Traditional (non-integrated) cardiac surgery

[DO_Surgeon]

I've seen this type of hand-holding in adult CT as well; IMHO it is almost purely a result of inadequate training rather than a reflection of the difficulty of the field. At my med school there were several attendings who seemed to think autonomy was a four letter word. The senior fellow struggled to put a patient on and off pump independently, and despite being three months from being an attending at the time would likely be unable to do a straightforward CABG on his own. He ended up doing a one year super fellowship to further improve. This was, per the residents, pretty reflective of the typical CT graduate's skill level from that program.

What program was this...I sure hope it's not where I am starting in July

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[ESU_MD]

Part of having a good first job is when your senior partners help you with the critical parts of your big cases, ie circ arrest time, etc.. Its not that one cant do it as a new guy, but things are gonna happen and this helps distribute the risk which can severely dampen a career. The same probably should happen more in general surgery too.

Now big brother need not be around for routine cabg or avr. These people are out there, and i personally know a few people who have never sewn in a mitral valve and had less than 10 distals in their training.

 

[JackADeli]

Part of having a good first job is when your senior partners help you with the critical parts of your big cases, ie circ arrest time, etc.. Its not that one cant do it as a new guy, but things are gonna happen and this helps distribute the risk which can severely dampen a career. The same probably should happen more in general surgery too...

Aside from "stuff happens", a senior partner assisting helps build the practice and community trust. It isn't just for the new guy, it really is an obligation/duty of a senior partner if he/she wants the practice to grow. And, as "stuff happens", that partner wants to mitigate as much as possible. A new guy/gal that has a significant bad outcome early has an almost insurmountable hill to climb in their community. So, you come into a community, you do not want a spectacular, high visibility failure with your senior partners on the sidelines. They need to be invested and supportive of the new high you migh bring based on training.

 

[dienekes88]

I think, based on conversations and observation, many "top programs" are not known so much for their "teaching" as much as they are known for their university name, attending name, and prior historical legends.
Bingo! We have a winner.

Obviously, you have a great deal more experience than I have. However, based on conversations and observation, I think that it would be grossly unfair to generalize this stereotype to all university programs. As I understand it, some top programs also have excellent operative experience.

Are you guys really CT haters?? ....or just jealous? there are plenty of open spots if you want to sign up!

Well, not that many integrated spots... it's pretty competitive. I wish there were more data about average Step 1 scores, research experience, etc.

(wouldnt it suck to have a ct surg sub-forum?)

Ha. It would only have two kinds of threads:

"IS CT SURG DYING?!1?"

"LET ME START ANOTHER THREAD ASKING ABOUT WHETHER INTEGRATED CT IS COMPETITIVE."

 

[pubhlthsurg]

4th yr here who matched into general surgery and is set on pursuing a career in CT. I worked with a CT surgeon in a small twn who rationalized why I should do GS 1st. It made sense and so i'm sticking to it.

 

[JackADeli]

...many "top programs" are not known so much for their "teaching" as much as they are known for their university name, attending name, and prior historical legends...

...you have a great deal more experience than I have. However, based on conversations and observation, I think that it would be grossly unfair to generalize this stereotype to all university programs. As I understand it, some top programs also have excellent operative experience...

That's why it's called a generalization. I do not note any use of the word "all" in my statement. Actually the word "many" that clearly implies NOT "all". There will clearly be programs with exceptional (i.e. exceptions) track records in resident hands on autonomy and training.

Accross all specialties, for years, applicants would always ask about, "how much will I do as a resident during a case...". That is standard when applying to general surgery. Plenty general surgery programs still had/have that "academic" mentality of rsidents FA and observe primarily through their 5-7yrs. When it came to CV/CT, folks just wanted to get in and have a "good name" on the diploma.

Times have changed. Applicants at all levels are not going to tolerate the old school ~abussive, non-operative "pay your dues" years of service. They want hands on, actual training/practice under guidance of mentor. This change has clearly found its way up into CV/CT residencies. It is clear based on the news you see monthly in the "throw away" general surgery news and other such that CT/CV has had increasingly rough time to recruit applicants.

