A survey of demographics, motivations, and backgrounds among applicants to the integrated 0 + 5 vascular surgery residency

Article Outline

• Abstract
• Methods
• Results
• Discussion
• Author contributions
• References
• Copyright

Objective

The 0 + 5 integrated vascular surgery (VS) residency has altered the training paradigm for future vascular specialists. Rising interest in these novel programs highlights our need to better understand the applicant pool. We compared demographics and surveyed recent applicants to our integrated program to gain more insight into their background and motivation for accelerated vascular training.

Methods

Demographics and objective parameters were determined from all 65 applicants to the integrated VS program at Stanford University Medical Center and compared to 58 applicants interviewed by the general surgery (GS) program at Harbor-UCLA Medical Center by querying the Electronic Residency Application System for the programs in 2009. There was no overlap of applicants between programs. An anonymous, voluntary Web-based survey was sent to these cohorts with a response rate of 82% for VS applicants and 60% for GS applicants. Subjects were queried regarding their background, personal experience, prior exposure to VS, and motivations for residency specialty selection.

Results

Applicants to integrated VS programs tended to be older, were less likely to be from a US medical school, had a higher number of publications, and a higher percentage of cardiovascular-related publications than the GS applicants. When stratified by the 27 VS applicants (41%) that were offered an interview, this highly selected and desirable group for training was nearly 40% female, more likely to have an additional degree (PhD, master's), just as likely to be in the top quartile of their medical school class (60%), and score equally well on standardized board examinations (90^th percentile) than the top GS applicants offered interviews. Survey data revealed that the majority of career choices (65%) were made during the third and fourth years of medical school. Factors most strongly influencing the decision to choose VS as a career were endovascular technologies/devices, challenging open vascular operations, clinical rotations on vascular surgery, the aging patient population, and perceived need for vascular surgeons and vascular surgeon mentorship. The most common reasons cited for particularly pursuing an integrated 0 + 5 VS training program were (1) more focused training/integration of cardiovascular medicine, (2) interest in catheter-based endovascular therapies, and (3) shorter time in training. Of the GS applicants, 58% indicated they would be interested in applying to an integrated residency in their subspecialty of interest, and 45% listed vascular surgery as a potential fellowship option after general surgery.

Conclusion

Applicants to 0 + 5 integrated vascular residencies were more likely to have rotated on a vascular surgery service, observed vascular cases, identified a vascular surgery mentor, and been actively involved in cardiovascular research. The quality of the top VS applicant based on class rank and test scores is comparable to the top GS applicants, yet the VS applicant has a higher percentage of advanced degrees, more publications, and more involvement in cardiovascular research. Institutional strategies to increase medical student exposure to vascular surgery clinically and via research programs will optimize our ability to attract and train the best candidates in these new training programs.

Concern about the diminishing quantity and quality of vascular surgery fellowship applicants over the past decade was one of several driving forces that ultimately led to the development of integrated 0 + 5 vascular surgery (VS) training programs in 2007.¹, ², ³, ⁴, ⁵, ⁶ While there has been a clear rise in the volume of procedures performed by vascular trainees, particularly with the widespread adoption of catheter-based techniques, the total number of US-trained surgical applicants to vascular fellowship has remained relatively flat.², ⁴, ⁵ In fact, there was significant concern among program directors in 2004 and 2005 because 21% of vascular fellowship positions were unfilled in the match.⁵, ⁶ Reasons touted for the inability to attract top medical students and surgical residents to VS focus on the new “generation” of medical students, desire of residents for more lifestyle-friendly surgical subspecialties, and the rising number of women in medical school.⁵, ⁷, ⁸

