Integrated Vascular Surgery - How competitive is it?

[Good Mountain]

Integrated Vascular Surgery - How competitive is it? Is it more competitive than applying for GS?

Note: I read these threads but none addresses this issue.
(http://forums.studentdoctor.net/archive/index.php/t-360450.html)
(http://forums.studentdoctor.net/showthread.php?t=343745&highlight=vascular)
(http://forums.studentdoctor.net/showthread.php?t=283824&highlight=vascular)

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[MyNameIsOtto]

I've been recently wondering about this myself.....👍

 

[CBMD]

Integrated Vascular is much more competitive than GS and getting more so as the programs become more evolved. Realize that this is still a fairly new program and has only been around 3 years so far. There were I beleive 14 or 16 programs this year but more are cropping up. I beleive there were about 160 applicants for those spots, and almost all of the candidates had extensive research experience, great grades, and stellar board scores as well as ties to some pretty stellar vascular surgeons. They went to the meetings, presented, got published, you name it. The first year or 2 it also had a lot to do with who you know, but now it's becoming more like any other specialized highly desirable field. For what it's worth, it's seems like a great program but there is still a lot of doubt about it in both vascular and general circles as to whether you will get enough experience to effectively be a vascular fellow after only 3 years of surgical training and how this will pan out outside of academics where a lot of vascualar surgeons still take general call, etc. I would recommend talking to some of the vascular surgeons at your program and get early contact with the programs that do have residencies to do an audition rotation, and also to talk to any residents currently in the programs. Hope this helps.

 

[Gentle]

"extensive research experience, great grades, and stellar board scores as well as ties to some pretty stellar vascular surgeons. They went to the meetings, presented, got published, you name it"

Not necessarily the case. I know someone who just matched into a combined Vasc and their board score wasn't stellar. However, they had great LORs. Don't even think they attended national vascular meetings.

Gentle

 

[funshi baba]

I was interested in integrated vascular initially but got discourage after a phone conversation with a PD at one of the prog i was interested in.

I asked the PD if doing 1 yr surgical internship prior to applying for int. vasc program would help. The answer was NO! He told me the field is fast evolving and they are looking for people that will contribute to it. So it will serve me best to take a yr off and consider NIH research. Strongly encourage me to go to meetings and conference.

I even signed up for the SVS (society for Vascular surgery), so i recieved current news. Lenox-Hill NY is the latest integrated prog open and that makes it about 17 total, i think. Most prog takes 1 or 2/ yr from what i have seen.

If u really interested, they have a mentor prog once u join SVS for $25, that can match you with a mentor. most mentor listed are PDs though, so most don't reply. Two PD replied me, one in NY and the other is in FL.

good luck

 

[GeraldMonroe]

I just read that with integrated vascular, you save 1 year. So, why would someone take a year to do a preliminary year or a research year instead of doing categorical general + vascular fellowship?

I'm guessing that the vascular fellowships are hyper competitive?

Another question : is general surgery really so bad that taking a single additional year to be boarded in it is that disgusting? I thought the problem with general surgery, at least from reading these forums, is that it doesn't pay well. But, relative pay changes all the time...

 

[Winged Scapula]

I just read that with integrated vascular, you save 1 year. So, why would someone take a year to do a preliminary year or a research year instead of doing categorical general + vascular fellowship?

I'm guessing that the vascular fellowships are hyper competitive?

Not at all. Vascular fellowships are not very competitive (for the most part).

Another question : is general surgery really so bad that taking a single additional year to be boarded in it is that disgusting?

For many yes. They figure if they aren't going to be doing general surgery, why should they spend one more minute, let alone one more year, to be board eligible. You cannot know the pain of surgical residency until you have done it.

I thought the problem with general surgery, at least from reading these forums, is that it doesn't pay well. But, relative pay changes all the time...

And it is only likely to go down. General surgery is one of the few medical specialties to earn less over the last 10 years (and not just less in terms of inflation, but less in terms of actual dollars). The government doesn't care how much training we have or the skills, they only want what the American public wants: the best medical care for the cheapest price. They want to be able to drive up in their Mercedes or BMW and see someone with 13+ years of education and then pay them less than what many other professions with less education, responsibility and sacrifice make.

 

[filter07]

Hands down General Surgery is the least appreciated field in all of medicine. By the time residents are done with General Surgery, they are able to do things that most people and even residents in other fields can't even imagine. They can treat cancer in countless areas of the body, handle emergency airways, traumas, vascular disease, put in virtually any line, manage the sickest patients in the hospital, operate on a wide age spectrum, help people lose weight, help someone through a burn that would have killed anyone 20 years ago, transplant vital organs, and make poop flow in so many different ways that your head will spin. What do we get for this nearly superhuman talent and level of training? A job market so demeaning and god-awful that around 70% take on additional training in fellowships.

General surgery used to be an awesome field. It is now reduced to a tiny niche of low paying cases that haven't been claimed by specialists, who are trained in fellowships that did not even exist in the past. Laparoscopic, colorectal, breast, oncology, trauma, vascular... they all took pieces of the pie and left the crumbs to the General Surgeon. Is it any surprise that salaries are down? No one in their right mind wants to be a General Surgeon anymore. Who can blame them?

 

[Anka]

First, primary care. Now general surgery. Soon all of medicine. And one day, the American public will look up from the stretcher at their darkest hour, bleeding, burned, or with cancer eating their guts and the face they will see will not be the best and the brightest, but the guy who couldn't get a union job as a plumber.

