Artigo Acesso aberto Revisado por pares

The Vascular Surgery Sub-board: Progress report

2000; Elsevier BV; Volume: 31; Issue: 5 Linguagem: Inglês

10.1067/mva.2000.106633

ISSN

1097-6809

Autores

G. Patrick Clagett, Keith D. Calligaro, Julie A. Freischlag, Frank W. LoGerfo, Glenn Steele, Jonathan B. Towne, Anthony D. Whittemore, Wallace P. Ritchie,

Tópico(s)

History of Medical Practice

Resumo

The Vascular Surgery Sub-board of the American Board of Surgery (ABS) emerged from deliberations between the leadership of the vascular societies (Society for Vascular Surgery/International Society for Cardiovascular Surgery [SVS/ISCVS]) and the ABS that spanned 2 years. The principal concern of the vascular leadership was that the needs of patients with vascular disease were not being appropriately met. To ensure the highest possible caliber of patient care, the leadership believed that responsibility for the educational curriculum and technical training with attendant certification should reside with vascular surgeons. The American Board of Vascular Surgery was legally incorporated in 1996 after an investigation regarding its feasibility. In June 1998, the ABS responded after lengthy deliberation by creating the Vascular Surgery Sub-board. The principal architect of this structure was Richard H. Dean, MD, and the model of government evolved at the ABS Retreat in January 1998. The model is patterned after the American Board of Internal Medicine, a group that has several specialty sub-boards. This process will allow maturing fields within surgery to gain operational authority over the training and certification of its specialists. It is anticipated that the next sub-board will be in pediatric surgery. For a maturing field of surgery that is not certified, the creation of an advisory council is possible. Currently, an Advisory Council for Surgical Oncology exists, and it is anticipated that other subspecialty areas, such as trauma and critical care, will become involved in this process. The composition of the Vascular Surgery Sub-board consists of ABS directors representing the SVS/ISCVS Joint Council (G. P. Clagett) and Association of Program Directors in Vascular Surgery (APDVS) (F. W. LoGerfo); two appointees from the SVS/ISCVS Joint Council (A. D. Whittemore and K. D. Calligaro); one appointee from the APDVS (J. B. Towne); an ABS director who is a vascular surgeon (J. A. Frieschlag); the chairman of the ABS (G. D. Steele, Jr); and the executive director of the ABS (W. P. Ritchie, Jr). This structure will ensure permanent strong representation from the vascular surgery community. Since its establishment in June 1998, the Vascular Surgery Sub-board has met on four occasions, has undertaken numerous tasks, and has discussed a wide range of issues. After reviewing the Vascular Surgery Qualifying (written) and Certifying (oral) Exami- nations, the sub-board determined that both needed considerable improvement. There was a striking absence of items designed to test in-depth knowledge in noninvasive testing. The sub-board believed that it was important to emphasize noninvasive testing as a critical, core component of vascular surgery and appointed an ad hoc subcommittee (Drs William M. Abbott, Gregory L. Moneta, J. Dennis Baker, and R. Eugene Zieler) to review, improve, revise, and expand the pool of qualifying examination items that involve noninvasive testing. This group developed more than 60 new multiple choice questions of excellent quality, a large portion of which will be on the October 2000 Vascular Surgery Qualifying Examination. The sub-board also directed attention to the Vascular Surgery Certifying Examination by appointing a subcommittee of ad hoc consultants (Drs Dennis F. Bandyk, James O. Menzoian, Kimberley J. Hansen, and Christopher K. Zarins). This group initially developed more than 50 new scenarios for which there were no cases or which were considered underrepresented in the existing case pool. All of the cases had supporting visual material including angiograms, waveforms, and other noninvasive testing visual material. Ten of these new cases were piloted at the May 1999 certifying examination and were well received by all examiners. A poll of the examiners documented the desire to have more in-depth, difficult clinical scenarios that would test the knowledge base of a true specialist in vascular disease. This ad hoc committee then turned to revamping the existing clinical scenarios in the certifying examination case pool. Appropriate arteriograms and other visual material were added in addition to updating and increasing the complexity of existing scenarios. The next certifying examination in May 2000 will be, in essence, a new examination. At its first meeting in September 1998, the sub-board addressed issues of training in vascular surgery and general surgery. The group reviewed the Residency Review Committee for Surgery's (RRC-S's) Program Requirements for Residency Training in Vascular Surgery. In large measure, these proposed program requirements were developed by the APDVS and forwarded to the RRC-S by Jack Cronenwett, MD. The sub-board supported the new requirements and proposed a change in the Program Requirements for Residency Education in General Surgery to the effect that when a general surgery residency program requests an increase