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Advance: Navigating the policy and political processes on Capitol Hill
THE UNDERLYING PROCESSES ASSOCIATED WITH advocacy—whether legislative, regulatory or political—are arduous and complex. As a result, measures of “success” are often characterized by progress within the process, or in other words, to advance a given initiative even if additional work is still required.
Admittedly, this innate feature of advocacy-related efforts can be frustrating and may beg the question, “why bother?”
To best answer this inquiry, we start from the beginning. “Advocacy” is defined as the act or process of supporting a cause or proposal. The Society for Vascular Surgery (SVS) engages in expansive advocacy efforts with an overarching goal to support its members and the patients they serve. To achieve this goal, the SVS monitors and engages in issues relating to workforce and physician wellness, easing regulatory burdens, and payment/reimbursement (to name a few). However, each of these example issue areas generates its own web of opportunities for engagement via both the legislative and regulatory processes. The existence of these opportunities brings us back to the notion of progress within the process. While our end-goal is the enactment of SVS-supported policies, the complexities of advocacy work often result in, or require, multi-year efforts. As result, shorter-term strategies are often driven by efforts to advance an initiative within the process. For a new piece of legislation, this might mean establishing a robust group of bipartisan cosponsors or securing a committee hearing. In the regulatory realm, we might focus on meeting with critical stakeholders from relevant agencies or delaying the implementation of a pol icy that we believe needs adjustment. While these aren’t “finish-line” objectives, they are critical steps in the process and denote a successful byproduct of our ongoing advocacy efforts.
These days, even the most passive observer of advocacy-related issues is likely aware of the heightened partisanship that is generating an especially difficult policy-making environment on Capitol Hill. While frustrating, it makes the SVS’ efforts to expand our advocacy footprint even
By engaging in these initiatives—responding to Voter Voice “Calls to Act,” contributing to SVS Political Action Committee (PAC) or joining our grassroots key contact network—you will help us advance our priorities through the legislative and regulatory processes. Together, we can make a difference. To learn more, visit vascular.org/advocacy
By Bhagwan Satiani, MD
ALTHOUGH RESEARCHERS DESCRIBE EUDAIMONIA as the practice of virtues like courage, wisdom, good humor, moderation and kindness, some have translated the writings of Greek philosopher Aristotle to mean achieving deep wellness and purpose. Certainly, if Aristotle says so, it must be true! Practicing medicine is certainly a “purpose,” but the quest for “deep wellness” has been lost over time and instead we are left with burnout for which we hope that wellness and resilience programs can lead us to happiness and eudaimonia. What does this mean for the modern physician, particularly for those employed by large organizations or groups? And is a healthy culture essential for happiness and well-being?
Bruce L. Gewertz, MD, a senior member of our society, expressed his thoughts on the importance of happiness and joy in a very thoughtful piece titled “Life, surgery, and the pursuit of happiness.”1 The Dalai Lama agrees. He explains that Buddhism believes that joy is humanity’s elemental nature and, therefore, our goal should be to return to it.
Most of us associate happiness with success. In truth, success likely follows happiness. Research studies show a direct relationship between life satisfaction and successful business outcomes.2 In turn, McKinsey has shown that employees life satisfaction greatly depends on their relationships with management. The share of satisfaction on the job depends 39% on interpersonal relationships and the share in interpersonal relationships at work depends 86% on relationship with management.3 The study also pointed out that 75% of those surveyed said that the most stressful aspect at work was their immediate boss leading to a toxic culture.4
In a survey by the Katzenbach Center, 84% of respondents pointed to culture as critically important. However, less than half reported that companies did a good job of managing culture in that it was not a priority initiative.5
Culture reflects the values of an organization and, if a “healthy” culture, ambiguous as it may be, is one of their values, it is seen as emphasizing employee satisfaction. In the longer term, we know that happier employees tend to be 12–20% more productive.
Furthermore, unhealthy “microstresses” from a culture of little autonomy, excessive workload, and mismatched values are setting people up for burnout.
A culture of well-being at work, to include not just the usual policy prescriptions such as evaluation of workloads, working hours, family-friendly policies etc., but an emphasis and monitoring of a healthy interpersonal organizational milieu is essential for people to thrive. It also helps to identify areas of moral distress and cognitive dissonance. A 2022 study showed that 66% of physicians perceived that their organizations do not prioritize physician well-being.6
Being mortals, we all struggle with being happy. Add to that a workplace with a culture that is driven by some leaders who are unaware or overlooking the impact of culture on employee happiness and burnout. There is therefore a continuous loop of damaging culture, unhappiness and burnout. By now we are aware of the conditions, including long work hours that lead to burnout in physicians, especially vascular surgeons who work some of the longest hours. A review of 47 multinational studies of physicians found that longer work hours were a strong predictor of burnout.7 It is also true that burnout is more correlated with a lack of enjoyment or fulfillment at work. However, deep happiness and hard but meaningful work, even with longer hours, makes us more resilient and able to deal with stress.
