Presidential address: The second-generation vascular surgeon

ORIGINAL ARTICLES

Presidential address: The second-generation vascular surgeon George Johnson, lr., M.D., Chapd Hill, N.C.

Most of us accept as inevitable the recurrent social phenomenon known as the presidential address. Decreed by constitution, hallowed by custom, and executed with varying degrees of oratorical finesse by a countless host of officeholders, it has provided for all of us a common ground of interest in our organizational existence. One of the more interesting aspects of the presidential a,~5ress is the selection of a suitable topic. Many members of this audience have passed through the protracted, minor agony of this selection process, while others who have escaped the onus of high office have wondered idly at the mechanisms which resulted in the choice of a particular subject. Most presidential addresses include in their preamble an apologia for the topic chosen, in addition to other clichds of form and content. This talk will be no exception? This introduction to "The Presidential Address" was delivered by C. Rollins Hanlon at the Eleventh Scientific Meeting of this socie~ on June 15, 1963 at Atlantic City, N e w Jersey. a It expresses my thoughts better than any words I could have chosen. I am in awe of the fact that you have chosen me as your president this past year. I humbly consider myself to be the first of a second generation of vascular surgeons to serve in this office, hence, the title o ~ my address. The great vistas of vascular surgery were opened by those who came before me. The point of view of Halsted expressed what I imagine most of the first-generation pioneers of vascular surgery felt: When confronted with an inoperable, malignant neoplasm one feels the great pity of it but not, as in the case of an aneurism, a peremptory challenge to face the exigency and cope promptly with a situation demanding sldlful, resourceful, and possibly even temerous intervention.-William Stewart Halsted, 19242

From the Departmentof Surgery,,Schoolof Medicine,University of North Carolina at Chapel Hill. Presented at the Thirty-fourth ScientificMeeting of the North American Chapter, International Society for Cardiovascular Surgery, New Orleans, La., June 10-11, 1986. Reprint requests: GeorgeJohnson,Jr., M.D., Departmentof Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27514.

I would not dare attempt to name those among you who are first-generation and those among you who are second-generation vascular surgeons. I will leave that for you to judge, lest I err. The foreword to the first edition of Vascular Surety by Rutherford 3 attempted to express the sentiments of a few of us who consider ourselves second-generation vascular surgeons: "This book is dedicated, with deep appreciation, to our teachers and those colleagues who have contributed so much to our kmowledge and practice of vascular surgery. ''3 Progress in the past 50 years of vascular surgery began with the learning of psychomotor skills and techniques. This was followed by the development of prostheses for both arterial and venous systems in the form of grafts, occlusive devices, and elastic stockings. The highlight of the past two decades has been the development of insmmaentation to define vascular anatomy and to monitor hemodynamics. The arterial prosthesis was hailed as one of the major contributions to surgery from 1945 through 1970. 4 Thesc achievements have been accomplished primarily by first-generation vascular surgeons. The pattern is past for the first generation of vascular surgeons; the pattern is set for the second; and the pattern is being decided for the third. What should be the goals fbr the present and for the next generation? Since I consider myself the first of the second generation to become president of one of the national vascular societies, I dare not interpret for my peers what needs there are in vascular surgeD7 today. I will devote the rest of this essay to the third-generation vascular surgeon. Perhaps I should call it "Immediate and Future Trends for the Cardiovascular Surgeon-As I See It." Or perhaps Lord Byron's words best express it: "The best of prophets of the future is the past. ''5 This essay has numerous contributors, although they may not wish the credit: W. Andrew Dale., W. Sterling Edwards, E. Stanley Crawford, George F. Sheldon, Ward O. Griffen, Norman L. Browse, Calvin B. Ernst, Jesse E. Thompson, D. Eugene Strandness, Frank J. Veith, Steven J. Burnham, J. Roland Folse, Blair A. Keagy, William T. Maloney, 211

212 Johnson

James S. T. Yao, James A. DeWeese, C. Rollins HanIon, Colin G. Thomas, John A. Schwartz, John J. Bergan, my closest associate, Marian, and many others who will remain unnamed, not because they did not contribute but because of a frustrating failure to remember everything as I should. President DeWeese, in his address to this society in 1985, discussed the goals of the vascular societies. 6 I would like to think the Joint Council has been responsive to his challenges. Under his leadership, your officers have been involved in the examination and certification of vascular surgeons and in the accreditation of vascular surgery training programs. As of March 1986 there were 43 programs approved with 65 fellowships compared with 38 programs and 51 fellowships in September 1985. (J. Boberg, Residency Review Committee, Accreditation Council on Graduate Medical Education, Chicago, Ill., personal communications, 1986.) As of March 17, 1986, 620 surgeons have been credited by the American Board of Surgery as having "Special Qualifications in General Vascular Surgery" ("Added Qualifications in General Vascular Surgery") compared with 545 surgeons in November 1984. Approximately 1700 surgeons had applied to take the examination. In the spring of 1986 in Dallas, 27.8% of 104 candidates who had passed the qualifying (written) examination did not pass the first certifying (oral) examination, which is given by certified vascular surgeons. (Data obtained from the American Board of Surgery, Philadelphia, Pa., personal communication, 1986.) Of the 620 surgeons now certified, only 342 indicated they were members of The International Society for Cardiovascular Surgery, North American Chapter (ISCVS/NAC), and 126 surgeons were members of the Society for Vascular Surgery (SVS). In other words, of the 1314 members of The ISCVS/NAC 342 (26%) are certified; and 126 (25%) of the 502 members of the SVS are certified. (Data obtained from the American Board of Surgery, Philadelphia, Pa., personal communication, 1986.) Of the 620 vascular surgeons now certified, 170 (27%) are academicians and 450 (73%) are in private practice. Ninety-four (15%) vascular surgeons are from California. The Journal of Vascular Surgery, under the preeminent leadership of D. Emerick Szilagyi, Michael E. DeBakey, Jesse E. Thompson, and recently, James C. Stanley, shines like a diamond. Its excellence needs no further comment from me. At the insistence of Norman M. Rich, a forum has been established for the regional vascular societies, with the Joint Council of the national societies at the time of the annual

