What would Charles Darwin say about collaborating with and training other specialties?

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Vascular surgery has evolved from a limited subspecialty of general and thoracic surgery into a complex and well-defined specialty. The introduction of endovascular treatments and their adoption and embrace by vascular surgeons has made our specialty exciting and attractive.

However, the increasing importance of these endovascular treatments also poses some dangers to vascular surgery. By using these endovascular techniques, other specialists have the tools to treat vascular lesions in vascular patients who previously could be treated by vascular surgeons only.

Dr. Frank J. Veith

Some of these other specialists have contributed to the development of endovascular treatment techniques and therefore have a legitimate claim to use these techniques on vascular patients. This certainly applies to interventional radiologists (IRs) and to some extent to interventional cardiologists (ICs).

More recently, cardiac surgeons, whose practices have been diminished by the development of better coronary stents and now transcatheter valves, are venturing more into the treatment of noncardiac vascular lesions and are trying, somewhat belatedly, to become expert in endovascular skills and methods and are using them to treat a panoply of noncardiac vascular lesions. To facilitate this, combined training programs have been proposed.

What is the impact of all this multispecialty outreach, and what is its effect on vascular patients and vascular surgeons? To the extent that different specialists can learn from each other’s skills and techniques and can cross train each other, it is probably a good thing for doctors and patients.

However, this multispecialty interest in noncardiac vascular lesions and patients has some serious potential downsides. When specialists expand their scope of practice to new areas as an add-on to their primary practice, they run the risk of becoming dabblers.

They may be able to use techniques without the appropriate knowledge base to know when the techniques should be used. As a result, they may do more harm than good, and health care costs will rise. In addition, the pool of patients justifiably needing treatment is limited. Thus, if more specialists consider themselves capable of treating a given lesion, it will surely increase the number of unnecessary procedures and complications. All these effects will be bad for patients and the health care system.

In 1996, in an SVS presidential address titled “Charles Darwin and Vascular Surgery” ( J. Vasc. Surg. 1997;25:8-18), I predicted the increasing importance of endovascular treatments and how they would replace most open surgical procedures. My predictions then, thought by most to be too high, have proven actually to be too low.

In that presidential address, I advised vascular surgeons to become endo-competent to avoid extinction. Thankfully they have done so. Because of this, our specialty survives in the endovascular era. I also advocated that vascular surgeons work together with other specialists (IRs and ICs) in vascular centers for the betterment of patient care.

With a few exceptions this has not happened for many reasons which can best be summarized as due to human nature with its tendencies to tribalism, self-interest, and competition for patients and dollars.

Undoubtedly these tendencies will continue to have negative consequences on the care of vascular patients. Nevertheless, vascular surgery, IR, and IC currently exist in the United States in a state of stable equilibrium in the provision of noncardiac vascular care. What will happen in the future remains uncertain.

What does all this have to do with Charles Darwin? Darwin in his classic book, The Origin of Species, hypothesized that there is a relationship between extinct and contemporary species of plants and animals, that there is a competitive struggle for life between species, and that preservation of favored species occurs through a process of evolution and natural selection.

In a Utopian world in which food and resources are unlimited, all species will flourish and prosper. However, the reality is that food and resources are not unlimited. So, in the struggle for life, there is intense competition between species for the available food, resources, and space. The species that are best evolved and adapted to win this competition will flourish and survive. The species that are least well adapted will wither and become extinct.

There are many analogies between medical specialties and species. Patients for a medical specialty are analogous to food for a species. Other resources and space for a species are analogous to access to patients, the workplace, and its resources for a specialty.

For vascular surgeons to prosper and flourish, they must have access to vascular disease patients and the resources to care for them optimally. These resources include the necessary skills. They also include the facilities such as noninvasive laboratories, operating rooms, angiography suites, and postprocedural care areas – with all the necessary permanent and disposable instrumentation and equipment to care for vascular patients and their lesions.

In the Darwinian sense, vascular surgeons are competing with IRs and ICs for scarce food and resources. The likelihood is that we will soon be competing with cardiac surgeons whose food source (patients needing open procedures) is going away.

Vascular surgeons have certain assets such as specialized training and a focus on noncardiac vascular disease, knowledge of its medical treatment and natural history, and the ability to do open vascular operations when needed.

However, these may not be enough to ensure our specialty’s survival, since the other specialties interested in the same patients and lesions as we do also have assets that may counteract their intrinsic liability of not being focused primarily on these patients or lesions.

So what about the often-heard recommendation that we collaborate with these other specialties interested in caring for vascular patients – that we cooperate and help them in their training and practice on their vascular disease patients? In an ideal Utopian world, we should do so, and all interested specialties should work together harmoniously as I suggested in 1996.

But here is what Charles Darwin, if he were alive today, would likely say about this. The real world is not such a Kumbaya place. Experience has shown over and over that human nature with its affinity for competition, tribalism, and self-interest works against Kumbaya. These traits, especially self-interest, which accounts for problems in our politics, our legal profession, and Wall Street, also causes problems for our specialty.

Darwin would also say that our patients, a target of opportunity for other specialties, are limited. So are the resources to take care of them optimally, like dollars, vascular laboratories, angiography suites, hybrid operating rooms, hospital beds, etc.

So regarding our relationship with other specialties interested in caring for vascular patients, especially cardiac surgery, Darwin would say: Vascular surgeons and cardiac surgeons are closely related specialties (species) that are competing for limited resources and space. Vascular surgery adapted more quickly than cardiac surgery to the endovascular revolution and will likely survive and prosper. However cardiac surgeons are aggressive and talented and have open skills.

They can learn endovascular techniques as we did. We should not train them and give away our current competitive advantage.

Vascular surgery must maintain and enhance its niche, possibly by increasing its recognition as a separate specialty. Lastly Darwin would say: Vascular surgery should never forget that it is in a struggle to survive. It should do everything it can to maintain and enhance its competitive edge.

Dr. Veith is professor of surgery at New York University Medical Center and the Cleveland Clinic. He is an associate medical editor for Vascular Specialist.

The ideas and opinions expressed in Vascular Specialist do not necessarily reflect those of the Society or publisher.

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