Still, there are plenty CV/CT residencies that, because of name, history, legend, are "big name".... and fail to modernize teaching paradigm. Something one should watch for in a so called "big name" is what the grads do? A "big name" grad, WITH plenty of hands-on training should not be requiring "superfellowships" to get a bread butter job = VATS and heart valves. At three years of hands-on training, a grad in 2011/12 should be very facile in VATS lobes and/or CABG with at least aortic valves and straightforward mitrals. A congenital fellowship is another animal and reasonable. But, IMHO, beware of a program, with "name" that its grads need a VATS fellowship for a general thoracic job or a aorta fellowship for a cardiac job.....

 

[DO_Surgeon]

That's why it's called a generalization. I do not note any use of the word "all" in my statement. Actually the word "many" that clearly implies NOT "all". There will clearly be programs with exceptional (i.e. exceptions) track records in resident hands on autonomy and training.

Accross all specialties, for years, applicants would always ask about, "how much will I do as a resident during a case...". That is standard when applying to general surgery. Plenty general surgery programs still had/have that "academic" mentality of rsidents FA and observe primarily through their 5-7yrs. When it came to CV/CT, folks just wanted to get in and have a "good name" on the diploma.

Times have changed. Applicants at all levels are not going to tolerate the old school ~abussive, non-operative "pay your dues" years of service. They want hands on, actual training/practice under guidance of mentor. This change has clearly found its way up into CV/CT residencies. It is clear based on the news you see monthly in the "throw away" general surgery news and other such that CT/CV has had increasingly rough time to recruit applicants.

Still, there are plenty CV/CT residencies that, because of name, history, legend, are "big name".... and fail to modernize teaching paradigm. Something one should watch for in a so called "big name" is what the grads do? A "big name" grad, WITH plenty of hands-on training should not be requiring "superfellowships" to get a bread butter job = VATS and heart valves. At three years of hands-on training, a grad in 2011/12 should be very facile in VATS lobes and/or CABG with at least aortic valves and straightforward mitrals. A congenital fellowship is another animal and reasonable. But, IMHO, beware of a program, with "name" that its grads need a VATS fellowship for a general thoracic job or a aorta fellowship for a cardiac job.....

Very Well Stated!

 

[dienekes88]

That's why it's called a generalization. I do not note any use of the word "all" in my statement. Actually the word "many" that clearly implies NOT "all". There will clearly be programs with exceptional (i.e. exceptions) track records in resident hands on autonomy and training.

Accross all specialties, for years, applicants would always ask about, "how much will I do as a resident during a case...". That is standard when applying to general surgery. Plenty general surgery programs still had/have that "academic" mentality of rsidents FA and observe primarily through their 5-7yrs. When it came to CV/CT, folks just wanted to get in and have a "good name" on the diploma.

Thanks for the clarification. Part of my response was to address the general attitude on SDN that "academic" is the same as "poor operative experience." Of course I'm only relying on what the residents and fellows are telling me and the little that I'm seeing.

Times have changed. Applicants at all levels are not going to tolerate the old school ~abussive, non-operative "pay your dues" years of service.

Well, I imagine one of the concerns might be that these are the same applicants you referenced earlier who focus on how "fun" surgery is without really knowing what surgery is all about. It all exists on a spectrum and what younger generations call "abuse" or "paying your dues" you might just call "work," e.g. scrubbing for a 5th lap chole or a 13th VATS wedge.

There's just a base amount of footwork that has to be done, and it seems that as time goes on, the willingness to do that work might be declining. There's a subset of students who hate memorizing. For example, they want to be taught how to read EKGs but don't want to memorize EKG criteria for LVH, LBBB, left atrial enlargement, etc. It's tough to learn to do something independently, if all the time is spent re-teaching the fundamentals.

They want hands on, actual training/practice under guidance of mentor. This change has clearly found its way up into CV/CT residencies. It is clear based on the news you see monthly in the "throw away" general surgery news and other such that CT/CV has had increasingly rough time to recruit applicants.

No doubt that is one of the reasons for the integrated track. As I understand it, the integrated programs have very high quality applicants.

Hands-on training is great, but isn't seeing a procedure several times very important when you're inexperienced? I feel like you have to know almost all the steps by heart (pardon the pun) before you try to do it.

