Vascular Specialist March 2018 by BIBA Publishing

Dr. Sheahan: I'm not your burnout guy.

Surgeon pain – a reality that must be changed.

8 Get ready for VAM Registration and housing now open. And be sure to bring your whole team! VOL. 14 • NO. 3 • MARCH 2018

LETTER TO THE EDITOR:

BY JOHN F. EIDT, MD

[Editor’s Note: At its January 2018 strategic planning retreat, the SVS Strategic Board of Directors and Executive Board discussed the merits of a Vascular Surgery residency Review Committee (RC) and have made a firm commitment to explore the process, beginning with the Association for Program Directors in Vascular Surgery (APDVS), on how best to proceed with submitting an application to the Accreditation Council for Graduate Medical Education (ACGME). SVS welcomes the input and support of all See Letter · page 6

Dr. Parveen Garg

BY BRUCE JANCIN FRONTLINE MEDICAL NEWS REP OR T I N G F ROM T H E AH A S C I EN T I F I C S ES S I ON S

ANAHEIM, CALIF. – Adherence to the American Heart Association’s widely publicized “Life’s Simple 7” program addressing key modifiable cardiovascular health factors substantially reduces the risk of developing peripheral arterial disease, Parveen Garg, MD, said at the American Heart Association scientific sessions. This is new evidence-supported information. Until

this new analysis from the landmark ARIC (Atherosclerosis Risk in Communities) study, the relationship between Life’s Simple 7 and peripheral arterial disease (PAD) hadn’t been studied. It’s a relationship worthy of examination, considering that more than 8 million Americans have PAD, and nearly 40% of them don’t have concomitant coronary or cerebrovascular disease, which raised the question of whether Life’s Simple 7 applied to PAD risk, noted Dr. Garg of the University of Southern California, Los Angeles.

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Embracing Life’s Simple 7 slashes PAD risk

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PRACTICE MANAGEMENT

Surgeon pain, disability on the rise BY KARI OAKES FRONTLINE MEDICAL NEWS

P E R S P E C T I V E by Dr. Samuel R. Money and Dr. Victor J. Davila

Pain is all too common

he evidence has been accumulating for decades: Practicing surgery can exact a toll on usculoskeletal pain secondary surgeons’ physical well-being in ways that skeletal pain, only exacerbating the to performing vascular surgery can shorten careers and contribute to professional shortage of vascular surgeons we is a real issue. Our group recently dissatisfaction. are currently experiencing. Efforts presented survey results showing that “Ergonomists have described the surgeon’s work should be made to educate vascular 44.2% of vascular surgeons experience environment and working conditions as equal surgeons on ergonomic modificamoderate to severe pain even before to, if not at times harsher than, those of certain tions to help reduce this problem. starting their operative day. During industrial workers,” wrote Sherise Epstein, MPH, Table height, posture, monitor their operative day, these numbers and the coauthors of the systematic review and height, and minimizing positions of increased to 78%. By the end of a full meta-analysis of studies addressing the issue. Ms. high stress during surgery are crucial day doing procedures, 83% of vascuEpstein, currently a 4th-year medical student at the to avoid chronic musculoskeletal Samuel R. Money, MD, lar surgeons reported moderate or seUniversity of California, San Diego, and her team pain (MSP) and injury. Formal mi(pictured) is Chair of Surgery and Victor J. vere pain. The physical costs of being found a high prevalence of work-related muscucro-breaks (stretching exercises at Davila, MD, is a general a vascular surgeon are real. The use loskeletal disorders and pain among surgeons and regular intervals during long cases) surgeon, both at the interventionalists, with pooled prevalence estimates of lead aprons, loupe magnification, are a cost-effective way to begin to Mayo Clinic, Phoenix. headlights, foot pedals, and monitors for pain among these physicians ranging from 35% combat MSP in the operating room. only magnifies these problems. to 60% of all respondents. Cervical spine disease, However, ergonomic education and The impact to the health care system is signifrotator cuff pathology, and degenerative lumbar careful attention to operating room and equipicant, with 6% of vascular surgeons stopping the spine disease were each reported by nearly one in ment setup can also be key components toward practice of vascular surgery because of musculofive respondents in the pooled analyses, with inminimizing MSP. creasing prevalence over the duration of the study period ( JAMA Surg. 2017 Dec 27. doi:10.1001/ and disability among at-risk physicians, who endure possible linkage between work-related pain and othjamasurg.2017.49). er factors, such as burnout and depression, that lead The results of the study are in line with previous long work hours, awkward positioning, and few Pain continued on page 5 work that finds a high – and increasing – rate of pain opportunities for breaks. The study also suggested a

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VASCULARSPECIALISTONLINE.COM • 3

FROM THE EDITOR

I am not your burnout expert BY MALACHI G. SHEAHAN III, MD DEPU TY M ED ICA L E D ITO R , VAS CU LAR SPE CIA L IST

ook, I am not a burnout expert. And neither are you (presumably). None of us know much, but that won’t stop the regulations from coming. Program directors are already being asked to provide “wellness plans.” Through the SVS, experts have been enlisted to help, but it is now clear that what works for others won’t necessarily work for vascular surgeons. The next step is up to us. We are the only ones with detailed knowledge of our lives. I believe we are moving closer to answers but still face a few significant hurdles. Don’t worry, there are solutions. Hear me out … Previously, I shared three studies with you, which found that vascular surgeons had the highest rates of suicidal ideation and career dissatisfaction among surgeons while spending more hours in the hospital than any other specialty. So what has been done to address these horrific numbers? Very little. We need answers now, but most of the data are over 10 years old. Much has changed in our specialty. The endovascular revolution created an entirely new working paradigm. A busy vascular surgeon used to perform 300 cases annually; now this number approaches 1,000. More procedures means more clerical work. Lead aprons and radiation exposure

have added new ergonomic and medical concerns. Reimbursement dynamics now favor shorter, more frequent patient interactions over longer, more complex cases. We are benchmarked against old work standards while CPT bundling continuously lowers current RVU designations. EMR was supposed to make our lives better; it has done the opposite. Patient-centered health care has become a mantra, but the measures taken often backfire. Practicing medicine where the desired outcome is a high score on patient satisfaction surveys will likely lead to unnecessary tests, poor cost allocation, and low physician fulfillment. Quality of care is now measured scrupulously while the quality of our lives remains undocumented. In the absence of organized reform, burnout appears to be increasing. A recent Mayo Clinic–AMA study found the current prevalence to be 54% among physicians. All of this has not happened overnight. I believe practic-

