Frank J. Veith, MD

A middle aged man goes to his primary care physician for his annual check-up. Because of an abnormal physical finding or laboratory test, he is referred to a specialist, who, after additional tests, recommends an operation with considerable risks. Before agreeing to the procedure, the man decides to seek a "second opinion." This sequence of events occurs routinely as the second opinion is generally accepted as one of the sacred cows of American medical care.

Let’s examine this sacred cow to see if it is a good thing or an overrated practice that serves little useful purpose. First the potential advantages. If the second specialist agrees with the first opinion, it can be reassuring to the patient and his family, but it really is unnecessary.

On the other hand, if the original specialist is less than optimal or motivated by the financial rewards of performing his recommended procedure, the second opinion can possibly benefit the patient by saving him from an unnecessary, wrong or possibly harmful operation. However, why not solicit the opinion of the second, better specialist first.

Now the downside. If the second specialist disagrees with the first, the patient faces a dilemma. He has to pick between the two specialists. How does he do this? Does he follow the advice of the more articulate and likeable specialist? Does he pick the opinion he likes despite being a non-expert? Does he solicit a third opinion – a tie breaker? Taking a vote on a medical or scientific question does not ensure arriving at the correct answer – especially if the vote is 2:1 and especially if one of the specialists is self-appointed or a full-fledged phony. So disagreement between the first and second specialist does not ensure better care. It can lead to confusion and uncertainty. It may lead to the wrong course of action. Our second opinion process may therefore be unnecessary or misleading, and is in reality not worth much.

What should replace this flawed sacred cow? In principle it is simple, in practice not so simple. The first specialist referral should be to an exemplary medical practitioner, one whose knowledge, judgment, skill level, and motivation can be trusted. Finding such an individual is complex. Referral patterns can be flawed and based on proximity, personality or economic considerations.

Examining a "top doctors list" can also be misleading since inclusion in some of these listings can be based on flawed criteria or even payment of a fee. Similar considerations may apply to some listings of top hospitals. Moreover, not every specialist in top hospitals is expert in all aspects of his or her specialty.

The key to finding an initial exemplary specialist whose first opinion can be trusted is to have that specialist identified by another knowledgeable physician who represents the patient’s interests. Such a "physician-trustee" can be a primary care physician with whom the patient has a solid relationship.

Alternatively, it can be a physician who is a friend, relative or acquaintance. In either case the physician-trustee has to take the time and make the effort to identify specialists he knows in the field in which the patient needs care. The physician-trustee must then make the additional effort to use these contacts to identify a first-rate specialist in the field and to explore the qualities, reputation, and results of this specialist by speaking to those who have worked with him directly and know him first hand.

Making such an effort is not a casual business in today’s complex medical environment. Yet it is one for which there is no other substitute. I have done it for friends and family on a number of occasions – often for patients who live in other cities and countries. It may take a number of phone calls to individuals in my own and other specialties within my own and other institutions. It does, however, produce positive results and solve the problem.

Unfortunately many who require expert specialty care in the United States do not have access to a dependable primary care giver or a trusted physician friend or relative who can serve as a physician-trustee.

Moreover, many insurance plans discourage specialist referrals or will only cover the costs of their selected, less than optimal in-network specialists. Finally, in the U.S. health care system even under the Affordable Care Act, no financial compensation is provided for physician-trustee services and the time and effort involved.

This deficiency must be corrected since physician-trustees can provide a uniquely valuable service. They can eliminate unnecessary financially motivated procedures; they facilitate identification of genuinely superior care-givers; and they enable patients to obtain referral to a specialist whose first opinion can be counted on to be dependable and who will deliver exemplary care. They also obviate the need for flawed and unnecessary second opinions.

Dr. Veith is Professor of Surgery at New York University Medical Center and the Cleveland Clinic. He is an associate medical editor for Vascular Specialist.

The ideas and opinions expressed in Vascular Specialist do not necessarily reflect those of the Society or Publisher.

A middle aged man goes to his primary care physician for his annual check-up. Because of an abnormal physical finding or laboratory test, he is referred to a specialist, who, after additional tests, recommends an operation with considerable risks. Before agreeing to the procedure, the man decides to seek a "second opinion." This sequence of events occurs routinely as the second opinion is generally accepted as one of the sacred cows of American medical care.

Let’s examine this sacred cow to see if it is a good thing or an overrated practice that serves little useful purpose. First the potential advantages. If the second specialist agrees with the first opinion, it can be reassuring to the patient and his family, but it really is unnecessary.

On the other hand, if the original specialist is less than optimal or motivated by the financial rewards of performing his recommended procedure, the second opinion can possibly benefit the patient by saving him from an unnecessary, wrong or possibly harmful operation. However, why not solicit the opinion of the second, better specialist first.

Now the downside. If the second specialist disagrees with the first, the patient faces a dilemma. He has to pick between the two specialists. How does he do this? Does he follow the advice of the more articulate and likeable specialist? Does he pick the opinion he likes despite being a non-expert? Does he solicit a third opinion – a tie breaker? Taking a vote on a medical or scientific question does not ensure arriving at the correct answer – especially if the vote is 2:1 and especially if one of the specialists is self-appointed or a full-fledged phony. So disagreement between the first and second specialist does not ensure better care. It can lead to confusion and uncertainty. It may lead to the wrong course of action. Our second opinion process may therefore be unnecessary or misleading, and is in reality not worth much.

What should replace this flawed sacred cow? In principle it is simple, in practice not so simple. The first specialist referral should be to an exemplary medical practitioner, one whose knowledge, judgment, skill level, and motivation can be trusted. Finding such an individual is complex. Referral patterns can be flawed and based on proximity, personality or economic considerations.

