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Presidential address: Proud past—bright future: A strategy for the new millennium

2001; Elsevier BV; Volume: 33; Issue: 1 Linguagem: Inglês

10.1067/mva.2001.111803

1097-6809

Jonathan B. Towne,

Peripheral Artery Disease Management

For the times they are a-changin'Bob Dylan (1963) The 54th Annual Meeting of the Society for Vascular Surgery (SVS) is the first of the new millennium. Moving through the year 2000, we have had numerous opportunities to reflect on the amazing changes that our civilization has encountered in just the past century. We must recognize that the specialty of vascular surgery has existed for only a fraction of those 100 years. I, like many others in this room, have had the good fortune to participate in virtually all of the significant advances in this specialty since beginning my fellowship with Dr Thompson in 1974. More recently, as an officer of the SVS for the past 6 years, I have been intimately involved with the professional activities of our specialty. From this privileged perspective, I have gained an understanding of our Society's proud past and have formulated some ideas about its future directions. As we enter the 21st century, a brief historical review of the milestones of this organization will allow us to place the future in better perspective. The concept of forming a society devoted to vascular surgery was developed by Dr J. Ross Veal, who organized a meeting on December 5, 1945, at the Southern Surgical Association, in Hot Springs, Va.1Ernest CB Yao JST The 50th anniversary celebration of the Society for Vascular Surgery.J Vasc Surg. 1996; 23: 957-959Google Scholar Attending this meeting to discuss this possibility were Drs Arthur Allen, Isaac A. Bigger, Arthur H. Blakemore, Barney Brooks, I. Mims Gage, and George D. Lilly. In San Francisco on July 3, 1946, the SVS was formed. There were 31 charter members, of whom only Drs Michael E. DeBakey and Harris B. Schumaker survive today. Dr Alton Ochsner was elected the first president, and the first scientific meeting of the SVS was held the following year in Atlantic City. Article II of the bylaws initially listed seven purposes of the Society, ranging from promotion, study, and research of vascular diseases to defining more clearly the role of surgery in vascular disease.2Yao JST Presidential address: the objects of the Society for Vascular Surgery—a second look.J Vasc Surg. 1994; 19: 189-197Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Other purposes included the teaching of vascular diseases to students and house officers, encouraging development and special training for young surgeons interested in the field, and, finally, having annual meetings. The SVS has been a dynamic organization that has adapted over the years to meet the changing needs of our specialty. Initial presentations of the Society dealt with thrombophlebitis, prevention of pulmonary embolism, hypertension, treatment of congenital pulmonic stenosis, coarctation of the aorta, treatment of essential hypertension, and causalgia. Revascularization of the heart was first presented in 1948, and the initial paper on temporary artificial maintenance of circulation, the forerunner of the current heart-lung machine, was presented in 1949.3Yao JST Ernst CB Fifty consecutive annual meetings of The Society for Vascular Surgery.J Vasc Surg. 1996; 23: 959-1017Abstract Full Text Full Text PDF Google Scholar Dr Robert R. Linton's address in 1948, entitled “Arteriosclerotic Popliteal Aneurysms,” was the first presentation in which the surgical treatment of arterial disease was discussed. Basic research was first included in 1951, when a study entitled “Growth of Preserved Aorta Homografts—an Experimental Study,” by Dr Julian Johnson and his colleagues, and a paper entitled “The Experimental Study of Respiration Maintained by Homologous Lungs,” by Wills Potts and his group, were presented. From this humble beginning, the SVS evolved through the years as a forum for presentations of cutting edge vascular research, which currently has evolved into the advanced techniques of cell biology, subcellular biochemistry, and gene manipulation. In 1950, the emphasis of the program focused increasingly on arterial occlusive disease of the intra-abdominal vessels, as well as femoral artery occlusive disease. In 1966, the SVS and the North American Chapter of the International Society for Cardiovascular Surgery (ISCVS) developed closer ties, with the two program committees meeting simultaneously. The Joint Council was formed to provide a governing body for both the North American Chapter and the SVS in 1975, and the following year, in Albuquerque, the societies had grown to the magnitude that a professional management group called PRRI was engaged to administer the scientific meeting and organizational business, a relationship that has been beneficial to our development and financial stability. In 1981, presentations on cardiac topics ceased to appear in the program because peripheral vascular surgery evolved separately from cardiac surgery. The SVS, in conjunction with the ISCVS, formed the Journal of Vascular Surgery in 1983. This premier peer-reviewed scientific journal proved to be a milestone in establishing vascular surgery as a clearly defined specialty.4Szilagyi DE The Journal of Vascular Surgery: 1982-1990.J Vasc Surg. 1996; 23: 1069-1076Abstract Full Text Full Text PDF Google Scholar As an adjunct, revenue from the publication provided the fiscal underpinning for many of the subsequent initiatives of the two societies. In the late 1980s, the Research Forum for basic investigative work was organized and incorporated as part of the scientific program, and the E. J. Wylie Traveling Fellowship was inaugurated. The Critical Issues Forum was initiated in 1988 and renamed the E. Stanley Crawford Critical Issues Forum in 1993. In 1984, the SVS Council began discussing the development of the Lifeline Foundation, an educational and research foundation. An initial contribution of $50,000 from the Society