Basic science curriculum in vascular surgery residency☆☆☆

Article Outline

• Abstract
• Materials and methods
  • Questionnaire
  • Vascular surgery residents' performance on basic science items on the VQE
  • VQE content outline and the vascular surgery unit of the surgical resident curriculum
  • Statistical analysis
• Results
  • Questionnaire
  • Vascular surgery residents' performance on basic science items on the VQE
  • VQE content outline and the vascular surgery unit of the surgical resident curriculum
• Discussion
• Recommendations
• Acknowledgements
• Appendix
• References
• Copyright

Abstract 

Recognizing the importance of basic science teaching in surgical education, the leadership of the Association of Program Directors in Vascular Surgery (APDVS) appointed a panel to gather information and to present its findings at the 1999 annual fall meeting of the Apdvs. A questionnaire was distributed to the program directors present. In addition, information was gathered from the American Board of Surgery regarding the basic science content in the vascular surgery item pool on the vascular surgery qualifying examination (VQE). The vascular surgery unit of the surgical resident curriculum was also analyzed. Fifty-three program directors (64%) completed the questionnaire. Although only two program directors felt that their residents were better prepared to answer basic science questions, the results of the Vqe showed that the examinees do not, as a group, perform differently on basic science items than on clinical management questions. In addition, only a minority of program directors (15%) use a specific method to monitor the learning process of their residents. The majority of the program directors responding (75%) felt that they were capable of teaching basic science to residents. Interestingly, almost half the 53 respondents (47%) said that a basic science curriculum should be comprehensive, not exclusively relevant to the clinical setting. Vqe content outline and the vascular surgery unit of the surgical resident curriculum revealed great emphasis on clinically relevant basic science information. The Apdvs panel recommends that a basic science curriculum should be comprehensive, yet clinically pertinent, and completely integrated with the clinical curriculum. In terms of how to teach basic science in vascular residencies, the panel supports teaching conferences that are problem-based with a faculty member acting as the “resource person” and with specific goals set for the conferences. The panel also suggested establishing a Web site that provides a series of questions, the answers of which could be readily available to trainees and program directors. such immediate feedback could be of great help to program directors to focus the learning process of their residents and monitor its progress. (J Vasc Surg 2001;33:854-60.)

The incorporation of basic science education in medical training was recommended in 1910 by Abraham Flexner in a landmark report commissioned by the American Medical Association in an effort to identify weak and inadequate medical schools.¹, ² The Flexner report proposed sweeping changes to strengthen the academic and scientific components of medical education.², ³, ⁴ In the “post-Flexnerian era,” schools unable to provide credible academic programs were closed. By the mid 1920s, 32 of 55 medical schools had closed.⁵, ⁶, ⁷ Some “marginal” schools went to extraordinary measures to ensure their survival, enlisting the help of politicians, lobbyists, and educators, in addition to their own fund raising efforts.⁴ This was followed by a major growth in basic science departments in the remaining medical schools, coupled with growth in basic science research. However, the utility of basic science in clinical medicine was not uniformly appreciated, resulting in fragmentation of teaching because basic science was not integrated in clinical medicine.⁵

Understanding the basic science underpinnings of disease processes is a well-established hallmark of modern medical education. Recognizing the importance of this relationship, the leadership of the Association of Program Directors in Vascular Surgery (APDVS) sought: (1) to gather information regarding the opinions of program directors on current basic science teaching in vascular residencies including evaluation, if any, of the basic science knowledge of vascular residents; (2) to gather information on the performance of vascular residents on the basic science items on the Vascular Surgery Qualifying Examination (VQE); and (3) to use this information to make recommendations on the integration of basic science teaching into vascular residencies. This report summarizes those findings and the resultant recommendations.

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Materials and methods 

Questionnaire 

The program directors attending the 1999 Annual Fall Meeting of the APDVS were given a 12-item questionnaire (Fig 1) designed to obtain information about the programs represented and to solicit opinions regarding whether basic science should be taught, what the content should be, and who should be teaching it.

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• Fig. 1. 

  Questionnaire distributed to vascular surgery program directors present at the Annual Fall Meeting of the APDVS held in San Francisco on October 10, 1999. Numbers in boldface indicate the numbers of respondents agreeing with a particular item. Note: The number of respondents to question 6 does not add up to the total number of respondents (53) because four respondents left that question unanswered.

In addition, program directors were asked to provide opinions regarding the most efficient way to teach basic science to vascular residents. Because there is a perceived weakness in the knowledge of basic science of vascular disease, the questionnaire included questions relating to the perception of program directors regarding the performance of the vascular residents on basic science items on the VQE.

