Annals of Vascular Surgery
Volume 24, Issue 2 , Pages 196-204, February 2010

General Versus Vascular Surgeon: Impact of a Vascular Fellowship on Clinical Practice, Surgical Case Load, and Lifestyle

  • Randall W. Franz, MD, FACS, RVT

      Affiliations

    • Corresponding Author InformationCorrespondence to: Randall W. Franz, MD, FACS, RVT, The Vascular and Vein Center at Grant Medical Center, 285 East State Street, Suite 260, Columbus, OH 43215, USA

The Vascular and Vein Center at Grant Medical Center, Columbus, Ohio

published online 06 January 2009.

Article Outline

An applicant shortage for vascular surgery (VS) residencies exists despite an increase in available training positions created to meet the growing demands for vascular surgeons. After 3 years of practice as an American Board of Surgery (ABS)-certified/board-eligible general surgeon, the author of this study attended an accredited 1-year VS training fellowship and received an ABS certificate of Added Qualifications in VS. The purpose of this review was to investigate the implications completing a vascular fellowship has had on VS procedure patterns, vascular procedure competency, clinical practice, career, and lifestyle with the aim of attracting trainees to the field of VS. The author's operative logs were reviewed retrospectively to summarize vascular procedures performed before and after the vascular fellowship. Statistical analysis was performed comparing the types and volume of vascular procedures before and after the vascular fellowship. Changes in professional career and personal life also were examined. The author performed 401 vascular procedures during 2.8 years as a general surgeon. In the first 3.4 years after the vascular fellowship, vascular procedure volume increased to 1563. The mean number of vascular procedures performed per year increased from 143.2 as a general surgeon to 459.7 as a vascular surgeon. The three major differences in vascular procedures occurring after the vascular fellowship were (1) a threefold increase in the number of vascular procedures performed, (2) a shift from major open to venous and endovascular procedures, and (3) an increase in case complexity. Specializing in VS also has resulted in increased career opportunities, more career satisfaction, a direct financial benefit, and more flexibility for lifestyle and family. Because of these positive changes, the author encourages medical students and residents interested in VS to explore the specialty early, seek vascular surgeons to serve as mentors, and enter one of the new VS pathways as early as possible in their career.

 

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Introduction 

The number of vascular procedures and the need for specialized vascular care in the United States are increasing due to the aging general population and the influx of the large “Baby-Boomer” generation into the age window during which atherosclerotic disease manifests.1, 2, 3, 4, 5 The continuing epidemics of obesity and diabetes also are expected to contribute to the rise.6 In addition, the success of treating degenerative and previously fatal diseases of the vascular system such as stroke, coronary artery disease, and renal failure has increased the life span of patients who now are living to older ages and are developing vascular complications with significant comorbidities in other organ systems that require medical management.5 Consequently, vascular patients tend to be some of the sickest in the hospital and require complex perioperative care.5

In 2006, there were more than 2500 surgeons holding either a certificate of Special or Added Qualification in Vascular Surgery (VS) from the American Board of Surgery (ABS).7 Currently, approximately 120 vascular surgeons are trained and certified yearly, but projections indicate that this number must increase by at least 50% to meet rising needs.6, 8 According to workforce estimates, an additional 1067 vascular surgeons will be needed by 2030 to join the expected 3000 vascular surgeons currently in practice.4, 6 Although the need for vascular surgeons is greater than ever and only is expected to increase, the number of well-qualified applicants for VS residencies has decreased over the past several years despite an increase in the number of available training positions.5, 8, 9, 10, 11, 12, 13, 14 Between 1997 and 2004, the number of training positions available in VS programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) increased by 34%, while the total number of active applicants to these programs decreased by 21%.9, 11 During this same time period, the number of vascular applicants with degrees from medical schools in the United States decreased by 36%.9, 10 In 2004 and 2005, there were fewer applicants than available VS positions, with 24 of 117 first-year positions unfilled in 2005.2

