Portal de Periódicos da CAPES

Presidential address: Towards competence in vascular care

2001; Elsevier BV; Volume: 34; Issue: 6 Linguagem: Inglês

10.1067/mva.2001.119227

1097-6809

John J. Ricotta,

History of Medical Practice

First of all, I would like to thank the members of the Eastern Vascular Society (EVS) for the honor of serving as your president for the past year. I am privileged to have been mentored by the first two presidents of this Society, Drs Norman Rich and James DeWeese, and through them to have been closely involved with the growth of the EVS throughout its 15-year history. The Eastern Vascular is very close to my heart. I hope that this year we have done something to advance the aims of our Society. I would like to thank all of you who have worked with me over the years and particularly this year's Executive Council and our administrative staff. Finally, I would also be remiss in not acknowledging the loving support of my wife and family, who are in large part, responsible for any degree of professional accomplishment I have enjoyed. I have chosen to use this opportunity to explore the concept of “competence” as it relates to the delivery of vascular care. This may seem a strange topic for some of you, since most of us accept as axiomatic the consistent delivery of not only “competent” but “excellent” vascular care to our patients. Nonetheless, as I hope to convince you, the definition and measurement of competence is an involved undertaking. Further, the issue of competence is enormously important to our patients and therefore demands our immediate attention and that of our vascular societies, including the Eastern Vascular. I contend that the definition and measurement of “competence” should be our guiding principle as we address the current controversies over who should treat patients with vascular disease. In the final analysis, our ability to address this issue constructively is our best hope to secure both our future as a medical specialty and the welfare of our patients. Finally, I will suggest some ways that the EVS can join with other professional vascular societies in pursuit of this goal. This year the EVS is celebrating its 15th anniversary. During those 15 years, tremendous changes have occurred in vascular surgery and in the professional lives of every vascular surgeon. Educationally, fellowship training in vascular surgery has become firmly established, we have our own Association of Program Directors, and our specialty is represented on the American Board of Surgery (ABS) and the Residency Review Committee for surgery. Excellent postgraduate education, spanning the full panorama of vascular disease, is available through meetings offered by our many professional organizations. We have not one but several journals devoted specifically to our specialty, and it requires an effort to keep up with the published literature. Research in vascular disease has become increasingly sophisticated and multidisciplinary. Happily, as these efforts have moved to the cellular and molecular level, vascular surgeons have not been left behind. Organizations such as the Lifeline Foundation, which the EVS has supported, have fostered the careers of young vascular surgeon investigators. Clinically, the discipline of vascular surgery has come of age. Outcomes of our signature vascular procedures have improved markedly during the last two decades. Procedures such as Thoracoabdominal aneurysm resection and visceral artery reconstruction, once performed in only a few centers, are now done with good results throughout the country. The entire field of endovacular surgery has developed within the last decade, due in large part to the efforts of vascular surgeons. We should all be proud that many of those who led and continue to lead the growth of vascular surgery are members of the EVS and a number have served as presidents of our organization. By these measures, vascular surgery is in its ascendance, and we should all be enjoying the maturation of our specialty. Yet this is not the case. The scope of our specialty is poorly understood by most of society. The complexity of the services we perform is underappreciated and undervalued by our health care system. Our position as the primary caregivers for patients with vascular disease is being questioned by other specialties. Within our own specialty of surgery, we are at odds over the appropriate qualifications necessary to be a practitioner of vascular surgery. We certainly face many challenges. In this climate it is easy to feel beleaguered and defensive. It is tempting to focus our concerns on the “future of our specialty” and the various doomsday scenarios that may befall us. These are certainly understandable and important perspectives. However, I submit that we consider a different approach, one that is centered in the perspective of the patient. We must not advocate primarily for our survival as a specialty, but rather insist on developing a system that provides the best possible care for patients with vascular disease. This approach has two great advantages. First, it is the right thing to do, and second, if properly articulated, it will give us a powerful ally in our patients. This is a significant strategic point. We are a small specialty, outnumbered by cardiology, interventional radiology, and general surgery. We will not win a turf war with any of these disciplines if the basis for resolution is the relative benefit to each specialty. We must be realistic; society does not have great interest in, or sympathy for, parochial arguments between specialty groups over their perceived professional prerogatives. The