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Change Doesn’t Come Easy! But It Is Needed

In selecting the subject of his presidential address, SVS President Michel Makaroun, MD, decided to focus on the inadequacy of vascular manpower to meet the demands and needs of the public.  

He quoted a favorite saying from Mark Twain that gave him the topic of his address, “I am in favor of progress; it’s change I don’t like.” He then proceeded to outline why changes are necessary and what the Society for Vascular Surgery is doing to help implement them.

“You are all familiar with the highlights of the problem: It is in our numbers! A problem with multiple facets, including unfilled jobs, increasing demand, maldistribution, and a demographic cliff of our membership,” Dr. Makaroun said.

The manifestations of this shortage are multiple. The number of advertised jobs far exceeds the number of graduates. There is also a significant maldistribution of the workforce. “We are concentrated in the northeast, and many populous states including Texas, Florida, and California are well below average,” he said.

Additionally, many community hospitals, in both suburban areas or small towns completely lack any access to vascular surgical care, even in states with seemingly adequate numbers.

The shortage problem in vascular surgery will get worse before it gets better, he added, saying “Our pipeline is simply not large enough to overcome an older retiring generation of vascular surgeons, with nearly half retiring before 65.”

“Change does not come easy!” Dr. Makaroun warned.

“We cannot ignore in the discussion of workforce issues, the major shifts, change, and uncertainty we are experiencing in health care delivery, education, and the generational change of our newest members,” he said.

More than 10% of vascular surgeons now practice primarily if not exclusively in ambulatory facilities. This direction is gathering steam and reduces the pool of vascular surgeons available to accept hospital practices and cover emergencies, particularly in underserved communities. “The most pressing concern is the inability of our specialty to provide vascular surgery services to the multitude of hospitals located in smaller communities.

“The SVS established a task force to study our manpower issues last fall. The taskforce was divided into three workgroups to focus on different areas of the problem," he said.

The first workgroup, under the leadership of Malachi Sheehan III, MD, and Jeffrey Jim, MD, focused on the obvious solution: a campaign to increase training programs and available positions. Unfortunately, this is only aspirational, since reality fails the SVS in this effort. The pool of general surgery graduates is finite, with competition from several specialties that are more analogous to modern general surgery than vascular surgery.

Increasing the number of integrated programs is less efficient because of a 5- to 6-year lag between initiation of a new program and graduation, but it can tap into an almost unlimited pool of applicants from medical school, and more recently some very qualified international medical graduates. This makes it potentially a far more effective solution for the long term, Dr. Makaroun said.

The workgroup attempted to contact all hospitals with a general surgery program and no associated vascular fellowship. Help in navigating the process of securing financing and applying for a new program was offered. A session was conducted at VAM for interested potential sites to start discussing the process, and representatives from 27 hospitals were there expressing interest.

The second workgroup, under the leadership of Rick Powell, MD, and Andy Schanzer, MD, was tasked with analyzing the entire spectrum of surgeons’ clinical activities and producing a valuation study that illustrates the economic and vital impact of vascular surgery for hospitals and patients. “The work of this group is essential to promote a healthier relationship between our specialty and our institutions, making vascular surgery more attractive for future recruits,” he said.

The third workgroup under the leadership of Will Jordan, MD, and Tim Sarac, MD, had the toughest job, said Dr. Makaroun. It was tasked with thinking outside the box and suggesting methods to address the most glaring need: the community hospitals, where most of the advertised jobs are, jobs that are being shunned by graduates of current training programs.

Dr. Makaroun cited the difficulties of recruitment of vascular surgeons to community hospital systems in small towns and rural areas, and he reminded people that recent general surgery graduates continue to offer vascular surgery services in such communities. Unfortunately, this is without any additional vascular training and most hospitals grant privileges without a VSB certificate when the need is demonstrated. “You all appreciate that recent graduates of general surgery programs do not have the breadth or depth of exposure to modern vascular surgery that an older generation did,” he added.

The workgroup explored many options to provide relief to community hospitals. But probably the most efficient, according to Dr. Makaroun, is to consider strategies that tap into new constituencies. One consideration to be explored is to offer a 3-year vascular surgery training opportunity to the dozens of qualified candidates in preliminary surgical positions unable to locate a categorical spot to finish their training. This process will lead to VSB certification, but will take some time to establish through the ACGME structure.

The workgroup developed an outline of a proposal for a community vascular surgery training program, as a first step. It has been sketched and will be part of the task force report submitted for review by the Executive Board of the Society.

The goals of the new pathway would be to improve local vascular care in underserved communities, while increasing the referral of appropriate cases to vascular centers. It would provide stress relief to isolated vascular surgeons, and where none exist, plant the seeds of a better work environment for vascular surgery graduates to reconsider this currently undesirable career choice.

The program is designed to offer an additional year of vascular surgery training to general surgery graduates already committed to a community practice, many of whom are already planning to offer vascular services anyway. The program will individualize training but focus only on low-complexity procedures, both open and endovascular, and more importantly the clinical situations that dictate referral, said Dr. Makaroun.

To maintain quality, the program will mandate the availability of mentorship, support, and real-time advice after completion of the program, through a regional “sponsoring vascular surgery service.” This service will also be responsible for retrospective peer review and root cause analysis of complications. In addition, the association with a sponsoring institution will facilitate and increase referrals of appropriate patients to higher level of care at a vascular surgery center.

“The suggested program graduates will not be board certified and will be performing mostly general surgery and low-complexity vascular cases part time in smaller communities. They will also require supervision by the board-certified graduates of the current training pathways, working in a regional vascular center, typically in a larger urban center. Instead of competing, they will actually complement our current trainees and provide an extension of their reach.” he stated.

“We must find a way to fill the vacuum now before the reality on the ground permanently excludes our specialty from this primary level of vascular care,” Dr. Makaroun said. “It is time for another bold step to preserve the legacy of our specialty in meeting the needs of our patients and the public.

“Progress is made through change even if we don’t like it!” Dr. Makaroun concluded.