Corner Stitch: What I wish I had known in vascular training

J. Aaron Barnes

Welcome newly matched vascular surgery residents into the fold! I am just over six months into my first attending position after completing my residency training at Dartmouth. While nothing reminds you of how much you don’t know or haven’t seen like being an early career attending, I suppose I am now in a position to reflect back on what I wish I knew or did differently in training. This is certainly not an exhaustive list, but I write this in the hopes that current trainees and those who just matched into vascular surgery are able to find something that resonates with them. 

You are a product of your environment 

“Gentle, gentle!” This was a phrase that had been said to me—and at me—countless times and at many different volumes throughout my training by a specific attending. I did not fully appreciate the extent to which this phrase was burned into my psyche until I noticed I was often muttering it to myself alone while operating as a new attending in Alaska. This is just one small example of how we become products of the environment in which we train. 

From quirky idioms to highly specific operative techniques, we are shaped by those who train us. Some of the things we learn are obvious—techniques are taught, knowledge is conferred through didactics—while others are subtle. How an attending explains long-term stroke risk in clinic, establishes and maintains a relationship with a referring provider, or speaks with a family after a poor outcome, are not taught but rather observed. I wish I had paid more attention to how my attendings practiced and navigated these crucial yet less obvious aspects of being a vascular surgeon as a trainee. 

The things that are ‘mindless’ can be anything but 

The night before I performed my first lower-extremity bypass as an attending, I pored over the patient’s chart and history, reviewed the diagnostic studies and pre-operative imaging, studied the anatomy, confirmed we had all necessary equipment available, and made contingency plans in case things went awry. I arrived the morning of surgery feeling ready. This confidence all came crashing down when the circulator asked me what drapes I wanted to use. It took longer than I want to admit to recall the default drape configuration from residency. Fortunately, I was able to pull the information from the recesses of my mind, and the case was soon underway. This instance, plus a few others that can be described as less than glamorous, made me wish I had paid closer attention to the seemingly mundane things like draping and room setup as a trainee. 

Go back to go forward 

As in many training programs, I had my pick of cases as a chief resident. My weeks were filled with open aortic cases, complex endovascular aortic aneurysm repairs (EVARs), carotid endarterectomies, transcarotid artery revascularizations, and a smattering of lower-extremity bypasses. Towards the end of my training, though, I was given the opportunity to perform various less complex procedures such as venous ablations, arteriovenous fistula creations, and straightforward peripheral bypasses without the assistance of an attending scrubbed in. These experiences were invaluable. Those “intern-level” cases are part of my current practice and I needed to freshen up on them. I needed to learn to operate alone, as I do many of my cases without an assistant today. While I am thankful for the experiences I did have, I wish I would have made more of an effort to seek out those autonomous experiences with simple cases earlier and more frequently in my training. 

There is a method to the madness

The transition from trainee to attending is a little bizarre. Seemingly overnight your role in the surgical hierarchy flips, and you suddenly have more say over your schedule, your cases, and your patients’ care. Now that I am a bit more removed from training, I can look back and see the gradual transition from trainee to attending. I can now appreciate so many aspects of my training program. Case conference forced me to come up with case plans, defend their indications, and have back-up plans. Sizing and ordering devices for EVARs in residency prepared me to do so confidently in the middle of the night as an attending for a rupture. Morbidity and mortality conferences taught me to critically examine my complications and identify areas to target to improve outcomes. In the moment and taken individually, these and many other aspects of training, can be seen as mundane. When taken as a whole, these tasks shape us into vascular surgeons. I am not sure it is possible to truly appreciate the entirety of training when you are in the midst of it, but I wish I had known as a trainee that I would eventually understand the method to the madness. 

J. Aaron Barnes, MD, is a vascular surgeon at Alyeska Vascular Surgery, in Anchorage, Alaska. 


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