Divisions deepen within vascular surgery.

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Divisions deepen within vascular surgery.

The divisions between the Executive Council of the Society for Vascular Surgery (SVS) and the SVS members on the American Board of Vascular Surgery (ABVS) have widened following a decision in June 2007 by the SVS’s Board of Directors to withdraw its cooperation with the ABVS and end all financial support for the organization. It is feared this latest breakdown in the relationship could damage the long held ambition of achieving independent status for vascular surgery.

According to the ABVS, the SVS withdrew from all discussions (and financial support) in an apparent effort to diminish the ABVS’s impact and role in gaining independence for vascular surgery. This action “was performed unilaterally without consultation with SVS members on the ABVS Board and without discussion with or approval of the membership of the SVS” (ABVS Newsletter September 2007). Following this, the SVS Executive Council then appointed an SVS Committee to explore the options for independence and announced the formation of a Vascular Special Action Committee (VSAC) in an e-blast to all SVS members dated July 25, 2007. No agenda or plans have been submitted to the membership. Vascular News talks to Dr Robert Hobson, current Chair of the ABVS, about the current impasse and how the ABVS can move the situation forward: “The SVS committee has eliminated the size of its support and they have appointed their own committee to evaluate independence and other options. One option is to become part of a family of Boards under the American Board of Surgery. This would constitute a cosmetic change only from our current position, as we would still have to go through the ABS for major decisions and selection of leaders. “The ABVS directors, who also represent vascular surgery and individual vascular surgeons are having a difficult time, also and have a limited understanding of why the SVS Executive Council has conducted itself in this unilateral decision making…it was particularly disappointing to see the ABVS disenfranchised without informing the SVS Membership and gaining its approval without any formal review of whether the SVS membership favored an independent ABMS-approved Board or not.” According to Hobson, an Independent Board is needed as vascular surgery has matured enough to be so recognized as a separate specialty which should not have to filter its major issues through general surgery. Over the last several years, competition between specialties to provide care for vascular disease patients has grown. This competition for non-cardiac vascular patients has grown recently with cardiothoracic (CT) surgeons becoming more aggressive about including non-cardiac patients in their area of expertise and vigorously pursuing endovascular training (eg. thoracic aortic endografting, etc.). He claims that these surgeons are basing eligibility for vascular specialty designation on their General Surgery (American Board of Surgery – ABS) Certification, and they are motivated to do so by the decreasing number of for coronary bypass operations. Other competition comes from Cardiology and Interventional Radiology as well as some interest from Vascular Medicine. In order to preserve the specialty of Vascular Surgery, the ABVS claims independence would allow vascular surgery to develop its own training programs through a separate Residency Review Committee in Vascular Surgery (RRCVS) and Individual certification by an Independent ABMS-approved Board of surgeons broadly trained in vascular surgery and totally committed to this specialty. “I think some of leaders believe that by maintaining our links with general surgery, it is better for our future trainees. I also think that some are vested with the ABS, and if we were to achieve independence they may lose their position within the ABS. There are also issues to do with General Surgery Program Chairs. Their disposition is different as they have to deal with training and financial matters for their departments,” added Hobson. “Now if you believe that the interests of your department are best suited by maintaining the status quo – you would be opposed to independence, as it would transfer control to the vascular chief. All of a sudden that would denote a departmental status to vascular surgery, equal to that of general surgery. “We reject the argument that approval of independence for Vascular Surgery results in fragmentation. As a patient, if you had an abdominal aortic aneurysm, you would want to go to the best qualified surgeon; someone who can offer open or endovascular repair. That is not a case for general surgeons who have had limited experience with vascular surgery during their residencies. Focused expertise will consistently win out over generalized training. This is not fragmentation, but is reflective of improving patient care.”

Primary certificate

Although, Hobson and the ABVS welcomed the Primary Certificate, he claims the balance of power still remains with the ABS. The society’s membership recognized that the Primary Certificate should be a way station to an independent Board status in a questionnaire supervised by DeLoitte and Touche in 2004. Although this wording was rejected by the ABS, the primary certificate has been a step in the right direction because it was an acknowledgement by the ABS that some of our trainees wanted to do vascular surgery instead of general so it allows them to become certified in vascular alone. “It also allows Program Directors to organize program that are innovative, which widens the opportunity. However all these programes must be approved by the ABS and are therefore not under the control of vascular surgery. With an expanding population – we need more surgeons that are trained in vascular disease management, but will RRC-surgery allow that to happen? If we had a separate board, we could automatically determine whether the programes could be approved. The basic fact remains that there is no autonomy as we still have to go to the ABS – even though vascular surgery has evolved as a specialty quite separate from general surgery.”

 

Future direction

“We see the ABVS as a vehicle for change and will recommend alterations in the bylaws to make the election process of the SVS more transparent and democratic, so we may develop a voice on the SVS Executive Council to balance the current leadership. The ABS acknowledges that we perform open surgery, but endovascular therapy is now emerging as the dominant procedure and we all have responsibilities for vascular laboratories as well as advances in newer techniques for vascular imaging. We would like the ABS to acknowledge that we are really vascular specialists not vascular surgeons alone. The term surgeon is no longer a description of what we do, 10-15 years ago it was but now we are about vascular disease management.” As a result the ABVS Board members voted in favor of a name change from The American Board of Vascular Surgery, Inc. to the American Board of Vascular Specialists, Inc. While we have worked industriously to obtain designation as “surgeons”, it may alter the American public’s perception of the specialty and its range of treatment options, which is a major goal of this proposal. “We recommend that the society submit an additional application to the ABMS for a separate Board. This ’Specialist’ definition may make it more difficult for the ABMS to turn us down out of hand, because we will not be applying for a Board (VSB-ABS) that already exists as we would be applying for the redefined specialty designation. We are prepared to collaborate with the SVS’s newly established committee on independence. We would like to have a serious discussion and involve all colleagues within vascular surgery, because if this infighting continues we may not have a specialty to defend in the future,” Hobson concluded.