What Does Vascular Surgery at an Academic Setting Look Like?

Session 47

Dr. Westley Ohman is an academic Vascular Surgeon in the St. Louis area. We discuss why he chose academics, what makes a good vascular surgeon and more.

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[01:54] Interest in Vascular Surgery

Westley had exposure to vascular surgery from an engineering standpoint as an undergrad. But it wasn’t until late in his third year and going into his fourth year with his sub-I’s that he had world-class mentors from the cardiac and vascular side of things. He was fortunate enough to be guided in his decision making. They supported him going into vascular seeing that’s where his interest and his skill set lie more than on the cardiac side.

He likes the interventional approach where you can treat aneurysm in one room with two small needle pokes in the femoral arteries and then patients go home the next day. Then in the next room, you can be doing an open aneurysm and the patients can stay for a week. You’re deciding which patient benefits from which and really try to master both open and endovascular surgery.

Westley is fortunate enough to where his mentors would let him manipulate the wires when it was safe to do so even as a medical student. So his appetite only went from there.

Other specialties in the running as he was going through his sub-I’s were cardiac surgery and cardiac interventions which he found interesting. But he can’t explain but the technical aspects of doing a fenestrated aneurysm appealed more to how he approaches problems and think about things. He also thought about neurosurgery more on the endometrial neurosurgery as opposed to true neurosurgery.

[04:50] Traits that Lead to Becoming a Great Vascular Surgeon

Westley sees spatial reasoning more so than any other surgical discipline. They do open surgery anywhere in the body. So you have to understand not just where the blood vessel runs but where’s the nearest muscle insertion or origin. Understand how you’re going to be able to tunnel your bypass graft or how you’re going to get exposure to that artery. And in the belly, understand where the important organs live as well as be able to manipulate the space in terms of where you’re going to run your bypass.

In short, you have to know every inch of the body to be able to successfully operate on somebody. He even jokes in medical school that he’s a practical radiologist. They know the anatomy from looking at pictures, but this is his practice on a daily basis.

[07:00] Types of Patients and His Decision to Stay in the Academic Setting

A big portion of the patients they’re treating are the end stage renal patients. They do access creation or maintaining functional access through dialysis or revisions. They also treat peripheral arterial disease that comes along with the disease brought about by end stage renal disease. Your average VA patient encapsulates a lot of vascular surgery from a general standpoint. They’re the smokers, the diabetics, the ones that don’t necessarily take the best care of their body. So they get peripheral arterial disease or aneurysm. But from an academic standpoint, he also gets a lot of the referrals for infected endografts, aneurysms, in and of themselves.

As to his thought process behind choosing academic versus community setting, he looked at jobs for both academic and community settings. One of the things that made him stay in the academics was a job available for him. When you’re going through looking for a job, the academic jobs are always posted about 4-5 months after the private practice jobs.

The complex endo interventions entail pushing the limits of what they can do from an interventional approach or minimally invasive approach while still doing right to a patient. It’s very easy to do something to a patient but determining if it’s the right way to do it. They also have to consider limiting the physiologic stress on aortic surgery patients. And this is what kept him in the academics.

Moreover, he has always wanted to be a big aortic surgeon having found the disease processes in terms of aneurysm and dissections fascinating. And a lot of the smaller hospitals and mid-sized hospitals just don’t have the resources to support the very sick and very challenging patient population. Westley clarifies it’s not the fault of the hospital. It’s just not their mission or their buildup. And it takes a very specific type of place to do it which he always saw himself doing as a surgeon.

[11:10] Percentage of Patients, Typical Day, and Taking Calls

Westley says two-thirds of his patients come in already diagnosed with a caveat. If he’d do thoracic outlet syndrome, they have one of the biggest, if not the biggest, thoracic outlet syndrome referrals in the country. Nearly 100% of those patients come in with a diagnosis in the ballpark. But for the remainder of his patients, he will get referrals from the hematologists or the rheumatologists. Once you get outside of the pure simple cases, you see patients in end stage renal disease and they need access or they’ve been smoking and they have peripheral arterial disease. So there are a lot of esoteric diagnoses they made in an interdisciplinary process.

This said, 25%-33% of his patients are usually an interplay between himself and another consulting physician where they bounce ideas off each other. But a lot of his diagnosis are not made from subtle physical exam findings. They’re important but they’re a more imaging-driven specialty.

