The vasculature united: Bringing together competing specialties for better patient care

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Ali AbuRahma

Incoming Society for Vascular Surgery (SVS) President Ali AbuRahma, MD, knows the topic of this year’s E. Stanley Crawford Critical Issues Forum at the Vascular Annual Meeting (VAM) might make him as many enemies as it will friends. “You are going to find some people who will love me and some people who will hate me,” he laughs, “Because some of the surgeons on the extremes don’t want anyone to touch the vascular specialty. On the other side, many cardiologists and interventional radiologists think vascular surgeons are doing some stuff they are not qualified to do.”

But AbuRahma is not dissuaded by any notion of warring tribes in the angiosuite. He picked this year’s issue quite deliberately—the role of multispecialty practice in vascular and endovascular surgery—with a burning question in mind: “Can we work together?”

“The reason I picked ‘Can we work together?’ is because, presently, it’s not uncommon in many centers, hospitals and universities to find the vascular surgeon not only in competition but even in political battles with others. Specialists are fighting each other because everybody thinks they will do a better job for vascular patients,” AbuRahma tells Vascular Connections in a recent interview.

That’s why the lineup of the forum includes not only AbuRahma providing the vascular surgeon perspective, but also viewpoints from interventional cardiology, interventional radiology and interventional vascular medicine.

From the vascular surgeon’s vantage point, the storied history of the specialty has deep roots.

“The reality is vascular surgery started with our specialty, and, as you know, that’s why we are celebrating 75 years of our existence as the SVS this year,” AbuRahma explains. “Our specialty goes back a very long time in the United States.

“In the last couple of decades, other specialists began to enter the field. Sometimes they are justified, sometimes they are not. Sometimes they are trained to do a great job for patient care, sometimes they are not— and that’s the reason that I felt, perhaps if I could get a session where we spend time and listen to one another, we could make progress.”

The three other speakers who will talk during the forum each come from multispecialty practices carrying out some type of vascular or endovascular work.

“Mark Bates, MD, happens to be one of my associates in my multidisciplinary group within my practice at West Virginia University School of Medicine/Charleston Area Medical Center in Charleston, West Virginia, where various specialists work together for vascular patient care, and I am the head of that group,” says AbuRahma. “He is a leader in the interventional cardiology field.

“From interventional radiology, we have James F. Benenati, MD, of Miami Cardiac & Vascular Institute. He was the president of the Society of Interventional Radiology, and he will discuss that perspective and what they can do in the vascular field. And we have Bruce Gray, DO, from the University of South Carolina in Greenville, who is very well respected for interventional vascular medicine.” Each speaker will deliver a 15- to 20-minute talk after which a panel discussion with opportunities for questions and answers will take place.

There is a stark backdrop to the very concept of multidisciplinary vascular care: Vascular surgeons are a relative minority in a crowded field of specialists who treat vascular disease, AbuRahma points out.

“Why are we a relative minority?”, asks AbuRahma. “Numbers wise, our SVS membership is around 6–7,000, but the number of surgeons who are active in the United States is somewhere between 3-4,000 people, and we see this relative minority doing probably over 30% of the vascular practice. Yet, there are almost 50,000 cardiologists, around 50,000 general surgeons, 20–30,000 cardiac surgeons, and 10–15,000 interventional radiologists. So the other specialties are much more in number, and they are doing a good percentage of vascular procedures.”

Which raises another of the main motivating factors behind the forum focus, AbuRahma continues. “Many of these specialists put themselves in the field because there is a shortage of vascular surgeons, therefore they think they can do it. This is somewhat understandable—but what we are hoping with this session is to demonstrate that those doing so should be qualified, and have the competency and training to do these procedures.

“Some procedures might be done 20–30% of the time by a non-vascular surgeon, but others are done almost over 50% of the time by non-vascular surgeons—some of them might be qualified, some might not be qualified.”

Appropriateness in care figures heavily at this juncture. “We’re going to be emphasizing not only appropriateness but also if the individuals doing the procedures are qualified and competent to do them,” AbuRahma says. “Because if you have the competency, and the training, then most of the time you might be following appropriateness in care. That is something that needs to be addressed.”

The aim is to drive home the importance of vascular centers of excellence like the one he operates at Charleston Area Medical Center in West Virginia. “We understand the drivers behind the specialties attracted to performing vascular procedures,” AbuRahma will tell VAM attendees during his segment. But so too the consequences, he will add: “There are quality challenges, including increased complications landing on vascular surgery practices; payment inefficiencies; and overutilization and unnecessary procedures.”

AbuRahma will end by posing some questions around how to tackle these issues going forward. Does the remedy take the form of defense and stopping others from doing procedures outside of their competency? Or, does the strategy look more like offence, demanding quality and competency, and enforcing training and education in order to facilitate competency in other specialties? “Of course, we need both to win,” AbuRahma will argue, “but the balance may have shifted strongly to needing an elite offense to win for patients and our specialty.”

Patient care is paramount, he adds. “I’m trying to find a somewhat middle ground where both will do the right thing for the right patient quality. I think it will be beneficial for the Society and patient care all over the country, whether they are being treated by x or y or z.”

When: Wednesday, Aug. 18, 10:45 a.m.–12:15 p.m. E. Stanley Crawford Critical Issues Forum

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