The American Association for Vascular Surgery: Advocate for independence

Abstract

As the first President of The American Association for Vascular Surgery (AAVS), a reorganized chapter of the International Society of Cardiovascular Surgery, I have been honored to serve in this leadership position. Service as President represents the culmination of a nearly three-decade journey for me: one that extends from Carmel, Calif, the site of our Society's 20th annual meeting in 1972 and my first encounter with this organization, to Baltimore, Md, and this 49th annual meeting in 2001. I have been fortunate to have an uninterrupted record of attendance at these annual events, thereby being afforded the opportunity to learn from and be challenged by the brightest minds and the most talented technical surgeons in American surgery. This experience has formed the basis for a challenging and rewarding career—one that I can recommend confidently to those in this audience, especially those who someday will mark Baltimore as their first encounter with our Association. I am grateful to my family, staff, and prior trainees, many of whom are in the audience today. I must particularly acknowledge my wife, Joan, who has been my partner for the last 20 years. I continue to be amazed and yet appreciative of her steadfast support and advice and the countless ways in which she has contributed to what elements of success I have enjoyed. Many of you know of my military background, and I would be remiss not to acknowledge the value of that wonderfully competent heritage. I shall always be indebted to the following group of military surgeons at Walter Reed General Hospital who guided me through training: General Carl Hughes, my departmental Chairman; General Thomas Whelan, the Surgeon General's Advisor in General Surgery; and Colonel Joseph Baugh, my program Director in General Surgery. However, my closest mentor was Dr Norman Rich. Without his support, I would not have initiated this practice I call academic vascular surgery. I am also indebted to Dr Kenneth Swan, then the Director of the Division of Surgery at the Walter Reed Army Institute of Research and now a faculty colleague in New Jersey. Dr Swan introduced me to the scientific method during a research fellowship year in an exciting environment of surgical investigation that included exposure to other young investigators, many of whom are current luminaries in American surgery, such as Wallace Ritchie, David Fromm, Alden Harken, David Reynolds, Creighton Wright, and Nelson Gurll. Subsequently, in New Jersey, my research associate Dr Walter Durán, Director of our Program in Vascular Biology, and Dr Ben Rush, a supportive Chairman, were always available and advised me through good and bad times. Today, I speak for the AAVS as an advocate for independence as we seek safe harbor during turbulent times in our evolution. As characterized by Christopher Hoenig, a former Director of Information Management in the General Accounting Office of the federal government, in his recently published book, The Problem Solving Journey,1Hoenig C The problem solving journey. : Perseus Books Group, Cambridge, Mass2000Google Scholar the growth, richness, and enduring character of a relationship depends on the simultaneous capability to exalt the individual and to recognize that individuals can only find their fullest expression within the group. Few of us will make the singularly important contribution, such as Voorhee's synthetic aortic prosthesis, Fogarty's catheter, or Parodi's endograft. However, the constellation of our academic activities, like a painting by Seurat, is contingent on many small individual contributions, analogous to the pointillists' artistic endeavors. Members of this Association should celebrate their individual achievements that are reflected in our annual clinical programs, composed of presentations on the basis of a competitive peer-review process. However, a successful AAVS also needs to generate a collective identity. A collective identity develops the strength and resources that we will need to make this final journey to independence. Maturing organizations, like this Association and indeed the speciality of vascular surgery, revolve around the debate of themes that I am posing as questions to you today: What is vascular surgery? What are its specialized components or pillars? Where are we now, and should independence for our specialty (The American Board of Vascular Surgery [ABVS]) be a part of our future? How deeply do we believe in the primacy of this specialty, and how committed are we to its worthiness in our management of patients with vascular disease? When Dr Wallace P. Ritchie, the current Executive Director of the American Board of Surgery (ABS), admonished vascular surgery in his 1997 presentation “Diplomate alert–vascular surgery,”2Ritchie WP Diplomate alert—vascular surgery.Letter to all diplomates, the American Board of Surgery. February 1997Google Scholar he suggested that vascular surgery was a component or pillar of general surgery. What he neglected to describe were the pillars of vascular surgery, components that separate our practice as unique. We are the proud offspring of general surgery and, like specialities before us, plastic surgery, colon and rectal surgery, and thoracic surgery, vascular surgery has come of age. I submit that the ABS should celebrate our unique