Westley can’t say there is a typical day for him, which has been a selling point for him. But if he’s on call at a major center, he could get a ruptured and aortic aneurysm and go do that. While he could also deal with a gunshot wound to an extreme median having to figure out how to reconstruct or what conduit to use. But it’s very easy to start your day with one procedure and then going to a different procedure. And then you bounce back upstairs to either do bypass or belly revascularization.

Outside of clinic days, he doesn’t really know what comes his way. Because even if he’s not on call, if they happen to get swamped and being pulled into other cases. So being able to be flexible and offer the full toolkit really allows his day to be as variable as the hospital needs him to be or as he wants it to be. He takes one and a half days of clinic per week so he basically spends more time in the OR or the cath lab or the interventional suite.

Westley describes being one of those rare groups with ten partners, nine of which will take call. So it ends up being a one in eight or so calls. He’d be on call a weekday, usually every other week. Then he’d have a weekend call every other month. For him, this is better than it was when he was in training. Outside of those large groups, it’s easy to be in a Q3, Q4 call.

That said, he’s in a major referral center so although it’s an infrequent call, it’s still a very busy call. Half of his calls, he’s operating most of the night, if not all of it, and still running the full day the next day. And the other half, he’s interacting with the referral line or fielding inpatient consults that don’t necessarily need to go to the operating room. But students should expect that there are going to be emergencies going into vascular surgery. Not a lot of their cases is that when something goes wrong can be sit on until the next morning.

[16:52] Work-Life Balance

Westley still finds having life outside of the hospital. He’s married to a fourth year general surgery resident. They have a toddler and two dogs. It’s tough. But since he’s finished training, their life has gotten significantly better. Regardless of what his wife is doing, he has time for what he wants to do in terms of family and career.

It’s about finding that right balance and for them, that right balance is a wonderful nanny who helps them out. This allows them to stay in the hospital late on a rare night that you need to.

[18:03] The Training Path to Vascular Surgery

Westley explains that there are two routes. One is the traditional two-year fellowship after a five-year general surgery program, known as the 5+2. There’s also the 0+5, which is 5 years of some amount of general surgery and a lot more vascular surgery. His program did it half and half for the first three years and the last two were only vascular, This allows you board certification only in vascular surgery.

From this, you can go on to do fellowships in cardiology or critical care to augment what you can offer. Westley comes from a 0+5 program where he could whatever he wanted anywhere in the body that he needed to be. I don’t think either pathway is the right way. I don’t think there’s a wrong way to go.

He noticed that his co-fellow who came from general surgery training when he started his fourth year, was more comfortable in the belly. But by the end of it, they were roughly equivalent. And he felt he had stronger interventional or endovascular skills. That because he didn’t learn laparoscopy whereas he did.

According to Westley, all of his friends who have done general surgery and the vascular don’t touch a laparoscope. And in fact, he’s more likely to touch one than they are just by accident.

Regardless of the setting, Westley stresses the importance of the quality of the training program. There are 5+2 programs that will prepare you for a very successful private practice. And there are some 0+5 that will prepare you for a very successful academic, doing the big cases and vice versa. He thinks that each program has its own individual strengths. When he sat down six years ago to make his rank list, his first three were integrated programs and his fourth was general surgery.

He would recommend students to figure out what you want from there and what you want your life to look like. They may not know that and think 5+2 is the way to go since they have their general surgery to fall back on. It’s not a bad decision. But it’s a mindset that a lot of vascular surgery is moving more towards 95%-100% vascular surgery. This is because of what they can do and how they can do it expanding every year.

In terms of competitiveness, Westley describes it as fairly competitive. He thinks there are slightly more applicants than there are spots. And in terms of the 0+5, when he applied, it was more competitive than dermatology. They still have 80 programs per one spot per year and they interview about 20-25 of them. And for the fellowship, the numbers are a little smaller.

A big debate going on is that a lot of the 0+5 programs were born out of the big academic centers. Michigan was the first to have it as well as Pitt and Dartmouth, which are big names in vascular surgery. At WashU, they keep both pathways open. They’re committed to matching one for each pathway per year. Part of that is having complementary learning that makes for a better learning environment.

Then there’s always the big academic centers that don’t have the 0+5. And the biggest leaders in vascular surgery right now say they will hopefully never have a 0+5 at their program. So even though it’s been out for almost a decade now, it’s still a very polarizing topic for some of the very senior people in the discipline.