VASCULAR SPECIALIST Medical Editor Russell H. Samson, MD Deputy Medical Editor Malachi Sheahan III, MD Associate Medical Editors Bernadette Aulivola, MD, O. William Brown, MD, Elliot L. Chaikof, MD, PhD, Carlo Dall’Olmo, MD, Alan M. Dietzek, MD, RPVI, FACS, Professor Hans-Henning Eckstein, MD, John F. Eidt, MD, Robert Fitridge, MD, Dennis R. Gable, MD, Linda Harris, MD, Krishna Jain, MD, Larry Kraiss, MD, Joann Lohr, MD, James McKinsey, MD, Joseph Mills, MD, Erica L. Mitchell, MD, MEd, FACS, Leila Mureebe, MD, David Rigberg, MD, Clifford Sales, MD, Bhagwan Satiani, MD., Larry Scher, MD, Marc Schermerhorn, MD, Peter Scheider, MD, Murray L. Shames, MD, Niten Singh, MD, Frank J. Veith, MD, Robert Eugene Zierler, MD Resident/Fellow Editor Laura Drudi, MD. Executive Director SVS Kenneth M. Slaw, PhD. Director of Marketing and Membership SVS Justin Cogswell Managing Editor SVS Beth Bales

Vascular Specialist is the official newspaper of the Society for Vascular Surgery and provides the vascular specialist with timely and relevant news and commentary about clinical developments and about the impact of health care policy. Content for Vascular Specialist is provided by Frontline Medical Communications Inc. Content for the News From the Society is provided by the Society for Vascular Surgery. The ideas and opinions expressed in Vascular Specialist do not necessarily reflect those of the Society or the Publisher. The Society for Vascular Surgery and Frontline Medical Communications Inc. will not assume responsibility for damages, loss, or claims of any kind arising from or related to the information contained in this publication, including any claims related to the products, drugs, or services mentioned herein.

4 • VASCULAR SPECIALIST

ing vascular surgeons are resilient by default. The majority of us trained prior to the enforcement of duty hour restrictions. Out of high school, I enrolled in a 6-year BA/ MD program (skipping 2 years of college seemed like a great idea in high school, less so when I got there). Half of my class never finished. In my intern year, six of the eight categorical residents dropped out. My odds of reaching PGY 2 were 12.5%. Fuzzy math aside, all of your stories are similar. We have proved our resilience over and over again. What is happening here is different. Burnout is described as emotional exhaustion, low self-esteem, and depersonalization/cynicism. It develops slowly, progressively as stressors increase. A common thread seems to be the feeling that you alone are not enough. Examine your daily life. What are your most common stressors? For me, they relate to time management, clinical documentation, and whatever fresh hell my kids’ teachers have cooked up for “school projects.”

Dr. Sheahan is the Claude C. Craighead Jr. Professor and Chair, Division of Vascular and Endovascular Surgery, Louisiana State University Health Sciences Center, New Orleans.

*****Scene***** Wife: Can you help Luke (kindergarten) finish his diorama? It needs to be a scale depiction of his 3 favorite scenes from Wagner’s Ring cycle. Me: Sure, I just need to complete

POSTMASTER Send changes of address (with old mailing label) to Vascular Specialist, Subscription Service, 151 Fairchild Ave., Suite 2, Plainview, NY 11803-1709. The Society for Vascular Surgery headquarters is located at 633 N. St. Clair St., 22th Floor, Chicago, IL 60611. Vascular Specialist (ISSN 1558-0148) is published monthly for the Society for Vascular Surgery by Frontline Medical Communications Inc., 7 Century Drive, Suite 302, Parsippany, NJ 07054-4609. Phone 973-206-3434, fax 973-206-9378 Subscription price is $230.00 per year. National Account Manager Valerie Bednarz, 973-206-8954, cell 973-907-0230, vbednarz@frontlinemedcom.com Digital Account Manager Rey Valdivia 973-206-8094 rvaldivia@ frontlinemedcom.com Classified Sales Representative Drew Endy 215-657-2319 cell 267-481-0133 dendy@frontlinemedcom.com Senior Director of Classified Sales Tim LePella, 484-921-5001, cell 610-506-3474, tlapella@frontlinemedcom.com Advertising Offices 7 Century Drive, Suite 302, Parsippany, NJ 07054-4609 973-206-3434, fax 973-206-9378 Letters to the Editor: VascularSpecialist@vascularsociety.org Editorial Offices: 2275 Research Blvd, Suite 400, Rockville, MD 20850, 240-221-2400, fax 240-221-2548 ©Copyright 2018, by the Society for Vascular Surgery Scan this QR Code to visit vascularspecialistonline.com

the wind tunnel testing on Jack’s (3rd grade) carbon-neutral peanut-free alternative fuel source rocket booster. Off stage – 7th Grade Son: The genetically modified spiders got loose again! *****End Scene***** We want to do a good job, but more hurdles are placed in our way. A recent AMA/Dartmouth Hitchcock study found that 50% of physicians’ time is spent performing data entry and other administrative work. Only 27% of time was spent on patient care. Every hour of face-to-face patient time requires 2 hours of EMR/clerical work. We are trapped in a bureaucratic prison. For years, every quality initiative was solved with a new form. To enter a simple note today, we must first “establish our relationship” with the patient, then ably click through a minefield of “warning boxes” signifying impending DVT prophylaxis catastrophes and antibiotic crimes and misdemeanors, next we scroll through a pre-populated postapocalyptic hellscape of minuteby-minute vital sign entries and lab values dating back to inception. Then, and only then, finally, ON PAGE 11, we can meagerly type: Patient at wound care, will come back on evening rounds. Another important component of the burnout syndrome is dehumanization. Recently I spoke with Donald Zimmerman, PhD, author of the Burnout continued on page 14

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MARCH 2018

PAD

P E R S P E C T I V E by Dr. Linda Harris

What has the greatest impact?

Simple from page 1

When the AHA originally developed the Life’s Simple 7 concept to support the organizational goal of substantial reduction of the burden of cardiovascular disease by the year 2020, the targets were coronary heart disease (CHD) and stroke. The scope of the program was later broadened to include all cardiovascular disease, including PAD. ARIC is a National Heart, Lung, and Blood Institute–sponsored prospective study of nearly 16,000 black or white individuals who were middle-aged at enrollment and have been followed for more than 2 decades. Dr. Garg’s analysis focused on 12,865 participants who were free of CHD, heart failure, prior stroke, and PAD at baseline, and have been followed for a median of 24 years. The metrics for Life’s Simple 7 consist of total cholesterol, blood pressure, blood glucose, smoking status, body mass index, physical activity, and adherence to a healthy diet score. Each element can be scored 2 points for ideal, 1 for intermediate, and 0 for poor. The composite Life’s Simple 7 score is rated optimal at 10-14 points, average at 5-9, and inadequate at 0-4. During follow-up, 3.4% of ARIC participants developed PAD sufficiently severe to involve hospitalization. The incidence was 5.2 cases per 1,000 person-years for the 1,008 subjects categorized as having an inadequate Life’s Simple 7 score, 1.1/1,000 person-years for the 8,395 people in the average category, and 0.4 cases/1,000 person-years for the 3,462 in the optimal Life’s Simple 7 group.

