Pediatric CT Surgery Pipeline Advice

[plukfelder2017]

Hi Folks,

Thank you for your contribution to this forum. I wouldn't have gotten into medical school and through boards/rotations without your assistance.

I am a 3rd year medical student applying to residency programs in this upcoming application cycle. I was initially intending on applying to integrated vascular surgery programs. After spending time on the pediatric cardiac surgery service, I feel a heightened sense of purpose and feel mentally prepared to commit to the trials and tribulations of this career field. I do see myself fitting into the culture of this service and have always considered pursuing it but did not feel prepared to follow suit until recently. Job prospects, training length, and outcome scrutiny were the rate limiting steps previously. Of note, I have also absolutely loved my time on the vascular and adult cardiac surgery services as well. Less so with core gen surg/thoracic, I just don't want to look back on my life with regrets.

My Stats:
US MD, step 1: Around 250, CK 4 months away
3rd year rotations: Honors surgery, medicine, peds etc
Publications>10 All Vascular
Letters (all vascular)

Questions:
1. Is Integrated vascular surgery>cardiac surgery fellowship>pediatric CT super fellowship a viable training pathway? Would I be able to obtain a board certification in congenital through this pathway? Would it be recognized/ACGME approved? I have tried looking at the AATS website but am unable to find info on this. I do understand that there are multiple individuals who have transitioned from integrated vascular surgery programs to cardiac surgery fellowships (ie. from the houston/cleveland/dc programs) but am unsure if anyone has pursued additional training beyond a cardiac fellowship.

2. Considering that the current tried, true, and tested pathway is GS>CT> congenital or I6>congenital, is the above pathway viable/practical? Would it lead to deficiencies in my surgical skillset? I am asking this question because the CHS that I followed had 0 core thoracic cases on his OR schedule. He was primarily performing palliative arterial/circuit reconstructions, ie pure CV work.

Thanks and I wish y'all a happy new year. Hopefully 2021 is better for all of us.

Best,
Plukfelder

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[LucidSplash]

Hi Folks,

Thank you for your contribution to this forum. I wouldn't have gotten into medical school and through boards/rotations without your assistance.

I am a 3rd year medical student applying to residency programs in this upcoming application cycle. I was initially intending on applying to integrated vascular surgery programs. After spending time on the pediatric cardiac surgery service, I feel a heightened sense of purpose and feel mentally prepared to commit to the trials and tribulations of this career field. I do see myself fitting into the culture of this service and have always considered pursuing it but did not feel prepared to trust my gut until recently. Job prospects, training length, and outcome scrutiny were the rate limiting steps previously. Of note, I have also absolutely loved my time on the vascular and adult cardiac surgery services as well. Less so with core gen surg/thoracic, I just don't want to look back on my life with regrets.

My Stats:
US MD, step 1: Around 250, CK 4 months away
3rd year rotations: Honors surgery, medicine, peds
Publications>10 All Vascular
Letters (all vascular)

Question
1. Is Integrated vascular surgery>cardiac surgery fellowship>pediatric CT super fellowship a viable pathway? Would I be able to obtain a board certification in congenital through this pathway? Would it be recognized/ACGME approved? I have tried looking at the AATS website but am unable to find info on this. I do understand that there are multiple individuals who have transitioned from integrated vascular surgery programs to cardiac surgery fellowships but am unsure if anyone has pursued additional training beyond a cardiac fellowship.

2. Considering that the current tried, true, and tested pathway is GS>CT> congenital is the above pathway viable/practical? Would it lead to deficiencies in my surgical skillset? I am asking this question because the CHS that I followed had 0 core thoracic cases on his OR schedule. He was primarily performing palliative arterial/circuit reconstructions, ie pure CV work.

Thanks and I wish y'all a happy new year. Hopefully 2021 is better for all of us.

Best,
Plukfelder

As far as viable, you should be fine. In terms of requirements to apply to congenital cardiac fellowship, you are required to have completed a CTS residency/fellowship. That you did vascular first isn't going to matter based on that requirement.

But I have to ask, why apply to vascular at all? Why not apply to integrated CTS instead?

 

[plukfelder2017]

@LucidSplash Thank you for your response. It's reassuring to hear that one can pursue CHS through this training pipeline.

It's a bit late in the process for me to apply integrated CT and unfortunately I don't have the flexibility to take a research year (finances) at this point. Additionally, there are only 30ish CT spots in the country and conversations with multiple I6 residents have shown that the training is quite variable with multiple programs having a thoracic>cardiac focus. I would not feel comfortable going straight to CHS if I apply and enter a lower volume training program with a thoracic focus.

