The explosion of therapeutic endovascular treatment options has also led to a need to tackle the issue of training in endovascular skills for the practitioners of the future. With the advent of laparoscopic surgery similar training issues were encountered, not least because endovascular surgery requires a different set of skills, not only technical but cognitive as well, when compared to open surgery (Neequaye et al, 2007). Indeed operating in a three dimensional field from a two dimensional view, altered haptics and emphasis on hand-fluro-eye co-ordination are all challenging skills to master. (Dessender et al 2011, Berger et al 2010).
Percutaneous coronary intervention completely transformed the treatment paradigm for cardio-thoracic disease. The impact on the cardiothoracic surgical specialty was profound due to a vastly reduced demand for open therapeutic surgery. Vascular surgeons are in a similar transitional phase as the modern specialty of vascular surgery continues to evolve. Vascular trainees must equip themselves with a skill set that will enable them to practice competently and confidently in both open and endovascular procedures. The endovascular surgeon is now a well-recognised and respected independent practitioner.
1.2.1 Training Challenges
Despite significant advances in various endovascular training techniques, surgical and interventional radiology trainees in England still rely on the somewhat outdated
apprenticeship model which was first introduced by William Halsted towards the end of the 19th century (Halsted 1904). The apprentice trainee learnt their trade from the consultant trainer, using real patients and with an emphasis on graded responsibility (Reznick et al 2006). The biggest challenge facing such a system is its subjective nature. Relying on trainers to select an appropriate case mix precludes any standardization and fails to meet any criteria to facilitate summative assessment (Ahmed et al, 2010).
Further challenges facing the current system of training in the UK include the medico-legal and ethical ramifications of training on patients, as well as issues of safety and cost. (Bridges et al, 1999).
The implementation of the European Working Time Directive (EWTD) has also hampered surgical training (Cairns et al. 2008). Trainees undergoing higher surgical training in the UK are now legally required to relinquish exposure to emergency and elective operating by a third in order to comply with the EWTD. Today’s trainees would take nine years to achieve the same level of operative experience as their counterparts achieved in just six, practising before the EWTD (Lamont et al 2005). Yet despite a reduction in clinical exposure there are no plans to extend the number of years of training to reach consultancy. Current trainees will have less experience than consultants from an earlier generation by the end of their training (Pandey et al, 2006).
Endovascular training itself faces several unique challenges; diagnostic angiography was previously the main training procedure for honing basic catheter and wire handing skills for the novice trainee. However the introduction and popularity of less invasive imaging techniques, such as duplex ultrasonography and magnetic resonance angiography, have seen diagnostic catheter angiography and its training opportunities diminish.
As the scope for endovascular therapy increases, due to the rapid innovation, evolution and refinement of technology, so too do therapeutic options for patients. Those previously unsuitable for open complex vascular procedures are
increasingly brought to the endovascular specialists’ table. A steadily ageing population present with ever more complex pathology. Such patients and their disease are less suitable for junior practitioners who require time and subsequently endovascular therapy tends to be a consultant led practice. Carotid Artery Stenting (CAS) is a prime example; a technically challenging procedure, performed by relatively few experts worldwide, with catastrophic consequences of technical error including disabling stroke and death (Van Herzeele (b) 2009). Subsequently training on patients is often inappropriate.
1.2.2 Endovascular Training Curricula
Over the past ten years UK general surgery has moved towards sub-specialisation. This shift has led to a climate where many generalists feel less competent to cover vascular emergencies. As early as 2004 the Vascular Society recommended centralising vascular services to higher volume centres and advocating specialist vascular surgeons to provide emergency cover for entire regions, or ‘networks’ of hospitals (Vascular Society 2004).
In response to the above challenges there has been a clear international trend towards independent certification in vascular surgery. Although many skills learnt in general surgical training are transferable, with ever increasing sub-specialisation these skills are less relevant to the modern day endovascular practitioner. Many of our European counterparts for example have formalised interventional radiology attachments and integrated simulator training courses within their professional curricula (Liapis 2009). Streamlined training programs and independent endovascular practice in high volume regional vascular centres is now widely agreed as the future for vascular and endovascular training.
The trend of limited training opportunities leads a ‘compelling argument against training vascular surgeons in the finer intricacies of breast or gastrointestinal surgery’ (Lamont et al, 2005). This is demonstrated by trainees in Denmark, who despite following a 40-45 hour working week, achieve, through targeted vascular
fellowships, trainee numbers of aortic aneurysm repair and infra-inguinal bypass, far in excess of those postulated to confer un-supervised compentency in the UK (Darke 2001).
It was widely accepted that the current training schedule of core general surgical training with latter vascular sub-specialisation was insufficient to meet the growing demands of endovascular surgeons. Endovascular fellowships either within the UK or abroad, served to fill in the gaps left during formal training. However, after years of campaigning the Vascular Society announced on March 16th 2012 that in the UK vascular surgery will also now stand alone with specialty status independent of general surgery. The first ‘vascular trainees’ began training in October 2013, the new curriculum contains endovascular competencies and it is hoped this new training programme will address the deficiencies seen in the old programme. Virtual reality simulation is utilized during a three day ‘boot camp’ prior to trainees commencing their posts, but has yet to be formally integrated thereafter. The draft curriculum is awaiting final approval but contains an integrated and streamlined programme of open vascular and endovascular skills training (Vascular Society 2012). As yet, simulation is yet to be formally integrated, but the restructuring of the specialty is recognition of current deficiencies and a need to get to grips with this rapidly evolving specialty.
Despite these recent advancements, gaps continue to exist in modern endovascular training and this climate has also opened the door for more novel training adjuncts to address the imbalance, principally simulation. The Chief Medical Officer acknowledged in his 2008 annual report that simulation affords a crucial role in safer patient care, and went on to recommend simulation-based training to become fully integrated and funded within the training curricula of surgeons at all training stages (Gilbody et al 2011). In the Northern Deanery general surgical trainees from core training stage one through until specialty training level seven have dedicated simulation skills training integrated into their postgraduate curriculum. Technical skills appropriate to trainees grade, stage and specialty interest, are taught using animal, human cadaver and virtual reality simulators in a dedicated training facility. Work is ongoing to formally assess
trainees progression in an attempt to prove the benefit of this innovative approach. But it is already apparent that simulation will form a crucial part of medical postgraduate training.