Should vascular surgery become an .independent specialty? Perspective of a program chairman and Residency Review Committee member Robert W. Barnes, M D Little Rock, Ark.
The emergence of vascular surgery as a subspecialty of general surgery has created tension and a sense of fragmentation of the parent discipline. This article reviews the present status of accredited medical specialties (n = 24) and subspecialties (n = 50) and confronts some current problems in the field of vascular surgery. Issues of resident training, practice opportunity, manpower, and specialty encroachment would not be alleviated by creation of a separate specialty of vascular surgery. Rather, in the view of a program director and member of the Residency Review Committee (RRC) for Surgery, educational reforms should be designed to facilitate career tracking of residents entering subspecialties while enhancing training and practice opportunities of general surgeons. A model is suggested that will significantly improve the resident operative experience in major vascular surgery for both general and vascular surgery trainees. A recent commitment of both the RRC and the American Board of Surgery to address these issues offers a creative opportunity to improve vascular training, manpower, and patient care while mitigating the threat of further fragmentation of general surgery. The title of this minisymposium reflects a national trend: for the past decade or more medicine has experienced progressive subspecialization and fragmentation. General surgery has not been exempted.1 The reasons for this evolution are many, including a desire on the part of residents to cope with the information ,explosion in medicine, to master increasingly complex medical technology, or to follow in the footsteps of academic role models who are often subspecialists. On the other hand, this trend toward subspecialization often reflects an increasing commitment to From the Department of Surgery, University of Arkansas for Medical Sciences and the Surgical Service, Little Rock Veterans Administration Medical Center, Little Rock. Presented at the Society for Vascular Surgery Critical Issues Forum, Los Angeles, Calif., June 3, 1990. Reprint requests: Robert W. Barnes, MD, Slot #520, UAM& 4301 W. Markham, Little Rock, AR 72205. 24/6/24163
control personal lifestyle, to minimize medicolegal risk, or, perhaps most irnportant, to enhance one's practice opportunity (i.e., marketability) in a competitive medical environment. Although the aforementioned reasons for subspecialization may represent advantages for the individual, the end result has caused pressures that have threatened the very existence of the parent specialty of general surgery and the practice opportunities for its graduates. These forces have led, on the one hand, to regulatory steps to limit further subspecialization or fragmentation and, on the other hand, to suggestions for education reform to facilitate career tracking for subspecialists as well a,; general surgeonS. As both a general surgery and vascular surgery program director, and a member of the RRC for Surgery, I have had a particular interest in exploring the opportunities for innovative educational restructuring of general surgical and subspecialty training to help solve the dilemma of fragmentation of our parent specialty. Thus my answer to the rhetorical question posed for this issues panel is a qualified "No": vascular surgery should not be a separate specialty, but we should not be satisfied with the current method of training general surgeons or surgical subspecialists. Let us explore some creative strategies that may mitigate some of the problems of surgical fragmentation while improving professional opportunities and patient care.
