Vascular Surgery Fellowships: Comparison of Two Programmes in Canada and the UK

The last decade witnessed the birth of vascular surgery as a standalone specialty. This was accompanied by the rapid development of endovascular techniques, which revolutionised the way vascular diseases are treated. This change in the practice of vascular surgery has had a great impact at all levels, but perhaps none greater than in the training of future vascular surgeons. Hence, there is an increasing demand for a generation of vascular surgeons who are versatile in performing the breadth of vascular and endovascular procedures.1Cronenwett J.L. Vascular surgery training: is there enough case material?.Semin Vasc Surg. 2006; 19: 187-190Crossref PubMed Scopus (34) Google Scholar, 2Stanley J.C. Barnes R.W. Ernst C.B. Hertzer N.R. Mannick J.A. Moore W.S. Vascular surgery in the United States: workforce issues. Report of the society for vascular surgery and the international society for cardiovascular surgery, North American chapter, committee on workforce issues.J Vasc Surg. 1996; 23: 172-181Abstract Full Text PDF PubMed Scopus (120) Google Scholar The structure of the training programme in vascular surgery has adapted to such a paradigm shift. For example, in 2012 Canada approved the establishment of the “0+5” direct entry integrated vascular residency.3Lotfi S. Jetty P. Petrcich W. Hajjar G. Hill A. Kubelik D. et al.Predicting the need for vascular surgeons in Canada.J Vasc Surg. 2017; 65: 812-818Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Similarly, the first generation of run through vascular trainees was recruited in 2013 in the UK, following the approval of the Vascular Curriculum by the General Medical Council (GMC). However, achieving competence in the full range of vascular procedures within a particular programme remains a challenge, and pursuing a fellowship in vascular and endovascular surgery is becoming increasingly popular. Seeking a national or international fellowship is a dilemma that vascular trainees in the UK frequently face. This report presents a comparison between a UK and a Canadian vascular fellowship conducted by a single trainee. A single vascular trainee completed both a nine and 12 month fellowship in vascular and endovascular surgery at the Freeman Hospital, Newcastle, UK, in 2015 (“fellowship UK”) and at the University of Toronto Hospitals, Toronto, Canada, in 2016 (“fellowship C”). Fellowship UK was at the level of specialty training year 7 (ST7) and fellowship C was at the level specialty training year 8 (ST8); hence, both fellowships were incorporated within the trainee's training programme and prospectively approved by the GMC. While fellowship UK was conducted at a single centre, fellowship C consisted of four month placements at three different centres: Toronto General Hospital, Sunnybrook Health Science Centre, and St Michael's Hospital. Acceptance in each programme was through a formal application and competitive interview process. Data regarding job specifications, clinical and academic achievements, on call commitments, clinics, and case logs were collected prospectively. Case logs were further partitioned into open and endovascular categories. In addition, operative participation was documented in each procedure. Participation was labelled “A” for assisted when the trainee's primary role was assisting a trainer, whereas a procedure was considered to be “P” when the trainee either performed the procedure under supervision, without supervision, or trained another trainee. A chi-square test was used to compare the proportions of open vs. endovascular procedures and performed vs. assisted cases, whereas a t test was used to compare the monthly numbers of on call days, clinics, and case logs. The average number per month of on call days, clinics, and operative procedures were 7.6, 8, and 24.3, and 6.1, 5.7, and 23.2 in fellowship UK and fellowship C, respectively (p = .02, .005, and .75, respectively). A breakdown of the surgical procedures is summarised in Table 1. The average number of cases per month and the proportion of endovascular cases were similar between the two fellowships, but significant differences existed at the level of trainee participation and in case distribution. Of all surgical procedures, the proportion of endovascular therapies was 42% (n = 93/219) in fellowship UK and 45% (n = 126/278) in fellowship C (p = .53). However, the trainee was the primary operator in 40% of the endovascular procedures in fellowship UK vs. 79% in fellowship C (p < .001). Endovascular trainers were primarily radiologists in fellowship UK, whereas fellowship C trainers were vascular surgeons. However, the proportion of performed open vascular procedures was higher during fellowship