| | Vascular surgery training and certification: An international perspectivePresented in part at the Annual Meeting of the Society for Clinical Vascular Surgery, Las Vegas, Nev, Mar 8-11, 2006, by Dr Cronenwett and at the Annual Meeting of the Association of Program Directors in Vascular Surgery, Washington, DC, Mar 29-31, 2007, by Dr Liapis. Received 8 April 2007; accepted 23 June 2007. published online 31 August 2007. ObjectiveVascular surgery (VS) practice has expanded to incorporate interventional procedures, and this has stimulated changes in training. The purpose of this study was to review current VS training and certification in different countries. MethodsA survey was completed by vascular surgeons involved with national certification in 34 countries. Results are expressed as the mean ± SD, with comparisons by χ2 and t tests. ResultsVS is currently an independent specialty in 15 surveyed countries, is a subspecialty of general surgery in 10 countries, and is not recognized as a specialty in nine countries. There has been a clear time trend toward independent certification. In countries with independent VS certification, the length of VS training is 3.7 ± 0.9 years plus 2.3 ± 0.7 years of associated core general surgery (GS), for a total training length of 5.9 ± 1.0 years. In countries with VS subspecialty certification, the length of VS training is 2.4 ± 0.5 years after 5.0 ± 1.1 years of GS, for a total training length of 7.4 ± 1.2 years (each P < .01 vs independent certification). The minimum required volume of major open VS operations during training is 151 ± 78 in countries with independent VS certification vs 113 ± 53 in countries with subspecialty certification. Endovascular requirements for training are established in 71% of countries with independent certification vs 37% of countries with subspecialty certification (P < .03). Countries with independent VS certification produce 5.4 ± 2.8 VS trainees per year per million population 65 years of age or older, vs 3.0 ± 1.8 in countries with subspecialty certification (P < .02). ConclusionsConsiderable variation exists in VS training in different countries. There is an international movement toward independent VS certification, with longer VS specific training but shorter overall residency duration. Counties with independent VS certification produce more trainees per year to serve their elderly population. Vascular surgery (VS) has evolved substantially as a discipline since it emerged from general surgery (GS) and cardiothoracic surgery (CTS) in the 1950s. During the 1950s and 1960s, the techniques of endarterectomy, aneurysm repair, and bypass surgery were applied to a broad spectrum of vascular pathologies by pioneering surgeons.1 By the early 1970s, the need for specialized training in VS was recognized,2 and during the last three decades, VS training and certification have become increasingly separate from GS and CTS.3 In recent years, the explosion of endovascular procedures has required even greater changes in VS training.4, 5 Although the status of VS training and certification has been reported from individual countries and regions,1, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17 no systematic international review has been undertaken; this was the purpose of this study. Methods  A survey concerning VS training and certification questions was sent to a vascular surgeon involved with national certification in 34 countries where the authors had such a contact. Questionnaires were returned from all 34 countries. Estimates of the population aged 65 and older were based on international census data18 for the year 2005. Statistical comparison of continuous variables was performed with the Student t test and of categorical values with the χ2 test. Data are expressed as the mean ± SD. Results Certification Of the 34 countries surveyed, VS is an independent specialty in 15—ie, no prerequisite certification in GS or CTS is required (Fig 1). In 10 countries, VS is a subspecialty of GS, meaning that VS certification is permitted only after prerequisite GS certification. Finally, in nine countries, VS is not an accredited surgical specialty. In five of these nine countries, VS is included in GS certification, in three countries VS is included in CTS certification, and in one country VS is included in either GS or CTS certification (Table I). The first country to recognize VS as a specialty was Italy (in 1974), when VS was also accorded independent certification in that country. From then until 1988, there was an increasing trend toward certification in VS as a subspecialty, and since 1988 certification in VS as an independent specialty has become predominant (Fig 2). The most recent country to recognize VS as a subspecialty was Sweden (in 2006), and the most recent countries to recognize VS with independent certification were Germany, Taiwan, and the United States (in 2005). The United Kingdom, Ireland, and Turkey anticipate the establishment of specialty certification in VS in the near future. Certification of trainees in VS is most frequently performed by national boards or medical associations (n = 15) and less frequently by the government (n = 9), a vascular society (n = 6), or the university or hospital that houses the training program (n = 4; Table II). The most frequently used tool to assess candidate qualification for VS certification