Meeting the challenge: Rejuvenating vascular surgery with the integrated training programs
2011; Elsevier BV; Volume: 53; Issue: 5 Linguagem: Inglês
10.1016/j.jvs.2011.01.028
ISSN1097-6809
Autores Tópico(s)Peripheral Artery Disease Management
ResumoThank you Dr AbuRahma for your lasting friendship and this very generous introduction. Members and guests, I am deeply honored to have served as the 24th President of the Eastern Vascular Society this past year. This society is close to my heart and has played a big part in my professional development, as it has done for many of you and no doubt will continue to do so in the future. It was at the Eastern that I first heard a presentation by Juan Parodi about “Clinical Experience with Balloon Expandable Stent Grafts” in May 1994. It was at the Eastern the same year in Montreal that I heard the first serious prodding to pursue endovascular skills by Frank Veith during his Presidential Address. That meeting changed my professional focus and ultimately my career. “B97” was my code for enrolling patients in the Eastern Vascular database, the first introduction of a regional database for quality assurance and tracking of outcomes. Had the I-Phone and I-Pad era been in full swing, that database would have survived as the largest repository of vascular outcomes today. Unfortunately, it succumbed to the snail mail of the time. The Eastern taught me the value of serious discussion of scientific ideas, because it always included long discussion periods after each scientific presentation, 10 minutes per paper during its early meetings. I am humbled to be now listed among a group of surgeons who led this society, including several of my heroes and many of my friends. It certainly is a long way from my days as a medical student and surgical resident at the American University of Beirut Hospital in a war-torn country where intolerance, hatred, and prejudice ruled; a period of my life where religious affiliation and zeal were more valued than openness, honesty, and empathy. I do hope and pray that partisan anger and religious bigotry, rearing their ugly head around the world, fail to establish a beachhead in my new adoptive country. It has certainly been a long and interesting journey punctuated by many successes, and more failures. My 87-year-old mother would be happy to tell you that standing here today is all due to my skills, talent, and superior intellect, but most of you know better; and for the few who do not, my wife, children, fellows, and partners in the audience today would be happy to correct you. I really owe the privilege of being here today to the support and help of too many individuals to list and thank, but some I must. Henry T. Bahnson, or “Hank” to his friends, a giant of American surgery, a master surgeon and inspiring leader, a man of few words who valued integrity, loyalty, and dedication to patient care above all, provided me with the unusual opportunity to finish my residency in the U.S. by accepting me as a third-year resident in 1980. Since then, Pittsburgh has been my home for the last 30 years, and although we considered moving at many junctures, I never found a better place to live, raise a family, and develop a career. I am eternally grateful to him for his trust, support, and guidance. Against his better judgment and despite my infamous temper, he hired me to join his faculty and was responsible for pointing me toward vascular surgery. I would also like to thank Marshall Webster, who finally overcame his cynicism and doubts and allowed me to get involved with the new emerging technology of endovascular aneurysm repair (EVAR) in 1995, and later entrusted me with the leadership of our division. His wisdom and support have been invaluable for our division reaching its potential. Most of my successes would not have been possible without an amazing and talented group of vascular surgeons, fellows, and residents who make me look far better than I really am. Their dedication, hard work, and intellect are a constant challenge to work harder just to keep up. Finally, I would like to thank my family, whose unwavering support and love carried me through some of the difficult times in my life and career: My son Sami, for his curiosity and dispassionate criticism that provides me with more insight into my personality flaws than I care to admit; my daughter Lena, for being my moral compass and my sounding board for many of my decisions; and last but not least, Silva, my wife, friend, and companion for the last 36 years who has led the three of us by example and hard-nosed dedication to both family and career. She is a tireless worker, a brilliant scientist, and a loving mother and wife, who never accepts mediocrity and has inspired us all to try and excel at what we do. Thank you. That brings me to the topic of my address: Meeting the challenge. We all seem to be facing an increasing number of daily challenges, whether related to individual patient care, understanding the ever more complex health care regulations, sidestepping the latest financial crises, deciphering the latest version of Microsoft Office, or simply finding where we saved that damn file. Our life seems more complex than ever in the face of a world changing at breakneck speed. More importantly, we are also facing collective challenges as a specialty of vascular surgery, from competition by other specialties to decreasing reimbursement for services, to a breathtaking increase in technologic innovations, to serious doubts about our ability to meet our manpower needs to