Last Slides Should Pack a Punch

When I lecture to interventionalists (cough, cardiologists), I often end with some variation on the following:

1. The common femoral artery is the left main of the leg, so why would you ever leave a stent across the LCX?

2. Claudication is like stable angina, so is it okay to intervene on a long LAD CTO for stable angina?

3. Gangrene and ulceration are like STEMI and Non-STEMI, only you can’t take the dressing down on an infarcted heart three times a day and wash away the debris.

4. If a LIMA to LAD isn’t a failure and lasts many years beyond the best stents, how is a femoral to tibial bypass a failure?

5. Why is that [insert technology] is a failure in the coronary circulation but the latest and greatest thing in the peripheral circulation?

6. Reversible ischemia is well demonstrated in the foot by lifting it off the bed and watching the color change. It’s too bad for vascular surgeons we can’t build a giant white box around this test and have have the hospital build a center around it.

7. The ABI is a great test of cardiac risk, not so much for peripheral vascular disease.

8. Hybrid revascularization works for the legs in the same way it works for the heart -you maximize the hand that you are dealt.

9. The nitinol throne is not won without some cost.

10. One day, in the far future, someone will dig up an ancient human that is more nitinol, stainless, steel, and chromium, than bone, from the mitral valve out to the fingers and toes.

A Dozen Snippets of Advice to Graduating Trainees


  1. Pass your boards and get your licenses. Board eligibility has the shelf life of a sack of dog food. After about two or three years, you better throw it out. While your apprenticeship with me and my partners has given you insight into the various styles and techniques of repairing arteries and veins, no hospital or insurance company will let you touch a patient without eligibility or certification. And while you are at it, maintain your certification  with CME’s. Apply for licenses early and diligently. You are like newly hatched baby sea turtles and the ocean is your board certification.
  2. Look the part. Stand up, look people in the eye, smile. Stay well groomed and wear clean clothes. Scrubs are acceptable only on days you are operating in the hospital, but no one should see you at the grocery store in them. Dress professionally, but don’t spend more money than your peers or partners. Clean fingernails a given.
  3. Remember, your first job is not like a first spouse and may not be forever. Exit strategies at a basic that can be negotiated from the start is coverage of a tail policy upon mutual separation. Triggers for retention salary (never bonus which is taxed differently) can be negotiated. For example, you take a rural job away from people you might want to marry –you may put in your contract that every year after a certain number you aren’t married, you get a raise. Same with partners who are said to be near retirement –people live longer and want to work longer, and you might find that promised increase in volume and salary does not come to fruition. Contracts can be structured for retention salary increases in those instances. Hard to recruit areas need to recognize that and be willing to increase your salary based on volume that would otherwise go to another partner if they could recruit them.
  4. While it can be viewed as a business transaction, you are setting out to take care of people in a community. Cultural competence is a huge advantage if you are not a native. Understanding the reluctance of an 80 year old Iowa farmer to get surgery in the fall because of the harvest may give you insights to head off argument –their fine sons or daughters may come home and help organize the harvest. Part of the process of getting to know the community is establishing some roots –I don’t mean marrying the mayor’s daughter or having three kids out of wedlock. It means joining clubs, churches, community organizations. It means attending the local fairs and buying from local stores even when Amazon would be a lot more convenient.
  5. Towns can be measured by metrics. How hard is it to get to New York from where you are. Is it in fact New York? How hard is it to get to your town from where your loved ones are? What is the swankiest brand of car sold in that town. Is sushi made by Japanese, is dim sum by Chinese, the pho by Vietnamese? Is there Korean food? Is there a Whole Foods? Is there a functioning public transportation system? Can you get fresh fish? How many pro sports teams are there? Is there a college nearby that you have heard of? How fast is the internet? Is there cell coverage? Do they drink the tap water? Is there a meth/heroin/oxycontin problem? Is the highest paid person in the state the football coach?
  6. Learn the limits of your hospital, your ICU, your floors, your consultants, your office staff, and yourself in equal measure of importance. Be patient and stick to simple straightforward low risk cases if possible and have partners co-scrub more challenging cases. Find and know the regional referral center if you are in a community hospital and don’t feel shy about referring patients beyond the capabilities of everything in the first sentence. Your results will be under a microscope, but the most important watcher is you.
  7. Take care of yourself. Exercise, eat right, and take up a leisure time activity that won’t result in lawsuits or court ordered DNA tests. Golf is great. Vacationing is okay, but spending every moment of time out of town sends the wrong message. Budget and start saving for retirement because you won’t be doing this forever. Pay down debts and don’t take on unnecessary debts. You don’t need a Porsche or a McMansion. If you have kids, stick to public schools and live modestly unless your spouse has a lot of money, then you’re a trophy spouse!
  8. Low hanging fruit of publicity –eating meals in the doctor’s lounge, chatting with staff in the OR lounge, attending staff functions, joining the local medical society. The ten minutes of conversation over a stale sandwich or rubbery, overcooked chicken works. Make sure to have business cards handy or your contact set up to share easily by text or email. Pro tip: having pens printed with your name and practice and number –the equipment and drug reps can’t give you swag but you can give them swag to give out. Give grand rounds or CME talks. Bring in your former faculty as guest speakers. Get an article in the local paper –it will end up on the web site, but mostly older people, ie your patients, will read actual papers. Social media and the internet –unless you are deeply committed to keeping a live presence there with frequent posts and comments, don’t bother. There are too many practice websites and doctors blogs that get refreshed every 3-5 years that they are a liability. You need to blog weekly or FB, Tweet, and Instagram post daily to get a following. That said, done right, you can control your image far better than the hive mind will. The people reading the internet won’t be your vascular patients, but it will be their kids who will search you out on the internet. The other tactic is to never, ever be on the internet.
  9. Humans, from the time of the Australopithecines and maybe before, are organized through direct personal relations in groups numbering up to ten or twenty. You will be in control of an OR or an office, and you have to learn how to do this well to be effective, and it will depend on forming good working relationships. This is not easy and mistakes will be made, but ultimately your success will depend on how well you orchestrate your team. Buying pizza for the team is a good way to get pizza for yourself, but will also earn the gratitude of your people.
  10. No amount of preparation on your part will make up for problems outside of your control. When managing these by “taking ownership,” usually by starting committees and study groups, takes up increasing part of your day and happen without compensation or acknowledgement, it is time to move.
  11. Surround yourself with smart competent people. No referral stream is worth the trouble of associating with stupid, incompetent people, because ultimately, you will become one of them. That said, graduating at PGY 5-7, maybe more, means that you are likely the most trained, most up to date individual in the medical community and to the degree you have to live and work there, you have to give something of yourself to take care of patients. If that means admitting a complex patient with an unrecognized exacerbation of a connective tissue disorder because they were referred to your clinic with foot pain, it may be simpler to simply admit the patient to your service and start the care and workup rather than trying to do an outpatient turf. Sending this patient to the emergency room or dismissing the patient with instructions to set up a specialist appointment washes your hands, but you are not taking care of this person are you?
  12. You are being paid to be smart and competent at vascular surgery like LeBron James was brought back to Cleveland to revive it economically and redeem its souls from perdition. Act accordingly.

