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Professional Courtesy
In an early Peanuts cartoon Charlie Brown asked Linus what he wanted to be when he grew up, and Linus replied that was going to be a country doctor: "Yup. I want to be on the right side of the ol' needle." That's probably as good a reason as any to become a "professional man."
At this time, when the idea of being a "pro" encompasses anyone from waiters to hair-dressers to river raft guides, it is useful to recall how the idea of a professional originated.
It was not until medieval times when universities were first being organized under religious auspices that the three Classical or "learned" professions emerged: the law, medicine, and the clergy. Each profession filled a valued role in society, and, accordingly, each was awarded prestige, status, and power. All three professions required long study to join their ranks, and all were governed by codes of ethics. The ethics of medicine were rooted in the oaths of Hippocrates and later Maimonides. Incorporated in those codes was the principle of respecting one's teachers and colleagues,which included the granting of "professional courtesy," by which one physician wouldcare for another (and his family) without charge. Both my family and I have been benefited from this tradition, but recent reports from other doctors suggest that professional courtesy today is honored more in breach than in fact.
My first act of professional courtesy came shortly after I entered practice. I was responding to the request of an older internist acquaintance who wished me to operate on his wife for unsightly symptomatic unilateral varicose veins. Truth be told, the symptoms were minimal, but the veins were so large that I confidently anticipated a very good cosmetic result, and this proved to be the case. I was proud just to be asked, since he could have asked any one of a number of vascular surgeons in our community, but he asked me.
In those days patients stayed in the hospital for 2 or 3 days until they were walking comfortably and unaided without limping. Within 2 weeks, my patient was free of bruising and fully recovered. Whether she or I was the happier with the outcome is long forgotten, but I recall receiving a small gift for having extended "professional courtesy." When her husband told me that he would rather I just sent a bill I replied "Absolutely not." I saw it as my duty -- I was probably too young to say "solemn duty" -- and indeed my honor to be able to care for his wife. He had medical insurance, of course, and I could have billed for the procedure, but I didn't.
Looking back, it might have been the first of countless occurrences where the insurance company came out on top when dealing with doctors. In not accepting the insurance was I invoking professional courtesy or merely self-indulgent hubris?
In ensuing years I have been priveleged to operate on and care for many doctors and their families. Other specialists, such as pediatricians, internists, and psychiatrists, have long-term and ongoing relationships with their doctor-patients that are less "one off" episodes than is usually the case with surgeons. For these kinds of specialties, providing "professional courtesy" may be a greater financial burden than for surgeons. Each doctor must decide for himself whether to charge for services rendered to a colleague or their family.
Insurance coverage is approaching universal and not to charge the "third party" insurer is, arguably, foolish. Insurers would mock us if they knew we elected not to bill by virtue of some lofty motivation. In the case of Medicare -- thanks to laws designed to prevent kickbacks and patient solicitation -- it is illegal not to bill a patient of any sort, including doctors. Even if one bills Medicare, one is additionally required by law to balance bills for the 20% of the bill that is not covered.
If the age of professional courtesy is past, how should we conduct ourselves in the future? Is professiona courtesy an anachronistic gesture that should be allowed to expire quietly?
The answer is not straightforward. What was once an arrangement between two people --a doctor and his patient, who incidentally was a doctor -- now includes many other participants tocomplicate the basic gesture. If a person has insurance, it seems wasteful not to bill for services.
Inded, a decade after the passage of the Medicare Act in 1965, the elderly went from being the worst insured group to the best iinsured, and Medicare patients were the vascular surgeons "target clientele." Fees and "real income" for procedures were also higher then, and were in 1970's dollars. In those years, if those with poor insurance, or no insurance at all, couldn't afford treatment, then surgeons commonly waived part or all of their fees. It was a simpler time.
Today, as we haltingly stumble towards "universal coverage," acts of charity and professional courtesy both appear destined to disappear. I would guess that other aspects of how doctors behave towards our patients will likewise face a major overhaul. And it won't make any difference what side of the needle you're on.
Dr. George Andros is the medical director of the Amputation Prevention Centery, Valley Presbyterian Hospital, Van Nuys, Calif., and the outgoing medical editor of Vascular Specialist.
In an early Peanuts cartoon Charlie Brown asked Linus what he wanted to be when he grew up, and Linus replied that was going to be a country doctor: "Yup. I want to be on the right side of the ol' needle." That's probably as good a reason as any to become a "professional man."
At this time, when the idea of being a "pro" encompasses anyone from waiters to hair-dressers to river raft guides, it is useful to recall how the idea of a professional originated.
