A Single Specialty in Noncardiac Vascular Disease

By Frank J. Veith, MD

I recently spent a week in Malmö, Sweden, visiting a vascular service led by a superstar interventional radiologist, Dr. Krassi Ivancev. In addition to his clinical and technical brilliance, Dr. Ivancev has leadership and organizational skills that have enabled him to put together a truly integrated vascular service in which talented and innovative vascular surgeons (Dr. Martin Malina and Dr. Björn Sonesson) work together in a seamless way with talented and innovative interventional radiologists (Dr. Mats Lindh and Dr. Ivancev himself).

Everyone utilizes all the open surgical and interventional skills that they are capable of, and everyone, as well as their fortunate trainees, learns each other's skills. There is a heavy emphasis by all on mastering optimal imaging techniques and on the exercise of good clinical judgment. The resulting patient care is the best I have seen anywhere in the world.

Why am I writing to comment about all this? It is simply because it provides a dramatic confirmation of a suggestion that I first made publicly at an SVS meeting in June 2002--that many of the problems that currently exist in the vascular disease management field would be solved if there existed a single specialty devoted to noncardiac vascular disease.

Turf wars between specialists, destructive competition, unnecessary procedures, and treatment of lesions rather than patients would be lessened markedly.

Instead of many specialties competing for the rewards of treating noncardiac vascular lesions, vascular disease would be managed by those with appropriate judgment, skills, and--most importantly--commitment to the field.

Specialists with skills derived from many different disciplines would work together in a single department or service without allegiance or obligations to a large department of medicine, surgery, or radiology, as is currently the case in most institutions and most countries. Dr. Ivancev's vascular service avoids all these impediments, and we should learn from this accomplishment. All, especially the patients, would benefit.

When I first made the suggestion in 2002 that there should be a separate specialty in noncardiac vascular disease, it appeared likely that vascular surgery in North America would get the American Board of Medical Specialties' approval for an independent American Board of Vascular Surgery (ABVS).

If that had occurred, it was my suggestion that the ABVS should transform itself into the American Board of Vascular Specialists with four equal components to represent vascular surgery, interventional vascular radiology, interventional vascular cardiology, and vascular medicine.

Physicians from each of the four disciplines would be eligible for certification by this new approved Board if they restricted their practice to predominantly noncardiac vascular disease and were committed largely to that specialty. Dabblers who wished to include vascular disease patients as part of their practice in another specialty would not be included. Most of the other directors of the ABVS agreed with this approach.

The Primary Certificate in Vascular Surgery was approved within the past year. Although it contains some elements that are good for vascular surgery, the Primary Certificate has kept the field a subspecialty of general surgery and has precluded the American Board of Vascular Surgeons from morphing into the American Board of Vascular Specialists.

This will make it harder than ever to evolve into a single vascular disease specialty. This in turn will make it more difficult or impossible to duplicate Dr. Ivancev's achievement in Malmö. Surgeons, physicians, and radiologists truly interested in noncardiac vascular disease will pay a price.

More importantly, vascular disease patients will pay an even greater price.

Dr. Veith is professor of surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, and is the William J. Von Liebig chair in vascular surgery at the Cleveland Clinic Foundation.