Since the inaugural three integrated VS programs participated in the match in 2007, there has been a fivefold increase in number of positions available in the match and an even steeper level of interest.⁹ Enhancing interest in the field, maintaining the viability of our specialty, and sustaining the workforce in VS may rely on appropriately matching the supply and demand of these novel training programs. There were nine applicants ranking programs for four positions in 2007, 31 for 9 positions in 2008, and 66 for 19 positions in 2009 (Table I). Rising interest, particularly among medical students, in these integrated vascular programs highlights the need to better understand this particular applicant pool. Previous surveys have focused on VS fellows and general surgery residents to determine reasons for choosing VS, most often citing technical aspects, role of mentorship, and complex decision making as the important factors.⁵

Table I. Match statistics for 0+5 integrated VS residency 2007-2010

VS, Vascular surgery; n/a, not applicable.

Given a different population of trainees to attract to the specialty of vascular surgery via new training paradigms, we sought to review the demographics and survey responses of applicants to an integrated VS program compared to a separate general surgery (GS) program to gain insight into the applicant's background, their motivation for accelerated vascular training, and whether the quality of the VS applicant pool was comparable to the most competitive GS applicants.

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Methods 

This study was approved by the National Resident Matching Program (NRMP) and our local Institutional Review Board. Review of all information obtained from the Electronic Residency Application Service (ERAS) of applicants to Stanford University's integrated VS residency program was retrospectively collected, de-identified, and compared to applicants to a traditional 5-year GS residency at Harbor-UCLA Medical Center. There was no overlap of the applicants to both programs. Particular attention was paid to demographics, performance on standardized examinations, educational experience, additional degrees, research time during medical school, grades on surgical clerkships, Alpha Omega Alpha (AOA) status, and class rank.

An online Web-based anonymous survey was then created, and all applicants to the VS program and those invited to interview for the GS program were asked to participate. The reason for this was to create similar numbers of respondents because there are typically several hundred applicants to a traditional GS residency. Also, in attempting to determine the overall quality of the VS applicant pool, we hoped to compare it to a more select group of residency applicants, namely the cohort chosen to interview for a competitive GS residency position. Decisions on which applicants to interview for the GS program were made by the program director (C.D.) and based on medical school transcripts, strength of coursework, class rank, AOA status, letters of recommendation, and research background. Although interview decisions are highly individualized, the program directors (R.L.D., J.T.L.) for the VS program used a similar review of the application to determine the top tier of VS applicants to offer interviews. The questions asked on the survey are shown in the Fig. The focus of the survey was on personal experience, prior exposure to VS, and motivations and future plans for career. The survey administered to the GS applicants was only slightly different, with appropriate changes in the questions regarding types of operations and research that motivate them. Instruction was given to the survey respondents that the information collected could not be traced to their application, and all efforts were made to blind decisions about interviews and rank lists from the survey results.

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• Fig. 

  Online questionnaire for applicants to 0 + 5 integrated vascular surgery (VS) residency.

Responses on the surveys administered were scored in two ways similar to previous reports⁵ with a Likert scale of 1-5, with 5 being very important and 1 listed as not important at all for each question. A rating average was created for each group based on the average response for the cohort, with >4.0 being considered a highly important average for the group. Additionally, scores of 1 and 2 were combined to create a percentage of “unimportant” and scores of 4 and 5 combined to create a percentage of “important” factors. Statistical analyses were performed using χ² test to compare categorical variables between groups and the Mann-Whitney rank-sum test used to compare continuous variables between the cohorts. Values of P < .05 were considered significant.

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Results 

Demographics and objective parameters obtained from the ERAS application are outlined in Table II. More than one-quarter of the applicants were female, 60% were from US medical schools, and 20% held additional advanced degrees. Approximately one-third of the applicants to our VS integrated program received honors on their surgical clerkship and were noted to be in the top quartile of their medical school class. When all 65 VS applicants were compared to the 58 GS applicants that were offered interviews, there were several differences. The VS applicant tended to be older (29 vs 27-years-old), less likely to have graduated from a US medical school (60% vs 100%), had more publications (3.9 vs 1.4), had more publications in cardiovascular research (46% vs 17%), and scored worse on United States Medical Licensing Examination (USMLE) step 1 (220 vs 232) and step 2 (222 vs 241) board examinations (all P < .01).

