Adili: Welcome to ‘Vessels in Focus’, the podcast of the German Society for Vascular Surgery and Vascular Medicine. In keeping with our motto, ‘We take a forward-looking approach to vessels’, we explore the latest developments, challenges and opportunities in our field once a month. My name is Farzin Adili; I am Director of the Department of Vascular Surgery at Darmstadt University Hospital and the current President of the DGG. Today’s topic is further training in vascular surgery. How can we design training and continuing professional development in such a way that it works in everyday clinical practice whilst remaining modern, practical and patient-centred? And how can we meaningfully integrate technological progress into training and continuing professional development? I have invited a highly competent guest to discuss this topic: Dr Katrin Meisenbacher, Senior Registrar at Heidelberg University Hospital, Head of the Commission for Training and Continuing Education within our professional association, and a Master of Medical Education – in other words, someone who is also very, very well versed in the theory of teaching. A very warm welcome, Katrin.
Meisenbacher: Hello Farzin, thank you very much for the invitation. I’m very much looking forward to our discussion.
Adili: Yes, with the Hospital Care Improvement Act and the Hospital Reform Adaptation Act, the introduction of hybrid DRGs for practically all vascular interventions, and the efforts to strengthen outpatient care, we are set to face entirely new framework conditions for service provision. And these framework conditions will, of course, also have a profound effect on training and further education in hospitals, but also in private practices. How do you see the situation?
Meisenbacher: Yes, I believe we are indeed at a turning point. These reforms not only have a profound impact on the structure of healthcare – think service groups and greater centralisation – but in our specific context here today, this also automatically means that further training will no longer be possible to the same extent at every hospital. So there will be areas of focus, and we must ask ourselves: where will trainees be able to acquire which skills?
And at the same time, I think that problems we’re already familiar with are also becoming somewhat more acute. We have an uneven distribution of case numbers between the individual centres and the respective hospitals. There’s immense time pressure in day-to-day work on top of that. Operating theatres have to run efficiently; you know that better than I do. And further training often takes a back seat. And ultimately, so does teaching methodology. I think surgical training has been structured in much the same way since the 1950s, as a sort of ‘on-the-go’, ‘learning on the job’ approach. But I believe that, firstly, this is no longer sufficient in a more complex and technologically advanced medical landscape, and secondly, it naturally does not correspond at all to evidence-based medical teaching. That is why we need new and structured solutions or networks.
Adili: Yes, you’re raising an important point. If our clinical caseload changes, if the diagnoses we treat change, then it’s foreseeable that individual hospitals will no longer perform every procedure in sufficiently high numbers. And that naturally also has an impact on service provision. How do you think we could resolve this dilemma?
Meisenbacher: Well, in the context of further training, I believe a practical solution would be for different clinics and practices to go beyond simply working closely together and actually merge. The key is forming networks. And then offering rotation models. This would enable doctors in further training to rotate through different institutions, for example from a university hospital to a specialist clinic and then on to a practice, or in the reverse order. And in doing so, they would naturally gain exposure to a much broader and more systematically structured spectrum, allowing them to learn specific surgical techniques, conservative approaches and, of course, interdisciplinary collaboration. I think this is essentially a paradigm shift. Training would then become less haphazard – or could become less so – and instead be much more structured and distributed more fairly. There are already plenty of wonderful examples of this from other specialist fields. And I believe this also exists on a smaller scale within our own field at many locations.
In my view, the aim should be to formalise this principle for sustainable surgical training through overarching structures – in other words, no more isolated individual programmes, but rather networks into which each institution can contribute its strengths. This is then reflected at the organisational level in such a way that training is no longer merely a matter of chance, but a predictable pathway. I think that would be a very good way to counteract this.
Adili: Yes, we need to move away from viewing teaching merely as a side issue or as something that is a ‘nice-to-have’, but rather as a central part of what we do, alongside patient care and, of course, research at universities, on the one hand. But on the other hand, this does of course require that we practically align our curricula and coordinate even more closely how we can offer young people a seamless continuing professional development programme, even though they work in completely different institutions – outpatient, inpatient, but also in hospitals at different levels of care. What do you think is needed to achieve such harmonisation in these curricula and to ensure that there is a binding commitment to actually implementing what is set out in these syllabuses?