accomplishments and support us in this movement toward independence. What is vascular surgery? What do we bring to the management of patients with vascular disease that is unique? What are vascular surgery's distinctive pillars (Table I)? Table IPillars of vascular surgery1. Open vascular surgical operations2. Endovascular surgical procedures3. Critical care4. Noninvasive vascular laboratory5. Basic science and clinical research6. Continuing medical education Open table in a new tab Historically, the operating room has been our theater of choice, our hallowed ground. The skillful performance of open operative procedures reinforces our commitment and value to patients with vascular disease. Other vascular disease specialists are unable to compete in this first area of interest; we distinguish ourselves by measuring up to the technical challenges of open operations and the complexity of the decision-making abilities required in patient management. This occupies the primary pillar in our identity. The second pillar, the most recent addition to our armamentarium, is endovascular surgery. Now embraced as a recommended addition for practicing vascular surgeons supplemented with minifellowships organized through the Endovascular Committee of the Joint Council and a formal requirement by the Residency Review Committee (RRC)–Surgery through its fellowships in vascular surgery, endovascular surgery has become an essential component of our practices. Although endovascular interventions trace their origins from Dotter and Judkins3Dotter CT Judkins MP Transluminal treatment of arteriosclerotic obstruction.Circulation. 1964; 30: 654-670Crossref PubMed Scopus (1288) Google Scholar and Gruntzig and Kumpe,4Gruntzig A Kumpe DA Technique of percutaneous transluminal angioplasty with the Gruntzig balloon catheter.AJR Am J Roentgenol. 1979; 132: 547-555Crossref PubMed Scopus (209) Google Scholar vascular surgeons, including Veith and colleagues,5Veith FJ Gupta SK Samson RH et al.Progress in limb salvage by reconstructive arterial surgery combined with new and improved adjunctive procedures.Ann Surg. 1981; 194: 386-401Crossref PubMed Scopus (175) Google Scholar Parodi and associates,6Parodi JC Palmaz JC Barone HD Transfemoral intraluminal graft implantation for abdominal aortic aneurysm.Ann Vasc Surg. 1991; 5: 491-499Abstract Full Text PDF PubMed Scopus (2977) Google Scholar and others in our specialty, have been instrumental in establishing their value to our practice. Some physicians in my peer group have been slow to embrace this component. However, I predict that proficiency in this arena will ultimately define our specialty. My straightforward recommendation to these colleagues and others in this audience would be to practice and participate in an endovascular program to acquire catheter and guidewire skills or suffer by being a diminished vascular surgeon. The third pillar of a practice is our facility with critical care. Critical care is a natural extension from the operating room and represents our commitment to the complete care of the patient with vascular disease. Although we will continue to rely on contributions from consultants, we must maintain our supervision of the postoperative patient and never become so busy that abrogating this responsibility becomes the normal practice. Our diagnostic acumen, the fourth pillar of our practice, is embodied in the noninvasive vascular laboratory. A significant percentage of these laboratories in this country are supervised by vascular surgeons, which has underscored our commitment to a physiologically sound basis for practice, an attraction that most of us regard as influential in our choice of this challenging surgical speciality. This practice separates us, for example, from colleagues in cardiothoracic surgery and represents a unique aspect of our practice. Basic science and clinical research form the fifth pillar of our speciality. The laboratory experience teaches us elements of the scientific method. Where else to better learn the most important lesson in experimental design? First, ask the correct question. Then, design the project, write the protocol, obtain critical review and necessary funding, analyze the data, prepare the abstract, and then be fortunate enough to present the data at a premier vascular surgical meeting and to publish the manuscript in a prestigious journal. I urge all of you, those in practice and those in academic positions, to embrace this formula. Involvement in clinical research is also an opportunity that should not be avoided. As emphasized by Dr Ralph Snyderman, Chairman of the Task Force on Clinical Research, American Association of Medical Colleges,7Snyderman R Chair's preface. Report of the AAMC Task Force on Clinical Research. American Association of Medical Colleges, 2000Google Scholar “The foundation for a constantly improving healthcare system is built on a base of clinical research. It is clinical research that allows the translation of research discoveries into practice and finds the methodology to determine what works best.”7Snyderman R Chair's preface. Report of the AAMC Task Force on Clinical Research. American Association of Medical Colleges, 2000Google Scholar The journey from the relevant clinical question to a funded program constitutes a wonderful training exercise with boundless opportunities to determine what is best for our patients. I recommend