Presidential address: Reflections
2001; Elsevier BV; Volume: 33; Issue: 2 Linguagem: Inglês
10.1067/mva.2001.112698
ISSN1097-6809
Autores ResumoI am honored to address you as the 44th president of the North American Chapter of the International Society for Cardiovascular Surgery (ISCVS), on this the occasion of our 48th annual chapter meeting. The winds of change are sweeping our society, and to place these changes into perspective requires a consideration of our history. The first meeting of the then-designated International Society of Angiology was held in 1951, and the first meeting of the North American Chapter in 1952. In 1957, the name of the society was changed to the International Cardiovascular Society, and in 1981 changed again to the International Society for Cardiovascular Surgery. We held a combined meeting with the Society for Vascular Surgery (SVS) for the first time in 1967. An increasing realization of the common issues facing the societies led to the formation and the first meeting of the Joint Council in 1975. For the next 25 years, the two societies grew together to the point where there is presently little to choose between them, because both are run by the Joint Council, which has assumed, for all practical purposes, total managerial control. Since its formation, the Society for Cardiovascular Surgery has increased internationally from three to seven chapters with a commensurate increase in membership. As of 1999, membership in the International stood at almost 3800, of which 1650 were from our North American Chapter. The last biannual meeting of the International took place in September 1999, in Melbourne, and the 50th anniversary of our North American Chapter will be observed during our annual meeting in Boston 2 years hence. During the past year there has been a growing belief among the councils of the SVS and ISCVS that either there should be a real difference between the two societies or we should consider combining into a single society. After much preliminary planning, a retreat was held in New Orleans in February 2000 to discuss this and other topics, and a meeting of the Strategic Planning Group was recently held to further consider changes in societal structure. Dr Towne will address this issue from the perspective of the SVS in his presidential address later at this meeting. For the North American Chapter, your council proposes a change in our name to the American Association for Vascular Surgery (AAVS) while retaining our chapter relationship to the ISCVS. One of the important reasons is to enhance our identity with HCFA and other governmental agencies as a truly North American Society. We wish to focus the activities of the AAVS specifically on the needs of the practicing vascular surgeon. As such, we propose the AAVS serve as an umbrella organization accommodating the leading regional and national vascular societies of which many, if not most, of you are already members. We propose that each of these societies have a voting membership on the council of the new organization. The AAVS will, in effect, belong to the practicing vascular surgeons in this country. At the recent meeting of the Strategic Planning Committee, it was recommended that we maintain two societies and that the AAVS have primary responsibility for governmental relations, especially as it concerns reimbursement issues, and with public education. We will participate with the SVS in maintaining an association with other groups caring for patients with vascular disease, including the Society for Cardiovascular and Interventional Radiology, the American College of Cardiology, the Society for Vascular Medicine and Biology, and others. As a professional society, we are light-years behind similar organizations in informing the lay public of basic information concerning the diseases and conditions we treat. The remarkable accessibility of the Internet to our population provides a readily available site for the dissemination of information. I am sure most of you are already receiving calls from patients wanting to discuss confusing material they have received on the Internet, much of which presently can be best described as self-serving baloney placed for purely commercial reasons. Clearly, we have an extraordinary opportunity to develop and disseminate to the public an accurate description of vascular disease and realistic expectations from vascular surgery. The AAVS intends to forge ahead on this front without delay. The AAVS recommends assigning primary responsibility for a number of important activities to the SVS including management of relations with the American Board of Surgery (ABS), the Association of Program Directors in Vascular Surgery, the Residency Review Committee in Surgery, and the Lifeline Foundation. Clearly, however, the AAVS will maintain a keen interest in following and participating in these activities as appropriate. We will continue to jointly administer the Journal of Vascular Surgery and the annual meeting, although more precise program separation will likely occur in the future. We will continue to share with the SVS the responsibility for nominations to the ABS and will, of course, continue with our periodic appointment to the Sub-board in Vascular Surgery. We recommend that, in effect, the joint council model of societal governance be substantially reduced or eliminated, with each society assuming independent responsibility for a designated group of critical functions. These proposed changes will be submitted to the membership for approval in the near future. I believe these structural societal changes will benefit our membership by substantially eliminating the redundant governance structure that has characterized us in recent decades and will permit a more precise direction of our attention to specific areas of interest. In the case of the AAVS, this will permit an intense focus on the needs of the practicing vascular surgeon. I express my appreciation and admiration to the members of both societies