it (Lee and Dr. Mom are still holding out)!

 

[hans19]

Whatcha think?

Wawaweeewah!!!

 

[chk]

HI..I matched in to one of the integrated vascular surgery programs and it is awesome. One aspect that may pre-surgery applicants are unaware of is how much endovascular there is in vascular surgery today.

I get a mix of open procedures, imaging, vascular medicine, etc, etc.

Lifestyle has much improved (in my humble opinion) because there are so many more endo cases (ruptured aortas can now be treated endovascularly and rarely even go to the ICU). There is a great mix. But I am really inpatient and like short cases too (there are plenty in vascular: SO many diagnostic angios, stents,IVC fiters angioplasties, fistulas/dialysis access which average 30 minutes...) Longer cases such as carotid endarterectomies, open AAA repairs are about 1-3 hour cases now. The cold leg bypass is probably one of the longer ones at 3.5 hours.... At least that has been my experience so far having done four months of vascular between my 3rd, 4th year of med school and intern year...

 

[Blade28]

Whatcha think? I'm making all the Admins do it (Lee and Dr. Mom are still holding out)!

Who's drawing all these Simpsonesque avatars?

 

[Winged Scapula]

Who's drawing all these Simpsonesque avatars?

Its http://www.simpsonizeme.com

Just upload a picture, adjust the hair, face, clothing, etc. and download the drawing.

I got it from The Lounge...of course, now they're making fun of us for doing it!

 

[Winged Scapula]

HI..I matched in to one of the integrated vascular surgery programs and it is awesome. One aspect that may pre-surgery applicants are unaware of is how much endovascular there is in vascular surgery today.

I get a mix of open procedures, imaging, vascular medicine, etc, etc.

Lifestyle has much improved (in my humble opinion) because there are so many more endo cases (ruptured aortas can now be treated endovascularly and rarely even go to the ICU). There is a great mix. But I am really inpatient and like short cases too (there are plenty in vascular: SO many diagnostic angios, stents,IVC fiters angioplasties, fistulas/dialysis access which average 30 minutes...) Longer cases such as carotid endarterectomies, open AAA repairs are about 1-3 hour cases now. The cold leg bypass is probably one of the longer ones at 3.5 hours.... At least that has been my experience so far having done four months of vascular between my 3rd, 4th year of med school and intern year...

If that had been true during my residency perhaps I would have liked vascular more!

 

[tcar18]

HI..I matched in to one of the integrated vascular surgery programs and it is awesome. One aspect that may pre-surgery applicants are unaware of is how much endovascular there is in vascular surgery today.

I get a mix of open procedures, imaging, vascular medicine, etc, etc.

Lifestyle has much improved (in my humble opinion) because there are so many more endo cases (ruptured aortas can now be treated endovascularly and rarely even go to the ICU). There is a great mix. But I am really inpatient and like short cases too (there are plenty in vascular: SO many diagnostic angios, stents,IVC fiters angioplasties, fistulas/dialysis access which average 30 minutes...) Longer cases such as carotid endarterectomies, open AAA repairs are about 1-3 hour cases now. The cold leg bypass is probably one of the longer ones at 3.5 hours.... At least that has been my experience so far having done four months of vascular between my 3rd, 4th year of med school and intern year...

can you tell me what the bread and butter cases are for vascular? also is there cross over with the interventional radiologists?

 

[johankriek]

can you tell me what the bread and butter cases are for vascular? also is there cross over with the interventional radiologists?

there is no bread and butter in vascular.. all the patients are obese smokers who continue to smoke diabetics.. they are generally the most non compliant patients. They are pains in the arses.. their potassiums are all high, their sugars are all high.. and when they bring the trainwrecks to the OR with a K of 6.2 nothing bread and butter about that.. They are all high risk patients and they can die at any moment in the operating room.. How would you like to lead a life like that? I have never met more miserable people in my whole entire life.. the patients and the vascular surgeons deserve each other..

so there is no bread and butter in vascular..

another thing.. I think vascular may be technically difficult because most vasc surgeons i meet are just not that good..

and when i tell the vascular guys .. hey his K is 6.2.. bring it down and come back to see me.. they throw a hissy fit like they are 2 years old..