 

[Pilot Doc]

To the OP trying to figure out the formula to get a integrated vascular spot ... there isn't one.

With less than 2 dozen slots a year, it's still going to be a game of who you know. it's going to be very idiosyncratic and unpredictable. I'm sure somebody will be able to trot out an example of a guy who made a 194 on his step 1 but still matched into a program. But in general the people who match are going to be very smart and very hard working - just like the people who don't match.

So if you want to do this ... work hard and have a backup plan.

And as for why you wouldn't want to be boarded in GS ... you get out of general surgery call! No more appies, SBO's, trauma etc.

 

[GeraldMonroe]

Wow. General surgery must really be the pits for you guys to describe it this way! It can't be as bad as giving people employment physicals or doing primary care on noncompliant patients, can it? I was under the impression that general surgeons cut people open and fix the broken parts.

 

[Winged Scapula]

Wow. General surgery must really be the pits for you guys to describe it this way! It can't be as bad as giving people employment physicals or doing primary care on noncompliant patients, can it?

Absolutely not. It is for the pleasure of operating and fixing people that we do it. But you have to understand that its pretty frustrating to spend all these years in training (and some of us had a pretty miserable residency), only to be derogated, unappreciated, underpaid and be faced with the constant threat of being sued.

 

[Winged Scapula]

And as for why you wouldn't want to be boarded in GS ... you get out of general surgery call! No more appies, SBO's, trauma etc.

Excellent point. Many hospitals base who has to take General Surgery call by whom is trained/BE in General Surgery. They don't care if you are fellowship trained (I"m lucky I'm in a big city where I have other options). Do an Integrated Vascular, Plastics, etc. program gets you out of that requirement.

 

[funshi baba]

If i were to read this thread about a yr ago, i would have switch from gen surg to IM or something else. But now, i just feel crazy for still wanting to do surgery.

I'll take surg over IM anyday of the yr though. I just can't see myself pushing that much medicine (no offense to IM guys).

Sorry, back to the topic.

 

[Gentle]

I've thought about intergrated Vascular, in the past. However, I really want to be good at GS cases which I don't think doing intergrated Vascular nor any other intergrated will really help me in that domain. My reason for wanting to be good at GS bread and butter cases and beyond is b/c my long term goal is to give back to where I come from. I'm from a developing country and no matter what fellowship I end up doing in surgery, I know that my GS skills will become very very handy when I'm in those remote areas of the country, probably alone, with patients needing apys, hernia repairs, bowel resections and stuff.

I might not be well informed so what does anyone thinks about not wanting to do an intergrated program because I want to be very comfortable with a wide variety of GS cases.

Thanks

 

[funshi baba]

I've thought about intergrated Vascular, in the past. However, I really want to be good at GS cases which I don't think doing intergrated Vascular nor any other intergrated will really help me in that domain. My reason for wanting to be good at GS bread and butter cases and beyond is b/c my long term goal is to give back to where I come from. I'm from a developing country and no matter what fellowship I end up doing in surgery, I know that my GS skills will become very very handy when I'm in those remote areas of the country, probably alone, with patients needing apys, hernia repairs, bowel resections and stuff.

I might not be well informed so what does anyone thinks about not wanting to do an intergrated program because I want to be very comfortable with a wide variety of GS cases.

Thanks

Your reasoning is sound to me because i am also from a developing country and there aren't much facility to do an advance procedures anyway. So good GS skills will definitely come in handy.

Another reason GS will be good is that it gives u time to actually pick out what u really like. You have five yrs to decide. you might be convinced its vascular for now until u are 2yrs deep and realize u hate it.

 

[GeraldMonroe]

It is kind of bizzare, reasoning that it's better to have less skills for slight or no time savings. Long term, it kind of seems like your control over your life and your career would be greater if you were a surgeon with more officially recognized qualifications.

I'm just an M-0, and it's entirely possible it really does work that way. Still, it's rather unusual.

 

[SocialistMD]

It is kind of bizzare, reasoning that it's better to have less skills for slight or no time savings.

What you need to do is see vascular surgery like you see any other surgical sub-specialty (e.g. neurosurgery). It doesn't matter if you have "less skills" when you are giving up operative knowledge you will never use. For example, vascular surgery is going the route such that they don't do any bowel surgery, so they don't need to know how to perform bowel anastamoses, just like neurosurgeons. I doubt you'll fault a neurosurgeon for not knowing how to perform a bowel anastamosis. In exchange, they are getting more exposure to the skills they use on a daily basis.

Long term, it kind of seems like your control over your life and your career would be greater if you were a surgeon with more officially recognized qualifications

In truth, they are actually increasing control over their lives/careers because they can avoid trauma/general surgery call by not being certified in general surgery.

 

[peacenjoy]

What you need to do is see vascular surgery like you see any other surgical sub-specialty (e.g. neurosurgery). It doesn't matter if you have "less skills" when you are giving up operative knowledge you will never use. For example, vascular surgery is going the route such that they don't do any bowel surgery, so they don't need to know how to perform bowel anastamoses, just like neurosurgeons. I doubt you'll fault a neurosurgeon for not knowing how to perform a bowel anastamosis. In exchange, they are getting more exposure to the skills they use on a daily basis.

In truth, they are actually increasing control over their lives/careers because they can avoid trauma/general surgery call by not being certified in general surgery.

"increasing control over their lives/careers" AND able to pick WHO your pt is likely to be.

 

[beaverfetus]

"increasing control over their lives/careers" AND able to pick WHO your pt is likely to be.

