Vascular Surgery Training – Horses for Courses

Vascular surgery training must aim to produce vascular and endovascular surgeons to deliver modern vascular surgery services to the community. Ideally, it should be available in the country of one's residence. Training in general should be rounded and wholesome covering all aspects of the new vascular curriculum specifically achieving the requisite numbers of index cases prescribed by the vascular specialist advisory committee (SAC).

Fellowships in the country of residence and abroad are equally competitive and have pros and cons, both in terms of training and remuneration.¹ Fellowships offer not only focused, concentrated training in areas of deficiency in the candidate's CV but also an extra armamentarium to the candidate to make them attractive to future employers. Different vascular units excel in certain aspects of vascular disease management and are therefore suitably placed for such fellowship programmes. With the requirement for mandatory endovascular training, fellowships became popular for vascular trainees in the UK, with a number of trainees heading abroad, east (Australia), or west (US/Canada) to fulfil such gaps in the CV. Such trends however have slowed down with the advent of endovascular fellowships in UK vascular units. Trainees aspiring to such training must produce documentary evidence to satisfy their local programme directors and the specialist advisory committee.

Al-Jundi et al.¹ have highlighted advantages and disadvantages of vascular fellowship programmes in two different countries. UK fellowship provided more hands on training, especially in open vascular surgical procedures whereas Canadian fellowship fulfilled aspirations in endovascular training much better than the UK. Trainees however missed out on endovenous training for the management of varicose veins in Canada. Also, vascular fellows in Canada may find themselves out of pocket, an important consideration. The log of operative experience between different fellows may differ as discussed below, however one must understand that the authors in this report describe experience of one vascular fellow which may not be applicable to others.

Despite equality and fair play in training, different trainees achieve a variable number of index operations during their experience. This is governed by personal ability and the aptitude of the trainee, and the level of rapport between the trainer and the trainee. Some trainees may find it challenging to achieve the required number of index cases as primary surgeons. In the UK, they may have to compete with radiology trainees for the endovascular component of their training, especially in those units where vascular surgeons do not have independent endovascular sessions in the job plan. In addition, fewer and fewer open vascular cases are being carried out in all vascular units because of the increased number of EVARs and peripheral endovascular interventions. This therefore reduces opportunities for exposure to open vascular surgery for vascular surgery trainees.

Although mandatory in their prescribed training, endovascular training is not the be all and end all of vascular training. Management of diabetic peripheral vascular disease forms a significant part of the workload for a consultant vascular surgeon. More vascular surgeons are required to treat diabetic feet both now and in the future in the UK. Carotid artery disease is still managed primarily by open surgery in Britain. In addition, open vascular surgery expertise will always be needed for vascular trauma. Efforts should be made by vascular units and vascular surgeons to look into ways and means of continuing to provide high quality open vascular surgery training in the recognised vascular surgery programmes. It is heartening to acknowledge that the UK fellowship programme provides a satisfactory experience in open vascular surgical experience and is better than that in Canada.¹

As part of their training, trainees must flourish educationally and produce publications on vascular surgery outcome data or audits. Those with an inclination for further education go through 2 years of supervised research experience for which they produce an MD or a PhD thesis. Also they must participate in prescribed courses such as ATLS, CRISP, etc., and get experience in presenting their audits and research to scientific forums. The requisite numbers of such educational activities are prescribed in the SAC requirements before being signed off for the completion of training. Educational opportunities in the two fellowship programmes in the UK and Canada were similar, as experienced by Al-Jundi et al.¹

Society needs a safe and accomplished vascular surgeon who can fit the bill. Of course, times are changing and so is the specialty. At the same time, public expectations change (increase) as well. It will therefore be difficult to predict the requirements of future vascular surgical training in the next 15–20 years.