what are the integrated programs in surgery and how competitive are they

[drseanlive]

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i just learned that there is a vascular surgery integrated option...does this exist for other subspec. in surg other than plastics?

 

[Blade28]

CT Surg has a small handful as well.

 

[SocialistMD]

CT Surg has a small handful as well.

I don't know that I would really consider them integrated as just "fast-track" programs, as you don't match into the existing programs, but rather apply for them from within an already existing surgery residency.

 

[Anka]

I don't know that I would really consider them integrated as just "fast-track" programs, as you don't match into the existing programs, but rather apply for them from within an already existing surgery residency.

Stanford and Penn are integrated 6 year programs with a direct match from med school. Neither results in general surgery board elig.

Anka

 

[Blade28]

Stanford and Penn are integrated 6 year programs with a direct match from med school. Neither results in general surgery board elig.

Anka

Yeah, that's what I remembered as well.

 

[SocialistMD]

Stanford's is an 8-year program that is a direct match, so I stand corrected (I didn't know this program existed; the first year of it will begin this July). From what I can tell, they are the only program that exists. Penn doesn't mention anything on their website about it.

 

[Celiac Plexus]

Stanford's is an 8-year program that is a direct match, so I stand corrected (I didn't know this program existed; the first year of it will begin this July). From what I can tell, they are the only program that exists. Penn doesn't mention anything on their website about it.

http://vascular.stanford.edu/fellowship/integratedresidencyinfo.html

It's actually a "0+5" program. The breakdown of training is on their web site which includes 6 months of general surgery training, 3 of which are in the intern year.

This is really interesting. Should this model prove viable (I'm sure there are a ton of doubters out there), other general surgery subspecialties will be looking hard at this model as well. I guess the general surgeon of tomorrow will still be necessary support these "pure" vascular surgeons when complications arise. Although since most of the work will be endovascular, there may not be that many complications that general surgeons are needed to help with.

 

[SocialistMD]

http://vascular.stanford.edu/fellowship/integratedresidencyinfo.html

It's actually a "0+5" program. The breakdown of training is on their web site which includes 6 months of general surgery training, 3 of which are in the intern year.

This is really interesting. Should this model prove viable (I'm sure there are a ton of doubters out there), other general surgery subspecialties will be looking hard at this model as well. I guess the general surgeon of tomorrow will still be necessary support these "pure" vascular surgeons when complications arise. Although since most of the work will be endovascular, there may not be that many complications that general surgeons are needed to help with.

We were talking about their CT program, not their vascular one, but I agree that many other specialties may end up going this route (for better or worse) if there is success seen.

 

[Celiac Plexus]

We were talking about their CT program, not their vascular one, but I agree that many other specialties may end up going this route (for better or worse) if there is success seen.

Wow. (removing foot from mouth)... It strikes me as unwise to ask a medical student to commit to 8 years of training straight out of medical school. It also strikes me as unwise for a program to make an 8 year commitment to a medical student. Then again, I apparently can't read very well either so maybe I'm the only thing here that's unwise.

 

[SocialistMD]

Wow. (removing foot from mouth)...

I was there with you earlier today, as I didn't know there was an integrated CT program until this morning. I also don't know how someone can know they want to be a vascular surgeon or a CT surgeon after a month or two rotation on it during medical school. I know that, had there been an integrated program for what I wanted to do coming out of med school, I would have been miserable in it now and would have never experienced what it is that I now know I want to do (read: I've changed my mind about my path since being a resident).

 

[Blade28]

Agree with the above.

It also scares me to think that people coming out of some of these new integrated Vascular/CT programs will in essence be "fellows" during their PGY-4 year.

There's lots of abdominal work to be had in Vascular (open AAA, RP bleeds, etc.) and CT (Heller, Nissen, Ivor-Lewis, etc.), and I wouldn't feel comfortable knowing that I'd learned all the necessary GI surgery during my first three years of residency.

My $0.02.

 

[Castro Viejo]

I've wondered about this since the new 0+5 programs have become a reality.

I really didn't start to feel comfortable in the belly until the end of my R4 year. Maybe it's just me, but I can't imagine an R3 knowing his way in and around everything. And then as an R4/Fellow? All of a sudden they're going to be the ones to come in in the dead of night to whack a patient who's got a ruptured AAA?

Sounds more like they'll just lose sphincter control.

