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Nostrums, quackery, and ethics in vascular surgery: how to remain true to the path of Hippocrates and still feed our families

2004; Elsevier BV; Volume: 40; Issue: 2 Linguagem: Inglês

10.1016/j.jvs.2004.05.008

1097-6809

Enrico Ascher,

History of Medical Practice

I would like to start by thanking you for the opportunity to have served this society in many capacities and, now, as your President. I am truly honored and humbled by the experience of working for the Eastern Vascular Society (EVS) in this high capacity and in these times of challenge for our specialty. The presidency of our nation's youngest yet largest regional vascular society has been one of the proudest achievements of my professional career. Here, I have developed many sincere and durable friendships. I have learned immensely from my predecessors, as well as from the future leadership, and I have witnessed the true commitment of an executive council that has been relentless in pursuing the highest standards for our regional society. As the complexity of our specialty evolves and the challenges become more sophisticated, I anticipate an even larger role for the EVS—beyond the scientific environment. We must band together as the largest regional group in this country to study and develop strategies that can help our members to fend off unfair competition. We should continue to explore methods of communicating the concept of a vascular specialist to our medical colleagues and to the lay public, and we are obliged to protect and defend ourselves from fraudulent expert witness testimony. No longer can we afford to concentrate solely on the most current and exciting scientific data. Issues including reimbursement, ethics, and recognition of vascular surgery as a mature and independent specialty should be addressed. These issues are crucial on both the national and regional levels. The world is changing and so must we. This Society has been proactive in developing programs focusing on the major areas that affect our daily clinical practices, and I call for all members to join in the effort. Complacency will only help those who are competing for our patients and will not thwart those who hinder the natural evolution of our continued success as vascular specialists. Last year, in my presidential address to the Society for Clinical Vascular Surgery, I chose to define the vascular surgeon as a vascular specialist.1Ascher E. Presidential address the modern vascular specialist—surgeon, clinician, and interventionist.J Vasc Surg. 2003; 38: 633-638Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar The intended role of a vascular specialist would be to provide total vascular care to patients presenting with vascular diseases as well as to actively participate in directing noninvasive vascular diagnostic laboratories. Also, for the first time ever, I called for a shortened 5-year training paradigm for vascular surgery to make vascular surgery residency more focused, effective, and attractive to potential candidates. Today, I choose to share with you my thoughts about ethics in vascular surgery and to call your attention to changes in the business of vascular surgery. Before I relate my thoughts on these subjects, allow me to take a moment to recognize a surgeon who has provided me with the necessary tools to build a productive career in vascular surgery. Indeed, vascular surgeons worldwide have benefited from the talent, creativity, and leadership of Frank J. Veith. Over the years, he has courageously and successfully tackled the most politically charged topics affecting vascular surgery. Frank is a brilliant strategist who tirelessly follows his goals and beliefs. Some of these have been to integrate endovascular treatment into the armamentarium of the vascular surgeon and to achieve vascular surgery board independence. His commitment to our specialty is inspiring, and I feel privileged to be a friend of this pioneer in vascular surgery. I would also like to recognize the influential role that Dr Robert Hobson has played in my career as a vascular surgeon. Although he was not directly involved in my surgical training, he has been a role model for me and for an entire generation of vascular surgeons. Bob is a true surgeon-scientist who has written many landmark clinical and basic science papers. He has accomplished greatly at the helm of every important vascular society in this country, and his friendly and welcoming demeanor is an asset to emulate as we try to attract the best and brightest among medical students and surgical residents to join vascular surgery. This is a rare public moment when one has the pleasure to show his appreciation to his or her family. To Katia, my lovely wife and companion of 28 years, I recognize your undivided attention, care, and support that have enabled me to realize many of my academic