WHY WE NEED A BOARD
JUSTIFICATION
Why We Need an Independent Board (ABVS)
Born from General Surgery in the 1940s, Vascular Surgery has evolved into a wholly distinct specialty rather than subspecialty, with its own surgical and minimally invasive techniques, research, and knowledge base.
Control of Our Training Programs
Dr. Alan M. Dietzek’s Society for Clinical Vascular Surgery presidential address in 2018, subsequently published in the Journal of Vascular Surgery in January of 2019, headdressed the anonymity of our specialty and outlined in great detail the reasons why an ABVS was so crucial for the future health and survival of our specialty. Dr Dietzek’s speech was delivered more than 3 years ago and the need for an ABVS is even more critical now. One of the key issues, if not the most crucial for the survival of our specialty is to have complete control over every aspect of our vascular surgery training programs. John Eidt, MD, Chair of the Vascular Surgery Board of the ABS from 2013-2016 stated in a recent lecture “The most critical aspect of defining the scope of our practice, and our identity, is through our training programs” and “A Review Committee dedicated to vascular training will have a positive impact on the quality of vascular surgery training”. Clearly, the SVS leadership agreed with this sentiment demonstrated supporting the Association of Program Directors in Vascular Surgery (APDVS) two recent applications to the ACGME for a separate Vascular Surgery RC. Both times, the most recent one approximately one year ago, the ACGME rejected these formal application requests. As a result, the approval and review of new and current vascular surgery residencies and fellowships, respectively, will remain under the auspices of the American Board of Surgery RC, composed of 16 members of which only 3 are vascular surgeons. The constraints imposed by this RC configuration do not allow for the manpower or time to develop, review and certify formalized vascular surgery subspecialty training programs, in areas such as venous disease, complex aortic disease, and others, which many leaders in vascular surgery believe are crucial if patients are to receive the best care possible in these increasingly more sophisticated areas of endeavor. It is also of questionable value to our specialty to have 3 vascular surgeons participating in the review of predominantly general and general subspecialty surgery program applications. Yes, it is better to have some representation from vascular surgeons on how vascular surgery training will be addressed in non-vascular surgery programs vs. no representation. But the real question is why vascular surgery training is part of any nonvascular surgery training program? The vast majority of general surgeons being trained today will never need to do a vascular anastomosis or procedure once they are in practice. Just as they will not need to put in a chest tube. That said, if the need to provide some vascular training to general surgeons is perceived as necessary because a general surgeon may one day practice in an area where there are no vascular surgeons, that can be negotiated between an ABVS and the ABS. This would be similar to the arrangement that thoracic surgery, part of the independent Board of Cardiothoracic Surgery, currently has with general surgery training programs. Another possibility is if we control all aspects of training and certification, we could approve the additional training slots needed to meet this societal need. Ultimately, our goal should be to decipher how to provide all US citizens, no matter where they live, the best vascular surgical care possible by fully qualified and certified vascular surgeons rather than by a general surgeon partially trained in a couple of vascular procedures.
With each passing year the gap between the numbers of trainees completing interventional radiology and cardiology residencies, with training in endovascular procedures, and those completing vascular surgery residencies and fellowships has continued to grow wider. It cannot be understated, that if we do not have complete control over the quality, quantity and sub-specialization of our training programs, the relevance of our specialty will diminish as we become an increasingly smaller percentage of those specialists working in the realm of vascular disease. We need our own RC if we hope to change the current trajectory.
Becoming an independent specialty would ensure that we have our own RRC as do all 24 member boards of the ABMS do now.