successful approach will be one that keeps the focus on what is best for the patients, rather than what is best for the doctors. A cornerstone of this strategy is to focus on the delivery of “competent” care for those with vascular disease. This is, or should be, an issue that resonates with our aging population who increasingly faces death or disability from vascular disease. To the extent that we successfully raise societal consciousness concerning the importance of vascular disease and focus the debate on competence and quality, we will maintain the high ground and the receptive ear of our patients. If we keep the focus on “competent” delivery of vascular care, I am confident that our future as a specialty will be assured. My focus today, competence in vascular care, stems from this premise. The issue of competence has become an increasing focus in health care. Historically our profession has considered competence as an afterthought, if at all, and turned its focus toward excellence. I am sure none of you are associated with “Centers of Competence,” whereas all of us are aware of, and many participate in, “Centers of Excellence.” Ironically, while these centers of excellence proliferate, concerns over medical competence are being raised with increasing frequency. Multiple reports of medical errors, whether in the lay press or from the Institute of Medicine, have stimulated our professional organizations to focus on this issue. The American Board of Medical Specialties (ABMS) and the American College of Surgeons have recently undertaken a coordinated effort to define and assure competence in medicine. The American College of Surgeons has chosen to focus on issues of competence in vascular surgery in a collaborative pilot effort with our national vascular societies. This is particularly fortunate, because it provides a unique opportunity to make the case that competent vascular care is best delivered by a well-trained, continually educated vascular surgeon. The ABMS has identified six general areas of competence, medical knowledge, patient care, interpersonal and communication skills, professionalism, practice-based learning and improvement, and systems based practice (Table I).1American Board of Medical Specialties American Board of Medical Specialties 2000 annual report and reference handbook.The Board. 2000Google ScholarTable ICompetencies as identified by the ABMSMedical knowledgePatient careInterpersonal and communication skillsProfessionalismPractice-based learningSystems-based practice Open table in a new tab The ABMS task force on competence has stated that “lifelong learning and an ongoing improvement of practice”1American Board of Medical Specialties American Board of Medical Specialties 2000 annual report and reference handbook.The Board. 2000Google Scholar maintain competence. Therefore, competence can only be attained by proper exposure during residency training and is maintained by continued practice and education and must be assessed by objective measures. Let us examine how these concepts apply to vascular care. The fundamental challenge in this arena is to define the knowledge base and patient exposure necessary to provide the basis for a competent vascular practitioner. In doing so, although we cannot set standards at unrealistic levels, we cannot begin at the “lowest common denominator,” nor can we be satisfied with the status quo. Our responsibility is to define the scope of training necessary to provide an optimal basis for contemporary vascular practice. Because medical knowledge and exposure to patient care begin with residency training programs, this process must begin with setting standards for training within residency programs. Currently, training programs that purport to provide training in vascular care exist in surgery, radiology, and internal medicine. The level of patient exposure and the degree of knowledge imparted in these programs are highly variable. To bring standards to a discipline that crosses multiple specialties and multiple training programs, one must begin by identifying common “core competencies” that are applicable across specialties. Once these are established, one can develop criteria for competence in each area that are not specialty specific. This is crucial, because the patient should expect equivalent levels of competence from practitioners regardless of specialty training. I believe these core competencies can be divided into five categories (Table II), spanning both diagnosis and treatment.Table IIProposed competencies in vascular careCompetencyPractitionerAnatomy and pathophysiology of arterial, venous, and lymphatic systemsAll practitionersDiagnostic testingAll practitioners Indications for testing (including follow-up) Relative efficacy of different tests Interpretation of testsClinical evaluation Vascular history and examinationVascular surgery Differential diagnosis of vascular diseasesVascular medicine Natural history of vascular diseases Medical versus surgical alternatives Risk factor evaluation/reduction Hypercoagulable states PharmacotherapyOpen interventionsVascular surgery Indications Operative techniques Perioperative care Follow-upPercutaneous interventions (procedure specific?)Vascular surgery Catheter/guidewire skillsInterventional cardiology PTA/stentInterventional radiology Stent graft ThrombolysisPTA , Percutaneous transluminal angioplasty. Open table in a new tab Specific areas of competence within each category are included as the basis for further discussion. In this model, all physicians would be expected to demonstrate competence in vascular anatomy, physiology, and diagnostic