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Presidential address: Vascular surgery and the Midwestern Vascular Surgical Society in the new millennium

2001; Elsevier BV; Volume: 34; Issue: 1 Linguagem: Inglês

10.1067/mva.2001.115605

1097-6809

Walter M. Whitehouse,

Cardiac, Anesthesia and Surgical Outcomes

It has been a great privilege and honor for me to serve as president of the Midwestern Vascular Surgical Society (MWVSS) over the past year. I remember attending the very first annual meeting in Chicago in 1977 as a resident. I was impressed with the prominent leaders of our specialty who attended and with the science that was presented. Both the Society and I have grown over the last 23 years, and I am extremely grateful to have had the opportunity to serve as your leader. In preparation for this opportunity to speak to you this morning, I have spent time contemplating the past as well as the challenges of our future. Although this is always a valuable exercise, its seems especially appropriate as we enter the new millennium, a time of unprecedented change. In examining my past, I recall some individuals who have played important roles in my life and have made significant contributions to whatever success I have achieved. I would like to recognize some of them. My parents instilled in me the importance of a work ethic and academic achievement and taught me important values about honesty, genuineness, and caring. My father, a successful academic radiologist, served as a role model for my professional achievement. Dr William Fry unveiled the excitement, demands, and challenges of the surgical treatment of disease for me when I was a medical student. Both he and Dr James Stanley fostered my interest in vascular surgery during my residency, and Jim served as a talented and unselfish mentor during my early academic career. Dr Christopher Zarins provided me with growth and challenge during my fellowship at the University of Chicago. Drs James Yao and John Bergan contributed to my development during that same year in Chicago. I have had the fulfilling experience of practicing with many talented partners who have enriched my surgical career. These friends and mentors have been instrumental in my professional life, and for that I am exceedingly grateful. Most important, however, has been my family. My wife, Rosanne, has given me unwavering support, love, and understanding. She has been my compass. She and our two sons, Brian and Shaun, have given me fulfillment that professional success alone could never have provided. Vascular surgery as a specialty is facing many challenges today. A number of these were thoughtfully examined by Dr Greg Sicard, our past-president, in his address last year. When preparing for my address today, I strongly felt that further consideration of some of these issues would be appropriate. As we enter this new millennium, I would like to consider some of these challenges and reflect on the impact on our patients as well as the role of our organization in meeting and solving them. The evolution of our society and its relationship to other vascular societies should be reviewed to put our role in some perspective. The organization of societies to support vascular surgery dates back to the establishment of two national societies. The Society for Vascular Surgery first met in 1947, and the International Society for Cardiovascular Surgery (ISCVS) (North American Chapter) first met in 1952. As vascular surgery grew, so did these organizations, providing a national forum for the discussion of the surgical treatment of vascular disease. As our specialty continued to evolve and the number of surgeons treating vascular disease increased, local and regional societies began to formally organize. The MWVSS was among the early regional developments. There are currently five major regional societies. The New England Society for Vascular Surgery (NESVS) was first established in 1973. It was followed by the MWVSS (1977), the Southern Association for Vascular Surgery (SAVS) (1977), the Eastern Vascular Society (EVS) (1984), and the Western Vascular Society (WVS) (1986). Active and senior membership in these societies currently includes 207 (NESVS), 354 (SAVS), 497 (EVS), and 162 (WVS). The MWVSS remains strong with 377 active and senior members. Each society varies somewhat in its membership requirements and objectives. Generally, they have established goals similar to the MWVSS. It is noteworthy that there are many local and smaller regional societies that fall within the geographic boundaries of the major regional societies. These may include several states (eg, Rocky Mountain Vascular Society), one state (eg, Michigan Vascular Society), or a portion of one state (eg, Cleveland Vascular Society). There has not been any formal organization or representation of these smaller societies at either the regional or national level. They do represent true grassroot organizations of our specialty, however. The MWVSS began with discussions among Drs John Bergan, Emerick Szilagyi, and John Pfeifer in October 1976. The founding meeting was held in March 1977. The objectives of the Society were established to be (1) the advancement of the science and art of peripheral vascular surgery and (2) the maintenance of high standards in the practice of peripheral vascular surgery. The first annual meeting was held in Chicago in September 1977. The Charles C. Guthrie Award was established in 1981 to further bolster the first objective of the Society. This award was to be given yearly to a resident or fellow based on outstanding basic or clinical research related to vascular disease. The Society has obviously grown and flourished since those early days. Many of our members have gone on to make significant contributions nationally, including nine who have served as presidents of one of our national societies. We remain a strong Society. The annual meeting attracts excellent clinical science every year. We must, however, continue to grow and ensure that all qualified surgeons providing