Vascular surgery training in the United States: A half-century of evolution
2008; Elsevier BV; Volume: 48; Issue: 6 Linguagem: Inglês
10.1016/j.jvs.2008.07.090
ISSN1097-6809
Autores Tópico(s)Cardiac, Anesthesia and Surgical Outcomes
ResumoThe purpose of this report is to succinctly review the history, evolution, and accreditation process of postgraduate surgical training programs in the United States, with emphasis on recent dramatic changes in vascular surgery training. Vascular surgery became a distinct specialty of surgery on March 17, 2005, when the American Board of Surgery (ABS) received approval from the American Board of Medical Specialties (ABMS) to offer a Primary Certificate in Vascular Surgery. The traditional requirement for 5 years of training and certification in general surgery was eliminated. Effective July 1, 2006, the ABS converted its certificate in vascular surgery from a subspecialty certificate to a specialty (primary) certificate. These landmark changes allowed the simultaneous development of new training paradigms. Multiple flexible training pathways leading to either dual certification (Traditional 5-2; Early Specialization Program 4-2) or vascular surgery certification alone (Integrated 0-5; Independent 3-3) now exist. New pathways require a minimum of 2 years of core surgery training and 3 years of advanced vascular training. There are currently 96 accredited traditional 5-2 programs, five 4-2 programs, and 11 0-5 integrated programs, with multiple additional institutions in the process of submitting 0-5 applications. The main obstacle preventing more rapid transition to the new pathways seems to be difficulty in obtaining funding for additional resident positions. Multiple flexible training paradigms are likely to coexist as vascular surgery continues to evolve. The purpose of this report is to succinctly review the history, evolution, and accreditation process of postgraduate surgical training programs in the United States, with emphasis on recent dramatic changes in vascular surgery training. Vascular surgery became a distinct specialty of surgery on March 17, 2005, when the American Board of Surgery (ABS) received approval from the American Board of Medical Specialties (ABMS) to offer a Primary Certificate in Vascular Surgery. The traditional requirement for 5 years of training and certification in general surgery was eliminated. Effective July 1, 2006, the ABS converted its certificate in vascular surgery from a subspecialty certificate to a specialty (primary) certificate. These landmark changes allowed the simultaneous development of new training paradigms. Multiple flexible training pathways leading to either dual certification (Traditional 5-2; Early Specialization Program 4-2) or vascular surgery certification alone (Integrated 0-5; Independent 3-3) now exist. New pathways require a minimum of 2 years of core surgery training and 3 years of advanced vascular training. There are currently 96 accredited traditional 5-2 programs, five 4-2 programs, and 11 0-5 integrated programs, with multiple additional institutions in the process of submitting 0-5 applications. The main obstacle preventing more rapid transition to the new pathways seems to be difficulty in obtaining funding for additional resident positions. Multiple flexible training paradigms are likely to coexist as vascular surgery continues to evolve. Understanding the evolution and current status of vascular surgery training requires some background of the history of graduate medical education in the United States. The processes of development of curriculum requirements, program accreditation, and pathways to board certification are difficult to fathom without a brief review of the governing bodies involved and their underlying purposes, authority, and complex interactions. This background knowledge allows one to better appreciate why the ongoing process of definition, recognition, and independent certification of vascular surgeons has been such a contentious one. The primary reason is not necessarily due to the genes we inherited as descendants of the American Revolution, but to the maze-like arrangement of the numerous organizations responsible for the oversight and certification of specific aspects of medical education that developed in the early 19th and 20th centuries. In the mid 1880s, the number of bona fide medical schools in the United States was limited; standardized curricula, organized oversight and monitoring, and quality control were lacking; and many schools were simply diploma mills. “Medicine at the beginning of the twentieth century was in a sorry state.”1Stephenson G.W. The American College of Surgeons and Graduate Education in surgery: a chronicle of advancement.Bull Am Coll Surg. 1971; 56: 10-15Google Scholar The American Medical Association (AMA), founded in 1847, was one of the first voluntary nonprofit educational associations. Little progress was made in medical education until the early 