Best General Surgery Program Type For CT Surgery

[Sirach38]

I have been reading a lot about academic vs. community vs. hybrid gen surg programs. Furthermore, within academics there are 5 year programs with no research requirement and programs that require as much as 3 years of research. My question is, if one's ultimate goal is to land a decent fellowship in CT surgery (or another not-so-competitive subspecielty eg. MIS, Vascular, or Trauma) after general surgery training, what type of program should one seek to go to? Should one go for a research heavy academic program, a 5 year academic program, a hybrid program, or a community program. This is assuming one desires to practice as a community thoracic surgeon after fellowship. I feel like everyone says, "If you want to practice academic medicine or do a fellowship, go to an academic program". But, does this apply to people wanting to do fellowhips in subspecialties that are not highly competitive? How valuable are research heavy academic programs for these type of subspecialties?

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[ThoracicGuy]

I have been reading a lot about academic vs. community vs. hybrid gen surg programs. Furthermore, within academics there are 5 year programs with no research requirement and programs that require as much as 3 years of research. My question is, if one's ultimate goal is to land a decent fellowship in CT surgery (or another not-so-competitive subspecielty eg. MIS, Vascular, or Trauma) after general surgery training, what type of program should one seek to go to? Should one go for a research heavy academic program, a 5 year academic program, a hybrid program, or a community program. This is assuming one desires to practice as a community thoracic surgeon after fellowship. I feel like everyone says, "If you want to practice academic medicine or do a fellowship, go to an academic program". But, does this apply to people wanting to do fellowhips in subspecialties that are not highly competitive? How valuable are research heavy academic programs for these type of subspecialties?

Academic programs usually will give you the best range of opportunities for fellowships as compared to most community based programs. I decided late to go into thoracic surgery. I had thought about both pediatric and colorectal surgery before settling on thoracic. You might change your mind as you go through your training.

I would recommend a good university program as your top choice. It'd be nice to have a good thoracic program at that place as well. Currently, CT fellowships are a buyer's market. With many programs going to the I6, that may not be the case down the road. There are some community programs out there that are well respected and place residents into fellowships. They might be worth a look as a secondary program. I would consider a so-called hybrid program to be in this same category as well.

 

[Sirach38]

Academic programs usually will give you the best range of opportunities for fellowships as compared to most community based programs. I decided late to go into thoracic surgery. I had thought about both pediatric and colorectal surgery before settling on thoracic. You might change your mind as you go through your training.

I would recommend a good university program as your top choice. It'd be nice to have a good thoracic program at that place as well. Currently, CT fellowships are a buyer's market. With many programs going to the I6, that may not be the case down the road. There are some community programs out there that are well respected and place residents into fellowships. They might be worth a look as a secondary program. I would consider a so-called hybrid program to be in this same category as well.

Thanks for the response. So for fellowships stick with academic programs as first options and community as backups. Now what are your thoughts on 5 years vs 6, 7, or 8 year academic programs. Is this extra research necessary for someone looking at thoracic?

 

[ThoracicGuy]

Thanks for the response. So for fellowships stick with academic programs as first options and community as backups. Now what are your thoughts on 5 years vs 6, 7, or 8 year academic programs. Is this extra research necessary for someone looking at thoracic?

At this time, I don't think research would really add much unless you were gunning for one of the top thoracic places out there. Those places are still ultra competitive. If you want to do research, go for it. Some programs would let you do a CC fellowship during that year as well, so that could be an added qualification for you if you wanted. But again, at this time, CT fellowships are a buyers market. There are far more spots that interviewees at this time.

 

[Sirach38]

At this time, I don't think research would really add much unless you were gunning for one of the top thoracic places out there. Those places are still ultra competitive. If you want to do research, go for it. Some programs would let you do a CC fellowship during that year as well, so that could be an added qualification for you if you wanted. But again, at this time, CT fellowships are a buyers market. There are far more spots that interviewees at this time.

A CCM fellowship seems like an awesome idea and would probably make you a better CT surgeon. Do you anticipate the CT fellowship market will change significantly in the next 5 years?

 

[ThoracicGuy]

A CCM fellowship seems like an awesome idea and would probably make you a better CT surgeon. Do you anticipate the CT fellowship market will change significantly in the next 5 years?

The only change that could have an effect is if significant numbers of programs switch to only i6 programs.

 

[SouthSideSteve]

A CCM fellowship seems like an awesome idea and would probably make you a better CT surgeon. Do you anticipate the CT fellowship market will change significantly in the next 5 years?

In my experience the only CT surgeons who do CC fellowships are the ones who can't operate. It's superfluous IMO.

 

[Sirach38]

If a program switches from the traditional route to the I6 it would take at least 3-4 years for them to completely eliminate the traditional route after starting the I6 because the new trainees starting the I6 program would have to be in general surgery training for 3-4 years. It may be a while longer before the traditional route is eliminated if at all. There seems to be a lot of push back against the I6.