 

[chk]

can you tell me what the bread and butter cases are for vascular? also is there cross over with the interventional radiologists?

Sure..for OPEN CASES (which there are still plenty of regardless of the endo cases) include carotid endarterectomies (carotid stenting is for specific risk stratified patients only, but we are trained to do both), AAA repair (endo cases can only be done if the anatomy of the aneurysm neck is a certain length), femoral-distal bypasses, arterial-venous fistulas creations for dialysis access, amputations, any trauma case requiring repair of blood vessels (usually requiring transection of a contralateral vein for a conduit for the arterial repair). The surgeons at my institution also do bypasses from central veins (IJ, subclavian, etc) to the right atrium for central vein stenosis cases..just depends how taleted you are and how much training you get..

For ENDO CASES, include arteriograms/stents/angioplasties of anything (lower extremity, carotids, abdominal vessels), stents for thoracic and infrarenal aortas, IVC fillters, angioplasty of fistulas that are malfunctioning, thrombolysis, uterine fibroid embolization, etc...

There is some crossover with IR, but there are plenty of patients to go around. I considered IR before applying for the integrated program, but I wanted to learn some surgical skills as well, and I believe the vascular surgeon is able to learn how to take care of the patient in house as well.

Hope this helps, let me know if you have any other questions..

 

[-Goose-]

there is no bread and butter in vascular.. all the patients are obese smokers who continue to smoke diabetics.. they are generally the most non compliant patients. They are pains in the arses.. their potassiums are all high, their sugars are all high.. and when they bring the trainwrecks to the OR with a K of 6.2 nothing bread and butter about that.. They are all high risk patients and they can die at any moment in the operating room.. How would you like to lead a life like that? I have never met more miserable people in my whole entire life.. the patients and the vascular surgeons deserve each other..

so there is no bread and butter in vascular..

another thing.. I think vascular may be technically difficult because most vasc surgeons i meet are just not that good..

and when i tell the vascular guys .. hey his K is 6.2.. bring it down and come back to see me.. they throw a hissy fit like they are 2 years old..

ouch.

 

[NDESTRUKT]

Whatcha think? I'm making all the Admins do it (Lee and Dr. Mom are still holding out)!

Is it wrong for me to say this? And if it is, please don't punish me by putting me on violation, but...

Dr. Cox, you're really hot...seriously.

 

[Winged Scapula]

Is it wrong for me to say this? And if it is, please don't punish me by putting me on violation, but...

Dr. Cox, you're really hot...seriously.

Its the yellow skin and hair isn't it?!

 

[NDESTRUKT]

In the community do surgeons have to take care of all the medical issues or do the hospitalists do this? It sounds like it would be cool to manage some of the medical issues but not the late night ones and just operate all the next day.

 

[Winged Scapula]

In the community do surgeons have to take care of all the medical issues or do the hospitalists do this? It sounds like it would be cool to manage some of the medical issues but not the late night ones and just operate all the next day.

It depends on your preference and the local environment. In the community hospital where I moonlight, it is fairly common practice for the surgeons, including vascular surgeons, to consult either the patient's PCP or the hospitalists to take care of medical issues for the patient. I had a bit of trouble doing that (coming from the academic environment where we did everything ourselves) and it was explained that: a) the surgeons weren't interested in doing the medical care and b) that it is a reciprocal relationship. The PCP or other medical group gets paid to take care of your patient, and so they will refer surgical patients to you.

I don't think you could arrange a situation in which you would say, "call me from 8 to 5 pm for medical issues. Anything after that or on weekends, call the PCP." Seems like a bit of an abuse of the system, to me. You either take on the responsiblity or you don't. Besides, most surgeons don't think "managing medical issues" are very cool.

But in any event, yes, it is possible to have the medical care of your patients managed by an internist or other medical specialist.