dreams as well as to fulfill an often absurd schedule. A respected physician in her own right, Katia is an accomplished nephrologist at the Albert Einstein College of Medicine who is an example of what a physician should be—that is, knowledgeable, dedicated, committed, and compassionate. To my children, Michael and Andrea, I wish to say that I love you and I am very proud of you. I would also like to recognize my mother, Emilia, and my late father, Samuel, for their guidance and support throughout my life. Today, I stand here before you as a fellow surgeon who is concerned about the very survival of our specialty, and I will impart to you my thoughts on how we must become proactive in the defense of our livelihood while maintaining acceptable codes of ethics. Ever since the modern evolution of our specialty as vascular surgeons, interventionists, and clinicians, we have been under a constant assault that continues to threaten our existence. I truly believe that we must stand together as a whole and compete with those who would falsely usurp that which we have thus far achieved, as we continue to remain faithful to ethical principles outlined for us by Hippocrates, Galen of Pergamum, and Moses Maimonides. It is easy for all of us to visualize the status of medicine as it was practiced in early US history. Doctors, both real and phony, peddled their miracle potions at carnival sideshows and on the road in their caravan wagons alongside the common peddlers of pots and pans. The problem was so rampant that the US Postmaster General was given authority in 1872 to forbid the use of the mail by “persons operating fraudulent schemes” in the initial effort to confront the unscrupulous purveyors of deception.2Mail Fraud, 18 U.S.C. Sect. 1341 (Jun 8, 1872)Google Scholar Thus was constituted the first federal power to regulate misleading advertising. Still, the “quacks” persisted in the fleecing of the gullible. The word quackery derives from the word quacksalve: “someone who boasts about his salves.” The modern-day definition of a quack is “a pretender to medical or other skill.” The Federal Drug Administration defines quackery as “the promotion for profit, of a medical remedy known to be false or unproven.”3Barrett S. Health frauds and quackery. FDA Consumer 1978;11:12-17Google Scholar Similarly, a nostrum is a medicine whose effectiveness is unproven and whose ingredients are usually secret—a popular but untested remedy for problems or evils. Even today, society is not free of nostrums. Chelation therapy, an unproven form of treatment for occlusive arterial disease, is still being widely used in this country. At the time, the culture of medical chicanery was so well integrated into American society that Mark Twain would introduce one of his most beloved characters, Colonel Beriah Sellers, who first appeared in Twain's 1873 novel The Gilded Age.4Twain M. The gilded age: a tale of to-day. New York: American Publishing Co; 1873Google Scholar Colonel Sellers is portrayed as a visionary who is convinced that his odd inventions will bring him fame and riches. One of his many schemes involves the marketing of the “Infallible, Imperial, Oriental Optical Liniment, and Salvation for Sore Eyes—the Medical Wonder of the Age! Small Bottles Fifty Cents, Large Ones a dollar!” Of course, this is just Colonel Seller's attempt to take care of his family. After all, as he explains, one could not feed his family on expectations. In the early 20th century it was still common practice to hawk cure-all potions and devices to rid all ailments and illnesses. However, it was the proliferation of dangerous electroconvulsive devices that moved the American Medical Association (AMA) to become involved in the regulation of medicines and devices. In 1905, the AMA established its Council on Pharmacy and Chemistry to decide which products were allowed to advertise in its official publications. One year later, the AMA created a Propaganda Department to collect and disseminate information about health quackery. In 1911, the first volume of Nostrums and Quackery, a compilation of health frauds of the day was published under the auspices of the AMA.5The American Medical AssociationNostrums and quackery. AMA Press, Chicago1911Google Scholar These frauds were so pervasive that they would require 9 extensive annual editions of unique articles to expose just the most well-known adventures. At that time, the AMA enacted a ban on advertising by physicians. This resulted in the AMA gaining further control of the medical profession in the United States that would have the effect of silencing competition to its membership. Control of the medical marketplace by the AMA was unchallenged until 1975, when the United States Federal Trade Commission (FTC) levied an antitrust suit against the American Medical Association.6Havighurst CC. The doctors' trust: self-regulation and the law. Health Aff 