Vascular Training Declines for General Surgery Residents

BY BRUCE JANCIN

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COLORADO SPRINGS -- The sharp shift away from open vascular operations in favor of endovascular procedures has had a deleterious impact upon general surgery resident training, Dr. Daniel J. Grabo said at the annual meeting of the American Surgical Association.

His analysis of national operative logs required by the Residency Review Committee (RRC) for all U.S. general surgery residents shows a 34% decline in graduates' overall mean volume of vascular cases over the past 10 years.

An even sharper drop has occurred for selected bread-and-butter major vascular operations. For example, general surgery residents who graduated last year performed an average of just four open elective abdominal aortic aneurysm repairs and 12 open femoral-popliteal bypasses, compared with 8 and 23, respectively, a decade earlier.

Moreover, there has not been a compensatory increase in training experience in endovascular procedures. In most programs, those cases are going instead to vascular surgery fellows, explained Dr. Grabo of Thomas Jefferson University, Philadelphia.

In the past 6 years, vascular surgery fellows' experience in endovascular abdominal aortic aneurysm repair jumped from an average of 10 to 50 cases.

Their balloon angioplasty case total climbed from 17 to 45. In contrast, general surgery residents went from an average of 1 to 2.3 endovascular abdominal aortic aneurysm repairs, while their experience with balloon angioplasty went from an average of 1 to 2.1 procedures.

Dr. Grabo hastened to add that general surgery residents graduating in 2006 still averaged 130 vascular surgery cases--far more than the minimum 44 required by the RRC. But the data suggest that the educational system is now turning out general surgeons of questionable competence to perform elective abdominal aortic aneurysm repair, carotid endarterectomy, lower leg bypass, and some other major operations, he said.

Audience reaction to this information was highly charged. "This august body needs to understand that general surgery is being raided. Every year we do [fewer] cases," warned Dr. Marc K. Wallack, professor of surgery at New York Medical College, New York City, and chairman of surgery at St. Vincent's Hospital and Medical Center, New York City. "How are we going to continue to train general surgeons if we continue to allow this invasion from within?

Basically we're going to see the fall of the general surgery empire. And all of us are general surgeons," he said, referring to the fact that subspecialty training typically begins only after completion of a 3-year general surgery residency.

Dr. K. Craig Kent observed that technologic advances have transformed the field of vascular surgery such that the traditional open cases "are becoming an endangered species. And if you think this is a problem now, fast forward 5 years. For those of us who have expertise in catheter intervention, there are no secrets about what the future will hold," said Dr. Kent, chief of vascular surgery at New York Presbyterian Hospital, New York City, and professor of surgery at both Columbia and Cornell Universities, New York City.

How are these increasingly rare open cases best used for training purposes? "If there's enough to go around--and this may be the case in a number of programs, at least today--let's train everybody. If there are not enough cases to go around--and this will increasingly be the issue--our obligation is to provide for our patients expertly trained surgeons who are capable of all vascular techniques.

If resources are scarce, we need to concentrate those resources in the hands of surgeons who will become the experts," Dr. Kent said. Besides, he added, general surgeons with little or no experience in endovascular techniques won't be able to compete with cardiologists and vascular surgeons in the marketplace.

Dr. Grabo said that creativity will be required to maintain the quality of residency training in vascular surgery in the face of declining cases. He suggested increased use of double scrubbing and operative simulators as ways for residents to gain operative experience.

When asked to comment on this paper, Dr. Joseph L. Mills, Professor of Surgery and Chief of Vascular Surgery at the University of Arizona, noted that the infrastructure of surgical training is rapidly evolving. "A multitude of factors including the rapidity of technological advances, public expectations, and limitations of the 80-hour work week for residents in training are all converging to mandate quantum changes in our century-old surgical training paradigm."

How are these changes to be implemented? Dr. Mills added: "SCORE (Surgical Council on Resident Education) was formed last year by the American Board of Surgery to work in concert with the America College of Surgeons (ACS) and the Association of Program Directors in Surgery (APDS) to redefine the specialty of general surgery and to design a structured modular training curriculum to provide surgeons in training with the skills they will need in practice.

Caseload distribution among trainees must reflect the anticipated scope of care they will provide when these trainees enter practice. "

The ABS currently certifies candidates in two subspecialties (Pediatric Surgery and Vascular Surgery). Additional areas of subspecialization are also developing.

And it is likely that in the intermediate future, recognition of additional surgical training and expertise in these areas will occur either through some form of additional certification or during the MOC (Maintenance of Competence) process, a program of ongoing learning and assessment that will augment the traditional 10-year written recertification examination, Dr. Mills added.

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