Your take on vascular surgery

[LGMD]

Hi im still in med school and have been thinking a lot about vascular surgery lately. Seems interesting , challenging yet rewarding and seems to have a good mix of traditional, open surgery and endovascular procedures. To tell te truth what catches my eye are the endovascular procedures. I would like to have an insight into what vascular surgery is really like and what the future holds for this specialty, how is the lifestyle while in fellowship and after fellowship?. I'd also like to know how it compares to cardiology and if there could be some overlap between both. Any info is greatly appreciated.

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[jubb]

At the community hospital that I worked at they had some very good interventional cardiologists who do quite a bit of peripheral work. I was almost considering going into interventional cardiology when I saw all of the stuff they can do. I saw a subclavian steal dilation, and a some stents in the arteries of legs that were completely cold that then became warm after the stent in addition to all the regular heart stents etc.

Here is what changed my mind. I don't think I could handle 3 years of internal medicine, 3 years of cardiology, and 1-2 years of interventional fellowship just to do some endovascular work. I'm not a person who could survive 6 years of medicine before getting to do procedures when in the same amount of time you could do a general surgery residency and a vascular fellowship to do the same thing, but also being able to fix any complications you create. The other option is vascular interventional radiology. Again I don't think I could tolerate sitting and looking at films all day for several years just to be able to do the procedures once I finished.

I think that endovascular stuff will be the way of the future for a lot of the aneurysms and blockages, but there will always be stuff that can't be done that way, or complications where they will need to call the surgeon in to fix it. If you just want to be a Cath Jockey and can tolerate looking at x-rays all day for several years before doing anything real, then Vascular interventional radiology may be the way to go, you don't have to worry about managing patients, as most likely they will be managed by the other service that is requesting your procedure and that may offer you a much better lifestyle. However other physicians may rather refer to a surgeon who will manage the patient as well as do the procedure. Definately something to think about.

Justin

 

[Tigger14]

I am starting a vascular surgery fellowship in July. I agree with several of jubb's points, and add a few.

1. A lot of people don't like vascular because they are sick patients. I love critical care, but doing a critical care fellowship and ICU coverage usually means a severely diminished operating schedule. Vascular is a great combination of sick patients who need surgery... from you.

2. Also, most of them do very well. There are jokes around about repeat operations and ultimate amputation, but that is not the rule. In all specialties there are frequent fliers; vascular is no exception.

3. It is delicate surgery, so your skills will have to be really good... vascular anastomoses do not tolerate rough handedness.

Having said that, I love endo and open surgery. Once you rotate through and talk to vascular surgeons at your hospital, you will have a better idea about it. Good luck.

 

[johankriek]

I am starting a vascular surgery fellowship in July. I agree with several of jubb's points, and add a few.

1. A lot of people don't like vascular because they are sick patients. I love critical care, but doing a critical care fellowship and ICU coverage usually means a severely diminished operating schedule. Vascular is a great combination of sick patients who need surgery... from you.

2. Also, most of them do very well. There are jokes around about repeat operations and ultimate amputation, but that is not the rule. In all specialties there are frequent fliers; vascular is no exception.

3. It is delicate surgery, so your skills will have to be really good... vascular anastomoses do not tolerate rough handedness.

Having said that, I love endo and open surgery. Once you rotate through and talk to vascular surgeons at your hospital, you will have a better idea about it. Good luck.

all i know.. vascular surgeons are one of the most frustrated specialists that i have come across.. moreover, all of their patients are wicked sick....everey last one of them... theyall have issues with this and that and cardiology clearance and dialysis and potassium and this etc etc etc

there is no bread and butter with vascular surgery.. and all of the patients are old.. so thus they are on medicare....... thus low reimbursement.

this gets old (pardon the pun) after a while.. sometimes all you wish for is an easy day with straight forward stuff.. and with vascular surgery there is none of that..

 

[imtiaz]

sometimes all you wish for is an easy day with straight forward stuff.. and with vascular surgery there is none of that..

not if you do veins.

 

[naegleria brain]

i talked to a vascular surgeon early last year.

it seems they are in competition for patients with interventional radiologists and cardiologists.

it seems anything heart related or directly next to the heart, cardiologists seem to get preference. anything intracranial, neurosurgeons have a strong hold (ie berry aneurysms, etc). the rest is fought over between interventionals and vascular surgeons.

he seemed peeved about it. yet he loves what he does, doesnt regret going into it, just wishes that there wasnt a race for patients each day.

i find it hard to believe that as a vascular surgeon you'll be out of a job though, and your salary will still trump 100 grand, probably even 200. so if that's what worries you, probably not a big deal if you really like the field

 

[Celiac Plexus]

A lot of good points made so far about the field....

