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Vascular training in general surgery residency programs: The Canadian experience

R. S. Sidhu, MD, FRCS(C),a,b M. Ko, MD,c L. Rotstein, MD, FRCS(C),c and K. W. Johnston, MD, FRCS(C),a Toronto, Ontario, Canada

Objectives: is traditionally considered a component of general surgery. There is growing evidence of improved patient outcome related to surgeon volume and vascular certification status. The American Board of Surgery in the United States, as well as until recently the Royal College of Physicians and Surgeons in Canada, requires that vascular surgery be considered an essential content area of general surgery training. This requirement is controversial. The purpose of this study was to describe experience and perceived competence in common vascular surgery procedures during general surgery residency training in Canada. Methods: This web-based survey was conducted between January and June 2002. General surgery program directors (GSPDs), vascular surgeons involved in general surgery training programs (VSs), and senior general surgery residents (SRs) from the 13 English-speaking general surgery programs in Canada were surveyed. Questions were asked regarding which vascular surgery procedures are appropriate for general surgeons to perform, which procedures SRs are trained to perform, and which procedures SR intend to perform. Results: The response rate was 62% for GSPDs, 57% for VSs, and 45% for SRs. Overall, 49% of SRs did not intend to perform any vascular procedures after training. GSPDs, VSs, and SRs indicated that most SRs should be and are trained to perform varicose surgery, leg amputation, and femoral (P > .05). In addition, GSPDs, VSs, and SRs indicated that SRs should not be and are not trained to perform infrainguinal bypass grafting, carotid , or abdominal (AAA) repair (P > .05). There were significant differences with respect to ruptured AAA repair: 49% of SRs, 25% of PDs, and only 12% of VSs believe that general surgeons should be trained to perform ruptured AAA repair (P < .05). Overall, 76% of VSs believe SRs receive too little vascular training. Conclusion: There is similarity between GSPDs, VSs, and SRs with respect to vascular surgery training in Canadian general surgery programs. Vascular surgery training cannot be considered a component of general surgery. More rotations or fellowship training is required to become competent in management of common vascular surgery procedures. Perhaps this level of competence should not be an objective of general surgery training. (J Vasc Surg 2003;38:1012-7.)