 

[johankriek]

It sounds like it would be cool to manage some of the medical issues .

then become an internist if you think it is so cool. seriously

 

[Serendipity100]

Anybody recently applied to integrated vascular programs?

Bump

 

[Blue Rover]

The endovascular revolution has completely changed vascular surgery. What were once extremely painful procedures (for both patient and surgeon) are now much less invasive, and lead to better outcomes.

At my institution, the attendings start at 7:15 AM and tend to finish at 5 PM at the latest, and often as early as 4 PM. In the meantime, they can do 1 or 2 big cases (e.g., open AAA, aortobifem) or multiple smaller cases (e.g. angios with possible PTA and stenting, AVF/G, CEAs). Between cases, they see their patients on the floor, staff consults, or put in the random IVC filter that Trauma needs.

Then, they're done for the day, except for when they're on call, and then they're hopping. Even then, though, our interventions are so much less morbid than before that the patients tend to be pretty quiet on the floor. (Now, the ED will always call with an acutely thrombosed graft, so you'll have to see those.) Still, it's a far cry from Transplant.

Depending on the size of the group, that call can vary, which is part of the reason that being part of a bigger group can really improve lifestyle dramatically, though that's true of any specialty.

Adding to the improved lifestyle is the little known fact that vascular surgery is rapidly turning into one of the best compensated surgical subspecialties, 2nd only to neurosurgery.

Why? For whatever reason, those endovascular procedures tend to bring large reimbursements for the hospitals, and they pay the physicians richly for being able to provide those services. That IVC filter I mentioned above? It's $15k for a 10 minute procedure.

The one thing to remember, though, is that this is still SURGERY, and it's imperative during the training to be as confident and proficient as the general surgeons in terms of technical skill and dedication.

 

[DOinMS]

There are more integrated vascular surgery residency (0+5) programs on ERAS this year. What is the general feeling among surgeons about this type of training (compared to the traditional 5+2)? Are the spots for the 0+5 programs fiercely competitive?

 

[filter07]

There are more integrated vascular surgery residency (0+5) programs on ERAS this year. What is the general feeling among surgeons about this type of training (compared to the traditional 5+2)? Are the spots for the 0+5 programs fiercely competitive?

The consensus from attendings at traditional 2 year fellowship programs were that the traditional pathway is proven and produces a well trained vascular surgeon with the pre-requisite technical skill. They also cite the need to be trained in general in order to produce good exposures for aortic cases, and the ability to deal with a hostile abdomen. Finally, there is concern that a primary certificate model exposes the training program to increased risk of attrition. 20% of general surgery residents quit. An integrated vascular surgery residency does not have the luxury of replacing open spots with a pool of prelim surgery residents, as much of the training is specialized from the first year onwards. In addition, most programs offer only 1-2 spots a year, and losing a resident puts undue burden on the reputation of the training program, as well as the workload for other residents.

For these reasons, many are quite reluctant to accept the primary certificate model. However there is a realization that there is great demand for the primary certificate from the applicant pool, and programs face the risk of losing the best and brightest future vascular surgeons to the primary certificate programs. Although one vascular surgery program director confided that primary certificate applicants were not as strong as predicted (during the first year of primary certificate), it seems now that in the second year of this pathway being available, competition is fierce.

 

[SocialistMD]

The consensus from attendings at traditional 2 year fellowship programs were that the traditional pathway is proven and produces a well trained vascular surgeon with the pre-requisite technical skill. They also cite the need to be trained in general in order to produce good exposures for aortic cases, and the ability to deal with a hostile abdomen.

To play devil's advocate, I'm sure that back in the day the general surgery trained neurosurgeons, ENTs and (especially) urologists and gynecologists said more or less the same thing about those specialties branching off and doing their own thing, yet here we are.

Finally, there is concern that a primary certificate model exposes the training program to increased risk of attrition. 20% of general surgery residents quit. An integrated vascular surgery residency does not have the luxury of replacing open spots with a pool of prelim surgery residents, as much of the training is specialized from the first year onwards.