It was not until medieval times when universities were first being organized under religious auspices that the three Classical or "learned" professions emerged: the law, medicine, and the clergy. Each profession filled a valued role in society, and, accordingly, each was awarded prestige, status, and power. All three professions required long study to join their ranks, and all were governed by codes of ethics. The ethics of medicine were rooted in the oaths of Hippocrates and later Maimonides. Incorporated in those codes was the principle of respecting one's teachers and colleagues,which included the granting of "professional courtesy," by which one physician wouldcare for another (and his family) without charge. Both my family and I have been benefited from this tradition, but recent reports from other doctors suggest that professional courtesy today is honored more in breach than in fact.
My first act of professional courtesy came shortly after I entered practice. I was responding to the request of an older internist acquaintance who wished me to operate on his wife for unsightly symptomatic unilateral varicose veins. Truth be told, the symptoms were minimal, but the veins were so large that I confidently anticipated a very good cosmetic result, and this proved to be the case. I was proud just to be asked, since he could have asked any one of a number of vascular surgeons in our community, but he asked me.
In those days patients stayed in the hospital for 2 or 3 days until they were walking comfortably and unaided without limping. Within 2 weeks, my patient was free of bruising and fully recovered. Whether she or I was the happier with the outcome is long forgotten, but I recall receiving a small gift for having extended "professional courtesy." When her husband told me that he would rather I just sent a bill I replied "Absolutely not." I saw it as my duty -- I was probably too young to say "solemn duty" -- and indeed my honor to be able to care for his wife. He had medical insurance, of course, and I could have billed for the procedure, but I didn't.
Looking back, it might have been the first of countless occurrences where the insurance company came out on top when dealing with doctors. In not accepting the insurance was I invoking professional courtesy or merely self-indulgent hubris?
In ensuing years I have been priveleged to operate on and care for many doctors and their families. Other specialists, such as pediatricians, internists, and psychiatrists, have long-term and ongoing relationships with their doctor-patients that are less "one off" episodes than is usually the case with surgeons. For these kinds of specialties, providing "professional courtesy" may be a greater financial burden than for surgeons. Each doctor must decide for himself whether to charge for services rendered to a colleague or their family.
Insurance coverage is approaching universal and not to charge the "third party" insurer is, arguably, foolish. Insurers would mock us if they knew we elected not to bill by virtue of some lofty motivation. In the case of Medicare -- thanks to laws designed to prevent kickbacks and patient solicitation -- it is illegal not to bill a patient of any sort, including doctors. Even if one bills Medicare, one is additionally required by law to balance bills for the 20% of the bill that is not covered.
If the age of professional courtesy is past, how should we conduct ourselves in the future? Is professiona courtesy an anachronistic gesture that should be allowed to expire quietly?
The answer is not straightforward. What was once an arrangement between two people --a doctor and his patient, who incidentally was a doctor -- now includes many other participants tocomplicate the basic gesture. If a person has insurance, it seems wasteful not to bill for services.
Inded, a decade after the passage of the Medicare Act in 1965, the elderly went from being the worst insured group to the best iinsured, and Medicare patients were the vascular surgeons "target clientele." Fees and "real income" for procedures were also higher then, and were in 1970's dollars. In those years, if those with poor insurance, or no insurance at all, couldn't afford treatment, then surgeons commonly waived part or all of their fees. It was a simpler time.
Today, as we haltingly stumble towards "universal coverage," acts of charity and professional courtesy both appear destined to disappear. I would guess that other aspects of how doctors behave towards our patients will likewise face a major overhaul. And it won't make any difference what side of the needle you're on.
Dr. George Andros is the medical director of the Amputation Prevention Centery, Valley Presbyterian Hospital, Van Nuys, Calif., and the outgoing medical editor of Vascular Specialist.
In an early Peanuts cartoon Charlie Brown asked Linus what he wanted to be when he grew up, and Linus replied that was going to be a country doctor: "Yup. I want to be on the right side of the ol' needle." That's probably as good a reason as any to become a "professional man."
At this time, when the idea of being a "pro" encompasses anyone from waiters to hair-dressers to river raft guides, it is useful to recall how the idea of a professional originated.
It was not until medieval times when universities were first being organized under religious auspices that the three Classical or "learned" professions emerged: the law, medicine, and the clergy. Each profession filled a valued role in society, and, accordingly, each was awarded prestige, status, and power. All three professions required long study to join their ranks, and all were governed by codes of ethics. The ethics of medicine were rooted in the oaths of Hippocrates and later Maimonides. Incorporated in those codes was the principle of respecting one's teachers and colleagues,which included the granting of "professional courtesy," by which one physician wouldcare for another (and his family) without charge. Both my family and I have been benefited from this tradition, but recent reports from other doctors suggest that professional courtesy today is honored more in breach than in fact.
