Integrated fellowship in vascular surgery and intervention radiology: A new paradigm in vascular training

The rapid development of endovascular techniques has had a significant impact on both the diagnosis and treatment of vascular disease as many less invasive and safer treatment modalities have evolved. Although the long-term durability of many of these procedures remains to be established, it is estimated that in the near future 40% to 70% of vascular interventions will be endovascular procedures. These changes have provided many challenges as well as sources of conflict between the various subspecialties involved in the care of patients with vascular disease. One of the most contentious issues relates to the lack of uniform credentialing criteria for the performance of endovascular procedures. Linked to this issue is the recognition of the need to modify the training programs most closely focused on vascular disease, vascular surgery and interventional radiology, in order to maintain pace with the rapid development of endovascular technology. 1 Standards to perform endovascular procedures have been published by many societies (Table 1). 2–7 Currently, many patients undergo endovascular procedures performed by physicians who have wide variances in their training and outcomes. These standards for endovascular training differ substantially. For example, cardiology has tiered categories of competency. In one category, an interventional cardiologist may perform renal or iliac artery interventions after only three proctored cases. 2 Of particular concern are “mini-fellowships” in endovascular techniques, which generally last less than 3 months and are clearly inadequate for training physicians with limited prior experience. Absent from any of these published standards is consideration of the cognitive components of the diagnosis and management of patients undergoing endovascular procedures. These cognitive components include knowledge of the physiology, anatomy, pathology, and natural history of specific vascular diseases, as well as the development of the clinical skills required to manage these patients. 7 Table 1. CRENDENTIALING STANDARDS The mission statement of the American Board of Medical Specialties states, “The intent of certification of physicians is to provide assurance to the public that the physician or specialist certified by a Board Member of the American Board of Medical Specialties has successfully completed an approved educational program and evaluation process which includes an examination designed to assess the knowledge, skills, and experience to provide quality patient care in that specialty.”2 Thirty years ago, vascular surgery itself faced a similar dilemma with the rapid development of open surgical techniques to treat vascular disease but inadequate training programs to teach both clinical and surgical skills specific to vascular disease. This resulted in surgeons with nonstandardized and often inadequate training who were performing complex vascular procedures. This controversy was addressed by the now-landmark presidential address of Edwin J. Wylie, MD, to the International Cardiovascular Society, entitled “Vascular Surgery: A Quest for Excellence.”8 The Wylie plan outlined the need for the development of post-residency training programs in vascular surgery whose curriculum and function were developed by the American Board of Surgery. Clearly there is a need to modify the training of vascular surgeons and interventional radiologists to meet the challenges created by the increasing proportion of patients who will undergo endovascular procedures. Vascular surgeons must be fully proficient in endovascular techniques and interventional radiologists require broad clinical training in order to adequately and safely apply these new endovascular techniques. Accordingly, there is a need to develop training programs that bridge traditional disciplines in order to adequately train the physicians who treat vascular disease. In response to this need, we initiated an integrated fellowship in vascular surgery and interventional radiology in 1999. The purpose of this report is to provide a 3-year interim analysis of this new training program. To evaluate the results of the integrated training program, we analyzed the procedures performed during the integrated fellowship, and we surveyed the attitudes of vascular surgery and interventional radiology faculty and fellows toward this new integrated fellowship.