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vascsurgthrowaway

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*I am moving this from a vascular surgery interview thread to its own topic to make it easier to find for future applicants.
**Also, I am sorry this got so long. I hope it is helpful.

An Opinionated Guide on Applying to Integrated (0+5) Vascular Surgery Residency (Based on the 2016 Match)
I thought I would add another anecdotal experience because I remember how little up-to-date information there was on applying to vascular surgery as I neared the end of my 3rd year. I was happy with where I matched this year. I only applied to the ~30 programs I was willing to go to, and I only interviewed at the 15-20 of those that I was most interested in. I did not receive initial invitations to interview at 3 programs, one of which was a “top” program, and the other two which were outside of my geographical region.

*Disclaimer: I went to a US Allopathic medical school with a strong research focus and a home integrated vascular surgery residency (but not a top 10 or Ivy League equivalent school). I have intentionally obfuscated my location / identity to some extent, but I’m sure you can figure it out if you try hard enough (I kindly request that you not).

**I apologize in advance if this is a mess, I would rather put some information out there while my memory is still fresh than nothing at all.

4th Year:
My first solid information about applying to integrated vascular surgery came from attending the SVS VAM before my 4th year. I had been seriously considering vascular surgery, and I had been nearing completion of a vascular surgery research project started before my clinical years. However, I was not sure I wanted to apply to vascular given how little I knew about what it would take to match to the type of program I was aiming for.

I attended the events of the student program, which included panels of recently matched residents and program directors as well as talks on how to perform well on sub-internships and the interview trail. Honestly, the experience was intimidating. I met a lot of students who had been pursuing vascular surgery with very strong mentorship and a record of presenting posters, etc at conferences. While I had been pursuing vascular research, I hadn’t actually had any output yet (and I wouldn’t until after rank list submission). I had also not fully engaged my mentor about how to pursue vascular.

Nevertheless, I opted to continue and started my 4th year with a home vascular surgery sub-i. There is plenty of good advice on how to excel on sub-i’s available elsewhere. I do have a few suggestions though. It can be stressful and disorienting being dropped into an unknown environment month to month: always take your time being observant and learning how things are done when you are starting. Try and spend as much time as you can with the patients in your team’s care, and try and learn how to be the kind of resident (and doctor) you want to be. Have some thoughts on who would be a good letter writer and talk with them sooner than later. Residents notice when you are engaged and working hard, you may be surprised by what makes it up the chain (and possibly into your LORs).

The faculty at my home institution were incredibly supportive, and to be honest, were the biggest factor in my matching. I ended up doing my away sub-i’s at two other academic vascular surgery programs.

Deciding where to do sub-i’s:
Overall, you should aim to do sub-I's at the programs you think you will most want to end up, and that will be a very individual decision (that may change!). Three total (i.e. two aways) is a reasonable number.

You can likely guess the most popular programs for sub-i's from the list of available rotations on VSAS. Popularity is more strongly correlated with location and perceived institutional quality than the actual quality of the vascular surgery program. The only way to truly know the nature of a program is to rotate there. Along the interview trail, you should always be vigilant about discrepancies between sub-i experiences and the sales pitch given to you by programs.

Stanford was by far the most popular choice, my guess is that 8-15 sub-I's were there over the summer/fall months. I would carefully consider what a letter from there would mean for your application, because it could result in your direct comparison to that many other applicants (could be very good --if you were one of the best, as perceived by them, neutral, or somewhat bad-- if you were labeled as average). That said, the sub-I at Stanford is possibly the best endovascular learning experience out there for rotating medical students.

I was surprised to learn along the way that there are some very solid programs that don't have many sub-I's, but that do take visiting students. These are generally programs that are not participating in VSAS including: MGH, BID, UPMC, and UCLA (still has a reasonable number due to location). There are equivalently great programs I am not mentioning here, simply because I don't know all the programs that don't participate in VSAS.

Where to Apply (i.e. Quick Program Facts):
To be clear: the below categories are not to say that “these are the good programs”. They are exactly as stated, information about size and baseline program features. A clear example: The University of Wisconsin, as far as I know, is a truly great program. World class faculty, multiple R01 Funded vascular labs, NIH T-32 grant, complex case load, and on and on… but they are not in these categories, because they are a 1 resident per year program, and they do not have built-in research years (though they seemed very open to residents pursuing dedicated research time). Another obvious example: Washington University, another one: Mayo Clinic, another one: University of Washington, another one: UCLA, another one: UPenn and this can go on ad infinitum…


Programs with 2 residents per year:
USF, LSU, MGH, UPMC, University of Massachusetts, Cleveland Clinic, Mount Sinai, Methodist
*Also, don’t forget to carefully evaluate programs that have yet to graduate residents / have no senior residents yet and are not discontinuing or shrinking their fellowship. Some will be adding rotations so that senior level trainees aren’t at the same place, but others will be putting more trainees at the same places they already are.