My first act of professional courtesy came shortly after I entered practice. I was responding to the request of an older internist acquaintance who wished me to operate on his wife for unsightly symptomatic unilateral varicose veins. Truth be told, the symptoms were minimal, but the veins were so large that I confidently anticipated a very good cosmetic result, and this proved to be the case. I was proud just to be asked, since he could have asked any one of a number of vascular surgeons in our community, but he asked me.
In those days patients stayed in the hospital for 2 or 3 days until they were walking comfortably and unaided without limping. Within 2 weeks, my patient was free of bruising and fully recovered. Whether she or I was the happier with the outcome is long forgotten, but I recall receiving a small gift for having extended "professional courtesy." When her husband told me that he would rather I just sent a bill I replied "Absolutely not." I saw it as my duty -- I was probably too young to say "solemn duty" -- and indeed my honor to be able to care for his wife. He had medical insurance, of course, and I could have billed for the procedure, but I didn't.
Looking back, it might have been the first of countless occurrences where the insurance company came out on top when dealing with doctors. In not accepting the insurance was I invoking professional courtesy or merely self-indulgent hubris?
In ensuing years I have been priveleged to operate on and care for many doctors and their families. Other specialists, such as pediatricians, internists, and psychiatrists, have long-term and ongoing relationships with their doctor-patients that are less "one off" episodes than is usually the case with surgeons. For these kinds of specialties, providing "professional courtesy" may be a greater financial burden than for surgeons. Each doctor must decide for himself whether to charge for services rendered to a colleague or their family.
Insurance coverage is approaching universal and not to charge the "third party" insurer is, arguably, foolish. Insurers would mock us if they knew we elected not to bill by virtue of some lofty motivation. In the case of Medicare -- thanks to laws designed to prevent kickbacks and patient solicitation -- it is illegal not to bill a patient of any sort, including doctors. Even if one bills Medicare, one is additionally required by law to balance bills for the 20% of the bill that is not covered.
If the age of professional courtesy is past, how should we conduct ourselves in the future? Is professiona courtesy an anachronistic gesture that should be allowed to expire quietly?
The answer is not straightforward. What was once an arrangement between two people --a doctor and his patient, who incidentally was a doctor -- now includes many other participants tocomplicate the basic gesture. If a person has insurance, it seems wasteful not to bill for services.
Inded, a decade after the passage of the Medicare Act in 1965, the elderly went from being the worst insured group to the best iinsured, and Medicare patients were the vascular surgeons "target clientele." Fees and "real income" for procedures were also higher then, and were in 1970's dollars. In those years, if those with poor insurance, or no insurance at all, couldn't afford treatment, then surgeons commonly waived part or all of their fees. It was a simpler time.
Today, as we haltingly stumble towards "universal coverage," acts of charity and professional courtesy both appear destined to disappear. I would guess that other aspects of how doctors behave towards our patients will likewise face a major overhaul. And it won't make any difference what side of the needle you're on.
Dr. George Andros is the medical director of the Amputation Prevention Centery, Valley Presbyterian Hospital, Van Nuys, Calif., and the outgoing medical editor of Vascular Specialist.
Questions on OECs
Several months ago we asked our readers to respond to an eleven-part questionnaire dealing with outpatient endovascular centers (OECs). Forty-three of you took the time to respond, and most answered nearly every question; we thank you for taking the time to do so. Moreover, about 30%-50% of participants provided valuable comments on why they answered as they did.
OECs are attracting governmental attention in California as the legislature is writing new rules and regulations to help the Board of Medical Examiners (BME) increase their OEC oversight. The BME includes several doctors, but non-medical members are numerous. The one qualification they all have in common is that they are political appointees, and when the BME members were publically scolded regarding OECs they pledged to serve their anointers with greater focus. I interpreted that as meaning that OECs and their owners will be in the BME’s crosshairs. That comes as no surprise from a state that sent Pete Stark to Congress for more than 30 years.
So what did our survey tell us? For openers, 95% supported the concept of the surgeon-owned OEC. Enhanced quality and efficiency were incentives mentioned by some responders, while others expressed concern about over-utilization and conflicts of interest. Without further elaboration one person said: "it has changed my life." Eighty-one percent did not believe that OECs caused a conflict of interest. In 19 of the responses (the second highest number), the majority praised better patient care and satisfaction, despite a minority voicing concern. A total of 25 respondents thought that fixed imaging systems were unnecessary and portable C-arms were at least "adequate." On the other hand, 26% of the 43 respondents thought that fixed imagers were the way to go, but none offered any comments in their defense.