that you lead or participate in relevant clinical trials A life-long commitment to continuing medical education is the final pillar in our practice. This commitment is embodied in this Association's purposes and principles. These are the pillars of the specialty of vascular surgery. We should work with this Association to guarantee the integrity of this unique practice and its independence and for the future of competent care for patients with vascular disease. As is consistent with the principles of this Association, we collectively admire the accomplishments of our colleagues on the Vascular Surgery Board (VSB) of the ABS, but I cannot deny the aspirations of an informed membership. All constituencies of our specialty, members of the AAVS and The Society for Vascular Surgery (SVS), the Program Directors in Vascular Surgery (APDVS), and junior and senior vascular surgeons, have expressed positively their preference for our specialty's independence (Table II). Support for our younger colleagues should be another commitment of this Association. This perceived separation of a previous component of general surgery should not be described as fragmentation of the base because it rather reflects in part the failure of broad-based competency in the face of focused expertise. We can no longer support a dual system of competency in the practice of vascular surgery. Graduates of a residency in general surgery cannot be expected to measure up to the rigors of a practice in vascular surgery; competency requires 1 to 2 years of additional training and completion of demanding qualifying and certifying examinations. The high-volume practices that characterize graduates of fellowships in vascular surgery have reported mortality rates after carotid endarterectomy and repair of abdominal aortic aneurysm that are significantly lower than those rates associated with average practices in general surgery or cardiothoracic surgery.8The Dartmouth atlas of vascular healthcare. Dartmouth Medical School: Center for the Evaluative Clinical Sciences, the Trustees of Dartmouth College, 2000Google Scholar General surgeons who undergo recertification 10 years after training performed a mean of 41 vascular operations in 1995, half of which were angioaccess procedures (Table III).9Hobson RW Practice patterns in vascular surgery: implications for the certification and training of vascular surgeons.J Vasc Surg. 1997; 26: 905-912Abstract Full Text Full Text PDF PubMed Scopus (8) Google ScholarTable IIIMean case volumes: vascular and general surgical procedures performed in 1995 by surgeons with recertification for American Board of SurgeryGroups123Number of surgeons in each group8790685Mean operations per year274352381Mean vascular operations*19719241Mean general surgical operations*77160340Percent of vascular operations*81%55%12%Percent of general surgical operations*19%45%88%*Case volumes and percentages of total cases are significantly different between groups (P <.05).Vascular diplomates (group 1) who were taking vascular recertification examinations performed 81% of their total caseload in vascular surgical procedures and vascular diplomates (group 2) who were taking the general surgical recertification examination performed 55% of their caseload in vascular surgical procedures, whereas general surgery diplomates (group 3) without certification in vascular surgery who took general surgical recertification examinations performed only 12% of their case volume in vascular surgical procedures (P <.05). Mean number of cases for each group are presented.(Reprinted from: Hobson RW II, Practice patterns in vascular surgery: implications for the certification and training of vascular surgeons. J Vasc Surg 1997;26:905-12.) Open table in a new tab According to Ritchie, Rhodes, and Biester,10Ritchie Jr, WP Rhodes RS Biester TW Authors' reply.Ann Surg. 2000; 232: 149-150Crossref PubMed Google Scholar the ABS seeks “…to create a relatively adaptable and versatile surgeon through broad exposure to all the basic elements of the surgical craft…”10Ritchie Jr, WP Rhodes RS Biester TW Authors' reply.Ann Surg. 2000; 232: 149-150Crossref PubMed Google Scholar However, their recently published data11Ritchie Jr, WP Rhodes RS Biester TW Work loads and practice patterns of general surgeons in the United States, 1995-1997: a report of the American Board of Surgery.Ann Surg. 1999; 230: 533-543Crossref PubMed Scopus (140) Google Scholar show that rural general surgeons, presumably one of the goals for producing the versatile general surgeon, perform even fewer vascular surgical procedures annually (eight index cases per year) as compared with urban general surgeons.Table IIResults of The American Association for Vascular Surgery/Society for Vascular Surgery 2000 questionnaire on an independent American Board of Vascular SurgeryAge of respondentsTotalYesNoAge (years) 30 to 40292 (80%)75 (20%)367 41 to 50455 (72%)176 (28%)631 51 to 60384 (59%)249 (41%)633 >60381 (58%)273 (42%)654Years in practicePractice experienceTotalYesNo <5244 (84%)46 (16%)2905 to 10191 (73%)70 (27%)261 >101053 (62%)852 (38%)1905OrganizationOrganizational membershipTotalYesNoSVS only85 (56%)66 (44%)151AAVS only536 (70%)231 (30%)767Both SVS/AAVS278 (61%)180 (39%)458APDVS44 (57%)33 (43%)77None586 (67%)285 (33%)871SVS, The Society for Vascular Surgery; AAVS, The American Association for Vascular Surgery; APDVS, the