UK (93%) than in fellowship C (80%) (p = .002). Breakdown of the surgical cases also revealed a significant difference in exposure to aortic procedures. The average number per month of open and endovascular aortic procedures was 3.9 in fellowship UK vs. 7.8 in fellowship C (p = .006). However, fellowship UK provided exposure to endovenous thermal ablation (n = 35), which is currently not offered in the Toronto public health service.Table 1A breakdown of the variety of procedures performed in the UK and Canadian fellowships.VariableUK (average/mo) or [%]Canada (average/mo) or [%]pPre-tax detection salary (€) per annum (per month)69,830 (5,819)44,210 (3,684)NAOn call days68 (7.6)73 (6.1).02Total clinics72 (8)68 (5.7).005Total operations219 (24.3)278 (23.2).75Open procedure126 [58%]152 [55%).53 Performed/supervised/trained others117 [93%]121 [80%].002 Assisted9 [7%]31 [20%].001 Aortic procedures7 (0.8)28 (2.3).001 Carotid cases (carotid endarterectomy, carotid body tumour, carotid subclavian bypass) and thoracic outlet syndrome procedure18 (2)25 (2.1).89 Peripheral revascularisation and femoral pseudoaneurym repair40 (4.4)45 (3.8).57 Renal access procedures0 (0)22 (1.8).04 Amputations18 (2)17 (1.4).26 Venous procedures36 (4)9 (0.75).001 others7 (0.8)6 (0.5)-Endovascular procedures93 [42%]126 [45%].53 performed/supervised/trained others37 [40%]99 [79%]<.001 Assisted56 [60%]27 [21%]- Endovascular aneurysm repair (EVAR/TEVAR, FEVAR, BEVAR)28 (3.1)65 (5.4).008 peripheral angiograms/iliac/femoral/tibial plasty +/- stenting65 (7.2)61 (5.1).4All aortic procedures35 (3.9)93 (7.8).006Note. Data are n (%) unless otherwise indicated. Open table in a new tab Note. Data are n (%) unless otherwise indicated. While both fellowships were clinically oriented, successful completion of fellowship C required conducting and publishing at least one original research project within 12 months. In total, two national presentations and one publication were achieved in fellowship UK vs. one national presentation, two regional presentations, and five publications in fellowship C. Two courses were attended in fellowship UK, whereas fellowship C offered four fully funded advanced endovascular courses in Canada and the USA. The annual salary for fellowship UK was €69,830, funded by The Newcastle upon Tyne Hospitals NHS Foundation Trust, vs. €44,210 in fellowship C, paid by the University of Toronto. Expenses incurred during the fellowships included renting single room accommodation at a monthly rate of €402, in addition to the annual professional fees (Table 2) for fellowship UK, whereas moving to Toronto was associated with greater expenses, including accommodation, flights, professional registrations, and memberships (Table 3), in addition to higher living costs.Table 2Expenses incurred during a vascular surgery fellowship in the UK (9 months).ExpenseAmount (€)RationaleGeneral Medical Council registration482Clinical practice requirementRoyal College of Surgeons of England annual membership608Professional feesIntercollegiate Surgical Curriculum Programme annual fees293Postgraduate training requirementMedical Defence Union134Indemnity feesRoom rental in Newcastle3,618Monthly rent £402Home base rent7,749Family accommodation in a different city; monthly rent £861Utility bills1,344—Total14,228—Average/month1,581— Open table in a new tab Table 3Expenses incurred during a vascular surgery fellowship in Canada (12 months).ExpenseAmount (€)RationaleCanadian Embassy work permit application86Temporary resident visaPGME visa processing fee86Requirement for temporary resident visaVisa medical assessment339Requirement for temporary resident visaReturn flight to Canada782Manchester–Toronto–Manchester, booked through Canadian AffairsCollege of Physicians and Surgeons of Ontario (CPSO) fees273Non-refundable application fee (€93), membership fee (€180)Canadian Police Information Centre criminal record check11CPSO requirementSource verification of medical degree (physician apply)232CPSO requirement; document fee (€82 for each medical credential document submitted for source verification)Canadian Medical Protective Association annual premium1,332Clinical fellow monthly rate €111University Health Insurance Plan280Family three month rate until Ontario Health Insurance Plan commencesPGME registration fee465Postgraduate training requirementRent for a one bedroom furnished apartment, including utility bills15,960Monthly rent €1,330Total18,846—Average/month1,654—Note. CPSO, College of Physicians and Surgeons of Ontario; PGME, Postgraduate Medical Education. Open table in a new tab Note. CPSO, College of Physicians and Surgeons of Ontario; PGME, Postgraduate Medical Education. This report presents a single trainee's experience of two consecutive fellowships