Vascular surgical training of general surgeons Calvin B. Ernst, MD, Detroit, Mich.
Improving availability and quality of vascular surgical care should be the goal and concern of all surgical program directors (SPDs). To accomplish these objectives within the rapidly changing surgical milieu, we must address not only the science and art of ,surgery issues but also the manpower and educational issues as well, because they all influence quality of care. A dilemma is how many surgeons should be r-!ined to provide vascular surgical care and who should provide this care and perform vascular operations. To address thc problem of quality of care, in 1969 after the Regional Medical Program legislation, several societies were asked to prepare documents on optimal resources for managing heart disease, stroke, and cancer. Drs. James A. DeWcese, F. William Blaisdell, and the late John H. Foster were asked to prepare the document for vascular surgery) In the course of preparation of the report, many vascular surgeons served as consultants, most of whom believed that there was considerable suboptimal vascular surgery being performed in the United States. The main reasons for this were inadequate vascular training and inadequate continuing vascular surgical experience. In that 1972 report, DeWeese et al) noted, "The l~ctors most responsible for the quality of vascular surgery were the judgment and technical skill of the surgeon, both developed through properly supervised training and experience. ''~ In discussing this , report, the late Dr. Jack Wylie stated, "Less than optimum performance can be expected from the general surgeon with an occasional vascular operation. ''~ He also noted that the report dearly affirmed the need for intensive training programs in vascular surgery under the direct supervision of experienced vascular surgeons. Obviously the major stimulus for Dr.
From the Divisionof Vascular Surgery, Henry Ford Hospital. Presentedat the Societyfor VascularSurgeryCriticalIssuesForum New York, N.Y., June 18, 1989. Reprint requests: CalvinB. Ernst, MD, Divisionof Vas~aflarSurgeD,, Henry Ford Hospital, 2799 W. Grand Blvd.,Detroit, MI 48202. 24/6/20460
Wylie to spearhead certification of vascular surgeons was not to limit the numbers of individuals performing vascular operations but to emphasize thc critical importance of adequate training and mature, sound judgment among those treating vascular diseases. Consequently this report served as a stimulus for establishment and evolution of approved vascular training programs. It appears that within the confines of general surgery, individuals committed to vascular surgery, who have developed and refined the spccial skills required for managing vascular diseases, will provide optimal care for patients with such problems and are the individuals who should provide the vascular surgical manpower. However, training issues relate to not only the quality of a young surgeon's education but also the quantity of vascular surgeons trained as well. Similar to other specialties, vascular surgical manpower planning must address significant professional and economic concerns. On the one hand, too many vascular surgeons may lead to the possibility of unnecessary operations, loss of competence, and ultimately poor care. On the other hand, if too few vascular surgeons are trained, problems may occur related to insufficient manpower that will limit patient access to vascular surgical care with the inevitable increase in morbidity and mortality, rates from vascular discases. The 1987 vascular surgical manpower analysis commissioned by the Society for Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery identified problems on which to focus--problems that, if solved, will go a long way toward providing the appropriate number of vascular surgeons to fulfill both practice and academic needs. 2 From that analysis it was estimated that there was a cohort of approximately 2400 surgeons in the United States who may be labeled justifiably as vascular surgeons. An oversimplification of the manpower equation assumed that if all vascular operations were performed by fially trained vascular surgeons and such a surgeon must perform at least 75 procedures yearly (the number suggested by more than 50% of pollcd vascular surgeons when defining a vascular specialist), 7600 vas95
96
Journal of VASCULAR SURGERY
Ernst
TaMe I. Characterization of the quality of general surgery resident training in vascular surgery Competent What is lacking? Nothing Case volume Case mix Mature judgment Optimal operative volmne (cases) 20-40 41-60 61-80 81-100
VPD (%)
SPD (%)
20
53*
7 36 22 82
37 ~ 25 27 33 ~
15 27 20 35
18 40 22 21
-~p < 0.001.
