Thoracic Option after Integrated Vascular(0+5)

[FarmerO]

As I understand it, currently the only way to enter a two/three year cardiothoracic fellowship is to have completed a 5-7 year general surgery residency and be eligible for board certification in general surgery. Does anyone have any knowledge about whether or not a integrated vascular graduate would ever be able to enter into a thoracic fellowship as an independent applicant? Would a 0+5 vascular program be thought of as inadequate preparation to handle a thoracic fellowship? Or would it be seen as something with it's own unique strengths, perhaps producing a candidate who brings some desirable skills into the program?

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[sickofwaiting]

I'm not sure about applying to fellowships after an integrated vascular residency, but Allegheny does offer an optional sequential vascular and thoracic residency. If you choose to do both, it ends up being 7 years.

https://www.ahn.org/education/graduate-medical-education/fellowships/vascular-surgery

 

[idiot07]

I've never heard of anyone doing it, but I'm pretty sure it's allowed. If you want to do general thoracic, I think the it's a bad idea as you won't have the baseline MIS skills to succeed in fellowship. If you're going to do academic cardiac surgery, I don't think it necesarily helps you that much (but it doesn't hurt you), as you're probably going to specialize in either cardiac or vascular and stick to that. If you want to subspecialize in aortic surgery or TAVR, I guess the wires skills/interventions would help you, but these can also be learned on the fly during ct. If you want to do coronary interventions, you're going to have to do some extra time after cardiac.

If however, you want to do private practice cardiac/vascular surgery, I think this would be awesome training. Many, many private practice cardiac jobs want you to do periphereal vascular too, and the ability to do both out of fellowship without on the job training would be very attractive to your future partners and hospital. I think you would be one of the busiest surgeons around very quickly.

Whether a vascular residency prepares you better for ct fellowship than gen surgery probably depends on the individual residencies. Many general surgery programs are losing their open vascular experiences which is helpful when you start ct but not vital. The knock on vascular residencies is they don't get enough open experience as well.

 

[mimelim]

I've never heard of anyone doing it, but I'm pretty sure it's allowed. If you want to do general thoracic, I think the it's a bad idea as you won't have the baseline MIS skills to succeed in fellowship. If you're going to do academic cardiac surgery, I don't think it necesarily helps you that much (but it doesn't hurt you), as you're probably going to specialize in either cardiac or vascular and stick to that. If you want to subspecialize in aortic surgery or TAVR, I guess the wires skills/interventions would help you, but these can also be learned on the fly during ct. If you want to do coronary interventions, you're going to have to do some extra time after cardiac.

If however, you want to do private practice cardiac/vascular surgery, I think this would be awesome training. Many, many private practice cardiac jobs want you to do periphereal vascular too, and the ability to do both out of fellowship without on the job training would be very attractive to your future partners and hospital. I think you would be one of the busiest surgeons around very quickly.

Whether a vascular residency prepares you better for ct fellowship than gen surgery probably depends on the individual residencies. Many general surgery programs are losing their open vascular experiences which is helpful when you start ct but not vital. The knock on vascular residencies is they don't get enough open experience as well.

Re: open experience

This month's JVS has an article about 5+2 vs. 0+5: http://www.jvascsurg.org/article/S0741-5214(15)01221-5/abstract

What 0+5 residents lose out on are the colectomies, whipples, trauma laps, etc. They have an equivalent open vascular experience and a vastly superior endo experience. I think the real question is how important are those open general surgery cases vs. increase in endo experience.

Re: cardiac/thoracic after IVS

Nobody has done it yet, but I think that the way ACGME thoracic fellowships are setup, you couldn't do it if you hadn't done GS first, but that is probably subject to change if someone pushed it.. We have an informal CV track that would allow for someone to spend 7 years here and get 2 full years of thoracic/cardiac in addition to their vascular training, but again, nobody has shown interest in it.

 

[dienekes88]

As I understand it, currently the only way to enter a two/three year cardiothoracic fellowship is to have completed a 5-7 year general surgery residency and be eligible for board certification in general surgery. Does anyone have any knowledge about whether or not a integrated vascular graduate would ever be able to enter into a thoracic fellowship as an independent applicant? Would a 0+5 vascular program be thought of as inadequate preparation to handle a thoracic fellowship? Or would it be seen as something with it's own unique strengths, perhaps producing a candidate who brings some desirable skills into the program?

What would the point be?

If you want to do thoracic surgery, you may be better off doing general surgery and then a general thoracic fellowship, though I don't know. I have a feeling that there is a lot of variability in the thoracic experience across integrated cardiothoracic surgery programs, so you would have to be pretty selective coming out of the gates as it were. I think there's reasonable translation of laparoscopy to VATS. Additionally, getting comfortable in the belly and being able to do your own gastric conduit is nice (especially if it's laparoscopic).

If you want to be a cardiac surgeon, you should think hard about doing an integrated cardiothoracic residency.

Re: open experience

This month's JVS has an article about 5+2 vs. 0+5: http://www.jvascsurg.org/article/S0741-5214(15)01221-5/abstract

What 0+5 residents lose out on are the colectomies, whipples, trauma laps, etc. They have an equivalent open vascular experience and a vastly superior endo experience. I think the real question is how important are those open general surgery cases vs. increase in endo experience.