reserves was made to found this organization.5Callow AD Research and emergenic of the Lifeline Foundation.J Vasc Surg. 1996; 23: 1054-1057Abstract Full Text Full Text PDF Scopus (2) Google Scholar The Lifeline Foundation supports research in vascular disease by enhancing the development of young surgical scientists and the advancement of vascular science through its comprehensive research funding. The foundation's mission provides a commitment to ensure that new knowledge concerning causes, treatment, and prevention of vascular disease is disseminated to the medical profession and the public. Calvin B. Ernst designed its logo. In 1992, the Lifeline Foundation started awarding the Resident Research Award, and more recently, in conjunction with the National Institutes of Health, has been able to fund investigators. As we look to chart our future course and define our mission, we need to have a clear understanding of why the SVS exists. This is a select society that recognizes academic excellence in vascular surgery. The privilege of membership is granted to vascular surgeons who have distinguished themselves with applied clinical or basic science research. Membership is a valued accomplishment and a reward of exceptional scholarship. With the honor of membership comes a responsibility to lead and to teach. For beyond the recognition of membership in a prestigious organization, the foremost mission of the SVS must be to maintain a link to those for whom we care—our patients. Vascular surgery needs to embrace a commitment to issues of patient education. It is important for our patients to realize the value of high-quality vascular surgery provided by our members, because ultimately, it is the citizens of our countries who will determine the viability of our specialty. This is going to be one of the more difficult tasks for our Society. We have done an excellent job of establishing the value of our work to our colleagues in surgery. These efforts need to be continued on a much grander scale. The development of the Society's Web site is an important beginning, but in this technologically advanced information age, we need to expand these efforts. The world must be able to appreciate our contributions and recognize the importance of vascular surgery in the health care of our countries. Other surgical organizations have invested significant resources in developing elaborate electronic media programs. It is important for our Society to maintain a proactive stance that effectively educates the public regarding the value of vascular surgery. We also need to establish relationships with our colleagues internationally. We have become global citizens, and the worldwide instantaneous electronic transfer of information essentially eliminates geographical professional boundaries. At the European Society for Vascular Surgery (ESVS) meeting in Copenhagen, I participated in their program directors of vascular surgery meeting and can report to you that the problems facing European vascular surgeons in terms of practice and training were similar to our own. Maintaining a global dialogue will expose the SVS to the innovative solutions of our international colleagues, with mutual benefit. Discussions have begun to develop closer collaboration with the leaders of the ESVS, with the consideration of joint meetings. These efforts will be continued by President-Elect Ramon Berguer this next year. At this point let me move on to what I believe are four basic problems confronting the specialty of vascular surgery and therefore becoming the charge of this Society. For these challenges we have a responsibility to provide leadership into the next millennium. The advances cataloged in the rich history of this specialty would not have occurred without dedication and financial commitment to answering basic questions about the diseases we treat. There has been a virtual revolution in the treatment of abdominal aortic aneurysms, with a variety of endovascular devices (two have been currently approved) working their way through various levels of the Food and Drug Administration's regulatory process. Percutaneous angioplasty and stenting have become the standard of care in iliac occlusive disease. Currently, endovascular techniques are being investigated for the treatment of carotid artery disease. The declines in reimbursement to vascular surgeons by the Health Care Financing Administration, coupled with a ratcheting down of expenditures by health maintenance organizations and other insurance carriers, must remain a major concern for our specialty. We have evolved from a time when those with only basic surgical training performed vascular surgery, to one where an increasingly greater percentage of vascular surgery is performed by those with specialized vascular training. With potential changes in the structure of surgical training programs, altered reimbursement profiles, and evolution of more complex endovascular techniques, a greater proportion of vascular surgery will, and should, be done by vascular surgeons. Funding still remains very problematic, and with the increasing emphasis on practice incomes by deans and department chairs, medical schools are less inclined to place emphasis on basic investigation. It is critical that our young faculty members have time and resources to allow them to develop their careers as scientists. Our Society needs to play an active role in the support of basic science laboratory investigation. The formation of the Lifeline Foundation was a beginning. The annual Research Initiatives Conference with very successful collaboration with investigators at the National Heart, Lung, and Blood Institute needs continued support. We need to be diligent mentors for young academic vascular surgeons. The program on Wednesday dealing with scientific communication and grantsmanship is another facet of developing research talent that deserves our commitment. The SVS needs to encourage the continued development of endovascular surgery and ensure that vascular surgeons play a significant role in its practice. We