What vascular specialists think

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Issues about training, leadership and centralisation were discussed by our European vascular specialists, while independence of the specialty and training issues were hot topics for their North American counterparts.The European perspective

Dr Elias Bastounis, Chairman of the Department of Surgery of the University of Athens Medical School, discussed challenges facing vascular surgeons in Greece. He highlighted the increase in the number of trainee surgeons, and the conflict with radiologists and cardiologists.

“The number of young people entering vascular surgery has increased,” said Bastounis. “The waiting list for training is from one to 10 years which means that we will soon be facing the problem of ‘medical inflation’ already confronted by other disciplines.

“There is also a conflict among vascular surgeons, radiologists and cardiologists as to who should perform endovascular interventions. However, the number of vascular surgeons trained in endovascular surgery, especially the younger ones, is growing and I believe vascular surgeons will soon be able to perform such operations routinely with or without the radiologists’ collaboration.”

Bastounis went on to expand on his views about endovascular treatment, saying he believed that in the following years the therapeutical concept of vascular diseases would be radically modified.

“I think that a multidisciplinary approach to treatment will be adopted,” he said. “Endovascular surgery will probably replace a large part of today’s conventional operations but I also believe that the absolute number of operations will not be substantially diminished due to the expected increase in the older population.”

Dr Marc Cairols, Chief of the Vascular Service at Bellvitge University Hospital (Barcelona) and Associate Professor of the University of Barcelona, however, argued that vascular surgeons should always offer the best proven treatment and not feel pressurised by industry into changing their practice without proof.

“We should be cautious as to what kind of treatment we apply to our patients,” he said. Cariols believes the profession “should not stay quiet in front of all of the ‘aggressions’ that we are suffering from other specialties, cardiologist, radiologists and so on”.

“When I see these specialties doing procedures, most of the techniques that they are doing we can do, first of all. And second, in my view, not all of their procedures are properly or well indicated,” he said.

“We must be leaders in the management of vascular disease. With patients getting older, we will need excellence in many areas for the elderly who are bound to have vascular problems. On the other hand we have to be provided with the technology and equipment. All vascular departments should fight with their administrators in order to get the up-to-date technology needed to keep up the level of excellence of treatment to our patients.”

Dr Peter Harris, President of the Vascular Society of Great Britain and Ireland, discussed the society’s concern about a progressive centralisation of vascular services in the UK, which would deny vascular surgeons opportunities to continue practicing vascular surgery in their own hospitals.

“Now I can tell you in my view that if we do not reform the specialty, as I have described, inevitably there will be a centralisation of vascular services and that will be driven by availability of resource and manpower,” Harris said.

“There are likely to be insufficient interventional radiologists in this country to maintain a service in anything like all of the hospitals in which vascular surgery is practiced now. Interventional Radiology is having an enormous problem in recruiting people into their specialty. Vascular surgery until very recently has been going down the same route, and we still have a problem recruiting vascular surgeons in some areas. If you don’t have the manpower to provide the service in all of the hospitals then what you have to do is centralise it.”

Harris said there would have to be networking of vascular services.

“This will be essential in order to secure acceptable and equitable specialist vascular ‘on-call’ rotas and it is clearly impractical to have all hospitals doing thoracoabdominal reconstructions,” he said.

“Inevitably there has to be centralisation of some of the most technically demanding and expensive treatments, but outside of those constraints it is clearly better, and it is what the patients want, to be treated if possible to the highest standard in the their own local hospitals.”

The view from North America

Dr Gregorio Sicard, Professor and Vice-Chairman of the Department of Surgery and Chief of the Division of General and Section of Vascular Surgery at Washington University Medicine, Barnes-Jewish Hospital, believes vascular surgeons are getting more and more recognition.

“I think that the endovascular field is what is separating us from general surgery,” said Sicard. “I think eventually, vascular surgery will be a separate board and will be fully recognised, like plastic surgery, urology etc. I have no doubt that this will happen. The timing is what I can’t predict, but I think most of us agree that vascular surgery is eventually going to be a separate specialty.”

