An increasing demand for integrated vascular residency training far outweighs the limited supply of positions
Article Outline
Objective
The integrated vascular surgery residency training paradigm (“0 + 5”) was first approved by the Accreditation Council for Graduate Medical Education (ACGME) in 2006, with the first residents beginning in 2007. We sought to evaluate the demand for these new positions and to better understand applicant pool demographics.
Method
The Association of American Medical Colleges (AAMC) was petitioned for data on applicants to traditional vascular surgery fellowship and integrated vascular residency training programs (years 2006-2009). In addition, 111 applications received at a single academic institution for the year 2009 were reviewed in depth.
Result
The number of traditional vascular fellowship applicants and the corresponding number of positions remained stable. In contrast, the number of integrated vascular resident applicants increased dramatically, with 152 applicants seeking to match into 19 available positions in 2009. For the year 2009, 88% of integrated vascular residency applicants did not match, while 16% of traditional fellowship positions went unfilled. The most notable difference between integrated residency and traditional fellowship applicants is the number of foreign medical graduates (68.7% vs. 26.7% in 2008, P < .001). Of the 111 integrated applicants applying for our single position (73% of entire 2009 applicant pool), the majority of applicants were residing in the United States (88.3%) and a sizable proportion (25.2%) had completed at least one full year of either surgical training or surgical research at an institution in the Unites States. Objective measures of academic success included mean United States Medical Licensing Examination (USMLE) Step 1 and Step 2 scores of 89.1 and 89.5, respectively. The mean number of peer-reviewed journal publications at the time of application was 2.8.
Conclusion
The number of integrated vascular surgery residency applicants far outweighs the number of available positions. Growing interest in more efficient and comprehensive vascular surgery training will continue to augment demand. As educators, vascular surgeons should seize this opportunity and aggressively expand the number of available integrated residency training positions.
Over the last decade, surgery has become less attractive as a career to medical students1, 2, 3, 4 and the rates of attrition from general surgery residency programs have increased.5, 6 The increased rate of specialization by surgical residents as manifested by >70% of general surgery residents seeking additional fellowship training,7 the mandated reduction in work hours, increased debt, and a desire to shorten the overall length of training have led to a reconsideration of many of the longstanding fundamental principles of surgical education in the United States. A consensus is emerging that surgical training programs need to use residents' time more effectively and efficiently, focusing more on the acquisition of judgment and technical skills than on service-oriented tasks.1, 8
Vascular surgical training has its own unique challenges. Beginning in 1989, all applicants pursuing a Certificate of Special or Added Qualifications in Vascular Surgery were required to have completed a vascular surgery training program accredited by the Accreditation Council for Graduate Medical Education (ACGME). These applicants were required, as a prerequisite, to have obtained American Board of Surgery (ABS) certification in General Surgery. This training structure, known as the traditional vascular surgery fellowship (5 + 1 program; five years of general surgery followed by one year of vascular surgery), mandated a minimum of six years of training after medical school. Over the ensuing years, this structure was the only option available to those interested in pursuing board certification in vascular surgery. A slight modification in this training structure came in 2004, when an additional second year of clinical vascular surgery training was mandated by the Residency Review Committee (RRC). This formal requirement, which had already been embraced voluntarily at many programs in order to meet the new training requirements necessitated by the adoption of catheter-based therapies (Fig 1), increased the minimum postgraduate training time for a vascular surgeon to seven years (5 + 2).9 This requirement established vascular surgery as one of the longest-length training programs of any specialty in surgery or medicine and, in doing so, did not address any of the many challenges currently facing surgery training programs.
Fig 1.
Bar graph demonstrating the number of accredited traditional vascular surgery training programs with one and two clinical years from 2001-2007.
