Vascular Surgery is An Unattractive Career Option for Current Basic Surgical Trainees: A Regional Perspective

Abstract

INTRODUCTION

The workload of vascular services will substantially increase in the foreseeable future with the recent changes in surgical training presenting a challenge to training and recruitment in vascular surgery. This study aimed to determine the current feelings towards vascular surgery as a career choice from basic surgical trainees (BSTs) within a single region.

MATERIALS AND METHODS

BSTs from a single region were questioned. Probable career specialty choice was ascertained, as were suggestions for changes to the career pathway of a vascular surgeon to make it a more attractive career choice.

RESULTS

Seventy-seven of 110 BSTs returned the questionnaire. Of the 77, 52 had previous experience of a vascular firm. Ten BSTs had been on a pure vascular firm as an SHO and 52 had been on a general surgical firm. No BST specified vascular surgery as their ultimate career choice. Career choices included general surgery (n = 30), orthopaedics (n = 17), plastic surgery (n = 9) and urology (n = 5). Thirty-three BSTs would not be tempted at all to a career in vascular surgery. Changes in the career structure that would result in BSTs contemplating a career in vascular surgery included the inclusion of endovascular surgery (n = 13), no compulsion to undertake a period of research (n = 5), pure vascular training (n = 2), more general surgical training (n = 2) and less onerous on-calls when older (n = 2).

CONCLUSIONS

The lack of trainees wishing to become vascular surgeons is of grave concern. Increasing the endovascular capabilities of vascular surgeons as well as altering the stance on research may have an increasingly positive role in recruitment.

Surgical training in general is presently undergoing great change. Modernising Medical Careers (MMC) and with it seamless training along with the imposition of the European Working Time Directive has meant that old fashioned surgical training is a thing of the past.^1,2 The introduction of these new initiatives has also stimulated much debate as to the methods and structure of training in surgery in general.^3,4 Specifically, given the rise in the prevalence of diabetes and an ageing population, the workload of vascular radiological and surgical services will substantially increase in the foreseeable future which places great emphasis on training appropriate number of vascular specialists.⁵ The recent changes in surgical training, therefore, present a specific challenge to training and recruitment in vascular surgery. This study aims to determine the current opinions of basic surgical trainees (BSTs) within a single region on training requirements as well as the prospect of a career in vascular surgery.

Materials and Methods

Data were collected anonymously using a single-paged questionnaire. This was distributed to all BSTs from the Yorkshire School of Surgery. BSTs were asked about their previous surgical and, specifically, vascular experience. Potential skills (operative and non-operative) gained from exposure to vascular surgery were ascertained. Core specialties for general surgical training and probable career specialty choice were established, as were potential changes to the career pathway of a vascular surgeon to make it a more attractive career choice. Out of 110 questionnaires distributed, 77 were returned (response rate 70%).

Results

Of the 77 BSTs, 32 were in the first year of the BST scheme, 27 the second and 18 the third. Figure 1 shows the actual experience of the BSTs within the surgical training scheme itself. Overall, 52 of all trainees had previous experience of vascular surgery, 14 as a student, 23 as a pre-registration house officer and 15 as a BST (five as part of a general surgical firm). The most common specialties that BSTs felt should form part of core training are shown in Figure 1. General surgery (72), A&E (52), orthopaedics (39) and vascular surgery (30) were the most common. Most BSTs felt a period of exposure to vascular surgery would give them core surgical skills – namely tissue handling, formation of an arterial anastomosis and skills for haemorrhage control (Table 1). Table 2 shows the proposed career choices of the BST group. The majority of the BSTs want a career in either general surgery (30) or orthopaedics (17). All these 47 trainees had experienced their chosen career choice as a BST (Table 3). No BST expressed vascular surgery as their chosen career path. Fifty-two BSTs either did not express an opinion or felt that no changes to the career pathway or job of a vascular surgeon would make them consider a career in vascular surgery. Table 4 shows those changes to the training and job specification for vascular surgery that would make BSTs consider a career in vascular surgery.

