American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

YFA Member Highlights

Keep the Wheels Turning: The Vascular Surgery Training Conundrum

Rafael D. Malgor, MD, FACSRafael D. Malgor, MD, FACS, Vascular Surgeon and Surgical Educator

I started my surgical training life more than 15 years ago, and my real passion for vascular surgery flourished during my two-year independent vascular surgery fellowship back home in Brazil. Moving to the United States to do research at the Mayo Clinic and train all over again in order to practice in the U.S. was not an easy decision. When I landed here, I remember talking about career development with one of my mentors, fellow Brazilian and, today, chief of vascular surgery at UT Houston, Dr. Gustavo Oderich. He told me that a new path to board certification in vascular surgery was now available, and it could take me as few as five years to become board-eligible in vascular surgery. Following his advice, I decided to apply for vascular surgery integrated residency. At the same time, I applied for general surgery residency out of skepticism and the uncertainty that permeated the new training paradigm.

Back in 2008, there were fewer than 15 programs offering this new training pathway and fewer than 20 spots available in the entire U.S. I was fortunate enough to match with Stonybrook University, which was one of the pioneering integrated vascular programs in the nation. A mix of happiness and uncertainty did hit me hard when I saw the match results. The vascular surgery integrated residency was a recent development, which was labeled as “experimental” by many general surgeons and dual board-certified general and vascular surgeons. The idea of not having as much exposure to abdominal cases was daunting. General surgery case assignments were expected to benefit the general surgery residents, who had a required number of major cases to be gathered to graduate. Over the past 15 years, none of these concerns turned out to be a determinant of the newly graduated vascular residents’ success in practice.

Today, there are 75 vascular surgery integrated residencies with more than 90 spots being offered every year for those graduating from medical school. More than 100 vascular surgeons trained in this paradigm have been practicing and helping to close the gap between a large shortage of vascular surgeons and the demand for vascular surgeons in the U.S. The vascular residents’ competency is attested by their program directors who now have five years to ensure adequate training as opposed to two years in the independent fellowship path.

All fine and good seeing the great success of vascular surgery residencies, but a word of caution must be voiced about the much slower increase rate in the number of independent vascular surgery fellowships compared with residencies. According to the ACGME Data Resource Book, in the 2007–2008 biennium, there were 96 accredited two-year independent fellowships and six integrated (0+5) residencies. In the 2017–2018 biennium, there were 109 accredited two-year independent fellowships and 60 integrated residencies, which represents a 13 percent versus 1,000 percent increase for both training paradigms.

Some traditional university-based programs, such as the University of Massachusetts, no longer have an independent vascular fellowship and others, such as the Mayo Clinic, have decreased the number of fellowship spots available to general surgery residents in order to accommodate integrated residents. It is clear that the landscape of vascular surgery training in the U.S. is changing fast, which is salutary to attend to the needs of our aging population. There is no question both vascular surgery training pathways are solid and graduate competent vascular surgeons. However, the explosive growth of vascular surgery integrated residencies and a slow-pace growth of independent fellowships must be discussed. Our ultimate goal must be to achieve an ideal balance between the two training paradigms in order to motivate, and to keep reasonable vascular surgery training options open to general surgery residents while responding to the shortage of vascular surgeons nationwide by condensing vascular surgery training.

Rafael D. Malgor, MD, FACS, is an associate professor of surgery and the two-year independent vascular surgery fellowship program director at the University of Colorado in Aurora, CO. He has been a firm advocate of keeping both vascular surgery integrated and independent fellowships in great balance to allow decisions to be made at different times of one’s professional life.

My Life as a Commission on Cancer State Chair

Ingrid M. Lizarraga, MBBS, FACSIngrid M. Lizarraga, MBBS, FACS, Clinical Associate Professor, Department of Surgery, University of Iowa Hospitals and Clinics

Truth be told, I had never heard of the Commission on Cancer prior to completing my breast surgery fellowship, despite having spent the previous five years in practice as a busy rural community general surgeon. I have since found that this is not an unusual situation. Although the 100-year-old American College of Surgeons-led quality program accredits more than 1,500 cancer programs treating more than 70 percent of all cancer patients in the U.S. and Puerto Rico, many surgeons not involved in cancer center administration are only peripherally aware of its significance.

I was introduced to the program when I was asked to become the Cancer Liaison Physician for my institution, a role that required me to examine our institutional performance data, compare it with national data and quality metrics, and determine where improvements could be made. This role is challenging. It requires you to be a detective, analyst, diplomat, and advocate all in one as you translate the patterns you see in the data into actionable findings to present to the leadership of your cancer center.

Three years later I was nominated to become the State Chair for Iowa. In that capacity, I was responsible for providing support to all the other CLPs in the state. State Chairs are also encouraged to help cancer programs in their state with accreditation issues, collaborate with other state chairs to develop CLP resources, and work with state cancer control programs on policy and advocacy. It is tremendously satisfying work, particularly in a rural state like mine. I strongly believe that a woman should not have to travel 50 miles to see me at the University of Iowa to receive high-quality care for her breast cancer, and I believe that CoC accreditation helps cancer centers of any size deliver consistently high standards of care. There are unique challenges that smaller rural hospitals face in maintaining and achieving accreditation, and I am proud to be able to support and advocate for these institutions as they work to do right by their patients. I also enjoy how my role allows me to engage with both general and subspecialist surgeons in every type of practice both within my state and nationally, since the CoC has a strong representation from both academic and community surgeons. I strongly encourage young fellows to consider becoming involved with the CoC, even (especially!) if cancer makes up only part of their practice.