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Vascular surgeons—leaders in vascular care
PRESIDENTIAL ADDRESS From the Society for Vascular Surgery
Vascular surgeons—leaders in vascular care K. Craig Kent, MD New York, NY
It has to be one of life’s most rewarding honors to serve as president of the society that embodies one’s specialty. I recall my first Society for Vascular Surgery meeting in 1987, 20 years ago. It would have been beyond my most imaginable belief to think that I might some day be president of this organization. Although I won’t burden you with “thank yous,” I want to express my admiration and warmest gratitude to three individuals: Ron Stoney, John Mannick, and Andy Whittemore. These are my mentors. They have served as role models for me throughout my career. I am deeply appreciative of the fact that they helped and cared at each step along the way. I would be remiss if I did not also express my gratitude to my parents. As Wayne mentioned, my father was a rancher with only a high school education, and my mom, a schoolteacher. During my years on the ranch I learned from my parents the value of hard work, the importance of honesty and integrity, the value of family, and the satisfaction that a passion for one’s profession can bring. These lessons have served me well over the years. I would also like to thank my children, Alycia and Eric, for being patient with me this past year and all of the years. My love for my profession is only superseded by my love for you. VASCULAR SURGEONS AS LEADERS Today more than ever, vascular surgeons need to be leaders. In the year 2015, there will be 87 million Americans older than the age of 55. We know that the prevalence of vascular disease in this age group is 12% and thus many of these individuals will become our patients. Our future patients will need—and deserve— expert and innovative care. Vascular surgeons, until recently, have been the practitioners that have led the way. A bit of history: Until the 1950s vascular disease was synonymous with old age. Most From Weill Medical College of Cornell University and Columbia College of Physicians and Surgeons New York Presbyterian Hospital. Presented at the Sixty-first Annual Meeting of the Society for Vascular Surgery, Baltimore, Md, Jun 7-10, 2007. Correspondence: K. Craig Kent, MD, FACS, New York Presbyterian Hospital, 525 E. 68th St, Payson 707, New York, NY 10021 (e-mail: [email protected]). J Vasc Surg 2008;47:231-6 0741-5214/$34.00 Copyright © 2008 by The Society for Vascular Surgery. doi:10.1016/j.jvs.2007.10.053
individuals with cardiovascular disease died of a heart attack in their 50s, 60s, or early 70s, and the remainder who survived to manifest peripheral vascular disease, suffered amputation or died of stroke, renal failure, or ruptured aneurysm. Enter the vascular surgeon. Pioneers such as Kunlin, Debakey, Wylie, Sylagli, Strandness, and so many others invented operations, developed devices, and investigated the natural history of vascular disease. All of these advancements allowed vascular surgeons to care for a growing population of patients. We were the leaders! We maintained this leadership role throughout many decades into the 80s and early 90s. We were successful for many reasons but primarily because of our devotion to our patients and our desire for excellence. We were also aided by the fact that the technology did not dramatically change. We may have produced better outcomes in the 90s than in the 60s, but the surgical principals remained the same. Moreover and importantly, no one else wanted to care for these patients. Vascular surgeons were hard working, technically precise, persistent individuals known for caring for a highly complex group of patients. God knows, nobody else wanted to perform an 8-hour femoral–pedal bypass! But in the late 90s, minimally invasive techniques matured, at first slowly but then more rapidly. It was no longer an onerous task to care for a patient with vascular disease. The required skill sets with the advent of catheter techniques overlapped with the skills of other interventionalists. Reimbursement for minimally invasive procedures became more favorable than traditional surgery, and there were more patients in need of treatment. In a matter of 10 years, the world changed dramatically for vascular surgeons. Instead of being leaders, in many ways we have become followers. Much of the new technology that we frequently use today was championed by others while we stayed on the sidelines fighting vehemently for the status quo. We let other organizations write the guidelines for vascular disease. Other groups worked with companies to develop and test new techniques. We let other specialists come into our communities and become the primary care providers for our patients. In sum, our position as leaders in the treatment of vascular disease has been and continues to be challenged. 231
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Well, none of this is new to you. The problem has been described by too many and on too many occasions. But what is the solution? Vascular surgeons need to recapture their role as leaders in vascular care. Although societies can help in this endeavor—and for the remainder of this address you will hear that the Society for Vascular Surgery is devoted to this mission—leadership needs to occur on an individual level. Vascular surgeons need to be leaders in vascular care in their local communities. The Society for Vascular Surgery can help produce this image; however, it is the responsibility of every individual in this room to rise to a leadership role. If each of us takes on this mission, collectively we will be successful. What are the leadership qualities that will allow us, individually, to accomplish this charge? There are many qualities of a leader. I have chosen several that I believe are important for us today. Skill. The first is skill. Vascular surgeons are already known as master surgeons. There are few who would debate that vascular surgeons perform amongst the most technically difficult procedures. However, we need to assure the world that we are also master physicians and that we can medically manage our patients with the latest pharmacy and with an in-depth understanding of the natural history of vascular disease. We need to perform catheter intervention with the same ability and skill as we do open surgery. Whatever the technique, we must be regarded as the best. It is easy to follow a leader that is able and skilled. Passion. The second characteristic of leadership is passion. A love of what we do. Admittedly, during the past few years, passion has been difficult to engender. Our world has been complex; and for many of us, it still is. There is, however, a great deal more certainty now than there was a few years ago. It is truly a great time to be a vascular surgeon. We have at our command two entirely different skills sets. We are open surgeons and also endovascular surgeons. Our patients have benefited from our new skills. They are able to survive longer and have fewer complications. Our lifestyle is improving, and we are paid more for endovascular techniques. There is good reason today for vascular surgeons to have passion. Vision. The third attribute of leadership is vision. Theodore Hesburgh once said, “The very essence of leadership is that you must have a vision.” We need to be capable of predicting the future; we can’t live in the past. What will vascular intervention be like 10 years from now? How do we move the specialty and ourselves to that place? What do our patients want? Embracing the status quo is rarely a characteristic of a true leader. New endovascular or medical technologies need to be developed by vascular surgeons. Service. The fourth attribute is service. As vascular surgeons, we have always been good at this; today we need to be better. Do we place our patients first and foremost? Are we providing continuity of care, a custom not always offered by other vascular interventionalists? Do we communicate well with our patients and with our referring physicians? Our patients and referring physicians might be tran-