 

[vascular2007]

To Drseanlilve,
Look on the google "vascular web" on google. Go to the medical student/resident section for training programs. Currently there are 10 programs out there. Dartmouth, UMichigan, UPittsburgh, URochester, UNorth Carolina, Mt. Sinai, USouthFlorida, SUNY, Stanford.

Good luck, I matched in 2007 and I love it.

 

[Blade28]

I really didn't start to feel comfortable in the belly until the end of my R4 year. Maybe it's just me, but I can't imagine an R3 knowing his way in and around everything. And then as an R4/Fellow? All of a sudden they're going to be the ones to come in in the dead of night to whack a patient who's got a ruptured AAA?

Exactly. Most PGY-3s become comfortable with, what, straightforward open colon resections, at the most? No way a brand-new PGY-4 would be comfortable with a huge AAA.

 

[maxheadroom]

I think that the problem that general surgery categoricals have when they look at integrated residents is that they're looking through the lens of a general surgery categorical. An R4 in an integrated vascular training program has spent three years in vascular training. They've been working their way up on the cases. While they might not be able to do all of the bowel stuff that a general surgery R4 can do, it doesn't matter. They don't need to do a right colon or a whipple -- they need to expose the aorta and gain proximal and distal control.

In addition, think about the numbers thing right now. There are only a handful of vascular residencies right now of the integrated model. Do you think that they're lacking for qualified applicants? I'm willing to bet that the average matched integrated vascular resident is a very competitive applicant in most other pools -- essentially you're taking high-performers out of medical school and focusing their intellectual development and their motor skills on becoming vascular surgeons. Why spend time taking out gallbladders and colons when you want to sew blood vessels and do caths?

Listen to Richard Reznick talk about the future of surgical education and you'll see that it's time for people to spend more time in the field that they're going to practice and less time being the floor bitch for the trauma service.

 

[SocialistMD]

I think that the problem that general surgery categoricals have when they look at integrated residents is that they're looking through the lens of a general surgery categorical. An R4 in an integrated vascular training program has spent three years in vascular training. They've been working their way up on the cases. While they might not be able to do all of the bowel stuff that a general surgery R4 can do, it doesn't matter. They don't need to do a right colon or a whipple -- they need to expose the aorta and gain proximal and distal control.

I agree, and I think that an R4 would be ready to perform an open AAA if s/he had spent the last 3 years doing fem-pops (something I did as an R-2), carotids and fistulas.

Listen to Richard Reznick talk about the future of surgical education and you'll see that it's time for people to spend more time in the field that they're going to practice and less time being the floor bitch for the trauma service.

If you listen to many of the people interested in surgical education in general or many vascular surgeons in particular, they will all echo this. Many of the leaders in surgical education see the 80-hour work week as the nail in the coffin of the breadth of general surgery training and that most specialties in general surgery will develop into an integrated or fast-track system.

 

[Pilot Doc]

I also don't know how someone can know they want to be a vascular surgeon or a CT surgeon after a month or two rotation on it during medical school.

I expect you can know it as well as you can know you want to be a neurosurgeon or an ENT or integrated plastics, etc.

And I suspect most of these programs will end up swapping R2/R3 level residents back and forth across tracks.

 

[SocialistMD]

I expect you can know it as well as you can know you want to be a neurosurgeon or an ENT or integrated plastics, etc.

Touche. Have I been getting carried away with my prolific posting today and you felt the need to reel me back in? 😉

However, I think it is a little different in that I knew I didn't want to operate on the brain, spine, bones or face and that I wanted to be in the belly, and I never really rotated on any of those services before fourth year. I also went to a medical school that really didn't have the vascular or cardiothoracic experience that we have here, so I guess that is also why I can't see how a med student can know based on a one-month rotation that they want to do it; I'm a surgeon who's being egocentric...

 

[Blade28]

Listen to Richard Reznick talk about the future of surgical education and you'll see that it's time for people to spend more time in the field that they're going to practice and less time being the floor bitch for the trauma service.

God that would be nice.

 

[GSresident]

God that would be nice.

If I am remembering right, I spent 2 months as an intern, 3 months as a second year, 3 months as a 3rd year, 3 months as a 4th year and 3 months as a 5th year on the trauma service. I always heard people make the argument that you needed 5 years of general surgery to be good. If this is the case then why did I spend a year and 2 months of my GS residency doing scutwork with little or no operative experience?