Table II. Demographics obtained from ERAS applications of all applicants to 0+5 VS program and those invited to interview at GS program

	VS program (n = 65)	GS program (n = 58)	P value
Female	17(26.1%)	24(41%)	.03
Age (mean)	29.1 years	27.4 years	<.01
US medical school graduates	39(60.0%)	58(100%)	<.01
Additional degrees (PhD, MPH, MS, MBA, JD)	13(20.0%)	7(12.1%)	.32
AOA Membership	4(6.2%)	10(17.2%)	.08
Honors in surgery clerkship	19(29.2%)	19(32.8%)	.69
Top quartile of class on Dean's letter	21(32.3%)	23(39.7%)	.45
No. of publications	3.9	1.4	<.01
% of publications in cardiovascular research	45.5%	16.7%	<.01
% of publications in basic science research	37.9%	40.5%	.40
USMLE step 1 score	219.5	231.9	<.01
USMLE step 2 score	222.5	241.2	<.01

AOA, Alpha Omega Alpha; ERAS, Electronic Residency Application Service; GS, general surgery; USMLE, United States Medical Licensing Examination; VS, vascular surgery.

Table III summarizes a more appropriate comparison of the top VS applicants (n = 27) who were offered interviews and the same GS applicants (n = 58) that were offered interviews. The top VS applicant in comparison to the top GS applicant now tended to be the same age and have the same likelihood of graduating from US medical schools. Nearly 40% of both of these select cohorts were female applicants. This top group of VS applicants was also more likely to hold an advanced degree (33% vs 12%) and still have more publications (4.3 vs 1.4) and a higher percentage of publications in cardiovascular research (57% vs 17%) than the GS interviewee. Board scores on step 1 and 2 were now similar between the two groups in this subset of VS applicants when compared to the highly selected GS applicants and in the 90^th percentile.

Table III. Demographics obtained from ERAS applications of top VS applicants invited to interview (45%) compared to GS applicants invited to interview

	VS program (n = 27)	GS program (n = 58)	P value
Female	10(37%)	24(41%)	.81
Age (mean)	27.4 years	27.4 years	.48
US medical school graduates	25(92.6%)	58(100%)	.09
Additional degrees (PhD, MPH, MS, MBA, JD)	9(33.3%)	7(12.1%)	.03
AOA membership	3(11.1%)	10(17.2%)	.53
Honors in surgery clerkship	15(55.6%)	19(32.8%)	.38
Top quartile of class on Dean's letter	16(59.3%)	23(39.7%)	.10
No. of publications	4.3	1.4	<.01
% of publications in cardiovascular research	57.2%	16.7%	<.01
% of publications in basic science research	46.7%	40.5%	.31
USMLE step 1 score	228.6	231.9	.21
USMLE step 2 score	238.3	241.2	.26

AOA, Alpha Omega Alpha; ERAS, Electronic Residency Application Service; GS, general surgery; USMLE, United States Medical Licensing Examination; VS, vascular surgery.

Survey results were posted from 81% of the VS applicant cohort (53 of 65) and 60% (35 of 53) of the GS residency applicants. Analysis of the survey responses provides additional significant differences (all P < .05) between the VS and GS applicant cohorts (Table IV). Eighty-seven percent of VS applicants rotated on VS for a mean time of 1.9 months vs 45% of GS applicants for a mean time of 0.5 months. The VS applicant observed a mean of 52 vascular cases over the 14 that GS applicants reported. Predictably, 91% of VS applicants identified a vascular surgeon as a mentor in medical school, compared to 45% for GS applicants. All respondents (VS and GS) revealed that the majority of career choices (65%) were made during the third and fourth years of medical school. Of the VS applicants, given the paucity of positions during the 2009 match, the majority of them applied for additional residency spots, including GS (64%), other surgical subspecialties (45%), and interventional radiology (26%). When asked about other surgical subspecialties, 58% of GS applicants responded they would have been interested applying to an integrated residency if it existed in their subspecialty of interest, and 45% listed VS as a potential fellowship option after GS.

