From the Editor: Knights of the Rectangular Table

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In my past editorials I have made it abundantly clear that I believe that vascular surgeons, like the Knights of the Round Table in the Arthurian legend, follow a chivalrous code of honor that guides us in placing a patient’s well-being ahead of financial reward. We ride out, catheter and knife at the ready, to defeat the malevolent atherosclerotic enemy. Yet I am now chagrined to acknowledge that we, too, have knights who have forsaken their code of chivalry – vascular surgeons who value the attainment of wealth or prestige as their raison d’être.

Our cadre of ethical doctors far outnumbers the avaricious few. But I am increasingly aware of board certified vascular surgeons offering or carrying out egregious or unnecessary interventions.

Dr. Russell Samson

Dr. Russell Samson

The following are but a few illustrations of this behavior:

• A website suggesting all men older than 40 years have a self-paid screening for AAA.

• An 80-year-old woman with recurrent swelling of her right leg being told that she needed an emergency ablation of her saphenous vein.

• An obese 50-year-old with no abdominal symptoms and a patent SMA having a stent placed in his celiac artery.

• A 20-year-old who had her saphenous vein ablated because she had a few spiders on her thigh.

• I encountered a patient after a vascular surgeon had inserted an endograft in an 85-year-old male with a 4.5-cm AAA.

• Another vascular surgeon performs yearly carotid arteriography to evaluate the possible progression of asymptomatic stenoses.

• Yet another vascular surgeon carried out a carotid endarterectomy for a 60% asymptomatic stenosis in a patient with end-stage lung cancer.

If you find your skin crawling as you read these examples, you are not the perpetrators. If you are blushing, you may be. If you don’t see the problems with these cases you are naive, very poorly educated, or simply greedy. Regardless, these examples shame us all because they bring discredit to a specialty long dedicated to appropriate care. Vascular surgeons are not only our patients’ treating physicians but also their ombudspersons. How is our specialty to be taken seriously when our own members deviate so dramatically from accepted practice guidelines?

The advent of endovascular treatments may explain some of these unnecessary procedures. Endovascular procedures, in general, are much easier to perform than open surgery. Frequently, resultant complications may not be as devastating, so surgeons may be more inclined to intervene earlier in the disease process. Also, it is more cost effective for a vascular surgeon to perform a quick SFA angioplasty and stent rather than a time-consuming and undercompensated femoropopliteal vein bypass. This is especially so if it is performed in the surgeon‘s outpatient facility.

Endovascular technologies also have the cache of being novel and state-of-the-art. Therefore, it is tempting for surgeons to promote their reputation by preferentially performing these ‘advanced’ procedures. New trainees may be especially seduced by the novelty of these techniques, but their lack of clinical experience may result in overutilization.

Clearly, the answer is not that we should perform surgery for surgery’s sake. If a patient has a valid reason for an endovascular procedure, so be it. But if an open procedure is the better option, we must not shy away from it for fear of being regarded as old fashioned.

The increasing adoption of endovascular therapies may not only explain unnecessary procedures but also why vascular surgeons are involved in an identity crisis. As endovascular procedures replace open surgeries, new graduates and even older surgeons may begin to feel uncomfortable performing complex surgeries. As a result, vascular surgeons are now so endo-oriented that we hardly operate. Further, it appears as if our vascular training programs are producing interventional radiologists or cardiologists and not vascular surgeons. If all we offer are endovascular therapies, we will not be able to delineate ourselves from other physicians. We need to reassure our patients and referring doctors that we are still the only specialty that can perform all methods of treatment for our patients, be it medications, surgery, balloons, stents, or whatever. Equally important is that we assure them that the therapeutic modality that we select will be the most appropriate and will not be driven by extraneous factors. Accordingly, we must reign in our wayward colleagues or face unacceptable repercussions.

University institutions have Morbidity and Mortality conferences to evaluate staff surgeons’ performance. Credentials committees have the ability to withdraw privileges for persistent inappropriate indications. Outpatient centers need to establish similar panels so that peer pressure can ensure appropriate treatment. The goal should be remedial education and not punishment. We need to make these “Dark Knights” aware of how their actions have a negative effect on the rest of us. Because, if left unchecked, castigation in the media and government action will punish all vascular surgeons and our legendary contributions to the management of vascular disease will fade from memory, just like Arthur and his knightly court.

Dr. Samson is a physician in the practice of Samson, Showalter, Lepore, and Nair, and clinical professor of surgery, Florida State University.

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