who are in the process of accomplishing these important structural changes and are devoting large amounts of time and effort to this activity. A committee of AAVS members headed by Dr William Pearce is currently addressing the issue of AAVS reorganization, and I express my appreciation to him and his committee for accepting this important assignment. It is traditional for the president, on the occasion of the annual address, to recognize those who have been of special importance to his career development. I proudly continue this worthy tradition. First, I acknowledge with profound appreciation the contributions of my wife, Ann, who combined her own university graduate education with full-time employment and motherhood, while holding the family together during an enjoyable, but occasionally tumultuous 9-year surgical residency. I guess it just took me longer than most. I have spent my entire career in Academic Vascular Surgery and am pleased to recognize the contributions of the four distinguished surgical chairmen under whom I have been privileged to serve (Figure).During my residency at Duke, I received wise and much appreciated counsel from my first chairman, Dr Clarence E. Gardner, and later from Dr David C. Sabiston, Jr. In my early faculty career at Oregon, Dr William W. Krippaehne provided abundant support, and most recently, I am pleased to acknowledge the considerable assistance received from Dr Donald D. Trunkey, who has been most supportive of the development of our Academic Vascular Surgery unit. Two additional professors who had a critical influence on my early career were Dr Keith S. Grimson, now deceased, professor of surgery at Duke and a true pioneer in the exciting new field of vascular surgery, and Dr Donald Silver, then a professor of surgery at Duke, who provided me a superb model of academic discipline as well as an excellent laboratory in which to work. I am honored to acknowledge the contributions of these two gentlemen to my surgical education in general and specifically to my decision to enter vascular surgery. I am also pleased to recognize the contributions of my senior faculty associate Dr Lloyd M. Taylor, Jr, who has assisted me mightily in the development of our vascular surgery unit at Oregon. In recent years I have had to tolerate the irreverence of Dr Greg Moneta, which I must admit I have come to accept with some fondness despite his Harvard background. The assistance and loyalty of my other vascular faculty associates, Drs Rich Yeager, James Edwards, and Greg Landry, are gratefully acknowledged. For the remainder of this address, I propose to make observations on a group of topics that I believe are important to vascular surgeons and the practice of vascular surgery. In preparing these remarks I have carefully reviewed prior presidential addresses and have concluded that they were generally designed to accomplish one of several things: some appeared designed to inform, some to motivate, and some to inspire. As far as I can tell this is the first that may be perceived as specifically designed to annoy, although I hasten to add annoyance for its own sake is hardly the objective. The topics I have selected for consideration include Health Care Financing, the Role of Functional Outcome Assessment in Vascular Surgery, Residency Education Including Certification in Vascular Surgery, and finally, my perception of the pernicious influence of the new generation of Entrepreneurialism in Vascular Surgery. Few topics have attracted and focused the attention of the US Congress with greater zeal than the costs of health care in America. They suddenly realized in the last decade that health care costs in this county were approaching 14% of the GDP and appeared to be rising exponentially. They looked forward to doomsday when they envisioned the health care budget consuming the entire federal budget and decided that draconian measures were required to restrain health care expenses. From the DRGs of the 1980s through RBRVS and the most recently balanced budget amendments of the late 1990s, all their actions appeared uniquely disadvantageous to vascular surgery. Their overall behavior led to the formulation of my current opinion of Congress, succinctly summarized as follows: Never underestimate the power of stupid people in large groups. You are all aware of the many measures that have resulted from the congressional attempts to control health care expenditures. We were significantly underrepresented in the Hsiao study, making us the last in line when the RBRVS payment schedules were created. I express my deep appreciation to Drs Hertzer, Trout, Zwolak, and Oblath and their associates for the time and effort expended on our behalf before HCFA and other governmental groups. They have been able to reduce the rate of decrease in our mite and may have even achieved a tiny increase. Nonetheless, for vascular surgeons a terrible financial problem persists. Reimbursement has decreased to the point where in many parts of the country it is fiscally impossible to open a onesurgeon office and enter the practice of vascular surgery. Many vascular surgeons have taken early retirement, and others are planning to do so. The number of trainees applying for vascular residency positions is disturbingly low, doubtlessly related in part to the trainees' perception of reimbursement matters. These issues threaten to have a significantly negative impact on vascular surgery manpower. I continue to be profoundly disturbed by the big picture of health care financing. I accept that both England and Canada seem to muddle through their health care needs with expenditures of about 7% of the GDP, while presently, the United States appears stuck at 13% to 14%; but, on the other hand, consider for a moment what you get. With few exceptions today in America a patient needing hospital care can expect immediate admission to a pleasant and modernly equipped facility and receive generally expert care rendered by a fully trained physician, none of