AD HOC COMMITTEE ON CORE SURGERY TRAINING & DEFINED MINIMUMS FOR CASE LOGS REPORT Carlos Bechara MD on behalf of the adhoc committee Associate

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1 AD HOC COMMITTEE ON CORE SURGERY TRAINING & DEFINED MINIMUMS FOR CASE LOGS REPORT Carlos Bechara MD on behalf of the adhoc committee Associate Professor, Program Director Houston Methodist hospital APDVS 2017

2 We have nothing to disclose in relation to this talk

3 WERE WE LEFT OFF LAST YEAR REGARDING CASE MINIMUMS AND CORE SURGERY ROTATIONS: Whether we should add other categories like dialysis and venous minimum cases* Decline in open operative experience*?role of courses and simulation There is variability in core rotations Experience varies among different institutions Can some of these be taught by vascular surgeons Other subspecialties reduced months on general surgery *affects fellowship and integrated programs

4 TOTAL CASE VOLUME REQUIRMENTS Residents in an integrated program should perform a minimum of 500 operations, to include 250 major vascular reconstructive procedures. (Core) IV.A.6.c).(1) Operative experience in excess of 1500 total cases must be justified by the program director. (Core) Residents in an independent program should perform a minimum of 250 major vascular reconstructive procedures. (Core) Operative experience in excess of 900 total cases must be justified by the program director. (Core)

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6 CASE LOG MINIMUMS VASCULAR SURGERY DEFINED CATEGORY MAPPINGS

7 ACGME PROGRAM REQUIREMENTS FOR GME IN VS

8 Abdominal (30) Aneurysm Repair - Open Repair Infrarenal A-I Aneurysm, Ruptured Aneurysm Repair - Open Repair Infrarenal A-I Aneurysm, Elective Aneurysm Repair - Repair Suprarenal Aortic Aneurysm Aneurysm Repair - Repair Thoracic Aortic Aneurysm Aneurysm Repair - Repair Thoracoabdominal Aortic Aneurysm Aneurysm Repair - Repair Other Aneurysm - Def Cat Credit Periph Obstructive - Aorto-Ilio/femoral endarterectomy Periph Obstructive - Aorto-ilio/femoral bypass, prosthetic Periph Obstructive - Aorto-ilio/femoral bypass, vein Periph Obstructive - Ilio-Iliac/femoral endarterectomy Periph Obstructive - Excise infected graft, abdomen or chest Periph Obstructive - Repair graftenteric/aorto-enteric fistula Abdominal Obstructive - Celiac/Sma Endarterectomy, Bypass Abdominal Obstructive - Renal Endarterectomy, Bypass Abdominal Obstructive - Embolectomy/thromb ectomy, renal Trauma - Repair Thoracic Vessels Trauma - Repair Abdominal Vessels Venous -Portal- Systemic Shunt

9 Aneurysm Repair - Repair Thoracoabdominal Aortic Aneurysm Aneurysm Repair - Repair Popliteal Aneurysm Aneurysm Repair - Repair Other Aneurysm - Def Cat Credit Cerebrovascular - Reoperative Carotid Surgery (Secondary Procedure Only) Cerebrovascular - Transcatheter Placement Carotid Artery Stent Cerebrovascular - Excise Carotid Body Tumor Cerebrovascular - Vertebral Bypass or Reimplantation/transposition Cerebrovascular - Direct Repair Aortic Arch Branches Cerebrovascular - Transluminal Balloon Angioplasty - Brachiocephalic Cerebrovascular - Transluminal Atherectomy - Brachiocephalic Cerebrovascular - Transcatheter Place of Intravasc Stent, Noncor. Cerebrovascular - Embolectomy/thrombectomy by Neck or Thoracic Incis Cerebrovascular - Other Major Cerebrovascular - Def Cat Credit Aneurysm or infected graft excision Complex (10) Periph Obstructive - Aorto- Ilio/femoral endarterectomy Obstructive - Aorto-Ilio/femoral endarterectomy Obstructive - Aorto-ilio/femoral bypass, vein Obstructive - Excise infected graft, abdomen or chest Obstructive - Repair graftenteric/aorto-enteric fistula Obstructive - Harvest Arm Vein (Secondary Procedure Only) Obstructive - Composite Leg Bypass Graft (Secondary Procedure Only) Obstructive - Re-Do Lower Extremity Bypass (Secondary Procedure Only) Obstructive - Other Major Peripheral - Def Cat Credit Penile revascularization, artery, with or without vein graft Penile venous occlusive procedure Abdominal Obstructive - Celiac/Sma Endarterectomy, Bypass Abdominal Obstructive - Renal Endarterectomy, Bypass Abdominal Obstructive - Embolectomy/thrombectomy, renal Abdominal Obstructive - Transluminal balloon angioplasty, renal Abdominal Obstructive - Transluminal atherectomy, renal Abdominal Obstructive - Transcatheter place of stent, renal artery Upper Extremity - Transcath place of intravasc stent, non coronary Trauma - Repair Thoracic Vessels Trauma - Repair Neck Vessels Trauma - Repair Abdominal Vessels Venous - Portal-Systemic Shunt Venous - Venous Reconstruction Venous - Repair A-V Malformation

