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.

"I really demand for technical precision. Vascular surgery has a way of humbling you."

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.

"No one truly knows when an academic job is going to pop up because of the difference in funding cycles."

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.

"There are days in my clinic where the diagnosis is made for the patient before they get there."

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.

"Going into vascular surgery, there should be the expectation that there are going to be emergencies."

[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.

"It really takes some soul searching from the student as to which pathway they think is best for them."

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