On the subject of carotid stenting, Sicard said he believes it is going to be an extremely popular procedure.

“Some people are predicting that as much as 75% of carotid surgery could be done by this technique by 2006, so I think it is a real issue. We perform these procedures at our institution, and initially, five years ago, I was a little reluctant as to whether this was a good move. I think it is going to happen. I think we need to train our residents and our vascular surgeons to do this procedure. We are, after all, the specialty that has taken care of carotid artery disease for 50 years.”

Past president of the Society for Vascular Surgery, Dr Richard Green, discussed how in the US the issue of vascular surgery becoming an independent specialty has been much debated over recent years.

“I have been a supporter of independence [for vascular surgery],” said Green, “but I don’t believe that it is a panacea for all that ails us.

“We have a certain amount of time to train physicians and we cannot afford to spend the vast majority of that time in training them to do procedures that they will never, ever do. I believe that we have to take away [time] from the general surgery training to include vascular training, interventional training and imaging training – all the things that vascular surgeons should know about.”

Green said that in the past, the only way to achieve this was through a separate independent board for vascular surgery. “However, recently following SVS negotiations with the American Board of Surgery (ABS), the ABS has submitted an application to the American Board of Medical Specialties (ABMS) to allow them to grant a Primary Certificate in vascular surgery,” he said. “If approved this would allow vascular surgical trainees to take the ABS exams in vascular surgery and be certified in that specialty without first being certified in general surgery.

Green said this was likely a “home run” for vascular surgeons. “It is likely an interim step but I think it is the step we should be taking right now and I think that we should all support the efforts to get this done,” he said.

Dr Frank Veith, Professor and Vice-Chairman of Surgery at Montefiore Medical Centre, the University Hospital for the Albert Einstein College of Medicine, also discussed the issue of independence. He said it was impossible to discuss the state of Vascular Surgery in the US without addressing the call for an independent board, for which he described himself as “a strong and frustrated proponent”.

“We have encountered enormous opposition within organised medicine and surgery [to an independent Board of Vascular Surgery]. Of course we are fighting but because of the enormous power of the establishment we are not getting where we should. We have been turned down by the American Board of Medical Specialties (ABMS).”

Veith described the ABMS as “an old boys club that is very good at maintaining the status quo, not allowing the specialty to evolve and be recognised in accordance with its development”.

“We have been trying to establish it [an Independent Board] for 10 years now and have been frustrated as we have tried to go through the proper channels either due to the self-interests of others or for reasons that we just don’t know. In addition, they have delayed our appeal, after having been turned down,” Veith said.

He discussed how the ABS continues to promote the idea that general surgeons should be able to do vascular surgery. “The General Surgery Certificate should not be a basis for doing vascular surgery, and it still is. The ABS and the ABMS are wrong on this issue,” he said. “As a result of that some patients suffer and die. We think this is a matter that the government should investigate and perhaps become involved in and that is why we are seeking congressional help.”

Dr Edward B. Diethrich of the Arizona Heart Institute discussed his keenness at creating a new training paradigm for the future.

“What should the future vascular specialist look like? It should include vascular surgery, catheter skills, imaging, tissue engineering. I would like to start rotations for fellows. We may even secure NIH funding,” he said.”As for vascular surgery, the writing is on the wall. They must adapt and learn catheter skills. They are set to lose carotid endarterectomy. Cardiologists have vascular surgeons on the run. The biggest expansion is in venous disease and the cardiac surgeons are already looking to retrain. 30% of new customers for the endovascular venous procedure are cardiac surgeons.”

What the interventional radiologists think

The future growth and development of interventional radiology was a major issue for our profiled interventionalists. In-depth interviews from the last 12 months with recently retired interventional radiology leader Dr Constantin Cope; past president of SIR Dr Anne Roberts and SIR president elect Dr Curtis Lewis; and Director of the Department Endoluminal and Endovascular, General Hospital Catalunya, Sant Cugat del Valles, Barcelona, Professor Manuel Maynar, can be found in Interventional News online at www.CXvascular.com.

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