Examining a "top doctors list" can also be misleading since inclusion in some of these listings can be based on flawed criteria or even payment of a fee. Similar considerations may apply to some listings of top hospitals. Moreover, not every specialist in top hospitals is expert in all aspects of his or her specialty.

The key to finding an initial exemplary specialist whose first opinion can be trusted is to have that specialist identified by another knowledgeable physician who represents the patient’s interests. Such a "physician-trustee" can be a primary care physician with whom the patient has a solid relationship.

Alternatively, it can be a physician who is a friend, relative or acquaintance. In either case the physician-trustee has to take the time and make the effort to identify specialists he knows in the field in which the patient needs care. The physician-trustee must then make the additional effort to use these contacts to identify a first-rate specialist in the field and to explore the qualities, reputation, and results of this specialist by speaking to those who have worked with him directly and know him first hand.

Making such an effort is not a casual business in today’s complex medical environment. Yet it is one for which there is no other substitute. I have done it for friends and family on a number of occasions – often for patients who live in other cities and countries. It may take a number of phone calls to individuals in my own and other specialties within my own and other institutions. It does, however, produce positive results and solve the problem.

Unfortunately many who require expert specialty care in the United States do not have access to a dependable primary care giver or a trusted physician friend or relative who can serve as a physician-trustee.

Moreover, many insurance plans discourage specialist referrals or will only cover the costs of their selected, less than optimal in-network specialists. Finally, in the U.S. health care system even under the Affordable Care Act, no financial compensation is provided for physician-trustee services and the time and effort involved.

This deficiency must be corrected since physician-trustees can provide a uniquely valuable service. They can eliminate unnecessary financially motivated procedures; they facilitate identification of genuinely superior care-givers; and they enable patients to obtain referral to a specialist whose first opinion can be counted on to be dependable and who will deliver exemplary care. They also obviate the need for flawed and unnecessary second opinions.

Dr. Veith is Professor of Surgery at New York University Medical Center and the Cleveland Clinic. He is an associate medical editor for Vascular Specialist.

The ideas and opinions expressed in Vascular Specialist do not necessarily reflect those of the Society or Publisher.

A middle aged man goes to his primary care physician for his annual check-up. Because of an abnormal physical finding or laboratory test, he is referred to a specialist, who, after additional tests, recommends an operation with considerable risks. Before agreeing to the procedure, the man decides to seek a "second opinion." This sequence of events occurs routinely as the second opinion is generally accepted as one of the sacred cows of American medical care.

Let’s examine this sacred cow to see if it is a good thing or an overrated practice that serves little useful purpose. First the potential advantages. If the second specialist agrees with the first opinion, it can be reassuring to the patient and his family, but it really is unnecessary.

On the other hand, if the original specialist is less than optimal or motivated by the financial rewards of performing his recommended procedure, the second opinion can possibly benefit the patient by saving him from an unnecessary, wrong or possibly harmful operation. However, why not solicit the opinion of the second, better specialist first.

Now the downside. If the second specialist disagrees with the first, the patient faces a dilemma. He has to pick between the two specialists. How does he do this? Does he follow the advice of the more articulate and likeable specialist? Does he pick the opinion he likes despite being a non-expert? Does he solicit a third opinion – a tie breaker? Taking a vote on a medical or scientific question does not ensure arriving at the correct answer – especially if the vote is 2:1 and especially if one of the specialists is self-appointed or a full-fledged phony. So disagreement between the first and second specialist does not ensure better care. It can lead to confusion and uncertainty. It may lead to the wrong course of action. Our second opinion process may therefore be unnecessary or misleading, and is in reality not worth much.

What should replace this flawed sacred cow? In principle it is simple, in practice not so simple. The first specialist referral should be to an exemplary medical practitioner, one whose knowledge, judgment, skill level, and motivation can be trusted. Finding such an individual is complex. Referral patterns can be flawed and based on proximity, personality or economic considerations.

Examining a "top doctors list" can also be misleading since inclusion in some of these listings can be based on flawed criteria or even payment of a fee. Similar considerations may apply to some listings of top hospitals. Moreover, not every specialist in top hospitals is expert in all aspects of his or her specialty.

The key to finding an initial exemplary specialist whose first opinion can be trusted is to have that specialist identified by another knowledgeable physician who represents the patient’s interests. Such a "physician-trustee" can be a primary care physician with whom the patient has a solid relationship.

Alternatively, it can be a physician who is a friend, relative or acquaintance. In either case the physician-trustee has to take the time and make the effort to identify specialists he knows in the field in which the patient needs care. The physician-trustee must then make the additional effort to use these contacts to identify a first-rate specialist in the field and to explore the qualities, reputation, and results of this specialist by speaking to those who have worked with him directly and know him first hand.

Making such an effort is not a casual business in today’s complex medical environment. Yet it is one for which there is no other substitute. I have done it for friends and family on a number of occasions – often for patients who live in other cities and countries. It may take a number of phone calls to individuals in my own and other specialties within my own and other institutions. It does, however, produce positive results and solve the problem.

Unfortunately many who require expert specialty care in the United States do not have access to a dependable primary care giver or a trusted physician friend or relative who can serve as a physician-trustee.

Moreover, many insurance plans discourage specialist referrals or will only cover the costs of their selected, less than optimal in-network specialists. Finally, in the U.S. health care system even under the Affordable Care Act, no financial compensation is provided for physician-trustee services and the time and effort involved.

This deficiency must be corrected since physician-trustees can provide a uniquely valuable service. They can eliminate unnecessary financially motivated procedures; they facilitate identification of genuinely superior care-givers; and they enable patients to obtain referral to a specialist whose first opinion can be counted on to be dependable and who will deliver exemplary care. They also obviate the need for flawed and unnecessary second opinions.