When asked about the effect of increased OEC activity, 62% opined that hospital volumes and expertise would decline. That makes sense even considering more liberal indications for intervention and the "cherry-picking" of the easier cases by OECs. There are only so many cases to go around and usually the doctors, not the hospitals, decide where the procedure will be performed. It seems paradoxical that the hospitals will wind up caring for the more difficult, more acute cases, while maintaining less overall experience. This subject will doubtless attract increased attention from "regulators" in the future.
I was intrigued by the answer to the question about OEC and hospital priveleges and viewed it as a portmanteau for concerns about quality of care in general. Nearly all (40 out of 43) believed that OEC practitioners should have equivalent hospital privileges, (but only eight offered comments, the fewest). The reasons given were varied including: "of course, we should not sacrifice quality;" "privileges will be required for the occasional admission;" a simple and unqualified "absolutely."
Referring to the possibility of over-utilization in OECs, 34 respondents thought it was a reasonable concern, with 18 offering varied and provocative comments. In a follow-up question – are OECs necessary because hospital based -fees have been cut excessively? – 65% said yes, commenting further that the efficiency of OECs, such as shorter case turnover times, was as much a driver of better financial compensation as fee profiles. Praise for the better morale, efficiency, and workflow streamlining of the OEC work environment crept into many of the questions.
As far as outcomes are concerned, only 1 respondent thought they were worse in OECs, and 98% thought they were as good or better. Improved patient satisfaction was cited more than once. Of those who owned or worked in OECs, more than 80% stated that they earned more by doing cases there rather than in the hospital. The nub of the remuneration was captured by one particular response: "by a longshot."
The final question came full circle back to where the questionnaire started, "Should the SVS develop a position paper on OECs?" To some the answer, in light of the ambiguity and controversy that our little questionnaire has kindled, is a resounding "Yes." At the very least we need a more comprehensive interrogation of the issue with more and better questions and a thorough profile of current practices. Two-thirds of the respondents were in favor of some sort of document, saying that it would help promulgate guidelines and prevent abuse that would result in "killing the golden goose," according to one comment.
On the other hand, not all feelings about SVS involvement were so felicitious. One expressed being tired of the "SVS, AMA telling us how to take care of our patients; the government does that well enough." Perhaps the overall ambivalence is summarized by this answer: "by maintaining no position they (the SVS) will not alienate or disenfranchise their members who do have an OEC."
So there you have it. Vascular Specialist published an editorial piece on OECs, and we sought to measure the sentiments of our readers, the members of the SVS. OECs appear to fill an important role and seem to be here to stay. Whether they will continue to provide a marginal improvement in payments to the owner-providers remains to be seen. Equally uncertain is their continued economic viability if they come to resemble a revolving door that has patients returning over and over for "re-dos."
At that point, it won’t make much difference what SVS or AMA think about OECs and quality and patient satisfaction. The sound you will hear is the Treasury when it turns off the printing presses.
Several months ago we asked our readers to respond to an eleven-part questionnaire dealing with outpatient endovascular centers (OECs). Forty-three of you took the time to respond, and most answered nearly every question; we thank you for taking the time to do so. Moreover, about 30%-50% of participants provided valuable comments on why they answered as they did.
OECs are attracting governmental attention in California as the legislature is writing new rules and regulations to help the Board of Medical Examiners (BME) increase their OEC oversight. The BME includes several doctors, but non-medical members are numerous. The one qualification they all have in common is that they are political appointees, and when the BME members were publically scolded regarding OECs they pledged to serve their anointers with greater focus. I interpreted that as meaning that OECs and their owners will be in the BME’s crosshairs. That comes as no surprise from a state that sent Pete Stark to Congress for more than 30 years.
So what did our survey tell us? For openers, 95% supported the concept of the surgeon-owned OEC. Enhanced quality and efficiency were incentives mentioned by some responders, while others expressed concern about over-utilization and conflicts of interest. Without further elaboration one person said: "it has changed my life." Eighty-one percent did not believe that OECs caused a conflict of interest. In 19 of the responses (the second highest number), the majority praised better patient care and satisfaction, despite a minority voicing concern. A total of 25 respondents thought that fixed imaging systems were unnecessary and portable C-arms were at least "adequate." On the other hand, 26% of the 43 respondents thought that fixed imagers were the way to go, but none offered any comments in their defense.
When asked about the effect of increased OEC activity, 62% opined that hospital volumes and expertise would decline. That makes sense even considering more liberal indications for intervention and the "cherry-picking" of the easier cases by OECs. There are only so many cases to go around and usually the doctors, not the hospitals, decide where the procedure will be performed. It seems paradoxical that the hospitals will wind up caring for the more difficult, more acute cases, while maintaining less overall experience. This subject will doubtless attract increased attention from "regulators" in the future.
