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YES
BY MALACHI G. SHEAHAN III, M.D.
Believe it or not, one thing just about all vascular surgeons will agree upon is the proper way to train. For most of us, the best way to become a surgeon is the way we became a surgeon. Therefore, unless there is some aberration in the readership circulation of Vascular Specialist, I begin this debate facing an uphill battle with most of you.
The question of how to become a vascular surgeon should not be some esoteric matter left to be debated in the late Friday session of some educational symposium. Indeed, I commend the editors for bringing this issue to a more public forum. As much as I enjoy listening to the twenty-seventh abstract redefining the risks of type 2 endoleaks at our national meeting, the matter of how to create a vascular surgeon will define our profession for years to come.
Data from the Association of American Medical Colleges shows that there is now one vascular surgeon for every 100,000 people in the U.S. That is one vascular surgeon for every 350 dialysis patients or one for every 2,600 individuals with peripheral artery disease. We are already in short supply and 40% of us are over 55 years old. Applicant numbers to traditional 5 + 2 programs have plateaued over the past 10 years, suggesting that expanding fellowship positions is not the answer. Who then will fill this gap? As Dr. Ian Malcolm warned us in “Jurassic Park,” life will find a way.
If vascular surgeons don’t act to address this need, I know two candidates who are interested. Both interventional cardiology (10% over 55) and interventional radiology (12% over 55) have younger workforces that are growing at a superior rate. Between 2008 and 2013, the largest increases in training positions offered among all medical specialties were seen in interventional cardiology and interventional radiology.
Luckily our profession has not been caught completely off guard. Integrated vascular residency positions were first offered in 2007. Based on the quality and quantity of applicants, the number of institutions offering the integrated 0 + 5 vascular residency has grown from 17 in 2009 to 51 in 2015.
As practiced today, vascular surgery bears little similarity to even a decade ago. Limb salvage, aortic interventions, vein care, and access management all require highly specific training not typically offered in a general surgery residency. Our new board certification emphasizes the ability to supervise and interpret radiologic tests. Vascular surgery training is no longer a honing of general surgical skills. We must teach and develop completely new areas of expertise in our trainees. I propose the longer we have to focus on these specific abilities, the better our product will be.
A classic argument against traditional 5 + 2 training is why have a postgraduate-year 4 or 5 performing a pancreaticoduodenectomy (Whipple procedure) when they will never perform one in practice? This, however, is a flawed point, as open abdominal cases contain many aspects that translate well to vascular surgery. I believe the enemy is not Allen O. Whipple, but rather Harvey J. Laparoscope.1 Much like the declining numbers of open aortic cases, laparoscopic surgery has replaced much of the open surgical volume in general surgery training programs. How well these skills translate to vascular is unknown, but at face value, the cross-applicability doesn’t seem to pass muster. So while no case is wasted, perhaps our trainees’ time could be spent more efficiently.
Integrated 0 + 5 programs give total control of the rotations and curriculum to the vascular program director. This allows a truly cohesive approach to developing vascular skills and knowledge over a five year period interspersed with core general surgery skills and principals. Surgery rotations such as trauma, ICU, and cardiothoracic surgery that provide the best educational content to our trainees can now be handpicked, while avoiding lower-yield content like advanced laparoscopy and breast. Quality control is now in the hands of a vascular surgeon.
After all, Erica, if the sanctity of the five year general surgery residency must be preserved, why do you run one of the world’s only 4 + 2 programs? Clearly you believe we can condense our trainees’ education without losing quality.
Using the available metrics and data points it would be difficult to prove superiority of the 0 + 5 pathway to the 5 + 2. Therefore, I will borrow a technique from my clinical trials’ friends and claim noninferiority. Follow my logic here and I promise not to include a convoluted endpoint like strokes, deaths, and non-Q wave MIs induced in training directors.
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.
We have all witnessed exceptional trainees in our programs. These trainees, regardless of their training program, sail through their surgical residencies. They meet all of the defined educational milestones, finish all of the program requirements, and demonstrate ability to care for patients unsupervised way before their set graduation date. For both these types of residents, educational landmarks, as defined by the ACGME, are of secondary importance and since only time determines completion of training, the curriculum becomes irrelevant. The question then becomes: why work to define a body of vascular surgical knowledge or a required set of technical and non-technical skills if competence is defined as time in training? Mal, surely you don’t support graduating a trainee simply because they have spent five years in training? Hopefully you would want to know that this graduating trainee is ready and competent to safely and autonomously practice the full scope of vascular surgical practice.