Meisenbacher: That is an important and, at the same time, difficult question. Well, I believe there are several levels that need to be addressed here. One is the methodological level. We need to modernise our teaching methods. We simply can no longer apply the ‘see one, do one, teach one’ approach in modern medicine, and certainly not in surgery. We’ll no doubt come back to that shortly. And then it’s certainly also a question of how we can train the trainers. In other words, ‘train-the-trainer’ concepts or ‘teach the teacher’. Of course, this has always been part of clinical practice – and for most people has been so for a very, very long time – but under different conditions than we have now. And if we say we want to create binding and overarching structured curricula that work for many sites, then we need not only ideas for content but also methodological expertise.
Adili: Yes, I can only agree with that. And yet we will also need to reach binding agreements on this, so that trainees can actually rely on the fact that, when they do rotate to a particular site, what is actually stated on the door or in the curriculum is indeed put into practice. If that isn’t the case, there must be some sort of sanctions in place, or at least a feedback mechanism must be established to ensure that training is actually provided in a binding manner, so that young people are willing to go to other institutions and don’t feel that, yes, they’re rotating out and then somehow end up in a sort of limbo.
Meisenbacher: Absolutely.
Adili: You hinted earlier that ‘see one, do one, teach one’ cannot be the future of teaching, simply given the demands of patient safety and the fact that every patient will be treated by a specialist and not used as a guinea pig. What do you think are modern methods for moving away from ‘see one, do one, teach one’ or from trial and error – which is, after all, a widely used construct in learning theory? What options are there? What are you doing in Heidelberg?
Meisenbacher: I’ll start with the bigger picture. Well, I believe that if you think about it purely from a didactic perspective, the reality is that modern continuing education now features many multimodal learning environments and approaches. These include simulation training – I’ll come back to that in a moment – but also support through virtual reality, and increasingly artificial intelligence; a lot is happening in this area, and simulation in particular plays a central role, especially in our field. We can already practise minimally invasive procedures such as TEWA and EVA very, very effectively on high-fidelity simulators. Some of these even offer haptic feedback, realistic imaging and variable complications. That’s a huge step forward. So we can no longer allow mistakes to occur on patients, or rather, they no longer happen directly on patients, but in a safe learning environment. Of course, there is always a bit of a counter-argument or difficulty: open surgery is significantly more challenging for simulation, in terms of access, complications and emergency situations. Nevertheless, there are, of course, good solutions for this too. Perfused models allow you to at least practise suturing and learn standard anastomoses, and this can then be supported by virtual reality – that is, immersive experiences – which can be practised repeatedly and in a personalised manner. In my view, simulation training is truly a key point. It can be considered important on several levels. We’ve just touched on technical skills – mistakes as learning opportunities that I can practise again and again and am actually allowed to make. And, of course, the aspect of non-technical skills. You mentioned it: patient safety. We know that the majority of errors and complications in surgery actually have less to do with technical causes and are instead due to team and communication problems. And that is just as important; it involves communication, teamwork, situational awareness, decision-making under pressure – all these things are part of our everyday clinical surgical practice, and all of them can be practised in simulation. In other words, we don’t just practise manual skills, but also collaboration and working together as a team. That’s how I’d put it. That’s also something we do here on a small scale, for example in our clinic – not just in postgraduate training, but also for the students.
Yes, I believe that, particularly given the circumstances we’ve already mentioned – working hours legislation, a shortage of young talent – we need to make training much, much more efficient and structured to integrate this, so that we can still learn all these skills and competencies. And one aspect that’s worth mentioning again is financial resources, of course. Operating theatre time is expensive; materials are expensive. And if we can shift part of the practical training to simulation centres, it’s likely to be cost-effective in the long run. The question is, how can we formally incorporate this into our further training regulations, for example?
Adili: Yes, you’re raising an important point there. You also mentioned finances and resources. What you’ve just described – perfused models, high-fidelity simulations, immersive scenarios – all of that costs money. And I’m imagining our colleagues in the individual hospital departments; it’s going to be very difficult to set up a suitable simulation lab in all 330 of the hospital departments we have. Absolutely. How do we best solve this? I mean, basically everyone needs to have access to such resources. Where do you think we should base this, and how do we organise it? Do we do this solely on an extra-curricular basis through courses, such as those we offer at the DGG Summer Academy? Or surely there needs to be more than that for the future?
Meisenbacher: Yes, well, you’ve just mentioned the Summer Academy. It’s true that we already offer courses, but currently they’re extracurricular. That means anyone who’s interested, who wants to, who’s able to, and so on, can attend these courses and, I believe, learn a whole lot of great things there. But it will still only be accessible to a fraction of the trainees, because there simply aren’t enough places. And I completely agree with you – of course it’s brilliant, in theory, to have such simulation centres or to view simulations as a fundamental method. But if it isn’t put into practice and if it isn’t feasible for the locations and the infrastructure, then it’s no good, to put it bluntly. And I honestly believe that networking and cooperation are very important for this too. You don’t need a simulation centre at every hospital, but it’s certainly possible to organise simulation days regionally or perhaps even across regions, for example for different clinics. You don’t always need a high-fidelity simulator either. You can quite simply – we’ve built models here, for example, using just a few pipes and cable ties – and these are ideal for very junior doctors, who don’t need a high-fidelity simulator. They can practise on these how wires work, how catheters work, and how to handle them. Anyone can build these themselves or borrow them from someone else. I believe we need to join forces for this too. It certainly isn’t feasible at each individual site.
And ideally, we would integrate the model-based exercises and simulation in such a way that a certain number of simulation runs, whether in different courses or at different centres, are recognised as training towards case numbers. Let me put it this way: we don’t want to move away from clinical caseloads. Nevertheless, this does reflect competence. We’ll certainly come back to that. But at the moment, this isn’t provided for in Germany. In other countries, of course. The USA, Scandinavia – and I mean Switzerland too – require a certain number of simulation centre sessions.
Adili: So I think it’s important that we, as trainers, demand that it has a fixed place in our curricula. And that we, as a professional association, but perhaps also as individuals, take the initiative to ensure that we maintain, create or finance these capacities. One can certainly take this a step further. After all, this doesn’t just affect us vascular surgeons, but certainly other surgical sub-specialities as well. When I think of open surgery now, for example laparotomy during open aortic surgery, we could of course share resources and then, naturally, share the costs as well. But I believe we will still have to invest a great deal of energy in building up the infrastructure needed to truly enable everyone to access these modern methods.
Meisenbacher: Yes, I agree. I see it exactly the same way. And I think it’s important to emphasise once again at this point that surgery remains a practical profession. Simulation shouldn’t replace anything, not clinical training. But it’s simply a wonderful method to complement that, to systematically build our skills and reduce errors. I think it’s important to reiterate here that we don’t want to advocate using simulation instead of real operations.
Adili: Yes, we now represent, so to speak, further training under the umbrella of the German Society for Vascular Surgery. And we have our Summer Academy, for example. We have our own courses or courses accredited by us from various providers who offer such programmes. And we simply need to promote the fact that such opportunities exist. And we should encourage training providers to actually send their staff to our courses. And at the end of the day, a certificate is awarded. One could imagine something similar for endovascular surgeons or specialists, at least for endovascular techniques and open surgery.
Meisenbacher: Absolutely.
Adili: So how does all this with simulation fit into the trend towards competency-based continuing medical education? We’ve had new continuing medical education regulations since 2018, implemented in 2020. They’re called competency-based. How does this now fit into this competency-based continuing medical education?
Meisenbacher: Perhaps I should briefly define this concept of competence-oriented or competence-based further training once again. Well, most of us grew up in an era where the focus was ultimately on what the trainee specialist had completed by the end. In other words, how many cases had they handled and how long had the training taken. Now, the focus is more on looking at what sort of doctor we actually want to have trained by the end. So we want to look at what they can actually do, rather than how much of it they have done. And if you now want to define that and provide further training accordingly, then you automatically have to ask: how can I actually make someone’s abilities measurable? So, for example, if I, as a senior consultant, assess a junior doctor’s competence in performing a procedure or carrying out a task, that is, in a way, very subjective. But that shouldn’t be the goal. We must try to make it measurable. And simulation centres are, of course, a good way to do that. I’d be happy to elaborate on how we could approach this measurability.
Adili: Yes, go ahead.
Meisenbacher: Right, well, I think it’s like this: when you have such a fine theoretical construct of competence-based training – and as you just said, the training regulations are already a few days old – implementation in clinical settings is likely still more or less the same as before at the vast majority of sites. This surely has a lot to do with the fact that people simply don’t know exactly how to implement it. What we need is a bridge between this theoretical, competence-based training concept and the real clinical workplace. To this end, a concept developed as far back as 2005 – quite a while ago, in fact – is recommended. It is called Entrustable Professional Activities, or EPAs for short. And these EPAs no longer describe me as a person, but rather describe a task that I carry out – clearly defined tasks that we can entrust to a trainee once the necessary competence has been demonstrated. Let me give a few examples from vascular surgery. These could include duplex scanning, post-operative management, or the management of acute limb ischaemia. Within these EPAs, there are various competencies: knowledge-based competencies, understanding, and practical skills. And these can then be discussed and assessed through workplace-based assessments. I won’t call it ‘testing’ – that’s always a tricky word. And in the end, the relevant trainer knows that next time I’ll either just need to stand by or perhaps even just be available by phone, and that I can entrust them with this task.
And now the connection should actually be: how does this fit into the context of simulations and skills labs? I believe these are actually ideal for this, because we can practise it successfully in the simulation. We can do it there under supervision or under facilitation. We can carry out the assessments there, and do so in a completely transparent manner. Where are the gaps? Which sub-competence is still lacking? What might need to be practised again? And then you can transfer that to the operating theatre. And ideally, we would use some form of digital assessment recording. Apps, for example, are very common in many countries for this purpose, and can be easily integrated into everyday life with very low barriers to entry.
So I believe it would be helpful, also for the curricular integration of competence-oriented continuing education, to map the content of our continuing education regulations into EPAs and then transfer these into clinical training in a structured manner. We in the Commission for Education and Continuing Education, as you know, are currently working on creating such EPAs for vascular surgery. And the aim, of course, is to expand these gradually and then make them available to the professional association, to all members of the professional association, so that we can simply work in a more practice-oriented, modern, measurable and also comparable way. I believe this is how we can ensure quality in the long term. And that is the goal for patient safety, but of course also for the quality of our further training and for the next generation.
Adili: Exactly, that would have been my next question. How does one, as I might say, a run-of-the-mill trainee or trainer, benefit from these EPAs? How does one access them? And there is already quite a bit available, including international publications from the USA, but also from the UK and Switzerland, which have, of course, been using EPAs in training for many years. And we at the DGG have now made it our mission to actually translate our continuing medical education regulations into EPAs in a practical way. Then every trainer will know how to actually teach a specific competence in everyday clinical practice. What are the learning objectives? Which teaching methods can be used to achieve this in the clinic? And last but not least, you said, yes, we don’t like testing or assessing, but teaching without testing is like cooking without tasting. Without testing, without convincing ourselves that someone has actually mastered a competence, we will never make our trainees aware of their own shortcomings, nor will they be able to recognise them and work on them. And on the other hand, we won’t know how good we are as teachers and what we might need to do to improve the training programme.
Many of you listening to us now are surely wondering, what can I put into practice as early as tomorrow? Or how can I get the PS out on the road as quickly as possible? Competence-based further training ahead of the EPA era, which will hopefully begin very soon for us.