 

[themockjock]

I'm not saying it will be eliminated entirely, but this is already happening now...this isn't theory. My friends interviewing this year are bummed that some traditional powerhouses didn't enter the match, and several programs they did interview at are dropping next year.

If you're at the medical student phase and serious about CT I'd 110% advise to go the integrated route.

Agreed... On the integrated trail this year there were LOTS of I6 PDs talking about how they were either planning on eliminating their traditional spots or dropping the number of traditional spots quite a bit. And that's just this year, it will only be worse in 5-7 years when you apply.

 

[Sirach38]

What kind of step scores does one have to have in order to have a realistic chance of matching into integrated CT? I couldn't find this info anywhere as the charting outcomes for 2014 only have integrated vascular scores. I'm competitive for gen surg but CT may be a different story.

I would like to go to Colorado for fellowship so hopefully their CT traditional program is still up and running by the time I finish residency.

 

[Sirach38]

Integrated vascular is a pretty good proxy for the competitiveness of integrated cardiac

So somewhat more competitive than general surgery but no where near plastics/ENT/Uro/Derm. My problem is my heart is not 100% on CT and I don't feel comfortable making the decision as a medical student. I feel that a general surgery residency will give me much more perspective and maturity to make a wise decision about subspecialty choice. Thanks for all your responses.

 

[ThoracicGuy]

So somewhat more competitive than general surgery but no where near plastics/ENT/Uro/Derm. My problem is my heart is not 100% on CT and I don't feel comfortable making the decision as a medical student. I feel that a general surgery residency will give me much more perspective and maturity to make a wise decision about subspecialty choice. Thanks for all your responses.

To me, this is the way it should be. I think the I6 model is not the best way forward, however, that's the direction many programs are moving. There will be some post-general surgery training paths available, but they will decrease more as time goes on. As it is already, many programs have shut down because of decreased numbers of people opting to train in it. The I6 model does seem to get more interest and ends up boosting the number of trained CT surgeons in the end. I think that's why programs are moving that direction.

If you aren't 100% sure that CT is what you want to do, going to a good General Surgery training program is the way to go.

 

[themockjock]

So somewhat more competitive than general surgery but no where near plastics/ENT/Uro/Derm. My problem is my heart is not 100% on CT and I don't feel comfortable making the decision as a medical student. I feel that a general surgery residency will give me much more perspective and maturity to make a wise decision about subspecialty choice. Thanks for all your responses.

I would just caution you... I6 is way more competitive than Plastics/ENT/Uro/Derm. IMO it's the most competitive match for any categorical program. This year there were ~120 applicants for 35 spots - you don't see those ratios of applicants to spots in any of the other specialties, and the applicants who make it to the interviews are all really good. Multiple people with PhDs, people with several papers in ATS/JTCVS/EJCTS, etc etc etc.

You should also know that it is a bit of a weird catch-22 that I6 applicants are in, as the stronger of an I6 applicant you are, the weaker a GS applicant you are and vice versa (I was a strong I6 applicant and got rejected from many GS programs that I would have been otherwise competitive for). So you should probably think if you want to just totally go for broke with the higher risk, higher reward I6 spot (and risk matching into a weaker GS program than you would be otherwise able) or play it more safe and focus on making your application as strong as possible for GS and treating the possibility of matching I6 as a bonus.

 

[SLUser11]

I would just caution you... I6 is way more competitive than Plastics/ENT/Uro/Derm. IMO it's the most competitive match for any categorical program.

I have no direct knowledge of the Thoracic Surgery match, but I find this extremely hard to believe. Looking at the 2014 data (http://www.nrmp.org/wp-content/uploads/2014/04/Main-Match-Results-and-Data-2014.pdf), half of the applicants were IMGs, many of whom were likely using a shotgun approach to surgical residency application rather than focusing solely on thoracic surgery (pg 43, only 27% ranked CT programs as first choice). I will agree that it's too competitive for IMGs, as they had a 0% match rate. For 2014, 50 US seniors ranked CT as their first choice with 34 spots available, and 80% of those spots filled by US seniors.

The graph on page 30 suggests that the number of spots is quickly increasing as well, so people reading this thread a few years from now will hopefully have a better chance of getting in.

It is certainly competitive, but not "way more competitive" than the other specialties you mentioned.

 

[SplenoMegastar]

I6 is more competitive in terms of ratio of applicants to spots.

Numbers (i.e. grades/boards/etc) wise it is not close to plastics. I have seen the applicants to both from the residency side.

At least for Step 1 and Step 2CK, the data given by the AAMC on Careers in Medicine doesn't agree here.