vascular care are included in our membership ranks. We must also actively participate in discussions regarding our second goal. Some recent organizational changes will facilitate that. Our Society has had indirect input to our national organizations in the past. An individual representing regional societies has held a seat on the Executive Council of the ISCVS. For the last 18 months, the MWVSS had an appointed representative as a member-at-large seated on the executive council of the ISCVS. As you are all aware, the ISCVS has recently become the American Association for Vascular Surgery (AAVS). Reorganization of that society is currently in progress. Although the details have not been finalized, it appears that the MWVSS will have a permanent seat on the Executive Council along with the four other major regional vascular societies. Five other societies (the American Venous Forum, the Peripheral Vascular Surgery Society, the Society for Clinical Vascular Surgery, the Canadian Vascular Society, and the International Society for Endovascular Specialists) will also have seats. Although these societies have some differences in their makeup, this reorganization will allow direct input and dissemination of information vital to our interests. These changes will support a more organized and efficient effort to enhance our specialty and address specific issues as they arise. In addition, this reorganization will allow individual societies to collectively benefit from pooled resources enabling the accomplishment of projects that could not otherwise be supported. Web development is a prime example of such a project. Both extensive patient education efforts and dissemination of organizational information can be accomplished more easily and less expensively with such combined effort. This is an extremely positive change from which we will all benefit. This new opportunity for the Society will allow us to collectively make more meaningful contributions to support our specialty. A number of critical issues and challenges face our specialty today. Dr Sicard examined a number of these issues in his address last year.1Sicard GA. Presidential address: challenge to our specialty: the vascular surgeon in the year 2010.J Vasc Surg. 2000; 31: 845-850Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar He explored the critical issues of reimbursement, competition, training, and research funding. These are all matters of ongoing importance, and the MWVSS must continue to contribute to discussions and the search for solutions. The complex and challenging issues surrounding the American Board of Surgery are being addressed at a national level. I would like to discuss some issues that may not have received as much attention as a result of the pressing controversies surrounding some of these other problems. As vascular surgeons, we provide care for an aging population. Not only is the population of the United States growing, but the number of those older than 65 years continues to increase substantially with the aging of the baby boom generation. It is projected that by the year 2008, 38.4 million or 12.6% of our nation's population will be in that age group.2National Health Care Expenditures Projections: 1998-2008. Health Care Financing Administration, Table 1.Google Scholar By the year 2050, the proportion of Americans older than 65 will approach 22% or nearly one in four. In addition, the health-related expenditures of our nation continue to grow and now represent 14.3% of our nation's gross domestic product. It is projected that by 2008, this will climb to 16.2%.2National Health Care Expenditures Projections: 1998-2008. Health Care Financing Administration, Table 1.Google Scholar These two factors will have a substantial impact on the affordability of health care in the future. The cost of prescription drugs has received the most recent visibility but is, in part, a surrogate for the cost of medical progress. The total expense for prescription drugs was $37.7 billion in 1990. This value is projected to grow to $243 billion by 2008.3National Health Care Expenditures Projections: 1998-2008. Health Care Financing Administration, Table 12a.Google Scholar As our nation ages and more patients present with vascular disease and as technology continues to expand, similar trends may be seen in the treatment of vascular disease. The current developments in the treatment of abdominal aortic aneurysms exemplify some of these changes. The balance of risk, clinical benefit, and cost benefit will become increasingly important. Appropriate application of new techniques will become similarly crucial. If we do not responsibly oversee these developments, someone else will. As new technology has become available in the past, restraint in its use has not always been well embraced. As better percutaneous techniques become available and other specialties become involved with applications of the techniques, potential overutilization will similarly have an impact on the expense of health care. We as vascular surgeons should be leaders in appropriate applications of these techniques. The evolution of the treatment of superficial femoral artery (SFA) disease in the setting of intermittent claudication is an example of a clinical situation with potential for such overutilization. The natural history of intermittent claudication is well documented. Although it is now recognized as less benign than once thought, a conservative approach to this condition has long been understood to be desirable. Lower extremity bypass procedures with saphenous vein were first described by Kunlin in 19494Kunlin J. Le traitment de l'arterite obliterante par la greffe veinuse.Arch Mal Coeur Vaiss. 1949; 42: 371Google Scholar and were the only other option for a number of years. The development of prosthetic materials and refinement of surgical techniques with improved instrumentation and suture material as well as in situ methods added to the surgeon's capabilities. Profundaplasty gained some recognition as an alternative. Dotter and Judkins5Dotter CT Judkins MP. Transluminal treatment of arteriosclerotic obstruction: description of a new technic and a preliminary report of its application.Circulation. 