Pregnancy and Vascular Surgery

[DrfluffyMD]

As a 3, the majority of my day is spent doing cases, with time set aside on certain days for educational conference or our resident clinic. We spend probably 2-2.5 hours daily on morning rounds and afternoon signout. None of these activities can be delegated to a PA or NP because they are at the heart of my surgical education.

What percentage of time were you doing cases as a 1 and a 2? Because those are the time when I see where the extra fat can be trimmed. My wife would have been extremely happy if there is more actual operating, which the whole world of surgery seem to be moving away from (and toward less invasive techniques or conservative mgmt)

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[DrfluffyMD]

...eliminate...rounds?

Am I seriously hearing this?

Only a radiologist...

Rounds are the core of patient care. Surgeons already take (too much) pride in the efficiency of our rounds. Turns out the patients have to be seen each day. I mean I guess we could just not make everyone come to rounds and only one person see the patients, but that seems like it would double down on "duplicated effort due to miscommunication"

As for refusing consults - (a) hard stop. You're putting patient safety on the line. I've seen "BS" consults that needed major help. I had one "redacted" consult that I took emergently to the OR. And, frankly, learning which consults are and are not "BS" takes a level of judgment that only comes with time and seeing a butt load of consults first. (b) that's also not a reflection of real life as an attending. If our attendings get called about a patient - the 100% of the time answer? "How can I help?"

Less documentation: my interns write zero daily progress notes or discharge summaries M-F. PAs do them all. The interns do it on the weekends, and at the VA. They are, as a result, very protected, but are also much less efficient at it than my cohort of chiefs since we didn't have such protection then. There is, of course, education and skill in learning to document actual medical thinking but I will freely admit most documentation isn't about that.

Much of what you are so eager to label as non-educational is just patient care. If you choose a private practice job after fellowship, you'll be doing it yourself. Forever.

Lots of high and mighty words. So let me refute them point by point.

If you check my post history, I advocate work rounds and seeing all angio patients in the hosptal and do post drain care ourselves rather than have surgery do it. Clinical model is the only way going forward.

But why do interns need to present for patients that they don't have who have no educational value?

BS consults: I see all consults myself. I actually writes IR consult notes even though I cannot (nor our attendings) can bill for them purely to increase visiblity of our field.

But too often I see surgery trainees do BS consults or admissions that have zero, zero benefit to the patients. In fact, some of those admissions are probably harmful as hospital is not a good environment for them to be in.

Lastly, again, personal insult like "only a radiologist". I considered that as an insult because I never think of myself as a radiologist. I told my faculty face to face that I thought about switching to surgery for awhile until IR came along and I have no interest to practice like a radiologist. Many IR held the same sentiment and one PD straight up told me that she will train me as a surgeon. As a field, we will be advancing into work that previously required surgery. I don't concern myself with open surgical techniques, but after that, anything goes.

The above goes to illustrate that it isn't the hours or the content I have problem with regarding surgical training, but the hubris, the underlying misogyny, the inefficiency in Junior training and sacrifice of education in the name of work that I have issue with

 

[Dr.LeoSpaceman]

Walk rounds. How much of that is actual rounding, vs education, vs walking?

There is very little wasted time on surgical rounds, namely because there cannot be. It generally takes me about 45-60 minutes to round on 10-15 patients, going up to about 1 hour 15 on the occasions when the census hits 20+. Add another 15 minutes on either end of rounds for me to review labs, radiology and consultant plans. Given that all of our patients are generally located on specific surgical units, little of that time is wasted. And I can usually shave time off if I'm not spending time to provide education to medical students. So far, I don't see any place where I've described "scut"...rather the activities which actually makes one a physician.

Bull**** consults in an environment where one cannot refuse consult.

In your extensive surgical experience, how many surgical consults are actual BS? We like to highlight the ones that are because they entertain us. But do you know what proportion of my day-to-day consults these make up? (Hint: Not very many.) Do you think that any consult that ends in "This patient doesn't need surgery" is BS? If so, you should probably excuse yourself from this thread as it belies your understanding of surgery as a discipline.

Duplicated effort due to miscommunication.

And lastly, what about a teaching vs nonteaching service? Not all patients are educational.

Miscommunication is not a function of surgical residency. That's a function of (poor) residents, and isn't unique to surgical residency.

Specifically, which surgical patients are not educational? It's easy to throw around generalities and catch phrases, but that doesn't mean it can be translated to practice.

A lot less documentation.

A lot less hierarchy.

Ok, assume we get rid of documentation for residents. Going to be a rude awakening when you make it into practice, as I'm fairly certain my attendings do more documentation than I do. So if you're suggesting that we change medical practice to require less documentation, I doubt anyone will object. But this isn't a function of surgical education or training, it's a function of the way our medical system is built.