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siently enamored by promises of innovation, new technology, and minimal invasiveness, but ultimately, they want a solid, thoughtful, and communicative physician providing care. Optimism. The last and perhaps most important attribute of the vascular surgeon leader is optimism. A philosopher once said, “I can’t change the direction of the wind, but I can adjust my sails to always reach my destination.” The treatment of vascular disease will evolve. We cannot control this evolution, but we can be the ones to help it find its way. Medical students and residents follow an optimistic leader. Referring physicians want to hear that we are strong and positive about our profession. Patients need to hear our confidence. Optimism is a shining star that everyone follows. There are many attributes of leadership; these are only a few. However, I believe at this juncture that these are attributes that are critical to our success in creating, maintaining, and expanding dominance for the specialty of vascular surgery. I have little doubt that vascular disease in the future will be treated by many specialists. It is estimated that in 2030 there will be almost 2 million vascular procedures performed each year. There is plenty to go around. The question is, who will be regarded as the leaders in vascular care? Let’s use these qualities—that are present within each of us—to send a clear message that the specialty in the lead is vascular surgery. EVOLUTION AND MATURATION OF THE SOCIETY FOR VASCULAR SURGERY So how can the Society for Vascular Surgery help recreate this leadership role for vascular surgeons? Let me begin by telling you about today’s SVS. We have evolved over the past several years in a way that is unprecedented. Where was the SVS 5 years ago? There were two societies, a division of leadership with competition between the SVS and the American Association for Vascular Surgery (AAVS). The SVS had no central administrative support. Our sole function, for the most part, was to run a national meeting. We were struggling with our identity. Should we be independent or should we not? How should we relate to the larger community of surgery? While the society was struggling, so were our members with a transformation in the way vascular surgery was practiced; our field was being redefined. Where is the SVS today? I would say strong and well. This began with the merger of the SVS and AAVS in 2003 to create an all-inclusive society, today’s SVS. We now have an office in Chicago with central administrative leadership. We have a sub-board in vascular surgery and a primary certificate. Not that the struggle for independence is over, but we have learned that independence of our specialty can be achieved in many ways, not just by the establishment of a separate board. The SVS has mature infrastructure put in place by our recent leaders. And with strong infrastructure has come great productivity. Many times through the year, I have asked myself why I was the fortunate one with the opportunity to inherit the society at such a great time. It
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was my predecessors, Jack Cronenwett, Tom Riles, Dick Green, Greg Sicard, and Enrico Ascher, who struggled through the years to create what is now a unified, mature, and functional organization. Today’s SVS has approximately 2300 members. We have an annual budget of $4.7 million and employ 11 individuals who work either at our central office in Chicago or in our ancillary office in Washington, DC. We have many goals, all with the central mission of empowering vascular surgeons. Our initiatives are numerous and include the areas of clinical practice, recruitment, education, research, branding, communications, international relations, advocacy, and reimbursement. Our goal over the past several years has been to make this your society, with a focus on the community-practicing vascular surgeon. We have many activities—as you will see—and participation in the activities of the society has been broad. To provide you with perspective, in 2003 there were 14 committees of the SVS with 93 volunteers for these positions. In 2007, only 4 years later, there are a total of 37 councils, committees, or working groups with over 250 individuals involved in societal activities. Inclusive are many of you in this room. The SVS wants broad participation. In fact, we have adopted a new policy where candidates for councils, committees, and leadership positions are chosen from solicited volunteers. This approach has led to significant enthusiasm on the part of SVS members. In 2007 we requested volunteers for 26 vacancies and over 120 individuals applied for these positions. We are working hard. Over this past year, there were more than 270 conference calls. The SVS Executive Council met by phone, without fail, every other Tuesday evening, and we estimate over 5000 hours were logged by vascular surgeons for SVS related efforts just this year. So what have we accomplished? I will not try to be comprehensive. In fact, it would be impossible in a 3-hour address to describe the depth and detail of the societies’ activities. I will, however, try to highlight a few of our more important programs and emphasize how these programs will empower you to be leaders in vascular care. SOCIETAL INITIATIVES Education. Let us begin with education. Education encompasses many themes. Today, however, the most important educational goal of our society is to train vascular surgeons in new and innovative technology. In support of this goal, it is my hope that we are able to provide for every vascular surgeon the opportunity to be trained in the full spectrum of endovascular techniques. It is here that I would like to introduce the concept of the fully endocompetent vascular surgeon, an individual who can perform expertly all endovascular techniques for peripheral vascular disease regardless of their complexity. This individual would have competence in all of the latest technology, including cerebral protection devices, .014 and rapid exchange systems, re-entry devices, and the like.
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To accomplish this task, there is a clear need for comprehensive endovascular training. As such, the SVS is in the process of developing new training paradigms that have as their goal the achievement of full competence in various endovascular techniques. As a pilot for these programs we have chosen carotid stenting. A new committee has been recently established under the auspices of the Education Council that is in the process of creating a program for comprehensive training in carotid stenting. Here is how this training program will function: ● ●
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Interested and qualified individuals will apply to the SVS for carotid stent training. Selection of trainees will be based upon prior endovascular experience and the likelihood that the trainee will eventually be able to perform carotid stenting at his or her local institution. For candidates that are chosen, an individualized training program will be designed that includes didactics, simulation, and hands-on experience. Trainees will be guaranteed access to at least 30 cerebral angiograms and 25 carotid stents over a period of a year.