Still, there are plenty CV/CT residencies that, because of name, history, legend, are "big name".... and fail to modernize teaching paradigm. Something one should watch for in a so called "big name" is what the grads do? A "big name" grad, WITH plenty of hands-on training should not be requiring "superfellowships" to get a bread butter job = VATS and heart valves. At three years of hands-on training, a grad in 2011/12 should be very facile in VATS lobes and/or CABG with at least aortic valves and straightforward mitrals. A congenital fellowship is another animal and reasonable. But, IMHO, beware of a program, with "name" that its grads need a VATS fellowship for a general thoracic job or a aorta fellowship for a cardiac job.....

Very true.

However, to me it seems slightly more complicated. As the fellows have explained to me, there are certain places that have a lot of thoracic training whereas other places are more cardiac focused. It actually wouldn't surprise me if someone came out of a very cardiac-heavy program feeling comfortable with AVRs, CABGs, and transplants but didn't feel great about doing VATS lobes and wedges or vice versa. Not every program is evenly distributed in experience and strength, right?

 

[SLUser11]

Thanks for the clarification. Part of my response was to address the general attitude on SDN that "academic" is the same as "poor operative experience." Of course I'm only relying on what the residents and fellows are telling me and the little that I'm seeing.

It sounds like you've taken a big drink of the kool-aid.

I wouldn't put heavy stock in the things your residents and fellows are saying, especially if it is different than the general SDN consensus. Often, people develop tunnel vision within their own institution, and they decide that "this is how it is everywhere" and their experience sums up the national experience.

There have been countless numbers of inaccurate generalizations that have developed as a result of this phenomenon.

The general attitude on SDN is not that academic=poor operative experience. The attitude is that big names don't guarantee good training, so the applicant should look beyond the flashy diploma and find a place that has balance. There are plenty of fantastic places to train in academia...most of them are outside NY, though....

 

[dienekes88]

It sounds like you've taken a big drink of the kool-aid.

I wouldn't put heavy stock in the things your residents and fellows are saying, especially if it is different than the general SDN consensus. Often, people develop tunnel vision within their own institution, and they decide that "this is how it is everywhere" and their experience sums up the national experience.

Fair enough. I won't deny that I've taken a big gulp of the kool-aid, I may or may not have jumped into the pool.

There have been countless numbers of inaccurate generalizations that have developed as a result of this phenomenon.

The general attitude on SDN is not that academic=poor operative experience. The attitude is that big names don't guarantee good training, so the applicant should look beyond the flashy diploma and find a place that has balance. There are plenty of fantastic places to train in academia...most of them are outside NY, though....

I agree that big names don't guarantee good training. ESU_MD said this at some point: When you're an attending solo in the OR at night, the name on your diploma won't save your *ss. Maybe I'm naive in thinking that working your butt off at a big name will get you good training (as is the case with working your butt off anywhere) and then give you a better shot at the fellowship of your dreams.

Correct me if I'm wrong, and maybe you'll fish me out of the kool-aid pool!

 

[JackADeli]

...Well, I imagine one of the concerns might be that these are the same applicants you referenced earlier who focus on how "fun" surgery is without really knowing what surgery is all about. It all exists on a spectrum and what younger generations call "abuse" or "paying your dues" you might just call "work," e.g. scrubbing for a 5th lap chole or a 13th VATS wedge....

Agreed there is a sprectrum. The issue is not the 5th lap chole in a day or 13th VATS wedge. Rather, the finer point in this discussion is, retracting or simply holding the camera while the ATTENDING does the 5th lap chole in the day or 13th VATS wedge. The big question as always is, "Are YOU, the resident, actually doing the case?".

There's just a base amount of footwork that has to be done, and it seems that as time goes on, the willingness to do that work might be declining. There's a subset of students who hate memorizing. For example, they want to be taught how to read EKGs but don't want to memorize EKG criteria for LVH, LBBB, left atrial enlargement, etc. It's tough to learn to do something independently, if all the time is spent re-teaching the fundamentals...

I agree and I suspect all surgeons agree, the trainee needs to do their part... this includes reading for the medstudent and/or resident lectures, memorzing those things that need memorizing, etc...Covering patients, taking call, answering consults, etc... is part of what one needs to do to get trained. That is not the point.

