Charles Dickens, Coach K, Pogo, and the recent history and future of vascular surgery
2010; Elsevier BV; Volume: 51; Issue: 5 Linguagem: Inglês
10.1016/j.jvs.2010.02.262
ISSN1097-6809
Autores Tópico(s)Cardiac, Anesthesia and Surgical Outcomes
ResumoIt is hard for me to believe that it has been 24 years since I attended my first meeting of the Southern Association for Vascular Surgery, as a guest, in Cerromar Beach, Puerto Rico. I remember that meeting as if it was yesterday. I was struck by how friendly everyone was, famous surgeons whose names I had only read in journals went out of their way to introduce themselves and say hello, the papers were terrific, and the venue was not bad either. I decided then and there that I had to get into this club! Fortunately, I was elected to membership a couple years later. However, never then, or at any time since did I ever expect to be standing here today as the President of this remarkable organization. There is no greater reward in academic medicine then to be recognized and respected by one's peers, and when I consider the 33 vascular surgeons who have preceded me in this office, I am truly humbled, and I thank you sincerely for this wonderful honor. I would not be standing here today without the help and support of many, many people, too numerous to mention individually, but especially my family: my professional, as well as my nuclear, family. I have been privileged to spend my entire career at one incredible institution, Johns Hopkins, and to work with so many amazing people. To my partners, past and present, and our Fellows, thank you for your support, your professionalism, and your friendship. We have been blessed with two beautiful children who are quickly becoming an outstanding young man and woman. Since I have spent most of my waking hours as a surgeon, and not as a father or husband, my bride, Patti, deserves all the credit for these terrific kids. I love you all very, very much. We have experienced a most remarkable recent history in vascular surgery and are facing rapidly changing, and perhaps tumultuous, times ahead in our health care system, and certainly in the practice of vascular and endovascular surgery. A British author, a college basketball coach, and a cartoon character. What in the world do they have to do with vascular surgery? Well, if you will allow me some license, I hope to show you that each of them, through their social commentary, is in fact related to the recent history and future of our specialty. Charles John Huffam Dickens was born in 1812 in Plymouth, Hampshire England, the second of eight children. By all accounts he was the most popular English novelist of the Victorian era, as well as a social activist. During his 58 years, he wrote 33 short stories, three nonfiction works, and 33 novels. His novels were such classics: Oliver Twist, David Copperfield, A Christmas Carol, and many others. He was the most popular English novelist of the Victorian era and in fact, many of his books have never gone out of print. His most significant work, in my view, was one of his two historical novels, A Tale of Two Cities.1Dickens C. Tale of Two Cities. Chapman and Hall, United Kingdom1959Google Scholar A Tale of Two Cities is the story of Paris and London in the years leading up to and including the French Revolution. Life was the best or the worst it could be, depending upon one's social standing. This book contains some of the most memorable lines in the history of English literature. Just consider the first paragraph of Chapter 1:It was the best of times, it was the worst of timesIt was the age of wisdom, it was the age of foolishnessIt was the spring of hope, it was the winter of despairWe had everything before us, we had nothing before us.In many respects, these words describe the recent history of vascular surgery as well. Our patients, the elderly are the fastest growing segment of the population. Over the next decade, the number of individuals over the age of 65 will increase by 50%. By 2030, one in five Americans, 70 million, will be age 65 or older.2Knickman J.R. Snell E.K. The 2030 problem: caring for aging baby boomers.Health Serv Res. 2002; 37: 849-884Crossref PubMed Scopus (269) Google Scholar, 3www.aamc.org/workforce/workforcechartsGoogle Scholar In fact the greatest increase will be among our oldest elderly, those over the age of 75, in whom arterial disease predominates (Fig). Vascular surgery is a growth area in medical practice. It is the spring of hope! In 1992, we performed about 600,000 vascular surgical operations.4Stanley J.C. The changing vascular surgery workforce.Semin Vasc Surg. 1997; 10: 6-71Google Scholar It has been estimated that by 2020 we will perform from 1.0 million to 1.8 million procedures.4Stanley J.C. The changing vascular surgery workforce.Semin Vasc Surg. 1997; 10: 6-71Google Scholar, 5Sidawy A.N. Presidential address: generations apart-bridging the generational divide