Presidential address: The vascular societies—How involved should they be?
1986; Elsevier BV; Volume: 3; Issue: 1 Linguagem: Inglês
10.1016/0741-5214(86)90063-7
ISSN1097-6809
Autores Tópico(s)Aortic aneurysm repair treatments
ResumoEDITORS' NOTE: With this issue the Journal of Vascular Surgery begins its publication as a monthly. It would be less than candid of the Editors to claim that when they first began to plan the Journal in the early days of 1983 they had foreseen that within a few months the volume of submitted articles of high merit would create an urgent need for expansion. Yet this is precisely what happened. The Journal has been fortunate enough to become such a favored forum in which to present reports of first-rate clinical and investigative studies that its bimonthly issues were unable to respond properly to the demand for publication space. It would be a flattering but wrong conceit for the Editors to believe that this vigorous growth was mainly the fruit of their efforts. In fact, many influences have contributed to the Journal's prosperity. Foremost has been the astonishing vigor of the investigative and literary productivity of the vascular surgeons not only in this country but across the breadth of the medically developed world that provided substance for creating a journal of quality. Every successful enterprise must be timed right. The birthdate of the Journal of Vascular Surgery obviously met this requirement since the response of contributors was prompt. Lively, and far-reaching. The timing was also right from another point of view: interest of the surgical community in a peer-reviewed publication of stringent standards whose goal was to provide a record of the advances in the rapidly evolving field of vascular surgery. We owe thanks to our subscribing readership—now numbering over 5000 and still growing—whose interest and loyalty were the momentum for a successful start. In giving their precious time to the demanding and tedious task of manuscript review with care, knowledge, and promptness, the Editorial Board made it possible for the Editors to select contributions of highest qualifications. The publisher, The C. V. Mosby Company, provided copyediting of exceptional merit and dressed the contents of the Journal in a typographical garment that was not only pleasing to the eye but dignified and distinctive. To all these collaborators the Editors want to express their sense of genuine appreciation. This kind of talented and enthusiastic support will assure the future prosperity of the Journal as it embarks on its new schedule of publication. The vascular societies—how involved should they be? In considering possible answers to this question I am going to draw on the experiences of the Society for Vascular Surgery (SVS) as well as the North American Chapter of the International Society for Cardiovascular Surgery (ISCVS), with apologies to other fine vascular societies with which I have not been as intimately associated. In addition these two societies have joined together through their Joint Council to represent the vascular community in many of the areas of involvement to be considered. In trying to answer our question we might first consider the opinions of our founding fathers. In 1947, when the SVS was founded, a constitution was accepted which stated that “the objects of this Society shall be (1) to promote the study and research of vascular diseases; (2) to define more clearly the role of surgery in these diseases; (3) to pool the experience and knowledge of the membership in order to standardize methods of studying and managing these diseases; (4) to standardize the nomenclature of these diseases; (5) to promote and encourage adequate teaching of these diseases to students, interns, and residents; (6) to encourage hospitals to develop special training for young surgeons in this field; (7) to hold annual meetings.” The 1952 constitution of the North American Chapter of the ISCVS, in addition to supporting their international parent, stated that its object should be “to promote investigation and study of the art, science, and therapy of cardiovascular diseases, to coordinate this knowledge and disseminate it.” These rather precise objectives would seem to charge the societies with primarily academic and educational activities. At the time of the inception of the societies the founding fathers apparently did not believe there was a need, and possibly even that it was proper, for the societies to become involved in matters of quality of care and socioeconomic problems. A loose interpretation of the published objects is required to sanction some of the current activities of the societies. Times can change, however, and it would seem pertinent to consider the opinions of the current members to determine the degree of the future involvement of the societies. Last year in preparation for another address entitled “Is the Role of the Vascular Societies Appropriate to Our Needs?” I had the opportunity to poll the