Recruiting Strategies for Potential 0+5 Vascular Residency Applicants

Article Outline

• Abstract
• Introduction
• Methods
  • Program Directors’ Survey
  • VSITE Survey
• Results
  • Program Directors’ Survey
    • Program Information and Attitudes
    • Information on General Surgery Residents Rotating Through the Vascular Service
    • Information on Student Involvement
    • Research Efforts
    • Mentoring Efforts
    • What strategies do you think have worked for you, and what have not worked?
  • VSITE Survey
    • When did you first become aware of vascular surgery?
    • When did you first COMMIT to vascular surgery?
    • What was the most important factor in your original interest?
    • What was the most important factor in making your final decision of a career?
    • What do you think is the most important recruiting tool to attract medical students to a career in vascular surgery?
    • What was the most important factor in your decision to become a vascular surgeon?
• Discussion
• Conclusions
• Acknowledgment
• Appendix
  • A Guide for Recruiting the 0+5 Resident
    • Step 1: Expose medical students to the field of vascular surgery: Set up formal interactions with them during each of the 4 years
    • Step 2: After all have been exposed at a basic level, identify those who might be truly interested and cultivate their interest at a high level
    • How to do these
• References
• Copyright

Background

The 0+5 integrated vascular residency training pathway was established in 2006 to allow for trainee-focused training culminating in vascular surgery certification only. An early concern was whether enough medical students could be recruited directly into a vascular internship without the exposure that a general surgery residency provides. We hypothesized that programs that send a large percentage of their general surgical graduates to vascular fellowships have models that can be adapted to medical student recruitment.

Methods

Opinions and practices were sought from program directors through survey and from trainees taking the Vascular Surgery In-Training Examination.

Results

Eight programs were identified that sent 20% or more of their residents to vascular fellowships over the past 5 years (projecting a mean of 1.6 residents entering vascular fellowships in 2011). Almost all such programs have a formal mentoring system in place that match mentors to residents by interest, and almost all send residents to academic meetings before their senior year. Seventy-five percent of such programs have formal vascular lecture exposure to the first and second year medical student classes, offer clinical shadowing experiences, and have time on the vascular service during the MS3 clerkship; 83% offer a third- or fourth-year elective in vascular surgery. Vascular Surgery In-Training Examination responses were collected from 156 fellows and 13 “0+5” residents. Although fellows had initially been attracted to vascular surgery by the technical aspects of the field learned during residency (43%), the most important factor initially attracting medical students was an interested mentor (46%). However, the most important factor for both residents and students in making a final decision was the technical aspects of the field (66% and 63%, respectively).

Conclusions

Although residents are automatically exposed to the field during residency, students can only be exposed to vascular surgery if a conscious effort is made by interested educators. Programs that send a high proportion of students and residents into vascular surgery tend to have planned exposure at the MS1 and MS2 levels, formal clinical rotations in place at the MS3 and MS4 levels, and pay personal attention to those who display interest. A guide is presented to help specifically plan these steps. Successful recruiting of students into a 0+5 integrated training program requires specific planning and action.

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Introduction 

Spurred, in part, by the adoption of endovascular techniques within the field of vascular surgery, there has been an increasing awareness over the past decade that vascular surgery training should be revised. The adoption of endovascular techniques means that we now have more to teach our residents, and the complexity and specialized techniques required suggest that there is less and less clinical overlap between general and vascular surgery practices. For both these reasons, there has been a significant push toward extending vascular training, concentrating vascular cases for vascular trainees, and making sure that vascular and nonvascular residents alike are training on cases they will actually perform in practice. Several early specialization vascular pathways now exist. The most commonly adopted paradigm, approved in 2006, is the 0+5 integrated pathway. Trainees choosing this option are matched as interns directly from medical school, perform 5 years of clinical training (24 months of general surgery and 36 months of vascular surgery), and are then admissible for certification by the American Board of Surgery in vascular surgery alone. As of January 2011, 27 integrated programs exist, with anticipated graduation of the first class in June 2012.