in its resident complement, the general surgery program director must certify to the RRC-S that such a change will not affect the quality of training in vascular surgery and other surgical specialty residency programs. At this same meeting, the sub-board considered the vascular surgery training requirements of general surgery residents. The sub-board formally requested that the APDVS and the Association of Program Directors in Surgery (APDS) form a joint committee to address this issue. Subsequent to this, representatives from the APDVS (Drs Robert Hobson, Jonathan Towne, Jack Cronenwett, and Frank Logerfo) and the APDS (Drs Henry Laws, Patrick O'Leary, Robert Barnes, and Richard Welling) met on several occasions. In August 1999, this group forwarded recommendations to the sub-board. To increase the flexibility of vascular surgery program directors and, also, to more appropriately train general surgery residents in case loads reflective of existing practice patterns, the group recommended that the current minimum requirement of 44 “defined category” operations in vascular surgery be expanded to include primary arteriovenous fistulas, vena caval filter placement, and thrombectomy or embolectomy of native arteries and angioaccess grafts. At its September 1999 meeting, the sub-board unanimously endorsed these recommendations and forwarded a letter to the RRC-S strongly urging the RRC-S to adopt them. Subsequent to this at its October 1999 meeting, the RRC-S approved this change in the type of cases that could count for the minimal requirement toward 44 vascular cases. The RRC-S also emphasized that “a balanced operative experience including reconstructive vascular surgery must be provided to general surgery residents.” At the request of the APDVS members on the Vascular Surgery Sub-board, the sub-board has forwarded a letter to the RRC-S seeking clarification of the phrase “balanced operative experience.” Early in its deliberations, the Vascular Surgery Sub-board requested that the phrase “General Vascular Surgery” be changed to “Vascular Surgery” on the ABS certificate. This term came about in the 1980s during the development of certification in vascular surgery and was a response to concerns of other surgical specialties such as neurosurgery and urology. The term General , as it relates to vascular surgery, was immediately dropped from all internal ABS correspondence and publications. The ABS then sought deletion of “General” from the certificate itself by petitioning the American Board of Medical Specialties (ABMS). Subsequently, the ABMS granted permission to the ABS to eliminate the word General from the certificate in vascular surgery. This change will be brought about on all certificates issued in vascular surgery by the spring of 2000. In addition, the chairman of the Vascular Surgery Sub-board will be a signatory on all new certificates. At its May 1999 meeting, the Vascular Surgery Sub-board spent considerable time revising the vascular surgery resident surgical operative log form for the ABS. The form was extensively revised to include endovascular and other procedures. In addition, the concept of primary and secondary procedures was developed so that a resident could list combined procedures, such as aortobifemoral bypass graft plus aortorenal bypass graft, femoral distal bypass graft plus profundaplasty, and iliac angioplasty plus distal bypass graft. Either procedure could count as the primary procedure, and all would be recorded. In this fashion, the breadth of experience of a vascular resident would be documented. Before this change, the trainee had to choose one or the other procedure as the index case. The intent of the Vascular Surgery Sub-Board was to affect change in vascular case counting at both the ABS and the RRC-S. The sub-board forwarded to the RRC-S the revised and expanded ABS operative experience report for the RRC-S's use. Ultimately, it is anticipated that the two operative lists will be similar if not identical. In this manner, a complete operative experience of vascular surgery trainees that reflects their entire experience will be available for the first time. The Vascular Surgery Sub-board has extensively discussed and considered changing entrance requirements to obtain ABS certification in vascular surgery. There are a large number of trained vascular surgeons who were excluded from the ABS vascular surgery examination process because they had not met either the educational or the clinical requirements in place for admission or did not apply before fellowship training in an Accreditation Council for Graduate Medical Education (ACGME)–accredited program became mandatory. The ABMS (the parent group of all boards) has, in essence, proscribed any further “grandfathering” beyond the initial start-up phase for a new certificate in any specialty. For vascular surgery, this time limit has long since expired. The Vascular Surgery Sub-board sought legal counsel who advised that the legal risks to both the sub-board and the ABS were prohibitive. Once any group or individual is allowed to take a board outside of the original, well-defined eligibility parameters, that board opens itself up to lawsuits from other individuals with varying backgrounds and training, all of whom want to obtain certification. All members of the sub-board concurred