On the Subject of Vascular Surgery Training: The Educational Rubric

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The legacy of educating vascular surgeons has been one of considerable turmoil and conflict. Distinct training programs were initially suggested by leading vascular surgeons in the early 1970s, but it was not until 1984 that the Residency Review Committee-Surgery (RRC-S) accredited its first training program. Initial training programs were 1 year in duration. Over the ensuing two decades, many programs voluntarily extended the clinical training to 2 years to accommodate the greater complexity of open procedures and introduction of endoluminal therapies. This change becomes mandatory in 2008. The future training of vascular surgeons will de facto increase to 3 years with implementation of the recently approved American Board of Surgery (ABS) Primary Certificate in Vascular Surgery. Implementation of the primary certificate will carry many pitfalls unrecognized today by most in the vascular surgery community.

The need for greater responsibility and control of the training of future generations of vascular surgeons was recognized a decade ago in the creation of the American Board of Vascular Surgery (ABVS). In fact, all 22 executive officers and council members of the Society for Vascular Surgery (SVS), the North American Chapter of the International Society for Cardiovascular Surgery, and the Association of Program Directors in Vascular Surgery (APDVS) signed the manifesto on the rationale for forming the ABVS (J Vasc Surg 25:411–413, 1997). This action at that time reflected a unanimity regarding training that has seldom been seen in any major learned surgical discipline. Shortly thereafter, the ABS created a subboard in vascular surgery, now known as the Vascular Surgery Board of the ABS (VSB-ABS); and in 2004 the ABS, with the support of the SVS and APDVS, applied to the American Board of Medical Specialists (ABMS) for the Primary Certificate in Vascular Surgery, which would not require prior general surgery certification. Final approval of the primary certificate by the Accreditation Council for Graduate Medical Education (ACGME) came in February 2006. Many viewed this as the birth of a different and presumed better way of training vascular surgeons.

Clearly, the need for change existed and the expectations that change must occur were universal. However, if vascular surgery is to maintain itself as a creditable discipline, successful implementation of the primary certificate becomes essential. In my view, few vascular surgeons are aware of the options and obstacles that now must be recognized and met to train future vascular surgeons. Independent and integrated pathways exist for an individual to be eligible to become ABS-certified in vascular surgery. The specific rubric categories of the primary certificate pathways deserve careful dissection. They are not the panacea suggested by many.

Independent 3 + 3 program. This path involves 3 years' training in core surgery under the direction of a general surgery program director, followed by 3 years' training in vascular surgery under the direction of a vascular surgery program director. Certification will be possible only in vascular surgery. These two training segments may be completed at two different institutions. However, most public discussions suggest that this training most often will take place at the same institution. A major impediment to this is that applicants must first be appointed to the general surgery residency. The fact is that it will be nearly impossible for any general surgery program director to assure that a given first-year house officer candidate will be accepted into this track. There will simply not be sufficient listings of those candidates interested in vascular surgery in the house officer match to guarantee such an appointment in the 3-year general surgery program. Thus, one of the potential benefits of the 3 + 3 program of having individuals reside at the same institution throughout their training is likely to be nonexistent. Certainly, the vascular surgery program director will not have responsibility for recruitment of individuals into the first 3 years of general surgery training and will never be directly responsible for the training components of those years. As an aside, other 3 + 3 programs involving different institutions for each training segment have been marginally successful in plastic surgery and were failures in thoracic surgery in the distant past.

Independent 5(1) + 2 program. The second independent path involves completion of a 5-year general surgery residency followed by 2 years of vascular surgery training. Credit for 1 year of the vascular surgery residency may occur if appropriate vascular surgery education can be demonstrated during the course of the 5-year general surgery residency. That will require very difficult differential tracking within any given general surgery residency program. This path allows individuals to become certified in both general surgery and vascular surgery but will likely be chosen by few individuals, given the self-selected specialization pursued by most practicing surgeons in contemporary times.

Independent ESP 4(1) + 2 program. The third independent path includes an early specialization program (ESP) that is highly structured to allow individuals to be eligible for general surgery certification after 4 years of residency training, and with 2 additional years of vascular surgery they may become certified in that specialty. However, this path mandates 1 year of vascular surgery training during the 4-year general surgery residency. Considering that this represents an average of 3 months of vascular surgery training during each year and that most trainees have 1 month of vacation, it means that only 8 months of each year remain to learn the requisite skills of general surgery. Such a total of 32 months' training in general surgery, compared to the usual 55 months in a conventional 5-year program, must be suspect. It is unlikely that many programs will opt for this training paradigm. In fact, the number of programs that have taken advantage of the ESP path since its existence can be counted on the fingers of one hand.

Integrated 5 program. The remaining path is an integrated program with 5 years of training under the direction of a vascular surgery program director. Certification will be in vascular surgery alone. Candidates enter training immediately after medical school. It includes 2 years of core surgical education followed by 3 years of vascular surgery training. This program carries the benefits of most other ABMS-approved surgical specialties, including neurosurgery, ophthalmology, orthopedics, otolaryngology, and urology. Considerable breadth in training can be offered over this longer time period. Furthermore, such a program can be tailored to more efficiently meet the technological changes within the discipline than would be the case if the training responsibility was shared with program directors of other disciplines.

The major disadvantage of the integrated 5-year program relates to the fact that it will require significant incremental increases in the number of graduate medical education-full-time equivalents (GME-FTEs) and funding for these trainees. Preliminary training positions, rather than categorical training positions, have been suggested as the source for these additional positions. However, preliminary positions are tightly regulated by the AC GME for each specialty. They are very limited in number. In the impact statement presented to the regulatory bodies approving the primary certificate, it was noted for the integrated 5-year program as well as the independent 3 + 3 program “that additional preliminary residents will be required in the institution, even if the number of finishing residents per year remains the same. We anticipate that…this will be accomplished slowly, and only in those institutions with sufficient internal and external funding for such residents.” This will be a major hurdle for most hospitals facing increasing GME costs at the same time their clinical revenues are decreasing.

The desire to have responsible control for the training and certification of vascular surgeons, expressed by those who established the ABVS, has as much merit today as it did a decade ago. The right decisions must be made. The nurturing of the primary certificate is now the responsibility of the vascular surgery community. Although it represents an important opportunity, the resources to accomplish its implementation are quite limited. Unfortunately, the 3 + 3 independent program has been touted most and was even highlighted in the VSB-ABS Spring 2006 newsletter, which stated that “The VSB-ABS anticipates that most applicants will be for a 3 + 3 paradigm—3 years of general surgery training followed by 3 years of vascular surgery training—though other types of integrated programs may be also proposed.” It is interesting that the independent 5 + 2 as well as the early specialization 4 + 2 formats were also discussed in the VSB-ABS newsletter but not a single word was mentioned of the 5-year integrated program. It is the latter program, under the guidance of a vascular surgery program director, that offers the best hope for the future of vascular surgery; and it is the only viable educational rubric that identifies vascular surgery as a truly independent specialty.