in vascular surgery.J Vasc Surg. 2003; 38: 1147-1153Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar We had everything before us! Unfortunately, vascular surgical manpower is not keeping pace with these demographic needs. In the state of Maryland, a microcosm of the country as a whole, today there is less than one vascular surgeon per 100,000 residents. There are currently 16 counties in the state with a combined population of 1.3 million without a vascular surgeon. Furthermore, 40% of practicing vascular surgeons in the state are over the age of 55; that is, nearly the age of retirement.6Maizel S. Maryland's surgical workforce-2007: an in-depth analysis and implicaitons for the future.J Am Coll Surg. 2009; 208: 454-461Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar For many patients with vascular disease, it is the winter of despair. But, the law of supply and demand has a positive side. Vascular surgical salaries reflect this critical need. A recent report noted that the median salary for a vascular surgeon in the United States in 2009 was $330,000. Including bonuses and fringe benefits the median compensation package was nearly $450,000.7http://swz.salary.com/salarywizard/layouthtmls/swzl_compresult_national_HC07000307.htmlGoogle Scholar The median starting salary was nearly $260,000.7http://swz.salary.com/salarywizard/layouthtmls/swzl_compresult_national_HC07000307.htmlGoogle Scholar For many in our specialty, especially our graduating Fellows, it is the best of times. Coincident with this demographic evolution has been technological revolution. Historically, the majority of vascular surgical procedures were open operations. In the relatively uncommon situation where a catheter-based intervention was indicated, we were more than happy to refer that patient to our colleagues, primarily in interventional radiology. The patients received the most appropriate care, we peacefully co-existed with our Radiology colleagues, the system worked. It was the best of times. But the endovascular revolution changed everything. It was a perfect storm! And, for several years during this transition, it was the worst of times. The growth of endovascular therapy marked an especially difficult and uncertain period in the history of vascular surgery. While today, as our memories fade, we may think that the transition of our specialty was smooth and seamless, it was anything like that. Suddenly, Interventional Radiologists were transitioning from a service-oriented specialty to patient care providers, and in many communities establishing their own clinics and outpatient practices. Cardiologists suddenly discovered the peripheral circulation! Endovascular therapy represented a real threat to the very existence of our specialty! We had nothing before us. The response of our leadership was mixed. Some of our thought leaders believed that this expansion of catheter-based therapy was a passing fad, to be ignored, and that we should continue to do what we were trained to do; namely, open surgery.8Porter J.M. Presidential address-reflections.J Vasc Surg. 2001; 33: 213-219Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar In hindsight, this attitude clearly was the age of foolishness. Others saw things very, very differently. They believed that endovascular therapy represented a remarkable advance in patient care that we must embrace.9Veith F.J. Presidential address: Charles Darwin and vascular surgery.J Vasc Surg. 1997; 245: 8-18Abstract Full Text Full Text PDF Scopus (48) Google ScholarIt was the age of wisdom. This brings me to my second protagonist, Coach K, Mike Krzyzewski, the head basketball coach of my alma mater, Duke University. The son of Polish immigrants, his father a fireman in Chicago, he graduated from West Point where he played basketball under Coach Bobby Knight. After serving his military commitment he returned to West Point where he was head coach for 5 years, before coming to Duke in 1980. During the last 29 years at Duke he has recorded 760 victories (833 total), 11 ACC tournament championships, 26 NCAA tournament bids, 71 NCAA tournament victories, 10 final four appearances, and three national championships, and an Olympic gold medal with the USA basketball team. Eight of his players have gone on to become head coaches at major universities. Throughout these three decades of success, he has never had an NCAA violation, not even a single investigation. But I include Coach K not for his unparalleled success on the court, but rather because of his contributions off the court. Krzyzeweski is also an Executive-in-Residence at the Fuqua/Coach K Center on Leadership and Ethics at the Fuqua School of Business at Duke, which he helped establish. He is a widely sought after motivational speaker at leadership and Fortune 500 company business conferences around the country and has now authored six books with significant focus on his principles of leadership. His