that reopening grandfathering was not possible. A great deal of thought and deliberation has focused on the role of vascular surgery as a primary component of general surgery training. Other primary components consist of alimentary tract; abdomen and its contents; breast, skin, and soft tissue; head and neck; endocrine system; surgical oncology; trauma; and critical care. The current ABS Booklet of Information reads: “A General Surgeon is one who has acquired specialized knowledge and experience related to the diagnosis, preoperative, operative, and postoperative management, including the management of complications, in nine primary components of Surgery all of which are essential to the education of a broadly based surgeon.” The ABS's stance is that this statement refers only to training and does not imply special expertise or competence. The ABS certificates do not define who can and who cannot practice vascular surgery. Vascular surgery privileges are determined by local credentials committees according to local criteria and peer review. The Vascular Surgery Sub-board considered these issues at length and unanimously agreed that vascular surgery training was important for general surgery residents and should remain a primary component, as long as the sub-board exists in its current role. It considered the statement in the ABS booklet and agreed that it referred only to training. The Vascular Surgery Sub-board has also considered its relationship with the RRC-S. Currently, there is strong vascular surgery representation (RRC-S members include Drs Lazar Greenfield, Jack Cronenwett, and Richard Welling). The three groups that determine membership on the RRC-S and submit nominees for these positions include the ABS, the American College of Surgeons (ACS), and the American Medical Association Council on Medical Education. To ensure continued strong representation on the RRC-S, the Vascular Surgery Sub-board has been granted the authority to nominate vascular surgeon representatives from the ABS when the current vascular surgeon representative's term expires. In addition, the Vascular Surgery Sub-board has contacted the ACS Advisory Council for Vascular Surgery to inform them of this development and to strongly suggest that the ACS Advisory Council composed mostly of vascular surgeons be the nominating source from the ACS. In this manner, there will be a minimum of two vascular surgeons on the RRC-S whose nominations to that group came from the vascular surgery community. In addition to these developments, the Vascular Surgery Sub-board has assumed operational authority over many aspects of the vascular surgery certification process. The Vascular Surgery Sub-board reviews in detail the psychometric and other statistical results of all vascular surgery examinations including the Qualifying Examination, the Certifying Examination, and the Recertification Examination. The sub-board previews all items to be included on these examinations for content and appropriateness. In addition, the sub-board determines the passing score on the Qualifying and Recertification Examinations. The sub-board appoints the individuals to be consultants for these examinations (individuals who develop new test items) and actively participates in this process by contributing new questions to the pool on an annual basis. The Vascular Surgery Sub-board also chooses and appoints examiners for the May Certifying Examination (oral examination) and also determines the examination site. In June 1998, the Joint Council of the SVS and the ISCVS along with the executive committee of the APDVS outlined 14 issues or “points” that would be used as a guide to assess the success of the Vascular Surgery Sub-board. At this time, it is appropriate to review these issues. Both the Joint Council and the ABS agreed to review the progress of the sub-board 18 to 24 months after its inception. Thus, it is timely to review the 14 areas of concern.1.Training Requirements in Vascular Surgery “Expectations: The Sub-Board will be given authority to define minimal standards for training in vascular surgery and communication of such to the RRC.” This has been accomplished, and the Vascular Surgery Sub-board has the authority to recommend standards for training in vascular surgery residencies. These recommendations can be transmitted directly to the RRC-S. Before doing so, the sub-board intends to seek input from the APDVS and Joint Council of the vascular societies.2.Certification and Recertification Requirements in Vascular Surgery “Expectations: The Sub-Board determines the criteria defining who may sit for certification and recertification examinations, as well as the standards required to pass such examinations. This includes the ability for the Sub-Board to review the possibility for individuals who have successfully completed prior PEEC-approved programs (programs in existence prior to the development of ACGME-approved Vascular Surgery residencies) to sit for examination provided they meet acceptable requirements as current vascular surgery practitioners.” The Vascular Surgery Sub-board has been given the authority to evaluate and define certification and recertification criteria and standards. The sub-board has also considered the grandfathering issue and, in concert with the ABMS, has determined that this is