1964; 30: 654-670Crossref PubMed Scopus (1225) Google Scholar first introduced the concept of arterial dilatation in 1964. Gruntzig and Kumpe6Gruntzig A Kumpe DA. Technique of percutaneous transluminal angioplasty with the Gruntzig balloon catheter.AJR Am J Roentgenol. 1979; 132: 547-552Crossref PubMed Scopus (204) Google Scholar described the use of balloon catheters for percutaneous transluminal angioplasty (PTA) in 1979, and the evolution of interventional techniques for the treatment of intermittent claudication began. Aggressive use of PTA resulted in the understanding that this technique had little value in the SFA except for isolated stenoses in carefully selected patients.7Karch LA Mattos MA Henretta JP McLafferty RB Ramsey DE Hodgson KJ. Clinical failure after percutaneous transluminal angioplasty of the superficial femoral and popliteal arteries.J Vasc Surg. 2000; 31: 880-888Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar With the subsequent development of laser-assisted angioplasty and atherectomy, a great deal of enthusiasm was again stimulated but with the same ultimate conclusions.8Geschwind HJ Dubois-Rande J Shafton E Boussignac G Wexman M. Percutaneous pulsed laser-assisted balloon angioplasty guided by spectroscopy.Am Heart J. 1989; 117: 1147-1152Abstract Full Text PDF PubMed Scopus (23) Google Scholar Now, we are faced with the development of stenting devices that may have an impact on long-term patency rates in the SFA.9Conroy RM Gordon IL Tobis JM Hiro T Kasaoka S Stemmer EA et al.Angioplasty and stent placement in chronic occlusion of the superficial femoral artery: technique and results.J Vasc Interv Radiol. 2000; 11: 1009-1020Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar This potential benefit has yet to be substantiated in the literature, however. Despite enthusiasm for the aggressive interventional treatment of SFA disease in the setting of claudication, the number of patients who are truly disabled and have desirable anatomy for PTA remains relatively small. Practitioners from other specialties are assaulting the SFA without the full understanding of the natural history of these lesions and without necessarily exhausting conservative measures first. I have personally seen several patients in our practice who have undergone SFA angioplasty with stent deployment throughout the entire length of the vessel at other institutions. This approach is one based on enthusiasm and reimbursement opportunity without adequate judgment or reflection on the long-term impact on the patient. Unfortunately, the promise of potential short-term results encourages the patient to undergo such procedures. I remember a pleasant 77-year-old patient of mine who presented with moderate claudication that he considered troublesome. We spent considerable time over a number of months discussing the pros and cons of interventional therapy. After exhausting possible conservative measures, we finally agreed to proceed with arteriography. This study demonstrated multiple segmental stenoses of the SFA with severe infrapopliteal occlusive disease. He was clearly not a surgical candidate in the absence of limb-threatening ischemia. He was satisfied with the conclusion that ongoing conservative management was appropriate. I saw him 1 year later, essentially unchanged clinically. In the interim, however, he had been seen in another state for a second opinion. At that institution, he underwent cerebral arteriography, renal arteriography, aortography, and lower extremity arteriography. Subsequent extensive SFA angioplasty with stent placement was performed. He experienced some improvement for several months but then returned to his previous state. That outcome was predictable, yet he was led to believe otherwise. This specific example demonstrates the potential for substantial overutilization of percutaneous procedures. This patient was fortunate that his extremity was not jeopardized. As technology for the treatment of vascular disease expands, we must remain vigilant. Critical scientific outcomes assessment before widespread application of new techniques is essential. The maintenance of high standards in the treatment of peripheral vascular disease is paramount. This can occur at various levels. Scientifically sound clinical science must continue to receive visibility at our regional and national meetings. Appropriate guidelines or standards can and have been developed by our national societies.10Fry WJ. Presidential address: who sets the standards?.J Vasc Surg. 1991; 13: 6-8Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar In our current environment, this development would ideally occur in conjunction with other societies representing the other specialties treating vascular disease. As leaders in the treatment of vascular disease, we must assume a leadership role in our own institutions by providing the wisdom necessary to ensure appropriate application of these invasive techniques. Hospital credentialling committees are now being faced with requests for peripheral interventional privileges from additional subspecialists and should look to vascular surgeons for guidance. Recommendations must be based on valid clinical science with the use of outcomes assessment. It is at this level that our input will be most needed. As has been demonstrated in the past, if we do not set the standards and ensure local compliance, someone will soon step forward to assist us in this task. Many examples would suggest that the latter is a suboptimal solution. Recently, employers have become organized to have an impact on more rapid change in the health care system driven by quality measures that they define. They are challenging our ability to do this ourselves. We are now facing a time of unprecedented pressures, changes, and conflicts. Reimbursement for our services is diminishing at a time when various compliance programs and other