Competency-based education is gaining momentum around the world as medical educators, physicians, and policy makers try to ensure that our graduating specialists are acquiring and demonstrating the competencies needed to practice in today’s rapidly evolving heath care systems. It is becoming the standard in training of physicians because of the perception that it provides more transparent standards and increased public accountability. Competency-based training is learner centric, outcomes based, and differentiated. A key distinguishing feature of CBE is that residents can progress through the educational process at different rates: the most capable and talented individuals should be able to make career transitions earlier, thus allowing them to enter the workforce at an accelerated rate. Others, requiring more time, would still attain the appropriate level of knowledge, skills, and attitudes needed to enter independent practice, and leave the program only when competent.
With the emerging reality of numerous nonsurgical specialties encroaching upon various traditional domains of vascular surgery, it is essential that our specialty lead the field in vascular education so as to maintain our stronghold on these areas of expertise. Competency-based training is a logical evolutionary step from our traditional years-in-place based system. Such training should improve, or at least verify, the quality of educational outcomes for our vascular trainees and our varying training programs. This model of education will allow comparisons among training programs, differing training tracks and even differing specialty practices. I urge the vascular surgery community to discuss this concept and ultimately to implement it.
Dr. Mitchell is a professor of surgery, program director for vascular surgery, and vice-chair of Quality, Department of Surgery, Division of Vascular Surgery, Oregon Health and Science University, Portland.
References
YES
BY MALACHI G. SHEAHAN III, M.D.
Believe it or not, one thing just about all vascular surgeons will agree upon is the proper way to train. For most of us, the best way to become a surgeon is the way we became a surgeon. Therefore, unless there is some aberration in the readership circulation of Vascular Specialist, I begin this debate facing an uphill battle with most of you.
The question of how to become a vascular surgeon should not be some esoteric matter left to be debated in the late Friday session of some educational symposium. Indeed, I commend the editors for bringing this issue to a more public forum. As much as I enjoy listening to the twenty-seventh abstract redefining the risks of type 2 endoleaks at our national meeting, the matter of how to create a vascular surgeon will define our profession for years to come.
Data from the Association of American Medical Colleges shows that there is now one vascular surgeon for every 100,000 people in the U.S. That is one vascular surgeon for every 350 dialysis patients or one for every 2,600 individuals with peripheral artery disease. We are already in short supply and 40% of us are over 55 years old. Applicant numbers to traditional 5 + 2 programs have plateaued over the past 10 years, suggesting that expanding fellowship positions is not the answer. Who then will fill this gap? As Dr. Ian Malcolm warned us in “Jurassic Park,” life will find a way.
If vascular surgeons don’t act to address this need, I know two candidates who are interested. Both interventional cardiology (10% over 55) and interventional radiology (12% over 55) have younger workforces that are growing at a superior rate. Between 2008 and 2013, the largest increases in training positions offered among all medical specialties were seen in interventional cardiology and interventional radiology.
Luckily our profession has not been caught completely off guard. Integrated vascular residency positions were first offered in 2007. Based on the quality and quantity of applicants, the number of institutions offering the integrated 0 + 5 vascular residency has grown from 17 in 2009 to 51 in 2015.
As practiced today, vascular surgery bears little similarity to even a decade ago. Limb salvage, aortic interventions, vein care, and access management all require highly specific training not typically offered in a general surgery residency. Our new board certification emphasizes the ability to supervise and interpret radiologic tests. Vascular surgery training is no longer a honing of general surgical skills. We must teach and develop completely new areas of expertise in our trainees. I propose the longer we have to focus on these specific abilities, the better our product will be.
A classic argument against traditional 5 + 2 training is why have a postgraduate-year 4 or 5 performing a pancreaticoduodenectomy (Whipple procedure) when they will never perform one in practice? This, however, is a flawed point, as open abdominal cases contain many aspects that translate well to vascular surgery. I believe the enemy is not Allen O. Whipple, but rather Harvey J. Laparoscope.1 Much like the declining numbers of open aortic cases, laparoscopic surgery has replaced much of the open surgical volume in general surgery training programs. How well these skills translate to vascular is unknown, but at face value, the cross-applicability doesn’t seem to pass muster. So while no case is wasted, perhaps our trainees’ time could be spent more efficiently.