not possible because of prohibitive legal risk to the sub-board, the ABS, and the ABMS.3.Oversight of Vascular Qualifying and Certifying Examinations “Expectations: The Sub-Board will have direct involvement in receiving psychometric analysis of examinations. The Sub-Board will also be involved in the establishment of examination methodology, including the setting of examination standards.” The Vascular Surgery Sub-board has assumed all of these responsibilities including establishing examination standards.4.Appointments of Consultants to Examination Committee and Examiners for Certifying Examination “Expectations: The Sub-Board has the authority to appoint all consultants to the Examination Committee and all examiners for the Vascular Certifying Examination.” The Vascular Surgery Sub-board appoints all consultants to the Examination Committee for Vascular Surgery, appoints ad hoc committees when appropriate to deal with examination deficiencies, and appoints all examiners, senior and associate, for the Vascular Surgery Certifying Examination.5.Training Requirements for General Surgeons in Vascular Surgery “Expectations: The Sub-Board has the responsibility to define standards, acceptable to the ABS, for general surgery training in vascular surgery.” This has been addressed and accomplished. New RRC training requirements are expected to be in place because of the concerted effort of the APDVS, the APDS, and the sub-board.6.Certification and Recertification Requirements for General Surgeons in Vascular Surgery “Expectations: The Sub-Board should participate in developing standards regarding Vascular Surgery requirements for certification and recertification in general surgery.” As noted in issue 5, this has been accomplished. In addition, the Vascular Surgery Sub-board participates in ABS deliberations regarding recertification issues in general surgery as it relates to vascular surgery.7.Vascular Surgery Component of General Surgery Qualifying and Certifying Examinations “Expectations: The Sub-Board has input into the Vascular Surgery component of the General Surgery Qualifying and Certifying Examinations.” The members of the Vascular Surgery Sub-board who are directors of the ABS have been actively involved in the vascular surgery component of these examinations. In fact, their input has been eagerly sought and well received.8.Relation to Other Surgical Specialties within the ABS “Expectations: The Chairman of the Sub-Board should be a member of the ABS Executive Committee if vascular surgery remains a primary component of training within the ABS lexicon. All substantial ABS issues regarding certification related to vascular surgery activities will be brought to the Sub-Board for action.” At the January 1999 meeting of the Vascular Surgery Sub-board, this issue was addressed. The chairman of the Vascular Surgery Sub-board was made an ad hoc member of the ABS Executive Committee. Since that time, the chairman has participated actively in all ABS Executive Committee meetings. At its most recent meeting, the ABS voted unanimously to change the ABS bylaws so that chairpersons of all sub-boards and advisory councils would be members of the ABS Executive Committee with full voting privileges. All issues regarding vascular surgery certification are brought to the sub-board for action.9.Administrative Support of ABS Sub-Board for Vascular Surgery “Expectations: Appointment of permanent surgeon to serve as Executive Secretary of the Sub-Board, with office located in ABS offices.” There currently is an administrative assistant at the ABS office to support sub-board activities. The Vascular Surgery Sub-board has determined that the appointment of a permanent executive secretary at the ABS would dilute the authority of the chairman of the sub-board and that the current administrative model is working well.10.Relation to Other Surgical and Medical Specialties “Expectations: The Sub-Board has the authority to develop interdisciplinary training and practice requirements related to certification and recertification that involve non-ABS surgical disciplines, and nonsurgical disciplines, such as endovascular training in cardiology and interventional radiology.” The sub-board has the authority to review, comment on, and make recommendations about all proposals related to interdisciplinary training. The sub-board most recently reviewed the proposed “Program Requirements for Residency Education in Endovascular Surgical Neuroradiology” submitted by the RRCs for diagnostic radiology and neurologic surgery. This new residency program is being proposed and will be certificated if approved. The Vascular Surgery Sub-board reviewed and officially critiqued this document. In addition, the sub-board considered the issue of developing a new training program with certification in endovascular surgery. It is worth noting that the sub-board has the authority to do this. It was believed that at the present time endovascular training is evolving in vascular surgery residencies and that an effort to establish separate endovascular training programs might have a negative impact on the development of endovascular training within established vascular surgery residencies.11.RRC Requirements for Vascular Surgery Program Approval “Expectations: Sub-Board given ability to petition the RRC-S with ABS