...No doubt that is one of the reasons for the integrated track. As I understand it, the integrated programs have very high quality applicants...

From what I hear, they do have high ranking candidates. I also very much suspect such "high ranking", unseasoned candidates will tolerate the, "pay dues" by "observe me operate and be amazed at how great I am", far less then anyone could have dreamed! But, there are suggestions from the attendings I speak to that integrated is being used to actually AVOID change.

Many (note I did not say "all") senior attendings in "old school" programs have limited aptitude or willingness to provide hands on teaching. The 5 + 2-3 model programs haave been scrambling for some years with very tiny applicant pool. I have heard programs being happy if they can break 10 applicants per interview cycle. The traditional programs that will land quality applicants have had to drastically change their approach and allow autonomy/hands-on. Difficult thing for MANY senior attendings.

However, the integrated, fresh out of med-school, unjaded applicant pool numbers in 100s per application cycle. These nice, young, unjaded/unseasoned applicants are still drinking kool aid, wanting to break the 80hr to prove their power, etc... and see this as a short cut! There will be some very, very disapointed residents in some "old school" programs that have converted to integrated just to keep afloat. I already hear those attendings using an excuse for observation/hands-off training.... "well, you have far less foundation experience then was required in the past. Your young and will enjoy an additional focused fellowship to build on this integrated foundation....".

...Hands-on training is great, but isn't seeing a procedure several times very important when you're inexperienced? I feel like you have to know almost all the steps by heart (pardon the pun) before you try to do it...

That's the koolaid they expect and love from the unseasoned integrated applicant... always waiting and believing you have time and will eventually get a turn. However, if you take pilot lessons, you don't sit and watch the flight instructor fly for 40 hours. You take martial arts, you don't just sit and watch the sensei go through Katas and then sweep the dojo floor. If you aare learning to play the piano, you don't sit and watch your music instructor for hours and days on end play different pieces. They may show you something and then watch you attempt to replicate the action. The same with surgery. At some point... early on, you need to be handed the instrument and start practicing under direct observation.

There is this 10 thousand hours of practice theory. That clock of 10k should start running during your residency in any field. A good portion of your 10 thousand hours of practice should be under the observation and guidance of a master-mentor. That is a fine point most attendings fail to recognize when citing 10 thousand hours. Instead, you graduate and stumble and/or suck at surgery. Your mentors at that point cite you need about ten years and 10k hours..."so don't worry, it takes time"!

...However, to me it seems slightly more complicated. As the fellows have explained to me, there are certain places that have a lot of thoracic training whereas other places are more cardiac focused. It actually wouldn't surprise me if someone came out of a very cardiac-heavy program feeling comfortable with AVRs, CABGs, and transplants but didn't feel great about doing VATS lobes and wedges or vice versa. Not every program is evenly distributed in experience and strength, right?

It would surpise me. That means they chose a name over the training! Anyone that is going to do a 12 month VATS superfellowship is not likely to be planning any kind of cardiac practice. The opposite is true too. Anyone going to do a 12 month aorta/valve fellowship is not likely to be planning any kind of general thoracic program. That/those scenarioes make no sense and again suggest someone seeking diploma name over training/competency....

And, frankly any grad that is not comfortable with VATS wedges is really in trouble. I did those in general surgery!

...Maybe I'm naive in thinking that working your butt off at a big name will get you good training (as is the case with working your butt off anywhere) and then give you a better shot at the fellowship of your dreams...

Yes, it is about hard work. But it needs to be the right kind of work! You can work hard on the track, transporting gear, etc.... That won't make you the faster runner. Being "Johnny on the Spot" on the floor all night long is not going to make you a good technical surgeon... and the exhaustion can work against you maximizing the operative opportunities you think you are earning by sacrificing these long nights!