The novel element of this training paradigm will be that it has as an end point, the achievement of competence in carotid stenting. We will consider this program successful only if all of its trainees become credentialed at their local institutions and eventually develop active practices in carotid stenting. The SVS has partnered with Cordis Endovascular in the development of this program. We expect to begin taking applications within the next month and initially four candidates will be chosen. Our hope is to expand the program to over 20 surgeons within the year. Building on what we anticipate to become a novel and successful paradigm for training, we intend soon thereafter to partner with EV3 to develop a similar program for training surgeons in advanced therapies for lower extremity occlusive disease. I am hopeful that many of you will take advantage of these programs. I have described just one of the SVS Education Council’s programs; however, there are many more that I do not have time to discuss in detail. A few of these are as follows: ●
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An Educational Products Committee has begun the process of establishing an online clearinghouse of educational information that has been evaluated by the committee and deemed useful for SVS members. The Post Graduate Education Committee will continue with its very successful courses in coding and is developing new courses in practice management and in the endovascular arena. These latter efforts are supported by robust grants from Abbott Laboratories and Boston Scientific. The annual meeting Program Committee, under the leadership of Rich Cambria, has created a superb meeting this year. New offerings include joint sessions with other vascular organizations, six breakfast sessions, as well as an R&D presentation from corporate partners.
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I want to personally thank Rich for the outstanding effort that he has made this year. It is not widely understood the amount of time necessary to create and manage the annual meeting. A Vascular Self-Assessment Program (VSAP) is being developed by the SVS with an anticipated first version in 2008. Like SESAP for general surgery, VSAP will help vascular surgeons keep up to date and prepared for their recertifying examinations. Lastly, I am proud to announce that the SVS has become the editor of Rutherford’s Textbook of Vascular Surgery. Rutherford’s text has become an icon in vascular surgery, and we are eager to have the SVS carry on this important tradition.
None of these activities would have occurred without the able leadership of Peter Lawrence, chair of the Education Council, and the administrative assistance of Patricia Burton from the Society office. Branding. So why doesn’t everyone realize that a vascular surgeon should be the practitioner of choice for their patients with vascular disease? There are several logical reasons why they should! 1. First, we are the only specialists devoted completely to the care of vascular patients. Although there is variation, interventional radiologists spend on average 30% of their time caring for vascular patients, cardiologists about 10%, and nephrologists, neurosurgeons, dermatologists, and neurointerventionalists even less. For vascular surgeons, the number is now and will always be 100%. If there is one concept that has been repeatedly proven in medicine, specialization leads to improved patient care. 2. Perhaps even more importantly, we are the only vascular practitioners who have the potential to provide all forms of therapy for our patients: medical, catheter-based, and operative. For the fully trained vascular surgeon, there is no conflict. There are multiple options in the tool kit and the ability to freely decide what is best for our patients. This all does seem to be good news, does it not? Unfortunately, perceptions do not always translate into reality. Although we think we are omnipotent, the rest of the world does not necessarily share this viewpoint! Is it possible that vascular surgery is one of the best-kept secrets in medicine? The SVS recently contracted a marketing agency to gain the unbiased perceptions of 70 referring physicians randomly chosen from around the country. Although the details of this analysis will be presented at a branding session on Saturday, I would like to share with you a few highlights. When asked about the types of procedures typically performed by vascular surgeons, 85% of these physicians stated that vascular surgeons provide surgical services that are invasive and complex. These same medical physicians refer patients with less complex disease to cardiologists or interventional radiologists for less invasive procedures. More
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than 25% of primary care physicians disagreed with the statement that vascular surgeons perform angioplasty and stenting. Moreover, more than 20% disagreed with the statement that vascular surgeons are trained and experienced in medical management of patients with peripheral vascular disease. So much for the assertion that we are triple threats, with medical, percutaneous, and surgical options for our patients. It is clear that we as vascular surgeons, with the help of the SVS, need to reverse these perceptions. To accomplish this task, 2 years ago the SVS established a Communications Committee within the society under the leadership of Bruce Perler. We complimented this committee with a public relations and communications team lead by Jill Goodwin. There have been numerous initiatives that the society has undertaken to brand vascular surgeons on a national level. Accomplishments within the last year include: ● Prominent vascular surgeons were featured in The New York Times, Newsweek, and the Wall Street Journal. In fact, vascular surgery and the society have been featured in hundreds of newspapers and journals this past year as well as on PBS. This coverage reached 48 million Americans with our message “see a vascular surgeon.” ● Vascular surgery and the society were highlighted in the Ultimate SAAVE Campaign featuring Jim Craig, who is in our audience today, the world famous captain of the US hockey team who lost his father to an undiagnosed ruptured aneurysm. ● Sponsored by Cook Incorporated, crews are at this meeting taping a 30-second public service announcement delivered by 50 vascular surgeons that will be aired on television and radio stations across the country. ● A branding tool kit has been created and is being released at this meeting. These are comprehensive materials that members can use to educate referring physicians and promote their practices to the public and to the media. This tool kit was included in your meeting tote bag and is available electronically on Vascular Web. Inclusive in this tool kit are: 1. instructions for creating a Web site, 2. media interviewing messages and guidelines, 3. a complete 1-year media plan with supporting materials, 4. Power Point presentations for grand rounds on specific topics—lower extremity vascular disease, carotid artery disease, aortic aneurysms, and venous disease, 5. guidelines for hosting a dinner for primary care physicians, 6. brochures that describe the various diseases that vascular surgeons treat as well as the procedures we perform, and 7. a separate tool kit for developing a screening event As leaders, we not only need to be skilled and to have a passion for our work but it is also necessary to communicate our talents and strengths to the rest of the world. I would
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encourage all of you to use these tools that the society has provided and create a grass roots initiative in your local communities. Let the public and referring physicians know that vascular surgeons are leaders in vascular care. Let’s change perceptions and let the world know our true potential. Recruitment. To remain a viable specialty we need to recruit the best and the brightest. Moreover, we need to increase our numbers to be capable of caring for the almost doubling of vascular interventions that will take place over the next 20 years. The SVS in concert with the Association of Program Directors in Vascular Surgery is actively addressing this issue. We now have 119 finishing fellows; I submit that the number needs to increase to 200 for vascular surgery to maintain its dominant role in the treatment of vascular disease. I also submit that many of you here today have vascular practices that are sufficiently robust to allow development of your own fellowship program. Moreover, those of you who have existing fellowships could increase your complement. The submission of an application for a new fellowship program can be an intimidating process, and the SVS wants to help. We have created infrastructure within the SVS to assist in the development of your fellowship application. The SVS can offer the following resources ●
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an administrator associated with the SVS office, who has significant expertise in preparing an application for a new fellowship, templates of applications, a list of directors for 0/5, 3/3, 4/2, and 5/2 programs who are willing to offer advice and assistance during the application process, and access to the vascular surgery representatives to the residency review committees who will also provide guidance and advice.