is inspection of a case log of recent operations; this is required in 81% of countries that offer VS certification. An oral examination is required in 77% of these countries, whereas 50% require a written examination to qualify for VS certification. Among countries where VS is an independent specialty, 87% require either an oral or written examination to qualify for certification. Among countries where VS is a subspecialty certification, 70% require either an oral or written examination (Table II). Training In countries where VS has independent certification, the mean duration of VS training is 3.7 ± 0.9 years, with a range of 2 to 5 years (Table I). In these countries, there is an associated mean training in general or core surgery of 2.3 ± 0.7 years, with a range of 1 to 3 years. Thus, the mean total duration of training to qualify for VS certification is 5.9 ± 1.0 years, with a range of 4 to 8 years, in countries where VS is an independent specialty. In countries where VS is a subspecialty after certification in GS, the mean duration of VS training after GS training is 2.4 ± 0.5 years, with a range of 2 to 3 years (Table I). The associated prerequisite GS training is a mean duration of 5.0 ± 1.1 years, with a range of 3 to 6 years. Thus, the mean duration of total GS plus VS training in countries where VS is a subspecialty is 7.4 ± 1.2 years, with a range of 6 to 9 years. Among countries where VS is not a certified specialty, VS training is incorporated either into GS or CTS residency training, sometimes as additional training in special vascular units and sometimes as additional nonaccredited training after GS residency (Table I). Among these countries, the mean duration of initial GS (or occasionally CTS) training is 5.4 ± 1.8 years, with a wide range of 2 to 8 years. Additional optional VS training is a mean of 2.1 ± 1.0 years with a range of 2 to 3 years. Thus, in countries without VS certification, the minimum total length of training required to practice VS is a mean of 7.1 ± 1.7 years, with a range of 5 to 9 years (Table I). The mean duration of specific VS training in countries with independent certification is significantly longer than that in countries with subspecialty certification or no certification in VS (P < .01; Fig 3). The mean duration of GS and total training in countries with independent certification is significantly shorter than that in countries with subspecialty certification or no certification in VS (P < .01; Fig 3). The accreditation of VS training programs is most frequently done by the government (n = 14) or national boards/medical associations (n = 13) and less frequently by vascular societies (n = 4) or universities (n = 2). This is done by review of application materials, with 54% of countries also requiring a site inspection by the accrediting authority (Table II). Nearly all countries have established a minimum volume of major open vascular operations that are required during training and for certification in VS (Table III). Among countries with independent VS certification, the minimum number of major open vascular operations is 151 ± 78 (mean ± SD). Among countries with subspecialty VS certification, the minimum required number of major open vascular operations is somewhat lower (113 ± 53; P < .10), but this number does not include operations that may have been performed during prerequisite GS training. There is substantial variation in the minimum number of major vascular operations required even among countries with independent VS certification, however; this number ranges from 30 in Italy to 300 in Australia/New Zealand (Table III). Half of the countries with VS certification have specific requirements for a minimum volume of major open vascular operations performed as a teaching assistant for a more junior trainee or as a first assistant for a more senior surgeon. Among the countries that have such requirements, there is wide variation, and in some countries the number of operations required as first assistant exceeds the minimum number required as the primary operator (Table III). Most countries (69%) have established a minimum volume requirement for minor open vascular operations such as varicose vein treatment. Among countries with independent certification, the mean minimum volume is 95 ± 55, whereas in countries with subspecialty certification, the mean minimum volume is 58 ± 38 (P < .06). Only 35% of countries have established a minimum volume of minor vascular operations to be performed as a teaching or first assistant, and these numbers vary widely (Table III). Among countries with independent VS certification, 71% have developed a minimum volume requirement for interventional/endovascular procedures, compared with only 37% of countries with subspecialty certification (P < .05). The mean minimum volume requirement for interventional procedures among countries with independent VS certification is 52 ± 45—significantly more than the mean minimum volume requirement of 19 ± 9 in countries with subspecialty certification (P < .03). On the basis of this analysis, countries with independent VS certification have higher minimum case volume requirements for VS training and certification compared with countries where VS has subspecialty certification status. Among countries where VS is not recognized as a specialty, but included within the GS or CTS training, the