1983;2:64-76Google Scholar The FTC charged that the ban on physician advertising discouraged competition and unfairly disadvantaged consumers. After years of legal battling, the FTC won the suit, and in 1982 the AMA ban on physician advertising was lifted. This has led to the subsequent return of the peddling of “snake oil” by some entrepreneurs that continues to this day. Deceptive euphemisms, phony authorships, biased educational seminars, paid celebrity endorsements, coupons, and “stampede” marketing tactics are just some of the numerous and questionable tactics that are employed today and are meticulously designed to corral consumers. Others have initiated sophisticated and coordinated campaigns designed to acquire a patient population that has traditionally, and rightfully, been the domain of vascular surgery. Whether we like it or not, the practice of medicine today is as much a business as it is a science practiced with art. For obvious reasons, it cannot be professed as philanthropy or be based solely on the Good Samaritan spirit. Not to recognize this reality is naive and tantamount to professional failure. If we are to embark together on the trek to professional survival, we must examine the basic philosophic principles that have guided the art of the practice of medicine for 2 and a half millennia.7Antiqua medicina. University of Virginia Health System 2003 May [cited 2003 Jun 30]. Available from: URL: http://hsc.virginia.edu/hs-library/historical/antiquaGoogle Scholar The oath of Hippocrates is the most well known of the philosophical oaths of medicine. It has been sworn to by most physicians in modern history and is considered to be the foundation upon which medical ethics are built. Adopted by Hippocrates' followers in the School of Cos more than 2,500 years ago, it appears on its face that the emphasis of this pledge is primarily directed at establishing a self-propagating secret society. Interestingly, Hippocrates specifically forbade the practice of surgery by physicians. Let me read excerpts from the Hippocratic Oath: To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art—if they desire to learn it—without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else. I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.7Antiqua medicina. University of Virginia Health System 2003 May [cited 2003 Jun 30]. Available from: URL: http://hsc.virginia.edu/hs-library/historical/antiquaGoogle Scholar These were the first historically recorded guidelines for the ethical practice of medicine. Galen, the revered physiologist, anatomist and surgeon of the second century AD, appears to have been the first to address the issue of compensation and dictated that money was not to be an instrument that defined a physician's principles. He wrote: “The physician should be contemptuous of money, interested in his work, self controlled, and just. Once he is possessed of these basic virtues, he will have all others at his command.”7Antiqua medicina. University of Virginia Health System 2003 May [cited 2003 Jun 30]. Available from: URL: http://hsc.virginia.edu/hs-library/historical/antiquaGoogle Scholar Galen was eclectic in his theories and believed that the best doctor is also a philosopher. This was certainly feasible in the aristocracy of Galen's time but not a viable option for today. In the 12th century the great philosopher and physician Moses Maimonides also rejected the idea of monetary reward. The following is an excerpt from his prayer: “Let not desire for wealth or benefit blind me from seeing the truth. Deem me worthy of seeing in the sufferer who seeks my advice a person neither rich nor poor. Friend or foe, good man or bad; of a man in distress, show me only the man. If doctors wiser than me seek to help me understand, grant me the desire to learn from them, for the knowledge of healing is boundless.”8Friedman H. Oath and prayer of Maimonides. Bull Johns Hopkins Hosp 1917;28:260-1Google Scholar These ancient codes have served physicians and patients well. However, we must now embrace a model of medical ethics that reflects today's socioeconomic climate. We cannot allow the loose interpretation of these prayers by politicians and administrators whose intent is to subjugate physicians to accept diminishing reimbursement. Nor can we afford to practice a model more suited to the priesthood than to health care providers. Interestingly, the specialty of vascular surgery is one of few that have not yet published a comprehensive code of ethics. Hopefully, this will soon be accomplished by the Society for Vascular Surgery (SVS). Currently, the SVS is developing a code of ethics for its membership that is intended to serve as guidelines in medical, ethical, social, and professional relationships in the practice of vascular surgery. This code represents the standards used to evaluate a member's maintenance of good professional standing