Nurses doing colonoscopies on black patients

[JP2740]

FYI, this has been discussed on this board before and guess who showed up to the thread? Anthony Kalloo himself. Check this out if interested:

If you do GI at Hopkins, you'll be sharing scopes with NP "fellows"

In the latest issue of Hopkins Medicine magazine, there's a column in there about an NP named Monica VanDongen. Here are some direct quotes from the article: "the young woman is unique: VanDongen is a nurse practitioner who completed a one-year, intensive medical fellowship in...

forums.studentdoctor.net

---

Members don't see this ad.

 

[VA Hopeful Dr]

What?! You need a GI appointment prior to a screening colonoscopy?

Usually its the NP doing it, but yes. We have 1 guy that does open access, but it requires the patients to answer the phone which is beyond 99% of my patients.

Even if not, its still 2+ months to schedule the scope at all.

 

[JP2740]

Usually its the NP doing it, but yes. We have 1 guy that does open access, but it requires the patients to answer the phone which is beyond 99% of my patients.

Even if not, its still 2+ months to schedule the scope at all.

So you want patients to be able to get open access without answering the phone? Like just walk into a colonoscopy without any communication and just get it done?

2+ months out for a routine, elective procedure isn’t bad to be honest.

 

[Lawpy]

FYI, this has been discussed on this board before and guess who showed up to the thread? Anthony Kalloo himself. Check this out if interested:

If you do GI at Hopkins, you'll be sharing scopes with NP "fellows"

In the latest issue of Hopkins Medicine magazine, there's a column in there about an NP named Monica VanDongen. Here are some direct quotes from the article: "the young woman is unique: VanDongen is a nurse practitioner who completed a one-year, intensive medical fellowship in...

forums.studentdoctor.net

Seeing that these comments are about me, I thought I should respond to my anonymous critics.
First there are definitely not enough gastroenterologists to meet the demand for screening colonoscopy. An Agency for Health Research and Quality report commissioned for the 2010 National Institutes of Health State-of-the Science Conference on Colorectal Cancer Screening found that the colonoscopy capacity would need to be substantially increased to continue to perform screening colonoscopies at the current rate after screening the 40% of the eligible population that has not yet been screened (Allen JD, Barlow WE, Duncan RP, et al. NIH state-of-the-science conference statement: Enhancing use and quality of colorectal cancer screening. NIH Consens State Sci Statements. 2010;27(1))
The State-of-the-Science Conference recommended that an increase in the endoscopic screening capacity is needed and recommended that expanding high-quality endoscopy training to non-physicians, such as nurse practitioners, may be warranted. Several studies have estimated the number of additional colonoscopists needed to meet the demand for screening colonoscopy. A 2004 study estimated that 1,000 additional colonoscopists were needed if 70% of the 2004 population was screened. At that time there were only 59 million Americans ages 50 to 74 years old that needed screening as compared to 80.5 million in 2010. Gastroenterologists are unlikely to meet the demand as the number of gastroenterology fellowship positions increased by only 50 between 2004 and 2009. Similarly, a report prepared on behalf of the colonoscope industry estimated an additional 1,000 colonoscopists were needed by 2020 to meet the rising demand for colorectal cancer screening.(The Lewin Group Inc. The impact of improved colorectal cancer screening on adequacy of future supply of gastroenterologists. 2009. Available from: http://www.crcawareness.com/files/Lewin-Gastroenterologist-Report.pdf. Accessed August 30, 2012)
These estimates do not account for the growing number of gastroenterologists working fewer hours due to changes in lifestyle and the increasing number of female gastroenterologists who tend to work fewer hours than their male counterparts.(Elta GH. GI training: Where are we headed? Am J Gastroenterol. 2011;106(3):395-397)
Secondly I am an International Medical Graduate and I care deeply for my patients and love the field of gastroenterology. I am a pioneer of Natural Orifice Translumenal Endoscopuc Surgery (NOTES) an emerging endoscopic field designed to empower gastroenterologists to perform more endoscopic procedures as an alternative to surgery. (Kalloo AN, Singh VK, Jagannath SB, Niiyama H, Hill SL, Vaughn CA, Magee CA, Kantsevoy SV. Flexible Transgastric Peritoneoscopy: A Novel Approach to Diagnostic and Therapeutic Interventions in the Peritoneal Cavity. Gastrointestinal Endoscopy 2004 July; 60(1):114-117) (NOTES: current status and new horizons; Khashab MA, Kalloo AN.Gastroenterology. 2012 Apr;142(4):704-710.e1. Epub 2012 Feb 17)