which is available for 7% of the GDP. I suspect the old adage is true: If you want nice fresh oats, you have to pay a little more. Oats that have already passed through the horse are available for a little less. Keep in mind, one of the most important jobs of Congress, if not the most important job, is budget prioritization. If the citizens demand health care that costs 14% of the GDP or even 20%, this seems to me to be the citizens' choice. We may even, God forbid, have to forego another class of nuclear attack submarines! Please do not misunderstand: I am not in favor of bureaucratically inefficient health care delivery or the knee-jerk purchase of billions of dollars of currently stylish breakthrough equipment without meticulous justification. Neither I nor anyone else can possibly object to improved efficiencies in health care, but I can and do object to the simplistic notion that national health care costs must conform to a predetermined percentage of the GDP. Another area that causes me much concern is the issue of a physician's choice of treatment having a direct effect on personal income. Surgeons are regularly required to make difficult choices between operative and nonoperative treatments, each with profoundly different personal income implications. I am not sure the Almighty herself could remain neutral in such situations. We must strive for the day when a physician's therapeutic choices have no impact on physician income. In my opinion, two shames of our present health care system are first, the 45 million or so citizens of this county with no provision at all for health care and second, the invasion of health care delivery by for-profit organizations, typically HMOs, whose primary objective is to divert as many finite dollars as possible from their intended health care objectives into corporate profits, including the salaries of obscenely well-compensated CEOs. For the former I see no solution other than providing a basic federally administered health care insurance policy much like the Oregon Health Plan. We as a nation are simply going to have to face the issue that we can no longer ignore the health care needs of this significant percentage of our population. Piecemeal approaches are inadequate. As a great American once said: You cannot leap a chasm in two jumps. I believe we must also provide brick and mortar facilities where these citizens can receive basic well-patient health care and that will serve as a convenient point of entry into the health care system for sick patients. These facilities can no doubt be adequately staffed in significant part by nurse practitioners and physician assistants. Numerous studies have shown that in outpatient clinics, expensive primary care physicians are expendable. In fact, producing more and more primary care physicians in a futile effort to reduce health care costs appears to have been one of the most conspicuously unsuccessful experiments of modern politicians. I am appalled to note that the Florida legislature has just approved funding for yet another General Practice Medical School, this one at the Florida State University. Sick patients require specialist care, and I suspect always will. Whatever primary care physicians do can generally be done as well and cheaper by paramedical personnel. In my opinion, about the last thing we need is another politically motivated GP medical school. What about the for-profit HMOs? We probably need not overly concern ourselves with these entrepreneurs. They already appear to be imploding. Profits are dwindling, federal fraud charges are increasing, and numerous courts are stripping them of their veneer of immunity from tort claims. Demands for a patients' bill of rights are loud on the land. In the words of my southern ancestors: good riddance to bad rubbish. A pox on them all. Few things in medicine interest me less than feel-good questionnaires in which patients are asked if some procedure or other improved their perception of feeling good or their perceived level of social functioning. I have always thought such stuff properly belonged as the subject of some obtuse doctoral thesis in social science. I continue to believe that many, if not most, patient responses to health care questionnaires are substantially preordained by how and by whom the questions are asked. Certain outcome measures, however, strike me as imminently important and realistic, including such post–vascular surgery considerations as walking ability, independent or dependent living status, wound healing including length of time devoted to care of surgical complications incident to the index procedure, and the need for subsequent surgical procedures. In my opinion, a keen knowledge of such outcome measures should form an essential component of surgical decision making, certainly including the planning of all surgical procedures. Consider for a moment a few lessons from history. In the 1960s before there was no convention for describing and publishing surgical results, most authors simply stated how many patients did or did not have successful repairs at randomly selected intervals after surgery. Then along came the life-table method of reporting results, which was immediately embraced by vascular surgeons. We became fascinated by such intriguing concepts as interval and cumulative patencies and began to display all our results in this fashion. Concepts such as primary patency, primary assisted patency, secondary patency, and limb salvage became everything. We seemed to happily accept such absurdities as a 5-year patency of some repair or another of 75% and a 5-year limb salvage of 85%, but a 5-year patient survival of only 50%. This of course introduced the important concepts of censured data, loss to follow-up, and the greatest contribution an individual patient can make to a life table: dying with a patent graft and a preserved limb. It is abundantly clear that our evaluation of the overall efficacy of numerous procedures has been measured by the too limited concepts