Furthermore, I loved my time on the vascular service. From FEVAR to open thoracos to lower extremity EV/open revascularization to TCAR/CEA, I see that the field has truly embraced technology while retaining open surgical fundamentals in ways that few other specialties have. After speaking to multiple surgical mentors, I have come to realize that this skillset is extremely valuable to develop and potentially transferrable.

Coming from my background/life circumstances, it has been a blessing to even enter medicine and honestly, at this point, I would really love to keep CHS open if I am capable of gaining the competence and dexterity necessary to succeed in the field.

Irrespective, thank you very much for your guidance. Happy new year!

 

[deleted50541]

Yes, that is a viable pathway to doing congenital. I do know someone who's done an integrated vascular residency and is completing their CT fellowship now, but their main interest is complex aortic work. I don't think you'll get much exposure to pediatrics in a vascular residency, so it will take a fair bit of extra effort to maintain a parallel focus on congenital if that's still your interest over the next several years.

My two cents about congenital. It's an incredibly rewarding profession, but requires a level of dedication and sacrifice few people can commit to. Even then, there are so few training spots and jobs that networking and knowing the right people is essential. Research in congenital surgery is a must. Plus you'll be competing against integrated and traditional candidates who likely have much more exposure to pediatrics/congenital than you'd get as a vascular resident.

Coming into your 4th year, if you're really serious about congenital, I would start to lay the groundwork now. Look at vascular programs associated with congenital heart centers. Pick the brains of the congenital surgeons you worked with on rotation and let them know you're interested. They can be your foot in the door. Get involved with the CHSS, attend their meetings, and look for scholarship opportunities such from the STS.

It's a long and hard road, but it can be done. Best of luck in the match!

 

[plukfelder2017]

@the negative 1 Thank you so much for your kind words and advice/feedback. I will do my best to speak to the CH surgeon that I had followed previously and will try to match at a program with a strong CH service. Would you mind if I reach out to you through private message as I move through the process?

 

[dienekes88]

Hi Folks,

Thank you for your contribution to this forum. I wouldn't have gotten into medical school and through boards/rotations without your assistance.

I am a 3rd year medical student applying to residency programs in this upcoming application cycle. I was initially intending on applying to integrated vascular surgery programs. After spending time on the pediatric cardiac surgery service, I feel a heightened sense of purpose and feel mentally prepared to commit to the trials and tribulations of this career field. I do see myself fitting into the culture of this service and have always considered pursuing it but did not feel prepared to follow suit until recently. Job prospects, training length, and outcome scrutiny were the rate limiting steps previously. Of note, I have also absolutely loved my time on the vascular and adult cardiac surgery services as well. Less so with core gen surg/thoracic, I just don't want to look back on my life with regrets.

My Stats:
US MD, step 1: Around 250, CK 4 months away
3rd year rotations: Honors surgery, medicine, peds etc
Publications>10 All Vascular
Letters (all vascular)

Strong work

Questions:
1. Is Integrated vascular surgery>cardiac surgery fellowship>pediatric CT super fellowship a viable training pathway? Would I be able to obtain a board certification in congenital through this pathway? Would it be recognized/ACGME approved? I have tried looking at the AATS website but am unable to find info on this. I do understand that there are multiple individuals who have transitioned from integrated vascular surgery programs to cardiac surgery fellowships (ie. from the houston/cleveland/dc programs) but am unsure if anyone has pursued additional training beyond a cardiac fellowship.

The pathway exists. However, if you want to do congenital, I would very strongly recommend that you do an integrated cardiac program. The skills you learn reading echo, CT, MR, and cath will help you a lot when you're looking at some of the crazy lesions you run into. The value of vascular surgery training in congenital is more limited. Like who cares if you have RPVI if you're doing heart surgery.

2. Considering that the current tried, true, and tested pathway is GS>CT> congenital or I6>congenital, is the above pathway viable/practical? Would it lead to deficiencies in my surgical skillset? I am asking this question because the CHS that I followed had 0 core thoracic cases on his OR schedule. He was primarily performing palliative arterial/circuit reconstructions, ie pure CV work.

Yeah, but there's still a lot of thoracic management: air leaks after redos, chylothorax, wound management... still have to do thoracotomies and manage the exposure for coarcts from the left chest and PDA ligations. Still have to do chest tubes and pigtails. Still need to manage the pulmonary vasculature.

