NEW YORK—The dramatic shift away from open surgery toward an endovascular approach has landed vascular practice at a stark crossroads, attendees at the VEITHsymposium (Nov. 19–23, 2019) heard during a lecture whose title bore a clear message: “How to teach competent open surgery in the endovascular era.”
The presentation, delivered by R. Clement Darling III, MD, chief vascular surgeon in the division of surgery at Albany Medical Center Hospital, Albany, New York, comes in the wake of a study published by the Journal of Vascular Surgery that found nearly half of senior trainees from 2010–2014 had performed less than five open abdominal aortic aneurysms (AAA) procedures.
Darling drew attention to numbers that demonstrate an open AAA training vacuum at many medical schools: “If you look at the data, there are 10 programs that didn’t even have their fellows graduate with any open aortic experiments, which is a little bit shocking, especially if you’re trying to give them credentials down the line,” he said. “It’s going to be hard to do that, especially for open surgery.”
His warning finds fertile ground in the recent research. The study—“The decline of open abdominal aortic aneurysm surgery among individual training programs and vascular surgery trainees”—finds intensifying concern over the proficiency of future surgeons.
“The variable and diminishing [open AAA repair] exposure among vascular surgery training programs highlights growing concerns surrounding competence in complex open repairs and suggest that only a small proportion of current trainees have ample opportunity to develop confidence and proficiency in this high-risk operation,” wrote a research team led by Margaret E. Smith, MD, of the department of surgery at the University of Michigan, Ann Arbor, Michigan.
For Darling, a snapshot of practice at his institution illustrates the point: “We’re in a 3‒1, 4‒1 endo[vascular] versus open group but we still do a fair amount of aortic surgery and open distal surgery as well as carotid surgery,” he explained.
“So the problem we are presented with is decreasing volume—and any of the volume that we are doing is more complex or redo from some of the interventional failures. Everything we do we fail at one point or another. Patients tend to be sicker and older, with less time to learn and fewer patients to learn from. And we have a higher scrutiny of what we do throughout the country.”
The problem of declining volume
Darling then posed the burning question that underscores the difference between the training received by previous generations of vascular surgeons and the current one: How do you teach when volume is declining?
“One thing we have tried to emphasize to our fellows is they don’t have to do to learn, and so many times when we’re doing an open aneurysm or an open aortobifemoral bypass we can actually bring multiple residents in there to show them the anatomy, show them the techniques so it will be a group learning instead of a single learning,” he said.
Darling emphasized the very different profile of the emerging generation of surgeons: their approach to work-life balance, their expectations—and their varying approaches to learning. There are those who learn intellectually, those who absorb through repetition, Darling continued. “But mostly, especially the millennial generation, people learn from positive reinforcement and being able to guide them through the learning.”
Continuing on the theme of overcoming the open surgery chasm, Darling returned to how he and his team approach training in Albany.
“I would argue, especially with aortic surgery, it’s more like flight training now,” he said. “We have a meeting before where we have the fellows present to us exactly how the technical aspects of the operation went […] We anticipate all the problems and then at the end with the nurses and the fellows, we go through a technical debriefing of what happened and how we can improve the situation.”
Students are exposed to a number of techniques, Darling continued: “We use simulation for open and endo[vascular]; a lot of video preparation, [which] allows them to see the anatomy because I think the most important thing is to have the anatomy in your mind’s eye; and team simulation and observation.
“So our approach is we sit in the morning and discuss every case, discuss every approach, discuss how we do it and the technical aspects of it. We make them visualize as well as verbalize exactly what we do and understand the potential pitfalls as we do it. We have a series of plans that are already arranged so no one does any thinking in the OR [operating room]; you do your thinking before you get to the OR, and answer all the questions then. And know what your endpoints in every operation are going to be.”
Darling reiterated the importance of group learning “especially in these days of low volumes,” adding: “All of us are smarter than one of us. As Napoleon said, amateurs discuss tactics and the professionals discuss [logistics]. Because it’s all about the logistics and the set-up of these operations: it has to be intellectual as well as tactile, and you’ve got to figure out exactly how you can adapt these younger students to a learning process.”
At the moment, Darling argued, students aren’t being trained well enough in open surgery owing to the field’s failure to adjust to the current generation’s particular needs and modes of learning. He prescribed the development of centers of excellence in order to create volume exposure as well as simulation, videos and active preparation to maximize the education of trainees as potential remedies.
Decade of dramatic change
For Smith et al, the investigators behind the recent study, the spur to action came in light of alarm over what they described as an inadequate level of open aortic repair exposure among trainees, leaving vascular surgery’s emerging practitioners unable “to develop the necessary confidence and competence to perform this high-risk procedure independently.”
