Vascular Surgery Integrated vs General Surgery

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SpikesnSpookes

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Hi everyone,

I'm 99% certain I want to do vascular surgery, but am wondering if the 5 year integrated programs will prepare me well enough versus a general surgery then fellowship approach. Does anybody have any insight to which approach is preferred?

I personally feel like the pros of doing general surgery residency is having the opportunity to re-evaluate which subspecialties are the best fit for me since as a medical student you have very minimal experience, but at this point I really think I'd be happy in vascular surgery. Obviously if I'd be a better surgeon going through a general surgery residency, I'd apply to some gen surg programs but have been leaning towards focusing my efforts on integrated programs for now.

Thanks for your time!

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Hi everyone,

I'm 99% certain I want to do vascular surgery, but am wondering if the 5 year integrated programs will prepare me well enough versus a general surgery then fellowship approach. Does anybody have any insight to which approach is preferred?

I personally feel like the pros of doing general surgery residency is having the opportunity to re-evaluate which subspecialties are the best fit for me since as a medical student you have very minimal experience, but at this point I really think I'd be happy in vascular surgery. Obviously if I'd be a better surgeon going through a general surgery residency, I'd apply to some gen surg programs but have been leaning towards focusing my efforts on integrated programs for now.

Thanks for your time!

The first integrated residents are just graduating in the last couple of years so there isn't any longterm data to answer the question. Some of the early reactions I have heard (in a talk at a meeting, I don't recall who) seems to be that while integrated residents have an initial edge in endovascular procedures and 5+2 have an edge in open cases after graduation (in terms of case length/efficiency, etc), the difference evens out in 18-24 months.
 
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If you are 100% sure why waste any life and potential income fiddling around with feces?
Easy decision!
 
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I'm also applying for vascular surgery in the 2018 match. I've gone back and forth on this for similar reasons, but ultimately decided that I'd prefer the integrated route. I'm definitely applying to general surgery programs as well, but I figured those that an extra two years is a lot of time, especially when a lot of the "stronger" surgery programs have 1-2 required research years. It can easily end up being 9 years before you're an attending if you go to a general surgery program that requires research.

Most of the people I've talked to say that integrated residents get more exposure to endovascular procedures early, so that's something else to consider. But like lucid said above, it seems the differences even out a couples years out of residency anyways. Now, if you're not a strong candidate for integrated then it might be better to go the gen surg route where matching is generally much less competitive and you could have a little more say in where you end up matching if that's important for you. Hope that helps!

Edit: away rotations in vascular are probably a good idea. That way you can get a better feel and hopefully make the right decision for yourself. If you end up doing gen surg I've heard it's ok to use your vascular letters, but it doesn't work the other way around since vascular wants vascular letters.
 
Do I have to do an away rotation for vascular? I have decent stats and lots of research and good letters, and will be doing a home sub-i for sure.
 
Do I have to do an away rotation for vascular? I have decent stats and lots of research and good letters, and will be doing a home sub-i for sure.
Sorry, I was speaking for myself since I don't have a home program. I've seen most say that if you have a home program, you should do an away or two if there's a particular program you're really interested in. But I guess for you it's be fine as long as you're able to get letters. I'm one of the unlucky few without a home program, so I'll have to do aways for all my vascular letters :(
 
My viewpoint is obviously skewed towards the value of a GS residency, but at our institution we have integrated residents as well as traditional fellows. After rotating on the services, the operative skills differences definitely hold up (integrated residents are better at endovascular, traditional fellows are more comfortable in open surgeries). But what I would also say is that anecdotally, the traditional fellows are better doctors as well. There's more to surgery than just the technical aspect, and (unsurprisingly) the traditional fellows are better at general service management and seem to have more mature medical decision making. That too probably evens out after a few years, and is it worth the extra time training? I'm not sure.
 
I'm a gen surg intern... but my advice is definitely do integrated if you're "99% sure" as you say. A majority of gen surg training now seems to be laparoscopic, which wouldn't help you at all for vascular. Choles, appys, hernias have nothing to do with vessels (except that you stay the hell away from them). Unless you really want to be taking gen surg call for some lifestyle hating reason, go integrated. 99% is pretty damn certain. I was only 50% sure about gen surg.

Even if gen surg -> vascular trained people hit the ground running at a higher level, that definitely balances out quickly, and is not worth the opportunity cost (i.e. 2 years of salary!). I would wager most surgical subspecialties will move toward an integrated route. Plus, you don't want to be caught out in the rain in 5 years if some programs transition to integrated only (which is already happening in plastics for example). I also don't think you can bank on getting a "better" gen surg program (since it's theoretically less competitive), since the best programs in every specialty are competitive.
 
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If you're fairly certain that you want to do vascular surgery, then you should just go ahead and do that. I think it's a good idea to apply to general surgery programs as a backup as integrated programs are fairly competitive (and rightfully so). The integrated residents that I have worked with have been incredibly strong in both open and endo (and just all around nice, smart people that I enjoy working with), which I think is more a testament to the program that they're in and the incredible diversity of cases they see (PM if you're interested in gaining more info).