and to evaluate qualifications for membership by applicants. To my knowledge, there will be 9 distinct areas of focus for addressing ethical issues of importance to every vascular surgeon: (1) vascular care provider; (2) health care providers; (3) patient and patient's family; (4) legal profession; (5) government; (6) insurance, compensation, and reimbursement agencies; (7) industry; (8) patients and research; and (9) community and world affairs. For each of these distinct areas, there are guidelines for identifying issues and their paths of resolution. They are not earth-shattering revelations, but rather common-sense realities. When these guidelines are finalized, I propose that they be adopted by the EVS as well as by the other regional and national vascular societies. We need to speak with one voice so there are no misunderstandings among vascular surgeons. In the meanwhile, I now lightheartedly offer to you my vision of a modern Ten Commandments for vascular surgeons that I believe can help us to define our purpose in the 21st century: 1.Respect your patients.2.Do your patients no harm.3.Do not misrepresent your abilities.4.Do not bear false witness against your colleague.5.Do not covet your colleague's practice.6.Do not steal your colleague's patients.7.Honor your mentors.8.Mentor your juniors.9.Share your knowledge with your peers.10.Advance the ideals of vascular surgery. I am pleased to inform you that your Council has voted favorably on my proposal to create an Ethics Committee to be chaired by Drs Keith D. Calligaro and Clement Darling, III. This ethics committee will evaluate meritorious complaints by members of any unfair, unethical, or unsafe practices by any institution or physician. An example of such a charge is a member who believes he or she has been affected by mail sent by other vascular specialists to their referring physicians claiming unsubstantiated superior results in their clinical practices. This overdue service from the society will go a long way to curb increasingly frequent abuses of “practice bashing.” All charges received by the Society will undergo review by the ethics committee. The defendant will then be afforded due process to address any allegation in writing. EVS members found to be not compliant with the Society's published ethical standards may be either censored or suspended for a specified period of time. Additionally, the EVS will pursue an affiliation with the SVS to extend their expert witness testimony program to include cases referred by EVS members. Vascular surgery has always been one of the minorities in the world arena of surgical specialties. Even though we have developed the techniques and standards of care for peripheral vascular disease, we are now on the brink of losing our status as the leaders in the prevention and management of vascular diseases. Today, I wonder how we came to this situation and what we can do to maintain our prominence in the care of peripheral vascular disease. Naturally, we desire to establish a legacy that will assure the welfare of our patients, facilitate our prosperity, and guarantee professional stability for the upcoming generation of vascular surgeons. Is the issue of our identity important? I believe so. Without a doubt we have been under a sustained assault by radiologists and cardiologists, and it is time to defend ourselves. On a daily basis, our patients hear advertisements on the radio, see portrayals in television shows, and read in newspapers and magazines of the association of cardiologists and interventional radiologists in the care of peripheral arterial disease. Rarely are vascular surgeons mentioned. How confident can our patients be when they are seeing the mysterious and little known entity, the vascular surgeon, and everyone else is proudly under the care of a cardiologist for their carotid disease? We have always been, and currently remain, an unknown and misunderstood consumer commodity. Interventional cardiologists are taking advantage of our little known status to move forward, aiming to take the lead in endovascular techniques and portray us as surgeons who are resistant to natural evolution. Consider this month's Concepts in Contemporary Cardiology conference in Houston and an ominously titled presentation, “Distal Protection and Low Profile Stent Delivery Devices Have Rendered Surgical Carotid Endarterectomy Extinct.” There are many obvious reasons why we remain largely unknown. One of these is that we are not recognized as an independent specialty from general surgery. However, there is hope in the horizon. The Councils of the EVS and the SVS, as well as the membership of the Association of Program Directors in Vascular Surgery have voted to support the continued efforts by the American Board of Vascular Surgery to achieve an American Board of Medical Specialties (ABMS)–approved independent board status. As you may know, the