of patency and limb salvage and their equivalents, without consideration of such critical information as the quality of the patient's life after surgery. Although few will argue that in vascular surgery results are everything, have we been considering the right results? We were most surprised recently to learn in our practice that if we defined optimal outcome after limb salvage surgery as patent graft, limb salvage, preservation of preoperative living status, prompt wound healing, and no need for additional surgery, only 15% of limb salvage patients enjoyed such an optimal result. A similar although somewhat lesser situation appears to pertain after aortic aneurysm repair. In my opinion, we simply must begin to concern ourselves with the total impact of our surgery on patients. For example, if limb salvage surgery results in saving the limb but restricts the patient to a nonambulatory nursing home existence and the need for several additional leg operations, the patient may spend most of the rest of his life dealing with the complications of and recovery from the index operation and may consider the surgery an overwhelming failure, whereas the surgeon, using the limited concepts of patency and limb salvage, probably would have recorded the procedure as an unqualified success. It is probable that a significant number of patients, if accurately and appropriately informed of the likelihood of such an outcome, may prefer early amputation so they can get on with the remainder of their limited life expectancy. A keen and accurate knowledge of outcome expectations that go far beyond the limited concepts of patency and limb salvage must become an automatic and essential component of vascular surgery decision making. An extension of this observation concerns the recommendation of prophylactic surgery in certain patients. For example, a number of papers in recent years have extolled the benefits of prophylactic carotid endarterectomy in octogenarians. However, consider for a moment that such a patient, according to national health statistics, has a life expectancy of about 5 years and a net surgical stroke benefit in the ACAS of 6% at 5 years. Compared with the risks and expense of surgery, do these minuscule stroke prevention benefits of 1% per year make any sense? Not to me they don't. On balance, I believe we have spent the last 40 years in vascular surgery substantially learning what we can do. I suspect we may spend the next 40 years learning what we should do. We are just beginning to understand that in many circumstances they may not be the same. For a certain number of aged and debilitated vascular patients, a recommendation for no operation may be preferable to a recommendation for surgery. In a number of fully informed limb salvage patients, an early decision for limb ablation may be preferable to persistent efforts at limb salvage. In a similar manner for certain patients with an abdominal aneurysm and prohibitive operative risks, the decision for no intervention may well be the best decision, the siren song of the endografters not withstanding. The summary message is simple: There is more to vascular surgery than patency, limb salvage, stroke-free existence, and procedural survival. We must all strive to develop a more accurate and better informed understanding of the full implications of surgery, an understanding predicated both on a clear understanding of the natural history of the untreated disease and a keen knowledge of the likely adverse effects of a surgical procedure. In the final analysis, this knowledge must be humanely combined with the realistic expectations of the fully informed patient to permit the formulation of optimal treatment recommendations. We must strongly reject the role of being only a monofocal surgical provider. We must be much more. In matters of vascular disease, we must truly become the patient's advocate, notwithstanding the opinion of a number of nurses that this is their exclusive, divinely appointed role. One of the most important professional responsibilities we face is optimal education of our trainees. A monumental step in the direction of controlling our own educational destiny took place with the organization of the Association of Program Directors in Vascular Surgery (APDVS). With the official selection of directors of the ABS by the Joint Vascular Council and the Program Directors and the de facto selection of an APDVS representative to the Residency Review Committee in Surgery, accomplished through the good offices of the American College of Surgeons, we are now in a position to have appropriately significant influence over our own educational destiny. We all must be willing to devote sufficient time and effort to the training of our residents. Under no circumstances should these trainees be regarded as merely the means to permit us to discharge our service obligations. If we are not working continuously to improve the residents' educational experience, we are not doing our job. I remain concerned that many of our residency programs provide too much of too few things. For the many components of vascular surgery not adequately represented in a particular residency, the program directors for years have been mulling over a plan for a state of the art interactive Internet-based educational program with the various residencies contributing segments. I am pleased to note that under the able leadership of Dr Blair Keagy this is about to occur. For the present, inadequate exposure to the totality of vascular surgery remains, in my opinion, one of the foremost problems facing vascular residency education. I suspect many of you have been disappointed when serving as an examiner for the ABS vascular certificate to note the narrow training of a number of supposedly fully trained vascular residents. This area must be continually reassessed. I pray that Internet interactive education begins quickly and achieves the desired success. In considering vascular residency education, I would like to