Accredited Training in Vascular Surgery: the UK Perspective Gareth Griffiths Department of Vascular Surgery, Ninewells Hospital, Dundee, UK Chairman of the Specialty Advisory Committee in General Surgery

History of UK Vascular Training 1960s – 1980’s – Small numbers of general surgeons doing occasional cases – Some vascular surgery in most hospitals – Special interest development within general surgery 1990s – 2000’s – Increasingly a functional monospecialty – Officially still an interest within general surgery – Issues Improved specialist outcomes Increasing difficulty of training in general and vascular

Vascular Surgery – A New UK Specialty 2012 – Officially recognised as a monospecialty – End result of much work by many within the Vascular Society – Training structures established Within UK specialty training system Meeting regulator’s requirements Newly designed within these limits – First UK vascular training programmes start in August 2013

UK Accreditation Process General Medical Council Standards – Stages of training – Trainee selection – Curriculum – Requirements for training units – Trainee assessment – Quality assurance – Life long learning

Stages of Training Foundation Years 1 and 2 Core Surgical Training – 2 years, 4 specialties (vascular surgery desirable) Specialty Training – 2 years Intermediate Breadth of elective and emergency vascular surgery 1 year general surgery - open abdominal – 4 years Final Open and endovascular Generic Professional Behaviour and Leadership Skills

Trainee Selection National, annual, single centre model 8 component, 2 hour interview – tests all aspects of the person specifications 11 assessors Single national ranking Ranking and applicant preference determine placement Quality assured by professional and lay assessors

National Selection Results General Surgery Internal Consistency (Cronbach’s  ) Inter-rater reliability (Intra-class correlation) >/= 0.8>/= 0.85 Agreement over awarded scores 96%97%

Curriculum Aim – Independent practice in “everyday” vascular surgery – Manage unselected vascular emergencies – Opportunity to develop a special interest – Referral to colleagues when appropriate – Excludes uncommon complex procedures

Curriculum Key Topics Limb ischaemia – acute and chronic, upper and lower limb Renovascular disease Aneurysm disease – aortic and peripheralMesenteric artery disease Carotid artery diseaseThoracic outlet syndrome Endovascular surgeryVascular anomalies Vascular trauma Vasospastic disorders and vasculitis Diabetic foot Venous disease – superficial and deep Vascular accessHyperhidrosis Vascular infections – native and prostheticLymphoedema

Curriculum Index Procedures AAA repair –elective open: tube and bifurcated (infrarenal)EVAR ruptured False aneurysm repair / exclusion Carotid Endarterectomy Redo surgery – removal of infected graft Infra-inguinal bypass – AK, BK, cruralVascular Access Popliteal aneurysm exclusion and bypassSFJ and SPJ ligation Embolectomy - femoral and brachial Endovenous LSV and SSV ablation Four compartment fasciotomyFoam sclerotherapy

Curriculum Selected Clinical and Technical Skills Most index procedures 4Thoracic outlet / cervical rib 3 Non standard open AAA repair 3Diagnostic angiogram 3 Infrarenal EVAR 3Angioplasty / stenting 2 TAAA open / endovascular 2CTA and MRA assessment 3 Renal artery bypass nephrectomy / renal transplant 3 Pre-op cardio-respiratory assessment4 Mesenteric embolectomy / bypass 3 Risk factor modification 3 Vascular access – primary 4 secondary 3 Ultrasound - superficial venous, intraoperative AAA size, guided cannulation4 Axillary botox treatment and thoracoscopic sympathectomy 3

Curriculum General Surgery Groin / incisional hernia repair 3 Emergency laparotomy3 adhesolysis small bowel resection Colonic resection 3 Laparotomy for bleeding 3 Splenectomy 3

Requirements for Training Units Supervised operating lists – 4 half days per week Supervised out patient clinic – 1 per per week Supervised ward round – 1 per week Supervised angiography meeting – 1 per week Formal teaching – 2 hours per week Morbidity and Mortality meetings Regular simulation practice Time for study and Workplace Based Assessment Educational facilities, study leave and expenses Assigned Educational Supervisor (AES) Initial, interim and final review for each placement

Training Programme Approval Programme applications assessed against: – Requirements for training units – Operative numbers – Case mix – Population covered Most approved, some required to merge Rolling assessment and approval of Training Programmes

Trainee Assessments Workplace Based Assessments (WBA – 40 per year) – Clinical Evaluation Exercise Originally designed by American Board of Internal Medicine Assessor observation of trainee:patient interaction – Case Based Discussion Detailed discussion of trainee’s management of a case – Procedure Based Assessment Derived from OSATS - University of Toronto Assesses all aspects of an operative procedure – Multi-source feedback 360 o assessment of performance in the work place 8-12 assessors - different grades and professions Includes self assessment Formative

Trainee Assessments Assigned Educational Supervisor (AES) report – Achievement of objectives – Knowledge, clinical and technical skills Annual Review of Competence Progression – Deanery and Specialty Advisory Committee input – Informed by WBA’s and AES report FRCS (Vascular) Examination – Section one: written – Section two: clinical and oral Programme Director and Deanery support Specialty Advisory Committee (SAC) support Summative

Quality Assurance Trainee surveys – General Medical Council (GMC) - generic, high level – Joint Committee for Surgical Training – surgically relevant Annual reports – Programme Director – Deanery – Specialty Advisory Committee (SAC) – Joint Committee for Surgical Training Visits – Deanery visits to programmes – GMC visits to Deaneries – Triggered visits – Externality provided by Specialty Advisory Committee (SAC)

Quality Assurance General Surgery 2012 Very good: – Achievement of 40 WBAs per year – Clinical experience and exposure – Clinical and operative teaching – Feedback Good: – Number of operating sessions per week – Number of out patient clinics per week Poor: – Formal teaching Vascular training can improve on these figures

Life Long Learning Mentoring Team working Continued professional development Annual appraisal Revalidation Skill development – Local need – Technological advancement

Summary Newly developing specialty Well structured accreditation system Learning from general surgical experience Accreditation is a life long process