There was significant initial concern that recruiting medical students directly into what has traditionally been viewed as a subspecialty of surgery would be difficult. Thus far, the number of applicants far exceeds available slots, but as the number of programs grows this relationship will likely change. Exposure to vascular surgery is extensive during surgical residency, ensuring that all potential candidates are exposed to the field, but such exposure is not similarly guaranteed (or, indeed, common) in medical school. It is our hypothesis that the most significant step in recruiting a medical student into a vascular internship (as opposed to a resident into a fellowship) is ensuring exposure to the field during medical school. This exposure does not happen without dedicated effort. This manuscript is a description of previous successful recruiting techniques (based on program and current trainee input), and is meant to be a guide that programs may choose to use to identify as many potential vascular surgeons for our training programs as possible.

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Methods 

Two sources of information were used for this project: a survey to all program directors (integrated and conventional fellowships) sent over the winter of 2008-2009, and a series of questions at the end of the 2009 Vascular Surgery In-Training Examination (VSITE).

Program Directors’ Survey 

This was sent to all 108 program directors accredited and active as of the academic year 2008-2009. The survey consisted of 23 questions, divided into the following six sections:

The surveys were sent by e-mail, with periodic reminders sent to all nonresponders through April 2009.

VSITE Survey 

This survey consisted of the following six questions:

Results of each survey, although quantitatively evaluated, were analyzed in a sociological sense—our goal was not to ascertain a mean or maximum numerical result, but rather to use the information in the surveys to determine what has worked in the past and what current trainees feel is most valuable, and to derive an overall pattern of action that will maximize recruitment of the right people. In general, we tried to identify programs that were successful recruiters and determine what they did to achieve this status. Responses were limited to one per program, and not all respondents answered all questions.

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Results 

Program Directors’ Survey 

Responses were ultimately received from 36 (33%) program directors; this included 9 of the 17 programs with accredited 0+5 integrated pathways (53% of those with integrated pathways responded; 25% of responses were from programs with an integrated pathway).

Of the 27 responders who did not have a 0+5 integrated pathway in place, three were “ready to go” and another five were planning on instituting such a program within the next few years. None of those who were not planning on instituting a 0+5 program felt that it was a bad idea—several did not have funding, whereas at least two programs did not have enough faculty. No respondent felt that the 0+5 training paradigm would fail, but the majority of respondents felt that the best option for the future is to offer approximately equal numbers of slots in the 0+5 and traditional fellowship pathways. Three programs felt that the 0+5 should (and will) become the only training option within the next 10 years.

Ninety-four percent of programs have general surgery residents rotate through their services (median of six in each year). Eight of the respondents reported that >20% of residents enter vascular surgical fellowships after graduation each year (survey mean: 14%); these were somewhat arbitrarily labeled “successful” programs with regard to fellowship recruiting. An increase in the number of general surgery residents planning on a career in vascular surgery in the last few years from successful programs was apparent (Fig. 1). Although this may reflect the fact that more residents are initially attracted to vascular surgery then eventually match (i.e., class of 2011 information for this survey was derived from statements made during the R3 year), it does suggest that many residents in successful programs become interested in the field relatively early. General surgery residents from successful programs spent a mean of 10 months on the vascular surgery service, although the majority of these rotations were at hospitals other than the program’s primary site. Almost all successful programs have formal mentoring in place (six of eight), pursue ad hoc research opportunities with residents (seven), and send interested general surgery residents to vascular surgery academic meetings (six).

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• Fig. 1 

  The number of residents per “successful” responding program per year entering the vascular surgery fellowship match (by graduation year); successful is defined as a program where >20% of residents enter vascular fellowships.

