Crawford Forum sets the stage for vascular surgery future

Ronald L. Dalman

It was an encapsulation of the existential questions surrounding vascular surgery. And it was just as the newly installed Society for Vascular Surgery (SVS) president Ronald L. Dalman, MD, had designed.

The Stanford University, California, vascular chief had intended it to be constructed this way. As is custom, the at-that-point SVS president-elect Dalman had been charged with devising the coveted E. Stanley Crawford Critical Issues Forum.

This year, of course, it took place during SVS ONLINE, the digital alternative to the Vascular Annual Meeting, canceled in the face of the ravages of the COVID-19 pandemic. It was part of the virtual conference’s opening day, June 20, a pivotal session aimed at guiding the vascular specialty into the future.

Dalman took the approach of returning the forum to its baseline, as former SVS president Crawford envisaged: charting the course of vascular surgery going forward.

Dalman’s forum contained a very deliberate narrative flow, all of which coalesced around the direction in which vascular surgery is headed.

The bottom line: What is vascular surgery and what is its future within the U.S. healthcare system?

Joseph Mills, MD, professor and chief at Baylor College of Medicine in Houston, highlighted the work being carried out to establish vascular surgery as a respected part of the medical firmament, setting the stage for the overarching theme of this year’s iteration of the forum.

“I want to create a vision for our members, I want to be able to position the SVS as leaders in this space,” he said. “Ultimately, we want to promote better outcomes in management of vascular care and vascular health for our patients.”

The mantra of vascular surgery—as vascular specialists providing comprehensive care—at this stage comes into sharp focus.

“We hold ourselves to be comprehensive vascular leaders and partners, and many of us have built practices based on this,” Mills said. “But, in many instances, we are viewed as highly technical surgeons who are relied upon for episodic interventions.

“So, to brand ourselves properly we have to do what we say we do, which is to provide comprehensive and longitudinal care.”

That tack neatly segued into the work of Richard Powell, MD, of Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, who carried on the theme of the forum with a talk on how the vascular specialty is valued within the U.S. healthcare system.

Vascular surgeons are critical to the safe operation of a safe operating room environment, he told SVS ONLINE. “How does the hospital administrator view vascular surgery?” was the core question posed by Powell.

“Our patients tend to be complicated. The average hospital administrator frequently has no idea what vascular surgeons do. I was surprised that this was the case. I have been on the Board of Trustees with Dartmouth for over 10 years and knew all the C-suite executives quite well. When I asked our own chief strategy officer, CFO and chief clinical officer and others what we do, they did not appreciate how frequently we help other services with both elective and, more importantly, with emergent surgical assists.”

The backdrop of much of this reality in which vascular surgeons operate is the specter of burnout. The SVS Wellness Task Force was set up to ameliorate and investigate what ails vascular specialists. The very genesis of the group came in response to data suggesting vascular surgeons were at higher risk than other specialties to burnout, said Dawn M. Coleman, MD, co-chair of the Wellness Task Force. “This was considered a critical issue in the face of a threatened workforce. We have approached proactively this uncomfortable space to de-stigmatize a culture of complacent suffering, specifically to optimize our recruitment and retention.”

Coleman, associate professor, surgery, at the University of Michigan in Ann Arbor, Michigan, made the link between reduced productivity and burnout, leading to the sort of lowered revenue incurred by hospitals and decreased quality of care suffered by patients that medicine seeks to avoid.

The bottom line—as envisaged by Dalman as he set up the Crawford Forum—was to draw into view the idiosyncrasies of vascular surgery and its central role in healthcare.

Which led to the session’s final speaker: Ben Harder, managing editor and chief of health analysis of U.S. News & World Report, publisher of respected national healthcare rankings that sorts out the best of American hospitals.

The backdrop to Harder’s inclusion on the Crawford Forum slate involves the existential questions that surround vascular surgery. In short, it is not listed as a distinct specialism in the platform’s analysis of the U.S. healthcare system, a situation Dalman would like to remedy.

But Harder outlined why vascular surgery as a distinct listing won’t be forthcoming.

“Going back to 1990, we identified about a dozen different areas of complex specialty care to evaluate hospitals,” he said. “It has never been our mission to evaluate each department or each service of a broad healthcare organization separately. So, I want to be clear that the cardiovascular rankings that we publish evaluates care that’s provided by medical cardiologists, interventional cardiologists, and by vascular surgeons as well as cardiothoracic surgeons. All of that is encompassed in that one specialty that we rank and publish. The reason for that is these disparate specialties and services provide care for overlapping patients.”

But Dalman was not finished. He pressed Harder further: “Vascular surgery works with a lot of other specialties, and if we quantify our contributions only in the framework of cardiovascular service line, that’s missing a significant contribution vascular surgeons make to health systems and patient outcomes. So, how do we more broadly capture what vascular surgeons bring to a health system?”

Harder demurred, again explaining that U.S. News & World Report does not deviate from its core ranking parameters.

Dalman had a final salvo. He asked Harder whether participation in registries such as the Vascular Quality Initiative (VQI) was a ranking criterion, to which the answer was negative. Not to be deterred, the new SVS president pushed further. “I would encourage you to use the VQI for that purpose,” Dalman added.


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