first book is entitled: Leading with the Heart. Coach K's Successful Strategies for Basketball, Business, and Life.10Krzyzewski M. Phillips D.T. Leading with the heart Coach K's successful strategies for basketball, business, and life. Warner Books, New York2000Google Scholar In this book Coach K presents his formula for dealing with difficult challenges, in business, in life, as on the basketball court. Specifically he advises that when faced with a particularly difficult challenge, one should:TAKE RESPONSIBILITY;COME IN WITH A GREAT GAME PLAN;GIVE IT TIME, ATTENTION, AND COMMITMENT;AND FOLLOW THROUGH WITH YOU COMMITTMENT.I would submit that this is exactly what we have done to address the endovascular revolution and the threat to our specialty, and how we must proceed in the uncertain era of health care reform ahead. We rejected the nihilistic philosophy of some and embraced this technology, and have made it out own, and we have become the leaders in the field! 11Eslami M. Csikesz N. Schanzer A. Messina L. Peripheral arterial interventions: trends in market share and outcomes by specialty, 1998-2005.J Vasc Surg. 2009; 50: 1071-1079Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar We have completely remade our specialty, something no other specialty has ever done and have accomplished this in record time-absolutely unprecedented! Our fundamental challenge was to acquire endovascular skills. Just a few years ago, very few vascular surgeons had endovascular expertise, and it was projected that relying just on approved vascular surgical fellowships would produce less than 600 endo-competent vascular surgeons by 2006.12Ouriel K. Kent K.C. The role of the vascular surgeon in endovascular procedures.J Vasc Surg. 2001; 33: 902-903Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Therefore, our GAME PLAN included obtaining endovascular training in so called “mini-fellowships,” nonaccredited endovascular training programs, ranging from a few weeks to a few-months in duration. Graduates of these programs returned home and trained their partners and their fellows. Beginning with nine mini-fellowship programs in 2000, it was estimated that by 2006 more than 1600 endo-competent vascular surgeons would be trained,12Ouriel K. Kent K.C. The role of the vascular surgeon in endovascular procedures.J Vasc Surg. 2001; 33: 902-903Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar and we succeeded. Last year, 80% of vascular surgeons taking the recertification examination were practicing endovascular therapy.13Source: Vascular Surgery Board, John Ricotta, MD (unpublished).Google Scholar We also incorporated endovascular case requirements into our fellowship training and added a year resulting in the 5 + 2 tract.14Mills Sr, J.L. Vascular training in the United States: a half-century of evolution.J Vasc Surg. 2008; 48: 908-978Abstract Full Text Full Text PDF Scopus (51) Google Scholar The results speak for themselves. From 2001 to 2007, the mean number of cases performed by graduating vascular surgery fellows nearly doubled, from 298 to 519 (Table I). This reflected a 442% increase in the number of endovascular cases, while our trainees also experienced a 7% increase in the number of open vascular surgical cases.15Schanzer A. Steppacher R. Eslami M. Arouis 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: 1139-1144Google ScholarTable IVascular fellows caseload: 2001-2007aMean (Reference 21).2001200220032004200520062007Open234.7233.9238.2242.5245.1252.6250.1Endovascular diagnostic22.243.161.686.0100.4113.1104.7Endovascular therapeutic41.558.978.2100.7125.7149.8164.4Total298.3335.9378.0430.2471.3515.6519.2a Mean (Reference 21Schanzer A. Nahmias J. Korenda K. Eslami M. Arous E. Messina L. An increasing demand for integrated vascular residency far outweighs the limited supply of positions.J Vasc Surg. 2009; 50: 1513-1518Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar). Open table in a new tab Coach K's second book is entitled Five-Point Play.16Krzyzewski M. Phillips D.T. Five point play Duke's Journey to the 2001 National Championship. Grand Central Publishing, Boston (MA)2001Google Scholar It's about the 2001 Duke national basketball championship team. It talks about the fingers of a hand, as a metaphor for a basketball team, but in fact, a metaphor for any team or organization, or even a surgical specialty facing difficult challenges. Krzyzewski points out that a finger is remarkably agile and can do lots of things, and pretty well, but in reality, each finger is not that strong, and is limited in what it can accomplish. However, if all five fingers come together and make a fist, the strength of that hand, the power of those five fingers, is so much greater than the sum of its components. Vascular surgery is one of the smallest specialties in medicine. In 2007, there were 2610 active vascular surgeons in the United States-the smallest of the 36 major specialties