Vascular surgery is traditionally considered a compo- tives to remove vascular surgery as a primary component of nent of general surgery. The American Board of Surgery general surgery.3 (ABS) considers vascular surgery to be one of the nine Currently, there is considerable controversy regarding “essential content areas” of general surgery. According the amount of vascular training general surgery trainees to the ABS, a general surgery trainee is expected to should receive and whether general surgeons should per- have “knowledge and experience related to the diag- form vascular surgery. nosis...management, including management of compli- Those who argue that vascular surgery be considered a cations, in the essential content areas.”1 separate specialty state that vascular surgery has evolved In Canada, the Royal College of Physicians and Sur- into a complete specialty, with its own domain of knowl- edge, surgical and minimally invasive interventions, and geons (RCPSC) sets objectives for specialty training. In the invasive and noninvasive imaging, that is distinct from 1996 objectives, the RCPSC required that every general general surgery.4 Furthermore, there is growing evidence surgery resident attain “sufficient knowledge and judgment that better vascular surgical outcome is related to surgeon to manage lesions of the vascular system.”2 In July 2002 volume and vascular certification status.5,6 the RCPSC modified the general surgery training objec- Those who argue that vascular surgery is a component of general surgery state that general surgeons must perform vascular surgery to meet the societal burden of vascular From Division of Vascular Surgery,a Centre for Research in Education,b and 7 Division of General Surgery,c University of Toronto. disease. Furthermore, vascular surgical skill is considered Competition of interest: none. essential to exposure and control of blood vessels in trauma Presented at the 24th Annual Meeting of the Canadian Society for Vascular and oncologic surgery.7 Surgery, Halifax, NJ, Oct 25-26, 2002. This controversy is exemplified by the public debate Reprint requests: R. S. Sidhu, MD, University of Toronto Faculty of , Centre for Research in Education at the University Health between the ABS and the newly created American Board of 7,8 Network, Eaton South, Rm 1-565, 200 Elizabeth St, Toronto, Ont, Vascular Surgery. The current situation in Canadian Canada M5G 2C4 (e-mail: [email protected]). programs has not been studied. Published online Sep 11, 2003. The purpose of this study is to describe the experience Copyright © 2003 by The Society for Vascular Surgery. 0741-5214/2003/$30.00 ϩ 0 and perceived competence in common vascular surgery doi:10.1016/S0741-5214(03)00611-6 procedures during general surgery training from a national 1012 JOURNAL OF VASCULAR SURGERY Volume 38, Number 5 Sidhu et al 1013 perspective. Specifically, the study was designed to address Table I. Survey form for general surgery program the following question with respect to common vascular directors surgery procedures: In Canada, are there significant differ- ences in the proportion of vascular surgeons, general sur- Dear Program Director: Please complete this form and click gery program directors, and senior general surgery resi- submit below. Thank you again for your cooperation. Please provide your e-mail address: dents who believe that a specific procedure should be part Location of residency program: of general surgery training and that the procedure is being Number of months of mandatory vascular rotations as a junior in taught in each respondent’s respective program? your program: Number of months of mandatory vascular rotations as a senior METHODS resident in your program: Please indicate which of the following vascular surgery A web-based survey was conducted between January procedures you feel a graduate from any general surgery and June 2002. All eligible participants were sent an e-mail program should be able to perform (without further training)? with a link to the survey home page. Repeat e-mails were e Elective abdominal aortic aneurysm (AAA) repair e sent to participants who did not respond to the first request. Ruptured AAA repair e Femoral embolectomy Eligible participants included all general surgery pro- e Infrainguinal bypass gram directors (GSPDs), vascular surgeons involved in e Varicose vein ligation/stripping general surgery training (VSs), and senior (postgraduate e e year 4 or beyond) general surgery residents (SRs) from the Arterviovenous fistula e Leg amputation 13 English-speaking general surgery programs in Canada. e None of the above Vascular surgeons were eligible for this study if general Please indicate which of the following vascular surgery surgery residents rotated on their clinical services. procedures you believe your general surgery graduates are Participants were asked which vascular procedures a adequately trained to perform? e graduate of any general surgery program should be able to Elective AAA repair e Ruptured AAA repair perform. They were also asked to indicate which vascular e Femoral embolectomy procedures graduates of their specific residency programs e Infrainguinal bypass are adequately trained to perform. SRs were further asked e Varicose vein ligation/stripping e which vascular procedures they intend to perform in surgi- Carotid endartectomy e Arteriovenous fistula cal practice. All participants were asked if general surgery e Leg amputation residents’ vascular exposure was too little, just right, or too e None of the above much. The survey forms are reproduced in Tables I Overall, how do you feel about the amount of vascular training (GSPD), II (VS), and III (SR). in your program: The survey focused on the following procedures: elec- tive abdominal aortic aneurysm (AAA) repair, ruptured AAA repair, lower-extremity arterial bypass grafting, ca- rotid endarterectomy (CEA), varicose vein surgery, femoral perform. For femoral embolectomy, 68% of VSs, 50% of embolectomy, leg amputation, and access GSPDs, and 57% of SRs indicated that this procedure surgery. The survey was reviewed by a psychologist to should be part of general surgery training. More than 80% ensure that it was balanced, unbiased, and unambiguous. of all three groups of survey participants indicated that To ensure clarity, a pilot survey was completed by residents varicose vein surgery should be part of general surgery not eligible for study entry. training. A similarly high proportion also indicated that leg For statistical analysis, the ␹2 test was used for all amputation should be part of general surgery. There were categorical data, to determine whether differences existed no significant differences (P Ͼ .05) between responses from between the three groups for each procedure. If P was VSs, GSPDs, and SRs for any of these three procedures. significant for the ␹2 test (Ͻ.05), the Fisher exact test was When participants were asked which of these three used to determine which pair or pairs of groups were procedures were being adequately taught in their general significantly different, correcting for experiment-wise error surgery residency programs, most respondents indicated (P ϭ .05) for multiple comparisons. that residents were being trained in these procedures: more than 50% for femoral embolectomy and amputation, and RESULTS more than 75% for varicose vein surgery (Table I). There The response rate was 62% for GSPDs (8 of 13), 57% were no significant differences (P Ͼ .05) between the for VSs (25 of 44 responding), and 45% for SRs (47 of 104 responses from VSs, GSPDs, and SRs for any of these three responding). All SRs had completed at least 3 months of procedures. vascular training. Hemodialysis access surgery. The results for dialysis Femoral embolectomy, varicose vein surgery, and access surgery (Table IV) indicate that fewer than 30% of leg amputation. Table IV summarizes the results for fem- VSs, GSPDs, and SRs believe general surgery residents are oral embolectomy, varicose vein surgery, and leg amputa- being adequately trained to perform these procedures. tion when participants were asked which procedures a There were no significant differences (P Ͼ .05) between the graduate of any general surgery program should be able to responses from VSs, GSPDs, and SRs. JOURNAL OF VASCULAR SURGERY 1014 Sidhu et al November 2003