Table IV. Survey data of applicants (response rate 82% VS and 60% GS)

GS, General surgery; VS, vascular surgery.

Factors strongly influencing the decision of VS applicants to choose vascular as a career are outlined in Table V. The most important factors include endovascular technologies/devices (92%), challenging open vascular operations (86%), their clinical rotation on vascular surgery (87%), the aging patient population, perceived need for vascular surgeons (75%), and vascular surgeon mentorship (75%). The most common reasons cited by VS applicants for pursuing an integrated 0 + 5 training program were more focused training/integration of cardiovascular medicine (90%), interest in catheter-based endovascular therapies (86%), and shorter time in training (69%). Table VI reveals the top factors influencing the decision of GS applicants to choose GS as a career, and these include their clinical rotation on GS (88%), challenging open surgical operations (77%), and a GS mentor (71%).

Table V. Survey results for applicants to integrated vascular surgery 0+5 residency

	Unimportant(score 1 or 2)	Important(score 4 or 5)	Rating average
How did these factors affect your decision to choose vascular surgery?
Endovascular technology/devices	0%(0/52)	92%(48/52)	4.5
Challenging open vascular surgical operations	0%(0/52)	86%(45/52)	4.46
Clinical rotation on vascular surgery	4%(2/53)	87%(46/53)	4.4
Patient population/need for vascular surgeons	31%(16/52)	75%(39/52)	4.12
Mentor/role model	6%(3/52)	75%(39/52)	4.12
Controllable lifestyle	50%(26/52)	17%(9/52)	2.44
Income potential/future earnings	56%(29/52)	17%(9/52)	2.37
Prior vascular surgery research	63%(32/51)	14%(7/51)	2.2
Why did you choose an integrated 0 + 5 vascular residency?
More focused training in cardiovascular diseases	4%(2/52)	90%(47/52)	4.5
Interest in catheter-based interventions	10%(5/51)	86%(44/51)	4.22
Shorter total training time	10%(5/52)	69%(36/52)	4
Research opportunities	20%(10/51)	51%(26/51)	3.53
Less general surgery training	45%(23/51)	27%(14/51)	2.67
Earlier income potential	54%(28/52)	19%(10/52)	2.46

Table VI. Survey results for applicants to general surgery residency

How did these factors affect your decision to choose general surgery?
	Unimportant (score 1 or 2)	Important (score 4 or 5)	Rating average
Clinical rotation/experience	3%(1/35)	88%(30/34)	4.56
Challenging open surgical operations	3%(1/35)	77%(27/35)	4.09
Mentor/role model	3%(1/35)	71%(25/35)	3.97
Minimally invasive techniques/technology/devices	18%(6/34)	59%(20/34)	3.5
Patient population/aging population	33%(12/35)	43%(15/35)	3.2
Income potential/future earnings	66%(23/35)	11%(4/35)	2.17
Prior research in general surgery	57%(20/35)	20%(7/35)	2.14
Controllable lifestyle	80%(28/35)	9%(3/35)	1.97

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Discussion 

In this study, the competitive 0 + 5 VS applicant is a distinct student from the top GS applicant. The 0 + 5 VS applicant tends to be slightly older, is more likely to have an advanced degree, has a high number of publications in cardiovascular research fields, has rotated on VS during medical school, and identified a VS mentor. The academic credentials of the top VS applicant are similar to the top GS applicants, often having an MPH, master's, or PhD degree, getting honors on their surgery clerkship, being identified in the top quartile of their medical school class, and scoring in the 90^th percentile on USMLE step 1 and 2 board examinations. Given the number of these high-quality applicants with credentials worthy of the top positions for any surgical specialty in the match, significant efforts among vascular surgeons and program directors should be made to provide clinical and research mentorship.