Journal of VASCULAR SURGERY

meeting. A standard nomenclature for vascular diseases is being developed by many of you under the guidance of Robert B. Rutherford. Manpower needs in vascular surgery are being evaluated by a committee under the leadership of Calvin B. Ernst. Stare dards and ethics, governmental relations, and perhaps more important than any of these, medicolegal problems are being examined by the Committee on Issues under the guidance of the president-elect of this society, Vallee L. Willrnan. Mthough most of you thought that the annual programs have been excellent, the Program Committee has responded to the voice of the minority and made some changes. I arn sure Secretary Barnes would appreciate your comment on these changes, not only for the program of the ISCVS but also as it compares with the progr.~ n for the SVS. After all, it is your program--it is you we are trying to accommodate. Basic Sdence in Vascular Surgery, a three-volume compilation of appropriate reprints primarily addressed to the vascular trainee, has been published by a committee "driven" by John M. Porter. 7 William H. Baker has taken the lead in forming a much-needed association of vascular program directors. Yes, President DeWeese, I think we have responded to your challenging address of June 1985; we are involved. LATERAL T H I N K I N G After I took office a questionnaire was mailed to each of you soliciting your thoughts on the accreditation of vascular training programs and the certification of vascular surgeons. Most presidents who send questionnaires use the results as a basis for their address; I have not. The accreditation and certifi~tion process has moved so fast I did not believe the survey response would reflect current thoughts. However, I appreciated the 81% return, an unheardof high response rate for a questionnaire. These results have been used frequently during the year in my endeavors to represent you. It was interesting to know that 38% of the members of this society are from the North, 51% do less than 100 vascular operations a year, and 59% are associated with a teaching institution. Sixty-six percent of us applied to receive certification in vascular surgery. Sixteen percent of those who applied were not allowed to take the examination. Of those surgeons who could not take the examination, 74% performed less than 100 vascular cases a year, and 10% performed less than 50 procedures. Instead of the questionnaire, I have chosen Lateral Thinking, a book by Edward de Bono, 8 as one of the themes of my address. "Lateral thinking" is

Volume 5 Number 2 Februaq, 1987

PresidentiM address: The second-generation vascularsurgeon 213

1980

25

¢J) Z 0 ._1 ,.J m

, ,o,[I 2000

20 15 10 5

10

20

30

40

5..._00

60

70

80

90

AGE (YEARS) Fig. 1. Changes in age of the population predicted from 1980 to 2010. Data obtained from US Bureau of the Census, 1984.1°

defined as the "breaking out of t h e . . , prisons of old ideas." It "is closely related to insight, creativity, and humor." Moreover, it "involves restructuring, escape, and the provocation of new patterns," and '% concerned with the generation of new ideas. ''8 "Lateral thinking" reminds me of an article that appeared in The New England Journal ofMedicine in 1972 entitled "Neurosurgery May Die. ''9 Dick Bergland chal!anged the leaders of neurosurgery to do some innovative thinking. Is there a chance that vascular surgery will die because of a lack of innovative thoughts by its leaders? In what follows, I must exclude cardiac surgeons (although I am one). Peripheral vascular surgeons have a different, unique responsibilitT. There are no medical specialists comparable to the gastroenterologists, nephrologists, endocrinologists, neurologists, nor cardiologists to evaluate the patient for the diseases we are responsible for treating. We cannot turn to a nonoperating physician--we might call him a "vascuologist'--to check on our endeavors. This leaves us with an awesome responsibility to the public to recommend both prevention and the best treatment for the diseases we encounter. This is unique because our role combines "gatekeeper," "servant," and "king" o f the castle. We are being challenged to defend these varied roles at the present time. Have we proposed too ITlany operations for claudication?

Have we performed too ma W prophylactic carotid endarterectomies? Are too many abdominal aortic aneurysms being resected? Have we sufficiently involved ourselves in disease prevention as have our colleagues who manage trauma victims' To help us address these issues, or even to decide whether we should, I will review recent and past trends, especially for the past 6 years, as documented by data concerning population, cause of death, hospital admissions, nmnber of operations, number of vascular surgeons, presentations related to vascular surgeu, and funding for research into the diseases of the vascular system.

