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Presidential address: Mind the gap

2007; Elsevier BV; Volume: 45; Issue: 6 Linguagem: Inglês

10.1016/j.jvs.2007.02.040

1097-6809

R. James Valentine,

Aortic aneurysm repair treatments

It is a great honor and privilege to stand before you today as your President. The Southern Association for Vascular Surgery has always been my favorite society. The excellent scientific programs, coupled with the warm camaraderie of the membership in the setting of exquisite resorts make this the best of the regional vascular societies. I am humbled and very grateful for the opportunity to serve as President. It is a highlight of my career, and an honor I must share with a number of people who have been important in my career and in my personal life. First, I want to acknowledge the three men who served as mentors during my years as an undergraduate and medical student: Drs Mel Williams, Bob Smith, and Atef Salam. All three were academically and technically brilliant, and all three set the standard for being role models. I am forever indebted to each of them. Next, I want to thank my two mentors from residency and fellowship training. Dr Bill Fry gave me the foundation of my surgical knowledge and taught me how to think like a surgeon. He also gave me a vascular fellowship. Dr Pat Clagett turned me into a vascular surgeon, and years later, he gave me a job. Pat has been one of my most important mentors, and he and his wife, Nancy, have become close family friends. I also want to acknowledge my associates at UT Southwestern: Drs Greg Modrall, Frank Arko, and Carlos Timaran. These are my partners who make it fun to come to work every day, and they have also helped me develop endovascular skills. Thank you all very much. Finally, I want to acknowledge my wife, Tracy, and my children, Beth and Jack. Every day I realize how lucky I am to have such an understanding and patient family. Thank you for putting up with the late calls, missed tennis matches and lacrosse games, and frequently changed plans. You are my greatest source of strength. I find it somewhat ironic that I have returned to the same island where I attended my first SAVS meeting in January of 1986. Looking back, the many changes that have occurred in vascular surgery over the past 20 years are nothing less than astounding. As a surgical educator, I am particularly interested in the new training paradigms that have emerged, but I am even more intrigued with the new generation of vascular surgeons that we are currently training. Although our specialty has never been in better shape to face the future, there are a number of looming problems that have grown out of our successful evolution. Permit me, if you will, to draw parallels between our specialty and one of the great urban engineering successes in modern times. The London Underground Railway System, also known as the “tube,” is arguably the best metropolitan subway system in the world. Originally constructed in 1863, the London Underground transports approximately 976 million passengers each year in the greater London metropolitan area. The success of the London Underground is due in large part to the constant modernization and diligent maintenance of a system that is more than 140 years old. However, modernization and maintenance have not been able to correct a lingering design flaw that persists to the present day. In early construction, sharp curves were needed in the rail lines that were built beneath public roads. This led to construction of curved train platforms that created large gaps between the platform and carriage at many stations (Fig 1). The gaps are deep–they extend all the way to the rail floor–and could easily admit a foot or an entire leg, resulting in serious injury. Rather than correcting the design flaw, the London Underground Limited relies on a public awareness campaign. Painted warning signs are ubiquitous, and recorded messages remind passengers to “mind the gap.” While I cannot comment on the success of the advertising campaign to prevent injury, it has been a great boon to the tourism industry. “Mind the gap” logos appear on tee shirts, mugs, posters, and any other imaginable trinket sold to tourists. “Mind the gap” has also become a common phrase in other industries: it is the name of a musical rock group and the title of a recent movie. The phrase has also been widely used by journalists to convey an obvious shortfall (eg, the budget deficit). But it has also been used to convey a warning that hidden problems may challenge apparent successes. It is in the latter vein that “mind the gap” might be used as a new mantra for vascular surgery. There has never been a better time to be a vascular surgeon. We all owe our past leaders a debt of gratitude for their vision, energy, and passion that redefined our specialty in the last 10 years. Let us take stock of where we are today. Vascular surgery has been reinvented, and we are a truly independent specialty responsible for our own destiny. We have a dedicated Vascular Surgery Board within the American Board of Surgery that allows our appointed members to write questions and independently determine thresholds for certification and recertification. We have won approval to train our residents in completely new pathways that shorten the length of training by 1 or 2 years. We are able to offer our patients every conceivable therapy for vascular disease, including medical treatment, endovascular procedures, and open operations. General surgeons are no longer being trained to perform index vascular procedures, meaning that peripheral vascular disease has become the domain of the certified specialist in vascular surgery. This successful movement to independence from the traditional specialty of general surgery has been the envy of other surgical specialties attempting reinvigoration. Cardiothoracic surgery and trauma critical care have already made inroads into redefining themselves, and other specialties are expected to follow soon. Despite these many advances, there are some looming gaps that may have profound consequences for our specialty. I will concentrate on two: the training gap and the expectation gap. The first gap is an effect of the rapid, widespread acceptance of endovascular technology by our specialty. The second gap is an effect of profound differences in the way that the newest generation of vascular surgeons views the world, compared to their older counterparts. Endovascular skills of the average vascular surgeon are improving steadily, and a larger proportion of vascular cases are being done with endovascular technology instead of open operations. There are many reasons that endovascular therapy has gained such popularity: it is