The approval of a vascular surgery primary certificate by the ACGME in July of 2006 was a watershed moment in the evolution of training in vascular surgery. This primary certificate eliminated the prerequisite to complete a general surgery residency in order to train in vascular surgery.10 This radical change in vascular surgery training requirements has allowed vascular surgery educators to respond to the challenges related to the duration of training, as well as to an increasingly complex vascular surgery curriculum that must now include open surgery, endovascular therapy, noninvasive vascular laboratory skills, and the principles of vascular medicine.11, 12, 13 Within just one year from the approval of the primary vascular certificate, the ACGME approved three new training pathways with the goal of increasing both effectiveness and efficiency (Table I). These included the “Early Specialization Program” (4 + 2), the “Independent Program” (3 + 3), and the “Integrated Program” (0 + 5).14
Table I. Vascular surgery training pathways approved by the Accreditation Council for Graduate Medical Education
| Pathway | Duration, yrs (GS + VS) | Board certification | Number of institutions |
|---|---|---|---|
| Traditional | 7 (5+2) | GS and VS | 1 or 2 |
| Early specialization | 6(4+2) | GS and VS | 1 |
| Independent | 6(3+3) | VS | 1 |
| Integrated | 5(0+5) | VS | 1 |
As of 2009, the most radical departure from the traditional training paradigm, the integrated program (0 + 5), has emerged as the new training paradigm of choice. The integrated residency in vascular surgery greatly increases the time spent learning vascular surgery and allows much greater freedom in developing a curriculum that is specific to the needs of the vascular surgery resident, all accomplished in a shorter period of training than any of the other pathways. The purpose of the present study is to evaluate how medical students have responded to the availability of a vascular surgery integrated residency program that allows for full training and board eligibility in five years. To accomplish this, we quantified the demand for these new integrated vascular surgery residency positions and analyzed applicant pool demographics.
Methods
The Association of American Medical Colleges (AAMC) was petitioned for data on applicants to traditional vascular surgery fellowship and integrated vascular surgery training programs for the years 2006 to 2009. The variables requested included demographic information such as age, gender, race, citizenship, location of current residence, and educational factors relating to both undergraduate and medical training. Test scores (United States Medical Licensing Exam [USMLE] and Educational Commission for Foreign Medical Graduates) were requested, however, these were not made available secondary to privacy agreements between the testing agencies and the AAMC. Data pertaining to the number of accredited programs, number of available positions, and number of applicants were also obtained from the AAMC. Whenever possible, these data were confirmed with the National Residency Matching Program (NRMP)15 and the American Medical Association FREIDA16 online information sites (no discrepancies between the three data sources were found). In order for a program to be considered accredited during a specific year, it had to have received its accreditation prior to the NRMP match date for that year.
All applications received at the University of Massachusetts Medical School Integrated Vascular Surgery Residency for the 2009 matriculation cycle were reviewed by two independent, blinded data abstractors (AS, JN); any discrepancy in the collected data prompted an additional review by a third data abstractor (KK). Demographic factors, previous training and education variables, and USMLE Step 1 and 2 scores were evaluated.
Statistics
Baseline characteristics were compared between groups using Fischer's exact test for categorical variables and Student's t test for continuous variables. All tests were considered statistically significant at an alpha level of 0.05 (P = .05, two-tailed). All analyses were performed using SAS version 9.1 (Cary, North Carolina). The University of Massachusetts Medical School Institutional Review Board reviewed the study protocol and approved an exemption from further review.
Results
Between 2006 and 2009, the total number of available traditional vascular surgery fellowship training positions has increased only slightly from 112 in 2006 to 121 in 2009 (Table II). The demand for traditional fellowship positions has nearly matched the supply, with an average over the four years studied of 1.2 applicants to every one available position (Fig 2). When looking specifically at the last three years, there has been a decreasing trend in the number of traditional fellowship applicants, with 152 applicants in 2007, 131 applicants in 2008, and 112 applicants in 2009. In contrast, the number of available integrated residency positions has increased, from zero in 2006 to 19 in 2009. The demand for integrated vascular surgery residency positions has also grown quickly, with 152 applicants seeking 19 available positions in the most recent application cycle (2009). Between 2007, when the first integrated vascular surgery residency programs were formed, and 2009, the average ratio of demand to supply was 9.8 applicants to every one available position, a nearly 10-fold greater demand than that for the traditional vascular surgery fellowship (Fig 3).
