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MILWAUKEE – General surgery residents in a community-based residency program experienced a significant 49% decline in open aortic surgeries over the last decade, an analysis showed.
In 2000-2001, residents were exposed to 20-25 open aortic cases per year, but now get in on 8-15 cases per year, said Dr. Adam Rothermel, a third-year general surgery resident at Mount Carmel Hospital in Columbus, Ohio, where the analysis was conducted.
"Open aortic cases are difficult to find, and our residents, as a whole, would agree that we're not coming out with good enough experience with these cases," he said at the annual meeting of the Midwestern Vascular Surgical Society.
The results reflect the exponential shift from open vascular surgery to endovascular procedures over the last decade, as well as the more recent implementation of the 80-hour resident work week.
The total number of carotid endarterectomy, infrainguinal bypass, and open aortic cases for the entire hospital decreased by 55%, 30%, and 71%, respectively, over the study period of 2000 to 2011.
Total resident cases over the same period were unchanged for carotid endarterectomy (77 vs. 84 cases), trended downward for infrainguinal bypass (62 vs. 52 cases), and were significantly lower for open aortic cases (43 vs. 8 cases) according to a review of resident case logs, Dr. Rothermel said.
He pointed out that a significant portion of vascular surgery in the United States is still performed by general surgeons, citing surveys showing that general surgeons performed 59% of the vascular procedures in the United States in 1985 (J. Vasc. Surg. 1987;6:611-21) and 49% in 1992 (J. Vasc. Surg. 1996:23:172-81).
Session moderator Dr. Jean E. Starr, medical director of endovascular services at Ohio State University Medical Center in Columbus, said the current results parallel what's found nationally. She went on to ask what the findings imply for general surgery residents when they've finished training, and how this will reflect on patient practice in light of general surgeons performing half of vascular surgeries in the United States.
"When you get out of your general surgery training from a community based program and are expected then, going into say a rural center, to perform these operations, you have to give pause," Dr. Rothermel replied.
"I don't think I have a good way to fix the problem at this point, but I think we need to be aware of the trend."
Audience member Dr. Joseph Giglia, principal investigator for the laparoscopic aortic surgery program at the University of Cincinnati Medical Center, countered by asking whether the findings really matter given that open aortic cases are decreasing significantly across the country.
He pointed out that the latest survey data were 20 years old, and submitted that general surgeons no longer perform 50% of vascular surgeries in the United States.
"I think these cases are important for our primary vascular residents to participate in," Dr. Giglia said.
"I think there has to be a sea change, a real shift in the paradigm about who's doing these cases and what we're going to do in the future."
Dr. Rothermel agreed that another survey should be conducted to better reflect current practice trends.
If vascular surgeons are to pick up the bulk of the caseload, however, efforts to recruit medical students to the specialty may need to be enhanced.
A recent survey of 338 medical students showed that 236 first- and second-year students had no clinical exposure to vascular surgery, while only 38 of the 102 third-year students had been exposed to vascular surgery after completing a general surgery rotation (Ann. Vasc. Surg. 2012 July 25 [doi:10.1016/j.avsg.2012.02.012]).
Nearly half (49%) of first- and second-year students said that they would consider vascular surgery, however, with another 19% willing to do so if the length of training were reduced, according to the survey.
Dr. Rothermel and Dr. Starr reported no conflicts of interest.
While it is true that general surgeons continue to perform a significant number of vascular operations, these procedures are largely limited to dialysis access and trauma. Based on surgical operative logs of surgeons seeking recertification by the American Board of Surgery, it appears that complex vascular procedures, including open abdominal aneurysms, are increasingly the domain of certified vascular surgeons. With available evidence supporting the relationship between surgical volume and outcome, this is a trend that is likely here to stay. The SCORE curriculum acknowledges this reality by not recommending substantial open vascular operative experience for general surgery residents other than dialysis access, amputations, and vascular trauma.
| Dr. John F. Eidt |
A more significant issue is the fact that vascular surgery residents are also reporting decreased experience with open abdominal surgery.
To some extent, the downward trend in open infrarenal AAA has been mitigated by an increase in a variety of complex debranching and hybrid procedures. Nonetheless, there is concern that current vascular residents may have insufficient operative experience with selected open complex procedures. One response has been growing interest in the development of robust surgical simulation.
While computer-based patient-specific simulation is on the horizon, it is extremely expensive, not universally available and still suffers from limitations in realism.
It is important to recognize that surgical simulation spans a broad spectrum including fundamental skills, cognitive task analysis, partial task trainers, open and endovascular models, crisis management and team training, in addition to high-end endovascular simulation.
