Future of Vascular Surgery?

[corona 247]

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Hello all,

I have been reading articles about the impact of cardiology and interventional radiology on vascular surgery. I am looking for input from any senior Gen Sx, vasc fellows on what they thing the future holds in terms of the "turf" of VS.

I also wanted to ask what is the typical work day for a community vasc surgeon in terms of hrs/night cases and lastly what the current ave salary is (i know there a high of number of variables with this last question, but I am just looking for broad averages)

Thanks!

 

[BlackLung]

...I have been reading articles about the impact of cardiology and interventional radiology on vascular surgery.

...what the current ave salary is...

Hard to say. Salary has markedly decreased ever since the $30-50K motivation to amputate was uncovered and went public. Now vascular surgeons are being forced to actually perform vascular surgery and do revascularizations. This "change" in practice will no doubt impact how motivated folks are to enter vascular surgery... as every resident knows amputations are the most enjoyable procedures. I just don't know what the world is coming to....

Seriously, can't say what the future is. AAA can be stented if angulation and diameter of access vessels are within acceptable tolerances.... and those stents are often placed by the vascular surgeons. Dialysis access will still be needed. Percutaneously accessed vessels that develop iatrogenic injury will still require a vascular surgical repair. We do not have good peripheral vascular stent options. We do not have good carotid options. I don't foresee a decreased need for vascular surgeons in the near future.

BL

 

[filter07]

Vascular surgery is a very secure field. The proportion of lower extremity endovacular interventions being done by vascular surgeons is increasing each year. Whereas 10 years ago, most were being done by interventional radiologists, now they comprise around 10% of lower extremity endovascular volume. Cardiologists are about 30-40%, vascular surgeons about 40-50%.

There are many, many more cardiologists than vascular surgeons, however cardiologists are busy taking over everyone's turf, not just vascular's. There are more than enough cardiac caths to go around, and they are reading their own cardiac imaging, doing TEEs, and being cardiovascular PCPs. IR is really not serious competition nowadays, due to the endo-heavy training of current vascular trainees, the paucity of IR fellows coming out of radiology, and the fact that very few IR practices have inpatients or see patients in clinic. The latter is changing but likely to be a minor component for a long time, because there is a culture in radiology that is not conducive to being overly clinical.

Reimbursement in vascular surgery is high compared to general surgery, but lower than orthopedic surgery or neurosurgery. Academic salary can begin below 200,000 whereas private practice salaries in underserved areas can be north of 600,000 starting. As a whole, there will be pressure to reduce reimbursement for endovascular procedures, which will likely reduce overall income for vascular surgeons. There are always threats to reduce reimbursement, which is met with heavy lobbying. No one knows what will result, but there is a big red target on endovascular procedures.

Overall, vascular surgery is a very secure field that pays relatively well. Turf wars with IR are not a problem, and I believe there will be enough cases for interventional cardiology and vascular surgery to co-exist. Reductions in salary are likely, and will be more significant to those who focus heavily on endovascular procedures. Job opportunities are abundant. There are at least 4-5 offers for every vascular fellow.

 

[TUHopeful]

I would only add that vascular surgeons as a specialty have been very aggressive in jumping into the endovascular and minimally invasive management of vascular disease. Vascular surgeons are uniquely trained to handle all aspects of vascular disease (endovascular, open surgery and medical management) where the cardiologist and IR cannot. As the patient population continues to get older, fatter and increasingly more diabetic, the demand for vascular surgeons will continue to outstrip the number of trainees, thus the development of integrated training programs to help entice more medschool graduates into the field.