And there is no hierarchy in IR? Where is this magical land where you don't have a division chief, who doesn't have a department chair, who doesn't report to the dean or a hospital CEO? Hierarchy is a fact of life in medicine (and in most professions). Unless you're going to go out and build your own surgical center, that's the way it goes.

As for hierarchy within surgical training, I don't ask any of my junior residents to do anything I'm not willing to do. Intern is off one day? Guess who's picking up the slack: me. But the reality of any training program is that graduated responsibility and progression to more complex tasks is the way learning works. Saying that the intern should show up and get to do the laparoscopic colectomy sounds great in theory, but it's like expecting a 2nd grader to do algebra before they've mastered multiplication tables. Can an attending do the colectomy with the intern? Sure, but the intern is going to gain very little from the experience because they don't have the skills required to actually participate.

Can we make that better or continue to put our heads in the sand?

There are actually a number of people who are trying to make this better. People, who unlike yourself, are surgical educators. And the interesting thing is that the ones with whom I've had the opportunity to speak wouldn't agree with your ideas of cutting training to 40 hours a week or reducing responsibility. And as for the women who leave surgery, you know the one thing that surgeons can't control? Their support system outside of the hospital. Because what makes it possible for me to be a surgeon and have a family is that my wife is amazing and takes care of many of the things for which I cannot be available. The women residents I know who have struggled do so not only because surgery residency is challenging (as it is for everyone), but because of the expectations their spouses place on them when they return home. So we can change the surgical training paradigm all we want, but if women are still expected to be a full-time surgeon AND a full-time wife/mother in the "traditional" sense then we are doomed for failure.

The goal of (any) training program is to create competent practitioners of that skill, not to make it accessible to everyone. There will always be trade-offs between what is required and what is desirable, or what is required and what people are capable of doing. The goal of designing surgical training should be to create competent surgeons as efficiently as possible. At that point, people can choose whether the compromises required complete that training are worth it. And yes, I would agree these compromises should be agnostic to age, gender, race, etc.

If you are interested in a thoughtful discussion of this from someone who is a woman and a surgeon, I'd encourage you to check out Caprice Greenberg's AAS Presidential Address from last year.

EDIT: And I will add, you compare IR to surgery as if surgeons would find it desirable to have a practice similar to that of IR. The thing is, we really don't. The advantage to all this other "non-educational" activity is that it means that we actually don't rely on people for many things. While things like IR can make our lives easier and make outcomes for the patients more tolerable, they aren't a necessity. I suppose we could try to cede control of the preoperative evaluation and post-operative care on to other services and just sit in the OR waiting for patients to show up. Not only would I worry about the quality of patient care, but it's also a seemingly poor decision from a practice-building standpoint.

 

[DrfluffyMD]

There is very little wasted time on surgical rounds, namely because there cannot be. It generally takes me about 45-60 minutes to round on 10-15 patients, going up to about 1 hour 15 on the occasions when the census hits 20+. Add another 15 minutes on either end of rounds for me to review labs, radiology and consultant plans. Given that all of our patients are generally located on specific surgical units, little of that time is wasted. And I can usually shave time off if I'm not spending time to provide education to medical students. So far, I don't see any place where I've described "scut"...rather the activities which actually makes one a physician.


In your extensive surgical experience, how many surgical consults are actual BS? We like to highlight the ones that are because they entertain us. But do you know what proportion of my day-to-day consults these make up? (Hint: Not very many.) Do you think that any consult that ends in "This patient doesn't need surgery" is BS? If so, you should probably excuse yourself from this thread as it belies your understanding of surgery as a discipline.


Miscommunication is not a function of surgical residency. That's a function of (poor) residents, and isn't unique to surgical residency.

Specifically, which surgical patients are not educational? It's easy to throw around generalities and catch phrases, but that doesn't mean it can be translated to practice.


Ok, assume we get rid of documentation for residents. Going to be a rude awakening when you make it into practice, as I'm fairly certain my attendings do more documentation than I do. So if you're suggesting that we change medical practice to require less documentation, I doubt anyone will object. But this isn't a function of surgical education or training, it's a function of the way our medical system is built.

And there is no hierarchy in IR? Where is this magical land where you don't have a division chief, who doesn't have a department chair, who doesn't report to the dean or a hospital CEO? Hierarchy is a fact of life in medicine (and in most professions). Unless you're going to go out and build your own surgical center, that's the way it goes.

