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Vascular Surgery Training: Is There Enough Case Material?
Vascular Surgery Training: Is There Enough Case Material? Jack L. Cronenwett, MD In recent years, vascular surgery fellowships have changed substantially to meet the requirements for interventional as well as open surgical training. Data from the Residency Review Committee for Surgery indicate that the average vascular fellow performed fewer than 15 interventional procedures in 2000, but that this volume had increased to more than 200 interventional procedures by 2005, an increase of 255%. During the same interval, there was a slight (4%) decrease in the average number of major open vascular reconstructions performed. In 2005, the average vascular fellow performed 450 primary procedures, nearly equally divided between open and interventional cases. Selected open operations, such as aortic aneurysm repair, have decreased in volume due to the substitution by endovascular procedures. Operative volume for vascular fellows has been preserved in part by a 19% reduction in major vascular operations performed by general surgery residents. However, with added overall volume due to the increased prevalence of vascular disease in the aging population, there appears to be adequate case material to train future vascular surgeons, as long as less commonly performed operations continue to be focused on vascular trainees. Semin Vasc Surg 19:187-190 © 2006 Elsevier Inc. All rights reserved.
T
HE EMERGENCE OF endovascular procedures catalyzed many recent changes in vascular surgery training. As these techniques became more frequently employed, it became clear that vascular surgeons required interventional training in addition to open surgical experience. In 2000, the Residency Review Committee for Surgery (RRC-S) modified the program requirements for vascular surgery training to require endovascular training. In addition, the RRC-S made provision for accreditation of a second clinical year to allow sufficient time for interventional training, beyond the 1 year that had traditionally been devoted to training in open surgery.1 This option for additional training also recognized the need for training in newer imaging modalities and medical management of patients with vascular disease. These measures were implemented to insure adequate training of complete vascular specialists. Initially, the new requirement for interventional training created challenges for most programs. Vascular surgery faculty often required additional experience with these techniques to become adequate mentors. Access to interventional
Department of Surgery, Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH. Address reprint requests to Jack L. Cronenwett, Department of Surgery, Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756. E-mail: [email protected]
0895-7967/06/$-see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1053/j.semvascsurg.2006.08.005
facilities and equipment was sometimes limited. Finally, a new curriculum for training in endovascular procedures had to be developed. Further, in 2000, a survey of recent vascular surgery residents (VSR) suggested that only 77% had any exposure to balloon angioplasty during training, and data from the RRC-S showed that the average experience with such cases in 2000 was fewer than 15 per VSR. This clearly did not meet credentialing requirements recommended by the Society for Vascular Surgery of a minimum of 100 diagnostic and 50 therapeutic interventional cases, of which at least half need to be performed as the primary operator.2 Faced with this challenge, the Association of Program Directors in Vascular Surgery developed a new curriculum for training that included interventional experience, and the RRC-S developed defined categories that for the first time specified minimum volume criteria for specific types of procedures during vascular surgery training.3,4 Further, in 2000 the RRC-S began tracking resident experience using a CPTbased system that allowed more accurate delineation of open and interventional experience.
Changes in Interventional Training Since 2000, when the requirement for interventional training was implemented, vascular surgery training programs have 187
J.L. Cronenwett
188
Figure 1 Average volume of procedures performed by vascular surgery residents who completed training from 1994 to 2005. Only primary procedures are included.
made substantial progress in increasing the interventional volume of VSR. In fact, during the past 5 years, the mean volume of primary interventional cases performed by VSR increased by 255% (Fig 1). (Primary procedures count only one procedure per encounter, even if multiple procedures are performed during the same operation.1) During this time, the volume of major open vascular reconstructions decreased only slightly (4%). Thus, in 2005, the mean operative experience of VSR reported to the RRC-S was 450 primary cases, nearly equally divided between open operations and interventional procedures. The total interventional experience of VSR is more accurately represented if all component procedures are counted, meaning additional secondary procedures performed during the same encounter as the primary procedure. The RRC-S recognized the importance of tracking both primary and secondary procedures in 2000, especially for interventional procedures, which often involve multiple components, sometimes even combined with open operations. By 2005, the mean number of total diagnostic angiographic component procedures had increased to more than 300 per VSR, and the number of therapeutic interventional component procedures to more than 140 (Fig 2). The number of primary interventional procedures, excluding endovascular abdominal aortic aneurysms (AAA) repair,
Figure 3 Average volume of interventional procedures performed by vascular surgery residents who completed training from 1994 to 2005. Only primary procedures are included.