support for the establishment of a separate committee or equivalent designated group within the RRC that will be responsible for vascular surgery training program standards and reviews.” The Vascular Surgery Sub-board has taken steps to ensure permanent representation on the RRC–S. Currently, vascular surgery representation at the RRC-S is strong and should remain so because of the Vascular Surgery Sub-board's initiatives. Future RRC-S nominees representing vascular surgery from the ABS will be determined by the sub-board.12.ABS Communication Regarding Vascular Surgery and General Surgery Certification “Expectations: Timely review and approval by the Vascular Surgery Sub-Board of all ABS communications regarding training and competence to practice vascular surgery by those with and without Certificates in Vascular Surgery.” The Vascular Surgery Sub-board has reviewed all ABS communications referring to these issues and has the ability to affect change when it perceives the need to do so. In addition to reconsidering the wording of the ABS Booklet of Information with regard to training and certification of general surgeons, the Vascular Surgery Sub-board is currently revising the ABS Booklet on Certification in Vascular Surgery.13.Status of the ABS Vascular Examination Committee “Expectations: The Vascular Examination Com- mittee should become a subordinate committee reporting to the Vascular Surgery Sub-Board, rather than a freestanding structure reporting directly to the ABS Executive Examination Committee.” The Vascular Surgery Sub-board has assumed all of the functions of the Vascular Examination Committee. The ABS Vascular Examination Committee no longer exists.14.Vascular Surgery as a Primary Component of General Surgery “Expectations: The Vascular Surgery Sub-Board supports general surgery training to allow competent practice of vascular surgery techniques, relative to care expected of broadly trained general surgeons and acknowledges that general surgeons do not have the requisite experience to provide the full spectrum of care to patients with vascular disease.” The Vascular Surgery Sub-board has carefully considered this issue and believes that vascular surgery training is important in the education of general surgeons and should remain a primary component of their overall training. The Vascular Surgery Sub-board does not support an implication that such training can be translated into competence to practice vascular surgery. The issue of linking competence to certification and recertification has become a major initiative undertaken by the ABMS, who has charged its 24-member boards to expand the meaning of board certification to include competence. Currently, board certification signifies that an individual has completed an ACGME-approved residency and has passed an examination. It does not imply any special competence. In response to widespread public and political concerns, the ABMS in general and the ABS in particular have undertaken an initiative to develop mechanisms of assessing competence among certificate-holders. At its January 2000 retreat, the ABS began preliminary plans and discussions, and precise details of this initiative are evolving. All have agreed that assessment of outcomes will be an important component of any plan to assess competence. The Vascular Surgery Sub-board has been involved in the ABS's Competence Initiative and has been approached to develop a pilot program. The vascular surgery community is ideally suited for this and is in the position of providing leadership in this initiative among surgical specialties. In addition to having well-defined index cases (such as carotid endarterectomy, aortic aneurysm repair, infrainguinal bypass graft) with agreed-upon parameters for morbidity and mortality, the vascular surgery community is comparatively homogeneous. There are also several vascular surgeons who have published outcome-assessment studies and could provide needed expertise. The details of a vascular surgery pilot program to assess competence have not been developed, but they will most likely involve a partnership with the national and regional vascular societies, be restricted initially to vascular certificate holders, involve the principle of continuous feedback to improve quality, and ensure strict anonymity. The Vascular Surgery Sub-board has worked effectively with the ABS, RRC-S, and the APDVS in addressing many of the initial concerns of the leadership in vascular surgery. We believe that real progress has been achieved, but recognize that much remains to be done. We believe that most will find the current achievements sufficient evidence that the Vascular Surgery Sub-board has assumed the operational authority over the education and certification of vascular surgeons. It is important to consider that this progress is occurring in a dynamic setting that requires redefinition of our specialty with regard to endovascular intervention and our relations with interventional radiology and cardiology, revision of the missions of our two national societies, and adaptation to the current volatile medical economic climate. Given the understandable anxieties associated with this extraordinary evolution, it is important to move carefully and thoughtfully, yet forcefully.

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