Dr. Veith is Professor of Surgery at New York University Medical Center and the Cleveland Clinic. He is an associate medical editor for Vascular Specialist.

The ideas and opinions expressed in Vascular Specialist do not necessarily reflect those of the Society or Publisher.

Today all we hear about is the high cost of U.S. health care, and how for our country to survive economically, it must cut doctors’ payments and spend less for health care, drugs, and medical devices. Certainly there is waste in the system and some physicians perform procedures that are unnecessary. But when one really needs good medical care and a good doctor, they are priceless.

Two recent dramatic examples in my own family made this clear to me. In one, a loved one developed a staphylococcal infection at an epidural injection site. Within 24 hours, she was desperately ill with a temperature of 104º, shaking chills, and excruciating back pain. She was expeditiously admitted to the ICU of an excellent community hospital and started on massive IV antibiotics. She underwent an urgent MRI, which revealed a paravertebral phlegmon. Blood cultures grew Staphyloccus aureus. She was seen repeatedly by her intensive care specialist and her orthopedic surgeon. When she did not improve, her orthopedic surgeon obtained a second MRI 36 hours after the first one. This, unlike the first, revealed an epidural collection, and she promptly underwent a three segment laminectomy to drain the abscess.

Although she required a second drainage procedure and careful adjustment of her IV antibiotics, she survived without any neurologic or cardiac damage. During her complicated and onerous 2½ weeks in the ICU, she was seen 2-3 times a day by both her intensivist and orthopedic surgeon, as well as by a variety of other specialists when they were needed. All made essential contributions to her recovery from this life-threatening illness. The skill and commitment of all these doctors, especially the orthopedic surgeon and the intensivist, made the difference in saving this young life. The care she received was priceless.

The second instance involved the cure of a life-threatening ventricular arrhythmia in a relatively young, productive individual. Although asymptomatic, this individual was having over 40,000 ventricular premature beats with runs of ventricular tachycardia in a 24-hour period. A highly skilled team of super-specialists in cardiac radiofrequency ablation procedures successfully eliminated the focus of these arrhythmias. However, the procedure was difficult and complicated. It took 7 hours and required both left and right heart catheterizations and crossing of the atrial septum and the aortic valve. Despite this, the individual was back at his usual work in 3 days, completely arrhythmia free. He has required no further subsequent treatment.

In both instances, the good care required by these skilled specialists and their colleagues was complicated and demanding but successful. It required enormous expertise and, more importantly, the commitment and dedication of those providing it. Sure, this care was expensive, but it was worth every penny. It was priceless, because the outcomes were life-saving and perfect. These priceless treatments restored two young, productive people to full health.

So in this rush to cut health care costs, let us remember that we in the United States have the best physicians and surgeons, the best hospitals, the best drugs, and medical devices in the world. Let us preserve these assets and not kill the goose that is laying the golden eggs of health care. Let us preserve and reward the priceless individuals and priceless care that can allow many of us in the United States to lead better, more productive lives than we otherwise would.

Dr. Veith is Professor of Surgery at New York University Medical Center and the Cleveland Clinic. He is an associate medical editor for Vascular Specialist.

The ideas and opinions expressed in Vascular Specialist do not necessarily reflect those of the Society or Publisher.

Today all we hear about is the high cost of U.S. health care, and how for our country to survive economically, it must cut doctors’ payments and spend less for health care, drugs, and medical devices. Certainly there is waste in the system and some physicians perform procedures that are unnecessary. But when one really needs good medical care and a good doctor, they are priceless.

Two recent dramatic examples in my own family made this clear to me. In one, a loved one developed a staphylococcal infection at an epidural injection site. Within 24 hours, she was desperately ill with a temperature of 104º, shaking chills, and excruciating back pain. She was expeditiously admitted to the ICU of an excellent community hospital and started on massive IV antibiotics. She underwent an urgent MRI, which revealed a paravertebral phlegmon. Blood cultures grew Staphyloccus aureus. She was seen repeatedly by her intensive care specialist and her orthopedic surgeon. When she did not improve, her orthopedic surgeon obtained a second MRI 36 hours after the first one. This, unlike the first, revealed an epidural collection, and she promptly underwent a three segment laminectomy to drain the abscess.

Although she required a second drainage procedure and careful adjustment of her IV antibiotics, she survived without any neurologic or cardiac damage. During her complicated and onerous 2½ weeks in the ICU, she was seen 2-3 times a day by both her intensivist and orthopedic surgeon, as well as by a variety of other specialists when they were needed. All made essential contributions to her recovery from this life-threatening illness. The skill and commitment of all these doctors, especially the orthopedic surgeon and the intensivist, made the difference in saving this young life. The care she received was priceless.

The second instance involved the cure of a life-threatening ventricular arrhythmia in a relatively young, productive individual. Although asymptomatic, this individual was having over 40,000 ventricular premature beats with runs of ventricular tachycardia in a 24-hour period. A highly skilled team of super-specialists in cardiac radiofrequency ablation procedures successfully eliminated the focus of these arrhythmias. However, the procedure was difficult and complicated. It took 7 hours and required both left and right heart catheterizations and crossing of the atrial septum and the aortic valve. Despite this, the individual was back at his usual work in 3 days, completely arrhythmia free. He has required no further subsequent treatment.

In both instances, the good care required by these skilled specialists and their colleagues was complicated and demanding but successful. It required enormous expertise and, more importantly, the commitment and dedication of those providing it. Sure, this care was expensive, but it was worth every penny. It was priceless, because the outcomes were life-saving and perfect. These priceless treatments restored two young, productive people to full health.

