Last night I had a nightmare

So I went back to the young surgeon and asked him if he could do an open operation. He shrugged his shoulders, and with some chagrin he explained he had done only one in his vascular residency. This was not only because there were so few aneurysms treated open, but because his OR time was reduced as a result of a mandate that residents could not work more than 40 hours a week and had to have at least 8 hours of sleep every night.

On the other hand, he had won the “Top Gun” competition at the Society for Clinical Vascular Surgery where he had successfully completed an aortic aneurysm surgery on a plastic mannequin. However, now in his first 3 years in practice he employed only endovascular techniques. He assured me, though, that he would read a textbook before the operation. Walking out of his office I noticed a framed picture in which he was surrounded by his beaming mother and grandmother as he was delivering the valedictorian speech at his grade school graduation.

The sheets were drenched with perspiration, and I cried out in my sleep, waking my wife.

“Who is going to be able to fix my aneurysm?” I said, waking myself.

“Calm down,” she said. “It’s only a dream.”

But was it? Are we training enough young surgeons in open surgery to maintain the surgical skills necessary to safely perform complex aneurysm surgery? Are our older surgeons maintaining proficiency as more and more procedures are performed percutaneously? Are the inroads from other specialties reducing overall aneurysm experience? Is the improvement in medical management slowing aneurysm growth and prevalence? Time will tell, but I believe training programs should be developing shared opportunities where programs strong in open procedures exchange their fellows with programs incorporating high-volume endovascular approaches. Further, older surgeons may need to refresh their skills in both open and endovascular procedures. Otherwise we may have to concede that Centers of Excellence may be the only way that patients can receive optimal care.