within the UK and Canada. A survey of vascular trainees in the UK revealed that half of them were in posts that do not offer endovascular training, 88% performed <10 peripheral angiograms, and 67% performed <10 endovascular aneurysm repairs over a 12 month period.4Karthikesalingam A. Buxton P. Marron C. Oshin O.A. Scurr J.R. Wall M. Deficiencies persist in the experience of UK vascular trainees: a survey of Rouleaux Club members.Vasc Endovasc Surg. 2012; 46: 358-363Crossref PubMed Scopus (5) Google Scholar Concerns are also raised regarding the exposure to sufficient open surgical procedures during training due to the increased prevalence of endovascular procedures. Such exposure remains vital not only for achieving the required level of competence, but also for maintenance of independent future surgical practice amongst the vascular trainees. For example, Tu et al. found that annual surgeon volume significantly influenced mortality after elective open abdominal aortic aneurysm (AAA) repair.5Tu J.V. Austin P.C. Johnston K.W. The influence of surgical specialty training on the outcomes of elective abdominal aortic aneurysm surgery.J Vasc Surg. 2001; 33: 447-452Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar Hence, seeking fellowships after completion of surgical training remains a vital route to achieving such standards. Several factors influence trainees' decisions to pursue such fellowships. The results here demonstrate increased expenses with a fellowship within Canada combined with a reduction in income. This represents a significant disadvantage for the Canadian fellowship, particularly for fellows who have dependents to support. Other popular destinations amongst UK fellows include the USA, Australia, and New Zealand, and comparison of incomes and expenses required for pursuing fellowships in these countries would be useful to develop a full insight into the financial aspects of the popular international fellowships. However, the Canadian fellowship offered better hands on exposure to endovascular therapies, a finding that is probably multifactorial. Firstly, the experience of the trainee in endovascular procedures would have naturally developed more when he moved from fellowship UK to fellowship C, which could have resulted in more substantial participation than what would have been offered at a more junior level. Also, the trainee was trained directly by his clinical supervisors (vascular surgeons) in fellowship C vs. trainers from a different specialty (radiologists) in fellowship UK. Conversely, the proportion of open vascular procedures that were performed by the trainee was higher in the UK than Canada. This could be explained by the exposure to complex open thoracic and thoraco-abdominal aortic procedures in Canada, which are more often performed by a senior multidisciplinary team of surgeons. Using operative case numbers as a surrogate for operative experience, there was no significant difference in this domain between the two fellowships; however, there was significantly higher exposure to open and endovascular aortic surgery in fellowship C, which is probably reflective of the practice patterns at individual institutions. This is important as the complexity of the open infrarenal AAA repair has changed in recent years. A steady increase in the percentage of suprarenal aortic clamping needed in open infrarenal AAA repair is being seen. This phenomenon is not unexpected as a short length of proximal aortic neck is a contraindication for standard infrarenal endovascular repair. Additionally, exposure to endovenous treatment of varicose veins was lacking in fellowship C. These differences highlight the individuality of fellowships and the importance of identifying clear fellowship goals and objectives before selecting a specific post. Other non-clinical advantages of an overseas fellowship include exposure to a different healthcare system, exploring a different culture, and building personal and professional relationships with colleagues at an international level. The presented comparative report is not without limitations. Firstly, this was a single trainee experience and the results cannot be generalised. Secondly, achievements obtained from a training programme can vary among different trainees due to variations in personal abilities to learn. Thirdly, the fellowships were conducted in specific centres and different vascular units might offer different exposure within each country. Finally, case logs provide uniform, trackable, and objective means of measuring operative experience; however, they might not be the best surrogate for accurately assessing technical skills gained or clinical experience in general. None. None.

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