Table II. Survey form used for vascular surgeons Table III. Survey form used for senior general surgery residents Dear Vascular Surgeon: Please complete this form and click on the submit button below. Dear Resident: Please complete the form below. Please provide your e-mail address: Location of residency training: Location of residency training program: Year of training: Level of training of general surgery residents on your service: Number of months of vascular rotations during residency Do you participate in a vascular surgery residency training (elective): program? Number of months of vascular rotations (required)? Please indicate which of the following vascular surgery Please indicate which of the following vascular surgery procedures you feel a graduate of any general surgery program procedures you feel a graduate of any general surgery program should be able to perform (without further training)? should be able to perform (without further training)? e Elective AAA repair e Elective AAA repair e Ruptured AAA repair e Ruptured AAA repair e Femoral embolectomy e Femoral embolectomy e Infrainguinal bypass e Infrainguinal bypass e Varicose vein ligation/stripping e Varicose vein ligation/stripping e Carotid endarterectomy e Carotid endarterectomy e Arteriovenous fistula e Arteriovenous fistula e Leg amputation e Leg amputation e None of the above e None of the above Please indicate the following vascular surgery procedures that After general surgery residency, which of the following vascular you believe your general surgery graduates are adequately surgery procedures do you intend to perform (without further trained to perform? training)? e Elective AAA e Elective AAA repair e Ruptured AAA e Ruptured AAA repair e Femoral embolectomy e Femoral embolectomy e Infrainguinal bypass e Inrainguinal bypass e Varicose vein ligation/stripping e Varicose vein ligation/stripping e Carotid endarterectomy e Carotid endarterectomy e Arteriovenous fistula e Arteriovenous fistula e Leg amputation e Leg amputation e None of the above e None of the above Overall, what do you feel about the amount of vascular training After general surgery residency, please identify which of the in general surgery? following vascular surgery procedures you believe you are Please provide any comments you may have regarding this study: adequately trained to perform? e Elective AAA e Ruptured AAA e Femoral embolectomy e Infrainguinal bypass AAA repair, lower-extremity arterial bypass graft- e Varicose vein ligation/stripping ing, and CEA. The results for AAA repair, lower-extrem- e Carotid endarterectomy ity arterial bypass grafting, and CEA are presented in Table e Arteriovenous fistula e IV. When asked if a graduate of any general surgery pro- Leg amputation e None of the above gram should be able to perform these procedures, VSs, Overall, how do you feel about the adequacy of vascular surgery GSPDs, and SRs indicated that these should not be part of training in your program? general surgery training. There were no significant differ- Do you have any comments regarding vascular training in ences (P Ͼ .05) between responses from VSs, GSPDs, and general surgery? SRs for any of these three procedures. The results were similar when participants were asked Significant differences were also found (P Ͻ .05) when which of these procedures residents in their specific pro- participants were asked if residents in their programs were grams are adequately trained to perform (Table IV). Again adequately trained to perform ruptured AAA repair (Table there were no significant differences (P Ͼ .05) between IV). Fifty percent of GSPDs, 28% of SRs, and only 8% of responses from VSs, GSPDs, and SRs for any of these three VSs indicated that residents were trained in ruptured AAA procedures. repair. Specifically, the proportion of VSs (8%) was signifi- Ruptured AAA repair. Responses were significantly cantly different (P ϭ .04) from the proportion of GSPD different (P Ͻ .05) when participants were asked if any (50%) indicating that residents in their respective programs general surgery graduate should be able to perform rup- were being trained in ruptured AAA repair. tured AAA repair (Table IV). For ruptured AAA repair, Intent to practice. Forty-nine percent of SRs indi- 49% of SRs, 25% of GSPDs, and only 12% of VSs indicated cated they do not intend to perform any vascular proce- that this procedure should be part of general surgery train- dures in their eventual practice (Fig 1). Forty-five percent ing. Specifically, the proportion of SRs (49%) was signifi- indicated they intend to perform varicose vein surgery, and cantly different (P ϭ .006) from the proportion of VSs 32% intend to perform amputation. Fewer than 10% indi- (12%) indicating that ruptured AAA should be part of cated they intend to perform AAA repair, lower extremity general surgery training. arterial bypass grafting, or CEA. JOURNAL OF VASCULAR SURGERY Volume 38, Number 5 Sidhu et al 1015

