Vascular Specialist, August 2020

16–17 MED SCHOOL Filling the pipeline: Establishing VSIGs and making them work to ensure vascular future

Vol.16 No.8 AUGUST 2020

Featured in this issue:

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PROFESSIONALISM The social media conduct conundrum

DEPRESSION Women with HIV and atherosclerosis

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Gender disparities SPECIAL ISSUE

Diversity, equity and inclusion: Disparities in medicine and vascular surgery

13 VQI A vascular VISION into EVAR patient care

Black/minority surgeons

Black/minority patients

- inequality of opportunity

- underinvestment - underrepresentation in leadership positions - racial profiling

- food deserts - higher rates of lower extremity complications

BY BRYAN KAY

vascular surgery itself grabbed the international spotlight under this aegis. A paper published in the Society for Vascular Surgery (SVS) peer-reviewed publication, the Journal of Vascular Surgery, sparked widespread derision for the nature of its classification of so-called “unprofessional” social media content among young vascular surgeons. Its primary target was generally interpreted to be female members of the specialty, garnering the viral moniker #Medbikini on, of all places, social media.

This month, Vascular Specialist continues its focus on systemic racism, broadening coverage with a special issue that explores matters of diversity, equity and inclusion across race, ethnicity and gender. Among

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ECENT MONTHS HAVE yielded a conversation on systemic racism perhaps unlike any other before. We’ve learned about how it manifests across society, how it impacts those on the receiving end, and how it can appear in subtle guises, including in healthcare. In the wake of the killing of George Floyd and the racial disparities exposed by the COVID-19 pandemic, last month Vascular Specialist explored what role the vascular specialty might play in this crucible, and looked at what that conversation should look like within vascular profession.

Events since have reminded everyone of another recurring area of disparity: that of inequity across gender. Unfortunately,

Vascular disease

Outcomes

our coverage, from SVS ONLINE we hear about the latest scientific findings in studies that investigate demographic disparities in peripheral arterial disease (PAD) and carotid revascularization.

From within the vascular surgery ranks, we hear from four African American practitioners who detail their personal experiences of racism as well as their clinical and research interests in the arena of healthcare disparities. And we hear about the research that gave rise to the SVS Diversity, Equity and Inclusion Task Force.

All of it nourishes a conversation that, unlike others before, doesn’t look like it will fade away anytime soon.

See page 3–9

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FROM THE EDITOR

On professionals and professionalism

BY MALACHI SHEAHAN III, MD

On March 19, 2019, I sat in the audience of the scientific sessions at the Annual Meeting of the Society for Clinical Vascular Surgery (SCVS). I was there with two of my trainees who were eagerly waiting to present their research. As we watched the abstract presentation “Prevalence of unprofessional social media content among young vascular surgeons,” I thought “Ah ha! A teachable moment.” This proved to be prophetic, although I was the one about to be schooled.

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fter the session I begrudgingly acknowledged the excellent job my trainees had done with their presentations (tough love is the only love to us Irish Catholics). Then I casually mentioned the “interesting” abstract on social media. Be careful, I warned, what you do online reflects not only on you, but also the program. I was allowed about 90 seconds of satisfaction for delivering this sage advice before my residents confronted me with an Instagram post of my wife (a vascular surgeon) pretending to drink out of a bottle of champagne during Mardi Gras, just two weeks earlier. Further digging easily uncovered other potentially unprofessional behavior such as bathing attire, cocktail parties, and my own unfortunate (although not very provocative) Halloween costumes. If Sun Tzu were alive today, he would be forced to add a new chapter to “The Art of War”: “Never stage a battle over the internet with millennials.”

Confronted with my hypocrisy, I reviewed my thought process. It would never occur to me that my wife’s postings were unprofessional, so why the need to judge the trainees so harshly? We can easily rationalize these impulses. In our minds they are young and vulnerable.

But what we’re really saying is these silly kids just don’t understand. Through our best intentions we are infantilizing our trainees, all of whom are adults by any other measure.

There are also much larger issues at play than the

VASCULAR SPECIALIST 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, Frank Pomposelli, MD, David Rigberg, MD, Clifford Sales, MD, Bhagwan Satiani, MD, Larry Scher, MD, Marc Schermerhorn, 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 Membership, Marketing and Communications Angela Taylor Managing Editor SVS Beth Bales

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maturity of our trainees. Modern society has a troubling history of using the term “professional” to marginalize women, minorities, and the LGBTQ community. A Black woman with natural hair, two men holding hands, a Muslim woman wearing a hajib, how many times have these actions or appearances been labeled unprofessional?

“Provocative” is another dangerous term and one that is almost always directed at women. What does it mean when a woman dresses or poses provocatively? Literally, it means they are invoking a strong reaction, with the implication it is deliberate. The further insinuation is that the bearers of this strong response, usually men, are powerless and therefore blameless in their actions.

Confronted with my hypocrisy, I reviewed my thought process. It would never occur to me that my wife’s postings were unprofessional, so why the need to judge the trainees so harshly?

Categorizing movements and ideas as “political” is another weapon commonly employed to suppress women and minorities. Labeling today’s advocates of same sex marriage as “unprofessional” is the same tactic used against past proponents of women’s suffrage and the civil rights movement. Even during this global pandemic, common sense precautions are often labeled political, usually to discredit experts.

As scientists, we must protect our role as educators and shine the light of evidence and truth into these conversations which have been co-opted from us. Rather than classify this behavior as unprofessional, we should view activism for science and human rights as our obligation. Indeed, the ACGME Core Competency of Professionalism calls for residents to exhibit an attitude of altruism and advocacy and to understand that they are accountable to not only the patient, but also to society as a whole.

A conversation on what constitutes appropriate professional conduct on social media is worth having. First, however, we must ensure that any guidelines could not be applied disproportionally to anyone based on their gender, sexual orientation, or ethnicity. Let’s make the most of this teachable moment.

Malachi Sheahan III is the Claude C. Craighead Jr. professor and chair in the division of vascular and endovascular surgery at Louisiana State University Health Sciences Center in New Orleans. He is the medical editor of Vascular Specialist.

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AUGUST 2020

SPECIAL ISSUE

GENDER EQUITY

APDVS reacts to JVS paper, re-avows commitment to diverse workforce

BY THE APDVS EXECUTIVE BOARD

VASCULAR SURGERY TOOK THE national stage during the last week of July as outraged medical professionals across the country responded to a visual abstract posted on Twitter which highlighted a study recently published in the Journal of Vascular Surgery. In short, the study

by Scott Hardouin, MD, et al, entitled “Prevalence of unprofessional social media content among young vascular surgeons,” missed the mark. Its authors suggest the intent was to “empower surgeons” to be cognizant of their social medial footprint available to the general public, including patients and potential employers.

Their “goal was to evaluate the extent of unprofessional social media content among recent vascular surgery fellows and residents,” and they went on to define “professionalism” with a subjective scoring system that demonstrated their own biases, supporting the following as “clearly unprofessional content.”

They wrote: “Health Insurance Portability and Accountability Act (HIPAA) violations, intoxicated appearance, unlawful behavior, possession of drugs or drug paraphernalia, and uncensored profanity or offensive comments about colleagues/work/patients.”

Meanwhile, “potentially unprofessional content” also cited included “holding/ consuming alcohol, inappropriate attire, censored profanity, controversial political or religious comments, and controversial social topics.” These categories were based on previously published studies of “unprofessional” social media content among general surgery and urology residents.1, 2 The methodology was flawed—and some might suggest unethical as three trainees created fake social media

accounts to “study” the 2018 accounts of new vascular surgery graduates (classes of 2016 and 2017). While the study had Institutional Review Board (IRB) approval, the “studied” individuals “waived consent.”

The authors further cited that “inappropriate attire included pictures in underwear, provocative Halloween costumes, and provocative posing in bikinis/swimwear… Controversial social comments were largely limited to comments centered around specific stances on abortion and gun control.”

Labeling these posts “potentially unprofessional” perhaps garnered the most backlash from social media, prompting the viral #Medbikini response on Twitter and Instagram, as countless women and men then posted pictures of themselves in bikinis or other casual attire in mutual support of such “unprofessional” behavior.

Many have criticized that the study unfairly targeted women and other minorities in vascular surgery, potentially deepening slow to change inequities despite years of efforts from our leadership.

The abstract passed through the program committee of a major vascular surgery society, was presented to a group of vascular surgeons at a national meeting, and then went through the peer review process for publication in our leading journal some six months ago. We feel this was a lapse in judgment, and clarified— again—the need to address gender and ethnic disparities in our specialty.