r Garg and colleagues assessed the While it is ideal for people to never engage ARIC (Atherosclerosis Risk in Comin bad habits, much of our country curmunities) study, sponsored from the rently does. Certainly the vast majority of NHBLI, for risk of PAD development patients we see have at least several factors related to “Life’s Simple 7” program. Not that would not qualify as healthy. For exsurprisingly, patients who did not smoke, ample, if an individual was a smoker at the ate a healthy diet, exercised, had normal onset of the study, and quit within 1 year cholesterol, blood pressure and glucose of being enrolled, would he have had as levels, and a normal body weight at inihigh a risk as those who were smokers, or tial assessment, had a significantly lower those who were not. As this sub study only Dr. Linda Harris is chief, chance of developing clinically significant division of vascular surassessed these characteristics at baseline, PAD over time. The ARIC study, and it is unclear whether they remained stable gery, State University multiple projects arising from it, should or changed over time. Clearly, most of of New York at Buffalo be applauded for their efforts to decrease us already encourage our patients to quit and an associate medcardiovascular mortality. smoking; exercise; control their diabetes, ical editor for Vascular Specialist. The true incidence of PAD in this study blood pressure, and cholesterol; and to eat is not known, as the only indicator of PAD a healthy diet. The question is how much was hospitalization. It is possible that paof an impact changing lifestyle has, and tients with “bad habits” were more often assessed for PAD, whether there is a critical time point at which it needs and diagnosed, whereas patients without “bad habits” to be done to decrease the risk of developing PAD or might not have been assessed, as was frequently the case progression once developed. We do know from smoking with women and cardiovascular disease a few decades ago. research that quitting does impact progression of PAD, A measure of ABI at baseline, and at multiple time points even once present. Less is known about some of the oththroughout the study would have been helpful. Popliteal er factors, such as diet and body weight. Further evaluaartery assessments, which were performed in the ARIC tion to see whether particular risk factors have more of study, were not reported in this substudy. an impact on PAD than others would also be helpful, as More importantly, what this sub study does not assess, would a more reliable measure of the true incidence of is the impact these lifestyle changes have once present. PAD in this population.

Compared with subjects in the inadequate category, those in the average group were 56% less likely to develop PAD. Those in the optimal Life’s Simple 7 category had an 86% reduction in risk. For each of the seven components of Life’s Simple 7 a person scored ideally in, the risk of incident PAD was reduced by 28% in a multivariate analysis fully adjusted for demographics,

Pain continued from page 3

to attrition in the surgical profession. Adrian Park, MD, who has long studied the issue of work-related musculoskeletal disorders (MSDs) among surgeons and interventionalists, was not surprised by the study’s findings. “These aren’t just sporadic instances of individual surgeons having a tough time; this is an increasingly broadly recognized problem. ... These are the consequences of surgeons simply getting up and going to work each week,” Dr. Park said in an interview. A total of 21 articles composed the meta-analysis, which included responses from 5,828 physicians. Most of the respondents were male (78.5%), with a mean age of 46 years and a mean 12.8 years in practice. The mean number of hours spent in procedures per week was 14.4. Fourteen studies met eligibility criteria for quantitative synthesis. A total of 4,245 physicians were included in this portion of the analysis: 1,232 orthopedic surgeons, 1,118 interventional cardiologists, and 582 general surgeons (other subspecialties made up the remainder). MARCH 2018

alcohol consumption, aspirin use, study site, left ventricular hypertrophy, and other potential confounders. The inverse relationship between Life’s Simple 7 score and PAD risk was stronger in women than men. However, the association didn’t differ by race. Dr. Garg noted that his study undoubtedly underestimates the true incidence of PAD in the ARIC

The career prevalence of degenerative lumbar spine disease was estimated at 19%. The investigators’ estimate of lumbar spine disease prevalence from their own data also showed an increase, to 21%, for studies published within the past decade. Rotator cuff pathology during the study period was estimated at 18% overall, and carpal tunnel syndrome at 9% overall; carpal tunnel syndrome also appears to be increasing in prevalence, estimated at 12% within the last decade. Twelve of the studies met criteria for inclusion in the quantitative synthesis of musculoskeletal pain. Neck, back, and shoulder pain were all common in this group. Neck pain had a 60% estimated 12-month prevalence; shoulder pain had a 52% prevalence; and back pain was reported for about half (49%) of respondents. Just 10 of the included studies addressed disability burden, said Ms. Epstein and her colleagues. Overall, 12% of physicians responding in this subset of studies reported that they required work

population, since a hospital diagnosis was required. Also, to date he and his coinvestigators have only analyzed the results in terms of baseline Life’s Simple 7 score. It would be useful to also document the impact of change in the score over time. Dr. Garg reported having no financial conflicts of interest. ■ bjancin@frontlinemedcom.com

modification, leave of absence, or early retirement because of work-related MSDs. A lack of awareness of ergonomic recommendations on the part of the surgeons themselves was identified in several studies. “A few studies have found that ergonomics education during medical training appears feasible, accepted, and effective at changing behaviors and reducing symptoms,” the investigators said. Work-related pain and disability among surgeons remains underreported and underestimated, according to both Dr. Park and the study investigators. Further research is needed, and the investigators wrote: “Ultimately, this work should be integrated with research on preventing surgeon burnout and attrition given shared risk factors.” Micro breaks can help

What’s the solution? Dr. Park says that some fixes are low tech, and can be put in place immediately. He and his team implemented a series of brief Pain continued on page 13 VASCULARSPECIALISTONLINE.COM • 5

