Analysis of the Current Applicant Pool to Vascular Surgery: Who Are They and Where Do They Come From?

Addressing Barriers to Entry and Retention of Women in Interventional Vascular Specialties With Proposed Solutions: A Scientific Statement From the American Heart Association

Representation of women in interventional vascular fields (interventional cardiology, interventional radiology, and vascular surgery) lags behind that in other specialties. With women representing half of all medical school graduates, encouraging parity of women in these fields needs to start in medical school. Barriers to pursuing careers in vascular intervention include insufficient exposure during core clerkships, early mentorship, visibility of women in the field, length of training, lifestyle considerations, work culture and environment, and concerns about radiation exposure. This scientific statement highlights potential solutions for both the real and perceived barriers that women may face in pursuing careers in vascular intervention, including streamlining of training (as both interventional radiology and vascular surgery have done with a resultant increase in percentage of women trainees), standardization of institutional promotion of women in leadership, and professional and industry partnerships for the retention and advancement of women.

Recruitment & Retainment of Vascular Surgeons: Prophylactic measures to improve the current workforce crisis

BACKGROUND

The vascular surgery workforce is in jeopardy with current and increasing shortages. This study explores target populations for recruitment and aims to identify potential modifiable and nonmodifiable risk factors associated with reduced job satisfaction among practicing vascular surgeons to improve retention and prevent early retirement.

MATERIALS AND METHODS

A cross-sectional national survey of surgeons (n=1043) was conducted from September 2016 to May 2017. Data included demographic and occupational characteristics, as well as psychological, work-life balance, work-environment, and job-satisfaction variables. Surgeons were grouped into general surgery (n=507), obstetrics and gynecology (n=272), surgical subspecialties (n=212), and vascular surgery (n=52). Vascular surgeons were recategorized as more satisfied and less satisfied, and potential risk factors for job dissatisfaction were identified.

RESULTS

As compared with general surgeons, obstetrics and gynecology, as well as other surgical subspecialties, vascular surgery tended to be male-dominated with higher rates of non-white, minority groups (p<0.05). Less vascular surgery respondents were found in the Midwest (p<0.001). Vascular surgeons worked more hours on average than other surgical fields and were less satisfied with work (p<0.05). Potential job dissatisfaction risk factors among vascular surgeons include: unhealthy work-life balance, poor camaraderie/coworker dissatisfaction, insufficient hospital support, hostile hospital culture, discontent with supervision, minimal patient diversity, dissatisfaction with work in general, and unhappiness with career choice (p<0.05).

CONCLUSIONS

Recruiting new vascular surgery trainees while simultaneously preventing early retirement and attrition is critical to combatting the current workforce crisis. Potential interventions include (1) re-branding of the field with prioritization of work-life balance, (2) increasing hospital administration's support, (3) creating a collaborative work environment, and (4) facilitating personal accomplishment in work.

The Changing Demographics of Surgical Trainees in General and Vascular Surgery: National Trends over the Past Decade

OBJECTIVE

Recent initiatives have targeted the issue of gender and ethnic/racial disparities in general surgery and vascular surgery. However, the prevalence of these disparities in general and vascular surgical training programs is unknown.

DESIGN

A retrospective analysis was conducted using data from three separate sources, including the US Graduate Medical Education annual report, Electronic Residency Application Service database, and National Resident Matching Program annual report. Demographic information regarding gender distribution and ethnic/racial identity was collected from 328 general surgery residency programs, 59 vascular surgery residency programs, and 100 vascular surgery fellowship programs across the US. The primary outcomes of this study were to evaluate national trends in gender and ethnic diversity in general surgery and vascular surgery training programs, including both traditional fellowship and integrated residency paradigms.

RESULTS

From 2011-2020, general surgery residency programs showed a positive trend towards both female applicants (from 31.9%-41.5%) and trainees (from 36.2%-43.1%) (p < 0.0001 each). The proportion of minority trainees decreased, primarily among Black (from 7.2%-5.4%) and Asian trainees (from 21.5%-19.2%) (p < 0.0001 each). Concurrently, the number of vascular integrated residency programs grew from 27 to 59, resulting in a fivefold increase in trainees (from 64-335). Despite this growth, there was no change in the proportion of women applicants or trainees for both vascular integrated residency (24.9% applicants; 36.2% trainees) and fellowship programs (27.4% applicants; 25.9% trainees) over the study period (p = 0.11, 0.89, 0.43, and 0.13 respectively). Moreover, there was no significant change in proportion of minority trainees in both vascular integrated residency and fellowship programs.

CONCLUSION

While general surgery programs have expanded in proportion of both female applicants and trainees, racial diversity has decreased. Gender and racial diversity in vascular training has not changed. Future initiatives in general and vascular surgery should focus on recruitment and promotion of proficient women and minority trainees.