As for hierarchy within surgical training, I don't ask any of my junior residents to do anything I'm not willing to do. Intern is off one day? Guess who's picking up the slack: me. But the reality of any training program is that graduated responsibility and progression to more complex tasks is the way learning works. Saying that the intern should show up and get to do the laparoscopic colectomy sounds great in theory, but it's like expecting a 2nd grader to do algebra before they've mastered multiplication tables. Can an attending do the colectomy with the intern? Sure, but the intern is going to gain very little from the experience because they don't have the skills required to actually participate.



There are actually a number of people who are trying to make this better. People, who unlike yourself, are surgical educators. And the interesting thing is that the ones with whom I've had the opportunity to speak wouldn't agree with your ideas of cutting training to 40 hours a week or reducing responsibility. And as for the women who leave surgery, you know the one thing that surgeons can't control? Their support system outside of the hospital. Because what makes it possible for me to be a surgeon and have a family is that my wife is amazing and takes care of many of the things for which I cannot be available. The women residents I know who have struggled do so not only because surgery residency is challenging (as it is for everyone), but because of the expectations their spouses place on them when they return home. So we can change the surgical training paradigm all we want, but if women are still expected to be a full-time surgeon AND a full-time wife/mother in the "traditional" sense then we are doomed for failure.

The goal of (any) training program is to create competent practitioners of that skill, not to make it accessible to everyone. There will always be trade-offs between what is required and what is desirable, or what is required and what people are capable of doing. The goal of designing surgical training should be to create competent surgeons as efficiently as possible. At that point, people can choose whether the compromises required complete that training are worth it. And yes, I would agree these compromises should be agnostic to age, gender, race, etc.

If you are interested in a thoughtful discussion of this from someone who is a woman and a surgeon, I'd encourage you to check out Caprice Greenberg's AAS Presidential Address from last year.

the support system you have isn't available to everyone. There is a huge gender disparity in this. I too, acknowledge how much easier when my coresidents have wives that cooks, cleans, run errands and are secretaries for them, being a personal chef, cleaner and secretary all at once.

Just because of the way our society is set up, it's much more common for this situation to be available to a man.

Is it fair to raise the bar so high that only people with a personal chef/cleaner/secretary can succeed in that enviornment?

 

[Dr.LeoSpaceman]

the support system you have isn't available to everyone. There is a huge gender disparity in this. I too, acknowledge how much easier when my coresidents have wives that cooks, cleans, run errands and are secretaries for them, being a personal chef, cleaner and secretary all at once.

Just because of the way our society is set up, it's much more common for this situation to be available to a man.

Is it fair to raise the bar so high that only people with a personal chef/cleaner/secretary can succeed in that enviornment?

Interestingly, I cook for us 3-4 nights a week and can find the time to do my own laundry. I also manage to complete a variety of household chores on a weekly basis. But the thing I cannot do is drop my child off at daycare or pick her up in the evening, so she takes care of this (along with an array of other things). But our split is a far cry from me having a personal assistant. When I'm having a lighter week, I do more at home. When I'm having a more challenging week, she does more. It's what one may call an equitable approach to having a family. So if having an equitable approach to family life is a bar unreachable by the average person, then your problem isn't with surgery but with social norms as they currently exist.

Let me turn this one back on you: As you say, your wife is a surgical resident. Assume she has a kid in residency. Have you talked about the way childcare is going to work? Are you going to be the one responsible for picking up the slack when she's on a tough clinical rotation, or are you just going to expect her to "make it work" while shaking your fist at the injustices of surgical residency?

 

[ACSurgeon]

Walk rounds. How much of that is actual rounding, vs education, vs walking?

Bull**** consults in an environment where one cannot refuse consult.

Duplicated effort due to miscommunication.

And lastly, what about a teaching vs nonteaching service? Not all patients are educational.

I am not a surgical educator, but I do participate in the hospital GME committee as a resident as well as my own radiology and IR GME. IRs work surgeon hours but the amount of BS we deal is far less. Why?

A lot less documentation.

A lot less hierarchy.

Look, again, I have no disrespect or ill wills toward surgeons. I work with them, they work with me. We rely on each other.

However, when some response to difficulties of training, disporportionately so for a woman, are crap like "biological differences" or "post partum emotions", you have a hard time gaining my sympathy.

In 2017, in a board which moderator is a welll known woman in surgery, instead of addressing the well known disparity of training satisfication and sustainability for women, people toss out stuff like that? Emotions!?

Just antedotal stuff, but five of the residents we take from surgery departments in the last 5-6 years were unfortunately, all women. All cite childcare and lifestyle as issue.

Can we make that better or continue to put our heads in the sand?

How do you not realize that time spent taking care of patients can't be 100% high yield (for lack of a better term?)

How do you suggest we make rounds more efficient when you mention "walking" as a waste of time? Do you propose that we don't see our patients?