 

[dienekes88]

Agreed there is a sprectrum. The issue is not the 5th lap chole in a day or 13th VATS wedge. Rather, the finer point in this discussion is, retracting or simply holding the camera while the ATTENDING does the 5th lap chole in the day or 13th VATS wedge. The big question as always is, "Are YOU, the resident, actually doing the case?". I agree and I suspect all surgeons agree, the trainee needs to do their part... this includes reading for the medstudent and/or resident lectures, memorzing those things that need memorizing, etc...Covering patients, taking call, answering consults, etc... is part of what one needs to do to get trained. That is not the point.From what I hear, they do have high ranking candidates. I also very much suspect such "high ranking", unseasoned candidates will tolerate the, "pay dues" by "observe me operate and be amazed at how great I am", far less then anyone could have dreamed! But, there are suggestions from the attendings I speak to that integrated is being used to actually AVOID change.

Many (note I did not say "all") senior attendings in "old school" programs have limited aptitude or willingness to provide hands on teaching. The 5 + 2-3 model programs haave been scrambling for some years with very tiny applicant pool. I have heard programs being happy if they can break 10 applicants per interview cycle. The traditional programs that will land quality applicants have had to drastically change their approach and allow autonomy/hands-on. Difficult thing for MANY senior attendings.

However, the integrated, fresh out of med-school, unjaded applicant pool numbers in 100s per application cycle. These nice, young, unjaded/unseasoned applicants are still drinking kool aid, wanting to break the 80hr to prove their power, etc... and see this as a short cut! There will be some very, very disapointed residents in some "old school" programs that have converted to integrated just to keep afloat. I already hear those attendings using an excuse for observation/hands-off training.... "well, you have far less foundation experience then was required in the past. Your young and will enjoy an additional focused fellowship to build on this integrated foundation....".That's the koolaid they expect and love from the unseasoned integrated applicant... always waiting and believing you have time and will eventually get a turn. However, if you take pilot lessons, you don't sit and watch the flight instructor fly for 40 hours. You take martial arts, you don't just sit and watch the sensei go through Katas and then sweep the dojo floor. If you aare learning to play the piano, you don't sit and watch your music instructor for hours and days on end play different pieces. They may show you something and then watch you attempt to replicate the action. The same with surgery. At some point... early on, you need to be handed the instrument and start practicing under direct observation.

There is this 10 thousand hours of practice theory. That clock of 10k should start running during your residency in any field. A good portion of your 10 thousand hours of practice should be under the observation and guidance of a master-mentor. That is a fine point most attendings fail to recognize when citing 10 thousand hours. Instead, you graduate and stumble and/or suck at surgery. Your mentors at that point cite you need about ten years and 10k hours..."so don't worry, it takes time"!It would surpise me. That means they chose a name over the training! Anyone that is going to do a 12 month VATS superfellowship is not likely to be planning any kind of cardiac practice. The opposite is true too. Anyone going to do a 12 month aorta/valve fellowship is not likely to be planning any kind of general thoracic program. That/those scenarioes make no sense and again suggest someone seeking diploma name over training/competency....

And, frankly any grad that is not comfortable with VATS wedges is really in trouble. I did those in general surgery!Yes, it is about hard work. But it needs to be the right kind of work! You can work hard on the track, transporting gear, etc.... That won't make you the faster runner. Being "Johnny on the Spot" on the floor all night long is not going to make you a good technical surgeon... and the exhaustion can work against you maximizing the operative opportunities you think you are earning by sacrificing these long nights!

All fair points. Things to think about as I start planning residency applications. I'll try to avoid the "many" and find the "exceptional."

Of course I realize that you have to operate to be good at operating, but just starting and being told every move to perform is not really operating either, is it? There has to be some modicum of balance. On the other hand, I do hope to operate like crazy during residency.

 

[SLUser11]

Maybe I'm naive in thinking that working your butt off at a big name will get you good training (as is the case with working your butt off anywhere) and then give you a better shot at the fellowship of your dreams.

Correct me if I'm wrong, and maybe you'll fish me out of the kool-aid pool!

Well, maybe that's a little naive, because most people in that situation will "work their butt off." And ultimately, you shouldn't train somewhere that makes it that hard to get good training. You don't want to come out well trained despite your program, but because of your program.

I think that most SDNers will agree that there are places with "big names" that also offer stellar training, so the two things are definitely not mutually exclusive. All that we ask is that you don't put your blinders on, get sucked in by reputation, and ignore some glaring defects in a place's training module.