cular surgeons were required. If, however, 107 vascular procedures per year (the average caseload of the polled vascular surgeons) was the denominator in the equation, and 571,000 procedures was a conservative estimate of the total number of vascular operations performed annually, approximately 5400 vascular surgeons were required. The 3000-vascular surgeon manpower deficit was made up by general surgeons, cardiac surgeons, and others performing vascular procedures. It is important to note that of all vascular operations performed, only 41% were performed by the vascular surgical cohort. The 1987 manpower study underscored the many permutations and pertubations that complicate manpower planning and the training of young surgeons. An unknown variable complicating training requirements is the extent to which nonvascular surgeons such as neurosurgeons, urologists, general surgeons, cardiothoracic surgeons, and osteopathic surgeons perform vascular procedures, although collectively such surgeons performed 59% of vascular operations. 2 To what extent individuals completing general surgical residencies, in which vascular training was marginal, should be involved in management of vascular surgical problems has not yet been determined. However, several factors including third-party reimbursement, professional liability, quality assurance criteria, hospital credentialing boards, and quality of training will clearly influence such surgeons' competence and ability to practice vascular surgery. General surgery resident rotations on a vascular service make such residents better general surgeons, but do they make them vascular surgeons? Should these surgeons perform carotid endarterectomies and distal tibial or visceral arterial reconstructions, or
should they provide only emergency care when a trained vascular surgeon is not available? Will thirdparty payors refuse reimbursement unless care is provided by a fully trained and possibly certified vascular surgeon? Will affordable liability insurance be available to such individuals? Can quality assurance criteria be met? Will hospital credentialing boards limit privileges only to those certified in vascular surgery? Clearly, training significantly influences all of these questions and to this end it is important that surgical leaders and policy makers define the type of vascular surgical procedures general surgeons should be trained to do and subsequently what procedures they should perform when they enter practice. To help address these important educational issues, in 1987 and 1988 questionnaires were mailed to each of the 55 program directors of R e s i d e ~ Review Committee-approved vascular surgical training programs and 290 SPDs. All 55 vascular program directors (VPDs) responded, and 267, (92%) SPDs responded, for an overall response rate of 322 of 345, or 94%. It is suggested that informarion obtained from analysis of questionaire responses should provide the basis for a dialogue between key individuals regarding vascular surgical training of general surgeons and ultimately serve as a foundation for improving vascular surgical training and care. Concerning the number of vascular surgeons being trained, 58% of VPDs believed we are training about the right number of vascular surgeons and one third thought we are training too few. Several of these latter responses indicated that if it eventuates that only fellowship-trained vascular surgeons should perform vascular operations, we are training far t ~ few. This was also a conclusion supported by the Society for Vascular Surgery-International Society for Cardiovascular Surgery manpower analysis. 2 Only 9% of VPDs thought we were training too many vascular surgeons. Of SPDs polled, 47% indicated that we are training the right number of vascular surgeons but 20% thought too many are being trained. What has been the impact of vascular training fellowships on general surgical training? Concern had been expressed that vascular fellowships would adversely affect caseload and operative experience for general surgery residents. Just the opposite was found in a 1984 analysis/ Of the 40 institutions surveyed by Perler and Zuidema, 3 there was an increase in vascular surgical case volume, more apparent in programs with vascular fellowships than in those without. Of note was that of the total surveyed
Volume 12 Number 1 Ju!v !990
Vascular surgery training ofgeneral surgeons 9 7
Table II. Responses regarding vascular procedures that general surgery residents should have "training in and what procedures they should perform in practice Training experience(%)
Perform in practice (%)
Type of operation
VPD (n = 55)
SPD (n = 267)
W ' D (n = s s )
SPD (n = 267)
None Renal revasc~larization Mesenteric revascularization Femorotibial bypass Carotid endarterectomy Aortofemoral bypass Femoropopliteal bypass Abdominal aortic aneurysm Embolectomy Trauma
2 6 7 24 29 56 58 76 84 98
0 38 52 63 74 92 91 92 97 99
1S 2 2 7 6 24 31 40 71 84
2 19 31 42 48 76 76 78 87 91