American Board of Surgery (ABS) has put forward an application to the ABMS for a Primary Certificate in Vascular Surgery; that is, vascular surgeons no longer need to pass general surgery boards before being certified in vascular surgery. This application received unanimous endorsement by the members of the ABS who recognized vascular surgery as a specialty and not subspecialty. Clearly, this is a stepping stone to complete board independence in vascular surgery. Until recently, the most significant public presentation of a vascular surgeon in the media may have been in the 1993 movie The Fugitive. Dr Kimble, a vascular surgeon, becomes suspicious that tissue samples from trial patients that he submitted for pathology were switched, and his friend, Dr Nichols, a cardiologist who was the primary investigator for the anti-plaque drug Provasic, orders his murder to prevent him from discovering the improprieties. However, Dr Kimball was not home when the killer struck, resulting in the murder of his wife, for which he was falsely convicted. At the end of the story, Dr Nichols is confronted as he delivers his keynote address to the Annual Meeting of the International Association of Cardiology and Dr Kimball, the vascular surgeon, is proven to be the good guy. After a decade of media anonymity, vascular surgeons have now once again been presented to the lay public. On November 20, 2003, an episode of the TV show ER depicted a medical transport helicopter crash. One of the central themes of this episode is the failure of vascular surgery to respond to numerous calls for emergency consultation for a patient who sustains carotid trauma. Finally, an emergency department resident places a carotid stent under fluoroscopy and saves the patient's life. References to the absent vascular surgeon were repetitive and unfavorable. This episode was seen in over 25 million homes in the United States—and many more worldwide.9Nielsen Media Research, New York, NY; November 20, 2003. Available from: URL: http://www.nielsenmedia.comGoogle Scholar This awesome negative publicity for our specialty will only increase and be reiterated in syndicated and rerun episodes. Improved communications with the media can only help to avert these potentially damaging situations. America has always been progressive, innovative, and possessed of frontier spirit, including its approach to medicine. While we, as vascular surgeons, must do much more to ensure our survival, we must not do so at the expense of our ethics or our honor, or to our charge to our patients. The total US health and medical advertising spending reached nearly $11 billion by the end of 2003. This has resulted in meticulously synchronized campaigns to promote drugs, devices, and procedures. Recently, the Internet has been an exponentially growing means by which physicians have been able to promote their practices, educate their patients, and communicate with other professionals. The amount of online advertising expenditures on health-related Web sites in 1999 was $200 million. This figure was near $350 million in 2003 and is predicted to be as much as $700 million in 2004. The once traditional media such as newsletters and advertising in newspapers and consumer magazines are no longer the only means. Internet-driven health informatics can be spontaneously distributed, without the lengthy preparation needed to disseminate a newsletter or magazine. Today's consumers actively participate in their care, more confident and inquisitive than those of just a few short years ago. Especially important for vascular surgeons, elderly patients are the fastest growing base of online health consumers. The electronic information age is no longer novel or limited to the young. We must vigorously publicize ourselves to the public and health care providers as the premiere body of expertise in the management of peripheral vascular disease. I believe that all national and regional vascular societies should join together in this effort. Therefore, I am calling for the establishment of a blue-ribbon panel that will define our common marketing goals and make recommendations as to how we may most effectively exploit these goals to their maximum potential. We must get out the message as loudly as we can afford it. The American Vascular Association has created effective marketing campaigns that have significantly contributed to increased awareness of the role of vascular surgery in the prevention and treatment of vascular diseases. Under the leadership of Bill Flinn, our current Recorder, this association has blossomed and its national screening program for aortic aneurysms, carotid disease, and lower extremity occlusive disease has been a tremendous success. In my opinion, it is appropriate to develop public awareness programs related to vascular diseases by medical societies, hospitals, or individual physicians. It is