Normalized Competitive Index: Analyzing Trends in Surgical Fellowship Training Over the Past Decade (2009-2018)

OBJECTIVE

There is a lack of literature describing how competitive surgical fellowships are, especially across specialties. Such information would be valuable to prospective candidates, especially as immediate postresidency subspecialty training becomes the norm for general surgery. Match-rates alone may be misleading indicators as programs may not fill positions with unqualified applicants. We propose a simple metric to analyze the competitiveness of various surgical subspecialties to each other and themselves over time.

DESIGN

Retrospective cohort study. The Competitive Index is defined as the percentage of filled programs within each specialty divided by the match-rate for that specialty. For ease of comparison, a Normalized Competitive Index (NCI) was developed, normalizing the metric for all specialties in that year to a value of 1.

SETTING

The National Resident Matching Program, The Fellowship Council, and the San Francisco Match publicly available match data from 2009 to 2018.

PARTICIPANTS

General Surgery Associated Fellowship Applicants (Abdominal Transplant, Colorectal, Surgical Oncology, Minimally Invasive Surgery, Pediatric, Plastic, Critical Care, Thoracic, and Vascular).

RESULTS

The overall match rate for all specialties was 74.6% and 84.0% of all programs were filled. Over the past decade, pediatric surgery was significantly more competitive than other specialties (NCI 1.67, p < 0.0001), while surgical critical care (NCI 0.58, p < 0.0001) and vascular (NCI 0.90, p < 0.0492) were significantly less competitive. When comparing the NCI within each specialty from the first 5 years (2009-2013) to the last 5 years, (2014-2018), surgical critical care (NCI 0.54 vs. 0.62, p = 0.0462) and thoracic (NCI 0.74 vs. 1.08, p=0.0025) became significantly more competitive, while transplant (NCI 1.10 vs. 0.92, p = 0.0343) and colorectal (NCI 1.32 vs. 1.09, p = 0.0021) became significantly less competitive.

CONCLUSION

The NCI is a metric which might be useful to prospective applicants and which could be provided annually by organizations sponsoring fellowship matching processes. Further research must be performed to establish what defines a qualified applicant in each specialty.

Vascular surgery: What increases the flow of students to the speciality?

OBJECTIVES

Vascular surgery is in increasing demand due to the higher prevalence of cardiovascular disease in the general population. Meanwhile, applications to join the speciality have been in decline in the last few years. St George's Surgical Society held a one-day conference to expose undergraduates to the speciality in the hope that this will inspire more undergraduates to pursue it as a career.

METHODS

The conference consisted of introductory lectures delivered by a consultant vascular surgeon, followed by practical skills workshops simulating aortic anastomosis on porcine aortas. Pre-course and post-course questionnaires assessed positive and negative perceptions of vascular surgery, knowledge of and self-reported confidence in practical surgical skills and utility of the course in their decision to potentially pursue a career in vascular surgery.

RESULTS

There was a significant increase of 27% ( p = 0.03) in the positive perception that vascular surgery includes a diverse range of procedures and subspecialties. Attendees reported a 27% significant increase ( p = 0.02) in the perception that vascular surgery had a wide array of opportunity for academic/research work. Finally, there was an 18% decrease ( p = 0.03) in the negative perception that vascular surgery is somehow female-unfriendly or discriminatory against females. There was also a significant rise in both interest (33%) and understanding (73%) of vascular surgery.

CONCLUSIONS

A one-day conference can significantly impact students' perception especially when there is a lack of exposure within the undergraduate curriculum. This course helped to increase positive perception and dispute negative misconceptions about the speciality. The simulation workshops held at this conference increased students' confidence and awareness of relevant surgical skills. This conference provided a unique experience that positively impacted and inspired students and thus served as an important supplement to core medical curriculum.

Impact of Integrated Vascular Residencies on Academic Productivity within Vascular Surgery Divisions

BACKGROUND

Changing training paradigms in vascular surgery have been introduced to reduce overall training time. Herein, we sought to examine how shortened training for vascular surgeons may have influenced overall divisional academic productivity.

METHODS

Faculty from the top 55 surgery departments were identified according to National Institutes of Health (NIH) funding. Academic metrics of 315 vascular surgery, 1,132 general surgery, and 2,403 other surgical specialties faculty were examined using institutional Web sites, Scopus, and NIH Research Portfolio Online Reporting Tools from September 1, 2014, to January 31, 2015. Individual-level and aggregate numbers of publications, citations, and NIH funding were determined.

