Throughout 2006, some of the most leading and influential vascular, endovascular and interventional specialists from Europe and North America have been featured in our ‘Profile’ section of Vascular News and its sister publication, Interventional News. This has given them the opportunity to voice their opinions and ideas on important matters such as training, differences in practice between countries and the increasing need of co-operation between vascular surgeons and interventional radiologists…
A European perspective…
According to Mr John Wolfe, past-President of the Vascular Society, the future of vascular surgery and interventional radiology lies with greater co-operation between both specialities: “I do not see any future for treating vascular specialists who have the capability of dealing with the patients whether their condition requires medical, surgical or endovascular treatment. There are an increasing number of patients where a radiologist and a surgeon are working simultaneously to produce a result.” Interestingly, he added that the Vascular Society is working very closely with the Royal College of Radiology on a curriculum for interventional vascular radiologists and vascular surgeons on a combined programme for the two specialities. “Obviously if we achieve that it would be fantastic because I do not think any country in the world has been able to get full cooperation between radiologists and surgeons,” Wolfe concluded.
In discussing how vascular surgery has changed over the years, Professor Frans Moll, said for him the most fundamental change has been the establishment of evidenced-based decision-making and clinical epidemiology. “When I first started to do vascular surgery in the 1970s we were extremely happy if the patient left the hospital alive and not crippled – but now we are really benefiting the patient – and that is the most fundamental change,” he said.
Moll added that the biggest challenge of the future was the correct implementation of new technologies for both percutaneous and minimally-invasive technologies: “We must decide – what disease for which patient and at what moment should they be treated and how should they be treated. Of course these answers will only come from evidenced-based research.”
Professor Jean-Pierre Becquemin highlighted the problems of recruitment in France and called for a unified training system: “We have a problem with attracting trainees; each year there are fewer trainees coming through. Also in medical school, 75% of students are women and few of them are attracted by such a demanding speciality. This is a problem because people in France and throughout Europe are living longer, and more people will require vascular treatments. Thus if there are fewer trainees, sooner or later there will be a problem. A unified training system is necessary. The UEMS certificate is an excellent first step.”
Professor Jesper Swedenborg, discussed his achievements during time as President of the European Society for Vascular Surgery: “I’ve tried to contribute to a change in the meetings. We have added two symposia sponsored by the Society itself, which will give the audience and the members robust rules how to handle some of the core elements in vascular surgery. We have incorporated the European Association for Vascular Surgeons in Training which was a separate unit, we’ve managed to negotiate with them and now they’re into the Society which I think is a good achievement because we can build from below and get our younger colleagues to work within the Society.”
He also echoed the words of Moll when assessing the greatest challenges facing vascular surgery: “The evolution is going very rapidly with the introduction of endovascular methods and that’s a challenge. How we handle that is and will, be very important. It’s been exciting – nothing is the same as it was really and endovascular surgery can make a revolution. But we have to be careful and watch for pitfalls.”
An American perspective…
Dr Bob Rutherford agreed with Moll and Swedenborg that the greatest challenge of the endovascular era is how to evaluate the new technologies: “It is becoming harder and harder to objectively evaluate these new technologies. It takes at least five years to organise, enrol, perform and analyse a properly powered randomised intervention comparison, something we don’t seem to do as well in the US as the UK and Europe.”
He highlighted the changes he had seen in his career: “In the first part of my career, vascular surgeons devoted themselves mostly to developing and refining open arterial reconstructive techniques, concentrating on the different bypass and anastamotic configurations, and comparing the performance of different bypass grafts. Then we sort of hit a plateau of refining and comparing existing open techniques during which we turned to methods of outcome assessments and uniform reporting standards. Then endovascular therapies came along, using percutaneous approaches, and nothing has been the same, or stable, since. Evaluating endovascular techniques is particularly difficult because of the rapid technological advances.”