[23:50] Advice to Students to Become Competitive

Just like for everything else, Westley says it comes down to having a reasonable Step 1 score. It’s going to be a very easy, quick, and dirty screening outlet. Another thing is that vascular surgery being a small field, doing a sub-I is absolutely critical. This allows you to get your name in the door in different places. And if you can, you get letters and phone calls fro not only your home institution, but other institutions as well. So this goes a long way towards building a competitive application. Especially at 0+5 level, it shows exploration and an interest. There are also people falling out of the pathway and having an empty spot for the next x number of years where you’re supposed to be training. Being able to show you know what you’re getting into goes a long way. This is something they look for when they’re interviewing applicants.

[25:30] Bias Against DOs and Subspecialty Opportunities

Westley doesn’t see any overt bias against DOs. They’ve interviewed some DOs in the last couple of years. It’s just that a lot of the big programs for vascular surgery aren’t associated with an osteopathic school. This is an extra hurdle the student has to go through. They have to show they’re investigated and they have the commitment. And if they can show that, then they could go further than the allopathic student who comes from a program that might have a great reputation for vascular surgery but didn’t necessarily show as much interest or build a competitive application packet.

In term subspecialty opportunities within vascular surgery, there are several ways to make your niche. There isn’t any formal ACGME fellowships. But as he said, what comes into anyone’s mind is there is advance aortic endografting fellowships. Cleveland Clinic has one as the Mayo Clinic, which they’ve rolled out as a complex aortic reconstruction fellowship. UT Houston also has it, which is where he went to medical school. These are big aortic referral centers so they attract the aortic “super” fellows to learn those techniques.

Moreover, Westley says it’s very easy to build a very heavy thoracic outlet syndrome practice if that’s where you want to make your mark. Because if you can do it well and show consistent outcomes, those are patients that will come to you. And the referrals will come to you as well fairly easily. A lot of people in the community end up either specializing or treatments for venous reflux. Those are disease process that he thinks they’ve undersold as a society or medical profession. There’s always one guy in town who’s that carotid surgeon just like the thyroid surgeon that get good outcomes with your carotid procedures. Referrals will also continue to come as well. But in terms of established training pathways, there aren’t any besides the aortic surgery.

[28:50] Working with Primary Care and Other Specialties

Westley wishes to thank primary care physicians which he considers as his very best friends.A lot of the medical management of vascular patients is driven by the primary care physician. Whether in terms of following the JNC guidelines and the AHA guidelines in terms of the best medical management. About a third of his clinic patients, he ends up getting or giving a phone call to the primary care physician to pick their brain about it. He thinks it’s underrecognized. In a large portion of society, everyone thinks about carotid disease and stroke but lower extremity and peripheral arterial disease and critical limb ischemia are fairly quick to pick up in terms of simple questions. These are quick and easy things that can prompt a referral to him and really impact the patient’s overall lifespan.

Other specialties he works the closest with include the cardiac surgeons, nephrologists, hematologists, trauma team, radiology, and primary care. He is fortunate where the turf war was fought by a generation before him so he no longer has to fight them. But they do interact a lot with the interventional radiology colleagues in a congenial relationship and not antagonistically. The same think with interventional neuroradiologists that have made a name for themselves in the intracranial work. They do most of the extra cranial carotid disease. If those issues had not been settled, Westley admits it would have been different.

As far as limiting their scope of practice in the future, Westley doesn’t really see this coming. He thinks a lot of the blame for the vascular being open for other specialties is they’ve done a poor job defining what’s the best treatment option for this disease process. And the interventional cardiologist or interventional radiologist has the skill set to treat those patients as equivalently as he does in terms of cutting a wire across the lesion. Or whether it could be putting a balloon or a stent.

Westley believes a way for vascular surgeons to really sell themselves is that mindset of having multiple skill sets. But also think whether they’re burning any bridges. If they can define who benefits from what procedure, and also market themselves as being the one-stop shop for lower extremity work. Either they protect their patient population or start to grow it. He won’t sit and tell that there aren’t interventional radiologists that can do phenomenal work in the peripherals. Or that the cardiologist can’t do a good work in the renal segment for instance. So he thinks it as not only someone who can put a hole in an artery or fix a remote artery, he can also make an incision and provide a definitive fix to that problem.

[35:49] Opportunities Outside of Clinical Medicine

The first thing that always comes to mind is a lot of early advances in the industry. The first stent was developed by a physician (not a vascular surgeon). And a lot of the newer stent grafting was pushed by a vascular surgeon or helped developed by a vascular surgeon. Where he’s at, they have a very large industry presence and they’re very active on clinical trials. The IP world for vascular surgery or devices in general has changed. Before, they’ll just run with it and sit back and collect royalties. But those easy-picking days are gone because they really want to see an idea almost brought to the market. This could be in terms of the background studies, safety and efficacy studies.