Part of the problem is that you don't understand the difference between a surgeon and a technician. We train to operate and manage patients. It takes time to learn how to manage patients efficiently and safely. Our patients are sick. Our operations are morbid. Our trainees need to learn how to take care of these patients.

And my mention of post partum emotions wasn't meant to be disparaging in anyway. It was from first hand experience of how disabling it can be. Not a sign of weakness or as a fault of the person experiencing it. But it was in response to the person who wanted to make it seem like giving birth was the only "biological" difference between the man and woman's role in having a baby.

There's certainly a lot of inefficiencies in surgical training. Having gone through the process, I'm not sure how to make it better. However, I am sure your ideas are NOT it.

 

[DrfluffyMD]

How do you not realize that time spent taking care of patients can't be 100% high yield (for lack of a better term?)

How do you suggest we make rounds more efficient when you mention "walking" as a waste of time? Do you propose that we don't see our patients?

Part of the problem is that you don't understand the difference between a surgeon and a technician. We train to operate and manage patients. It takes time to learn how to manage patients efficiently and safely. Our patients are sick. Our operations are morbid. Our trainees need to learn how to take care of these patients.

And my mention of post partum emotions wasn't meant to be disparaging in anyway. It was from first hand experience of how disabling it can be. Not a sign of weakness or as a fault of the person experiencing it. But it was in response to the person who wanted to make it seem like giving birth was the only "biological" difference between the man and woman's role in having a baby.

There's certainly a lot of inefficiencies in surgical training. Having gone through the process, I'm not sure how to make it better. However, I am sure your ideas are NOT it.

My issue with rounds is that why can't there be a teaching and non teaching service? I am sorry if I was insinuate that rounds aren't necessary. They are very necessary.

 

[ACSurgeon]

Is it fair to raise the bar so high that only people with a personal chef/cleaner/secretary can succeed in that enviornment?

Sorry, not everyone can accomplish everything. Some people are more capable than others. It's not about having a personal assistant. It's about what you can handle and accomplish. Yes, the bar is set high and should be set high.

I agree that there's room to make this rigorous process less painful. But you don't do that by cutting the hours or lowering the bar.

 

[Dr.LeoSpaceman]

My issue with rounds is that why can't there be a teaching and non teaching service? I am sorry if I was insinuate that rounds aren't necessary. They are very necessary.

To answer your question: Non-teaching surgery services do exist. They're called the "Medicine Service".

 

[ACSurgeon]

My issue with rounds is that why can't there be a teaching and non teaching service? I am sorry if I was insinuate that rounds aren't necessary. They are very necessary.

Some places have that. Some busy trauma centers will have the non-op trauma patients awaiting dispo cared for primarily by NPs. At our community hospitals we only round on patients we operate on.

I think a better proposition would be to have all teaching services run by the residents and giving them more autonomy. Some of the waste of time, especially as a senior, comes when you round on patients and have to manage patients exactly how your attending wants. Rather than rescuing the volume or experience, we need to look for ways to make the time spent more educational.

 

[Light at end of tunnel]

You didn't actually refute any of them.

That may be a matter of opinion.

 

[DrfluffyMD]

Some places have that. Some busy trauma centers will have the non-op trauma patients awaiting dispo cared for primarily by NPs. At our community hospitals we only round on patients we operate on.

I think a better proposition would be to have all teaching services run by the residents and giving them more autonomy. Some of the waste of time, especially as a senior, comes when you round on patients and have to manage patients exactly how your attending wants. Rather than rescuing the volume or experience, we need to look for ways to make the time spent more educational.

Hit the nail in the head there. I think we should all have less hury and wait and operating.

My wife loves the OR, but it can be so hard for her to get there when she was more junior.

I agree some of my statements are inflammatory, but they were written in anger and frustration from a spouse's perspective.

 

[Dr.LeoSpaceman]

So when does a patient become "non-teaching"? Versus teaching?

Basically it's "social visit" patients, or patients where we are purely technicians and have completed appropriate post-op follow-up.

 

[DrfluffyMD]

I'm not opposed to the concept, particularly for fields like trauma.

But one problem in surgery is that learning to take care of patients means learning how to take care of complications. Complications are rare. You have to round on about a thousand lap choles to see and manage one bile duct injury. And yeah, sure I can read a book or hear someone else tell me how they managed a complication, but that's just not the same. So to some degree this "low yield" repetition is necessary in order to get adequate volume. It's the difference between a well read mid-level resident and an attending in many cases - the resident knows exactly what to do because they've read all the books, but the attending has better insight into deviation from the normal postop course because they've seen it a thousand more times.

So when does a patient become "non-teaching"? Versus teaching? Is it strictly a volume question? Surgery doesn't handle their services like medicine for the most part - you can't just "cap" the service because admissions are dictated by the attendings' elective OR schedules. I can't just say oh the HPB service is capped, sorry Dr. X your whipple goes to the other team now.