testing, presumably through a similar core curriculum. Competence in clinical evaluation and management would include fundamentals of history and examination, familiarity with treatment options, and nonsurgical treatment of vascular problems. This would be most important for vascular surgeons and those in the emerging field of vascular medicine. Open interventions would continue to be the purview of vascular surgery, with emphasis on indications, technique, and perioperative care. Finally, competence in percutaneous interventions would include guidewire skills and the full array of endovascular therapy. Equivalent, procedure-specific levels of competency would be expected from all practitioners. An individual physician would be expected to attain competence in three or more categories. It is crucial that all “stakeholders” in this effort, ie, vascular surgeons, interventionalists, and vascular medical specialists, agree on these definitions. The ABMS may be the best vehicle to achieve this end. PTA , Percutaneous transluminal angioplasty. To provide some level of consistency (and credibility), we must work to develop standards of knowledge base and patient exposure for each of the five core areas in vascular disease. Although there can be multiple models to achieve this end, there should be a uniform assessment tool for each area of competence. Each training program should be evaluated (across specialties) on its ability to provide knowledge and experience in patient care in one or more of the five core competencies. Eventually, the scope of practice of the graduates of these programs must be defined by the core competencies provided by their training program, and mastery demonstrated by an independent examination process. To date, only our vascular fellowship programs have attempted to provide training programs that address each of the five core competencies, although we are still seeking consistency in this regard. Our vascular programs are well suited to provide and measure knowledge and patient care in the areas of clinical and imaging diagnosis as well as operative and some nonoperative management. We are less consistent in the areas of endovascular intervention and management of “medical” vascular disease such as clotting disorders and risk factor reduction. Recently, the Association of Program Directors in Vascular Surgery has stated that training in endovascular interventions will be a requirement of vascular surgery residency training; the issue of more depth in medical management has not been discussed. Interventional radiology programs have focused on competency in diagnostic imaging and percutaneous intervention, but for the most part have not been concerned with the other four core competency areas. Vascular medicine programs are currently in their infancy, and most exist within the context of a cardiology fellowship. The specialty of cardiology has unilaterally declared the management of peripheral vascular diseases within their sphere of competence, despite the meager exposure to diagnosis and management of peripheral disease or exposure to the noninvasive vascular laboratory in their fellowship training programs. At present, in many cardiology training programs vascular disease is an “add on,” and that exposure is largely through application of percutaneous interventions in the cardiac catheterization laboratory, rather than an understanding of pathophysiology, natural history, diagnostic testing, and long-term outcomes. Attempts to question the legitimacy of cardiologists' involvement in peripheral vascular care have been singularly ineffective. Our focus cannot and should not be to argue against vascular practice by cardiologists and radiologists. However, we can and must insist on standard curricula for each area of competence, and that programs containing competencies that cross specialties be evaluated in a standard fashion. We must also tie the scope of future clinical practice on each core area to training and assessment. This does not require a “new specialty” of vascular disease, with a common training program that combines portions of traditional training in vascular surgery, interventional cardiology, and interventional radiology. It is my prejudice that the differences in personality, perspective, and goals of the constituent specialties will make such an approach impractical. Vascular surgeons are first and foremost surgeons, drawn to the specialty by the degree of complexity in decision-making and the technical challenges of operative intervention, including the challenges of perioperative care. Our specialty's emphasis will continue to be on the evaluation and treatment of symptomatic vascular disease by every available modality. It is unrealistic to believe that we will change our focus to either risk factor reduction or performance of diagnostic imaging studies. Involvement with percutaneous angiography is seen by most of us as a necessary means to an end, access to percutaneous and endovascular interventions, and not a goal in itself. On the other hand, radiologists have been drawn to the field primarily through imaging and the application of percutaneous techniques. They are not interested in open surgery or preoperative or postoperative care and with rare exceptions have little interest in long-term patient management. Their goals appear to be increased involvement in initial evaluation of symptomatic patients and the ability to apply percutaneous therapies in an appropriate manner. Cardiologists have become interested in peripheral vascular disease because it affects most of their patients. They need to become knowledgeable about management