The APDVS is actively developing and validating a series of fundamental endovascular skills modeled on the highly successful Fundamentals of Laparoscopic Surgery (FLS). One of the key features of FLS is that trainees must participate in deliberate practice in order to achieve established performance criteria.
Endovascular simulation has suffered from a lack of standardized metrics of performance and has sometimes been considered nothing more than advanced video games with little relationship to actual surgery.
In order to maximize the value of every open operative experience, it is expected that trainees will be required to achieve specified metrics of endovascular proficiency before progressing to more advanced activities including operations.
The 0+5 programs have proven remarkably popular with medical students as there are more than three applicants for each position. Still, despite the popularity, the total applicant pool represents less than 0.5% of the more than 18,000 graduating U.S. medical students.
Clearly, we must continue to provide pathways to vascular experience for medical students including suture labs, surgical simulation, research opportunities, and elective rotations. Finally, there is growing evidence that we are not training enough vascular surgeons to meet the needs of the aging population.
The addition of 40 new 0+5 residency positions over the past few years has resulted in a transient increase in the total number of first- year positions to approximately 160. But the cap on graduate medical education funding may require some programs to discontinue their 5+2 slots. Unless additional funding is forthcoming, the growth of vascular surgery as a specialty may be severely restricted. Clearly, these challenges represent opportunities for novel and creative solutions.
Dr. John F. Eidt is at the University of South Carolina School of Medicine Greenville, and is an associate medical editor for Vascular Specialist.
While it is true that general surgeons continue to perform a significant number of vascular operations, these procedures are largely limited to dialysis access and trauma. Based on surgical operative logs of surgeons seeking recertification by the American Board of Surgery, it appears that complex vascular procedures, including open abdominal aneurysms, are increasingly the domain of certified vascular surgeons. With available evidence supporting the relationship between surgical volume and outcome, this is a trend that is likely here to stay. The SCORE curriculum acknowledges this reality by not recommending substantial open vascular operative experience for general surgery residents other than dialysis access, amputations, and vascular trauma.
| Dr. John F. Eidt |
A more significant issue is the fact that vascular surgery residents are also reporting decreased experience with open abdominal surgery.
To some extent, the downward trend in open infrarenal AAA has been mitigated by an increase in a variety of complex debranching and hybrid procedures. Nonetheless, there is concern that current vascular residents may have insufficient operative experience with selected open complex procedures. One response has been growing interest in the development of robust surgical simulation.
While computer-based patient-specific simulation is on the horizon, it is extremely expensive, not universally available and still suffers from limitations in realism.
It is important to recognize that surgical simulation spans a broad spectrum including fundamental skills, cognitive task analysis, partial task trainers, open and endovascular models, crisis management and team training, in addition to high-end endovascular simulation.
The APDVS is actively developing and validating a series of fundamental endovascular skills modeled on the highly successful Fundamentals of Laparoscopic Surgery (FLS). One of the key features of FLS is that trainees must participate in deliberate practice in order to achieve established performance criteria.
Endovascular simulation has suffered from a lack of standardized metrics of performance and has sometimes been considered nothing more than advanced video games with little relationship to actual surgery.
In order to maximize the value of every open operative experience, it is expected that trainees will be required to achieve specified metrics of endovascular proficiency before progressing to more advanced activities including operations.
The 0+5 programs have proven remarkably popular with medical students as there are more than three applicants for each position. Still, despite the popularity, the total applicant pool represents less than 0.5% of the more than 18,000 graduating U.S. medical students.
Clearly, we must continue to provide pathways to vascular experience for medical students including suture labs, surgical simulation, research opportunities, and elective rotations. Finally, there is growing evidence that we are not training enough vascular surgeons to meet the needs of the aging population.
The addition of 40 new 0+5 residency positions over the past few years has resulted in a transient increase in the total number of first- year positions to approximately 160. But the cap on graduate medical education funding may require some programs to discontinue their 5+2 slots. Unless additional funding is forthcoming, the growth of vascular surgery as a specialty may be severely restricted. Clearly, these challenges represent opportunities for novel and creative solutions.
Dr. John F. Eidt is at the University of South Carolina School of Medicine Greenville, and is an associate medical editor for Vascular Specialist.
While it is true that general surgeons continue to perform a significant number of vascular operations, these procedures are largely limited to dialysis access and trauma. Based on surgical operative logs of surgeons seeking recertification by the American Board of Surgery, it appears that complex vascular procedures, including open abdominal aneurysms, are increasingly the domain of certified vascular surgeons. With available evidence supporting the relationship between surgical volume and outcome, this is a trend that is likely here to stay. The SCORE curriculum acknowledges this reality by not recommending substantial open vascular operative experience for general surgery residents other than dialysis access, amputations, and vascular trauma.
| Dr. John F. Eidt |
A more significant issue is the fact that vascular surgery residents are also reporting decreased experience with open abdominal surgery.