forces increase the overhead of practice. Interventional techniques may replace some of our time-tested surgical procedures in the near future. Nonsurgeons will perform many of these procedures. The tendency to treat existing lesions without the understanding of natural history is dangerous but increasingly prevalent. Our work hours have gradually increased at an unrelenting pace such that we have focused on efficiency and have less time to spend with our patients. Information is at the fingertips of all of our patients who are computer literate and can use the Internet. If the patients are not computer literate, their children are. I am amazed at the number of my elderly patients who come to the office with printouts from Web pages regarding the newest cutting edge techniques such as aortic stent grafting. Unfortunately, the information is frequently incomplete or incorrect. This presents a setting where more time may be necessary to have a meaningful interchange with the patient regarding his disease. It is no wonder that patients feel confused and unimportant. The patient's perception of this scenario should be of great concern. We need to examine how we are practicing today. For a multitude of reasons the public holds us in less esteem than in the past. A 1996 Gallup survey reported that only 15% of those surveyed had a high opinion of the medical profession, down from 40% in 1983.11Robert Wood Johnson Poll, December 11, 1989. Daniel Yankelovich Group Storrs Conn Roper Center for Public Opinion Research; Apr 5, 1996.Google Scholar Data concerning our specialty per se are not available. In general, surgeons are held in higher esteem. However, the message is clear. Our patients feel that they are not being served well. We are in part responsible. We have become focused on technical procedures more than interpersonal relationships with our patients. We have at times become focused on the problems of our practices and ourselves rather than our patient's problems. To better serve our patients, we need to better understand their expectations. Patients expect that we will abide by four principles as we diagnose and treat them.12Axelrod DA Goold SD. Maintaining trust in the surgeon-patient relationship: challenges for the new millennium.Arch Surg. 2000; 135: 55-61Crossref PubMed Scopus (67) Google Scholar Reflection on these principles may assist us in setting certain priorities as we sort through these challenges that face us. The first two principles include beneficence and nonmaleficence. These can be traced back to the Hippocratic oath that we have all professed. In today's framework, this means that patients demand that we offer therapy that has been clinically tested and has predictable and beneficial outcomes. Patients also expect that these interventions will be performed appropriately and skillfully without exposing them to unnecessary or inappropriate risks. The third principle is that of autonomy. Patients reserve the right to decide what is best for themselves after we have informed them of their options. While this seems to be readily evident, it is a significant change from patient expectations a generation ago. In addition, the decision that the patient makes is based on the education that he or she received from the surgeon and other sources. The presentation of factual information is critical in the doctor-patient relationship. The information must be accurate and objective, yet it must be delivered in an unbiased manner that the patient can understand. New therapeutic modalities are presenting new challenges for this education process. Stent-grafting for abdominal aortic aneurysms is an excellent example. Some differences between open and endovascular aneurysm repair are more subtle than are first obvious. Certainly, the less invasive technique may appear intuitively advantageous. However, there presently appears to be no significant difference in mortality. In addition, the long-term results are certainly better defined with the open surgical technique. The need for long-term follow-up also enters into the equation. As a result, subtle differences in the presentation of this information can easily sway the patient's decision-making process. A balanced presentation of short-term and long-term risks and benefits is critical, yet the patients may not be able to hear their options in a balanced fashion. This can become a very time intensive process further complicating the doctor-patient relationship. The last principle is justice. This implies that we, as physicians, will participate in the fair distribution of treatment options and services. This principle is becoming more challenging as the cost of medical care continues to escalate. Our participation can be at many levels. The most basic, however, is to ensure appropriate application of technology in our own practices and the hospitals in which we practice. In this way, we can continue to support the maintenance of high standards in the practice of peripheral vascular surgery. Our patients expect nothing less of us. As we enter this new millennium, diverse obstacles and opportunities await vascular surgery as a specialty and vascular surgeons as individuals. We must not only use the resources and strategies that are available now, but also create new solutions if we are going to survive and thrive as a specialty to provide the high-quality care that our patients have come to expect. The MWVSS will continue to serve as an effective regional resource with members capable of substantial accomplishments. These accomplishments may be at the national level with our new alignment with the AAVS, at the regional level with MWVSS work, or at the local level with regional or national societal support. Our challenge will be to maximize the opportunities that are presented to us as an organization and develop methods to support the individual vascular surgeon, our members, facing the challenges of health care today. There is immense talent within this society, and I know that we are capable of responding to the challenges ahead.