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

Our best test for measuring cognitive development during vascular training remains the Vascular Surgery In-Training Examination (VSITE). Looking at the 2015 results, the L5 integrated residents received a better average standard score (565 vs. 542) than their L2 fellowship counterparts. In fact, the L5 integrated residents had a superior score on seven of the nine vascular sub-tests.

For technical skill acquisition, we can look at both Accreditation Council for Graduate Medical Education (ACGME) case logs and the Fundamentals of Vascular Surgery (FVS) exam. The largest study of vascular surgical experience was published by P. Batista and colleagues from Thomas Jefferson University, Philadelphia, in 2015. They found integrated residents had performed 12% more vascular procedures than traditional 5 + 2 residents (851 vs. 758) despite 2 years less training time. Our own FVS exam was conducted on more than 280 vascular trainees representing all levels from both paradigms. On this validated exam of technical skill, 94% of PGY 5 integrated residents received a passing score, compared with 92% of PGY 7 fellows. Interestingly, means scores were significantly higher for PGY 5 integrated residents vs. first year fellows (P less than .005) despite the former group receiving one year less training.

Perhaps the final barrier to the success of the integrated pathway is our own preconceived notions. Doubters often cite some unmeasurable like “maturity” as a deterrent. Do we question the maturity of the general surgeon with five years of residency? How about the pediatrician or general practitioner with fewer? Isn’t maturity a key aspect of any physician?

I believe it is time to put our doubts to rest and embrace this new paradigm. We now have ample evidence that under the supervision of a vascular program director, a competent surgeon can be produced in five years.

These young people may not have followed our exact path, but they are our future.

Dr. Sheahan is an associate professor and the program director of the Vascular Surgery Fellowship at the Health Sciences Center, School of Medicine, Louisiana State University, New Orleans.

References

1. Possibly not the actual name of the inventor of the laparoscope, but I’m working on a deadline here. [Editor’s Note; A summary of the complex history of the development of laparascopy can be found here: J Laparoendosc Adv Surg Tech A. 1997 Dec;7:369-73.]

NO

BY ERICA L. MITCHELL, M.D.

Dr. Sheahan has already convinced himself that he has won this debate because he honestly believes that he has persuaded the Vascular Specialist readers of the merits and benefits of the integrated vascular surgery training paradigm. While I respect Mal for supporting a 5 year training paradigm, I am prepared to argue for a potentially even shorter surgical training model than that set by the integrated 0 + 5 (and in some cases 0 + 6 or 0 + 7) time-based archetype.

I propose, and implore, that vascular surgery educators adopt a competency-based educational (CBE) framework in which trainees complete their training when competence has been met and demonstrated through objective performance benchmarks, whether that is after 7 years, 5 years, or even 4 or fewer years of vascular surgical training.

The goal of all graduate medical education is to ensure that the graduating physician is competent to practice independently in his or her chosen field of medicine. For nearly a century, surgical training has been based on the apprenticeship model as articulated by Halsted. Residents work with faculty members on clinical rotations, gaining experience while providing service to patients. The rotations have formal educational goals and objectives, but resident experience relies heavily on the patients who present to the clinical service. The time in training is set and for vascular surgery, the required time in training is either 5 years via the integrated 0 + 5 track or 6-7 years via the early-specialization or traditional training tracks. Board eligibility requires completion of this training time, documentation of operative case logs, and a “ready to practice independently” attestation from the vascular surgery program director. It is unusual for surgical residents not to complete their program or to remain in their program for additional training, despite recent evidence suggesting that current surgical training may be resulting in suboptimal experiences.1

As a consequence of time-based residency training, residents completing vascular surgical training vary in competence, and currently there is no mechanism to solve this situation. While, I am sure you will agree, none of us think we are graduating incompetent vascular surgeons, we do, however, come across residents or fellows whom we believe are not yet ready for autonomous practice at completion of their training, regardless of their training paradigm. With time determining completion of training these residents, unfortunately, at the end of their designated training period the training is done, regardless of demonstrated skills or knowledge. While this is concerning, we also see the counter to this unprepared resident.