Figure 1.

Actual jobs exposure and preferred job exposure as part of a BST scheme. Gen, general surgery;Orth, orthopaedic surgery; Uro, Urology;Vasc, vascular surgery;CTH, cardiothoracic surgery; An, anatomy demonstrating;Pl, plastic surgery;Ne, neurosurgery.

Table 1.

BST perception of skills that they will obtain in a period of vascular surgical training

Skill	Number of BSTs
Tissue handling	35
Anastomosis	33
Control haemorrhage	25
Management of ischaemic limb	24
Management of co-morbidities	7
Anatomy	6

Table 2.

Career choices of all BSTs

Career choice	Number of BSTs
General surgery	30
Orthopaedics	17
Plastic surgery	9
Urology	5
Radiology	2
ENT	2
Transplant surgery	1
Maxillofacial surgery	1
Paediatric surgery	1
Neurosurgery	1
A&E	1
General practice	1
Unknown	6
Vascular surgery	0

Table 3.

Number of trainees that had experienced their chosen career whilst a BST

Career choice	Number of BSTs	Number of trainees experiencing their chosen career
General surgery	30	30
Orthopaedics	17	17
Plastic surgery	9	6
Urology	5	5
Radiology	2	0
ENT	2	2
Transplant surgery	1	1
Maxillo-facial surgery	1	0
Paediatric surgery	1	1
Neurosurgery	1	1
A&E	1	1
General practice	1	0
Unknown	6

Table 4.

Specific changes that would make vascular surgery an attractive career option

Change	Number of BSTs
Include radiology and endovascular training	13
No obligation to undergo a period of research	5
Less on-call commitments when older	2
Continue a period of general surgical training alongside vascular surgical training	2
Pure vascular surgical training	2
More exposure to vascular surgery as a junior doctor	1

Discussion

Vascular disease is likely to become more prevalent as both life expectancy and type 2 diabetes mellitus increase.⁵ Combined with the proliferation of novel pioneering techniques in the field of vascular and endovascular surgery, it is likely that there will be continued demand for vascular practitioners, be they predominantly surgical or endovascular in nature. Increasingly, practice is changing, with pure vascular surgeons rather than general surgeons with an interest in vascular surgery delivering vascular services, either as a team member in major centres or as part of a network in smaller centres.⁶ The fact that no BST within our study wanted to pursue a career in vascular surgery is disturbing. Most of the respondents had at some time in their medical training (either undergraduate or postgraduate) been exposed to a period of vascular training. However, less than 30% of trainees had been exposed to vascular surgery as a BST. Despite this, the majority of BSTs felt that exposure to vascular surgery was important for their surgical training providing them with a wide variety of skills – both surgical and non-surgical. Indeed, more BSTs want a period of exposure to vascular surgery than are actually getting it within our region although a proportion of trainees had not yet completed their 3-year rotation. The lower number of year-3 trainees in our study may have skewed the data. However, although there are a total of 140 posts in the Yorkshire School of Surgery, only 110 were occupied by trainees on the training scheme. The rest were either stand-alone posts or ‘filled’ by trainees who had resigned. Because of this, they were excluded from the study, but it is likely that those who had resigned were likely to be the more senior trainees. At the time of this study, there were five units that were either pure vascular units or in which the vast majority of the workload was vascular within the Yorkshire school of surgery with the BSTs taking part in the general surgical acute rota in all but one of these. It is, therefore, difficult to see how more BSTs could gain more exposure in vascular surgery in the non-foundation based training programmes. Currently, the Vascular Society is designing a new training structure for vascular surgeons with the aim of delivering comprehensive training in the vascular specialty as well as allowing maximum flexibility for trainees to customise their own training.⁷ The overall aim is to produce a vascular specialist of the future capable of both surgical and radiological intervention. However, given the results of our study, there are a number of questions that the Vascular Society will need to address. First, will early entry into a pure vascular training scheme recruit enough trainees to provide a vascular surgical service in years to come? It would appear from our results that exposure to a period of vascular surgery as a medical student or PRHO is insufficient to stimulate would-be surgeons to go down the vascular route. Indeed, our own personal experience is that the role of surgery as a whole in the undergraduate curriculum is diminishing. This needs to be addressed and a more pro-active approach towards the integration and stimulation of students in the field of vascular surgery needs to be promoted. Our results would also suggest that the amalgamation of endovascular training with vascular training is likely to appeal to more junior doctors. Most vascular trainees have welcomed the development of a pure vascular training scheme, but care needs to be taken that this is not to the detriment of the ‘craft’ of vascular surgery. Furthermore, the development of foundation programmes needs to offer those wishing to undertake surgical and, more specifically, vascular training, the opportunity to make the most of their 2-year programme. This may be at the polar opposite to those who have developed and head the foundation scheme, but the reality is that if there is not a continuing stream of trainees undertaking a career in vascular surgery then it will become a dying specialty. Indeed, it is essential that surgery as a whole does not become a forgotten specialty in this time of foundation training and, as such, incorporation of vascular surgery as part of the 4-month ST1 posts would increase the exposure of trainees to the specialty.