Re: cardiac/thoracic after IVS

Nobody has done it yet, but I think that the way ACGME thoracic fellowships are setup, you couldn't do it if you hadn't done GS first, but that is probably subject to change if someone pushed it.. We have an informal CV track that would allow for someone to spend 7 years here and get 2 full years of thoracic/cardiac in addition to their vascular training, but again, nobody has shown interest in it.

Three points:

1) I'm surprised that the 0+5s don't have more open vascular experience than the 5+2s. After all, the 5+2 guys have maybe 3 months of vascular and then 2 years of fellowship. Shouldn't the 0+5 guys have way more open cases? There are no doubt required general surgery months, and ICU time, but it can't be >2 years and 9 mos. of it.

2) Just because the number of open cases is the same doesn't mean that the resident learns the same thing. The experience of exposing for a Whipple or a colectomy goes far in being very comfortable in the belly for when you're doing a transabdominal open AAA. This is not to say that the 0+5 can't do it, but I would guess that 5+2s would feel more comfortable. I could be wrong, though.

3) Not surprising that the 0+5s have a better endo experience. The question I have now is this: do 0+5s seek out more endo experience? Are the places where they have 0+5 residencies more endo-focused, because it appears that they don't do any more open than the 5+2 places. Is there a difference in competition for cases (would depend on number of fellowship spots per year, number of 0+5s you're bringing in, and other manpower issues)?

There are pros and cons to both.

 

[mimelim]

Three points:

1) I'm surprised that the 0+5s don't have more open vascular experience than the 5+2s. After all, the 5+2 guys have maybe 3 months of vascular and then 2 years of fellowship. Shouldn't the 0+5 guys have way more open cases? There are no doubt required general surgery months, and ICU time, but it can't be >2 years and 9 mos. of it.

2) Just because the number of open cases is the same doesn't mean that the resident learns the same thing. The experience of exposing for a Whipple or a colectomy goes far in being very comfortable in the belly for when you're doing a transabdominal open AAA. This is not to say that the 0+5 can't do it, but I would guess that 5+2s would feel more comfortable. I could be wrong, though.

3) Not surprising that the 0+5s have a better endo experience. The question I have now is this: do 0+5s seek out more endo experience? Are the places where they have 0+5 residencies more endo-focused, because it appears that they don't do any more open than the 5+2 places. Is there a difference in competition for cases (would depend on number of fellowship spots per year, number of 0+5s you're bringing in, and other manpower issues)?

There are pros and cons to both.

#1 This isn't that surprising. 0+5 have 24 months of non-vascular surgery training (gen surg and 'vascular related' rotations) and most big open cases are upper level cases that aren't done by interns or second years. The bulk of the open bypasses are performed at most institutions by 4th/5th years who are in the 'equivalent' of fellowship years.

#2 Open AAA repair is a minuscule part of vascular training now. The number of graduating fellows that are planning (or should be planning) to do open AAA as a part of their practice is small and shrinking. I was just at the Methodist open aortic course a couple weeks ago and virtually every faculty there teaching (from multiple institutions) was saying that open AAA volume across the country has been dropping so fast that APDVS/SVS was struggling to figure out how to train people and whether or not to get rid of the open AAA component of case logs. I went through the course partnered with a 5+2 and there is no question that his comfort in the abdomen was well beyond mine (granted he has 2 additional years of training than I do) and it makes sense that 5+2s will have a lot more comfort.

Most vascular trainees, regardless of pathway, will end up with 5-15 EVARs per open AAA. Community practices that ratio sky rockets. With the fenestrated market ramping up and non-vascular interventionalists getting into the market, it is unlikely for this to change. I'm not commenting if this is good or bad for patients, but it is the reality.

#3 Most of the big open centers in the US have 0+5 programs. There are one or two hold outs, but virtually everyone is transitioning over to 0+5. We are actually keeping our 5+2 as are some of the other high volume centers. Our first year fellows are on the same level as our 4th year IVS residents, second year fellows same as 5th year with regard to hierarchy and case distribution.

 

[dienekes88]

#1 This isn't that surprising. 0+5 have 24 months of non-vascular surgery training (gen surg and 'vascular related' rotations) and most big open cases are upper level cases that aren't done by interns or second years. The bulk of the open bypasses are performed at most institutions by 4th/5th years who are in the 'equivalent' of fellowship years.

#2 Open AAA repair is a minuscule part of vascular training now. The number of graduating fellows that are planning (or should be planning) to do open AAA as a part of their practice is small and shrinking. I was just at the Methodist open aortic course a couple weeks ago and virtually every faculty there teaching (from multiple institutions) was saying that open AAA volume across the country has been dropping so fast that APDVS/SVS was struggling to figure out how to train people and whether or not to get rid of the open AAA component of case logs. I went through the course partnered with a 5+2 and there is no question that his comfort in the abdomen was well beyond mine (granted he has 2 additional years of training than I do) and it makes sense that 5+2s will have a lot more comfort.

