ABVS: History and Current Status October 2003The American Board of Vascular Surgery (ABVS) was incorporated in 1996 by the Presidents, Immediate Past Presidents, Presidents Elect, and Secretaries of the Society for Vascular Surgery and the International Society for Cardiovascular Surgery-North American Chapter (subsequently the American Association for Vascular Surgery). The needs and rationale for this action were clearly stated in a document signed by the executives and council members of these two organizations, as well as the officers of the Association of Program Directors for Vascular Surgery (APDVS). That statement was published in the Journal of Vascular Surgery in 1997. It was also the subject of four subsequent presidential addresses before the SVS and AAVS. At the onset, the vast majority of vascular surgeons supported this effort to become the newest member of the American Board of Medical Specialties (ABMS). Nevertheless, this movement was vigorously opposed by the American Board of Surgery (ABS), who subsequently created a Sub-Board in Vascular Surgery and attempted to address many of Vascular Surgery’s concerns. Unfortunately the substantive issues of Vascular Surgery being a primary pillar (now an essential training component) of general surgery residency and true autonomy with our own Residency Review Committee for Vascular Surgery were not resolved. In 2001, the SVS and AAVS leadership surveyed all North American vascular surgeons in an independent poll conducted by Deloitte and Touche. One unambiguous question was asked: “Should Vascular Surgery seek an ABMS-approved independent specialty Board?” Among the respondents, 66% answered yes, and 79% of those in practice less than 10 years took an affirmative position. Following this poll and with sponsorship from all the national and major regional Vascular Societies, an application to become an ABMS-approved independent Board of Vascular Surgery was submitted in May 2002. The application was addressed in a hearing before the Liaison Committee for Specialty Boards (LCSB) on December 18, 2002. The LCSB is comprised of four members representing the AMA and four additional members representing the ABMS. At that time, the Chairman of the LCSB, representing the AMA, was James Borland Jr, a gastroenterologist from Jacksonville, Florida. The other AMA representatives were Richard Allen (Obstetrics-Gynecology), Emmanuel Cassimaitis (Psychiatry) and Rebecca Patchin (Anesthesia-Pain Management). The ABMS representatives were David Nahrwald (Surgery), Harvey Meislan (Emergency Medicine), John Strauss (Dermatology) and Nicholas Vick(Neurology). Subsequent to this meeting a letter dated December 20, 2002 was received from Dr. Stephen Miller, Secretary to the LCSB, denying the application. This was followed by an ABVS letter dated December 26, 2002 requesting specific information as to the shortfalls of the application, such that a decision regarding an appeal might be made on a rational basis. That request was followed by a two sentence-single paragraph letter dated December 30, 2002 from the LCSB, stating that the application had been denied based on a “totality of criteria”. No specific shortcomings were provided regarding the denial. However, we believe differences of opinion within our own surgical community regarding the need for a new Board were relevant to the application’s initial failure. An appeal has been requested and will be heard by an Appeal Board that is advisory to the LCSB. It is important to try every possible approach within the ABMS system to gain their approval for a new Board. In addition, in the interest of our profession and patients with vascular disease, it seems reasonable to encourage the ABMS to meet its responsibility to Society by enhancing specialty care. A committed ABVS Board of Directors cannot do this alone. The process will require a major effort over the next several years and, most importantly, it will require the commitment of all vascular surgeons. Many of the Vascular Surgery community do not understand the reason for the Board movement and the conflict it has generated. It is reasonable to readdress the issues surrounding the ABVS actions, in hopes of removing any vague rhetoric from future discussions about the need for a new Board. The sole basis for establishing an independent ABMS-approved ABVS is to better serve the public and profession in the surgical care of patients with vascular disease. To accomplish this task an independent Board will be required to provide more timely and responsive development of standards for training and certifying vascular surgeons, an effort that will be markedly enhanced by creation of a Residency Review Committee for Vascular Surgery to evaluate and approve training programs. Expanding technology in vascular surgery clearly mandates the need for longer training programs to adequately educate practitioners in new endovascular therapies, imaging modalities, and the nonoperative management of vascular diseases. These subjects are extremely relevant to all of our practices, and have been incorporated into the recommended “Guidelines for Hospital Privileges in Vascular Surgery” published in 2002 in the Journal of Vascular Surgery. Unfortunately, the American Board of Surgery (ABS) and the Residency Review Committee for Surgery (RRC-S) have addressed this issue by adding to the length of existing vascular training. That change has simply compounded the many years of postgraduate education and indebtedness required for a young trainee to become a vascular surgeon. This extension of training evolved at a time the pool of fellowship applicants has markedly decreased, and by some measures it appears that the quality of applicants is less than that of those entering other surgical disciplines not