Abstract
Background:
Surgical training is constantly adapting to better prepare trainees for an evolving landscape of surgical practice. Training in vascular surgery additionally underwent a paradigm shift with the introduction of the integrated training pathway now more than a decade ago. With this study, we sought to characterize the needs and goals of our current vascular surgery trainee population.
Methods:
The Association of Program Directors in Vascular Surgery Issues Committee compiled a survey to assess demographics, current needs, and goals of trainees and to evaluate trainee distress using a validated seven-item Physician Well-Being Index. The survey was distributed electronically to all current vascular surgery trainees and recent graduates in the academic years 2016–2017 and 2017–2018, and responses were recorded anonymously.
Results:
During the 2 years of the survey, the response rate was 30% (n = 367/1196). The respondents were 55% (n = 202) integrated vascular residents and 45% (n = 165) vascular surgery fellows. In each year of the survey, 60% (n = 102/170) and 58% (n = 86/148) of trainees expressed a desire to pursue academics in their careers, whereas 37% (n = 63/174) and 35% (n = 53/152) indicated their program had structured academic development time (2016–2017 and 2017–2018, respectively). Fifty-five percent (n = 96/174) and 52% (n = 79/152) stated that the overall impact of collaborative learners was positive. More than 60% of respondents in both years of the survey indicated experiencing one or more symptoms of distress on a weekly basis. The frequency of distress was associated with older age and with the presence of an advanced degree in both years of the survey. Sex, level of training, presence of collaborative learners, and having protected research time were not associated with frequency of distress in either year of the survey.
Conclusions:
These results highlight an opportunity for programs to further evaluate the needs of their trainees for academic development during vascular surgery training to better accommodate trainees’ career goals. Further investigation to identify modifiable risk factors for distress among vascular surgery trainees is warranted.
Keywords: Resident education, Workforce, Database
The health care system has changed dramatically during the past several decades in ways that continue to reshape surgical training. The technologic advances in surgical care, the revolution of the electronic medical record, and the resident work hour regulations have dramatically altered surgical residency training.1 Trainees face numerous challenges to comply with external regulations while striving to achieve competency for increasingly complex and specialized care.
Concurrently, vascular surgery training has seen a paradigm shift in the past decade with the implementation of integrated vascular surgery residency programs along-side traditional 5 + 2 fellowship programs to contribute to the vascular surgery workforce. Dansey et al2 identified high rates of satisfaction (>90%) in regard to education, case selection, peer interaction, and faculty among integrated vascular surgery residents. Yet, technical challenges, long and unpredictable work hours, and high-stakes outcomes of vascular surgery impose an increasing burden of stress on vascular surgery trainees.
Now, more than a decade since the inception of the integrated training program, we sought to characterize who our current traditional and integrated learners are, what they want from training, and what obstacles they perceive in their training. This will allow training programs in vascular surgery to refine their educational programs to better meet the evolving needs of their trainees as they prepare to enter practice in a rapidly changing field.
METHODS
In 2016, the Issues Committee of the Association of Program Directors in Vascular Surgery (APDVS) redesigned the annual training survey in an effort to assess contemporary learners in the era of established integrated vascular training programs. The survey was vetted by the APDVS Executive Council. To optimize future recruitment and retention to the specialty, the survey focused on contemporary learner motivators, wellness, professional development needs and expectations, and perceived impact of collaborative learners. The annual training survey was issued electronically by Survey Monkey to all integrated vascular surgery residents and independent vascular surgery fellows in North American programs during the fall of the 2016–2017 academic year. To confirm reproducibility of the data, the survey questions were repeated during fall of the 2017–2018 academic year.
Demographic data collected included age, sex, year in training, presence of advanced degrees, type of practice, anticipated future salary, and weekly workload. In addition, information about exposure to collaborative learners from other subspecialties, mentorship, research and career development opportunities, top motivators, perceived threats to the specialty, and overall satisfaction with training was also collected (Supplementary Fig, online only). The primary outcome variable was a seven-item validated Physician Well-Being Index. Individual demographic data were analyzed by descriptive statistics. Each year of respondents (academic cohort) was analyzed separately. Univariate analyses were performed to compare demographics across years and to evaluate the association of variables with distress frequency within each year. Contingency tables were analyzed by Fisher exact test because of sample size using SAS 9.4 software (SAS Institute, Cary, NC).