Thanks and I wish y'all a happy new year. Hopefully 2021 is better for all of us.

Best,
Plukfelder

Would suggest keeping your options open. I wouldn't do congenital unless you also like adult cardiac surgery, because there's no guarantee that you'll still want to do it when you're a Pgy9.

I will say that the attraction to congenital is obvious. However, its very difficult to understand how complex the lesions are: how much physiology you have to deal with, how complicated the anatomy is, etc. The books don't do it justice because there are so many intermediate lesions and one off lesions, and complicating factors, etc. While it seems really exciting to see all these new and interesting lesions all the time when someone else is making the decisions. When you're the boss and you've got a couple young parents in the office, things don't seem so fun.

Best of luck. Keep plugging away.

 

[_DeBakey_]

I have an interest in doing vasc --> CT as well, so I think you taking this approach is awesome. I'm still a lowly pre-clinical student but I would assume all the vasc training may help with working with some of the smaller blood vessels in congenital?

 

[LucidSplash]

I have an interest in doing vasc --> CT as well, so I think you taking this approach is awesome. I'm still a lowly pre-clinical student but I would assume all the vasc training may help with working with some of the smaller blood vessels in congenital?

CT surgeons work with some pretty small blood vessels - coronary arteries aren’t the biggest vessels in the body.
Look it will probably be fine to do vascular as a residency then CTS as a fellowship then congenital as a super fellowship. But this idea that doing vascular will give you some kind of special leg up on the pathway is frankly a little absurd. It will be fine but it’s not like people will be fawning over you because you do something so much better than people who did an I-6 or the Gen surg pathway. Vascular patient population is the polar opposite of congenital honestly. And what we are really learning/teaching in any surgical specialty is the decision making and the peri op care. The technical aspects is less than 50%. I can teach almost anyone to sew in a circle. I can sew a tibial or pedal anastomosis, so I bet with some additional training I could sew a coronary. But the management is the difference, the decision making, which tool are you going to take out of the toolbox for a given situation.

So just stop with the rationalization that doing vascular gives you a leg up some how. It will be fine. But it isn’t going to make you some kind of special pony. It will be good and it will be fine. But not something unique.

 

[ed*26]

As others have said, you can get to congenital CT by any pathway (including vasc > CT) that will get you board certified in CT. And it does seem like you really like vascular, and you should do whatever will make you the happiest. But if you're serious about congenital then you should really see what the congenital surgeons think, because its hella competitive and it seems circuitous to spend six years learning minimally invasive approaches to fixing junky arteries in old folks when you really want to be doing open repairs on babies.

nd conversations with multiple I6 residents have shown that the training is quite variable with multiple programs having a thoracic>cardiac focus (UVA etc).

I'm not sure where you heard this. I've been told repeatedly that most I6 programs are largely focused on cardiac, to the point that if I was considering thoracic that I should follow the traditional route. Why not dual-apply into vascular and CT?

 

[dienekes88]

CT surgeons work with some pretty small blood vessels - coronary arteries aren’t the biggest vessels in the body.
Look it will probably be fine to do vascular as a residency then CTS as a fellowship then congenital as a super fellowship. But this idea that doing vascular will give you some kind of special leg up on the pathway is frankly a little absurd. It will be fine but it’s not like people will be fawning over you because you do something so much better than people who did an I-6 or the Gen surg pathway. Vascular patient population is the polar opposite of congenital honestly. And what we are really learning/teaching in any surgical specialty is the decision making and the peri op care. The technical aspects is less than 50%. I can teach almost anyone to sew in a circle. I can sew a tibial or pedal anastomosis, so I bet with some additional training I could sew a coronary. But the management is the difference, the decision making, which tool are you going to take out of the toolbox for a given situation.

So just stop with the rationalization that doing vascular gives you a leg up some how. It will be fine. But it isn’t going to make you some kind of special pony. It will be good and it will be fine. But not something unique.

Well said. And compared to an i6 resident, a vascular resident who subsequently does CT may be at a disadvantage in congenital heart surgery. The critical part being: the sewing can be challenging, but it's not the only hard part.

