Ensuring vascular surgical training is on the
Erica L. Mitchell, MD,aSonal Arora, MD,band Gregory L. Moneta, MD,aPortland, Ore; and London,
Approval of the primary certificate in vascular surgery eliminated the requirement for certification in general surgery
before vascular surgery certification. New training paradigms for training in vascular surgery have emerged driven by the
desire to offer greater flexibility of training and to shorten the length of training. Many of these changes are based upon
“expert opinion,” promise, and “logic” without objective evaluation of the residents or the training programs themselves.
To be on the forefront of surgical education, vascular surgery will need to adopt methods of curriculum development
firmly grounded in educational principles and use modern assessment tools for the evaluation of competence and
performance. This report presents the evolution and challenges to the current vascular surgical training model and then
argues for a more rigorous and scientific approach to training in vascular surgery. It presents an analysis of potential
avenues for placing education and training in vascular surgery on the forefront of modern surgical education. (J Vasc
New training paradigms in vascular surgery have
evolved since the American Board of Medical Specialties’
(ABMS) approval of a primary certificate in vascular surgery
in 2005, which eliminated the need for prior certification in
general surgery. These new training pathways were primar-
ily developed to improve the efficiency of vascular surgical
training and to make it more attractive to residents and
medical students. However, although these newer ap-
proaches offer greater flexibility and have shortened the
overall length of training, they have been developed largely
based on “expert opinion” and “logic” without objective
At the same time, medical education is moving in the
opposite direction into an outcomes-based era with an
objective and scientific approach to program development
and assessment. Surgical training is now also entering this
new phase heavily influenced by educators trained in edu-
cational theory and objective assessment of resident and
program performance. To remain on the forefront of sur-
gical education, vascular surgery will also need to move in
this direction of rigorous curriculum development, quanti-
tative assessment of vascular resident performance, and
objective evaluation of the effectiveness of new and tradi-
tional vascular surgical training pathways. This report illus-
trates the challenges with the current vascular surgical
training models and develops an argument for a more
scientific and quantitative approach to vascular surgical
training followed by an analysis of potential methods for
placing education and training in vascular surgery on the
forefront of modern surgical education.
Evolution of vascular training programs. Over the
last 40 years, vascular surgery has evolved into a de juro
independent specialty with a defined large patient base, a
large body of specialty specific knowledge, and highly tech-
nical open and catheter-based procedures. Vascular surgery
was long regarded as a core component of general surgery
and, before 1982, there were no specific training programs
solely dedicated to teaching vascular surgery.1Vascular
surgery was performed primarily by general and cardiotho-
racic surgeons as part of a more global practice.
Although one of the primary purposes for the establish-
ment of the Society for Vascular Surgery®(SVS) in 1947
was “to encourage hospitals to develop special training for
young surgeons in the field”; organized training beyond
the core 5 years of general surgery training did not come
until many years later.2In the late 1960s, E. Jack Wiley
demonstrated that vascular surgery outcomes were im-
proved if the surgeon’s practice was confined to vascular
surgery. Dr Wiley called for the establishment of formal
residencies in vascular surgery in his 1970 presidential
address “A Quest for Excellence” addressed to the North
American Chapter of the International Cardiovascular So-
ciety.3After this, a report from the Committee on Vascular
Surgery of the Inter-Society Commission of Heart Disease
From the Division of Vascular Surgery, OP11, VirtuOHSU Surgical Simu-
lation Center, Oregon Health & Science University;aand Department of
Surgery and Cancer, Imperial College London, St. Mary’s Hospital,
Competition of interest: none.
Reprint requests: Erica L. Mitchell, MD, Division of Vascular Surgery,
OP11, Oregon Health & Science Center, 3181 SW Sam Jackson Park Rd,
Portland, OR 97239 (e-mail: email@example.com).
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 competition of interest.
Copyright © 2011 by the Society for Vascular Surgery.
Resources outlined the essentials of a vascular surgery pro-
gram which acted as the foundation for establishment of
formal residencies in vascular surgery.4,5
During the next several years, leaders in vascular sur-
gery spearheaded efforts to approve vascular surgery as a
specialty in itself and prepared guidelines for “the essentials
of training programs in vascular surgery.”1In 1972, they
petitioned for the establishment of a certificate of “Special
Competence in Vascular Surgery,” but these guidelines were
only approved by the American Board of Surgery (ABS) and
American College of Surgeons in 1982. During the interim,
ing minimum standards of training in vascular surgery
Committee” group.6Final approval by all regulatory groups,
including the ABMS, resulted in the approval of the initial 17
vascular surgery residency programs.