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12 Fellows

13 IVS

14 Open Procedures McCoy, A. C., et al. (2013).J Surg Educ 70(6):

15 CAS for Fellows

16 CAS for IVR

17 THE COMMITTEE CAME UP WITH 12 Questions FOCUSED ON MINIMUN CASE LOGS Core general surgery rotations SURVEY SENT TO 180 PD S 45 RESPONDED (25%)

18 PURPOSE We are not going to solve all these problems Have an understanding from other PD s about their struggles Are some of the issues faced by all programs or few? Case volume General surgery experience

19 Q1 SPECIFY YOUR CURRENT DETAILS BELOW. ANSWERED: 45 SKIPPED: 0

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22 Q2: SHOULD THE FOLLOWING CATEGORIES HAVE SET MINIMUM CASE REQUIREMENTS?

23 Q2: SHOULD THE FOLLOWING CATEGORIES HAVE SET MINIMUM CASE REQUIREMENTS? Consensus: 1- Add a venous defined category with a Minimum of 20 cases 2- Dialysis also to be added as a defined category, 10 cases

24 Q3: SHOULD CAS (TCAR AND TRANSFEMORAL CAS) WITH CEA BE ADDED UNDER THE CEREBROVASCULAR MINIMUM CASE REQUIREMENT? Yes - Minimum Case Requirement of 10 Yes - Minimum Case Requirement of 20 Yes - Minimum Case Requirement of 30 Yes - Minimum Case Requirement of >50 No

25 Q4: WHAT SHOULD HAPPEN TO THE 100 DIAGNOSTIC CASE MINIMUMS? Leave requirement as is remove Reduce to 50 Add it to endovasc therapeutic and keep it at 100 Add it to endovasc therapeutic but reduce to 50

26 Q4: WHAT SHOULD HAPPEN TO THE 100 DIAGNOSTIC CASE MINIMUMS? Leave requirement as is remove Reduce to 50 Consensus: keep as is Add it to endovasc therapeutic and keep it at 100 Add it to endovasc therapeutic but reduce to 50

27 Q5: PLEASE ANSWER THE FOLLOWING QUESTIONS: Would you allow your resident to go to another program that has high case volume in one of the required categories (e.g. open AAA, CEA, CAS or complex Endo AAA, etc.) to gain additional experience? Should APDVS endorse courses (e.g. open AAA, CAS, complex Endo AAA, etc) to help meet requirements? Would you send your trainees to an APDVS-endorsed course (e.g. open AAA, CAS, complex Endo AAA, etc) to help them broaden their experience and/or meet requirements? Would you hire a graduate who attended an APDVS-endorsed course (e.g. open AAA, CAS, complex Endo AAA, etc) but didn't meet the case requirement during training? Would you hire a graduate who was below the minimum in one of the core categories during training but the Program Director signed off that they were competent in that area?

28 Q6: WHAT ARE ACCEPTABLE MINIMUM CASE REQUIREMENTS WOULD YOU SUGGEST FOR THE FOLLOWING PROCEDURES?

29 Q6: WHAT ARE ACCEPTABLE MINIMUM CASE REQUIREMENTS WOULD YOU SUGGEST FOR THE FOLLOWING PROCEDURES?

30 Q6: WHAT ARE ACCEPTABLE MINIMUM CASE REQUIREMENTS WOULD YOU SUGGEST FOR THE FOLLOWING PROCEDURES? Add another category TORSO instead of focusing on open AAA repair: (20 cases) OPEN AAA REPAIR-chest/ABD Endograft explant Thoracotomy ABF for AIOD IVC related surgeries Renal vein transposition PV reconstruction Spine exposure Iliac conduits Visceral surgeries

31 Q6: WHAT ARE ACCEPTABLE MINIMUM CASE REQUIREMENTS WOULD YOU SUGGEST FOR THE FOLLOWING PROCEDURES? Add another category TORSO instead of focusing on open AAA repair: (20 cases) OPEN AAA REPAIR-chest/ABD Endograft explant Thoracotomy ABF for AIOD IVC related surgeries Renal vein transposition PV reconstruction Spine exposure Iliac conduits Visceral surgeries Might as well add another category for complex endo AAA repair, 10 cases

32 ORTHO Urology: 27 categories Including Robotic surgery

33 Q9: HOW LONG DO YOU FEEL GENERAL SURGERY CORE ROTATION REQUIREMENTS SHOULD BE FOR VASCULAR SURGERY INTEGRATED RESIDENTS?