I was intrigued by the answer to the question about OEC and hospital priveleges and viewed it as a portmanteau for concerns about quality of care in general. Nearly all (40 out of 43) believed that OEC practitioners should have equivalent hospital privileges, (but only eight offered comments, the fewest). The reasons given were varied including: "of course, we should not sacrifice quality;" "privileges will be required for the occasional admission;" a simple and unqualified "absolutely."
Referring to the possibility of over-utilization in OECs, 34 respondents thought it was a reasonable concern, with 18 offering varied and provocative comments. In a follow-up question – are OECs necessary because hospital based -fees have been cut excessively? – 65% said yes, commenting further that the efficiency of OECs, such as shorter case turnover times, was as much a driver of better financial compensation as fee profiles. Praise for the better morale, efficiency, and workflow streamlining of the OEC work environment crept into many of the questions.
As far as outcomes are concerned, only 1 respondent thought they were worse in OECs, and 98% thought they were as good or better. Improved patient satisfaction was cited more than once. Of those who owned or worked in OECs, more than 80% stated that they earned more by doing cases there rather than in the hospital. The nub of the remuneration was captured by one particular response: "by a longshot."
The final question came full circle back to where the questionnaire started, "Should the SVS develop a position paper on OECs?" To some the answer, in light of the ambiguity and controversy that our little questionnaire has kindled, is a resounding "Yes." At the very least we need a more comprehensive interrogation of the issue with more and better questions and a thorough profile of current practices. Two-thirds of the respondents were in favor of some sort of document, saying that it would help promulgate guidelines and prevent abuse that would result in "killing the golden goose," according to one comment.
On the other hand, not all feelings about SVS involvement were so felicitious. One expressed being tired of the "SVS, AMA telling us how to take care of our patients; the government does that well enough." Perhaps the overall ambivalence is summarized by this answer: "by maintaining no position they (the SVS) will not alienate or disenfranchise their members who do have an OEC."
So there you have it. Vascular Specialist published an editorial piece on OECs, and we sought to measure the sentiments of our readers, the members of the SVS. OECs appear to fill an important role and seem to be here to stay. Whether they will continue to provide a marginal improvement in payments to the owner-providers remains to be seen. Equally uncertain is their continued economic viability if they come to resemble a revolving door that has patients returning over and over for "re-dos."
At that point, it won’t make much difference what SVS or AMA think about OECs and quality and patient satisfaction. The sound you will hear is the Treasury when it turns off the printing presses.
Several months ago we asked our readers to respond to an eleven-part questionnaire dealing with outpatient endovascular centers (OECs). Forty-three of you took the time to respond, and most answered nearly every question; we thank you for taking the time to do so. Moreover, about 30%-50% of participants provided valuable comments on why they answered as they did.
OECs are attracting governmental attention in California as the legislature is writing new rules and regulations to help the Board of Medical Examiners (BME) increase their OEC oversight. The BME includes several doctors, but non-medical members are numerous. The one qualification they all have in common is that they are political appointees, and when the BME members were publically scolded regarding OECs they pledged to serve their anointers with greater focus. I interpreted that as meaning that OECs and their owners will be in the BME’s crosshairs. That comes as no surprise from a state that sent Pete Stark to Congress for more than 30 years.
So what did our survey tell us? For openers, 95% supported the concept of the surgeon-owned OEC. Enhanced quality and efficiency were incentives mentioned by some responders, while others expressed concern about over-utilization and conflicts of interest. Without further elaboration one person said: "it has changed my life." Eighty-one percent did not believe that OECs caused a conflict of interest. In 19 of the responses (the second highest number), the majority praised better patient care and satisfaction, despite a minority voicing concern. A total of 25 respondents thought that fixed imaging systems were unnecessary and portable C-arms were at least "adequate." On the other hand, 26% of the 43 respondents thought that fixed imagers were the way to go, but none offered any comments in their defense.
When asked about the effect of increased OEC activity, 62% opined that hospital volumes and expertise would decline. That makes sense even considering more liberal indications for intervention and the "cherry-picking" of the easier cases by OECs. There are only so many cases to go around and usually the doctors, not the hospitals, decide where the procedure will be performed. It seems paradoxical that the hospitals will wind up caring for the more difficult, more acute cases, while maintaining less overall experience. This subject will doubtless attract increased attention from "regulators" in the future.
I was intrigued by the answer to the question about OEC and hospital priveleges and viewed it as a portmanteau for concerns about quality of care in general. Nearly all (40 out of 43) believed that OEC practitioners should have equivalent hospital privileges, (but only eight offered comments, the fewest). The reasons given were varied including: "of course, we should not sacrifice quality;" "privileges will be required for the occasional admission;" a simple and unqualified "absolutely."
