Changes in board certification could improve vascular surgery training☆

Article Outline

• Certification and accreditation
• Current vascular surgery training
• Improving vascular surgery training
• Possible training paradigms
• Required changes in certification
• Copyright

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Certification and accreditation 

Certification in Vascular Surgery (VS) in the United States is currently the responsibility of the American Board of Surgery (ABS), which is also responsible for certification in General Surgery (GS). The ABS is one of 24 certifying boards that are members of the American Board of Medical Specialties (ABMS). As such, it is responsible for certifying those surgeons who are found to be qualified after meeting specific training requirements and completing an examination process. Certification in VS is specifically overseen by the Vascular Surgery Board (VSB), a component board of the ABS. Details of the ABS and VSB structure can be found on their Web site (www.absurgery.org). It should be noted that the ABS is responsible for certification of individuals, and is not responsible for hospital credentialing or surgeon reimbursement.

Accreditation of VS training programs in the United States is the responsibility of the Accreditation Council for Graduate Medical Education (ACGME), which develops accreditation standards and reviews accredited programs for compliance. In VS and GS, this is done by the Residency Review Committee for Surgery (RRC-Surgery), one of 26 specialty-specific review committees of the ACGME. Details of the ACGME and RRC-Surgery structures can be found on their Web site (www.acgme.org). It should be noted that the RRC-Surgery is responsible for establishing minimal training requirements in VS training programs, but is not responsible for individual surgeon certification. However, surgeons seeking certification by an ABMS Board must successfully complete an ACGME-accredited residency training program.

Currently, VS is a specialty board of the ABS, such that primary certification in GS is required before a secondary certificate in VS can be obtained. Similarly, completion of an ACGME-accredited residency program in GS is a prerequisite for VS training in an ACGME-accredited program. However, recertification in GS is not required to maintain certification in VS.

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Current vascular surgery training 

The ACGME currently requires a minimum of 1 year for VS training following the completion of GS residency. In order to meet increased training demands for interventional and endovascular techniques, most VS training programs have added an additional year, or converted a previous “research year” to clinical training. Of 93 ACGME-accredited training programs, 49 are currently accredited for 2 years, and most others include a nonaccredited second year. GS training requires a minimum of 5 clinical years, and many residents complete 1 to 2 years of research training, especially if they wish to be competitive for the best specialty training programs. Thus, most VS residents currently spend a minimum of 7 years in clinical training following medical school, and many spend 8 to 9 years including research. Long length of training has been found to be a negative incentive for medical student choice of specialty field. The extent to which this affects the attractiveness of VS training is difficult to precisely define, but most believe that a shorter, more efficient training paradigm would be regarded favorably by most trainees.

In recent years, there has been some declining interest by medical students in GS and other specialties that are regarded as demanding in terms of lifestyle issues. Although the number of applicants for GS training increased during the past year, a substantial reduction during the previous years caused considerable alarm about potential future shortages of general surgeons. Because GS training is a prerequisite for VS training, any reduction in the number of GS residents would reduce the applicant pool for VS to some extent. During the past 8 years, the number of training positions available in VS in ACGME-accredited programs has increased by 27%, from 82 in 1997 to 103 in 2004 (Fig). During the same time, however, the total number of applicants to these programs decreased by 14%, from 126 in 1997 to 108 in 2004. The number of US medical school applicants decreased by fully 24%, from 107 in 1997 to 81 in 2004. Thus, during the VS resident match last year, only 81 US medical graduates were available for 103 positions. This trend is alarming given the projected future increases in workforce needs in VS.

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• Fig. 

  National resident matching program results for ACGME-accredited vascular surgery programs during the past 8 years.

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Improving vascular surgery training 

The Association of Program Directors in Vascular Surgery (APDVS) has developed a comprehensive clinical curriculum that includes vascular medicine, vascular laboratory, and endovascular/interventional training. Many residents are attracted to the increased breadth in the discipline of VS, and few would argue that appropriate training can be accomplished in less than 2 years. In fact, a training task force sponsored by the Society for Vascular Surgery (SVS) and the APDVS recently concluded that 2 years of clinical training in VS should be the minimum requirement, and that pilot programs allowing even more VS-specific training should be established. This expansion in duration for VS-specific training, combined with the perceptions that overall length of training is a disincentive, has forced an examination of the necessity for all vascular surgeons to complete full GS training.