Vascular Surgery RRC

the educational content. The current program requirements in vascular surgery, applicable to both integrated Letter from page 1 and independent pathways, prescribe partner organizations across the specialand two RCs that relate to the Amer- 36 months of vascular-specific trainty of vascular surgery. In the following ican Board of Psychiatry and Neuing in addition to a variable amount letter to the editor, John Eidt details why rology (Psychiatry and Neurology). of “surgery” experience. vascular surgeons should support the esThus, there is a precedent that would For independent programs (5+2), tablishment of a separate Vascular Sursupport the concept of two RCs reit is expected that trainees obtain at gery residency RC within the auspices of lated to the ABS. least 12 months of vascular training the ACGME. – Russell Samson, MD, The Surgery RC consists of 16 during general surgery residency in Medical Editor, Vascular Specialist.] members that have been nominated addition to the 24 months of vascuby one of four organizations: ABS, lar training during fellowship. For It is my belief that the Accreditation integrated programs Council for Graduate Medical Ed(0+5), the program ucation (ACGME) should establish requirements include Dr. Eidt is vice chair an autonomous Review Committee 24 months of “core of vascular surgery at (RC) for vascular surgery. I believe surgery” rotations Baylor Hamilton Heart that vascular surgery has achieved in addition to the 36 and Vascular Hospital, sufficient differentiation from other months of vascularDallas, and an associate surgical and medical specialties to specific rotations. The medical editor for Vasjustify such an action and I believe core rotations are decular Specialist. that an independent Review Comsigned to ensure that mittee would have a beneficial effect vascular trainees have a on vascular surgery education. broad exposure to the The ACGME is an independent, essentials of patient not-for-profit, physician-led orgaAmerican College of Surgeons (ACS), care including fluid and electrolyte nization that sets the educational AMA, and American Osteopathic As- balance, management of shock and standards for graduate medical edsociation (AOA). Each nominating or- resuscitation, critical care, wound ucation in the United States. The ganization submits a list of qualified care, nutrition, surgical infection, and ACGME was founded in 1981 as candidates from which the RC elects thrombosis and hemostasis. the restructured offspring of the new members for a 6-year term. These core surgical skills may be Liaison Committee for Graduate The chairman of the Surgery RC is obtained on a variety of rotations Medical Education (LCGME). The elected by the members and serves a based on the resources unique to LCGME, initially established in 1972 3-year term. each institution. There have been onby the American Medical Association The current chairman is Jeff going discussions with the Vascular (AMA), the American Board of Medi- Matthews, MD, a hepatobiliary sur- Surgery Board regarding the need for cal Specialties (ABMS), the American geon and Chief at the University specific case minimums, the need for Hospital Association (AHA), the of Chicago. The vascular surgeons required rotations and the duration Association of American Medical on the Surgery RC are Joe Mills, and content of “core” surgery. Colleges (AAMC) and the Council of MD, Jim Valentine, MD, and DaApplications for new programs Medical Specialty Societies (CMSS), vid Han, MD. The Surgery RC is can be submitted to the residency was somewhat dysfunctional owing responsible for reviewing General RC throughout the year and are reviewed by the members during three meetings annually. Until recently, ACGME policy precluded the approval of new (5+2) vascular surgery programs in institutions Vascular surgery is the only medical or that did not have a General Surgery surgical specialty with a primary certificate program. This policy was recently changed by the Board of Directors that does not have an independent RC. to give greater discretion to the RCs in determining specialty-specific needs. The RC Surgery at its September 2017 meeting determined that new applications for fellowship to complex reporting and approval Surgery, Complex General Surgical programs without an affiliated surprocesses. Oncology, Hand Surgery, Pediatric gery program will be considered Since 1981, the ACGME has asSurgery, and Surgical Critical Care for accreditation. This is welcome sumed the administrative responin addition to Vascular Surgery pro- news and will allow surgeons like sibility for ensuring the quality of grams including both independent Tim Sullivan, at Abbott Northwestgraduate medical education in the (5+2) and integrated (0+5) vascular ern, to submit an application for United States. In the 2016-2017 acaprograms. an independent vascular program demic year, there were 130,000 resThe Surgery RC, in consultation despite the absence of a surgery idents and fellows in approximately with the Program Directors, the ABS residency in his hospital. 10,700 programs. There are currently and others, sets the standards for surWhile the ACGME is responsible 28 Review Committees that largely gical training in the form of the Pro- for setting and reviewing program reflect the member boards of the gram Requirements, which describe standards, the member Boards of ABMS. There are two RCs that relate in detail the roles of the faculty, the the ABMS are responsible for the to the American Board of Radiology responsibilities of the sponsoring certification of individual physicians. (Radiology and Radiation Oncology) institution, and the composition of The Vascular Surgery Board of the 6 • VASCULAR SPECIALIST

ABS sets the requirements for initial certification and maintenance of lifelong certification, and develops the In-Training examination, the Qualifying and Recertification Exams (written), and the Certifying Exam (Oral). Recent discussions have focused on improving the MOC process including alternatives to the 10-year recertification exam. The VSB functions largely autonomously within the framework of the ABS. Technically, the primary certificate in vascular surgery is awarded by the ABS (rather than the VSB) though the requirements for certification are independently determined by the VSB. The chairman of the VSB (currently Vivian Gahtan, MD) also serves as a Director of the ABS, must be currently certified in General Surgery, participate in the committee activities of the ABS and serve as an examiner for the General Surgery certifying (oral) exam. At the present time, approximately 70% of certified vascular surgeons are also certified in Surgery, a proportion that will decrease with the influx of trainees from integrated (0+5) programs. The members of the VSB are nominated by the major national and regional vascular societies and elected by the VSB independent from the ABS. It is my opinion that the current Board structure has largely served the interests of the vascular surgery community as evidenced by the autonomy of the VSB to set the standards for vascular surgery certification free from ABS oversight. The chief drawback is that vascular surgery does not have a seat at the ABMS and relies on the ABS to represent the interests of vascular surgery in this important forum. The American Board of Medical Specialties (ABMS) is the parent organization for 24 member boards including the American Board of Surgery, the American Board of Internal Medicine (Cardiology), and the American Board of Radiology (Interventional Radiology). The ABS offers primary certification in Surgery and Vascular Surgery and secondary certificates in surgical critical care, complex surgical oncology, pediatric surgery, hand surgery and palliative care. Vascular surgery is the only medical or surgical specialty with a primary certificate that does not have an independent RC. There is a separate Review Committee for colorectal surgery despite the fact that certification by the American Board of Colorectal Surgery requires prior certification in Surgery by the ABS, a curious anomaly arising from the fact that the Colorectal Board predatMARCH 2018

I think vascular surgeons are in the best position to determine the best way to train vascular surgeons.

were developed in a collaborative manner with input from both General surgery and Vascular surgery and a vascular surgeon is always assigned to review new vascular surgery programs. In addition, it can be argued that cross-pollination between surgery, surgical oncology, pediatric surgery, surgical critical care, and vascular surgery may allow for the rapid adoption of best practices. But for the future of vascular surgery training, I would argue that we ought to begin a dialog with the ACGME to consider the merits (and drawbacks) of an independent Vascular Surgery Review Committee. It seems apparent that general surgery, surgical oncology, pediatric surgery, and surgical critical care have more in common with each other than with vascular surgery. There is some evidence that surgical training is largely specialty-specific with limited transferability. For example, I am not aware of any evidence that competence in the MARCH 2018

performance of laparoscopic cholecystectomy significantly improves the ability to perform vascular procedures. Rotations on cardiology, thoracic surgery, transplant, interventional radiology, and hematology may have more relevance to eventual vascular practice than rotations on breast, GI and burn services.

The question is who should be responsible for making these decisions: an RC composed of vascular surgeons or an RC composed predominately (>80%) of non–vascular surgeons. I think vascular surgeons are in the best position to determine the best way to train vascular surgeons just as surgical

specialists in orthopedics, ENT, neurosurgery, urology, ophthalmology, plastic, and thoracic surgery determine their optimal training paradigms. The success (or demise) of the future of vascular surgery should be in the hands of those with the most skin in the game: vascular surgeons. ■

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ed the establishment of the ABS by more than a dozen years. So where is vascular surgery now? We have active national and regional societies, two training paradigms, textbooks, journals, a primary certificate, a national quality registry, and innovative research initiatives. We’ve come a long way in short time but I think that we need to continue to strive to improve our specialty. One important step would be the establishment of an independent RC for vascular surgery. I believe that vascular surgeons should be responsible for determining the optimal methods for training the next generation of vascular surgeons. I should emphasize that I have no complaint with the performance of the Surgery RC. In fact, the Surgery RC has been remarkably responsive to the needs of the vascular community. The current program requirements for vascular surgery

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VAM Registration, Housing Now Open