 

[thedrjojo]

Will the integrated program in Vascular become like Urology/Ortho/NS/ENT where its 100% residency, or will it become like Plastics where it is like 60/40 between integrated programs and fellowships? I think since the vascular combo programs are 3 and 3 I believe (vs 5 and 2 for fellowship route, which is the same for Plastics) where as those above mentioned programs are all 1 and 4 (except NS which is 1 and 5/6), it may go the way of Plastics. What about CT as well? Will those integrated programs pick up as well? 10-20 years from now are PGY 4 and PGY 5 general surgery residents going to only be headed for Peds, Trauma/CC, Min Invasive, Onc, Transplant, or Private Practice? Will any of these other ones develop integrated pathways? I could see trauma/cc developing into some Emergency Medicine/Surgery/CC hybrid, but I don't think the other ones could work as integrated pathways.

 

[TUHopeful]

Will the integrated program in Vascular become like Urology/Ortho/NS/ENT where its 100% residency, or will it become like Plastics where it is like 60/40 between integrated programs and fellowships?.

I doubt it, but I'm not great at forecasting the future. Vascular surgeons still do some very very big belly cases, as well as trauma. Their patients often require critical care as well. I don't know how you could be a competent vascular surgeon without some strong general surgery fundamentals, over and above what you get as an intern. The other specialties you listed aren't quite as intricately intwined with general surgery, IMVHO.

 

[JackADeli]

I doubt it, but I'm not great at forecasting the future. Vascular surgeons still do some very very big belly cases, as well as trauma. Their patients often require critical care as well. I don't know how you could be a competent vascular surgeon without some strong general surgery fundamentals, over and above what you get as an intern. The other specialties you listed aren't quite as intricately intwined with general surgery, IMVHO.

I must disagree. I have thought some of these high end subspecialties going the integrated route would really be a mistake.... up until recently. When I looked at some of the integrated rotation schedules, it became clear that if followed and done correctly it would produce higher quality. I would also add that most vasc surgeons I know fellows & attendings have little to no interest in trauma and much prefer to be consulting rather then primary managing on traumas. As for critical care, I suspect that will be well integrated. When looking at other specialties now integrating into six years I see the critical care going beyond SICU and including MICU and even CICU/Cardiology ICU. I think a well planned out integrated program can do a good job at training a vascular surgeon.

JAD

 

[filter07]

In my opinion, if you can't learn how to be a proper vascular surgeon after training in vascular surgery for 5 years, there's something wrong. It makes no sense to say that you have to do a bunch of surgeries in other specialties to be a good vascular surgeon. If you really needed a bunch of experience opening bellies as an attending, you would think you would see enough over 5 years of training to be prepared. Conversely, if you open only a few bellies over 5 years, you have to wonder how relevant that is to modern vascular surgery.

Sure it's nice to have someone who can handle every single problem, but that's not a good policy. I would rather have several 5-year trained vascular surgeons that can do most bread and butter vascular surgeries, than one jack of all trades vascular surgeon. What's the big deal with bellies anyway, if you need help, call up a general surgeon to help you.

You don't see spine surgeons doing 5 years of general surgery or CT surgery just to get thoracic spine exposure.

 

[TUHopeful]

I think my comments must not have been very clear. I think the 0+5 programs are great and the right direction (that's what I'm applying for). I was just pointing out that all of the integrated programs have 2 years of "general surgery training", not one like in ENT, ORTHO, URO, and NEURO. I think the way the rotations are laid out for the integrated programs will provide more and better vascular training than the tradition 5+2 training. I just think that for the foreseeable future that vascular surgeons will be under the domain of the ACS and I don't believe there is any real push for that to change or to condense the vascular surgery training any further.

There are still indications for open AAA repair (which is the gold standard and provides the most durable repair) and those folks will spend some time in the ICU usually. The attendings I worked with do their own exposures and manage those patient while they are in the ICU. I think the 0+5 programs will provide the correct amount of critical care experience. As for trauma, I'm not saying that the vascular surgeon should be primary, just that they probably need the two years of general surgery training to get the correct amount of trauma experience as well.

 

[JackADeli]

...There are still indications for open AAA repair (which is the gold standard and provides the most durable repair) and those folks will spend some time in the ICU usually.

...As for trauma, I'm not saying that the vascular surgeon should be primary, just that they probably need the two years of general surgery training to get the correct amount of trauma experience as well.

Well, most major teaching centers that do vascular surgery.... have plenty of open AAA numbers.

As for trauma... I don't get it. How much trauma are you expecting a PGY1/2 to get that translates into meaningful training for a vascular surgeon? Also, the trade-off is that the more time during PGY1/2 given over to trauma is time taken away from potentially more useful experiences. Remember (at least the places I have been), the vast majority of trauma experiences, especially at the junior level, was/is non-operative babysitting. I definately do not see a fresh out of med-school integ-vasc PGY1/2 being called upon to do the major operative vasc trauma.... I think, at least how I am reading it, you are over-valuing the trauma experience in this matter.

JAD

 

[TUHopeful]

.... I think, at least how I am reading it, you are over-valuing the trauma experience in this matter.

JAD

Let's clarify the discussion. Of the 4 current training tracks for vascular surgery, the newest 0+5 programs are the most streamlined and I believe give you the most bang per year in training. They require 24 mo. of core surgical training and 36 mo. of vascular training. In the 24 months of core surgical training there are required ICU and trauma rotations. I'm simply stating that I think that seems to be the appropriate amount of exposure and as far as I know there isn't a push to streamline the process any further. Are you stating that you believe it should be more streamlined?

 

[JackADeli]

...as I know there isn't a push to streamline the process any further. Are you stating that you believe it should be more streamlined?

First, I don't claim to be the expert on what makes the best vascular surgery training program. Having said that, and having gone through GSurgery residency and board certification, IMHO trauma as a component of training is often excessive in relation to what it actually provides. Further, based on my experiences and the colleagues I know within the vascular arena.... trauma as a core component to becoming a vascular surgeon is IMHO vastly over-rated. I don't know what the colleges/boards/societies are going to do with integrated vascular. But, I do not see it as a detriment to future vascular surgeons to markedly curtail how much of the core training involves trauma rotations.... aka PGY1 & 2 obligatory babysitting blocks. But, that's just my views on the matter.

...How much trauma are you expecting a PGY1/2 to get that translates into meaningful training for a vascular surgeon? Also, the trade-off is that the more time during PGY1/2 given over to trauma is time taken away from potentially more useful experiences...

regards,
JAD

 

[TUHopeful]

First, I don't claim to be the expert on what makes the best vascular surgery training program. Having said that, and having gone through GSurgery residency and board certification, IMHO trauma as a component of training is often excessive in relation to what it actually provides. Further, based on my experiences and the colleagues I know within the vascular arena.... trauma as a core component to becoming a vascular surgeon is IMHO vastly over-rated. I don't know what the colleges/boards/societies are going to do with integrated vascular. But, I do not see it as a detriment to future vascular surgeons to markedly curtail how much of the core training involves trauma rotations.... aka PGY1 & 2 obligatory babysitting blocks. But, that's just my views on the matter.

I certainly see your point of view, and I'm sure I'll whole heartily agree here in a couple of years. I think its a matter of fundamentals. If I knew two years ago I was going to do vascular surgery, why should I have to take 6wks of psych? Why did I have to suffer 2 semesters of organic chemistry? As a general surgeon, how many kidney transplants will you ever do now that you are out of residency? Some things you build on and some things you need the exposure so you can speak the language. Are a few months of trauma during a five year training period too much? I don't know, but it seems reasonable to me. The 0+5 is the newest and most streamlined track, and the powers that be feel like we need at least of couple of months of trauma. All I was trying to say initially is that I believe vascular surgeons need more general surgery experience as compared to ENT and ortho, and I don't see the training getting anymore streamlined in the near future.

All that being said, I'm just an applicant. I haven't had to suffer through a few "non-operative" months, but I don't think it will be to the detriment of my training. I probably should reserve final judgment for a couple of years.

Respectfully,

TUHopeful

 

[JackADeli]

I certainly see your point of view, and I'm sure I'll whole heartily agree here in a couple of years. I think its a matter of fundamentals. If I knew two years ago I was going to do vascular surgery, why should I have to take 6wks of psych? Why did I have to suffer 2 semesters of organic chemistry? As a general surgeon, how many kidney transplants will you ever do now that you are out of residency? Some things you build on and some things you need the exposure so you can speak the language. Are a few months of trauma during a five year training period too much? I don't know, but it seems reasonable to me. The 0+5 is the newest and most streamlined track, and the powers that be feel like we need at least of couple of months of trauma. All I was trying to say initially is that I believe vascular surgeons need more general surgery experience as compared to ENT and ortho, and I don't see the training getting anymore streamlined in the near future.

All that being said, I'm just an applicant. I haven't had to suffer through a few "non-operative" months, but I don't think it will be to the detriment of my training. I probably should reserve final judgment for a couple of years.

Respectfully,

TUHopeful

I follow you and get your perspective...

I think as we approach something without any experience it is very easy to simply sacrifice things in the belief "it really won't be a big deal". However, in training, that is being altered to increase/improve the production of certain specialists.... i.e. integrated plastics, vascular, thoracic, etc... Folks need to think long and hard about each and every rotation block. The goal is to enhance the training. Can you do trauma for 1, 2, 3, or more months? Sure, it is done every year by so many residents accross the country. The question is not can it be done. The question has to be one of what value is added by doing the rotation??? Wasting a 1, 2, 3 or more months of that precious time doing a babysitting rotation is.... IMHO too high a price. Uro, ENT, ED and others accross the country have asked this question. In so doing, they have eliminated or markedly truncated or restricted what rotations one will do during "off-service" rotations/transitional years.

When it comes to trauma, I do not see the value added. If a trauma comes through that requires a vascular surgeon, I am certain the 4th or 5th year integrated vasc resident will be there with the vascular attending involved in the complex vascular trauma. So, does their ability to function at that level really require "x" number of months of babysitting on the trauma service as a PGY1 or 2?

As for your comparison to kidney transplants.... again, I think not applicable comparison. There are transferable skills from doing kidney transplants. There are vascular anastamosis, ureter anastamosis and/or repairs, vascular access issues. Aside from the actual transplanting of the organ, a good number of these skills are actually applicable in a general surgery practice... depending on the scope of your practice. For example, ureters do get injured in major abdominal procedures done by GSurgeons (hopefully not often).

 

[corona 247]

Thanks for the replies and resulting discussion.

Was reading an article that discussed the future of carotid stenting, and who is best trained to carryout those procedures. What is everyone opinion about the future of CEA with the advent of CAS and the turf battle that seems to be coming yet again with VS, rads, and cardio.

Thanks

 

[NJDIF]

Thanks for the replies and resulting discussion.

Was reading an article that discussed the future of carotid stenting, and who is best trained to carryout those procedures. What is everyone opinion about the future of CEA with the advent of CAS and the turf battle that seems to be coming yet again with VS, rads, and cardio.

Thanks

IMO, CEA is here to stay. I dont think the post op data associated with CAS is suggestive enough to replace CEA as the gold standard. I don't think the vasc guys have to worry about the cardiologists taking over this one.

 

[JackADeli]

...Was reading an article that discussed the future of carotid stenting, and who is best trained to carryout those procedures. What is everyone opinion about the future of CEA with the advent of CAS and the turf battle that seems to be coming yet again with VS, rads, and cardio...

I guess you must ask what are the skills involved in CA stenting? Then ask are those procedural skills attainable by vascular surgeons??? To those questions, it is obvious vascular surgeons trained today have plenty of "catheter skills" to perform this procedure. Thus, you need to ask the next group of very important, though often ignored/forgotten, questions....
1. Who will manage this patient's disease and/or evaluate disease pre-op?
2. Who will manage/care for patient post-op? Consider the reperfusion cerebral edema issues associated with cerebral revasc/reperfusion....
3. Who will manage the operative complications?