c ~Jy 6% reported a decrease in vascular case volume. Also evident from this analysis was that the overall qualitative impact of vascular fellowships on vascular 4urgical training for general surgery residents was positive. O f respondents, 72% indicated that the vascular fellowship had improved the quality of vascular surgical training for the general surgery residents, 14% noted no change, and only 8% believed it had weakened their programs. Assuming that vascular fellowships do not adversely influence a general surgery resident's vascular training and, in fact, may improve it, how did the 322 VPDs and SPDs perceive the general surgery resident and his ability to practice vascular surgery competently on completion of training? Here there were statistically significant differences between opinions of VPDs and SPDs. Only 20% of VPDs believed general surgery residents were competent to 6o the full spectrum of vascular surgery compared with 53% of SPDs (Table I). When asked what was lacking in their respective general surgery programs to provide comprehensive training, 37% of SPDs indicated "nothing," compared with only 7% of VPDs. The single most important deficit affecting a general surgery resident's competence, again perceived differently between VPDs and SPDs, was lack of mature judgment gained through experience in managing vascular problems, which was cited by 82% of VPDs compared with 33% of SPDs (Table I). Although there was general agreement that general surgery residents should perform more than 40 operative procedures, many VPDs indicated that more than 80 were necessary (Table I). To predict future vascular manpower requirements and the number of trainees to meet them, the question, 'qVhat vascular procedures should general surgery residents be exposed to or trained to do and
Table III. Responses regarding training in new technology Current training (%) Technicalprocedure Angioscopy Laser Dilation
Future training (%)
VPD
SPD
VPD
SPD
36 27 53
17 25 56
82 73 76
85 83 90
what they should do once in practice?" must be addressed by both VPDs and SPDs and ultimately by certifying and credentialing bodies. From this survey it was apparent that VPDs think that training in certain vascular procedures during the general surgery residency does not qualify the individual to perform such procedures in practice (Table II). Some VPDs suggested that general surgery trainees do no vascular surgery in practice but only one believed general surgery residents should not receive any vascular training. Very few VPDs indicated that once in practice general surgery residents should perform renal or mesenteric reconstructions (2%), femorotibial bypasses (7%), or carotid endarterectomies (6%) (Table II). A minority of VPDs supported subsequent practice to include aortofemoral bypasses (24%), femoropopliteal bypasses (31%), and abdominal aortic aneurysm repairs (40%). Some noted that aneurysm repairs should be restricted to management of ruptured aortic aneurysms. The majority of VPDs indicated that general surgery residents should be able to perform embolectomy procedures (71%) and repair injured vessels (84%) once in practice. In contrast, SPDs indicated that general surgery residents should perform renal (19%), mesenteric (31%), femorotibial (42%), and carotid reconstruc-
Journal of VASCULAR
98 Ernst
tions (48%) on entering practice (Table II). The majority of SPDs indicated that general surgery trainees should perform aortofemoral bypasses (76%), femoropopliteal bypasses (76%), and abdominal aortic ancurysm repairs (78%) once in practice. Of significance was that both VPDs and SPDs agreed that, with the exception of cmbolectomies and vascular trauma, what general surgery residents are trained to do and what they should do in practice differ. These data imply a two-tier training program, one for specialists who are trained to perform the full spectrum of vascular operations and the other for generalists trained to do the less demanding but common procedures. Both VPDs and SPDs supported inclusion of newer nonoperativc technologies in training programs (Table III). Although angioscopy, laser techniques, and arterial dilation mcthods werc not currently widely taught, both VPDs and SPDs anticipated incorporating such techniques into their training programs. As it relatcd to vascular surgical hospital privileges, 80% ofVPDs favorcd limiting such privileges to surgeons who complete training in an approved vascular training program compared with 29% of SPDs. This does not mandatc that Board Certification is required to practice vascular surgcry but it clearly emphasizes, from the VPDs' perspective, that adequate training is a requirement. Most surgical educators agrec that a kcy ingredient in successful vascular training programs for both general surgery residents and vascular trainees is availability of sufficient teaching material from which to acquire mature judgment and experience. The definition of sufficicnt minimal operative experience fluctuates but has been suggested by the Residency Kcview Committee for Surgery to be 40 cases, bascd on the average cxperiencc reportcd by general surgery training programs. Therefore because the minimal experience is based on an average volume of 40 cases, thc implication is that one half of residency programs have insufficient vascular surgical volume to mcct the minimal vascular training rcquirements. As noted previously, however, there does not appear to be enough optimally trained vascular surgeons graduating from approved vascular surgical training programs to meet vascular surgical manpower nceds. 2 Therefore gcneral surgeons must supplement vascular surgical manpowcr. To ensure that gcneral surgeons continue to contribute to the