memberships regarding the appropriateness of the current and possible future activities of the societies.1DeWeese JA. Is the role of the vascular societies appropriate to our needs? (In press.)Google Scholar The questionnaire was sent to 1217 persons who belonged to SVS, ISCVS, or both, and 923 of these (76%) answered. The results of the questionnaire should therefore be helpful to us in considering the question, “How involved should we be?” During the past few years the societies have been most involved in the following activities: (1) the annual scientific program; (2) fostering the examination and certification of vascular surgeons; (3) establishing and supporting the accreditation of vascular surgical training programs; (4) establishing the Journal of Vascular Surgery, and (5) providing a forum for the regional vascular societies. It is appropriate to discuss these past and present activities before a discussion of possible future involvements of the societies. The annual scientific program has been the center of the societies' activities. The first meeting of the SVS was held in 1947 and nine papers were presented during the 1-day meeting. The first 2-day combined meeting was held in 1952 and approximately 400 people attended. In 1984, 1337 physicians attended the 3-day meeting at which 48 papers were presented. The quality of the papers presented at the meetings has been excellent and almost all have been published in prestigious journals. The lively and frank discussions further increase the value of the program. The “giants” of vascular surgery are usually found in the first few rows ready to discuss the papers and many a young surgeon has been flattered to see the spontaneous appearance of Drs. Geza de Takats, Robert Linton, Harris Schumacker, D. Emerick Szilagyi, Charles Rob, or E.J. Wylie at the podium. A young surgeon could be proud to see the “giant” appear but he also has to be prepared for some corrective counseling. I remember well the gentle admonition of Dr. Alton Ochsner when he pointed out in the discussion of one of the first papers I presented at the vascular meetings that “venography was a ‘bastard’ term.” The term mixed a Greek and Latin derivative and should more correctly be “phlebography.” The constitutions of the societies clearly supported the annual meeting and 85% of the membership who returned their questionnaires thought it fulfilled their needs (Table I).Table IResults of questionnaire to members of Society for Vascular Surgery and International Society for Cardiovascular Society (923 of 1217 members responding)ResponsesYes(%)No(%)None(%)Present activities Does annual meeting fulfill needs?785(85)65(7)73(8) Was examination and certification of vascular surgeons an appropriate concern?683(74)185(20)55(6) Were accreditation vascular surgical training programs an appropriate concern?840(91)65(7)18(2) Should we publish Journal of Vascular Surgery?775(84)120(13)28(3) Should we support yearly meeting of regional vascular societies?821(89)83(9)19(2)Possible future activities Should we establish registry?379(41)498(54)46(5) Should we have standards and ethics committee?609(66)295(32)19(2) Should we be involved in governmental relations?415(45)480(52)28(3) Should we have manpower committee?766(83)129(14)28(3) Should we have medicolegal affairs committee?545(59)350(38)28(3) Open table in a new tab In the late 1960s some responsible vascular surgeons became concerned about the quality of vascular surgery being performed in the United States. This concern was expressed well by Drs. Edwin J. Wylie and Jack A. Cannon in their presidential addresses before the ISCVS in 1970 and 1971.2Wylie EJ Vascular surgery: A quest for excellence.Arch Surg. 1970; 101: 645-648Crossref PubMed Scopus (32) Google Scholar, 3Cannon JA Surgical Judgment in vascular surgery.Arch Surg. 1971; 103: 521-524Crossref PubMed Scopus (11) Google Scholar In a paper presented at the 1972 meeting by Drs. DeWeese, Foster, and Blaisdell, the answer to the problem was identified as the improved training and continued experience of surgeons performing vascular operations.4DeWeese JA Blaisdell FW Foster JH Optimal resources for vascular surgery; Committee on vascular surgery.Arch Surg. 1972; 105: 948-961Crossref PubMed Scopus (45) Google Scholar At the same meeting the societies passed a resolution stating that they “recommend and endorse a certification method for recognition of special competence in vascular surgery under the aegis of the American Board of Surgery (ABS).” During the ensuing 10 years representatives of the vascular societies remained active in the deliberations of the ABS. Finally, as a result of the efforts of Drs. Blaisdell, Fry, Garrett, Szilagyi, Thompson, Wylie, and others, the American Board of Medical Specialties (ABMS) in 1982 approved the application of the ABS with representation from the American Board of Thoracic Surgery to grant “Certificates of Special Qualifications in General Vascular Surgery.” In June 1982 an examination