So in this rush to cut health care costs, let us remember that we in the United States have the best physicians and surgeons, the best hospitals, the best drugs, and medical devices in the world. Let us preserve these assets and not kill the goose that is laying the golden eggs of health care. Let us preserve and reward the priceless individuals and priceless care that can allow many of us in the United States to lead better, more productive lives than we otherwise would.

Dr. Veith is Professor of Surgery at New York University Medical Center and the Cleveland Clinic. He is an associate medical editor for Vascular Specialist.

The ideas and opinions expressed in Vascular Specialist do not necessarily reflect those of the Society or Publisher.

Today all we hear about is the high cost of U.S. health care, and how for our country to survive economically, it must cut doctors’ payments and spend less for health care, drugs, and medical devices. Certainly there is waste in the system and some physicians perform procedures that are unnecessary. But when one really needs good medical care and a good doctor, they are priceless.

Two recent dramatic examples in my own family made this clear to me. In one, a loved one developed a staphylococcal infection at an epidural injection site. Within 24 hours, she was desperately ill with a temperature of 104º, shaking chills, and excruciating back pain. She was expeditiously admitted to the ICU of an excellent community hospital and started on massive IV antibiotics. She underwent an urgent MRI, which revealed a paravertebral phlegmon. Blood cultures grew Staphyloccus aureus. She was seen repeatedly by her intensive care specialist and her orthopedic surgeon. When she did not improve, her orthopedic surgeon obtained a second MRI 36 hours after the first one. This, unlike the first, revealed an epidural collection, and she promptly underwent a three segment laminectomy to drain the abscess.

Although she required a second drainage procedure and careful adjustment of her IV antibiotics, she survived without any neurologic or cardiac damage. During her complicated and onerous 2½ weeks in the ICU, she was seen 2-3 times a day by both her intensivist and orthopedic surgeon, as well as by a variety of other specialists when they were needed. All made essential contributions to her recovery from this life-threatening illness. The skill and commitment of all these doctors, especially the orthopedic surgeon and the intensivist, made the difference in saving this young life. The care she received was priceless.

The second instance involved the cure of a life-threatening ventricular arrhythmia in a relatively young, productive individual. Although asymptomatic, this individual was having over 40,000 ventricular premature beats with runs of ventricular tachycardia in a 24-hour period. A highly skilled team of super-specialists in cardiac radiofrequency ablation procedures successfully eliminated the focus of these arrhythmias. However, the procedure was difficult and complicated. It took 7 hours and required both left and right heart catheterizations and crossing of the atrial septum and the aortic valve. Despite this, the individual was back at his usual work in 3 days, completely arrhythmia free. He has required no further subsequent treatment.

In both instances, the good care required by these skilled specialists and their colleagues was complicated and demanding but successful. It required enormous expertise and, more importantly, the commitment and dedication of those providing it. Sure, this care was expensive, but it was worth every penny. It was priceless, because the outcomes were life-saving and perfect. These priceless treatments restored two young, productive people to full health.

So in this rush to cut health care costs, let us remember that we in the United States have the best physicians and surgeons, the best hospitals, the best drugs, and medical devices in the world. Let us preserve these assets and not kill the goose that is laying the golden eggs of health care. Let us preserve and reward the priceless individuals and priceless care that can allow many of us in the United States to lead better, more productive lives than we otherwise would.

Dr. Veith is Professor of Surgery at New York University Medical Center and the Cleveland Clinic. He is an associate medical editor for Vascular Specialist.

The ideas and opinions expressed in Vascular Specialist do not necessarily reflect those of the Society or Publisher.

Vascular surgery is an exciting field. It also faces enormous challenges. These include a difficult economic climate and intense competition from other specialties, both interventional and surgical. Vascular surgery has certain assets, such as its commitment only to the management of vascular disease and its ability to provide medical, open surgical and interventional treatments, depending on which is best for the patient. However, these assets are balanced by liabilities, such as impaired access to interventional suites, the public perception that other specialties can provide better less invasive treatments, and weak influence or power within institutions or departments.

These liabilities are real and impact on both individual vascular surgeons and the specialty as a whole. It is because of these liabilities that vascular surgery has only maintained a degree of stability despite the enormous growth in the number of vascular patients and the introduction of exciting new means of treating these patients less invasively, more safely and more effectively.

How can we overcome these liabilities and make our specialty survive and prosper? The answer is creativity. If we develop new and better ways to manage and treat vascular patients and let the world know we are the innovators, our specialty will grow and prosper. Patients will seek out those that developed the new and better treatments and come to them. Having more patients needing treatment will increase the influence and power of vascular surgeons within institutions and departments.

Let’s look at some examples. I have had experience with three. The first was so-called limb salvage surgery. In the 1960s and 1970s, no one was interested in patients with toe and foot gangrene. However, as techniques were developed to improve the limb circulation in such patients, they flocked to those who could provide these treatments, even though many physicians and surgeons expressed doubts and skepticism about their value.

Later, when less invasive interventional treatments were also developed for improving the circulation, again patients sought out the centers that could provide them. Sure, the open and endovascular treatments for these ischemic problems were difficult to perform. They required skill and commitment. But when they worked, patients found out about them and requested them. The skeptics were eventually proven wrong, and creativity was rewarded.

However, even today skeptics exist with regard to some newer endovascular treatments below the inguinal ligament. I suspect they will again be proven wrong as the treatments improve and indications for use are crystalized.

A second example was endovascular grafts and EVAR. In the beginning, after Juan Parodi’s first demonstration of feasibility, these procedures were regarded with enormous skepticism and even derision. Complications and failures were highlighted by many. But as the techniques and devices were made better, results improved. Innovating vascular surgeons and centers gained in stature, and their patient loads increased. Creativity in developing new and better treatments reaped its rewards for individual surgeons, institutions, and our specialty.

