Vascular surgery's identity

Abstract

It is our belief that improving the identity of vascular surgery and vascular surgeons will directly lead to improved care of patients having vascular diseases. To understand why we hold this opinion, the origins of vascular surgery and its evolution as a defined specialty must be examined. It also requires an understanding of how specialties are recognized in the United States and what vascular surgery's place is in the hierarchy of medicine. Vascular surgery is the acknowledged medical specialty that cares for patients having diseases of arteries and veins other than those within the heart or head. The treatment of traumatic injuries involving arteries and veins, usually by ligation, was the birth of the specialty centuries ago. It was not until the early 1900s that techniques for vascular anastomoses evolved, and it was not until heparin anticoagulation and synthetic vascular grafts became widely available in the 1950s that vascular surgical techniques evolved to effectively treat occlusive, aneurysmal, and traumatic vascular lesions. By the 1960s, vascular surgery had reached its adolescence. At first, these new techniques were employed primarily by general and cardiothoracic surgeons as part of their practices. Because the arterial lesions being treated were threatening to patients' lives, limbs, and brains and because the procedures were technically demanding, it soon became apparent that special expertise and experience were important in achieving good patient outcomes.1Wylie E.J. Vascular surgery: a quest for excellence.Arch Surg. 1970; 101: 645-648Crossref PubMed Scopus (32) Google Scholar This led the American Board of Surgery (ABS) in the 1980s to recognize vascular surgery as a subspecialty of general surgery, having its own special training programs, examinations, and certification. These changes were fraught with many public and private conflicts between the leaders of the ABS and the vascular community.2DeWeese J.A. Accreditation of vascular training programs and certification of vascular surgeons.J Vasc Surg. 1996; 23: 143-153Abstract Full Text Full Text PDF Google Scholar However, it was generally agreed that additional training in vascular surgery improved patient outcomes. Nevertheless, many general surgeons and thoracic surgeons without extra vascular surgery training continued to operate on patients with vascular diseases. That practice received uncompromising support from the ABS, which continued to claim that vascular surgery was a primary component of training and board certification in general surgery. In the 1980s and 1990s, two events happened that had an impact on vascular surgery and propelled its evolution into a more distinct and separate specialty.3Veith F.J. Presidential address: Charles Darwin and vascular surgery.J Vasc Surg. 1997; 25: 8-16Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar First was the introduction of many new and more complex open surgical procedures and associated medical treatments. All required greater skills and mastery of additional knowledge. Second was the revolutionary introduction and rapid evolution of endovascular treatment for most vascular lesions. This, too, mandated that vascular surgeons acquire a greater fund of knowledge and new technical skills necessitating additional training. It appeared that these evolutionary developments clearly differentiated vascular surgery from its general surgery and cardiothoracic surgery ancestors. It is a fact that vascular surgeons have a much more global responsibility for the diagnosis, medical management, and broad surgical treatments of their patients than do many other surgical specialists who have medical counterparts to share in patient care. This has led to vascular surgery's universal recognition as a distinct, separate, and independent specialty in virtually all parts of the civilized world. However, the issue of vascular surgery's independence in the United States, in our opinion, remains incomplete. Vascular surgery's attempts to gain its own American Board of Medical Specialties (ABMS) board were complex and created some of the most disruptive professional and personal controversies the specialty had ever witnessed.4Stanley J.C. Veith F.J. The American Board of Vascular Surgery and independence of vascular surgery. ABVS history and appendices.Ann Vasc Surg. 2016; 37: 1-331Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar These turbulent times, depicted in 70 copies of published statements and personal correspondence generated during two decades by those favoring independence and those opposing it, revealed the marked animosity generated by the vascular community in challenging the status quo.4Stanley J.C. Veith F.J. The American