better serve our patients and solidify our competitive advantage. Despite the prevailing pessimism, I stand here to declare that the sky is not falling, as I have been repeatedly told by many since I set foot in the U.S. Vascular surgery is doing well and has risen to meet most of the challenges thrown its way. In the words of Henry Ford: “When everything seems to be going against you, remember that the airplane takes off against the wind, not with it.” I would like to start with a famous saying that has always intrigued me: “May you live in interesting times.” Undoubtedly, this applies to all of us, as these are indeed very interesting times in vascular surgery. The origin of the saying is unknown but represents what is believed to be one of a triad of old Chinese curses. Those who coined it or popularized it clearly value stability, serenity, and comfort over turbulence and strife. For me, it has always symbolized the opposite: a blessing to live in periods of change and upheaval. It certainly makes life more exciting, offering us the opportunity and thrill to conquer the untold hurdles that we constantly face. Robert Kennedy's words in his day of affirmation speech in South Africa in 1966 ring a very personal note with today's vascular surgeon:One danger is comfort; the temptation to follow the easy and familiar path … . There is a Chinese curse which says “May he live in interesting times.” Like it or not, we live in interesting times. They are times of danger and uncertainty; but they are also the most creative of any time … . Everyone here will ultimately be judged—ultimately judge himself—on the effort he has contributed to building a new … . society.1Kennedy R.F. Day of affirmation address.http://www.jfklibrary.org/Historical+Resources/Archives/Reference+Desk/Speeches/RFK/Day+of+Affirmation+Address+News+Release.htmGoogle Scholar The last 20 years have certainly provided and continue to provide many challenges. Many we have met and emerged as a stronger group, but we cannot be lulled to sleep, as we are still tackling other challenges we only partially met and more yet that are lurking in the shadows begging for attention and solutions. I will provide an example of each. For those tired of fighting, help is on the way from an unlikely source: medical students flocking to our specialty. Their talent, youthful enthusiasm, and commitment are great building blocks for a solid and competitive future for our specialty. One major challenge we did meet was first articulated in the Presidential Address of Frank Veith to this society at its Eighth Annual Meeting.2Veith F.J. Transluminally placed endovascular stented grafts and their impact on vascular surgery.J Vasc Surg. 1994; 20: 855-860Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar I was in the audience and still remember vividly the bold predictions that innovations in endovascular therapy will forever change the landscape of what we do and how we treat vascular disease. The challenge issued then by Dr Veith was that we must adapt to the changing nature of our specialty by embracing the new endovascular technology and by taking a leadership role in integrating it in our therapeutic armamentarium. That, we did. Today, almost all vascular surgeons perform some if not most of the endovascular interventions in their hospitals. Nationwide we perform 70% of endovascular aneurysm repairs, and about a one-third of peripheral and carotid stent procedures while numbering 175 therapeutic endovascular interventions, four times the volume of 2001.6Schanzer A. Steppacher R. Eslami M. Arous E. Messina L. Belkin M. Vascular surgery training trends from 2001-2007: a substantial increase in total procedure volume is driven by escalating endovascular procedure volume and stable open procedure volume.J Vasc Surg. 2009; 49: 1339-1344Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar Granted, this is not uniform across all fellowships, but it certainly is a far cry from where we started. The trend has continued after 2007. Our University of Pittsburgh Medical Center (UPMC) fellows have nearly doubled this number in the last 3 years, moving our average up >350 cases per graduating fellow. Our continued challenge is to avoid resting on our laurels and to continue the trend started in the early 2000s providing all members of our new generation the tools they need to compete in the marketplace. A major challenge that we only partially met and continue to tackle is the independence of our specialty and the definition of our identity. You all remember the strong push and divisive fight for an independent board for vascular surgery (American Board of Vascular Surgery) spearheaded by several past presidents of this society, namely Drs Veith and Hobson, with the support of all vascular societies in the U.S. and >70% of our members. Although we failed in our stated goal, acting on our convictions actually achieved most of the elements we were seeking, including the declaration of a primary certificate status for vascular surgery, the formation of an autonomous Vascular Surgery Board of the American Board of Surgery, the reduction in the required caseload and scope of procedures that general surgery residents should become familiar with, and the acquiescence by the American Board of Surgery in a somewhat timid statement that “comprehensive knowledge and management of conditions in vascular surgery generally requires additional training.” This challenge continues to be of some concern. Some of us continue to be burdened with meeting the goals of