Current surgical specialties and subspecialties There are at present 24 medical specialties that have RRCs for program accreditation and specialty boards for certification of the graduates. 2 Of these 24, 10 are surgical specialties, including general surgery. Only two specialties, colon and rectal surgery, and thoracic surgery, require completion of training in general surgery as a prerequisite for the specialty. Plastic surgery requires at least 3 years of general surgery education, although in the past, most trainees complcted general surgical training before entering the specialty. Currently only otolaryngology and urology require i year ofprelirninary training in gen615
616 Barnes
eral surgery, which is recommended for neurologic surgery and optional for the remaining surgical specialties. There are currently 50 recognized subspecialties in 13 of the aforementioned specialties accredited by the Accreditation Council for Graduate Medical Education. 3 Graduates of these training programs may receive certificates of special or added qualifications in the subspecialty from the parent specialty board. Eleven of these subspecialties are in surgical specialties, including six in orthopedic surgery, four in general surgery, and one in plastic surgery. Internal medicine and pathology have the greatest number of recognized subspecialties, 11 and 10, respectively. The subspecialties of general surgery include pediatric surgery, vascular surgery, surgical critical care, and hand surgery. The American Board of Surgery grants certificates of special qualifications in pediatric surgery and, until recently, in vascular surgery. Currently the board grants certificates of added qualification in vascular surgery, surgical critical care, and hand surgery. The board has elected not to recognize other subspecialties of general surgery until a consensus is reached in controlling further fragmentation of the specialty. Current problems in vascular surgery Vascular surgery is beset with problems of adequacy of training, practice opportunity, manpower, and specialty encroachment. Each of these issues contributes to tensions within the field and to reactions by our vascular societies, as evidenced by this panel discussion. As both a director of two training programs and a member of the RRC for Surgery, I recognize the problems of providing adequate education and operative experience for both general and vascular surgery residents. I have previously commented upon methods to reduce the friction between these two groups of trainees. 4 Nevertheless, the two major hurdles for most program directors continue to be marginal major vascular caseload, particularly for general surgery residents, and concurrent assignment of the two trainees, with the potential adverse effect on the independent judgment and decision making of the general surgery resident. These two problems ha the vascular training of the general surgery resident lead to the issue of increased restriction of practice oppommity when seeking hospital credentialing. Many general surgeons arc encountering resistance in obtaining privileges in severn of the principal components of the specialty in-
journal of VASCULAR SURGERY
cluding vascular and head and neck surgery. These challenges are undoubtedly contributing to the quest of general surgeons for postgraduate training in vascular surgery. The number of Accreditation Council for Graduate Medical Education-approved training programs in vascular surgery, currently 59 with 80 residents, is insufficient to provide the vascular surgical manpower for this country,s Most vascular surgical care is provided by general surgeons. Unfortunately; the average general surgery resident is not exposed to a sufficient volume or breadth of vascular operative experience to qualify for the minimum numbers (70 major cases) suggested by the Ad Hoc Committee of our Joint Council for the Society for Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery.6 Data from the "Resident Statistics Summary" of the RRC for Surgery suggest that the average major vascular operative experience of general surgery- residents is about 50 cases. The 10th percentile experience, which is used to define the minimum numbers of~ cases for various general surgical procedures, is only about 14 malor vascular operations. Such meagcr experience will not provide the general surgeon with competence, let alone expertise, in vascular surgery. The final issue facing our discipline is the encroachment by other specialists into vascular medicine and interventional procedures. Mthough vas-, cular diagnosis and therapy have always interested some internists, neurologists, radiologists, and neurosurgeons, recent incursion into the discipline by intervcntional cardiologists and otolaryngologists has created concern and tension in the field. Of particular concern is the practice of carrying out vascular intervention by individuals desiring skill in coronary interventional therapy, in the absence of in-depth knowledge of the field of pcripheral vascular disease. 7
A proposal: Education reform To facilitate career goals ofresidcnts entering surgical specialties and subspecialties, while enhancing the training and practice oppornmities for general surgeons, I have recommended changes in our educational pathways of the surgical residency.8 In essence, all residents, regardless of specialty interest, would take 1 or 2 years of basic surgery to develop knowledge and skills fundamental to all surgical disciplines. Residents could then enter either a surgical specialty such as neurologic, orthopedic, otolaryngologic, or urologic surgery, or they could pursue intermediate surgery in preparation for general sur-
Volume 12 Number 5 November 1990
Perspective of a program chairman
617
Table I. Mean major vascular operative experience for general surgery resident (reporting total all years) and presubspecialty resident (reporting junior years) before (observed) and after (expected) institution of early tracking and caseload rcallocation General surgery (PG5) resident
Presubspecialty (PG4) resident
Operative category
Observed
Expected
Observed
Expected
Total vascular Aneurysm Ccrebrovascular Peripheral obstructive Intraabdominal obstructive Upper extremity Extracavitary Portal decompression Miscellaneous Access Amputations
128 11 9 23 I 1 5 1 32 23 21
182 23 18 46 2 3 9 3 34 23 21
74 4 3 8 0 1 2 0 22 17 17
78 0 0 0 0 0 0 0 31 23 21
Data based on 1988-1989 "Resident Statistical Summary" of the Residency Review Committee for Surgery.