Eighty-six percent of respondents (31 programs) work directly with medical students. Perhaps of unusual significance, every single “no” responder also either felt that they would never under any circumstances initiate a 0+5 program or left this question blank. The most common interaction, interestingly, was a formal lecture in any year (77% of the 31 programs working with medical students), followed by third-year clerkship rotations (71%), fourth-year subinternships (68%), and clinical shadowing opportunities during the first and second years (65%). Sixty-one percent of responding programs offer informal mentoring and 55% include them in ongoing scheduled and ad hoc academic events. The lowest response rates, approximately 32%, were for formal clinical/translational research and formal basic science research programs in place, although 42% of programs have ad hoc research efforts underway and 50% send interested students to academic meetings.

Programs were deemed “successful” from a 0+5 recruiting standpoint if they reported that any of the students at their institution was planning on applying to a 0+5 integrated pathway; 12 of the 36 responders met this criterion. The percentages of those offering lectures, shadowing, and third-year rotations were the same as the group as a whole, but marked differences were seen in other areas. Eleven of the 12 successful programs (92%) have ad hoc but organized clinical research efforts offered to interested students, and 10 (83%) offer a fourth-year subinternship. Seventy-five percent of successful programs have formal vascular requirements during the third-year clerkship and 75% send students to academic meetings. Again, there seems to be a very obvious trend toward an increasing number of students from successful programs considering 0+5 training (Fig. 2); even allowing for bias, these data are very encouraging.

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• Fig. 2 

  The number of medical students per responding program entering the vascular surgery 0+5 integrated residency match (by graduating year). 2010 data, collected in 2009, reflect the number of third-year students who were “planning” on entering the match at that time.

On average, around one resident and one student at each institution each year are involved in clinical/translational research, whereas only about one-third of the student population per year is involved in basic science research, which is somewhat lower than authors’ experience and may reflect sample bias. Only 50% of respondents report any funded basic science research efforts within their programs, and only 30% of programs have structured, formal research efforts of any kind available to residents and students.

Only 39% of respondents have formal mentoring programs for students in place. Of these, the majority (54%) of such relationships are guided, where a student’s interest leads to an appropriate mentor being matched with him or her. Thirty-six percent of the time, the student simply selects a mentor, and in only 9% of programs, the relationship is truly random. The vast majority of such mentoring relationships are geared toward the future (i.e., career counseling) rather than school itself (although such relationships, if and when they exist, may not be as likely to involve clinically active vascular surgeons and so are likely underreported here). By contrast, 60% of programs have formal mentoring in place for residents, and the bulk of such mentoring revolves around residency and education itself rather than the future.

Things that seem to be common at successful programs include early exposure to the field, concentration of attention during the clinical years, and focused mentoring. By contrast, basic science research opportunities and randomly assigned mentors do not seem to be effective or common at these sites.

VSITE Survey 

As it was mandatory to finish the 2009 VSITE, response rates were 100%. The following information was received from 156 traditional fellows and 13 0+5 residents:

Fifty-four percent of the fellows described first being aware of vascular surgery in medical school, although most did not start to think seriously about this as a career until the first half of their residency. Although 69% of 0+5 residents first learned about the field in medical school, 15% learned about it in college (10% of fellows) and 15% through family or other sources (10% of fellows).

Although 50% of fellows committed late in residency, a full 12% report they had committed during medical school (obviously all 0+5 residents reported committing during medical school).

The plurality of fellows (43%) reported being initially interested by the technical aspects of the field, whereas 36% reported being influenced in this regard by an individual mentor. By contrast, individual mentorship was the spark for most 0+5 residents (46%), with the technical aspects of the field being most important in only 23%.

The large majority of both fellows (66%) and 0+5 residents (69%) made their final decisions based on the actual technical and clinical aspects of the field (i.e., what we do all day), although about a quarter in each group reported that the single most important factor was their mentor.

Both fellows and 0+5 residents felt that mandatory medical school clerkship experience during years 3 and 4 (36% and 39%, respectively) and exposure during years 1 and 2 (31% each) were most important. Interestingly, only 1% of fellows and no 0+5 residents felt that research involvement was most important.