With advances in endovascular technologies and minimally invasive techniques over the past two decades, the field of VS has undergone remarkable changes that, in turn, require changes in training.6, 15, 16, 17 In February 2006, the ACGME approved the Primary Certificate in VS, which eliminates the requirement of certification in general surgery (GS) prior to certification in VS.5, 18 As a result, there are now four different training paradigms to become a vascular surgeon.6, 7, 15, 18, 19 The standard 7-year track requires 5 years of GS residency plus 2 years of VS with the option of board certification in GS in addition to VS certification. Two 6-year tracks are available. The Early Specialization (ESP) model requires 4 years of GS training followed by 2 years of vascular training, with all 6 years required at the same institution, and also allows the option of board certification in GS besides the VS certification. The other 6-year track, known as the Independent or “3+3” program, results in VS certification only and is designed for residents who match in initial surgical training. The 5-year integrated (“0-5”) track is an option for trainees who match during medical school and results in VS certification only. Requiring a minimum of 2 clinical years in VS ensures additional time to train vascular specialists who are experts not only in traditional open surgery but also in interventional training, newer imaging modalities, and medical management and diagnosis of patients with vascular disease.1 These multiple training options allow trainees the flexibility of selecting VS as a career choice at various stages of training—during medical school, during initial surgical training, or after completion of GS training. In addition, trainees are able to choose a VS certificate alone or in conjunction with a GS certificate. The ultimate goal of the redesigned program is to recruit more trainees to address the shortage of vascular surgeons and to properly train them to meet the demands of a 21st-century vascular practice.6 Reasons cited for not choosing VS and GS training programs include poor mentorship, financial considerations, and lifestyle.9, 10, 14, 20, 21, 22, 23, 24, 25, 26, 27 In addition, increased competition by interventional practitioners from multiple medical and surgical fields has led to uncertainty of the role of vascular surgeons in endovascular surgery.2

After 3 years of practice as an ABS-certified/board-eligible general surgeon, the author of this study attended an accredited 1-year VS training fellowship and received an ABS certificate of Added Qualifications in VS. Given the current predicament, the primary goal of this review was to investigate the implications completing a vascular fellowship has had on VS procedure patterns, vascular procedure competency, clinical practice, career, and lifestyle with the aim of attracting trainees to the field of VS. Statistical analysis also will be performed comparing the types and volume of vascular procedures before and after the vascular fellowship. In addition, changes in both professional career and personal life were examined.

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Materials and Methods 

A retrospective review of the author's operative logs was conducted with institutional review board approval to summarize vascular procedures performed before and after a vascular fellowship. The pre−vascular fellowship group consisted of vascular procedures performed as a general surgeon in private practice at two institutions between August 1997 and June 2000. Cases were performed at a 125-bed rural institution and a 476-bed urban institution. The post−vascular fellowship group was composed of vascular procedures performed after returning to private practice between July 2001 and December 2004 at three institutions. The author performed surgeries at the same institutions before the vascular fellowship and also at a 682-bed urban institution. Procedures were categorized according to the major groupings established by the Residency Review Committee for Surgery (RRC) and as summarized in Cronenwett's review of VS training in the United States.11 A χ2 analysis was used to compare categorical data, with odds ratio (OR) analysis using 95% confidence intervals (CIs) to measure the association between the two variables. Individual procedure comparisons were not conducted if less than five cases were performed in both the pre− and post−vascular fellowship groups. Ninety-five percent CIs were used throughout the statistical analysis. A difference was considered to be statistically significant when the p value was ≤0.05 with a power of at least 0.8. Statistical analyses were performed using SigmaStat® Software, version 2.0 (SPSS, Inc., Chicago, Illinois).

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Results 

The author performed 401 vascular procedures during 2.8 years in private practice as a general surgeon. In the first 3.4 years after completion of a vascular fellowship, the volume of vascular procedures increased to 1563. The mean number of vascular procedures performed per year, therefore, increased from 143.2 as a general surgeon to 459.7 as a vascular surgeon, which translates into an approximate threefold increase in annual volume of vascular procedures after completion of the vascular fellowship. The distribution of procedures according to RRC major groupings is presented in Table I and reveals a shift in case composition after the vascular fellowship. As a general surgeon, the majority of vascular procedures were major open procedures. Even with a total increase in the number of major open procedures performed after the vascular fellowship, the case pattern shifted to more minor open and endovascular procedures. The increase in case volume after the vascular fellowship was observed in all major groupings. The RRC major groupings are further subdivided as shown in Tables II through IV.