As far as "competition for patients" goes... you will get referrals based on many factors. Some of them you can control and some you cannot. But the one common theme among all busy physicians that I have known in my short medical career is this: they are all very good, compassionate, complete physicians. If you are good, and work hard, you will develop a good reputation and you will have plenty of patients to treat.

And to address the concern that interventional radiologists are competing for endovascular work, well I find that notion interesting. At my institution we spend a good deal of time at predominantly 2 hospital systems. At my home institution the vascular surgery department does not do any endovascular work: no endovascular AAAs, no carotid or renal angioplasty or stenting, etc. All of the arteriograms, peripheral angioplasty, stenting, etc is referred by our vascular surgery department to the interventional radiology department. The main reason is that we do not have an endovascular trained vascular surgeon to do this kind of work (at our home institution), and of the vascular surgeons we do have are too busy to do this work. At the other hospital we rotate through, the vascular surgeons do all of the interventional work. Our residents have done endovascular aortic aneurysm repairs (both excluder and zeniths), cryoangioplasty, every kind of arteriogram and angioplasty you can imagine, etc...

So the notion that interventional radiologists are taking away vascular surgery work is false. If you are a resident or a student right now, interested in vascular surgery, rest assured that the vast majority of training programs are training their fellows to do endovascular work, and the future may find interventional radiologists with significantly less consults from vascular surgeons.

On the compensation front... endovascular work pays well right now. One of our residents will be starting a vascular surgery fellowship in July and is already being recruited. According to him most of the job offers for fellowship-trained vascular surgeons who can, and are willing to do endovascular work, start in the 250-300k/yr range with 400-600k/yr potential.

 

[jubb]

I think ultimately people will want to refer to the one stop provider. The vascular surgeon can manage the patient having the procedure and correct any complications. A well trained vascular surgeon should be the one getting the referrals.

Justin

 

[maxheadroom]

I only did three months of vascular in my prelim years, but I learned very quickly that vascular call can be unbelievably painful. After your third cold foot in a week at midnight, you'll start to wonder what you're doing in vascular. I'd go IR or cards. Both have the advantage of doing exclusive cath lab work. While the medicine training would be painful, if you're interested in stents and angioplasties (despite the new NEJM article), you're probably better off NOT being a surgeon. As a vascular surgeon you'll be called to manage other peoples' complications. Makes you sound like a stud when you're a medical student, but in real life it gets really, really old. Nothing like spending three hours in the OR to bill about half of what the inciting physician billed for 45 minutes worth of work. Just my two cents, though.

 

[Celiac Plexus]

I only did three months of vascular in my prelim years, but I learned very quickly that vascular call can be unbelievably painful. After your third cold foot in a week at midnight, you'll start to wonder what you're doing in vascular.

Good point. However, most of our cold feet initially get a tpa catheter placed by the interventional radiologist. I'd wager that tpa catheter placement will gladly be left to the realm of IR.

It should be noted that interventional radiologists earn very high incomes, but the price of that is a horrendous schedule. As a "lifestyle" field I would rank IR as among the worst.

Fyi: my knock on vascular isn't the cold feet. It's the diabetic feet.

 

[Tigger14]

No doubt, diabetic feet are not a draw to vascular surgery. But then, neither are enterocutaneous fistulas and perianal abscesses to general surgery, for one example. This actually came up in one of my interviews... "what is your least favorite part of vascular surgery?" and I gave a pretty blunt but not unprofessional answer about feet. Needless to say, I matched at that program.

 

[toxic-megacolon]

Does anyone else think that peripheral vascular surgery is getting to be kind of a scam? I'm seeing more and more angiograms on patients with pulses, bypasses on patients with claudication, etc etc....
And not to mention the natural history of fem-pop going on to fem-chop.
It seems that the only people that do well from peripheral bypass surgery are the patients who never really needed it in the first place.

 

[davidjones]

Hey,

Point of interest I am in rads and going into VIR and feel I can give you some insight as well.

I personally was torn between integrated vascular, integrated IR (DIRECT pathway), and traditional pathway (DR than 1-2 years of IR fellowship).
Was not at all interested in cardiology, though I did like medicine when I was a medical student, I find cardiologists to be an overall intolerable bunch of people :-D.

