General surgeons getting less vascular training

Vascular surgical practice has evolved with the introduction of minimally invasive technology and advancement of endovascular techniques, and as such, the training of the vascular surgical specialist too has evolved. This article highlights the effect of these technological advancements on the vascular surgical fellowship training experience and points out the effect of this embracing of endovascular techniques by academic centers in their general surgery trainee vascular surgical experience. Open operative case numbers are declining and endovascular case numbers are increasing significantly.

As traditionally performed open procedures are being substituted for endovascular repairs, the open operative experience for vascular surgery trainees is declining or staying stable at the expense of the general surgery resident experience. Open cases (open aneurysm repairs, aortofemoral artery bypasses, visceral artery bypasses, carotid endarterectomies), because they are performed infrequently now, have become fellow cases.

Dr. Erica L. Mitchell

Endovascular cases, which have increased over 300%-400%, too are essentially fellow cases (or in 0+5 programs, which are not discussed in this manuscript, vascular surgery resident cases) because the endovascular skill set does not appear to translate or transfer (and therefore is not considered relevant to the general surgery resident planning on a fellowship or career in the traditional surgical specialties) into open and laparoscopic skills desired by general surgery trainees.

Unfortunately, this open to endovascular operative experience shift will only increase with the introduction and early adoption (in academic centers) of complex endovascular techniques for the management of complex obstructive and aneurysmal arterial disease. A review of case log data for 0+5 and 5+2 residents completing programs in 2014-2015 reveals the operative experience and continued decline in open operative case numbers and increases in endovascular case numbers.

Vascular surgery training programs and their faculties have a responsibility to make sure the operative experience of general surgery residents is a worthwhile one. We, the faculty, need to keep encouraging general surgery residents to come to the operating room, even if they are not the primary surgeons. To make this worthwhile for them (because residents will not come to the operating room if there is nothing to be gained for themselves), we have to let them participate in the case somehow. One of the most critical aspects of a vascular surgical procedure is the operative exposure.

Having the general surgery residents participate in the vascular exposure is not only formative to their understanding of surgical anatomy, and applicable to all aspects of surgical practice, it is also critical to trainee development of decision making, judgment, and situational awareness. These exposures can and should be logged, using the e-code, to receive ACGME case log credit for vascular surgical procedures. E-codes, additionally, allow more than one resident to take credit for an arterial exposure and repair. We must also encourage trainees to come to the angio suite, while these cases, on the outset do not seem relevant to general surgery training, they do provide the learner with a greater appreciation of the complexity of vascular anatomy.

Importantly, as long as we continue to train vascular surgery specialists via the traditional 5+2 paradigm, we must keep general surgery residents, rotating through our services, interested and engaged in the management of vascular diseases. The simplest way to engage them is to make them feel relevant and to make them feel relevant they have to participate, both inside and outside of the operating room. It is, after all, our duty as surgical educators and advocates for our specialty to train the next generation of vascular surgical specialists!

Dr. Erica L. Mitchell is professor of surgery, program director for vascular surgery, and vice-chair of quality, department of surgery, Oregon Health & Science University, Portland. She is an associate medical editor of Vascular Specialist.