The Association of Program Directors in Vascular Surgery (APDVS) was indirectly associated with this study as our directory was used to compile a list of graduating vascular surgery trainees from 2016 to 2018. We have already posted a statement

SVS vows to learn from journal episode

BY RONALD L. DALMAN, MD

The recent publication and retraction in the Journal of Vascular Surgery (JVS) of the article entitled “Prevalence of unprofessional social media content among young vascular surgeons” has prompted significant dialogue and outreach from Society for Vascular Surgery (SVS) members to the leadership of the Society. We have listened and continue to welcome your feedback and thoughts, particularly from members in the early stages of their career.

AUGUST 2020

on SVSConnect confirming that the APDVS was not involved in the planning, nor the conduct of this study, and immediately removed the internal, password-protected roster of program directors and trainees.

Additionally, all future access to this information will be limited to requests for research, which will be vetted by the issues committee and the appropriate APDVS

made by many within our field of vascular surgery, we recognize the monumental work ahead in enhancing surgical culture in the name of patient care, addressing healthcare disparities, prioritizing vascular surgeon well-being, and optimizing surgical education for vascular surgery trainees.

As such, the APDVS re-avows its commitment to supporting all vascular

committee for educational value, with final approval by the APDVS Executive Board.

The Executive Board would like to further extend our statement and broadly declare that we support our trainees’ excellence, independence and their diversity. The rising generation of vascular surgeons has been raised in the digital era of social media and, perhaps more than any cohort of surgeons, they are most aware of their online presence.

The system needs to mature and adapt, and the APDVS is committed to supporting and moving forward critical cultural and educational efforts that support our diverse workforce of current program directors, vascular surgery trainees, and rising recruits. Diversity is powerful, and our trainees more than anyone should have a supportive training culture to thrive.

The APDVS and its program directors have often been an advocate for these priorities. And while strides have been

surgery program directors and trainees with these vital missions.

SVS LEADERSHIP CONCURS WITH THE DECISION of the editor-in chief of JVS to retract the publication and agrees there was clear unconscious bias and methodologic flaws in both the paper and the review process.

In its constitution and bylaws, the SVS embraces the core values of diversity, inclusion, fairness, and equity. As a professional medical and membership Society, the SVS is fully dedicated and focused on embracing and supporting the individual and collective efforts of its members in their pursuit of excellence. The publication of this paper in the Society’s journal was not aligned with these essential core values and has prompted the SVS to accelerate changes already underway to significantly improve the culture of the JVS, the Society and the specialty.

Over one year ago, the SVS formed a Diversity, Equity, and Inclusion Task Force to look at the breadth and scope of the SVS and make recommendations to strengthen the Society’s alignment to its core value on diversity, equity and inclusion. The report of the Task Force and its recommendations were presented to the Executive

References 1. Koo K., Ficko Z., Gormley E.A. Unprofessional content on Facebook accounts of US urology residency graduates. BJU Int. 2017;119(6):955–60.

2. Langenfeld S.J., Cook G., Sudbeck C., Luers T., Schenarts P.J. An assessment of unprofessional behavior among surgical residents on Facebook: a warning of the dangers of social media. J Surg Educ.

2014;71(6):e28–32.

The APDVS Executive Board writing team was made up of Murray Shames, MD, Jason Lee, MD, Malachi Sheahan III, MD, Dawn M. Coleman, MD, and William Robinson, MD.

Board on July 29. The SVS leadership looks forward to communicating the outcome of this deliberation to its membership as we all shape the future of the SVS together.

While the judgment and decision-making regarding the publication of this paper is unfortunate in the negative light it cast on our specialty, both deserved and undeserved, it represents an opportunity for the Society— and all of its members—to embrace the moment and fully commit to working together to solidify positive change for the future. We will learn form this experience and emerge stronger as a result.

Thank you for making your voices heard. The SVS will continue to work hard to earn your trust, respect and ensure you are proud to be a vascular surgeon and member of the SVS. Ronald L. Dalman is SVS president.

vascularspecialistonline.com • 3

SPECIAL ISSUE

HEALTHCARE DISPARITIES

Black patients in areas with lowest PAD rates disproportionally at 'higher risk for amputation'

BY BRYAN KAY

It’s among the most topical areas of discussion in current U.S. cultural life: Black people face disparities in terms of healthcare outcomes. And the recently concluded SVS ONLINE digital conference produced fresh research in the affirmative.

DATA PRESENTED DURING and regional disparities in Scientific Session 8 on July 2 the prevalence of peripheral suggested that Black patients artery disease and diabetes in areas with the lowest rates and amputation rates among of peripheral artery disease Medicare patients.”

(PAD) and diabetes are at Eid was part of a research disproportionally higher risk team that set out to investigate for amputation. But areas patients with PAD and with higher prevalence of the diabetes at increased risk for disorder have the lowest rates Mark A. Eid non-traumatic amputations. of amputation, suggesting “The associations of race with that these locations are better equipped amputation risk among patients with both to care for these high-risk patients, say PAD and diabetes is not well understood in investigators behind the study from which recent national patient cohorts,” they cited. the data came.

Accessing data from the Centers for The conclusions were delivered by Medicare & Medicaid Services (CMS) presenting author Mark A. Eid, MD, a from 2007–2016, Eid et al identified a surgery resident at Dartmouth Hitchcock 10.5 million-plus cohort of patients Medical Center, in Lebanon, New concurrently diagnosed with both PAD Hampshire, in a talk entitled, “Racial and diabetes. Patients were followed from

Study identifies disparities in early revascularization for symptomatic carotid stenosis

BY BRYAN KAY

Data from a new study carried out in Texas found disparities in those undergoing early carotid revascularization along gender, race and ethnic lines.

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research team from Baylor College of Medicine in Houston demonstrated that women are less likely to receive early intervention than men, and African American and Hispanic patients are similarly less likely than those categorized as Caucasian.

The data were presented by Harold Hsu, MD, a vascular fellow at the institution, during SVS ONLINE Scientific 4 • Vascular Specialist

25.9

amputations per 1,000 between 2007–2016

Black patients had almost a two-fold higher rate of amputation as compared to white patients

52.2 vs. 30.7 per 1,000 patients

the time of diagnosis in order to identify major and minor amputation events, the investigators said, and stratified by race—Black, white and Hispanic—to determine differences in outcomes.

“We examined associations between the regional prevalence of PAD and diabetes, and amputation rates, at the level of the state and the hospital referral region,” they went on.

The average rate of amputation between 2007 and 2016 was 25.9 amputations per 1,000 patients with PAD and diabetes, Eid et al found. Analyzed by race, Black

Session 7 on July 1. Setting the scene, Hsu explained that trials such as CREST established that carotid revascularization—carotid endarterectomy (CEA) and carotid artery stenting (CAS)—has unequivocal benefits to patients presenting at hospital with stroke, transient ischemic attack Harold Hsu or amaurosis fugax, in reducing further stroke in the ipsilateral hemisphere.

Recent literature has demonstrated a benefit to early CEA with a combined mortality and stroke rate of 3.6% for patients treated at three to seven days compared to 5.4% for patients treated beyond 15 days, he said.

It was at this juncture that the researchers decided to probe gender, ethnicity and race to find out whether there were any disparities in early revascularization. The study cohort was derived from the Texas Department of State Health Services database, which the investigators queried to identify all patients older than 45 years old who were admitted to non-federal Texas Hospitals from 2009 to 2013 with a diagnosis of carotid artery stenosis and either transient ischemic attack, stroke or amaurosis fugax.

The team found 27,132 patients—12,802 women, 14,330

“Black patients in areas with the lowest rates of PAD and diabetes are disproportionally the highest risk for amputation overall”— Mark A. Eid et al patients had almost a two-fold higher rate of amputation as compared to white patients (52.2 vs. 30.7 per 1,000 patients; p<0.001) and similar rates when compared to Hispanic patients (52.2 vs. 46.5 per 1,000 patients; p=0.09), the researchers revealed.

“However, states with larger populations of patients with diabetes and PAD had lower rates of amputation across all races,” Eid said. “We also observed an indirect and significant association between regional prevalence of PAD and diabetes, and amputation risk for both white and Black patients.”

Eid et al said that the implications of the study show that regions with higher prevalence of PAD and diabetes “paradoxically have lower rates of amputation, perhaps due to better infrastructure and resources.”

They further concluded: “Concomitant PAD and diabetes is common among Medicare patients, yet rates vary by more than six-fold across the U.S. Regardless of location or prevalence of disease, people of color are disproportionally at higher risk for amputation. Black patients in areas with the lowest rates of PAD and diabetes are disproportionally the highest risk for amputation overall.”

men—who met the inclusion criteria, with most of those who were treated aged between 60–80 years old. In terms of race and ethnicity, those included further broke down as 16,430 white, 4,489 Hispanic and 2,750 Black.

