President-elect of the Society for Vascular Surgery, Ronald Dalman, talks to Vascular News about various aspects of his career. He also considers future development in the field and offers advice to aspiring surgeons.
What led you to become a vascular surgeon?
Experience with mentors and role models—in medical school, Professor Gerald Zelenock at the University of Michigan was my advisor and confidant. He, along with future vascular surgeons Robert Zwolak and Timothy Kresowik and vascular section chief James Stanley inspired me by their example: knowledgeable, capable, confident, and compassionate leaders in their respective domains. During residency in the vascular surgery division faculty at the University of Washington (UW) in Seattle, D Eugene Strandness and Alec Clowes, were equally inspirational in their own way—always asking questions, striving to understand the natural history of vascular disease, leveraging the (then) new abilities of medical ultrasound and physiologic testing to increase diagnostic precision, guide intervention and optimise care. It did not hurt that Kaj Johansen, chief of vascular surgery at Harborview Medical Center and a pioneer in protocolised regional management acute aortic emergencies, also served as the surgery residency program director. Of all the surgical subspecialties represented at UW in the 1980s, vascular and trauma surgery were at the forefront of their respective areas of research and innovation. During fellowship with John Porter, Lloyd Taylor and colleagues in Portland, Oregon, I learned the true meaning of the term “high-quality vascular surgery” based on their example and uncompromising standards.
What are the most significant ways you have seen the vascular field develop over the course of your career?
Well, the endovascular revolution, now in its third decade, and its integration into mainstream vascular practice, is the most obvious answer. But quality vascular practice today has benefited from so many landmark accomplishments: the development of evidence-based practice, as enabled by the Vascular Quality Initiative and similar registry initiatives; the blossoming of effective medical management options to improve longevity and quality of life in vascular patients; the initiation and success of direct training pathways worldwide for vascular specialists, and the corollary recognition of vascular surgery as a distinct and primary medical specialty; the convergence of vascular specialists worldwide into highly influential writing and consensus committees such as the Lower Extremity Global Guidelines Writing Group… far beyond any one procedure, device or outcome assessment metric, the recognition that quality vascular care is an essential element of good overall health, and deserving of substantial capital and intellectual development by surgeons, healthcare systems, and corporations world-wide is the defining development of my professional lifetime. Keep in mind that the Society for Vascular Surgery (SVS) was founded to champion and celebrate excellence in the technical management of vascular disease by surgical pioneers of the early 20th century. While remaining committed to that ideal, the concept of the “vascular specialist” has come to mean so much more to both the public and our professional colleagues—an extremely validating transition to experience over the last three decades.
How do you anticipate the field might change in the next decade, and what developments would you most like to see realised?
Acknowledging that predictions are generally a fraught exercise, the societal and financial trends driving the volume to value transition are an undeniable and relentless catalyst for change. We will almost certainly see an ever-increasing emphasis on quality and cost-effective outcomes with a framework of population-health considerations. Holistic patient, rather than symptom, management is already becoming the norm. Within a resource-constrained environment, how do we optimise vascular health, function, and quality of life? How do we precisely quantify the benefits that accrue from vascular interventions when necessary? Technical surgical excellence will always command a premium—where, when, and how can it be delivered in the most cost-effective and sustainable manner possible? The “Medicare for all” controversy roiling political discussions this year in the run-up to the 2020 US Presidential Election is only just the beginning of a much larger health care re-organisation in the USA and most developed nations worldwide. Healthcare resources will flow to those with the best justification for their need—that is our challenge, both individually and collectively—to make the case that vascular care remains a top health care priority.
What do you hope to achieve as president of the SVS?
This question has challenged all my presidential predecessors. For some, the moment was thrust upon them; Peter Lawrence stepped up to address the challenge of overutilisation and ethical practice considerations in response to the seminal New York Times (NYT) report in 2015, and in doing so defined our speciality and membership as voices of reason and restraint in this critical discussion. For others, such as Michel Makaroun in 2019, championing recognition of the more subtle but no less compelling challenge of maintaining access to quality vascular care at a critical juncture in the evolution of our specialty has been a more planned and predetermined focus. In survey after survey, our members convey pride in the care they provide to some of most vulnerable members of our society, while at the same expressing frustration at the lack of recognition that vascular surgeons receive for the essential role(s) they play in the healthcare system. As a corollary to Makaroun’s access to care focus in 2019, the SVS launched a multi-pronged effort to accurately value and brand the essential services vascular surgeons provide to our society. Both my immediate predecessor Kim Hodgson and I are building off these efforts to ensure that quality vascular care is appropriately recognised and rewarded by the public and our many partners in health care financing and delivery. Assuming no unanticipated NYT-level disruptive moments this coming year, we plan to leverage the branding, valuation, and wellness initiatives, when they are complete, to proportionately recognise and reward the value that vascular surgeons provide to our healthcare system.
What advice would you give someone starting their career in vascular surgery?
Once you are comfortable with your surgical skills, judgement, and practice rhythm (and this usually takes more than a few years), when working in a larger organisation such as a university or employed position, several axioms have served me well. First, know yourself—develop your own career path, be the surgeon/investigator/partner/mentor you want to be, not who you think others want you to be. This is most important for long-term career and personal satisfaction. If your current situation is not providing you the opportunities you want, look elsewhere. Secondly, strive to understand what is expected of you in all circumstances. This cannot be stressed enough—if your personal goals are not well-aligned with those of your partners or larger organisation, neither you, nor they, will reach them. Thirdly, collaborate aggressively and ambitiously across disciplines—for myself, the strongest and most powerful collaborations arose from individuals and groups far afield from my department and school. Commercial entities, complementary disciplines such as engineering, health policy and research, implementation science—these relationships have provided me with extraordinary opportunities in my own career. As vascular surgeons, we have unique insights into novel solutions for common problems. As you gain experience and success in your own career, those hard-won insights are intellectual bitcoin for powerful collaborations—leverage them to their full extent. Finally, own the problem—we in our specialty are uniquely privileged to provide full-spectrum care for an increasingly common, morbid, and highly expensive spectrum of disease. As emphasised on the #comprehensivevascularcare Twitter thread, our future depends in the breath of our expertise and ability—not mere technicians, diagnosticians, risk-factor experts or public health advocates, but rather all of that, and more: vascular surgeon specialists. Our value is, and should remain, as experts of the disease process we have worked so hard to understand. That expertise provides our patients the ever-improving quality of life they have gained under our care and the success and influence our specialty enjoys today.
How do you like to spend your time outside of work?
Time with my wife Jocelyn, a general surgeon, and our two adult children Jessie and Jackson. We love living in Northern California and being part of the Stanford Community. When we have time together outside of work we enjoy playing golf, snow skiing, bicycling (mountain and road), and just being outdoors in and around our home in Portola Valley.