In 2006, the Accreditation Council for Graduate Medical Education approved the Primary Certificate in Vascular Surgery, which eliminates the requirement for certification in general surgery prior to certification in vascular surgery. This created more than one training pathway.

•  0+5 Track:  Vascular surgery integrated track for trainees who match during medical school. Three years are devoted to vascular surgery and two years to core surgical training. Core surgery rotations may occur throughout the first four years of training. Eligible for board certification in vascular surgery only.
•  3+3 Track:  Residents currently match during medical school. Residents receive three years of vascular surgery training following three initial years of preliminary general surgery training at the same institution. Eligible for board certification in vascular surgery only.
•  4+2 ESP (Early Specialization Program) Track:  Available to residents in programs with ESP accreditation. Allows for early entry into vascular surgery with the traditional chief year of general surgery serving as the first year of vascular training. Eligible for vascular surgery and general surgery certification.
•  5+2 Track:  Five years of general surgery residency plus two years of vascular surgery training. Eligible for board certification in both general surgery and vascular surgery.

“In the traditional school paradigm, we spent nine years in training,” says Vikram S. Kashyap, MD, chief of vascular surgery at University Hospitals Case Medical Center and Case Western Reserve University School of Medicine in Cleveland. “The newer 0+5 model is the paradigm of the future because it streamlines training, and trainees are focusing on newer areas that are relevant to vascular surgery and vascular disease, such as vascular imaging and cardiovascular risk stratification.” It also eliminates rarely performed procedures, such as pedicure surgery or OB/GYN rotations in a traditional general surgery residency, he adds.

A self-described champion of the 0+5 model, Jack L. Cronenwett, MD, of the vascular surgery department at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., says it was created for physicians focused on vascular surgery only. “Then the five-year program is more efficient,” Cronenwett says. The new programs also represent the recognition of the autonomy of vascular surgery subspecialty, he adds.

What do residents think of their training? To find out, the Association of Program Directors in Vascular Surgery leadership sent a survey to all vascular surgical trainees (integrated [0+5], independent current and new graduates [5+2]) addressing various aspects of the educational experience. Of 412 surveys sent, 163 responded: 46 integrated, 96 fellows and 21 graduates (J Vasc Surg 2012;55[2]:588-598).

Lead author Michael C. Dalsing, MD, chief of the division of vascular surgery at  Indiana University (IU) School of Medicine in Indianapolis, says that at the time, only about 30 schools in the U.S. were live with 0+5 programs. Today, it is closer to 40 to 45.

When choosing a program for training, the integrated residents singled out program atmosphere and the independent residents total clinical volume, according to survey results. “The integrated residents were much more concerned with the program atmosphere because they have to stay in one place for five years,” Dalsing explains. “They are focused on how the faculty communicated with their residents, and if the environment was benign to foster learning and nurture them.”  

The respondents said their “concerns after training” were thoracic and thoracoabdominal aneurysm procedures and business aspects.

In terms of clinical training, integrated trainees found periprocedural discussion the best feedback (79 percent), with 9 percent favoring written test review. Surgical training and vascular laboratory and venous training were judged “just right” by 87 percent and 71 percent. However, 65 to 70 percent said that business aspects needed “more emphasis.”

Likewise, the independent program trainees also found periprocedural discussion the best feedback (71 percent), with 12 percent favoring written test review. Surgical training and vascular laboratory/venous training were “just right” by 87 percent and 60 to 70 percent, respectively. Similar to the integrated trainees, many of the independent program trainees wanted more emphasis on business aspects.

In terms of the feedback about more business training, the trainees targeted drawing up a contract, contracts with employees and running a business. “In the past, we’ve learned these skills on the job, but now we should be a little more aggressive in giving them some of that information,” Dalsing says. In fact, IU now sends its trainees to coding classes for those basic skills.

“None of us really finished the clinical training with very much understanding of the business of healthcare or the business of medicine,” adds Kashyap. “Quite frankly, the hospital systems often evaluated us on RVUs [relative value units] and professional billing, or in terms of DRG [diagnosis related group]-based technical revenue.” Now the emphasis is shifting away from procedures to value and quality. “Especially when the payment model starts to move toward ACOs [accountable care organizations] and global reimbursement, it will become a lot more apparent what different individuals bring to a healthcare system.”

To better understand the current system, Case Western has trainees meet on a quarterly basis with billing specialists and attend the annual budget meeting, where participants discuss revenue and net loss and income. “There they get an appreciation of those considerations,” Kashyap says.

Appropriateness of Training: Vascular Surgery Residents' Opinion

Ind: Independent program responses; Int: integrated program responses. J Vasc Surg 2012;55:588-598.

New procedures

“Over the past 20 years, there has been an evolution toward more endovascular and less open vascular procedures, partly due to a shift in referrals,” Cronenwett says. He cited a recent analysis that evaluated trainee procedures from 2001 to 2007; it showed that the volume per trainee of open vascular procedures remained relatively constant, except for a slight decrease in the open aortic volume, where there was a 17 percent decrease.

“On average, that represented 50 cases per year down to 41 cases per year for residents, which is still a relatively high volume,” Cronenwett says. “At the same time, endovascular aneurysm repair increased by 300 percent.”

The increase in endovascular procedures for vascular surgeons may result from the referring physicians. “There has been a substantial increase in the number of endovascular procedures performed by all specialists, and the percentage performed by vascular surgeons has increased significantly,” notes Cronenwett. He adds that many patients or referring providers view a physician who can perform both the open and the endovascular procedures as unbiased. “If one refers a patient to a provider who can only perform an open procedure or who can only perform an endovascular procedure, then they have an inherent bias in what they’re going to recommend.”

Both Dalsing and Cronenwett see the procedure base of vascular surgeons continuing to grow with new technologies in the U.S., particularly renal denervation. “Vascular surgeons have treated renal vascular hypertension for years with open surgery, and in more recent years, with catheter-based stent therapy,” Cronenwett says. “If renal denervation becomes established as optimal treatment, vascular surgeons will continue to trigger the request of hypertension as they always have, simply now with a new modality that they will be able to apply because of their endovascular technique and skills, just like an interventional cardiologist or radiologist.”

Kashyap also sees the sandbox as large enough for all to play, seeing an overlap between vascular surgeons, interventional cardiologists and interventional radiologists for peripheral interventions. “We truly all have to come together as a heart team, all working in the same space to try to optimize the treatment of these patients,” he says.