This month, Corner Stitch highlights one of the papers recently presented at the Vascular and Endovascular Surgery Society (VESS) 2023 winter meeting in Whistler, British Columbia, Canada (Feb. 23–26). Nallely Saldana-Ruiz, MD, a senior vascular surgery fellow at the University of Washington in Seattle, and colleagues studied the trainee experience in open aortic reconstruction in the modern endovascular era—a topic on the minds of many trainees that sometimes influences how senior medical students rank programs. Here, she tells Christopher Audu, MD, what they found.
CA: Congrats on presenting at VESS 2023! Can you give us a synopsis of the study you presented?
NSR: Thank you. Presenting at VESS 2023 was truly a great experience. We were honored with the opportunity to share our work. Vascular surgery is a rapidly evolving field. While trainees around the country are exposed to many procedures during their years of training, some literature has demonstrated a wide variation in trainee experience and comfort with common procedures, including infrapopliteal revascularizations and in treating abdominal aortic aneurysm (AAA) disease.
We noted a paucity of data on the trainee experience with complex aortic surgery, and wanted to understand what the complex thoracoabdominal aortic disease trainee experience was for recent vascular surgery graduates. We collected anonymous survey data from U.S. vascular surgery trainees who graduated in 2020. We wanted to get a better understanding of their experience during training, as well as learn about their current practice and any desire for additional training. Our study adds the unique perspective of early-career vascular surgeons and is strengthened by the anonymous nature of the survey. This allowed participants the opportunity to freely share their experience and how that experience may have shaped their current practice patterns.
The limitations of the study include the small number of participants and the overall response rate. While it is certainly possible that the data can be biased by those who chose to answer the survey, we believe the responses provide a valuable insight into the early-career surgeon experience.
CA: What anecdotes or observations prompted this study?
NSR: The impetus for the study came from reading recent data, which demonstrated a wide variation in trainee experience with infrapopliteal bypasses and endovascular procedures. In their 2018 paper “Vascular fellow and resident experience performing infrapopliteal revascularization with endovascular procedures and vein bypass during training,” McCallum et al demonstrated a significant variation in trainee experience and comfort with treating infrapopliteal arterial disease.
They suggest that a quarter of vascular surgery trainees were receiving insufficient exposure to infrapopliteal open and endovascular procedures. Their study found that 27% of vascular surgery trainees performed 10 or less infrapopliteal vein bypasses, while 29% performed 10 or fewer infrapopliteal endovascular procedures. Given these data and the paucity of data on the experience of trainees with treating complex aortic disease, we were compelled to ask the questions.
CA: From your analysis, what does your team think is the “number needed to learn” for trainees to feel comfortable treating complex aortic disease as junior attendings?
NSR: It is important to recognize that we never stop learning, even as we transition out of our trainee roles. It is also essential to acknowledge that the “number needed to learn” will vary from trainee to trainee. Learning is different from mastery, and if you ask five different surgeons the same question you will certainly get five different answers. Still, I think it likely takes anywhere between five to 10 cases before you feel comfortable with attempting to independently manage the pathology. For thoracoabdominal aortic aneurysm (TAAA) disease, learning how to approach and care for patients is challenging on many fronts.
As an early-career surgeon, we will be faced with the complexities of decision-making and planning, all while carefully considering our patient’s physiology, anatomy, and fitness. Thus, “learning” is truly a long-term endeavor that is never complete.
CA: What do you propose that trainees who don’t have that sort of TAAA volume do to gain a certain level of comfort with this option—especially the open component?
NSR: The thoracoabdominal aortic disease training at the University of Washington is robust, and as trainees we are very fortunate to have such opportunities. Still, there is great benefit from cadaveric and simulation courses around the country for all trainees. Learning through simulation and didactics in a controlled environment, such as through courses like “The Big Apple Bootcamp,” the “Moore course,” and the open aortic training course at Houston Methodist Hospital, gives trainees unique exposure to the technical and clinical aspects of managing thoracoabdominal disease. However, I believe that there is no substitute for doing cases with those who manage and treat patients with thoracoabdominal disease often.
CA: Should the Association of Program Directors in Vascular Surgery, SVS or other vascular surgical societies make this a priority and sponsor open or simulation courses to help address this training gap?
NSR: Simulation and access to additional training should be supported. Additionally, some of the most beneficial aspects of participating in simulations and didactics center on the learning that occurs through interaction. So much of our clinical growth comes from
learning the intricacies of treating complex pathology through the experience of others. These are skills that cannot be mastered with independent simulation alone. In fact, one of the key findings of our study was that the vascular graduates who continued to treat complex aortic disease in their practice were doing so with the participation of their partners. This highlights that as young surgeons we continue to learn from our mentors and colleagues.
CA: In your estimation, what was the most surprising finding from your study?
NSR: One thing we found most surprising was that while most trainees reported doing a low number of complex open and endovascular aortic cases during their training, many were performing them in practice. When we looked closer at the data, we noted that most of our trainees were doing these cases with partners. Early-career surgeons working closely with senior partners in early practice is not surprising at all, and our data helped us to understand that our current training paradigm is one in which we continue learning from others.
CA: I have a feeling you may have already alluded to it, but what is the biggest takeaway you’d like our readers to gain from this work?
NSR: Continuing to learn in the years following our formal trainee period is a critical part of our lifelong learning process. Still, because we found that the experience with the management of open and endovascular complex aortic disease treatment varied among trainees in our study, additional training in the form of simulation, dedicated courses, or “super fellowships” can provide effective educational adjuncts.
Additionally, regionalization and the high-volume center—which provides dedicated care to patients with specific disease pathologies— may also afford the interested trainee the opportunity to learn a certain skillset in the form of visiting rotations and externships.
Christopher Audu, MD, is the Vascular Specialist resident/fellow editor.