Instead, use your resources to get a feel for good places to train, then apply intelligently, and look at the places for yourself. When you are there, be sure to ask some hard-nosed questions about autonomy and case numbers. It's not rude, in my opinion, because all places will agree (on paper) that it's essential, and you need to know these things. Any place that dances around these types of straight-forward questions (e.g. ABSITE/board scores, probations, protected teaching time) has something to hide.

Also, don't forget to talk to the senior med students from the facility. They will often sugar-coat things a little, but they are more likely to either purposefully or accidentally spill the beans.

One anecdotal note about CT surgery: It appears very sexy to medical students, and I was almost positive that was what I wanted to do....I changed my mind early on in residency, finding things I enjoyed a lot more, and I'm awfully glad integrated programs weren't prominent then....

I have to admit, although it's off topic, that I'm also a little leery of the integrated vascular programs, because students really only get a snapshot experience, and most general surgery residents grow to hate vascular....

 

[dienekes88]

Well, maybe that's a little naive, because most people in that situation will "work their butt off." And ultimately, you shouldn't train somewhere that makes it that hard to get good training. You don't want to come out well trained despite your program, but because of your program.

I think that most SDNers will agree that there are places with "big names" that also offer stellar training, so the two things are definitely not mutually exclusive. All that we ask is that you don't put your blinders on, get sucked in by reputation, and ignore some glaring defects in a place's training module.

Instead, use your resources to get a feel for good places to train, then apply intelligently, and look at the places for yourself. When you are there, be sure to ask some hard-nosed questions about autonomy and case numbers. It's not rude, in my opinion, because all places will agree (on paper) that it's essential, and you need to know these things. Any place that dances around these types of straight-forward questions (e.g. ABSITE/board scores, probations, protected teaching time) has something to hide.

Also, don't forget to talk to the senior med students from the facility. They will often sugar-coat things a little, but they are more likely to either purposefully or accidentally spill the beans.

I'm going to take that to the bank. Thanks for the tip.

One anecdotal note about CT surgery: It appears very sexy to medical students, and I was almost positive that was what I wanted to do....I changed my mind early on in residency, finding things I enjoyed a lot more, and I'm awfully glad integrated programs weren't prominent then....

It has all the appearances of being sexy, and admittedly I have somewhat limited experience. My research is all in cardiac surgery, but I've really only scrubbed maybe 5 cases and seen another 10 cases on top of that. However, many of my seniors have told me that one of the most important things is to make sure that you like reading about the field, and cardiac, thoracic, and congenital heart surgery are the only topics on which I will independently pick up reading material. Trying to work my way through Sabiston & Spencer Surgery of the Chest right now. Awesome stuff.

I have to admit, although it's off topic, that I'm also a little leery of the integrated vascular programs, because students really only get a snapshot experience, and most general surgery residents grow to hate vascular....

Agree c above.

The part really pushes me away from it (prior to growing to hate it during general surgery) is the fact that so much is going endovascular. I imagine there'll be a day when people have to do fellowships in open repair with all the fenestrated and branched aortic grafts and carotid stenting. I like open cases.

 

[JackADeli]

...Of course I realize that you have to operate to be good at operating, but just starting and being told every move to perform is not really operating either, is it?...

YES! It is. You may not land the airplane during your flight lesson, but are you not flying when in the air with the flight instructor.... Again, you do not simply sit and watch the sensei and sweep the dojo for a few years and then test for a black belt! As a resident in any specialty, the goal should be maximum participation to your level of ability. That is the only way you will build on and increase ability and thus further participation.

...One anecdotal note about CT surgery: It appears very sexy to medical students, and I was almost positive that was what I wanted to do...

Bingo! That's why some "big Name" crappy training programs are changing to integrated. They can't compete with the limited, albeit seasoned general surgery applicant pool. Thus, via integrated, they have "hot shot" but naive applicants.

....I imagine there'll be a day when people have to do fellowships in open repair with all the fenestrated and branched aortic grafts and carotid stenting. I like open cases...

Ahhhh, I believe I have heard that same comment relative to other specialties for almost a decade. I still haven't seen any real "open General Surgery" fellowships.

 

[DoctwoB]

Ahhhh, I believe I have heard that same comment relative to other specialties for almost a decade. I still haven't seen any real "open General Surgery" fellowships.