Most vascular trainees, regardless of pathway, will end up with 5-15 EVARs per open AAA. Community practices that ratio sky rockets. With the fenestrated market ramping up and non-vascular interventionalists getting into the market, it is unlikely for this to change. I'm not commenting if this is good or bad for patients, but it is the reality.

That is pretty unfortunate. JVS had an interesting article in 2014 by Raux et al. Open vs. f-EVAR for complex AAA. f-EVAR was associated with increased odds of 30-d mortality (9.5%) and complication compared with open. One should never bet against technology, but I think the rumors surrounding the death of the open operation are greatly exaggerated. Moreover, there's data suggesting that long term outcomes are better with open repair. Really, it's not so different from the PCI vs. CABG debate. Fortunately, a lot of these endovascular devices are getting to be pretty easy to use. Unfortunately, a lot of the applications of these devices (tons of thrombus, angulated neck, f-evar, branched devices, etc.) are beyond the skill level of someone who is more of a dabbler.

#3 Most of the big open centers in the US have 0+5 programs. There are one or two hold outs, but virtually everyone is transitioning over to 0+5. We are actually keeping our 5+2 as are some of the other high volume centers. Our first year fellows are on the same level as our 4th year IVS residents, second year fellows same as 5th year with regard to hierarchy and case distribution.

Probably for the best given the direction that technology is going.

 

[PB n J]

To answer your question, I was at the Eastern Vascular meeting two years ago and a PD from a CT program stated, rather directly, that 0+5 residents make excellent CT fellows and were quite frequently this program's top choices in applicants. He cited various reasons but the most stand out examples were experience in handling delicate tissues, familiarity with instrumentation, and knowledge of disease processes and management.

 

[deleted745951]

To add on to the thread for those who are interested (though it would defeat the purpose of doing vascular surgery given it already has so much on its hands). Check this out https://www.abts.org/media/14772/2017-Booklet-of-Information-3-10-17.pdf. Knowledge is power.

"GENERAL REQUIREMENTS Certification by the American Board of Thoracic Surgery may be achieved by completing one of the following four pathways and fulfillment of specific requirements: 1. Pathway One is the successful completion of a full residency in General Surgery approved by the ACGME, followed by the successful completion of an ACGMEapproved Thoracic Surgery residency. Successful completion of a 4/3 General Surgery/Thoracic Surgery Joint Training Program approved by the ACGME fulfills the requirements of Pathway One. With regards to single accreditation, osteopathic candidates will need to complete at least three years (PGY 3-5) in a general surgery residency program that was fully accredited by the ACGME, followed by the successful completion of an ACGMEapproved Thoracic Surgery residency. Pathway Two is the successful completion of a full (5 years) residency in General Surgery, Cardiac Surgery, or Vascular Surgery approved by the Royal College of Physicians and Surgeons of Canada, followed by the successful completion of an ACGME-approved Thoracic Surgery residency. Pathway Three is the successful completion of a six-year integrated Thoracic Surgery residency developed along guidelines established by the TSDA and approved by the ACGME (RRC-TS). Pathway Four is the successful completion of an ACGME-approved Vascular Surgery residency (5 years) that can lead to primary certification by the ABS followed by the succesful completion of an ACGME-approved Thoracic Surgery residency"

 

[CTFellowMD]

If your plan is to do cardiac surgery, then I think this is a feasible option. With the need for strong endovascular skills in cardiac now, you would make for an excellent candidate and your vascular training would give you a very strong background.

If your plan is thoracic, you will be very unprepared. You will not have the MIS skills for VATS or MI Foregut work, and will not be comfortable enough with bowel.

 

[deleted745951]

If your plan is to do cardiac surgery, then I think this is a feasible option. With the need for strong endovascular skills in cardiac now, you would make for an excellent candidate and your vascular training would give you a very strong background.

If your plan is thoracic, you will be very unprepared. You will not have the MIS skills for VATS or MI Foregut work, and will not be comfortable enough with bowel.

Do you believe said candidates would face any bias against GS candidates?

 

[CTFellowMD]

Do you believe said candidates would face any bias against GS candidates?

It's hard to say. This is a very unique situation that I haven't encountered before. I think it would be all about how the applicant sold him or herself to the programs during interviews.

-Why did you go into vascular if you didn't want to be a vascular surgeon?
-What do you bring to the table that a normal general surgery applicant doesn't?
-What has your cardiac experience been during residency to ensure you really want to be a cardiac surgeon?

If the applicant could answer those questions well, and also had a competitive application compared to the other applicants (absite or vsite scores, research, etc) + LOR from well known cardiac surgeons, I think the person would be sought after.

 

[_Rod_of_Asclepius_]

I'm not sure about applying to fellowships after an integrated vascular residency, but Allegheny does offer an optional sequential vascular and thoracic residency. If you choose to do both, it ends up being 7 years.

Vascular Surgery Residency Program | ahn.org

This must be quite competitive though! How competitive are the 0+5 Vascular programs??

 

[LucidSplash]

This must be quite competitive though! How competitive are the 0+5 Vascular programs??

Extremely