It’s an issue increasingly knocking on the door of program directors and section chiefs in hospitals across the country as COVID-19 cases escalate in their areas: the redeployment of vascular surgeons and trainees to other areas of care.
It formed a central plank in a discussion over education, training and wellness during the second in the new Society for Vascular Surgery (SVS) virtual Town Hall series designed to help the specialty through the worst ravages of the coronavirus crisis.
Amy Reed, MD, professor and chief of the division of vascular surgery at the University of Minnesota in Minneapolis and SVS secretary, made the case that vascular fellows be “last in line” as general surgery residents and trainees are picked off to staff up for coming surges in COVID-19 cases.
“There’s been a lot of discussion about this and we’ve been impacted here—and that is providing care beyond vascular surgery,” explained Reed during the Town Hall, Friday. “From a faculty standpoint, I’m sure most all of you have been asked to say what else can you do besides vascular surgery—if you’re critical care-boarded, or can you staff an ICU [intensive care unit] and be an attending for a period of time.
“Many of us have put our names in to be available for that should that come into play. For fellows and trainees, if you have not been asked about this by your institution, your department of surgery and GME [graduate medical education] office, you likely will be. We’ve essentially taken the stance that our fellows are the last in line for this.”
In the case of Reed’s institution, each hospital is staffed with one member of faculty alongside one fellow. “Our fellow is essential,” she said. “This may not be the same scenario with the integrated resident unless it’s your fifth year resident,” Reed added, urging program directors to advocate for fellows as central to vascular surgery service.
SVS president and moderator Kim Hodgson, MD, chair of the division of vascular surgery at Southern Illinois University School of Medicine in Springfield, Illinois, concurred, before adding: “But the interesting thing to me is that the hospitals more or less own the residents and fellows, don’t they? Because they pay their salaries. So is this a hard fight to win?”
Reed responded “last in line” isn’t a position usually adopted, further explaining that general surgery program directors tend to understand the rationale behind such a designation. “Already our surgical residents were pulled from our service, and we said, ‘Okay, you’re just going to leave us with the fellow and the faculty.’ I think everyone understands that. We can’t have a ruptured aneurysm come in and just be functioning with an APP [advanced practice provider] and a faculty.”
Co-moderating, Alan Lumsden, MD, the medical director of Houston Methodist DeBakey Heart & Vascular Center in Houston, explained how some of his residents had been recruited as scribes for infectious disease consultants—the first instance they had been asked to provide support that was not vascular-related. “It wasn’t a very popular thing and, to be honest with you, it was more a last minute need.”
Dawn M. Coleman, MD, program director for the integrated vascular residency program and fellowship at the University of Michigan in Ann Arbor, described a situation in her department where residents, faculty and members of the APP force are being primed for side-by-side redeployment
“As our hospital prepares for a full surge of COVID care, while the vascular emergencies are still continuing to come in—and, to be honest, we have been busier than ever—there’s a pressing need at a hospital level to use our workforce to its fullest capacity,” said Coleman, also a member of the SVS Education Committee.
“We’ve been navigating issues of resident redeployment and where they’re going to be strongest suited, and for some of our trainees that may be in the critical care unit. We have surgical residents sitting side by side with the faculty staffing these pop-up ICUs. We also have individuals with COVID-related concerns, who are high risk, or have vulnerable families at home, so we’re really looking for guidance on how to use them most effectively.”
Gilbert R. Upchurch, MD, chair of the department of surgery at the University of Florida College of Medicine in Gainesville and chairman of the Vascular Surgery Board, returned to the original point made by SVS secretary Reed.
“We cohorted our residents about 10 days ago, as well as our fellows,” he said. “I agree with Amy [Reed] that the vascular fellows, the cardiothoracic fellows and the plastic surgery fellows, etc., have a skillset that serves typically on their own service. A fellow and attending can take on almost any challenge. And that’s sort of what we’ve done. I think there will come a time—if you’re in New York or Los Angeles—where we all become critical care doctors but for now the fellows are preserved and on their service.”
That was a position initially taken up in Houston, but vascular surgeons are “easy pickings”—ripe for being being pulled in to provide other modes of care, Lumsden said. “When bodies are needed, all of a sudden they look to the surgery services, and go: ‘We’re not doing any surgery; you’ve got half your residency program sitting at home. Oh, by the way, we need them.'”
Upchurch agreed the day would come when they would be turned into critical care doctors or a line service, but settled on the point of vascular surgeons as acute care surgeons. “Depending on where you are, anywhere from 30–50% of what you do is actually acute vascular care.”
Upchurch ended with a sobering picture delivered from colleagues operating on the frontlines in one of the worst-hit parts of Europe: “Even in Italy, my friends tell me COVID-19 presents with a vasculitis; they’re managing lots of embolic and thrombolic complications of the lower extremities in particular,” he said.