easier, the patients go home sooner, and there are fewer complications. It is also more lucrative. Endovascular procedures have also formed an increasingly larger proportion of cases in vascular fellowships. Operative data from the Accreditation Council for Graduate Medical Education (ACGME)1Vascular surgery case log statistical reports 1999-2006 [database on the Internet]. Chicago (IL): Accreditation Council for Graduate Medical Education, 2006. Available from: http:www.acgme.org/residentdatacollection/documentation/statistical_reports.asp. Accessed November 21, 2006.Google Scholar show that endovascular aneurysm repair (EVAR) now account for approximately 75% of all elective aneurysm procedures in vascular training programs. There has been a steady increase in EVAR experience since 2000; vascular fellows finishing in 2006 performed an average of 44.5 EVARs during their 2 years of training (Fig 2, A). There has also been a dramatic increase in the number of therapeutic endovascular procedures for occlusive disease, from a mean of 9.7 in 2000 to a mean of 81.5 in 2006 (Fig 2, B). Although the huge increase in endovascular experience is desirable and necessary for complete training, it comes at a cost. ACGME data also demonstrate an equally dramatic decrease in the number of open procedures performed by vascular fellows. For example, vascular fellows who finished in 2006 had performed a mean of 14.8 open infrarenal aneurysm repairs and nine aortofemoral bypasses during their 2 years of training (ie, a mean of 7.4 open aneurysm repairs and 4.5 aortofemoral bypasses per year.) These data suggest that finishing fellows are well trained in endovascular skills, but there is growing concern that many have not had an adequate experience in open vascular operations. Endovascular technology is improving steadily, but the most difficult vascular problems still need to be treated with open operations, especially endovascular failures. The ability to perform these operations is the feature that separates a vascular surgeon from an interventional radiologist. The operative skills that defined vascular surgery just a few years ago resulted from the work of countless innovators and many decades of trial and error. Current trends suggest that these skills could be lost in one generation. Open surgical proficiency requires judgment, knowledge, and a technical skill set that can only be learned from performing open operations. Before becoming an expert in complex open surgery, the vascular surgeon must learn to perform the operations in more straightforward circumstances. However, straightforward problems are currently being treated with endovascular techniques. Paradoxically, the scope of vascular surgery is increasing due to endovascular therapy while simultaneously decreasing due to reduced operative experience. The experience gap will be further widened by shortened training paradigms: trainees will not be exposed to advanced general surgery procedures, further diminishing their ability to master open vascular skills. In effect, the 0 + 5 pathway may produce interventional radiologists who can perform femoral artery cutdowns. Despite the many achievements in our specialty, applications to vascular surgery fellowships remain disappointing. Historically, about 100 individuals in US residency programs have applied each year for the vascular surgery match, well above the number of approved fellowship positions. Although there has been a steady increase in the number of approved spots, applications from US residents have not increased. In fact, there has been a dramatic decrease in the number of US applicants to vascular surgery programs since 2000 (Fig 3). Despite small gains in 2005 and 2006, the number of applicants was still well below the number of available positions. The decrease in applications to vascular fellowships paralleled the trend in applications to general surgery residency 2 years earlier. Although general surgery applications have increased to 1998 levels, vascular surgery applications remain well below historic norms (Fig 4).Fig 4Proportion of available positions offered in the general surgery match (GS) that were filled by applicants from allopathic US medical schools compared to the proportion of positions offered in the vascular surgery match (VS) filled by applicants trained in US general surgery residencies.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Why has vascular surgery lost its appeal? Many explanations have been offered, but the main reason is that the current generation of medical students and surgery residents have widely different expectations compared to vascular surgeons in practice. Although the fellowship application rate will eventually improve, the expectation gap will not change. To improve the popularity of our specialty and to attract future vascular surgeons into our practices, we must first understand the educational and social environment of current trainees. Three areas deserve emphasis: new training requirements, the focus on lifestyle, and educational debt. On June 30, 2008, the first group of residents trained completely under the 80-hour duty hour rules will finish general surgery training. The ACGME duty hour restrictions have been completely inculcated into the minds of surgery trainees, and they have had a profound impact on the behavior of current residents and recent graduates. As a result of the strict limitation on the number of consecutive hours that a resident is allowed to work, trainees have developed a shift mentality. They are used to working a specific period of time before being completely relieved of all clinical responsibilities. After that time, they are not reachable, and they expect others to assume complete responsibility for their patients. These habits run contrary to those of vascular surgeons who trained before the era of duty hour restrictions. We work hard, treat emergencies at odd hours, and enjoy caring for our own patients. The impact of the duty hour restrictions pales in comparison to the attitudinal changes associated with the current generation of young adults. Much has been written about the group of adults who were born between 1965 and 1979, also known as “Generation X”.2Sidawy A.N. 