It appears many of the commenters on this forum are more concerned with their own financial gain as opposed to seeking cost effective care for patients. If you are willing to engage in a meaningful discussion about the training of NPs to perform colonoscopy, I would be happy to do so...just own up to your opinions and identify yourselves.
Anthony Kalloo
[email protected]

Wow this guy is even worse than i thought

 

[JP2740]

Wow this guy is even worse than i thought

I won’t give my opinion on him but I did chuckle at “I care deeply about my patients and love the field of GI” thing.

 

[efle]

Uh oh looks like the hunch that studies will show no inferiority on procedures might be supported. I still dont understand what during my MD was supposed to make me better at doing a colonoscopy.

Regarding the racism allegations someone please ELI5 because I dont understand at all how the institution numbers are relevant. His personal patient base is whats relevant. If his patients for screenings are ~75% black what's the issue?

 

[Lawpy]

Uh oh looks like the hunch that studies will show no inferiority on procedures might be supported. I still dont understand what during my MD was supposed to make me better at doing a colonoscopy.

Regarding the racism allegations someone please ELI5 because I dont understand at all how the institution numbers are relevant. His personal patient base is whats relevant. If his patients for screenings are ~75% black what's the issue?

noninferiority studies consistently have major design problems and aren't reliable. The study got pretty trashed on here

 

[Lawpy]

Can someone please explain to me why midlevels are monopolizing procedures instead of training nurses or techs to do these specialized tasks? Why are we wasting money paying midlevels when a specialized tech can do them at a much lower cost?

 

[efle]

noninferiority studies consistently have major design problems and aren't reliable. The study got pretty trashed on here

And yet if this study had shown inadequate detection rates it would be celebrated

 

[Lawpy]

And yet if this study had shown inadequate detection rates it would be celebrated

I doubt it but won't be surprised

 

[Ho0v-man]

Uh oh looks like the hunch that studies will show no inferiority on procedures might be supported. I still dont understand what during my MD was supposed to make me better at doing a colonoscopy.

Regarding the racism allegations someone please ELI5 because I dont understand at all how the institution numbers are relevant. His personal patient base is whats relevant. If his patients for screenings are ~75% black what's the issue?

Exactly. As much as I hate scope creep (ironic use of the word “scope” here), procedures aren’t anything special that only a physician can do. That being said, this becomes a slippery slope that will definitely lead to GI NPs running their own clinics and just scoping everyone regardless of indications and mismanaging things like IBD. But that’s just the grave we’re digging ourselves I suppose.

 

[VA Hopeful Dr]

So you want patients to be able to get open access without answering the phone? Like just walk into a colonoscopy without any communication and just get it done?

2+ months out for a routine, elective procedure isn’t bad to be honest.

No, I'm saying that's why not many people around here do open access scheduling - because patients don't answer the phone and don't set up their voice mail.

2+ months isn't ideal because the longer something takes the more likely noncompliance becomes.

 

[Lawpy]

Exactly. As much as I hate scope creep (ironic use of the word “scope” here), procedures aren’t anything special that only a physician can do. That being said, this becomes a slippery slope that will definitely lead to GI NPs running their own clinics and just scoping everyone regardless of indications and mismanaging things like IBD. But that’s just the grave we’re digging ourselves I suppose.

Why NPs? Why not train a tech to do it?

 

[Redpancreas]

FYI, this has been discussed on this board before and guess who showed up to the thread? Anthony Kalloo himself. Check this out if interested:

If you do GI at Hopkins, you'll be sharing scopes with NP "fellows"

In the latest issue of Hopkins Medicine magazine, there's a column in there about an NP named Monica VanDongen. Here are some direct quotes from the article: "the young woman is unique: VanDongen is a nurse practitioner who completed a one-year, intensive medical fellowship in...

forums.studentdoctor.net

Ahhh this is what I was talking about!

 

[KnuxNole]

What?! You need a GI appointment prior to a screening colonoscopy?

In my community, yes. The physicians will not do the procedure until a formal appointment is made.

 

[Redpancreas]

Why NPs? Why not train a tech to do it?

Agreed. Let’s just get techs to do a one year course in an endoscopy. Physicians can learn it to supervise. Then what value does an NP provide? Nothing.