was passed by 14 current members of the ABS and the American Board of Thoracic Surgery. In November 1983 a written examination for qualified surgeons was given in several centers; there were 476 candidates of whom 388 (82%) became certified. In 1984 another 186 candidates took the examination and 143 passed it. The objectives stated in their constitutions do not suggest that the societies should be involved in the certification of vascular surgeons.1DeWeese JA. Is the role of the vascular societies appropriate to our needs? (In press.)Google Scholar In 1983 74% of the responding members thought it was an appropriate activity of the societies (Table I). On the other hand, 39 members made written comments of concern about the rigid requirements for taking the examination, the inappropriateness of questions on the examination, or the examination process in general (see Questionnaire results on p. 4). Similar objections have reached the Joint Council and the ABS and the American Board of Thoracic Surgery. For this reason the societies have remained involved with the board in the vascular examination process. Positive actions have occurred within the past year including the following: (1) The two societies through their Joint Council will become participating organizations with the ABS and be asked to nominate replacements for Drs. Jesse Thompson and H. Edward Garrett when they complete their terms of office in 1986 and 1987. (2) At the request of the Joint Council the ABS extended the deadline for eligibility to take the examinations for vascular residents in programs approved by the Program Evaluation and Endorsement Committee (PEEC) from June 30, 1985 to June 30, 1986 if they were in programs that were still in the process of seeking approval from the Accrediting Committee for Graduate Medical Education (ACGME) on June 30, 1985. (3) At the request of the ABS the Joint Council selected 10 members of the societies to assist with the written vascular examination process. The members took the examinations and rated them as to appropriateness and fairness of the questions. Their input was used by the board to help establish the passing grade. They have also submitted questions to the Vascular Committee of the ABS to be considered for use in future examinations. (4) The Joint Council has also been asked to submit a list of 20 individuals to act as oral examiners when this examination is first given in June 1986. (5) The two presidents of the societies attended the meeting of the Credentials Committee of the ABS. It appeared that the committee was selecting candidates for the examination fairly on the basis of their interpretation of the current published guidelines for determining eligibility. (6) The members of the societies and the Joint Council, however, have expressed concerns regarding the rigidity of the guidelines for eligibility to take the examination. The concerns have included the requirements for the performance of a minimum number of major vascular operations in 1 year, membership in societies, and continued academic endeavors. These requirements are of special concern when applied to individuals who have completed accredited vascular surgical residencies, since similar rules are not applied to individuals applying for the parent ABS and almost all other specialty boards. A meeting of representatives of the ABS and the Joint Council to discuss these issues is planned.Tabled 1Questionnaire resultsSelected commentsAnnual meetingComments of eight members included “no longer interests internists,” “needs more cardiac,” “same authors year after year,” “more animal research,” “lacking in basic science,” “separate cardiac papers,” “too large—needs smaller group for in-depth discussions”Examination and certificationComments of 41 members included “requirements too stiff,” “criteria for examination too narrow,” “one hundred cases a year is impossible,” “not well done,” “outcome disappointing,” “lost control,” “examination too long,” “too much insider activity,” “avoid labor unions,” “protectionism,” “sequestration,” “vascular surgical and cardiothoracic surgical residents should automatically qualify,” “academia has the major vote,” “requirements should be even stiffer,” “limit those who do vascular surgery to those with formal training”Vascular training programsComments of five members included “activities of the Residency Review Committee are inappropriate,” “most backward step in 50 years,” “should not be an accreditor”Journal of Vascular SurgeryComments of 15 members included “too many journals,” “removes us from main stream and other general surgeons will get second-rate and third-rate articles,” “limited audience—we are talking to ourselves”Regional vascular societiesOnly one comment, “duplication of effort”Possible future activitiesRegistriesComments of 46 members included “costly,” “waste of time, cancer taught us that,” “too difficult,” “too standardized,” “garbage in, garbage out,” “too large a membership,” “registries