A third example is the newer endovenous treatments to ablate the greater saphenous and other veins less invasively. These treatments work, and because of their less invasive nature, patients seek out those who perform them. This has opened up a new treatment area of opportunity for vascular surgeons. It now comprises a large portion of many vascular surgeons’ practices.

The three examples I have mentioned are now accepted areas of treatment in vascular surgery – all introduced largely by vascular surgeons. All three have also been adopted by other specialists, and there is nothing wrong with that. However, what are we to do about the uncertain future?

We vascular surgeons must continue to be creative. We must devise newer and better techniques for treating vascular disease. We must publicize and document the fact that these innovations have been made by vascular surgeons. This requires not only scientific publication but also an effective public relations campaign on all levels.

For vascular surgeons these new or better techniques can be medical, interventional or open surgical. Examples of medical treatment are those that slow the growth of aneurysms or the development and progression of atherosclerotic lesions.

Patients will seek out these creative improvements and come to the practitioners or centers that provide them. When they do, they will also return when they need a subsequent intervention or open surgical treatment. Our success as vascular surgeons will be enhanced.

The same is true for innovative, safer or better endovascular or open surgical procedures. When properly documented in the scientific peer-reviewed literature and appropriately publicized in the lay media, this creativity will enhance the stature and importance of Vascular Surgery.

Even though we exist in a highly competitive and difficult environment, this creativity more than anything else will help individual vascular surgeons and vascular surgery in general to survive and prosper.n

Dr. Frank J. Veith is Professor of Surgery at New York University Medical Center and the Cleveland Clinic. He is an associate medical editor for Vascular Specialist.

The ideas and opinions expressed in Vascular Specialist do not necessarily reflect those of the Society or publisher.

Vascular surgery is an exciting field. It also faces enormous challenges. These include a difficult economic climate and intense competition from other specialties, both interventional and surgical. Vascular surgery has certain assets, such as its commitment only to the management of vascular disease and its ability to provide medical, open surgical and interventional treatments, depending on which is best for the patient. However, these assets are balanced by liabilities, such as impaired access to interventional suites, the public perception that other specialties can provide better less invasive treatments, and weak influence or power within institutions or departments.

These liabilities are real and impact on both individual vascular surgeons and the specialty as a whole. It is because of these liabilities that vascular surgery has only maintained a degree of stability despite the enormous growth in the number of vascular patients and the introduction of exciting new means of treating these patients less invasively, more safely and more effectively.

How can we overcome these liabilities and make our specialty survive and prosper? The answer is creativity. If we develop new and better ways to manage and treat vascular patients and let the world know we are the innovators, our specialty will grow and prosper. Patients will seek out those that developed the new and better treatments and come to them. Having more patients needing treatment will increase the influence and power of vascular surgeons within institutions and departments.

Let’s look at some examples. I have had experience with three. The first was so-called limb salvage surgery. In the 1960s and 1970s, no one was interested in patients with toe and foot gangrene. However, as techniques were developed to improve the limb circulation in such patients, they flocked to those who could provide these treatments, even though many physicians and surgeons expressed doubts and skepticism about their value.

Later, when less invasive interventional treatments were also developed for improving the circulation, again patients sought out the centers that could provide them. Sure, the open and endovascular treatments for these ischemic problems were difficult to perform. They required skill and commitment. But when they worked, patients found out about them and requested them. The skeptics were eventually proven wrong, and creativity was rewarded.

However, even today skeptics exist with regard to some newer endovascular treatments below the inguinal ligament. I suspect they will again be proven wrong as the treatments improve and indications for use are crystalized.

A second example was endovascular grafts and EVAR. In the beginning, after Juan Parodi’s first demonstration of feasibility, these procedures were regarded with enormous skepticism and even derision. Complications and failures were highlighted by many. But as the techniques and devices were made better, results improved. Innovating vascular surgeons and centers gained in stature, and their patient loads increased. Creativity in developing new and better treatments reaped its rewards for individual surgeons, institutions, and our specialty.

A third example is the newer endovenous treatments to ablate the greater saphenous and other veins less invasively. These treatments work, and because of their less invasive nature, patients seek out those who perform them. This has opened up a new treatment area of opportunity for vascular surgeons. It now comprises a large portion of many vascular surgeons’ practices.

The three examples I have mentioned are now accepted areas of treatment in vascular surgery – all introduced largely by vascular surgeons. All three have also been adopted by other specialists, and there is nothing wrong with that. However, what are we to do about the uncertain future?

We vascular surgeons must continue to be creative. We must devise newer and better techniques for treating vascular disease. We must publicize and document the fact that these innovations have been made by vascular surgeons. This requires not only scientific publication but also an effective public relations campaign on all levels.

For vascular surgeons these new or better techniques can be medical, interventional or open surgical. Examples of medical treatment are those that slow the growth of aneurysms or the development and progression of atherosclerotic lesions.

Patients will seek out these creative improvements and come to the practitioners or centers that provide them. When they do, they will also return when they need a subsequent intervention or open surgical treatment. Our success as vascular surgeons will be enhanced.

The same is true for innovative, safer or better endovascular or open surgical procedures. When properly documented in the scientific peer-reviewed literature and appropriately publicized in the lay media, this creativity will enhance the stature and importance of Vascular Surgery.

Even though we exist in a highly competitive and difficult environment, this creativity more than anything else will help individual vascular surgeons and vascular surgery in general to survive and prosper.n

Dr. Frank J. Veith is Professor of Surgery at New York University Medical Center and the Cleveland Clinic. He is an associate medical editor for Vascular Specialist.

