Commentary

SVS (Specialty of Vascular Surgery): Why, How, and When


 

 

The November 2016 issue of Annals of Vascular Surgery was devoted entirely to the history of the American Board of Vascular Surgery (ABVS) and the unsuccessful attempt to establish an independent specialty of Vascular Surgery.  The manuscript is methodically detailed by founders of the ABVS, James Stanley, MD, and Frank Veith, MD, and supplemented by commentaries from past board members as well as thought leaders in vascular surgery. In an attempt to maintain neutrality, readers are also provided with many of the documents that were either supportive or contrary to the development of the ABVS. Most senior vascular surgeons will recall the intense discussion and sometimes acrimonious arguments that accompanied the progress of the Board and its failed attempt to be recognized by the American Board of Medical Specialties (ABMS). 

Younger vascular surgeons may not realize that the ABVS was ever established. Some may not even realize that, until relatively recently, vascular surgeons were not able to claim board certification even if they had completed a fellowship. Accordingly, as an historical document detailing an important aspect of the evolution of our specialty, this edition of Annals of Vascular surgery is a must read.

Cogent arguments both for and against an independent specialty were made by the leaders of our specialty at the time that the ABVS was being developed. Unfortunately, this did not lead to a uniform policy but rather long-standing, rancorous, and bitter divisions that in all probability prevented the ABVS from being recognized by the ABMS. Despite this failure, the debate around this issue elevated the stature of vascular surgery when the American Board of Surgery conceded that vascular surgeons could now claim “Board certification in vascular surgery” without having to be trained in general surgery. However, all important modifications to the current design of vascular residency and fellowship programs still need to be decided by the American Board of Surgery and its associated Residency Review Committee for Surgery (RRC-S). Further, many hospital administrators subordinate vascular surgery by insisting that vascular surgeons' interests be controlled by general or cardiothoracic surgeons. 

Most notably, this issue of Annals reignites fundamental questions that are at the heart of our existence as vascular surgeons. For example, has vascular surgery matured sufficiently to be considered a distinct specialty equivalent to other surgical specialties such as orthopedics, colorectal, urology, and otolaryngology surgery? If so, why did this not occur earlier? Does it warrant becoming independent from the American Board of Surgery such that only vascular surgeons will be in control of training programs, graduate education, and the practice of vascular surgery at universities, hospitals, and community practices? More significantly, why should these institutions, health agencies and the lay public care that there is a separate independent specialty – vascular surgery? The answer to these questions becomes apparent by an analysis of four historic elements that have changed since the ABVS was being formulated. 

First, and perhaps most importantly, the argument for an ABVS occurred when vascular surgery had just entered the endovascular revolution.  How difficult it must have been for those early vascular surgeons to realize that within a few years perhaps upward of 70%-80% of all procedures would not be performed in a standard operating room but rather an angiography suite, cath lab, or hybrid room? Could they envisage an era where abdominal aneurysms were treated not only without a laparotomy scar but even without a groin incision? That carotid endarterectomy may be replaced by a stent or that varicose veins would be abolished by an outpatient laser procedure?  Without such foresight, general surgeons and even those early vascular surgeons had to believe that vascular surgery, as then practiced, required general surgery training.

 A second historical reality that impacted the progress of the ABVS was the fragmentation of the governance of vascular surgeons on both a local and national level. Locally, university surgeons, assuming that vascular surgery was an intrinsic part of general surgery, may have been concerned that their leadership roles would be diminished if they were relegated to division heads rather than department chairs. Nationally, there existed three bodies representing vascular surgeons, each with its own leadership and motivations. These were the Society for Vascular Surgery (SVS), the North American chapter of the International Society for Cardiovascular Surgery (NA-ISCVS) which later changed its name to the American Association for Vascular Surgery (AAVS) and the Society for Clinical Vascular Surgery (SCVS). 

The SVS at the time was predominantly an academic association with its primary goal being the annual meeting. The SCVS

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