Change Doesn’t Come Easy! But Is Needed

Dr. Makaroun cited the difficulties of recruitment of vascular surgeons to community hospital systems in small towns and rural areas, and he reminded people that recent general surgery graduates continue to offer vascular surgery services in such communities. Unfortunately, this is without any additional vascular training and most hospitals grant privileges without a VSB certificate when the need is demonstrated. “You all appreciate that recent graduates of general surgery programs do not have the breadth or depth of exposure to modern vascular surgery that an older generation did,” he added.

The workgroup explored many options to provide relief to community hospitals. But probably the most efficient, according to Dr. Makaroun, is to consider strategies that tap into new constituencies. One consideration to be explored is to offer a 3-year vascular surgery training opportunity to the dozens of qualified candidates in preliminary surgical positions unable to locate a categorical spot to finish their training. This process will lead to VSB certification, but will take some time to establish through the ACGME structure.

The workgroup developed an outline of a proposal for a community vascular surgery training program, as a first step. It has been sketched and will be part of the task force report submitted for review by the Executive Board of the Society.

The goals of the new pathway would be to improve local vascular care in underserved communities, while increasing the referral of appropriate cases to vascular centers. It would provide stress relief to isolated vascular surgeons, and where none exist, plant the seeds of a better work environment for vascular surgery graduates to reconsider this currently undesirable career choice.

The program is designed to offer an additional year of vascular surgery training to general surgery graduates already committed to a community practice, many of whom are already planning to offer vascular services anyway. The program will individualize training but focus only on low-complexity procedures, both open and endovascular, and more importantly the clinical situations that dictate referral, said Dr. Makaroun.

To maintain quality, the program will mandate the availability of mentorship, support and real-time advice after completion of the program, through a regional “sponsoring vascular surgery service.” This service will also be responsible for retrospective peer review and root cause analysis of complications. In addition, the association with a sponsoring institution will facilitate and increase referrals of appropriate patients to higher level of care at a vascular surgery center.

“The suggested program graduates will not be board-certified and will be performing mostly general surgery and low-complexity vascular cases part- time in smaller communities. They will also require supervision by the board-certified graduates of the current training pathways, working in a regional vascular center, typically in a larger urban center. Instead of competing they will actually complement our current trainees and provide an extension of their reach.” Dr. Makaroun stated.

“We must find a way to fill the vacuum now before the reality on the ground permanently excludes our specialty from this primary level of vascular care,” Dr. Makaroun said. “It is time for another bold step to preserve the legacy of our specialty in meeting the needs of our patients and the public.

“Progress is made through change even if we don’t like it!” Dr. Makaroun concluded.