Table II. The supply and demand for traditional and integrated vascular surgery training positions between 2006 and 2009
| Traditional fellowship | Integrated residency | |
|---|---|---|
| Application year | 2006 | |
| Number of available positions | 112 | 0 |
| Number of applicants | 145 | 0 |
| Ratio of applicants to positions | 1.29 | n/a |
| Application year | 2007 | |
| Number of available positions | 119 | 4 |
| Number of applicants | 152 | 49 |
| Ratio of applicants to positions | 1.28 | 12.3 |
| Application year | 2008 | |
| Number of available positions | 116 | 9 |
| Number of applicants | 131 | 112 |
| Ratio of applicants to positions | 1.13 | 12.4 |
| Application year | 2009 | |
| Number of available positions | 121 | 19 |
| Number of applicants | 112 | 152 |
| Ratio of applicants to positions | 0.93 | 8 |
Fig 2.
Traditional vascular surgery fellowship supply and demand (2006-2009).
Fig 3.
Integrated vascular surgery residency supply and demand (2006-2009).
Demographic information for all traditional fellowship and integrated residency applicants was available for the year 2008. Analysis of these data (Table III) revealed that applicants to both traditional fellowship and integrated residency training programs had similar mean ages (32.1 vs. 30.1, P = .82) and gender proportion (females, 18.3% vs. 16.1%, P = .77). There was a significantly greater proportion of non-white applicants for the integrated residency programs (58.0% vs. 40.5%, P = .007). The most notable difference between the two applicant pools was the relatively small proportion of US medical school graduates applying for integrated residency positions. The proportion of US medical school graduates applying for an integrated residency position was significantly smaller than the proportion applying for a traditional position (31.3% vs. 73.3%, P < .0001). Similarly, the proportion of applicants with United States citizenship was significantly smaller among the integrated residency applicants than among the traditional fellowship applicants (58.0% vs. 88.6%, P < .0001). However, 82.4% of the integrated residency applicants were residing in the United States during the year in which their application was received.
Table III. Comparison of the traditional and integrated applicant pools for the year 2008
| Traditional fellowship n (%) | Integrated residency n (%) | P value | |
|---|---|---|---|
| Number of applicants | 131 | 112 | |
| Age (mean) | 32.1 years | 30.1 years | .82 |
| Female | 24(18.3) | 18(16.1) | .77 |
| White race | 78(59.5) | 47(42.0) | .007 |
| US medical school graduate | 96(73.3) | 35(31.3) | <.0001 |
| US citizen | 116(88.6) | 65(58.0) | <.0001 |
| Residing in US | 127(97.0) | 92(82.4) | .0001 |
The University of Massachusetts Division of Vascular and Endovascular Surgery received 111 applications (73% of the entire applicant pool, n = 152) for the one position available during the 2009 application cycle (Table IV). The majority of applicants were born outside the United States (76.1%) and had received either their undergraduate (60.4%) or their medical school (68.5%) educations outside of the United States (59.5% of applicants received both outside of the United States). At the time of application, the majority of applicants were residing in the United States (88.3%) and a sizable proportion (25.2%) had completed at least one full year of either surgical training or surgical research at an institution in the Unites States. Objective measures of academic success included mean USMLE Step 1 and Step 2 scores of 89.1 and 89.5, respectively. The mean number of peer-reviewed journal publications at the time of application was 2.8.
