New York City -- Patients undergoing high-risk vascular surgery have a much better chance of survival if a vascular rather than a general surgeon performs the surgery, new studies are showing.
This is why Frank J. Veith, MD, is heading an effort to have vascular surgery recognized as a specialty board under the umbrella of the American Board of Medical Specialties (ABMS).
Veith is professor and vice-chairman of surgery at Montefiore Medical Center, the University Hospital for the Albert Einstein College of Medicine; has authored or co-authored more than 1,000 original articles in medical journals; and serves on the editorial boards of four vascular surgery journals.
He hosts the annual international VEITH Symposium, now in its 30th year, which explores current critical issues and controversies in the field of vascular disease management.
Veins1: Why does it matter to patients whether or not vascular surgery is granted specialty status?
Dr. Veith: If we don’t resolve this in a timely manner, there won’t be enough competent vascular surgeons to provide for society’s needs.
Vascular surgery, over the last 15, 20 years, has become very much a defined specialty. We clearly are very separate from general surgery. The other specialties have applied for and received specialty status in the past. Some examples are neurosurgery, orthopedics, gynecology and obstetrics. All of them have their own specialty boards.
The sole reason for establishing an independent ABMS-approved American Board of Vascular Surgery (ABVS) is to better serve the public. An independent board is clearly needed for the development of educational and certification standards for vascular surgeons.
Veins1: Aren’t general surgeons trained in how to perform these procedures?
Dr. Veith: General surgeons, who perform about 30% of the 60,000 abdominal aortic aneurysm repairs done in the United States each year, do have some vascular training. They don’t have as much training and experience as vascular surgeons and many aren’t up to date on the latest technologies and the latest endovascular techniques, which are improving outcomes and in many cases saving more lives compared to traditional surgery. A general surgeon may not have the judgment and experience to know when to operate or not. That’s bad for the American public.
Veins1: How would a vascular surgeon’s training be affected if vascular surgery was a specialty?
Dr. Veith: To become a vascular surgeon now requires training as a general surgeon, then having another one or two years of subspecialty training.
Creating a specialty board would streamline the process. There could be one or two years of general surgery training, followed by another three years of vascular training. Why must doctors train to be general surgeons if they’re going to specialize solely in vascular surgery?
The training period now in place for vascular surgeons meets or exceeds that of many existing surgical and medical specialties.
Veins1: Is it a good thing to streamline training?
Dr. Veith: The training issue is a definite concern and if it is streamlined it will be more appealing to those doctors who want to focus on vascular surgery. Overall the number of doctors going into general surgery is dropping, with vascular surgery numbers down even more.
Veins1: What must happen before vascular surgery becomes a specialty?
Dr. Veith: The ABMS, an organization of 24 approved medical specialty boards that helps ensure certification and training standards, must give its approval. It considered an application from the ABVS in 2002 to obtain specialty status but denied it, in part because of opposition from the American Board of Surgery (ABS), one of its member boards. We are appealing.
Veins1: What is the significance of the Wall Street Journal study and the University of Michigan/Johns Hopkins University study?
Dr. Veith: Both studies showed a large disparity in mortality rates between general and vascular surgeons.
Overall mortality is about 5% in abdominal aortic aneurysm (AAA) surgeries. But in the University of Michigan/Johns Hopkins University study of 3,912 AAA cases, the mortality rate was 76% higher with general surgeons rather than vascular surgeons. And in the Wall Street Journal analysis of 5,128 AAA patients in a Pennsylvania database over a three-year period, general surgeons had a 73% higher mortality rate than did vascular surgeons.
The December Wall Street Journal article (“The Surgery Your Doctor Shouldn’t Perform”) will help bring more awareness to the general public. We’ve started to try to inform the lay press and the media.
Veins1: What is the purpose of your board, the American Board of Vascular Surgery?
Dr. Veith: The ABVS was formed in 1996. Most doctors holding ABS Certificates of Added Qualification in Vascular Surgery supported its foundation, and the goal was to improve training standards and certification of vascular surgeons.
Although the ABS opposed the ABVS specialty status application, some ABS directors have said they would consider approving multiple track-type training that would allow certification in vascular surgery. We on the ABVS are cautiously supporting this, but the idea may not work because vascular surgery will remain under the control and governance of the ABS, which represents largely general surgery.
Veins1: Why was your application denied?
Dr. Veith: The ABMS never gave a reason for denying the application but said that the decision was based on a totality of criteria. Denial by the ABMS was ludicrous. The public is ill served. Primary board status for vascular surgery is a clinical imperative for our patients.
Veins1: How did you become a vascular surgeon?
Dr. Veith: I basically got in before it was a true specialty. I was trained as a general surgeon but haven’t done general surgery in over 25 years. I liked the vascular field because it was challenging and difficult. I also found personal satisfaction in helping pioneer some of the newer technologies such as limb salvage with vascular bypasses. I was an early advocate of stents as well, and I’ve been doing endovascular AAA repair since 1992.
Veins1: What is your focus in your practice these days?
Dr. Veith: I perform a lot of endovascular AAA repairs. In traditional AAA surgery a long incision is required. With the new endovascular techniques, a small incision is made in the groin and a catheter is used to place a stent framework with an attached tubular graft through the artery into the aneurysm. The endograft expands, strengthening the aorta and preventing rupture of the AAA.
I also do a lot of carotid artery (neck) surgery and small artery bypasses in the lower extremities to treat gangrene and to save legs.
Veins1: How will your practice be affected if vascular surgery earns the specialty status you seek?
Dr. Veith: It’s not going to have any influence on my practice or me at all. It’s the right thing to do for the public. Because Americans are living longer, vascular experts anticipate an increase of aging patients who will require the services of a vascular specialist.
But a lot of people don’t need treatment. Most artery blockages are benign and there are enough collateral arteries to provide adequate circulation in most cases. A vascular surgeon should have the expertise to examine a patient and know when and when not to treat.