RESULTS

The mean size of the vascular divisions was 5 faculty. There was no correlation between department size and academic productivity of individual faculty members (R² = 0.68, P = 0.2). Overall percentage of vascular surgery faculty with current or former NIH funding was 20%, of which 10.8% had major NIH grants (R01/U01/P01). Vascular surgery faculty associated with integrated vascular training programs demonstrated significantly greater academic productivity. Publications and citations were higher for vascular surgery faculty from institutions with both integrated and traditional training programs (48 of 1,051) compared to those from programs with integrated training alone (37 of 485) or traditional fellowships alone (26 of 439; P < 0.05).

CONCLUSIONS

In this retrospective examination, academic productivity was improved within vascular surgery divisions with integrated training programs or both program types. These data suggest that the earlier specialization of integrated residencies in addition to increasing dedicated vascular training time may actually help promote research within the field of vascular surgery.

Endovascular training of vascular surgeons in the USA

Current trends in vascular surgery in the USA are driven by increased demand for endovascular procedures. Traditionally-trained vascular surgeons have adapted to these trends by acquiring endovascular skills; vascular surgery fellowships were standardized to 2-years to incorporate endovascular training. However, the traditional "5 + 2" training paradigm appears to be less appealing to the current generation of surgical students, resulting in fellowship positions going unfilled, and potentially predicting a shortage of vascular surgeons. Recognition of this trend has led to the adoption of alternative training pathways, in particular the integrated "0 + 5" pathway, to supplement the traditional "5 + 2" independent pathway. The integrated pathway has several perceived advantages for vascular surgery trainees including early teaching of endovascular skills. However, it has challenges that include maintaining open operative skills and changing strategies to attract candidates from among the pool of medical students instead of the pool of general surgery residents. Simulators, both open and endovascular, are playing an increasingly important role in training programs as well as for outreach programs to medical students. Recruitment strategies for future generations of vascular surgeons in the USA may need to consider residents' lifestyle preferences as well as outreach to traditionally underrepresented groups such as women and minorities.

The relative influence of available resources during the residency match: a national survey of canadian medical students

BACKGROUND

Many medical students find choosing a residency challenging. There are several steps involved, including determining one's own priorities, arranging electives, choosing a training program and site, and preparing an in-depth application and a rank order list. Many resources are available to assist students, including the Canadian Resident Matching Service website, program websites, career counselors, career information sessions, mentors, peers, family/friends, and the Canadian Medical Residency Guide. Our study explored the relative impact of these resources on the career decision-making process.

METHOD

We invited medical students in their final year at 12 Canadian medical schools to complete an online survey. Questions included identifying the relative utility of resources in the context of each component of the decision-making process. Responses were analyzed using descriptive statistics.

RESULTS

The response rate was 71% (1076 of 1518). Overall, mentors, family/friends, and peers had the most impact on students' decision making. Career counselors, websites, and the Canadian Medical Residency Guide had much less impact. Family/friends were most frequently cited as essential to the process; however, family/friends and peers were equal in having some impact.

CONCLUSIONS

Our findings suggest that students are most influenced by family, friends, and peers, who are not involved in the formal residency selection effort. Appreciating the impact of these influences on students' decision making is important to understanding how they decide on their future careers. The study supports continuation of mentorship programs. Future work could focus on qualitative research to further characterize resource use.

Trends in research time, fellowship training, and practice patterns among general surgery graduates

SUMMARY

A comparison of research experience, fellowship training, and ultimate practice patterns of general surgery graduates at a university-based surgical residency program. Research experience correlated with pursuing fellowship training and predicted an eventual academic career. More recently, graduates have been able to obtain fellowships without a dedicated research year, perhaps reflecting shifting fellowship training opportunities.

BACKGROUND

We hypothesized that the relationships among dedicated research experience during residency, fellowship training, and career choices is changing as research and fellowship opportunities evolve.

METHODS

Comparison of research experience, fellowship training, and ultimate practice patterns of general surgery graduates for 2 decades (1990-1999, n = 82; 2000-2009, n = 98) at a university-based residency program. Main outcome measures were number of years and area of research, fellowship training, and practice setting.

RESULTS

Compared by decade, graduates became increasingly fellowship-trained (51.2% vs 67.3%; p < 0.05) and pursuit of fellowship training increased for both research and nonresearch participating graduates. The number of residents completing more than 1 year of research doubled (9.8% vs 22.4%, p < 0.05). By decade, the percentage of female graduates increased significantly (22% vs 41%, p = 0.005), with more women participating in dedicated research (17% vs 51%, p < 0.001) and seeking fellowships. The number of graduates going into specialty practice and academic/clinical faculty positions increased over time.

CONCLUSIONS

Surgical residents have completed more dedicated research years and became increasingly fellowship-trained over time. The proportion of female graduates has increased with similar increases in research time and fellowship training in this subgroup. In the earlier decade, dedicated research experiences during surgical residency correlated with pursuing fellowship training, and predicted an eventual academic career. More recently, graduates have obtained fellowships and academic positions without dedicated research time, perhaps reflecting shifting fellowship opportunities.