options and wish to become facile in the application of percutaneous therapies. However, they too have no interest in perioperative care, and with the exception of a small group of vascular medical specialists, neither are they interested in medical management or long-term follow-up of vascular patients. The emerging specialty of vascular medicine shares the vascular surgeon's interest in evaluation and management of the patient with vascular disease, but the emphasis is distinctly different and often complementary. It seems to me that with this variety in backgrounds, combined training programs, and a combined specialty, combined training programs are not likely to evolve. Rather, I believe the solution to be development of specialty-specific training experiences, based on common core competencies, that provide equivalent curricular experiences across specialties and are subject to similar standards of assessment and review. This is the only way to develop legitimate roles for each of the specialties interested in the care of vascular patients. What about the proper training of a vascular surgeon? Credible standards must be set that are pertinent to the scope of vascular surgery in the 21st century. This cannot be rooted in the outmoded paradigms of current surgical education, but requires a critical and objective analysis of the current and future scope of vascular care, with emphasis on what is in the best interests of the majority of patients with vascular disease. In my view, it requires recognition that training afforded in a general surgery residency is insufficient to provide a competency for the contemporary practice of vascular surgery and that additional exposure to vascular surgery is needed to attain competence in medical knowledge and patient care. Those who insist that this position would “fragment” surgery have been vehemently opposed to such a concept. However, I submit that their concerns are overstated and the difference between graduates of general surgery and vascular surgery training programs is inescapable on close reflection. Vascular surgery has a supplemental curriculum approved by the RRC in surgery, qualifying, and certifying examinations approved by and administered through the ABS, and a Certificate of Special Competence issued by the ABS. How is it possible for the granting organization to maintain that persons who have not had this training, passed these examinations, or obtained this certificate are qualified to practice the specialty? It is hard for any specialty organization to argue against the recognition of further specialization without the appearance of self-interest. Data abound on the improved outcomes in vascular surgery when these operations are performed by those who hold the vascular surgery Certificate.2The Dartmouth atlas of vascular health care. : AHA Press, Chicago2000Google Scholar, 3Pearce WH Parker MA Feinglass J Ujiki M Manheim LM. The importance of surgeon volume and training in outcomes for vascular surgical procedures.J Vasc Surg. 1999; 29: 768-776Abstract Full Text Full Text PDF PubMed Scopus (254) Google Scholar, 4Tu JV Austin PC Johnston KW. The influence of surgical specialty training on the outcomes of elective abdominal aortic aneurysm surgery.J Vasc Surg. 2001; 33: 447-452Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar These data cannot be explained away, and they must not be ignored. The unique training required to practice vascular surgery and the primacy of vascular surgeons in defining this training and evaluating trainees have recently been accepted by the ABS and the RRC for surgery. These bodies must now concede that a core program in general surgery and core certification by the ABS are not in themselves sufficient to confer competence in medical knowledge and patient care in vascular surgery. For many of us, this is the crux of our ongoing disagreement with our general surgical colleagues. Recently, Bob Hobson, one of our past presidents, and Ramon Berguer, this year's guest lecturer, opened what many of us see as a constructive dialogue with the ABS toward achieving an independent Board of Vascular Surgery whose relationship with the ABS would be based on cooperation, collegiality, and mutual respect. These efforts deserve our unified support, for they offer the prospect of real progress without divisiveness and are in the best interest of all parties, particularly our patients. Your EVS Executive Council has endorsed their efforts, and we hope that our membership will join in this support. There is no question that general surgery residents must continue to be exposed to a broad spectrum of surgical care, including a core experience in vascular surgery. The surgical techniques inherent in vascular operations are a critical part of their development. They will have a need to expose and control vessels, treat vascular trauma, and perform some basic vascular procedures, such as dialysis access, caval filter insertion, and catheter thromboembolectomy. However, the greater good is not served by supporting a position that allows graduates of general surgical training programs without additional training in vascular surgery to perform vascular reconstructive procedures. Their training does not prepare them to meet the current standards for elective vascular reconstruction, and they should not expect to perform these procedures. Acknowledging the differences in training between vascular and general surgery residents does not devalue the primary ABS certificate. On the contrary, it acknowledges the reality that modern surgical care is a highly specialized and complex process whose training