 

[joker2400]

CiM seems to be behind by at least a year. The numbers provided there are quite different than what are presented in Charting the Outcomes, 228 for GS, 244 for plastics, and 242 for I6. One of the deans here at my school told me that CtO is probably more representative of the current situation

 

[Sirach38]

I would just caution you... I6 is way more competitive than Plastics/ENT/Uro/Derm. IMO it's the most competitive match for any categorical program. This year there were ~120 applicants for 35 spots - you don't see those ratios of applicants to spots in any of the other specialties, and the applicants who make it to the interviews are all really good. Multiple people with PhDs, people with several papers in ATS/JTCVS/EJCTS, etc etc etc.

You should also know that it is a bit of a weird catch-22 that I6 applicants are in, as the stronger of an I6 applicant you are, the weaker a GS applicant you are and vice versa (I was a strong I6 applicant and got rejected from many GS programs that I would have been otherwise competitive for). So you should probably think if you want to just totally go for broke with the higher risk, higher reward I6 spot (and risk matching into a weaker GS program than you would be otherwise able) or play it more safe and focus on making your application as strong as possible for GS and treating the possibility of matching I6 as a bonus.

Why is there an inverse relationship between your application's strength for GS and your application's strength for CT?

 

[Sirach38]

Because general surgery programs don't want to be anyone's back up. So the more that they can "smell" CT on your application, the more likely a general surgery program is to reject you.

Got it. If you have two separate apps with different letters and research this wouldn't be an issue I suppose.

 

[kgwgk]

I have heard conflicting messages about the wisdom of applying to both integrated CT and general at the same institution. Is this considered poor form? General surgery residency is (for now) a possible pathway into CT surg, but I also understand that the general application would in this case scream "backup." I guess the more important question is, would it help a little, not help at all, or hurt?

 

[mimelim]

If a program switches from the traditional route to the I6 it would take at least 3-4 years for them to completely eliminate the traditional route after starting the I6 because the new trainees starting the I6 program would have to be in general surgery training for 3-4 years. It may be a while longer before the traditional route is eliminated if at all. There seems to be a lot of push back against the I6.

I'm not saying it will be eliminated entirely, but this is already happening now...this isn't theory. My friends interviewing this year are bummed that some traditional powerhouses didn't enter the match, and several programs they did interview at are dropping next year.

If you're at the medical student phase and serious about CT I'd 110% advise to go the integrated route.

I just got back from SCVS, there were multiple presentations on the trends in integrated vascular (IVS), this was followed by discussion by some of the biggest names in Vascular regarding their programs (Dan Claire (CCF), Makaroun (UPMC) etc.). This is what I gleaned and has been confirmed being on the residency side of 3 matches now.

#1 There is always push back from the older surgeons when you change things. It will never change.
#2 IVS and I6 CT are here to stay. You can not compare the traditional GS+fellowship applicants with the integrated applicants. Completely different board scores, completely different research profiles, completely different drive. Yes, the top fellowships have amazing fellows, but there simply aren't enough quality people finishing 5 years of GS and saying, "Lets do 2 more years of vascular".
#3 Not everywhere is ready for integrated residents. You have to be skeptical about brand new programs. There is a HUGE mentality shift from, "We need to polish someone with 5 years of surgical experience." to "We need to turn an MS4 into a vascular surgeon." People drastically under estimate what this means in terms of dedication to residents and their education.
#4 Traditional pathway will always exist. Big programs like CCF, UPMC, Houston Methodist, Wash U. will keep their fellowships along side their integrated residencies. Some will run parallel, some will fill in gaps created by people spending differing amounts of time in the lab, but spots are always going to exist. The number of spots will gradually decrease, but if the demand exists, fellowship spots will exist.

It's much harder to hide than you'd think. You can't hide your research. And a lot of LOR writers will inadvertently give it away.

That's why as he said the stronger your CT app, the weaker your GS - because you can't hide the obvious interest in CT

With proper planning, you can minimize this. It requires foresight and the buy-in of your letter writers. While it would be difficult to have an extremely strong GS application, there is no reason a strong student shouldn't have a very competitive application. But yes, it does put you in an awkward spot.

I have heard conflicting messages about the wisdom of applying to both integrated CT and general at the same institution. Is this considered poor form? General surgery residency is (for now) a possible pathway into CT surg, but I also understand that the general application would in this case scream "backup." I guess the more important question is, would it help a little, not help at all, or hurt?

Do not apply to both. If GS is paying attention at all, they will ask I6 if they got an application and just toss yours out. After the last couple of seasons, it is extremely rare for someone to get interviews with both programs.

 

[themockjock]

I have heard conflicting messages about the wisdom of applying to both integrated CT and general at the same institution. Is this considered poor form? General surgery residency is (for now) a possible pathway into CT surg, but I also understand that the general application would in this case scream "backup." I guess the more important question is, would it help a little, not help at all, or hurt?