Regarding vascular and IR competing for patients. I think it's extremely region dependent, there are some places where IR will do all the work, some places where there is a division of labor (50/50 or 33/33/33 with cards), and the MAJORITY, though not most, places where Vascular dominates. I personally think the middle is the best, particuraly in the multi-specialty heart and vascular center, which how it is at my institution. Everyone shares PAD responsibilities, and call is rotated among each specialty, and then each specialty will field consults on a qweek basis for "cold legs". Non-invasive vascular imaging went to rads, except for carotid and LE US which was done by vascular. CTA/MRA done by rads. And cards has their thing as well.

Aortic repairs, and large arterial interventions done by vascular. carotid stenting is split 50/50 between rads and vascular. AVMs done by rads.
Venous stuff is kind of eat what you kill. I believe everyone does IVC filters, Vascular does the most, IR primarily for cancer patients we see in our oncology clinic, and cards for their patients. And then whoever is on call for that particular week or day.

We actually did an intra-institutional study and found out that financially all 3 specialties benefited, but more importantly everyone worked collabaratively, people had better attitudes and the patients benefited from varioius experties.

The reason I chose IR is because you can do more than arterial work, I am particularly interested in oncologic work, including the CT/MR/US guided stuff. And I also like the fibroid stuff that we're doing, since a large pecentage of patients are actually sent to IR or self-refer to IR before being seen by the gyn, and than we have the opportunity to work-up dysfunctional uterine bleeding (which sadly I enjoy).

I was at first hesitant, b/c as some people above mentioned there is a real chance you can become a catheter jockey and have little to no say in patient management. That is rapidly changing, there have always been places like the Miami Vascular Institute which was started by and run by IR and has vascular surgeons and cards as partners. All 3 manage their own patients, do outpatient pre and post op evals etc. However, there were relatively few. In the last few years I have spoken to people in IR and people applying, and the selling point for most IR fellowships now and in fact DR residencies with an IR component is IR clinic, and separate admission and consult services. Some places even have resident IR clinics, where you get continuity of care.

The reason I chose the DR route is for the above, and you do need some imaging background to do most of the procedures in IR, particularly the non-vascular stuff.

The problem with doing DR to IR (at least for now) is because it's really two separate specialties, particularly with people now going into DR only to do IR and not because they don't want to see or f/up on patients. And many IR jobs are in DR practices, and you just don't make as much money doing a run-off and stenting a femoral artery, seeing the patient in clinic before and after and rounding on them as you would doing the procedure and then reading a stack of MRIs. But there are more and more mixed-specialty practices where IRs can work with surgeons and solo-IR practices.

and to re-iterate a few points on the competition for patients. If you are good IR, cardiologist, or vascular surgeon who goes out and markets themselves, does a good job, follows up on patients, and diminishes the headaches for the referring physician (i.e. arranging admission, sending letters, arranging outpatient procedures) you will be good to go. With the baby boomers getting older and a predicted physician shortage I think there is more than sufficient work to go around.

 

[davidjones]

Also I wanted to add that the reason IRs salaries are higher than vascular surgery (though not by a whole lot) is because the average salaries take into account people who do IR part time and the rest of the time read films. It's not IR that pays highly it's DR, particularly MRI. Those IRs who do purely interventional work make similar incomes as vascular surgeons who do endovascular work, which is to say upper 300K.

And do not pick a job based on income potential. If you decide on either IR, VS, or cardiology, while there are places where there is collegiality, there are many more where there isn't and unless you love your field the various politiking and turf issues will make you a miserable person.

 

[filter07]

We actually did an intra-institutional study and found out that financially all 3 specialties benefited, but more importantly everyone worked collabaratively, people had better attitudes and the patients benefited from varioius experties.

Can you expand more on this part? I am interested in inter-specialty collaboration and I think we should share knowledge and practice guidelines amongst each other. It would be great if you can show that patients are better off and there is financial benefit to collaboration.

 

[davidjones]

Filter that study was done a few years before I got there, I am trying to find it on pubmed, but don't remember the exact title of the article. I will ask one of the attendings tomorrow about it and forward you a link.