suw~Y
vascular surgical manpower pool, selective training will be required in programs lacking sufficient teach-' ing material. Even in programs with abundant vascular volume, selective training would further enhance general vascular surgery residents' education and qualifications to practice vascular surgery. To this end it is suggested that not all general surgery resi• dents require or even desire exposure to vascular surgical training. Should vascular surgical training case volume be diluted by those surgeons ultimately destined to other surgical specialties? It seems difficult to justify vascular training for endocrine, plastic, and colorectal surgeons, as well as those entering critical care medicine. Offering vascular surgical training to specialists in trauma and cardiothoracic surgery however, is justified more easily. Therefore to ensure quality vascular surgical c ~ through adequate training and in keeping with the survey opinions of 322 SPDs and VPDs, a two-tier training concept is suggested only for those individ? uals anticipating that vascular surgery will constitute a significant portion of their practice• Primary vascular training includes management of vascular trauma, embolectomies, abdominal aortic aneurysm repairs, aortofemoral bypasses, and femoropopliteal reconstruction for both general surgery residents and vascular trainees. Complex tertiary care expertise requires special training beyond a general surgery residency. Such training, now provided by approved vascular fellowships, additionally qualifies individuals to manage thoracicoabdominal aortic aneurysms and perform visceral, carotid, and femorocrural reconstructions, as well as newer percutaneous and endovascular procedures. It is suggested that t r a i n ~ programs for primary and tertiary vascular surge&fs be structured in this manner to use teaching material with maximum effectiveness and therefore improve the quality of vascular surgical care through comprehensive education. REFERENCES 1• DeWeese JA, Blaisdell FW, Foster JH. Optimal resources for vascular surgery. Arch Surg 1972;105:948-61. 2. Ernst CB, Rutkow IM, Cleveland RJ, Folse JR, Johnson G Jr, Stanley JC. Vascular surgery in the United States: report of the Joint Society for Vascular Surgery-International Society for Cardiovasoalar Surgery Committee on Vascular Surgical Manpower. J VASC SURG 1987;6:611-21. 3, Perler BA, Znidema GD. The effect of vascular fellowships on general surgical residency training. Ann Surg 1984;200:24754.
Improving availability and quality of vascular surgical care should be the goal and concern of all surgical program directors (SPDs). To accomplish these objectives within the rapidly changing surgical milieu, we must address not only the science and art of ,surgery issues but also the manpower and educational issues as well, because they all influence quality of care. A dilemma is how many surgeons should be r-!ined to provide vascular surgical care and who should provide this care and perform vascular operations. To address thc problem of quality of care, in 1969 after the Regional Medical Program legislation, several societies were asked to prepare documents on optimal resources for managing heart disease, stroke, and cancer. Drs. James A. DeWcese, F. William Blaisdell, and the late John H. Foster were asked to prepare the document for vascular surgery) In the course of preparation of the report, many vascular surgeons served as consultants, most of whom believed that there was considerable suboptimal vascular surgery being performed in the United States. The main reasons for this were inadequate vascular training and inadequate continuing vascular surgical experience. In that 1972 report, DeWeese et al) noted, "The l~ctors most responsible for the quality of vascular surgery were the judgment and technical skill of the surgeon, both developed through properly supervised training and experience. ''~ In discussing this , report, the late Dr. Jack Wylie stated, "Less than optimum performance can be expected from the general surgeon with an occasional vascular operation. ''~ He also noted that the report dearly affirmed the need for intensive training programs in vascular surgery under the direct supervision of experienced vascular surgeons. Obviously the major stimulus for Dr.