Generally no, as others have said. There are others though that are more than open to it and whose PDs are more than open for both - UPMC, UVa, MCW, and Northwestern are the ones that come to mind - at Northwestern, the PD (Dr. Meyerson) is PD for both GS and I6 and she seems completely open to having candidates apply to both of her programs. I went on my GS interview there and then a couple of weeks later interviewed there for I6. You can also dual apply at Duke and they will invite you to one giant interview where you interview for both GS and I6 on the same day.

I know that Penn, Columbia, Emory, Stanford, Michigan, UW, Sinai are all hostile to dual applicants (their GS people are at least). I can't speak for the other programs but they are probably less than accommodating.

Regardless, there are some programs that on the face of it don't seem to care. Of course I don't know what goes on during the ranking meetings, but there were several places that I dual applied and the GS people were at the very least willing to have me come out and interview with them...

 

[CTFellowMD]

.... if one's ultimate goal is to land a decent fellowship in CT surgery (or another not-so-competitive subspecielty eg. MIS, Vascular, or Trauma) after general surgery training,......

...Currently, CT fellowships are a buyer's market......

Unfortunately, the trend of traditional CT fellowships being non competitive and easy to obtain is over. Some data tidbits from last year:

In 2011 there were 99 applicants for 113 spots. // Last year, 114 applicants for 87 spots.
Last year they listed 4 unfilled spots (in reality, only 2 - Kansas and Nebraska), and 31 unmatched applicants (overall 73% match rate)
If you look at only US grads, there were 87 applicants, 65 who matched (75% match rate)

http://www.nrmp.org/wp-content/uploads/2015/02/Results-and-Data-SMS-2015.pdf
Thoracic on page 82

This year there appears to be at least 5-10 less spots, as more traditional fellowships have closed in favor of I6.

So what am I saying? If you have an interest in CT, do anything you can to get an integrated spot. The traditional fellowships are becoming very competitive with no guarantee of a fellowship spot after your gen surg residency as was the case for many years.

 

[ThoracicGuy]

Unfortunately, the trend of traditional CT fellowships being non competitive and easy to obtain is over. Some data tidbits from last year:

In 2011 there were 99 applicants for 113 spots. // Last year, 114 applicants for 87 spots.
Last year they listed 4 unfilled spots (in reality, only 2 - Kansas and Nebraska), and 31 unmatched applicants (overall 73% match rate)
If you look at only US grads, there were 87 applicants, 65 who matched (75% match rate)

http://www.nrmp.org/wp-content/uploads/2015/02/Results-and-Data-SMS-2015.pdf
Thoracic on page 82

This year there appears to be at least 5-10 less spots, as more traditional fellowships have closed in favor of I6.

So what am I saying? If you have an interest in CT, do anything you can to get an integrated spot. The traditional fellowships are becoming very competitive with no guarantee of a fellowship spot after your gen surg residency as was the case for many years.

Looks like the I6 programs are really taking a bite out of this for general surgery residents. I personally like the traditional method better. I had the chance to see different areas of surgery to be able to make an informed decision to do CT surgery. Now its getting harder to be able to have that option. The same thing is happening in plastics as well and probably vascular to some degree.

 

[mimelim]

Plastics is getting close to a done deal. I think it's down to less than a third of the total positions are available through the traditional pathway. Someone posted the numbers on here a few months ago in the plastics forum.

I hope for CT and vascular there will still be opportunities for the "late bloomers" (or as one of our vascular faculty is fond of saying - the general surgery residents who've "seen the light").

This is purely anecdotal, but I hypothesize that the biggest obstacle for the integrated vascular programs at the moment is the integrated cardiac pathway. Over the last few years we have had a lot of students who were pondering both and have ended up in cardiac. As the I6 programs expanded in the past few years, I think there has been a lot of internal poaching from the same pool of potentially interested students that would have otherwise applied in vascular. Vascular residencies just had a bit of a "head start" on the integrated pathway. Now CT is catching up.

There will always be traditional fellowship positions available. Certainly the competitiveness will fluctuate as always, but there will always be spots. There are a lot of places that simply have no desire to teach interns/2nd years the basics or don't have the volume for 5+ trainees in addition to the big programs that will simply run both concurrently.

As for I6 and Vascular, I have to admit, I really haven't seen it. Maybe it is really new, but we definitely compete a heck of a lot more with GS than I6. Our applicants in general are fixated on vascular because of whatever they were exposed to. That isn't to say that they wouldn't be equally happy in an I6 program, or doing colorectal, plastics, MIS etc, but weren't exposed to them early enough. But, they for the most part are focused only on Vascular. I think a big part of this is the endovascular aspect of vascular. Cardiac, like everything, is going more minimally invasive and there is a place for CV surgery in TAVR programs, but being 50%+ of someone's practice, can only really be found in vascular.

