Commentary

Letters to the Editor: 'Endo hubris' - We got letters


 

[Editor’s Note: Dr. Russell Samson’s June editorial, “Endo hubris,” discussed the balance between open and endovascular surgery. His article garnered the most reader comment we have yet received. The letters that follow carry on this important discussion with a variety of voices from across the vascular community.]

To the Editor:
Thank you for your article, “Endo Hubris.” Your observations raise many deeper issues in our specialty of vascular surgery. It appears we vascular surgeons may be among a dwindling few that actually consider vascular surgery a specialty. With so many other specialists performing endovascular procedures, what is so “special” about our “specialty?” It is a keen observation and one made even more odious when one considers the fact that we do not even have our own board.

I also attended the last SVS meeting in San Diego and was happy to see it well attended and full of interesting presentations and discussion topics. However, one subject noticeably absent was having vascular surgery mature into a separate specialty with its own board. I don’t understand why we as a specialty group don’t discuss this. To me it is the most important issue facing our specialty as it relates to other specialties now and the future. Please let me explain.

Wouldn’t it be ideal if all surgeons could be equally competent at all types of operations, in all body regions? We could have one board which would certify all surgeons, certainly this would save money and be more efficient. Also, any boarded surgeon would be able to provide all surgical procedures in any part of the country, which would improve our nation’s access to subspecialty care. Sound good?

Yes, it does, but in reality, this is not reasonable nor feasible. Neurosurgeons take 6-7 years to train in brain and spine surgery. Orthopedic surgeons train as long to become the skeletal experts they are. Urologists also train many long years to become the masters of the genitourinary system. Combine all of these training programs together to make the ultimate surgeon and we would have surgeons in their 50’s or 60’s before being able to start practice. Then they would require adequate numbers of all cases to maintain proficiencies and maintenance of certification. That doesn’t sound good, that sounds absurd.
So goes my argument for having vascular surgery be an independent specialty. We have separate boards for neurosurgery, orthopedics, and urology because it is clearly safer for patients and allows for more advancement in each specialty. At present, we vascular surgeons are considered a subspecialty of general surgery, though we do have a “primary certificate” which allows for the independent attainment of vascular surgery board certification. So why don’t we just have a separate board? This question came up many years ago and caused a civil war in the world of vascular surgery.

A strong case for the independence of vascular surgery was put forth by Dr. Frank Veith et al. over a decade ago. The goal then was to form the American Board of Vascular Surgery (ABVS), independent from the American Board of Surgery. At that time there was already much progress in vascular surgery, including an official Certificate of Added Qualifications for Vascular Surgery by the American Board of Surgery. Also, there were existing accredited training programs for vascular surgery in the form of fellowships. To make a long story short, this motion was defeated after a bitter feud within the leadership of vascular surgery societies. The motion was defeated despite the endovascular revolution and the clear differentiation of vascular surgeons from their general surgery colleagues. Even more remarkable, the motion was defeated despite a 1997 survey showing that 91% of boarded vascular surgeons favored the formation of the ABVS.
So why does it matter? After all, patients are not routinely aware of the various boards and their purveys. They only want good outcomes from their operations. Well, I would argue that it probably doesn’t matter much on the national level, although an argument could be made about representation of specialties for Medicare reimbursement rates. I would argue, however, that the defeat of the ABVS in 2005 had significant effects down at the hospital and practice level. Vascular surgeons face severe challenges today with representation in hospital administration, equitable allocation of hospital resources, work-life balance, competition from interventional cardiology and radiology, to just mention a few. Even having adequate public awareness for peripheral vascular disease and our specialty has been lacking. These adverse forces can collectively, negatively impact our patient outcomes.

In summary, many challenges as such could have been averted with the formation of the ABVS, simply because our interests at the local level would have been addressed by an authoritative board of vascular surgeons answering only to the American Board of Medical Specialties (ABMS). It stands to reason that hospitals organize service lines in at least some accordance with the ABMS represented specialties. Our defeat in 2005 was really a blow to our representation in local hospitals and multispecialty groups. Hopefully, we will rekindle this effort in the future for the sake of our specialty and the patients we serve.

Jeffrey H. Hsu, MD, FACS
Regional Chief of Vascular Surgery
Southern California Permanente Medical Group, Kaiser Permanente – Southern California

To the editor:
I always enjoy your editorials in Vascular Specialist, and I even agree with you, most of the time. But I think you hit a home run with the most recent editorial on endo hubris. I have long felt that the only thing that really separates us from the non-surgeon interventionists is that we can do the open surgical operations when they are either necessary or better. So thanks for bringing this issue to a broad audience.

Jerry Goldstone MD
Professor Emeritus, Surgery, Case Western Reserve University School of Medicine; Past president, International Society for Cardiovascular Surgery, North American Chapter

To the Editor:
Your recent editorial “Endo hubris” is completely on point. While it is certainly important that vascular surgeons continue to be leaders in endovascular innovation, it would be a big mistake for us to marginalize open surgical skills. We wrote about such endo-exuberance in the early days of EVAR, realizing that some patients were (and still are) best served by an expertly performed open vascular procedure. Sadly, that skill set for performing larger open vascular procedures is waning as the volume for teaching continues to decline.
The ability to perform open vascular procedures is THE differentiator that sets us apart from all others providing vascular services. Let’s hope that our specialty does not let it wither away.

W. Charles Sternbergh III, MD
Professor and Chief, Vascular and Endovascular Surgery,
Vice-Chair for Research, Department of Surgery
Ochsner Health System
New Orleans, La.