Population We all recognize the increase in the age of our population. A 34% increase in the population older than 65 years of age is predicted by the year 2010, although the total population will increase by only 19%. 1° This prediction is well depicted in Fig. 1 and suggests an increased need to manage diseases of the elderly in the first part of the twentT-first century. Death rates The decrease in the death rate from circulatou diseases and the increased rate from malignant neoplasms since 1950 are widely recognized. However, there has been no decrease in the death rate from

Iournal of VASCULAR SURGERY

214 Johnson

1000 ICD6

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ICD9

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10

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AORTIC ANEURYSM

1 t l l l t l l l ~ = l l l

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55

60

65

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70

75

80

YEAR

Fig. 2. Mortality rates in the United States? ~

Table I. Causes o f death in the United States, 1979 and 1983 Rate per 100,000 Population

All causes

Malignant neoplasms Major cardiovasculardisease Acute myocardialinfarction Cerebrovasculardisease Other diseases of arteries, arterioles, and capillaries Chronic liver disease and cirrhosis Accidents and adverse effects

Total No. 1983

1979

1983

2,019,201

852.2

862.8

179.6 435.4 133.8 75.5 8.9 i3.2 46.9

189.3 419.2 i22.3 66.5 9.0 11.7 39.5

442,986 981,098 286,300 155,598 20,958 27,266 92,488

% Change + +

1.2 5.4

-

3 . 7

8.6 -11.9 + 1.1 11.4 -15.8 -

-

NOTE: Crude rates from National Center for Health Statistics, U.S. Department of Health, Education and Welfare, Public Hea_~;~:, Service.n

abdominal aortic aneurysms, one example o f peripheral vascular disease (Fig. 2). I1 This is o f particular concern because deaths caused by peripheral vascular disease are likely to increase as the elderly population increases. More current data have shown that deaths from cancer increased during the past 4 years, whereas those deaths caused by cardiovascular disease and trauma have decrcased (Table I). Deaths from myocardial infarction and stroke decreased; however, deaths as a result o f peripheral vascular disease showed a slight increase. Another important trend is the 29% decrease in the rate o f deaths from diabetes mellitus in the 45- to 74-year-old age groups from 1969 to 1971 vs. those from 1979 to 1981. I2 This finding may explain the increase in the number o f diabetic patients we have noticed ha our practice.

Prevention and improved care o f the vascular complications in these patients need to be addressed by research--a challenge to the "vascuologist." Discharge diagnoses On the basis o f an approximate 5% sample, data available from the National Center for Health Statistics give some insight into trends in the prevalence o f disease. TM 14 O f patients discharged from nonfederal hospitals, the first-listed diagnoses o f abdominal aortic aneurysm, myocardial infarction, and occlusion/stenosis o f the carotid arte U have been among those to increase the most in the past 6 years. In contrast, the diagnoses o f acute appendicitis, hemorrhoids, duodenal ulcer, inguinal hernia, and diseases usually associated with the more youthful po D

Volume 5 Number 2 Februat3, 1987

Presidential address." The second-generation vascular surgeon

215

T a b l e I I . First-listed discharge diagnoses in i 9 7 9 a n d 1984

Diagnosis

ICD-9

1979

1984

% Change

Cataracts Hyperplasia prostate Diseases of circulatory system AAA (without rupture) Acute myocardial infarction Occlusion/stenosis carotid AAA (with rupture) Arteriosclerosis of extremity Cholelithiasis Neoplasms Acute appendicitis Diabetes mellitus Injury and poisoning Inguinal hernia Chronic liver disease and cirrhosis Duodenal ulcer Hemorrhoids

366 600 390-459 441.4 410 433.1 441.3 440.2 574 140-239 540 250 800-999 550 57I 532 455

383 235 4907 20 433 41 5 22 447 2402 229 600 3635 475 102 162 159

481 270 5593 42 700 63 6 23 488 2576 230 593 3472 440 82 !22 120

+ 26 + 15 + 14 + 1i0 + 62 + 54 + 20 + 5 + 9 + 7 0 I - 4 7 - 20 - 25 - 25

AAA = abdominal aortic aneurysm. NOTE:Numbers are expressed in fllousands. Crude data uncorrected for population, age, sex, and race, obtained from U.S. Department of Health and Human ServicesYa4

T a b l e I I I . Selected procedures, 1979 a n d 1984

Procedure

ICD-9

1979

1984

% Change

Resection of AAA Operation on vessels of heart Arteriovenous fistula for hemodialysis Total hip replacement Operation on lens Carotid endarterectomy Femoropopliteal bypass Below-knee amputation Above-knee amputation Insertion of cardiac pacemaker Partial excision of large intestine Diagnostic procedures on stomach Lobectomy of lung Mastectomy Total abdominal hysterectomy Appendectomy Ligation and stripping of varicose veins

38.44 36 39.27 81.5 13 38.12 39.29 84.15 84.17 37.7 45.7 44.1 32.4 85.4 68.4 47.0 38.5

10 117 12 60 556 54 46 23 24 130 133 189 22 112 499 311 62

24 251 23 106 968 95 68 32 33 170 166 224 24 121 482 294 47

+ 140 + 115 + 92 + 77 + 74 + 76 + 48 + 39 + 38 + 31 + 25 + 19 + 9 + 8 3 - 5 - 24

AAA = abdominal aortic aneurysm. See note for Table II.