While on the surface I'd agree, and for the immediate future it should be a concern, in the end, I still see this as yet another surgical specialty branching out on its own, much as urology, neurosurgery and ENT before it. Eventually, there will be 2-3 residents/year at each program, allowing for some attrition without total devastation.

However there is a realization that there is great demand for the primary certificate from the applicant pool, and programs face the risk of losing the best and brightest future vascular surgeons to the primary certificate programs.

If they were going to be vascular surgeons anyway, where is the real loss?
Just because someone has a 270+ on Step 1 and is junior AOA (the kind of applicant most programs [mine included] salivate over) doesn't mean s/he will be the best, or even a very good surgery resident. Plus, if you allow people who truly know what they want to do an early and frequent exposure to what they really want to do, minimizing the stuff they see as supurfluous (particularly the current generation me), they will be happier and more focused. Thus, you may actually decrease the attrition, as most of the people I know who left surgery did so because the ends no longer justified the means and they found different avenues (anesthesiology, interventional radiology) to the same ends that were much more pleasant on which to travel.

I don't know what the answer is, but I think the early specialization for vascular and cardiothoracic surgery is here to stay. Operating in the chest and the extensive use of percutaneous endoluminal techniques are so far removed from general abdominal surgery that it only seems fitting to allow for more training in those specialized areas, foregoing the final year or so of general surgery education. While I'm still not sure about the 0+5 programs (mostly because I haven't looked at their curricula to see how much general surgery exposure they get), that may be the next logical step in the era of limited work hours and physicians unwilling to train 12+ years to gain the same exposure and skill their professors had at the end of their training. The truth is, CT and vascular surgeons don't need to know how to operate on the GI tract (with the exception of the esophagus for thoracic, but even then they can have a general surgeon take care of the abdominal portion of the procedure if they want to). There are no "vascular" or "cardiothoracic" hospitals, so there are always general surgeons around to help out if they get into trouble (that's how it happens here right now), and vice versa. Am I upset that I won't get to do as many open AAAs as my predecessors? Of course, but our vascular fellows today don't get to do as many open AAAs in two years as the chief residents from my program got in 10 weeks some 15 years ago, as it is just technological progress.

 

[beaverfetus]

is there any reason a vascular surgeon couldn't have a practice virtually identical to an IR's ?

 

[SocialistMD]

is there any reason a vascular surgeon couldn't have a practice virtually identical to an IR's ?

Aside from abscess drains, I guess a vascular surgeon could structure his/her practice to mirror that of an interventional radiologist. However, why would s/he want to give up CEAs, vascular (dialysis) access cases, open fem-pops, fem-distals, ax-fems, aortobifems, etc...? Most vascular surgeons don't go into vascular because they like wires and the risk of sterility; they like to play with vessels.

 

[LadyWolverine]

I too am interested in this discussion. I'm an MS3, currently considering an integrated vascular surgery program versus a traditional radiology residency with ultimate intent to enter IR. I enjoy both diagnostic and interventional radiology and am extremely interested in the future promises of these fields, but I am equally drawn to the OR as well as the emergency/trauma setting. I'm definitely a "procedure" person who also likes being in the ED. Furthermore, I enjoy seeing patients in clinic, and would like to incorporate some outpatient visits as part of my practice. Finally, I have a basic research background in vascular biology, and may wish to continue my research career at some point in the future.

Vascular surgery seems like a perfect fit for someone like me - the problem is, I feel pulled in 3 directions at once, which is making it quite difficult to select a career path. I am equally interested in vascular surgery, radiology/IR, and emergency medicine. While each field is significantly different, there is considerable overlap, especially when it comes to my particular interests.

I don't know if I'm prepared to commit to a surgical residency/career, but I'm afraid that if I choose radiology/IR, I will miss both the open cases in the OR as well as the emergency/trauma setting. If I select emergency medicine, I fear that I won't have the OR, the vascular bent, or the long-term patient relationships that I seem to enjoy.