gery or one of its subspecialties. Intermediate surgery ,4"or 2 or 3 years would provide increasing surgical knowledge and skills, the final year of which would include senior level responsibility. After 4 years of basic and intermediate surgery, residents could elect to enter such surgical specialties (or subspecialties) as plastic, thoracic, colorectal, or pediatric surgery. Residents desiring a career in general surgery would take an additional 1 or 2 years of advanced general surgery, which would include experience with com{,lex surgical procedures such as vascular, gastrointestinal, hepatobiliary, thoracic, head and neck, or oncologic surgery. Individuals who wished to practice vascular surgery could either complete advanced general surgery training with significant exposure to major vascular operative procedures or enter a postgraduate vascular surgery residency. Regardless of pathway, the individual should meet the criteria for hospital privileges in vascular surgery suggested by the Ad Hoc Committee for our joint council. 6 Recently I presented data regarding the impact Of such reforms in surgical education on resident .operative experience. 9 Providing that early tracking occurred for residents entering surgical specialties or subspecialties and that appropriate major operative cases were reserved for general surgery residents, the major operative experience of the average general surgery resident would increase by approximately 25%. Significant increases would occur in all of the principal components of general surgery. Through caseload reassignment, the average resident entering a surgical subspecialty after 4 years of general surgery could anticipate a 10% increase in major operative experience compared to that reported by current
residents during the junior (prechief resident) years. Table I illustrates the current (observed) and the anticipated (expected) major operative experience in vascular surgery for the average resident completing 4 years (as surgeon, junior' years) or 5 years (total all years, including chief year) if the aforementioned educational reforms and caseload reallocation were instituted. These data are based on the "Resident Statistical Summary" of 1009 residents from 286 programs reporting to the RRC for Surgery for 1988 to 1989. The projections are based on the assumption that 50% of residents would enter another surgical specialty or subspccialty after 4 years and that such residents would not perform major (category I or II) vascular procedures. Such procedures would be reserved for the general surgery resident who would complete 5 years, including the chief year. These reforms would increase the mean vascular operative experience for general surgery residents by 42% from an average of 128 cases to 182 procedures. The experience in major (category I and II) vascular surgery would double from the current 51 cases to 104 procedures. For residents entering other surgical specialties or subspecialties, the mean vascular experience would remain at about 75 cases but would consist exclusively of category III cases. DISCUSSION
Vascular surgery has been an integral principal component of general surgery training as well as an important evolving subspecialty of surgery. Despite the tensions that have developed between the parent specialty and vascular surgery with the establishment of Accreditation Council for Graduate Medical
618 Barnes
Education-approved training programs and certificates of special or added qualifications in general vascular surgery, the education of both general and vascular surgeons and vascular surgical care have improved over the past decade. 1° I do not think that surgical education or patient care would be enhanced by creating a separate specialty, including an R_KG and board for vascular surgery. On the other hand, I do believe that significant changes must be made in our surgical residency to alleviate the current problems of training, practice restrictions, manpower limitations, and specialty encroachment facing both general and vascular surgeons. The suggestions for educational reform ideally will offer a constructive alternative to the disruptive choice of creating a separate specialty of vascular surgery. Through the combination of early tracking of residents into subspecialties and major vascular caseload reallocation, operative experience for both general and vascular surgery trainees could be enhanced. This broader educational exposure to major vascular caseload should facilitate hospital credentialing and practice opportunity. The educational reforms would lessen the disparity of operative experience between the general surgery resident and the vascular trainee and improve the manpower pool of surgeons capable of providing good care for patients with vascular diseases. Finally, improving the standards of vascular surgery would provide a benchmark with which to compare and limit vascular interventions by specialists in other disciplines without comparable educational experience. Implementation of these educational reforms will require cooperative support of RRCs and specialty
Journal of VASCULAR SURGERY