That's obvious, but I would suggest that perhaps the "angry spouse" perspective is not the best one for education reform.

An angry spouse with extensive GME experience in a procedural field. There are a lot of things with surgery GME that is NOT seen in any other GME.

A nonteaching patient can be easily readmitted to teaching service, I think.

 

[Dr.LeoSpaceman]

An angry spouse with extensive GME experience in a procedural field. There are a lot of things with surgery GME that is NOT seen in any other GME.

And as pointed out elsewhere, "procedural field" is not synonymous with surgery and doesn't provide you with unique insight on how surgery should work. Your arguments boil down to "Why can't surgery be like IR?" Well, because the Venn diagrams for surgery and IR don't overlap all that much. As we explain to every medical student who posts here, being a surgeon isn't just "doing procedures". The fact that you seem to equate operating more with the only thing necessary to become a competent surgeon suggests that you don't actually understand that. And if you don't have a functional understanding of that concept, you're going to continue to find this discussion frustrating. Out of curiosity, what does your wife say about this?

Also, you referenced hubris above as a reason surgery frustrates you. An IR PD telling you that they will train you to be a surgeon is the definition of the word.

 

[DrfluffyMD]

But not a patient care field.



the point is then lost. You can't learn to recognize complications when you only take care of them after the complication has occurred

I have done a surgery prelim year and both my home and future IR fellowship admit and manage their own patients, so we do take care of patients, albeit not extensively.

Your second point is very good. Point taken.

 

[ACSurgeon]

I agree some of my statements are inflammatory, but they were written in anger and frustration from a spouse's perspective.

Keep in mind your wife will vent to you about things she probably can't vent to coworkers about. When you're tired and have five consults that need your attention and you get called about a SBO in someone who is clearly just constipated or has an ileus can be very frustrating AT THE MOMENT. I hope your wife can appreciate that these consults are still important in her being facile at differentiating sick from not sick, true obstruction from everything else the non-surgeons call us about to r/o obstruction. That's the only way she'll be able to hear about these consults as a senior resident or as an attending while scrubbed and unavailable for thorough review and be able to accurately come up with a plan. Having loads of scut distracting from important work is how you learn to prioritize tasks.

When you're a burned out surgery resident, everything seems bad. But I think we all recognize the benefit in some of the busy work that we go through in training. As the spouse, you probably hear more complaining and less about her proudest and most exciting experiences.

Or your wife might be at a bad program.

 

[DrfluffyMD]

And as pointed out elsewhere, "procedural field" is not synonymous with surgery and doesn't provide you with unique insight on how surgery should work. Your arguments boil down to "Why can't surgery be like IR?" Well, because the Venn diagrams for surgery and IR don't overlap all that much. As we explain to every medical student who posts here, being a surgeon isn't just "doing procedures". The fact that you seem to equate operating more with the only thing necessary to become a competent surgeon suggests that you don't actually understand that. And if you don't have a functional understanding of that concept, you're going to continue to find this discussion frustrating. Out of curiosity, what does your wife say about this?

Also, you referenced hubris above as a reason surgery frustrates you. An IR PD telling you that they will train you to be a surgeon is the definition of the word.

I consider IR and surgery on the same spectrum of patient care. The old model of IR, which you maybe more familiar with, is all about "you send'em, we stick'em". The new model which people are actively try to implement encompass procedural periprocedural care, which I understand make up a large percentage of surgery and is a big point of my frustration (does it take 80 hours for 2-3 years to gain basic competency in that? I am not sure).

There really isn't much cross over between the technical aspect of IR and surgery, which I agree, though that is changing with advances in the field. And if you are a vascular surgeon, much of your time is spent practicing IR.

However, the periprocedural care are much more similar than you think, and that's the part where it overlap. The ultimate goal of IR training is to master everything that is currently surgery with the exception of actual operative skills.

By the way, the IR PD i spoke with has been trained in general surgery as well, and there are people out there who have such training. I may even pursue it myself.

 

[Dr.LeoSpaceman]

does it take 80 hours for 2-3 years to gain basic competency in that?

Yes. The fact that you seemingly don't like the answer doesn't mean it's not true. This because the rate limiting factor to the whole equation is how many patients you come in contact with per day, whether that's on rounds, in the clinic, in the OR, or as consults. Completely eliminating all activity related to these patients except for the evaluation/medical decision making or operative experience isn't going to increase the number of patients you will see as there is some theoretical maximum based on things related to the practice setting. So instead of having more experiences in a shorter time, you will simply have more time in between each experience. The end result? Similar time spent "at work", though that time may be marginally less stressful.

