General Surgery Programs Afford Trainees Bound for Vascular Surgery Fellowships Increased Vascular Case Experience

Abstract

Educators have recently begun to call into question the value of general surgery training prior to completion of a 2-year vascular surgery fellowship. We hypothesized that general surgery residents destined to enter vascular surgery fellowships have an enriched experience in vascular surgery compared to general surgery residents who enter other specialties. We obtained Accreditation Council for Graduate Medical Education case records of general surgery residents completing training in the years 2015-2018. We then stratified graduates into those who went on to enter a vascular surgery fellowship program (GSVS) versus those who went into other fields (GS). Case records were broken down into standard operative categories applied by the RRC for surgery/Accreditation Council for Graduate Medical Education. Each category was compared with a two-sided Student t-test. In addition, we examined experience with general surgery cases we deemed relevant to vascular surgery practice and those not directly relevant to vascular surgery. Between 2015 and 2018 there were 3242 graduates of general surgery programs who did not go on to vascular fellowships and 342 graduates who did enter vascular surgery fellowship programs. As shown in Table I, GSVS residents had significantly greater operative experience in every vascular surgery category than GS residents. Notably, they had twice the exposure to the major categories of aneurysm repair, cerebrovascular repair, and peripheral obstructive. In aggregate, GSVS residents completed 187.2 major vascular reconstructive procedures compared to 108.7 procedures for GS residents. Table II demonstrates the comparative experience in overall general surgery cases. Notably, GSVS residents had less exposure to a variety of cases of less direct relevance to vascular surgery including breast, esophagus, stomach, small intestine, large intestine, anorectal, biliary, spleen, hernia, endocrine, thoracic, complex laparoscopic and endoscopy cases. Conversely, GSVS residents had similar operative exposure to most cases of relevance to vascular surgery including skin and soft tissue, head and neck, abdominal–general, organ transplantation, and trauma. Total cases and major cases did not differ. It is unclear whether increased vascular exposure during general surgery training leads to vascular surgery as a career choice or if residents interested in vascular surgery are now afforded more opportunity to do vascular cases through increased training flexibility in general surgery programs. Regardless, general surgery training appears to offer an enriched vascular and relevant general surgery training experience to those candidates who go on to vascular fellowships. Ongoing analysis is necessary to determine the optimal content of general surgery training necessary for those trainees interested in vascular surgery.Table ICase TypeGeneral surgery residents who did not go on to complete a vascular surgery fellowship (GS)General surgery resident who did go on to complete a vascular surgery fellowship (GSVS)Mean number of casesStandard errorMinimum number of casesMaximum number of casesMean number of casesStandard errorMinimum number of casesMaximum number of casesP valueAneurysm repair5.1500.08605012.6700.569066.0000 Open infrarenal aneurysm repair0.8160.0240171.5200.100010.0000 Endo repair infrarenal aneurysm2.4150.0530236.8250.352039.0000Cerebrovascular9.6930.14207817.6780.8030104.00008.5150.13307515.0350.7160100.0000Periph obstructive18.0810.225012237.5441.3342182.0000 Aortofemoral bypass0.8610.0230121.7870.139028.0000 Femoral-popliteal bypass, vein2.2820.0450253.8300.183019.0000Infrapopliteal bypass, vein1.8780.0410264.1370.236026.0000Abdominal obstructive0.5130.016091.4330.102013.0000Upper extremity1.8010.0350243.0580.159026.0000Thrombolysis/mech thromb0.6480.0260331.5760.136020.0000Vascular trauma2.5240.0430233.6290.173021.0000Endovascular diagnostic6.8120.190011716.6931.0240132.0000 Arteriography4.8800.142010812.7630.7620104.0000Vascular access31.0680.333020145.5291.3742145.000016.0010.19408323.8360.808096.0000Amputations15.4140.188012021.7190.791196.0000 Amputation, below knee5.3990.0730357.6200.296040.0000 Amputation, above knee3.8090.0550285.9770.256033.0000Extra-anatomic bypass1.5700.0320162.8980.150016.0000Endovasc therapeutic0.2460.011070.7870.07508.0000Venous8.3740.14508414.1930.602069.0000Miscellaneous vascular6.0310.0830479.1870.416061.0000Total vascular108.7031.01613506187.1825.57550582.0000 Open table in a new tab Table IICase typeGeneral surgery residents who did not go on to complete a vascular surgery fellowship (GS)General surgery resident who did go on to complete a vascular surgery fellowship (GSVS)P valueMean number of casesStandard errorMinimum number of casesMaximum number of casesMean number of casesStandard errorMinimum number of casesMaximum number of casesSkin and soft tissue59.7790.424524158.3101.37114153.2867Head and neck22.8040.231011621.9590.692187.2570Breast64.1920.507127356.0791.3156153.0000Esophagus11.8580.1520719.6400.361035.0000Stomach39.0180.454229334.8771.1713216.0011Small intestine36.8960.256314334.5500.8927186.0118Large intestine141.2270.68842339132.0232.11039266.0000Anorectal33.3690.287120528.3710.732182.0000Abdomen-general43.6280.354316842.7751.3737296.5478Liver9.9820.1090589.4010.305035.0734Biliary126.2510.73330341118.4742.22642288.0010Pancreas10.3080.1400889.7810.421051.2445Spleen2.6990.0370162.2950.102013.0002Hernia130.7320.64231337118.8831.82546318.0000Endocrine33.4980.375529127.5500.9218107.0000Complex laparoscopica135.8971.36353528125.8683.44675275.0077Hand2.5070.10201772.4330.219026.7579Thoracic39.4350.469529834.7660.87315118.0000Pediatric26.3540.251112726.0120.782394.6735Genitourinary4.0870.0810623.8040.236046.2776Gynecology2.2400.11201491.6780.282085.1164Plastic23.8990.371124222.1350.8822115.0657Nervous system0.0440.005060.0500.02206.7998Orthopaedics1.3590.0720801.0960.181049.2505Organ transplant10.7330.211021910.2780.534058.4994Trauma29.0750.315216230.1671.0224143.2866Endoscopy138.2380.88926511121.0292.00865327.0000Ophthalmology0.0550.005050.0440.01101.3503aIncludes data for year 2017-2018 only. Open table in a new tab