Invited commentary

Abstract

We probably all remember the satisfying sound of the multiphasic Doppler signal immediately after our first successful lower extremity bypass as a trainee, particularly as the foot pinked up when the clamps were removed. Lower extremity revascularization and limb salvage remain cornerstones of vascular surgery education and require intense attention to technical skill, delicacy, and some amount of swiftness. Very few vascular operations or interventions have outcomes that are so black or white when they fail, and the tolerance of success is measured in millimeters and often related to the technical details of the exercise. Volume–outcome relationships are well established for leg bypass, also indicating the precision and technical efficiency required for optimal limb salvage. Dr Scarborough and colleagues from Duke University Medical Center report in this provocative article the negative effect that surgical trainee participation has on early postoperative graft failure when analyzing the National Surgical Quality Improvement Program (NSQIP) database. The finding that having surgical residents as part of the operative team essentially has a 29% higher chance of early failure brings to light several issues plaguing surgical educators and residency program directors. Fortunately, morbidity and mortality are not adversely affected in the propensity-matched data by trainee involvement. In this new era of duty hour restrictions, many attendings already feel the trainees are not operating enough. More and more surgical residents are relying on fellowships or junior faculty positions to be “finishing schools” to successfully transition into practice. Additional pressures on faculty to operate more, faster, and better also affect the level of involvement and autonomy the trainee has during all types of vascular procedures. Findings in this NSQIP analysis may therefore force us to more prospectively and accurately determine what the trainee-related causes are that worsen surgical outcomes. Although I obviously agree with the authors that the solution to this dilemma is not to prohibit trainees from participating in surgery, much more emphasis needs to be placed on skills acquisition and competency assessments as methods to prepare surgical trainees for ultimate success when they are in the operating room. Much like the putting green before a round of golf, the simulation center/skills laboratory needs to be a warm-up zone for surgical trainees. National resources need to be provided to allow program directors to safely and efficiently train the future vascular surgery workforce. Formalized and mentored skills milestones of various vascular technical skills need to be identified, validated, and tested to create a skills curriculum for all future vascular surgeons. Although one-on-one faculty-to-trainee teaching in the operating room can never be completely replaced, those valuable interactions can be made much more meaningful when basic technical skills and operative plans have already been deliberately practiced outside of the operating room environment. Surgical trainee participation during infrainguinal bypass grafting procedures is associated with increased early postoperative graft failureJournal of Vascular SurgeryVol. 55Issue 3PreviewThis study was conducted to determine the potential effect of surgical trainee participation during infrainguinal bypass procedures on postoperative graft patency rates. Full-Text PDF Open Archive