Referring to the possibility of over-utilization in OECs, 34 respondents thought it was a reasonable concern, with 18 offering varied and provocative comments. In a follow-up question – are OECs necessary because hospital based -fees have been cut excessively? – 65% said yes, commenting further that the efficiency of OECs, such as shorter case turnover times, was as much a driver of better financial compensation as fee profiles. Praise for the better morale, efficiency, and workflow streamlining of the OEC work environment crept into many of the questions.
As far as outcomes are concerned, only 1 respondent thought they were worse in OECs, and 98% thought they were as good or better. Improved patient satisfaction was cited more than once. Of those who owned or worked in OECs, more than 80% stated that they earned more by doing cases there rather than in the hospital. The nub of the remuneration was captured by one particular response: "by a longshot."
The final question came full circle back to where the questionnaire started, "Should the SVS develop a position paper on OECs?" To some the answer, in light of the ambiguity and controversy that our little questionnaire has kindled, is a resounding "Yes." At the very least we need a more comprehensive interrogation of the issue with more and better questions and a thorough profile of current practices. Two-thirds of the respondents were in favor of some sort of document, saying that it would help promulgate guidelines and prevent abuse that would result in "killing the golden goose," according to one comment.
On the other hand, not all feelings about SVS involvement were so felicitious. One expressed being tired of the "SVS, AMA telling us how to take care of our patients; the government does that well enough." Perhaps the overall ambivalence is summarized by this answer: "by maintaining no position they (the SVS) will not alienate or disenfranchise their members who do have an OEC."
So there you have it. Vascular Specialist published an editorial piece on OECs, and we sought to measure the sentiments of our readers, the members of the SVS. OECs appear to fill an important role and seem to be here to stay. Whether they will continue to provide a marginal improvement in payments to the owner-providers remains to be seen. Equally uncertain is their continued economic viability if they come to resemble a revolving door that has patients returning over and over for "re-dos."
At that point, it won’t make much difference what SVS or AMA think about OECs and quality and patient satisfaction. The sound you will hear is the Treasury when it turns off the printing presses.
The FREEDOM trial: Is it sui generis?
I have never understood how the cardiology community is able to organize so many excellent trials while vascular surgeons struggle to complete a small handful. Appearing long after the well done NASCET and ECST, the recent CREST trial raised as many questions as it answered. In the future it will be exponentially more difficult to organize valid trials because many need to have three-armed studies: one for each intervention, presumably open and endovascular, and a noninterventional arm for medical/nonrevascularization approaches. As far as investigations on legs are concerned our only reliable example is the BASIL trial, now approaching its 10th anniversary.
Whatever the reasons in the past, I am convinced that we need to do a better job stratifying our patients and their disease on clinical grounds before we embark on selecting diagnostic studies and therapies. While there is no shortage of literature on the theory and practice of vascular intervention, I believe we lack a credible evidence base for much of what we do to patients. Such is not the case for cardiologists, however, for the management of triple vessel coronary disease in diabetics.
Academic cardiologists are standing in line to commend the recently completed FREEDOM trial. FREEDOM was many years in the planning and execution to answer the question "Should diabetic patients with multivessel coronary artery occlusive disease be treated with open or percutaneous intervention?" What were the limitations of prior trials that made it necessary to conduct this massive 8-year effort involving 136 centers in 20 countries? When surgical therapy appeared to best PCI catheter therapy the comparison was inapproriate; angioplasty needed to include stents. When newer trials yielded similar results indictating surgical superiority over stents the same line of reasoning was invoked; you’re comparing surgery to out-dated technology. It wasn’t a proper trial if it didn’t include drug-eluting stents. The surgeons couldn’t keep up because just around the corner there would always be the "new new thing" that would demonstrate PCI dominance. The same limitation also applied to surgical bypass; during the era of PCI hegemony the surgeons were actively improving their long-term outcomes by using better conduits for revascularization such as internal mammary and radial arteries and other operative improvements. Unfortunately, the matter remained unsettled because the studies were inadequately powered or failed to enroll enough diabetic patients. As a result, this large and important population eluded the generalizability of the trials. The FREEDOM trial addressed these limitations and concluded that diabetic patients with triple vessel disease were advised not to receive ad hoc PCI at the time of the "diagnostic coronary angiogram." No more "we’re already here, we may as well fix it;" "those other two arteries really aren’t so bad, let’s just do the LAD, etc., etc." Instead, the patient should either receive CABG and if uncertainty lingers, then come to a consensus under the auspices of a "multidisciplinary team". That all makes sense to me. Just because the catheter is positioned to do an angioplasty, that’s no reason to do the wrong procedure.