Maybe not for open general surgery yet, but if open volume drops enough then fellowships do become necessary. The example I'm thinking of is open vascular neurosurgery and clipping aneurysms. Endovascular has eaten into the open volume so much that people will do open vascular fellowships for more experience except at a very few residency programs. Its not hard to imagine the same happening for some open general procedures.

 

[ACSurgeon]

Maybe not for open general surgery yet, but if open volume drops enough then fellowships do become necessary. The example I'm thinking of is open vascular neurosurgery and clipping aneurysms. Endovascular has eaten into the open volume so much that people will do open vascular fellowships for more experience except at a very few residency programs. Its not hard to imagine the same happening for some open general procedures.

It actually really is hard to imagine. The difference in technique between endovascular and open vascular is much greater than the difference between laparoscopic and open gen surg.

Endovascular does not entail clamping major vessels, suturing vessels as they bleed into your face, dissecting through planes of crap in re-do re-do re-do fem-pop cases, etc.

Most laparoscopic gen surg (that I've seen) involves the same techniques as open: clamping, cutting, cauterizing, and suturing. Also, trauma surgery should ensure that all gen surg trainees get enough ex-laps (and the technique that comes with that). I would have added hepatobiliary to the list of open experiences, but it seems like lap-whipples and lap-hepatectomies are becoming increasingly common.

Then of course, all the minimally invasive gen or vascular surg that gets converted to open will probably give enough of the basics anyhow... we'll see how I feel about this in 5-9 years!

 

[JackADeli]

Maybe not for open general surgery yet, but if open volume drops enough then fellowships do become necessary. The example I'm thinking of is open vascular neurosurgery and clipping aneurysms. Endovascular has eaten into the open volume so much that people will do open vascular fellowships for more experience except at a very few residency programs. Its not hard to imagine the same happening for some open general procedures.

Sure, and those same arguments almost verbatim (just insert general surgery/vascular surgery in for the specialtl) have been stated for almost a decade in some fields.

Open vascular clipping neurosurgery fellowship.... presumably, you would need adequate volume for any such fellowship. It would be a catch 22. Need a fellowship, cause you have no training, cause there was no volume in your major university program. So, you go to which major university that will have the corner on the nations total volume of now rare open neurosurgery procedure.....

Of course, in all things, you need to remember the trainees. They will be tired of the training period and now they are excited to do an open fellowship fior ?1year at some mecca center... so they can do that 1-2 open vascular cases a year, after they graduate and leave the mecca?

 

[ESU_MD]

Does any surgeon not like open surgery?

 

[DoctwoB]

Does any surgeon not like open surgery?

Maybe not, but eschewing minimally invasive or endovascular for open because its "not real surgery" is a quick route to have other specialties eat your volume.

 

[filter07]

Of course, in all things, you need to remember the trainees. They will be tired of the training period and now they are excited to do an open fellowship fior ?1year at some mecca center... so they can do that 1-2 open vascular cases a year, after they graduate and leave the mecca?

It'll be pretty interesting if community vascular surgeons end up being one-trick endovascular guys. Then you really have to question what exactly the community vascular surgeon offers that differentiates them from IR or interventional cards. Personally I think having a bunch of community vascular surgeons that are unwilling or unable to do open surgery is really going to raise a lot of uncomfortable questions.

As far as open fellowships go, some aggressive endovascular-heavy programs are finding themselves without enough open cases and are seriously considering sending trainees for mini fellowships (a few months) to the community or out of the country.

 

[JackADeli]

Maybe not for open general surgery yet, but if open volume drops enough then fellowships do become necessary. The example I'm thinking of is open vascular neurosurgery and clipping aneurysms. Endovascular has eaten into the open volume so much that people will do open vascular fellowships for more experience except at a very few residency programs. Its not hard to imagine the same happening for some open general procedures.

...Of course, in all things, you need to remember the trainees. They will be tired of the training period and now they are excited to do an open fellowship fior ?1year at some mecca center... so they can do that 1-2 open vascular cases a year, after they graduate and leave the mecca?

It'll be pretty interesting if community vascular surgeons end up being one-trick endovascular guys...

