On March 17, 2005, the American Board of Surgery (ABS) received approval from the American Board of Medical Specialties (ABMS) to offer a primary certificate in vascular surgery, opening the opportunity for vascular surgeons in the US to become directly board-certified in vascular surgery without first becoming certified in general surgery, as is currently required.

Contemporaneously, the American Board of Vascular Surgery (ABVS) lost its appeal filed with the AMA and ABMS seeking to overturn ABMS's 2002 rejection of ABVS's application for vascular surgery to become an independent medical board. Frank J. Veith, MD, is Chairman of the American Board of Vascular Surgery & Professor and Vice Chairman of Surgery at Montefiore Medical Center & the Albert Einstein College of Medicine (Bronx, NY) and has been an advocate for separate board certification for vascular surgeons. Dr. Veith recently spoke to us regarding those efforts, primary certification, and the future of vascular surgery.

Endovascular Today: Is the recent primary certification in vascular surgery beneficial for vascular surgeons?

Frank Veith, MD: It is beneficial in some ways, but it's detrimental in others. It's beneficial because (1) it gives us some potential for increased flexibility in our training, (2) it clearly proves that vascular surgery is a separate and distinct specialty, and (3) it proves that even our opponents in our battle for independence as a specialty (the strongest one being the ABS) recognize that we are a separate and distinct specialty. It is detrimental because every other surgical specialty has its own board, so why should vascular surgery, when it has clearly and admittedly by all, matured to independent specialty status, be under the control of another board with possible conflicting interests to ours? Why should vascular surgeons be under the control of general surgeons, when our practice is often more akin to interventional radiology or cardiology than to general surgery?

EVT: Which of the other surgical specialties have their own boards?
Dr. Veith: All of them. Any separate specialty in surgery has its own board—neurosurgery, cardiac surgery, urology, gynecology, orthopedics, plastic surgery, ENT, and several others.

EVT: What is the benefit of having your own board?

Dr. Veith: When there are issues relating to training, certification, and governance, one specialty may well be in conflict with another specialty, particularly general surgery. If vascular surgery remains under the control of general surgery, it is clear that the interests of vascular surgery will often not be represented and will not be well served. Indeed, that has been the state of affairs for the last 30 years. This is what led to the effort to have an independent board in vascular surgery that began in earnest in 1996.

EVT: How does this conflict manifest itself?

Dr. Veith: In many ways; take training, for example. A training program director has the responsibility of training vascular surgeons. If there is scarce clinical material and the vascular program director is obligated to use that material to train general surgery residents to be competent in vascular surgery, then the material is not available to the vascular surgery trainees. This has been a continuing problem for the last 10 or 15 years, during which time we have been obligated to give cases that clearly should be performed by a vascular surgeon to general surgery residents. This occurred even when these cases were limited in number and when the general surgery trainees would never perform them. In all likelihood, this problem will continue under the primary certificate arrangement because the ABS has not changed its position on training general surgery residents in vascular surgery, which they still consider an essential training component for general surgeons.

The residency review committee in surgery and the ABS are basically hand-in-glove organizations that represent what they consider to be the interests of general surgery. If there is a conflict, the interests of general surgery have, in almost every instance, been served and vascular interests have not been served. Of course, this has led to a number of conflicts. When we went to our appeal to ABMS, the representatives for the ABS maintained that they want vascular surgery to continue to be an essential component of general surgery. Moreover, they will continue to require that training in vascular surgery is offered to general surgeons so they can take care of vascular surgical problems, or emergencies in small and medium-sized cities. We believe that is not in the best interest of patients or those communities. We should be enabled to train more vascular surgeons, so that individuals in those communities can be served by well-trained vascular surgeons and not by general surgeons who are poorly trained or only partly trained in vascular surgery.

EVT: What would a separate board for vascular surgeons provide that primary certification does not?

Dr. Veith: A separate board for vascular surgeons would provide many benefits that will not necessarily accrue under the primary certificate. It will help to establish that vascular surgery is in fact a separate specialty in the eyes of the public, in the eyes of government, and in the eyes of referring physicians. It will also allow us to change our training paradigms in a more responsive, agile way than we can with the cumbersome system that is currently in place where things have been controlled by the ABS and the Residency Review Committee in Surgery. Another reason we need an independent board is malpractice. Under the present arrangement, any general surgeon can testify against a vascular surgeon in a malpractice case, because we are all under the same board. They will most likely not have the same level of experience or training as a vascular surgeon, but by nature of the board certification, they are able to testify as an equal.

If we didn't have a problem, we wouldn't have fought so hard to have an independent board. We are not revolutionaries or radicals; it is because of continuing frustrations and conflicts that most vascular surgeons recognize that we are a separate specialty and we should be recognized as such. And although this primary certification does it in a somewhat backhanded way, why not go all the way? Some of us believe that the primary certificate was a ploy to keep vascular surgery under the control of the ABS, and in fact, it was. It boils down to governance and control. There is no reason for a separate specialty to be controlled by another specialty, unless it is for the benefit of that other controlling specialty (ie, general surgery). For example, if neurosurgery were controlled by general surgery, it would be a lesser specialty and its interests would not be represented. That is why separate boards exist. The events of the past year or two have been quite illogical in the sense that a special arrangement has been devised that acknowledges the reality that vascular surgery is a separate specialty, but for the purposes of general surgery, the control has been maintained by general surgery.