The study focused primarily on vascular surgery and IR, and looked at the effects of combining the 2 specialties into one center on the amount of procedures done by each specialty and change in reimbursement. It basically showed that rads procedures went up by a few more percent (which would make sense, since in a combined specialty practice they would be doing more arterial work), but the vascular surgeons also got a slight bump in number of procedures because all of the imaging being done at the center, and patients were identified and were referred to whoever was on call that day. And everyone says that after a few years in operation, the center has become very well known and has a huge referral base. Only 2 IRs out of five even want to do significant arterial work, the rest like the UFEs (we have a great fibroid center w/ob/gyn), Oncologic, though all 5 share call and consult responsibilities.

A few of the vascular guys have wanted to do a bit AVM stuff, and got a bit of that business without any tempers flaring or turf issues being brought up because everyone was working towards the benefit of the patient.

The attitude improvement and collegiality have been primarily anecdotal, though I've asked some of the VS guys and IR guys and they both agreed that collegiality greatly improved after the center was formed. Same was when cardiology joined the fray, though the study wasn't repeated with all 3 specialities, it doesn't seem to me anyone is suffering financially. And there is a lot of inter-discipline referring. For instance if one of the cards patients has a occluded carotid it will get referred to either IR or Vascular, depending who is on consults that day.

Dialysis work is shared between vascular and IR, with vascular doing all fistulas and grafts, IR doing majority of venous complications related to ESRD and dialysis, and both sharing the treatment of AVG/aVF complications. Venous mapping is done by vascular.

Patient benefit was also anecdotal. For instance if someone who had a type 2 endoleak and needed a CT-guided repair it will get done in 24 hours of the leak being identified by IR. If in the midst if a patient with AAA being followed by VS or IR is noted to have coronary artery disease, they will likely be seen within 24-48 hours of the diagnosis, outpatient or inpatient. And the center has a huge number of PAs/NP/SW who work specifically on these patients.
Similarly, the center has 24/7/365 coverage for emergencies including cardiac, AAA stuff, cold legs, bleeds and traumas.

I don't think this kind of thing is possible everywhere obviously, but is certainly possible at most major academic centers where everyone is salaried anyway. There are plenty of disciplines that cross over: ortho/neurosurg for spine, ortho/GS/Plastics for hand, and they seem to do ok, so why not us. I went to med school where there was a great deal of animosity between all 3 departments (cards, surg, rads) and it just wasn't fun to be there or work. I rotated in all 3 and they all just b$tched about each other.

Like I said I will try to to post the citation tomorrow if I can find it, and if we have updated numbers I will post those as well (if I am allowed)

 

[filter07]

Thanks for the response. The study will be very interesting. I have many friends training in IR (from medical school and internship) and would be very interested in inter-specialty collaboration once I'm out in practice.

 

[davidjones]

Hey filter,

I haven't been able to find the study (it's from Mayo), and didn't get a chance to get out of the reading room today, but I did find a similar one. Perhaps someone from U of Rochester could comment?. http://www.sciencedirect.com/scienc...23a70f80a6b0eec84214f0b88c5c7942&searchtype=a

let me know if you can't access it

I think I got 2 studies mixed up, the statistics I quoted you were from a different study and I am trying to find that article. But you can see that the results here, while not outright fantastic certainly support the idea of mutli-specialty groups without financial loss or loss of patients. Furthermore much has changed in both vascular and IR and the type of collaboration that can be brought to bare now I think will greatly improve.

Particularly in a setting of an endovascular or a minimally invasive treatment center where not only vascular work is done, but also all of the minimally invasive things IR does now like biopsies, ablations, drain placements, perc choles/nephs, venous disease, oncologic work, fibroids etc. I'm sure in a practice where everyone develops mutual respect and everyting goes into one big pot and split evenly among partners and associates IR wouldn't have a problem sharing with vascular how to do some non-vascular disease work, and vascular would not have a problem sharing the vascular work load.

.

 

[filter07]

Thanks for taking the time to track down the article. No worries on the other one. I talk shop with an IR buddy sometimes and it is pretty interesting how we have different approaches. It seems pretty intuitive that combining our knowledge and experience can help both parties become better providers.

 

[davidjones]

no problem filter. I do remember from that other article that all the money went into one pot and divied up based on RVUs not necessarily the number of procedures, i.e. an open AAA repair is more RVUs than a run-off (not sure how much more) so the all ended up making slightly more money than they did separately.

I'm glad there are people like you and your IR buddies. I've noticed much more colegiality between vascular and IR lately, hopefully that is the trend rather than an outlier. Not only is it better for a nice work environment, but it's better for the bottom line too