Evolution of a specialty. Initially, vascular surgery
training consisted of 1 year of clinical training after com-
pletion of an Accreditation Council for Graduate Medical
Education (ACGME) accredited general surgery residency
(5?1). Many programs added a year of research and, by the
late 1980s to early 1990s, most vascular training programs
in the United States were 2 years in length; 1 year of
research and 1 clinical year. With an increased emphasis on
catheter-based techniques, it became obvious that training
in vascular surgery would require 2 clinical years; this was
mandated by the Residency Review Committee for Surgery
(RRC-S) in 2004, establishing vascular surgery as one of
the longest training programs.7,8More focused and per-
haps more efficient training paradigms beyond the tradi-
tional 5?2 program were subsequently advocated.9In
2003, the Early Specialization Program 4?2 was approved
and trainees could enter vascular surgery residency after a
condensed 4-year residency in general surgery. Recruit-
ment to vascular surgery, however, remained low.
For major changes in vascular surgical training to oc-
cur, more control of training by vascular surgeons was
needed. The primary certificate was approved by the ABMS
and ABS on March 17, 2005, and by the Accreditation
Council for Continuing Medical Education on July 1,
2006.10The primary certificate has eliminated the prereq-
uisite to complete a general surgery residency before vascu-
lar training. A new integrated training pathway (0?5) has
emerged and trainees can enter vascular surgical residency
directly from medical school.11Graduates from this pro-
gram are eligible for certification in vascular surgery only
(Fig 1). Currently, 24 programs offer integrated 0?5 vas-
cular training and the number is growing.12
Current regulatory oversight of vascular surgical
education. There are many stakeholders involved in train-
ing the next generation of vascular surgeons. These are
The Vascular Surgery Board-American Board of
Surgery. The Vascular Surgery Board-American Board of
Surgery (VSB-ABS) certifies individuals in vascular surgery.
Board certification is voluntary and hospital privileges are
the function of the individual hospital credentialing com-
mittees.11For the 5?2 and 4?2 tracks, certification can be
achieved in both general and vascular surgery (Fig 1).
However, candidates can choose not to certify in general
surgery and certify solely in vascular surgery. To be eligible
for the vascular surgery qualifying examination (QE) and
certifying examination (CE), candidates must pass the gen-
eral surgery qualifying examination (GS QE) if training was
completed before the primary certificate (2005-2006) or
either the GS QE or the surgical principles examination
(SPE) if training was completed after 2006. The SPE, a test
of core surgical knowledge, followed by the vascular sur-
gery QE and CE, is the only certification pathway for
residents training in a 0?5 track.11
The ABS is also responsible for the Vascular Surgery
In-Training Examination (VSITE) offered annually to res-
the certification process.
The Accreditation Council for Graduate Medical
Education and the Residency Review Committee for
Surgery. The ACGME through the RRC-S certifies resi-
dencies are discharging their educational responsibilities
successfully. The Residency Review Committee (RRC)
years. RRC program requirements are detailed and encom-
pass program curriculum, work environment, work hour
Fig 1. The current pathways for postgraduate education in vascular surgery and associated American Board of Surgery
examinations required for certification. The Traditional (5?2) and Early Specialization Program (4?2) can lead to
certification in both general and vascular surgery. The Integrated (0?5) pathway allows for certification in vascular
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Robert S. Rhodes, MD, Philadelphia, Pa
Dr Mitchell and her colleagues review the evolution of
vascular surgery training and raise concerns as to whether the
recent advent of integrated (0?5) residency programs will
produce vascular surgeons comparably competent to those that
complete independent (5?2) programs. The authors ascribe the
advent of the 0?5 paradigm to the desire to offer greater
flexibility in the framework of shorter training. Although unar-
guably true, perhaps a more important factor was the progres-
sive applicability of endovascular techniques and a correspond-
ing decrease in open surgery. This change raised questions
about the value of senior level non-vascular surgery experiences
during (general) surgery residency vs the time needed for
adequate exposure to the broadening therapeutic options that
characterize vascular surgery.
The authors’ specific concern about the new pathway is that
it lacks objective evaluation of the residents or the training
programs, particularly relative to the traditional 5?2 approach.
Yet a further analysis using Miller’s pyramid (their Fig 2) as a
framework, suggests that both pathways, and many other spe-
cialties programs, have similar deficiencies; valid, objective mea-
sures exist for some competencies but not for many others.
Specifically, the bottom tier of the pyramid, Knows, can be
measured with multiple-choice examinations that have estab-
lished psychometric validity and reliability. Although graduates
of 0?5 programs will not be admissible to the Vascular Surgery
Qualifying Examination until after the first cohort of trainees
complete their training in 2012, trainees from both pathways
have taken the Vascular Surgery In-Training Examination each
of the past 3 years. On the 2010 Vascular Surgery In-Training
Examination, 5?2 trainees had a better overall performance
than level I and level II 0?5 trainees, but level III 0?5 trainees
had better a overall performance than level I or level II 5?2
trainees. Thus, by level III, 0?5 trainees seem to have made up
for any initial deficits in their fundamental knowledge of vascu-
JOURNAL OF VASCULAR SURGERY
Volume 53, Number 2