general surgery residencies at our institutions ahead of our own training goals, and we have failed so far to eliminate vascular surgery from being listed as a primary component of general surgery training. We continue to hope for a separate Residency Review Committee (RCC) for vascular surgery, although our representation on the surgery committee has improved significantly the last few years. As we continue to strive for more, and that we will, we should not be oblivious to the fact that we have achieved a considerable measure of control and independence that has served our speciality well, while keeping us aligned with a large surgical constituency that can, and has helped our interests in fending off challenges from other specialties. We have more presidents of the Eastern to thank for their efforts in this area, Drs Ricotta and Sidawy. This brings me to our current challenges and the dangers that continue to exist and may actually be picking up steam. A little anecdote here, that I borrow from a newsletter I receive, may illustrate the importance of vigilance, the virtue of humility, the danger of overconfidence and underestimating one's opponents, and most importantly the unlimited promise of talented youth:Jim Brown is arguably the best all-around athlete ever. He was a track star, one of the nation's finest lacrosse players, averaged 38 points per game on his high school basketball team, and broke all sort of NFL records as a running back for the Cleveland Browns. In 2002, The Sporting News named him the greatest football player of all time. He was pretty handy with a tennis racquet, too. And he liked to wager on his matches. At a Las Vegas tennis club in 1979, Brown was frustrated when his opponent cancelled a money match at the last minute. A stranger approached him with a young boy. His proposal was preposterous. He bet Brown that his nine-year-old son (short and scrawny even for his age) could beat him in tennis. And he was cocky about it. He offered to put up his house. We can only imagine what ran through Brown's mind. After all, this wasn't a bet. It was an insult. He countered that they should make the bet an even $10,000. The club owner tried to warn Brown. But while he did reduce his wager, he wouldn't be talked out of the match, insisting that “the man needs to be taught a lesson.” And so Jim Brown strode off to the courts with Mike Agassi and his young son Andre in tow. It didn't take Brown long to recognize he had been hustled.7Spiritual wealthhttp://www.spiritualwealth.com/2010/07/02Google Scholar Time does not permit me to discuss all our current challenges. Please allow me to focus on a couple: First among our current challenges is the changing face of health care delivery and financial restructuring underway. Hyperbundling and Accountable Health Organizations (ACO) will further pressure small independent vascular practices. They will accentuate the trends towards larger vascular groups and a closer alignment with hospital facilities for improved risk sharing and a better reimbursement for our services. This may actually be a blessing in disguise and not something to fear if we enter into this alliance with open eyes and understanding of the mutual benefits involved for both parties. This may provide us with the ability to better accentuate our patient-centric focus and our strong commitment to improve vascular outcomes and differentiate ourselves from specialties that only focus on lesion treatment. I predict that we have the opportunity to come out ahead with this trend, and to secure a position as the preferred partner for both institutions and health care payers in the delivery of quality and cost-effective vascular care. Second, and more serious among our remaining challenges, is the continued and progressive encroachment of other specialists on our traditional role as the primary care givers for patients with peripheral vascular disease. Cardiologists have not been shy for the last decade about their stated goals of taking over all vascular care: legs, brain, and kidneys are becoming the fifth heart chamber!8White C.J. A call to arms … legs, brains and kidneys!.J Am Coll Cardiol Intv. 2009; 2: 476-477Google Scholar The American Board of Internal Medicine no longer certifies its diplomates in “cardiology” but in “cardiovascular disease,” without necessarily adding any education in the “vascular” segment. Cardiologists have also effectively blocked certification so far of “vascular medicine” as a specialty. They have made giant strides both in peripheral interventional training and clinical practice especially in the field of carotid artery stenting where they perform nearly half of the procedures in the U.S. It is not stopping there. I saw recently a patient who had just come from her cardiologist's office with her legs wrapped. She had just had a laser ablation of her saphenous veins, but to his consternation, preferred to see a vascular surgeon for her abdominal aortic aneurysm (AAA). This may not continue to happen in the future as more and more cardiologists are now starting to perform AAA procedures, as the profile of new devices decreases, and they learn how to use percutaneous closure devices. With 14F to 16F EVAR devices becoming available in the next couple of years, this trend will accelerate. Although the number of interventional cardiologists is less than you may think, as they probably are 240. Two are PhDs, 9 have master's degrees, 1 has a master of business administration degree, and 2 are also PharmD, and 12 list more than 10 peer