has increased exponentially over the past 5 years (Fig 3). In 2005, the average VSR performed an equal number of diagnostic arteriograms and therapeutic interventions, the large majority of which were balloon angioplasty and stents (Fig 3). When secondary arteriograms and balloon angioplasty/ stent procedures are also considered, it is apparent that nearly all current VSRs receive sufficient experience to meet Society for Vascular Surgery credentialing guidelines for such procedures. This is quite a dramatic improvement in the last 5 years. It reflects substantial effort by program directors and faculty to receive training, develop access to facilities, and find sufficient case material.
Changes in Open Surgical Training Five years ago there was substantial uncertainty concerning the ability of vascular training programs to develop and provide sufficient interventional experience for VSR. This has clearly been accomplished, and vascular surgeons have assumed a primary role for this training in most programs. Now, however, the opposite concern has arisen, namely whether of not there is a sufficient volume of major open
Figure 2 Average volume of primary and secondary arteriographic and percutaneous transluminal angioplasty (PTA) or stent procedures performed by vascular surgery residents who completed training from 2001 to 2005.
Vascular surgery training
189
Figure 5 Total volume of major open vascular operations performed by vascular and general surgery residents in the United States during 2002-2005. Only primary procedures are included. Figure 4 Average volume of aortic aneurysm repairs performed by vascular surgery residents who completed training from 1994 to 2005. Only primary procedures are included. The hatched portion of the bar in 2000 estimated the number of endovascular repairs because these were not tracked by the Residency Review Committee for Surgery until 2001, but were performed in 2000.
vascular operations to provide adequate future training for VSR. Endovascular repair of AAA has had a substantial impact on the volume of open AAA repairs by VSR. From 2001 to 2005, the mean volume of elective infrarenal AAA repairs per VSR decreased by 27% (Fig 4). During the same period, the mean volume of endovascular AAA repairs increased 212%. Ruptured and suprarenal open AAA repair volume was relatively constant during this time. Thus, in 2005, of elective infrarenal AAA repairs performed by VSR, fully 70% were performed by endovascular methods while only 30% were repaired with open surgery. Overall, from 1999 to 2005, there have been nearly twice as many total infrarenal AAA repairs performed by VSR, indicating an overall volume increase, due to endovascular repairs, despite the 27% decrease in open AAA repair (Fig 4).
Vascular and General Surgery Residents The trend toward more interventional and less open surgical treatment of vascular disease means that fewer open operations will be available for training, unless the total number of procedures increases substantially. Given the aging population, and especially the influx of the large Baby-Boomer generation into the prime years of atherosclerotic disease manifestation, the total number of vascular procedures is increasing. However, the total number of major open vascular operations performed in the United States by both VSR and general surgery residents (GSR) has decreased by 15% over the past 4 years (Fig 5). During the same time, the number of endovascular primary procedures has increased by 137% (Fig 6). Thus, while the total number of open and endovascular procedures has increased substantially, there was a net decrease in major open vascular operations available for training VSR and GSR. This change has been distributed differently between these types of trainees. Nearly all the
additional endovascular cases have been performed by VSR (Fig 6), while the decrease in major open operations has been absorbed by VSR (Fig 6). During the past 4 years, there has been a 19% decrease in total major open vascular operations performed by all GSR, but only a 1% decrease in these operations performed by all VSR (Fig 5). Similarly, in the past 4 years, the number of total endovascular cases done by all VSR has increased by 216%, while the number of these procedures done by GSR has increased by 49% (Fig 6). Although more of the total major open vascular and endovascular operations available for resident training have been focused on VSR in recent years, GSR performed 76% of the total major vascular reconstructions available for training in 2005. Yet, in 2005, the mean number of major vascular reconstructions performed by GSR was 55 compared with 186 for VSR (Figs 1 and 7). This is because there are 10-fold more GSR who complete training each year (1,022 in 2005) compared with VSR (103 completed training in 2005). Furthermore, there were 250 GS training programs in 2005, compared with only 89 VS programs. Thus, 64% of GSR training programs do not have an associated VSR training program, which prevents cases performed in these programs from being focused on VSR. Previous analysis indicated that GSR in programs that were associated with vascular surgery training programs performed a comparable number of major vascular reconstructions as GSR in programs associated with vascular training programs, because the latter institutions had an
Figure 6 Total volume of endovascular procedures performed by vascular and general surgery residents in the United States during 2002-2005. Only primary procedures are included.