The 10 Things That They Don’t Teach You in Vascular Surgery Fellowship


  1. Unless you are going out and setting up shop on your own, which is very unlikely, you will be signing a contract. The contract shapes your work life and forms the foundation of your business model. Not understanding this will set you up for headaches. It is worthwhile not only to have a lawyer review it, but also a business savvy physician.
  2. Every medical community has a Jabba the Hut, who is obvious, but there is usually a hidden Sith Lord as well.
  3. People generally will behave in ways that reinforce their worldviews. Add to that the fact that most people stop picking up new ideas or techniques after training, and you have people who practice as much on belief over evidence. This becomes dangerous in hospital privileging committees which are often a tool for killing off young competitors before they pose a threat. The Torquemadas and vascular Taliban are out there, young one, waiting to pounce on your first complication with that new-fangled whatchamacallit.
  4. The easy way to grade the livability and economic level of a town or a burg is looking at what car dealerships are there. Similar metric –is there sushi made by an actual Japanese sushi chef?
  5. Technically, you may press the EMTALA based federal law that you only need to be on call every third day to get paid for any extra days of call.
  6. Veins and dialysis access are far more complex and common than what you may think working for the chairman at Humanity’s Best Hospital. So are limb salvage and wound care.
  7. You are only as good as your team. As nice as you are, patients will hate you if you have an uncaring office staff or hospital rounding crew. As good as you are, your results will be poor without excellent anesthesia, critical care, and floor nursing. Take good care of your partners.
  8. Be careful about high paying jobs in tiny hospitals with no other vascular surgeons. The reasons for this are legion, and frankly, no matter how good you are, you need to be aged like good steak, and that means partners who have been out for a while seasoning you. Also, being solo means it is impossible to find coverage for vacation, unless you put it in your contract that the hospital or employer will pay for locums coverage during your vacation or fly you back first class if you need to come back from vacation and then return you to vacation with offsets for extra days –I have seen all of this and it can happen as long as you negotiate it.
  9. Strive to get better, and that means keeping track of metrics like OR times, contrast volume, fluoroscopy time, blood loss, length of stay, and complications, for standard cases like: Elective Open AAA Repair, EVAR, carotid endarterectomy, infrageniculate bypass with vein. You should get better every year.
  10. Open surgical skills are going to be far more valuable than you think, and it’s not the anastomosis. If all you want to do is the anastomosis and you think you “did the case” if that is all you got to do, you have been fooled by the oldest staff trick in the book. The value is in figuring out first why an operation is chosen, how it is performed, and how it is healed, and having plans B, C, D, and E. Even when an endovascular approach is planned, you have to have in mind the open alternative.

Top Ten Daily Gift Suggestions for Your Favorite Staff Surgeon


1. Beef Jerky, organic, traditional flavor

2. Tall Blonde Roast, two fingers of half and half

3. Honest, hard work

4. 12 inch Subway Club, with mozzarella, toasted, lettuce, tomato, olives, onions, sweet onion relish, and Sriracha, liter of water

5. Hygiene and grooming

6. An updated list with good news

7. Articulate, thoughtful, organized speech

8. Coordination

9. Good Halloween candy

10. Dark chocolate from DGC office