Not surprisingly, 71% of fellows felt that it was their experience during residency (17% mentor, 11% medical school rotation), whereas 46% of 0+5 residents felt that it was a medical school rotation (31% mentor, 23% research or didactic classroom activity).

Finally, although not part of our survey, several other answers are worth reporting. Only about half of the fellows pursued their residency at an institution that had a vascular surgery fellowship. The majority of fellows (63%) are certain they will limit their practice to vascular surgery (22% are not sure and 15% will definitely do some general surgery).

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Discussion 

What do these responses show? First, the 0+5 pathway seems to be relatively popular at this point, and most program directors are enthusiastic about it. Programs that successfully train and recruit fellows include almost a full year of vascular surgery during residency, engage in formal mentoring, and pursue research and academics with interested residents. Programs that successfully recruit medical students to the integrated program usually have exposure to them in lecture format during the first 2 years, and offer clinical activities during the last 2. They almost always engage interested students in clinical research, and three-quarters send interested students to vascular surgery meetings. Finally, although a variety of factors (mentorship, lectures, shadowing) initially spark interest in medical students, it is usually the technical aspects of the field (i.e., what a vascular surgeon does all day) that are responsible for a trainee’s final decision, whatever the level.

As discussed previously, there was some concern when the 0+5 integrated pathway was initiated whether we would have enough applicants to fill the available slots. This has not been the case; the number of students who are interested and who ultimately rank a 0+5 program not only continue to far exceed the number of available slots, but the number of interested applicants has almost tripled since 2007 (Fig. 3).

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• Fig. 3 

  Students applying for 0+5 integrated residency programs (red line: “interested”), students who actually entered the match (green line: “entered match”), and the number of available slots (blue line: “available places”) by year of the match. The number of “interested” students, derived from the Association of American Medical Colleges data, was ascertained and reported by Schanzer et al. through 2009¹ and re-reported to us for 2010, whereas the number of available positions and the number of students who actually entered the 0+5 match are as reported by the National Residency Match Program.

Who are these applicants? Dr. Schanzer et al. analyzed these data through 2009, and examined the qualifications of 111 applicants to the University of Massachusetts program.¹ Sixty-nine percent of the applicants were graduates of a foreign medical school, although 90% were living in the United States and 25% had completed at least 1 year of American residency. The mean board score of this cohort was approximately 90%. Similar results were seen when the Stanford program was analyzed by Dr. Lee et al.² Sixty-five students applied to their program in 2009, and were compared with the 58 general surgery applicants who were interviewed. The integrated program had a higher percentage of foreign medical graduates (40% vs. 0%) and lower board scores (United States Medical Licensing Examination step 1: 220 vs. 232; step 2: 223 vs. 241, both highly significant).

The applicant pool as a whole, however, is not the real story. The Stanford group reanalyzed the 27 0+5 applicants they invited to interview, and again compared qualifications of these applicants with those of the general surgical residency applicants who were interviewed. Within this pool, 37% were female and 93% American medical school graduates; rates were no different from the general surgery group. Thirty-three percent of 0+5 candidates, however, had advanced degrees (such as PhDs, law degrees, or MBAs), as compared with 12% of general surgical candidates (p < 0.03), 56% had achieved honors in their surgery clerkship (vs. 33%; nonsignificant), and board scores were not different from the general surgery group (step 1: 229 vs. 232, step 2: 238 vs. 241). 0+5 interviewees had more publications as a whole (mean: 4.3 vs. 1.4, p < 0.01) and a higher proportion of these were related to cardiovascular disease (57% vs. 17%, p < 0.01).²

Although we do not have hard data, these finding are identical to what we have observed in Rochester. A substantial percentage of 0+5 applicants include candidates who we would not judge as being highly qualified—often older foreign medical graduates with mediocre board scores who may have started training in another field. We view these candidates as not truly attracted to vascular surgery, but rather simply “signing up” for whatever is available. By contrast, as quantitatively illustrated by Dr. Lee and clearly seen at all 0+5 programs, the top 25% or so of applicants (who are typically invited to interview) are as good as the best of the general surgery pool. Board scores and academic rank are just as good, and truly qualified 0+5 applicants tend to have more research experience in general. Figure 4 modifies Figure 3 by projecting the number of truly qualified 0+5 candidates as 25% of the total pool. Note that, by using this metric, the number of truly qualified applicants is not much greater than the total number of slots available, and also seems to be fairly close to the number of originally interested applicants who eventually formally enter the match.