 

[efle]

Agreed. Let’s just get techs to do a one year course in an endoscopy. Physicians can learn it to supervise. Then what value does an NP provide? Nothing.

You're onto something here, I know you're trying to be sarcastic but if you plopped me in a suite as a premed versus now I would be equally (in)competent. Procedures are closer to a tradecraft than they are to an academic profession like law, scientific research or the cerebral parts of medicine.

 

[Ho0v-man]

Why NPs? Why not train a tech to do it?

I’m fine with that. I assumed that whoever did the procedure has to write the report and that requires some degree of an education.

 

[Lawpy]

You're onto something here, I know you're trying to be sarcastic but if you plopped me in a suite as a premed versus now I would be equally (in)competent. Procedures are closer to a tradecraft than they are to an academic profession like law, scientific research or the cerebral parts of medicine.

I’m fine with that. I assumed that whoever did the procedure has to write the report and that requires some degree of an education.

The point is why do midlevels even exist if we can just delegate procedures or clinic duties or preop/postop work to specialized techs?

 

[Lawpy]

This brings up a related point on what's exactly the point of med school if much of the learning on clinical medicine is done in residency/fellowship?

 

[Matthew9Thirtyfive]

Exactly. As much as I hate scope creep (ironic use of the word “scope” here), procedures aren’t anything special that only a physician can do. That being said, this becomes a slippery slope that will definitely lead to GI NPs running their own clinics and just scoping everyone regardless of indications and mismanaging things like IBD. But that’s just the grave we’re digging ourselves I suppose.

Like yeah, if you take an NP and train them for years to do these and how to recognize lesions, what needs to be biopsied, etc., then they will probably have similar detection rates...because you're basically giving them a fellowship in screening c-scopes. But that is NOT what will end up happening out in the real world. What will happen is you'll have an NP learn to do the monkey skills of a c-scope, which really isn't that technically challenging (and I know because I have done that part of it) and then be loosed onto unsuspecting patients to get unnecessary biopsies or have suspicious lesions missed because they don't know what they're looking for. And the patients who will disproportionately suffer are the poor ones.

 

[Lawpy]

What we need to do is to revise or even replace the severely outdated Flexner report.

 

[Matthew9Thirtyfive]

You're onto something here, I know you're trying to be sarcastic but if you plopped me in a suite as a premed versus now I would be equally (in)competent. Procedures are closer to a tradecraft than they are to an academic profession like law, scientific research or the cerebral parts of medicine.

I get that you don't want anyone to trash your institution, but I can't tell if you're intentionally separating things or if you're just not seeing them. You realize that the actual skills part of the procedure is just one aspect of it, and that basically anyone can learn to do that, right? The part where you want a physician doing your procedure isn't because there's some magical thing about being an MD that lets you do a scope better. It's knowing what to do with what you find and how to manage complications and unexpected findings.

 

[Lawpy]

I get that you don't want anyone to trash your institution, but I can't tell if you're intentionally separating things or if you're just not seeing them. You realize that the actual skills part of the procedure is just one aspect of it, and that basically anyone can learn to do that, right? The part where you want a physician doing your procedure isn't because there's some magical thing about being an MD that lets you do a scope better. It's knowing what to do with what you find and how to manage complications and unexpected findings.

The specialized techs in the proposed system are still being supervised by physicians. What i'm questioning is the existence of midlevels

 

[Matthew9Thirtyfive]

The specialized techs in the proposed system are still being supervised by physicians. What i'm questioning is the existence of midlevels

How are they supervised? Is the attending in the room watching the whole procedure?

 

[Lawpy]

How are they supervised? Is the attending in the room watching the whole procedure?

Probably not so there's an aspect of trust involved. I know i saw a gas thread where a CRNA royally screwed up the anesthesia and the patient was awake when getting surgery. The attending was apparently away with many anesthesia posters empathizing with the attending's actions

There's going to be risk and the liability will likely fall heavily on the tech and partially shared by the supervising attending

 

[efle]

I get that you don't want anyone to trash your institution, but I can't tell if you're intentionally separating things or if you're just not seeing them. You realize that the actual skills part of the procedure is just one aspect of it, and that basically anyone can learn to do that, right? The part where you want a physician doing your procedure isn't because there's some magical thing about being an MD that lets you do a scope better. It's knowing what to do with what you find and how to manage complications and unexpected findings.