“Adjusting for hospital volume, insurance coverage, area of residence, acute medical illness (including subarachnoid hemorrhage and intracranial hemorrhage), and chronic comorbidities, rates of early carotid intervention remained significantly lower for women (odds ratio [OR] 0.85; 95% confidence interval [CI] 0.79–0.91), persons categorized as black (OR 0.60; 95% CI 0.53–0.69), and persons categorized as Hispanic (OR 0.77; 95% CI 0.70–0.86),” Hsu said.

Elaborating, Hsu said women were significantly less likely to undergo early revascularization when compared to men at a rate of 13.9% vs. 18.2%. Likewise, Hispanic (13.6%) and Black (10%) patients were also significantly less likely than Caucasians (17.9%). Further analysis on presentation and comorbidities showed that patients who presented with transient ischemic attack or amaurosis fugax are much more likely to receive early intervention on the initial admission as opposed to those who presented with stroke at 76.8% vs. 13.4%. Further research is needed to find patient, physician or system-based factors that could help explain the difference in the intervention rates discovered by the research team, Hsu added.

AUGUST 2020

‘If I had gone along the path advised, I would never have become a surgeon’

BY BRYAN KAY

Some of the formative educational experiences described by Olamide Alabi, MD, read like textbook examples of the subtleties many see as baked into U.S. society, multiplying down the years as the very face of systemic racism in the country.

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hese days, Alabi is an assistant professor of surgery in the division of vascular surgery and endovascular therapy, department of surgery, at Emory University School of Medicine in Atlanta.

Back in her schooldays, she was the gifted daughter of immigrant parents from Nigeria—her father a scientist, her mother a social worker—who raced through advanced classes in math and science, yet still found herself sent to a McDonald’s franchise on work experience while classroom contemporaries were lined up with professionals such as physicians, college professors and lawyers.

“Interesting is one way to describe that,” Alabi muses.

The stark juxtaposition between her academic abilities and the measure of a guidance counselor jarred, too.

“They talked to me about tech opportunities, community college opportunities, as opposed to university-level opportunities.”

These might seem like isolated, unfortunate events or microaggressions, Alabi says. “But if I would have gone along the path of those people, who I’m sure meant well in some respects, I would never have become a surgeon, that’s for sure.” She credits the engagement of her parents for helping set her on a trajectory that might otherwise have ended somewhere far short of her capacity.

Onward through college and beyond into her faculty and vascular surgery career, a similar theme runs as if a thread from those early experiences: “These things don’t change, unfortunately, and there’s very little support for Black and brown people who look like me and who go through these things at all levels of academia.”

The reinforcement of white male culture through the use of such surgical mannequins (see related story on page 9) represents another signpost identified by those who’ve been on the conveyor belt. Alabi has other examples. “I can talk about elementary-age or schoolage children: When you have children who want to play with dolls, by and large those dolls, if you’re an

‘Significant’ number of vascular surgery faculty suffer workplace sexual harassment

BY BRYAN KAY

The Journal of Vascular Surgery August issue featured a paper whose findings established a significant number of faculty of vascular surgery training programs had experienced workplace sexual harassment after an anonymous survey.

AUGUST 2020

underrepresented minority don’t look anything like them,” she explains. “When it comes to mannequins or lectures that are provided on, say, dermatological manifestations or (a), (b) or (c), those manifestations are almost exclusively pictured on majority members of society, so predominantly white and Olamide Alabi predominantly male.

“I remember we would have a Black patient come in with a particular rash, and people would say, ‘I don’t know what this is. I have never seen it on this skin type.’”

Alabi shifts to the particular racial disparities exposed in the world of vascular surgery. Indeed, she was drawn

“There’s no accessibility to healthier foods; you can’t even find a grocery store; there’s more or less only fast food locations everywhere” to Atlanta in part to tackle disparate outcomes in lowerextremity vascular disease among people of color. The systemic fault lines are to be found up and down the system. “One of the reasons I moved to the southeast was because, number one, there’s a high proportion of underrepresented minorities who are the patients here, so a lot of Black and brown people. Another reason is because the rates of lower extremity amputations are

“GENDER DISPARITY AND SEXUAL harassment in vascular surgery practices,”

by Matthew R. Smeds, MD, division chief of vascular surgery at St. Louis University School of Medicine, and Bernadette Aulivola, MD, director of the division of vascular surgery and endovascular therapy at the Loyola University Health System in Chicago, led to the creation of the Society for Vascular Surgery (SVS) Diversity, Equity and Inclusion Task Force.

The researchers stepped into the space of sexual harassment as a set of unwelcome behaviors or obscene remarks—known, they point out, to be more pervasive in male-dominated workplaces—that creates intimidating or hostile environments.

The survey Smeds and Aulivola deployed was emailed to 52 training sites across the U.S, querying the type of gender bias and sexual harassment faculty members had experienced. They further sought to establish details such

disproportionately high in this region and that’s something I particularly wanted to focus on.”

She then poses a pointed question: Why? “The predominant theme that I would hear is: ‘It’s the patient’s fault.’” Rationales she hears for assigning blame onto patients: They come in too late; they lack trust in the healthcare system.

Alabi is having none of those explanations. “Since being here, just talking about the ones who come in ‘too late,’ I find many of these people find themselves under the care of a physician—not a vascular surgeon—for years,” she says. “They were doing their best to be seen about their problems and that problem was not appropriately addressed.” Which neatly sets up Alabi’s career ambitions as an academic surgeon: “I am an early career investigator and my overarching goal is to reduce the rate at which people get major lower-extremity amputations and particularly targeting vulnerable populations, being Black and brown patients as well as veterans.”

She is plagued, though, by a bigger question. “There are a lot of studies about health disparities and health equity, particularly when it relates to ‘Black race.’ But what does Black race mean? If there’s no real genetic component that predisposes people to have these poor outcomes, then what does Black race really mean? Is it a surrogate for a high-risk group based on where they live—so is it place not race? Is it a surrogate for a higher rate of—or higher rate of untreated—comorbidities, so microvascular disease, hypertension, smoking, diabetes, renal disease? To me, Black race is the way that people have tried to frame this, knowingly or unknowingly, so that it is unsolvable. I think the bigger problem is actually the social determinants of health, so it’s place not race.”

On the ground, in places predominantly Black or brown, signs of disinvestment can be stark. It’s often chronic, going back hundreds of years, Alabi points out. “These pre-pandemic ills have been going on for so long, they’ve been pervasive and there has been no real public health push to fix these things. Because what’s the bottom line if you’re a policymaker? Why do I have to fix the fact that there are food deserts in these particular locations? There’s no accessibility to healthier foods; you can’t even find a grocery store; there’s more or less only fast food locations everywhere. How do you fix those things, should we fix those things and how am I going to allocate money to something like that? Clearly, it hasn’t been important from a political standpoint.” That is to say, Alabi concludes, the social determinants of health are just as important as the political ones in the theater of disparities and inequities.

as characteristics of the perpetrators, locations as well as reporting mechanisms and any barriers to reporting.

Chief among the findings, Smeds and Aulivola found that of 149 respondents, 48 (32%) thought harassment occurred more commonly in surgical specialties with historical male dominance.

Sixty-one (41%) reported having experienced workplace harassment, with unwanted sexually explicit comments or questions and jokes, being called “a sexist slur or nickname, or being paid unwanted flirtation” the most common behaviors cited.

“Harassment was high in both men and women, although women had a higher likelihood of being harassed (67% of women respondents vs 34% of men respondents; p=0.001) and on average had experienced 2.6 (of 11) types of harassment,” they write.

The majority of harassment came from hospital staff, although women were more

likely to receive harassment from other faculty, the investigators go on. Though 84% of respondents acknowledged institutional reporting mechanisms, only 7.2% of harassing behaviors were lodged.

Furthermore, 30% feared repercussions or felt uncomfortable identifying as a target of sexual harassment. Only 59% would feel comfortable discussing the harassment with departmental or divisional leadership.

“In examining workplace gender disparity, female surgeon responses differed significantly from male surgeon responses in regard to perceptions of gender differences,” the researchers add.

Female vascular surgeons believe gender influences hiring, promotion, compensation, and assumptions of life goals, they conclude. Further research is required in this area, the authors add.

SOURCE: DOI.ORG/10.1016/J. JVS.2019.10.071 vascularspecialistonline.com • 5

SPECIAL ISSUE

RACIAL DISPARITIES

‘Improving disparities in healthcare is not a matter of slapping some paint on something and doing whatever is a quick fix’

BY BRYAN KAY

Andrew Gonzalez, MD, had a heart for underserved and underresourced communities embedded early. The son of a pediatric hematologist mother who worked at Cook County Hospital in Chicago for 31 years, his mom spent a lot of her time treating large numbers of the city’s indigent population. It was a parental backdrop that had so much of an impact, it would eventually lead Gonzalez into vascular surgery.