u l a t i o n have decreased (Table II). These data have n o t been adjusted for age or sex a n d could be misleading b u t are consistent with those reported by R u t k o w a n d E r n s t 1~ for 1979 t h r o u g h 1983. Procedures A b d o m i n a l aortic a n e u r y s m repair, arteriovenous fistula for hemodialysis, a n d coronary artery bypass are a m o n g the procedures o f which performance has increased the m o s t in the U n i t e d States in the past 6 years (Table I I I ) ) 3,14 W h e n these procedures are presented in the b r o a d categories established by the W o r l d H e a l t h O r g a n i z a t i o n I C D - 9 Codes, the n u m ber o f operations o n the cardiovascular system, as

reported by the N a t i o n a l Center for H e a l t h Statistics, is second only to operations o n the eye. Manpower The Old Crow didn't get old by being the fastest of the birds, or the strongest, or the bravest. He got old by being wily. H o w m a n y vascular surgeons are there in the U n i t c d States? Data o n physician m a n p o w e r are difficult to collect a n d even m o r e difficult to use i n predicting future needs. I, like the O l d Crow, k n o w better t h a n to assess or predict vascular m a n p o w e r needs. M o n e y , years, a n d m a n y people have been

Journalof VASCULAR SURGERY

216 Johnson

Table IV. National Institutes of Health grants to department of surgery physicians only, 1981 to 1984 Category

No. of applications

% Funded

Total Cancer Neurosurgery Cardiovascular Cardiac Vascular Orthopedics

1923 539 284 188 104 84 65

30 22 27 43 56 26 28

NOTE: Data derived from information furnished by Mr. R. F. Moore, National Institutes of Health, Bethesda, Maryland. The categorywas derived by the author from the title.

used to address the physician manpower issue with no unanimity of opinion. 16-19 No consensus was reached even with the help of the nation's best statistical epidemiologists. Statistics may not lie but they can cause much disagreement. According to data collected and published by the American Medical Association (AMA) for 1984, 36,323 physicians in the United States record their primary practice as "general surgery. ''2° The absolute number of responses (519,546) to their "Record of Physicians' Professional Activities" questionnaire is believed by the AMA membership to represent more than 90% of the physicians in the United States, regardless of membership in the AMA (G. Roback. Survey and Data Resources, Department of Data Release Services, AMA, Chicago, 111., personal communication, 1986). Only 7 0 5 7 physicians did not indicate their specialty. O f the "general surgeons" 2234 reported that their primary practice was "cardiovascular surgery"; this was in addition to 2169 "thoracic surgeons." The reported number of thoracic surgeons compares with an estimated 2291 surgeons certified by the American Board of Thoracic Surgery and designating their primary practice as thoracic surgery in 1984. 21 These figures might be interpreted to mean both AMA "thoracic surgeons" and "practicing certified thoracic surgeons" were the same. Thus, the "AMA cardiovascular general surgeons" were probably vascular surgeons. The number of physicians who reported that they had a primary, secondary, or tertiary practice in "cardiovascular surgery" totaled 3460 (G. Roback, Survey and Data Resources, Department of Data Release Services, AMA, Chicago, Ill., personal communication, 1986). This might be yet another indication of how many general surgeons perform vascular surgery. These data have no relation to certification. In

fact, some of these surgeons probably do not meet the qualifications for fellowship in the American College of Surgeons (ACS). Only 19,643 fellows are classified as general surgeons in the ACS as of 1986, whereas 36,323 dassificd themsclvcs as "gcncral surgeons" in response to the AMA questionnaire. Of the initiates entering the ACS in 1983, 666 wcrc gcneral surgeons; in 1984, 718 were general surgeons; and in 1985, 687 initiates wcrc gcncral surgeons, for an average of 690 per year. Ofthc 687 general surgery initiates in 1985, i21 (18%) stated that more than 40% of their practicc was devoted to vascular surgery (F. Padberg, Director, Fellowship and Graduate Education Departments, ACS, Chicago, pcrsonal communication, 1986). Three (13%) of the 23 general surgery applicants from North Ca ~::~ olina in 1986 listed morc than 25 "Residency Review Committee category I or II vascular operations" on the caseload submitted with thcir application for ACS fellowship. I emphasize that thcsc practice patterns were not established and that the data do not include the category III operations, such as operations for varicose vcins, embolectomy, and arteriovenous fistula for hemodialysis. Thus it seems reasonablc that approximately 18% of thc general surgeons entering practice currently will devote a major portion of their time to vascular surgery.

Fundamental research It is in the very areas where technical advances are most frequent that there is greatest need for a statement of fundamental principles. Geza de Takats, 1959s2

Recognizing that cardiovascular diseases are the leading causes of death in the United States and probably the leading causes of disability, I thought it appropriate to investigate funding from the National Institutes of Health (NIH) (R. F. Moore, Department of Health and Human Services, NIH, Bethesda, Md., personal communication, 1986). This information was used as a marker, a relative indicator. I make no prediction on the future of research funding, much less the survival of the NIH. I was interested to know how well we, the specialists in cardiac and vascular surgery, were fulfilling our responsibility to society in presenting our ideas for control and cure of these diseases to the funding agencies. In the four years 1981 through 1984 there were 1923 grant applications from medical doctors in departments of surgery; 597 (30%) were funded (Table W). Cancerrelated projects appropriately received the largest number of grants. Although grants related to cardiac problems were more numerous, I was pleased to fin,~:~