The most important factor revealed in this survey cited by the VS applicants for choosing the specialty remains the technical aspects of our specialty. Endovascular technology, innovations in our field and the continued challenge of even more complex open vascular reconstructions are the main attraction for most VS applicants, confirming the opinions of more experienced VS fellows and GS chief residents in previous studies.⁵ In a separate large medical student survey of 1365 respondents at 9 US medical schools sponsored by the Association for Surgical Education, students also have been found to be attracted to surgery for the demands and technical challenges of the specialty.⁸ The opportunity for students and trainees to actively participate in surgical procedures is likely to be rewarded in the long run by increased interest in the specialty. In a study of third-year surgical clerks on a 12-week rotation, students who sutured, drove a laparoscopic camera, and felt involved in the operating room were the most likely to be interested in surgery.¹⁰ Many strategies have been proposed to allow students to be more involved on their surgical rotations, including better outpatient education³ and the potential utility of surgical simulation. In our study,¹¹ utilizing the nonrisky environment of high-fidelity simulation to allow first- and second-year medical students to perform endovascular interventions, we have been able to increase interest in vascular surgery from 9% to 70% after the course.

Another important aspect cited by VS applicants in this study, was the opportunity to work with a vascular surgeon as a mentor. The importance of this recruitment tool cannot be underestimated and has been recommended by most authors who have surveyed students and trainees.⁵, ⁶, ⁷, ⁸ It is no surprise that of the GS applicants in this study, none of whom applied to an integrated VS program, less than half of them had rotated on VS. There simply was not an opportunity to recruit these competitive applicants into an integrated VS residency position. Medical schools interested creating an integrated 0 + 5 VS residency need to focus efforts on providing exposure of the third-year surgical clerk into a VS service, or even providing preclinical exposure in medical school. At both Stanford and Harbor-UCLA, a VS faculty member is the primary clerkship director for the core third-year surgery rotation, allowing ample opportunity at both institutions for the third-year medical student to rotate on VS.

The positive influence vascular surgeons have, even on the GS applicant in this study, is highlighted by the fact that 45% of them identified a vascular surgeon as a mentor. In addition, this same proportion (45%) is considering vascular training after GS residency. Even with limited exposure to students who ultimately choose GS, the rewarding aspects of our specialty can be conveyed to medical students to increase the recruitment pool for the 5 + 2 programs in the future. This becomes important, because there has been a declining number of applications to GS residencies, which provides the cohort to fill VS fellowships.⁶, ⁸, ¹⁰ Most importantly to program directors of 5 + 2 VS fellowships, there has been a stagnant size of the VS applicant pool from 1989 to 2003.⁴ Reported reasons include a change of priorities of medical students in “generation X”,¹² increased numbers of women in medical school,⁷ and the length of training time. The development, rise, and careful review of applicants and graduates of 0 + 5 integrated VS residencies may be particularly suited to address these concerns to maintain a steady future supply of young trainees.

We were impressed by the percentage of female applicants found in this study. Women in VS continue to be underrepresented, particularly with more than half of medical students now in the United States being female.⁷ This significant issue can only be partially reversed by focusing on the positive aspects of our specialty and providing appropriate mentorship for all applicants. Nearly 40% of the applicants invited for our 0 + 5 VS residency were women, a much higher percentage than what has been seen in VS fellowship applications. Having the pool of US medical students to attract to VS rather than of GS residents, provides a higher likelihood of recruiting women to the specialty. The focused training provided by the 0 + 5 integrated VS residency translates to a shorter training period, which might be an important consideration for women interested in VS who have reported in surveys being concerned about childbearing issues, lifestyle-controlled practices, and daycare on site.⁷ Shorter training time in this study was cited by 69% of the 0 + 5 VS applicants as an important reason for this particular training paradigm, again highlighting one of the main advantages of the integrated VS residency.

