Colleague Commentary: The Primary Certificate in Vascular Surgery: What Next?

Dr. Ricotta

In February of 2006 the American Board of Medical Specialties approved a primary certificate in vascular surgery. Programs can apply for accreditation to award this certificate beginning in July of 2006.

This effort, which has been a major goal of the vascular surgical community since 1996, will allow residents to complete training in vascular surgery without completing the traditional 5 years of general surgery training. It provides maximum flexibility to vascular training programs, allowing vascular certification by no less than four training models. It also presents a tremendous challenge to the Association of Program Directors in Vascular Surgery and its constituent programs, who will have to develop curricula to train this new group of surgeons.

As these curricula are developed it will be important to have a clear idea of who we are and what we want to be. There is still some debate on this issue. Historically tied to general surgery and open operations, our specialty is in the midst of a transition which embraces endovascular therapies and aligns our clinical interests more closely with those of interventional radiologists and cardiologists as well as neurosurgeons and cardiac surgeons. Talk continues of a new "vascular specialist" who can be trained through multiple pathways who will devote himself or herself to the global treatment of vascular disease. As we move forward in the development of curricula it will be important to consider how much we want to embrace this path.

The skills need by a vascular surgeon were well defined by Dr. Robert Hobson in his presidential address to the American Association for Vascular Surgery. They include knowledge of vascular anatomy and physiology, maturity of operative and nonoperative treatment of vascular disease--including open and endovascular treatment, preoperative evaluation, and perioperative care (including critical care of the vascular patient)--and the understanding of vascular imaging including the noninvasive vascular laboratory.

This combination of knowledge and skills distinguishes vascular surgery from other specialties. We blur this distinction at our peril and the peril of our successors. While we share specific interventional and surgical procedures with other specialists, the breadth of knowledge and expertise to treat the vascular system as a whole is ours uniquely.

A medical specialty is not based on a set of procedures, which are mutable, but on mastery of a body of knowledge, of which procedures are one part. After a long struggle to have the unique nature of vascular surgery recognized by organized medicine, we would be ill advised to minimize this uniqueness by merging with others to become "specialists" instead of remaining "surgeons." Clearly, there is a need for intellectual, academic, and educational collaboration with other specialists interested in particular aspects of vascular disease. Joint meetings and joint publications such as this one play an important role in advancing the field of vascular disease.

As we develop our training programs we will need to collaborate with other specialists, including general surgeons, to provide adequate training for our residents. It is likely that we may wish to explore certificates of added qualifications in one or more areas of vascular disease and in doing so develop educational modules in collaboration with other specialists. There is precedent for this in hand surgery, head and neck surgery, and critical care. However, we must retain our unique role as the pluripotential practitioner of vascular disease in its broadest sense, and our programs should reflect this unique character of our specialty. The primary certificate is a major step forward, but there is much work to do and we need to proceed with care and reflection that will serve our future colleagues in vascular surgery well.