From the Divisionof Vascular Surgery, Henry Ford Hospital. Presentedat the Societyfor VascularSurgeryCriticalIssuesForum New York, N.Y., June 18, 1989. Reprint requests: CalvinB. Ernst, MD, Divisionof Vas~aflarSurgeD,, Henry Ford Hospital, 2799 W. Grand Blvd.,Detroit, MI 48202. 24/6/20460
Wylie to spearhead certification of vascular surgeons was not to limit the numbers of individuals performing vascular operations but to emphasize thc critical importance of adequate training and mature, sound judgment among those treating vascular diseases. Consequently this report served as a stimulus for establishment and evolution of approved vascular training programs. It appears that within the confines of general surgery, individuals committed to vascular surgery, who have developed and refined the spccial skills required for managing vascular diseases, will provide optimal care for patients with such problems and are the individuals who should provide the vascular surgical manpower. However, training issues relate to not only the quality of a young surgeon's education but also the quantity of vascular surgeons trained as well. Similar to other specialties, vascular surgical manpower planning must address significant professional and economic concerns. On the one hand, too many vascular surgeons may lead to the possibility of unnecessary operations, loss of competence, and ultimately poor care. On the other hand, if too few vascular surgeons are trained, problems may occur related to insufficient manpower that will limit patient access to vascular surgical care with the inevitable increase in morbidity and mortality, rates from vascular discases. The 1987 vascular surgical manpower analysis commissioned by the Society for Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery identified problems on which to focus--problems that, if solved, will go a long way toward providing the appropriate number of vascular surgeons to fulfill both practice and academic needs. 2 From that analysis it was estimated that there was a cohort of approximately 2400 surgeons in the United States who may be labeled justifiably as vascular surgeons. An oversimplification of the manpower equation assumed that if all vascular operations were performed by fially trained vascular surgeons and such a surgeon must perform at least 75 procedures yearly (the number suggested by more than 50% of pollcd vascular surgeons when defining a vascular specialist), 7600 vas95
96
Journal of VASCULAR SURGERY
Ernst
TaMe I. Characterization of the quality of general surgery resident training in vascular surgery Competent What is lacking? Nothing Case volume Case mix Mature judgment Optimal operative volmne (cases) 20-40 41-60 61-80 81-100
VPD (%)
SPD (%)
20
53*
7 36 22 82
37 ~ 25 27 33 ~
15 27 20 35
18 40 22 21
-~p < 0.001.
cular surgeons were required. If, however, 107 vascular procedures per year (the average caseload of the polled vascular surgeons) was the denominator in the equation, and 571,000 procedures was a conservative estimate of the total number of vascular operations performed annually, approximately 5400 vascular surgeons were required. The 3000-vascular surgeon manpower deficit was made up by general surgeons, cardiac surgeons, and others performing vascular procedures. It is important to note that of all vascular operations performed, only 41% were performed by the vascular surgical cohort. The 1987 manpower study underscored the many permutations and pertubations that complicate manpower planning and the training of young surgeons. An unknown variable complicating training requirements is the extent to which nonvascular surgeons such as neurosurgeons, urologists, general surgeons, cardiothoracic surgeons, and osteopathic surgeons perform vascular procedures, although collectively such surgeons performed 59% of vascular operations. 2 To what extent individuals completing general surgical residencies, in which vascular training was marginal, should be involved in management of vascular surgical problems has not yet been determined. However, several factors including third-party reimbursement, professional liability, quality assurance criteria, hospital credentialing boards, and quality of training will clearly influence such surgeons' competence and ability to practice vascular surgery. General surgery resident rotations on a vascular service make such residents better general surgeons, but do they make them vascular surgeons? Should these surgeons perform carotid endarterectomies and distal tibial or visceral arterial reconstructions, or