Programs with Built-In Research Years (Consider if you are strongly interested in academics / research - usually NIH T-32 or institutionally funded - a small number of programs mention the option to pursue research years - but from observation - this rarely ever happens and funding is not guaranteed):
Yale (6 year program), Dartmouth (6 year program), Methodist (6 year program), BID (7 year program), University of Michigan (7 year program), UPMC (7 year program), MGH (7 year program), Stanford (7 year program), Northwestern (7 year program - 2 research years are technically optional, but almost every resident has done it)

Programs with high open case volume or complex endovascular case volume:
Consult a mentor about which programs are the best for you. If you want to be an open aortic surgeon, you probably should end up at one of a handful of programs with adequate open aortic volume. Same deal for advanced endovascular techniques (custom fenestrated grafts, Investigational devices, etc.).
**Of note, there are programs that have surgeons who do very complex open and endovascular procedures with relatively low case volume. On the interview day, they may show you those awesome cases, but keep in mind that case complexity doesn't imply a busy vascular surgery service / high case volume.

The Interview Gauntlet:
You will start hearing about interviews in a haphazard way sometime after MSPEs go in. You will likely have to deal with clashing interview days, so if you are more meticulous about it than I was, you can try and scout out interview dates before offers start going out. Reply as quickly as humanly possible to interview invites, it can make the difference between interviewing somewhere and not. If you can’t get to your email / ERAS, then get someone to help you if possible (It baffles me that some programs invite too many people and then do a first-come first-serve system).

You will quickly notice that you are seeing the same group of 30-40 people at every interview (10-20 at a time). By the second half of interviews, I had already effectively met every applicant at every interview. This was apparently a strong year of vascular surgery applicants. I would disregard Charting the Match 2014. Many applicants I met on the trail seemed to have strong academic performance, and more often than not, vascular research or another strong tie to the field. You will start to get an idea of which applicants want to go where, and you will start to realize the vascular match isn’t as straightforward as in larger fields since there is only one position per program for the most part (and each program interviews 20-40 applicants). What this amounts to, is that even as a great applicant, you may not have a great chance of matching at some of the programs you interview at (and you might get a sense of that along the way). I will talk a bit about ranking strategy near the end.

Interviews:
The interviews were largely casual and there was almost no pimping. There were 2-3 programs that had intense interview days, but even then, the interviewers were seeing if you would dig yourself into a hole as opposed to them throwing you into one.

Importance of Individual Factors:
- Personal Statement: This is almost completely irrelevant as long as it is passable. Mine was largely generic without miraculous, hilarious, or tragic personal stories.

- LORs: Possibly the most important part of getting interviews and being taken seriously at big programs. Ideally, the program director personally knows your letter writers, and your letters say very good things about you. You will be surprised by how small the world of vascular surgery is. Interviewers at almost every program knew one or more of my letter writers personally (or at least academically).

- Scores / grades: This was probably my strong point. However, academic performance was clearly not the most important single factor. Again, I’m not sure charting the match 2014 applies anymore. There were at least a handful of people, if not more, who would not be out of place numerically applying to ENT, Urology, Derm, Ortho, etc. That said, there seemed to be a wide range of academic performance overall.

- Sub-i’s: I noticed a trend that applicants who did zero vascular sub-i’s or no aways did not necessarily fare as well in the match despite being numerically qualified. Doing the sub-i’s teaches you a lot about the reality of vascular surgery and is a clear signal that you have considered what you are signing up for. Among the greatest fears of any program is investing the time, money, and effort into training a resident who decides vascular surgery isn’t for them after all. There seemed to be a small number of applicants who did not really do vascular sub-i’s (mostly dual applying to general surgery, and had possibly done a vascular elective) or didn’t do aways (this could be fine in some circumstances — but you probably know if that is the case for you).