 

[Ibduggan]

Hello,

I am a pre med who has been accepted to medical school attending in the fall. I too have a deep interest in congenital. I have shadowed at Lurie Childrens in Chicago, Miami Childrens, and Advocate Christ in Illinois. Have seen numerous congenital surgeries. I am wondering which medical school did you attend, and which surgeons were you exposed to? I am working on an interview project where I interview congenital heart surgeons around the country. I have interest around 65 asking similar questions as you. What have you been told about the field? I’m trying to determine if the medical school I attend will effect my ability to gain opportunities to enter that field.
Would love to chat about the topic

 

[dienekes88]

Hello,

I am a pre med who has been accepted to medical school attending in the fall. I too have a deep interest in congenital. I have shadowed at Lurie Childrens in Chicago, Miami Childrens, and Advocate Christ in Illinois. Have seen numerous congenital surgeries. I am wondering which medical school did you attend, and which surgeons were you exposed to? I am working on an interview project where I interview congenital heart surgeons around the country. I have interest around 65 asking similar questions as you. What have you been told about the field? I’m trying to determine if the medical school I attend will effect my ability to gain opportunities to enter that field.
Would love to chat about the topic

Focus on being a superstar in medical school so that you can go to one of the best residencies. Its a small field, so developing a relationship with a surgeon at a congenital heart surgery training program would be helpful.

ETA: didn't realize you were choosing among several schools. Nice job!

 

[Ibduggan]

I appreciate it. I’m choosing medical schools now and have the chance to do UW Madison, Pitt, or UCSF wasn’t sure if that stage mattered much. I noticed many congenital heart surgeons went to a variety of schools from Ivy to public state schools that were mid tier. I agree best is to set up a relationship with a congenital surgeons have spoken to about 60 of them so far all have been extremely friendly and open

 

[dienekes88]

I appreciate it. I’m choosing medical schools now and have the chance to do UW Madison, Pitt, or UCSF wasn’t sure if that stage mattered much. I noticed many congenital heart surgeons went to a variety of schools from Ivy to public state schools that were mid tier. I agree best is to set up a relationship with a congenital surgeons have spoken to about 60 of them so far all have been extremely friendly and open

It's a niche field. Most people seem to be happy to hear that young people are interested.

Go where you really feel the most comfortable. Better to be in a good environment where you can really succeed than be at a "better" school where you may struggle for a variety of reasons (far from family, challenging social environment, whatever).

Of the above programs, I think only Pitt has an i6, though UCSF has a FastTrack gen surg/thoracic surgery program. You're lucky to have options. Now you just have to figure out where you can thrive and what the definition of "thriving" is. You also have to take into consideration the possibility that when you're applying for residency you may not even want to be a surgeon.

 

[plukfelder2017]

I appreciate it. I’m choosing medical schools now and have the chance to do UW Madison, Pitt, or UCSF wasn’t sure if that stage mattered much. I noticed many congenital heart surgeons went to a variety of schools from Ivy to public state schools that were mid tier. I agree best is to set up a relationship with a congenital surgeons have spoken to about 60 of them so far all have been extremely friendly and open

Whoa. Strong work. Very impressive acceptance list. Just chipping in to say listen to some of the more senior members on the board. I can provide you with some med school clerkship/board advice but am a lowly med student who has yet to match into a viable residency program.

 

[Ibduggan]

I appreciate this information. I have strongly tried to consider choosing a school where I’d be the most happy. UCSF is great program but I’m a Midwest kid with 0 family ties there. So debating how well I’d do outside my comfort area with no support network. & you bring up a good point I may not even like surgery. Appreciate all the advice

 

[The Notorious ABD]

I appreciate this information. I have strongly tried to consider choosing a school where I’d be the most happy. UCSF is great program but I’m a Midwest kid with 0 family ties there. So debating how well I’d do outside my comfort area with no support network. & you bring up a good point I may not even like surgery. Appreciate all the advice

I'm a CT fellow at UPMC, the congenital department is quite strong here, would be better than UW, not sure about UCSF.

 

[BigRedBeta]

@plukfelder2017

Sorry late to this thread, and you've probably already made some decisions already. But as a PICU attending (and as such have more than a fair amount of time interacting with the congenital CT surgeons), would 100% say that vascular surgeons have severely limited, IF ANY AT ALL, pediatric exposure. In 6 years of training and another 5+ years as an attending, I've spoken with a vascular surgeon exactly 1 time and they weren't at the children's hospital. I can remember vividly the 2 other patients who needed vascular and the utter s***show it was trying to figure out the next steps. Generally, if there's any sort of quasi-vascular thing the CCT surgeons handle it, and if they can't, then things shuffle to adult facilities, but these are extraordinarily rare instances. Therefore, I think going the integrated vascular route presents an extra challenge to be met vs the more traditional routes.