recognized by the Association of American Medical Colleges (AAMC) (Table II).172008 Physician specialty data.http://www.aamc.org/workforce/specialtyphysiciandatabook.pdfDate: November 2008Google Scholar To put this in perspective, there were 104,904 internists, 103,315 family practitioners, and 21,511 cardiologists (Table II).172008 Physician specialty data.http://www.aamc.org/workforce/specialtyphysiciandatabook.pdfDate: November 2008Google Scholar And just as a finger, our small numbers limit our strength. But, when we come together and speak as one specialty, like a hand in Five Point Play, our strength is magnified several-fold, and there is nothing we cannot accomplish, and that is exactly what we have done, and how we must act in the coming era of health care reform.Table IINumber of physicians in practice in USA (2007)(Source: AAMC, Reference 172008 Physician specialty data.http://www.aamc.org/workforce/specialtyphysiciandatabook.pdfDate: November 2008Google Scholar)Allergy and immunology4222Anatomic/Clinical Pathology15,668Anesthesiology38,724Cardiovascular Disease21,511Child/Adolescent Psychiatry7312Dermatology10,390Emergency Medicine30,742Endocrinology5448Family Medicine103,315Gastroenterology12,086General Surgery27,769Geriatric Medicine3769Hematology/Oncology11,802Infectious Disease6424Internal Medicine104,904Neonatal/Perinatal Medicine4054Nephrology7550Neurologic Surgery4921Neurology12,620Obstetrics/Gynecology39,869Ophthalmology17,846Orthopedic Surgery20,032Otolaryngology9,220Pediatrics54,061Physical Medicine/Rehabilitation8048Plastic surgery6671Preventive medicine7084Psychiatry39,371Pulmonary disease/critical care11,567Radiation oncology4,209Radiology-diagnostic27,562Rheumatology4,568Thoracic surgery4,820Urology9916Vascular surgery2610 Open table in a new tab We have achieved a record of accomplishment unequaled by other specialties that dwarf us in terms of numbers and monetary resources. Our small specialty, through the Society for Vascular Surgery (SVS), led a coalition that championed passage of the SAAVE Act to provide free AAA screening for new Medicare beneficiaries that will literally save thousands of lives; we have pioneered the use of simulators in surgical training; and we are leading the reform of surgical training paradigms. Perhaps most importantly, we ended years of vitriolic and senseless contention among ourselves and came together through the Vascular Surgery Board (VSB) in the spirit of Five Pont Play. In a span of less than 3 years, the American Board of Surgery (ABS) recognized the Vascular Certificate as a Primary Certificate in 200618American Board of Surgerywww.absurgery.orgGoogle Scholar; it recognized the VSB as “the sole body that has authority and responsibility for defining vascular surgical training, certification standards, and examination” in 200719SVS and ABS joint statement on vascular surgery training and certification.http://www.vascularweb.org/professionals/Education/Joint_Statement_on_Training.htmlGoogle Scholar; and in 2008 the ABS eliminated vascular surgery as a core component of general surgery residency training.20General surgery residency patient care curriculum outline Surgical Council on Resident education (SCORE).http://www.surgicalcore.org/Date: 2008-2009Google Scholar We became an independent specialty, no longer a part of general surgery. One impediment to recruitment into surgical specialties in general is the length of our training programs. Vascular surgery had a GAME PLAN for that. As a result of our Primary Certificate, we established the 0 + 5 integrated program of vascular surgical training. From four programs in 2007 we have grown to 17 programs offering 19 training positions in 2009, and are attracting truly outstanding applicants, 152 in 2009 (Table III).21Schanzer A. Nahmias J. Korenda K. Eslami M. Arous E. Messina L. An increasing demand for integrated vascular residency far outweighs the limited supply of positions.J Vasc Surg. 2009; 50: 1513-1518Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar We need more 0 + 5 programs, but funding is an obstacle and we are going to have to fight for it.Table III0 + 5 vascular surgery integrated programsSource: Reference 21Schanzer A. Nahmias J. Korenda K. Eslami M. Arous E. Messina L. An increasing demand for integrated vascular residency far outweighs the limited supply of positions.J Vasc Surg. 2009; 50: 1513-1518Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar.2006200720082009Number of positions04919Number of applicants049112152 Open table in a new tab While health policy experts predict a shortage of at least 125,000 to 200,000 physicians in the United States by 2025 due to the aging of the population and our workforce,22Dill M.J. Salsberg E.S. The complexities of physician demand: Projections through 2025.November 2008Google Scholar, 23Cooper R.A. The coming era of too few physicians.Bull Am Coll Surg. 2009; 93: 11-18Google Scholar and while