The ideas and opinions expressed in Vascular Specialist do not necessarily reflect those of the Society or publisher.

Vascular surgery is an exciting field. It also faces enormous challenges. These include a difficult economic climate and intense competition from other specialties, both interventional and surgical. Vascular surgery has certain assets, such as its commitment only to the management of vascular disease and its ability to provide medical, open surgical and interventional treatments, depending on which is best for the patient. However, these assets are balanced by liabilities, such as impaired access to interventional suites, the public perception that other specialties can provide better less invasive treatments, and weak influence or power within institutions or departments.

These liabilities are real and impact on both individual vascular surgeons and the specialty as a whole. It is because of these liabilities that vascular surgery has only maintained a degree of stability despite the enormous growth in the number of vascular patients and the introduction of exciting new means of treating these patients less invasively, more safely and more effectively.

How can we overcome these liabilities and make our specialty survive and prosper? The answer is creativity. If we develop new and better ways to manage and treat vascular patients and let the world know we are the innovators, our specialty will grow and prosper. Patients will seek out those that developed the new and better treatments and come to them. Having more patients needing treatment will increase the influence and power of vascular surgeons within institutions and departments.

Let’s look at some examples. I have had experience with three. The first was so-called limb salvage surgery. In the 1960s and 1970s, no one was interested in patients with toe and foot gangrene. However, as techniques were developed to improve the limb circulation in such patients, they flocked to those who could provide these treatments, even though many physicians and surgeons expressed doubts and skepticism about their value.

Later, when less invasive interventional treatments were also developed for improving the circulation, again patients sought out the centers that could provide them. Sure, the open and endovascular treatments for these ischemic problems were difficult to perform. They required skill and commitment. But when they worked, patients found out about them and requested them. The skeptics were eventually proven wrong, and creativity was rewarded.

However, even today skeptics exist with regard to some newer endovascular treatments below the inguinal ligament. I suspect they will again be proven wrong as the treatments improve and indications for use are crystalized.

A second example was endovascular grafts and EVAR. In the beginning, after Juan Parodi’s first demonstration of feasibility, these procedures were regarded with enormous skepticism and even derision. Complications and failures were highlighted by many. But as the techniques and devices were made better, results improved. Innovating vascular surgeons and centers gained in stature, and their patient loads increased. Creativity in developing new and better treatments reaped its rewards for individual surgeons, institutions, and our specialty.

A third example is the newer endovenous treatments to ablate the greater saphenous and other veins less invasively. These treatments work, and because of their less invasive nature, patients seek out those who perform them. This has opened up a new treatment area of opportunity for vascular surgeons. It now comprises a large portion of many vascular surgeons’ practices.

The three examples I have mentioned are now accepted areas of treatment in vascular surgery – all introduced largely by vascular surgeons. All three have also been adopted by other specialists, and there is nothing wrong with that. However, what are we to do about the uncertain future?

We vascular surgeons must continue to be creative. We must devise newer and better techniques for treating vascular disease. We must publicize and document the fact that these innovations have been made by vascular surgeons. This requires not only scientific publication but also an effective public relations campaign on all levels.

For vascular surgeons these new or better techniques can be medical, interventional or open surgical. Examples of medical treatment are those that slow the growth of aneurysms or the development and progression of atherosclerotic lesions.

Patients will seek out these creative improvements and come to the practitioners or centers that provide them. When they do, they will also return when they need a subsequent intervention or open surgical treatment. Our success as vascular surgeons will be enhanced.

The same is true for innovative, safer or better endovascular or open surgical procedures. When properly documented in the scientific peer-reviewed literature and appropriately publicized in the lay media, this creativity will enhance the stature and importance of Vascular Surgery.

Even though we exist in a highly competitive and difficult environment, this creativity more than anything else will help individual vascular surgeons and vascular surgery in general to survive and prosper.n

Dr. Frank J. Veith is Professor of Surgery at New York University Medical Center and the Cleveland Clinic. He is an associate medical editor for Vascular Specialist.

The ideas and opinions expressed in Vascular Specialist do not necessarily reflect those of the Society or publisher.

The Affordable Care Act (ACA) has the laudable goals of extending health care insurance coverage and reducing overall health care costs. However, hidden in the over 2,400 pages of this bill are a number of provisions, many as yet unrecognized, which will have detrimental effects on our national economy, multiple parts of the health care industry, as well as most medical practitioners. 

One of the most onerous aspects of the ACA is the Sunshine Act, which is intended to bring transparency to any and all financial relationships between industry and physicians. This ACA provision mandates that everything a drug company or medical device maker provides to a physician must be disclosed and, after September 30, 2013, it must be published in detail on the Internet.

These disclosures must include pens, thumb drives, shirts and meals, as well as grants for research or travel to present data at meetings and consultant fees for proctoring cases in which new devices are used by physicians unfamiliar with them.

The purpose of this provision is to expose any financial bias or conflict of interest which might increase costs or influence and thereby corrupt research findings, medical education and ultimately medical practice.

On its face governmental involvement in this area might seem justified by the facts that such financial conflicts might lead to care which is unnecessary or harmful to patients (the public), and that government and the taxpayer are largely paying the bills.

Moreover, there have been a few flagrant abuses of the industry-doctor financial relationship in which conflicts of interest have risen to the level of gross commercialism with physicians receiving outlandish sums for providing fraudulent data or promoting drugs or products in a way unjustified by the scientific evidence. So the goal of providing more transparency to the financial relationships between industry and doctors seems a reasonable one.

Don't be fooled. The Sunshine Act's specifics are anything but reasonable. Doctors' judgments and actions are clearly not going to be corrupted by a pen, a thumb drive, or a meal.