are hard to catalog,” “not practical to monitor,” “let regional societies do it,” “some regional societies have abandoned these,” “too large a membership,” “in conjunction with other societies,” “could help to influence diagnosis-related groups”Standards and ethicsComments received from 25 members; 13 thought it could be handled by the American College of Surgeons. Other comments included “a ball of wax,” “too many forms,” “too many in effect,” “only in an advisory role,” “let regional societies do it,” “let local hospitals do it,” “question legality and the lawyers' access to sensitive material”Governmental relationsComments received from 25 members; 17 thought that the American College of Surgeons were doing this. Other comments included “could be done by AMA, ATS, AMC,” “in spades,” “very much so,” “ad hoc committees”ManpowerComments of 19 members included “should be done by American College of Surgeons or AMA,” “should be done every 5 years,” “very important,” “ad hoc committees,” “not our business,” “control the number of trainees,” “regulate the number of training programs,” “one of our most important nonscientific functions”Medicolegal affairsComments of 11 members included “should be done by the American College of Surgeons,” “work with American College of Surgeons,” “set up a review panel,” “should review malpractice suits for merit and service expert witnesses,” “ad hoc committees,” “should be done by regional societies”General comments“Suggested reading, The Rise and Fall of Nations by Moncure Olsen,” “promote more effort, promote the study of and research of vascular diseases,” “promote a Directors of Vascular Surgical Training Programs Association,” “research not stressed enough,” “should support multicenter studies,” “SVS has gradually eliminated cardiac surgery from its agenda—appropriately,” “renal transplantation access procedures and venous insufficiency not stressed enough in training programs,” “support NSMR at local and federal levels,” “tends to nurture the egos of a select few,” “constitution too laissez faire,” “this questionnaire for brothers with the scalpel,” “should have an employment bureau,” “take a strong stand against smoking,” “abolish an elite ISCVS and a superelite SVS and make one society—the capabilities and intelligence quotients of members in both are probably the same” Open table in a new tab During the deliberations of the ABS, it became obvious that monitoring of the training of a vascular surgeon was as important as the examination of his knowledge if improved quality of care of vascular patients was to be guaranteed. The initial attempts to obtain approval to establish accreditation of vascular training programs by the Residency Review Committees (RRCs) for Surgery and for Thoracic Surgery reached an impasse in 1980. The societies therefore recommended that vascular training programs should be inspected and acceptable programs approved by a committee of the two societies.5Blaisdell FW Vascular surgery training: Quo vadis.Surgery. 1979; 86: 783-790PubMed Google Scholar The PEEC of the two societies approved 38 vascular surgical training programs in 1981 and an additional 14 in 1982. Finally, however, accord was reached by all interested bodies and in November 1982 the ACGME approved the application of the RRC for Surgery with representation for the RRC for Thoracic Surgery to approve training programs in general vascular surgery. As of February 1985 the RRC has considered 61 applications and accredited 29 programs that provide training for 42 residents. The constitution of the SVS includes an objective “to encourage hospitals to develop special training for young surgeons in this field” and would support at least that society's activities with the Joint Council. Ninety-one percent of the members who responded considered this to be an appropriate activity of the societies (Table I). As the accreditation process has progressed, however, a number of members have expressed concern regarding the actions of the RRC for Surgery. The societies, therefore, have remained involved. During the past year, the Joint Council's activities have included a request for representation on the RRC for Surgery from the Joint Council. Nominations for membership on the RRC are from its three parent organizations, the ABS, the American College of Surgeons (ACS), and the American Medical Association (AMA). It is, therefore, not possible for the societies to designate a member of the committee. On the other hand, the RRCs have indicated that to obtain vascular representation when new positions are available, they are requesting the parent organizations to include a member of the vascular community in their nominations. The Joint Council has also formed a committee under the chairmanship of Dr John Porter to proceed with the development of a course of study on basic sciences that could be made available to vascular residents because of the RRC's dissatisfactions with the teaching of basic sciences in some programs. A