Launch Pad columnist Adam Talbot (Manchester, UK) explores what can be gained from looking beyond formal teaching in vascular surgery.
Much of what defines vascular surgery is not found in guidelines, textbooks, or trial data. It is picked up more quietly on ward rounds, in operating theatres, and in the space between formal teaching. Alongside the visible curriculum of evidence-based practice and operative skill, there is also something less explicit: a hidden curriculum. It consists of the unspoken lessons about decision-making, responsibility, and what it means to provide good care. It is not unique to vascular surgery, but it is rarely acknowledged, and even more rarely discussed. It has a real influence on how we think and how we act, especially when decisions are not straightforward.
One of the clearest times this becomes apparent is when complications occur. Vascular surgery is an unforgiving specialty, and complications are part of the job, even when decisions are sound and procedures are well executed. What is much less visible is everything that sits alongside it. There is very little formal teaching on how to deal with complications on a personal level. How to reflect on them, how to process them, or how to carry the sense of responsibility that often comes with them. Support, where it exists, is inconsistent and often informal. By the time vascular surgeons reach independent practice, they are expected not only to make complex decisions, but also to live with their consequences. That expectation is rarely stated out loud, but it is widely felt. Over time, these experiences shape how surgeons think about risk, outcomes, and themselves.
Another part of this hidden curriculum lies in the language used in everyday practice. Terms become familiar and are often used without much reflection, yet they can carry underlying assumptions. Take the concept of ‘limb salvage’. It is widely used and easily understood, but it frames the clinical problem in a particular way. It suggests a binary outcome: the limb is either saved, or it is lost. The language itself subtly directs attention towards the limb as the endpoint, rather than the person.
Alongside this is how non-intervention is perceived. Operating is visible. It fits naturally with how surgeons are trained and how success is often understood. Not intervening can feel different and sometimes harder to explain, particularly when emotions are high. This is often the case in patients with advanced frailty and chronic limb-threatening ischaemia, where the balance between benefit and burden is uncertain. In these situations, deciding not to operate is not passive. The intention is the same as with intervention: to do what is in the patient’s best interests. But it does not always feel that way in practice.
Within that sits the question of when not to operate. It is something that is talked about more, particularly as the patients we treat become older and more complex. Even so, these decisions are rarely clear cut. They often sit in a grey area, where more than one option seems reasonable. Learning how to navigate this is part of becoming a vascular surgeon, but it is not something that is usually taught directly. It develops over time, shaped by experience and by the people and environments around us.
The hidden curriculum will always be there, shaped by experience, by culture, and by the realities of clinical practice. But bringing parts of it into view changes how we relate to it. It allows space to reflect not only on what we do, but how we think, how we speak, and how we carry the consequences of our decisions. In a specialty defined by difficult choices, that awareness may matter as much as any guideline.
Adam Talbot is a specialty trainee in vascular surgery based in Manchester, UK, and education representative for the Rouleaux Club—the vascular trainees’ association for Great Britain and Ireland.