Some of his partners are working on small drug molecules and working with industry from that standpoint. One of his former partners who moved on from the University of Michigan was big in “nanotherapeutics.” They’re pushing the envelope of how they can augment devices with small drug molecules to bridge the device industry and the pharmaceutical aspect of it.

Moreover, he knows other vascular surgeons who have tried to move into more of a healthcare policy standpoint. They don’t only look at the cardiovascular system but also the cardiology or nephrology world. Westley believes there has to be a healthy relationship with industry right now in terms of devices, balloons, grafts, and stents.

[39:15] What He Wished He Knew and What He Likes the Most and Least

When he was in training, he would curse the middle of the night and thought he should have gone to a place that’s not a major level 1 trauma center. He really doesn’t like operating that much in the middle of the night.

And in that moment, he was tempted to curse and throw an instrument. And as he looks back, he thought that was actually an opportunity to learn how to approach new problems. He thinks it really made him a better surgeon. Would he pick vascular surgery all over again? Westley is absolutely sure, but just with a caveat that there are going to be a lot of nights and late days if you’re going to do the big cases. If you want to design your practice to where you are treating venous reflux all day, then you’re not going to have any inpatients. And you’re going to live a very comfortable life. So it depends on what you want.

What he likes the most about being a vascular surgeon is being able to treat any disease process outside of the head and the heart. Because it always keeps his days different. And he really enjoys interacting with not only other surgical disciplines but also other medical disciplines. And in terms of approaching and managing those problems. Not every patient that comes across him needs an operation. But almost uniformly, he’ll be interacting with either the primary care physician or some sort of medicine subspecialist to help provide some input on the disease process. He would still be treating patients even without a scalpel or without a needle.

What he likes the least is not operating at night. He often jokes with his trainees but there really is nothing more humbling than vascular surgery. He finds it very demanding from a technical aspect. Sometimes, he finds himself losing more sleep now as an attending than he did as a trainee. He’s worried about whether it’s okay enough to where he can leave the operating room or does he need to work on the problem. He likes the challenge but it’s starting to wear on him. So he’s starting to explore with his senior problems as to how to deal with it. Not to wear him down but to motivate him to either do better in that moment or do better for the next patient.

[43:05] Major Changes in Vascular Surgery in the Future

Westley explains that there’s always going to be turf wars and he thinks that should be a call to better ourselves and better define ourselves. There’s always going to be pushing the envelope. Fifteen to twenty ears ago, the only way to treat aneurysm was a big belly incision. Then they got to a groin cut downs and rudimentary endovascular devices. Today, he can do a complex paravisceral aneurysm through a procedure that at the one month follow up, you can’t even tell they had an operation from the outside.

That said, the explosion of minimally invasive techniques is going to allow more and more people who say they have the skills with wires and catheters to come into their “turf.” It’s going to be up to the next generation to show that they can do it a lot better and here’s how.

Eventually, all hardware fails. It’s just a matter of whether or not the patient lives long enough for the device to get fatigued. Westley adds that as all hardware fails, it’s only a matter of time until the device can get fatigued. In which case, they’ll require an open conversion and you do want them to be at a major aortic referral center. It’s not just about putting in the equipment but being able to manage all the complications that come from it. This is where vascular surgeons are going to help be able to define themselves.

[45:30] Final Words of Wisdom

Westley says vascular surgery is one of the more dynamic and rapidly changing surgical disciplines not only in terms of who they can treat and how. But also, pushing the envelope of what may be inoperable now. Ten years from now, you may already have a very simple device or very simple fix that you may very well be a part of developing. It’s not for everyone. But people who will love this are those who welcome the technically demanding challenge or the opportunities of the spatial challenges that come along with vascular surgery. If you’re good at it and you have inclination towards it, you’re going to love it.

Especially for the general surgery resident who may only do it as an intern or a second year, not to see as a full breath and just be taking care of the patients. It’s so much more than that once you get into the operating room. If you have the opportunity to rotate as a senior, by all means you should. It is night and day from just managing them post-operatively or sewing a simple fistula. And he was quick to discover there’s no such thing as simple fistula, which he thought it was as a second year resident. When you’re doing the more challenging cases either technically or intellectually, it’s incredibly rewarding even though the patients may be challenging at times.

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