The amount of time it takes for someone to get their surgery legs is person dependant. I saw people graduating their chief year who just didn't seem to get it. I saw second years who could operate just as well as the chiefs. Whenever someone starts spouting off about needing more years of training what I hear is someone saying they want more cheap labor.

 

[Celiac Plexus]

If I am remembering right, I spent 2 months as an intern, 3 months as a second year, 3 months as a 3rd year, 3 months as a 4th year and 3 months as a 5th year on the trauma service. I always heard people make the argument that you needed 5 years of general surgery to be good. If this is the case then why did I spend a year and 2 months of my GS residency doing scutwork with little or no operative experience?

The amount of time it takes for someone to get their surgery legs is person dependant. I saw people graduating their chief year who just didn't seem to get it. I saw second years who could operate just as well as the chiefs. Whenever someone starts spouting off about needing more years of training what I hear is someone saying they want more cheap labor.

Wow. I couldn't agree more. My training program has a total of 10 months of trauma spread out over 3 years. Almost 20% of my residency has been spent on the trauma service, during which time I have done about 4% of my cases. I have long held the view (privately) that this has been a poor use of my training time since I will in all likelihood never take general surgery trauma call once I am done with my training.

 

[maxheadroom]

Those were the same views of the surgical specialty program directors at my place. GenSurg was using their interns/juniors for too much trauma time and not enough "real surgery" time. En masse, the plastics/ortho/ENT/Uro residents went from having 2-3 months of trauma as interns to one month. The plastics R2s and R3s went from having one month and two months, respectively, to having NONE. We replaced it with Derm, Ophtho, and a second month of Ortho Hand. GenSurg bitched because they had to do more trauma. Guess what? Nobody cares. Trauma is their $hit rotation -- they can staff it with their own residents. Suddenly the GenSurg chairman is interested in hiring PAs/NPs to carry the load because of the ridiculous burden of the Trauma service.

 

[vascular2007]

"I think that the problem that general surgery categoricals have when they look at integrated residents is that they're looking through the lens of a general surgery categorical. An R4 in an integrated vascular training program has spent three years in vascular training. They've been working their way up on the cases. While they might not be able to do all of the bowel stuff that a general surgery R4 can do, it doesn't matter. They don't need to do a right colon or a whipple -- they need to expose the aorta and gain proximal and distal control."

Right on. I'm in my R1 year as an integrated resident and have 10+ IVC Filters, numerous amps, stents, plasties, assisted with numerous fistulas (with my loops!), first assisted many CEAs. Scrubbed in on tons of EVARS carotid stents....I think the training model is different.

 

[Winged Scapula]

Those were the same views of the surgical specialty program directors at my place. GenSurg was using their interns/juniors for too much trauma time and not enough "real surgery" time. En masse, the plastics/ortho/ENT/Uro residents went from having 2-3 months of trauma as interns to one month. The plastics R2s and R3s went from having one month and two months, respectively, to having NONE. We replaced it with Derm, Ophtho, and a second month of Ortho Hand. GenSurg bitched because they had to do more trauma. Guess what? Nobody cares.

Hmmm...here, here.

I spent a year or 20% of my residency on the trauma service, not including the overnight trauma call I took as a senior and moonlighting resident when on other services. In a hospital with mostly blunt trauma, it can become mind-numbingly routine.

I think it valuable to see how a trauma service functions but for the subspecialty guys who aren't ever going to have to do a PEG or PET or Bronch, etc. its probably a waste of time to do more. Obviously, many subspecialists will have to cover trauma as an attending but a subspecialty resident on a trauma service is not going to the OR with ENT or PRS except as an observer, even if that's the residency they're doing.

 

[maxheadroom]

Glad to hear that things are working well for you, vascular2007.

The point is that residency should be about EDUCATION. While there will be SERVICE associated with it, the service component should be part of the education. When residency becomes more focused on service than education, it's time to rethink the whole thing.

That's the whole point of integrated programs. Surgeons in PRS, ENT, Ortho, GU, CTVS, and Vascular don't need all of that GenSurg crap. Why waste lots of your time and the taxpayers' money doing things that you'll never do again?

 

[TrojanDoctor]

just a quick shout out to the handful of people who applied to these integrated programs or knows a little about them... Did any of the new integrated vascular programs take a med student that WASN'T from their home institution?

 

[SocialistMD]

just a quick shout out to the handful of people who applied to these integrated programs or knows a little about them... Did any of the new integrated vascular programs take a med student that WASN'T from their home institution?