Vascular surgery residents' performance on basic science items on the VQE 

Information regarding the 708 basic science items that comprise the vascular surgery item pool was obtained from the American Board of Surgery. One hundred thirty of these items were deemed to be “basic science.” These items were further categorized and subcategorized into various basic science areas. All these items were used on examinations in the last 8 years, and most had been used within the last 2 years. When an item had been used on multiple examinations, the performance characteristics for only its most recent use on a VQE were considered. In addition to the 130 items, 10 basic science items were identified that had been on a VQE during the last 3 years, but they were then deleted from final scoring because the examinees performed poorly with those items (ie, < 30% of the examinees answered the item correctly).

VQE content outline and the vascular surgery unit of the surgical resident curriculum 

The content of these outlines was examined by the panel to identify the current test requirements for residents in vascular surgery and in general surgery. In addition, any duplication between the two sets of requirements was identified.

Statistical analysis 

Analysis of variance was used to assess the results of performance on the basic science items of the VQE. A P value less than .05 was considered significant.

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Results 

As of October 1999, there have been 81 vascular surgery residency programs approved by the Accreditation Council for Graduate Medical Education, with a total of 100 vascular surgery residency positions. Although vascular surgery residency is approved for 1 year, 53 of these programs are 2-year programs; the extra year is used mainly for research (basic science, clinical, or both). In addition, there are seven free-standing programs that offer a total of seven positions.⁸

Questionnaire 

A total of 53 program directors responded to the questionnaire. Their answers to questions 1 through 10 are given in Fig 1. Although the vast majority of program directors (94%) responding thought that basic science should be taught during vascular surgery residencies, only 13 respondents (24%) actually require a specific text to be read by the residents. Most program directors thought that their vascular residents are less prepared (37% of program directors) or equally prepared (51% of program directors) to answer the basic science questions on the VQE than they are to answer the clinical questions. Only two program directors felt that their residents were better prepared to answer basic science questions. Although a majority of program directors (68%) said that they monitor the “learning process” of their residents, only a minority (15%) use a specific method to do so. When asked about the specific methods used, only one responded with the use of a “brief” examination to evaluate the preparation for the VQE. The remaining seven respondents maintain frequent contact with the residents to discuss various clinical and basic science topics, thereby helping the program director to evaluate the residents' preparation for the VQE. Most of the respondents (75%) thought that they were prepared to teach basic science issues to residents. In addition, only 23 (43%) said that a specific faculty member, rather than all faculty, can teach basic science topics. Interestingly, almost half the respondents (47%) said that a basic science curriculum should be a comprehensive one and not one that is only clinically relevant.

The answers to question 12 of the questionnaire, “What would be the best and the most efficient way to teach basic science topics to vascular residents?” are summarized in Fig 2.

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• Fig. 2. 

  Answers to question 12 of the questionnaire (see Fig 1): What would be the best and most efficient way to teach basic science topics to residents?

Vascular surgery residents' performance on basic science items on the VQE 

The basic science categories on the VQE and the performance characteristics of the examinees are summarized in Table I. The number and percent of the basic science items in each category are listed in the second and third columns of Table I, respectively. The overall value of PT (percent of examinees answering correctly) was 71% and the overall R value (discrimination index between high scorers and low scorers) was 0.23. These values are similar to the PT and R values for each VQE given during this period (data not shown). Thus, even though basic science items are a minority of the test items, they do not, as a group, produce scores any different than do clinical management items.

Table I. Categories of basic science items that appeared on the VQE

PT, Percent of examinees answering the items correctly; R, discrimination index (between high scorers and low scorers); < 50%, examinees answering less than 50% of the items correctly.

The fourth and fifth columns of Table I show the respective average PT values and average R values within each of the basic science categories. These PT values range from 56% to 94% and the R values from 0 to 0.35. However, the low number of items in some categories (eg, biochemistry, prosthetic graft materials) makes an accurate comparison difficult. The analysis of variance of the differences among PT values within categories with eight or more items reveals statistically significant differences among the groups (P = .013, F = 2.668).

To assess the difficult topic areas, the 140 basic science items were filtered for items where the PT value was less than 50% (ie, less than half the examinees answered correctly). Twenty-five such items were identified. The sixth and seventh columns in Table I list the number and the percentage of these items, respectively, among the basic science categories. Anatomy, physiology, coagulation, and pathology contain the preponderance of these items. The keywords of the 25 items with PT values less than 50% are shown in Table II to avoid problems that might arise because of an arbitrary assignment into a basic science category.

Table II. Keywords of the items with PT value less than 50%

PT, Percent of examinees answering the items correctly.