 

[Smurfette]

@plukfelder2017

Sorry late to this thread, and you've probably already made some decisions already. But as a PICU attending (and as such have more than a fair amount of time interacting with the congenital CT surgeons), would 100% say that vascular surgeons have severely limited, IF ANY AT ALL, pediatric exposure. In 6 years of training and another 5+ years as an attending, I've spoken with a vascular surgeon exactly 1 time and they weren't at the children's hospital. I can remember vividly the 2 other patients who needed vascular and the utter s***show it was trying to figure out the next steps. Generally, if there's any sort of quasi-vascular thing the CCT surgeons handle it, and if they can't, then things shuffle to adult facilities, but these are extraordinarily rare instances. Therefore, I think going the integrated vascular route presents an extra challenge to be met vs the more traditional routes.

The only times I ever saw a vascular surgeon involved with a peds patient were all traumas. Mostly gangbangers, so not little kids. Anecdotal, but makes sense as kids are generally a far healthier population with nice vasculature compared to what a vascular surgeon is used to.

 

[LucidSplash]

The only times I ever saw a vascular surgeon involved with a peds patient were all traumas. Mostly gangbangers, so not little kids. Anecdotal, but makes sense as kids are generally a far healthier population with nice vasculature compared to what a vascular surgeon is used to.

As a fellow, had 3 total consults: 2 premie babies with leg issues from line placements that got better without any intervention. And a 6-7 year old kid with a terrible dog bite injury that took out the brachial vein and artery. F***ing terrible night. Did bypass with GSV, vessels sized like tibials. Called in the senior attending most skilled at distal bypass after the first bypass went down twice. 2nd attempt also went down 2x, vessels just too small, vein too small, blood pressure too low (normal for kid, low for a bypass). Put the kid on heparin. A week later arm/hand still alive and had a Doppler signal radial and ulnar. Kids are basically salamanders in my opinion. but yeah, very rare to see a vascular surgeon on the Peds floor and that’s how it should be.

 

[TypeADissection]

As a fellow, I had maybe 4-5 consults on peds. 2 for VA ECMO requiring DPCs (f*cking painful). 3 for bypasses after an ATV, sledding and trampoline accidents that resulted in posterior knee dislocations. If my memory serves me correctly, they were 11, 9 and 6-7, respectively. The ATV and sledding accident were within 2-weeks of each other. I just remember doing the distals by parachuting interrupted 7-0s. Kill me. Thankfully a lot of the central lines and other issues were done by Peds IC and Peds CTS.

 

[Medstart108]

The way I see it, its not a big deal what you choose. Peds CT is unreal, difficult, but if you like it, you will find a way. The Peds CT people I see do it because of an undying passion and I see people who have done so much training they are in their early 40s before landing their first job and that is probably when they finally start learning how to do the complex cases in the field. At the end of the day, whether you did an integrated vascular or a general surgery residency i don't think matters because the real residency doesn't start until you choose to do the Peds CT fellowship anyways.

 

[robellis]

I appreciate it. I’m choosing medical schools now and have the chance to do UW Madison, Pitt, or UCSF wasn’t sure if that stage mattered much. I noticed many congenital heart surgeons went to a variety of schools from Ivy to public state schools that were mid tier. I agree best is to set up a relationship with a congenital surgeons have spoken to about 60 of them so far all have been extremely friendly and open

You’re a premed and you’ve already spoken to 60 congenital cardiac surgeons?

 

[Ibduggan]

You’re a premed and you’ve already spoken to 60 congenital cardiac surgeons?

That’s correct I worked on a personal interest project regarding practice model, work life balance, qualities seen in the field, training paradigms, experiences within the field etc talked to about 70 or so now. Many chiefs to fellows

 

[robellis]

That’s correct I worked on a personal interest project regarding practice model, work life balance, qualities seen in the field, training paradigms, experiences within the field etc talked to about 70 or so now. Many chiefs to fellows

How did you get in contact with 60 congenital cardiac surgeons? There’s like barely any of them out there

 

[Ibduggan]

How did you get in contact with 60 congenital cardiac surgeons? There’s like barely any of them out there

Good question. Just traditional networking & email. You can go on university websites and obtain their emails, or sometimes their emails are on their recent publications. I was working on an interview project on the field from their POV so you can also go through their Administrative assistants if you want to contact them. Funny too a lot of them are very active on social media. And there is somewhere are 170 or so in this country practicing some sort of congenital heart surgery.