I don't get it, you mean you get to choose that all your patients will be old with vascular risk factors?

 

[GeraldMonroe]

I'm still skeptical that in the long run this is the best decision.

Case 1 : you learn to do general surgery, which includes training in a long, long list of procedures and techniques, over a period of 5 years. At the end of it, you become board eligible, and are allowed to do a long list of procedures. Then, you spend 2 more years practicing as a fellow to perform vascular procedures, and you get a similar packet of things you are eligible to do at the end of it. (I understand that board certification is optional in both
cases)

Case 2 : same as above, except you maybe save a year and can only do a shorter list of procedures, but you have 1 extra year of vascular training.

In the long run, reimbursements and working hours must fluctuate tremendously. With a stroke of a pen, medicare could decide that vascular procedures are not worth as many "RVUs" and cut reimbursements to what general surgeons make per hour of work. With another stroke of a pen, medicare could provide funding for a raft of extra integrated vascular spots, which someone would fill, even if it was IMGs.

I'm not saying it would happen, it's just that more skills and knowledge historically has always been a good hedge against change.

One thing I'm not clear on : suppose they teach you how to make the 'poop flow' in an integrated vascular program. Are you still licensed to perform any 'poop' procedures you have sufficient case experience in, even if you are only Board Eligible for vascular?

 

[beaverfetus]

I'm still skeptical that in the long run this is the best decision.

Case 1 : you learn to do general surgery, which includes training in a long, long list of procedures and techniques, over a period of 5 years. At the end of it, you become board eligible, and are allowed to do a long list of procedures. Then, you spend 2 more years practicing as a fellow to perform vascular procedures, and you get a similar packet of things you are eligible to do at the end of it. (I understand that board certification is optional in both
cases)

Case 2 : same as above, except you maybe save a year and can only do a shorter list of procedures, but you have 1 extra year of vascular training.

In the long run, reimbursements and working hours must fluctuate tremendously. With a stroke of a pen, medicare could decide that vascular procedures are not worth as many "RVUs" and cut reimbursements to what general surgeons make per hour of work. With another stroke of a pen, medicare could provide funding for a raft of extra integrated vascular spots, which someone would fill, even if it was IMGs.

I'm not saying it would happen, it's just that more skills and knowledge historically has always been a good hedge against change.

One thing I'm not clear on : suppose they teach you how to make the 'poop flow' in an integrated vascular program. Are you still licensed to perform any 'poop' procedures you have sufficient case experience in, even if you are only Board Eligible for vascular?

who needs a hedge when we have decades of reimbursement patterns to look at. The gods of medicare money turned their backs on general surgery years ago. I'd bet just about anything that the more endovascular vascular can claim the higher the reimbursement will go.

Not to mention you save 2-4 (depending on whether you get side tracked by research; common at some gen surg programs), and DONT have to play with poop quite as long.

I'm more interested in what fellowships you would be eligible for after an integrated vasc residency. One would think transplant fellowships and CT might eventually accept integrated vasc applications

 

[Pilot Doc]

One thing I'm not clear on : suppose they teach you how to make the 'poop flow' in an integrated vascular program. Are you still licensed to perform any 'poop' procedures you have sufficient case experience in, even if you are only Board Eligible for vascular?

Any physician is licensed to perform any operation. All psychiatrists are licensed to perform hernias, AAA (open and endo) as well as solid and hollow organ transplants. Likewise all CT surgeons are licensed to perform insight oriented psychotherapy as well as ECT. And medicare will pay for them too.

The issue is not licensure but what the person who owns your operating room will let you do and what they will make you do. That varies widely by location . Until we get a significant number of non-GS boarded vasc people in practice, ti will be hard to say how that plays out. Presumably the what they will make you do part will follow tradition for CT, plastics, etc in that you won't have to take gensurg call. As for what they'll let you do - hard to say. But I bet if you operate on bowel, you're gonna have to take bowel call. Bad tradeoff.

As for hedging ... it's a cost benefit analysis. Sure you can get GS boarded with 1 extra year. You can get occupational med boarded for 2 years and FP for 3. Family practice would be a great hedge - but many people would rather have that year of their life back and tolerate the risk of massive health care system change just like they already tolerate the innumerable small risks of all sorts of bad things happening.

 

[SocialistMD]

As for hedging ... it's a cost benefit analysis. Sure you can get GS boarded with 1 extra year. You can get occupational med boarded for 2 years and FP for 3. Family practice would be a great hedge - but many people would rather have that year of their life back and tolerate the risk of massive health care system change just like they already tolerate the innumerable small risks of all sorts of bad things happening.

Yeah, why didn't I just do an IM residency during my lab time instead of this basic science stuff...😉

 

[Pilot Doc]

Yeah, why didn't I just do an IM residency during my lab time instead of this basic science stuff...😉

or peds - even better

 

[SocialistMD]

or peds - even better

More appropriate, at least.

 

[GeraldMonroe]

Well, a followup question that I think will clarify things.

I understand that residents log what cases they worked including the position (primary surgeon/first assist/retractor b*tch) and the procedure.

So, at the end of residency, you can print out a sheet "I did xxx lap choles, xxx appys, ect"

And I've heard hospitals 'credential' you to perform a particular procedure based upon whether you met the minimum number of cases for that procedure. Presumably, there is some way you can assist another attending if you're short a few cases so that you can get privileges.

What I am getting at : does that mean that every procedure you trained on during the 3 general surgery years in an integrated residency is fair game? Meaning, you could ask to be credentialed on those, and receive reimbursement from insurance?