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ith the opening of registration and housing, the 2018 Vascular Annual Meeting officially takes a big step forward. All scientific meetings and exhibits will be at the Hynes Convention Center. Committee meetings, the SVS Board of Directors meeting, and alumni and committee receptions will be held at the Sheraton Boston Hotel, the VAM headquarters hotel. Attendees have several hotel options to meet a variety of needs. (See vsweb.org/VAM18 for the complete list of VAM hotels and pricing.) To receive the special VAM rates, attendees must reserve their rooms through MCI (formerly Wyndham Jade) by May 22. After that, attendees must make their own housing arrangements. Of course, the real excitement lies in the meeting itself. “This year, it’s all about the vascular team,” said SVS President R. Clement Darling III, M.D. “There are reasons for everyone to attend – surgeons, nurses, nurse practitioners, technologists, PAs. We have special programming for PAs and the Society for Vascular Nursing has aligned its schedule with VAM.” (See story on next page.) In addition, Dr. Darling cited: • Topics and practical sessions for community practitioners and young surgeons, including on clinical practice guidelines, practice management, even physician burnout. • More opportunities to interact with presenters. • Ideas and translational research participants can take home to their practices. • VAM on Demand. “If you miss a session, you can catch up at home,” said Dr. Darling. VAM on Demand is available at a big discount before the meeting closes. The VAM Planner and a new, mobile app will help each attendee design his or her own meeting (see story below). Familiar favorites will be back, Dr. Darling added, including workshops, postgraduate courses, a full day of events for international members, collaborative sessions with other societies, plenty of opportunities to network and connect with friends and colleagues, and educational credits, not to mention the chance to explore a fascinating city. “We have a great mix of old activities and some new initiatives,” said Dr. Darling. “And we’re excited for you to experience it all at VAM 2018.”■

Acorn Street in the famous Beacon Hill neighborhood is one of the most photographed streets in Boston. Artisans and trades people of the 19th century lived there; today, these row houses are considered a prestigious address.

Personalize VAM Experience With VAM Planner

his year’s VAM attendees will enjoy a new schedule website and planner. VSweb.org/VAMPlanner offers a full range of options to VAM attendees, who will be able to create a personal VAM schedule filled with individual “must-attend” activities. Website visitors can learn about sessions and faculty and can filter, by format, such details as audience, area of interest, and credits. Searching the program is an easy way to explore VAM ahead of time. A bonus – this year the online planner will sync with the mobile app. The planner includes the full schedule, of course, plus faculty; activities for fellows, residents, and students; general VAM information; and links to the Society for

8 • VASCULAR SPECIALIST

Vascular Nursing and Vascular Quality Initiative programs. “Spotlight” will present interesting information about VAM and what attendees can expect. All VAM social activities are part of the planner as well. These include not only the alumni receptions, Vascular Live programming, and industry-sponsored satellite symposia, but also the Friday evening Closing Reception in the Exhibit Hall, new this year. To access the planner, SVS members will use their SVS log-in credentials. Non-members will need to establish an account. Make VAM your own. Visit the VAM Planner site starting March 26.

About VAM 2018 Join us for the 2018 Vascular Annual Meeting. When: June 20-23 Where: Hynes Convention Center, Boston Scientific Sessions: June 21-23 Exhibit Hall: June 21-22 Register: vsweb.org/VAM18 MARCH 2018

S TON

JUNE 20–23 VSweb.org/VAM18

his year’s Vascular Annual Meeting, June 20-23 in Boston, is geared to the entire vascular team: doctors, vascular nurses, PAs working in the vascular setting, technologists … everyone. In fact, VAM’s theme is “Home of the Vascular Team – Partners in Patient Care.” So, SVS members, consider bringing your team members along. The Society for Vascular Nursing will hold its 36th Annual Conference in conjunction with VAM. The SVN meeting will be June 20-21 and the registration fee includes access to both meetings. Both meetings take place at the Hynes Convention Center in Boston. The SVN program will focus on vascular areas, including carotid disease, venous, aneurysms, lower extremity and PAD, wound care,

critical limb ischemia, and renal disease. “VAM will include sessions on most, if not all, of these topics,” said Program Committee Chair Matt Eagleton, M.D. “We at SVS hope that after the SVN conference closes, those participants come to VAM to learn even more about vascular illnesses. Our final two days include a host of sessions, much of it relevant to vascular nurses and others on the vascular team.” SVS created a section within the affiliate membership category late last year for physician assistants, and already has more than 135 members. The PAs will have an afternoon of programming on Thursday created by and for them. PAs submitted ideas for programming – interesting

SquaredPixelS/e+/getty imageS

Bring Your Vascular Team to VAM; Programming Scheduled for PAs

cases, quality initiatives – and also will speak on topics relevant to PAs in the vascular setting. In addition, VAM will present a vascular team forum Friday, June 22. “Improving Metrics in Clinical Practice” is set for 1:30 to 3 p.m.

“I can’t wait to feel the energy and enthusiasm that will be part of VAM this year,” said Dr. Eagleton. “Our students and residents have always contributed interest and passion to VAM. We’ll be turning the dial up a few notches. It’s going to be great.”

VASCULAR RESEARCH INITIATIVES CONFERENCE

Register for VRIC Today May 9, 2018 | San Francisco, California The Vascular Research Initiatives Conference brings together researchers to better understand the biology of vascular disease, with presentations and discussion of new research and possibilities. ACCOMMODATIONS:

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For more information visit vsweb.org/VRIC18

MARCH 2018

VASCULARSPECIALISTONLINE.COM • 9

NEWS FROM SVS

WASHINGTON UPDATE:

health care costs and reduces access to care. SVS participates in the Health Coalition on Liability and Access (HCLA), which supports the resolution. This coalition represents physicians and patients working to reduce medical lawsuit abuse and enacting federal legislation that eliminates inconsistent and ever-changing state liability laws. The coalition has now turned its attention to the Senate, which presently has not introduced a companion bill. Though consideration is seen as an uphill battle, the HCLA “remains committed to advancing true reform legislation.” The SVS will likely organize a grassroots effort when legislation is introduced. The SVS and coalition also support the Good Samaritan Health Professionals Act, H.R. 1876/S.781,

i nternational guidelineS center

he SVS Washington office is working to get legislation introduced in the Senate on medical liability reform that is identical to a House bill. The House of Representatives passed House Resolution (H.R.) 1215, Protecting Access to Care Act, in June 2017. This comprehensive medical liability reform legislation is similar to laws already enacted in Texas and California. It would cap non-economic damages for pain and suffering at $250,000, create a three-year statute of limitations for filing lawsuits and allow states to keep laws that may differ from federal laws. It also would ease the cost burden shared by both patients and physicians, as a lack of federal liability reform increases

The State of Medical Liability Reform

Get AAA, Other Guidelines in Several Forms QUALITY:

he new abdominal aortic aneurysm (AAA) guidelines are some of the most extensive ever developed by the Society for Vascular Surgery, with 112 recommendations and 774 supporting references. For convenience, the guidelines are included in the SVS iPG Mobile App and have been turned into a Pocket Guide. An educational slide set can be used as a teaching tool. Mobile App

The free app was launched in Fall 2015 and is available at Google Play and iTunes. It features concise summaries of the latest SVS clinical practice guidelines. Each summary includes key information, an abstract and an explanation of the GRADE framework used to evaluate quality scientific evidence and strength of guideline recommendation. Pocket Guides