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 (29) Google Scholar The current group of residents and fellows represent their younger brothers and sisters. Although there are some interesting differences between the two groups, the overarching interest in lifestyle remains the same. ACGME data show that medical students continue to favor specialties associated with a controllable lifestyle. Vascular surgeons have a reputation for being among the hardest working surgical specialists,3Winslow E.R. Bowman M.C. Klingensmith M.E. Surgeon work hours in the era of limited resident workhours.J Am Coll Surg. 2004; 198: 111-117Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar and vascular surgery call is often punctuated with limb- and life-threatening emergencies. In a 2004 survey conducted by the Association of Program Directors in Vascular Surgery, lifestyle concerns were cited as the most important reason why medical students did not choose a career in vascular surgery.4Calligaro K.D. Dougherty M.J. Sidawy A.N. Cronenwett J.L. Choice of vascular surgery as a specialty: survey of vascular surgery residents, general surgery chief residents, and medical students at hospitals with vascular surgery training programs.J Vasc Surg. 2004; 40: 978-984Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar To attract more applicants to our specialty, we must change the perception that vascular surgeons are constantly available at odd hours and have no home life. Overwhelming medical school debt may also have an impact on the application rate for vascular fellowships. Debt burden weighs heavily on the minds of the current generation of trainees. Compared to 1982, there has been a more than seven-fold increase in the mean educational loan debt of a finishing medical student. According to projections from the Association of American Medical Colleges,5Jolly P. Medical school tuition and young physician indebtedness. American Association of Medical Colleges, 2004. Report available at: http:www.aamc.org/studentdebt/. Accessed December 10, 2006.Google Scholar the mean educational debt for students finishing medical school in 2007 is expected to be $120,000 for public schools and $160,000 for private schools. Loan deferments during residency training would increase the latter to $204,000 after 5 years and $225,000 after 7 years, assuming a 5% compound interest. The cost savings associated with fewer years of training would seem to be a major appeal of the shortened training paradigms, but the popularity of these programs is yet to be determined. In the meanwhile, salary has become an important issue for finishing residents. Your new partner will expect a high salary, even if he or she works fewer hours and does less work than other members of the group. The successful evolution of vascular surgery into an independent specialty is proof that vascular surgeons are willing to accept change. By acknowledging the emerging differences in training and expectations, practicing vascular surgeons have an opportunity to ensure the quality of the specialty. All vascular surgeons have a stake in this issue. Bridging the training gap will require commitment from all vascular surgeons, regardless of their current practice environment. First, vascular fellowship program directors must improve the training experience in open vascular surgery. This will not be easy, but it is a matter of practical importance. Applicants to vascular fellowships are well aware of the unbalanced training that resulted from the heavy emphasis on endovascular procedures. Five years ago, applicants flocked to programs with the best endovascular experience, but the trend has now reversed. Because all programs now have active endovascular components, applicants are seeking fellowships that offer the best experience in open complex cases. Programs that do not offer this training will not be able to compete in the diminishing pool of candidates and may ultimately face loss of accreditation due to repeated failure in the match. Training in complex open operations must continue beyond fellowship. Practicing vascular surgeons should be prepared to help recent graduates whose experience in open procedures has been limited or inadequate. These young surgeons will need mentoring from their older partners, just as the older surgeons benefited from learning new endovascular skills from their junior associates. New partners should be encouraged to scrub in on every complex open case in your practice, and you should expect them to ask for help in the operating room. They should be encouraged to take on challenging open cases, and attempts to shunt these cases to their older partners should be discouraged. The expectation gap may be an opportunity for recruiting residents and students to our specialty. To gain share in the market of senior medical students, we need to show that being a vascular surgeon is not incompatible with a controllable lifestyle. Current vascular fellows may not be concerned with duty hour requirements, but their potential successors certainly will be. Duty hours should be closely monitored in vascular training programs, and full compliance should be expected. Vascular surgery program directors need to increase the exposure of junior medical students to vascular surgery rotations, and vascular surgeon role models need to be developed in the community. Regardless of the practice situation, all vascular surgeons should act as interested mentors and serve as professional role models. First and second year medical students would leap at the chance to shadow practicing vascular surgeons in their daily routines. The expectation gap also represents an opportunity to recruit new partners for vascular practices, an important issue considering the increasing competition. Modern recruiting begins long before the individual has finished fellowship. A resident’s heavy debt load can be translated into an opportunity for practices that can afford to wait for 1 or 2 years. An excellent prospect can be signed on and given a stipend during training that can be deducted from future salary. The successful recruiter will also recognize that young surgeons have an interest in lifestyle. We should not tell recruits how busy we are and that our spouses are mad at us because we never get home. Instead, quality of life and family values should be emphasized. I am living testimony that an older vascular surgeon can have a great life out of the hospital, and for that I thank my family: Tracy, Beth, and Jack. The training and expectation gaps are products of success in vascular surgery, but they need to be addressed soon. Vascular surgeons must be competent in open and endovascular procedures, and they must remain current with new therapies as they evolve. The decreasing application rate for vascular fellowships raises concern that we may not be able to meet the requirements of an aging population. Attracting more applicants will require us to accept new attitudes and accommodate changing expectations. However, mentoring continues to be the key to maintaining the quality of vascular surgery. Rudolph Matas, the seal bearer of the Southern Association for Vascular Surgery, recognized in 1925 the importance of mentoring for young surgeons: