The need for simulation-based education (SBE) in vascular surgery has gained increasing acceptance, in parallel with a shift from open to endovascular surgery and a change in work-hour legislation1,2. In 2018, a general needs assessment (GNA-2018) identified and prioritised a list of technical procedures to guide the development of future SBE in vascular surgical training3. The next step is to develop and implement these simulation-based training programs ensuring that these procedures can be taught and learned in a safe environment to meet vascular surgical trainees' (VST) needs. In collaboration with the European Society of Vascular Surgery (ESVS) and the Union Européenne des Médecins Spécialistes (UEMS), the VASSIM study aimed to assess the current state of speciality training in vascular surgery, including the availability of SBE recommended in the GNA-2018 and to expose facilitators and barriers associated with its implementation.

The VASSIM steering group, consisting of content experts in vascular surgery and medical education, invited 338 key opinion leaders across Europe to participate in a three-round survey. Invitees were identified based on their leadership positions and membership in different ESVS and UEMS committees and groups. The first round collected demographic information and training status, availability of SBE, and finally a free text submission of facilitators and barriers to implementation of SBE. After a rigorous sorting and categorization in the steering group, the second round asked participants to score facilitators and barriers on a Likert scale 1-5. In round three, the top 15 facilitators and barriers respectively were ranked in order of importance by each participant.

In total 148 responded to the invitation and answered the first round, representing 30 European countries. Respondents were primarily senior colleagues (professor 33%, associate professor 22%, consultant 33%, staff specialist 3%, trainee 8%, and 1% unspecified). In total, 64% of the respondents spent more than 5 hours per week supervising trainees in a clinical environment while only 16% spent supervising trainees more than 5 hours per week in a non-clinical setting (figure 1). The GNA-2018 top three prioritised procedures - basic open skills, basic endovascular skills, and vascular imaging interpretation - are available as SBE in 24 (80%), 23 (77%), and 20 (67%) of the participating countries, respectively (table 1). No pass-fail standard is required to progress to the next level in their speciality training curriculum, according to 59% of the respondents. Most participants (87%) agreed or strongly agreed that there was a need for structured and evidence-based SBE in vascular surgery. When asked if SBE should be a mandatory part of the curriculum, 81% either agreed or strongly agreed. Nevertheless, 80% of the respondents stated SBE in their country was not compulsory (figure 2). The top five ranked facilitators for implementation of SBE (by order): structured SBE programs, availability of simulation equipment locally, good quality simulators, availability of simulation equipment regionally, and a dedicated person to run the training program. The top five ranked barriers to implementation of SBE were: lack of a structured simulation-based curriculum for vascular surgery, costs of simulation equipment, lack of dedicated time for faculty to teach in simulation, no culture of using SBE, and clinical work overload.

The VASSIM study has outlined the current training conditions in vascular surgery across Europe. The use of SBE is widespread, but the need for systematic and structured SBE programs in vascular surgical training with compulsory participation and certification remains. The three highest prioritized SBE procedures defined in GNA-2018 are widely implemented, and as a whole, the availability follows the ranking of the procedures. To stimulate the implementation of SBE in vascular surgical training, structured SBE programs, simulation equipment, and dedicated staff should be available to run these programs, which should be addressed by the vascular surgical community and stakeholders. Clinical work overload, change of culture, and facultys' dedicated time for SBE are areas that must be considered.

[1] Reznick RK, MacRae H. Teaching surgical skills--changes in the wind. N Engl J Med 2006;355:2664-9. https://doi.org/10.1056/NEJMra054785. [2] Joels CS, Langan EM 3rd, Cull DL, et al. Effects of increased vascular surgical specialisation on general surgery trainees, practicing surgeons, and the provision of vascular surgical care. J Am Coll Surg 2009;208:692-7, quiz 697.e1; discussion reply 697-9. https://doi.org/10.1016/j.jamcollsurg.2008.12.029. [3] Nayahangan LJ, Van Herzeele I, Konge L, et al. Achieving Consensus to Define Curricular Content for Simulation Based Education in Vascular Surgery: A Europe Wide Needs Assessment Initiative. Eur J Vasc Endovasc Surg 2019;58:284-91. https://doi.org/10.1016/j.ejvs.2019.03.022.