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• Fig. 4 

  This is identical to Figure 3, but with the addition of the group of applicants judged to be “high quality” based on the experiences of Lee et al.,² the University of Rochester, and discussions with other program directors. This is thought, on the basis of these experiences, to be approximately 25% of the total pool of “interested” applicants, and is shown in black.

The issue of recruitment thus remains important. Dr. Singh et al. polled recent medical school graduates entering military residency programs to ascertain their knowledgebase regarding vascular surgery (75% of whom were entering nonsurgical residencies).³ Two-thirds had never had a vascular surgery rotation during medical school. Only 23% correctly identified the “procedures a vascular surgeon performs” and 56% reported that they would consult interventional radiology or cardiology if a patient of theirs needed an arteriogram. This is a group that, by definition, did not include any integrated residents (and only 25% surgeons), but these findings still suggest that we have a long way to go.

From noting what strategies have worked for successful programs and analyzing how integrated residents (and fellows) were attracted to our field, we propose the following recruitment strategies. There are two major steps to this process: (1) making a candidate aware of the field in general, and (2) cultivating any interest expressed to the level where a realistic career choice can be made. It cannot be stressed enough that this process must be active rather than passive. Although exposure to vascular surgery is ensured during residency, it is not in medical school—and this factor may well be the critical difference. A detailed guide to recruiting medical students into a 0+5 residency program based on these concepts is presented in the Appendix.

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Conclusions 

It is easy to overlook the simple fact that medical students are not automatically exposed to vascular surgery as the general surgery residents are. Exposure to our field is an absolute requirement for a student to consider the 0+5 integrated pathway, and this almost never happens without conscious effort by those who want to see our field grow. Such exposure must start in the first year of medical school and continue each year afterward. After exposure to all is ensured, those students who demonstrate potential interest must be cultivated and exposed to the full breadth of our field. This two-step process has worked well for many programs, and is a framework for anyone interested in recruiting students as future vascular surgeons to follow.

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The authors thank Robert S. Rhodes, MD, for his assistance with data collection during the VSITE and for his helpful comments and suggestions regarding this manuscript.

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Appendix 

A Guide for Recruiting the 0+5 Resident 

From noting what strategies have worked for successful programs and analyzing how integrated residents (and fellows) were attracted to our field, we propose the following recruitment strategies. There are two major steps to this process: (1) making a candidate aware of the field in general, and (2) cultivating any interest expressed to the level where a realistic career choice can be made. It cannot be stressed enough that this process must be active rather than passive. Although exposure to vascular surgery is ensured during residency, it is not in medical school—and this factor may well be the critical difference.

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References 

1. Schanzer A, Nahmias J, Korenda K, Eslami M, Arous E, Messina L. An increasing demand for integrated vascular residency training far outweighs the limited supply. J Vasc Surg. 2009;50:1513–1518
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2. Lee JT, Teshome M, de Virgilio C, Ishaque B, Qiu M, Dalman RL. A survey of demographics, motivations, and backgrounds among applicants to the integrated 0+5 vascular surgery residency. J Vasc Surg. 2010;51:496–503
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3. Singh N, Causey W, Brounts L, Clouse WD, Curry T, Andersen C. Vascular surgery knowledge and exposure obtained during medical school and the potential impact on career decisions. J Vasc Surg. 2010;51:252–258
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4. Burack JH, Irby SM, Carline JD, Ambrozy DM, Ellsbury KE, Stritter FT. A study of medical students’ specialty-driven pathways: trying on possible selves. Acad Med. 1997;72:534–541
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