Table I. Operations before and after vascular fellowship
Pre vascular fellowship (n = 401)Post vascular fellowship (n = 1551)
Total operations401 (100.0%)1551 (99.2%)
Major open procedures206 (51.4%)355 (22.9%)
Aneurysm3 (0.7%)24 (1.5%)
Cerebrovascular120 (29.9%)141 (9.1%)
Peripheral76 (19.0%)159 (10.3%)
Abdominal obstructive4 (1.0%)8 (0.5%)
Upper extremity0 (0.0%)1 (0.1%)
Extra-anatomic3 (0.7%)22 (1.4%)
Minor open procedures91 (22.7%)671 (43.3%)
Vascular access for dialysis12 (3.0%)35 (2.3%)
Venous55 (13.7%)623 (40.2%)
Miscellaneous24 (6.0%)13 (0.8%)
Endovascular procedures104 (25.9%)525 (33.8%)
Endovascular diagnostic0 (0.0%)50 (3.2%)
Endovascular therapeutic104 (25.9%)475 (30.6%)
Total revision operations0 (0.0%)12 (0.8%)
Table II. Major open procedures before and after vascular fellowship
Major open procedurePre vascular fellowship (n = 401)Post vascular fellowship (n = 1551)
Aneurysm3 (0.7%)24 (1.5%)
Cerebrovascular120 (29.9%)141 (9.1%)
Peripheral76 (19.0%)159 (10.3%)
Abdominal obstructive4 (1.0%)8 (0.5%)
Upper extremity0 (0.0%)1 (0.1%)
Extra-anatomic3 (0.7%)22 (1.4%)

Major open procedures 

There was a significant difference in the number of major open procedures performed before and after the vascular fellowship (p < 0.001, power = 1.000, OR = 3.6, 95% CI, 2.8-4.5) (Table I). The odds of performing a major open procedure were 3.6 times more likely before than after the vascular fellowship. Examining the volume of RRC major subcategories before and after the vascular fellowship, significantly higher numbers of cerebrovascular (p < 0.001, power = 1.000, OR = 4.3, 95% CI, 3.2-5.6) and peripheral (p < 0.001, power = 1.000, OR = 2.0, 95% CI, 1.5-2.8) procedures were performed prior to the vascular fellowship.

The range and complexity of major open vascular cases expanded after the vascular fellowship, as indicated by the following list of procedures not performed as a general surgeon: ruptured abdominal aortic aneurysm (AAA) repair; common femoral artery−common femoral vein fistula; complex bypasses (ileoprofunda-anterior tibial, iliac-popliteal, axillary-axillary, axillofemoral, axillobifemoral, axillary-brachial, iliac-common femoral, and iliac-superficial femoral); lower extremity fasciotomies; and lower extremity thrombectomies (Table II). Examining the individual case volume of major open vascular procedures before and after the vascular fellowship, significantly higher numbers of above and below knee femoropopliteal bypasses (above, p < 0.001, power = 0.998, OR = 2.4, 95% CI, 1.6-3.6; below, p = 0.002, power = 0.881, OR = 3.2, 95% CI, 1.5-6.8) and carotid endarterectomies (CEA) (p < 0.001, power = 1.000, OR = 4.3, 95% CI, 3.3-5.7) were performed prior to the vascular fellowship.

Minor open procedures 

There was a significant difference in the number of minor open procedures performed before and after the vascular fellowship (p < 0.001, power = 1.000, OR = 0.4, 95% CI, 0.3-0.5) (Table I). The odds of performing a minor open procedure were 60% lower before than after the vascular fellowship. A significantly lower number of venous procedures were performed prior to the vascular fellowship (p < 0.001, power = 1.000, OR = 0.2, 95% CI, 0.1-0.3). The odds of performing a minor open venous procedure were 80% less likely before than after the vascular fellowship. Conversely, a significantly higher number of miscellaneous minor open procedures were performed prior to the vascular fellowship (p < 0.001, power = 1.000, OR = 7.5, 95% CI = 3.8-14.9). The odds of performing a miscellaneous minor open procedure were 7.5 times higher before the vascular fellowship versus after the fellowship.