RESULTS
The annual training survey was sent to 1196 vascular surgery trainees, of which 367 responded, achieving a response rate of 30%, comparable to the survey response rate in previous years.3 Of those respondents, 53% (n = 191) were integrated residents and 68% (n = 245) were male. The composition of 55% integrated residents (n = 97 and n = 94 in 2016–2017 and 2017–2018, respectively) and 45% fellows (n = 86 and n = 77, respectively) during each year of the survey reflects a composition similar to the recently published work by Janko and Smeds.4 Compared with previously published APDVS survey results, this represents a larger percentage of respondents from the integrated training paradigm (previously 28.3%). Our results correlate with the relative current number of training spots in each type of training paradigm. Per the Accreditation Council for Graduate Medical Education database, there are 59 of the 0 + 5 programs and 108 of the 5 + 2 programs. In addition, our respondents were 68% male, which is also comparable to recently published data (64% male) but represents a decrease from previously published APDVS survey results (77% male).3,4 The median age in both years of the survey was 32 years. Of the respondents, 37% endorsed advanced degrees (beyond a doctor of medicine), and 11% relayed intention to pursue an advanced degree. There were no differences in these demographic variables between the 2016 and 2017 cohorts (Table I).
Table I.
The survey demographics remained similar between the two academic years reported
| Demographics | 2016–2017 (N = 187) | 2017–2018 (N = 176) | P value |
|---|---|---|---|
| Residents | 52% (n = 97) | 53% (n = 94) | .6354 |
| HO1 | 20 | 19 | |
| HO2 | 16 | 21 | |
| HO3 | 25 | 29 | |
| HO4 | 12 | 9 | |
| HO5 | 13 | 9 | |
| ADT/lab | 7 | 6 | |
| Recent graduate | 4 | 1 | |
| Fellows | 46% (n = 86) | 44% (n = 77) | .6354 |
| F1 | 34 | 40 | |
| F2 | 39 | *> | |
| Recent graduate | 13 | 0 | |
| Male | .7313 | ||
| Female | 33% (n = 62) | 31% (n = 55) | |
| Age, years, median (IQR) | 32 (30–34) | 32 (29–34) | .9383 |
| Advanced degree | 36% (n = 68) | 39% (n = 68) | .6722 |
| MBA | |||
| MA | 8 | 4 | |
| MS | 36 | 28 | |
| PhD | 9 | 13 | |
| MPH | 7 | 8 | |
| JD | 1 | 2 | |
| Other | 3 | 9 |
IQR, Interquartile range.
The majority of trainees (60.1% and 58.1% in 2016–2017 and 2017–2018) stated an intention to pursue an academic career (6.5% and 8.1% academic with basic/translational research, 5.3% and 6.1% academic with quality improvement/health policy, 21.1% and 16.9% academic with education, and 27.1% and 27.0% clinical academic). Despite this, only a third of trainees reported that their training program incorporated protected time for academic development (Table II).
Table II.
The majority of trainees reported a desire to incorporate academia into their long-term career, in various forms, whereas the minority of respondents reported that protected academic development time was part of their training program
| Career goals | 2016–2017 (N = 170), No. (%) | 2017–2018 (N = 148), No. (%) |
|---|---|---|
| Academic, basic/translational | 11 (6.5) | 12 (8.1) |
| Academic, quality improvement/health policy | 9 (5.3) | 9 (6.1) |
| Academic, educational | 36 (21.2) | 25 (16.9) |
| Academic, clinical research | 46 (27.1) | 40 (27.0) |
| Community + teaching | 50 (29.4) | 43 (29.1) |
| Community, clinical | 14 (8.2) | 17 (11.5) |
| Military | 4 (2.4) | 2 (1.4) |
| (N = 174) | (N = 152) | |
| Dedicated mentored time for academic development | 65 (37.4) | 53 (34.9) |
When asked what could enhance satisfaction with training, the top responses included enhanced operative entrustment and autonomy, increased focus on the business of surgery, structured/mandatory and sponsored academic development time, increased case volume, assigned mentoring, and structured simulation (Table III). Trainees stated that the top perceived threats to the vascular surgery specialty are competing specialists and physician burnout (Table III).
Table III.