As might be expected, the percentage of items in a category where the PT value was less than 50% correlates with the average PT value for the category.

VQE content outline and the vascular surgery unit of the surgical resident curriculum 

Basic science is part of every component of the VQE content outline (detailed list, online only). The following components are included: arterial system, venous system, lymphatic system, trauma, complications, miscellaneous, and total vascular system. Each component contains subdivisions; for example, the arterial component includes: carotid-vertebral disease, upper extremity arterial insufficiency, thoracic outlet/ vasospastic disease, aortoiliac disease, celiac/mesenteric disease, renal arterial disease, and femoropopliteal disease. In addition to clinical knowledge, basic science knowledge is required for each subdivision. This basic science knowledge includes anatomy, physiology/pathophysiology, and pathology/pathogenesis. For example, knowledge of the following is required to have an understanding of the anatomy of the carotid-vertebral disease: the anatomy of the seventh, ninth, eleventh, and twelfth cranial nerves and their functions; nerves encountered during carotid endarterectomy and their functions; baroreceptors and chemoreceptors and their functions; carotid-vertebral collateral pathways; and the anatomy of the carotid and vertebral arteries. It is necessary to possess knowledge of the physiology of cerebral blood flow and the pathogenesis of carotid stenosis to attain a grasp of the physiology and pathophysiology of carotid-vertebral disease.

The two objectives of the vascular surgery unit (unit 4.8) of the surgical resident curriculum are (1) to demonstrate knowledge of the anatomy, physiology, and pathophysiology of the vascular system, including congenital and acquired diseases and (2) to demonstrate the ability to surgically manage the preoperative, operative, and postoperative care of patients with arterial, venous, and lymphatic disease. Therefore, the first objective, regarding the demonstration of knowledge of the anatomy, physiology, and pathophysiology of the vascular system, reveals a significant overlap with the basic science knowledge requirement in the VQE content outline.

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Discussion 

Although basic science may not always seem useful to medical trainees, this knowledge promotes the understanding of disease processes. Understanding was defined by Sweeney⁵ as “the possession of a theoretical framework into which new information can be inserted.” Sweeney formulated the objectives of teaching basic science during medical education; these objectives were to provide understanding of the biological basis of disease as a context for learning, to understand the significance of new advances, to understand how a treatment will act, to be able to explain concepts to patients in a manner that helps them understand their condition, and to understand the irrational thinking about health and disease. Therefore, according to Sweeney, understanding appears to be the justification for studying basic science.⁵ This understanding proves important in gaining knowledge about new advances, such as gene therapy or the reaction of the arterial wall to endovascular graft placement—issues that can be very pertinent clinically.

The same objectives apply to incorporating basic science into the curriculum of vascular residencies. Added benefits include encouraging new trainees to pursue the development of the science of vascular disease and improving performance on the VQE. Although program directors that answered the questionnaire expressed concern that their residents were less prepared to take the basic science part of the VQE (Fig 1), the results of the residents' examinations did not justify these concerns. Test values on basic science items were similar to those values for the entire VQE.

Although there may be some weakness in specific subcategories or topics (Table I), it is important to recognize that poor performance on an item may result from unintended problems in the way the item is written or interpreted by the candidates. Even though an item is deleted from the item pool if less than 30% of the examinees answer the item correctly, not all misleading items meet this criterion. For instance, the item on the etiology of false aneurysm had a PT value of greater than 30% (although < 50%). The answer options for these items included arterial wall failure and infection. In clinical practice, the frequency of a particular etiology often depends on the interval from the initial operation. However, in the question this interval was not specified, thus making the correct response somewhat ambiguous. Such flaws are more easily detected retrospectively than prospectively, leading to continuous refinement of test items.

Although most program directors (95%) thought that basic science teaching should be included in the curriculum of vascular residencies, half thought that it should be a clinically relevant curriculum. Almost 50% responded that the curriculum should be a comprehensive one, which again emphasizes the importance the program directors place on basic science teaching in vascular residencies. Basic science is part of every component of the VQE content outline, and basic science knowledge is required for each of the subdivisions of the outline. This includes anatomy, physiology/pathophysiology, and pathology/pathogenesis. However, the vast majority of the basic science questions are clinically relevant. Seldom, if ever, are molecular biology or cell signaling pathway questions included in the VQE. The clinical relevancy of basic science questions lends itself to easier incorporation of basic science into the clinical teaching of vascular residencies, but the curriculum is not comprehensive.