As far as open fellowships go, some aggressive endovascular-heavy programs are finding themselves without enough open cases and are seriously considering sending trainees for mini fellowships (a few months) to the community or out of the country.

Just for clarity and to limit confusion.... You do understand that comment you were quoting was in reference to NEUROSURGERY open vascular procedures, i.e. aneurysm clipping and such. These cases are rapidly becoming few and far between even at major university and thus less likely a grad going into community NEUROSURGERY practice will do 12 months "super-fellowship" for something they will rarely see in the community. Can it be done in a few months? Probably not if the actual numbers are so scarce even at the universities. A NEUROSURGERY "super-fellow" will be hard pressed to get a true training experience in a couple months.

 

[Stare Decisis]

JAD,

I apologize for my laziness of not re-reading every post if this has already been addressed previously. What responsibility do the applicants assume in finding and ranking programs with good operative experience? Or in choosing a path that offers the ability to become a well-rounded surgeon? Many of my co-applicants on the trail were warned from numerous avenues about certain programs where the operative experience was nil and they just had to have the name. The group of applicants that apply to highly competitive specialties is littered with a type of personality that desires a name brand pedigree, training be damned. This is obviously directed at competitive applicants that have some input into where they match and not those who would be happy to just "end up somewhere."

The big names would change their tune if we(students) stopped fawning over these programs just to end up retracting for several years. I suspect sub specialty applicants will not be able to do this because of the massively entitled egos that you find on the trail whose singular objective is to match at a place with an impressive name. My point is, most of the students who choose those big names could have gone elsewhere and in my experience this is usually suggested at some point during the process. They choose to put their heads in the sand. While programs have the duty to train, appliants can drive this objective forward at the "ballot box" so to speak.

 

[DoctwoB]

JAD,
I suspect sub specialty applicants will not be able to do this because of the massively entitled egos that you find on the trail whose singular objective is to match at a place with an impressive name.

Do you remember what they say about ASSumptions?

 

[JackADeli]

...What responsibility do the applicants assume in finding and ranking programs with good operative experience? Or in choosing a path that offers the ability to become a well-rounded surgeon?...

That is real easy... if you are under age 18, ask your mama!

But, as an adult in a ~market situation, you have 100% responsibility to investigate and use all resources to the best of your ability for YOU to make and informed decision. If you are shopping for a car, it is not dealership's duty to inform you their product may be inferior to a competitor. So too, in residency, YOU must take responsibility for YOUR choices. Failure to do the leg work, to plan, to research, etc.... and just choose a name is on YOU the applicant = the buyer.

...The group of applicants that apply to highly competitive specialties is littered with a type of personality that desires a name brand pedigree, training be damned...

YOU get what you shop for... again an individual choice. They choose name over product, so be it. Just don't complain later after you got what you shopped for [i.e. name] but not the product [training] you would like.....

It's not rocket science. At some point folks need to stop wanting everything while expecting someone else to have the accountability/responsibility. That is being an adult, it is self-actualization. And, it surprises me in the medical field, "higher then average intelligence", making life and death decisions for others but often complaining and expecting others to be responsible for our own choices and our own decisions.... from loans, residency, etc, etc, etc....

 

[filter07]

Just for clarity and to limit confusion.... You do understand that comment you were quoting was in reference to NEUROSURGERY open vascular procedures, i.e. aneurysm clipping and such. These cases are rapidly becoming few and far between even at major university and thus less likely a grad going into community NEUROSURGERY practice will do 12 months "super-fellowship" for something they will rarely see in the community. Can it be done in a few months? Probably not if the actual numbers are so scarce even at the universities. A NEUROSURGERY "super-fellow" will be hard pressed to get a true training experience in a couple months.

I was just commenting that the same problems are seen in vascular surgery too.

 

[JackADeli]

I was just commenting that the same problems are seen in vascular surgery too.

No problem... again it was to clarify as the quoted excerpt out of context might be confusing/misleading.

Having said that, I suspect the volume issues are different between "regular"/peripheral vascular surgery and vascular neurosurgery. That is the issue of aneurysms and their overall volume and their open vs interventional tx. I suspect the number/volume of open PERIPH vascular still remains relatively ~high while the same is not likely true in neurosurge aneurysm.... But, I haven't look at those comparative numbers recently.