Point/Counterpoint: So you think you can make a vascular surgeon in 5 years?

YES

BY MALACHI G. SHEAHAN III, M.D.

Believe it or not, one thing just about all vascular surgeons will agree upon is the proper way to train. For most of us, the best way to become a surgeon is the way we became a surgeon. Therefore, unless there is some aberration in the readership circulation of Vascular Specialist, I begin this debate facing an uphill battle with most of you.

The question of how to become a vascular surgeon should not be some esoteric matter left to be debated in the late Friday session of some educational symposium. Indeed, I commend the editors for bringing this issue to a more public forum. As much as I enjoy listening to the twenty-seventh abstract redefining the risks of type 2 endoleaks at our national meeting, the matter of how to create a vascular surgeon will define our profession for years to come.

Data from the Association of American Medical Colleges shows that there is now one vascular surgeon for every 100,000 people in the U.S. That is one vascular surgeon for every 350 dialysis patients or one for every 2,600 individuals with peripheral artery disease. We are already in short supply and 40% of us are over 55 years old. Applicant numbers to traditional 5 + 2 programs have plateaued over the past 10 years, suggesting that expanding fellowship positions is not the answer. Who then will fill this gap? As Dr. Ian Malcolm warned us in “Jurassic Park,” life will find a way.

If vascular surgeons don’t act to address this need, I know two candidates who are interested. Both interventional cardiology (10% over 55) and interventional radiology (12% over 55) have younger workforces that are growing at a superior rate. Between 2008 and 2013, the largest increases in training positions offered among all medical specialties were seen in interventional cardiology and interventional radiology.

Luckily our profession has not been caught completely off guard. Integrated vascular residency positions were first offered in 2007. Based on the quality and quantity of applicants, the number of institutions offering the integrated 0 + 5 vascular residency has grown from 17 in 2009 to 51 in 2015.

As practiced today, vascular surgery bears little similarity to even a decade ago. Limb salvage, aortic interventions, vein care, and access management all require highly specific training not typically offered in a general surgery residency. Our new board certification emphasizes the ability to supervise and interpret radiologic tests. Vascular surgery training is no longer a honing of general surgical skills. We must teach and develop completely new areas of expertise in our trainees. I propose the longer we have to focus on these specific abilities, the better our product will be.

A classic argument against traditional 5 + 2 training is why have a postgraduate-year 4 or 5 performing a pancreaticoduodenectomy (Whipple procedure) when they will never perform one in practice? This, however, is a flawed point, as open abdominal cases contain many aspects that translate well to vascular surgery. I believe the enemy is not Allen O. Whipple, but rather Harvey J. Laparoscope.1 Much like the declining numbers of open aortic cases, laparoscopic surgery has replaced much of the open surgical volume in general surgery training programs. How well these skills translate to vascular is unknown, but at face value, the cross-applicability doesn’t seem to pass muster. So while no case is wasted, perhaps our trainees’ time could be spent more efficiently.

Integrated 0 + 5 programs give total control of the rotations and curriculum to the vascular program director. This allows a truly cohesive approach to developing vascular skills and knowledge over a five year period interspersed with core general surgery skills and principals. Surgery rotations such as trauma, ICU, and cardiothoracic surgery that provide the best educational content to our trainees can now be handpicked, while avoiding lower-yield content like advanced laparoscopy and breast. Quality control is now in the hands of a vascular surgeon.

After all, Erica, if the sanctity of the five year general surgery residency must be preserved, why do you run one of the world’s only 4 + 2 programs? Clearly you believe we can condense our trainees’ education without losing quality.

Using the available metrics and data points it would be difficult to prove superiority of the 0 + 5 pathway to the 5 + 2. Therefore, I will borrow a technique from my clinical trials’ friends and claim noninferiority. Follow my logic here and I promise not to include a convoluted endpoint like strokes, deaths, and non-Q wave MIs induced in training directors.