For me, having found out today that I've matched vascular surgery along with a bunch of other great PGY-4's, I can say that I find general surgery to be a grind that is unnecessary in many aspects. I have long lost interest in bariatric surgery, anything related to the anus and running down for traumas where my main role is to babysit for orthopedics/neurosurgery. On the other hand, I am incredibly thankful for the skillsets that I've developed during the course of my residency, the autonomy to operate as a senior resident and the opportunity to learn the nuances of clinical decision making. I don't think you can wrong either way, but if there is a more direct way to get to what you want then you should do that. I'll also offer this, there are residents in my program that are categorical general surgery residents who didn't match integrated. As junior residents who now live the unique pains that come with vascular surgery, have now been dissuaded from pursuing it as a career and are angling for other avenues. It's one of those things you can't really know until you're there so try to get as much exposure as you can and have fun along the way. Cheers.
 
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If you're fairly certain that you want to do vascular surgery, then you should just go ahead and do that. I think it's a good idea to apply to general surgery programs as a backup as integrated programs are fairly competitive (and rightfully so). The integrated residents that I have worked with have been incredibly strong in both open and endo (and just all around nice, smart people that I enjoy working with), which I think is more a testament to the program that they're in and the incredible diversity of cases they see (PM if you're interested in gaining more info).

For me, having found out today that I've matched vascular surgery along with a bunch of other great PGY-4's, I can say that I find general surgery to be a grind that is unnecessary in many aspects. I have long lost interest in bariatric surgery, anything related to the anus and running down for traumas where my main role is to babysit for orthopedics/neurosurgery. On the other hand, I am incredibly thankful for the skillsets that I've developed during the course of my residency, the autonomy to operate as a senior resident and the opportunity to learn the nuances of clinical decision making. I don't think you can wrong either way, but if there is a more direct way to get to what you want then you should do that. I'll also offer this, there are residents in my program that are categorical general surgery residents who didn't match integrated. As junior residents who now live the unique pains that come with vascular surgery, have now been dissuaded from pursuing it as a career and are angling for other avenues. It's one of those things you can't really know until you're there so try to get as much exposure as you can and have fun along the way. Cheers.

Incredible - thank you for excellent post.

If you by chance know - anything in particular sway them from wanting to do vascular and pursuing something else? What made you continue pursuing vascular?
 
The failure rate in vascular surgery is what many general surgery residents loathe about this field. When you're used to cranking out hernias and gallbladders and then never seeing patients again after a postop visit, it can be very discouraging to see the same players in the ED with a thrombosed fistula, bypass failure, wound complications, etc. I think it takes a different mindset when approaching the vascular patient, because there is a longitudinal aspect to their care.

For me, I view it like a batting average in baseball. For every 10 limbs that come through the door, maximal medical/lifestyle/surgical management may only yield 3 salvaged limbs; but that's a reality that I know up front and can live with (and go to the hall of fame with if I was a ball player). You can't make chicken salad with chicken s**t and many patients are notoriously noncompliant with their medications or never stop smoking and hence will make many surgery residents quite jaded. I just don't take it personally and you can't. Many residents first response is to just amputate everybody and call it a day. But for me, I choose not to be so flippant with people's limbs and lives.

In the end, there are myriad reasons why I chose to continue on with vascular surgery. Some of it is the wide range of procedures on different areas of the body we get to do, the sophisticated anastomoses, application of technology to fix complex aneurysms, etc. But really, it just makes sense. And when we boil it down, that's why we end up doing a lot of what we do when choosing surgical fields; it either makes sense to us or it doesn't. I'm going into vascular eyes wide open and count myself very fortunate. I don't envy the decision you have to make as a medical student, but if you're fairly certain that this is what you want to do; then go for it. I'm sure I'll run into you at some conference in the future, and first beer is on me. Cheers.
 
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Hi everyone,

I'm 99% certain I want to do vascular surgery, but am wondering if the 5 year integrated programs will prepare me well enough versus a general surgery then fellowship approach. Does anybody have any insight to which approach is preferred?

I personally feel like the pros of doing general surgery residency is having the opportunity to re-evaluate which subspecialties are the best fit for me since as a medical student you have very minimal experience, but at this point I really think I'd be happy in vascular surgery. Obviously if I'd be a better surgeon going through a general surgery residency, I'd apply to some gen surg programs but have been leaning towards focusing my efforts on integrated programs for now.

Thanks for your time!

Integrated and it isn't even close. Seeing vascular pathology for 5 years vs. 2 years makes a very big difference. You can easily make an argument that you will have better open technical competence if you go GS + VS fellowship and there have been PD surveys that say as much, but you are also talking about an additional 2 years of training, so it really isn't a fair comparison. In every other regard, IVS wins out.
 
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