“IT WAS ONE OF THE ONLY TWO Chicago Hospitals that poor Black patients could have care back when she first started there in the 1960s,” explains Gonzalez, an assistant professor of surgery and research scientist at the Indiana University School of Medicine, division of vascular surgery. “I grew up in medicine. With my mother’s practice at County being what it was, an underresourced hospital providing so much care to poor, minority and immigrant patients, my perspective on American medicine in general as well as the needs of disenfranchised populations probably is a little different than most physicians.”

His own minority background—halfBlack, half-Filipino—is something he identifies as atypical in the popular imagination: That is to say, he was raised by an African American single mother after his Filipino father abandoned the family early shortly after his birth, Gonzalez says.

Deeper still, healthcare and academia both run deep in his family. On the maternal side his lineage descends from a Scotsman who immigrated to the Caribbean island nation of St. Kitts and Nevis. That branch of the family tree landed on the shores of the U.S. His great-great-grandmother, a midwife, immigrated from St. Kitts to New York

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City to take over the practice of an obstetrician who, as family legend has it, returned to Germany to fight for the Kaiser in World War I. His grandfather—the Andrew Gonzalez descendent of enslaved people— had the opportunity to attend a master’s program at NYU after their family sold their prized hog in a small town in Kentucky. There, his grandfather met his grandmother while studying literary criticism of early African American writings.

Then his mother picked back up the healthcare thread, heading to medical school at the historically Black college of Howard University in Washington, D.C., during the era of segregation.

All of which set the stage for Gonzalez to assume the mantle of a family tradition. Almost inevitably, that would mean at some point a research focus on healthcare disparities. Before assuming his current role, he had undertaken a research fellowship at the University of Michigan.

“During this time, I published a few papers on disparities in outcomes for

certain patients,” he says. “One of them looked at a national study evaluating hospital volume and inpatient mortality after open AAAs [abdominal aortic aneurysms] in vulnerable patients. We defined ‘vulnerable’ patients as Black or low socio-economic status.”

Gonzalez said they found that while there seemed to be a volume-outcome effect for all patients undergoing major surgery, Black patients had disproportionately worse outcomes in low-volume hospitals. Aside from the main finding, Gonzalez emphasized the study highlights: “There are very complex relationships between race, socioeconomic status and hospital factors,” going on to say that “gaining a deep understanding of how to improve disparities in healthcare—and in the country in general—is not just a matter of slapping some paint on something and doing whatever is a quick fix. For some of the underlying factors, we don’t even know why they’re happening, much less what to do about them.”

Away from the science, Gonzalez describes his version of the all-too-familiar experience of being Black on campus. “A lot of people have the idea that, ‘Well, you’re a doctor, so it’s different.’ Sure, in the hospital, and maybe if people know who you are and if they’re too afraid to say something overtly racist. But, even in surgery residency, you have to leave the hospital at some point. When that happens, you’re just another Black guy on the street. I’ve been hassled, clearly followed, for walking while Black. Not

“Even in surgery residency you have to leave the hospital at some point. When that happens, you’re just another Black guy on the street”— Andrew Gonzalez

arrested, not charged.”

Gonzalez sees such frivolous interactions as indicative of the “pretense” suffered by minorities—“meaning some people in authority take an action that’s seemingly in their power, but they’re doing it for ulterior motives. Rules that no one anywhere is ever hassled for...like jaywalking on an internal campus street.

Can you really jaywalk on a non-public street? Or was that just an excuse to see my ID and run a background.”

Back on the subject of working toward fixing disparities in healthcare outcomes, Gonzalez recalls the example of his mother once more.

“She gave out vaccinations,” he says.

“The hospital would drive doctors and nurses into the neighborhoods and give people polio vaccines and stuff like that.

Now it’s not really possible to do some of those things given everybody’s work schedules, administrative requirements, and the general corporatization and depersonalization in modern healthcare delivery.”

For vascular surgery in particular, for conditions such as peripheral arterial disease and end-stage renal disease, a number of social determinants of health play into outcomes, Gonzalez argues. “I don’t think that the outreach from our organized vascular societies is as robust as it could be. For all we know it might be a better vascular public health intervention to send docs out to the barber shops and do education on PAD like the urologist did for prostate cancer in African American men, but I don’t think the sense of urgency/excitement exists around that compared to say doing outreach in other countries.”

That is the philanthropic side of medicine as he understands it.

“Growing up in the inner-city with a single mother and looking outside of our window—we had to live close to Cook County Hospital because there wasn’t really babysitting or any of that—on the weekends for the clinic, the line would wrap around the entire block.

I’m not 100% certain why our [surgical] societies don’t have widespread organized outreach efforts within the United States as opposed to always going to other countries and doing it.”

AUGUST 2020

SPECIAL ISSUE

PROFILING

Doubted as a doctor during mid-flight medical emergency and once asked: ‘Shouldn’t you be playing basketball?’

BY BRYAN KAY

In a vascular surgery career spanning 20 years, Vincent Rowe, MD, has seen it all: Tending to patients at bedside, the vascular surgical services chief at Los Angeles County + USC Medical Center has had his very presence as a doctor called into question. In social conversation, upon answering the query of what he does for a living by stating that he is, in fact, a physician, he’s had to confront the response that suggested he should be playing basketball. On an airplane journey, he’s been asked to produce his medical license during an on-board medical emergency after answering a call for the aid of a doctor.

I

t’s been demoralizing to the point he now often refuses to identify himself as the senior medical professional that he is in certain social and everyday-life scenarios.

Yet, Rowe, professor of clinical surgery at the Keck School of Medicine of University of Southern California and a faculty member of the USC Cardiac and Vascular Institute, is philosophical about the differences between individual slights and the more insidious presence of systemic racism— and what it all means.

“It’s hard to categorize whether just a few individual negative interactions characterize systemic racism,” he says. “I’ve had things said to me from when I was in Tennessee all the way to just a month ago. Things that were racially insensitive and hurtful. But I don’t know if that means I’m experiencing the systemic problem.”

But ostensibly small—or sometimes subtle— instances of discrimination could mount up into something more.

“For example, over the years, when I walked into a patient’s room, in clinic or in the hospital, there were numerous times where I felt I wasn’t the doctor,” Rowe says. “They would comment to me, ‘Oh, when is the doctor coming?’ Or, ‘Who are you?’ And I would say, ‘Oh, I’m Dr. Rowe.’ Or even just the comment of, ‘Oh, why are you a doctor? You look like you should be playing basketball.’ Why? Because I’m a tall Black male, I can’t be doctor—I have to be a basketball player?”

Over the course of time, Rowe says, such discourse wore him down.

“When I would travel on vacation with my wife, if I started a conversation on a plane with someone, they would ask, ‘What do you do?’

And I would say, ‘I’m a doctor.’ It was as if they couldn’t believe it, so they would have to keep asking me. Questions, questions, questions to solidify the fact that I actually was a doctor.

It got to the point that when we traveled, or even when I was around the city, or we were at an event, and we started a conversation with people where they asked me what I did, I wouldn’t say I was a physician. I would say I was an actor, struggling actor, or an electrician, and then I wouldn’t get any additional questions.”

more systemic parts.”

As a surgeon in Los Angeles, he has witnessed healthcare disparities along racial lines from both a clinical point of view and from the vantage point of a researcher.

Over time, he took a special interest in race-related

called the BEST trial—the best endovascular or surgical treatment for patients with lower extremity disease—and I’m hoping that that national randomized trial that our institution was a part of will be able to find a more precise answer to the differences in outcomes based on race for patients with lower extremity disease.”

#METOO

Vincent Rowe

“They would comment to me, ‘Oh, when is the doctor coming?’”—Vincent Rowe

STOP-AND-FRISK The more visceral aspects of systemic racism—like the stop-and-frisk and profiling actions of police—were omnipresent when he was a student. “I got pulled over [driving] numerous times by policemen because of that during college and medical school especially. All of those things have always happened, and those to me are the 8 • Vascular Specialist

The country has lived these moments of consciousness over racial disparities before, only for the zeitgeist to move on, but he sees the storm that followed the killing of George Floyd by police as one that will prove to be more enduring.

“I think the majority of America is in a more accepting state and a different mindset,” explains Rowe. “I think a lot of that has to do with the #MeToo movement. I think America finally said, ‘Look, we’re going to stop this harassment of women that’s been occurring, and we’re going to look into the past. We’re going to not only look into it and say it’s wrong, but we’re going to prosecute people for it.’”

The consequences of that movement, Rowe continues, opened up a sensitivity in the country, creating fertile ground for change in other areas of the culture. “It’s at a good time that that mindset of America is still open toward racial inequity. There’s going to be some change—I don’t know how much—but I think there will be.