I know the med student who matched to the CT program at Stanford wasn't from Stanford. I don't know if he did an away rotation there, though.

 

[AJSmith]

just a quick shout out to the handful of people who applied to these integrated programs or knows a little about them... Did any of the new integrated vascular programs take a med student that WASN'T from their home institution?

Neither of the two Stanford intern CT surgery spots went to internal candidates; I'm not sure whether they did away rotations there. The Penn integrated spot went to someone from Penn.

 

[tcar18]

Glad to hear that things are working well for you, vascular2007.

The point is that residency should be about EDUCATION. While there will be SERVICE associated with it, the service component should be part of the education. When residency becomes more focused on service than education, it's time to rethink the whole thing.

That's the whole point of integrated programs. Surgeons in PRS, ENT, Ortho, GU, CTVS, and Vascular don't need all of that GenSurg crap. Why waste lots of your time and the taxpayers' money doing things that you'll never do again?

I agree that as the body of skills and knowledge required for competence grows it becomes necessary for further focus and that the only way to do this in any reasonable time frame is to ax the lower yield rotations but...

this trend scares the cr*ap out of me. I'm looking over my third year schedule and I don't have gs until march. I'm not remotely interested in pursuing any of the other rotations before gs so that leaves me what like 2 months to decide what path I want to pursue before aways? When do I get time to experience plastics, ct, ortho, vascular, etc. The advantage of gs for me is that my interest in plastics is not mutually exclusive to peds or ct.

I guess thats it... I just need another year of medical school (yes i actually said that... board studying does that to my brain).

 

[DrDude]

How many more integrated CT surgery residencies are there besides Penn and Stanford?

 

[Anka]

How many more integrated CT surgery residencies are there besides Penn and Stanford?

They're the only one's in last years match (www.nrmp.org, look at the 2008 Match data)... I heard there are other programs considering them. The 3 and 4 programs are more common (I think UVa, BWH both have them).

Anka

 

[not me]

just a quick shout out to the handful of people who applied to these integrated programs or knows a little about them... Did any of the new integrated vascular programs take a med student that WASN'T from their home institution?

Dartmouth, Michigan, Pitt (2 spots), Stanford, and UNC Chapel Hill all took external candidates. Rochester and South Florida both took internal candidates. I am not sure about Mt. Sinai or Stonybrook and I may be forgetting somewhere but it seems the general trend is that programs are taking external candidates.

P.S. I will reply to your PM when I am not so tired 🙂

 

[TrojanDoctor]

No worries buddy, hit me back on the PM whenever... With such few integrated vascular spots, I would have guessed that most of them went to internal candidates. I mean with only one spot available every year, If i was a PD I wouldn't want to take the chance of getting some yahoo. At least with someone from your own school, you probably know them pretty well. Like, how interested in vascular they really are. Like discussed above, how does someone out of medical school know they want to do vascular? I mean, I really want to do vascular but I've not had great exposure to fields like CT, plastics, ENT... When matching right out of medical school, there has to be a higher chance of matchees changing their mind and wanting to go into some other field. I wonder if thats true for the other surgical fields like the integrated plastics or integrated CT.

 

[DrDre311]

No worries buddy, hit me back on the PM whenever... With such few integrated vascular spots, I would have guessed that most of them went to internal candidates. I mean with only one spot available every year, If i was a PD I wouldn't want to take the chance of getting some yahoo. At least with someone from your own school, you probably know them pretty well. Like, how interested in vascular they really are. Like discussed above, how does someone out of medical school know they want to do vascular? I mean, I really want to do vascular but I've not had great exposure to fields like CT, plastics, ENT... When matching right out of medical school, there has to be a higher chance of matchees changing their mind and wanting to go into some other field. I wonder if thats true for the other surgical fields like the integrated plastics or integrated CT.

Nope. Plastic surgery is the best field in medicine. People leaving integrated plastics spots is extremely rare.

 

[Blade28]

Plastic surgery is the best field in medicine.

Second to CT, that is. 😉

 

[DrDre311]

Second to CT, that is. 😉

One of the faculty guys at University of Chicago is boarded in both plastics and CT. They do some cool stuff there.

 

[tcar18]

One of the faculty guys at University of Chicago is boarded in both plastics and CT. They do some cool stuff there.

Hot.

love it when people come up with plastics + x combos.

do you know what stuff he does?

 

[SocialistMD]

do you know what stuff he does?