To some extent, the downward trend in open infrarenal AAA has been mitigated by an increase in a variety of complex debranching and hybrid procedures. Nonetheless, there is concern that current vascular residents may have insufficient operative experience with selected open complex procedures. One response has been growing interest in the development of robust surgical simulation.
While computer-based patient-specific simulation is on the horizon, it is extremely expensive, not universally available and still suffers from limitations in realism.
It is important to recognize that surgical simulation spans a broad spectrum including fundamental skills, cognitive task analysis, partial task trainers, open and endovascular models, crisis management and team training, in addition to high-end endovascular simulation.
The APDVS is actively developing and validating a series of fundamental endovascular skills modeled on the highly successful Fundamentals of Laparoscopic Surgery (FLS). One of the key features of FLS is that trainees must participate in deliberate practice in order to achieve established performance criteria.
Endovascular simulation has suffered from a lack of standardized metrics of performance and has sometimes been considered nothing more than advanced video games with little relationship to actual surgery.
In order to maximize the value of every open operative experience, it is expected that trainees will be required to achieve specified metrics of endovascular proficiency before progressing to more advanced activities including operations.
The 0+5 programs have proven remarkably popular with medical students as there are more than three applicants for each position. Still, despite the popularity, the total applicant pool represents less than 0.5% of the more than 18,000 graduating U.S. medical students.
Clearly, we must continue to provide pathways to vascular experience for medical students including suture labs, surgical simulation, research opportunities, and elective rotations. Finally, there is growing evidence that we are not training enough vascular surgeons to meet the needs of the aging population.
The addition of 40 new 0+5 residency positions over the past few years has resulted in a transient increase in the total number of first- year positions to approximately 160. But the cap on graduate medical education funding may require some programs to discontinue their 5+2 slots. Unless additional funding is forthcoming, the growth of vascular surgery as a specialty may be severely restricted. Clearly, these challenges represent opportunities for novel and creative solutions.
Dr. John F. Eidt is at the University of South Carolina School of Medicine Greenville, and is an associate medical editor for Vascular Specialist.
MILWAUKEE – General surgery residents in a community-based residency program experienced a significant 49% decline in open aortic surgeries over the last decade, an analysis showed.
In 2000-2001, residents were exposed to 20-25 open aortic cases per year, but now get in on 8-15 cases per year, said Dr. Adam Rothermel, a third-year general surgery resident at Mount Carmel Hospital in Columbus, Ohio, where the analysis was conducted.
"Open aortic cases are difficult to find, and our residents, as a whole, would agree that we're not coming out with good enough experience with these cases," he said at the annual meeting of the Midwestern Vascular Surgical Society.
The results reflect the exponential shift from open vascular surgery to endovascular procedures over the last decade, as well as the more recent implementation of the 80-hour resident work week.
The total number of carotid endarterectomy, infrainguinal bypass, and open aortic cases for the entire hospital decreased by 55%, 30%, and 71%, respectively, over the study period of 2000 to 2011.
Total resident cases over the same period were unchanged for carotid endarterectomy (77 vs. 84 cases), trended downward for infrainguinal bypass (62 vs. 52 cases), and were significantly lower for open aortic cases (43 vs. 8 cases) according to a review of resident case logs, Dr. Rothermel said.
He pointed out that a significant portion of vascular surgery in the United States is still performed by general surgeons, citing surveys showing that general surgeons performed 59% of the vascular procedures in the United States in 1985 (J. Vasc. Surg. 1987;6:611-21) and 49% in 1992 (J. Vasc. Surg. 1996:23:172-81).
Session moderator Dr. Jean E. Starr, medical director of endovascular services at Ohio State University Medical Center in Columbus, said the current results parallel what's found nationally. She went on to ask what the findings imply for general surgery residents when they've finished training, and how this will reflect on patient practice in light of general surgeons performing half of vascular surgeries in the United States.
"When you get out of your general surgery training from a community based program and are expected then, going into say a rural center, to perform these operations, you have to give pause," Dr. Rothermel replied.
"I don't think I have a good way to fix the problem at this point, but I think we need to be aware of the trend."
Audience member Dr. Joseph Giglia, principal investigator for the laparoscopic aortic surgery program at the University of Cincinnati Medical Center, countered by asking whether the findings really matter given that open aortic cases are decreasing significantly across the country.
He pointed out that the latest survey data were 20 years old, and submitted that general surgeons no longer perform 50% of vascular surgeries in the United States.