Table IV. Characteristics of the integrated resident applicant pool that applied to the University of Massachusetts Medical School Integrated Residency for the year 2009
| Number (%) | |
|---|---|
| Number of applicants (n) | 111 |
| Number of available positions (n) | 1 |
| Age (mean) | 30.4 years |
| Male (%) | 88(79.3) |
| White race (%) | 37(33.3) |
| Born in US (%) | 27(23.9) |
| US Citizenship (%) | 44(39.6) |
| Reside in US (%) | 98(88.3) |
| Completed medical school (%) | 76(68.5) |
| US Undergraduate degree (%) | 44(39.6) |
| US medical school (%) | 35(31/5) |
| Foreign medical school (%) | 76(68.5) |
| USMLE Step 1 score (mean) | 89.1 |
| USMLE Step 2 score (mean) | 89.5 |
| Number of publications (mean) | 2.8 |
| Secondary degree⁎ (%) | 18(16.2) |
| > One year in US for research or surgery | 28(25.2) |
| Worked as MD abroad (%) | 32(28.4) |
⁎PhD, MPH, RN, MBA, PharmD. |
The University of Massachusetts applicant cohort was then stratified according to whether or not applicants had attended medical school in the United States (Table V). Salient findings include the absence of statistically significant differences between foreign and US medical graduates in: 1) USMLE Step 1 scores, 2) USMLE Step 2 scores, and 3) number of peer-reviewed publications. Moreover, foreign medical graduates had more frequently completed medical school than had US medical graduates by the time of application. Interestingly, of the US medical graduates, 40% of the applicants were female.
Table V. Characteristics of foreign medical school graduates and US medical school graduates who applied to the University of Massachusetts Medical School integrated vascular surgery residency during the year 2009
| Foreign medical graduates n (%) | US medical graduates n (%) | P value | |
|---|---|---|---|
| Number of applicants (n) | 76 | 35 | |
| Age (mean) | 31.9 years | 29.2 years | .01 |
| Male (%) | 67(88.2) | 21(60.0) | .002 |
| White race (%) | 25(32.9) | 12(34.2) | .89 |
| Born in US (%) | 7(9.2) | 19(55.9) | <.0001 |
| US citizenship (%) | 10(13.2) | 34(97.1) | <.0001 |
| Reside in US (%) | 63(82.9) | 35(100) | .01 |
| Completed medical school (%) | 66(86.8) | 10(28.6) | <.0001 |
| US undergraduate degree | 10(13.2) | 34(97.1) | <.0001 |
| USMLE Step 1 score (mean) | 89.3 | 88.8 | .74 |
| USMLE Step 2 score (mean) | 89.5 | 89.6 | .96 |
| Number of publications (mean) | 3.1 | 2.2 | .55 |
| Secondary degree⁎ (%) | 0.1 | 1.8 | <.0001 |
| Worked as MD abroad | 29(38.7) | 2(5.9) | <.0001 |
⁎PhD, MPH, RN, MBA, PharmD. |
Discussion
Contrary to a widely expressed concern that the limited exposure of medical students to vascular surgery would result in a small applicant pool for the integrated vascular surgery residency program,12, 17, 18 the demand for this new training pathway, in its first three years, has exceeded that of the traditional vascular surgery fellowship by nearly 10-fold. Indeed, the academic quality of the applicants to the integrated vascular surgery residency compares favorably with those of any training program in surgery. The mean USLME Step 1 and Step 2 scores of applicants to the integrated residency were 89.1 and 89.5 respectively; of note, there was no statistically significant difference in scores between foreign medical graduates and US medical school graduates. In addition, the commitment of integrated residency applicants to high academic achievement was evidenced by the high proportion of applicants with previous research experience, yielding a mean of 2.8 peer-reviewed publications per applicant.
This study demonstrates a high level of interest on the part of medical students in a residency pathway that allows them to complete their vascular surgery specialty training and to become board-eligible in just five years. These findings clarify current demand for integrated vascular residency positions, and provide reassurance that an inadequate vascular surgery integrated resident applicant pool is unlikely. It is also clear that a significant proportion of this demand is coming from applicants outside of the US. This finding should strengthen the conviction that vascular surgeons in the US need to strive towards increasing medical student exposure to vascular surgery and improving the overall quality of these early experiences.17
While the fundamental goals of the integrated vascular surgery residency do not differ from those of the general surgery residency, the specific curriculum needs have diverged significantly from those of general surgery. At this time, extensive training in laparoscopy, gastrointestinal surgery and endoscopy, or endocrine surgery is no longer imperative for the optimal training of the vascular surgeon. Rather, the optimal training of the vascular surgeon now requires comprehensive training in multiple diagnostic modalities, including non-invasive vascular testing, computed tomography, magnetic resonance imaging, and catheter angiography, as well as an increased fund of knowledge relating to cardiovascular medicine. Training in specialties closely allied with vascular surgery, cardiology and cardiothoracic surgery, as well as anesthesia and surgical critical care, is now mandatory if vascular surgeons are to retain the ability to provide comprehensive inpatient and outpatient care of their patients. Recognizing these diverse needs, the integrated vascular surgery residency curriculum is intentionally flexible allowing vascular surgery educators to design a specific program that can take advantage of local resources available at a given institution.