Fears that the quality of applicants for fellowship has diminished in the past years among program directors has been mostly anecdotal, and certainly data suggest that there are several obstacles that prevent GS residents from choosing VS as a specialty, including operations being too long or stressful, loss of procedures and revenue to other interventionalists, and vascular patients being “too sick”.⁵ This severely hampers the ability to recruit the best GS residents into 5 + 2 VS fellowships. Efforts at recruiting for the 0 + 5 VS residency, given the much larger cohort, can help this problem. In this study, and during our recent residency match process, we were particularly impressed with the caliber of the 0 + 5 VS applicant. Several were MD-PhD students or had other master's degrees, most had received honors on their surgical clerkships (56%), and were in the top quartile of their class based on their dean's letters (60%). Review of the demographic data in this study revealed the top VS applicant to be just as competitive, if not better, than the top GS applicants (Table III).

As a group of program directors, earlier exposure to clinical VS, research projects, or mentors will also be helpful in allowing medical students to understand what VS is. Efforts by the Society for Vascular Surgery and the Association for Program Directors in Vascular Surgery via the extensively revised Web site and medical student recruitment programs can have significant impact on influencing students' choices. Our survey revealed that more than two-thirds of the surgical applicants chose their specialty choice during their third or fourth years of medical school, meaning many had already had their minds made up prior to entering the clinical years of medical school. A prospective study of students' changes in specialty interests over the course of medical school was conducted via survey in 15 medical schools and found more intensive introduction to some specialties earlier in premedical and preclinical curricula benefited certain specialties, particularly nonprimary-care fields.¹³ In a survey involving plastic surgery residencies, one of the most thriving specialties with a 34% increase in the number of applicants from 2002 to 2005, applicants cited exposure to plastic surgery and compatibility with plastic surgery mentors as the most influential factor.¹⁴ The authors recommended this exposure occur prior to the third-year surgical clerkship, as many times plastic surgery is not a core third-year rotation. Courses in VS and the opportunity to do cardiovascular research during the preclinical years should be promoted as a way to increase medical student interest in our field.

There are several limitations to our study, namely that only one integrated VS residency and a separate GS residency program were involved. The results may not be applicable to the entire country of medical students, as there may be some regional or even institutional biases among the students involved in the survey. Also, the fact that the two institutions were different might account for some of the differences between the VS and GS applicant, because various programs will attract different students. Future studies and survey information will need to be collected to better identify the best recruitment strategies that may be regionally-dependent or even institution-dependent. Such data will also help with future curriculum design to provide trainees with the optimal environment that will maximize education and limit attrition, a significant concern among the 19 programs currently approved. As with any survey data, one cannot underestimate the inherent bias in answering questions, particularly because these were applicants to our respective programs. Finally, the large proportion of foreign medical graduates applying for these novel positions might affect the results, as most other surgical subspecialties do not have such a high number of these applicants. The background, demographics, and potential responses from this cohort might skew the data and not provide the appropriate information for program directors in these currently very competitive residency positions.

In summary, we found that applicants to 0 + 5 integrated vascular residencies were more likely to have rotated on a VS service, observed vascular cases, identified a VS mentor, and been involved in cardiovascular research. The quality of the VS applicant based on test scores and class rank is comparable to the top GS applicants, yet the VS applicant often has more advanced degrees, more publications, and more intensive involvement in cardiovascular research. Institutional strategies to increase medical student exposure to VS at the clinical and research levels will optimize our ability to attract and train the best candidates in these new training programs. Identifying, mentoring, and ultimately recruiting the top students into integrated 0 + 5 VS residencies will populate these new programs with the brightest and most skilled trainees and maximize chances for the success of this new training paradigm.

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Author contributions 

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References 

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