I don't know how to go about making such a big decision. I've gotten in touch with the chairs/advisors from all 3 departments at my school, but I need to start scheduling 4th year electives very soon and I'm feeling very lost. I would appreciate some insight from anyone involved in vascular surgery.

 

[Skialta]

To Lady Wolverine

There is definite overlap between IR and vascular, but EM is not anywhere close to either radiology or surgery. If you really think you want to do anything with trauma then general surgery would be a better track. At least where I went to medical school and now as a resident the EM guys only manage the airway during trauma and on level ones it is anesthesia. Anything interesting in trauma is going to a surgeon in about 10 -15 minutes from the time it hits the door. At some of the hospitals I rotate at I have empathy for the fact that the EM guys actually did a residency to be able to just call consults.

I see your real issue as whether you want to be a surgeon or a radiologist. I have seen there are a few programs out there where surgery residents can go directly into interventional radiology tracts. I am biased, but vascular gives you the ability to operate and still be in the interventional world.

Good luck with your choice.

 

[sleeping]

... I have seen there are a few programs out there where surgery residents can go directly into interventional radiology tracts...

Where was this? I always wondered if you can do a year of IR after surgery. A good combination of IR + Trauma. As well, those procedures pay quite well.

 

[Black Surgeon]

whats the lifestyle of a vascular surgeon like ? much call?

Where is njbmd when you need her? she is also a vascular surgeon and always has very insightful perspectives.

 

[bkz]

Adding to the improved lifestyle is the little known fact that vascular surgery is rapidly turning into one of the best compensated surgical subspecialties, 2nd only to neurosurgery.

Why? For whatever reason, those endovascular procedures tend to bring large reimbursements for the hospitals, and they pay the physicians richly for being able to provide those services. That IVC filter I mentioned above? It's $15k for a 10 minute procedure.

Bump...
could someone please explain why medicare/insurance companies reimburse so highly for vascular procedures? I know there is a large overlap with IR, but I don't understand why these procedures have such high reimbursement rates (beyond procedures tending to pay higher in general). Sorry if this is an obvious question.

Would appreciate njbmd's opinion as well

 

[Castro Viejo]

Where was this? I always wondered if you can do a year of IR after surgery. A good combination of IR + Trauma. As well, those procedures pay quite well.

You can do a year of IR. I've known General Surgery residents who have gone into IR fellowships after training or as a transition to a Radiology residency. You won't qualify to sit for the Rads boards or the IR CAQ, however, so I doubt you'd get privileges to practice any interventional/endovascular stuff at most hospitals.

 

[Winged Scapula]

Bump...
could someone please explain why medicare/insurance companies reimburse so highly for vascular procedures? I know there is a large overlap with IR, but I don't understand why these procedures have such high reimbursement rates (beyond procedures tending to pay higher in general). Sorry if this is an obvious question.

Would appreciate njbmd's opinion as well

Insurance companies pay well for any image guided procedure whether its a radiologist, vascular or breast surgeon doing it.

As to why, who knows? Clearly the radiologists were much more active in getting reimbursement rates higher than general surgeons were.

Its not obvious...that's the problem with reimbursement. There is little to no regard for how much training or how long it takes you to do something. I make nearly as much for a 15 min image guided biopsy in my office than I do for a modified radical mastectomy.

 

[Castro Viejo]

Where is njbmd when you need her? she is also a vascular surgeon and always has very insightful perspectives.

The lifestyle of Vascular Surgeons has improved quite a bit in my time from medical school to my current fellowship training in Vascular Surgery.

Redo bypasses aren't quite as rampant as they used to be. We can thank wires and catheters for that. 8 to 10 hour aneurysm repairs in morbidly obese patients have become a relatively rare event now that we can throw in an endograft in about 2 or 3 hours.