I would ask everyone in this room to consider whether your practice will support a high-quality fellowship. If the answer is yes, consider using SVS resources to make this happen. Help us increase the number of vascular fellowship positions to 200. Accompanying this initiative are many others directed at enhancing our recruitment efforts. We have with us today over 70 students and residents from around the country who have an interest in vascular surgery. Could I have our visitors stand for a round of applause? Other initiatives related to recruitment include: ● ●
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a white paper on how to identify funding for 0/5 programs, a yearly mailing to first-, second-, and third-year general surgical residents encouraging them to consider a career in vascular surgery, the establishment of a resident and student section of the SVS, and a mentoring program linking SVS members with residents/students.
I would like to thank WL Gore for its generous support of
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the activities of the recruitment task force and its help in developing these recruitment initiatives. Research. Being at the vanguard in research should be a critical goal of vascular surgeons if we are to maintain a leadership role in the treatment of vascular disease. True leaders have vision. They understand where their specialty will be in 10 years. If our referring physicians as well as the public perceive vascular surgeons to be innovators of new treatments and technology and responsible for measuring outcomes, they will look to us to care for their patients. Shouldn’t the next New England Journal of Medicine article addressing peripheral stenting versus angioplasty emanate from vascular surgeons? One of the missions of the SVS over the last year has been to reinvigorate clinical research in the society. At a fall retreat of the Research Council, under the leadership of Rick Powell, a 5-year strategy for research was created, and the following are some of the initiatives that were developed: ●
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We learned from our industrial colleagues that vascular surgeons, compared with other specialists, frequently do not have the infrastructure or the focus to effectively carry out clinical trials. To rectify this problem, the SVS in partnership with industry has developed a yearly clinical research course, the purpose of which is to mentor vascular surgeons in the methodology of clinical trials as well as prospective clinical studies. We have also created a clinical research database on the SVS Web site, which will be searchable and contains information regarding over 160 potential vascular surgery trial sites. The SVS has introduced three yearly $15,000 seed grants designed to encourage SVS members to develop proposals for multicenter clinical trials. Applications will be reviewed by the newly formed Clinical Research Committee, and the recipients will be chosen based on the merit and the potential of the trial to eventually receive peer-reviewed support. In selected instances, clinical research will be conducted within the SVS. The SVS has just recently developed a partnership with Lifeline Screening. Lifeline has agreed to provide the SVS with its complete data set of over 5 million people screened for vascular disease as well as the resources to analyze this data. We anticipate that the findings from the analysis will be pivotal and provide new information about which patients should be the target of screening.
As you can see, the SVS strongly believes that leadership requires vision, and vision can be enhanced by vascular surgeons being leaders in research. Advocacy. In the arena of advocacy, the SVS has made a significant impact! We led the effort to gain reimbursement for screening for abdominal aortic aneurysms, which came to fruition in January of this year. In sum, the SVS was responsible for the first-ever preventive benefit available for patients with vascular disease.
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Centers for Medicare and Medicaid Services (CMS) reimbursement for carotid stenting has been in flux and controversial. As most of you know, the SVS has played an active role in this process working closely with the Food and Drug Administration, CMS, and other governmental agencies. Owing to the efforts of the SVS and its individual members, these agencies consider vascular surgeons as major stakeholders in carotid stenting. The carotid stent registry developed by the SVS and supported by Boston Scientific now includes over 3700 patients and has set the standard for measuring outcomes for carotid intervention. Recently, CMS considered a proposal to expand coverage of carotid stenting to include high-risk asymptomatic patients. SVS was integrally involved in this process, advocating that CMS increase coverage for anatomic high-risk patients but not at physiologic high risk. SVS’s comments to CMS were heard, and in April the proposal to increase coverage of carotid stenting for asymptomatic physiologic high-risk patients was rejected pending further study. The role of the SVS in this process was pivotal. These and many other initiatives have been developed under the auspices of the Clinical Practice Council, ably led by Keith Calligaro. The Clinical Practice Council is also overseeing the development of practice standards, reporting standards, and credentialing papers. We are setting new definitions for vascular disease from the perspective of vascular surgeons. Reimbursement. We need to thank the Governmental Relations Committee and its active membership for the many initiatives surrounding reimbursement. This group has achieved so much, however, one accomplishment is especially notable. As we all know, the Deficit Reduction Act, which went into effect in January of this year, provided across the board cuts to the technical component of all office-based imaging services, including vascular ultrasound and physiologic testing. However, in an effort organized by the SVS, which included almost 800 letters sent from SVS members and an additional 18 members of congress to CMS, plus vigorous lobbying by the SVS Government Relations staff, the physiologic vascular lab
codes were removed from these cuts. Physiologic vascular labs or ankle-brachial index measurements are performed primarily by vascular surgeons and account for $62 million worth of services each year. Let me be clear: SVS related efforts this past year have saved vascular surgeons on a yearly basis over $60 million in vascular testing revenue. Remember this dollar amount next time you are asked to donate to the SVS political action committee. CLOSING There are so many additional areas where the society has made great advances. We have made headway in international relations and in communications. We now have a newspaper and a biweekly e-mail update to our members. I wish I had the time to describe it all. Perhaps some of you are wondering if we are doing too much? Is the society spread too thin? Have we lost focus? I can tell you with assurance: this is not the case. We are 2300 strong, 2300 passionate, devoted, innovative, and hard working individuals. There is little we can’t accomplish. As Henry Ford once said, “Nothing is particularly hard if you divide it into small jobs.” We now have the infrastructure in a robust society to accomplish all of this. We are supported by Becky Maron our executive director and a team of 10 superb individuals in our administrative office. Becky, will you and your team rise for a round of applause? How should I end? None better than with a prescription from the SVS for success. Each of us needs to return to our community with a mission. . . to let the world know that we are skilled surgeons and skilled interventionalists; that we are passionate about our specialty, that we have vision, that we are best at service. Most importantly, that we are optimistic about the future. With this prescription, I am assured that the world will perceive VASCULAR SURGEONS AS LEADERS IN VASCULAR CARE! I will close by saying again what an honor it has been to be your president, an honor that in my life is unparalleled. Thank you for your time. Be well.