The range and complexity of minor open procedures also expanded after the vascular fellowship, as indicated by the following list of procedures not performed as a general surgeon: greater saphenous vein high ligation; saphenous vein stripping; subfascial endoscopic perforator vein surgery (SEPS); and transilluminated powered phlebectomy surgery (TIPPS) (Table III). Examining the individual case volume of minor open vascular procedures before and after the vascular fellowship, significantly lower numbers of greater saphenous vein high ligation (p < 0.001, power = 1.000, OR = 0.01, 95% CI, 0.0008-0.206), SEPS (p < 0.001, power = 1.000, OR = 0.01, 95% CI, 0.0007-0.175), and TIPPS (p < 0.001, power = 1.000, OR = 0.01, 95% CI, 0.0004-0.106) were performed prior to the vascular fellowship. On the contrary, a significantly higher number of digit amputations (p < 0.001, power = 0.997, OR = 6.9, 95% CI, 2.7-17.5) and temporal artery biopsies (p < 0.001, power = 0.999, OR = 8.0, 95% CI, 3.0-21.5) were performed prior to the vascular fellowship.

Table III. Minor open procedures before and after vascular fellowship
Minor open procedurePre vascular fellowship (n = 401)Post vascular fellowship (n = 1551)
Vascular access for dialysis12 (3.0%)35 (2.3%)
Venous procedures55 (13.7%)623 (40.2%)
Miscellaneous procedures24 (6.0%)13 (0.8%)

Endovascular procedures 

There was a significant difference in the number of endovascular procedures performed before and after the vascular fellowship (p = 0.004, power = 0.828, OR = 0.7, 95% CI, 0.5-0.9) (Table I). The odds of performing an endovascular procedure were 30% lower before than after the vascular fellowship. A significantly lower number of diagnostic endovascular procedures were performed prior to the vascular fellowship (p < 0.001, power = 0.949, OR = 0.04, 95% CI, 0.002-0.606). The odds of performing a diagnostic endovascular procedure were 96% less likely before than after the vascular fellowship.

The range and complexity of endovascular procedures also expanded after the vascular fellowship (Table IV). Prior to the vascular fellowship, no carotid artery angiograms were performed as diagnostic procedures. In terms of endovascular therapeutic procedures, no endovascular aneurysm repairs were performed before the vascular fellowship and the only angioplasty/stenting procedures that were performed were of the iliac and femoral arteries. Although not performed as a general surgeon, the difference before and after the vascular fellowship was significant for both carotid artery angiograms (p < 0.001, power = 0.949, OR = 0.04, 95% CI, 0.002-0.606) and renal artery angioplasties with stents (p < 0.001, power = 0.974, OR = 0.03, 95% CI, 0.002-0.529). The odds of performing a carotid artery angiogram were 96% less likely before than after the vascular fellowship. The odds of performing a renal artery angioplasty/stent were 97% less likely before than after the vascular fellowship.

Table IV. Endovascular procedures before and after vascular fellowship
Pre vascular fellowship (n = 401)Post vascular fellowship (n = 1551)
Endovascular diagnostic procedures0 (0.0%)50 (3.2%)
Endovascular therapeutic procedures104 (25.9%)475 (30.6%)
Aneurysm repair, elective0 (0.0%)36 (2.3%)
Angioplasty and stenting91 (22.7%)356 (22.8%)
Inferior vena cava insertion/removal13 (3.2%)65 (4.2%)
Venous0 (0.0%)18 (1.2%)

Revision procedures 

Revision procedures were not performed as a general surgeon; however, taking into account the difference in case volume, there was no significant difference in the number of revision procedures performed before and after the vascular fellowship (Table V). The most common revision performed post-fellowship was the lower extremity bypass redo operation.

