Homans Lecture: Celebrating the past and looking to the future
AT THE 2016 VASCULAR ANNUAL MEETING
NATIONAL HARBOR, MD – “Specialties are like species,” said Frank J. Veith, MD, “they must evolve or go extinct.”
Dr. Veith of the New York University Langone Medical Center made this comparison in his 2016 Homans Lecture on the topic of “The future of vascular surgery,” at this year’s annual meeting hosted by the Society for Vascular Surgery.
Dr. Veith reviewed the history of vascular surgery, touched on its present status, and speculated on its potentially bright future. The vascular specialty has evolved dramatically over the past decades, especially in the area of embracing the endovascular revolution, said Dr. Veith, with that revolution putting vascular surgery at the forefront of research to develop new techniques.
His witnessing such innovations as those developed by Dr. Juan Parodi, and being a part of the early history of endovascular surgery, convinced Dr. Veith of its long-term importance to the development and survival of the specialty.
In his 1996 SVS Presidential Address, he predicted that 40%-70% of the open operations being done then would be replaced by endovascular procedures. “Accordingly, to survive, I recommended that vascular surgeons become endocompetent, learn how to do these procedures, and embrace them.” Dr. Veith added that, although his recommendation was not greeted with open arms by everyone, endovascular techniques moved forward.
In fact, “vascular surgeons often lead in developing many evolving endovascular procedures that are currently the standard of care,” he said.
Dr. Veith pointed out that a wide variety of conditions are now amenable to endovascular treatment, although some, including carotid disease, remain controversial. He listed examples of those conditions that he felt were still best treated with open surgery: thoracic outlet and entrapment syndromes, some ascending aorta and arch lesions, a few rare aneurysms not suited for endovascular treatment, some Takayasu’s lesions, some congenital and genetic aortic and renal artery lesions, some infected arteries and arterial grafts, a rare recurrent or complex lower-extremity lesion, some carotid lesions, and some failed endovascular treatments.
“Our specialty has embraced the endovascular revolution and become endocompetent,” he said. “It is why vascular surgery is doing as well as it is today.” He added. “Vascular surgery is presently an exciting, vibrant specialty in the United States.”
Dr. Veith noted, “Well-trained vascular surgeons are the only ones who can provide the most appropriate, full spectrum of care for patients with vascular disease, outside the head and the heart – whether that treatment be medical, endovascular, or open. There are abundant numbers of patients who require our skills. In addition, we use fascinating technology and have good industry relationships. And finally, many patients regard their vascular surgeon as a key doctor who they see regularly. As a result of these advantages, many bright medical students and general surgery residents are choosing to train as vascular surgeons. Vascular surgery should be flourishing.”
However, despite the fact vascular surgery is an exciting and vibrant specialty, and the best for treating vascular disease outside of the heart and the brain, the vascular specialty has significant problems competing with other specialties, he said.
He blamed in part the size and structure of the specialty, in particular with regard to its competition.
“Vascular surgery competes, as it always has, with general and cardiac surgeons. However, general surgeons have become less competitive, but cardiac surgeons have become more in need of work, and thus more active beyond the heart and thoracic aorta – as their open operations are replaced by coronary stents and transcatheter valves. More importantly, as vascular treatments become increasingly endovascular, vascular surgery will be competing with interventional radiology and, importantly, interventional cardiology.”
He outlined a number of major challenges these other disciplines create, in part, because of the DRG/RVU/dollar orientation of institutions, and the fact that most institutions still consider vascular surgery a subspecialty of general or cardiac surgery, or a subordinate part of a Heart & Vascular Center, with administrative control of these centers rarely in the hands of vascular surgeons. Moreover, when institutional resources – like angiography suites or hybrid operating rooms are distributed, the interests of vascular surgery are often represented by a general or cardiac surgeon – or worse a cardiologist,” he added.
He stated that these conditions limit vascular surgery’s ability to get its fair share of institutional resources.
“The competitive playing field is not level, and vascular surgeons are disadvantaged in the Darwinian struggle to survive,” he stated.
“To survive, vascular surgery needs to unify, recognize this inequity, and fix it. This can only be done if all vascular surgeons engage vigorously in this issue. We need equal administrative status with cardiac and general surgery in our institutions,” Dr. Veith advised.
