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Ann Thorac Surg 2001;72:1116-1117
© 2001 The Society of Thoracic Surgeons
a Department of Cardiothoracic and Vascular Surgery, University of Rochester, Rochester, New York, USA
Address reprint requests to Dr DeWeese, Department of Cardiothoracic and Vascular Surgery, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY 14642
e-mail: deweesepnj{at}aol.com
Thoracic surgeons were intimately involved in the early phases of the certification of vascular surgeons and the accreditation of vascular surgical training programs. They were represented or participated in all of the following activities: [1, 2]
Many cardiothoracic surgeons do have an interest in vascular surgical operations. This begins during their general surgical residency. Doctor Wilcox obtained the operative experience records during the general surgical training of 112 thoracic residents who completed their thoracic training in 1993 [3]. During their general surgical training, the residents were involved with a mean number of 222 vascular operative cases. During their chief resident year in general surgery, they were the responsible surgeon on a mean number of 86 cases, which is almost twice the number (n = 44) required by general surgical boards and also more than the 75 required of vascular fellows during their year of fellowship.
For many, this operative experience continued during their thoracic surgical residency. The ABTS and RRC for thoracic surgery asks the residents to record the number of thoracic vascular operations and also the number of peripheral arterial operations performed. The ABTS kindly furnished information concerning the vascular surgical operations performed during their thoracic residency by 117 residents completing their thoracic training in June 2000 (personal communication from the ABTS). A mean number of 17.4 peripheral vascular and thoracic vascular operations were performed. There were 45 residents who performed more than 10 operations, 7 who performed more than 40 operations, and 6 who performed more than 70 operations.
Many board-trained thoracic surgeons still have an interest in performing vascular operations. Cohn and colleagues [4] in 1995 surveyed 2,677 practicing surgeons who were board certified or board eligible in thoracic surgery. He found that 54% performed vascular operations. There were 33% of the surgeons who performed more than 25 vascular operations each year, and 19% performed more than 50 operations per year. There were 7% who had vascular certification.
More recently a comprehensive review of all Medicare Part B Current Procedural Terminology (CPT) claims data for 1996 to 1997 was published [5]. Provider-specific information was used to identify whether major vascular procedures (aneurysm repair, endarterectomy, and arterial bypass) were performed by board-certified general surgeons, vascular surgeons, or cardiothoracic surgeons. Twenty-nine percent of the operations were performed by cardiothoracic surgeons.
At this time, however, conditions are occurring that may affect the vascular training of thoracic surgeons during their general surgical and thoracic residencies.
First, there is an expressed need to increase the period of training in all thoracic residency programs to at least 3 years. To accomplish this without extending the years of surgical experience required for certification in thoracic surgery, the completion of a 5-year residency in general surgery would no longer be required. Although I believe that a 4-year general surgical program with the final year of senior responsibility would be ideal, some think that 2 to 3 years would be adequate. Any decreased time spent in general surgery residencies could decrease the number of major vascular operations performed by the residents.
Vascular training in general surgical programs can also be affected by the recent increase in the use of endovascular devices for the treatment of vascular lesions. Many of these operations are being performed by cardiologists and radiologists and are not available to residents in general surgical and thoracic surgical programs. There are many programs, however, in which many endovascular operations are being performed on surgical services with or without the involvement of radiologic interventionalists.
Vascular training of general surgical and thoracic residents may or may not be affected by the maturing of vascular surgery as a specialty. The ABTS became a primary board in 1971 after 21 years as a subsidiary of the ABS. Vascular surgery has been closely affiliated with the ABS since 1982, originally as a committee, later as a subboard, and most recently as a Board of Vascular Surgery of the ABS. They are now seeking the status of a primary board with the help of the ABS. It may be that even if vascular surgery had a separate board that the number of vascular operations performed by general surgery residents would not decrease. Currently, the RRC for general surgery requires that each general surgical resident perform 44 major vascular operations for accreditation of their program. It is unlikely that this requirement would change even if vascular surgery had its own board. This supposition is based on the fact that general surgical residents are still required by the RRC for general surgery to perform at least 20 thoracic operations during their residency for accreditation of the program.
There have been several studies on the workforce needs to provide quality care of vascular diseases in our rapidly growing aging population [6]. It is predicted that there will be an increasing need for surgeons well trained in vascular surgery. It is predicted that the current numbers of surgeons completing vascular surgical residency programs will not be able to meet these needs [6]. Cardiac and vascular surgery share many common interests, including similar disease processes requiring treatment, operative approaches, operative techniques, and operative skills. Cardiothoracic surgeons with vascular surgical training in both their general surgical and cardiothoracic residencies may well be called on to fill a void in many communities.
There is good reason for the certifying and accrediting bodies of general surgery, vascular surgery, and thoracic surgery to work together to assure that there are well-trained and competent surgeons to fulfill the vascular surgical needs of all patients. This would best be accomplished by the establishment of a Conjoined Board of Vascular Surgery by the ABS and ABTS and the RRCs of both specialties. If this cannot be accomplished, thoracic surgery could still be involved in the following ways:
For the reasons stated, I believe it is very important that thoracic surgery be involved in vascular surgery, preferably by the formation of a conjoined board, but at least in the manner described.
References
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