I have no problem in general with different specialists doing procedures felt to be more suited to another specialist. But, competency in surgical care start before the procedure and extends out after the procedure. I think it fundamentally wrong for someone to do an interventional procedure and have the post-op care handled by the surgeons.... Currently, the model relative to vascular seems to be IR and Cards stenting and admitting to vascular. Cards does not function this way when they stent the heart.... why???

 

[RegularNihilist]

If I knew two years ago I was going to do vascular surgery, why should I have to take 6wks of psych? Why did I have to suffer 2 semesters of organic chemistry?

I don't know? Why do you think it is this way? Could egomania among physicians be the reason? Wanting to be the ones knowing everything about the human body (on paper).

 

[thedrjojo]

I guess you must ask what are the skills involved in CA stenting? Then ask are those procedural skills attainable by vascular surgeons??? To those questions, it is obvious vascular surgeons trained today have plenty of "catheter skills" to perform this procedure. Thus, you need to ask the next group of very important, though often ignored/forgotten, questions....
1. Who will manage this patient's disease and/or evaluate disease pre-op?
2. Who will manage/care for patient post-op? Consider the reperfusion cerebral edema issues associated with cerebral revasc/reperfusion....
3. Who will manage the operative complications?

I have no problem in general with different specialists doing procedures felt to be more suited to another specialist. But, competency in surgical care start before the procedure and extends out after the procedure. I think it fundamentally wrong for someone to do an interventional procedure and have the post-op care handled by the surgeons.... Currently, the model relative to vascular seems to be IR and Cards stenting and admitting to vascular. Cards does not function this way when they stent the heart.... why???

CREST (a multicenter study comparing CEA to stenting, which was actually started at my home center UMDNJ-Newark) will hopefully answer the question of CEA vs Stenting.

As for the follow up, I agree with you. I hate these specialties that get to do the procedures and then turf the future care... they are becoming less and less doctors and more just technicians. That being said, I know at our institution, getting PICC's, Pigtails, Drains, etc, I do really like the ability to send the patient to IR to get the procedure done. So there is some good with the bad.

 

[superspeed]

This post is old - but just wanted to see what you guys thought about the future of vascular surgery? 0+5 here to stay? competition from IR / cards?

 

[Oxer45]

This post is old - but just wanted to see what you guys thought about the future of vascular surgery? 0+5 here to stay? competition from IR / cards?

Lets see IR/Cards do bypass for critical limb ischemia.

You see, there is always some overlap between specialties. Most people get worried and think the world is coming to an end cause there will be competition. But the truth of the matter is, each specialty has some core stuff that others wouldn't dare to touch/bother to touch. How often do you see a vascular surgeon managing CHF,MI, arrhythmia. If you were a cardiologist, would you be shaking in your boots cause you think some vascular surgeon is gonna come and take away all your arrhythmia pts? Cardiologists are as interested in necrotic limb as you are in the heart.

 

[mimelim]

This post is old - but just wanted to see what you guys thought about the future of vascular surgery? 0+5 here to stay? competition from IR / cards?

0+5 is here to stay.

IR/Cards gets the cases we are too busy for.

 

[Med0123]

0+5 is here to stay.

IR/Cards gets the cases we are too busy for.

mimelim, I know that the 0+5 route gives you the skills do perform IR procedures, what about the 5+2 route? in those 2 years do you think most of the fellowships available gives you access and some training in angiointervention?

 

[droliver]

You realize that the short track vascular program was created largely because of funding issues of residents rather then a belief it necessarily produced better surgeons. Programs would gradually have to pick up more of the costs associated with training residents for a 2nd specialty, as in the traditional model of residency funding for sub-specialty fellowships (CTVS, vvascular, plastics, transplant).