universal health care coverage will exacerbate this demand,22Dill M.J. Salsberg E.S. The complexities of physician demand: Projections through 2025.November 2008Google Scholar many so called experts believe that we have, and will continue to have, an excess number of specialists. They believe the real deficiency is in primary care physicians. Furthermore, in this era of increasing pressure for health care cost containment, it's argued that specialists drive up costs. In recent congressional testimony, Dr David Goodman, Director of the Center for Health Policy Research at Dartmouth advocated limiting the number of specialists we train as a strategy to effectively slow the growth of health care spending.24Goodman D.C. Linking workforce policy to healthcare reform Hearing on workforce issues in health care reform: assessing the present and preparing for the future.Testimony before the United States Senate Committee on Finance. March 12, 2009Google Scholar This strategy is founded on the argument that greater physician, and in particular specialist, supply, does not result in better health care.23Cooper R.A. The coming era of too few physicians.Bull Am Coll Surg. 2009; 93: 11-18Google Scholar A recent Dartmouth study concluded that states with greater Medicare spending and more specialists had poorer health outcomes.25Baiker K. Chandra A. Medicare spending, the physician workforce, and beneficiaries quality of health.Health Aff. 2004; (W4-184-7)Google Scholar However, this research is flawed. Specifically, it has been demonstrated that states with higher Medicare expenditures in fact spend less on health care overall due to larger social burdens such as more uninsured individuals and a greater percentage of the population living below the poverty line. In fact when total health care spending per capita is examined, the evidence shows that states with higher per-capita health care expenditures have better-quality health care.23Cooper R.A. The coming era of too few physicians.Bull Am Coll Surg. 2009; 93: 11-18Google Scholar Furthermore, states with more specialists have better health care. We do have a positive impact! The Balanced Budget Act of 1997 limits Medicare funding for additional trainees in graduate medical education.26Salsberg E. Rockey P.H. Rivers K.L. Brotherton S.E. Jackson G.R. US Residency training before and after the 1997 balanced budget act.JAMA. 2008; 300: 1180Crossref Scopus (80) Google Scholar In recent congressional testimony, Dr Fitzhugh Mullan, Professor of Medicine and Health Policy at George Washington University argued that Medicare graduate medical education funding should be utilized as a strategy to influence the physician workforce distribution in this country, and in particular to increase the number of primary care physicians at the expense of specialists.27Mullan F. testimony before the Senate Finance Committee Workforce issues in health care reform: assessing the present and preparing for the future.March 12, 2009Google Scholar To attract medical students to primary care and away from higher paying specialties, the Medicare Payment Advisory Commission has recommended an increase of up to 10% in payment for primary care services, to be offset by a reduction in payments to specialty physicians,28Pear R. Shortage of doctors proves obstacle to Obama goals.The New York Times. April 27, 2009Google Scholar and this recommendation has been debated in Congress as part of health care reform. A Massachusetts health care Commission has recommended that the payment system in the state be changed from a fee-for-service to a capitation model, and specifically argued that the current system “results in specialists such as surgeons and cardiologists earning substantially more than primary care doctors, contributing to a shortage of these doctors.”29Kowalczyk L. State seeks to revamp way doctors, hospitals are paid.Boston Globe. May 7, 2009Google Scholar It is clear who will have the bull's-eye on their backs as our healthcare system continues to evolve! However, our patients, the elderly, are most profoundly threatened by health care reform and proposed cuts in Medicare. In 2008 we spent $462 billion on 45 million Medicare beneficiaries, including $8 billion on the treatment of 12 million beneficiaries with peripheral arterial disease,302009 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds.Google Scholar, 31Hirsch A.T. Hartman L. Town R.J. Virnig B.A. National health care costs of peripheral arterial disease in the Medicare population.Vasc Med. 2008; 13: 209-251Crossref PubMed Scopus (243) Google Scholar and it is projected that the system will become insolvent in 7 years.32National Coalition on Health CareHealth insurance costs.http://www.nchc.org/facts/cost.shtmlGoogle Scholar Even the Congressional Budget Office (CBO) has recently concluded that these proposed Medicare cuts will limit seniors' access to health care.33McCaughey B. Government