Vascular surgeons—leaders in vascular care K. Craig Kent, MD New York, NY
It has to be one of life’s most rewarding honors to serve as president of the society that embodies one’s specialty. I recall my first Society for Vascular Surgery meeting in 1987, 20 years ago. It would have been beyond my most imaginable belief to think that I might some day be president of this organization. Although I won’t burden you with “thank yous,” I want to express my admiration and warmest gratitude to three individuals: Ron Stoney, John Mannick, and Andy Whittemore. These are my mentors. They have served as role models for me throughout my career. I am deeply appreciative of the fact that they helped and cared at each step along the way. I would be remiss if I did not also express my gratitude to my parents. As Wayne mentioned, my father was a rancher with only a high school education, and my mom, a schoolteacher. During my years on the ranch I learned from my parents the value of hard work, the importance of honesty and integrity, the value of family, and the satisfaction that a passion for one’s profession can bring. These lessons have served me well over the years. I would also like to thank my children, Alycia and Eric, for being patient with me this past year and all of the years. My love for my profession is only superseded by my love for you. VASCULAR SURGEONS AS LEADERS Today more than ever, vascular surgeons need to be leaders. In the year 2015, there will be 87 million Americans older than the age of 55. We know that the prevalence of vascular disease in this age group is 12% and thus many of these individuals will become our patients. Our future patients will need—and deserve— expert and innovative care. Vascular surgeons, until recently, have been the practitioners that have led the way. A bit of history: Until the 1950s vascular disease was synonymous with old age. Most From Weill Medical College of Cornell University and Columbia College of Physicians and Surgeons New York Presbyterian Hospital. Presented at the Sixty-first Annual Meeting of the Society for Vascular Surgery, Baltimore, Md, Jun 7-10, 2007. Correspondence: K. Craig Kent, MD, FACS, New York Presbyterian Hospital, 525 E. 68th St, Payson 707, New York, NY 10021 (e-mail: [email protected]). J Vasc Surg 2008;47:231-6 0741-5214/$34.00 Copyright © 2008 by The Society for Vascular Surgery. doi:10.1016/j.jvs.2007.10.053
individuals with cardiovascular disease died of a heart attack in their 50s, 60s, or early 70s, and the remainder who survived to manifest peripheral vascular disease, suffered amputation or died of stroke, renal failure, or ruptured aneurysm. Enter the vascular surgeon. Pioneers such as Kunlin, Debakey, Wylie, Sylagli, Strandness, and so many others invented operations, developed devices, and investigated the natural history of vascular disease. All of these advancements allowed vascular surgeons to care for a growing population of patients. We were the leaders! We maintained this leadership role throughout many decades into the 80s and early 90s. We were successful for many reasons but primarily because of our devotion to our patients and our desire for excellence. We were also aided by the fact that the technology did not dramatically change. We may have produced better outcomes in the 90s than in the 60s, but the surgical principals remained the same. Moreover and importantly, no one else wanted to care for these patients. Vascular surgeons were hard working, technically precise, persistent individuals known for caring for a highly complex group of patients. God knows, nobody else wanted to perform an 8-hour femoral–pedal bypass! But in the late 90s, minimally invasive techniques matured, at first slowly but then more rapidly. It was no longer an onerous task to care for a patient with vascular disease. The required skill sets with the advent of catheter techniques overlapped with the skills of other interventionalists. Reimbursement for minimally invasive procedures became more favorable than traditional surgery, and there were more patients in need of treatment. In a matter of 10 years, the world changed dramatically for vascular surgeons. Instead of being leaders, in many ways we have become followers. Much of the new technology that we frequently use today was championed by others while we stayed on the sidelines fighting vehemently for the status quo. We let other organizations write the guidelines for vascular disease. Other groups worked with companies to develop and test new techniques. We let other specialists come into our communities and become the primary care providers for our patients. In sum, our position as leaders in the treatment of vascular disease has been and continues to be challenged. 231
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Well, none of this is new to you. The problem has been described by too many and on too many occasions. But what is the solution? Vascular surgeons need to recapture their role as leaders in vascular care. Although societies can help in this endeavor—and for the remainder of this address you will hear that the Society for Vascular Surgery is devoted to this mission—leadership needs to occur on an individual level. Vascular surgeons need to be leaders in vascular care in their local communities. The Society for Vascular Surgery can help produce this image; however, it is the responsibility of every individual in this room to rise to a leadership role. If each of us takes on this mission, collectively we will be successful. What are the leadership qualities that will allow us, individually, to accomplish this charge? There are many qualities of a leader. I have chosen several that I believe are important for us today. Skill. The first is skill. Vascular surgeons are already known as master surgeons. There are few who would debate that vascular surgeons perform amongst the most technically difficult procedures. However, we need to assure the world that we are also master physicians and that we can medically manage our patients with the latest pharmacy and with an in-depth understanding of the natural history of vascular disease. We need to perform catheter intervention with the same ability and skill as we do open surgery. Whatever the technique, we must be regarded as the best. It is easy to follow a leader that is able and skilled. Passion. The second characteristic of leadership is passion. A love of what we do. Admittedly, during the past few years, passion has been difficult to engender. Our world has been complex; and for many of us, it still is. There is, however, a great deal more certainty now than there was a few years ago. It is truly a great time to be a vascular surgeon. We have at our command two entirely different skills sets. We are open surgeons and also endovascular surgeons. Our patients have benefited from our new skills. They are able to survive longer and have fewer complications. Our lifestyle is improving, and we are paid more for endovascular techniques. There is good reason today for vascular surgeons to have passion. Vision. The third attribute of leadership is vision. Theodore Hesburgh once said, “The very essence of leadership is that you must have a vision.” We need to be capable of predicting the future; we can’t live in the past. What will vascular intervention be like 10 years from now? How do we move the specialty and ourselves to that place? What do our patients want? Embracing the status quo is rarely a characteristic of a true leader. New endovascular or medical technologies need to be developed by vascular surgeons. Service. The fourth attribute is service. As vascular surgeons, we have always been good at this; today we need to be better. Do we place our patients first and foremost? Are we providing continuity of care, a custom not always offered by other vascular interventionalists? Do we communicate well with our patients and with our referring physicians? Our patients and referring physicians might be tran-