minimum volume of vascular operations varies substantially (Table III). There is a large variation in the number of VS training programs and the number of trainees per year among countries with VS certification (Table IV). When normalized according to population, countries with independent VS certification produce an average of 5.4 ± 2.8 VS trainees per year for each million persons 65 years of age and older. This is significantly more than the number of vascular trainees per year of 3.0 ± 1.8 per million persons 65 years of age and older in those countries where VS has subspecialty certification status (P < .02; Table IV). The number of major open vascular operations actually performed by VS trainees is recorded in 67% of countries with independent VS certification and averaged 208 ± 176 operations in 2005. Only 37% of countries with subspecialty VS certification record the number of major open vascular operations performed by VS trainees, which averaged 91 ± 95 in 2005 (P < .07 vs countries with independent VS certification). The average number of interventional procedures (both diagnostic and therapeutic, counting one procedure per patient encounter) was recorded by fewer countries, but it averaged significantly more in countries with independent VS certification (104 ± 103) than in countries with subspecialty VS certification (21 ± 14; P < .05; Table IV). Thus, there was more operative and interventional experience by trainees in countries with independent compared with subspecialty VS certification, but this comparison did not include procedures performed during prerequisite GS training in countries with subspecialty VS certification. Individual countries and regions Asia In China, VS is incorporated into 4 to 5 years of GS training in a regional hospital that certifies trainees on the basis of a local examination because there is no national or provincial oversight of the these programs. Opportunities for VS training vary widely between centers. Surgical training in Hong Kong is a legacy of the British system and is administered by the College of Surgeons as a conjoined program with the Royal College of Surgeons of Edinburgh and the Royal Australasian College of Surgeons.10 VS remains a part of GS residency, which consists of 6 years of surgical training after several years of preliminary training, and it includes 6 months of VS rotations at the senior level. Nonaccredited VS training after GS residency is available at selected centers. In Taiwan, before 2005, VS was largely performed by cardiovascular surgeons. In 2005, however, a primary certificate in VS was established by the Taiwan Society for Vascular Surgery, with training consisting of 3 years of GS followed by 2 years of VS. In India, three VS fellowships of 2-year duration after GS residency were initiated 5 years ago in Delhi, Bangladesh, and Hyderabad. These have been expanded to a 3-year VS certificate program since 2006 with open and interventional training supervised by vascular surgeons. In most major hospitals in India, however, patients with vascular disease are treated by general surgeons, cardiovascular surgeons, cardiologists, or radiologists. In Japan, VS training is included within a 3-year CTS residency that follows a 5-year GS residency. It is possible to emphasize VS procedures during training, but a point system required for certification emphasizes cardiac and complex aneurysm procedures. Australia In 2002, Australia and New Zealand established independent certification in VS, with a requirement for 5 years of VS training after 3 years of core GS training. Included within VS residency are 2 years of CTS and 3 years of VS training and a minimum requirement of 300 major vascular operations, 100 arteriograms, and 50 interventional procedures. The Vascular Section of the Royal Australasian College of Surgeons has developed sophisticated curriculum modules and learning requirements for their VS residency programs.19 Americas In Argentina, VS training is included within a 3-year CTS residency, which follows a mandatory 4-year GS residency. Recently, the University of Buenos Aires has initiated an independent VS residency, but separate VS certification does not exist. In Brazil, although separate VS training existed for many years, certification in VS was just established in 2003 and can be achieved after 2 years of preliminary GS training followed by a 2-year VS residency. In Mexico, certification in VS is possible only after preliminary GS certification after 4-year GS and 2-year VS residencies. In Canada, VS certification can be obtained only after GS certification after 5-year GS and 2-year VS residencies. All training programs are university based and regulated by the Vascular Surgery Committee of the Royal College of Physicians and Surgeons of Canada.12 Training consists of 15 months of clinical VS and 9 months of electives that include vascular laboratory, interventional procedures, and vascular medicine. Although a minimum volume of VS operations is not established, the certifying board makes a qualitative judgment about the experience of each trainee. Uniform goals and objectives have been developed for all programs.20 In the United States, VS certification was established in 1982 as a subspecialty after certification in GS. However, in 2005 the prerequisite for preliminary GS certification was eliminated, and three distinct