have demonstrated that vascular surgeons can master these techniques. The development of a session of this meeting dedicated solely to endovascular surgery indicates the strides that our members have made in this now rapidly emerging field. It is important for vascular surgeons to maintain their hegemony in the treatment of all aspects of vascular occlusive disease. In the operating room, portable digital fluoroscopy units with road mapping capability may well become the pocket Doppler transducer of the next generation of vascular surgeons. Sophisticated radiologic techniques and the associated hardware must be part of the armamentarium of the modern-day vascular surgeon. There are a variety of strategies to achieve these goals; they will depend on local customs and experience. One paradigm is the traditional combination of interventional radiologists working in concert with vascular surgeons. This relationship obviously will require compromise on occasion. As in most business situations, the difficulty comes in negotiating the fiscal relationships. A second strategy for an endovascular program involves the vascular surgeon performing and controlling all aspects of diagnosis and treatment of vascular disease. Certainly, this model is the most efficient way of ensuring that vascular surgeons are skillful with catheter technology. Within some medical centers, this may result in a rather contentious environment and may not be applicable for all. Another relationship may find vascular surgeons working with cardiologists. Interventional cardiologists are relatively new participants, in terms of those who perform peripheral vascular interventions. They often have good catheter skills and are frequently willing to collaborate with vascular surgeons in a vascular disease unit, which could be mutually beneficial. We need to work with the program directors in vascular surgery and the American Board of Surgery's Sub-board of Vascular Surgery to ensure that our vascular surgery fellows have been fully exposed to all modalities of vascular intervention before they complete their training. To be competitive in the marketplace, vascular surgeons must be involved in the evolution in endovascular techniques. The use of stented grafts for the treatment of aneurysm disease clearly demonstrates the need for sophisticated experience in the management of patients treated with this new technology. The high incidence of technical complications with these grafts on long-term follow-up demonstrates the need for savvy clinical judgment and for ongoing development of interventional techniques with more advanced technology. Research into the effect of endoluminal devices on the progression of abdominal aortic aneurysm disease and the ultimate morbidity and mortality of endoluminal repair needs continuous, rigorous surveillance and analysis. Although recent efforts have focused on product development, in the future we must better understand the interactions between the aortic wall and the endoluminal device. We must establish a basic science foundation on which further advances in product development can be built. The SVS must continue to support the ongoing work of the Government Relations Committee of the Joint Council. Initial work in this area in dealing with the Health Care Financing Administration was undertaken by Norm Hertzer, who was followed by Hugh Trout. Currently, Bob Zwolak leads this effort for our profession. Despite the intense work of the Government Relations Committee, success has been limited to restoring a few percentage points to the Medicare fee schedule. These gains have not been enough to counteract the large cuts that were originally instituted without our participation in the resource-based relative value scale process. The recent success of Bob Zwolak and Gary Seabrook in obtaining work values for 14 new Current Procedural Terminology codes for endovascular repair of abdominal aortic aneurysms is a significant accomplishment. With component coding methodology, placement of a typical aortic endograft will be assigned a number of relative value units, which is slightly above the work value for conventional, open aneurysm repair. With luck, this will serve as a benchmark to increase other vascular surgery codes in the future. Because of the work of this Committee, at least in the short term, the fiscal integrity of vascular surgery has been tenuously preserved. However, we must accept that there will be an ongoing battle to be waged over the next decade. The next issue that is going to affect medicine has to do with the concept of establishing ongoing credentialing.6Nahrwold DL Presidential address: toward physician competency.Surgery. 1999; 126: 589-593Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar The SVS has been a leader in this for the last decade and a half. Dr William J. Fry appointed an outcomes committee when he was president that began our involvement in this area. Dr Norman Hertzer stressed the importance of outcomes in his presidential address. Vascular surgery has led the way in the studying of outcomes. Carotid endarterectomy is probably the best studied clinical entity in the history of medicine, in terms of disease progression and the effect of surgical intervention on the occurrence and survival of stroke. As certifying boards develop standards for concurrent credentialing of surgical specialists, vascular surgery is in a superb position to lead the way, because much of the outcome data on which the surgical competence is based has already been collected. These data will undoubtedly demonstrate that fully trained vascular surgeons have better mortality and morbidity profiles and that quality care, in the long term, costs less. The most important challenge we face is the continuing evolution of vascular surgery as a distinct specialty. The development of the Journal of Vascular Surgery into the premier vascular journal in the world has established our scientific and academic credentials. The Association of Program Directors of Vascular Surgery has defined the