He then discussed the various training paradigms and the likely affect this will have on vascular surgeons: “I believe all the new shorter training paradigms will end in a specialisation within our specialty, with some concentrating on certain aspects of what we identify as vascular surgery more than others, which might work fine in larger group practices, but be difficult in smaller practice settings. Although we are seeing vein clinics, with surgeons who only deal with venous surgery, springing up all over the US. Meanwhile positions in our fellowship training programmes are going unfilled. In the face of all these changes and challenges, I feel blessed to have had my professional career fall during the ‘golden age of vascular surgery’.”
Dr John Bergan, President-elect of the American College of Phlebology, outlined his aims as the next president of the College: “There is a great need to provide resources for the next generation of phlebologists. Phlebology is now a designated medical specialty sanctioned by the American Medical Association. This means residents can now select phlebology as their primary or secondary area of practice. It also means that we can provide education and post-graduate training in the best ways to deliver treatment. There is a prime need to create and expand venous training programmes and find investments for venous research,” he added.
Away from training, Dr Rodney White, spoke of his concerns regarding the Agency for Health Research and Quality’s report regarding EVAR for abdominal aortic aneurysms. He said the report, which threatens funding for high-risk patients in the US (70-80% of the US indication for this therapy), is based on data that is available from sources that do reflect the US experience with endografts in high-risk patients.
He added that EVAR is a very rapid and developing technology that is still in its infancy and needs encouragement from the agencies, not the withdrawal of funding at a very critical stage. The SVS has taken measures to represent these views: “The Society has adopted the view that is recognises and accepts its responsibility to be the leader in addressing issues related to care of vascular patients. A priority for the Society has been development and implementation of outcomes tools not only to provide data on patient outcomes but also to provide appropriate data on which to make regulatory and payment decisions. The SVS is also making every effort to collaborate with other societies and regulatory agencies, in particular, with the America College of Cardiology and Society of Interventional Radiology, in an attempt to satisfy the need for parity in data collection and analysis”
Interventional radiology views
Dr Tony Watkinson, echoed the words of John Wolfe in welcoming greater co-operation between societies: “I foresee a continuing growth and increase in endovascular and minimally invasive solutions to manage an increasing number of acute and chronic conditions. All this will hopefully mean the expansion of current training ideas into other specialities and will prevent many of the turf war battles that have occurred and are occurring in other parts of Europe and the USA.”
However, Kathy Krol, past-President of the SIR, believes that in the US at least interventional radiologists have benefited through co-operation with other specialties; “I think we have conquered, to some extent, the competition we faced. I think collaboration with other societies, specialities and with different levels of caregivers is essential. We are also addressing the issue of people not knowing who we are or what we do – we have strategic planners working on this now. It is how we are perceived, it is hard to describe what an interventional radiologist does.”
According to Gary Becker, past-President of the SIR, the expansion of interventional radiology into other areas (such as interventional oncology) can only be achieved through the an interventional radiology gaining the unique attributes necessary: “Interventional oncology has traditionally involved medical oncology, surgical oncology and radiation oncology – in each one of those a specialist brings to the table a unique orientation and a unique set of skills. Now, if the interventional radiologists want to stand shoulder to shoulder in equal status, they are going to have to demonstrate something unique that they can bring to the table.”
Dr Bob White commented that away from turf wars, training programmes and endovascular techniques, patient care skills are a fundamental part of being a physician: “I’m Oslerian in my thinking (from Sir William Osler, the Oxford Regius professor of medicine who established the concepts of residencies at Johns Hopkins in 1886). His teaching was that you were a better physician if you obtained a complete patient history prior to any treatment. I think we must adopt this 150%. What I try to teach is that patient history and follow-up are everything in interventional radiology. We started an interventional radiology admitting service at Johns’ Hopkins Hospital in 1980. When I came to Yale I started an admitting service here as well. I’ve written a lot of articles about how to practice interventional radiology. Having said that, I don’t believe that an interventional radiologist needs to know every medicine or all the care like an internist. We depend on consultants. I want to be thought of as a referring doctor as well as an admitting doctor.”