Friday, January 02, 2004

ED NOTE: I actually began this post on 12/31 but I could not access Blogger for the most part yesterday. Unfortunately I am on call today and have been unable to get to my computer to get it posted until now. Enjoy!!!

This article from SF gate (originally printed in The Wall Street Journal). The story describes efforts to have the American Board of Medical Specialists to create a separate board of vascular surgery. To excerpt:

The overall mortality rate from abdominal aortic aneurysm surgeries averages about 5 percent. But when general surgeons perform the surgery, the mortality rate is 76 percent higher than when vascular surgeons do it, according to a recent University of Michigan/Johns Hopkins study of 3,912 cases. Other studies have reached similar findings.

I cannot argue with the statistics presented in the story demonstrating that fellowship-trained vascular surgeons have a lower mortality rate performing aortic aneurysm repair. (The abstract of the source material may be found here). I do question how much advantage a fellowship-trained low-volume surgeon would compare with a high-volume general surgeon. My partner (who is a fellowship-trained high-volume surgeon) subscribes to the Journal of Vascular Surgery and I will review the statistics and report back. As I have posted before on 12/2 and 11/28 one does better with a high volume surgeon and/or hospital with certain complex procedures.
But some feel that other steps are required:

Vascular specialists want the American Board of Medical Specialties, an influential professional group, to make vascular surgery a separate specialty, with its own certificate of expertise. Doctors say this would lead most hospitals to decide that only vascular surgeons should perform nonemergency vascular procedures, just as only neurosurgeons can do surgery on brain aneurysms, and only cardiac surgeons can operate on the heart.

However, I do not think that the creation of a separate vascular surgery board will help with the problem as presented.
First of all there is no national body which determines what procedures a surgeon may or may not perform. Each individual hospital sets their own standards for privileges. Some hospitals require fellowship training and/or certification, while others may not (the same may be said for managed care organizations). Smaller or rural hospitals may not initiate a requirement for board certification.
Secondly, any changes, after they were initiated, would take several years to show the effects desired. That is because the "grandfathering" that would occur. Even the most vocal proponents of the creation of a new board agree that would have to occur:

Many general surgeons, of course, are highly competent, and some have done extensive aneurysm repair operations, gaining significant expertise in the process. Dr. Veith and others say such surgeons should be eligible to qualify for a full vascular certificate if one is created

What Dr. Veith and others in the story do not point out is that a mechanism to insure a level of expertise is in place at the American Board of Surgery. The ABS offers a special certification in vascular surgery, which requires the completion of a fellowship. So the certification issue has already been addressed.
Is it economics? Not according to the story:

A change in policy, of course, would also be a business windfall to the vascular surgeons, but they insist the motivation is successful medical outcomes, not profit

In addition:

Speaking about the broader debate, David H. Nahrwold, president of the ABMS, declined to discuss the vascular surgeons' campaign. But he says that, generally speaking, one downside of limiting certain medical therapies to specialists is doctors' availability for patients.

Leading vascular surgeons argue that there are enough vascular specialists to do the necessary operations. Currently, there are about 2,100 vascular surgeons in the U.S. Moreover, they say, if vascular surgery becomes an independent specialty, it could lure more medical residents into the field.

The conditions mentioned in the recent New England Journal of Medicine (esophageal and pancreatic cancer) that were studied to measure volume-related outcome are not common and rarely present as emergencies. Aortic aneurysms are becoming more common along with other forms of peripheral vascular disease. By limiting the number of providers, access may be limited, especially for patients in rural areas, or even medium-to-small cities. Given the current difficulties in filling general surgical residency slots, I think the expectation that creation of an independent board will "lure" more residents into the specialty is optimistic at best.

The desire of vascular surgeons to have their own board is nothing new, as I have heard the arguments since I was a medical student. I think that two of the motivating factors behind the drive to have a "board of their own" are a desire for respect and a desire for control.

The respect factor comes from the fact that plastic surgery, thoracic surgery, and colo-rectal surgery all have their own boards represented at the ABMS. The vascular surgeons would like to be on a level playing field.

As far as control goes, vascular surgery is a specialty undergoing a great deal of change. The advent of endovascular techniques has opened the treatment of all types of vascular disease, aneurysms, carotid disease, and peripheral vascular disease. Many of these procedures are being done by cardiologists and radiologists and not by vascular surgeons. This is a source of great concern to vascular surgeons. (One of my attendings went to a meeting where a speaker began his talk on this issue with the statement that the specialty of vascular surgery would "cease to exist in ten years"). As non-invasive means for treating coronary artery disease have become more effective, cardiothoracic surgeons have increased the amount of non-cardiac vascular surgery they perform. Then there is the amount of vascular procedures done by general surgeons. The vascular surgeons are taking from all sides and wish to try to get some control of the wild ride they are on.

As this rant comes to a close, two more points:
One problem with centralization of procedures is that the treatment of the emergent patient may suffer. A surgeon does not learn how to handle aortic aneurysms by only operating on ruptured ones, they build experience with elective cases during daylight hours. A patient with a ruptured AAA is not likely to tolerate a trip to the vascular referral center. As I have posted before:

.....If the mortality rates are bad for low-volume surgeons doing elective cases, just you wait for the figures for no-volume surgeons doing emergency cases.....

Anyway, patients should inquire as to their surgeon's experience in performing procedures, especially complex ones. Primary care physicians should be roughly familiar with the experience of the surgeons they refer to, in case the patient is too intimidated to ask.

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