After hearing about the FREEDOM trial and then reading the paper and its supporting references, three questions nag at me. The first one is the simplest. In the dominion of cardiology, what is a multidisciplinary team? The cardiology conferences that I have attended center the discussion on which stent, how many stents, etc. When have we gone a stent too far rarely seems to come up. Although there is expressed interest in expanding the team approach, the main cardiac multidisciplinary teams seem to be those associated with implanting transcatheter aortic valves (TAVI), in which case they team up with thoracic surgeons.
The concept of a multidisciplinary team has been around for decades when dealing with the neuro-ischemic diabetic foot. The team approach has proven its effectiveness in preventing ulceration and healing feet in jeopardy of amputation. I’ll be on the look out for this new cardiac team in the hospitals where I practice.
Secondly, I wonder if arterial disease in the coronary circulation might have some lessons to teach us in the diabetic foot. The heart has three vessels with regionalized perfusion corresponding with myo-ischemic lesions in the three arterial territories. To me this suggests a similarity to the diabetic foot with its three runoff vessels that develop patterns of arterial occlusion that are cognate to the sites of foot ulceration. All three cardiac and leg vessels are in the 2- to 3-mm diameter range. I wonder if there might be a lesson in these parallels? And that’s not just because the overwhelming majority of the patients in the FREEDOM study had triple-vessel disease. And I’m not referring to the so-called angiosome theory. The majority of neuro-ischemic ulcerated diabetic feet have triple-vessel arterial disease, most with arterial calcification thrown in for good measure just to make things harder.
Of course not all diabetic foot ulcers are ischemic and many can achieve healing with skillful foot care by a diabetic podiatrist. My point is this. Three out of three vessel disease is as sign of aggressive arteriosclerosis and durable revascularization occurred in the cardiac setting only with bypass surgery. On average, each patient who underwent angioplasty needed three or four more additional interventions. This need for repeat intervention occurs all too commonly in the neuro-ischemic diabetic foot as well. I lack the data to support the policy of bypass first but by a similar token there is no evidence to recommend "angioplasty first."
Isn’t is about time that we, too, devise flexible and appropriate treatment paradigms to revascularize diabetic feet at risk and heal them in the shortest possible time? It is probably too much to hope for a trial as conclusive as the FREEDOM trial but we need to organize trials or a registry for ourselves before the tsunami of diabetic patients engulfs us.
Thirdly, I was unable to understand how so many patients were eligible for inclusion and so few were trial-eligible: 32,966 patients were considered possibly eligible by virtue of receiving a coronary arteriogram for angina pectoris/signs of myocardial ischemia; only 3,309 met the criteria for randomization. I wish that the trialist had provided more information on why the other 29,657 were excluded. What happened to those patients during the 7 years required to complete this study? Likewise, of the 3,309 patients eligible for randomization, 1,409 refused randomization; what happened to them? It was quite an undertaking to screen nearly 33,000 patients and end up with 1,900 – less than 6% trial-eligible patients that were randomized. That percentage is less than the BASIL trial. Having said all of that, congratulations to the investigators on their study and for getting someone to pay for it. The money was well spent.
Dr. Andros is the Medical Editor of Vascular Specialist.
I have never understood how the cardiology community is able to organize so many excellent trials while vascular surgeons struggle to complete a small handful. Appearing long after the well done NASCET and ECST, the recent CREST trial raised as many questions as it answered. In the future it will be exponentially more difficult to organize valid trials because many need to have three-armed studies: one for each intervention, presumably open and endovascular, and a noninterventional arm for medical/nonrevascularization approaches. As far as investigations on legs are concerned our only reliable example is the BASIL trial, now approaching its 10th anniversary.
Whatever the reasons in the past, I am convinced that we need to do a better job stratifying our patients and their disease on clinical grounds before we embark on selecting diagnostic studies and therapies. While there is no shortage of literature on the theory and practice of vascular intervention, I believe we lack a credible evidence base for much of what we do to patients. Such is not the case for cardiologists, however, for the management of triple vessel coronary disease in diabetics.