should they provide only emergency care when a trained vascular surgeon is not available? Will thirdparty payors refuse reimbursement unless care is provided by a fully trained and possibly certified vascular surgeon? Will affordable liability insurance be available to such individuals? Can quality assurance criteria be met? Will hospital credentialing boards limit privileges only to those certified in vascular surgery? Clearly, training significantly influences all of these questions and to this end it is important that surgical leaders and policy makers define the type of vascular surgical procedures general surgeons should be trained to do and subsequently what procedures they should perform when they enter practice. To help address these important educational issues, in 1987 and 1988 questionnaires were mailed to each of the 55 program directors of R e s i d e ~ Review Committee-approved vascular surgical training programs and 290 SPDs. All 55 vascular program directors (VPDs) responded, and 267, (92%) SPDs responded, for an overall response rate of 322 of 345, or 94%. It is suggested that informarion obtained from analysis of questionaire responses should provide the basis for a dialogue between key individuals regarding vascular surgical training of general surgeons and ultimately serve as a foundation for improving vascular surgical training and care. Concerning the number of vascular surgeons being trained, 58% of VPDs believed we are training about the right number of vascular surgeons and one third thought we are training too few. Several of these latter responses indicated that if it eventuates that only fellowship-trained vascular surgeons should perform vascular operations, we are training far t ~ few. This was also a conclusion supported by the Society for Vascular Surgery-International Society for Cardiovascular Surgery manpower analysis. 2 Only 9% of VPDs thought we were training too many vascular surgeons. Of SPDs polled, 47% indicated that we are training the right number of vascular surgeons but 20% thought too many are being trained. What has been the impact of vascular training fellowships on general surgical training? Concern had been expressed that vascular fellowships would adversely affect caseload and operative experience for general surgery residents. Just the opposite was found in a 1984 analysis/ Of the 40 institutions surveyed by Perler and Zuidema, 3 there was an increase in vascular surgical case volume, more apparent in programs with vascular fellowships than in those without. Of note was that of the total surveyed
Volume 12 Number 1 Ju!v !990
Vascular surgery training ofgeneral surgeons 9 7
Table II. Responses regarding vascular procedures that general surgery residents should have "training in and what procedures they should perform in practice Training experience(%)
Perform in practice (%)
Type of operation
VPD (n = 55)
SPD (n = 267)
W ' D (n = s s )
SPD (n = 267)
None Renal revasc~larization Mesenteric revascularization Femorotibial bypass Carotid endarterectomy Aortofemoral bypass Femoropopliteal bypass Abdominal aortic aneurysm Embolectomy Trauma
2 6 7 24 29 56 58 76 84 98
0 38 52 63 74 92 91 92 97 99
1S 2 2 7 6 24 31 40 71 84
2 19 31 42 48 76 76 78 87 91
c ~Jy 6% reported a decrease in vascular case volume. Also evident from this analysis was that the overall qualitative impact of vascular fellowships on vascular 4urgical training for general surgery residents was positive. O f respondents, 72% indicated that the vascular fellowship had improved the quality of vascular surgical training for the general surgery residents, 14% noted no change, and only 8% believed it had weakened their programs. Assuming that vascular fellowships do not adversely influence a general surgery resident's vascular training and, in fact, may improve it, how did the 322 VPDs and SPDs perceive the general surgery resident and his ability to practice vascular surgery competently on completion of training? Here there were statistically significant differences between opinions of VPDs and SPDs. Only 20% of VPDs believed general surgery residents were competent to 6o the full spectrum of vascular surgery compared with 53% of SPDs (Table I). When asked what was lacking in their respective general surgery programs to provide comprehensive training, 37% of SPDs indicated "nothing," compared with only 7% of VPDs. The single most important deficit affecting a general surgery resident's competence, again perceived differently between VPDs and SPDs, was lack of mature judgment gained through experience in managing vascular problems, which was cited by 82% of VPDs compared with 33% of SPDs (Table I). Although there was general agreement that general surgery residents should perform more than 40 operative procedures, many VPDs indicated that more than 80 were necessary (Table I). To predict future vascular manpower requirements and the number of trainees to meet them, the question, 'qVhat vascular procedures should general surgery residents be exposed to or trained to do and
Table III. Responses regarding training in new technology Current training (%) Technicalprocedure Angioscopy Laser Dilation
Future training (%)
VPD
SPD
VPD
SPD
36 27 53
17 25 56
82 73 76
85 83 90
what they should do once in practice?" must be addressed by both VPDs and SPDs and ultimately by certifying and credentialing bodies. From this survey it was apparent that VPDs think that training in certain vascular procedures during the general surgery residency does not qualify the individual to perform such procedures in practice (Table II). Some VPDs suggested that general surgery trainees do no vascular surgery in practice but only one believed general surgery residents should not receive any vascular training. Very few VPDs indicated that once in practice general surgery residents should perform renal or mesenteric reconstructions (2%), femorotibial bypasses (7%), or carotid endarterectomies (6%) (Table II). A minority of VPDs supported subsequent practice to include aortofemoral bypasses (24%), femoropopliteal bypasses (31%), and abdominal aortic aneurysm repairs (40%). Some noted that aneurysm repairs should be restricted to management of ruptured aortic aneurysms. The majority of VPDs indicated that general surgery residents should be able to perform embolectomy procedures (71%) and repair injured vessels (84%) once in practice. In contrast, SPDs indicated that general surgery residents should perform renal (19%), mesenteric (31%), femorotibial (42%), and carotid reconstruc-