“I’ve been talking about this a lot. For 20 years, I only talked about science and now I’m talking about race. America is ready for it. There’s going to be some backlash. But it’s going to come from a very small group. The #MeToo movement prepared us because it has really cracked open some atrocities that were happening to women.”

DRAINING vascular disease outcomes.

“When I started working at our county facility, I saw there was a significant amount of poverty and patients representing with diseases much more out of control than in our private facility,” Rowe explains.

“It was somewhat interesting to me to see that the patients seemed to have in some areas different outcomes based on race. That’s when I started looking at least at lower extremity disease on the outcomes of patients based on race.

“I published a few articles, but I never was able to really, clearly define it with a large grant and a big multicenter institutional study. We just took part in a national study

Rowe then turns to a useful metaphor that underscores the stalking effect of race as having any sort of bearing on a person’s life. “You don’t want things to have an impact based on your race,” he says. “But you’re always thinking about it. It’s almost like the app on your phone that’s always running in the background. Maybe you don’t press to use it, and you hope you don’t have to, but it’s still running in the background and it’s draining your battery.

“That’s the analogy. It’s in the background, I guess it’s still there but it’s draining you a bit. Hopefully you go through days and days without it ever asserting itself. But you still always wonder because it’s back there in your mind. That’s how it feels.”

AUGUST 2020

‘Casting a wider net’ when researching genetic and molecular factors of disease

BY BRYAN KAY

For vascular surgeon and research scientist Elsie Gyang Ross, MD, the world of data science might hold some of the answers to the kind of healthcare disparities on which the current cultural climate has refocused minds.

ROSS, AN ASSISTANT PROFESSOR OF vascular surgery at the Stanford University Medical Center in Stanford, California, runs a research lab—largely focused on data science—that is starting to look into some of the issues related to disparities in healthcare.

“Something that’s getting a lot more attention now is using genetics to revolutionize how we deliver medicine and make things more personalized,” she explains. “But what often doesn’t get mentioned is the genetic data that we have for the most part comes from a very narrow band of the population, typically Caucasians or people of European descent.

What that means for precision health for minorities does not get discussed a lot. And it has the potential to further disadvantage a group of people who tend to be already disadvantaged in the healthcare system.”

Ross’ research zeroes in on the use of big data and advanced analytics to find novel risk factors for peripheral artery

disease (PAD) and improve risk prediction for vascular disease through precision health approaches.

In this vein, Ross is about to begin work in the vascular space aimed at broadening the data pool—meaning the recruitment of a more diverse patient population—so that the findings are more widely applicable.

“I’m soon to be working on a project where we’re looking at molecular mechanisms of peripheral vascular disease

“I think where race and, quite frankly, more gender has played a role is in being on faculty”— Elsie Gyang Ross

‘White male culture in medical school could perpetuate healthcare disparities’

BY BRYAN KAY

An often omnipresent culture of white male representation in medical schools could “lead even the most well-meaning students to perpetuate healthcare disparities in their future practices,” a recent perspective published in the New England Journal of Medicine argues.

LASHYRA NOLEN, BS, A FIRST-YEAR STUDENT at Harvard Medical School in Boston, runs through how such an environment affects medical education and, ultimately, the quality of care graduates might go on to

AUGUST 2020

with the goal of casting a wider net for recruitment—including minorities specifically in our research on the molecular level—just to make sure we’re not making conclusions based on a narrow band of the population.”

On a personal level, Ross says she enjoyed a medical education and residency free of racial bias, a time inspired by an environment that included a number of fellow African American vascular residents and surgeons positioned above her as her career trajectory developed. “I think where race and, quite frankly, more gender has played a role is in being on faculty, mostly because I start to wonder when I have interactions with patients what their perceptions of me are.”

As the cultural moment plays out, Ross believes this time the renewed focus could be different. “Just within my university, I’m a part of two different departments and divisions, and every committee or department I’ve been a part of has talked about this,” she says. “Whereas, before, one or two people might be interested in saying something but it never became a concerted effort to make changes within our purview.”

Ross also sees a degree of complacency in the U.S. over equity and racial medical outcomes. “I remember when I was applying for colleges, and

provide in a piece entitled, “How medical education is missing the bull’s-eye.”

She highlights an example of how this culture can manifest itself, referencing a microbiology class that took a look at Lyme disease. Quoting her professor, she writes: “‘A hallmark of stage 1 Lyme disease is a bull’seye rash, erythema migrans, which typically appears three days after infection,’ the professor explained confidently.” Behind him, Nolen goes on, was an image of a prominent red bull’s-eye rash on white skin. “Shortly after the explanation, a classmate raised his hand and asked the professor, ‘How do you recognize this rash in patients with darker skin?’ The professor responded that

“Is the diagnosis of Lyme disease in Black and brown patients delayed? Do these patients therefore present with more advanced symptoms, such as neurologic disorders and arthritis, than white patients?”— LaShyra Nolen

affirmative action started to become a dirty word, then eventually there were laws and lawsuits about whether or not you could use race for admissions practices,” she says. Then came the election of President Barack Obama to the White House. Eyes were taken off the ball, Ross considers.

“There are issues of systematic racism against minorities, and the only way to solve these issues is to systematically figure out ways to improve the stature and wellbeing of minorities. That involves being more proactive.”

The problems start early, she goes on.

“By the time you’re looking to recruit someone for medical school, or for faculty, it’s just way too late.”

Elsie Gyang Ross

it is more difficult to see the rash on melanated skin and moved on to the next slide.”

That got her thinking. She ponders such questions as: “Is the diagnosis of Lyme disease in Black and brown patients delayed? Do these patients therefore present with more advanced symptoms, such as neurologic disorders and arthritis, than white patients?” She adds: “More research revealed that my hypotheses were correct.”

Furthermore, Nolen goes on to outline possible prescriptions that could be instituted in the early years of a medical degree in an effort to address iniquities.

She calls for medical schools to obtain female-bodied mannequins “so that students can comfortably learn about the nuances of performing CPR [cardiopulmonary resuscitation] on patients with breasts.” She also writes that “medical educators should strive to include images of more than one skin type in their learning material.”

Summing up, Nolen provides a snapshot of possible real-world consequences of omnipresent white male representation in medical school. “If medical students and trainees are taught to recognize symptoms of disease in only white patients and learn to perform lifesaving maneuvers on only male-bodied mannequins, medical educators may be unwittingly contributing to health disparities instead of mitigating them,” she writes.

“Most worrisome, the United States may be in danger of graduating large numbers of physicians who are unable to serve the needs of our ever-diversifying patient population.”

SOURCE: DOI:10.1056/NEJMP1915891

vascularspecialistonline.com • 9

CAROTID STENOSIS

Depression linked to more prevalent subclinical atherosclerosis among women living with HIV

BY BRYAN KAY

Women living with HIV who reported a high burden of psychosocial risk factors like symptoms of depression, stress and post-traumatic stress disorder (PTSD) were more likely to have prevalent subclinical atherosclerosis compared with those indicating a low burden, a study published in the Journal of the American Heart Association (JAHA) found.

MATTHEW E. LEVY, PHD, OF THE department of epidemiology in the Milken Institute School of Public Health at The George Washington University, Washington, D.C., et al further stated women with the virus who persistently reported high depressive symptoms over approximately equal to seven years had a greater risk of incident subclinical atherosclerosis compared with those who either rarely, never or sometimes reported high depressive symptoms.

People living with HIV have an elevated risk of subclinical atherosclerosis and cardiovascular disease, which is attributed in large part to chronic inflammation and immune activation, according to the research team. Additionally, women living with the virus have an almost equal to three times greater cardiovascular disease

10 • Vascular Specialist

risk compared with HIV‐negative women.

This suggests that the HIV‐associated cardiovascular disease risk is greater among women compared with men, they argue, though the cause is not well understood.

Identification of novel pathways that can explain the excess risk among women with HIV is needed, Levy et al write. That brings the team to the novel pathway of depression. “One potential [cardiovascular disease] pathway that remains understudied among [the group], despite women living with HIV and particularly [those] of color being disproportionately affected, is depressive symptoms and psychosocial risk,” the investigators elaborate.

Participants were women aged 25–60 years in the Women's Interagency HIV Study—a multicenter prospective observational cohort study of women

living with HIV and demographically similar HIV‐uninfected women at risk of infection—who had participated in a cardiovascular disease sub-study between 2004 and 2012. They were initially recruited and enrolled in 1994–1995 or 2001–2002.

During semiannual visits, participants completed structured interviews, and physical and laboratory assessments.

Participants with a known history of coronary heart disease were excluded to ensure currently “at risk” participants.