Or is the last part the sticking point : do the good, private insurance companies simply refuse to pay anyone who is not board eligible for performing a procedure in a certain 'coding category'.

 

[Pilot Doc]

As a general rule, the answer to any credentialing question is "it depends".

Lots of factors, but it generally boils down to money. If a liberal credentialing policy will bring extra business to a facility, you're likely to get privileges. Likewise, if your procedure of choice is going to steal business from someone who is already bringing big $$ to the facility, fat chance.

In the situation of a general surgeon applying for credentials at a facility, there will typically be a list of basic procedures that any general surgeon will get privileges for based on completing a residency. (hernias, appendectomy, etc) For newer or more specialized procedures (lap colon, whipple) you may need to provide specific proof of training.

Whether you could get privileged for GS type cases without being GS boarded ... who knows. Nobody's out there yet. I suspect it that's really an interest to you, you should do the extra year.

Reimbursement is another issue. Winged Scapula can probably comment on this more intelligently than I, but you might have trouble getting contracts with insurance plans, although I doubt they'd deny an out of network claim. The bigger question is whether the holders of good private insurance who are presumably moderately sophisticated would want to patronize you instead of someone who is fully trained

Well, a followup question that I think will clarify things.

I understand that residents log what cases they worked including the position (primary surgeon/first assist/retractor b*tch) and the procedure.

So, at the end of residency, you can print out a sheet "I did xxx lap choles, xxx appys, ect"

And I've heard hospitals 'credential' you to perform a particular procedure based upon whether you met the minimum number of cases for that procedure. Presumably, there is some way you can assist another attending if you're short a few cases so that you can get privileges.

What I am getting at : does that mean that every procedure you trained on during the 3 general surgery years in an integrated residency is fair game? Meaning, you could ask to be credentialed on those, and receive reimbursement from insurance?

Or is the last part the sticking point : do the good, private insurance companies simply refuse to pay anyone who is not board eligible for performing a procedure in a certain 'coding category'.

 

[SocialistMD]

The other thing you have to remember is that the days of the true general surgeon are becoming numbered. Studies are showing more and more that, not surprisingly, specialists are better at complex procedures, so the days of the surgeon who does an aortic repair and a colon resection are almost over. Endoluminal techniques are even causing more of a gap in the training of the generalist and the vascular specialist.
Ask 100 vascular surgeons if they miss bowel surgery and I bet 95 would say "no."

 

[maxheadroom]

The other thing you have to remember is that the days of the true general surgeon are becoming numbered. Studies are showing more and more that, not surprisingly, specialists are better at complex procedures, so the days of the surgeon who does an aortic repair and a colon resection are almost over. Endoluminal techniques are even causing more of a gap in the training of the generalist and the vascular specialist.
Ask 100 vascular surgeons if they miss bowel surgery and I bet 95 would say "no."

95/100?? Try 99.9/100

Except for the old-school guys, almost all of the vascular surgeons with whom I've worked are glad to brag about their complete ignorance of the gut.

 

[GeraldMonroe]

I've wondered about this. Poop is gross. But then, so is anatomy lab and Ob/Gyn. Wouldn't a general surgery resident get used to it, even if his dream was to some day to pass the pearly gates of vascular or plastics?

 

[SocialistMD]

I've wondered about this. Poop is gross. But then, so is anatomy lab and Ob/Gyn. Wouldn't a general surgery resident get used to it, even if his dream was to some day to pass the pearly gates of vascular or plastics?

Sure you get used to it, but if you don't want to do it and you don't have to, why would you?

 

[GeraldMonroe]

Well, I figured after a while it would grow on you. Rerouting poop might get to be fun. It might be a crappy job, but someone's got to do it.

Also, the poop has to get out somehow, without leaking into the abdomen. Otherwise the patient will die. So general surgeons do save lives.

 

[SocialistMD]

Well, I figured after a while it would grow on you. Rerouting poop might get to be fun. It might be a crappy job, but someone's got to do it.

Also, the poop has to get out somehow, without leaking into the abdomen. Otherwise the patient will die. So general surgeons do save lives.

Your terrible pun aside, that is why people do general surgery. Typically, if you do vascular, you don't care about operating on the bowel and are more interested in rerouting the blood's plumbing. Not everyone hates operating on the intestines; some of us actually enjoy it, which is why we do it. Personally, I'm not a fan of vascular (more the patient population than the futility of the procedures, but that's neither here nor there) surgery and would much rather be up to my elbows in poo than creating another AV-fistula. And you bet your @$$ general surgeons save lives; no one here, in the general surgery forum, ever said otherwise.

 

[maxheadroom]

Your terrible pun aside, that is why people do general surgery. Typically, if you do vascular, you don't care about operating on the bowel and are more interested in rerouting the blood's plumbing. Not everyone hates operating on the intestines; some of us actually enjoy it, which is why we do it. Personally, I'm not a fan of vascular (more the patient population than the futility of the procedures, but that's neither here nor there) surgery and would much rather be up to my elbows in poo than creating another AV-fistula. And you bet your @$$ general surgeons save lives; no one here, in the general surgery forum, ever said otherwise.

The patient population in Vascular surgery requires a very special kind of doctor who will just smile and nod when the vasculopath keeps smoking and watching their glucose hover at 300+. The cases are pretty cool, but the patients drive me nuts.

 

[Winged Scapula]

And I've heard hospitals 'credential' you to perform a particular procedure based upon whether you met the minimum number of cases for that procedure. Presumably, there is some way you can assist another attending if you're short a few cases so that you can get privileges.