recommendation was made to the RRC and adopted by them that, although desirable, vascular residents not be required to have experience in performance of angiograms during their training. This action was taken in response to a request from the RRC for the opinion of the Joint Council. The Joint Council made a request to the RRC to reconsider its guidelines, which (1) do not allow a general surgical senior resident and vascular resident to be on the same service and (2) require general surgical residents in a program with a general vascular surgical residency to perform a minimum number (reported to be 40) major vascular operations during their training. These points were discussed at a RRC meeting attended by the presidents of the two societies. There was unofficial acceptance by the RRC that the general surgical resident and vascular resident could be on the same overall service as long as they had independent authority and patient selection. It was understood that both might participate in the same operation but only one could receive credit for performing the operation. It was also unofficially stated that on such services the “rare” operation could be assigned to the vascular resident. The Joint Council continues to believe, however, that in some programs there is a definite advantage to having both residents participate in the same operations with the vascular resident serving as a teaching assistant. The RRC has continued to demonstrate that they consider it important that general surgical residents perform a significant number of vascular reconstructions during their training and this number is reported to be 40. Accreditation has been denied to some vascular surgical training programs because of this “numbers game.” The Joint Council continues to object to this guideline because (1) minimum numbers of required operations have not been established in other general surgical areas, such as head and neck surgery and endocrine surgery, and (2) the minimum number rule is applied only to those institutions seeking vascular surgery training programs and not to general surgical programs without vascular residencies. These concerns will again be discussed at a special meeting of representatives of the Joint Council and the RRC. Support is abundant for the continued involvement of the societies in both the accreditation of vascular training programs and the certification of vascular surgeons. Some members are upset with the slowness of the maturation process of these activities and request even more direct involvement by the societies. The Joint Council is confident, however, that continued improvement in quality of vascular surgical care can best be accomplished by working within the system. The Journal of Vascular Surgery (JVS) was published bimonthly by The C.V. Mosby Company beginning in January 1984. The copyright for the JVS is held by the SVS and the North American Chapter of the ISCVS. The Editor-in-Chief is Michael DeBakey and the Senior Editors are Drs. D. Emerick Szilagyi and Dr. Jesse E. Thompson. The Societies retain ownership of the name of the JVS and any net income from the publication in the future will be shared by the societies on the one hand and The C.V. Mosby Company on the other, in equal amounts. The constitutions of both societies clearly indicate that the Journal would be an appropriate activity of the Societies. Eighty-four percent of the members responding to the questionnaire agreed (Table I). A few of the members who commented were concerned about the possible failure of the JVS (see Questionnaireresults, p. 4). Time has erased these concerns. The JVS is flourishing; it has had many compliments and has been financially successful. Circulation has increased to 4540 subscribers. Beginning Jan. 1, 1986, it will be published monthly. JVS has certainly proved to be an important involvement of the societies. A number of local and regional vascular societies were formed in the early 1970s. Activities vary from society to society. The educational activities may consist of anything from a weekly vascular conference to a yearly scientific program. Membership in these societies is restricted in some by interest only, but in most by vascular caseload, training, the yearly submission of numbers of operations and their results to a registry, or even membership in the SVS or ISCVS. As these societies appeared, many individuals questioned what the relationship between these societies and the national societies should be. The Joint Council appointed a committee consisting of Drs. Norman Rich and John Foster to answer this question. As an ongoing evaluation of these possible relationships the national societies provide organizational support for a 1-day meeting of representatives of all of the regional vascular societies to share their experiences. The meeting is held on the day preceding the annual meeting of the national societies. This unusual activity has proved to be quite important. There is no written agreement nor