Second, should we be exposing more BSTs to vascular surgery to encourage the development of more vascular trainees? Our results show that all trainees wishing to undertake orthopaedics or general surgery as a career had been exposed to these specialties as a BST. This, along with the fact that 30 trainees wished to have vascular surgery as part of their rotation, enforces the view that more trainees should be exposed to vascular surgery at the BST or equivalent level. Senior house officers in general do not partake in enough operative surgery. In part, this is due to restrictions on working patterns resulting in a greater part of their time being taken up by on-call commitments or time off following on-call. Higher surgical trainees are less experienced than they use to be and the current restrictions upon their working time means that there is more competition for cases. Potential ways of increasing operative experience for BSTs throughout the country include making better use of day-case facilities with consultantled lists biased towards training.⁸ This may be in conflict with service provision but a balance between this and training needs to be reached. Varicose vein and day-case renal access work will expose trainees to appropriate skills. One objection to this is the unreliable attendance of juniors to the lists due to the implementation of the shift systems. Strict time-tabling for BSTs would prevent this from happening. There are also an increased number of surgical skills courses available for vascular trainees.⁹ These courses allow trainees to undertake core vascular skills using cadaveric models, which will give trainees a head start and allow them to get maximum benefit from their time in theatre. Increasing the awareness and availability of the courses and reducing the costs will expose more trainees to the skills of vascular surgery.

Finally, how are we going to make vascular surgery a more attractive career choice? There are clearly major issues with regard to recruitment. Just under 50% of BSTs would not be tempted into vascular surgery. This means that there is a significant group of BSTs who may still consider a career in vascular surgery if changes were made to the career structure. These include incorporation of an endovascular commitment as well as the lack of reliance on research to get a national training number. It is indeed likely that a year of endovascular training will be incorporated in any new vascular surgical curriculum. A study undertaken in the US showed that technical aspects, role of mentors, and complex decision-making involved in vascular surgery were the most important reasons that junior surgeons and medical students would choose vascular surgery as a specialty.¹⁰ The importance of mentorship to surgical trainees cannot be overestimated. The implementation of the shift system has resulted in a breakdown of the traditional ‘firm’ system and with it the rapport established between the consultant and the junior staff. The implementation of 4-month posts in foundation training will further affect mentorship and, as such, there is a strong need for consultants to encourage trainees into vascular surgery. Life-style concerns were the most important reason why medical students did not choose vascular surgery as a career.¹⁰ This may well be the most important issue that needs addressing here in the UK especially given the increasing percentage of medical students that are women. Flexible training schemes should be encouraged if this is to improve the recruitment to vascular surgery.

Conclusions

Despite, the imminent start of MMC in August 2007, there is still no firm template for training. The Vascular Society is attempting to introduce a specialised training scheme for vascular surgery although time is running out. The lack of trainees wishing to become as vascular consultant needs urgent attention if the speciality is going to continue to prosper.