An analysis of vascular surgical manpower requirements and vascular surgical rates in the United States

Abstract

In the January 1986 issue of the Journal of Vascular Surgery (J VASC SURG 1986;3:74-83), there was an important article that dealt with vascular surgical manpower requirements and rates in the United States. The tentative conclusions of that article merit your close attention. I believe that these conclusions are inaccurate for two reasons. The conclusions were based on an estimate of 1600 “vascular surgeons” in the United States. This is the number of surgeons who applied to take the examination for the “Vascular Boards.” In addition, the article stated that the caseload requirement for admission to the examination was 100 vascular cases. With regard to caseloads, admission to the examination requires a minimum number of cases per year that must be performed by the applicant. This minimum is not 100 vascular cases, but 100 major reconstructive vascular procedures. In the requirements spelled out by the American Board of Surgery, cases that may be included in this category include carotid and vertebral reconstructions, abdominal aortic aneurysm operations, aorto-ilio-femoral reconstructions, and peripheral bypass operations. Cases that may not be counted in the minimum requirement include repair of injured peripheral vessels, dialysis access operations, embolectomy, varicose vein procedures, major amputations, and sympathectomy. According to the figures cited in the article, there were 95,000 carotid endarterectomy procedures, 74,000 peripheral bypass operations, 39,000 operations for abdominal aortic aneurysms, and 28,000 aorto-ilio-femoral bypass operations done in the United States in 1983. For computing caseloads, however, the figure of 553,000 total vascular procedures in 1983 is used. If “major vascular reconstructive procedures” are counted, and the “minor” procedures are not, the total number of the “major” procedures is 236,000. If these cases are then divided by the total number of vascular surgeons, the caseload becomes much smaller. My second area of concern involves the total number of “vascular surgeons” in the United States. The article by Rutkow and Ernst made an assumption that the 1600 surgeons who applied to take the examination were probably the bulk of those surgeons who would consider themselves “vascular surgeons.” In my community of approximately 400,000 people, there are 25 surgeons who consider themselves “vascular surgeons” and advertise themselves as this specialty in the Yellow Pages of the telephone book. All but two of these surgeons also practice general surgery. All are certified by the American Board of Surgery. However, only two surgeons applied to take the examination for Certification of Special Qualifications in General Vascular Surgery because of the restrictive caseload requirement. If this number may be applied in any way to the general situation across the United States, and I believe that it may, then there are about 10 surgeons who consider themselves “vascular surgeons” for every one vascular surgeon who applied to take the examination for the “Vascular Boards.” Thus, there may be 16,000 surgeons who are responsible for the total 553,000 vascular cases per year and the 236,000 “major vascular reconstructions” per year. This represents an average of 15 cases of “major vascular reconstructions” per surgeon and an average of 35 total vascular cases of all categories per surgeon. Why are we training any more “vascular surgeons” at all? Wouldn't it make more sense to set a more realistic caseload requirement and certify a much larger number of surgeons who are actually doing all these cases? This would probably serve to “weed out” the occasional vascular surgeon and markedly improve the quality of vascular surgery done throughout the United States. More realistic requirements might include a minimum caseload of 40 to 60 major vascular reconstructions, with consideration of the outcome of the surgeon's cases over several years. Thus, the surgeon who does 25 carotid endarterectomy cases per year might qualify to take the examination, if he could show from his last consecutive 100 cases that his operative morbidity and mortality figures were acceptable to the board.