programs require focus and redesign. It is encouraging that the leadership of the ABS may reconsider their long held position on this matter. We need to make our case strongly to them and work toward new training paradigms in which trainees in both general and vascular surgery are educated in areas relevant to their future practice, within a reasonable time frame. Various programs for the training of vascular surgeons with early tracking to reduce general surgery exposure and increase interventional exposure are currently under consideration. Given the length of current surgical training programs, the increasing trend toward postresidency fellowships by graduates of general surgery training programs, and the need to expand the scope of vascular surgery training, these proposals require careful consideration. A program in vascular surgery must remain sensitive to the current and future clinical needs of its trainees. Any early tracking programs in vascular surgery must assure proficiency and competence in perioperative care (including critical care), management of vascular trauma, and proficiency in general abdominal surgery, as well as the other competencies of vascular care. After all, it is our ability to perform surgery and our expertise in perioperative care that continue to distinguish us from cardiologists and radiologists. One such proposal would consist of a “4 + 2” format (Fig), with the first 2 years of residency devoted to basic surgical techniques, performance of minor operations, and principles of surgical care.The second 2 years would involve basic exposure in abdominal surgery, laparoscopy, critical care, pediatric surgery, trauma, thoracic surgery, and vascular surgery. After this common training period, vascular residents would concentrate on the competencies required for vascular practice, while senior general surgery residents would obtain focused exposure in their unique areas of future practice such as advanced laparoscopy, oncology, and complex gastrointestinal operations. Such a program would provide the vascular surgery graduate with the skills to deal with straightforward intestinal anastomosis, hernia repair, and cholecystectomy, all of which may be part of his or her future practice. At the same time, it would concentrate experience in complex gastrointestinal procedures and oncologic and endocrine operations in the experience of the general surgical residents, who will and should be the ones to provide this care in their future practice. The underlying premise should be to provide society with well-trained surgeons, through training programs that will continue to attract “the best and the brightest.” It is likely that there will be several pathways to achieve certification as a vascular surgeon in the future, one of which will certainly include eligibility for an ABS certificate in surgery. While the basis for competence in knowledge and patient care is established in residency training programs, it is maintained by a pattern of “lifelong learning and assessment.” This involves continuing medical education. Professional societies such as the EVS have traditionally played their most important role in this area. Indeed, the core function of our Society is to provide continuing education for those who care for patients with vascular disease. This has been done primarily through our annual meeting. Recently, the EVS, like many organizations, has attempted to alter the format of the annual meeting to meet the changing needs of our membership. This year we have added a satellite course in noninvasive vascular diagnosis, an “experts panel” on lower-extremity revascularization, and a poster session. We hope that each adds value to our program. The satellite program provides a focused didactic experience in an area important to all vascular surgeons, noninvasive diagnosis. Our “experts panel” is designed to take advantage of the wealth of talent we have within our organization and to provide increased interaction between these persons and the membership as a whole in a more informal session. We hope the poster session will facilitate exchange of information in both basic science and clinical areas between our members. The Executive Committee has realized for some time that many members of our Society have significant contributions to make, whether they are in basic research or clinical observation. Not all of these contributions are most suited to podium presentation. We hope that a less formal poster session will increase membership participation and contribute to our overall educational mission. In the years to come we will remain open to suggestions on how to further improve the educational content of our annual program. Interpersonal communication skills and professionalism are attitudinal competencies, which begin during medical school, are reinforced during residency training, and are maintained by lifelong involvement in professional organizations. I believe that educational approaches similar to the one outlined above, which set objective educational standards across specialties, will foster the interspecialty communication and respect that are so important in our professional development. Such an approach establishes the cornerstone of professionalism, which is to put the common good above personal advantage. Professional societies have much to add in these areas of competence as well. Our annual meetings are occasions for professional communication, in both formal and informal settings. Since our Society's inception we have used the Issues session to bring in experts both inside and outside vascular surgery to discuss topics of general interest