Program Directors in Vascular Surgery. Open table in a new tab Vascular diplomates (group 1) who were taking vascular recertification examinations performed 81% of their total caseload in vascular surgical procedures and vascular diplomates (group 2) who were taking the general surgical recertification examination performed 55% of their caseload in vascular surgical procedures, whereas general surgery diplomates (group 3) without certification in vascular surgery who took general surgical recertification examinations performed only 12% of their case volume in vascular surgical procedures (P <.05). Mean number of cases for each group are presented. (Reprinted from: Hobson RW II, Practice patterns in vascular surgery: implications for the certification and training of vascular surgeons. J Vasc Surg 1997;26:905-12.) SVS, The Society for Vascular Surgery; AAVS, The American Association for Vascular Surgery; APDVS, the Program Directors in Vascular Surgery. Specialization in vascular surgery does not alter our specialty's pledge to support the training of residents in general surgery. These trainees should know the vascular anatomy associated with major general surgical procedures and be competent in the management of vascular trauma, catheter-based and operative interventions for angioaccess, venous surgical procedures to include vena caval interruption, management of deep venous thrombosis, and venous reconstructive procedures and amputations. We agree with the ABS10Ritchie Jr, WP Rhodes RS Biester TW Authors' reply.Ann Surg. 2000; 232: 149-150Crossref PubMed Google Scholar that the surgeons should also be familiar with other procedures, but we disagree with the Board12Hobson RW Berguer R Letter to the editor.Ann Surg. 2000; 232: 149Crossref PubMed Scopus (5) Google Scholar on the concept of the surgeon being primarily responsible for the performance of index vascular cases, such as repair of abdominal and thoracoabdominal aneurysms, lower extremity bypass grafting procedures, carotid endarterectomy, and bypass grafting for aortoiliac occlusive disease, along with the performance of emerging endovascular procedures. These cases should be the primary responsibility of surgeons who specialize in vascular surgery. Vascular surgeons also must acquire competency in the noninvasive diagnosis of vascular disease and the supervision of vascular laboratories. Many of us recommend that the ABS devote its time and effort to defining the specialty of general surgery rather than preoccupying itself with the affairs of another established speciality. In my opinion, an exciting future is guaranteed for general surgeons in the identification of a competency in the surgical management of upper and lower abdominal benign and malignant disease, advanced laparoscopic methods for accomplishing surgical procedures with less invasive methods, and management of the trauma victim. I know there are naysayers in this audience concerning the desired role for the ABS, many of them in powerful current and immediate past leadership positions. I say to them to trust in the integrity of this Association's membership. Do not underestimate this membership's intelligence when 70% of our responding members voted for independence (Table II). Join us in this endeavor. This way, as a united society, we and the Directors of the ABS will enjoy the opportunity to ensure our future and the competency of care for patients with vascular disease throughout this country. An initial means of addressing this question is to describe whether or not the councils of the two vascular societies and the Joint Council have functioned satisfactorily while simultaneously considering the issue of independence. I would like to present a progress report to the membership. The Councils of the AAVS and the SVS and the Joint Council have met on three occasions since the June 2000 meetings, a historic tripling of our activity over any prior year of our recent past. The Council of the AAVS has completed its reorganization, which will provide full voting privileges for each of the other national and regional vascular societies in this country and international representation from the International Society of Endovascular Specialists and The Canadian Vascular Society for Vascular Surgery (Fig 1).The representatives of each of these societies met with the Council of the AAVS during a luncheon at the Clinical Congress of the American College of Surgeons in October 2000. We worked together in the review and revision of bylaws and made recommendations regarding the new organization's purposes and principles. Documents have been completed, circulated, and reviewed by the members of this Association, and a final vote on these bylaws will be held at the business luncheon. The AAVS seeks to represent the entirety of vascular surgical practice. In this context, the Government Relations Committee, also supported by funding from the SVS, has made important contributions to our practices. Dr Bob Zwolak, current Chair of the Committee, and his colleagues have orchestrated the completion of CPT codes for endovascular repair of abdominal aortic aneurysm and numerous additional CPT codes for many vascular surgical procedures that were never previously included. Their work on the practice expense base rate has also been of considerable importance and carries with it the promise of actual improvement in reimbursement. The