1900s, when the drive toward the standardization and regulation of medical training and practice for the greater public good was led by the AMA and the American College of Surgeons (ACS). In 1905 the AMA published, for the first time, medical school specific pass rates for licensure examinations, based on which only 50% of existing medical schools were approved. In 1910 Abraham Flexner and N. P. Colwell performed a landmark survey of all 155 schools, and the following decade saw the establishment of the AMA Council on Medical Education and Hospitals. Additional periodic surveys were conducted, and in 1928 the AMA House of Delegates approved the first training standards, Essentials for Approved Residencies and Fellowships.2Stoll D. The residency review committee for surgery: structure and function.Semin Vasc Surg. 2002; 15: 147-154Abstract Full Text PDF PubMed Google Scholar The development, standardization, and monitoring of training was also spearheaded simultaneously and jointly by the ACS. The first Clinical Congress was held in 1910 to improve surgical education, was conceived by Franklin Martin, and was enthusiastically attended by more than 1300 surgeons. This effort rapidly led to the development of the “Committee for Standardization of Surgery” in 1912, whose charge was to “formulate minimum requirements which should be possessed by any authorized graduate in medicine who is allowed to perform, independently, operations in general surgery and any of its specialties.” The ACS continued to formulate educational standards during the next two decades, culminating in the 1937 publication of its own standards for surgical residency programs, Fundamental Requirements for Graduate Training in Surgery.2Stoll D. The residency review committee for surgery: structure and function.Semin Vasc Surg. 2002; 15: 147-154Abstract Full Text PDF PubMed Google Scholar The American Board of Surgery (ABS) is an independent, nonprofit organization founded in 1937 for the purpose of certifying surgeons who have met a defined standard of education, training, and knowledge. After a series of meetings beginning in 1948, representatives from the ABS joined members of the ACS and the AMA Council on Medical Education and Hospitals in an effort to coordinate the evaluation of surgical residency training programs. From these joint discussions, a tripartite committee was formed and named the Conference Committee on Graduate Training in Surgery. After a protracted process of negotiations over a period of years, this committee evolved into the Residency Review Committee for Surgery (RRC-S), which was established in 1951. The ACS, AMA, and ABS agreed to share committee appointments and divide administrative and accreditation costs among the three founding entities. The functions of the RRC-S, which remain basically the same to this day, were to develop program requirements and standards as well as to evaluate and approve or disapprove individual training programs. The Medicare Program was developed in 1965 during the presidential term of Lyndon B. Johnson and included funding for graduate medical education with the attendant requirements for public and governmental oversight. The Liaison Council for Graduate Medical Education (LCGME) was founded in 1972, largely to provide such oversight. The LCGME was succeeded by the creation of the Accreditation Council for Graduate Medical Education (ACGME) in 1983, whose purpose was to oversee the administrative, policy, and business aspects of the accreditation. The specific duties of accrediting individual programs and monitoring their performance were (and still are) delegated to the RRC. The role of the ABS is to certify graduates of RRC-approved programs through a process of qualifying (written) and certifying (oral) examinations. At the beginning of the 20th century, multiple surgical specialties were evolving. For example, the American Board of Ophthalmology was incorporated in 1917, followed by the American Board of Otolaryngology in 1924. With the rapid formation of more specialty boards, there was a perceived need for overall coordination of their various activities. The Advisory Board for Medical Specialties was formed in 1933 and is the predecessor of the American Board of Medical Specialties (ABMS), which was finally incorporated as such in 1970.3Friedmann P. The American Board of Surgery and the ABMS: the role of boards.Semin Vasc Surg. 2002; 15: 155-157Abstract Full Text PDF PubMed Google Scholar The purpose of the ABMS is to function as a federation of autonomous boards and to work with both the AMA and ACGME to approve the establishment of new specialty boards. The ABMS now has 24 member boards, including the ABS. Before this period, no specific training programs existed in vascular surgery, and vascular surgery was practiced by general and cardiothoracic surgeons. Initial vascular surgery training programs were basically apprenticeships with early pioneers in vascular surgery. One of the