and to provide new perspectives for consideration. This year, we are exploring two new areas for the EVS to increase communication. The Executive Committee will recommend further opening the membership of the EVS to nonsurgeons. I personally believe that this is an important means of developing a commonality of experience and educational background essential to the contemporary care of the patient with vascular disease. We differ from our nonsurgical colleagues in experience, approach, and prejudice as regards the management of vascular disease. We must stop talking only to ourselves and begin talking with our nonsurgical colleagues. We all have much to learn. I believe that the best forum for this is the relatively low-key atmosphere of a regional meeting, which provides a forum for interchange in both academic and social environments. I expect that the EVS will retain its essential “surgical” character, but I believe we can use our annual meeting to begin broader dialogues with nonsurgeons on areas of mutual interest. I hope the Society will agree to expand the scope of membership and that our members will seek out nonsurgeons with a commitment to the treatment of vascular disease and encourage them to seek membership in our organization. We have also begun an effort in education of both primary care physicians and the public on issues of vascular care and the role played by the vascular surgeon. This has been a neglected area, and one that is part of our professional responsibility. Your Executive Committee charged Drs Calligaro, Makaroun, and Perler with producing educational materials in the areas of peripheral vascular, aneurysmal, and cerebrovascular disease aimed at patients and primary care physicians. They have done an excellent job, and soon we hope to have this work finalized and available for the education of your patients and colleagues. I believe that efforts at public and professional education are important for the welfare of our patients and serve to reaffirm the important role vascular surgeons and our regional societies play in the delivery of vascular care. We look forward to additional efforts in the future and will work with the Education Committee of the American Association for Vascular Surgery in this regard. Assessment of competence is the pivotal issue now confronting medicine in general and surgery in particular. As a well-defined specialty with several signature operations where outcomes are clearly established, vascular surgery is in a good position to assess outcomes. There are considerable data that suggest a relationship between outcomes, training, and operative volume. I believe that the decision by the leadership of our national vascular societies to cooperate in this effort is a vital step in solidifying the central role of vascular surgery in the care of the patient with vascular disease in the years to come. Assessment of competence involves both cognitive assessment and outcomes assessment. Cognitive assessment has traditionally fallen to national professional organizations such as the ABMS and their member boards through a well-established and well-validated methodology. This will certainly continue. Outcomes assessment has been much more difficult to achieve. Again, I believe that the EVS has a potential role to play in this area. The vascular registry, which was until recently a much-debated requirement for membership in our organization, was an initial attempt to address clinical outcomes. Many of the founders of the EVS, including my mentors, Drs DeWeese and Rich, felt that a registry was a cornerstone of this organization. While the concept was sound, the voluntary nature of the registry and the lack of independent review severely limited its value, and it was ultimately dropped as a requirement. In recent years, efforts to target specific operations such as carotid endarterectomy have been undertaken. Again, these efforts have proven too difficult to complete without specific targeted resources. I hope that we can learn from the failures of our past efforts in this area and resurrect the idea of a targeted registry, subject to objective external review. The power of such data would be tremendous. There are a number of factors that suggest that such an effort may be feasible in the foreseeable future. Most important is the impetus toward measurement of competence by the American College of Surgeons. Equally important is the interest in sponsoring clinical research by the Lifeline Foundation. The directors of Lifeline have explicitly indicated that they would consider potential clinical research projects from regional vascular societies. I am hopeful that in the near future the EVS will be able to organize a targeted review of clinical outcomes that will provide unique and important data for our profession and our patients. In closing, I would again like to thank you for the honor of serving on your Executive Committee for many years and for serving this year as your president. This organization has a special place in my heart, and its membership includes some of my closest friends and colleagues. I believe that the EVS is uniquely situated to make significant contributions to the development and assessment of competence in vascular care in the years to come. It is vital for all of us that we do so. I hope we will take up this challenge, for our own professional growth and above all for the benefit of the patients we serve. We must always place our patients ahead of ourselves, and realize that our foremost responsibility is to be sure we provide them with caring, compassionate, and competent physicians to meet their needs.