The November 2016 issue of Annals of Vascular Surgery was devoted entirely to the history of the American Board of Vascular Surgery (ABVS) and the unsuccessful attempt to establish an independent specialty of Vascular Surgery. The manuscript is methodically detailed by founders of the ABVS, James Stanley, MD, and Frank Veith, MD, and supplemented by commentaries from past board members as well as thought leaders in vascular surgery. In an attempt to maintain neutrality, readers are also provided with many of the documents that were either supportive or contrary to the development of the ABVS. Most senior vascular surgeons will recall the intense discussion and sometimes acrimonious arguments that accompanied the progress of the Board and its failed attempt to be recognized by the American Board of Medical Specialties (ABMS).
Younger vascular surgeons may not realize that the ABVS was ever established. Some may not even realize that, until relatively recently, vascular surgeons were not able to claim board certification even if they had completed a fellowship. Accordingly, as an historical document detailing an important aspect of the evolution of our specialty, this edition of Annals of Vascular surgery is a must read.
Cogent arguments both for and against an independent specialty were made by the leaders of our specialty at the time that the ABVS was being developed. Unfortunately, this did not lead to a uniform policy but rather long-standing, rancorous, and bitter divisions that in all probability prevented the ABVS from being recognized by the ABMS. Despite this failure, the debate around this issue elevated the stature of vascular surgery when the American Board of Surgery conceded that vascular surgeons could now claim “Board certification in vascular surgery” without having to be trained in general surgery. However, all important modifications to the current design of vascular residency and fellowship programs still need to be decided by the American Board of Surgery and its associated Residency Review Committee for Surgery (RRC-S). Further, many hospital administrators subordinate vascular surgery by insisting that vascular surgeons’ interests be controlled by general or cardiothoracic surgeons.
Most notably, this issue of Annals reignites fundamental questions that are at the heart of our existence as vascular surgeons. For example, has vascular surgery matured sufficiently to be considered a distinct specialty equivalent to other surgical specialties such as orthopedics, colorectal, urology, and otolaryngology surgery? If so, why did this not occur earlier? Does it warrant becoming independent from the American Board of Surgery such that only vascular surgeons will be in control of training programs, graduate education, and the practice of vascular surgery at universities, hospitals, and community practices? More significantly, why should these institutions, health agencies and the lay public care that there is a separate independent specialty – vascular surgery? The answer to these questions becomes apparent by an analysis of four historic elements that have changed since the ABVS was being formulated.
First, and perhaps most importantly, the argument for an ABVS occurred when vascular surgery had just entered the endovascular revolution. How difficult it must have been for those early vascular surgeons to realize that within a few years perhaps upward of 70%-80% of all procedures would not be performed in a standard operating room but rather an angiography suite, cath lab, or hybrid room? Could they envisage an era where abdominal aneurysms were treated not only without a laparotomy scar but even without a groin incision? That carotid endarterectomy may be replaced by a stent or that varicose veins would be abolished by an outpatient laser procedure? Without such foresight, general surgeons and even those early vascular surgeons had to believe that vascular surgery, as then practiced, required general surgery training.
A second historical reality that impacted the progress of the ABVS was the fragmentation of the governance of vascular surgeons on both a local and national level. Locally, university surgeons, assuming that vascular surgery was an intrinsic part of general surgery, may have been concerned that their leadership roles would be diminished if they were relegated to division heads rather than department chairs. Nationally, there existed three bodies representing vascular surgeons, each with its own leadership and motivations. These were the Society for Vascular Surgery (SVS), the North American chapter of the International Society for Cardiovascular Surgery (NA-ISCVS) which later changed its name to the American Association for Vascular Surgery (AAVS) and the Society for Clinical Vascular Surgery (SCVS).
The SVS at the time was predominantly an academic association with its primary goal being the annual meeting. The SCVS was a casual community of predominantly private practice surgeons. The AAVS was the most representative but it did not have the infrastructure to be a dominant force. Further, there also existed the Association of Program Directors in Vascular Surgery (APDVS). This division was compounded by the formation of the ABVS. Despite three polls of vascular surgeons, the majority of which supported an independent specialty, the divided leadership of these various organizations refused to abide by the voice of their respective memberships. The destructive internecine arguments that developed are detailed in the Annals manuscript, and this disunion of the vascular community and its leadership clearly hampered a collective identity.