Volume 5 Number 2 February 1987

Presidential address: The second-generation vascular surgeon 217

that of the 84 applications related to vascular diseases, 23 (26%) were funded. This compares favorably with the overall funding of applications. Thus, the NIH awarded $4.7 million to medical doctors in departments of surgery for research in vascular diseases during this period. The subject and amount of the grant and whether the primary investigator was a member of the ISCVS are shown in Table V. The number of researchers holding a Ph.D. receiving and controlling funding for projects that might be considered surgical research, relative to the number of clinicians, has been of concern. (W. P. Longmire, Jro, Report from the Conjoint Council on Surgical Research. Presented before the Annual Meeting of the Society of University Surgeons, Richr'nmd, Va., 1985.) In addition, the number of grants awarded surgeons relative to our colleagues in other fields of medicine is being addressed by a conjoint council on surgical research under William P. Longmire, Jr. Sheldon noted, "Physicians were principal investigators of 31.1% of investigator-initiated NIH grants in 1972, but principal investigators of only 20.2% of grants in 1982. "2a Moore presented it well, when he said, "It is essential for the surgeon to remain the educated bridge tender for surgical research.''~ None of the money awarded for vascular research went to Ph.D. holders as primary, investigators in a department of surgery. Of 18 principal investigators (some were awarded two grants) only 10 were members of the ISCVS. Progralll

Are we, the second-generation vascular surgeons, stimulating the third generation to accomplish the work in basic research that needs to bc done? Are the programs of the two vascular societies conducive to development of new ideas, or do they consist of uncontrolled, retrospective re-reports of results of old ideas? The programs of The ISCVS/NAC for the past 5 years have been reviewed. There have been 553 authors for the 121 papers presented, or 4.6 authors per paper. According to my calculations, 17% of these papers were related to fundamental research in vascular surgery. Our recorder, James S. T. Yao, reports that of the 1206 abstracts submitted since he took office in 1983, only 140 (12%) were related to fundamental research (Table VI). The overall acceptance rate is only 7%, whereas that for research papers has been 11%. From these figures you can see why it is much *F. D. Moore. Alpha Omega lecture delivered at the Universiw of North Carolina, Department of Surgery, School of Medicine, hapel Hill, N.C., April 10, 1986.

Table V. National Institutes of Health grants funded for vascular surgery, 1981 to 1983 Topic

No.

Endothelium Hemodynamics Thrombosis Arteriosclerosis Prosthesis AAA Diabetes Ultrasound Arterial regeneration Variceal bleeding Total ISCVS members only

6 4 3 3 2 1 1 1 1 _II 23

Amount (in thousands of dollars) $ 513 399 256 2684 192 49 212 154 82 173 $4714 $1281

Member of ISCVS 3 3 I 0 0 1 1 1 0 __0 l0

AAA = abdominal aortic aneurysm. See note for Table IV.

easier to become president and give a presidential address than it is to get on the program by submitting an abstract. The Program Committee obviously gives priority to presentations related to the advancement of our knowledge of the physiology and biochemistry of vascular-related problems. I am happy to report that the paucity of abstracts related to fundamental research was dramatically reversed this year through the efforts of Allan D. Callow, Christopher K. Zarins, Robert W. Barnes, Brian L. Thiele, Calvin B. Ernst, and many others who worked hard on revising the program. I also reviewed other forums for research reports in our field (Table VII). Although the 1985 meeting of the American Heart Association was a good forum for the cardiac surgeon, it did not support much work in peripheral vascular disease. Only 0.4% of the papers presented at the annual meeting were related to vascular disease. The other three organizations reviewed each attracted and supported a forum for fun&mental problems in vascular surgery equal to our own.

SUMMARY AND P R E D I C T I O N S What worthwhile thoughts might be drawn from the variant bits of data just presented? Can these trends be interpreted and allow for some prediction for the future? Is it true that "the best of prophets of the future is the past?" Population, deaths, discharge diagnoses, and procedures The maturing "baby boom" of the 1950s will produce a large, if temporary, bulge in the elderly population--the patients for the third-generation

218

Journal of VASCULAR SURGERY

Johnson

Table VI. Program of the ISCVS, North American Chapter Abstracts Submitted* Accepted Research Submitted* Accepted Program research

1983

1984

1985

1986

267 9%

275 8%

374 6%

290 7%

21 10% 8%

14 14% 9%

34 21% 32%

71 6%+. 21%+,

Total 1206 7% 140 11% 17%

Table made in part with data furnished by lames S. T. Yao, M.D., Recorder of the ISCVS/NAC. *Majority submitted to both ISCVS and the Society for Vascular Surgery. tDoes not include Breakfast Sessions.

NOTE:

Table VII. Fundamental research presentations (cardiac and vascular), 1985 and 1986 Organization

Total

Cardiac

Vascular

American College of Surgeons Forum American Heart Association Association for Academic Surgery Society of University Surgeons

276

18%

4.0%

1848

--*

0.4%+.

152

5%

19.0%

45

9%

7.0%

Data collected from program books of various organizations by author. *Mostty cardiac. +.In addition, there were 71 related presentations.

NOTE:

vascular surgeons. This group will probably increase the demand for managing geriatric diseases, of which vascular problems are a part. The increasing survival of the patient with diabetes, who will nonetheless continue to have complications, will have an impact on practice patterns. Will more "vascuologists" be required? Can we surgeons take some credit for the continued decrease in deaths from cardiovascular disease? Has the increase in usage of health care resources by cardiovascular surgeons (as indicated by discharge diagnoses and procedures) helped lower this mortality rate? Some of the largest increases in discharge diagnoses in the United States are related to cardiovascular diseases. Is it too bold to state that the recent increase in the number of prophylactic carotid cndarterectomies and a more aggressive policy in coronary artery revascularization have helped maintain the continued decrease in the incidence of stroke and death from myocardial infarction? On the contrary, an increase in utilization of health care resources for carcinoma of the colon, breast, and lung has not been associated with a decrease in the mortality rate associated with these diseases.