"I think these cases are important for our primary vascular residents to participate in," Dr. Giglia said.
"I think there has to be a sea change, a real shift in the paradigm about who's doing these cases and what we're going to do in the future."
Dr. Rothermel agreed that another survey should be conducted to better reflect current practice trends.
If vascular surgeons are to pick up the bulk of the caseload, however, efforts to recruit medical students to the specialty may need to be enhanced.
A recent survey of 338 medical students showed that 236 first- and second-year students had no clinical exposure to vascular surgery, while only 38 of the 102 third-year students had been exposed to vascular surgery after completing a general surgery rotation (Ann. Vasc. Surg. 2012 July 25 [doi:10.1016/j.avsg.2012.02.012]).
Nearly half (49%) of first- and second-year students said that they would consider vascular surgery, however, with another 19% willing to do so if the length of training were reduced, according to the survey.
Dr. Rothermel and Dr. Starr reported no conflicts of interest.
MILWAUKEE – General surgery residents in a community-based residency program experienced a significant 49% decline in open aortic surgeries over the last decade, an analysis showed.
In 2000-2001, residents were exposed to 20-25 open aortic cases per year, but now get in on 8-15 cases per year, said Dr. Adam Rothermel, a third-year general surgery resident at Mount Carmel Hospital in Columbus, Ohio, where the analysis was conducted.
"Open aortic cases are difficult to find, and our residents, as a whole, would agree that we're not coming out with good enough experience with these cases," he said at the annual meeting of the Midwestern Vascular Surgical Society.
The results reflect the exponential shift from open vascular surgery to endovascular procedures over the last decade, as well as the more recent implementation of the 80-hour resident work week.
The total number of carotid endarterectomy, infrainguinal bypass, and open aortic cases for the entire hospital decreased by 55%, 30%, and 71%, respectively, over the study period of 2000 to 2011.
Total resident cases over the same period were unchanged for carotid endarterectomy (77 vs. 84 cases), trended downward for infrainguinal bypass (62 vs. 52 cases), and were significantly lower for open aortic cases (43 vs. 8 cases) according to a review of resident case logs, Dr. Rothermel said.
He pointed out that a significant portion of vascular surgery in the United States is still performed by general surgeons, citing surveys showing that general surgeons performed 59% of the vascular procedures in the United States in 1985 (J. Vasc. Surg. 1987;6:611-21) and 49% in 1992 (J. Vasc. Surg. 1996:23:172-81).
Session moderator Dr. Jean E. Starr, medical director of endovascular services at Ohio State University Medical Center in Columbus, said the current results parallel what's found nationally. She went on to ask what the findings imply for general surgery residents when they've finished training, and how this will reflect on patient practice in light of general surgeons performing half of vascular surgeries in the United States.
"When you get out of your general surgery training from a community based program and are expected then, going into say a rural center, to perform these operations, you have to give pause," Dr. Rothermel replied.
"I don't think I have a good way to fix the problem at this point, but I think we need to be aware of the trend."
Audience member Dr. Joseph Giglia, principal investigator for the laparoscopic aortic surgery program at the University of Cincinnati Medical Center, countered by asking whether the findings really matter given that open aortic cases are decreasing significantly across the country.
He pointed out that the latest survey data were 20 years old, and submitted that general surgeons no longer perform 50% of vascular surgeries in the United States.
"I think these cases are important for our primary vascular residents to participate in," Dr. Giglia said.
"I think there has to be a sea change, a real shift in the paradigm about who's doing these cases and what we're going to do in the future."
Dr. Rothermel agreed that another survey should be conducted to better reflect current practice trends.
If vascular surgeons are to pick up the bulk of the caseload, however, efforts to recruit medical students to the specialty may need to be enhanced.
A recent survey of 338 medical students showed that 236 first- and second-year students had no clinical exposure to vascular surgery, while only 38 of the 102 third-year students had been exposed to vascular surgery after completing a general surgery rotation (Ann. Vasc. Surg. 2012 July 25 [doi:10.1016/j.avsg.2012.02.012]).
Nearly half (49%) of first- and second-year students said that they would consider vascular surgery, however, with another 19% willing to do so if the length of training were reduced, according to the survey.
Dr. Rothermel and Dr. Starr reported no conflicts of interest.
Major Finding: General surgery residents in a community-based program experienced a significant 49% decline in open aortic surgeries from 2000 to 2011.
Data Source: Review of all carotid endarterectomy, femoro-popliteal bypass, and open aortic surgeries performed at a community hospital and by residents from 2000 to 2011.
Disclosures: Dr. Rothermel and Dr. Starr reported no conflicts of interest.