requiring the completion of a general surgery training program. The disciplines of neurosurgery, orthopedics, otolaryngology, and urology have not seen the same impact on their residencies as has vascular surgery. This is a major issue for the vascular surgery community. The training required to have competency in Vascular Surgery clearly cannot be integrated easily into the present educational paradigm without extending training beyond the existing 5+1 and 5+2 programs. Efforts to establish a 4+2 program were hoped to be widely implemented as a step towards reducing the lengthy training required for individuals to be eligible to be certified in Vascular Surgery. This new paradigm was supported by an educational task force composed of members from the SVS, AAVS and the APDVS. They also proposed a 3+3 integrated program as a pilot study, with individuals matching into this training directly from medical school. The latter would have gone a long way towards addressing ABVS concerns, but such has not been possible under the current ABMS-ABS bylaws requiring certification in the primary specialty (ie General Surgery) before subspecialty (ie Vascular Surgery) certification occurs. In regard to the 4+2 program, the APDVS requested that the RRC-S review the relatively rigid exclusionary criteria that will prevent its widespread introduction, but they were unwilling to alter their stance. Unfortunately many believe the 4+2 program will not meet the perceived need to make Vascular Surgery more desirable and less of a burden during training. Furthermore, having a two-tract system of training general surgeons within the same residency has not met with favor by many Program Directors in General Surgery. The ABVS has proposed a 3+3 integrated track of training that would allow individuals, not desiring to practice general surgery, to be fully trained as vascular surgeons. Such a training paradigm does not simply take individuals after 3 years of “core general surgery” residency and place them in an isolated vascular surgery fellowship, but like other integrated programs, it would include rotations during the 4th, 5th, and 6th years on certain general surgery services, such as trauma, in a manner that would result in a broadly trained mature surgeon at the completion of the fellowship. Importantly, the ABVS also proposed a training paradigm similar to that backed by the ABS that would allow individuals to be certified in both General Surgery and Vascular Surgery, with a realization that this training would be longer in duration. Given the extreme pressures being placed on all surgical training programs regarding limited work hours one must consider the additional impact on the relatively short duration but intense training in the surgical specialties like Vascular Surgery. In our case, with the loss of open cases because of endovascular interventions, individuals will be exposed to many fewer open procedures and their competence may be less than desired. Earlier entry into vascular specialty training with a longer period of time to be exposed to needed open and endovascular procedures would go a long way to address this issue. This is a major concern in a considerable number of programs. Practitioners should be concerned about the loss of interest by many bright young individuals in the specialty of Vascular Surgery. Opportunities for established vascular surgeons to recruit into their practices individuals who have been trained with skills to apply new technologies to patient care are currently sparse. The inability to provide the broadest care for patients with vascular disease has already been sensed by many vascular surgeons “in the real world” and the pressures to improve and expand one’s therapeutic capabilities will not be less in future years. Four Ad Hoc committees of the ABVS have been formed to carry out strategic efforts of the Board during the next few years. Opportunities for all vascular surgeons to serve the ABVS exist on: 1) the Public Affairs Committee whose purpose is to disseminate information regarding the ABVS to lay members of the public. Enrico Ascher MD is the Chair; 2) the Medical Affairs Committee whose purpose is to develop relations with other medical organizations regarding the ABVS. Robert W. Hobson II MD is the Chair; 3) the Financial Affairs Committee whose purpose is to develop fundraising and oversee ABVS budgetary matters. James C. Stanley MD is the Chair; and 4) the Legal Affairs Committee which will advise on legal issues affecting the ABVS. Thomas F. O’Donnell Jr MD is the Chair. The ABVS represents all of Vascular Surgery, both academicians and private practitioners, and values the diversity of both groups in helping its committees. The Vascular Surgery community deserves respect for having gathered the support and momentum to complete an application to become an ABMS board. It was disappointing to have the LCSB initially deny the application, and thus prevent its consideration by the entire voting members of the ABMS. The tenets of the ABMS must be respected, but we should appropriately question the pressure that has been placed on the LCSB by others to avoid what we believe is an important responsibility to the public and our profession at improving the care of patients with vascular disease by more rigorous specialty training and certification processes. The issue of training adequate numbers of physicians to provide competent care of patients with vascular disease will not go away, nor will the ABVS. The Directors of the ABVS believe that it is in the best interest of Vascular Surgery to persist in pursuing an independent Board, and we ask all vascular surgeons to volunteer their time and support to the effort. James C. Stanley, M.D. |
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