reviewed papers, making our choice for two positions all the more difficult. What has changed to stimulate this interest in vascular surgery, especially among medical students? Why are we finally appealing to women to enter our specialty? First, the shorter training period of 5 years may be a factor allowing students, especially women, to enter their desired specialty in a more realistic time frame. Many general surgery programs are 6 or 7 years to be followed by 2 more years of vascular fellowship. A direct path to specialty training is clearly attractive but probably only a minor enticement, as we have experienced no handicap for our 7-year UPMC program, which includes 2 compulsory years of research. The applicants do not seem to focus only on the length of training but mainly on their desire to start their chosen specialty as early as possible without acquiring unnecessary skills and knowledge. There is no shortage, either, of candidates clearly charting an academic career path having prepared with additional training and demonstrated scholarly activities. Second, the changing nature of vascular practice seems to be more attractive to generation Y or the “echo boomers” currently graduating from medical schools. They are also known as the “Gamer” or “Net” generation, generally marked by an increased use and familiarity with communications, media, and digital technologies. Vascular surgery has moved heavily into this area and has added considerable variety to our therapeutic armamentarium by introducing the whole gamut of advanced imaging and endovascular interventions, which seem to be quite attractive to this group. In the process we have also shortened procedure times, hospital stays, and the service census making an acceptable life style possible. The emergence of larger group practices, decreasing the call frequency, seems to be also contributing to the attractiveness of vascular surgery. By last count in the Eastern Vascular region there are at least 11 academic groups of 8 vascular surgeons or more, 2 with more than 15, a far cry from a decade ago. The vast expanse of our specialty, including a renewed focus and interest in venous procedures, also seems to permit individual surgeons to customize their practice to what they enjoy, improving job satisfaction. In addition, medical students seem to appreciate more than general surgery residents some of the peculiar aspects of our services, especially the medical and preventive vascular care we deliver, the lifelong relationships we develop with our patients, and the variety of techniques we use in the operating room, angiography suites, or the noninvasive vascular laboratory. Finally, the income of young vascular surgeons has escalated quite rapidly in the last few years, making it quite competitive with other specialties. At least the low pay that characterized the late 90s is no longer a significant deterrent from entering our specialty. The change has been fueled by hospital competition for our services, as recognition of the huge contribution margin of vascular surgery, has made hospitals very eager to participate in their recruitment. Even in 2002, net revenues from a vascular surgeon to the hospital exceeded $2,000,000.14Merritt Hawkins and AssociatesPhysician inpatient/outpatient revenue survey.http://www.merritthawkins.comDate: 2002Google Scholar Our specialty disappeared from the Merritt Hawkins survey in their 2004, 2007, and the recently released 2010 report. How much did our contribution margin grow to, is a well guarded secret but does depend on institution, individual surgeon, and type of practice. This large contribution margin will continue to fuel the trend towards hospital employment, which will keep incomes higher than true reimbursement of our professional services can maintain in a traditional private practice setting. I do not have a good estimate for you about how many of us are currently employed and how many of our younger colleagues are choosing these institutional affiliations, but in a report released last week, a survey by the American College of Cardiology estimates that currently 30% of cardiologists are either employed or in discussions to be employed for similar reasons escalating their average salaries.15Fierce Healthcare Newsletterhttp://www.fiercehealthcare.com/story/certain-specialty-doctors-high-demand/2010-09-27Google Scholar No longer can we claim that vascular surgical income is eroding. The 2007 Medical Group Management Association (MGMA) mean income for vascular surgeons was $371,253. Merritt Hawkins recruitment specialists recommend compensation in the range of $325,000 to $400,000 for any effective recruitment. At a recent Association of Program Directors in Vascular Surgery (APDVS)-sponsored lunch for second-year fellows during a review course on the West Coast, <10% of respondents indicated they would accept total compensation of <$300,000 in their first year. Hospital involvement may be the funding mechanism for such an explosion in salaries, but an increased demand for our services as well as the demographic nature of our specialty has resulted in several job openings per graduating fellow adding to the upward pressure on compensation. This is compounded by the fact that 34% of the 2532 self-declared practicing vascular surgeons in the U.S. are older than age 55, and are contemplating slowing down or even retirement in the near future.16Merritt Hawkins vascular surgery recruitment analysis 2008.Google Scholar This creates many
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