I have zero pride in the institution, they were a disgrace to many of my brilliant classmates in the match this year. Not to mention the bad parts of their history. If this was done at MGH I'd still think you could train me just as easily to competently screen prior to my MD. Youd think they would be inadequate at detecting polyps if the degree conferred some intellectual advantage.

 

[Lawpy]

I have zero pride in the institution, they were a disgrace to many of my brilliant classmates in the match this year. Not to mention the bad parts of their history. If this was done at MGH I'd still think you could train me just as easily to competently screen prior to my MD. Youd think they would be inadequate at detecting polyps if the degree conferred some intellectual advantage.

Do you think the Flexner report should be replaced because its badly outdated

 

[efle]

Do you think the Flexner report should be replaced because its badly outdated

Lawper sometimes I wonder if you're an AI

 

[Lawpy]

Lawper sometimes I wonder if you're an AI

I'm thinking through multiple solutions at once!

 

[Matthew9Thirtyfive]

Probably not so there's an aspect of trust involved. I know i saw a gas thread where a CRNA royally screwed up the anesthesia and the patient was awake when getting surgery. The attending was apparently away with many anesthesia posters empathizing with the attending's actions

There's going to be risk and the liability will likely fall heavily on the tech and partially shared by the supervising attending

Get real. The liability there would be a 100% on the physician. What is the difference between using an NP or a tech in this fashion?

 

[Lawpy]

Get real. The liability there would be a 100% on the physician. What is the difference between using an NP or a tech in this fashion?

I mean i know because the liability is profit-driven and physicians earn more than techs/midlevels. That's a bad way to go about these cases because the liability should fall heavily on the tech doing the procedure

It phases out the midlevels completely. The techs would just need to have specialized training for the procedures they're going to perform. It can make the techs cheaper than midlevels.

 

[efle]

Get real. The liability there would be a 100% on the physician. What is the difference between using an NP or a tech in this fashion?

Nobody freaks out about brand new fellows with experienced supervision, I imagine a brand new NP or PA fellow would be OK with a similar arrangement. I'm of course always ready to eat my hat when studies come out showing inferiority, that would only be good news for the value of our degrees in general. But every time I ask around on SDN or reddit it sounds like the studies have yet to be done or showed no differences.

 

[Matthew9Thirtyfive]

Nobody freaks out about brand new fellows with experienced supervision, I imagine a brand new NP or PA fellow would be OK with a similar arrangement. I'm of course always ready to eat my hat when studies come out showing inferiority, that would only be good news for the value of our degrees in general. But every time I ask around on SDN or reddit it sounds like the studies have yet to be done or showed no differences.

What studies are you talking about? There are literally zero studies looking at comparing unsupervised midlevels to physicians. All of them, the midlevels were supervised and/or had access to physicians to consult (e.g., in the ICU, they had ICU fellows and attendings to ask questions to). So where are these studies showing they are equal?

 

[Matthew9Thirtyfive]

I have zero pride in the institution, they were a disgrace to many of my brilliant classmates in the match this year. Not to mention the bad parts of their history. If this was done at MGH I'd still think you could train me just as easily to competently screen prior to my MD. Youd think they would be inadequate at detecting polyps if the degree conferred some intellectual advantage.

Hmm, I'm not sure if I necessarily agree. I think things like detecting polyps and stuff are where residency/fellowship comes in. I think the advantage the degree gives us is more intellectual. It gives us a foundation to build off of to really be where the buck stops. Someone with no formal education on pharm, pathophys, etc. just doesn't have the foundation to really synthesize that knowledge, which is super evident when you look at how midlevels manage things like mental health, etc.

 

[efle]

What studies are you talking about? There are literally zero studies looking at comparing unsupervised midlevels to physicians. All of them, the midlevels were supervised and/or had access to physicians to consult (e.g., in the ICU, they had ICU fellows and attendings to ask questions to). So where are these studies showing they are equal?

Oh I forsee them practicing supervised. Like the model of several NPs in a primary clinic with an MD supervising, I can see outpatient scope centers with several NPs (and sedation by CRNAs) with supervising MDs.

 

[Matthew9Thirtyfive]

Oh I forsee them practicing supervised. Like the model of several NPs in a primary clinic with an MD supervising, I can see outpatient scope centers with several NPs (and sedation by CRNAs) with supervising MDs.