Integrated 0 + 5 programs give total control of the rotations and curriculum to the vascular program director. This allows a truly cohesive approach to developing vascular skills and knowledge over a five year period interspersed with core general surgery skills and principals. Surgery rotations such as trauma, ICU, and cardiothoracic surgery that provide the best educational content to our trainees can now be handpicked, while avoiding lower-yield content like advanced laparoscopy and breast. Quality control is now in the hands of a vascular surgeon.
After all, Erica, if the sanctity of the five year general surgery residency must be preserved, why do you run one of the world’s only 4 + 2 programs? Clearly you believe we can condense our trainees’ education without losing quality.
Using the available metrics and data points it would be difficult to prove superiority of the 0 + 5 pathway to the 5 + 2. Therefore, I will borrow a technique from my clinical trials’ friends and claim noninferiority. Follow my logic here and I promise not to include a convoluted endpoint like strokes, deaths, and non-Q wave MIs induced in training directors.
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.
We have all witnessed exceptional trainees in our programs. These trainees, regardless of their training program, sail through their surgical residencies. They meet all of the defined educational milestones, finish all of the program requirements, and demonstrate ability to care for patients unsupervised way before their set graduation date. For both these types of residents, educational landmarks, as defined by the ACGME, are of secondary importance and since only time determines completion of training, the curriculum becomes irrelevant. The question then becomes: why work to define a body of vascular surgical knowledge or a required set of technical and non-technical skills if competence is defined as time in training? Mal, surely you don’t support graduating a trainee simply because they have spent five years in training? Hopefully you would want to know that this graduating trainee is ready and competent to safely and autonomously practice the full scope of vascular surgical practice.
Competency-based education is gaining momentum around the world as medical educators, physicians, and policy makers try to ensure that our graduating specialists are acquiring and demonstrating the competencies needed to practice in today’s rapidly evolving heath care systems. It is becoming the standard in training of physicians because of the perception that it provides more transparent standards and increased public accountability. Competency-based training is learner centric, outcomes based, and differentiated. A key distinguishing feature of CBE is that residents can progress through the educational process at different rates: the most capable and talented individuals should be able to make career transitions earlier, thus allowing them to enter the workforce at an accelerated rate. Others, requiring more time, would still attain the appropriate level of knowledge, skills, and attitudes needed to enter independent practice, and leave the program only when competent.
With the emerging reality of numerous nonsurgical specialties encroaching upon various traditional domains of vascular surgery, it is essential that our specialty lead the field in vascular education so as to maintain our stronghold on these areas of expertise. Competency-based training is a logical evolutionary step from our traditional years-in-place based system. Such training should improve, or at least verify, the quality of educational outcomes for our vascular trainees and our varying training programs. This model of education will allow comparisons among training programs, differing training tracks and even differing specialty practices. I urge the vascular surgery community to discuss this concept and ultimately to implement it.
Dr. Mitchell is a professor of surgery, program director for vascular surgery, and vice-chair of Quality, Department of Surgery, Division of Vascular Surgery, Oregon Health and Science University, Portland.
References
YES
BY MALACHI G. SHEAHAN III, M.D.
Believe it or not, one thing just about all vascular surgeons will agree upon is the proper way to train. For most of us, the best way to become a surgeon is the way we became a surgeon. Therefore, unless there is some aberration in the readership circulation of Vascular Specialist, I begin this debate facing an uphill battle with most of you.
The question of how to become a vascular surgeon should not be some esoteric matter left to be debated in the late Friday session of some educational symposium. Indeed, I commend the editors for bringing this issue to a more public forum. As much as I enjoy listening to the twenty-seventh abstract redefining the risks of type 2 endoleaks at our national meeting, the matter of how to create a vascular surgeon will define our profession for years to come.
Data from the Association of American Medical Colleges shows that there is now one vascular surgeon for every 100,000 people in the U.S. That is one vascular surgeon for every 350 dialysis patients or one for every 2,600 individuals with peripheral artery disease. We are already in short supply and 40% of us are over 55 years old. Applicant numbers to traditional 5 + 2 programs have plateaued over the past 10 years, suggesting that expanding fellowship positions is not the answer. Who then will fill this gap? As Dr. Ian Malcolm warned us in “Jurassic Park,” life will find a way.
If vascular surgeons don’t act to address this need, I know two candidates who are interested. Both interventional cardiology (10% over 55) and interventional radiology (12% over 55) have younger workforces that are growing at a superior rate. Between 2008 and 2013, the largest increases in training positions offered among all medical specialties were seen in interventional cardiology and interventional radiology.