Journal of VASCULAR
98 Ernst
tions (48%) on entering practice (Table II). The majority of SPDs indicated that general surgery trainees should perform aortofemoral bypasses (76%), femoropopliteal bypasses (76%), and abdominal aortic ancurysm repairs (78%) once in practice. Of significance was that both VPDs and SPDs agreed that, with the exception of cmbolectomies and vascular trauma, what general surgery residents are trained to do and what they should do in practice differ. These data imply a two-tier training program, one for specialists who are trained to perform the full spectrum of vascular operations and the other for generalists trained to do the less demanding but common procedures. Both VPDs and SPDs supported inclusion of newer nonoperativc technologies in training programs (Table III). Although angioscopy, laser techniques, and arterial dilation mcthods werc not currently widely taught, both VPDs and SPDs anticipated incorporating such techniques into their training programs. As it relatcd to vascular surgical hospital privileges, 80% ofVPDs favorcd limiting such privileges to surgeons who complete training in an approved vascular training program compared with 29% of SPDs. This does not mandatc that Board Certification is required to practice vascular surgcry but it clearly emphasizes, from the VPDs' perspective, that adequate training is a requirement. Most surgical educators agrec that a kcy ingredient in successful vascular training programs for both general surgery residents and vascular trainees is availability of sufficient teaching material from which to acquire mature judgment and experience. The definition of sufficicnt minimal operative experience fluctuates but has been suggested by the Residency Kcview Committee for Surgery to be 40 cases, bascd on the average cxperiencc reportcd by general surgery training programs. Therefore because the minimal experience is based on an average volume of 40 cases, thc implication is that one half of residency programs have insufficient vascular surgical volume to mcct the minimal vascular training rcquirements. As noted previously, however, there does not appear to be enough optimally trained vascular surgeons graduating from approved vascular surgical training programs to meet vascular surgical manpower nceds. 2 Therefore gcneral surgeons must supplement vascular surgical manpowcr. To ensure that gcneral surgeons continue to contribute to the
suw~Y
vascular surgical manpower pool, selective training will be required in programs lacking sufficient teach-' ing material. Even in programs with abundant vascular volume, selective training would further enhance general vascular surgery residents' education and qualifications to practice vascular surgery. To this end it is suggested that not all general surgery resi• dents require or even desire exposure to vascular surgical training. Should vascular surgical training case volume be diluted by those surgeons ultimately destined to other surgical specialties? It seems difficult to justify vascular training for endocrine, plastic, and colorectal surgeons, as well as those entering critical care medicine. Offering vascular surgical training to specialists in trauma and cardiothoracic surgery however, is justified more easily. Therefore to ensure quality vascular surgical c ~ through adequate training and in keeping with the survey opinions of 322 SPDs and VPDs, a two-tier training concept is suggested only for those individ? uals anticipating that vascular surgery will constitute a significant portion of their practice• Primary vascular training includes management of vascular trauma, embolectomies, abdominal aortic aneurysm repairs, aortofemoral bypasses, and femoropopliteal reconstruction for both general surgery residents and vascular trainees. Complex tertiary care expertise requires special training beyond a general surgery residency. Such training, now provided by approved vascular fellowships, additionally qualifies individuals to manage thoracicoabdominal aortic aneurysms and perform visceral, carotid, and femorocrural reconstructions, as well as newer percutaneous and endovascular procedures. It is suggested that t r a i n ~ programs for primary and tertiary vascular surge&fs be structured in this manner to use teaching material with maximum effectiveness and therefore improve the quality of vascular surgical care through comprehensive education. REFERENCES 1• DeWeese JA, Blaisdell FW, Foster JH. Optimal resources for vascular surgery. Arch Surg 1972;105:948-61. 2. Ernst CB, Rutkow IM, Cleveland RJ, Folse JR, Johnson G Jr, Stanley JC. Vascular surgery in the United States: report of the Joint Society for Vascular Surgery-International Society for Cardiovasoalar Surgery Committee on Vascular Surgical Manpower. J VASC SURG 1987;6:611-21. 3, Perler BA, Znidema GD. The effect of vascular fellowships on general surgical residency training. Ann Surg 1984;200:24754.