 

[idkwhattodomkay]

Rising MS2 here interested in CT. Can anybody give me a run down of what is needed to be competitive for I6? I am at a top 10 and plan to do a research year so hopefully there will be more spots available by the time I match in a few years. What Step 1 scores, how much research, etc. would all be useful to know. There seems to be some conflicting information. Thanks!

 

[adenocard]

Rising MS2 here interested in CT. Can anybody give me a run down of what is needed to be competitive for I6? I am at a top 10 and plan to do a research year so hopefully there will be more spots available by the time I match in a few years. What Step 1 scores, how much research, etc. would all be useful to know. There seems to be some conflicting information. Thanks!

Check out the AAMC's CiM webpage (https://www.aamc.org/cim/) - you should have access as a medical student.

Like someone else mentioned, the CiM webpage seems to be a little behind but the average Step 1 score for those matching in integrated CT was a 242. Research (would be helpful if it's in cardiac but not absolutely necessary) is a must. Try to find a mentor in your CT department and express interest NOW. Scrub with them, round with them, get to know them and most of all meet the people in the department. CT surgery is a very small field where everyone knows everyone and having people that will write you strong letters will be paramount when you go to apply. AOA is +/-, it is a nice thing to have on the application but not necessary. By the time you apply a few more programs should be opening.

- Step 1 >240 (study for your classes this year, this is how you study for boards during the year. Don't waste uworld until dedicated step time)
- Good grades +/- AOA
- Research - i.e., publications, presentations at regional or national meetings
- Expressing interest early and showing your dedication to the field. Most places have 1 or 2 spots and want an attrition rate of 0%. They cannot afford to have you drop out of their program so they need to be convinced you are serious about being a cardiac surgeon.
- Away rotations are important. You should talk with your mentor during your 3rd year about a few places to do aways and go there and WOW them. Get up early, stay late, be a team player. Also read, read, read.
- Make connections with the I6 residents/fellows at your program and/or the one you're interested in matching. At most places the residents/fellows get a say in who the program takes.
- Be nice to EVERYONE. This should go without saying but you need to be a team player for everyone, especially while you're on aways. No one wants to spend 6 years with a jerk.
- Apply for scholarships through the STS/AATS/WTS (if you're a woman). They will pay for you to go to national meetings where you can engage with faculty from across the country and it's a good resume booster.

If you're looking for more specific information check out the slides from the STS LTTF scholarship the STS puts on for med students/residents every year. It has some great information in the slides:

http://www.sts.org/sites/default/files/documents/2015CombinedPresentationsforWeb.pdf

 

[addy]

the average Step 1 score for those matching in integrated CT was a 242.

That seems incredibly low for how competitive everyone makes it seem.

 

[addy]

As I said above, it seems scary competitive because of the low number of spots.

The biggest issue is that because it is so small, connections and research are huge. So it is really important to get in early with the right people, or to consider taking time off for research.

Because these programs are only one or two residents per year, they are super paranoid about attrition, and as a result prize commitment to the field super highly. So early interest, exposure, and evidence of dedication to the field are really key.

Yeah, I got you. Is there any talk within the surgical field about the surgical/overall competence of the i6 folks vs the fast track vs. 5+3 graduates that are out in the field now?

 

[adenocard]

That seems incredibly low for how competitive everyone makes it seem.

This data is from the CiM webpage which lists the source as the Characteristics of Entering Residents, 2012-2013 from the AMA, so the data is a few years out.

The match this year was said to be increasingly competitive, so I would venture in the 245-250 range? I know someone personally that didn't match this year that on paper absolutely should have. I went to the STS meeting in January and the talk was all about how much more competitive it has become in the past few years, fellowships included. Seems like the field banked on attracting top talent with the I6 programs and it's working. As someone earlier said, people on the interview trail with PhD's, their own R01's, oral presentations at national meetings, etc.

 

[idkwhattodomkay]

Thanks for the replies. Good info. I have been networking some with some of the CT fellows here so hopefully I'll get into some research soon and have a productive year off. I am definitely not interested in a PhD though.

I am going to hope that some more programs begin to open in the next few years. Anybody have any more info on new integrated programs that are projected to open soon?

 

[ThoracicGuy]

Yeah, I got you. Is there any talk within the surgical field about the surgical/overall competence of the i6 folks vs the fast track vs. 5+3 graduates that are out in the field now?

As @SouthernSurgeon said, the I6 program is really too new to tell yet. I know that most CT surgeons are not used to teaching the basic fundamentals of surgery as they are traditionally getting someone who has already been through 5 years of training. I personally like the 5+2/3 track better as it gives you that experience prior to CT. As well you can get double boarded, so that's nice too. As for the I6 program and integrated vascular, you only get boarded in CT or vascular.

I hear lots of comments about current vascular grads not having much experience with open AAAs as so many are being done endovascularly these days. But when they get out in practice and are working on their own, they could be in trouble when it comes to having to do it open.