formal relationship between the individual regional societies and the national societies or even between themselves. With the exception of the suggested importance of belonging to a regional vascular society in the application blank for the ISCVS, there is no evidence of official recognition of the regional societies by the two national societies. This activity was apparently not foreseen as an important objective of the SVS by our founding fathers. On the other hand, 89% of members who responded to our questionnaire believed it was an important area for involvement (Table I). Other areas of involvement, which other societies considered to be of importance, and might also be considered by the vascular societies are (1) registries, (2) standards and ethics, (3) government relations, (4) manpower, and (5) medicolegal affairs. To improve the quality of vascular surgical care, the Committee on Optimal Resources for Vascular Surgery recommended that “the vascular team should assume responsibility for developing an organized system for collecting the results of treatment of vascular diseases.”4DeWeese JA Blaisdell FW Foster JH Optimal resources for vascular surgery; Committee on vascular surgery.Arch Surg. 1972; 105: 948-961Crossref PubMed Scopus (45) Google Scholar The results of these findings could then be used for (1) self-analysis, (2) comparison of one's own results with those of others or published reports, (3) comparison of institutional records with those of other institutions or published reports, and (4) the establishment of standards for an organization for the purpose of changing professional behavior or for regulatory purposes. The validity of comparisons is dependent on several factors, including whether the reports are voluntary or mandatory, the accuracy of the reports, the selection of patients, as well as the technical skills of the surgeon and team. At least one regional vascular society (the Upstate New York Vascular Society) requires the annual reporting of an individual's numbers of cases and results as a criterion for continued membership. This society annually publishes the pooled results, which allows each person to compare his results with those of the group. The individual's results are not published and therefore cannot be compared with the results of other members nor used for regulatory purposes. On the other hand, one local society uses the reported results as a means of determining continued membership.6Plecha FR Avellone JC Beven EG DePalma RG Hertzer NR A computerized vascular registry: Experience of The Cleveland Vascular Society.Surgery. 1979; 86: 826-835PubMed Google Scholar Cardiac surgical registries have been established by the Veterans Administration and also the New York State Department of Health. These registries are comprehensive mandatory systems with the annual reporting of results. They effectively set standards and can be used for regulatory purposes.7Griffiths SP Zazula BM Courtney D Spencer FC Malm JR Trends in cardiovascular surgery (1961 to 1977): Review of the New York city and state experience.Am J Cardiol. 1979; 44: 555-562Abstract Full Text PDF PubMed Scopus (15) Google Scholar The only society that has attempted to establish a voluntary open heart registry is the Society of Thoracic Surgeons. It has not yet been established as to what use will be made of that information. The national societies at one time showed an interest in the establishment of a registry and in 1980 appointed a Data Retrieval Committee. At the Joint Council meeting in 1983, the committee reported that support existed for a national data base in vascular surgery. The Joint Council, however, reconsidered its position and the Data Retrieval Committee was disbanded; the Joint Council instead appointed a committee to look at the more basic issue of data collection and specifically to “establish adequate definitions of disease and statistical reporting methods.” This committee consists of Dr. Robert Rutherford as Chairman and Drs. J. Dennis Baker and Calvin Ernst as members. Both constitutions appear to support the concept of registries. On the other hand, a poll of the membership indicated that only 41% of members believed that one should be established and 46 members were prompted to provide succinct reasons for the Societies not to become involved (Table I, see also Questionnaireresults, p. 4). It appears that the Joint Council's current attitude that we should act only as a study group or in an advisory fashion has wisely sensed the feelings of the membership with regard to registries. A number of organizations have been concerned with problems related to standards and ethics. Their activities have consisted of publishing guidelines for standards of practice and/or responding to complaints of substandard or unethical surgical practices. There are some published guidelines for vascular surgical standards. One of these was published by the Intersociety for Hear
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