Few, if any, general surgery trainees feel competent to deal with the full spectrum of vascular disease. Similarly to the way in which vascular surgery has evolved, it seems that general surgery in Canada has evolved into a specialty with focus on the gastrointestinal tract, trauma, breast disease, and endocrine disorders. This has left most vascular surgery in Canada to be performed by vascular surgeons. The results of this study are important because, here- tofore, the vascular training experience in Canadian general surgery programs was not known. Unlike in the United States, there is no central database (operative logs) for resident operative experience in general surgery. The RCPSC does not stipulate minimum number of cases re- quired for program accreditation (analogous to Accredita- tion Council for Graduate Medical Education require- ments) or certification (analogous to ABS requirements). Given this reality, it is impossible to compare Canadian operative experience in terms of number of cases with that of the United States. Until the RCPSC makes such a Fig 1. Percentage of senior residents who intend to perform database mandatory, it is unlikely that validated operative selected vascular surgery procedures. experience numbers from Canadian programs will be avail- able. Because of this lack of information, this study is significant as an initial investigation into the current Cana- dian experience. Current vascular surgical practice patterns of Canadian general surgeons have been incompletely reported in the literature. In Ontario, a substantial proportion (20%) of AAA repairs are performed by general surgeons,6 and most carotid are performed by certified vascu- lar or neurosurgeons.9 A review of the literature provides no further information regarding the practice patterns of Canadian general surgeons with respect to infrainguinal bypass grafting, hemodialysis access, or other vascular pro- cedures. This paucity of information must be addressed by future research studies. Until this information is known, the full effect of the implications of the present study remains speculative. Fig 2. Overall impression of adequacy of vascular surgery experi- There were significant differences with respect to rup- ence during general surgery training. tured AAA repair. Although most senior residents and their program directors believe general surgical trainees are not Overall impression. When asked about their overall and should not be trained in elective aneurysm repair, half impression of vascular training in general surgery, most VS of the senior residents believe they should be trained to (76%) believed it is too little. Most GSPDs (88%) believe it perform ruptured AAA repair. There are two reasons for is just right. For SRs, 47% believe their vascular training is this paradox. First, surgeons are recognizing that elective too little, and 51% believe it is just right (Fig 2). surgical outcome is related to surgeon volume and certifi- cation status; hence, as supported by the results of this DISCUSSION study, they believe high-volume certified surgeons should The results of this study indicate that there is similarity perform elective surgery. Second, Canada has a sparse between GSPDs, VSs, and SRs with respect to vascular population, distributed over a large geographic area. In surgery training objectives in Canadian general surgery many northern areas, patients who require emergency sur- programs. gery are 4 to 6 hours from the nearest general surgeon and Currently, varicose vein surgery, leg amputation, and another 2 to 6 hours from a vascular service. Given this femoral embolectomy can be considered part of general reality, and the reality of poor climate and travel conditions, surgery training. However, the major vascular surgery pro- it is easy to see why some may expect general surgeons to be cedures, including AAA repair, lower-extremity arterial by- prepared to repair the occasional ruptured aneurysm. pass grafting, and CEA cannot be considered part of gen- Given the paucity of published information regarding eral surgery training in Canada. Controversy exists as to the the proportion of ruptured aneurysms that are currently place for ruptured AAA repair. being repaired by general surgeons in Canada, further study JOURNAL OF VASCULAR SURGERY 1016 Sidhu et al November 2003

