• Título: Cooperación entre los programas de formación de EEUU y Latino América: Ahora es el momento
  • Fecha: 02-01-2015
  • International cooperation between vascular surgery programs to optimize education in the United States and Latin America: the time is right

    Surgical practice and education, as a whole and specifically in the vascular surgery arena, have dramatically changed in the last twenty years. This change has been driven by several factors, including legal and financial issues of a current surgical practice. In the United States (US), from the times of the Halstedian model of training, current surgical education is far from what it used to be. Training paradigms in vascular surgery have been dramatically reduced. An expected consequence of his reduction, with the limitation of an 80-hour work-week (averaged over 4 weeks), has been a negative impact on vascular surgical volume. Reimbursement rates for surgical procedures have been also radically reduced and continue to be, and medical litigation continues to be an issue on the rise. The current climate for surgical career is adverse to say the least. To become and to be a surgeon in 2014 is clearly not he same as being a surgeon 20 years ago.

    This is a worldwide problem, although with some differences among different regions of the world. For instance, in Latin America, the opportunities for advanced, state-of-the-art surgical education, which are often offered in the US, Europe or Australia, are limited and highly dependent on financial resources. This often requires financial coverage of airfare, lodging, fees for training necessary to perform complex surgical procedures, their ability to apply the newly gained concepts and skills is limited by financial constraints of local health care models, which have limited access to expensive surgical tools and devices needed for the execution of a particular procedure.

    A sad reality of most Latin American developing countries is caused the model by which most US-based endovascular companies have attempted to engage the market: the distributorship model. This complex model acts as a safety-net for large companies, since the local distributor assumes most of the risk involved in developing the business in uncharted seas; the unfortunate repercussion is the resulting ridiculous product overpricing (i.e. a 0.014 ́ ́ angioplasty balloon in the US may cost $US 200, whereas in an emerging market the same product may be as high as $US 1,500).

    Due to the latter, vascular surgical interventions remain by large, open complex interventions, which, in many occasions, are what patients need, but in many other instances, these open interventions prove to be too invasive for patients that are often frail and in very poor medical condition. Patients then, if financially able, are tasked with finding a practitioner abroad that is capable and willing to perform the endovascular procedure needed, with ensuing multiple financial and logistic hurdles to overcome. Or the practitioner is asked to travel to a Latin country to perform this intervention, which is often complicated by similar financial and logistic hurdles, but also fails to overcome the availability restriction of certain endovascular tools to perform these procedures. This is an important component of the ever growing, unsupervised and non-regulated medical tourism.

    In the US, costs are less of a problem in terms of our ability to obtain medical devices such stents, balloons or catheters. In fact, this country has experienced a technological explosion during the last 15-20 years, currently performing most vascular interventions through minimally invasive techniques. In a typical vascular practice, it is not uncommon to hear that a practitioner performs over 80% of his/her entire caseload through endovascular, minimally invasive methods. In our practice, the only areas in vascular surgery still dominated by open interventions are carotid and hemodialysis access interventions. Such a practice requires the use of devices and tools that are often quite expensive. Our restrictions are more set by the Food and Drug Administration and the speed at which new devices and technologies are approved for use in this country. Far from being an ideal situation, this has also caused tremendous implications for surgical training. The number of open cases that are performed nowadays in the US has dramatically dropped to alarming levels, making surgical training in standard procedures such as an open repair of an abdominal aortic aneurysm or a femoro- pedal arterial bypass a rare event. In current vascular practice, there is a real and strong need for proficiency with open procedures. Endovascular interventions have not completely replaced open procedures, and in my opinion we are far from this hypothetical situation. Therefore, graduates from current surgical training programs are in a disadvantageous position when joining established surgical practices.

    This discrepancy in access to resources has enormous implications on vascular surgery training, while creating an evident need for advanced training in peripheral interventions and vascular surgery education in Latin American countries. A surgeon is ultimately the sum of his or her cumulative operative experience, whether as the operating surgeon or assistant surgeon. Therefore it is imperative to utilize any possible opportunity to maximize this experience.

    Several alternatives for a solution have been sought. For instance, conducting surgical tutorials via videoconferencing or telemedicine undertaking at remote hospitals has been suggested, with positive results. For surgeons however, the hands-on experience is irreplaceable.

    We herein propose to incorporate away rotations overseas, in an exchange fashion between trainees in the US and those in Latin countries, for a number of months in order to improve the experience of US trainees in open vascular procedures and the endovascular experience of physicians overseas. As vascular practitioners in the US of Latino origin, our mission must be to take our strength in education and knowledge to those in need internationally. Guided by the belief that unnecessary amputations increase mortality and have a drastic negative economic impact, proper education and training will greatly improve the lives of the patients, their families and the communities in which they live. This could be accomplished by training and mentoring leading physicians and their team of healthcare providers. The ultimate goal is to create a network of physicians who can exchange ideas, new technologies and rely on each other as resource for vascular care.

    There are several examples of similar educational vascular surgical programs between the US and foreign countries, such as for instance China, that have been recently instituted, with enormous success. We must direct our efforts to the implementation of similar exchange programs between our region and the US. This will require significant dedication of time and financial resources. Fortunately, the recent economic growth of several Latin American countries has attracted the attention of several vascular device companies, and they have expressed their interest in supporting our mission. We have contacted several industry company officers as well as vascular surgery opinion leaders in both the US and Latin America in order for this to happen, and the level of interest is quite high. We believe that this is a project that has an enormous potential to change vascular training and to impact positively the care of vascular patients worldwide.

    The potential positive effects on vascular surgery education and care are limitless. This process would test the trainee’s individual resilience and ability to adapt to new and sometimes strange-seeming situations, which could prove to be a major determinant in whether the future surgeon would thrive in his or her place of employment. This could have the benefit of producing surgeons who can work comfortably in any setting. Their surgical volume experience will be for sure enriched. Several professional networks of vascular practitioners would be created, which would serve as a constant source of future consulting.

    Several caveats to our proposal could be cited. For instance, the negative effects of social displacement, insufficient means to assert operative skills and quality of overseas faculty, language barriers and/or the potentially unsafe situation of some places in Latin America. This must be balanced against the positive results cited above. Away rotations from main campuses within the US have been the mainstay of training in this country. Globalization mandates at least to explore this possibility in this time of uncertainty in vascular surgery training. Our position in the vascular map and the timing is ideal. This is an opportunity that we cannot let pass by.

    Luis R Leon Jr.,1-5

    Miguel F Montero-Baker1-2, 4-5

    University of Arizona Health Science Center, Tucson, Arizona1 Vascular and Endovascular Surgery Section - Tucson Medical Center, Tucson, Arizona2 Arizona College of Osteopathic

    Medicine, Midwestern University, Phoenix, Arizona3 Pima Heart Physicians - Vascular and Endovascular Surgery

    Section4 Pima Vascular PC5

  • Fuente: Revista Técnicas Endovasculares Volumen XVII - Número 3 - Septiembre-Diciembre 2014

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