J.L. Cronenwett
190
Figure 7 Average volume of procedures performed by general surgery residents who completed training from 1994-2005. Only primary procedures are included.
overall higher vascular volume necessary to establish a vascular training program.1
Future Opportunities and Challenges Key questions that arise from this analysis are whether there is sufficient case material to expand vascular surgery training programs to produce enough well-trained vascular surgeons to meet future workforce requirements. In terms of endovascular procedures, the answer is clearly yes. In part, this is because these new procedures have been focused heavily on VSR with little involvement by GSR. However, it is also because these procedures are more frequently performed, and have been fully embraced by vascular surgery faculty and program directors. As the equivalency or superiority of these procedures is further established, even greater volumes are likely. In fact, it is likely that there will be more exposure for GSR to endovascular procedures, simply due to workforce distribution within training programs, and the availability of GSR in institutions without vascular training programs. In terms of open vascular operations, the overall volume is decreasing. Thus far, this reduction has largely been absorbed by GSR, such that VSR have continued to have adequate volume of open surgical experience in most programs. If this volume continues to decrease, there will predictably be more tension between the optimal training of VSR versus GSR. Because few current finishing GSR practice vascular surgery without additional VSR training,5 it seems logical that VSR training in open procedures must be preserved at the expense of GSR, if this becomes necessary. Certainly this has
already occurred with certain index operations, such as open AAA repair. This trend will challenge the community of surgical educators to carefully define the necessary training in open surgery for vascular surgery specialists, as well as the minimum open surgical training for general surgeons without additional VSR training. Presumably, such decisions will be based on practice profiles, which suggest that index open vascular operations in training can be preserved for VSR, while GSR will gradually experience less open vascular training. Fortunately, there is enough case volume to support many additional VSR with little reduction in the training of GSR. In fact, in order to increase the number of VSR in 2005 by 50%, the volume of major open vascular surgery operations performed by the average GSR would have only needed to decrease by 18%, to an average volume of 45 cases, which still meets the current minimum volume requirement of the RRC-S.4 Based on this analysis, there would appear to be sufficient case material to train future VSR in both open and endovascular surgery. However, it is likely that future GSR will gradually experience a reduction in vascular training, especially if the trend in reduction of open operations in favor of endovascular procedures continues. However, it is likely that GSR will still receive sufficient training in open vascular surgery to serve them well in their usual practice. This will be necessary in order to insure that future vascular surgeons will maintain excellent open surgical skill.