Trainees rank their top areas for improvement in training and the biggest perceived threats to vascular surgerya
| 2016–2017 (N = 165), No. (%) | 2017–2018 (N = 143), No. (%) | |
|---|---|---|
| Areas for improvement | ||
| Enhanced operative autonomy/entrustment | 73 (44.2) | 66 (46.2) |
| Increased focus on the business of surgery | 63 (38.2) | 66 (46.2) |
| Structured/mandatory/sponsored academic development time | 53 (26.1) | 31 (21.7) |
| Assigned mentoring | 39 (23.6) | 27 (18.9) |
| Increased case volume | 36 (21.8) | 37 (25.9) |
| Structured simulation training | 32 (19.4) | 32 (22.4) |
| Perceived threats | ||
| Competing specialists | 130 (78.8) | |
| Physician burnout | 105 (63.6) | 84 (58.7) |
Respondents selected three for areas for improvement and two for perceived threats.
While on general surgery rotations, 85% of vascular residents stated that they had a reasonable or acceptable operative experience, with <10% indicating that they had an inadequate experience on general surgery rotations. Less than 30% thought that collaborative learners negatively affected their case volume, whereas 45% were unaffected. The majority of vascular trainees stated that the overall impact of collaborative learners was positive (Table IV).
Table IV.
The majority of trainees found the impact of collaborative learners on training to be positive, by facilitating didactics and cross-disciplinary mentoring without compromising case volume or training experience
| Working with collaborative learners | 2016–2017 (N = 174), No. (%) | 2017–2018 (N = 152), No. (%) |
|---|---|---|
| Has impact on case volume | 49 (28) | 42 (28) |
| Facilitates didactics | 102 (59) | 70 (46) |
| Facilitates cross-disciplinary mentoring | 98 (56) | 90 (59) |
| I still receive acceptable or an equivalent training experience | 76/89 (85) | 74/87 (85) |
| Is positive | 96/174 (55) | 79/152 (52) |
Remarkably, across both academic cohorts, >60% of respondents self-reported one or more features of distress on a weekly basis. There was no difference in frequency of distress between residents and fellows and no difference between junior and senior trainees.
On a weekly basis or more frequently, 24% of respondents in 2016–2017 and 19% in 2017–2018 felt burned out from work; 28% and 25% worried that work was hardening them emotionally; 18% and 15% felt bothered by emotional problems; 14% and 11% felt that all the things they need to do were piling up so high that they could not be overcome; 15% and 20% felt down, depressed, or hopeless; 5% and 9% felt that physical health had interfered with ability to do daily work; and 4% and 5% had fallen asleep while stopped in traffic or driving. Despite stating this frequency of distress and burnout, 94% were satisfied with their training, with 51% being very satisfied.
On univariate analysis, older age and having an advanced degree were the only factors significantly associated with increased frequency of distress in both years (P values <.05). Sex, level of training, presence of collaborative learners, and having protected research time were not associated with frequency of distress. Aspirations of an academic career were associated with a protective effect on frequency of distress features in 2017–2018 but not in 2016–2017 (Table V).
Table V.
An increased frequency of distress correlates with older age and the presence of an additional advanced degree in both academic years reported
| Distress frequency | ||||||||
|---|---|---|---|---|---|---|---|---|
| 2016–2017 | 2017–2018 | |||||||
| Never | Less than weekly | Weekly or more | P value | Never | Less than weekly | Weekly or more | P value | |
| Sex | ||||||||
| Male | 12 (10.9) | 76 (69.1) | 22 (20.0) | .128 | 12 (11.5) | 73 (70.2) | 19 (18.3) | .8329 |
| Female | 7 (13.0) | 29 (53.7) | 18 (33.3) | 7 (14.9) | 31 (66.0) | 9 (19.2) | ||
| Age, years | ||||||||
| 25–30 | 10 (19.6) | 32 (62.8) | 9 (17.7) | .032 | 2 (3.8) | 45 (84.9) | 6 (11.3) | .0226 |
| 31–35 | 9 (11.4) | 52 (65.8) | 18 (22.8) | 13 (19.4) | 40 (59.7) | 14 (20.9) | ||
| 36+ | 0(0) | 21 (61.8) | 13 (38.2) | 4 (12.9) | 19 (61.3) | 8 (25.81) | ||
| Level of training | ||||||||
| Junior | 10 (19.2) | 31 (59.6) | 11 (21.2) | .1239 | 7 (12.1) | 43 (74.1) | 8 (13.8) | .4981 |
| Senior | 7 (8.0) | 56 (63.6) | 25 (28.4) | 11 (12.9) | 56 (65.9) | 18 (21.2) | ||
| Advanced degree | ||||||||
| Yes | 7 (14.0) | 23 (46.0) | 20 (40.0) | .0037 | 8 (16.7) | 25 (52.1) | 15 (31.3) | .0069 |
| No | 12 (10.5) | 82 (71.9) | 20 (17.5) | 11 (10.7) | 79 (76.7) | 13 (12.6) | ||
| Academic aspiration | ||||||||
| Yes | 13 (13.0) | 66 (66.0) | 21 (21.0) | .4053 | 15 (17.1) | 61 (69.3) | 12 (13.6) | .0478 |
| No | 6 (9.4) | 39 (60.9) | 19 (29.7) | 4 (6.4) | 43 (68.3) | 16 (25.4) | ||
Values are reported as number (%). Boldface P values are statistically significant.