In the end, if you think that CT or vascular is the path for you, going for the I6/integrated program is good. If you don't get into it, there will still be a way into it after general surgery training.

 

[addy]

As @SouthernSurgeon said, the I6 program is really too new to tell yet. I know that most CT surgeons are not used to teaching the basic fundamentals of surgery as they are traditionally getting someone who has already been through 5 years of training. I personally like the 5+2/3 track better as it gives you that experience prior to CT. As well you can get double boarded, so that's nice too. As for the I6 program and integrated vascular, you only get boarded in CT or vascular.

I hear lots of comments about current vascular grads not having much experience with open AAAs as so many are being done endovascularly these days. But when they get out in practice and are working on their own, they could be in trouble when it comes to having to do it open.

In the end, if you think that CT or vascular is the path for you, going for the I6/integrated program is good. If you don't get into it, there will still be a way into it after general surgery training.

What's the advantage of being double boarded?

 

[ThoracicGuy]

What's the advantage of being double boarded?

If you do general thoracic, some jobs out there have a component of general surgery with them, so double boarded can be a bonus. You can also use it as a marketing tool.

 

[ThoracicGuy]

Does it impact credentialing/privileges - for stuff like laparoscopy if you wanted to do lap nissens for hiatal hernias or for the abdominal mobilization portion of an esophagectomy?

I wouldn't think so since those procedures fall in the realm of general thoracic as well. I did see some job listings for purely general thoracic jobs that did require general surgery boards for some reason...

 

[adenocard]

The CiM website also says the average hours worked by attendings is approximately 62 hours a week. Does this sound right? It seems people at my institution work more than this but they're also very academically involved.

One of the biggest factors for me is a balanced family life, but CT has been notorious for being one of the more difficult subspecialties.

 

[addy]

If you do general thoracic, some jobs out there have a component of general surgery with them, so double boarded can be a bonus. You can also use it as a marketing tool.

What if you want to do academics? My guess is it wouldn't matter?

 

[ThoracicGuy]

What if you want to do academics? My guess is it wouldn't matter?

The general thoracic job I mentioned above was an academic job and it required general surgery boards in addition to thoracic boards. For cardiac jobs, that would be less likely. In the future with more thoracic trained people not even eligible for general surgery boards, it will probably be less of an issue.

 

[Psai]

For i6 cardiac - not enough grads to know yet

For integrated vascular - major concerns about inadequate open surgical experience

yeah i heard that at our hospital they went from doing several open aortas a week when the attendings were training to maybe 30 a year now
is there a lot of open surgical experience in general surgery still? all i'm seeing is lap appys, lap choles, robotic this, minimally invasive that

 

[SouthernSurgeon]

yeah i heard that at our hospital they went from doing several open aortas a week when the attendings were training to maybe 30 a year now
is there a lot of open surgical experience in general surgery still? all i'm seeing is lap appys, lap choles, robotic this, minimally invasive that

Not as bad as youd think.

The problem for vascular is that >80% of aortic cases nationally are now being done endo.

For general surgery you may have that high of utilization of MIS for appys and choles but that's it.

For more complex stuff - colorectal surgery its about 35-40% MIS nationally (and that's mostly chip shot segmental colectomies, not pelvic stuff or TACS). Way lower rates than that for MIS whipples, liver, etc. I haven't looked at my case logs in a while but I'm sure I've done more open abdominal operations than lap.

Plus for open abdominal surgery there is a lot more "cross-training" - the exposure for X procedure is the same as the exposure for Y procedure, a bowel anastomosis is a bowel anastomosis, etc. whereas endo vascular versus open vascular surgery is a totally different skill set.

Even comparing lap to open there is still some cross applicsbility - it's the same operation being done with either approach, involving the same planes, anatomy, and dissection.

The old school paradigm was that you taught someone the anatomy and how to cut and sew, and they could then put those pieces together and do an operation. While that's obviously a gross oversimplification, there is an element of truth to it...there's a lot of overlap from case o case and the skills you learn mobilizing the colon for trauma apply just as well when you're mobilizing it for a tumor resection.

 

[Trauma Surgeon]

yeah i heard that at our hospital they went from doing several open aortas a week when the attendings were training to maybe 30 a year now
is there a lot of open surgical experience in general surgery still? all i'm seeing is lap appys, lap choles, robotic this, minimally invasive that

I raised this question a while ago in this forum. The problem is that the new attendings here in Europe have done a couple of open "elective" aortas during their training and are heavily enodvascular trained and run a endo-practice. So what happens when they are called in middle of night for a ruptured AAA? I can tell you as general surgeons, we do a better job dissecting down to the area of interest but we are lacking the experience in fixing the problem (grafting) since during our training the few open cases that the department had went to vascular resident/fellow. I'm not sure my younger vascular colleagues are so much better or confident either!