Not necessarily. I have privileges at several hospitals and have only been asked to document specific numbers for certain "special privileges". I've never seen an application ask for a minimum number of cases for those things included under General Surgery Core Privileges.

Every hospital has a slightly different format (and I've typed this elsewhere in this forum, but its probably faster to just type it again) and specifics as to what you "get" with general surgery.

Most will want a procedural log for recent residency grads but I've never heard of someone requesting something that they didn't have enough - ie, if its enough for ABS, its enough for the hospital (save for Pilot Doc's comment below about competition). Some want documentation from your residency PD that you have been trained in the procedures you are requesting (obviously for recent grads and first time applicants for privileges).

For example, I am reapplying for privileges at one hospital and the Delineation of Privileges is:

ADMIT patients with problems related to general surgery; provide consultation for problems related to general surgery; other diagnostic tests and procdures for problems related to general surgery' and treat patients with general surgery problems.

CORE PROCEDURAL PRIVILEGES: All General Surgeons are eligible to apply for the following core procedures.
Amputations
Anal and Rectal Surgery (including hemorrhoidectomy, drainage of rectal abscesses and rectal problems)
Biliary Tract Surgery (including cholecystectomy, common duct procedures and biliary enteric bypass)
Breast Surgery (including biopsy and resection for cancer)
Gastroduodenal Surgery (of esophagus, stomach and duodenum)
Splenectomy or Splenic Repair
Hepatic Resections
Hernia Repair (including all hernias of abdominal wall and peritoneal cavity)
Surgery of the intestine small and large (including resection with anastomosis, internal bypass (NOT for obesity) and external diversion)
Pancreatic Surgery (including resection and diversion)
Radical Cancer Surgery (including regional lymph node dissection)
Head and Neck Surgery (including thyroidectomy, parathyroidectomy, tracheotomy, and salivary gland resection)
Split thickness skin grafts
Varicose veins (actually spelled VERIcose veins on the app! 🙄 )

For the following SPECIAL PROCEDURES and ENDOSCOPY PROCEDURES: general surgeons are encouraged to apply provided specific training criteria are met:
Laparoscopic procedures related to general surgery
Laser Argon/Co2/YAG
Conscious Sedation
Thorascopic Laser Surgery
Endovenous Radiofrequency Ablation
Male Sterilization
Sentinel Lymph Node Biopsy
Stereotactic Biopsy
Biliary Stenting
EGD
Colonoscopy
Colonscopy with Polypectomy
ERCP
Esophageal Variceal Sclerosis
Esophageal Dilatation
Flex Sig
PEG
Sigmoidscopy with Biopsy
Sphincterotomies

What I am getting at : does that mean that every procedure you trained on during the 3 general surgery years in an integrated residency is fair game? Meaning, you could ask to be credentialed on those, and receive reimbursement from insurance?

Fair game as in, can you request privileges in it? Sure. However, it remains to be seen how hospitals will manage this. The application I am filling out for reappointment to the hospital above clearly says that be granted General Surgery privileges you must be Board Eligible AND in the process of being BC (ie, only for people within their 5 years of eligiblity) or Board Certified. Thus, currently it sounds as if you will not be granted general surgery privileges without being BE/BC. I can't see any hospital making the Delineation of Privileges even MORE detailed (ie, focusing on what you did during your 3 years of gen surg and giving you privileges for those procedures only).

Or is the last part the sticking point : do the good, private insurance companies simply refuse to pay anyone who is not board eligible for performing a procedure in a certain 'coding category'.

They can and they have. If an insurance company decides you are not trained in a procedure, they can deny payment.

This has happened in the past and been successful adjudicated in the situation of surgeons performing image guided biopsies. Some insurance companies were denying reimbursement for these procedures because all of their documentation required that it be done by a radiologist. Surgeons had to prove that they had sufficient training to do these procedures and that if the training met the ACR requirements, that there was no reason you should deny reimbursement based on what residency the physician completed.

Much of the time this isn't caught by the massive insurance companies and technically if you are licensed, you can do anything. Whether or not hospitals will give you privileges or insurance companies pay, is another matter entirely.

As a general rule, the answer to any credentialing question is "it depends".

Lots of factors, but it generally boils down to money. If a liberal credentialing policy will bring extra business to a facility, you're likely to get privileges. Likewise, if your procedure of choice is going to steal business from someone who is already bringing big $$ to the facility, fat chance.

Absolutely. Fancy hospital X has no incentive to piss off fat cat Dr. Gastroenterologist and allow you to do ERCPs (for example).

The minute I start to try and do "real" general surgery is the minute the general surgeons start to scream and make me take general surgery call. Don't fool yourself into thinking that these hospitals or your colleagues aren't thinking about THEIR bottom line.

In the situation of a general surgeon applying for credentials at a facility, there will typically be a list of basic procedures that any general surgeon will get privileges for based on completing a residency. (hernias, appendectomy, etc) For newer or more specialized procedures (lap colon, whipple) you may need to provide specific proof of training.

Exactly. Every hospital I've applied to has some basic procedures included under general surgery and most also have a supplemental list of advanced laparoscopic skills, etc. Vascular Surgery is almost always a separate procedure list from General Surgery.

Whether you could get privileged for GS type cases without being GS boarded ... who knows. Nobody's out there yet. I suspect it that's really an interest to you, you should do the extra year.

Right. We don't know the answer yet.