As we've all said elsewhere, this "new model" of IR sounds great. And if that's the new paradigm for it, then that's fantastic. But if that's the case, then get ready for IR to get more like surgery and not surgery to get more like IR. And by "trained in general surgery", do you mean was a board-eligible general surgeon or someone who completed a few years of surgical residency and switched to IR? Because I find it difficult to believe someone who completed surgical residency honestly believes they can teach someone to be a surgeon within the confines of an IR residency as they are currently structured. If they do then it is, as I said, hubris.

 

[DrfluffyMD]

Yes. The fact that you seemingly don't like the answer doesn't mean it's not true. This because the rate limiting factor to the whole equation is how many patients you come in contact with per day, whether that's on rounds, in the clinic, in the OR, or as consults. Completely eliminating all activity related to these patients except for the evaluation/medical decision making or operative experience isn't going to increase the number of patients you will see as there is some theoretical maximum based on things related to the practice setting. So instead of having more experiences in a shorter time, you will simply have more time in between each experience. The end result? Similar time spent "at work", though that time may be marginally less stressful.

As we've all said elsewhere, this "new model" of IR sounds great. And if that's the new paradigm for it, then that's fantastic. But if that's the case, then get ready for IR to get more like surgery and not surgery to get more like IR. And by "trained in general surgery", do you mean was a board-eligible general surgeon or someone who completed a few years of surgical residency and switched to IR? Because I find it difficult to believe someone who completed surgical residency honestly believes they can teach someone to be a surgeon within the confines of an IR residency as they are currently structured. If they do then it is, as I said, hubris.

Looks like this particular PD completed their surgical training. I am just quoting him and I believe him consider certain IR practioners to be surgical subspecialists. This is not my opinion.

 

[Trauma Surgeon]

Query: Are men "worse fathers" for going back to work after they become fathers? Or is this just women who bear the brunt of your personal judgement (not fact) about what is takes to be a parent? Is it only women who have given birth or does this extend to adoption and surrogacy? Saying a pregnancy is irresponsible/selfish/stupid is certainly not a fact, it is an opinion.

The argument in your post is accurate if having a child would affect your life and the life of your coworkers for a day or two, or maybe a week and at most a month or two. But, children are a lifetime commitment, and during their first years of life they are totally dependent on their parents taking care of them.

There was a post a couple of years ago by Blondebella (I think) that described her situation as a new mom in surgical residency. I recommend for every surgical resident to read it!

Disclaimer: father of 2, my wife is a stay home mom.

 

[DrfluffyMD]

The argument in your post is accurate if having a child would affect your life and the life of your coworkers for a day or two, or maybe a week and at most a month or two. But, children are a lifetime commitment, and during their first years of life they are totally dependent on their parents taking care of them.

There was a post a couple of years ago by Blondebella (I think) that described her situation as a new mom. I recommend for every surgical resident to read it!

Disclaimer: father of 2, my wife is a stay home mom.

Do you think you can take care of your children nearly as well or not? Assuming that you are a female surgeon and your partner is a stay at home dad?

 

[Trauma Surgeon]

40 hour weeks. 7 clinical years.

If that is what you want then I suggest Sweden for you!
But be aware, there are a lot of downside to this which is not the topic of this thread and for that reason I don't elaborate...

 

[Trauma Surgeon]

Do you think you can take care of your children nearly as well or not? Assuming that you are a female surgeon and your partner is a stay at home dad?

I KNOW that I can't take care of my children as well as my wife! That is a conscious grown-up decision made on my part. The problem with the women in surgery (which there are 3 in my own family: mom OBGYN, aunt Optho and the other one ortho) is that they resent the surgical society (and them selfs) for not having spent more time with their children. I think in part it is that the society, especially being from middle east originally, have a different view and expectations of women.
To answer your second question: if breastfeeding was not an issue, no I don't think it matters if it is a stay home dad taking care of the child. As long as someone is always there for the unexpected fever, nights when they can't sleep, taking them to the doctor for check ups, the days they just don't want to get dressed and want to finish what ever they are doing (you get the picture)...

 

[ACSurgeon]

I consider IR and surgery on the same spectrum of patient care. The old model of IR, which you maybe more familiar with, is all about "you send'em, we stick'em". The new model which people are actively try to implement encompass procedural periprocedural care, which I understand make up a large percentage of surgery and is a big point of my frustration (does it take 80 hours for 2-3 years to gain basic competency in that? I am not sure).

There really isn't much cross over between the technical aspect of IR and surgery, which I agree, though that is changing with advances in the field. And if you are a vascular surgeon, much of your time is spent practicing IR.

However, the periprocedural care are much more similar than you think, and that's the part where it overlap. The ultimate goal of IR training is to master everything that is currently surgery with the exception of actual operative skills.