 

[SouthernSurgeon]

I raised this question a while ago in this forum. The problem is that the new attendings here in Europe have done a couple of open "elective" aortas during their training and are heavily enodvascular trained and run a endo-practice. So what happens when they are called in middle of night for a ruptured AAA? I can tell you as general surgeons, we do a better job dissecting down to the area of interest but we are lacking the experience in fixing the problem (grafting) since during our training the few open cases that the department had went to vascular resident/fellow. I'm not sure my younger vascular colleagues are so much better or confident either!

I talked to a buddy who did the traditional fellowship path (general surgery followed by 2 years) at a program that also has an integrated vascular residency.

His take was that the traditional fellows were way more comfortable operating open, but that the integrated residents even 2-3 years behind him in training (so PGY3 or so) were better endovascularly than he was at the completion of his fellowship. The traditional fellows often rely on the mid and senior level integrated residents to teach them endo skills.

But he would get worried about integrated residents needing to do abdominal exposures (very few open aortas and even very few aortobifems these days apparently) and lacking comfort in the abdomen and in the neck. Basically that when it comes to open surgery they are good at sewing anastomoses but not at exposure or any anatomy outside their comfort zone.

I guess the question though is going into the future, how much does that really need to be a part of their skill set? Even for ruptured AAAs there has been a major paradigm shift towards doing these endo.

 

[CTFellowMD]

Congrats to anyone who went through this years Thoracic match. Like last year, it was extremely competitive.

Approximately 30% applicants unmatched. No unfilled spots. The days of Thoracic being an applicants market seem to be over.

 

[spicysoup55]

Congrats to anyone who went through this years Thoracic match. Like last year, it was extremely competitive.

Approximately 30% applicants unmatched. No unfilled spots. The days of Thoracic being an applicants market seem to be over.

What distinguished the applicants that matched from the applicants that did not match?

 

[dienekes88]

yeah i heard that at our hospital they went from doing several open aortas a week when the attendings were training to maybe 30 a year now
is there a lot of open surgical experience in general surgery still? all i'm seeing is lap appys, lap choles, robotic this, minimally invasive that

Several open aortas per week and now only 30 per year? Are you talking about vascular surgeons doing open abdominal aortic aneurysms? Or are you talking about aortic surgery in general? Hopefully your cardiac surgeons are doing roots, ascendings, arches, descending thoracic aortic aneurysms, and thoracoabdominal aortic aneurysms open.

Not as bad as youd think.

The problem for vascular is that >80% of aortic cases nationally are now being done endo.

For general surgery you may have that high of utilization of MIS for appys and choles but that's it.

For more complex stuff - colorectal surgery its about 35-40% MIS nationally (and that's mostly chip shot segmental colectomies, not pelvic stuff or TACS). Way lower rates than that for MIS whipples, liver, etc. I haven't looked at my case logs in a while but I'm sure I've done more open abdominal operations than lap.

Plus for open abdominal surgery there is a lot more "cross-training" - the exposure for X procedure is the same as the exposure for Y procedure, a bowel anastomosis is a bowel anastomosis, etc. whereas endo vascular versus open vascular surgery is a totally different skill set.

Even comparing lap to open there is still some cross applicsbility - it's the same operation being done with either approach, involving the same planes, anatomy, and dissection.

The old school paradigm was that you taught someone the anatomy and how to cut and sew, and they could then put those pieces together and do an operation. While that's obviously a gross oversimplification, there is an element of truth to it...there's a lot of overlap from case o case and the skills you learn mobilizing the colon for trauma apply just as well when you're mobilizing it for a tumor resection.

So much of general surgery is becoming nonoperative management and laparoscopic technique. Even when the case is open, the laparoscopic devices are being used. Bowel anastomoses are done with staplers. Open lobectomies are performed with staplers too.

I raised this question a while ago in this forum. The problem is that the new attendings here in Europe have done a couple of open "elective" aortas during their training and are heavily enodvascular trained and run a endo-practice. So what happens when they are called in middle of night for a ruptured AAA? I can tell you as general surgeons, we do a better job dissecting down to the area of interest but we are lacking the experience in fixing the problem (grafting) since during our training the few open cases that the department had went to vascular resident/fellow. I'm not sure my younger vascular colleagues are so much better or confident either!

Where I am, the vascular surgeons have an endo first approach to ruptured AAAs.

I presume it partly depends on your approach. If you are going trans-abdominally, taking down the ligament of treitz, opening the retroperitoneum, etc. then I could see that. Some people prefer a retroperitoneal approach, though.

I talked to a buddy who did the traditional fellowship path (general surgery followed by 2 years) at a program that also has an integrated vascular residency.

His take was that the traditional fellows were way more comfortable operating open, but that the integrated residents even 2-3 years behind him in training (so PGY3 or so) were better endovascularly than he was at the completion of his fellowship. The traditional fellows often rely on the mid and senior level integrated residents to teach them endo skills.