There are only a couple of studies that have actually looked at this, and they have essentially demonstrated equivalence when the midlevels are appropriately supervised, meaning the cases are appropriately screened and all labs, etc are followed up by the physician. And even with that, the ones that looked more in depth showed that the midlevels were only making appropriate decisions in 50-60% of the cases. So even though the ultimate outcomes were equal, it was only because the supervising physicians were involved and had adequately trained and supervised.

That hardly shows any sort of equivalence, and you can’t really extrapolate that to just letting midlevels do c scopes Willy nilly.

 

[Ho0v-man]

The point is why do midlevels even exist if we can just delegate procedures or clinic duties or preop/postop work to specialized techs?

I agree.

Like yeah, if you take an NP and train them for years to do these and how to recognize lesions, what needs to be biopsied, etc., then they will probably have similar detection rates...because you're basically giving them a fellowship in screening c-scopes. But that is NOT what will end up happening out in the real world. What will happen is you'll have an NP learn to do the monkey skills of a c-scope, which really isn't that technically challenging (and I know because I have done that part of it) and then be loosed onto unsuspecting patients to get unnecessary biopsies or have suspicious lesions missed because they don't know what they're looking for. And the patients who will disproportionately suffer are the poor ones.

I agree. And that’s what NPs are after. Just doing as much high reimbursement stuff with as little training as possible. I’m not arguing any of that. I’m arguing that cash cow procedures that don’t really need 11 years of education prior to the first time you do one aren’t going to protect you from midlevels. One needs to just read posts from PMHNPs to know that all any of them care about is making money with minimal effort. To be fair, lots of physicians are the same way, our training just adds tons of hurdles to doing that so that we’re actually competent.

It will absolutely lead to increased healthcare costs and worse patient outcomes that disproportionately affect the most vulnerable populations.

But it’ll happen because it’ll make someone money. Welcome to America.

 

[efle]

There are only a couple of studies that have actually looked at this, and they have essentially demonstrated equivalence when the midlevels are appropriately supervised, meaning the cases are appropriately screened and all labs, etc are followed up by the physician. And even with that, the ones that looked more in depth showed that the midlevels were only making appropriate decisions in 50-60% of the cases. So even though the ultimate outcomes were equal, it was only because the supervising physicians were involved and had adequately trained and supervised.

That hardly shows any sort of equivalence, and you can’t really extrapolate that to just letting midlevels do c scopes Willy nilly.

Yeah of course having a group of NPs and CRNAs running a scope center with no doctors involved sounds insane. I'd love a link on the 50% error rate being rescued by supervisors, seems like we have nothing to worry about if that can be demonstrated a few times.

 

[JP2740]

Exactly. As much as I hate scope creep (ironic use of the word “scope” here), procedures aren’t anything special that only a physician can do. That being said, this becomes a slippery slope that will definitely lead to GI NPs running their own clinics and just scoping everyone regardless of indications and mismanaging things like IBD. But that’s just the grave we’re digging ourselves I suppose.

Yea this is more complicated than simply looking for non inferiority of nurses doing screening colonoscopies. See my post on page 1

 

[JP2740]

Like yeah, if you take an NP and train them for years to do these and how to recognize lesions, what needs to be biopsied, etc., then they will probably have similar detection rates...because you're basically giving them a fellowship in screening c-scopes. But that is NOT what will end up happening out in the real world. What will happen is you'll have an NP learn to do the monkey skills of a c-scope, which really isn't that technically challenging (and I know because I have done that part of it) and then be loosed onto unsuspecting patients to get unnecessary biopsies or have suspicious lesions missed because they don't know what they're looking for. And the patients who will disproportionately suffer are the poor ones.

The number of supervised colonoscopies that has been set to perform the procedure adequately is much lower than what most people think it should be too. You know they’re going to train nurses to hit those bare minimums.

 

[Ho0v-man]

Yea this is more complicated than simply looking for non inferiority of nurses doing screening colonoscopies. See my post on page 1

I already have, but thanks for the homework assignment, teach!

 

[efle]

The number of supervised colonoscopies that has been set to perform the procedure adequately is much lower than what most people think it should be too. You know they’re going to train nurses to hit those bare minimums.

Inadequate standards seems like a much bigger issue than who's being trained. We REALLY need to cut down on the useless hoop jumping in MD school and IM residency if the fellowships arent providing adequate experience in 3 years.