paradigms for VS training were established in 2006.21 First is the traditional VS fellowship after 5 years of complete GS residency. The minimum requirement for VS fellowship was increased from 1 to 2 years, for a total minimum training duration of 7 years, leading to certification in both GS and VS. Second is the “3 + 3” program, consisting of three preliminary years of GS followed by three years of VS residency, leading to certification in VS alone after a total of 6 years of training. Finally, a new integrated VS residency paradigm was established, consisting of a 5-year total VS residency after medical school, of which 2 years are core GS and 3 years are VS, leading to certification in VS only. Currently there are 94 accredited 2-year VS fellowship programs for graduates of GS residency, but only 5 accredited independent 5-year VS residencies for graduates of medical school. However, accreditation of new programs has been available for only 1 year, and it is anticipated that many current 2-year VS fellowship programs will transition to 5-year or 3 + 3-year VS residencies in the future. This will provide multiple training paradigms depending on whether trainees are interested in VS certification alone or VS plus GS certification. The minimum required operative experience in any paradigm is 200 major vascular procedures, with appropriate distribution.22 Endovascular and interventional experience is explicitly required. A national curriculum has been developed by the Association of Program Directors in Vascular Surgery for the traditional 2-year fellowship, which is being adapted for the new paradigms.23 Europe In most European countries, VS certification is offered, but in five surveyed countries no VS certification was possible. In the United Kingdom and Ireland, VS training is included within GS residency. Trainees interested in VS complete a minimum of 2 years of VS training in specialized units during the senior years of their GS residency. They receive standard GS certification, but a specialty interest in VS is indicated on their certificate. However, extensive changes in this paradigm are currently being negotiated which anticipate a hybrid training program in VS, vascular interventional radiology, and vascular medicine. After the two foundation years of preliminary residency required of all medical school graduates, vascular specialists in the proposed track would enter a 6-year residency program that would allow concentration in VS, vascular interventional radiology, or vascular medicine, but with substantial overlap of curriculum leading to certification as a vascular specialist with a designated concentration. No precise target date is established, given the complexity of these negotiations among different specialties. In Russia, VS training is contained within a 3-year CTS residency and is organized so that interested trainees can emphasize VS, but no separate VS certification exists. In Turkey, VS training is included in a 5-year GS residency in two institutions, whereas, more commonly, VS training is obtained as part of a 5-year CTS residency in 54 institutions. No separate VS certification is offered, but plans are being developed for a new 3-year VS residency program after GS residency that would lead to separate VS certification. In Belgium, VS training is included within a 6-year GS residency. However, interested surgeons may obtain 2 years of VS training after GS residency in 1 of 13 specialized VS units, and this leads to an unofficial certificate issued by the Belgium Society for Vascular Surgery. In the remaining 18 European countries surveyed, VS certification is offered either independently of GS (n = 11) or as a subspecialty after GS certification (n = 7). This is reflected in the decision of the Union Européenne des Médecins Spécialistes to designate VS as an independent specialty section in 2004.6 This allowed vascular surgeons to directly represent VS at European governmental institutions concerning VS issues. Although medical specialty certification remains the prerogative of each European country, the European Board of Surgery Qualification in Vascular Surgery (EBSQ-Vasc) established criteria for certification and an annual examination in 1996.9 Trainees who complete minimum training requirements, including minimum operative volume, and who successfully pass an oral and practical examination are awarded the title of Fellow of the European Board of Vascular Surgery. Thus far, only a small proportion of all European vascular surgeons have completed the examination process because it is not required for practice within their country. However, some countries, such as Switzerland, have already endorsed the EBSQ-Vasc as an appropriate criterion for national certification, and academic surgeons are motivated to seek Fellowship status as an indication of their credentials. The expanded European Union and the ruling that allows professionals the right of free movement across Europe has created a pressing need for accelerated harmonization of training and certification in VS.6 Thus, it is anticipated that the EBSQ-Vasc will become more widely used as a uniform examination among European countries in the future. A minimum of 6 years of total residency training, including 2 years of VS-specific training, is required, combined with a minimum of 120 nonvascular operations and 200 major arterial