inappropriate, however, to use this information as part of a scheme to divert patients away from physicians who are delivering equally good care. Increasingly, some major universities do advertise their physicians as the “best in the region” without proof. This practice should be discouraged since it is unfair and it may have a negative impact on their physicians' reputations. Careful consideration should be exercised to avoid returning to the era of nostrums and quackery—perceived or real. Kaiser Permanente, for example, invests $60,000,000 annually for advertisement, and it gained nearly 500,000 new members in 1999 alone. In that same year, they were sued for fraud over mass market advertisement stating that their physicians had total patient medical management control.10Kaiser sued for fraud over mass-market advertising. The Foundation for Taxpayer and Consumer Rights 1999 Mar 16. Available from URL:http://www.consumerwatchdog.org/Google Scholar Because we have an obligation to share our medical expertise with other professionals, we may not claim that we have sole ownership of a procedure. However, factually supported claims regarding our total commitment to the prevention, diagnosis, and treatment of vascular diseases are acceptable. It is naive to assume that these goals can be achieved without the support of consultants in marketing and advertising; these experts will make recommendations for political and business strategies and act as our principals in the conduct of our campaign. Let us address the business of vascular surgery. As you know, the United States is the number 1 nation in the world in terms of health care spending. On a per capita basis, health spending in the United States is 50% higher than in the next highest nation. Our health care costs constitute 14.9% of our gross domestic product and these costs are expected to rise to 18.4% within the next decade. Unfortunately, nearly one third of the $1.6 trillion we now spend on health care goes to care that is repetitive, or at a minimum, fails to improve patient health. Hospital costs are rising as well; fully 25% of all health care dollars are dedicated to administration. In 1999, that meant $300 billion went to pay for administrative bureaucracy.11Clinton HR. Now can we talk about health care? NY Times Magazine 2004 Apr 18. p. 26-31, 56Google Scholar A substantial portion of this hospital bureaucracy is already being performed by you, the vascular surgeon, without fair compensation for your time and effort. It is time to challenge our administrators for adequate reimbursement for our work. For example, if you are responsible for the running of the hospital's vascular laboratory, you should receive appropriate monetary compensation beyond the professional component. There are many similar programs where surgeons routinely perform uncompensated labor. Some full-time vascular surgeons are taxed and taxed again for the privilege of working in an academic institution. We need to be more determined when negotiating new contracts with the hospital administration. We are a very profitable group of surgeons for the hospital, but we often underestimate our influence and value. These are difficult times for vascular surgeons trying to establish, maintain, and grow their practices. Various factors, including rising malpractice premiums, increasing staff salaries and benefits, and federal regulations all seem to be at work against the business of medicine. Rather than getting discouraged, we should think about strategies to minimize this burden and maximize our productivity. Why not enlist the help of our organization, the EVS, to start looking into these issues? Many of these issues are prevalent enough that it should not be difficult to generate interest among our members. In the meantime, one should question everything related to his or her practice. Create a vascular center where other vascular services can be provided with the intent of providing total vascular care. Develop a plan to attract new patients and do not hesitate to devote up to 5% of your practice's total revenue to marketing. Retain efficiency consultants who specialize in health care and who can recommend ways to improve workflow, decrease costs, and increase revenue. A basic truth is that the practice of medicine is a high-volume, low-profit business. We can no longer depend on surgical cases to be our major source of revenue—we need to look for other sources of income. For example, in 2003, only 40% of the income for the Vascular Institute of New York was directly attributable to vascular operations and endovascular procedures. Interventional radiologists are reported as the most highly paid physicians, having the highest median compensation in 2002 at $401,000.12Compensation and productivity survey. Alexandria (Va): The American Medical Group Association; October 2002. Available from: URL: http://www.cejkasearch.com/content.asp?intPageID=264&intSubNavID=33Google Scholar Interventional radiologists also received the highest percentage salary increase among specialties, at 33.7% from 1999 to 2002. Cardiac surgeons earned only a 2.8% increase. Interventional radiologists also received the highest percentage salary increase, with a 12.64% increase from $356,000 to $401,000 (Table I). Table IAMGA compensation and productivity survey, 2003 report12Compensation and productivity survey. Alexandria (Va): The American Medical Group Association; October 2002. Available from: URL: http://www.cejkasearch.com/content.asp?intPageID=264&intSubNavID=33Google ScholarSpecialtyYear1999–20022002200120001999% Change$ ChangeRadiology: interventional401,000356,000306,000300,00033.67101,000Cardiac / thoracic surgery400,500401,440389,926389,4742.8311,026Cardiology: cath lab329,494310,500286,000279,71017.8044,543General surgery269,122255,304244,794243,36210.5925,760 Open table in a new tab A separate study showed that vascular surgeons with more than 3 years experience earned a net income of $329,000, including base salaries, net income, or hospital guarantees minus expenses.13Allied Physicians, Inc, Los Angeles Times and the Rand McNally Group; March 2003. Available at URL: http://www.allied-physicians.com/salarysurveys/physician-salaries.htmGoogle Scholar This is the second lowest rate of compensation—just above the rate paid to general surgeons (Table II). The Stanford University School of Medicine places median salaries for vascular surgeons even lower—just $256,000 (1999-2000).Table IINet compensation for physicians with more than 3 years experience12Compensation and productivity survey. Alexandria (Va): The American Medical Group Association; October 2002. Available from: URL: http://www.cejkasearch.com/content.asp?intPageID=264&intSubNavID=33Google ScholarSpecialtyCompensationSurgery: cardiovascular$515,000Cardiology: interventional$468,000Surgery: vascular$329,000Surgery: general$291,000 Open table in a new tab What is the value of expertise in vascular surgery? A below-average salary is hardly satisfactory. How can we attract and maintain talent with compensation that is close to last amongst comparable specialties? The business of vascular surgery is faltering. Most vascular surgeons are not businessmen to begin with. Therefore, as in all businesses, we must “meet the bottom line”—something that we have failed to fully address. Before I make my closing remarks, please allow me a moment to thank those who are the pillars of my service at Maimonides Medical Center. I would like to thank Anil Hingorani, MD, my partner and friend, who continues to amaze me with his clinical and academic production; William Yorkovich, RPA, our research coordinator, for his hard work and unwavering commitment to the service over the past 12 years; Eleanor Iadgarova, RN, for her enormous dedication to our clinical practice; Natalia Markevich, MD, RVT, whose skills and enthusiasm for vascular ultrasound is moving us to the next level; Theresa Jacob, PhD, for her basic science contributions to our program; Richard Schutzer, MD, for his enthusiasm and endovascular skills; Sergio Salles-Cunha, PhD, for helping me build one of the largest and most reliable vascular laboratories in this country; and, last but not least, Anne Ober, our assistant administrator who works with her heart and does everything well. Consumers are now being educated by other specialties. They are enlightening themselves in the important matters affecting every aspect of their health care—including disease processes, treatment options, payor reimbursements, and provider selection. What they are learning now may well be impossible to unlearn. The time to act is now, before the opportunity to define ourselves becomes forever lost to us. We need to identify ourselves not only to patients and health care providers, but also to those who will become our next generation of vascular surgeons. We must rekindle an interest in our specialty. Vascular societies should recognize well-trained vascular surgeons who are willing to go to medical schools in their area to entice and counsel the best and brightest medical students to join us in vascular surgery. For continuity in this endeavor, these volunteer surgeons should also be available to provide counsel to interested medical students in their consideration of vascular surgery as a career. Also, we cannot sit idly and wait for cases to be referred to us. In the past, we reigned supreme in peripheral vascular care because no one else had the skills. That is simply no longer the case. The time is now to aggressively compete against interventional radiologists and cardiologists and to strive for our independence as a specialty. We are few, but we are strong and determined. We will overcome these and future challenges because we are a fair and hard-working group of surgeons.