Board of Vascular Surgery and independence of vascular surgery. ABVS history and appendices.Ann Vasc Surg. 2016; 37: 1-331Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar(pp25-240) We believe most individuals completing a vascular surgery residency or fellowship in the past 20 years are likely to have little understanding of why and how their discipline sought to have its own ABMS-approved independent board. It is, therefore, worth reviewing the organizations in the United States that control specialty designation, including that of vascular surgery. Most important of these governing bodies are the boards and the residency review committees. To better understand what an independent specialty was at the time vascular surgery sought independence, one must recognize the dominant role played by the ABMS.5Annual report and reference handbook—2002. American Board of Medical Specialties, Research and Education Foundation, Evanston, Ill2002Google Scholar It was then—and remains so today—the most important arbiter of medical specialty identification in North America. Since its establishment in 1933, the ABMS has been a self-sustaining body composed currently of 24 specialty boards. The stated mission of the ABMS is to “serve the public and the medical profession by improving the quality of health care through setting professional standards for lifelong certification in partnership with Member Boards.” In that regard, one of the ABMS's most impactful roles is to approve new specialty boards in the United States. In 1996, an American Board of Vascular Surgery (ABVS) was incorporated by all eight executive officers of the Society for Vascular Surgery (SVS) and the North American Chapter of the International Society for Cardiovascular Surgery (NC-ISCVS), later known as the American Association for Vascular Surgery, which was subsequently incorporated into the SVS in 2004. The rationale for the formation of the ABVS was announced in a published document accompanied with actual signatures of 22 leaders of the vascular surgery community, representing the executive councils and all officers of the SVS, NC-ISCVS, and Association of Program Directors in Vascular Surgery (APDVS).6The American Board of Vascular Surgery: rationale for its formation.J Vasc Surg. 1997; 25: 411-413Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar The ABVS received strong support from all North American vascular surgery societies, with an initial poll in 1997 documenting that 80% of the SVS and NC-ISCVS members and 91% of those holding an ABS certificate of Added Qualifications in Vascular Surgery supported the ABVS's seeking ABMS approval.7Stanley J.C. 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 Support was even greater among those younger than 60 years. Three subsequent polls in 1998, 2000, and 2004 documented continued support from the vascular surgery community.4Stanley J.C. Veith F.J. The American Board of Vascular Surgery and independence of vascular surgery. ABVS history and appendices.Ann Vasc Surg. 2016; 37: 1-331Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar(pp9-11,19) In the late 1990s, there were two principal reasons the ABVS sought approval to become an ABMS board. The most important reason was to improve care for vascular disease patients by eliminating a system in which there were two groups performing vascular procedures, one that was well trained and certified in vascular surgery and another that was less well trained but deemed competent to practice vascular surgery by virtue of their general surgery certification. The second reason was the fact that vascular surgery had evolved to a point at which it fulfilled all the published ABMS requirements to become a new separate specialty.5Annual report and reference handbook—2002. American Board of Medical Specialties, Research and Education Foundation, Evanston, Ill2002Google Scholar(pp73-77) In 2002, the ABVS petitioned the Liaison Committee for Specialty Boards of the ABMS to become one of their boards. The application documented how each ABMS-required criterion to become a new specialty board had been fulfilled, including its clear economic feasibility.4Stanley J.C. Veith F.J. The American Board of Vascular Surgery and independence of vascular surgery. ABVS history and appendices.Ann Vasc Surg. 2016; 37: 1-331Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar(pp261-331) The application was endorsed by North America's 13 major vascular surgery societies. Nevertheless, the ABVS pursuit of independence was strongly opposed by the ABS.4Stanley J.C. Veith F.J. The American Board of Vascular Surgery and independence of vascular surgery. ABVS history and appendices.Ann Vasc Surg. 2016; 37: 1-331Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar(pp33-38,103-104) Surprisingly, the