Right carotid artery ultrasounds were performed in 2004–2005 and again in 2010– 2012. “We defined the presence of focal plaque as localized intima‐media thickness >1.5mm in at least 1 of 6 locations: the near and far walls of the common carotid artery, carotid bifurcation and proximal internal carotid artery,” the researchers

explain. For cross‐sectional analyses, they defined prevalent focal plaque at the time of the final carotid ultrasound measurement in 2010–2012 and excluded participants with a known history of coronary heart disease. Three psychosocial risk factors were defined using self‐ reported data: high depressive symptoms, high perceived stress, and probable PTSD. Results show that among 700 women (median age 47 years), there were two classes of psychosocial risk—high (n=163) and low (n=537)—with corresponding prevalence of depression (65%/13%), high stress (96%/12%), and probable post-traumatic stress disorder (46%/2%).

Among women with HIV, plaque prevalence was 23% and 11% in high versus low psychosocial risk classes (adjusted odds ratio [aOR], 2.12; 95% CI, 1.11–4.05), compared with 9% and 9% among HIV‐ negative women (aOR, 1.07; 95% CI, 0.24– 4.84), respectively.

New plaque formation occurred among 17% and 9% of women living with HIV who reported high depressive symptoms at ≥45% versus <45% of visits (aOR, 1.96; 95% CI, 1.06–3.64), compared with 9% and 7% among HIV‐negative women (aOR, 0.82; 95% CI, 0.16–4.16), respectively.

The study shows that psychosocial risk factors were independent for subclinical atherosclerosis in women with HIV, the authors write.

SOURCE: DOI.ORG/10.1161 JAHA.120.016425

AUGUST 2020

October 2019 | Issue 01

Clinical trials confirm efficacy of TLC-NOSF dressing for the safe treatment of leg ulcers

Michael Edmonds:

Diabetic foot care: A new era

Page 6

William Ennis:

Profile

Results from two open prospective trials have revealed that the TLC-NOSF sucrose octasulphate dressing, with poly-absorbent fibres, represents an effective and safe treatment for the local management of leg ulcers. In addition, cost-effectiveness studies examining the economic impact of the dressing have demonstrated that significant annual cost savings can be achieved with TLC-NOSF sucrose octasulphate dressings.

Page 12

IWGDF unveils new infection and PAD guidelines for diabetic foot patients

Members of the International Working Group on the Diabetic Foot (IWGDF) presented up-to-date guidelines for the diagnosis, prognosis and treatment of diabetic foot ulcers at the 29th conference of the European Wound Management Association (EWMA; 5–7 June, Gothenburg, Sweden), highlighting development on the areas of infection and peripheral arterial disease (PAD).

S

ylvie Meaume (Hôpital Rotschild, Paris, France) presented the findings of the NEREIDES and CASSIOPEE multicentre trials at the European Wound Management Association’s (EWMA) 29th conference (5–7 June, Gothenburg, Sweden). She said: “It is difficult to treat these wounds and 40–50% of venous leg ulcers remain unhealed after 12 months.

Also, the problem of recurrence is a major issue, with there being more than a 70% recurrence rate within three months.”

An effective treatment of leg ulcers

The NEREIDES and CASSIOPEE trials aimed to assess the efficacy and safety of the TLC-NOSF dressing in the local management of leg ulcers at different stages of the healing process, and were conducted across a total of 35 centres, hospitals and private practices in France. Patients with non-infected, moderately to heavily exudative leg ulcers—either of venous or mixed aetiology—were treated with the dressing and

FIRST REVEALED AT the 8th International Symposium on the Diabetic Foot (22–25 June 2019, The Hague, The Netherlands), the eight new documents also include guidelines for the prevention of wounds, wound classification and wound healing.

The process of making the guidelines, according to Benjamin A Lipsky (University of Washington, Seattle, USA), involved the formulation, by a multidisciplinary working group, of clinical questions and key outcome measures “that clinicians would care about” when treating patients with diabetic foot problems. These questions were reviewed by clinicians and a systematic review of the complete scientific literature was subsequently performed. Once this had been achieved, recommendations were graded to establish how useful they might be.

Continued on page 5

Continued on page 2

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VQI

A Vascular VISION: Improved patient care

BY BETH BALES

Call it a VISION for improving patient care by being able to see how specific hospitals or institutions perform in terms of long-term patient outcomes following endovacular aneurysm repair (EVAR).

VISION IS THE VASCULAR IMPLANT Surveillance and Interventional Outcomes Network. It is a partnership between the Society for Vascular Surgery (SVS) Patient Safety Organization’s Vascular Quality Initiative (VQI) and Medical Device Epidemiology Network (MDEpiNet).

The goal is to improve the safety and effectiveness of vascular care. MDEpiNet brings together public and private leaders, experts, and resources to advance a national patient-centered medical device and surveillance system.

VISION developed algorithms to allow VQI EVAR patients to be matched to five years of Medicare claims data. Claims linkage allows very complete follow-up

at the centers.

“The VQI believes that monitoring longterm performance after EVAR is critical to the care of AAA patients. Providing feedback to members is an important step to improving the quality of care for patients with vascular disease,” said VQI medical director Jens Eldrup-Jorgensen, MD. “By allowing each center to review its EVAR performance in relation to others, this data can be used to focus quality improvement initiatives across the VQI.” Goodney noted that long-term surveillance is vitally important information to have, but that it is also difficult to get for a variety of reasons, including that surveillance may have been

“By allowing each center to review its EVAR performance in relation to others, this data can be used to focus quality improvement initiatives across the VQI”—Jens Eldrup-Jorgensen on CMS patients (greater than 65 years of performed at a different center than where age, dialysis, etc.) and over time, often for treatment was received or due to lack of many years. Subsequent reports provide follow-up care. five-year performance outcomes, including Currently, the matched data sets contain reintervention, survival, and imaging all VQI cases from Jan. 1, 2003 to Dec. 21, surveillance rates for each center and the 2016. Of the nearly 30,500 cases eligible for VQI overall. matching, a total of 76% were able to be VQI collects demographic, clinical, matched for the indexed procedure. procedural and outcomes data from more VISION’s primary goal is to facilitate than 680 participating centers across 46 low-cost, high-value and real-world states and Canada, captured in 14 registries. evidence research through the creation of a “This provides new and very valuable national repository of linked clinical-claims insights into the effectiveness of care for analytic datasets. patients treated for aortic aneurysm,” said Secondary objectives are to measure Philip P. Goodney, MD, of Dartmouththe safety and effectiveness of vascular Hitchcock Medical Center, principal devices, including predictor derivation and investigator for VISION. “We now comparative effectiveness; health disparities will be able to know, based on what and outcomes; and the impact of medical surgeons decided to do, the survival and practice guidelines and healthcare policies. reintervention rates for VQI-Medicareeach of their patients derived outcomes and for centers as a in VISION that are Webinar available whole.” available include death; for viewing Centers will receive procedure-specific survival, reintervention adverse outcome Goodney discussed VISION and its ramifications during and surveillance such as stroke, aortic VQI ONLINE, the VQI virtual reports specific to their rupture, or amputation; annual meeting. A recording center—indicating how reintervention; of the July 21 session is now that center is doing readmission; postavailable—at no charge—at compared to national procedure imaging; and the VQI ONLINE tab at benchmarks—with a cost. A reintervention is vsweb.org/Planner2020. goal of improving the defined as any open or quality of vascular care endovascular procedure AUGUST 2020

680 VQI plumbs 680 participating centers across 46 U.S. states and Canada, captured in 14 registries following the initial procedure that is related to the durability of EVAR. All patient confidentiality is carefully maintained in the matching of the claims and VQI data, Eldrup-Jorgensen emphasized. Use of the data is

governed by a Data Use Agreement (DUA) between Weill Cornell Medical College and the Centers for Medicaid and Medicare Services (CMS).

For more information on VQI, visit vqi.org.

VESAP5 available for purchase

BY BETH BALES

The fifth edition of the Vascular Educational Self-Assessment Program (VESAP), with a substantially enlarged section on vascular ultrasound and imaging, is now available for purchase.

AND BECAUSE OF THE EXISTING financial stresses and increased demand for online learning, SVS is offering an early-bird 20% discount for a limited time.

The Vascular Lab section, produced in

cooperation with the Society for Vascular Ultrasound, may be purchased separately.

Successful completion satisfies the threeyear continuing medical education (CME) requirement of the American Registry for Diagnostic Medical Sonography in order to maintain Registered Physician in Vascular Interpretation (RPVI) certification.

VESAP5 topics align with VSCORE (the SCORE curriculum specific for vascular surgery training programs and followed by the Vascular Surgery Board) and questions are based on current practice, trends and guidelines.

The comprehensive package offers 97.5 CME credits. VESAP5 Vascular Lab offers 30 CME credits. As with the fourth edition, VESAP5 will also include a companion mobile app for use in an offline setting.