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siently enamored by promises of innovation, new technology, and minimal invasiveness, but ultimately, they want a solid, thoughtful, and communicative physician providing care. Optimism. The last and perhaps most important attribute of the vascular surgeon leader is optimism. A philosopher once said, “I can’t change the direction of the wind, but I can adjust my sails to always reach my destination.” The treatment of vascular disease will evolve. We cannot control this evolution, but we can be the ones to help it find its way. Medical students and residents follow an optimistic leader. Referring physicians want to hear that we are strong and positive about our profession. Patients need to hear our confidence. Optimism is a shining star that everyone follows. There are many attributes of leadership; these are only a few. However, I believe at this juncture that these are attributes that are critical to our success in creating, maintaining, and expanding dominance for the specialty of vascular surgery. I have little doubt that vascular disease in the future will be treated by many specialists. It is estimated that in 2030 there will be almost 2 million vascular procedures performed each year. There is plenty to go around. The question is, who will be regarded as the leaders in vascular care? Let’s use these qualities—that are present within each of us—to send a clear message that the specialty in the lead is vascular surgery. EVOLUTION AND MATURATION OF THE SOCIETY FOR VASCULAR SURGERY So how can the Society for Vascular Surgery help recreate this leadership role for vascular surgeons? Let me begin by telling you about today’s SVS. We have evolved over the past several years in a way that is unprecedented. Where was the SVS 5 years ago? There were two societies, a division of leadership with competition between the SVS and the American Association for Vascular Surgery (AAVS). The SVS had no central administrative support. Our sole function, for the most part, was to run a national meeting. We were struggling with our identity. Should we be independent or should we not? How should we relate to the larger community of surgery? While the society was struggling, so were our members with a transformation in the way vascular surgery was practiced; our field was being redefined. Where is the SVS today? I would say strong and well. This began with the merger of the SVS and AAVS in 2003 to create an all-inclusive society, today’s SVS. We now have an office in Chicago with central administrative leadership. We have a sub-board in vascular surgery and a primary certificate. Not that the struggle for independence is over, but we have learned that independence of our specialty can be achieved in many ways, not just by the establishment of a separate board. The SVS has mature infrastructure put in place by our recent leaders. And with strong infrastructure has come great productivity. Many times through the year, I have asked myself why I was the fortunate one with the opportunity to inherit the society at such a great time. It
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was my predecessors, Jack Cronenwett, Tom Riles, Dick Green, Greg Sicard, and Enrico Ascher, who struggled through the years to create what is now a unified, mature, and functional organization. Today’s SVS has approximately 2300 members. We have an annual budget of $4.7 million and employ 11 individuals who work either at our central office in Chicago or in our ancillary office in Washington, DC. We have many goals, all with the central mission of empowering vascular surgeons. Our initiatives are numerous and include the areas of clinical practice, recruitment, education, research, branding, communications, international relations, advocacy, and reimbursement. Our goal over the past several years has been to make this your society, with a focus on the community-practicing vascular surgeon. We have many activities—as you will see—and participation in the activities of the society has been broad. To provide you with perspective, in 2003 there were 14 committees of the SVS with 93 volunteers for these positions. In 2007, only 4 years later, there are a total of 37 councils, committees, or working groups with over 250 individuals involved in societal activities. Inclusive are many of you in this room. The SVS wants broad participation. In fact, we have adopted a new policy where candidates for councils, committees, and leadership positions are chosen from solicited volunteers. This approach has led to significant enthusiasm on the part of SVS members. In 2007 we requested volunteers for 26 vacancies and over 120 individuals applied for these positions. We are working hard. Over this past year, there were more than 270 conference calls. The SVS Executive Council met by phone, without fail, every other Tuesday evening, and we estimate over 5000 hours were logged by vascular surgeons for SVS related efforts just this year. So what have we accomplished? I will not try to be comprehensive. In fact, it would be impossible in a 3-hour address to describe the depth and detail of the societies’ activities. I will, however, try to highlight a few of our more important programs and emphasize how these programs will empower you to be leaders in vascular care. SOCIETAL INITIATIVES Education. Let us begin with education. Education encompasses many themes. Today, however, the most important educational goal of our society is to train vascular surgeons in new and innovative technology. In support of this goal, it is my hope that we are able to provide for every vascular surgeon the opportunity to be trained in the full spectrum of endovascular techniques. It is here that I would like to introduce the concept of the fully endocompetent vascular surgeon, an individual who can perform expertly all endovascular techniques for peripheral vascular disease regardless of their complexity. This individual would have competence in all of the latest technology, including cerebral protection devices, .014 and rapid exchange systems, re-entry devices, and the like.
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To accomplish this task, there is a clear need for comprehensive endovascular training. As such, the SVS is in the process of developing new training paradigms that have as their goal the achievement of full competence in various endovascular techniques. As a pilot for these programs we have chosen carotid stenting. A new committee has been recently established under the auspices of the Education Council that is in the process of creating a program for comprehensive training in carotid stenting. Here is how this training program will function: ● ●
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Interested and qualified individuals will apply to the SVS for carotid stent training. Selection of trainees will be based upon prior endovascular experience and the likelihood that the trainee will eventually be able to perform carotid stenting at his or her local institution. For candidates that are chosen, an individualized training program will be designed that includes didactics, simulation, and hands-on experience. Trainees will be guaranteed access to at least 30 cerebral angiograms and 25 carotid stents over a period of a year.
The novel element of this training paradigm will be that it has as an end point, the achievement of competence in carotid stenting. We will consider this program successful only if all of its trainees become credentialed at their local institutions and eventually develop active practices in carotid stenting. The SVS has partnered with Cordis Endovascular in the development of this program. We expect to begin taking applications within the next month and initially four candidates will be chosen. Our hope is to expand the program to over 20 surgeons within the year. Building on what we anticipate to become a novel and successful paradigm for training, we intend soon thereafter to partner with EV3 to develop a similar program for training surgeons in advanced therapies for lower extremity occlusive disease. I am hopeful that many of you will take advantage of these programs. I have described just one of the SVS Education Council’s programs; however, there are many more that I do not have time to discuss in detail. A few of these are as follows: ●
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An Educational Products Committee has begun the process of establishing an online clearinghouse of educational information that has been evaluated by the committee and deemed useful for SVS members. The Post Graduate Education Committee will continue with its very successful courses in coding and is developing new courses in practice management and in the endovascular arena. These latter efforts are supported by robust grants from Abbott Laboratories and Boston Scientific. The annual meeting Program Committee, under the leadership of Rich Cambria, has created a superb meeting this year. New offerings include joint sessions with other vascular organizations, six breakfast sessions, as well as an R&D presentation from corporate partners.