first such programs was begun by Edwin J. Wylie, MD, at the University of California, San Francisco.4Goldstone J. New training paradigms and program requirements.Semin Vasc Surg. 2006; 19: 168-171Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar In his presidential address to the North American Chapter of the International Cardiovascular Society (ICVS, later NA-ISCVS), Dr Wylie, also a future president of the Society for Vascular Surgery (SVS), called for the establishment of formal residencies in vascular surgery to improve training for surgeons and outcomes for patients. The SVS had been founded in 1947, and one of its primary purposes, as defined in its bylaws, was “To encourage hospitals to develop special training for young surgeons in this field.” Wiley Barker, William Blasidell, Jack Cannon, Andrew Dale, James DeWeese, Sterling W. Edwards, Henry Ellis, John Foster, Keith Reemtsma, Charles Rob, D. Emerick Szilagyi, Jesse Thompson, and many other individuals deserving of special recognition spearheaded these efforts to establish vascular surgery as a specialty. The Joint Councils of the SVS and NA-ICVS met in 1971 and 1972 and formed a vascular surgery committee for “Certification of Special Competence in Vascular Surgery” under the aegis of the ABS.5DeWeese J.A. Accreditation of vascular training programs and certification of vascular surgeons.J Vasc Surg. 1996; 23: 1043-1053Abstract Full Text Full Text PDF Google Scholar Letters recommending the establishment of this certificate were sent to the ACS, ABS, and the American Surgical Association (ASA). The ACS was supportive of this initiative in principle. During the next several years, Dr Wylie and a Vascular Committee of the Joint Council of Vascular Societies prepared guidelines for “the essentials of training programs in vascular surgery,” which were presented to the ABS in June 1974. The ABS was not prepared to separately certify vascular surgeons at that time; instead, a standing Committee for Vascular Surgery was established. Then, as now, it is important to recall that guidelines and approval for training programs were under the purview of the RRC-S, not the ABS. By the mid to late 1970s, the guidelines had been approved by the RRC-S and were forwarded to the appropriate governing bodies (ABS, ACS, and LCGME) for approval. The LCGME tabled the guidelines, primarily because of objections from the American Board of Thoracic Surgery (ABTS). Bypassing this roadblock, the Joint Vascular Council (SVS and NA-ICVS) and membership voted in 1979 to proceed with accrediting vascular training programs using the “essentials” document that had been prepared years earlier. The Joint Council, chaired by Dr Wiley and Dr Barker, appointed a vascular credentials committee, which was named the Program Evaluation and Endorsement Committee. Seventeen programs were initially approved, and by 1982, 52 vascular programs had been approved.5DeWeese J.A. Accreditation of vascular training programs and certification of vascular surgeons.J Vasc Surg. 1996; 23: 1043-1053Abstract Full Text Full Text PDF Google Scholar The climate for vascular surgery gradually improved. In 1977 the ABS agreed to the principle that it could issue certificates in subspecialties of surgery. Five years of negotiations between the Joint Council, ABS, ABTS, and ABMS led to the creation of a “Certificate of Special Qualifications in General Vascular Surgery.” The substitution of the term qualifications for competence caused some controversy, as did the addition of the term “general,” which was apparently added to be sure that other boards of the ABMS would not block the certificate. In 1982 the first 14 ABS Certificates of Special Qualifications in General Vascular Surgery were issued after successful completion of a written examination. All of these initial examinees were members of the ABS, ABTS, or the vascular committee of the ABS; the first vascular certificate was, fittingly, issued to Dr Wylie.4Goldstone J. New training paradigms and program requirements.Semin Vasc Surg. 2006; 19: 168-171Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar, 5DeWeese J.A. Accreditation of vascular training programs and certification of vascular surgeons.J Vasc Surg. 1996; 23: 1043-1053Abstract Full Text Full Text PDF Google Scholar Written (qualifying-QE) examinations for the vascular qualifications certificate have been given continuously since 1983; oral (certifying-CE) examinations were added in 1986. As of December 2007, 2676 Diplomates have been certified in vascular surgery, 1612 have recertified once, and 444 have recertified twice. From 1987 to 2007, the first-time pass rates on the QE and CE have been 17.2% and 15.8%, respectively (data obtained from ABS). The ACGME was founded in 1981 and soon thereafter approved guidelines for training programs in vascular surgery. The RRC-S began reviewing vascular training programs in 1983 and accredited the first such programs in 1984. Programs endorsed