By the way, the IR PD i spoke with has been trained in general surgery as well, and there are people out there who have such training. I may even pursue it myself.

General surgery services don't function the way an IR service would. We don't have "peri-procedural patients." We admit patients with all their acute and chronic comorbidities. Our complications are more varied. The perioperative period is a time to continue resuscitating patients, discovering post-op MI/stroke/sepsis/hemorrhage or missed traumatic injuries. The length and complexity of our procedures and therefore peri-operative care is different than IR.

 

[DrfluffyMD]

General surgery services don't function the way an IR service would. We don't have "peri-procedural patients." We admit patients with all their acute and chronic comorbidities. Our complications are more varied. The perioperative period is a time to continue resuscitating patients, discovering post-op MI/stroke/sepsis/hemorrhage or missed traumatic injuries. The length and complexity of our procedures and therefore peri-operative care is different than IR.

The type of care you described in the quote is exactly the type of care that some institution (like Miami Vascular and Rush) are pioneering and all IRs are striving toward. That's the whole point of the residency program. Rush, in particular, have taken much of vascular surgery/PAD business.

I actually advocate a closer working relationship and integration of a vascular surgery plus IR practice, for the benefit of patients.

If IRs cannot wake up at 4am and go home at 10pm as well as providing round the clock coverage and the care you cited in your post, we don't deserve to do PAD.

 

[DrfluffyMD]

At this point the title should just be renamed to "False equivalents: The thread".

IR and surgery are different specialties. Surgeons do take care of patients. Comparing IR and surgery is no different than comparing ortho to rheumatology. Why does this upset you?

Would you like to quote me on where exactly I stated a false equivalence?

 

[Light at end of tunnel]

And when will residents learn how to do this "scut"?

I think it take 2-3 years for a resident to become proficient at managing surgical patients and being able to manage things while scrubbed in a case. Once you're an attending at a private hospital, it's just you, and you better be ready.

You feel it takes 2-3 years to learn to do bottom of the barrel "work"?

Yet at the same time only 4 years to learn to become a general surgeon?

Bruh, you're killin me here

 

[Dr.LeoSpaceman]

You feel it takes 2-3 years to learn to do bottom of the barrel "work"?

As discussed by a few of us this "bottom of the barrel work" is known as "being a physician". I'm not sure how to react if this concept is foreign to you.

General surgery has two components: the medical care of surgical patients (which you may recall as making up most of the shelf exam), and the technical aspect of actually performing the surgeries. When it takes 3 years to complete a basic IM residency, and at least another 3 to complete a procedural subspecialty (e.g. GI) is it really that crazy to believe that it actually does take 5 years to become proficient at both aspects of patient care within general surgery? As we've said, the comparison to IR makes no sense as it eschews the patient care aspect. Yes I understand that if what Fluffy says is true there is a move to add this to IR's scope of practice. However, as I said before, if this is the case then there should be an expectation that IR training is going to start looking a lot more like a surgical sub-specialty.

 

[VA Hopeful Dr]

As discussed by a few of us this "bottom of the barrel work" is known as "being a physician". I'm not sure how to react if this concept is foreign to you.

General surgery has two components: the medical care of surgical patients (which you may recall as making up most of the shelf exam), and the technical aspect of actually performing the surgeries. When it takes 3 years to complete a basic IM residency, and at least another 3 to complete a procedural subspecialty (e.g. GI) is it really that crazy to believe that it actually does take 5 years to become proficient at both aspects of patient care within general surgery? As we've said, the comparison to IR makes no sense as it eschews the patient care aspect. Yes I understand that if what Fluffy says is true there is a move to add this to IR's scope of practice. However, as I said before, if this is the case then there should be an expectation that IR training is going to start looking a lot more like a surgical sub-specialty.

I think this is really key here. I'm an FP but one of the things all of us non-procedure based people notice pretty quickly is the difference in patient management of general surgery compared to pretty much everyone else.

You know who hardly ever consults us for pre-op "clearance"? General surgery.

You know who never consults for management of pre-existing hypertension/diabetes on surgical patients? General surgery.

You know who still admits their own patients versus always just being a consultant, even for an obvious surgical patient? You get the idea.

 

[Light at end of tunnel]

@FaytlND @VA Hopeful Dr

Yea, your explanation makes sense. I can buy that.

 

[ACSurgeon]

You feel it takes 2-3 years to learn to do bottom of the barrel "work"?

Yet at the same time only 4 years to learn to become a general surgeon?

Bruh, you're killin me here

It's not like you spend 100% of your time learning the "bottom of the barrel" work. You're also slowly learning technical skills. By the end of my third year I could do an appy, a lap chole, a bowel resection, etc. my last two years were spent refining those skills and learning to lead the operation and not need as much assistance from my attending.