Meisenbacher: Yes, we hope so. But there is actually still a bit of work ahead of us. And I think it’s also – as we briefly touched on earlier – that one cannot expect us to fundamentally change everything all at once, nor can everyone completely overhaul their own training concepts, as every clinic has its own. But I think what we can do quite effectively is to integrate very small, more modern teaching methods into our daily routine and at least raise our team’s awareness a little bit that they exist. You don’t need a huge investment for that; you don’t need a skills lab, nor do you need much money. Let me just give a few examples. Keyword: micro-teaching. You know that very, very well too. Yes, we don’t always need long training days that only take place once or twice a year with nothing in between; instead, we can easily and simply incorporate very short teaching sessions into our daily routine. For example, we perform duplex sonography, and afterwards I take ten minutes straight away to discuss the specifics of haemodynamically relevant carotid stenosis with my colleagues, for instance. Or in the operating theatre, we perform a bypass and then take some time afterwards. You could call this feedback, but if you simply formalise it consciously and integrate it, it’s often hugely effective, and spontaneous learning opportunities frequently arise as well. In teaching, we call these ‘teachable moments’, but the name isn’t really that important; rather, I believe it’s a question of how I direct my attention towards them.
Yes, here’s another example from the last few days: a patient is hoarse following carotid surgery; you can simply take note of this during rounds, or you can discuss it specifically in that context. And you can do this together with the students and trainees. Why is that the case? What exactly is the recurrent nerve? What are the risks? How do we proceed from here, and so on? Or another classic example is vasospasm in angiography. We can either just accept it, or we can explain the situation and discuss the causes and management straight away, thereby integrating lots of little training units. These often stick incredibly well with the trainees because they’re simply linked to a current and real-life situation. It’s one way, for example, of integrating something like this very easily into everyday practice. And it’s an evidence-based method, apart from anything else.
Adili: Yes, absolutely. It makes perfect sense. For those interested, I’ve taken the liberty of compiling some of these methods for the latest issue of the Vascular Surgery journal. So anyone who’d like to read it is welcome to have a look at the latest issue of Vascular Surgery. Yes, continuing education thrives on creativity, collaboration and trying out new things. Or how do you see it, Kathrin?
Meisenbacher: Yes, I see it exactly the same way. I think we’re currently inclined to view everything in a slightly negative light. Everything is changing in the healthcare sector. We no longer have young talent, we no longer have money. Everything is speeding up and the framework conditions are changing. But you can also look at it from the other side. I believe it could just as easily be a huge opportunity, because we now have the chance to actively shape this as a professional association, but of course also as every individual manager and senior consultant involved in continuing education. So every hospital, every practice can already take small steps today. And it might sound a bit melodramatic put like that, but together we can always change the bigger picture. I believe we are at the beginning of a very exciting development. And in my vision, in my ideal scenario, further training would – hopefully soon, but probably within the next ten years – be such that we really have individualised learning pathways. So everyone has a digital logbook. We don’t just document; we link learning recommendations. This is individually tailored. We create hybrids of simulation and clinical practice, which can also be incorporated into further training and specialist accreditation. We have networked structures as standard. We have very clear rotations. A much broader spectrum of experience emerges. We integrate non-technical skills; that is very, very important to me personally. Communication, teamwork. These are trained just as naturally as performing an anastomosis. And yes, international networking would be even better. I think that’s actually really good and easily achievable these days. There are podcasts like this one. There are podcasts in many other surgical societies in Germany and internationally too. And nowadays, it’s also very easy to take part in online simulations with others, for example. I believe this would be a form of further training that is patient-centred, modern and sustainable, and which makes our speciality attractive to the next generation. That, I believe, is the exciting thing about it.
Adili: So the hospital reform and everything that lies ahead – and which makes us all a bit anxious – does have a positive side after all. Or, to paraphrase Churchill, ‘Never let a crisis go to waste.’ We’re using this crisis to actually make things better. Yes, our time is up, dear Katrin. Thank you very much for the insights and the practical tips, and to everyone listening. If you’d like to take a look at what the private academy has to offer – that is, our course offerings – you’re welcome to do so on our website. The relevant simulation training sessions and courses are also posted there. And if you have any other questions, do have a look at the show notes, and of course you can contact Katrin and me directly at any time. Dear Katrin, thank you very much once again. I’ve really enjoyed this. Would you like to say anything else?
Meisenbacher: Yes, thank you for the invitation. I’ve really enjoyed it too. I’m delighted that we’re covering this topic here in this podcast. And thank you very much.
Adili: That’s all for today’s ‘Focus on Vessels’. I’ll say goodbye for now and hope you’ll continue to support us and tune in again next time. Thank you very much.