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I want to personally thank Rich for the outstanding effort that he has made this year. It is not widely understood the amount of time necessary to create and manage the annual meeting. A Vascular Self-Assessment Program (VSAP) is being developed by the SVS with an anticipated first version in 2008. Like SESAP for general surgery, VSAP will help vascular surgeons keep up to date and prepared for their recertifying examinations. Lastly, I am proud to announce that the SVS has become the editor of Rutherford’s Textbook of Vascular Surgery. Rutherford’s text has become an icon in vascular surgery, and we are eager to have the SVS carry on this important tradition.
None of these activities would have occurred without the able leadership of Peter Lawrence, chair of the Education Council, and the administrative assistance of Patricia Burton from the Society office. Branding. So why doesn’t everyone realize that a vascular surgeon should be the practitioner of choice for their patients with vascular disease? There are several logical reasons why they should! 1. First, we are the only specialists devoted completely to the care of vascular patients. Although there is variation, interventional radiologists spend on average 30% of their time caring for vascular patients, cardiologists about 10%, and nephrologists, neurosurgeons, dermatologists, and neurointerventionalists even less. For vascular surgeons, the number is now and will always be 100%. If there is one concept that has been repeatedly proven in medicine, specialization leads to improved patient care. 2. Perhaps even more importantly, we are the only vascular practitioners who have the potential to provide all forms of therapy for our patients: medical, catheter-based, and operative. For the fully trained vascular surgeon, there is no conflict. There are multiple options in the tool kit and the ability to freely decide what is best for our patients. This all does seem to be good news, does it not? Unfortunately, perceptions do not always translate into reality. Although we think we are omnipotent, the rest of the world does not necessarily share this viewpoint! Is it possible that vascular surgery is one of the best-kept secrets in medicine? The SVS recently contracted a marketing agency to gain the unbiased perceptions of 70 referring physicians randomly chosen from around the country. Although the details of this analysis will be presented at a branding session on Saturday, I would like to share with you a few highlights. When asked about the types of procedures typically performed by vascular surgeons, 85% of these physicians stated that vascular surgeons provide surgical services that are invasive and complex. These same medical physicians refer patients with less complex disease to cardiologists or interventional radiologists for less invasive procedures. More
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than 25% of primary care physicians disagreed with the statement that vascular surgeons perform angioplasty and stenting. Moreover, more than 20% disagreed with the statement that vascular surgeons are trained and experienced in medical management of patients with peripheral vascular disease. So much for the assertion that we are triple threats, with medical, percutaneous, and surgical options for our patients. It is clear that we as vascular surgeons, with the help of the SVS, need to reverse these perceptions. To accomplish this task, 2 years ago the SVS established a Communications Committee within the society under the leadership of Bruce Perler. We complimented this committee with a public relations and communications team lead by Jill Goodwin. There have been numerous initiatives that the society has undertaken to brand vascular surgeons on a national level. Accomplishments within the last year include: ● Prominent vascular surgeons were featured in The New York Times, Newsweek, and the Wall Street Journal. In fact, vascular surgery and the society have been featured in hundreds of newspapers and journals this past year as well as on PBS. This coverage reached 48 million Americans with our message “see a vascular surgeon.” ● Vascular surgery and the society were highlighted in the Ultimate SAAVE Campaign featuring Jim Craig, who is in our audience today, the world famous captain of the US hockey team who lost his father to an undiagnosed ruptured aneurysm. ● Sponsored by Cook Incorporated, crews are at this meeting taping a 30-second public service announcement delivered by 50 vascular surgeons that will be aired on television and radio stations across the country. ● A branding tool kit has been created and is being released at this meeting. These are comprehensive materials that members can use to educate referring physicians and promote their practices to the public and to the media. This tool kit was included in your meeting tote bag and is available electronically on Vascular Web. Inclusive in this tool kit are: 1. instructions for creating a Web site, 2. media interviewing messages and guidelines, 3. a complete 1-year media plan with supporting materials, 4. Power Point presentations for grand rounds on specific topics—lower extremity vascular disease, carotid artery disease, aortic aneurysms, and venous disease, 5. guidelines for hosting a dinner for primary care physicians, 6. brochures that describe the various diseases that vascular surgeons treat as well as the procedures we perform, and 7. a separate tool kit for developing a screening event As leaders, we not only need to be skilled and to have a passion for our work but it is also necessary to communicate our talents and strengths to the rest of the world. I would
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encourage all of you to use these tools that the society has provided and create a grass roots initiative in your local communities. Let the public and referring physicians know that vascular surgeons are leaders in vascular care. Let’s change perceptions and let the world know our true potential. Recruitment. To remain a viable specialty we need to recruit the best and the brightest. Moreover, we need to increase our numbers to be capable of caring for the almost doubling of vascular interventions that will take place over the next 20 years. The SVS in concert with the Association of Program Directors in Vascular Surgery is actively addressing this issue. We now have 119 finishing fellows; I submit that the number needs to increase to 200 for vascular surgery to maintain its dominant role in the treatment of vascular disease. I also submit that many of you here today have vascular practices that are sufficiently robust to allow development of your own fellowship program. Moreover, those of you who have existing fellowships could increase your complement. The submission of an application for a new fellowship program can be an intimidating process, and the SVS wants to help. We have created infrastructure within the SVS to assist in the development of your fellowship application. The SVS can offer the following resources ●
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an administrator associated with the SVS office, who has significant expertise in preparing an application for a new fellowship, templates of applications, a list of directors for 0/5, 3/3, 4/2, and 5/2 programs who are willing to offer advice and assistance during the application process, and access to the vascular surgery representatives to the residency review committees who will also provide guidance and advice.