An important question that can not be answered by this study design is whether the extremely positive response to the integrated vascular surgery residency “0 + 5” has implications for other surgical specialties. What could not be measured objectively nor communicated in a quantitative manner was the passion and commitment evident in the applicants for the Integrated Residency Program at the University of Massachusetts Medical School. The applicants were cognizant of the paradigm shift and the implications that accompanied it; they embraced the challenges and potential pitfalls of entering a new residency training program. The long duration and perceived inefficiency of the traditional vascular surgery training pathway appeared to have weighed heavily in applicants' decisions to pursue the 0 + 5 program.
If this new vascular surgery integrated residency proves to be successful in meeting the needs of its residents, re-evaluation of other seven year training programs may be appropriate. This seems especially poignant considering that over 70% of general surgery residency graduates are now completing one to two years of fellowship training in order to practice within what has long been considered the scope of general surgery: trauma, breast, colorectal, laparoscopic, and acute care surgery.1, 7
Such a reduction in the time required to complete residency training may also aid in addressing the need for residents to begin repaying ever-growing educational debts (The mean student debt after medical school surpassed $100,000 in 2003).1 Furthermore, as the United States population continues to expand, available Medicare funding for resident training is unlikely to expand commensurate with the need to train more surgeons.17 Thus, shorter, more focused residency training programs may also help to facilitate the training of a larger number of residents.
There are significant limitations of this study. This study makes use of the only available data on integrated vascular residency applications and, because the integrated residency has only been in place for three years, we are only able to provide data on this short time period. Additional follow up data will be necessary to inform estimates of impact on the competence of graduating integrated vascular surgery residents. Furtheremore, the data that could be obtained from the AAMC upon which the results are based were themselves quite limited. Nonetheless, the rapid increase in the number of high quality and highly motivated applicants is clear. This enthusiasm suggests that the recent decision by the American Board of Surgery to grant a primary certificate in vascular surgery may prove to be a watershed moment in the history of surgical training in the United States.
It is our feeling that rather than being overly concerned about potential pitfalls such as the possibility of increased attrition rates6 or decreased exposure to general surgery, vascular educators should respond constructively and energetically to the challenge created by this high level of interest by medical students here and abroad. Perhaps greatest among these challenges, is how to avoid training the “super-specialist” - a surgeon who works within a continually narrowing scope of practice, as has occurred within some surgical specialties.7 Such a narrow scope of practice is at variance with perhaps the single most important attribute of the tradition in general surgery training - the capacity and the desire of surgeons to provide comprehensive care to all of their patients, including patients with the most complex illnesses. It is our perspective that the evolution in the scope of training and practice of vascular surgeons today enables a surgeon to meet virtually all of the needs of their patients, including clinical diagnosis, diagnostic testing, the full spectrum of treatment options, and the long-term follow-up of their patients. Thus, rather than a retreat from one of the most important and most valued attributes of general surgery training, the integrated vascular surgery residency has the opportunity to build and extend upon this tradition.
Author contributions
We gratefully acknowledge Mona Signer, Gwen Garrison, and Walter Fitz-William at the AAMC who provided the data included in this study.
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Competition of interest: none.
The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a competition of interest.
PII: S0741-5214(09)01386-X
doi:10.1016/j.jvs.2009.07.061
© 2009 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