Acknowledgment Data used to prepare this article were obtained from the Residency Review Committee for Surgery as published on the Accreditation Council on Graduate Medical Education Website (www.acgme.org) and represent an update on the author’s previous publication.1
References 1. Cronenwett JL: Changes in board certification could improve vascular surgery training. J Vasc Surg 39:913-915, 2004 2. White RA, Hodgson KJ, Ahn SS, Hobson RW 2nd, Veith FJ: Endovascular interventions training and credentialing for vascular surgeons. J Vasc Surg 29:177-186, 1999 3. Association of Program Directors in Vascular Surgery. Clinical curriculum. Available at: www.apdvs.vascularweb.org. Accessed October 23, 2006 4. Accreditation Council on Graduate Medical Education. Vascular surgery defined categories. Available at: www.acgme.org/acWebsite/downloads/ oplog/450CatMin.pdf. Accessed October 23, 2006 5. Cronenwett JL, Birkmeyer JD: Dartmouth Atlas of Vascular Health Care. Chicago, IL, American Hospital Association, 2000
T
HE EMERGENCE OF endovascular procedures catalyzed many recent changes in vascular surgery training. As these techniques became more frequently employed, it became clear that vascular surgeons required interventional training in addition to open surgical experience. In 2000, the Residency Review Committee for Surgery (RRC-S) modified the program requirements for vascular surgery training to require endovascular training. In addition, the RRC-S made provision for accreditation of a second clinical year to allow sufficient time for interventional training, beyond the 1 year that had traditionally been devoted to training in open surgery.1 This option for additional training also recognized the need for training in newer imaging modalities and medical management of patients with vascular disease. These measures were implemented to insure adequate training of complete vascular specialists. Initially, the new requirement for interventional training created challenges for most programs. Vascular surgery faculty often required additional experience with these techniques to become adequate mentors. Access to interventional
Department of Surgery, Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH. Address reprint requests to Jack L. Cronenwett, Department of Surgery, Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756. E-mail: [email protected]
0895-7967/06/$-see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1053/j.semvascsurg.2006.08.005
facilities and equipment was sometimes limited. Finally, a new curriculum for training in endovascular procedures had to be developed. Further, in 2000, a survey of recent vascular surgery residents (VSR) suggested that only 77% had any exposure to balloon angioplasty during training, and data from the RRC-S showed that the average experience with such cases in 2000 was fewer than 15 per VSR. This clearly did not meet credentialing requirements recommended by the Society for Vascular Surgery of a minimum of 100 diagnostic and 50 therapeutic interventional cases, of which at least half need to be performed as the primary operator.2 Faced with this challenge, the Association of Program Directors in Vascular Surgery developed a new curriculum for training that included interventional experience, and the RRC-S developed defined categories that for the first time specified minimum volume criteria for specific types of procedures during vascular surgery training.3,4 Further, in 2000 the RRC-S began tracking resident experience using a CPTbased system that allowed more accurate delineation of open and interventional experience.
Changes in Interventional Training Since 2000, when the requirement for interventional training was implemented, vascular surgery training programs have 187
J.L. Cronenwett
188
Figure 1 Average volume of procedures performed by vascular surgery residents who completed training from 1994 to 2005. Only primary procedures are included.
made substantial progress in increasing the interventional volume of VSR. In fact, during the past 5 years, the mean volume of primary interventional cases performed by VSR increased by 255% (Fig 1). (Primary procedures count only one procedure per encounter, even if multiple procedures are performed during the same operation.1) During this time, the volume of major open vascular reconstructions decreased only slightly (4%). Thus, in 2005, the mean operative experience of VSR reported to the RRC-S was 450 primary cases, nearly equally divided between open operations and interventional procedures. The total interventional experience of VSR is more accurately represented if all component procedures are counted, meaning additional secondary procedures performed during the same encounter as the primary procedure. The RRC-S recognized the importance of tracking both primary and secondary procedures in 2000, especially for interventional procedures, which often involve multiple components, sometimes even combined with open operations. By 2005, the mean number of total diagnostic angiographic component procedures had increased to more than 300 per VSR, and the number of therapeutic interventional component procedures to more than 140 (Fig 2). The number of primary interventional procedures, excluding endovascular abdominal aortic aneurysms (AAA) repair,
Figure 3 Average volume of interventional procedures performed by vascular surgery residents who completed training from 1994 to 2005. Only primary procedures are included.
has increased exponentially over the past 5 years (Fig 3). In 2005, the average VSR performed an equal number of diagnostic arteriograms and therapeutic interventions, the large majority of which were balloon angioplasty and stents (Fig 3). When secondary arteriograms and balloon angioplasty/ stent procedures are also considered, it is apparent that nearly all current VSRs receive sufficient experience to meet Society for Vascular Surgery credentialing guidelines for such procedures. This is quite a dramatic improvement in the last 5 years. It reflects substantial effort by program directors and faculty to receive training, develop access to facilities, and find sufficient case material.
