LAUSR

shortage of vascular surgeons, but if we diminish the number of training programs by centralizing cases, what trainee will want to go to a hospital where the vascular surgeons refer complex aortic cases elsewhere? Such a policy will certainly result in fewer training programs, unless the fellows at the low-volume hospitals are shipped out for months at a time to the high-volume hospitals. But we all agree we must do what is best for our patients. This study illustrated that natural selection may play a role in centralization. More than 10% of low-volume hospitals in this review stopped doing open JR-AAA repairs during this time period (although the authors point out that some continued to do a low volume of cases). This result occurred not because the surgeons were ordered to send their patients to a higher volume hospital but more likely because the surgeons at the low-volume hospitals did not feel comfortable doing these rare cases anymore, or even more likely, patients with complex aortic aneurysms were not being referred to the low-volume hospital anymore. Word gets around.