boards, as well as the specialty societies. To this end, both the RRC for Surgery and the American Board~ of Surgery have taken steps to address these problems of specialization, fragmentation and other issues of mutual concern. I am hopeful that from this effort will come a creative strategy for improved education and practice opportunities for our trainees interested in vascular surgery without the need for creation o~ a separate surgical specialty. REFERENCES 1. Organ CH. Fragmentation and specialization. Arch Surg 1987;122:639. 2. Accreditation council for graduate medical education: 19881990 Directory of graduate medical education programs. Chicago: American Medical Association, 1989, 10-11. 3. Accreditation council for graduate medical education: 1988 1990 Directory of graduate medical education programs. Chi cago: American Medical Association, 1989, 15-116. 4. Barnes RW. Minimizing problems between vascular trainee and general surgery residents. J Vase SURe 1990;12:91-4. 5. Rutkow IM, Ernst CB. An analysis of vascular surgicaa manpower requirements and vascular surgical rates in the United States. J VAsc SURG 1986;3:74-83. 6. Moore WS, Treirnan RL, Hertzer NR, Veith FJ, Perry MO, Ernst CB. Guidelines for hospital privileges in vascular surgery. J Vase SURG 1989;10:678-82. 7. Strandness DE, Barnes KW, Katzen BT, Ring EJ. Indiscriminate use of laser-assisted angioplasty. N Engl J Med 1989;321:1417. 8. Barnes KW. The next generation of surgical residencies. Arch Surg 1990;125:433-6. 9. Barnes RW, Lang NP. The surgery residency: is it a time for a change? Am J Surg (Submitted), 10. Perler BA, Zuidema GD. The effect of vascular fellowships on general surgical residency training. Ann Surg 1984;200: 247-53.
The emergence of vascular surgery as a subspecialty of general surgery has created tension and a sense of fragmentation of the parent discipline. This article reviews the present status of accredited medical specialties (n = 24) and subspecialties (n = 50) and confronts some current problems in the field of vascular surgery. Issues of resident training, practice opportunity, manpower, and specialty encroachment would not be alleviated by creation of a separate specialty of vascular surgery. Rather, in the view of a program director and member of the Residency Review Committee (RRC) for Surgery, educational reforms should be designed to facilitate career tracking of residents entering subspecialties while enhancing training and practice opportunities of general surgeons. A model is suggested that will significantly improve the resident operative experience in major vascular surgery for both general and vascular surgery trainees. A recent commitment of both the RRC and the American Board of Surgery to address these issues offers a creative opportunity to improve vascular training, manpower, and patient care while mitigating the threat of further fragmentation of general surgery. The title of this minisymposium reflects a national trend: for the past decade or more medicine has experienced progressive subspecialization and fragmentation. General surgery has not been exempted.1 The reasons for this evolution are many, including a desire on the part of residents to cope with the information ,explosion in medicine, to master increasingly complex medical technology, or to follow in the footsteps of academic role models who are often subspecialists. On the other hand, this trend toward subspecialization often reflects an increasing commitment to From the Department of Surgery, University of Arkansas for Medical Sciences and the Surgical Service, Little Rock Veterans Administration Medical Center, Little Rock. Presented at the Society for Vascular Surgery Critical Issues Forum, Los Angeles, Calif., June 3, 1990. Reprint requests: Robert W. Barnes, MD, Slot #520, UAM& 4301 W. Markham, Little Rock, AR 72205. 24/6/24163
control personal lifestyle, to minimize medicolegal risk, or, perhaps most irnportant, to enhance one's practice opportunity (i.e., marketability) in a competitive medical environment. Although the aforementioned reasons for subspecialization may represent advantages for the individual, the end result has caused pressures that have threatened the very existence of the parent specialty of general surgery and the practice opportunities for its graduates. These forces have led, on the one hand, to regulatory steps to limit further subspecialization or fragmentation and, on the other hand, to suggestions for education reform to facilitate career tracking for subspecialists as well a,; general surgeonS. As both a general surgery and vascular surgery program director, and a member of the RRC for Surgery, I have had a particular interest in exploring the opportunities for innovative educational restructuring of general surgical and subspecialty training to help solve the dilemma of fragmentation of our parent specialty. Thus my answer to the rhetorical question posed for this issues panel is a qualified "No": vascular surgery should not be a separate specialty, but we should not be satisfied with the current method of training general surgeons or surgical subspecialists. Let us explore some creative strategies that may mitigate some of the problems of surgical fragmentation while improving professional opportunities and patient care.