A Word From ABVS Chairman,
Dr. Alan Dietzek
Noteworthy: The Well-Being of Vascular Surgeons: Dr. Benjamin Starnes, ABVS Co-Chairman
Changing the Perception of Our Specialty Within Surgery
How can practicing vascular surgeons in the community distinguish themselves from the abundance of less well trained, so called experts, in the diagnosis and management of peripheral vascular diseases when the lay public, and even other physicians don’t fully comprehend what vascular surgeons do, what the specialty of Vascular Surgery is and how our training is distinct from those of other medical and surgical specialists. Possibly, more impactful, is that this lack of understanding of our specialty extends to those individuals with careers in the management of our health care institutions. Despite a growing number and percentage of vascular surgeons currently employed by hospitals and health systems, many of the decision-making administrators occupying their C-suites, have little or no knowledge of specifically what vascular surgeons do or the critical role they play in the surgical services they enable a hospital to provide and consequently, the outsized economic impact they have on their institution’s bottom line. Vascular surgery is perceived as just another division or section in their departments of general surgery. The contribution margins of a division of vascular surgery, however, are almost always in the top 3of a health care system or hospital. The contribution margins per vascular surgeon FTE are often the highest of any specialty in many medical systems. . Vascular surgeons also help to increase the contribution margins of other surgical specialties by providing the security of “backup” for unanticipated, oft times life-threatening bleeding associated with more complex, higher paying, nonvascular surgical procedures. Finally, vascular surgeons generally perform procedures with a case mix index (CMI) higher than the average CMI for most hospitals. Increasing the average CMI of a health care system or hospital by only 0.01 can result in an increase in reimbursement from CMS in the millions of dollars. Yet this often not appreciated by administrators and chiefs of surgery alike
Reasons for Not Having an Independent Board
It Costs too Much
Many within the SVS leadership, past and present, have stated that it would cost an independent board of our small size, too much money to operate without having to charge our members exorbitant fees. We have thoroughly researched this, and this is flatly untrue. We have looked at the costs of office space and personnel and have also communicated directly with the leadership of other small boards. We have determined that the costs to our members would be no more than they are now. We have also been in direct communication with the leadership of the ABMS regarding a variety of issues including costs of membership. This is directly related to the number of members which a board has. There is no economy of scale in this regard. The costs per member are the same for 30,000 members as it is for 3,000 members. Presently, these costs are being passed onto to us through our membership in the ABS.
We Have No Expertise in Testing and Certification
The ABS has the expertise in, and ownership of, all testing and certification programs
This is true. However the entire portion of Vascular Surgery Board test creation and oral examinations are done by vascular surgeons. The one area we would need to develop or utilize a consultant for is test psychometrics. Would the ABS refuse to help us in our efforts to certify vascular surgeons and test residents and fellows if we elected to seek independent board status? This is not your grandfather’s ABS. In our discussions with Dr. Jo Buyske (ABS President & CEO), she made it clear that if the leadership of the SVS wishes to pursue independent board status, the ABS would not stand in our way. Understandably, we may have to pay for past and future ABS help with certification and testing but over time we would fully assume these tasks as other small boards have done. It would not be reasonable for the ABS to become our adversaries rather than supporters. Our goals within the surgical world are too similar and complementary for this too occur.
As a Small Board We Would Have No Power Within the ABMS
False. Although I have been told by many in the SVS leadership that because of our small size we would have no say on the ABMS board – this is not the case. In fact, each of the current 24 member boards has one vote no matter the size of the board! While there are some issues in which larger boards have greater voting power, the great majority of issues are decided by the one board one vote rule.
The ABMS Will Not Allow Us to Become an Independent Board?
Although there have been no new member boards accepted to the ABMS since 1991, this is not because the ABMS doesn’t want to approve new boards. Their mission is to ensure the quality of American medicine for the American people through certification but they are also a business. We have had direct communication with the ABMS and they have made it clear that the only reason there are no new member boards is that criteria for independent board status were not met by the applicants. Vascular Surgery as a specialty meets all the criteria to be an independent board from the perspective of differentiation from other specialties, training and education. In addition, the applicants current parent board, the ABS in our case, must support the application. If Dr. Buyske will stay true to her word, as I believe she will, the ABS will support our application to the ABMS if we provide a unified voice as a specialty that we wish to do this. That is, our leadership – the Society for Vascular Surgery (SVS) and the SVS membership must agree that an independent board would be best for our specialty. And there’s the rub. Although to this point the SVS leadership has not supported ABVS efforts to seek independent board status they have not provided to us, or to you, the reasons why. The leadership of the ABVS met with the SVS leadership 2 years ago and we made the following recommendations:
- That all efforts be made to inform and educate the SVS membership about the pros and cons of seeking an independent board and
- Shortly thereafter the membership be polled about this issue.
Both recommendations were rejected.
We Would love to hear from you
It is the strong belief of the ABVS leadership that once the issues and reasons for board independence are outlined, the membership of the SVS will want the SVS leadership to advocate for an independent ABVS. We will continue to work with the SVS to achieve this important goal. We do not wish to go back to the adversarial, friendship destroying, events of the past. We may disagree on how to get there but will always bear in mind that these are our brothers and sisters in arms. We can do this! And when we do, imagine the immense pride we will all have in an independent American Board of Vascular Surgery.
We hope that this communication has been informative for you. If so inclined, please reach out to us to let us know whether you support our mission or reasons why you don’t or if you have questions you feel have not yet been answered about an independent ABVS. For those of you who already support the quest for an independent ABVS, please reach out to the SVS leadership by email and let them know you endorse this very important undertaking. Thank you.