For more information visit vsweb.org/VESAP.

VESAP5 Pricing Comprehensive Package

Vascular Lab module

Purchaser

Early-bird Pricing

Full Price

Early-bird Pricing

Full Price

SVS Member

$457w

$610

$225

$300

SVS Candidate

$408

$544

$204

$272

Nonmember MD

$536

$715

$267

$357

Allied Health nonmember

$461

$615

$231

$308

vascularspecialistonline.com • 13

REIMBURSEMENT

Don’t throw away money: Attend virtual coding workshop

BY BETH BALES

With continued concerns over COVID-19 and restrictions on in-person gatherings, the Society for Vascular Surgery (SVS) will hold its 2020 Coding and Reimbursement Workshop virtually. The main workshop will be held Sept. 25 and 26. The optional E & M workshop, with a separate registration and fee, will be held Sept. 24.

CODING DIRECTLY IMPACTS A SURGERY practice’s bottom line; if done incorrectly, surgeons can leave money on the table. That is why faculty members frequently stress that surgeons or designated staff should know to accurately code procedures and stay current with ever-changing guidelines.

“We want to make sure that doctors optimize their revenue. The course is their opportunity to hear about accurate coding, the kind of coding that will optimize their revenue,” said Teri Romano, a coding and reimbursement specialist/consultant and longtime faculty member for the SVS workshop.

“It’s more important than ever,” she said, given

14 • Vascular Specialist

Medicare upcoming reduced surgical payment reimbursements – which the SVS and other surgical associations are fighting, new Evaluation and Management codes and anticipated changes in the Physician Fee Schedule. The guidelines for E&M codes have been completely revised, taking effect Jan. 1, 2021, with either “time” or “medical decision-making” to be the only determinants for level of service and reimbursement. These changes will be presented in the optional workshop, Romano said. “Surgeons will have to modify their documentation to fit these new guidelines,” she said.

Participants at previous workshops find the experience well worth it. “This course is part of our compliance plan to stay up to date on our billing protocols,” said one attendee from a previous workshop. Another reported learning how critical thorough dictation is and a third said, “I will most definitely alter my documentation practices.”

Faculty members are Sean P. Roddy, MD, SVS CPT (Current Procedural Terminology) code advisor and chair of the SVS Policy and Advocacy Council; Romano; Sunita D. Srivastava, MD, vice chair of the SVS CPT/RUC (RVS Update Committee) Committee; and Robert M. Zwolak, MD, who has extensive vascular surgery coding expertise.

Main course fees are $620 for members, $670 for non-members and $175 for residents/trainees. Fees for the optional workshop are, respectively, $70, $80 and $35. This event is currently planned to be a live online program and will not be offered on demand at a later date. The optional workshop will not be recorded.

For more information, including the program agenda, visit vsweb.org/Coding2020

AUGUST 2020

VASCULAR FUTURE

Integrated vascular residency recruitment: Start pipeline earlier, engage more deeply

BY BRIGITTE SMITH, MD

Our great specialty and the patients we serve face an impending critical shortage of vascular surgeons in the decade ahead.

The Association of Program Directors in Vascular Surgery (APDVS) and the Society for Vascular Surgery (SVS) have recognized this issue and responded by redoubling recruitment efforts through the work of their student and resident recruitment and outreach committees. Among various recruitment efforts, the importance of establishing and actively programming vascular surgery interest groups (VSIGs) have been emphasized.

may be insufficient. Channeling medical students into the vascular pipeline demands a multifaceted approach.

In order to inspire students to sustain interest and fully explore a career in vascular surgery, we need to give them more than pizza and some Polytetrafluoroethylene (PTFE) to sew on. After several years as the faculty advisor for the University of Utah VSIG, I’ve come to appreciate three phases of recruitment: early engagement, sustaining interest and mentorship for success.

Early engagement is all about generating excitement and curiosity, as well as sharing our professional identity as providers of #ComprehensiveVascularCare. Students can’t choose a career they haven’t heard of, so getting the word out is an important first step—and it’s never too early.

I participate in this camp by giving a lecture about vascular surgery and providing a hands-on experience with expired sheaths, wires and catheters. The high school students love it and the MS1 students—who thought they wanted to be cardiologists—show up in my clinic to shadow.

PRE-MED

“I first met Dr. Smith in an elective course she teaches about QI to first-year students.

I had no prior knowledge about vascular surgery but was intrigued by her comments about her patients and career that were woven throughout the lectures as examples”— Madeline DeAngelo

To fill the pipeline at the outset of medical school, we need to engage with high school STEM and undergraduate pre-medicine programs. Academic and community vascular surgeons alike should engage in recruitment at this broad level, where grass-roots initiatives can truly have an impact. Pre-medical students need to distinguish themselves among their peers, as medical school admission is becoming increasingly competitive. Any opportunity you can offer them to assist in your clinic or research lab will enhance their application while providing early exposure to vascular surgery. Reach out to your nearest college campus, find out if they have a pre-med program, and offer to provide opportunities to interested students.

Here at the University of Utah, first-year (MS1) students host an annual, week-long “Camp Cardiac” summer program for local high school students. I am not too proud to participate in a cardiac program! Every summer,

PRE-CLINICAL MEDICAL STUDENTS Integration of vascular surgery content into the preclinical curricula of medical schools is a task that can only be addressed at the local level. After serving on multiple committees and subcommittees for our Liaison Committee on Medical Education (LCME) site visit this past year, I can tell you that the LCME is focused on process measures

AAUB

VSIGS ARE A GREAT PLACE TO START, BUT OUR standard line-up of VSIG events—including lectures, case presentations, and even hands-on simulation events—

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in the accreditation of medical schools and, in general, does not evaluate schools in terms of specific curricular content, nor the specialists who are selected to teach it.

Furthermore, all politics are local. Faculty must engage with their local dean’s office to identify where, when and how vascular surgery topics are taught in their curricula.

With many schools moving to the likes of case-based, problem-based and team-based learning, stepping in for a traditional lecture about peripheral arterial occlusive disease is unlikely to be an option. Consider more creative ways to share your expertise through curricula on end-oflife decision making, physical exam skills, or, as in my case, quality improvement (QI). Since I started, the number of shadowing requests I receive each year has more than tripled.

“I first met Dr. Smith in an elective course she teaches about QI to first-year students. I had no prior knowledge about vascular surgery but was intrigued by her comments about her patients and career that were woven throughout the lectures as examples. Since shadowing her, I’ve become the co-president of my institution’s VSIG, and am involved with multiple vascular surgery research projects,” says Madeline DeAngelo, an MD-candidate, class of 2023, at the University of Utah School of Medicine.

While the return on investment is admittedly low in the early engagement phase, the time commitment and effort to prepare are minimal. A VSIG can fill much of the need for fun events and pizza with pre-clinical medical students,

and is often the mechanism that initially exposes students to vascular surgery. Unfortunately, many institutions lack this crucial starting point. Only 48 VSIGs are listed on the SVS website, while 59 integrated vascular surgery residency programs participated in the National Resident Matching Program in 2020. With 155 allopathic and 36 osteopathic medical schools in the United States, we can’t rely on the 30% of medical schools that have an integrated program to recruit through their local VSIG—but they should lead the way. Cultivating curiosity and supporting students to investigate our specialty as a career choice is the important follow up that needs to occur.

SUSTAINING INTEREST Sustaining interest requires deeper and more personal engagement and availability. Vascular surgery faculty, residents and fellows should provide contact information at all early engagement activities. When students reach out to express their interest, we must enthusiastically respond.

“Our VSIG decided to host an endovascular simulation event for interested students with a cap on attendance to ensure everyone who came received plenty of time with the devices and attention from the faculty,” says DeAngelo.

“This was a huge hit at my institution. Students mentioned that it was the most exciting and hands-on event they’d ever attended (across all specialties). The integration of

anatomical knowledge with the technical skills of using the equipment provided a really unique experience.

I hope all VSIGs are able to provide these kinds of immersive events for students.”

As students express their interest more deeply, offer to mentor them on a research project. Many students have free time between the MS1 and MS2 years to engage in research, which can sustain their interest. Ideally, research projects should be thoughtfully selected to optimize the chance to present at a regional or national meeting.

The SVS hosts an incredible student and resident program at the Vascular Annual Meeting (VAM) each year. Unfortunately, many students identify the cost of attending VAM as a significant barrier. Vascular divisions and individual vascular surgeons should consider sponsoring a student to attend.

MENTORSHIP FOR SUCCESS Personal mentorship is important throughout the process.

The SVS VSIG toolkit highlights the importance of organizing and promoting mentorship opportunities.