Current surgical specialties and subspecialties There are at present 24 medical specialties that have RRCs for program accreditation and specialty boards for certification of the graduates. 2 Of these 24, 10 are surgical specialties, including general surgery. Only two specialties, colon and rectal surgery, and thoracic surgery, require completion of training in general surgery as a prerequisite for the specialty. Plastic surgery requires at least 3 years of general surgery education, although in the past, most trainees complcted general surgical training before entering the specialty. Currently only otolaryngology and urology require i year ofprelirninary training in gen615
616 Barnes
eral surgery, which is recommended for neurologic surgery and optional for the remaining surgical specialties. There are currently 50 recognized subspecialties in 13 of the aforementioned specialties accredited by the Accreditation Council for Graduate Medical Education. 3 Graduates of these training programs may receive certificates of special or added qualifications in the subspecialty from the parent specialty board. Eleven of these subspecialties are in surgical specialties, including six in orthopedic surgery, four in general surgery, and one in plastic surgery. Internal medicine and pathology have the greatest number of recognized subspecialties, 11 and 10, respectively. The subspecialties of general surgery include pediatric surgery, vascular surgery, surgical critical care, and hand surgery. The American Board of Surgery grants certificates of special qualifications in pediatric surgery and, until recently, in vascular surgery. Currently the board grants certificates of added qualification in vascular surgery, surgical critical care, and hand surgery. The board has elected not to recognize other subspecialties of general surgery until a consensus is reached in controlling further fragmentation of the specialty. Current problems in vascular surgery Vascular surgery is beset with problems of adequacy of training, practice opportunity, manpower, and specialty encroachment. Each of these issues contributes to tensions within the field and to reactions by our vascular societies, as evidenced by this panel discussion. As both a director of two training programs and a member of the RRC for Surgery, I recognize the problems of providing adequate education and operative experience for both general and vascular surgery residents. I have previously commented upon methods to reduce the friction between these two groups of trainees. 4 Nevertheless, the two major hurdles for most program directors continue to be marginal major vascular caseload, particularly for general surgery residents, and concurrent assignment of the two trainees, with the potential adverse effect on the independent judgment and decision making of the general surgery resident. These two problems ha the vascular training of the general surgery resident lead to the issue of increased restriction of practice oppommity when seeking hospital credentialing. Many general surgeons arc encountering resistance in obtaining privileges in severn of the principal components of the specialty in-
journal of VASCULAR SURGERY
cluding vascular and head and neck surgery. These challenges are undoubtedly contributing to the quest of general surgeons for postgraduate training in vascular surgery. The number of Accreditation Council for Graduate Medical Education-approved training programs in vascular surgery, currently 59 with 80 residents, is insufficient to provide the vascular surgical manpower for this country,s Most vascular surgical care is provided by general surgeons. Unfortunately; the average general surgery resident is not exposed to a sufficient volume or breadth of vascular operative experience to qualify for the minimum numbers (70 major cases) suggested by the Ad Hoc Committee of our Joint Council for the Society for Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery.6 Data from the "Resident Statistics Summary" of the RRC for Surgery suggest that the average major vascular operative experience of general surgery- residents is about 50 cases. The 10th percentile experience, which is used to define the minimum numbers of~ cases for various general surgical procedures, is only about 14 malor vascular operations. Such meagcr experience will not provide the general surgeon with competence, let alone expertise, in vascular surgery. The final issue facing our discipline is the encroachment by other specialists into vascular medicine and interventional procedures. Mthough vas-, cular diagnosis and therapy have always interested some internists, neurologists, radiologists, and neurosurgeons, recent incursion into the discipline by intervcntional cardiologists and otolaryngologists has created concern and tension in the field. Of particular concern is the practice of carrying out vascular intervention by individuals desiring skill in coronary interventional therapy, in the absence of in-depth knowledge of the field of pcripheral vascular disease. 7