Joint Council approved expenditures of more than $170,000 in this activity this year, which has also included a partial stipend for the Committee's Chairman. The development of a new web site, VascularWeb, has also been an important topic of consideration at the Council of the AAVS. Our President-Elect, Dr Bill Pearce, and his committee have worked industriously on our behalf. An allocation of $350,000 was approved by the Joint Council to initiate VascularWeb, and an editorial board for its management is in place. Each of the participating societies has contributed to the Web site Committee, and the new web site will become active this summer. The Council of the AAVS has established the American Vascular Association, a division devoted to public education in vascular disease, a first effort in our societies' history. A Task Force on Public Education has been appointed with the chairmanship of Dr Bill Flinn. Three major committees (Development, chaired by Dr Tom O'Donnell; Public Awareness, chaired by Dr. Flinn; and Community Outreach, chaired by Dr. Michael Silva) have been appointed for the purposes of designing programs to improve the public's image of vascular surgeons and to enhance the public's knowledge of vascular disease. The task force will use our specialty's extensive network of noninvasive vascular laboratories to consider a screening program with techniques devised by many surgeons in this audience. The Endovascular Committee, chaired by Dr Greg Sicard, has assembled a listing of institutions that sponsor mini-fellowships in endovascular surgery. The committee also has recommended a process for accreditation of these programs through the Joint Council. The AAVS Council enthusiastically has endorsed the SVS's establishment of a Board of Technology, which will be liaison to the Food and Drug Administration and to principal industrial partners. We will work with the SVS to develop a clinical research organization, a grouping of institutions willing to fast-track protocols for clinical trials on innovative vascular devices, pharmaceuticals, and other new management tools. These accomplishments show unequivocally that the current societal councils in conjunction with the Joint Council are uniquely able to integrate and implement a recommendation for independence into an overall program of benefit for vascular surgery and our patients. The presumption that independence for vascular surgery is a recent topic of discussion is contradicted by the history of our societies and this specialty. Dr Jim DeWeese, one of our societies' admired past presidents, has reviewed the record in great detail. His paper should be mandatory reading for all surgeons engaged in this current debate.13DeWeese JA Accreditation of vascular training programs and certification of vascular surgeons.J Vasc Surg. 1996; 23: 1043-1053Abstract Full Text Full Text PDF Google Scholar Generally, progress with the ABS has been slow. When I began attending these meetings in 1972, Dr Edwin J. Wylie had described his proposal for accrediting training programs in vascular surgery and certifying their graduates in his 1970 Presidential Address, “Vascular surgery: a quest for excellence”.14Wylie EJ Presidential address: vascular surgery: a quest for excellence.Arch Surg. 1970; 101: 645-648Crossref PubMed Scopus (32) Google Scholar However, it was not until 1982, the year of his untimely death, that his dream became a reality and he was thereby awarded the first “Certificate of Special Qualifications in General Vascular Surgery.” Yearly written (qualifying) examinations have been conducted since 1983 and oral (certifying) examinations since 1986. As of the most recent certifying examination (May 2001), 895 Certificates of Special Qualifications and 1158 Certificates of Added Qualifications have been awarded by the ABS. The current annual certification of approximately 100 graduates in vascular surgery by the ABS identifies us with a group of American Board of Medical Specialities (ABMS)–approved boards (Table IV) that have a comparable number of graduates.Table IVAverage number of diplomates annually (most recent 10-year period)*No. of diplomatesAmerican Board of Colon Rectal Surgery46American Board of Nuclear Medicine70American Board of Medical Genetics87Vascular Surgery (ABS 2001)100American Board of Neurological Surgery117American Board of Allergy and Immunology127American Board of Thoracic Surgery145American Board of Plastic Surgery197*Source: American Board of Medical Specialties, 2000 Annual Report, Evanston, Ill.ABS, American Board of Surgery. Open table in a new tab Consequently, we should not permit others to suggest that we are too small to consider independence. ABS, American Board of Surgery. In 1990, the Crawford Issues Forum's topic15DeWeese JA Crawford issues forum: should vascular surgery become an independent speciality?.J Vasc Surg. 1990; 12: 605-606Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar was “Should Vascular Surgery become an independent specialty?” The Forum was chaired by Dr DeWeese, who concluded that “most vascular surgeons are satisfied with their current status”.15DeWeese JA Crawford issues forum: should vascular surgery become an independent speciality?.J Vasc Surg. 1990; 12: 605-606Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar However, in 1996, his opinion changed.13DeWeese JA Accreditation of vascular training