I would ask everyone in this room to consider whether your practice will support a high-quality fellowship. If the answer is yes, consider using SVS resources to make this happen. Help us increase the number of vascular fellowship positions to 200. Accompanying this initiative are many others directed at enhancing our recruitment efforts. We have with us today over 70 students and residents from around the country who have an interest in vascular surgery. Could I have our visitors stand for a round of applause? Other initiatives related to recruitment include: ● ●
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a white paper on how to identify funding for 0/5 programs, a yearly mailing to first-, second-, and third-year general surgical residents encouraging them to consider a career in vascular surgery, the establishment of a resident and student section of the SVS, and a mentoring program linking SVS members with residents/students.
I would like to thank WL Gore for its generous support of
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the activities of the recruitment task force and its help in developing these recruitment initiatives. Research. Being at the vanguard in research should be a critical goal of vascular surgeons if we are to maintain a leadership role in the treatment of vascular disease. True leaders have vision. They understand where their specialty will be in 10 years. If our referring physicians as well as the public perceive vascular surgeons to be innovators of new treatments and technology and responsible for measuring outcomes, they will look to us to care for their patients. Shouldn’t the next New England Journal of Medicine article addressing peripheral stenting versus angioplasty emanate from vascular surgeons? One of the missions of the SVS over the last year has been to reinvigorate clinical research in the society. At a fall retreat of the Research Council, under the leadership of Rick Powell, a 5-year strategy for research was created, and the following are some of the initiatives that were developed: ●
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We learned from our industrial colleagues that vascular surgeons, compared with other specialists, frequently do not have the infrastructure or the focus to effectively carry out clinical trials. To rectify this problem, the SVS in partnership with industry has developed a yearly clinical research course, the purpose of which is to mentor vascular surgeons in the methodology of clinical trials as well as prospective clinical studies. We have also created a clinical research database on the SVS Web site, which will be searchable and contains information regarding over 160 potential vascular surgery trial sites. The SVS has introduced three yearly $15,000 seed grants designed to encourage SVS members to develop proposals for multicenter clinical trials. Applications will be reviewed by the newly formed Clinical Research Committee, and the recipients will be chosen based on the merit and the potential of the trial to eventually receive peer-reviewed support. In selected instances, clinical research will be conducted within the SVS. The SVS has just recently developed a partnership with Lifeline Screening. Lifeline has agreed to provide the SVS with its complete data set of over 5 million people screened for vascular disease as well as the resources to analyze this data. We anticipate that the findings from the analysis will be pivotal and provide new information about which patients should be the target of screening.
As you can see, the SVS strongly believes that leadership requires vision, and vision can be enhanced by vascular surgeons being leaders in research. Advocacy. In the arena of advocacy, the SVS has made a significant impact! We led the effort to gain reimbursement for screening for abdominal aortic aneurysms, which came to fruition in January of this year. In sum, the SVS was responsible for the first-ever preventive benefit available for patients with vascular disease.
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Centers for Medicare and Medicaid Services (CMS) reimbursement for carotid stenting has been in flux and controversial. As most of you know, the SVS has played an active role in this process working closely with the Food and Drug Administration, CMS, and other governmental agencies. Owing to the efforts of the SVS and its individual members, these agencies consider vascular surgeons as major stakeholders in carotid stenting. The carotid stent registry developed by the SVS and supported by Boston Scientific now includes over 3700 patients and has set the standard for measuring outcomes for carotid intervention. Recently, CMS considered a proposal to expand coverage of carotid stenting to include high-risk asymptomatic patients. SVS was integrally involved in this process, advocating that CMS increase coverage for anatomic high-risk patients but not at physiologic high risk. SVS’s comments to CMS were heard, and in April the proposal to increase coverage of carotid stenting for asymptomatic physiologic high-risk patients was rejected pending further study. The role of the SVS in this process was pivotal. These and many other initiatives have been developed under the auspices of the Clinical Practice Council, ably led by Keith Calligaro. The Clinical Practice Council is also overseeing the development of practice standards, reporting standards, and credentialing papers. We are setting new definitions for vascular disease from the perspective of vascular surgeons. Reimbursement. We need to thank the Governmental Relations Committee and its active membership for the many initiatives surrounding reimbursement. This group has achieved so much, however, one accomplishment is especially notable. As we all know, the Deficit Reduction Act, which went into effect in January of this year, provided across the board cuts to the technical component of all office-based imaging services, including vascular ultrasound and physiologic testing. However, in an effort organized by the SVS, which included almost 800 letters sent from SVS members and an additional 18 members of congress to CMS, plus vigorous lobbying by the SVS Government Relations staff, the physiologic vascular lab
codes were removed from these cuts. Physiologic vascular labs or ankle-brachial index measurements are performed primarily by vascular surgeons and account for $62 million worth of services each year. Let me be clear: SVS related efforts this past year have saved vascular surgeons on a yearly basis over $60 million in vascular testing revenue. Remember this dollar amount next time you are asked to donate to the SVS political action committee. CLOSING There are so many additional areas where the society has made great advances. We have made headway in international relations and in communications. We now have a newspaper and a biweekly e-mail update to our members. I wish I had the time to describe it all. Perhaps some of you are wondering if we are doing too much? Is the society spread too thin? Have we lost focus? I can tell you with assurance: this is not the case. We are 2300 strong, 2300 passionate, devoted, innovative, and hard working individuals. There is little we can’t accomplish. As Henry Ford once said, “Nothing is particularly hard if you divide it into small jobs.” We now have the infrastructure in a robust society to accomplish all of this. We are supported by Becky Maron our executive director and a team of 10 superb individuals in our administrative office. Becky, will you and your team rise for a round of applause? How should I end? None better than with a prescription from the SVS for success. Each of us needs to return to our community with a mission. . . to let the world know that we are skilled surgeons and skilled interventionalists; that we are passionate about our specialty, that we have vision, that we are best at service. Most importantly, that we are optimistic about the future. With this prescription, I am assured that the world will perceive VASCULAR SURGEONS AS LEADERS IN VASCULAR CARE! I will close by saying again what an honor it has been to be your president, an honor that in my life is unparalleled. Thank you for your time. Be well.