Although they agreed that some form of basic science should be taught, the program directors did not agree on how to teach it or on how to monitor the learning process. Only 24.5% said that they require a specific text to be read by the residents. When they were asked to give an opinion on how to teach basic science, many suggestions were offered (Fig 2). Respondents thought that assigned text, lectures, and conferences were good ways to go about it. However, the value of conferences is controversial. Other specialties have struggled with this issue.⁹, ¹⁰ Cruz et al⁹ reported on a national survey of chief residents in dermatology to characterize the role of basic science conferences. Although the survey showed that chief residents valued these conferences, it also showed that they were dissatisfied with the structure and content of these conferences. The authors summarized the residents' comments in three general areas: (1) conferences and course outlines were poorly organized and had little structure; (2) “experts” primarily addressed their own areas of interest, leading to spotty coverage of the broad spectrum of topics related to skin diseases; and (3) there was little attempt to vary presentations to meet the special needs of residents at different levels of understanding.⁹ The results of this survey led the authors to implement a new method in teaching basic science to dermatology residents.¹⁰ An integrated basic and clinical science conference series was established for resident trainees in dermatology. This series was favorably evaluated by the residents.¹⁰ Sensing the inadequacy of didactic conferences, a few vascular surgery program directors recommended innovative ways to provide basic science teaching. One way was to put the vascular trainees in charge or ask them to provide basic science teaching to surgical residents. This suggestion is an interesting one because it forces the vascular trainee to prepare a topic well enough to be able to teach it. In a way, this represents a natural progression in the learning process. In addition, this should also force the faculty to adequately prepare the vascular trainees before asking them to teach basic science to surgical residents. It is important to emphasize that a faculty member should be present when such assignments are implemented.

Another interesting suggestion was a Web-based curriculum. Before the presentation, our panel discussed this issue and presented it as an alternative way to teach the curriculum. A version of a Web-based curriculum would be recommended to enhance and monitor the teaching process. There was also a recommendation to have the APDVS put together a teaching syllabus for vascular residents and program directors, as well as a review course dedicated to basic science.

Monitoring of the learning process of the residents is only performed by 15% of program directors. Those who undertake this supervision do so by means of frequent interactions with residents during rounds, teaching conferences, and conferences prepared by the residents. Only one respondent administers a test that includes basic science questions. Therefore, only one program provides a quantitative method to evaluate the didactic knowledge of the residents in preparation for the VQE. The lack of an “in-service” examination in vascular surgery leaves program directors without a standardized instrument to evaluate the learning progress made by trainees during vascular residency. The in-service or “in-training” examination provides an important tool to evaluate the progression of learning in a surgical training program. Steffes and Dulchavsky¹¹ have found that there is a progression in the didactic knowledge during a surgical residency, but progression is slower for the knowledge of basic science. It is important to note that because a good number of vascular surgery programs are 2 years long, an in-service examination would be more favorable to these programs because vascular residents have an extra year (which is usually used for research) to prepare for the examination. However, even if a vascular inservice examination is instituted, the required year of vascular surgery training is not long enough to allow timely return of in-service examination results, providing the program director with only limited time to alter the teaching process of a certain trainee during his or her year of training. A Web-based question-and-answer program can provide the program director with an ongoing way of monitoring the vascular knowledge of the trainee, allowing for immediate changes.

Among the answers given to our questionnaire, there was also no agreement on who should teach basic science. Although 75% of program directors felt comfortable in teaching this subject, only 56% thought that all faculty members can teach it. The rest would assign a specific faculty member to be responsible for teaching basic science. This issue is especially important because one respondent thought that it would be ideal if the program directors and faculty were role models to the vascular trainees. The feeling of 44% of the program directors that their faculty was not comfortable in teaching basic science (Fig 1) is quite telling. It is of paramount importance that the faculty show interest and be involved in the learning and teaching processes of basic science. It is not adequate to pay “lip service”; rather, faculty teaching and involvement are essential in establishing and promoting a basic science curriculum. If faculty from basic science departments are called on to help in teaching, they should be discouraged from simply lecturing on issues of interest to the teacher. Instead, they should concentrate on teaching pertinent issues essential to the understanding of the basic science of vascular disease. This can be established by putting together a core curriculum that emphasizes and streamlines the teaching efforts in vascular residencies.

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Recommendations 

We propose the following recommendations:

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Acknowledgements 

We would like to acknowledge the leadership of the Association of Program Directors in Vascular Surgery, especially President Robert W. Hobson II, MD, and Secretary Frank W. LoGerfo, MD, for initiating the panel and supporting its efforts. We would like to thank Richard F. Neville, PhD (in Educational Administration), Professor Emeritus and Dean of Arts and Sciences at the University of Maryland, Baltimore County, for reviewing the manuscript and providing valuable input.

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Appendix 

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References 

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