 

[JP2740]

Inadequate standards seems like a much bigger issue than who's being trained. We REALLY need to cut down on the useless hoop jumping in MD school and IM residency if the fellowships arent providing adequate experience in 3 years.

Oh yea the fellowships are definitely providing enough in 3 years. I’m saying that if there is a nurse fellowship I doubt they’ll reach the colonoscopy numbers of a fellowship trained GI doc who’s numbers far surpass what is required nationally. I would say I was semi-comfortable solo scoping when I doubled what is required nationally. Most fellowships give way more colonoscopies than what is required

i do agree with useless hoop jumping. There’s no reason why a GI needs to do 3 years of IM. Should be a 4 year residency. 1 IM+3 GI, but then all these hospitals would lose the labor

 

[Lawpy]

Oh yea the fellowships are definitely providing enough in 3 years. I’m saying that if there is a nurse fellowship I doubt they’ll reach the colonoscopy numbers of a fellowship trained GI doc who’s numbers far surpass what is required nationally. I would say I was semi-comfortable solo scoping when I doubled what is required nationally. Most fellowships give way more colonoscopies than what is required

i do agree with useless hoop jumping. There’s no reason why a GI needs to do 3 years of IM. Should be a 4 year residency. 1 IM+3 GI, but then all these hospitals would lose the labor

Wait that's a very good point. Cards, GI and heme/onc should all be like rads, derm in having a 1 yr IM + 3 years of that fellowship training

@elementaryschooleconomics @medgator is radonc residency 1 yr IM + 4 years of radonc residency?

@Lem0nz why can't we make surgical oncology a surgical subspecialty with 1 yr gen surg + 5 yrs surg onc?

Sorry for the tags i'm just thinking out loud here

 

[Matthew9Thirtyfive]

Yeah of course having a group of NPs and CRNAs running a scope center with no doctors involved sounds insane. I'd love a link on the 50% error rate being rescued by supervisors, seems like we have nothing to worry about if that can be demonstrated a few times.

The study is cited in the book "Patients at Risk." I can get the cite if you don't have that book. But you should get it, because I think it would be a great read for you, and it's really inexpensive.

 

[Lawpy]

The study is cited in the book "Patients at Risk." I can get the cite if you don't have that book. But you should get it, because I think it would be a great read for you, and it's really inexpensive.

Wait when was that book out?? I need to get it since i havent heard of this

 

[efle]

The study is cited in the book "Patients at Risk." I can get the cite if you don't have that book. But you should get it, because I think it would be a great read for you, and it's really inexpensive.

Cite plz dont have it

 

[Matthew9Thirtyfive]

Wait when was that book out?? I need to get it since i havent heard of this

It came out within the last year. Very much has an objective, but it has a lot of data in it presented accurately.

Book | Patients at Risk

 

[Lem0nz]

Wait that's a very good point. Cards, GI and heme/onc should all be like rads, derm in having a 1 yr IM + 3 years of that fellowship training

@elementaryschooleconomics @medgator is radonc residency 1 yr IM + 4 years of radonc residency?

@Lem0nz why can't we make surgical oncology a surgical subspecialty with 1 yr gen surg + 5 yrs surg onc?

Sorry for the tags i'm just thinking out loud here

All of surgical oncology is rooted in general surgery. The bowel work requires basic and complex bowel knowledge of how the tissue responds when normal, inflamed, perforated. There's vascular work that you need the vascular background for (portal vein resections, vena cava resections for sarcoma, extremity sarcoma resections, vascular tumors, occasional arterial bypasses for more exotic things). To understand the complex biliary anatomy you absolutely need to know the simple biliary anatomy. You need to have a very strong foundation and working knowledge of the chest if you're going to do esophagus work or need to do partial diaphragm resections. You need to know enough about plastics and herniology to understand when you can do simple closures or when you need to do complex closures and if/when to call a specialist. A lot of general surgery covers the straightforward cancers too: colon, skin, breast, thyroid/parathyroid. Etc. Finally, MANY surgical oncology jobs will have some component of general surgery call, and sometimes trauma call. This is getting less, but is still probably at least 25 if not 50% of jobs (the component may be small, like 2 calls/month or as high as 10 calls/month, but its not zero).

Surgical oncology should never be decoupled from general surgery. You absolutely need all, literally all, of the fundamentals provided by a general surgery residency from the ICU to the floor to the OR.

A 4+2 or 3+3 model could be entertained.