Once the VSIG has helped to make connections, the onus is on us to commit to building meaningful, longitudinal relationships. We can all identify the early mentors who inspired us to pursue vascular surgery. These mentors were available, making time in packed schedules to meet with us one-on-one. They treated us like colleagues, respected us as professional adults, and didn’t sugar-coat the reality of life as a vascular surgeon. They went the extra mile for us, inviting us to scrub on cases during non-surgical rotations and connecting us with colleagues across the country. At least, that’s what my mentors at the University of Wisconsin did for me, and what I try my best to do for my students today. These relationships are incredibly important to ensure students interested in vascular surgery are successful in the match, during residency and as they join our proud ranks as faculty.

Finally, we can all personally benefit from VSIG events and providing mentorship. Each of my partners and fellows who have participated in a VSIG event have come away re-energized by these young professionals.

“At one VSIG event, I was taught by a faculty member how to maneuver various catheters and wires and felt like I became a junior vascular surgeon, just for a few seconds,” says DeAngelo. “That one-on-one interaction left me fueled to pursue the specialty and investigate additional involvement opportunities.”

To protect and grow our great specialty, we must engage students early on in their careers, sustain their interest through opportunities to explore the field, and, most importantly, serve as their mentors. Each program that participates in the NRMP and matches an outstanding future vascular surgeon should commit to mentoring at least one student to enter the match each year. If we make this simple commitment, no program should ever go unfilled, and we will be better equipped to meet the needs of our patients in the years ahead. .

Brigitte Smith is vice chair of education for the University of Utah department of surgery, program director of the vascular surgery fellowship, local VSIG advisor, and member of the SVS Resident and Student Outreach Committee.

AUGUST 2020

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REMEMBRANCES

Memories of Thomas Monahan, clinician and surgeonscientist

BY JASON MACTAGGART, MD

I FIRST MET THOMAS MONAHAN, MD, in 2008 when he was the incoming junior vascular surgery fellow at UCSF. I didn’t know much about him, but he appeared to be a rather intense Bostonian while he scouted out the office, so I was a bit concerned about our upcoming time together. Over the next year we toiled in the trenches, running the service and learning vascular surgery from some of our specialty’s most creative and innovative leaders. On the rare occasion we had some free time together, we’d grab a beer or two at Kezar Pub or play bocce on the empty croquet courts in the shadows of the eucalyptus trees.

During these times and many others over the next decade — through late-night phone calls and time spent at meetings _ I learned a lot about Tom as a surgeonscientist and as a person, coming to love him like a brother.

Growing up in the 1980s and 90s, Tom was competitive in many sports and became an especially good golfer.

His background of excellence in both individual and team sports was obvious when one witnessed his exceptional ability to focus, his capacity for very hard work, and his knack for surrounding himself with the best teammates,

coaches and mentors. After finishing his research fellowship during the middle of his general surgery training, Tom maintained his focus on the same idea all the way through to the funding of his RO1 research grant. During fellowship, on his weekends off, he could often be found in our little office with his music blaring, “Just banging it out” he’d say while poring over spreadsheets of his basic science data.

Like any successful athlete, Tom was

outwardly serious nature only intensified his strategic use of deadpan humor and huge grin that often resulted in bursts

Just as Tom mapped out molecules and experiments to find weak links in the complex mechanisms of neointimal hyperplasia, he also had in his mind a clearly defined path for his academic career always looking for ways to improve and was never afraid to ask others for assistance or an honest opinion. In turn, one could also always trust Tom to give his true assessment of a situation, even if it wasn’t what you wanted to hear. His

Remembering Evan Charles Werlin EVAN CHARLES WERLIN, MD, WAS BORN Dec. 22, 1985, and passed away peacefully May 27, 2020, following a three-year, hard-fought battle against a rare form of cancer.

Evan graduated from Brown University and the University of Pennsylvania School of Medicine, and was an outstanding general surgery resident at University of California San Francisco. A dedicated teacher, Evan received the UCSF Teaching Excellence Award for Cherished Housestaff (TEACH) in 2017 and the William P. Schecter Trauma Resident of the Year Award in 2019.

He completed a two-year research fellowship with me, studying vascular injury and resolution, and we were able to learn from his importance advances at the Vascular Research Initiatives Conference.

of decompressive laughter. His sense of humor likely contributed to his superhuman resilience in dealing with his own personal tragedies and the difficulties we all experience in the clinical realm. As a kid, I imagine Tom was one of those few

Most recently, Evan matched into the Vascular Surgery Fellowship program at UCSF. In addition to his passion for surgery, Evan loved music, exotic travel, snowboarding, cats and throwing pottery.

Evan would have made an excellent and compassionate vascular surgeon, and will long be remembered by his colleagues at UCSF.

BY MICHAEL CONTE, MD

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Thomas Monahan

that could turn a bad-hop grounder to the gut into a double play while others would crumple into the dirt as the baserunners headed for home.

Just as Tom mapped out molecules and experiments to find weak links in the complex mechanisms of neointimal hyperplasia, he also had in his mind a clearly defined path for his academic career. All of that was only part of a life that included his creative outlet of music, a strong sense of purpose to provide service for those most in need, and unwavering commitment to his family, friends and coworkers. As a former distance runner like Tom, driving the stone and tree-lined streets of his hometown on the sunny, early fall day of his funeral, I could imagine Tom running, thinking through a difficult problem and finding his answer along the cool blue waters of Scituate Harbor.

Peace be with you, my brother, Saint Ignatius would be proud.

Thomas Monohan, an exceptional clinician and surgeon-scientist, died Sept.

12, 2019, at the age of 44.

Jason MacTaggart is an associate professor in the department of surgery, division of vascular surgery, at the University of Nebraska Medical Center in Omaha, was set to honor Thomas Monahan at this year’s canceled Vascular Research Initiatives Conference (VRIC), but remembers him here in its stead.

Evan, who matched into the vascular surgery fellowship program at UCSF, would have made an excellent and compassionate vascular surgeon, and will long be remembered by his colleagues

Evan Charles Werlin

Michael Conte is professor and chief in the division of vascular and endovascular surgery at the University of California, San Francisco. Like Jason MacTaggart, he was to remember Evan Charles Werlin at VRIC.

AUGUST 2020

VENOUS DISEASE

AHA, ISTH release joint statement on future VTE research priorities

Program at the University of Vermont Medical Center in Burlington, Vermont, et al, it was issued on behalf of the American Heart Association Council on Peripheral Vascular Disease; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; Council on Epidemiology and Prevention; and the International Society on Thrombosis and Haemostasis.

It was co-published in both Circulation and Research and Practice in Thrombosis and Haemostasis.

Setting, the scene, the authors write: “Venous thromboembolism [VTE] is a major cause of morbidity and mortality. The impact of the U.S. Surgeon General’s ‘The Surgeon General’s Call to

BY BRYAN KAY

The American Heart Association (AHA) and the International Society on Thrombosis and Haemostasis (ISTH) issued a joint scientific statement July 8 outlining research priorities in the field of venous thromboembolism (VTE).

“AT THE FUNDAMENTAL RESEARCH LEVEL (T0), researchers need to identify pathobiological causative mechanisms for the 50% of patients with unprovoked venous thromboembolism and to better understand mechanisms that differentiate hemostasis from thrombosis,” the statement reads.

Written by first-named author Mary Cushman, MD, medical director of the Thrombosis and Hemostasis

AUGUST 2020

“Is the diagnosis of Lyme disease in black and brown patients delayed? Do these patients therefore present with more advanced symptoms, such as neurologic disorders and arthritis, than white patients?”— LaShyra Nolen

Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism’ in 2008 has been lower than expected given the public health impact of this disease. This scientific statement highlights future research priorities in venous thromboembolism, developed by experts and a crowdsourcing survey across 16 scientific organizations.”

The statement goes on to encourage a multidisciplinary approach to tackle VTE. It continues: “At the human level (T1), new methods for diagnosing, treating, and preventing venous thromboembolism will allow tailoring of diagnostic and therapeutic approaches to individuals.

“At the patient level (T2), research efforts are required to understand how foundational evidence impacts care of patients (e.g., biomarkers). New treatments, such as catheter-based therapies, require further testing to identify which patients are most likely to experience benefit.

“At the practice level (T3), translating evidence into practice remains challenging. Areas of overuse and underuse will require evidence-based tools to improve care delivery. At the community and population level (T4), public awareness campaigns need thorough impact assessment.

“Large population-based cohort studies can elucidate the biological and environmental underpinnings of venous thromboembolism and its complications. To achieve these goals, funding agencies and training programs must support a new generation of scientists and clinicians who work in multidisciplinary teams to solve the pressing public health problem of venous thromboembolism.”

SOURCE: DOI.ORG/10.1161/ CIR.0000000000000818

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