34 Q9: HOW LONG DO YOU FEEL GENERAL SURGERY CORE ROTATION REQUIREMENTS SHOULD BE FOR VASCULAR SURGERY INTEGRATED RESIDENTS? 37.8% 62.2%

35 Q10: SHOULD GENERAL SURGERY CORE ROTATIONS FOR VASCULAR SURGERY INTEGRATED RESIDENTS BE INSTITUTION SPECIFIC?

36 Q11: SHOULD THERE BE A MINIMUM NUMBER OF GENERAL SURGERY CASES FOR VASCULAR SURGERY INTEGRATED RESIDENTS?

37 Q12: RANK THE FOLLOWING TEACHING/EDUCATIONAL OBJECTIVES THAT VASCULAR SURGERY INTEGRATED RESIDENTS SHOULD GAIN FROM THEIR GENERAL SURGERY ROTATIONS

38 Acceptable Core Training Rotations Acute Care/Consult Surgery Trauma surgery General surgery Cardiac/cardiothoracic surgery Thoracic surgery Transplantation Surgical oncology Plastic surgery Urology Neurological surgery ENT, Orthopedic Surgery Endocrine surgery Bariatric surgery Colorectal surgery Hepatobiliary Pediatric surgery Laparoscopic surgery Critical care (med/surg ICU, CCU) Anesthesiology Emergency Dept Burn service Geriatrics Neurology Pulmonary Nephrology Research Cardiology Hematology Interventional Cardiology Vascular Medicine Cross- sectional imaging Vascular lab R1 vascular rotation

39 Acceptable Core Training Rotations Acute Care/Consult Surgery Trauma surgery General surgery Cardiac/cardiothoracic surgery Thoracic surgery Transplantation Surgical oncology Plastic surgery Urology Neurological surgery ENT, Orthopedic Surgery Endocrine surgery Bariatric surgery Colorectal surgery Hepatobiliary Pediatric surgery Laparoscopic surgery Critical care (med/surg ICU, CCU) Anesthesiology Emergency Dept Burn service Geriatrics Neurology Pulmonary Nephrology Research Cardiology Hematology Interventional Cardiology Vascular Medicine Cross- sectional imaging Vascular lab R1 vascular rotation No podiatry

40 CONSENSUS Make core rotations 18 months. Keep Vascular rotations at least 36 months Remaining 6 months up to the discretion of the PD Institution specific Emphasis on critical care, trauma and acute care surgery Can be vascular Allow for electives No minimum case requirement for core rotations

41 UROLOGY The ABU mandates a minimum of five clinical years of postgraduate medical training. The training must include: 48 months in an ACGME-approved urology program Three months of general surgery in an ACGME-approved surgical program Three months of core surgical training (e.g., intensive care unit, trauma, vascular surgery, cardiac surgery, etc.) in an ACGME-approved surgical program Six months of other rotations, not including dedicated research time, in an ACGME- or RCPS(C)-approved core surgery program

42 ORTHOPEDICS A minimum of six months of structured education in surgery, including the areas of multi-system trauma, plastic surgery/burn care, intensive care, and vascular surgery A minimum of one month of structured education in at least three of the following specialty areas: emergency medicine, medical/cardiac intensive care, internal medicine, neurology, neurological surgery, rheumatology, anesthesiology, musculoskeletal imaging, and rehabilitation A maximum of three months of orthopaedic surgery

43 NEUROSURGERY As of July 1, 2009, the training program in neurological surgery no longer requires a prerequisite year of general surgery. The neurological surgery training program is at least 72 months in duration. Programs can be approved for up to 84 months of training: 72 months for clinical and didactic education and 12 months for research or subspecialty training.

44 THANK YOU

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48 CONCLUSION We have a problem with open exposure Abd exploration/loa Open AAA repair What is the solution? Simulation Courses Electives at high volume centers Outside the US Role of APDVS Credentialing Rollover cases from GS?