The ideal VS training paradigm would be efficient, effective, and flexible. An efficient program would shorten the overall length of training by eliminating preliminary rotations during GS residency that traditionally have provided more service than education on various surgical subspecialties. For surgeons who will practice only VS, even some GS rotations could be eliminated, such as endocrine or breast surgery. A more effective VS training program would allow more VS-specific training in both open and endovascular surgery, as well as vascular medicine, vascular laboratory, vascular imaging, and other evolving components of the full spectrum of contemporary VS. A flexible training paradigm would allow surgeons who intend to practice only VS to reduce GS training, while allowing surgeons who intend to practice both GS and VS to continue robust training in both disciplines. It would also allow specialty selection at various stages of training, including during medical school, after several years of initial surgical training, and after completion of full GS training.

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Possible training paradigms 

In order to provide efficient, effective, and flexible VS training, several different training paradigms should be available. The current paradigm of complete GS and VS training should be continued as one option. This results in dual certification and requires a minimum of 7 years (5 years for GS, 2 years for VS). The ABS has recently proposed an early specialization program (ESP) in an attempt to decrease total training for GS and VS to 6 years. The ESP allows qualified programs to create a combined 6-year program by integrating GS and VS training within the same institution. This option would result in dual certification, but is unlikely to be developed at many centers because of multiple restrictions, including the inability of trainees to transfer to a different VS program after completing 4 years of GS.

Training programs must also be developed that would result in VS certification alone, without GS certification. Several surveys have shown that most VS residents practice little GS, a trend that seems to be increasing. A VS-only training program could be created in two tracks, similar to current training tracks in plastic surgery. One would be an independent program in which 3 years of VS training follow 3 years of core surgical training, analogous to “3+3” plastic surgery programs. In such a program, the first 3 years would be supervised by the GS program director, and the last 3 years would be supervised by the VS program director. Applicants could match into such VS programs at various times during their first 3 years of core surgical training. The second VS-only paradigm would be an integrated track in which the entire training program would be supervised by the VS program director. Appropriate rotations would be arranged in GS and other related disciplines, and applicants would match into such VS programs during medical school, as they do for neurosurgery or the integrated plastic surgery programs. With appropriate efficiencies, the duration of such programs might be a total of 5 years.

Thus, three distinct training paradigms could be envisioned for ideal VS training. These would include a 7-year track for certification in both GS and VS, a 6-year VS-only independent track (3+3) for residents who match during initial surgical training, and a 5-year VS-only integrated track for trainees who match during medical school (Table).

Table. Proposed tracks for vascular surgery training

GS, General Surgery; VS, Vascular Surgery; PGY, postgraduate year; MSY, medical student year.

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Required changes in certification 

The current construct of ABS Board certification and ACGME program accreditation does not allow for the development of VS-only training, since full GS training is now a prerequisite. Thus, in order to develop more flexible training paradigms, a change in Board certification and program accreditation is required. One option is to develop an independent Board and RRC for VS, as proposed by the American Board of Vascular Surgery (ABVS). A second, more recently considered option, is to change VS to a primary certificate under the jurisdiction of the ABS. This option would eliminate the requirement for prerequisite GS certification, and would allow certification in VS alone. There are multiple examples where ABMS boards have jurisdiction for different primary certificates, such as Diagnostic Radiology and Radiation Oncology under the American Board of Radiology. Parallel changes would be required by the ACGME and RRC-Surgery to allow the accreditation of training programs offering VS-only training, either as integrated or independent programs, and the creation of a RRC-Vascular as part of the RRC-Surgery.

Both of the above options for change in certification and accreditation have their proponents and detractors whose opinions are based on perceived advantages and disadvantages. These issues are currently being carefully explored by the SVS, APDVS, ABS, ABVS, and RRC-Surgery. It is important that a solution emerges that will allow the creation of VS-only training and certification in addition to dual GS and VS training and certification. In order to meet the workforce needs of the future, VS training must be efficient, effective, and flexible. To accomplish this, changes in Board certification and program accreditation are essential.