SVS has partnered with Guidelines Central to create a Pocket Guide version of the AAA guidelines. It lists all recommendations, tables with helpful evaluation and risk-scoring schemes as well as treatment algorithms. Cost for the digital version is free for SVS members and $8.99 10 • VASCULAR SPECIALIST

for non-members. The printed Pocket Guide is $11.95. SVS also has Guideline Pocket Guides for three other recent guidelines: Diabetic Foot Infection, Peripheral Arterial Disease and Venous Leg Ulcers. All are free online for SVS members ($8.99 for non-members). The printed guides cost $9.95 for diabetic foot, $11.95 for PAD and $13.95 for leg ulcers. All three cards and the Pocket Guides are available as a bundled set. The digital version is $27.99 for non-members (free to members) while the printed bundle is $37.95. Educational Slide Set

SVS members now can access the slides that present the AAA guidelines, a useful tool to help educate vascular professionals and colleagues about state-of-the-art practices in vascular care. As with the Pocket Guides, content is available for the four most recent guidelines. The slides and online pocket guides are available at vsweb.org/Guidelines. The SVS seeks ideas for other knowledge tools to help disseminate and implement guideline-concordant care. Send recommendations to guidelines@vascularsociety.org. ■

bipartisan legislation introduced in both the House and Senate. The House bill was passed by the Energy and Commerce Committee on Feb. 14. These companion bills would eliminate the threat of medical liability lawsuits for licensed health care providers who assist victims of federally declared natural disasters. SVS and 29 other health care organizations signed a letter supporting the legislation (see vsweb.org/Samaritan) writing that it “will ensure that an adequate supply of trained health care professionals are ready, willing and able to volunteer their services during a catastrophe and that they will not be deterred or turned away due to the threat of lawsuits.” ■

Still Time to Join TCAR Project VQI:

ascular surgeons can still join the SVS Vascular Quality Initiative’s (SVS VQI) surveillance project to evaluate the safety and effectiveness of trans-carotid artery revascularization (TCAR) in comparison with carotid endarterectomy (CEA). In a TCAR procedure, carotid stenosis is treated with a stent inserted into the proximal common carotid artery via a neck incision. Flow reversal during the stent placement provides cerebral protection. Initial publications suggest that TCAR may have a lower stroke rate than CEA, potentially due to avoidance of aortic arch catheterization combined with the carotid flow reversal. Project leaders want to obtain more data about real-world outcomes of TCAR compared with CEA. Additional information about the project can be found at vsweb.org/TCARSurveillance. Procedures must be performed on high-surgical risk patients (asymptomatic or symptomatic) using FDA-approved or FDA-cleared devices labeled for the transcarotid approach. To qualify for Medicare coverage, data about the procedure and one-year follow-up must be submitted to the SVS VQI Carotid Artery Stenting (CAS) Registry. Surgeons must be set up to enter TCAR cases into the registry. Sites interested in participating in the project can enroll in the SVS VQI CAS Registry if they do not already participate and obtain the National Clinical Trial identifier required for billing. For more information, contact vqi@m2s.com or call (603) 298-6717. ■ MARCH 2018

NEWS FROM SVS

VQI:

QPP Webinar Materials Are Available Online

aterials from the February webinar on the Quality Payment Program, including how surgeons can still avoid reimbursement penalties for 2017, are now available online. The materials will also inform surgeons and their staff how to: • Get started with 2018 reporting • The increased requirements to avoid penalties and obtain bonus payments • The MIPS (Merit-based Incentive Payment System) reporting requirements to maximize reimbursement based on their 2018 data. The SVS Quality and Performance Measures Committee and the SVS Patient Safety Organization presented the webinar. It also included information on the SVS Vascular Quality Initiative (SVS VQI) and how

FROM JVS:

Distinguish Between Diabetes Types A

review suggests physicians and surgeons pay increased attention to insulin-dependency in diabetics with chronic limb-threatening ischemia. Such diabetes is associated with poorer outcomes after first-time revascularization for the patients compared with noninsulin-dependent diabetics or nondiabetics. The study is published in the April Journal of Vascular Surgery and is available free through May 31. Visit vsweb.org/JVS-DMvCLTI. ■

it can help vascular surgeons meet MIPS requirements. The SVS VQI is an approved Qualified Clinical Data

Registry, which provides 25 quality measures that can be used to fulfill the Quality Measures component of

MIPS reporting requirements. View the materials at vsweb. org/215webinar. ■

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NEWS FROM SVS

AFFINITY PROGRAM:

VS members may think their disability insurance plans have them covered. But in cases of disability or illness, their incomes as vascular surgeons, specifically, may not as secure as they believe. The SVS has teamed up with Principal® to help members guard their incomes as vascular surgeons. “This coverage helps replace more of your income if you can’t work due to a disabling illness or injury. It supplements your existing group

Is Your Income Adequately Protected?

long-term disability insurance,” said Mark Blocker, of SVS’ Affinity Program of expanded benefits. SVS members receive a 10 percent discount. Coverage can’t be canceled and renewal is guaranteed, at the same rate, to age 65 or 70. Other advantages include: • Taxes. Participants are eligible to receive $17,000 in monthly benefits tax-free. Group employer-paid benefits are taxed. If that benefit is $15,000 a month, taxes likely re-

duce that to $9,000 a month. • Ownership. Participants own their SVS policies; rates and discounts are guaranteed even in the case of changing practices. And there are no new medical questions or exams. • Simplicity, with few medical/financial requirements. • Extended coverage, with the vascular surgery specialty covered to age 65 or 70. Many group plans either do not cover a specialty or may do so for a limited time such

as 24 months. After that, group plans can limit benefits to “any gainful occupation,” not the vascular surgery specialty. “This can make a big difference in benefits,” said Blocker. Receive a quote for a comprehensive proposal, and/or policy comparisons with existing coverage, with just contact information, income and date of birth. Contact Blocker at 312-291-4472 or at Mark@ nationalaffinity.net. ■

SPOTLIGHT ON LEADERSHIP:

Interview with Dr. Bhagwan Satiani A: I believe the efforts of many are creating a homogenization of leadership. strong foundation for change, and we will continue Jim Kouzes, the famed author and speaker, says on this positive path because the data demonstrate that “envisioning exciting possibilities and enlisting that diversity is simply good for business. In 2015, others in a shared view of the future is the attribute McKinsey completed a survey of 346 that most distinguishes leaders from Inspiring and communicating a Shared Vision; companies’ research (mostly based in non-leaders.” Our leaders have to be Importance of adding leadership to learning the United States and the United Kingforward-looking and share their vision portfolio of vascular surgeons. dom), noting an anemic increase in of what diversity really means for our average gender representation on their societies. Diversity should be practiced This is the latest column in this year’s series highlighting executive teams of only 2 percentage not only in the traditional sense of the evidence-based behaviors and attributes that define points, to 14 percent, and ethnic and people’s physical attributes but also of great leadership. cultural diversity by 1 percentage ideas and thought. We will be stronger point, to 13 percent. So change is slow. for it. had the privilege of interviewing Dr. Bhagwan However, in a more recent study of Satiani, professor of clinical surgery in the Division more than 1,000 companies covering Q: As you think about the future of Vascular Diseases & Surgery, and Medical Director, 12 countries, and using two measures of vascular surgery, how can SVS DR. GARCIA-TOCA Non-Invasive Vascular Laboratory and Director of of financial performance, a statistically members best position themselves the Faculty Leadership Institute at Wexner Medical significant correlation was shown beto lead effectively? Center at The Ohio State University tween diversity of the leadership team A: I tell our medical students that I would pick College of Medicine in Columbus, and and financial performance. In this the same specialty if I had another life to live. It commissioner and secretary of the study, companies in the top quartile is the single most innovative specialty, which atstate of Ohio Minority Health Comfor gender diversity on executive teams tracts the brightest and therefore has a boundless mission. His professional interests and were 21 percent more likely to outper- future. My suggestions include: stay current with accomplishments are impressive and form on profitability and 27 percent knowledge and envision how to stay ahead of the include clinical research with more more likely to have superior value cre- curve, involve yourself in SVS affairs to influence than 170 peer-reviewed publications, ation. Thus, there are obvious benefits change, give to the political arm of SVS, take several book chapters, coordinating to supporting a diverse work force, and advantage of SVS offerings, stay curious to solve and teaching physician leadership dethese benefits will ultimately catalyze clinical and research problems even in private velopment and business education to continued change. practice, and do not ever forget your families that residents and physicians, and conductIn medicine and surgery, diversisupport you every day. DR. SATIANI ing practice management seminars ty is commonly oversimplified as a for surgical residents. Most pertinent means to increase quotas of gender, Q: How can SVS best support its members to to this article, his current research focuses on faculty race and sexual orientation represented in the work lead change in the healthcare system and in their retention, physician work effort and compensation is- force. I believe we must expand our definitions and own practices? sues, appropriateness of utilization of diagnostic tests, constructs of diversity beyond physical attributes A: Continuing to survey membership to stay in touch and physician shortages. I talked with Dr. Satiani to the power that is created through synergy of with their needs. Push to get involved more on the about his expertise regarding leadership. new and diverse perspectives. If the members of political side. Private practitioners constitute about a group of leaders sitting around a table all look two-thirds of the membership. Having been one for Q: During your career, you have advocated alike, think alike and have similar backgrounds, it almost 25 years, I know some issues are more pressin multiple publications for more diversity in is unlikely they will be able to do much more than ing for that community. Leadership positions should membership and leadership positions in vaspreserve the status quo, which in business is not a be shared with the entire membership. If people are cular societies. What can be done to inspire a winning formula. As leaders, we need to find our given a chance, most will rise to the challenge. Leadership continued on page 13 shared vision on this topic? voice and values and speak out when we see the BY MANUEL GARCIA-TOCA, MD CLINICAL ASSO CIATE PR O FE SSO R O F SU RG ERY, S TANF ORD UN IV E R SITY, ON BEHALF O F THE L E A D E R SHIP DEVELOPME N T A N D D IV E R SITY CO M M IT T EE

12 • VASCULAR SPECIALIST

MARCH 2018

NEWS FROM SVS

VRIC:

Clowes Lecturer to Discuss Aneurysmal Location

system “absolutely pivotal” in regulating blood pressure affects other areas of the circulatory system and could be an underlying cause of aortic diseases, according to Alan Daugherty, PhD. Dr. Daugherty, associate vice president at the University of Kentucky, will discuss his research at the SVS Vascular Research Initiatives Conference DR. DAUGHERTY in May. His talk, “Angiotensin II and Cellular Complexity of the Aorta, a Recipe for Aneurysmal Location,” is the second annual Alexander W. Clowes Distinguished Lecture. This lecture at VRIC honors the late Dr. Clowes, an SVS member, frequent VRIC presenter and renowned surgeon-scientist. “The renin-angiotensin system is a hormone system that has been known for decades to regulate blood pressure and fluid balance,” said Dr. Daugherty. It is now known that the system has many bioactive peptides, although the much of the focus remains on numerous effects

exerted by angiotensin II. Angiotensin II is produced from a precursor called angiotensinogen through cleavage by the enzymes renin and angiotensin-converting enzyme (ACE). Drugs that stop the synthesis or activity of the angiotensin II, such as ACE inhibitors and angiotensin receptor blockers (ARBs), are currently used to treat blood pressure and congestive heart failure, but may also be useful to treat aortic diseases as well, Dr. Daugherty said. His current research focuses on how angiotensin II works as a regulator of producing and propagating aortic bulges. Working with mice, he and his colleagues have discovered that “the aorta doesn’t just bulge anywhere during infusion of angiotensin II. The bulges are localized to one region in the abdominal aorta, and also in the aortic area adjacent to the heart,” said Dr. Daugherty. “There are biological properties of angiotensin II that we haven’t recognized fully,” he said. “We don’t know why it’s causing the pathology that is experimentally in a very localized manner.” The researchers hope that inhibiting the actions of angiotensin III will

Leadership continued from page 12

bine this knowledge with what you observe at work and outside. Only by learning your own strengths and weaknesses and capitalizing on your personal strengths can you lead successfully.■

Q: Which leadership skills have you found to be most critical in your day-to-day leadership success? A: While I do not consider myself a ‘successful’ leader, I have been able to teach based on my observations of both successful and less successful leaders. I believe authenticity and integrity are ahead of all the technical and relational skills we teach. After those two, being selfaware about your own dominant style and being versatile using it, knowing the art of compromise and sharing your knowledge with others are very important. Followers are much smarter than leaders think and are able to spot fake actors. Q: For those on the learning path of leadership, are there practical pieces of advice you can provide that may save them time and discomfort? A: Watch those who inspire you and attach yourself to them so you can learn from them. Read as much as you can about leadership, then comMARCH 2018

egister today for the Vascular Research Initiatives Conference and prepare to be immersed in research that ultimately can change lives. “Think of VRIC as the ‘Annual Meeting’ for basic and translational vascular researchers,” said Edith Tzeng, M.D., chair of the SVS Research and Education Committee. “We’re presenting research before it reaches the patient – but it’s research that can eventually lead to great breakthroughs in patient care.”

reduce aortic diseases, he said. “We hope that the highly consistent data in animal models can be translated to human studies.” He cautioned that drug selection will be important, as major differences exist in drug properties and their effectiveness in reducing aortic diseases.