Thirdly, the members of the ABVS argued that an independent specialty was necessary in order to train vascular surgeons in the evolving field of endovascular procedures. However, many established leaders balked at this proposal and resisted incorporating such training into their programs. Their refusal to assist in the education of endo-competent vascular surgeons and the development of an independent specialty allowed cardiologists and interventional radiologists to infiltrate the field. Now, the argument for an independent specialty of vascular surgery is not so much with general surgeons but rather with Cardiologists and interventional radiologists.
Fourth, the ABS at the time still considered itself an authoritative Board protective of an all-encompassing General surgery. Its leaders feared that separation of vascular surgery would lead to a stampede with other subspecialties such as pediatric and hand surgery clamoring for independence.
It is not surprising that there was little chance that the ABVS would succeed. However, much can be learned from this historical review that predicts a new initiative in today’s healthcare environment will likely be successful and benefit not only vascular surgeons but also their patients.
In this modern era the practice of vascular surgery involves multiple disciplines and various forms of therapy. As I have frequently claimed, vascular surgeons “operate, medicate, and dilate”. When so much of what vascular surgeons do is beyond the realm of open surgery, wouldn’t most agree that vascular surgery should not be controlled by a governing body, the ABS, whose primary motivation remains operative therapy?
On the other hand, the current ABS recognizes all its subspecialties are similarly morphing away from general surgery and so the ABS is evolving into a Federation of quasi-independent boards. Accordingly, it is likely to be less resistant to a fully independent vascular specialty board existing under its umbrella organization.
Concomitantly, heads of divisions of vascular surgery in universities as well as community practice hospitals can no longer rely on the largesse of chairpersons of general or cardiothoracic surgery since most will not have clinical vascular experience. Accordingly, these vascular surgeons must have complete autonomy with titles and positions elevated to chairs of a department rather than a division.
Vascular surgeons should also acknowledge that they can no longer claim total control of vascular patients. Vascular internists, cardiologists, interventional radiologists and even interventional nephrologists are all involved. An attempt to block further inroads will alienate these other specialties who in turn will attempt to deny us independent specialty designation. We need to work in conjunction, while remaining the only specialty that can offer all forms of therapy. By providing quality care vascular surgeons will gain the respect of government, insurance agencies and our patients and thus support for our independent status.
Although our small specialty of probably no more than 3000 active vascular surgeons is still represented by many differing societies, the SVS has now become the de facto union of vascular surgeons. It has the ability to bring together all factions and it has the finances, the manpower and the organizational structure to represent all vascular surgeons on the national and international level. As such it is already recognized by governmental and commercial agencies as the authoritative voice of vascular surgeons. The SVS, which has built a strong relationship with the APDVS, is also in a strong position to support and facilitate the undergraduate and postgraduate training of vascular surgeons and strengthen all aspects of an independent specialty of vascular surgery. Although there may still be disagreements about whether vascular surgery should be an independent specialty, the SVS should be the organization that serves as “convener” and ultimately implements the decision of the majority of vascular surgeons. It may be appropriate that the SVS Executive Committee authorizes one more survey of its membership to determine whether we continue to seek independent specialty designation and to approve it as a binding membership referendum.
The plusses and minuses should be carefully defined and much thought given to how the questions in the opinion poll are defined. Whatever the results, they should stand, and be implemented.
Finally, as a practicing vascular surgeon and not necessarily in my role as medical editor of the Vascular Specialist I would like to thank Dr. Timothy M. Sullivan and the Annals of Vascular Surgery for publication of this review and Drs. Stanley and Veith for providing us with the gift of historical perspective. Now our goal should not be to repeat history, but rather to learn from our past experiences. I am sure most will commend Drs. Stanley and Veith and all the other vascular surgeons who dedicated so much of their time in the pursuit of an independent vascular specialty.
However, we should not demonize those that held a contrary view, for most were a product of their times. As recent Nobel Laureate Bob Dylan has written, “The times they are a’changing,” and they are changing in our favor. ■