Changes in Open Surgical Training Five years ago there was substantial uncertainty concerning the ability of vascular training programs to develop and provide sufficient interventional experience for VSR. This has clearly been accomplished, and vascular surgeons have assumed a primary role for this training in most programs. Now, however, the opposite concern has arisen, namely whether of not there is a sufficient volume of major open
Figure 2 Average volume of primary and secondary arteriographic and percutaneous transluminal angioplasty (PTA) or stent procedures performed by vascular surgery residents who completed training from 2001 to 2005.
Vascular surgery training
189
Figure 5 Total volume of major open vascular operations performed by vascular and general surgery residents in the United States during 2002-2005. Only primary procedures are included. Figure 4 Average volume of aortic aneurysm repairs performed by vascular surgery residents who completed training from 1994 to 2005. Only primary procedures are included. The hatched portion of the bar in 2000 estimated the number of endovascular repairs because these were not tracked by the Residency Review Committee for Surgery until 2001, but were performed in 2000.
vascular operations to provide adequate future training for VSR. Endovascular repair of AAA has had a substantial impact on the volume of open AAA repairs by VSR. From 2001 to 2005, the mean volume of elective infrarenal AAA repairs per VSR decreased by 27% (Fig 4). During the same period, the mean volume of endovascular AAA repairs increased 212%. Ruptured and suprarenal open AAA repair volume was relatively constant during this time. Thus, in 2005, of elective infrarenal AAA repairs performed by VSR, fully 70% were performed by endovascular methods while only 30% were repaired with open surgery. Overall, from 1999 to 2005, there have been nearly twice as many total infrarenal AAA repairs performed by VSR, indicating an overall volume increase, due to endovascular repairs, despite the 27% decrease in open AAA repair (Fig 4).
Vascular and General Surgery Residents The trend toward more interventional and less open surgical treatment of vascular disease means that fewer open operations will be available for training, unless the total number of procedures increases substantially. Given the aging population, and especially the influx of the large Baby-Boomer generation into the prime years of atherosclerotic disease manifestation, the total number of vascular procedures is increasing. However, the total number of major open vascular operations performed in the United States by both VSR and general surgery residents (GSR) has decreased by 15% over the past 4 years (Fig 5). During the same time, the number of endovascular primary procedures has increased by 137% (Fig 6). Thus, while the total number of open and endovascular procedures has increased substantially, there was a net decrease in major open vascular operations available for training VSR and GSR. This change has been distributed differently between these types of trainees. Nearly all the
additional endovascular cases have been performed by VSR (Fig 6), while the decrease in major open operations has been absorbed by VSR (Fig 6). During the past 4 years, there has been a 19% decrease in total major open vascular operations performed by all GSR, but only a 1% decrease in these operations performed by all VSR (Fig 5). Similarly, in the past 4 years, the number of total endovascular cases done by all VSR has increased by 216%, while the number of these procedures done by GSR has increased by 49% (Fig 6). Although more of the total major open vascular and endovascular operations available for resident training have been focused on VSR in recent years, GSR performed 76% of the total major vascular reconstructions available for training in 2005. Yet, in 2005, the mean number of major vascular reconstructions performed by GSR was 55 compared with 186 for VSR (Figs 1 and 7). This is because there are 10-fold more GSR who complete training each year (1,022 in 2005) compared with VSR (103 completed training in 2005). Furthermore, there were 250 GS training programs in 2005, compared with only 89 VS programs. Thus, 64% of GSR training programs do not have an associated VSR training program, which prevents cases performed in these programs from being focused on VSR. Previous analysis indicated that GSR in programs that were associated with vascular surgery training programs performed a comparable number of major vascular reconstructions as GSR in programs associated with vascular training programs, because the latter institutions had an
Figure 6 Total volume of endovascular procedures performed by vascular and general surgery residents in the United States during 2002-2005. Only primary procedures are included.