DISCUSSION
The results of the 2016–2017 and 2017–2018 APDVS training surveys yielded several important findings. First, the majority of respondents reported a desire to incorporate academics into their long-term career, whereas only a third of respondents indicated that their training program had dedicated time for academic development, as defined by the respondent. These findings suggest a potential discrepancy between what programs currently provide and what vascular trainees want and need to achieve their goals of pursuing an academic career. Together, these results illustrate an opportunity to enhance structured time for academic development.
Next, whereas most vascular trainees are satisfied with their training program, operative autonomy ranked as the area in greatest need of improvement. The majority of studies suggest a deterioration in the level of confidence of general surgery graduates compared with previous generations, inversely correlated with higher case volume and advanced age.5 Solutions to increase trainees’ confidence have centered around the use of simulation, as simulation has been demonstrated to produce procedural proficiency comparable to direct patient care in many procedures.6 Our results similarly showed that trainees ranked an increase in simulation as a high priority. The incorporation of a simulation-based core competency curriculum for vascular training has been advocated as a mechanism to supplement and to enhance training, mitigating effects of work hour restrictions, rapidly advancing technology, and need to be competent in rare surgical and endovascular techniques.7 Simulation would provide the additional benefit of demonstrated proficiency in a low-risk setting, facilitating greater operative autonomy, and it has been demonstrated to result in surgical skills transfer to the patient care setting.6 The issue of operative autonomy is a topic for discussion, and finding ways to improve training will likely be multifactorial. Further studies will help elucidate the best methods to achieve this.
Third, the majority of trainees reported a positive experience working with collaborative learners from across specialties during their training. Most respondents also identified that they were treated the same as their general surgery counterparts while on general surgery rotations. Only a few respondents expressed concern about collaborative learners detracting from the case volume for vascular trainees. This overall positive experience with collaborative learners contrasts, however, with the perceived dynamic between practicing vascular surgeons and these other specialists. Competing specialists were identified as the number one threat to the field of vascular surgery in our survey in both 2016 and 2017. The long-term effect of collaborative learning in an era of increasing subspecialization will need to continue to be evaluated moving forward. Whereas competing specialists was a top concern for trainees, the second ranked threat to vascular surgery in both years of the survey was identified as physician burnout.
Finally, an alarming 60% of respondents reported experiencing distress on a weekly basis. This was the most surprising finding in the 2016 survey. We thought that it was important to repeat the survey the following year to make sure this was not an isolated, spurious result. The high prevalence of self-reported distress was confirmed in the 2017 survey. A similarly high prevalence of burnout, 69%, has been reported in general surgery trainees.8 In our vascular trainee cohort, distress frequency interestingly correlated with the presence of an additional advanced degree besides a medical degree. Furthermore, distress frequency correlated significantly with age, with older trainees being more likely to experience distress more frequently. In our vascular trainee cohort, aspiring to pursue an academic career trended toward a lower rate of burnout. Senior level of training, sex, experience with collaborative learners, and having protected research time did not appear to influence the rate of burnout.