Deaths caused by abdominal aortic aneurysm and other peripheral vascular diseases do not seem to be decreasing. Perhaps a more aggressive operative ir~ tervention for the unruptured abdominal aortic aneurysm will reverse the continued increase in total deaths from the ruptured aneurysm: There were 5739 deaths from ruptured aneurysms in the United States in 1979 and 6068 deaths in 198311 (data obtained from the National Center for Health Statistics, U.S. Department of Health, Education and Welfare, Public Health Service, personal communication, 1986). A quote attributed to Winston Churchill, as he ruminated dreamily on the prospect of the houses of Parliament being half filled with brandy, is: . . . so little accomplished; so much to be done. There is a shrill cry that "too many operations" arc being done. This cannot be ignored, neither can it be addressed immediately. It may take years to determine the appropriateness of these operations. I suspect that most a r e indicated and am reassured that these societies have taken a scholarly and responsibl,:: approach to investigating the indications for carotid endarterectomy by working with neurologists and neurosurgeons in some multicenter studies to accumulate reliable information.

Manpower Given the incrcasing elderly population with the steady, apparent increase in the number of patients with peripheral vascular disease, is there an increased nccd for vascular surgeons in the twenty-first century? As C. Rollins Hanlon 24 said in 1978: Physician-to-population ratios, as a measure o f the adequacy or inadequacy of medical care, have been discredited

so many times that it is scarcely necessary to add another lash to what now should be a thoroughly dead horse. Although I would like to remain an "Old Crow," a presidential address should contain some prophecy.

Volmne 5 Number 2 February 1987

Presidential address: The second-generation vascular surgeon 219

Therefore, let us assume that the AMA's "general cardiovascular surgeons" are mostly surgeons performing peripheral vascular surgery--roughly 2200 in number. Another 1200 "general surgeons" appear to bc doing some vascular surgery. Let us further assume that there are enough surgeons performing vascular surgery at the present time. (For the purposes of this analysis wc will set aside the question of the abilities of those physicians doing vascular surgery, although it cannot be ignored.) With the use of data from thc ACS, we can estimate that 18% of the graduates from current training programs each year will perform a "significant" amount of vascular surgcry; that is, 121 new general surgeons qualified for fellowship in the ACS and p:',rorming a "significant" number of vascular operations will enter the surgery manpower pool each year. Now, let us look at those who have "special (added) qualifications in general vascular surgery." On the basis of current data, it would be reasonable t o predict that by 1990 there will be 1000 surgeons certified with "special (added) qualifications in general vascular surgery." Let us also assume that there will be 100 surgeons graduating from vascular fellowship programs each year. If each of these practiced an average of 25 years and if the age of the pool of 1000 surgeons was fairly well distributed (average age of those certified at present is 46 years) (data obtained from the American Board of Surgery, Philadelphia, Pa., personal communication, 1986), each year 40 surgeons would leave the pool while 100 would enter. This would give us 1300 certified vascular surgeons by 1995 and 2200 certified vascular sm'geons by 2010. A somewhat larger number of general surgeons doing a "significant" amount of vascular operations is derived from the ACS data. We do not know how much overlap there is between these two groups. Moore and Langas predict that by 2010 "essentially all practicing physicians in the United States will be board certified." They did not suggest that all vascular surgery would be done by board-certified general vascular surgeons; however, that is conceivable. Will the number be sufficient? What is the correct answer? I do not know. There are so many factors involved; for instance, new knowledge is always changing medicine. The control of poliomyelitis "demolished" a large area of orthopedic practice. Will a nonoperative method for treating athcrosclerosis markedly decrease the need for vascular surgeons? Moore, 26 after giving more thought to this than I, concluded, " . . . the best index we have for the op-

timal supply of surgeons in this country is related to the phenomena of local communiF needs .... ,26 A recent article in the A C S Bulletin states that some manpowcr studies have led to inappropriately " . . . inflated projections of new, fully trained surgeons. "27 The number of vascular surgeons required on the basis of present data probably lies somewhere between the number of surgeons who will be boardcertified general vascular surgeons and the number of general surgeons who do less than 25 major vascular cases each year. On the basis of current need there will not bc enough board-certified gcneral vas-. cular surgeons to do the work. Regardless of the right answer, the first-generation vascular surgeons have accomplished their goals of building an "elite" group of vascular surgeons, although many are not members of this sodet~7. Whether this will benefit the population of the United States is, and will be, impossible to determine. However, there is no return. It will nor be changed. The die is castY Fundamental research Those who are enamoured of practice without sdcnce are like a pilot who goes into a ship without rudder.., and never has any certainty where he is going. Leonardoda Vinci~9 The data on procedures and discharge diagnoses reflect primarily the accomplishments of the first-generation vascular surgeons. They developcd the prosthetic graft, psychomotor skills and techniques, and mcthodology for anatomic and hemodynamic evaluation. While wc second-generation vascular surgeons have not been idle--endothelial seeding, the in situ saphenous vein graft, understanding of the synthesis and effects of prostaglandins, technical advances such as the angioscope and laser, and hemorhcology of blood flow, increased understanding and control of the coagulation cascade are but a few of the accomplishments made in our generation--none of these has had the impact ofthc vascular prosthesis, the techniques, and the instrumentation. So where do we, as the physicians responsible for treating vascular diseases, go from here? The next big breakthrough might be the development of a small-vessd prosthesis that works as well as the saphenous vein, a technique to rapidly perform vascular anastomoses, the ability to better control thrombosis without bleeding, the means to increase perfusion by controlled viscosity, or a m e t h o d of measuring the extent of irreversibly ischemic tissue. Or perhaps it is the recently developed blood vessel model built from col-

