Vascular recruitment a “universal problem”: The global perspective

Sophie Renton

Across the globe, vascular recruitment is struggling. This was the reason why delegates convened at the 2019 Charing Cross Symposium (CX; 15–18 April, London, UK) for a session dedicated to the topic, where representatives from three continents explained exactly how and why the vascular specialty is experiencing this decline in physician numbers, and what the international community can do about it.

Trevor Cleveland, president of the British Society of Interventional Radiology (BSIR) and the session chair, summarised the key takeaways from the afternoons discussion to Vascular News: “Everybody recognises recruitment is a problem. There is a lack of exposure of students and trainees to vascular procedures early on; if you show them what you are doing, they get enthused by it and stay on. Getting that exposure in medical students and junior doctors is crucial. Also, the reality of it is that we have an aging population of operators, who we are going to lose quite a lot of—so we have a numbers problem. There is a problem getting people in; there is a problem with the numbers going out. Then there is also a difficulty with those doing it having an unenviable work-life balance.”

Hans-Henning Eckstein (Munich, Germany) kicked off the session by outlining ways in which medical students can be attracted to vascular surgery. He said that vascular specialists need to target medical students earlier on in their undergraduate years, pointing to the declining attractiveness of vascular surgery between the first year of medical school (where 34.4% said they would be interested in a vascular career) and the last (where this figure was 15.5%). One reason for this, he explained, is a generational difference in attitude to work. Eckstein pointed to the work-life balance of vascular surgeons, saying that potential recruits possibly believe the specialty would “require too many sacrifices” from them. In addition to lifestyle issues, he told the CX audience to “keep in mind that currently, approximately 70% of all medical students are female”, saying that the stereotypical image of surgery as a masculine discipline had to be changed.

Providing an overview of vascular recruitment in Europe, European Society for Vascular Surgery (ESVS) president Henrik Sillesen (Copenhagen, Denmark) voiced many of the same concerns. “Vascular recruitment is not as easy as it used to be” he remarked. “It is still OK for big university centres, but it is certainly challenging outside those, in smaller, more rural centres”. He went on to say that the training is “regulated in several [European] countries to a point that is ridiculous”. He then detailed educational, organisational, economic and personal factors which are affecting vascular recruitment, such as whether or not the specialty is housed in its own department, or if it pays well. One of the more important educational factors, he said, was whether or not the students would have the opportunity to learn endovascular techniques in the vascular department—Cleveland returned to this point later on to say that overall, the older generation of vascular surgeons are those providing the open procedures. As they retire, the newer generation are less confident in those procedures, a point made by European Board of Vascular Surgery (EBVS) president Armando Mansilha (Porto, Portugal) when he reviewed the reasons why candidates are not successful in the EBVS exam.” To improve recruitment, Sillesen said, “it is important to create a good working environment, with reasonable hours and vacation time”. He called attention to the six weeks’ paid leave offered to physicians in Northern Europe, and that institutions should provide “good opportunities for education, research and travel”.

Michel Makaroun (Pittsburgh, USA), Society of Vascular Surgery (SVS) president, stepped up to the podium to provide the North American angle. He agreed with previous speakers concerning the dearth of future vascular surgeons, calling it a “universal problem”. The two “major problems” in vascular recruitment in the USA, he said, were a significant shortage of vascular surgeons and the maldistribution of workforce.

To the latter point, he echoed Sillesen’s sentiments, saying that vascular specialists were concentrated in urban areas. An SVS survey in 2017 found that only 6% of respondents practice in a rural setting, defined as having a population of fewer than 100,000. “The vascular specialty has the highest anticipated need of all specialities, but we are not producing enough vascular surgeons to get a significant increase in numbers,” Makaroun told attendees. Currently, 42% of US vascular surgeons are over the age of 55, and “the majority are trying to retire as soon as possible”, Makaroun said. He added that current training pathways in the USA are “not adequate to address the issues”, but that a task force on alternate pathways is studying the problem.

Alberto Muñoz (Bogotá, Colombia), president of the World Federation of Vascular Societies (WFVS), provided the South American perspective on training pathways: “We have training programmes in most of our countries, and it is important to note that in most of the countries, general surgery training is required. We have issues with migration, as in some countries it is mandatory to have general surgery certification.” Following the SVS 2018 annual meeting (20–23 June, Boston, USA), where it was reported that the USA had 1.4 vascular surgeons per 100,000 people, the WFVS decided to carry out their own investigation. According to their calculations, across the entirety of South America, there is an average of one vascular surgeon per 94,793 people. However, there have been no studies, Muñoz said, evaluating the expected need for vascular surgeons in the region.

Mansilha told the CX audience that, for EBVS, it was crucial to have “European standards of training and education for vascular surgery”. At CX on Monday, the EBVS announced the approval of a document delineating their training programme and its requirements, which Mansilha outlined. He stressed his belief in the importance of having a standard, European exam for vascular surgeons “not only for prestige, but also to consider the minimal requirements in Europe to facilitate the free exchange” of physicians.

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