Table V. Revision procedures before and after vascular fellowship
Pre vascular fellowship (n = 401)Post vascular fellowship (n = 1551)
Major open revisions0 (0.0%)11 (0.7%)
Carotid endarterectomy redo operation0 (0.0%)3 (0.2%)
Lower extremity bypass redo operation0 (0.0%)8 (0.5%)
Minor open revisions0 (0.0%)1 (0.1%)
Arteriovenous graft pseudoaneurysm repair0 (0.0%)1 (0.1%)

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Discussion 

Despite the need for vascular surgeons and the increase in the number of available training positions, the number of well-qualified applicants for VS residencies has decreased over the past several years.5, 9, 11, 12, 13 The findings of various surveys and questionnaires reveal the following possible reasons for the decreasing number of applicants in VS training programs: poor mentorship, financial considerations, lifestyle, and other factors.9, 10, 14, 26 According to a series of surveys conducted by Calligaro and Dougherty and colleagues, 9, 10 VS residents and GS chief residents reported technical aspects of the specialty, influence of mentors, and complex decision-making involved in VS as the three most important reasons for choosing VS as a specialty. Fourth-year medical students also graded technical aspects of the specialty and the role of mentors as top reasons for choosing VS but also listed the positive value of endovascular capabilities as an important reason.9 VS residents and GS chief residents cited concern about future loss of cases to other interventionalists, such as radiologists and cardiologists, as a reason for not choosing VS, while medical students selected a negative lifestyle associated with being a surgical resident and a surgeon as the most important negative factor for not choosing the specialty.9 Given the current predicament, the primary goal of this review was to examine the implications becoming a vascular surgeon has had on VS procedure patterns and clinical practice with the aim of attracting trainees to the field of VS.

Increase in surgical case volume 

The greatest impact of the VS fellowship was the threefold increase in the number of vascular procedures performed. The increase in case volume after the vascular fellowship was observed in all major RRC groupings, for both routine and complex cases. This observation supports other studies that demonstrate an overall increase in case volume, not just in complex cases, as a result of specializing in VS.28 Specializing in VS has enabled the author to compete and obtain privileges in larger institutions in larger cities with larger patient volumes. After returning to private practice postfellowship, the author was able to obtain privileges at a larger 682-bed institution that previously denied him privileges to perform vascular procedures as a GS. With the knowledge of vascular disease management gained during the vascular fellowship, the author is able to medically manage more complex patients with multiple comorbidities. The extensive training obtained during the vascular fellowship enables him to perform both routine and complex vascular and venous procedures. The increased patient and procedure volume is a direct consequence of referrals from primary care providers, consultations due to the affiliation with a large metropolitan institution, and patients who directly seek a vascular surgeon to manage their conditions, many of whom prefer vascular surgeons to manage vascular disease.8, 29

Shift toward venous and endovascular procedures 

Another key difference between procedure patterns before and after the fellowship was the shift from major open to venous and endovascular procedures, which is supported by the significant differences in these categories before and after the fellowship. This shift also coincides with the trend of less open procedures performed overall now in the United States documented in the literature.5, 8, 12, 14 According to the literature, practicing general surgeons are performing fewer vascular procedures and GS trainees no longer are trained to perform index vascular procedures.4, 14 Consequently, vascular surgeons are becoming the specialists for treating peripheral vascular disease (PVD).

The primary reason for the change in the author's case pattern is the extensive training in the latest venous and endovascular techniques, as well as vascular disease medical management, obtained during the vascular fellowship. As a general surgeon, vascular cases were limited primarily to cerebrovascular and peripheral open procedures, as evidenced by the significantly higher volumes of those particular cases performed before the vascular fellowship. Endovascular techniques were not considered for femoropopliteal bypasses, carotid disease, or venous disease due to limited endovascular surgical training during GS residency. Furthermore, no carotid angiograms were performed before the vascular fellowship, which, again, is primarily due to limited endovascular training as a general surgeon. Another consequence of the increased use of endovascular techniques is the change in the type of open AAA repairs that are performed. Because EVAR now is used to treat the more straightforward AAA cases, the open AAA repairs that are performed are more complex. Therefore, VS training is essential to better manage these more complex reconstructions. Although there was no significant difference in the number of these procedures performed before and after the vascular fellowship in the current review, there is a trend toward a higher number of EVAR procedures performed after the fellowship, as none were performed before and 30 were performed after the fellowship. The significant increase in venous procedure volume after the fellowship may reflect referral patterns and patient preference and suggests that patients are more likely to see vascular rather than general surgeons for venous disease management. Newer venous techniques, such as greater saphenous vein high ligation and endovenous laser ablation, SEPS, and TIPPS, became a significant portion of the author's postfellowship case volume.30

Another dramatic change in case pattern occurring after completion of the vascular fellowship was in the number of endovascular cases performed. This significantly higher incidence supports the general trend observed in the United States toward endovascular procedures.5, 11, 14 As a result of advancements in VS over the past decade, vascular surgeons have three management approaches to vascular disease: (1) conservative medical management, (2) open procedures, and, now, (3) endovascular procedures.14 The knowledge and skill set required for all three management approaches were honed during the author's vascular fellowship. This multidisciplinary, three-pronged specialization equips vascular surgeons to better manage and treat patients with vascular diseases compared with general surgeons.