220 Johnson

lagen and vascular cells, s° These are some of the potential areas of development; "lateral thinking" by the third generation will give the answers. This year a research committee under the leadership of Dr. Christopher Zarins was created to determine whether a group of research-oriented vascular surgeons could, develop the fundamental science of vascular disease. Their answer is prophetic: " . . . essential to the advancement of vascular surgery as a clinical specialty is expansion of the body of fundamental knowledge relevant to the cardiovascular system in health and disease. This encompasses, but is not limited to, the interrelated disciplines of developmental biology, anatomy, physiology, pharmacology, epidemiology, molecular and cellular biology, biochemistry and genetics." (C. K. Zarins, Chairman, Committee on Research, ISCVS/NAC, personal communication, 1986.) I am impressed that they believed that these endeavors were essential to "vascular surgery as a clinical specialty" and that they emphasized our responsibility in "health and disease." Continued research needs to be encouraged if we are going to prevent the development of the abdominal aortic aneurysm, manage the complications of diabetes, develop a small-vessel prosthesis, and prevent the continued complications, although few, of failed bypass grafts. What should we do to stimulate fundamental research in vascular diseases? Or do we need to do more? Although there seemed to be relatively few applications for research grants for vascular disease, perhaps that is enough. It would appear that the N I H gives vascular disease the same portion of funding per application it does other diseases. With the use of very raw data, data that include diseases that vascular surgeons do not manage and exclude some diseases they do manage, mortality rates and hospital discharge diagnoses are compared to N I H research funding. Cardiovascular diseases caused 49% of the deaths in 1983; vascular diseases, including cerebrovascular, caused 9%. ~ The circulatory system accounted for 15 % of first-listed hospital discharge diagnoses in 1984; vascular diseases accounted for 4%. is Cardiovascular disease received 10% of department of surgery N I H grants for the period 1981 to 1984; vascular disease received 4%. Cardiovascular disease received 25% of department of surgery N I H money for the period 1981 to 1984; vascular disease received 7%. (R. F. Moore, Department of Health and Human Services, NIH, Bethesda, Md., personal communication, 1986.) On the basis of thesc data vascular disease appears to receive appropriate funding.

)'ournai of VASCULAR SURGERY

Program The program committees of this and other organizations havc included research related to vascular disease vcry generously. I am proud that we share the products of our invcstigative efforts with other organizations. I also hope that we continue to support our own program as we did this ycar. CONCLUSIONS One must be careful not to make far-reaching conclusions on the basis of current emotions. However, aftcr going over in my mind this extensivc review of data relevant to vascular surgery, I see my sccond-generation colleagues as quiet, but effective contributors to progress in the field. All of us are proud to have implemented thc advances dcvcloFTnt by our predecessors, and more than a few have made their own major contributions. As a second-generation vascular surgeon, I have two final thoughts to leave with you. My first reflection is expressed succinctly by Edward de BonoS: "The only method for changing ideas is conflict." Early in my career Nathan A. Womack taught me the positive power of conflict. Each day attending surgeons and house staff gathered to discuss why we were doing the operation planned for the next day. We often had tensc, yet scholarly discussions, with Dr. Womack acting as catalyst to the conflict. There are probably few facts in this address that cannot be challenged on some statistical grounds. But although individual conclusions made here may not hold up against such criticism, I feel the address will have been a success if it stirs such healthy conflict. Like Dr. Womack, I want to s t ~ ulate some emotion, some agreements, some d~agreements. If this in turn stimulates new discussion, "lateral thinking," ncw expcriments, I will have been a part of the continuing intellectual growth of our society. My second thought relates to the third-generation vascular surgeon. I predict that Zarins, Shepard, Taylor, Clowcs, Thiele, Kcagy, Miller, Schwartz, Clagctt, Sumpio, Sottiurai, and Graham are but a few of the names that will be in common usage when problems in vascular disease arc discussed. I encourage each of you to look not only for thc fundamental research in vascular surgery but also at prevention of these diseascs. Unfortunately, "the twenty-first century physician will face even greater challenges tied to overall health-care costs, governmental regulations of health care, the relation of physicians to hospitals and the interdependence of medical center and university. "~1 I hope that some of the third-generation