A proposal: Education reform To facilitate career goals ofresidcnts entering surgical specialties and subspecialties, while enhancing the training and practice oppornmities for general surgeons, I have recommended changes in our educational pathways of the surgical residency.8 In essence, all residents, regardless of specialty interest, would take 1 or 2 years of basic surgery to develop knowledge and skills fundamental to all surgical disciplines. Residents could then enter either a surgical specialty such as neurologic, orthopedic, otolaryngologic, or urologic surgery, or they could pursue intermediate surgery in preparation for general sur-
Volume 12 Number 5 November 1990
Perspective of a program chairman
617
Table I. Mean major vascular operative experience for general surgery resident (reporting total all years) and presubspecialty resident (reporting junior years) before (observed) and after (expected) institution of early tracking and caseload rcallocation General surgery (PG5) resident
Presubspecialty (PG4) resident
Operative category
Observed
Expected
Observed
Expected
Total vascular Aneurysm Ccrebrovascular Peripheral obstructive Intraabdominal obstructive Upper extremity Extracavitary Portal decompression Miscellaneous Access Amputations
128 11 9 23 I 1 5 1 32 23 21
182 23 18 46 2 3 9 3 34 23 21
74 4 3 8 0 1 2 0 22 17 17
78 0 0 0 0 0 0 0 31 23 21
Data based on 1988-1989 "Resident Statistical Summary" of the Residency Review Committee for Surgery.
gery or one of its subspecialties. Intermediate surgery ,4"or 2 or 3 years would provide increasing surgical knowledge and skills, the final year of which would include senior level responsibility. After 4 years of basic and intermediate surgery, residents could elect to enter such surgical specialties (or subspecialties) as plastic, thoracic, colorectal, or pediatric surgery. Residents desiring a career in general surgery would take an additional 1 or 2 years of advanced general surgery, which would include experience with com{,lex surgical procedures such as vascular, gastrointestinal, hepatobiliary, thoracic, head and neck, or oncologic surgery. Individuals who wished to practice vascular surgery could either complete advanced general surgery training with significant exposure to major vascular operative procedures or enter a postgraduate vascular surgery residency. Regardless of pathway, the individual should meet the criteria for hospital privileges in vascular surgery suggested by the Ad Hoc Committee for our joint council. 6 Recently I presented data regarding the impact Of such reforms in surgical education on resident .operative experience. 9 Providing that early tracking occurred for residents entering surgical specialties or subspecialties and that appropriate major operative cases were reserved for general surgery residents, the major operative experience of the average general surgery resident would increase by approximately 25%. Significant increases would occur in all of the principal components of general surgery. Through caseload reassignment, the average resident entering a surgical subspecialty after 4 years of general surgery could anticipate a 10% increase in major operative experience compared to that reported by current