To further core knowledge of vascular laboratory topics, the author also obtained the registered vascular technologist (RVT) credential. Another alternative is the newly available American Registry of Diagnostic Medical Sonographers’ Registered Physician in Vascular Interpretation (RPVI) examination.31 The Clinical Practice Council of the Society for Vascular Surgery (SVS) endorses the recommendation by the Inter-societal Commission for Accreditation of Vascular Laboratories (ICAVL) that physicians become certified as an RVT or RPVI for noninvasive vascular laboratory interpretations and examinations.19 Afterward, continuing medical education credits specific to laboratory training ensures familiarity with the latest technologies.31 Once in private practice, active participation in the vascular laboratory is imperative not only for patient care but also in building a referral base.

New therapeutic endovascular techniques learned during fellowship enabled the addition of elective aneurysm repair (EVAR), a wide range of angioplasty/stenting applications, and saphenous vein laser ablation to the post−vascular fellowship case load. The decreased use of bypasses postfellowship is, in part, directly related to the increase in angioplasty/stenting techniques. Compared with traditional open procedures, endovascular techniques offer the following advantages to the surgeon: (1) easier to perform, (2) more rapid rehabilitation, and (3) fewer complications.14 GS residents are performing less endovascular procedures compared with VS residents.11 Therefore, the significantly higher volume of endovascular cases is a direct consequence of specializing in VS. This shift may be of particular interest to trainees, as the positive value of endovascular capabilities has been cited by fourth-year medical students as an important reason for considering VS.9

To be successful in the current environment with increased competition from other specialties, emphasis on skills must be shifted to endovascular techniques.5 Skill sets that should be mastered include percutaneous access to the vascular system and the advanced skills for endovascular placement of aortic grafts in both the infrarenal and the thoracic aorta for the treatment of aneurysmal disease, as well as skills in carotid stenting.5 The skill set of a vascular surgeon must encompass a wide range of procedures, from the ability to operate on the perirenal and suprarenal aorta to the ability to manipulate catheters into the internal carotid artery.5, 17 The range of cases performed postfellowship demonstrates that the author was able to successfully transfer the skills learned during fellowship to his private practice.

Increase in surgical case complexity 

The third major difference was in the complexity of cases performed after the vascular fellowship. This was particularly evident when examining the increase in aortic procedures, extra-anatomic and upper extremity bypasses, and revision procedures. The variety and complexity of cases performed after the fellowship address the technical aspects and complex decision making of the specialty, which are among the most important reasons cited for choosing the specialty by VS residents, GS chief residents, and fourth-year medical students.9, 10 As a result of the increase in case load and complexity of cases, the author began referring certain cases, such as temporal artery biopsies and digit amputations, to general surgeons and podiatrists within the institution to increase his availability to perform complex vascular procedures, which explains the significantly higher number of miscellaneous minor open procedures in general, and temporal artery and digit amputations more specifically, performed prior to the fellowship. Indeed, the results of this review indicate that significantly less temporal artery biopsies were performed after the vascular fellowship.