EVT: Why would ABMS have permitted neurosurgery, for instance, to have its own board, but not vascular surgery?

Dr. Veith: Part of the explanation lies with training dollars, the graduate medical education dollars that an institution receives for every trainee in that specialty. Some of those dollars accrue to those departments that train those trainees. If the general surgery department head loses trainees, they will lose some of that money. With separate board certification, instead of having a vascular surgical resident with 1 or 2 years of training, we may have four vascular residents that have 3 or 4 years of training. That shift will come at the expense of individuals in general surgery. Although I cannot say for sure, it is very possible that these factors have influenced the ABS to fight so hard against an independent board. In addition, if vascular surgery becomes a separate specialty, I believe the ABS is concerned that other components of general surgery may try to become a separate specialty.

EVT: You mentioned earlier that patients would be better served by separate board certification. How would this affect patient care?

Dr. Veith: We have been seeking an independent board that will ultimately benefit the public and provide better patient care. In December 2003, The Wall Street Journal ran an article highlighting this problem. Their article was based on a University of Michigan/Johns Hopkins study of 3,912 patients requiring abdominal aortic aneurysm (AAA) surgical repair. The study demonstrated that general surgeons performing this procedure had a 76% higher mortality rate than vascular surgeons. Despite that alarming statistic, general surgeons still perform 30% of the AAA surgical repairs in this country (Journal of Vascular Surgery. 2003;38:739-744). The Wall Street Journal looked at Pennsylvania's uniquely extensive database of medical records compiled by its Health Care Cost Containment Council, which produces public reports on the quality of medical care. They worked with Michael Pine & Associates, which helps Pennsylvania evaluate its hospitals. The research took into account the medical severity of each case. The findings of that study showed that in more than 5,000 AAA operations performed in Pennsylvania over 3 years, general surgeons had a 73% higher mortality rate than did vascular surgeons. It is clearly in the public interest to have vascular surgeons doing vascular surgery.

EVT: What is the position of the ABS on this issue?

Dr. Veith: Well, of course they rationalize their position. For example, they say that we need to have general surgeons who perform vascular surgery in a small community or a medium-sized community. Our position is that poorly trained general surgeons performing these procedures are not in the best interest of patients. If the general surgeon performs the procedure in a suboptimal fashion, he should not be doing it. The ABS has prevented us from training more vascular surgeons who would be available to staff these areas. Until there are enough well-trained vascular surgeons, it would be better to transport the patient needing complicated vascular surgery to a center that can do it adequately and a vascular surgeon who is well trained just as is now done for complicated neurosurgery or cardiac surgery. Such transfer is clearly better than having a procedure performed by a less well-trained general surgeon who has poor outcomes.

EVT: Why did the Society of Vascular Surgery (SVS) go along with this?

Dr. Veith: The SVS went along with it for a number of reasons. There were some individuals who honestly believed that it was better to get the primary certificate, which was obtainable, than to struggle hard and perhaps for several years to get an independent board. And possibly, they were right. There were other members of the SVS who I believe represented the interests of general surgery by virtue of the fact that they were either on the ABS as directors, or were department chairs in general surgery. I think they represented their own interests or the interests of general surgery rather than the interests of vascular surgery. There was honest disagreement over the primary certificate. However, an independent Deloitte and Touché poll showed that most vascular surgeons accepted the primary certificate only as a way station to an independent board. The ABS rejected this concept. The rank and file of vascular surgeons opposed the primary certificate if it was not a way station to an independent board. We believe that they would have preferred a separate board to the primary certificate if it came down to a decision between the two.

EVT: Didn't the ABVS support primary certification until recently?

Dr. Veith: The ABVS originally supported the primary certificate as a way station to an independent board. We withdrew that support because the ABS did not agree that this primary certification would be an interim step.
EVT: Can ABVS still use the primary certification as that interim step?

Dr. Veith: Many of us believe that passage of the primary certificate will make the achievement of an ABMS-approved independent board more difficult. Under the bylaws of the ABMS, each specialty can only have one certifying board. For vascular surgery to get an independent board, the ABS would have to give up the primary certificate. This is highly unlikely in view of the strong opposition that they have exhibited to the independent board concept.

EVT: When did the campaign for an independent board begin?

Dr. Veith: The idea of an independent specialty or board for vascular surgery has been around since the 1970s, when it was recognized that specialization brings better outcomes. That idea was promoted in the 1970s by Dr. Jack Wiley and others, and it led to the certificate of special or added qualifications in vascular surgery, totally under the control of the ABS.

EVT: This year, the American Board of Vascular Medicine has pursued a separate route and simply started their own board certification outside of the ABMS. Why didn't ABVS do that instead?

Dr. Veith: It is possible that we will pursue an independent board outside the ABMS. We are not going to give up, because vascular surgery still needs an independent board. Pursuit of such a board is clearly the right thing to do for the public and for the specialty. The vast majority of vascular surgeons believe that they are part of a separate well-defined specialty, which should be represented by an independent board.

What do you think are the chances of success in getting a separate board for vascular surgeons?

Dr. Veith: There are three things we can do. One is to mount an effort to have an independent board outside the ABMS structure. This is difficult but doable. Second, we must continue to get public exposure of this issue. After all, the public interest is being served poorly by what has happened by the actions of the ABMS and the ABS. Ultimately, we must get congressional support to put pressure on the ABMS to do its job and to be fair, honest, and interested in patient safety and well-being and the public interest. Unfortunately, they have not done so to date.