- Research: My vascular research experience was weaker than what I perceived the average qualified applicant to have. I had one long-running, and brutal, vascular surgery project that I started in my 2nd year that has recently been completed, but the work was accepted too late for interview / ranking season. Ideally, you will have presented at least a poster prior to interview season. Some applicants, I'm not sure exactly how many, had significantly more vascular research output ranging from posters to publications. Don’t be discouraged if you don’t have a strong vascular surgery research background, in retrospect, I’m guessing the high output group was the minority of applicants. Finally, I don't want to mislead about what kind of applicant I was, I did have significant non-vascular surgery research experience.

- Non-research accomplishments: There were applicants who seemed to do very well without a strong research background, but they usually had a strong interest in other areas (i.e. global health, business, tech, etc.).

- Other interests: This will come up constantly during interviews, the interviewers want to know that you are a real person with real interests.

- Interview: I know I am not the best interviewee. Some interviews went very well, and some did not go very well. The interview does make a big difference though. I would recommend following advice better than my own on how to prepare.

- Home Institution: Being from a school with a home program is a huge advantage. That advantage grows more significant if you have the support of faculty who are known on the regional / national level. This cannot be underestimated. If you don’t have a home program, I strongly recommend doing an away rotation as early as possible in your 4th year at a large academic vascular surgery program. While there (can be more than one place over the early months of 4th year) you should try and get LORs and find a mentor who you click with. There is also some degree of regionality. If you are from the south, west coast, midwest, or east coast, you will generally have a stronger shot within that region (though you are by no means trapped in a region).

Post-Interview:
Making a final rank list is a challenging process. As you do so, keep the following in mind:

1. Understand the match algorithm (it isn’t just a magical black box) — see the NRMP website and videos.

2. The only meaningful signal you can send is to your #1 ranked program. Everything else is pretty meaningless. You can email your top 5 or so if you want, but your emails will likely be disregarded. Of course, even telling a program they are your #1 guarantees no advantage, except to tell a program that already likes you that you are taking them seriously. Be honest, don’t tell multiple programs they are your #1. Vascular surgery is a small world.

3. The other, and most powerful, signal that can happen post-interview and pre-rank list submission is when your home or friendly chairman / program director calls your top choice chairman / program director and has a brief conversation with them about you. I honestly have no clue how this happens or what is discussed, but I know it does happen. This seems to be most effective when they know each other. (It should go without saying that your chairman / program director should know who you are.) Overall, this accomplishes a couple of things: 1. It gives the program more confidence that you are a real, honest, hardworking person, 2. It tells the program that you definitely are interested in them. Again, this is all speculation, I don’t actually know much about what goes on with this, but it is mentioned in the University of Michigan Surgery Residency Application Guidebook. [http://surgery.med.umich.edu/portal/education/mse/Residency_GuideBooklet_2015.pdf].

4. There may, or may not, be some post-interview communication that comes your way. I never received any guarantees or strong hints that I would or would not match at my top choice program prior to match day, though there was polite correspondence (thank you’s, etc). I have heard that other programs go as far as to not communicate at all post-interview. Don’t have any expectations with regard to post-interview communication.

5. Remember that technically, per the University of Michigan Surgery Residency Application Guidebook, “Programs are not allowed to reciprocate this [your revealing that you are ranking the program #1] if they are or are not interested”. Also keep in mind if you do receive post-match communication, per the NRMP match agreement neither programs or applicants should “solicit verbal or written statements implying a commitment”, though mutual interest may be expressed.

Post-Match Analysis:
The overall US senior match rate was ~64%. Many people ended up where I predicted they would from the interview trail (their top choices). Unfortunately, some qualified and awesome people who interviewed at >10-15 places did not match in vascular surgery this year. I don’t mention that to be pessimistic, but more so to justify this write-up. Having more information going into the process can make all the difference. There are plenty of spots (nearly 60 across the country) and if you know what you are getting yourself into, there is no reason you can’t match.

Summary:
LORs, sub-i’s, and having a home program where you performed well are probably the most important factors for matching well. I don’t have a clear estimate of average academic performance (and wouldn’t be surprised if it is bimodal anyway - split by program tier), but I would estimate that things have gone up to some degree from Charting the Match 2014. As in any field, demonstrated commitment to vascular surgery via vascular surgery research output helps (whether it makes you shine as an outstanding applicant, or compensates for somewhat lower academic performance, etc.). I would not recommend casually applying as a general surgery applicant with minimal experience or background with vascular surgery rotations. It seems to me that the tide has shifted and more medical students have started to see how great of a field vascular surgery is (it really is awesome!). Best of luck to those applying next year!
 
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