I personally think it's kind of short sighted to try and truncate the exposure and training of vascular surgeons, as there can be a LOT of overlap with traditional surgery and in many areas of the country vascular surgeons still do general surgery as a large part of their practice. It would be hard to practice just vascular (with an emphasis on endovascular surgery) at most places outside of large metro areas or other tertiary centers.

 

[mimelim]

mimelim, I know that the 0+5 route gives you the skills do perform IR procedures, what about the 5+2 route? in those 2 years do you think most of the fellowships available gives you access and some training in angiointervention?

I need to go to sleep, but in short. What you refer to as "IR procedures" are better termed endovascular. Interventional radiologists, cardiologists, nephrologists and vascular surgeons do endovascular procedures in different parts of the body. 5+2 trained vascular surgeons are getting a 2 year dedicated fellowship in vascular surgery. While they get less early exposure to endovascular compared to those in the 0+5, they get ample at most places.

 

[mimelim]

You realize that the short track vascular program was created largely because of funding issues of residents rather then a belief it necessarily produced better surgeons. Programs would gradually have to pick up more of the costs associated with training residents for a 2nd specialty, as in the traditional model of residency funding for sub-specialty fellowships (CTVS, vvascular, plastics, transplant).

I personally think it's kind of short sighted to try and truncate the exposure and training of vascular surgeons, as there can be a LOT of overlap with traditional surgery and in many areas of the country vascular surgeons still do general surgery as a large part of their practice. It would be hard to practice just vascular (with an emphasis on endovascular surgery) at most places outside of large metro areas or other tertiary centers.

I'm sure this is true and I'm sure the vascular fellowships will remain, but simply to a smaller extent.

 

[superspeed]

what do you guys think about the future of vascular job spots/security/salary?

 

[ESCrawford]

You realize that the short track vascular program was created largely because of funding issues of residents rather then a belief it necessarily produced better surgeons. Programs would gradually have to pick up more of the costs associated with training residents for a 2nd specialty, as in the traditional model of residency funding for sub-specialty fellowships (CTVS, vvascular, plastics, transplant).

I personally think it's kind of short sighted to try and truncate the exposure and training of vascular surgeons, as there can be a LOT of overlap with traditional surgery and in many areas of the country vascular surgeons still do general surgery as a large part of their practice. It would be hard to practice just vascular (with an emphasis on endovascular surgery) at most places outside of large metro areas or other tertiary centers.

My perception of the motivation for the 0+5 training program (and I've sat in more than one national meeting about the issue) is that it's a combination of a desire to be completely independent from general surgery, a strategy to attract better candidates to the field, and a belief that the training will ultimately be better with five years of concentrated exposure to cardiovascular disease. Funding issues cut both ways at the moment--it's sometimes hard to find funding for those extra residents when starting a 0+5. At least two 0+5 programs I know of have closed due to de-funding by the department of surgery.

As far as whether the end product is better with the 0+5, who really knows? Clearly, these residents will have more exposure to endovascular techniques, duplex ultrasound, and medical management of cardiovascular disease. In some programs, they will have less exposure to major abdominal vascular cases, but how many of those are you even going to be doing in a typical community practice? The chip-shot infra-renal AAA's are all endo, and the juxta-viscerals are mainly going to tertiary referral centers. Aorto-bifems are increasingly rare. So what's more relevant to practice--comprehesive endovascular skills or the the ability to do open thoraco-abdominal aneurysms? I suspect the former.

I really don't understand the idea that you need to practice general AND vascular to be financially viable outside of a major center. That may have been true in the recent past when many vascular surgeons only did open surgical reconstructions. But today, for someone who does cosmetic venous surgery, runs their own vascular lab, does all of their own endovascular work, AND does open surgical reconstruction, there is more than enough business virtually anywhere. Plus, less and less general surgery trainees are doing vascular cases without fellowship training, so the competition from general surgery is decreasing as time goes on.

Job market at the moment for vascular is extremely good in comparison to other surgical subspecialties.