Reimbursement is another issue. Winged Scapula can probably comment on this more intelligently than I, but you might have trouble getting contracts with insurance plans, although I doubt they'd deny an out of network claim.

As I noted above, the insurance companies also do their own credentialing and decide whether you are trained to do certain procedures. They can always deny you based on what they consider inappropriate procedures for your specialty. I'd imagine (and again this is only a guess since this hasn't been an issue yet) that if you are trained as a Vascular Surgeon they will deny General Surgery codes because you aren't trained to the BE/BC requirement in that specialty.

The bigger question is whether the holders of good private insurance who are presumably moderately sophisticated would want to patronize you instead of someone who is fully trained

I wouldn't and I don't even have good private insurance. 😉

I've wondered about this. Poop is gross. But then, so is anatomy lab and Ob/Gyn. Wouldn't a general surgery resident get used to it, even if his dream was to some day to pass the pearly gates of vascular or plastics?

Ignoring the vaguely misogynistic comment about Ob-Gyn being gross, most surgeons don't think poop or anatomy lab is "gross". So of course we get used to it, generally MUCH earlier than residency, otherwise we wouldn't be general surgeons. I frankly am much more grossed out by children picking their nose and eating it than I am in looking at someone's vajayjay or a belly full of succus.

Well, I figured after a while it would grow on you. Rerouting poop might get to be fun. It might be a crappy job, but someone's got to do it.

Also, the poop has to get out somehow, without leaking into the abdomen. Otherwise the patient will die. So general surgeons do save lives.

I'm not sure it grows on you. You learn to deal with it, you realize you ARE saving lives and you do what the patient needs. Residents who go into colorectal aren't necessarily anymore interested in poop than the rest of us, but enjoy the operations, the patients, the pathology, etc. I have a high tolerance for high maintenance patients, hence my choice of a specialty. I know many others who prefer trauma so they don't have to talk to patients, etc.

We've all chosen our paths for various reasons. I'm sure most of us are not enthralled with fecal matter, at least not in Freudian terms, but rather see it as a necessary part of the job we do. If you can't handle it, then general surgery isn't the job for you.

As Pilot Doc noted, it remains to be seen what the outcomes will be for those without BE in general surgery and seeking hospital privileges. I'm fairly sure that 99.8% of vascular surgeons (except the old school guys) have no interest in doing belly cases. I have no interest in doing amputations or vascular bypasses. Most CT surgeons have no interest in anal rectal cases. Most colorectal surgeons have little interest in trauma, and so on.

 

[GeraldMonroe]

Thanks for the extremely detailed reply, Winged Scapula.

That's a pretty substantial list of things a general surgeon is allowed to do. I would assume some of those things overlap heavily into the turf of the other specialty surgeons.

In any case, giving up that list in return for a smaller list of procedures that currently pay better seems like a chancy prospect. In the long run, the insurance industry does have to bow to supply and demand. If they under-pay general surgeons for long enough, eventually there won't be enough of them left. Further, the fact that you can take general surgery call if you were double boarded means that you are able to perform a service the hospital does need. Wouldn't that give you more negotiating power than if you were only boarded in Vascular?

 

[Winged Scapula]

Thanks for the extremely detailed reply, Winged Scapula.

That's a pretty substantial list of things a general surgeon is allowed to do. I would assume some of those things overlap heavily into the turf of the other specialty surgeons.

Sure. The field of general surgery is necessarily broad as is the education. With the increasing subspecialization, you have many fear the end of the general surgeon as we know him/her, claiming that all general surgeons can do are hernias, appys, skin and soft tissue cases.

You are trained in HP surgery, although a HP surgeon may do it better. You are trained in Vascular, although the Vascular surgeon may be more facile. Where your turf ends and that of the fellowship trained surgeon starts depends highly on your environment. Most general surgeons aren't going to be regularly doing the more complex cases, but it depends on your level of comfort and training.

In any case, giving up that list in return for a smaller list of procedures that currently pay better seems like a chancy prospect. In the long run, the insurance industry does have to bow to supply and demand. If they under-pay general surgeons for long enough, eventually there won't be enough of them left.

Unlikely. There will always be people who will go into surgery even with a lower salary. However, if the numbers become really critically low, then the government will have to step in with incentives to train in general surgery.

Further, the fact that you can take general surgery call if you were double boarded means that you are able to perform a service the hospital does need. Wouldn't that give you more negotiating power than if you were only boarded in Vascular?

Maybe. But you are making the common mistake that pre meds and young medical students make:

1) that you want to take general surgery call
2) that as a specialty trained surgeon you will want to do general surgery

Every few months we get some HS student posting on here about how they want to be a Neurosurgeon AND a CT surgeon. You can't do it all.

I suppose if you really wanted to do general surgery and didn't let on about that fact and weren't required to do it as a vascular surgeon, you could use that (taking GS call) as a leverage point. I think surgery is increasingly heading toward superspecialization with more Integrated programs but its too early to predict what will happen to general surgery or getting privileges at hospitals when you're done with such programs.

 

[kocker]

who needs a hedge when we have decades of reimbursement patterns to look at. The gods of medicare money turned their backs on general surgery years ago. I'd bet just about anything that the more endovascular vascular can claim the higher the reimbursement will go.

Not to mention you save 2-4 (depending on whether you get side tracked by research; common at some gen surg programs), and DONT have to play with poop quite as long.