J.L. Cronenwett
190
Figure 7 Average volume of procedures performed by general surgery residents who completed training from 1994-2005. Only primary procedures are included.
overall higher vascular volume necessary to establish a vascular training program.1
Future Opportunities and Challenges Key questions that arise from this analysis are whether there is sufficient case material to expand vascular surgery training programs to produce enough well-trained vascular surgeons to meet future workforce requirements. In terms of endovascular procedures, the answer is clearly yes. In part, this is because these new procedures have been focused heavily on VSR with little involvement by GSR. However, it is also because these procedures are more frequently performed, and have been fully embraced by vascular surgery faculty and program directors. As the equivalency or superiority of these procedures is further established, even greater volumes are likely. In fact, it is likely that there will be more exposure for GSR to endovascular procedures, simply due to workforce distribution within training programs, and the availability of GSR in institutions without vascular training programs. In terms of open vascular operations, the overall volume is decreasing. Thus far, this reduction has largely been absorbed by GSR, such that VSR have continued to have adequate volume of open surgical experience in most programs. If this volume continues to decrease, there will predictably be more tension between the optimal training of VSR versus GSR. Because few current finishing GSR practice vascular surgery without additional VSR training,5 it seems logical that VSR training in open procedures must be preserved at the expense of GSR, if this becomes necessary. Certainly this has
already occurred with certain index operations, such as open AAA repair. This trend will challenge the community of surgical educators to carefully define the necessary training in open surgery for vascular surgery specialists, as well as the minimum open surgical training for general surgeons without additional VSR training. Presumably, such decisions will be based on practice profiles, which suggest that index open vascular operations in training can be preserved for VSR, while GSR will gradually experience less open vascular training. Fortunately, there is enough case volume to support many additional VSR with little reduction in the training of GSR. In fact, in order to increase the number of VSR in 2005 by 50%, the volume of major open vascular surgery operations performed by the average GSR would have only needed to decrease by 18%, to an average volume of 45 cases, which still meets the current minimum volume requirement of the RRC-S.4 Based on this analysis, there would appear to be sufficient case material to train future VSR in both open and endovascular surgery. However, it is likely that future GSR will gradually experience a reduction in vascular training, especially if the trend in reduction of open operations in favor of endovascular procedures continues. However, it is likely that GSR will still receive sufficient training in open vascular surgery to serve them well in their usual practice. This will be necessary in order to insure that future vascular surgeons will maintain excellent open surgical skill.
Acknowledgment Data used to prepare this article were obtained from the Residency Review Committee for Surgery as published on the Accreditation Council on Graduate Medical Education Website (www.acgme.org) and represent an update on the author’s previous publication.1
References 1. Cronenwett JL: Changes in board certification could improve vascular surgery training. J Vasc Surg 39:913-915, 2004 2. White RA, Hodgson KJ, Ahn SS, Hobson RW 2nd, Veith FJ: Endovascular interventions training and credentialing for vascular surgeons. J Vasc Surg 29:177-186, 1999 3. Association of Program Directors in Vascular Surgery. Clinical curriculum. Available at: www.apdvs.vascularweb.org. Accessed October 23, 2006 4. Accreditation Council on Graduate Medical Education. Vascular surgery defined categories. Available at: www.acgme.org/acWebsite/downloads/ oplog/450CatMin.pdf. Accessed October 23, 2006 5. Cronenwett JL, Birkmeyer JD: Dartmouth Atlas of Vascular Health Care. Chicago, IL, American Hospital Association, 2000