It is also reasonable that physicians be compensated fairly for the time spent away from their practice in providing consultant services, participating in educational activities or conducting industry sponsored research, some of which produces valid and important scientific data unobtainable without industry support.

The JUPITER trial is one such example, proving the value of statins in decreasing strokes and myocardial infarctions in high-risk patients with normal lipid profiles. To lump funds received from industry for such meritorious activities together with excessive financial rewards for unjustified promotional activity, as the Sunshine Act's reporting will do, is unfair.

Doctors should not be presumed to be corrupt just because they are paid for legitimate services -- just as are all other professionals.

In addition, the Sunshine Act will require industry to expend many millions of dollars in tedious record keeping and documentation of multiple miniscule details. This plus the implication of taint will discourage relationships between industry and physicians which will have many detrimental effects on medical education and more importantly on U.S. medical innovation.

The latter is already lagging far behind that in other parts of the developed world because of stringent FDA requirements. All these unintended consequences of the Sunshine Act will have a profound negative effect on patient care in our country and thus be harmful to the U.S. public at large.

There are two possible solutions to the problems resulting from the Sunshine Act in its present form. The first is to remove the negativism and unfairness of its reporting requirement by several modifications. The requirement of reporting small and trivial items like pens, thumb drives and meals should be eliminated.

Reporting of only substantial sums in excess of $10,000 or $25,000 should be required. This would decrease markedly the administrative burden of Sunshine reporting.

Moreover, it should be mandated that all funds received from industry by a physician not be listed as a lump sum, but be qualified by the time involved and the type of service rendered.

Just because a physician receives a large payment does not mean it is evil, a bribe, or unjustified. In all other fields, excellence, creativity, knowledge, contribution, and time commitment are rewarded financially, and this should be the case in the industry-doctor relationship arena as well.

A second solution to fix the Sunshine Act and make it fair is to apply all its provisions to Members of Congress and all other elected and non-elected employees of our Federal Government.

After all, just like medical practitioners and those in the health care industry, our federal officials -- and employees -- actions impact on the well-being of our society, and all these individuals in government are paid by the taxpayers.

So let's be fair and apply the same Sunshine Act reporting requirements to those in government to avoid corruption of their actions by unfair and opaque conflicts of interest.

Thus, the Sunshine Act should be fixed. More importantly ,the transparency of its requirements should be allowed to shine on Congress and other federal employees who are paid by the public to support its interests.

If these two corrective actions cannot be taken, the Sunshine Act should be done away with entirely.

Dr. Veith is Professor of Surgery at New York University Medical Center and the Cleveland Clinic. He is an associate medical editor for Vascular Specialist. 

The ideas and opinions expressed in Vascular Specialist do not necessarily reflect those of the Society or Publisher.

The Affordable Care Act (ACA) has the laudable goals of extending health care insurance coverage and reducing overall health care costs. However, hidden in the over 2,400 pages of this bill are a number of provisions, many as yet unrecognized, which will have detrimental effects on our national economy, multiple parts of the health care industry, as well as most medical practitioners. 

One of the most onerous aspects of the ACA is the Sunshine Act, which is intended to bring transparency to any and all financial relationships between industry and physicians. This ACA provision mandates that everything a drug company or medical device maker provides to a physician must be disclosed and, after September 30, 2013, it must be published in detail on the Internet.

These disclosures must include pens, thumb drives, shirts and meals, as well as grants for research or travel to present data at meetings and consultant fees for proctoring cases in which new devices are used by physicians unfamiliar with them.

The purpose of this provision is to expose any financial bias or conflict of interest which might increase costs or influence and thereby corrupt research findings, medical education and ultimately medical practice.

On its face governmental involvement in this area might seem justified by the facts that such financial conflicts might lead to care which is unnecessary or harmful to patients (the public), and that government and the taxpayer are largely paying the bills.

Moreover, there have been a few flagrant abuses of the industry-doctor financial relationship in which conflicts of interest have risen to the level of gross commercialism with physicians receiving outlandish sums for providing fraudulent data or promoting drugs or products in a way unjustified by the scientific evidence. So the goal of providing more transparency to the financial relationships between industry and doctors seems a reasonable one.

Don't be fooled. The Sunshine Act's specifics are anything but reasonable. Doctors' judgments and actions are clearly not going to be corrupted by a pen, a thumb drive, or a meal.

It is also reasonable that physicians be compensated fairly for the time spent away from their practice in providing consultant services, participating in educational activities or conducting industry sponsored research, some of which produces valid and important scientific data unobtainable without industry support.

The JUPITER trial is one such example, proving the value of statins in decreasing strokes and myocardial infarctions in high-risk patients with normal lipid profiles. To lump funds received from industry for such meritorious activities together with excessive financial rewards for unjustified promotional activity, as the Sunshine Act's reporting will do, is unfair.

Doctors should not be presumed to be corrupt just because they are paid for legitimate services -- just as are all other professionals.

In addition, the Sunshine Act will require industry to expend many millions of dollars in tedious record keeping and documentation of multiple miniscule details. This plus the implication of taint will discourage relationships between industry and physicians which will have many detrimental effects on medical education and more importantly on U.S. medical innovation.

The latter is already lagging far behind that in other parts of the developed world because of stringent FDA requirements. All these unintended consequences of the Sunshine Act will have a profound negative effect on patient care in our country and thus be harmful to the U.S. public at large.

There are two possible solutions to the problems resulting from the Sunshine Act in its present form. The first is to remove the negativism and unfairness of its reporting requirement by several modifications. The requirement of reporting small and trivial items like pens, thumb drives and meals should be eliminated.

Reporting of only substantial sums in excess of $10,000 or $25,000 should be required. This would decrease markedly the administrative burden of Sunshine reporting.