I'm more interested in what fellowships you would be eligible for after an integrated vasc residency. One would think transplant fellowships and CT might eventually accept integrated vasc applications

I agree beav, this could be very interesting. It seems logical that integ vasc people could be eligiable for ct, transplant and maybe hand. The ineteresting part is that this would open an entirely new training path to about .5 of all fellowships effectively cutting the gs in half, and perhaps acting as the nail in the coffin so to speak- bowel people vs non bowel. I'm not sure if the powers that be are ready for that.

 

[Smurfette]

I don't think transplant would be an option without more gen surg (pancreas transplants, roux limbs for bile ducts in complicated liver transplants, etc.). Also, transplant surgeons usually become the primary doc for their post op patients...so they do any surgeries they need as well (parathyroids, bowel obstrcutions, liver resections, biliary reconstructions etc.).
For straight forward transplants, vascular is of course adequately trained for (especially kidneys), but the more complicated stuff can get pretty crazy really fast.

 

[maxheadroom]

I agree beav, this could be very interesting. It seems logical that integ vasc people could be eligiable for ct, transplant and maybe hand. The ineteresting part is that this would open an entirely new training path to about .5 of all fellowships effectively cutting the gs in half, and perhaps acting as the nail in the coffin so to speak- bowel people vs non bowel. I'm not sure if the powers that be are ready for that.

Smurfette is right -- transplant requires too much General Surgery to really follow integrated Vascular very well. While hands do have blood vessels in them, the similarities stop there. Sure, General Surgeons can go through Hand fellowships (usually in an attempt to get into PRS), but the majority of Hand is done by Ortho and PRS because the skill sets for those two disciplines line up with those used in Hand surgery.

 

[beaverfetus]

I don't think transplant would be an option without more gen surg (pancreas transplants, roux limbs for bile ducts in complicated liver transplants, etc.). Also, transplant surgeons usually become the primary doc for their post op patients...so they do any surgeries they need as well (parathyroids, bowel obstrcutions, liver resections, biliary reconstructions etc.).
For straight forward transplants, vascular is of course adequately trained for (especially kidneys), but the more complicated stuff can get pretty crazy really fast.

with all due deference to your experience, it seems conspicuous that this would be the case since currently a urologist that has none of the aforementioned skills relating to para-thyroid and biliary surgery, is qualified to apply for solid organ transplant fellowships. I know for a fact Maryland regularly trains members of the stream team in renal/panc AND liver.

My guess is with the current shortage in applicants you could get trained from just about any scalpel wielding residency. But transplant seems like a chip shot from vascular, particularly given the 2-3 years you are going to spend with the general surgeons.


see you can even train at the mecca as a coc-doc
http://www.upmc.com/Services/Transp...e/Pages/TransplantationFellowshipProgram.aspx

 

[Smurfette]

with all due deference to your experience, it seems conspicuous that this would be the case since currently a urologist that has none of the aforementioned skills relating to para-thyroid and biliary surgery, is qualified to apply for solid organ transplant fellowships. I know for a fact Maryland regularly trains members of the stream team in renal/panc AND liver.

My guess is with the current shortage in applicants you could get trained from just about any scalpel wielding residency. But transplant seems like a chip shot from vascular, particularly given the 2-3 years you are going to spend with the general surgeons.


see you can even train at the mecca as a coc-doc
http://www.upmc.com/Services/Transp...e/Pages/TransplantationFellowshipProgram.aspx

Not entirely sure of your background on this. At my hospital, ALL GU residents do a rotation on transplant. I think it is a RRC requirement, the goal of course being a renal transplantation experience and experience in dealing with that particular patient population.
There are always fellowships that will accommodate people with different backgrounds...i.e. Hand fellowships will take ortho/PRS/gen surg, critical care will take anesthesia/gen surg/OBGyn(!)/neurosurg, etc. But most programs have a preference for the background of those who match. A program heavy into renal transplant is more likely to take a GU guy than a program that does a lot of small bowel and liver transplants (who may not even interview a GU guy due to his presumed skill set). I guess what I am trying to say is that finding a program to train you with a "non-standard" background is not going to be easy, as there may only be a handful of places where you realistically have a shot. And, urologists being credentialed at a hospital nowadays (i.e. not grandfathered in from days of yore) for transplant (beyond kidneys) has got to be rare.

While transplant is not a particularly popular fellowship, it also is a tough job market once you finish (especially if you want to do livers), and some grads do general surgery until they finally can land a transplant job somewhere.

 

[core0]

Not entirely sure of your background on this. At my hospital, ALL GU residents do a rotation on transplant. I think it is a RRC requirement, the goal of course being a renal transplantation experience and experience in dealing with that particular patient population.
There are always fellowships that will accommodate people with different backgrounds...i.e. Hand fellowships will take ortho/PRS/gen surg, critical care will take anesthesia/gen surg/OBGyn(!)/neurosurg, etc. But most programs have a preference for the background of those who match. A program heavy into renal transplant is more likely to take a GU guy than a program that does a lot of small bowel and liver transplants (who may not even interview a GU guy due to his presumed skill set). I guess what I am trying to say is that finding a program to train you with a "non-standard" background is not going to be easy, as there may only be a handful of places where you realistically have a shot. And, urologists being credentialed at a hospital nowadays (i.e. not grandfathered in from days of yore) for transplant (beyond kidneys) has got to be rare.

While transplant is not a particularly popular fellowship, it also is a tough job market once you finish (especially if you want to do livers), and some grads do general surgery until they finally can land a transplant job somewhere.