Strategies to combat and to prevent burnout are necessary at both the personal and institutional level. Potentially modifiable risk factors for burnout that have been identified in the literature include facilitating social engagement and belonging, cultivating self-efficacy, fostering emotional intelligence, formal mentoring, and adhering to the 80-hour work week.4,9–11 Several surgical residency wellness programs to combat burnout have been reported in the literature in recent years. The Balance in Life program in the Department of Surgery at Stanford University uses four pillars to promote resident and trainee wellness. The program emphasizes professional wellness through team building; physical wellness by facilitating access to medical care, nutrition, and fitness; psychological wellness by addressing the unique stressors in surgical training; and social wellness through programmatic noneducational events.12 The Medical University of South Carolina implemented a pilot program within the Department of Neurosurgery to facilitate resident wellness, incorporating regular group exercise programs as well as education on mental health and sleep hygiene, with significant improvement in resident well-being metrics after 1 year.13 In a randomized controlled trial, the University of California, San Francisco, identified a role for a formal mindfulness training program among surgical trainees. Comparable to soldiers in combat or high-performance athletes, the trainees expressed a desire to improve performance and mitigate undesirable behavioral changes frequently arising during a demanding, prolonged period of intense training. The mindfulness program was cost-effective and well attended, and the residents in the intervention group continued the mindfulness practice long after the study was completed.14 The University of Arizona implemented the Energy Leadership Well-Being and Resiliency Program, with significant improvement in the residents’ perception of their training experience.15 Continued investigation to identify modifiable risk factors for burnout will aid in the development and more widespread implementation of such programs.
There are several limitations to this study. First, our response rate of 30%, although similar to comparable surveys, was insufficient for a robust multivariate statistical analysis. The trainees who may be most affected by distress may have been more likely to fill out the survey, raising the possibility of sample bias.3,4 Furthermore, the study may also be limited by recall bias, although we strove to mitigate this by repeating the survey in both 2016–2017 and 2017–2018, both of which demonstrated similar results. Even though augmenting structured academic development ranked in the top ways to improve the training experience, our findings did not account for academic development time pursued by vascular fellows during their general surgery residency training. Furthermore, we intentionally did not define “academic development” but rather allowed trainees to interpret this entity. Further investigation into what constitutes a satisfactory academic development experience will be necessary.
In addition, whereas we did not detect any sex-associated differences, our study was not designed to explore the various domains of burnout, which have been demonstrated to have sex-associated differences among surgical trainees.16,17 An additional limitation is that our survey did not evaluate modifiable factors for distress. Recently, Janko and Smeds4 identified several potentially modifiable factors that were associated with burnout in vascular surgery trainees, including lower self-efficacy, lack of a mentor, increased 80-hour work week violations, and having fewer programmatic social events. The 2018 annual training survey delves into identifying modifiable risk factors. Although we think that certain characteristics of vascular surgery (advanced imaging, expanding endovascular and open surgical treatment options, high-acuity patient population, comprehensive care, interventions that dramatically improve quality of life) motivate trainees to enter this field, a future survey will be required to answer this question. The survey was not comprehensive. It was intentionally designed to be concise, to minimally deter participation by busy trainees, and to identify areas for future study.
CONCLUSIONS
Results of the APDVS training survey characterize the current vascular trainee population, composed of both fellows and integrated residents. Training programs may consider the opportunity to develop more structured academic development time, as most trainees express a desire to incorporate academics into their career. Whereas distress is prevalent among vascular trainees and increases with age and with the presence of an advanced degree (in addition to doctor of medicine), the majority of trainees report satisfaction with their training program. Furthermore, there is a growing interest broadly in surgery to enhance psychological well-being and performance among surgical trainees. Further studies to hone in on modifiable risk factors will be necessary to enhance such programs in successfully combating distress and preserving the satisfaction and effectiveness of our future vascular workforce.
Supplementary Material
ARTICLE HIGHLIGHTS.
Type of Research: Multicenter survey collected by the Association of Program Directors in Vascular Surgery
Key Findings: The majority of vascular trainees express a desire to pursue academics, whereas only a third of respondents describe protected academic development time. Although >60% of trainees experience distress on a weekly basis while in training, >90% of trainees are satisfied with their training program.
Take Home Message: These survey results demonstrate high satisfaction with vascular surgery training while highlighting areas for growth and improvement in training programs to better meet the needs of their trainees.
Acknowledgments
K.E.H. is supported by NIH grant 1F32HL137292.
Footnotes
Presented in the Plenary Session of the 2018 Vascular Annual Meeting of the Society for Vascular Surgery, Boston, Mass, June 20–23, 2018.
Additional material for this article may be found online at www.jvascsurg.org.
The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest.
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