Vascular Surgeons have lifestyles that reflect the type of practice they want. Some have gone into venous practices where they typically deal with chronic venous insufficiency and make quite a bit of money doing it. Others have picked up entirely non-surgical practices where they practice Vascular Medicine and perform/interpret noninvasive vascular laboratory studies (PVRs, ABIs, Duplex ultrasound, etc.). These are certainly NOT typical practice scenarios for fresh out of fellowship graduates, but these are viable options.

 

[Castro Viejo]

As to why, who knows? Clearly the radiologists were much more active in getting reimbursement rates higher than general surgeons were.

Interestingly enough, I read somewhere that CMS reimbursements for diagnostic radiology were cut by 30% whie Anesthesia reimbursements were raised by the same percentage.

The SGR formula is ******ed.

 

[jackbauer]

Some interesting comments on here about patients. It seems like transplant / cardio / vascular patients are considered to be the worst - they are either alcoholics or obese diabetics, neither of which lends itself greatly to compliance with the doctors orders. Do you think these are really the fields with the worst patients, i.e., do you think endocrine/minimally invasive or ortho/neuro/ENT patients are better to work with? How much would you consider the patient population as a factor in you decision of residency/fellowship?

 

[Winged Scapula]

Interestingly enough, I read somewhere that CMS reimbursements for diagnostic radiology were cut by 30% whie Anesthesia reimbursements were raised by the same percentage.

The SGR formula is ******ed.

Indeed.

What was the old joke?

Something about when the fight broke out over reimbursement, radiologists showed up with knives, orthopods with guns and general surgeons were busy n the ED seeing consults and didn't show up at all (hence the low rates).

Radiology reimbursements have dropped. I know I make less this year for a stereotactic guided biopsy and for reading my images than I did last year. Too had I can't operate and administer anesthesia at the same time!

 

[Castro Viejo]

Radiology reimbursements have dropped. I know I make less this year for a stereotactic guided biopsy and for reading my images than I did last year. Too had I can't operate and administer anesthesia at the same time!

Wait until I build my Anesthesia robot. I might be able to bring in that professional fee AND the facility fee.

 

[bkz]

Thanks for the responses WS and Castro
Sounds like reimbursement is not very easy to predict.

It also seems like you guys are saying the way to keep doing open procedures would be to focus mainly on veins (please correct me if I misinterpreted that).

Some interesting comments on here about patients. It seems like transplant / cardio / vascular patients are considered to be the worst - they are either alcoholics or obese diabetics, neither of which lends itself greatly to compliance with the doctors orders. Do you think these are really the fields with the worst patients, i.e., do you think endocrine/minimally invasive or ortho/neuro/ENT patients are better to work with? How much would you consider the patient population as a factor in you decision of residency/fellowship?

Wouldn't this sorta be considered 'job security'? There isn't a treatment more definitive than surgery for these kinds of cases, right?

 

[Castro Viejo]

Thanks for the responses WS and Castro
Sounds like reimbursement is not very easy to predict.

Only because there are slight changes annually. It's actually quite amusing.

It also seems like you guys are saying the way to keep doing open procedures would be to focus mainly on veins (please correct me if I misinterpreted that).

Yeah, you misinterpreted that. Plenty of vein cases are not open. With RF closure and endovenous laser blah blah treatments, many vein cases never see a knife. I mean, seriously, vein practices wouldn't be as attractive as they are if it meant taking a knife to skin all the time and doing SFJ ligations with stab phlebectomies all day long.

Wouldn't this sorta be considered 'job security'? There isn't a treatment more definitive than surgery for these kinds of cases, right?

Oh, there are plenty of other treatments that are not inferior to conventional operative approaches to venous disease and, in some cases, preferred and superior as far as cutting down morbidity. RF closure (look up the VNUS device), endovenous laser coagulation, Trivex (although this one is nasty...), etc.

I apologize for misleading you with my original statement.

I meant that there are plenty of different practice types in vascular surgery, from general vascular surgery to vein practices to vascular medicine practices. You can choose to embrace all vascular techniques or decide to be an open only or endo only type person.

 

[bkz]

thank you, very appreciated