Table IV. Percentage of respondents indicating which procedures should be performed by a graduate of any general surgery program and which are adequately trained in their specific programs

Percent of each surveyed group Percentage of each surveyed group indicating that a graduate of any indicating the procedures that general general surgery program should be able surgery graduates of their particular to perform procedure (without program are adequately trained further training) to perform Procedure VS GSPD SR VS GSPD SR

Femoral embolectomy 68 50 57 52 75 55 Vein surgery 96 88 83 92 88 74 Amputation 84 50 83 76 50 70 Dialysis access surgery 44 13 26 8 13 28 AAA repair 4 0 15 8 13 19 Infrainguinal bypass grafting 0 0 4 0 13 15 CEA 0 0 6 0 0 9 Ruptured AAA repair 12 25 49 8 50 28

VS, Vascular surgeons; GSPD, general surgery program directors; SR, senior general surgery residents; AAA, abdominal aortic aneurysm; CEA, carotid endarterectomy. in this area is recommended. Given the geographic limita- programs.11-14 It is inevitable that there will soon be a tions of Canada, expedient repair of a ruptured aneurysm similar decrease in interest in fellowship training programs. by a certified vascular surgeon, or a well-trained, high- At the same time, the population is aging and the field volume general surgeon, remains a difficult challenge. of vascular surgery is expanding to include vascular medi- Limitations of this study are related to the survey cine, endovascular therapy, and noninvasive imaging, as method. The response rate for senior residents was only well as traditional open surgery. Given the expansion of 45%. However, this compares favorably with similar stud- vascular surgery and the pressure on all residency programs ies10 and is a sufficient sample from which to draw conclu- to reduce training hours (and provide an enhanced envi- sions. Senior residents were also asked to describe their ronment to improve recruitment), it is unlikely that future competence in vascular procedures and their practice in- general surgeons will be trained in the full spectrum of tent. Inasmuch as these residents had not yet completed vascular disease management. This reality has been ac- their training, the responses may not accurately reflect their knowledged by the ABS. In the most recent definition of eventual competence and practice. To address this concern, general surgery, the ABS stated that experience in the the survey was restricted to residents in the final 2 years of essential content areas may not include the full spectrum of training. Despite this restriction, some postgraduate-year-4 procedural complexity, especially if approved fellowship residents may not have fully completed their vascular sur- training exists in that content area. gery experience. This limitation must be taken into account To attract the best and brightest, leaders in vascular in extrapolating the results of this study. Finally, some surgery education must consider reducing the total training residency programs may offer the opportunity for a resident time required to become a vascular surgeon, while wres- to obtain further vascular training to meet individual future tling with how to include surgical, endovascular, research, practice requirements. This survey was not designed to and vascular laboratory training in their programs. identify programs that provide this type of “optional” The requirement for completion of a full general sur- vascular training. gery residency must be reviewed. Vascular surgery rotations during general surgery train- The results of this study raise many questions. Will ing seem to provide significant exposure to the “basic” there be enough trained specialists to deal with the burden procedures (eg, varicose vein stripping). The objectives of of vascular disease? Should the structure of vascular training the vascular rotations have changed from learning how to be changed, because there is little in common with general comprehensively manage vascular disease to gaining facility surgery (eg, entry into vascular training programs without with vascular exposure and control, exposure to vascular finishing general surgery)? Should Canadian general sur- surgery as a possible career choice, and an appreciation for gery programs make more of an effort to include vascular the complexity of decision-making required. training? The implications of these questions should be the In North America, surgery is facing a crisis. Surgery is focus of further research. slowly losing its stature as one of the “elite” programs. Increasing medical student debt, perceived and real lifestyle CONCLUSION limitations of surgical training, an increasing proportion of Vascular surgery cannot be considered merely a com- female medical students, concerns about remuneration, ponent of general surgery in Canada. More rotations or and duration of surgical training have resulted in a de- fellowship training is required for a general surgery trainee creased number of applicants to general surgery residency to become competent in complete management of vascular JOURNAL OF VASCULAR SURGERY Volume 38, Number 5 Sidhu et al 1017

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