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.

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