Moreover, it should be mandated that all funds received from industry by a physician not be listed as a lump sum, but be qualified by the time involved and the type of service rendered.

Just because a physician receives a large payment does not mean it is evil, a bribe, or unjustified. In all other fields, excellence, creativity, knowledge, contribution, and time commitment are rewarded financially, and this should be the case in the industry-doctor relationship arena as well.

A second solution to fix the Sunshine Act and make it fair is to apply all its provisions to Members of Congress and all other elected and non-elected employees of our Federal Government.

After all, just like medical practitioners and those in the health care industry, our federal officials -- and employees -- actions impact on the well-being of our society, and all these individuals in government are paid by the taxpayers.

So let's be fair and apply the same Sunshine Act reporting requirements to those in government to avoid corruption of their actions by unfair and opaque conflicts of interest.

Thus, the Sunshine Act should be fixed. More importantly ,the transparency of its requirements should be allowed to shine on Congress and other federal employees who are paid by the public to support its interests.

If these two corrective actions cannot be taken, the Sunshine Act should be done away with entirely.

Dr. Veith is Professor of Surgery at New York University Medical Center and the Cleveland Clinic. He is an associate medical editor for Vascular Specialist. 

The ideas and opinions expressed in Vascular Specialist do not necessarily reflect those of the Society or Publisher.

The Affordable Care Act (ACA) has the laudable goals of extending health care insurance coverage and reducing overall health care costs. However, hidden in the over 2,400 pages of this bill are a number of provisions, many as yet unrecognized, which will have detrimental effects on our national economy, multiple parts of the health care industry, as well as most medical practitioners. 

One of the most onerous aspects of the ACA is the Sunshine Act, which is intended to bring transparency to any and all financial relationships between industry and physicians. This ACA provision mandates that everything a drug company or medical device maker provides to a physician must be disclosed and, after September 30, 2013, it must be published in detail on the Internet.

These disclosures must include pens, thumb drives, shirts and meals, as well as grants for research or travel to present data at meetings and consultant fees for proctoring cases in which new devices are used by physicians unfamiliar with them.

The purpose of this provision is to expose any financial bias or conflict of interest which might increase costs or influence and thereby corrupt research findings, medical education and ultimately medical practice.

On its face governmental involvement in this area might seem justified by the facts that such financial conflicts might lead to care which is unnecessary or harmful to patients (the public), and that government and the taxpayer are largely paying the bills.

Moreover, there have been a few flagrant abuses of the industry-doctor financial relationship in which conflicts of interest have risen to the level of gross commercialism with physicians receiving outlandish sums for providing fraudulent data or promoting drugs or products in a way unjustified by the scientific evidence. So the goal of providing more transparency to the financial relationships between industry and doctors seems a reasonable one.

Don't be fooled. The Sunshine Act's specifics are anything but reasonable. Doctors' judgments and actions are clearly not going to be corrupted by a pen, a thumb drive, or a meal.

It is also reasonable that physicians be compensated fairly for the time spent away from their practice in providing consultant services, participating in educational activities or conducting industry sponsored research, some of which produces valid and important scientific data unobtainable without industry support.

The JUPITER trial is one such example, proving the value of statins in decreasing strokes and myocardial infarctions in high-risk patients with normal lipid profiles. To lump funds received from industry for such meritorious activities together with excessive financial rewards for unjustified promotional activity, as the Sunshine Act's reporting will do, is unfair.

Doctors should not be presumed to be corrupt just because they are paid for legitimate services -- just as are all other professionals.

In addition, the Sunshine Act will require industry to expend many millions of dollars in tedious record keeping and documentation of multiple miniscule details. This plus the implication of taint will discourage relationships between industry and physicians which will have many detrimental effects on medical education and more importantly on U.S. medical innovation.

The latter is already lagging far behind that in other parts of the developed world because of stringent FDA requirements. All these unintended consequences of the Sunshine Act will have a profound negative effect on patient care in our country and thus be harmful to the U.S. public at large.

There are two possible solutions to the problems resulting from the Sunshine Act in its present form. The first is to remove the negativism and unfairness of its reporting requirement by several modifications. The requirement of reporting small and trivial items like pens, thumb drives and meals should be eliminated.

Reporting of only substantial sums in excess of $10,000 or $25,000 should be required. This would decrease markedly the administrative burden of Sunshine reporting.

Moreover, it should be mandated that all funds received from industry by a physician not be listed as a lump sum, but be qualified by the time involved and the type of service rendered.

Just because a physician receives a large payment does not mean it is evil, a bribe, or unjustified. In all other fields, excellence, creativity, knowledge, contribution, and time commitment are rewarded financially, and this should be the case in the industry-doctor relationship arena as well.

A second solution to fix the Sunshine Act and make it fair is to apply all its provisions to Members of Congress and all other elected and non-elected employees of our Federal Government.

After all, just like medical practitioners and those in the health care industry, our federal officials -- and employees -- actions impact on the well-being of our society, and all these individuals in government are paid by the taxpayers.

So let's be fair and apply the same Sunshine Act reporting requirements to those in government to avoid corruption of their actions by unfair and opaque conflicts of interest.

Thus, the Sunshine Act should be fixed. More importantly ,the transparency of its requirements should be allowed to shine on Congress and other federal employees who are paid by the public to support its interests.

If these two corrective actions cannot be taken, the Sunshine Act should be done away with entirely.

Dr. Veith is Professor of Surgery at New York University Medical Center and the Cleveland Clinic. He is an associate medical editor for Vascular Specialist. 

The ideas and opinions expressed in Vascular Specialist do not necessarily reflect those of the Society or Publisher.