Pulmonoplasties and Lingular botox mostly. You know, practical stuff. 😉

 

[Blade28]

Hot.

love it when people come up with plastics + x combos.

We've got a great attending here - he's triple-boarded in Plastics, Surg Onc and General Surgery.

 

[DrDre311]

Hot.

love it when people come up with plastics + x combos.

do you know what stuff he does?

Lots of chest wall recon. Really cool stuff I didn't encounter anywhere else. The guy's name is Larry Gottlieb, I think, and the PRS chair is a guy named David Song who came up with a titanium sternal implant for recon after mediastinal badness. It's cool stuff.

 

[tcar18]

mediastinal badness.

= excellent.

 

[Blade28]

Lots of chest wall recon. Really cool stuff I didn't encounter anywhere else. The guy's name is Larry Gottlieb, I think, and the PRS chair is a guy named David Song who came up with a titanium sternal implant for recon after mediastinal badness. It's cool stuff.

Damn that is cool.

It's always tough managing chest wall wounds when the sternal wires get infected. Usually all we have in our armamentarium is wide debridement and drainage, which doesn't always work.

 

[DrDre311]

Damn that is cool.

It's always tough managing chest wall wounds when the sternal wires get infected. Usually all we have in our armamentarium is wide debridement and drainage, which doesn't always work.

If you have access to PRS Journal you should look up some of Song's stuff. That was his logic in dreaming up that implant; he keeps one in his office and it was neat to play around with it. I read up in preparation for that interview and was really fascinated by the chest wall stuff they were doing.

Although it isn't CT related, I also thought the nerve conduit stuff that Robert Weber did at Scott & White was pretty awesome.

 

[maxheadroom]

Dre,

I agree -- Song is both a stud and a really nice guy. Super, super smart and at the same time very down to earth. That would qualify as a "rarebird" in academic PRS.

 

[thedrjojo]

anyone know if they've started to generate any numbers from the integrated programs? I know CT is only its first year and has 3 slots, and in the NRMP vascular is in its 2nd year, had 4 slots the first year and 9 last year, so its probably too early and too few people to generate numbers, but it'd be interesting to see the student pool that applied and got into it... is it ungodly (like avg 250, multiple pubs), up there with Plastics and ENT (avg 240, research needed but not necessarily pubs), or is it, with only like 25 people applying this year for the Vascular (and 9 with the CT), lower numbers.

 

[DrDre311]

anyone know if they've started to generate any numbers from the integrated programs? I know CT is only its first year and has 3 slots, and in the NRMP vascular is in its 2nd year, had 4 slots the first year and 9 last year, so its probably too early and too few people to generate numbers, but it'd be interesting to see the student pool that applied and got into it... is it ungodly (like avg 250, multiple pubs), up there with Plastics and ENT (avg 240, research needed but not necessarily pubs), or is it, with only like 25 people applying this year for the Vascular (and 9 with the CT), lower numbers.

I haven't seen numbers on these programs. Maybe the AAMC/NRMP will come out with some when this year's "Charting Outcomes in the Match" comes out, but there was no statistical breakdown for the more esoteric programs (integrated vascular, CT, combined IM-specialty residencies, etc.) in previous editions.

With such a small applicant pool for an extremely small number of slots the "average" statistics are likely to be skewed in one direction or the other and vary widely from year to year.

My personal feeling is that CT and vascular are pretty esoteric in terms of med students actually being certain that they want to limit themselves to this field. In addition, the post-GS fellowships in these fields are not nearly as competitive as independent plastics residencies; so it's likely that these integrated/combined models will not be as competitive as plastics simply because the integrated/combined CT/vascular training concept is small and still in its nascent phase (as opposed to hypercompetitive applicants being consciously funneled towards the integrated model as in PRS). However, I've got no proof to support this and I could be completely wrong.

 

[Winged Scapula]

In addition to the excellent treatise by Dr. Dre is the fact that some of these programs took internal candidates - in which case academic stuff (ie, USMLE, gpa) is likely to give some wide berth to taking a candidate you really know. Pure speculation on my part I know, but I would venture there is more of a possiblity that you could get one of those spots with lower #s if you were an inside candidate. As Dre said, the data will likely be all over the place.

 

[Michael Scott]

Just a heads up for those interested in the new integrated vascular. UMass now has a program. So, thats at least one extra spot for those of us that are going the vascular route! Anyone have any info about the gsurg or vascular there? I thought the program was in Boston, but I guess its in Worcester, about an hour away...