body of knowledge encompassed by the specialty of vascualr surgery with the development of curriculum for vascular laboratory, clinical, and basic science. The creation of a Sub-board of Vascular Surgery in the American Board of Surgery has led to all aspects of the examination and certification of vascular surgeons being conducted by vascular surgeons. The formation of the Advisory Committee on Vascular Surgery by the American College of Surgeons is the acknowledgment by the largest surgical organization in North America that we are a separate and clearly defined specialty. It is important to view these changes as an evolution. The current status will continue to evolve as the needs of our vascular surgery trainees change. I have proposed to the Sub-board of Vascular Surgery that the Residency Review Committee (RRC) for Surgery be petitioned to develop a Sub-RRC for Vascular Surgery. This will better meet the needs of our vascular fellowship programs. The RRC for Radiology has successfully created such an entity by developing a separate RRC for both Diagnostic Radiology and Radiation Therapy. We have evolved from a time when vascular surgery was a mere component of a general surgeon's repertoire, to a time when increasingly, a greater proportion of vascular surgery is performed by those with specialized training. We need to maintain our standard of quality and continue to strive for technical excellence. These are exciting and challenging times. When confronted with conflict or competition, an organization must anticipate change, react rapidly, respond intelligently, and embrace the newest ideas. It is certain that the SVS needs to be proactive as it continues its leadership role into this new and challenging era. As we have done many times in our first 54 years, we need to continue to adapt to the changing needs of our specialty. Aware of its proud past, the SVS needs to continue to meet the rapidly changing needs of the future. These times as never before are times of change. Every aspect of our professional life is under siege. The opportunity to seize the initiative and to create a vascular disease treatment model for the coming years is upon us. Change is not limited to our professional lives, but involves the whole of society. It is estimated that the population will double in the next 30 years and that the ethnic mix of that population will change as well. The rate of new developments is greater than has ever been encountered in the history of civilization. Just look at computer technology as an example. New developments remain “cutting edge” for months, not years. With this explosion of technology come quantum leaps in the fund of information available to the populace. What is awesome today, with the advances in the Internet, is that a poor farmer in a Third World country has an opportunity to have access to almost the same information as a graduate student at one of our most prestigious universities. Change observes no loyalties and rewards only those who are nimble and can most quickly react to the new priorities. We cannot let old ideas that have become obsolete consume our time and energy. We must go forward in our thinking and have a “can do” attitude. We must be able to think “outside the box” and recognize that some of the issues that were dominant in running our organizations are no longer relevant, no matter the investment of time, energy, and even emotional zeal. We must realize when it is time to move ahead and not be hamstrung by old ideals, old wars, and old disagreements. My favorite car as a high school and college student was a '55 Chevy with three deuces as carburetors and a Hurst floor shift and glass packs. This car got 6 mpg and polluted the environment. As wonderful as they may seem in retrospect to some, the 1950s are over. As far as vascular surgery is concerned, the '80s and '90s are over. We will surely cherish those times as we reminisce in years to come, but they are over. We need to adapt and move forward. For those of us that are older, this is difficult, because we tend to be set in our ways. In reality, our only option is to get with the program. The SVS needs to look to our younger members for counsel and advice. They have grown up in this information age and probably can adapt better, at least I hope so. My chief criticism of all surgical organizations in which I participate is that they are often dominated by the elders, the group that is the least able to react to the issues for change and who are reactionary in thought and ideas. We must not continue to fight past wars instead of dealing with future changes. We must be broad-minded enough to listen to the ideas of others, we must have the intellectual courage and confidence to come to consensus, and we must realize that in the give and take of an organization, no one gets everything he supports. We have to critically look at the agenda of our Society and have the courage to discard tenets that are no longer meaningful. Most difficult of all, we the leaders need to know how, with grace, to pass on the torch to the next generation and complete the transition from leader to wise senior adviser. In conclusion, let me return to the ballad of Bob Dylan who was perhaps more prophetic than we might have ever imagined when he wrote these words in 1963: Come gather ‘round people Wherever you roam And admit that the waters Around you have grown And accept it that soon You'll be drenched to the bone, If your time to you is worth savin' Then you better start swimmin' Or you'll sink like a stone, For the times they are a-changin'. The line it is drawn The curse it is cast The slow one now will Later be fast. As the present now Will later be past The order is rapidly fadin' And the first one now Will later be last For the times they are a-changin'.* It has been a privilege to serve as your president. We must permit these changing times to lead us toward a bright future. Thank you. Thanks to Gary R. Seabrook, MD, and Hugh H. Trout III, MD, for editorial assistance and Roberta Sutton for manuscript preparation.