Pain continued from page 5

breaks, taken every half hour during a procedure, that they dubbed “targeted stretching micro breaks.” These are 45- to 50-second breaks during which a series of exercise physiologist–designed brief stretches are undertaken that do not require breaking scrub. In a study of 66 surgeons and operating room staff, Dr. Park, chair of the department of surgery at Anne Arundel Medical Center, Annapolis, Md., and his collaborators found that surgeons reported less pain and fatigue, and improved mental focus, when they took micro breaks during a procedure. When surgeons took micro breaks, operative time was no longer than when they didn’t take the breaks (Ann Surg. 2017 Feb;265[2]:340-6). “We do this all the time in our operating room now,” said Dr. Park. “And it makes a difference in terms of pain, in terms of alertness, in terms of stamina. And it costs nothing.” Major redesign of tools and workspace

Other targets for technological improvement include offering better-designed handles for laparo-

The Vascular Research Initiatives Conference will be held Wednesday, May 9, in San Francisco. For the past several years, VRIC has been held the day before the American Heart Association’s Arteriosclerosis, Thrombosis and Vascular Biology (ATVB) Scientific Sessions, May 10-11. The title of this year’s AHA meetings is “Vascular Discovery: From Genes to Medicine.” Both meetings will be at the Hilton San Francisco Union Square. Visit vsweb.org/VRIC18.

“We need to be specific about the drug and pick the one that will be highly effective in reducing the effects of angiotensin II around the clock, day after day,” he said. ■

scopic instruments. Dr. Park made the point that the influx of women – whose hands are smaller on average than men’s – into the surgical professions makes this a particularly pressing issue. In addition, a fundamental redesign of the operating room will eventually be in order, he said, contrasting the surgeon’s environments with that of an airline pilot. In the cockpit, the pilot sees a “heads-up” display of a limited amount of data, with an eye to controlling the cognitive workload for the operator. By contrast, said Dr. Park, in the OR, there are “lights flashing, and things pinging,” and pieces of equipment don’t “talk” to each other, presenting sometimes overwhelming sensory input that just potentiates the stress of the environment. Operating room design, he said, should move toward an ergonomically improved and stimulus-controlled environment. “It has never felt safe or appropriate to talk about ourselves.” But for the good of the profession, and ultimately for patient care, “this has to change,” Dr. Park concluded. Ms. Epstein and her coauthors reported no conflicts of interest. ■ koakes@frontlinemedcom.com VASCULARSPECIALISTONLINE.COM • 13

Burnout continued from page 4

textbook “Person-Focused Health Care Management.” His thoughts on health care were dramatically altered after spending 43 days in an ICU following abdominal aortic aneurysm repair. He describes the experience as “my worst nightmare that then got worse and then never ended.” While we can learn from his experience, how many of us were trained to face this horror? Dehumanization is a natural protective response, especially when we have so little time for patient interactions. Compassion fatigue sets in when we don’t have the time and resources to care for our patients. While poor outcomes have been cited as a result of burnout, this appears to be an end-stage result. The Minimizing Error, Maximizing Outcome (MEMO) study funded by the AHRQ found that physicians often served as a buffer between their patients and poor medical environments. The organizational flaws that led to burnout also independently resulted in substandard patient care.

The burnout physicians experienced was a symptom of the defective health care system and not causative of the poor care. Doctors were literally sacrificing their well-being to care for their patients. Not surprisingly, attitudes regarding burnout vary significantly between health care executives and physicians. A New England Journal of Medicine survey of their Insights Council found that 96% of respondents agreed that burnout is a moderate or serious problem, although physicians were significantly more likely than executives to rate the problem as “serious.” Opinions on solutions varied as well, with executives more likely to support redesign of EMR, while physicians favored reduction of documentation and clerical work. Obviously the physicians’ solution would be more costly to the corporation as the executives deflected the problem back to the EMR designers. Neither group favored the use of resilience/wellness programs as a primary solution. Of all the remedies proposed, I

find resilience training to be especially egregious. Studies consistently show a 40%-50% prevalence of burnout among physicians. How can this be an individual problem? Why train doctors to endure a broken system? This type of problem solving is why burnout continues to flourish. Doctors are not suffering from a disease but rather exhibiting a symptom. To arrive at possible solutions, let’s look at the elite athlete analogy. What are you trained to do? What are your exceptional skills? For me it is clearly EMR documentation (just checking to see if any of my residents have read this far). How many of us would describe ourselves as expert at billing? Paperwork? Medication reconciliation? Discharge summaries? Should LeBron James hawk 16-ounce Miller Lites in the nosebleeds during halftime? This may sound like I am expressing a cocky attitude that these tasks are beneath us, but we now have concrete evidence that forcing physicians to perform these duties hurts patient care and literally kills us. Full stop. Physician

burnout can lead to suicide in the absence of clinical depression. While hopelessness is part and parcel of the burnout syndrome, there are now potential solutions within our grasp. Clearly a reduction in clerical duties will be a key component of any realistic plan. Our time must be proportioned. Few of us are asking to work less. Reducing patient interactions while increasing the average time of these encounters has been shown to reduce burnout without decreasing work hours. We want to do a good job. It is time to remove these barriers. Our next steps have already been taken, and for me it represents the best example of the potential of Vascular Specialist and the SVS. Under the leadership of SVS President Clem Darling, MD, and Executive Director Ken Slaw, PhD, a task force was created to address this issue. Ably chaired by Dawn Coleman, MD, and including Sam Money, MD, from the SVS Executive Council and Past SVS President Julie Freischlag, MD, the Burnout continued on page 15

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14 • VASCULAR SPECIALIST

MARCH 2018

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task force has collaborated with actual burnout experts Tait Shanafelt, MD, and Susan Hallbeck, PhD, to create a survey designed to identify the causes, prevalence, and potential solutions to the burnout problem in vascular surgery. The first survey has been completed and will be issued to all SVS members this month to coincide with the SCVS annual symposium. The second, which will focus more on physical issues, will

be released during the VAM in June. Look, no one hates surveys more than I do. We simply have to get this information. Each survey is designed to only take 10 minutes. Things are going to change one way or another. Let’s lead, not wait to follow. With your help this will be the last time I write this ignorantly on this crisis. Vascular surgeons are few in number but this gives us the potential to deliver the most comprehensive self-assessment any specialty has ever performed. Lend your

voice to the coming change. Finally, there are now innovations in use which have proved beneficial in mitigating burnout. A Stanford University School of Medicine program allows physicians to “bank” time spent on committees, teaching, or other administrative duties and exchange these credits for home delivery meals, cleaning services, or even work tasks such as grant applications and paper writing. While the physicians could certainly afford to

pay for these assistances, the success of the program demonstrates it is the time saved in arranging the services that the doctors truly valued. Our happiness seems to excel when we spend our time performing the tasks for which we are best suited. It is time to change. When a system reaches this point, something breaks. Let’s stop being the thing that breaks. Fill out the survey. Get involved. There is time to act before we all burn out on burnout. ■

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The first implant of the GORE® EXCLUDER® Conformable AAA Endoprosthesis occurred recently in the United States. The successful procedure took place in December 2017 at Maimonides Medical Center in New York by Robert Rhee, MD, Chief of Vascular and Endovascular Surgery, and National Principal Investigator. This EVAR device, which is the first to feature angulation control, is part of an investigational clinical study approved by the U.S. Food and Drug Administration (FDA). The clinical study will assess the safety and effectiveness of the device in treating infrarenal abdominal aortic aneurysms (AAA) in patients with challenging anatomy. The clinical study consists of two sub-studies, each assessing the device for a different range of patient anatomies. The implantation by Dr. Rhee is part of the short neck sub-study to assess the device in aortic neck angles of 0 to

MARCH 2018