Also, I resent the terminology of "bottom of the barrel work". This isn't just scut paperwork. This includes managing floor and ICU patients. Learning to handle 10-15 consults during a night shift while managing a few crashing patients on the floor. If it takes 3 years to train an internist who's destined to do a fellowship or be a coordinator of care as a hospitalist, why do you think it would take less than 2-3 years for surgery residents to learn those same skills while also developing the fundamental technical skills of becoming a surgeon?

I won't argue that there are many efficiencies in surgical training. But that's not unique to surgery. This is rampant in our entire education system from college to Med school to graduate medical education in any specialty. You figure out how to make the process 100% efficient, and you'll win a Nobel prize or something.

 

[Dr.LeoSpaceman]

I think this is really key here. I'm an FP but one of the things all of us non-procedure based people notice pretty quickly is the difference in patient management of general surgery compared to pretty much everyone else.

Much appreciated. But I do want to go on record as saying that we do try to respect our limits. I may ask medicine or cardiology to see a patient pre-op, but we try to teach that it's for pre-op "evaluation" and not "clearance". Sounds like semantics but I think most believe that the person that the only person that really clears a person for surgery is the surgeon, in the context of their medical evaluation and the potential risks/benefits of the planned operation. And while I do try to manage routine post-operative medical issues without bothering a consultant, I will get someone involved if it's going to be a new issue regarding long-term follow-up. Yes I can (and do) start people on anti-hypertensives, insulin or rate control agents to temporize an issue, but if I'm not going to managing these things 6 months from now I would prefer it be done with the input of the requisite service/provider.

 

[DrfluffyMD]

I honestly think the clinical education in surgery is unparalleled and that's the type of education all procedural specialties should strive toward, but my big issue is how the balls to the wall 90 hour week thing doesn't work for everyone.

Being a guy with no kid who is moving away from partner for fellowship, I am just fine working 90-100 hrs a week.

However, many people with children are not. Is there a way to structure training so that both side can be satisfied?

My proposal is the creation of longer programs with shorter defined hours and perhaps less inefficiencies for people who need shorter hours.

I am not a surgical educator so I'll speak on behalf of my specialty.

The current IR DR residency has one year of internship, 3 years of diagnostic radiology (40-50 hr weeks) and 2 years of IR (80-100 hr weeks)

If I become a director of IR/DR residency, I would pioneer two tracks, with the first track being more surgically minded, with mandatory surgery internship and 6 years of total training, the last two years being IR and average 80 plus hours.

The second track, perhaps I can call it the "dedicated proceduralist" tract rather than the interventional clinician tract, would allow the trainee to pick their internship, including allowing transitional years (which is currently allowed by DR IR)

The 2 years of IR training would be extended into 3 years, with the total residency becoming 7 years. However, the average hours in those three years would be 35-45 hours a week. Those proceduralist track trainees will also not be on as much evening call (perhaps half as much as the regular track). They will still have clinical experiences, which will be geared more toward outpatient experiences like working up laser vein ablation, infertility and fibroid treatments, etc.

Meanwhile, people in the regular tract will gain the outpatient skills plus inpatient skills that happen after 5pm, and can still graduate one year earlier due to the overall hours worked.

In effect, folks from this tract will not gain as much inpatient management skills and procedural skills in things like TIPS or complex hepatobiliary or PAD work, but this tract will still set them up for a nice outpatient clinical life style, or the current generation of nonclinical IR's work model of "you ship'em I stick'em".

 

[Light at end of tunnel]

It's not like you spend 100% of your time learning the "bottom of the barrel" work. You're also slowly learning technical skills. By the end of my third year I could do an appy, a lap chole, a bowel resection, etc. my last two years were spent refining those skills and learning to lead the operation and not need as much assistance from my attending.

Also, I resent the terminology of "bottom of the barrel work". This isn't just scut paperwork. This includes managing floor and ICU patients. Learning to handle 10-15 consults during a night shift while managing a few crashing patients on the floor. If it takes 3 years to train an internist who's destined to do a fellowship or be a coordinator of care as a hospitalist, why do you think it would take less than 2-3 years for surgery residents to learn those same skills while also developing the fundamental technical skills of becoming a surgeon?

I won't argue that there are many efficiencies in surgical training. But that's not unique to surgery. This is rampant in our entire education system from college to Med school to graduate medical education in any specialty. You figure out how to make the process 100% efficient, and you'll win a Nobel prize or something.

Thank you for that. It does seem that there is much to be gained in the form of this so called "scut work" and that it plays an essential and necessary part in contributing to a proficient general surgeon.