But he would get worried about integrated residents needing to do abdominal exposures (very few open aortas and even very few aortobifems these days apparently) and lacking comfort in the abdomen and in the neck. Basically that when it comes to open surgery they are good at sewing anastomoses but not at exposure or any anatomy outside their comfort zone.

I guess the question though is going into the future, how much does that really need to be a part of their skill set? Even for ruptured AAAs there has been a major paradigm shift towards doing these endo.

Very interesting. I wonder if there will be a lot more two-team cases as a result.

Fortunately, cardiac surgery is still very heavily weighted towards open surgery. However, it is becoming increasingly necessary for cardiac surgeons to obtain wire skills to participate in the TAVRs and TEVARs.

 

[just_a_guy]

What distinguished the applicants that matched from the applicants that did not match?

Hey can we revisit this? What is the distinction? Is it likely, or even possible, to get a fellowship without 2 extra years of research and just 5 of general?

 

[ThoracicGuy]

Hey can we revisit this? What is the distinction? Is it likely, or even possible, to get a fellowship without 2 extra years of research and just 5 of general?

You should be able to get a spot with just 5 years if you have an otherwise reasonable application. Just five years ago they couldn't give these spots away. Now its a bit harder since so many programs have switched to I6 that you have fewer options. Will research help? As always it can if you are productive. If you are early in residency, will the number of available spots be less when you apply? They sure could. It's a tough question to answer with having to predict the future.

 

[Sirach38]

I have a question that relates more to the integrated vascular surgery but can really apply to many of the other integrated surgery subspecialties. So now that the 5+0 programs are becoming more popular and an increasingly number of vascular surgeons will not be board certified in general surgery, what will these surgeons do when they run into a general surgery problem during a big vascular operation. At the institution that I am rotating through, the vascular surgeons do all of their own general surgery. For example, if they knick the bowel or need to do a splenectomy during a big open AAA repair, they would do the splenectomy themselves or repair the bowel. They all have privileges to do general surgery cases and take care of pretty much any intraabdominal problem that they run into during a vascular operation. Now, the new generation of vascular surgeons may not have these privileges since they are not board certified. Does this mean that they will need to call in a general surgery to do a splenectomy, bowel repair, etc.? I imagine that urologist have to call in a general surgery if they get into non-urological trouble in the abdomen so I would imagine that future vascular surgeons may be the same way. Does this now mean that if you are in private practice doing open vascular procedures you would then have to have general surgeons on call for back up in case you need a splenectomy etc.? Seems like this would make you less marketable and would be a huge downside of going integrated. Any thoughts?

 

[ThoracicGuy]

I have a question that relates more to the integrated vascular surgery but can really apply to many of the other integrated surgery subspecialties. So now that the 5+0 programs are becoming more popular and an increasingly number of vascular surgeons will not be board certified in general surgery, what will these surgeons do when they run into a general surgery problem during a big vascular operation. At the institution that I am rotating through, the vascular surgeons do all of their own general surgery. For example, if they knick the bowel or need to do a splenectomy during a big open AAA repair, they would do the splenectomy themselves or repair the bowel. They all have privileges to do general surgery cases and take care of pretty much any intraabdominal problem that they run into during a vascular operation. Now, the new generation of vascular surgeons may not have these privileges since they are not board certified. Does this mean that they will need to call in a general surgery to do a splenectomy, bowel repair, etc.? I imagine that urologist have to call in a general surgery if they get into non-urological trouble in the abdomen so I would imagine that future vascular surgeons may be the same way. Does this now mean that if you are in private practice doing open vascular procedures you would then have to have general surgeons on call for back up in case you need a splenectomy etc.? Seems like this would make you less marketable and would be a huge downside of going integrated. Any thoughts?

You'd call an intraoperative consult to one of your general surgeon colleagues. Both thoracic and vascular trainees through the integrated programs and thoracic in all instances don't have to or can't get boarded in general surgery. This will become more and more prevalent as time goes on.

 

[Sirach38]

You'd call an intraoperative consult to one of your general surgeon colleagues. Both thoracic and vascular trainees through the integrated programs and thoracic in all instances don't have to or can't get boarded in general surgery. This will become more and more prevalent as time goes on.

So this would mean that you can't operate in a group that didn't have general surgeons around ie. a strictly vascular practice?

 

[ThoracicGuy]

So this would mean that you can't operate in a group that didn't have general surgeons around ie. a strictly vascular practice?

Sure you could. If your hospital has a vascular surgeon they will also have general surgeons. I do thoracic and vascular surgery. I am general surgery boarded as well, but if something more than a small repair to bowel happens, I'll be calling the general surgeons in. It's not that I can't do it, but if they develop complications related to whatever is going on, I'd rather have someone that focuses on that to take care of it.