operations, of which the trainee must have been the primary surgeon in at least 50%. Discussion During the past 20 years, there has been a clear international trend toward independent certification in VS (Fig 1). This reflects the increased differentiation of VS from GS and CTS, which during the past 10 years has largely been due to widespread adoption of endovascular procedures. In the plurality of countries surveyed, VS certification can be obtained independently, but there are substantial geographic variations and historical differences. In light of this trend, it is somewhat surprising that VS is not a recognized surgical specialty in 26% of countries surveyed. This is especially true for several European countries given that VS has been recognized as an independent specialty by the European Union. However, in most of the countries where VS is not a recognized specialty, active planning and negotiations are under way to develop separate certification. A potential advantage for VS training among countries with independent certification is that the length of training is shorter and a larger proportion is devoted to VS (Fig 3). Shorter total training is likely to be more attractive for many medical students who have incurred large debt.24 Early selection of VS training, however, requires exposure to the specialty and to appropriate mentors, and this may be a challenge at some centers. At present, the United States is unique in offering different paradigms of different durations leading to VS certification, depending on whether full GS training and certification is included. This option of multiple pathways depending on specific career goals may be more attractive to prospective applicants.25 Most revealing in this analysis of VS training is the substantial variation that exists in the minimum length of training and the minimum volume of operative and interventional procedures among different countries. Furthermore, there seems to be a substantial difference in the role of trainees, with some countries emphasizing experience as the primary operator and others experience as the first assistant. This may not be surprising given the different historical traditions, but it raises the question of whether there is a universal optimal training paradigm. Also revealing in this survey was the difficulty in obtaining precise estimates of the volume of operations actually performed by VS trainees and other elements of the data presented in this article. This suggests the need for more uniform data collection strategies, perhaps with central coordination to facilitate the exchange of these data between different countries. It is also apparent that educational curricula and other educational tools, such as simulation devices, are being developed quite independently in different countries. Given the ease of electronic international communication, this would seem to be a fruitful area for improved collaboration among VS program directors in all countries. Author contributions Conception and design: JLC, CDL Analysis and interpretation: JLC, CDL Data collection: JLC, CDL Writing the article: JLC Critical revision of the article: JLC, CDL Final approval of the article: JLC, CDL Statistical analysis: JLC Obtained funding: Not applicable Overall responsibility: JLC Acknowledgement The authors are grateful to their colleagues in each country who contributed the information for this report | | |  | Region | Country | Contributor | |
|---|
| Asia | China | Stephen W. K. Cheng | | | | Hong Kong | Stephen W. K. Cheng | | | | India | Rajiv Parakh | | | | Japan | Hiroshi Shigematsu, Takao Ohki | | | | Taiwan | Po J. Ko | | | Australia/New Zealand | | Robert A. Fitridge | | | Americas | Argentina | Mariano Norese | | | | Brazil | Maximiano Albers, Telmo P. Bonamigo | | | | Canada | Kenneth Harris | | | | United States | Jack L. Cronenwett | | | | Mexico | Jorge Cervantes | | | Europe | Austria | Josef Klocker, Gustav Fraedrich | | | | Belgium | Andre Nevelsteen | | | | Croatia | Lidija Erdelez | | | | Cyprus | Nicos Angelides | | | | Czech Republic | Petr Stadler | | | | Denmark | Jes Sandermann, Torben V. Schroeder | | | | Finland | Maikael Railo, J. P. Salenius | | | | France | Jean-Baptiste Ricco | | | | Germany | Klaus Balzer | | | | Greece | Christos D. Liapis, E. Avgerinos | | | | Hungary | Lajos Matyas | | | | Ireland | Pierce Grace | | | | Italy | F. Benedetti-Valentini, Piergiorgio Cao | | | | The Netherlands | Jacob Buth, J. Hajo van Bockel | | | | Norway | Anne K. Lindahl | | | | Portugal | J. D. Menezes, Louis Mendes Pedro | | | | Slovakia | Vladimir Sefranek | | | | Spain | Rosa M. Moreno, M. Doblas | | | | Sweden | Bengt Lindblad, David Bergvist | | | | Switzerland | Bernard Nachbur | | | | Russia | Alexey Svetlikov | | | | Turkey | Cuneyt Koksoy | | | | United Kingdom | Julian Scott, Peter Harris, Peter Lamont | | | | |
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a Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH b Department of Vascular Surgery, Athens University Medical School, Athens, Greece.  Reprint requests: Jack L. Cronenwett, MD, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03755.
Competition of interest: none. PII: S0741-5214(07)01069-5 doi:10.1016/j.jvs.2007.06.033 © 2007 The Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved. | |
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