by the Program Evaluation and Endorsement Committee were transitioned to ACGME-accredited programs between 1984 and 1986. Beginning in 1989, after a 5-year transitional or grandfathering period, all those sitting for the Vascular Certificate (“Special” evolved into “Added” Qualifications, the latter term applied to graduates of ACGME-accredited fellowship programs; both designations on Vascular Certificates were dropped by the ABS in 1998), and all applicants for the Certificate of Special or Added Qualifications in Vascular Surgery were required to have completed ACGME-approved vascular training programs, which generally consisted of one dedicated vascular training year after completion of an accredited general surgery residency (5-1 pathway). ABS Certification in General Surgery was a prerequisite for vascular surgery training and subspecialty certification. In a few instances, Vascular Certification was possible after completion of an accredited cardiothoracic surgery program, if the vascular case volume was deemed adequate. The latter pathway was short lived and gradually disappeared. The Association of Program Directors in Vascular Surgery (APDVS) began as an informal gathering of vascular program directors during the annual meetings of the SVS. It was formally incorporated in 1993, with two of its founders, William Baker and John M. Porter, serving as its first two presidents. The APDVS has been well organized, and during a relatively short span, developed detailed curricula in basic science, clinical science, and the vascular laboratory; it has also been very influential in providing input to the RRC-S regarding training standards. From 1984 to 1995, many vascular programs added an additional year of training (5-2), but the second year was primarily research, and only the clinical year was an accredited one. Although the political landscape had smoothed substantially since the 1970s and early 1980s, leading vascular surgeons in the 1990s pushed for recognition of vascular surgery as a specialty distinct from general surgery, based on the premises that the diagnosis and management of vascular disease had sufficiently evolved and that patient outcomes were improved when care was provided by a specialist in vascular surgery rather than a general surgeon who occasionally performed vascular operations.6DeWeese J.A. Should vascular surgery become an independent specialty.J Vasc Surg. 1990; 12: 605-606Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 7Barnes R.W. Ernst C.B. Vascular surgical training of general and vascular surgery residents.J Vasc Surg. 1996; 24: 1057-1063Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 8Stanley J.C. Barnes R.W. Ernst C.B. Hertzer N.R. Mannick J.A. Moore W.S. Vascular surgery in the United States: workforce issues-report of the Society for Vascular Surgery and the International Society for Cardiovascular Surgery, North American Chapter, Committee on Workforce Issues.J Vasc Surg. 1996; 23: 172-181Abstract Full Text PDF PubMed Scopus (120) Google Scholar The increasing number of trained vascular surgeons who confined their practice to vascular surgery felt that the requirement to recertify in general surgery before being eligible for recertification in vascular surgery was nonsensical and unnecessary. In addition, an RRC-S–approved general surgery training program was a prerequisite for institutions to have an approved vascular surgery training program, excluding many solid freestanding vascular surgery programs from ACGME accreditation. Vascular surgery was still defined an essential component of general surgery, with training requirements in vascular surgery mandated for general surgery residents. Many vascular surgeons believed this paradigm led to a two-class system for vascular training in the United States, with general surgery training preparing “the surgeon to perform certain simple vascular procedures, whereas the vascular surgery fellowship prepares surgeons for performing more complex vascular surgery.” The vascular surgeon was not really recognized as a specialist, despite the additional certificate, and the public was unable to distinguish between a general and vascular surgeon (certified in general surgery alone, with no additional vascular training) and the true vascular surgeon who had completed additional fellowship training.9Veith F.J. Presidential address: Charles Darwin and vascular surgery.J Vasc Surg. 1997; 25: 8-18Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar, 10Hobson R. Presidential address: Practice patterns in vascular surgery—implications for the certification and training of vascular surgeons.J Vasc Surg. 1997; 26: 905-912Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar In 1996 this impasse with the ABS and the RRC-S led to the decision to attempt formation of a Primary Specialty Board of Vascular Surgery, the American Board of Vascular Surgery (ABVS). This initiative was presented by consensus of the SVS, NA-ISCVS, and the