ABVS application was rejected without any explanation as to what specific criteria had not been met.4Stanley J.C. Veith F.J. The American Board of Vascular Surgery and independence of vascular surgery. ABVS history and appendices.Ann Vasc Surg. 2016; 37: 1-331Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar(pp133-135) A formal request regarding what shortcomings existed in the application resulted in a reply that no minutes were taken during the hearing and thus specific reasons for the rejection could not be ascertained.4Stanley J.C. Veith F.J. The American Board of Vascular Surgery and independence of vascular surgery. ABVS history and appendices.Ann Vasc Surg. 2016; 37: 1-331Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar(p139) Three years later in 2005, a complex formal appeal of the Liaison Committee for Specialty Boards' rejection was similarly denied by an ABMS-American Medical Association (AMA) appeals board.4Stanley J.C. Veith F.J. The American Board of Vascular Surgery and independence of vascular surgery. ABVS history and appendices.Ann Vasc Surg. 2016; 37: 1-331Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar(198-201) Vascular surgery's struggle to become an independent ABMS board continued, and it is our opinion that when independence as an ABMS board seemed irrefutable, the ABS with the support of certain SVS leaders advanced a number of lesser concessions delaying the complete independence that most vascular surgeons considered inevitable. The most visible concession occurred when the ABS expanded its established vascular advisory committee and labeled it the ABS Vascular Surgery Board.4Stanley J.C. Veith F.J. The American Board of Vascular Surgery and independence of vascular surgery. ABVS history and appendices.Ann Vasc Surg. 2016; 37: 1-331Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar(pp58-60) However, the ABS Vascular Surgery Board chair had to be actively credentialed in general surgery, and the final authority regarding vascular surgery training issues continued to remain with the ABS directors, of whom a majority were general surgeons and a distinct minority were vascular surgeons. Nevertheless, the ABS, SVS, and APDVS leadership did respond to the persisting need for independence. In 2005, this resulted in the Residency Review Committee for Surgery (RRC-S) approval of an ABS-issued primary certificate in vascular surgery, which became a reality in 2006 when the Accreditation Council for Graduate Medical Education (ACGME) provided final approval.4Stanley J.C. Veith F.J. The American Board of Vascular Surgery and independence of vascular surgery. ABVS history and appendices.Ann Vasc Surg. 2016; 37: 1-331Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar(pp217-220) This allowed medical students to directly enter 0+5-year vascular surgery residency programs, leading to their being eligible for certification in vascular surgery. Two prior options to become eligible for certification in vascular surgery were maintained, namely, the 5+2-year vascular surgery fellowships and the 4+2-year early specialization programs, although the latter was infrequently pursued.4Stanley J.C. Veith F.J. The American Board of Vascular Surgery and independence of vascular surgery. ABVS history and appendices.Ann Vasc Surg. 2016; 37: 1-331Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar(pp232-233) The opportunity to obtain a primary certificate in vascular surgery without the burden of having to successfully complete a general surgery residency represented an important step toward recognizing that vascular surgery is indeed a unique and separate specialty. However, we believe vascular surgery still lacked full autonomy like other comparable surgical specialties having independent ABMS-approved boards (enumerated in the following). The training arena for vascular surgery has changed dramatically since 2006. Competence in vascular surgery requires much more than simple technical or procedural competence. In spite of the perceived success of vascular surgery training programs,8Kiguchi M. Leake A. Switzer G. Mitchell E. Makaroun M. Chaer R.A. Perceptions of Society for Vascular Surgery members and surgery department chairs of the integrated 0+5 vascular surgery training paradigm.J Surg Educ. 2014; 71: 716-725Crossref PubMed Scopus (16) Google Scholar,9Tanious A. Wooster M. Jung A. Nelson P.R. Armstrong P.A. Shames M.L. Comparison of the integrated vascular surgery resident operative experience and the traditional vascular surgery fellowship.J Vasc Surg. 2017; 66: 307-310Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar we question whether the majority of the nearly 1200 trainees in the existing 60 or so integrated (0+5) programs and a little more than 100 independent (5+2) fellowships are adequately educated to provide competent care in the entire spectrum of vascular disease. We consider this to be an issue of pressing importance to the APDVS, the ACGME (RRC-S), and the ABS Vascular Surgery Board. We suggest that major change is warranted in both the content of training future vascular surgeons and its oversight by the ACGME, which should establish a Residency Review Committee for Vascular Surgery (RRC-VS) that would more efficiently and better assess the character of vascular surgery training programs than does the existing RRC-S, which currently includes only three vascular surgeons among its 19 members. The mission of the ACGME is “to improve healthcare and population health by assessing and advancing the quality of resident physicians' education through accreditation.”10Accreditation Council for Graduate Medical Education.https://www.acgme.orgDate accessed: January 8, 2020Google Scholar The current RRC-S is composed of 16 voting members, including 14 surgeons, 1 resident trainee, and 1 lay person representing the public. The surgeons are appointed by the ACGME Board for 6-year terms, being chosen from nominees proposed by the ABS, the American College of Surgeons, the AMA, and the American Osteopathic Association. Three nonvoting ex officio members include the current ABS Executive Director, the Associate Director of the American College of Surgeons, and the AMA Vice President, The RRC-S has responsibilities overseeing accreditation in (general) surgery and what it recognizes as five surgical subspecialties (complex general surgical oncology, hand surgery, pediatric surgery, surgical critical care, and vascular surgery). Vascular surgery is the only surgical specialty having an ABMS-recognized primary certificate without its own independent RRC.10Accreditation Council for Graduate Medical Education.https://www.acgme.orgDate accessed: January 8, 2020Google Scholar We believe the perceived contradictions as to how the ABMS bylaws were applied to the ABVS application in 2002 and 2005 are troublesome, but that is history. Nevertheless, the recent ABS and APDVS failure to convince the ACGME to establish an RRC-VS is difficult to explain, and the missed opportunity to better the oversight of vascular surgery training programs should not be overlooked. In the year of that failure, 2019, a past chair of the ABS Vascular Surgery Board, John Eidt, was very clear about this issue11Eidt J.F. Vascular surgery: taking the next steps toward autonomy.Semin Vasc Surg. 2019; 32: 14-17Crossref PubMed Scopus (1) Google Scholar:The question is who should be responsible for making critical decisions about the content of vascular surgery training: an [R]RC composed entirely of vascular surgeons or an [R]RC dominated by >80% non-vascular surgeons. It is axiomatic that vascular surgeons are in the best position to determine the optimal method to train vascular surgeons… There is another compelling issue that has received little public discourse among surgical educators. Vascular surgery knowledge and practice in recent decades have expanded to include a multitude of diagnostic tools ranging from noninvasive testing and imaging to complicated catheter-based arteriography, complex medical therapies, and many very different and complex endovascular technologies as well as many specialized open operations. We believe many existing training experiences have serious shortcomings, whether involving provision of adequate numbers of open abdominal and lower extremity arterial reconstructions, placement of fenestrated and branched aortic endovascular grafts, complex venous procedures, or even in-depth training in noninvasive laboratory testing. We also believe that some of these practice areas within vascular surgery represent legitimate subspecialties and that not every training program will be able to provide comprehensive training in each one of them. Similar issues have evolved in 20 of the 24 ABMS boards where practice areas have become subspecialized enough to require advanced training with resultant subspecialty certification.12American Board of Medical Specialties.https://www.abms.orgDate accessed: January 8, 2020Google Scholar It seems imperative that the vascular surgery community must address the issue of subspecialization in our discipline, a topic better addressed sooner rather than later. We would posit that an independent ABMS board would clearly be best able to act on the matter of subspecialty recognition and certification. In the 14 years since the ABVS application was rejected by the ABMS, the issue of general surgeons' being credentialed by hospitals to perform complex vascular operations has been largely resolved. Currently, we