Luckily our profession has not been caught completely off guard. Integrated vascular residency positions were first offered in 2007. Based on the quality and quantity of applicants, the number of institutions offering the integrated 0 + 5 vascular residency has grown from 17 in 2009 to 51 in 2015.
As practiced today, vascular surgery bears little similarity to even a decade ago. Limb salvage, aortic interventions, vein care, and access management all require highly specific training not typically offered in a general surgery residency. Our new board certification emphasizes the ability to supervise and interpret radiologic tests. Vascular surgery training is no longer a honing of general surgical skills. We must teach and develop completely new areas of expertise in our trainees. I propose the longer we have to focus on these specific abilities, the better our product will be.
A classic argument against traditional 5 + 2 training is why have a postgraduate-year 4 or 5 performing a pancreaticoduodenectomy (Whipple procedure) when they will never perform one in practice? This, however, is a flawed point, as open abdominal cases contain many aspects that translate well to vascular surgery. I believe the enemy is not Allen O. Whipple, but rather Harvey J. Laparoscope.1 Much like the declining numbers of open aortic cases, laparoscopic surgery has replaced much of the open surgical volume in general surgery training programs. How well these skills translate to vascular is unknown, but at face value, the cross-applicability doesn’t seem to pass muster. So while no case is wasted, perhaps our trainees’ time could be spent more efficiently.
Integrated 0 + 5 programs give total control of the rotations and curriculum to the vascular program director. This allows a truly cohesive approach to developing vascular skills and knowledge over a five year period interspersed with core general surgery skills and principals. Surgery rotations such as trauma, ICU, and cardiothoracic surgery that provide the best educational content to our trainees can now be handpicked, while avoiding lower-yield content like advanced laparoscopy and breast. Quality control is now in the hands of a vascular surgeon.
After all, Erica, if the sanctity of the five year general surgery residency must be preserved, why do you run one of the world’s only 4 + 2 programs? Clearly you believe we can condense our trainees’ education without losing quality.
Using the available metrics and data points it would be difficult to prove superiority of the 0 + 5 pathway to the 5 + 2. Therefore, I will borrow a technique from my clinical trials’ friends and claim noninferiority. Follow my logic here and I promise not to include a convoluted endpoint like strokes, deaths, and non-Q wave MIs induced in training directors.
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.
We have all witnessed exceptional trainees in our programs. These trainees, regardless of their training program, sail through their surgical residencies. They meet all of the defined educational milestones, finish all of the program requirements, and demonstrate ability to care for patients unsupervised way before their set graduation date. For both these types of residents, educational landmarks, as defined by the ACGME, are of secondary importance and since only time determines completion of training, the curriculum becomes irrelevant. The question then becomes: why work to define a body of vascular surgical knowledge or a required set of technical and non-technical skills if competence is defined as time in training? Mal, surely you don’t support graduating a trainee simply because they have spent five years in training? Hopefully you would want to know that this graduating trainee is ready and competent to safely and autonomously practice the full scope of vascular surgical practice.
Competency-based education is gaining momentum around the world as medical educators, physicians, and policy makers try to ensure that our graduating specialists are acquiring and demonstrating the competencies needed to practice in today’s rapidly evolving heath care systems. It is becoming the standard in training of physicians because of the perception that it provides more transparent standards and increased public accountability. Competency-based training is learner centric, outcomes based, and differentiated. A key distinguishing feature of CBE is that residents can progress through the educational process at different rates: the most capable and talented individuals should be able to make career transitions earlier, thus allowing them to enter the workforce at an accelerated rate. Others, requiring more time, would still attain the appropriate level of knowledge, skills, and attitudes needed to enter independent practice, and leave the program only when competent.
With the emerging reality of numerous nonsurgical specialties encroaching upon various traditional domains of vascular surgery, it is essential that our specialty lead the field in vascular education so as to maintain our stronghold on these areas of expertise. Competency-based training is a logical evolutionary step from our traditional years-in-place based system. Such training should improve, or at least verify, the quality of educational outcomes for our vascular trainees and our varying training programs. This model of education will allow comparisons among training programs, differing training tracks and even differing specialty practices. I urge the vascular surgery community to discuss this concept and ultimately to implement it.
Dr. Mitchell is a professor of surgery, program director for vascular surgery, and vice-chair of Quality, Department of Surgery, Division of Vascular Surgery, Oregon Health and Science University, Portland.
References
