An Interview with K. Craig Kent, MD

The outgoing President of the SVS discusses the challenges facing vascular surgery, the role of the individual surgeon, and the bright future he sees for the specialty.

By K. Craig Kent, MD

At the 2007 Society for Vascular Surgery (SVS) meeting, you gave an outstanding presidential address, which discussed the recent accomplishments of the society and the challenges it has faced. What are some of the most important steps the society has taken in recent years?

There have been many significant achievements, but importantly, we have firmly established vascular surgery as a leader in the care of patients with peripheral vascular disease. We have accomplished this by retraining our members in interventional techniques. We have facilitated the involvement of our members in clinical trials and research programs. We have also strived to further the national presence of vascular surgery, working very closely with agencies such as CMS, the FDA, and the NIH, as well as industry partners, to ensure that vascular surgery contributes to the larger decisions that are being made regarding the treatment of vascular disease. These were important steps because for a few years, there was uncertainty regarding the direction of our specialty. Due to the efforts of the society as well as our individual members, this uncertainty is now gone. It is clear that vascular surgeons will continue to play a prominent role in the treatment of vascular disease in years to come.

Another step for the SVS that has been positive is the building of strong relationships with other societies, such as the Society of Vascular Medicine, the Society for Cardiac Angiography and Interventions, and the Society of Interventional Radiology, to name a few. We have recently initiated an interactive dialog with these groups. Many of our national initiatives are now collaborative, and I anticipate that this will happen more frequently as these relationships mature.

How would you characterize the challenges that vascular surgery has faced in the past 5 to 10 years? How are they unique to those faced by the other specialties?
Every physician who treats vascular disease has faced challenges. Some are specialty-specific and others are not. But all of us have had to play catch-up in one way or another; each specialty has found it necessary to evolve in a unique way to keep pace with this constantly progressing field. Cardiologists entered the peripheral arena with an understanding of cardiac disease and an excellent set of catheter skills, but it was necessary for cardiologists to learn how to tailor those skills and their knowledge for use in the periphery. Interventional radiologists had to develop clinical-based practices and also keep up with the technology. Ten years ago, most surgeons did not have the necessary guidewire and catheter skills that would allow the performance of interventional techniques. However, vascular surgeons did bring to the table a strong background in peripheral vascular disease, as well as robust clinical practices. Admittedly, vascular surgeons were at first somewhat wedded to the status quo, and many were reluctant to embrace new technology.

It soon became clear that the SVS needed to encourage its members to leave the status quo, train in catheter techniques, and evolve with the technology. I am extremely impressed with how our specialty has evolved over the past 5 years. There are very few surgeons who have not learned catheter techniques, and many are now fully endocompetent. All of our fellowship programs now provide complete training in catheter techniques. We have more room to grow, as I pointed out in my presidential address, but we are headed in the right direction and at a rapid pace.

I believe that each specialty has encountered hurdles, but all three groups have actually been reasonably successful. There is a cohort of cardiologists with profound knowledge of peripheral vascular disease, many radiologists now have robust clinical practices, and a substantial number of vascular surgeons now have excellent guidewire and catheter skills. You cannot stop medical progress or new technology. There is a tremendous desire on the part of patients to have less-invasive means of treatment. And in response to this desire, each of the specialties has evolved. We are not necessarily in competition with each other. In some ways, we are in competition with ourselves to keep up with the technology and provide the best possible care.

In your address, you mentioned that many referring physicians have an incorrect perception of the current role of the vascular surgeon. How can this be rectified?
The first place to start is to make sure you are indeed a "fully endocompetent" vascular surgeon or that your practice has this capability. If a vascular surgeon does not offer a full array of surgical and interventional techniques, it will be impossible, or for that matter inappropriate, to try to change the perceptions of referring physicians. With this in mind, the SVS has created a number of advanced training opportunities that will allow its members to gain skills in thrombolysis, complex lower-extremity intervention, and carotid stenting. But, if a surgeon does offer all options, including advanced catheter techniques, it is critically important that this information be relayed to referring physicians. Convincing the outside world that vascular surgeons do something besides surgery is not an easy task, but it is possible. The SVS can play a major role in branding vascular surgeons as vascular specialists that are experts in minimally invasive treatments for vascular disease. There is a great deal of power associated with the ability to offer all of the options including medical treatments, surgery, and catheter intervention. We are the only specialty that can accomplish this, and we need to let this be known. When one physician can provide all of the therapeutic alternatives, decisions about medical care are no longer conflicted. Through outreach and communication, it is critically important that vascular surgeons make patients and the community of physicians aware of their skills and abilities. The SVS last year was able to send this message via radio and print to thousands of patients and referring physicians. To help our individual members accomplish this mission, we have created a branding tool kit. This tool kit includes slide presentations, information about how to launch a Web site, organize a dinner for referring physicians, brochures for patients and referring physicians, etc. More information can be obtained by calling the SVS offices at (800) 258-7188.

What are some of the issues facing vascular surgery in terms of recruitment to the specialty?
A few years ago, there was a great deal of uncertainty about the specialty and its direction. For residents who were evaluating our specialty at that time, the eventual role that vascular surgery would assume in the care of patients with peripheral vascular disease was not clear. However, over the last couple of years, we have seen a significant increase in recruitment. This is reflective of the fact that vascular surgeons have become adept with new technologies, and it is clear to those who have might have an interest in the specialty that vascular surgery will remain a dominant force in the care of patients with vascular disease. That vascular surgeons have at their command a variety of catheter-based techniques and new technology combined with the fact that they are trained to be traditional surgeons has caught the interest of many young physicians.

However, additional challenges must be overcome to continue to increase our recruitment. One is that it takes "too long" to become a vascular surgeon. Candidates must spend 5 years in a surgical residency, then 2 years in vascular fellowship, followed perhaps by 2 years in research. The new generation of physicians is not interested in devoting 10 years to learn a specialty. One of our great accomplishments, a year or so ago, was the development, in collaboration with the American Board of Surgery, of a new training mechanism called the primary certificate. With this, medical students can decide to become vascular surgeons in their third or fourth years of medical school and then apply directly to a vascular surgery program. These new training programs are 5 years long instead of 7 or more. When these students finish, they will have a certificate of specialization in vascular surgery; they will not be board-certified in general surgery. With today's environment of specialization, most vascular surgeons do very little, if any, general surgery, so the lack of a specialty certificate in general surgery is not an impediment. In the first year after instituting this program, we had more medical students apply than we were prepared to handle, and the number has continued to increase. In short, this new training paradigm has become very popular. It is clear to us that it will substantially increase interest in our specialty.

What is your opinion on whether the specialty needs to have its own independent board?
I think the primary certificate has helped considerably in allowing vascular surgeons to have their own training paradigms, and this is what boards are all aboutÑhow people are trained. Although the primary certificate is not the same as a separate board, it does represent a considerable step forward in achieving our goal. Many of us believe that vascular surgery should be an independent specialty, but it is not clear that an independent board, at this point in time, is the most effective means of getting there. I believe our efforts are best devoted to the further development of our specialtyÑhelping vascular surgeons become established as leaders of vascular health care in their communities. This can be accomplished by training all vascular surgeons to be fully endocompetent, by focusing on outreach and branding, by emphasizing the importance of vascular surgeons' involvement in research, and the development of new technology. Our attention at the moment should be on achieving these goals because reaching them will effectively establish vascular surgery as a strong, independent specialty. I believe our initial efforts in this regard have been very successful, but we have a long way to go.


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