believe there is another important reason for vascular surgery to have its own ABMS-approved board. That is its present subspecialty status in most institutions, where it is a division of a larger entity, usually a department of general or cardiothoracic surgery or a heart and vascular center. In these circumstances, the interests and needs of vascular surgeons are often subordinated to those of the larger entity. Thus, the needs of vascular surgery in terms of resource distribution, including staffing, operating room or angiography suite equipment, space, and dollars, are often left unmet or poorly met. Vascular surgery frequently does not have a seat at the table where these resources are distributed.2DeWeese J.A. Accreditation of vascular training programs and certification of vascular surgeons.J Vasc Surg. 1996; 23: 143-153Abstract Full Text Full Text PDF Google Scholar As a result, the care of vascular patients may be put at risk. Having a separate ABMS-approved board will not solve all of vascular surgery's challenges, but we believe it will allow more control over our own affairs and provide us with status within institutions approaching that of orthopedics, neurosurgery, thoracic surgery, urology, obstetrics-gynecology, plastic surgery, and general surgery. It is noteworthy that plastic surgery took 3 years and thoracic surgery took 23 years to leave their affiliation with the ABS and to establish their independence as ABMS-approved boards. The latter events resulting in a new independent ABMS board are uncommon. In fact, it was in 1979 that emergency medicine became the last new specialty to do so. The public has a much clearer understanding of ABMS-recognized surgical specialties than they do of vascular surgery. We believe having such status will certainly improve vascular surgeons' presently clouded identity.13Dietzek A.M. Presidential address: vascular surgery is the best kept secret in medicine and my thoughts on how we can change that.J Vasc Surg. 2019; 69: 5-14Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar True independence, given legitimacy by the ABMS, is the status vascular surgery richly deserves and needs.13Dietzek A.M. Presidential address: vascular surgery is the best kept secret in medicine and my thoughts on how we can change that.J Vasc Surg. 2019; 69: 5-14Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar,14Veith F.J. Homans Lecture: a look at the future of vascular surgery.J Vasc Surg. 2016; 64: 885-890Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar In 2019, the ABS moved to create multiple internal “boards” within its own organization. This action would allow its two specialties having ABMS-approved primary certificates (general surgery and vascular surgery) as well as four subspecialties (complex general surgical oncology, hand surgery, pediatric surgery, and surgical critical care) to have somewhat separate roles within the ABS. The relevance of the ABS in creating greater internal autonomy remains unknown, but it cannot be equated with legitimate ABMS board independence. One answer to the “ABMS board issue” would be for the recent ABS Associate Executive Director for Vascular Surgery (currently, one of the ABS Vice Presidents) and the current members of the ABS Vascular Surgery Board, with the full support of the APDVS and the SVS, to petition the ABMS to become a fully independent board like the American Board of Plastic Surgery did when it separated from the ABS in 1941. The vascular surgeons on the ABS Vascular Surgery Board have done an exceptional job of maintaining the high-quality examination processes used in the certification of vascular surgeons, the continued production of the Vascular Surgery In-Training Examination, and the improved maintenance of certification processes.15Ozaki C.K. Perler B.A. Mitchell M.E. Gahtan V. The role of the Vascular Surgery Board in surgical education.Semin Vasc Surg. 2019; 32: 5-10Crossref PubMed Scopus (3) Google Scholar The Vascular Surgery Board of the ABS deserves our applause. However, their work efforts are almost exclusively “operational.” There is no question that if they became the core of an independent ABMS board, they would have a clearer and more forceful voice in developing a needed “strategic” plan for improving the training criteria and certification processes of future vascular surgeons. We believe vascular surgery and vascular surgeons are an unrecognized asset within the nation's health care system. All too often, the public and many primary care physicians do not know what we do. This perception will be corrected somewhat by ABMS independent board recognition, but more is required. Vascular surgery as a specialty needs to better establish its brand. Until the present