Financial and lifestyle impact 

The most apparent benefits of the increased volume are job and financial security, which should ease the financial considerations that have been cited as a reason for not applying to VS programs.9, 10, 14, 26, 27 On a case-by-case basis, reimbursement for VS is higher than for GS. In addition, the potential for financial security will be even more important in the future given the impending decreased reimbursements by Medicare. Furthermore, the concerns expressed by some VS residents and GS chief residents over future loss of cases to other interventionalists, such as radiologists and cardiologists, has not significantly affected the author's case volume.9

Although lifestyle considerations are major factors cited by residents and medical students as deterrents for entering VS, the author has experienced the contrary after specializing in VS and believes that there are many misconceptions regarding lifestyle constraints or factors that may have been issues in the past are no longer relevant in contemporary VS.8, 9, 10, 14, 26, 27 As a general surgeon and not a specialist, mobility is more limited. This should be a major consideration when determining career choice, as one in three physicians change practices within the first 5 years.32 Specializing in VS enabled training in new vascular and endovascular procedures, which, in turn, increases career longevity. Conversely, the ability to perform vascular procedures as a general surgeon typically is limited to what was learned during residency. With changing technology, this experience may not prevail, as GS residents are no longer being trained in the full range of endovascular techniques.11

Institutions are more willing to invest in the marketing of vascular surgery (VS) practices as vascular surgeons are in demand and, hence, are of increased value to the institution. Colleague rapport among peers also has improved, as vascular surgeons are part of a smaller, tight-knit community, which, in the author's experience, tends to support one another rather than viewing peers as competition. Specializing in VS also allows participation in VS societies. Finally, as a specialist, more academic opportunities and research support generally are available.

Addressing the perception of excessive work hours, on-call volume and patterns have changed after the vascular fellowship. The author no longer takes call for GS, which decreases the amount of time on call. In addition, as a vascular surgeon, there are fewer emergencies while on call and those cases that are managed are likely to have a more definitive outcome (i.e., more likely to result in performing a procedure). The majority of consults may be seen the next business day and not on an emergent basis. With approximately 75% of vascular practice now dedicated to endovascular therapies, the long hours and number of returns to the hospital during nighttime hours have decreased.8 The work load also is becoming more manageable with the continued implementation of physician assistants and nurse practitioners, which assists in decreasing the work week.5 Cross-coverage and signing out to partners on call are additional measures that may be used to reduce workload.6 Such improvement in lifestyle should prove beneficial to medical student recruitment and promote career satisfaction and retention of young surgeons.6

Study limitations 

Study limitations include the difference in time intervals before and after the vascular fellowship (2.8 versus 3.4 years). However, to account for this difference, the increase in procedure volume also was calculated on an annual basis. In addition, because each group encompassed different time periods, some changes in volume are due to the rapid advancements in endovascular techniques, in addition to the fellowship training. Several factors that also contributed to the increased vascular procedure volume after the fellowship included a larger referral base, a bigger catchment area, and increased marketing. Finally, entering a fellowship after several years of private practice is atypical. In addition, as of July 1, 2008, the pathway in which the author specialized in VS is no longer an option. A fellowship that is 2 years in length is especially important in the current environment due to the continuing advancements in the vascular laboratory arena and the ongoing expansion of endovascular procedures. However, the author's unique career path made the comparison possible and is representative of the typical patterns observed in GS and VS.

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Conclusion 

The aim of this study was to illustrate the successful transition from GS to VS in multiple areas, including surgical volume, vascular procedure competency, career advancement, personal lifestyle, and financial aspects. The training obtained during the VS fellowship and the resultant skill set has enabled the author to better manage and treat patients with vascular disease. Using a previously described model of physician satisfaction that suggests that a physician's happiness is a function of (1) income, (2) practice autonomy, and (3) leisure, VS certainly has fulfilled the requirements.2, 33 Because career opportunities have increased significantly since specializing in VS, the author has more control over career decisions and lifestyle choices. The career is more satisfying now due to the increase in surgical volume, complexity of cases, and management of a wide array of patients. There also has been a direct financial benefit due to the increased wages associated with a medical specialty and the increased patient volume. Specializing in VS also has reduced the number of hours on call and has allowed a more structured routine, which benefit lifestyle and family. Due to the positive changes that have occurred as a result of specializing in VS, the author encourages medical students and residents interested in VS to explore the specialty early, seek vascular surgeons to serve as mentors, and enter one of the new VS pathways as early as possible in their careers.

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The author thanks Jodi F. Hartman, MS, and Michelle L. Wright, MPH, for their editorial and statistical analysis assistance.

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PII: S0890-5096(08)00424-X

doi:10.1016/j.avsg.2008.11.004

Annals of Vascular Surgery
Volume 24, Issue 2 , Pages 196-204, February 2010

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