The research team wrote: “The evolution in surgical management of abdominal aortic aneurysm (AAA) from open AAA repair to endovascular aneurysm repair (EVAR) has been accompanied with apprehension regarding vascular surgery trainees’ exposure to [open AAA repair]. The use of EVAR increased rapidly after its approval in 1999 with the proportion of AAA treated endovascularly increasing from 5% in 2000 to 74% in 2010; only 15% of AAA in Medicare beneficiaries were treated with [open AAA repair] in 2014.”
The team sought to better understand variation in open repair training among vascular surgery trainees across the U.S. They studied Medicare beneficiaries undergoing EVAR or open AAA repair at accredited vascular surgery training intuitions between 2010 and 2014. “We aimed to understand AAA repair trends within individual programs as well as to evaluate individual trainees’ opportunity for [open AAA repair] exposure,” they wrote.
In a retrospective review of prospectively acquired data from the Centers for Medicare and Medicaid Services, the researchers identified accredited vascular surgery training program hospitals, with open repair and EVAR volume aggregated at the program level. The number of senior vascular surgery trainees per year at each program was then captured. “The training program all-payer total AAA repair volume was calculated based on the national proportion of patients undergoing AAA covered by Medicare in the Vascular Quality Initiative,” they explained. “Temporal trends in program and vascular surgery trainee [open AAA repair] and EVAR volume were calculated.”
A total of 119,408 (77%) EVAR and 35,042 (23%) open repair cases were identified in the Medicare database over the five-year period studied, the authors explained. “Of these, 21% were performed among the 111 training programs, including 22,227 (73%) EVAR and 8,416 (27%) [open AAA repair]. The total [open repair] volume among training programs decreased by 38% during the study period, from a median of 29.1 to 18.2 [open repair]. In 2014, 25% of programs performed fewer than 10 [open repairs] annually. Among senior vascular surgery trainees, the median number of [open repairs] decreased from 10 in 2010 to 6.4 in 2014 and approximately one-half of senior trainees had exposure to fewer than five [open repairs] in 2014.”
Since its approval 20 years ago, EVAR has steadily replaced open repair as the go-to procedure. Only a year afterward, the investigators observed, open repair volume decreased from 88% in 1998 to 77% in 2000. Two years later, the surgical community started to speak out about operative training in open repairs for future surgeons, they wrote. “Over the past 20 years, workforce concern for future surgeons’ competence in performing [open surgery] has exponentially grown.”
Shifting institutional policy might demand change in the current dynamic, the authors continue. “The 2018 Leapfrog Group volume standards state that hospitals should perform a minimum of 15 [open aortic repairs] annually and surgeons should perform a minimum of 10 [open repairs] annually to be credentialed. Although the usefulness of [open repair] volume as a quality metric is questioned, many healthcare systems are implementing these standards and barring surgeons who do not perform a minimum of 10 [open repairs] per year. Our results demonstrate that a significant proportion of senior vascular surgery trainees will perform fewer than 10 [open repairs] in their training and may be ill-equipped to safely meet these credentialing standards.”
Doubt cast over remedy
Smith et al note that exposure to open repair varies across the country with nearly half of all learners performing fewer than 10 in their final years of training. Prior suggestions put forth to address the shortfall are “untested or may have unintended consequences,” they wrote in conclusion.
By way of example, the research team referenced simulation-based open repair training, which they described as “low fidelity and unlikely to provide nuanced skills necessary for proficiency.”
The authors continued: “Regionalization of [open repair] to specific centers, as suggested in previous studies, may result in few trainees exposed to this procedure, thus failing to address the declining number of surgeons with [open repair] expertise.” This remedy may exaggerate healthcare disparities among vulnerable populations, they argue.
The investigators outline their own prescription amid a rapidly changing clinical training experience for AAA management. They cite clear technical standards, redefined volume and case-mix thresholds, systematic performance measurement of trainees, and the leverage of quality collaborative efforts such as the Vascular Quality Initiative in order to track the clinical outcomes of junior surgeons.
This, the authors write, “may be necessary to ensure trainees are ready for independent aortic practice when entering the workforce.”
Furthermore, the researchers zeroed in on the shifting sands of EVAR’s long-term benefits and cost-effectiveness. As this process plays out, they add, a growing population of patients may elect open repair “and healthcare policies may preclude continued widespread use of EVAR as is currently proposed in the United Kingdom’s National Institute for Health and Care Excellence guidelines, which significantly restrict the use of EVAR.
“Although EVAR will likely remain the most common approach for AAA in the U.S., both institutional and specialty-wide initiatives must be studied to ensure future vascular surgeons are provided the expertise needed to perform high-risk [open repair] when necessary.”
Back at the VEITHsymposium in New York, meanwhile, Darling left his audience with another simple message: “I think Charles Darwin was correct when he said the stronger of species survive,” he told those gathered. “It’s not the most intelligent; it’s the one most adaptable to change.”