time, vascular surgery has done a poor job doing so.13Dietzek A.M. Presidential address: vascular surgery is the best kept secret in medicine and my thoughts on how we can change that.J Vasc Surg. 2019; 69: 5-14Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Other interventional specialists, especially interventional cardiologists, are treating increasing numbers of patients with noncardiac vascular diseases. Many of these other specialists have a legitimate stake in providing vascular care, and they possess many assets that enable them to do so.14Veith F.J. Homans Lecture: a look at the future of vascular surgery.J Vasc Surg. 2016; 64: 885-890Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar,16Veith F.J. Stanley J.C. Key steps to maintain our identity as vascular surgeons and to promote the well-being of patients and our specialty.in: Current vascular surgery. Amika Press, Northfield, IL2019: 303-308Google Scholar But most of those in other specialties have broad responsibilities beyond treating vascular diseases alone, unlike vascular surgeons, whose sole focus is on vascular diseases. It comes as no surprise that recent vascular surgery trainees considered “competing specialists” to be the top perceived threat to the specialty of vascular surgery.17Hekman K.E. Wohlauer M.V. Magee G.A. Shokrzadeh C.L. Brown K.R. Carsten C.G. et al.Current issues and future directions for vascular surgery training from the results of the 2016-2017 Association of Program Directors in Vascular Surgery annual training survey.J Vasc Surg. 2019; 70: 2014-2020Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar We believe that vascular surgeons can flourish in such a competitive medical environment by providing the best care possible, resisting the temptations to overtreat, and managing the whole patient and not just a patient's lesion. They must brand themselves as the complete vascular disease physician.13Dietzek A.M. Presidential address: vascular surgery is the best kept secret in medicine and my thoughts on how we can change that.J Vasc Surg. 2019; 69: 5-14Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar,14Veith F.J. Homans Lecture: a look at the future of vascular surgery.J Vasc Surg. 2016; 64: 885-890Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar Such branding efforts are a justified reality in the United States today. Vascular surgeons deserve a better, more forceful voice informing the public about their specialty. The SVS and other vascular societies must mount a robust public education campaign, targeted to other physicians and the lay public, to inform them about vascular disease, its prevention as well as treatment, and to let them know who we are and what we do.13Dietzek A.M. Presidential address: vascular surgery is the best kept secret in medicine and my thoughts on how we can change that.J Vasc Surg. 2019; 69: 5-14Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar,14Veith F.J. Homans Lecture: a look at the future of vascular surgery.J Vasc Surg. 2016; 64: 885-890Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar,16Veith F.J. Stanley J.C. Key steps to maintain our identity as vascular surgeons and to promote the well-being of patients and our specialty.in: Current vascular surgery. Amika Press, Northfield, IL2019: 303-308Google Scholar Undertaking such an effective marketing effort will be expensive, but a better informed group of referring physicians and an educated public will be worth the costs. If we do not inform others of our specialty's assets, vascular surgeons will become individually disadvantaged, and our specialty will become less important in the medical hierarchy. Ultimately, however, it is all about providing better patient care. The challenges facing vascular surgery have only been exacerbated by what is generally recognized as an unmet need to adequately expand the number of training programs to meet future workforce needs.18Arous E.J. Judelson D.R. Simons J.P. Aiello F.A. Doucet D.R. Arous E.J. et al.Increasing the number of integrated vascular surgery residency positions is important to address the impending shortage of vascular surgeons in the United States.J Vasc Surg. 2018; 67: 1618-1620Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar Vascular surgery needs to more vigorously establish its leadership role in modern medicine. To do this, it must address its gaps in contemporary training, become an ABMS independent board, codify recognition of its subspecialty expertise, and unmask its unclear identity by marketing what the specialty and its practitioners contribute to contemporary medicine. Accomplishing this will improve the well-being of the specialty, but more important, it will better the care of patients afflicted with vascular diseases.