say a word about the role of research training. Few changes have been more laudable than the emphasis in recent years on evidence-based medical practice. The importance of scientifically valid clinical research has been recognized by everyone. Opportunities abound for us to address many of the vexing clinical problems facing vascular surgery by the design and conduct of careful clinical trials. What a wonderful opportunity we have in our vascular residency training programs to combine prospective clinical research with resident education and patient care. Residents so trained will be prepared to continue with a career in academic vascular surgery or to write clinical research reports from the perspective of clinical practice. This brings me to the subject of basic science or bench research in the training of vascular surgical residents. We should strive to be the best at what we do. I observe that, in the main, world-class bench research in vascular disease, as well as in medicine in general, is being performed by individuals with a PhD, followed by years of focused postdoctoral training, who regularly work 60 to 70 hours per week on their narrowly drawn bench projects. It makes no sense to me to encourage a clinical vascular surgery resident to dabble for 1 or 2 years in such an activity where they will almost assuredly never be competitive, at least as long as they wish to continue to be a clinical vascular surgeon. While they no doubt learn a certain discipline and subliminal milieu training, it is an inefficient method of instruction and ultimately a nonproductive use of critical time. If the same time and effort were devoted to clinical research training, the resident would receive a research skill useful for a lifetime. Training vascular surgical residents in cutting-edge basic research is simply perpetuation of the romantic fiction that it is possible to do world-class clinical vascular surgery 4 days a week and world-class bench research the remaining 1 day. It won't happen. The sooner we face this and devote this precious time to productive training in clinical research, the better off our specialty will be. Next, I would like to briefly address the issue of certification in vascular surgery. I am sure you are all generally familiar with the difficulty vascular surgery has historically experienced in achieving recognition as a legitimate discipline separate and distinct from general surgery. In my opinion, the ABS, under the able stewardship of Dr Wallace Ritchie, has made monumental progress in recent years in its accommodation of vascular surgery. We currently have two directors on the ABS and a sub-board in vascular surgery with members appointed by the vascular societies and the program directors. I am pleased to report that the sub-board is indeed very much alive and functioning quite well. A timely and well-written progress report describing the activities of the Sub-board in Vascular Surgery by Dr Clagett and associates is available in the May 2000 issue of the Journal of Vascular Surgery. I express appreciation to our board members, Drs Clagett and LoGerfo, for their excellent efforts on our behalf, and to Drs Towne, Whittemore, Calligaro, and Zarins for their contributions as members of the sub-board. As many of you know, the idea of exploring the formation of an American Board of Vascular Surgery was suggested in 1996. While this may or may not have served as a stimulus to facilitate negotiations between the ABS and vascular surgery, I do believe this is an issue whose time has passed. I have no desire to see vascular surgery separated from the corpus of American surgery, as represented by the ABS and the Residency Review Committee in Surgery. Keep in mind that we are dependent on general surgery to provide our vascular residents with their basic surgical training. We are obviously not prepared to assume responsibility for all surgical training of our residents beginning at medical school graduation. With the impossibility of getting a new board of vascular surgery approved by the American Board of Medical Specialties, either as a free-standing or conjoint board notwithstanding, it is important to keep in mind that we do not constitute a critical mass in the overall big picture. If we were a board, we would be among the smallest, certifying fewer than 100 trainees per year. It is most unlikely we would be financially self-sufficient and would likely have to rely on charitable contributions from diplomates for fiscal survival. It is clear to me that our future lies with our remaining firmly in the mainstream of American surgery. We have achieved a great victory: the future is ours. The amount of vascular surgery being performed by newly trained general surgeons in practice is practically nil. The observation that some vascular surgery continues to be performed by cardiac surgeons does not, in my opinion, constitute an insurmountable problem. In summary, we are in the process of developing an excellent relationship with the ABS, one that I do not wish to jeopardize. I respectfully state my belief that it is time for the nascent American Board of Vascular Surgery to exit, with our thanks. Devotion of more time and money to this futile and ultimately counterproductive endeavor appears quite foolish. I urge everyone involved to put this divisive matter behind us and devote future attention to more productive activities. I am reminded of the famous quotation attributed to P. J. O'Rourke: “Politics should be limited in its scope to war, protection of property, and the occasional precautionary beheading of a member of the ruling class.” I hasten to add I have not yet reached the stage of favoring the precautionary beheading of anyone, although I retain this as an option. I have saved until last the topic that has caused me the most distress, namely, entrepreneurialism in medicine in general and vascular surgery in particular. There is an underlying basic truth th
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