Exploring patient involvement in decision making for vascular procedures.

BACKGROUND: Developing patient-centered approaches to health care requires increased engagement of patients in their own care, including treatment decisions. Current levels of patient involvement in treatment choices have not been quantified, however, and whether patients desire greater decision-making responsibility is unknown. We conducted a prospective study to explore patients' desired vs experienced roles in treatment decisions, characterize perceptions of treatment outcomes, and identify important sources of information. METHODS: Patients undergoing elective vascular procedures completed a survey consisting of multiple choice, Likert scale, and open-ended questions. Statistics are displayed as mean ± standard deviation or count (%). Differences among procedure categories were evaluated using χ(2) or the Fisher exact test at P < .05 based on responses scored 1 to 2, indicating importance, agreement, or satisfaction based on a 1 to 5 Likert scale where 1 = "very important," "strongly agree" or "very satisfied". RESULTS: Of 101 patients who were contacted, 81 participated. Procedure categories included abdominal aortic aneurysm (AAA) repair in 20, arteriovenous (AV) hemodialysis access in 21, carotid endarterectomy (CEA) in 20, and intervention for lower extremity peripheral arterial disease (PAD) in 20. Participants preferred discussion of all treatments being considered vs only the provider's recommended treatment (90% vs 56%) and choosing together with the provider vs having the provider choose for them (93% vs 62%). Although participants indicated adequate information to ask questions without feeling overwhelmed, only 77% agreed that they had the opportunity to ask questions and only 54% indicated that they were offered a choice. Thirty-seven participants (46%) considered their first treatment was successful, 38% considered a subsequent treatment was successful, and 16% considered none of their treatments were successful. Participants undergoing PAD and AV access procedures most often felt confused or overwhelmed (25% and 24%, respectively, vs 0% for AAA and CEA; P < .01). Patients with PAD had adequate information least often (70% vs 85% for AAA, 100% for AV access, and 95% for CEA; P = .01), had the lowest satisfaction with understanding of their diagnosis (65% vs 95% for AAA, 100% for AV access, and 95% for CEA; P < .01), and most often considered none of their treatments successful (35% vs 0% for AAA, 15% for AV access, and 15% for CEA; P = .02). Providers were identified as the most important information source. CONCLUSIONS: Patients have variable levels of participation in decision making related to vascular procedures and often consider their treatments unsuccessful. Although providers are important sources of information, patients still prefer to discuss all options being considered and contribute to shared decision making.

For Love, Not Money: The Financial Implications of Surgical Fellowship Training.

Surgical residents cite increased income potential as a motivation for pursuing fellowship training, despite little evidence supporting this perception. Thus, our goal is to quantify the financial impact of surgical fellowship training on financial career value. By using Medical Group Management Association and Association of American Medical Colleges physician income data, and accounting for resident salary, student debt, a progressive tax structure, and forgone wages associated with prolonged training, we generated a net present value (NPV) for both generalist and subspecialist surgeons. By comparing generalist and subspecialist career values, we determined that cardiovascular (NPV = 698,931), pediatric (430,964), thoracic (239,189), bariatric (166,493), vascular (96,071), and transplant (46,669) fellowships improve career value. Alternatively, trauma (11,374), colorectal (44,622), surgical oncology (203,021), and breast surgery (326,465) fellowships all reduce career value. In orthopedic surgery, spine (505,198), trauma (123,250), hip and joint (60,372), and sport medicine (56,167) fellowships improve career value, whereas shoulder and elbow (4,539), foot and ankle (173,766), hand (366,300), and pediatric (489,683) fellowships reduce career NPV. In obstetrics and gynecology, reproductive endocrinology (352,854), and maternal and fetal medicine (322,511) fellowships improve career value, whereas gynecology oncology (28,101) and urogynecology (206,171) fellowships reduce career value. These data indicate that the financial return of fellowship is highly variable.