Care's assault on seniors.Wall Street Journal. July 23, 2009Google Scholar Well my colleagues, we can be fearful and depressed, we can be frustrated and angry, and we can assume it is the winter of despair, or we can follow Coach K's admonition and “TAKE RESPONSIBILITY.” And that leads me to my final protagonist: Pogo. Pogo was the central character of a comic strip created by Walter Kelly that ran from 1948 through 1975. It was set in the heart of the region of the Southern Association for Vascular Surgery, Okefenokee Swamp in Georgia. Pogo engaged in political and social satire through the adventures of its comical animal characters, which were portrayed in a good-natured way to reflect the spectrum of human nature, and with wit and physical humor so as to appeal to both adults and children. In one notable episode, from Earth Day, 1971, Pogo and Porkypine come upon a once beautiful forest that had been littered, and Pogo utters perhaps the most quoted line of the nearly 30-year history of the comic strip. He says, “Yep son, we have met the enemy and he is us.” We have met the enemy and he is us! Vascular surgeons are a tiny minority of the health care system, a spec in the health care universe, and we are not responsible for the impending financial collapse of Medicare, but we are one of the litterers, we do contribute to the problem, and therefore we can be a positive force in reform by doing what we do best-by leading by example! Whether we like it or not, whether we want to admit it or not, we are all engaged in the business of medicine, and a fundamental component of that business today is direct-to-consumer advertising. In fact, the United States is one of only two countries in the world that permits direct-to-consumer medical advertising, and New Zealand is trying to do away with it. While this historically exclusively involved pharmaceuticals, that changed during a Dallas Cowboys-New York Jets football game in November, 2007, when a commercial appeared for the Cypher drug-eluting coronary stent, and now other medical devices are also being marketed directly to the consumer.34Boden W.E. Diamond G.A. DTCA for PTA- crossing the line in consumer education?.New Engl J Med. 2008; 358: 2197-2200Crossref PubMed Scopus (19) Google Scholar In 2005, pharmaceutical companies spent $4.1 billion on television and internet advertising. Medical device manufacturers spent $116 million in 2005 but this had increased to $191 million by 2007.35Mitka M. Direct-to-consumer advertising of medical devices under scrutiny.JAMA. 2008; 300: 1985-1986Crossref PubMed Scopus (16) Google Scholar In an era of increasing competition for patients and clinical revenue, the medical community has also pursued aggressive marketing strategies, not only through paid advertisements, but also more subtly through press releases and stories in the lay press about our latest techniques. Many of us do it. It is not my intent to condemn marketing-it does create a more informed patient population. But, there must be truth in advertising! What concerns me, what makes us the “enemy” in Pogo's world, is that at times we have exaggerated the “promise” of new technologies as proven therapy in these marketing efforts, and this is wrong. In a recent analysis of 200 research press releases from academic medical centers, 29% were found to overstate the significance of the research findings.36Woloshin S. Schwartz L.M. Casella S.L. Kennedy A.T. Larson R.J. Press releases by academic medical centers: not so academic?.Ann Intern Med. 2009; 150: 613-618Crossref PubMed Scopus (81) Google Scholar This is a particular concern in the arena of endovascular therapy. Consider one early example. In the late 1980s the Food and Drug Administration, based on a series of 219 patients with no long-term follow-up, approved the hot tip laser as a means of recanalizing femoral-popliteal occlusive disease. This was high tech, it was star wars, it was exciting, and it was ripe for strategic marketing. A near laser hysteria gripped our world! Almost immediately hundreds of hospitals acquired this technology and thousands of patients were treated. Many institutions utilized the “promise” of hot tip laser angioplasty in aggressive marketing campaigns. Unfortunately, many of these ads were hyperbole and misleading: presenting laser angioplasty as a “breakthrough,” when in fact there was a paucity of reported data; misrepresenting the mechanism of treatment which was simply burning a channel through the occlusion, and not “vaporizing” it in seconds; and suggesting it would replace bypass surgery when typically only short lesions were being successfully treated. Most importantly, hot tip laser angioplasty did not work! At Johns Hopkins our interventional radiologists acquired the technology and began treating patients, and we collaborated with them. The results were terrible—a 1-year patency of
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