The work ethic responsible for hard work and efficiency has transformed itself into an “overwork culture,” which exists in many if not most institutions and practices driven by productivity incentives leading to financial rewards. A challenge to the ‘pursuit of happiness’ has been the push by employers, including academic institutions to enshrine productivity incentives in employment contracts. It may succeed in the short term until we experience time poverty and even ‘“famine”—a collective cultural failure to effectively manage our most precious resource, time.”8 The bet is that working harder to earn more will make physicians happier. An institutional culture of pushing working harder may make physicians (and the institution of course) richer but counteracts simultaneous efforts to prevent burnout.
I have mentioned previously that “time affluence” is at a low and some claim there is ‘famine’ based upon a Gallup survey of 2.5 million Americans showing that 80% declared insufficient time each day to accomplish what they wanted to do.
Purpose or meaningful work is the second component of eudaimonia. That does not necessarily mean profitable work. If sage leaders constantly model the purpose, rather than profit alone, organizations thrive and grow 5–7% more than the market.9 In 2014, CEO Satya Nadella affirmed Microsoft’s purpose as to “…empower every person and every organization on the planet to achieve more.” So, purpose, strategy and culture have often been identified as the triad leading to success, which means better relationships, kindness, and psychological safety among other elements.
Finally, in an increasingly VUCA (volatility, uncertainty, complexity, and ambiguity) world with increasing workloads and physician shortages the most critical parts of the eudaimonia equation are being overlooked. A balance between working harder, i.e., increased productivity and physician well-being is surely needed. Now. Ahora!
References
1. https://pubmed.ncbi.nlm.nih.gov/19620538/.
2. https://www.shawnachor.com/project/harvard-business-reviewthe-value-of-happiness/.
3. Tallas T, Schaninger B. The boss factor: Making the world a better place through workplace relationships.
4. https://www.physicianleaders.org/articles/doi/10.55834/ plj.6849841215.
5. https://www.strategyand.pwc.com/gx/en/insights/2011-2014/ cultures-role-organizational-change.html.
6. 2022 Well-Being in Healthcare: Trends & Insights.
7. E Amoafo, N Hanbali, A Patel, P Singh. What are the significant factors associated with burnout in doctors? Occup Med (Lond) 2015 Mar;65(2):117-21. doi: 10.1093/occmed/ kqu144. Epub 2014 Oct 16. https://hbr.org/cover-story/2019/01/time-forhappiness.
https://hbr.org/2019/08/181-top-ceos-haverealized-companies-need-a-purpose-beyondprofit.
BHAGWAN SATIANI, MD, is a Vascular Specialist associate medical editor.
“RECYCLE THAT VEIN!”—THAT WAS THE appeal from the authors of a new study that investigated the explantation of mature arteriovenous fistulas (AVFs) from patients with venous outflow obstruction in one extremity and translocation of them to the contralateral extremity. Led by Guillermo A. Escobar, MD, program director of the vascular surgery fellowship and residency at Emory University in Atlanta, the small study’s abstract was put to the audience at the Society for Clinical Vascular Surgery (SCVS) 50th Annual Symposium (March 25–29) in Miami, and presented by Brandi Mize, MD, an Emory vascular surgery resident.
The authors note that unresolvable venous obstruction in cases of a patent AVF brings extremity dysfunction and pain, traditionally followed by the ligation and disposal of a mature vein. This leads to “prolonged dialysis catheter dependence” as a new vein is sought for maturation or a prosthetic is used. They say it can be “especially devastating” when there is not an appropriate alternative vein for access as catheter dependence leads to further central stenosis. Escobar et al sought to establish whether the translocation of even “potentially aneurysmal or thrombus-laden” AVFs was an effective treatment for the swelling associated with venous obstruction as well as a means of providing “early, autologous access” to reduce patients’ dependence on dialysis catheters. They asked: “Why ligate a >10mm autologous conduit?”
The authors removed matured AVF in patients with venous outflow obstruction and repaired them ex vivo if needed. Following this, they were then reimplanted in patients’ contralateral extremities to form a new AVF.
They evaluated four patients facing occluded central or extremity outflow veins despite multiple attempts at endovascular resolution. “All patients had complete resolution of their original symptoms,” Escobar et al state. All went from experiencing “severe swelling, pain and a disfigured extremity”—even with “elephantiasis and ulceration of the arm”—to having a functional access following the procedure, with a mean time to use of 44 days (median 37) and as early as 20 days in their study, though Escobar et al add that earlier access is likely “feasible in as little as 14 days.” Primary patency was a mean of 315 days (median 300). Though three of the four needed repair or partial resection of AVF aneurysms before the implantation of their fistula in the contralateral extremity, only one required reintervention in the form of angioplasty of outflow vein without interruption of dialysis.
In their conclusion, the authors state: “Translocation of mature venous conduits to new sites seem very successful even if they require repair/resection of aneurysmal portions.” They note that “surgical times are long,” as the harvest, repair and reimplantation takes a mean time of almost 8hrs. The procedure also demands “meticulous technical skill” for the repair and anastomosis of what they call “a very mismatched vein to a radial artery,” but they say that it appears to offer resolution of symptoms and the creation of a functional, autologous access.
“In addition, there is short catheter dependence compared to traditional approaches of ligation, recreation and awaiting unpredictable AVF maturity,” they add.—Benjamin Roche