APDVS and published in the February 1997 issue of Journal of Vascular Surgery.11SVS Council, ISCVS-NA Executive Council, APDVS Executive CommitteeThe American Board of Vascular Surgery: rationale for its formation.J Vasc Surg. 1997; 25: 411-413Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar The underlying two principles of this proposal were to provide “constant improvement in the efficient and excellent care of patients with vascular disease” and to develop and maintain “the best means for training professionals to care for patients with vascular disease.”11SVS Council, ISCVS-NA Executive Council, APDVS Executive CommitteeThe American Board of Vascular Surgery: rationale for its formation.J Vasc Surg. 1997; 25: 411-413Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar Although pursued with honorable intentions and based on sound premises, this application was ultimately denied in December 2002 by the Liaison Committee for Specialty Boards (LCSB), the organization that receives and responds to applications for development of a new independent specialty. The LCSB consists of eight members, four from the AMA, and four from the ABMS. While pursuing the direct route to recognition of vascular surgery as a distinct specialty (an independent board), the leadership in vascular surgery simultaneously continued to work within the existing governing bodies to achieve the same goal. This latter approach resulted, after complex negotiations and considerable deliberation, in the formation of the Vascular Surgery Sub-board of the ABS, established in June 1998 as the first ABS sub-board and patterned after sub-boards of the American Board of Internal Medicine (ABIM); this ingenious approach was spearheaded by Richard Dean.12Clagett G.P. Calligaro K.D. Freischlag J. LoGerfo F. Steele G.D. Towne J.B. et al.The Vascular Surgery Sub-board: progress report.J Vasc Surg. 2000; 31: 1060-1065Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar The Joint Council of the SVS and ISCVS (subsequently fused into a single vascular society—the SVS—in 2003) outlined 14 specific points that would be used to assess the success and progress of the Vascular Surgery Sub-board. These included primarily issues related to control of training and certification and recertification requirements in vascular surgery, oversight of Vascular QE and CE, appointment of examination consultants, relationships with other specialties, establishment of RRC requirements for vascular surgery, and the elimination of complex vascular surgery as an essential component of general surgery. In large part, these issues were resolved, thereby setting the stage for the recent major paradigm shift in vascular surgery training in the United States. The explosive development of endovascular therapy in the 1990s forced the establishment of training requirements in endovascular surgery. Endovascular training and volume requirements for vascular programs were submitted to and approved by the RRC-S in 2000 and became mandatory for accredited vascular surgery training programs in 2004. By this juncture, the 5-1 training pathway had functionally evolved into a 5-2 model, the second year being necessary to provide adequate exposure to endovascular surgery, with the research year falling by the wayside in most programs. The result was a training period of at least 7 years (after 4 years of college and 4 years of medical school), with up to 9 years for those pursuing any research. Trainees were thus in their mid 30s before they could begin independent practice and many had already accumulated substantial student loan indebtedness, estimated on average to be $100,000.13Sidawy A. Presidential address: generations apart—bridging the generational divide in vascular surgery.J Vasc Surg. 2003; 38: 1147-1153Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar The protracted training period and large incurred debt were strong disincentives for medical students and residents to pursue vascular surgery. The difficulties in trainee recruitment into the 5-2 pathway for vascular surgery were highlighted in the 2004 and 2005 vascular surgery matches, when there were insufficient applicants to fill the available vascular surgery positions (Table I). Prolonged training and the prerequisite for 5 years of preliminary general surgery training with its perceived poor lifestyle were major reasons cited by medical students for not selecting a career in vascular surgery.13Sidawy A. Presidential address: generations apart—bridging the generational divide in vascular surgery.J Vasc Surg. 2003; 38: 1147-1153Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar, 14Perler B.A. When I grow up, I want to be successful like daddy: I just don't want to be a doctor.J Vasc Surg. 2007; 45: 627-634Abstract Full Text Full Text PDF PubMed Scopus (6) Google ScholarTable IVascular surgery resident match dataVariable20002001200220032004200520062007Enrolled programs8184878890949292Active positions919398103110117112119 