programs and certification of vascular surgeons.J Vasc Surg. 1996; 23: 1043-1053Abstract Full Text Full Text PDF Google Scholar “It is my prediction that in time Vascular Surgery will have an independent board. It may take a while. After close affiliation with the ABS, it took Plastic Surgery three years, colon and rectal surgery 14 years, and thoracic surgery 23 years to establish their independence.”13DeWeese JA Accreditation of vascular training programs and certification of vascular surgeons.J Vasc Surg. 1996; 23: 1043-1053Abstract Full Text Full Text PDF Google Scholar How long will it be for vascular surgery? After presidential addresses by Veith16Veith FJ Presidential address: Charles Darwin and vascular surgery.J Vasc Surg. 1997; 25: 8-18Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar and Stanley17Stanley JC Presidential address: the American Board of Vascular Surgery.J Vasc Surg. 1998; 27: 195-202Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar and the incorporation of the ABVS, approval by the SVS, AAVS, and the Program Directors in Vascular Surgery Councils followed18Special communication J Vasc Surg. 1997; 25: 411-413Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar (Fig 2) and independence appeared to be within our grasp.These initiatives, however, stimulated reactions from the ABS and the establishment of the Sub Board in Vascular Surgery and its recent designation as the Vascular Surgery Board, ABS. The advertised success of this approach cooled some enthusiasm for independence but ultimately sharpened debate on this topic.19Towne JB Vascular surgery and the American Board of Surgery: political reality.J Vasc Surg. 2001; 33: 899-901Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar The issues of competency in the management of patients with vascular disease and the need for an altered training paradigm will move us to the establishment of an independent board. Concerns about competency, length of training, decreasing numbers of qualified candidates for general and vascular training programs, and results of the recent poll of our membership concerning independence were discussed with Dr Ritchie and Dr Frank Lewis, Chairman, ABS, in Philadelphia last March. Dr R. Berguer and I asked for their support of a proposal for independence—the concept of an independent ABVS, “a Board down the corridor from the ABS,” built on interdependence and mutual respect. A Board of Directors appointed equally in part by the ABS, the Joint Council, and the regional and other national societies would preserve appropriate interest by the ABS in affairs that also influence its trainees. With a separate RRC-Vascular Surgery, we could better evaluate our training programs and begin the important task of piloting alternatives to the current 5-year program for general surgery and 1-year to 2-year program for vascular surgery for dual certification. The potential for programs with 2 years of core training in general surgery and 4 years in vascular surgery or with 3 years in general surgery and 3 years in vascular surgery for certification in vascular surgery alone requires consideration. Unfortunately, the RRC-Surgery currently cannot even consider these options. Dr Ritchie was informed by the ABMS that only programs with certification first in general surgery could be reviewed. Although many candidates will continue to desire dual certification in the future,9Hobson RW Practice patterns in vascular surgery: implications for the certification and training of vascular surgeons.J Vasc Surg. 1997; 26: 905-912Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar an alternative of shorter duration for certification in vascular surgery alone needs to be evaluated. My optimism about this goal of independence was buoyed by recent decisions made by another national vascular society, The Society for Clinical Vascular Surgery, and the largest regional vascular society, The Eastern Vascular Society. Both societies have supported the proposal for an independent ABVS, ideally with the support of the ABS. Although an original letter from Dr Ritchie (written communication, March 28, 2001) suggested to me an “opportunity for compromise”, meetings between Dr Berguer and me and the Vascular Surgery Board of the ABS and correspondence from Drs Ritchie and Lewis have been disappointing. Rather than appointing thoughtful leaders from the ABS to meet with our societal leadership to evaluate and debate the pros and cons of our proposal, the Executive Committee of the ABS has unanimously rejected the proposal (written communication, May 24, 2001) without considering the opportunity for further joint discussions. How many times in our history are we going to be relegated to this dependency position and in turn be asked to thank the ABS for its generosity? How long must we be subservient to the anachronistic principles currently espoused by the ABS? Outmoded training paradigms are in urgent need of re-evaluation. Although we will continue to work with the ABS because it represents the only current option, my unqualified recommendation is for the membership of this Association to approve the preparation and submission of an application to the ABMS for an independent ABVS. At the end of the day, I remain optimistic about achieving this goal. Independence, dedicated to competency in the management of vascular disease, will become a reality.