Brothers and sisters, unite!

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In this month’s Vascular Specialist, there are two letters to the editor that seem to imply a division in the SVS membership. The letters indirectly suggest that the SVS comprises two camps, on the one hand, academics, and on the other, community-based physicians. Further, although the majority of the membership comprises primarily of nonacademic surgeons, the leadership is, and will remain, predominantly composed of University-employed physicians. Implicit also is that there may not be a common agenda.

However, many questions come to mind: Are we truly a house divided? If so, how did this come about? Do community and academic surgeons indeed have different concerns that split us into camps? If so, how can we come together because the aphorism “United we stand, divided we fall” will have critical implications for the future of our specialty.

Dennis Gable writes that “the SVS is often (and historically) thought of as a society reserved for academic surgeons” because it is regarded solely as a vehicle to arrange a national academic meeting (the VAM). However, he counters that incorrect assessment by describing many fundamentally important roles that the SVS plays in the daily lives of practicing vascular surgeons. He encourages members to go online (at www.vascularweb.org) and see for themselves all that the SVS is doing for vascular surgery, vascular surgeons and their patients. The Society’s strong advocacy efforts on reimbursement issues, for example, have prevented millions of dollars in payment cuts, something hugely important to members in community practice.

However, many older surgeons will recall a period when only a select few could join the Society for Vascular Surgery as it was then constituted. Entry was reserved for nationally recognized researchers or those with an extensive list of publications. At that time, it was even difficult to become a member of the International Society for Cardiovascular Surgery. Community surgeons who had limited or few current publications were almost totally excluded. That was the impetus for community surgeons to form the Society for Clinical Vascular Surgery. However, some years back the SVS expanded beyond just the meeting and sought to be inclusive rather than restrictive. Membership is now virtually guaranteed to all board-certified vascular surgeons in good standing. Even members of allied health groups such as nurse practitioners and physician assistants are encouraged to become affiliate members. The SVS inspires female and minority medical students to become vascular surgeons and future members.

Further, 7 years ago, current President Bruce Perler, then chair of the Clinical Practice Council, initiated the Community Practice Advisory Committee in an effort to address the concerns of community members. I had the privilege of being its first chairperson. The current chairperson of that committee, Richard Lynn, now serves on the Board of the Society. Additionally, the SVS has made a concerted effort to add community surgeons to all of its committees.

Even the annual meeting has increasingly added multiple sessions addressing topics of interest to community surgeons. As attendance at these session proves, academic and employed physicians have found them to be equally informative. This is the result of the changing economic and health care environment that has blurred the lines between academic and nonacademic practices. Is there, then, any real division that separates the university surgeon from his or her community counterpart? Personally I believe there is none. If there is, it is simply a historical memory that has failed to disappear when confronted with the reality of the present.

However, Carlo Dall’Olmo and Dennis Gable, community surgeons who have been very active in SVS leadership positions (Carlo as Chair of the PAC and Dennis as Membership Chair), both recognize the absence of community surgeons on the SVS Executive Committee. Does this imply a conspiracy? Of course not! Rather, it is a result of the many factors briefly outlined in their letters. I have had the benefit of discussions with both men, as well as current and past SVS Presidents, so perhaps I can paraphrase their thoughts on this issue.

Carlo suggests that it is a result of a governance structure that rewards leadership positions based not only on service to the Society but also on academic achievements. He, as well as many others, suggests that our leaders should be elected, based not only on their publications and research, but also they must have proven dedication to the Society as well as providing a manifesto or platform explaining their goals for its future. Indeed, most if not all current and past executive members have been some of the most prolific researchers and have also effectively served on multiple committees over many years. If not for their hard work (unpaid and purely voluntary), our Society would never be in the viable situation it is now. We certainly owe a great deal of gratitude to the many academics who have so effectively stewarded our organization.

Some also have questioned whether busy community practice surgeons will be equally able to comply with the time-consuming demands of the Executive Committee. The presidency is almost a full-time position, yet it remains unpaid. Accordingly, a private-practice surgeon will need the backing of his or her partners or sufficient finances to counter the loss of income. Academic surgeons also have busy lives running departments, lecturing students, and operating on the most-challenging cases. Surely then, if candidates have proven themselves through years of conscientious labor on SVS committees, the manner of their employment or source of income should not influence their electability.

Dennis also explains that many private practice surgeons have a laissez-faire attitude leaving the multitude of committee appointments to these dedicated academic surgeons. On the contrary, I have spoken with numerous community surgeons who claim to have volunteered for committee or leadership positions and have not yet been appointed. Perhaps it is a self-fulfilling situation. The composition of the SVS Nominating Committee, which proposes the slate for SVS officers, originally comprised the immediate past, current, and future presidents. The composition was changed several years ago and now includes the two immediate past presidents, a representative from the affiliated vascular societies, a representative from the SVS Councils, and recently, an at-large member elected by the SVS membership. The objective was to encourage participation from someone, possibly a community practice surgeon, who had the support of the general membership.

However, it is problematic for community surgeons to gain sufficient exposure or national recognition to be elected unless they publish and lecture prolifically. Since the nominating committee has always consisted of academic surgeons, it could be argued that they would necessarily favor academics. On the other hand, such favoritism may be based simply on the fact that they are more familiar with one another. It is conceivable that as more community surgeons prove their organizational skills by serving on various committees, some will become well known and electable. As yet, the current pool of eligible community surgeons is small, whereas there are many academic surgeons clearly deserving of appointment.

Interestingly, there are now academic members of the current Executive Committee who were formerly in private practice or are currently in situations that can be regarded as both academic and community based. This suggests that the lines between academic and community practice have blurred sufficiently enough that we should no longer consider ourselves as belonging to different camps. Also, for the last 3 years, I have been a guest at the SVS Board of Directors meetings, where I have witnessed intense deliberation on multiple issues of equal concern to both academic and private surgeons. In fact, some current leaders are so certain that we are all the same that they question whether the addition of community surgeons will add new insights that might modify the daily function and future agenda of the SVS.

Consistent with the necessity for full disclosure, I am a community-practice surgeon, although I was in full-time academics for the first 6 years of my practice and now hold a position as a clinical professor at Florida State University Medical School in Tallahassee. With this background, I suggest that negating the value of community input is an incorrect concept. Private practice has many challenges, which include diverse issues such as maintaining IT departments, staffing, electronic medical records, Stark issues, malpractice insurance requirements, PQRS requirements, contract issues, partnership contracts, and competition with other specialists and hospital groups. Even current training paradigms are affecting private practitioners. Accordingly, it is imperative that their concerns are heard at the highest level. Perhaps, too, having community-practice representation on the Executive would be seen as a positive impetus to encourage more unaffiliated community doctors to join the Society.In September, Pope Francis visited America. During his speech to the United Nations, he made the following statement: “The contemporary world, with its open wounds which affect so many of our brothers and sisters, commands that we confront every form of polarization which would divide it into these two camps.”

Vascular surgeons and the Society for Vascular Surgery would do well to heed his words.

Dr. Samson is a clinical professor of surgery (vascular) at Florida State University Medical School, is president of Mote Vascular Foundation, and an attending vascular surgeon, Sarasota (Fla.) Vascular Specialists. Dr. Samson also considers himself a member of his proposed American College of Vascular Surgery.

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