Volume 5 Number 2 February 1987

Presidential address: The second-generation vascular su,~qeon 221

vascular s u r g e o n s can be shielded f r o m these socioe c o n o m i c issues so that t h e y can serve society b y "lateral t h i n k i n g " in the science o f medicine, specifically vascular surgery. Thus, the fiature o f vascular surgery lies in the o u t s t r e t c h e d , eager, a n d w e l l - t r a i n e d hands o f the t h i r d - g e n e r a t i o n vascular s u r g e o n s - - t h e true "elite" o f vascular surgery. I p r e d i c t that because o f the efforts o f the t h i r d - g e n e r a t i o n vascular surgeons, an a c c o m p l i s h m e n t in vascular s u r g e r y will be listed a m o n g the t o p t e n in s u r g e r y in the next 10 years. T h e r e will be s o m e "lateral t h i n k i n g . " N o , "Mrs. Calabash, w h e r e v e r y o u a r e " - - v a s c u l a r surgery will n o t die. I am indebted to Ms. Gene Roback of the Statistical Se,_~on of the American Medical Association for assistance in obtaining data on surgical manpower from the American Medical Association; to Ms. Lou Ann Brower for her valuable editorial assistance; to Ms. Jean Melton for her help in library research; to Dr. Frank Padberg, Director, Fel~lowship and Graduate Education Departments o f the American College of Surgeons; to Mr. Robert Moore of the Statistical Section o f the National Institutes o f Health; to Dr. John Boberg and Dr. Judith Armbruster of the Residency Review Committee; to all the personnel who answered the phone at the National Center for Health Statistics; to the American Board o f Surgery; and last, but not least, to my faithful secretary, Ms. Fumi Wells, who helped me through dozens of revisionsl REFERENCES

1. Hanlon CR. The presidential address. Arch Surg 1964; 88:1-4. 2. Halsted WS. Surgical papers by William Stewart Halsted; vol I. Baltimore: The Johns Hopkins Press, 1924:487. 3. Rutherford RB, ed. Vascular surgery. Philadelphia: WB Saunders Co, 1977:v. 4. Surgery in the United States, a summary report of the study on surgical services for the United States, vol 2. The American College of Surgeons and The American Surgical Association~ 1976. 5. Gordon GN. Journal of George Noel Gordon, Lord Byron, Jan 28, 1821. 6. DeWeese JA. Presidential address: The vascular societies-How involved should they be? J VASCSUnG 1986;3:1-9. 7. Joint Council of the International Society for Cardiovascular Surgery and the Society for Vascular Surgery. Basic science in vascular surgery. January 1986. 8. de Bono E. Lateral thinking; Creativity step by step. New York: Harper Colophon Books, 1973:9-13. 9. Bergland RM. Neurosurgery may die. N Engl J Med 1972; 288:1043-6. 10. Projections of the population of the United States, by age, sex, and race: 1983 to 2080. Current Population Reports, Population Estimates and Projections, US Dept of Com-

11.

12. 13.

14.

15.

16.

17.

18.

19.

20.

21. 22. 23.

24. 25.

26. 27. 28. 29. 30. 31.

merce, 1984; (Bureau of the census; series P-25, no 952, pp 43-5). Vital statistics of the United States, 1950 through 1980, mortality. Hyattsville, Maryland: National Center for Health Statistics. Diabetes mortality sharply declined in past decade. Statistical Bulletin. Metropolitan Life Insurance Co, 1985;66(4):2-9. Haupt BJ, Graves E. Detailed diagnoses and surgical procedures for patients discharged from short-stay hospitals, United States, 1979. Hyattsville, Maryland: National Center for Health Statistics, DHHS PHS 82-1274-1, 1982. Detailed diagnoses and surgical procedures for patients discharged from short-stay hospitals, United Statcs, 1984. Hyattsville, Maryland: National Center for Health Statistics, DHHS PHS 85-1743, 1985. Rutkow LM, Ernst CB. An analysis of vascular surgical manpower requirements and vascular surgical rates in the United States. J VASCSURG 1986;3:74-83. Graduate Medical Education National Advisory Committee. Interim report to the Secretary. Department of Health, Education and Welfare. Washington, DC: DHEW Pub No HR& 1979. Zuidema G, ed. Study on surgical services for the United States, Long form report. Chicago: American College of Surgeons, 1975. Projections of physician supply in the U.S., March 1985. DHHS, Bureau of Health Professions, Office of Data Analysis and Management, ODAM Report No 3-85. A report to the President and Congress on the status of health professions personnel in the U.S. Washington, DC: Bureau of Health Manpower, 1978; Health Resources Administration, DHEW Publication No. HRA 79-93. Physician characteristics and distribution in the U.S., 1984 ed. Chicago: Survey and Data Resources, Department of Data Release Services, American Medical Association, 1984. Directory of medical specialists. 21st ed. Philadelphia: Marquis Who's Who, Inc, 1983-84. de Takats G. Vascular surgery. Philadelphia: WB Saunders Co. 1959:v. Sheldon GF. 1984 AAST Presidential Address: Medical education and the trauma surgeon--The role of the AAST. J Trauma 1985;25:727~39. Hanlon CR. Director's memo: Shortages and percentages. ACS Bull 1978;63(7):1. Moore FD, Lang SM. Board-certified physicians in the United States, speciality distribution and policy implications of trends during the past decade. N Engl J Med 1981; 304:1078-84. Moore FD. Surgical manpower: Past and present reality, estimates for 2000. Surg Clin North Am 1982;62:579-602. Misek G, Hynds-Karnell L. Surgical residents in the eighties. ACS Bull 1986;71(4):4-9. Griffen WO, Humphries JW Jr, Folse JR. Vascular surgery and accreditation. Ann Surg 1986;203:231-5. Leonardo da Vinci. Manuscript G from The Notebooks of Leonardo da Vinci, Vol. II. McCurdy E, trans. 1978. Weinberg CB, Bell E. A blood vessel model constructed from collagen and cultured vascular cells. Science 1986;231: 397-400. Hanlon CR. Director's memo. ACS Bull Dec 1984; p i.