Future Need for Subspecialization in Vascular Surgery in India

INTRODUCTION Vascular surgery has been the most technology-driven professional surgical field that is separated distinctly from general surgery and is recognized as an independent specialty in many countries. Although in India, the first Department of Vascular Surgery was started in 1978 at the Madras Medical College, and a 2-year training program offering a master’s degree (MCh) in peripheral vascular surgery was started in 1985.[1] It took a long time to get recognized by other specialties as an independent specialty. In many countries, it has reached at least subspecialty status.[2] The management of patients afflicted with vascular diseases is being revolutionized by the ever-growing endovascular therapeutic options, and vascular surgeons are challenged by the skepticism of whether they are sufficiently specialized or whether they need to subspecialize to provide optimal care. In brief, there would be need for further specialization “within” vascular surgery. This is highly debatable, and its implications impact directly the self-conception of the vascular surgeon and the scope of vascular surgery. This article aims to discuss the advantages and the limitations of a specialization within vascular surgery. NEED BEHIND SPECIALIZATION Surgical specialization is driven by a series of interacting factors [Table 1]. A rapidly expanding understanding of disease biology, the continuous conceptual shift toward minimal invasive therapeutic modalities, the concomitant technological evolution, the complexity of evidence-based treatment algorithms, and the fear of litigation all contribute to the belief that “expertise requires limitation of scope.” Whatever the driving force, in-depth knowledge, evidence-based treatment, and technical mastery of demanding procedures are associated with improved patient outcomes.[3] Naturally, specialization goes with an understanding of the centralization of services. This leads to some advantages, larger units or higher centers are more likely to afford expensive high-tech infrastructure while realizing economic savings through rationalization which is very much relevant to the Indian setup. Having the full spectrum of management available will encourage clinically appropriate management more readily than in an environment with limited resources. Another important aspect is centralization means a large patient volume with improved training opportunities. This facilitates the establishment of subspecialist interests, which, in turn, are associated with improved outcomes and reduced chances of success for malpractice allegations.[4,5] In addition, clinically meaningful trials are easier to perform in specialized environments to advance the knowledge in the field. In vascular surgery, the benefits of specialization and centralization have been clearly shown for the management of abdominal aortic aneurysms and carotid surgery.[6,7] Specialization is perceived to improve lifestyle, professional credentials, and job security, since expertise usually comes along with reputation, independence, and increased reimbursement.[8]Table 1: Main drivers of specializationLIMITATIONS OF SPECIALIZATION The positive relationship between increased specialization and improved patient outcomes certainly does not continue to infinity. No randomized controlled trial has been conducted so far about the degree of subspecialization and clinical outcomes with extent of improvement. It is very clear that increasing specialization is shifting the balance from a “patient-centered approach” toward “disease- or technology-centered management.” This is known to generate additional costs driven by specialist training, added reimbursement, and innovative technology.[8] In addition, specialization narrows working options for doctors to concentrated specialist services with associated inflexibility, while overcentralization signifies long distances and reduced availability of services for patients. Moreover, the focusing on technology-based care creates ethical issues as the “technology hype cycle” leads to new technology being adopted before safety and efficacy are established. As most surgical innovations enter practice without regulatory oversight, practice is running ahead of evidence.[9,10] Thereby, patients are exposed not only to the learning curve of new technology but also to an uncontrolled learning curve of any given surgeon, while the efficacy of the intervention might not even be certain and may not establish itself as a therapeutic modality. Thus, a large center volume alone may be of limited benefit. Another limitation of overspecialization is readily seen in nonelective care, where it most easily leads to insufficient professional coverage. For instance, in a recent analysis of 1554 emergency patients, 23% needed a highly complex operation, of which 30% did not even closely match the subspecialty of the responsible consultant surgeon.[11] On a smaller scale, this probably applies for nonelective vascular surgery as well and has important implications for future training programs. Finally, although over the past decades, medicine has been dedicated in many countries to unlimited progress and technological innovation that comes with thriving specialization, there is now general agreement that current annual increases in health costs are economically disastrous and unsustainable. Drastic changes in overall values, patients’ expectations and demands, industrial profit-seeking, and research aims will be inevitable to reduce these costs.[12] Therefore, within this changing environment of surgical practice and education, the future surgical workforce is unlikely to encompass the same depth, breadth, and availability of services that general surgeons historically provided.[13] As the division of expertise progresses, the workforce of surgeons needed to provide standard service will grow. Hence, the gained quality of care for certain patients that is afforded by increased specialization needs to be balanced against the limitations that it entails for other patients, society, and, last but not least, for the surgeon himself as extreme subspecialization is likely to produce a generation of bored and dissatisfied surgeons. For vascular surgery, the emerging challenges are to determine the optimal level of specialization within vascular surgery and to define its role and scope within vascular care. POTENTIAL FUTURE DIRECTIONS Overall, all emerging training programs essentially aim at similar goals, and their structure is astonishingly heterogeneous,[2] indicating that the ideal modalities have yet to be defined. A common feature seems to be the integration of virtual–reality simulators, at least for endovascular training. Although the value of simulation for bridging the gap between reduced training time and clinical reality is no longer debated, corresponding training scenarios for open surgical procedures are much less established. Of course, such surrogate scenarios cannot entirely substitute for clinical experience; however, their integration into the official vascular surgery curriculum might meet at least some of the current challenges, particularly as open vascular surgical procedures have decreased in clinical practice drastically. Open vascular surgery workshops are being offered and propagated at present in India and Internationally (Open cadaveric vascular dissection courses are regularly conducted by Care Hospital Hyderabad and MS Ramaiah Hospital, Bangaluru, in India every year and http://www.vascularinternational.Org Internationally). Virtual reality training should be made mandatory to improve surgeons’ skills, surgeons have to focus on dedicated training time and should reach competent specialization through certified completion of a defined curriculum rather than by attending to a fixed duration of training. A typical vascular patient is elderly, morbid, and often frail, he should preferably enter “one door” to find unbiased access to all vascular care under one roof of the “vascular centre.”[14] First propagated in the late 1980s, this concept is still unique in its promise to overcome the limitations of individualized specialization. Only interdisciplinary workup including conjoint evaluation by vascular surgeons, interventionalists, cardiologists, and including conjoint development of a comprehensive treatment plan offers both “breadth” of encompassing patient care and “depth” of subspecialization expertise. Prerequisites, however, are mutual basic expertise to facilitate discussions on common grounds and upfront negotiations of reimbursement distributions. Hence, the vascular surgeon of the future should realistically (1) have profound expertise in one field, be it endovascular or open surgical; (2) have an in-depth knowledge of the available evidence; (3) be an integral part of a multidisciplinary team that offers the whole therapeutic spectrum; and (4) have a thorough understanding of vascular biology. Vascular surgery training programs need to provide such “relative specialists” and should probably consider collaborative efforts with other vascular specialist training programs to reach this ambitious goal. However, as a “core knowledge” is paramount, any vascular training must encompass general aspects of vascular surgery care just as any surgical training program must continue to train core surgical skills.