Interestingly the current urology RRC standards call for expertise in renal transplant for urology. Even more interesting the new standards that start in 2009 move renal transplant from core knowledge to must receive didactic instruction. This probably reflects a fairly large number of urology programs that don't have access to a transplant program. The programs that I have direct knowledge of (4-5 high volume programs) don't have urology residents (they also don't have urologists on staff). Realistically in any program with fellows its unlikely that a resident is going to get to do much operating. I think that urology residents getting transplant fellowships and rotation through the service is going to be dependent on having staff urologists in the program.

One issue with integrated vascular surgery and transplant is, are the graduates going to have enough advanced laprascopic experience. Laprascopic nephrectomies are becoming derigeur at most programs.

David Carpenter, PA-C

 

[SocialistMD]

I don't think transplant would be an option without more gen surg (pancreas transplants, roux limbs for bile ducts in complicated liver transplants, etc.). Also, transplant surgeons usually become the primary doc for their post op patients...so they do any surgeries they need as well (parathyroids, bowel obstrcutions, liver resections, biliary reconstructions etc.).
For straight forward transplants, vascular is of course adequately trained for (especially kidneys), but the more complicated stuff can get pretty crazy really fast.

You guys are missing the big picture; why on God's green earth would a vascular surgeon want to do transplants? Transplant surgery isn't a part-time, fill-the-day-while-I-don't-have-a-AAA-to-repair kind of field, and the call is murder compared to that of a vascular surgeon.

Where's Castro to back me up on this?

 

[Smurfette]

You guys are missing the big picture; why on God's green earth would a vascular surgeon want to do transplants? Transplant surgery isn't a part-time, fill-the-day-while-I-don't-have-a-AAA-to-repair kind of field, and the call is murder compared to that of a vascular surgeon.

Where's Castro to back me up on this?

Very true. I was looking at it as a hypothetical "finishing up vasc surg residency, what are my options" point of view...given the new 3+3, people are making the choice early on before they have exposure to other subspecialties.
Certainly vascular call (sane...usually) and transplant call (insane) are two entirely different animals.

 

[umean2tellme]

Hello. I'm an MS0 but I had a question or two maybe you surgeons could enlighten me on. I read what everyone said regarding privileges, but how does that work abroad? I mean, I want to do medical missions at some point in my career, and as a surgeon do you need to show proof that you were trained in a particular procedure in order to do it? I like gen surgery (at least the idea of it) b/c I like variety and being able to see/do a lot of different procedures and work with lots of patients with lots of problems. As a general surgeon, do you ever get to work up patients from the ED or is it like every patient you see they basically are diagnosed for you and you just do the procedure and handle them from there?

Also, is there some kind of master list that gives you more or less what types of procedures/treatments a particular specialty is expected to know/do? thanks.

 

[SocialistMD]

I read what everyone said regarding privileges, but how does that work abroad? I mean, I want to do medical missions at some point in my career, and as a surgeon do you need to show proof that you were trained in a particular procedure in order to do it?

Usually the "work abroad" is sponsored by American institutions. You are approved by them, and they go based on your training here.

As a general surgeon, do you ever get to work up patients from the ED or is it like every patient you see they basically are diagnosed for you and you just do the procedure and handle them from there?

During residency, that depends on where you train. Some programs have EM residencies where you generally get them with some sort of diagnosis whereas other programs triage patients to either surgical or medical and the residents work them up from there. In practice, you will honestly not want to work them up anymore. Luckily, you'll either have EM physicians or residents to do that for you.

Also, is there some kind of master list that gives you more or less what types of procedures/treatments a particular specialty is expected to know/do? thanks.

Neurosurgery: Everything brain, spine and (sometimes) peripheral nerve.
Ortho: All bones, joints, ligaments not in the face or skull.
ENT: All skull bones and all soft tissues of the head and neck.
Urology: Anything kidney, ureter, bladder and prostate.
Plastics: Hands, peripheral nerves and face (plus all of the cosmetic stuff).
General Surgery: Everything else.

 

[Castro Viejo]

You guys are missing the big picture; why on God's green earth would a vascular surgeon want to do transplants? Transplant surgery isn't a part-time, fill-the-day-while-I-don't-have-a-AAA-to-repair kind of field, and the call is murder compared to that of a vascular surgeon.

Where's Castro to back me up on this?

Fact: 99.9% of Vascular Surgeons I have met in my travels as medical student, General Surgery resident, and now Vascular Surgery Fellow have no interest in performing General Surgery operations.

And Transplant isn't a part time job as Socialist has said. There's no way for you to do both Transplant and Vascular and hope to be doing the right thing for your patient despite there being some overlap in skill set between the two (a vascular anastomosis is a vascular anastomsis).

Finally, Vascular Surgery is way more lifestyle friendly than General Surgery, Transplant, or Trauma. Why on earth would we give that up only to end up on a helicopter at 4AM to go to a harvest? No thanks. I'll keep to my wires and catheters with the occasional scalpel.

Medicine is becoming a place where a knowledge, technology, and skill explosion has taken place and while there is some need for a generalist, the specialists and subspecialists rule. With outcomes closely watched by everyone from speciality societies to state medical boards and, soon, the Federal Government and with data established and emerging that the more you do of a particular procedure the better you are, you can bet specialty medicine will continue to grow.

 

[RisingSun]

I know that I am kind of reviving an old thread here. Wanted to note that last year apparently there were 152 applicants for 18 positions, per an abstract that is in the May 2009 supplemental of the Journal of Vascular Surgery. So yeah, it is pretty competitive, but it looks like a lot, almost 70%, of those were international grad applicants, so while the competition among AMG may be fierce it is probably better than 152 for 18 spots.