To the Editor:
I read your commentary today regarding open surgery with interest (“Endo hubris”). Based on my recent involvement with the Vascular Annual Meeting (VAM) as well as the Vascular Surgery Board and Residency Review Committee for Surgery, I feel compelled to respond to some of the points you raised.
On behalf of my colleagues on the program and related SVS Committees, we are pleased to learn that you enjoyed the San Diego meeting, marijuana aromas and all! However, the implication that the program was imbalanced or biased towards endovascular presentations and solutions deserves comment. As you know, the plenary sessions are composed of investigator-submitted abstracts, all original content, and the Program Committee builds the plenaries based on the quality and diversity of the submitted abstracts. So as a first clarification, the content of the program largely reflects the interest of members and others who submit abstracts to the VAM.

I assure you that high-quality, compelling abstracts regarding open surgical procedures and outcomes are not disadvantaged in the selection process, and a number (including presentations on carotid body tumors, cervical ribs, pediatric renovascular hypertension, removal of infected endografts, carotid endarterectomy with proximal intervention, and open reconstruction of SVC syndrome, among others) were included within each plenary session. Additionally, the videos selected for the program included a large number of unusual and relevant open procedures, including the NAIS procedure from Johns Hopkins in the opening plenary, as well as a number of excellent open surgical videos on the “How I do it” video session on Saturday.

Secondly, your anecdote regarding the “excellent surgical resident” and his comfort with open pararenal AAA repair deserves comment as well. As you know, formal vascular training does not and cannot convey mastery in the practice of surgery. Rather, the training and fellowship process is intended to produce safe and competent surgeons, individuals who will continue to grow in their confidence and ability through their first several years in practice. In reality we’d expect any trainee today, let alone 10 or 20 years ago, to anticipate the need for assistance in safely exposing and repairing a pararenal aortic aneurysm early in their practice experience, particularly in today’s environment of registries, OPPE, FPPE, and hypersurveillance of surgical outcomes. The resident’s response (a first-year fellow, actually) was absolutely the right one under the circumstances, and I’d expect a different answer after his first few years in practice, if not by the end of his fellowship.

As you may also know, there are proposals under consideration to require open procedure case minimums for board eligibility and continuing program accreditation. This process is controversial, as no clear guidelines exist regarding “how much is enough,” but efforts are underway to ensure that each trainee performs sufficient numbers of the open arterial reconstructive procedures that define our specialty. In the process of preparing for these discussions, we were pleased to learn that, from ACGME case log data, the average numbers of open arterial operations (abdominal, peripheral and cerebrovascular reconstructive) performed by trainees have not declined over the last several years, despite perceptions to the contrary.

As a parting comment, you may have also noticed that the entire first plenary session at VAM was thematically focused on the limitations of endovascular aortic disease management, with a number of late complications considered, along with their potential solutions. This was not coincidental, as with any maturing technology, the long-term consequences of the endo-adventurism of the last 15 years are only now becoming apparent. Throughout the meeting, we took every opportunity to contrast the potential of new technology with the unknown and potentially deleterious consequences associated with early adoption.
Regarding the importance of highlighting the advantages of open surgery to our patients and colleagues when appropriate, I couldn’t agree with you more.

Despite our best efforts, however, patients will always be attracted to “minimally invasive” solutions regardless of their limitations. In my opinion, our specialty has managed this transition relatively well in the endovascular era, constantly benchmarking new techniques against old standards, and embracing the new when proven to be most advantageous to patients.

Regarding the range of commercial exhibitors participating in this year’s VAM, it is incumbent upon us as SVS members to emphasize to our local vendors and contractors that their presence at the VAM is a significant draw for attendance at the meeting, and that we appreciate their continued support.
Thanks for continuing to produce such spirited and inspiring commentaries for the Specialist, as well as your overall capable editorial stewardship of this important publication.

Ron Dalman, MD
Program Chair Emeritus, SVS Vascular Annual Meeting, 2015-2017
Member, Vascular Surgery Board, American Board of Surgery
Member Emeritus, Residency Review Committee for Surgery, 2010-2016

Dr. Samson replies:
At the outset I would like to thank Dr. Dalman for taking the time to write this letter and for his words of support for my other editorials.
I understand that some may take offense at some of the possible inferences in my editorial. However, it was certainly not my intention to malign the meeting. On the contrary, as I stated at the outset of my editorial, the meeting was outstanding in every aspect and I commend his committee on producing the finest, all-encompassing meeting I have ever attended. I was extremely proud to be a member of a Society that could create such an event. Nor did my editorial suggest that there was bias in selection of endovascular subjects instead of open procedures. Rather, as Dr. Dalman writes, “the content of the program largely reflects the interest of members and others who submit abstracts to the VAM.” In other words, a society of members whose interests now are largely directed towards endovascular procedures. Further, having run multiple meetings in the past, I am aware of the need to incorporate commercial exhibitors and their importance to the meeting. I used the fact that the majority of exhibitors displayed endovascular equipment as another example of the burgeoning influence of endovascular therapies.

I must admit that I thought long and hard before using the paragraph about the excellent vascular fellow. [See my editorial on page 3.] I was impressed by his talk and by the quality of his presentation. I was also very impressed by his candor in answering the question put to him from the audience. From Dr. Dalman’s letter it is apparent that he deserves praise, as does his fellowship training. However, multiple surgeons who were in the audience came up to me afterwards and that was partly the impetus for the editorial. The fact remains that we have an identity problem. I myself suffer from “Endo hubris” and waning surgical expertise. How we address this “malady” may be fundamental to the future of vascular surgery.

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