residents during the junior (prechief resident) years. Table I illustrates the current (observed) and the anticipated (expected) major operative experience in vascular surgery for the average resident completing 4 years (as surgeon, junior' years) or 5 years (total all years, including chief year) if the aforementioned educational reforms and caseload reallocation were instituted. These data are based on the "Resident Statistical Summary" of 1009 residents from 286 programs reporting to the RRC for Surgery for 1988 to 1989. The projections are based on the assumption that 50% of residents would enter another surgical specialty or subspccialty after 4 years and that such residents would not perform major (category I or II) vascular procedures. Such procedures would be reserved for the general surgery resident who would complete 5 years, including the chief year. These reforms would increase the mean vascular operative experience for general surgery residents by 42% from an average of 128 cases to 182 procedures. The experience in major (category I and II) vascular surgery would double from the current 51 cases to 104 procedures. For residents entering other surgical specialties or subspecialties, the mean vascular experience would remain at about 75 cases but would consist exclusively of category III cases. DISCUSSION
Vascular surgery has been an integral principal component of general surgery training as well as an important evolving subspecialty of surgery. Despite the tensions that have developed between the parent specialty and vascular surgery with the establishment of Accreditation Council for Graduate Medical
618 Barnes
Education-approved training programs and certificates of special or added qualifications in general vascular surgery, the education of both general and vascular surgeons and vascular surgical care have improved over the past decade. 1° I do not think that surgical education or patient care would be enhanced by creating a separate specialty, including an R_KG and board for vascular surgery. On the other hand, I do believe that significant changes must be made in our surgical residency to alleviate the current problems of training, practice restrictions, manpower limitations, and specialty encroachment facing both general and vascular surgeons. The suggestions for educational reform ideally will offer a constructive alternative to the disruptive choice of creating a separate specialty of vascular surgery. Through the combination of early tracking of residents into subspecialties and major vascular caseload reallocation, operative experience for both general and vascular surgery trainees could be enhanced. This broader educational exposure to major vascular caseload should facilitate hospital credentialing and practice opportunity. The educational reforms would lessen the disparity of operative experience between the general surgery resident and the vascular trainee and improve the manpower pool of surgeons capable of providing good care for patients with vascular diseases. Finally, improving the standards of vascular surgery would provide a benchmark with which to compare and limit vascular interventions by specialists in other disciplines without comparable educational experience. Implementation of these educational reforms will require cooperative support of RRCs and specialty
Journal of VASCULAR SURGERY
boards, as well as the specialty societies. To this end, both the RRC for Surgery and the American Board~ of Surgery have taken steps to address these problems of specialization, fragmentation and other issues of mutual concern. I am hopeful that from this effort will come a creative strategy for improved education and practice opportunities for our trainees interested in vascular surgery without the need for creation o~ a separate surgical specialty. REFERENCES 1. Organ CH. Fragmentation and specialization. Arch Surg 1987;122:639. 2. Accreditation council for graduate medical education: 19881990 Directory of graduate medical education programs. Chicago: American Medical Association, 1989, 10-11. 3. Accreditation council for graduate medical education: 1988 1990 Directory of graduate medical education programs. Chi cago: American Medical Association, 1989, 15-116. 4. Barnes RW. Minimizing problems between vascular trainee and general surgery residents. J Vase SURe 1990;12:91-4. 5. Rutkow IM, Ernst CB. An analysis of vascular surgicaa manpower requirements and vascular surgical rates in the United States. J VAsc SURG 1986;3:74-83. 6. Moore WS, Treirnan RL, Hertzer NR, Veith FJ, Perry MO, Ernst CB. Guidelines for hospital privileges in vascular surgery. J Vase SURG 1989;10:678-82. 7. Strandness DE, Barnes KW, Katzen BT, Ring EJ. Indiscriminate use of laser-assisted angioplasty. N Engl J Med 1989;321:1417. 8. Barnes KW. The next generation of surgical residencies. Arch Surg 1990;125:433-6. 9. Barnes RW, Lang NP. The surgery residency: is it a time for a change? Am J Surg (Submitted), 10. Perler BA, Zuidema GD. The effect of vascular fellowships on general surgical residency training. Ann Surg 1984;200: 247-53.