Filled868989918793106115 Unfilled54912232464Active applicants107107108108100108129139 Matched868989918793106115 Unmatched2118191713152324Applicant demographics US graduate848168768295 US foreign311471415 Pathway000111 Osteopath5235104 Foreign162314191124 Canadian011000108108100108118139 Open table in a new tab It also was apparent to many vascular surgeons involved in training that because of the rapidly changing and increasingly endovascular landscape, the parallel decline in the number of open procedures and the corresponding need to preserve those procedures for trainees who would most benefit, the need to expand training in vascular medicine and noninvasive testing, and the inherent imbalance (reversed weight) between general and vascular training in the 5-2 model, it would be necessary to develop new training pathways not only to preserve the specialty but also to provide sufficient vascular specialists to meet the needs of patients in the 21st century.15Cronenwett J.L. Changes in board certification could improve vascular surgery training.J Vasc Surg. 2004; 39: 913-915Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar There was widespread agreement that the total training period could be shortened and should be refocused, but the precise method to best train the next generation of vascular surgeons was unclear. The initial step toward reducing the training length occurred in 2003 when the RRC-S and ABS approved initiation of the Early Specialization Project (ESP). This model began as a pilot project. It requires 4 years in general surgery training, followed by 2 years in vascular surgery training16LoGerfo F. A “four plus” future for general surgery and vascular surgery: maintaining the union.J Vasc Surg. 2002; 35: 1073-1077Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar; both general and vascular training program must be ACGME-approved, and all 6 years of training must be at the same institution. The fourth year of general surgery training is at the chief resident level and is counted toward both general and vascular certification. The ESP (4-2) shortened total training by 1 year and leads to dual board certification, but has been limited in its application. Currently, only five such programs are in existence (Table II). Most projections have indicated a sharply increasing demand of at least 50% for vascular surgeons in the next 20 to 25 years, primarily due to the epidemiology of vascular disease (baby boomers, increasing rates of obesity and diabetes) and the increasing use of endovascular therapies.13Sidawy A. Presidential address: generations apart—bridging the generational divide in vascular surgery.J Vasc Surg. 2003; 38: 1147-1153Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar, 14Perler B.A. When I grow up, I want to be successful like daddy: I just don't want to be a doctor.J Vasc Surg. 2007; 45: 627-634Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar The 4-2 training model was an insufficient response to accommodate this developing critical need.Table IIAccreditation Council for Graduate Medical Education–accredited integrated and early specialization vascular surgery programs0-5 Integrated vascular surgery programs • Dartmouth-Hitchcock Medical Center • Indiana University School of Medicine • University of Michigan • University of North Carolina Hospitals • University of Pittsburgh Medical Center • University of South Florida • Mount Sinai School of Medicine • Stanford University • State University of New York at Stony Brook • University of Rochester • University of Massachusetts4-2 Early Specialization Programs • McGaw Medical Center of Northwestern University • Oregon Health and Science University • University of California, San Francisco • University of Texas Southwestern Medical School • Washington University, St Louis Open table in a new tab In 2004 the VSB, SVS, and APDVS began joint preparation of an application for a primary certificate in vascular surgery, seeking elimination of general surgery certification as a prerequisite. The three organizations recognized the need for a new paradigm in vascular surgery training that would better address needs of the specialty and patients. These efforts came to fruition, and vascular surgery became a distinct specialty of surgery on March 17, 2005, when with ABMS approval, the ABS agreed to offer a Primary Certificate in Vascular Surgery.17Vascular Surgery Board of the American Board of Surgery. Primary certificate passes final hurdle. Newsletter; Spring 2006.Google Scholar In October 2005, training program requirements for this certificate were approved by the RRC-S, with substantial input from the VSB and the APDVS. The traditional requirement for 5 years of training and certification in general surgery was eliminated. With the ACGME's approval, effective July 1, 2006, the ABS converted its certificate in vascular surgery from a subspecialty certifica
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