Academic cardiologists are standing in line to commend the recently completed FREEDOM trial. FREEDOM was many years in the planning and execution to answer the question "Should diabetic patients with multivessel coronary artery occlusive disease be treated with open or percutaneous intervention?" What were the limitations of prior trials that made it necessary to conduct this massive 8-year effort involving 136 centers in 20 countries? When surgical therapy appeared to best PCI catheter therapy the comparison was inapproriate; angioplasty needed to include stents. When newer trials yielded similar results indictating surgical superiority over stents the same line of reasoning was invoked; you’re comparing surgery to out-dated technology. It wasn’t a proper trial if it didn’t include drug-eluting stents. The surgeons couldn’t keep up because just around the corner there would always be the "new new thing" that would demonstrate PCI dominance. The same limitation also applied to surgical bypass; during the era of PCI hegemony the surgeons were actively improving their long-term outcomes by using better conduits for revascularization such as internal mammary and radial arteries and other operative improvements. Unfortunately, the matter remained unsettled because the studies were inadequately powered or failed to enroll enough diabetic patients. As a result, this large and important population eluded the generalizability of the trials. The FREEDOM trial addressed these limitations and concluded that diabetic patients with triple vessel disease were advised not to receive ad hoc PCI at the time of the "diagnostic coronary angiogram." No more "we’re already here, we may as well fix it;" "those other two arteries really aren’t so bad, let’s just do the LAD, etc., etc." Instead, the patient should either receive CABG and if uncertainty lingers, then come to a consensus under the auspices of a "multidisciplinary team". That all makes sense to me. Just because the catheter is positioned to do an angioplasty, that’s no reason to do the wrong procedure.
After hearing about the FREEDOM trial and then reading the paper and its supporting references, three questions nag at me. The first one is the simplest. In the dominion of cardiology, what is a multidisciplinary team? The cardiology conferences that I have attended center the discussion on which stent, how many stents, etc. When have we gone a stent too far rarely seems to come up. Although there is expressed interest in expanding the team approach, the main cardiac multidisciplinary teams seem to be those associated with implanting transcatheter aortic valves (TAVI), in which case they team up with thoracic surgeons.
The concept of a multidisciplinary team has been around for decades when dealing with the neuro-ischemic diabetic foot. The team approach has proven its effectiveness in preventing ulceration and healing feet in jeopardy of amputation. I’ll be on the look out for this new cardiac team in the hospitals where I practice.
Secondly, I wonder if arterial disease in the coronary circulation might have some lessons to teach us in the diabetic foot. The heart has three vessels with regionalized perfusion corresponding with myo-ischemic lesions in the three arterial territories. To me this suggests a similarity to the diabetic foot with its three runoff vessels that develop patterns of arterial occlusion that are cognate to the sites of foot ulceration. All three cardiac and leg vessels are in the 2- to 3-mm diameter range. I wonder if there might be a lesson in these parallels? And that’s not just because the overwhelming majority of the patients in the FREEDOM study had triple-vessel disease. And I’m not referring to the so-called angiosome theory. The majority of neuro-ischemic ulcerated diabetic feet have triple-vessel arterial disease, most with arterial calcification thrown in for good measure just to make things harder.
Of course not all diabetic foot ulcers are ischemic and many can achieve healing with skillful foot care by a diabetic podiatrist. My point is this. Three out of three vessel disease is as sign of aggressive arteriosclerosis and durable revascularization occurred in the cardiac setting only with bypass surgery. On average, each patient who underwent angioplasty needed three or four more additional interventions. This need for repeat intervention occurs all too commonly in the neuro-ischemic diabetic foot as well. I lack the data to support the policy of bypass first but by a similar token there is no evidence to recommend "angioplasty first."
Isn’t is about time that we, too, devise flexible and appropriate treatment paradigms to revascularize diabetic feet at risk and heal them in the shortest possible time? It is probably too much to hope for a trial as conclusive as the FREEDOM trial but we need to organize trials or a registry for ourselves before the tsunami of diabetic patients engulfs us.
Thirdly, I was unable to understand how so many patients were eligible for inclusion and so few were trial-eligible: 32,966 patients were considered possibly eligible by virtue of receiving a coronary arteriogram for angina pectoris/signs of myocardial ischemia; only 3,309 met the criteria for randomization. I wish that the trialist had provided more information on why the other 29,657 were excluded. What happened to those patients during the 7 years required to complete this study? Likewise, of the 3,309 patients eligible for randomization, 1,409 refused randomization; what happened to them? It was quite an undertaking to screen nearly 33,000 patients and end up with 1,900 – less than 6% trial-eligible patients that were randomized. That percentage is less than the BASIL trial. Having said all of that, congratulations to the investigators on their study and for getting someone to pay for it. The money was well spent.
Dr. Andros is the Medical Editor of Vascular Specialist.
I have never understood how the cardiology community is able to organize so many excellent trials while vascular surgeons struggle to complete a small handful. Appearing long after the well done NASCET and ECST, the recent CREST trial raised as many questions as it answered. In the future it will be exponentially more difficult to organize valid trials because many need to have three-armed studies: one for each intervention, presumably open and endovascular, and a noninterventional arm for medical/nonrevascularization approaches. As far as investigations on legs are concerned our only reliable example is the BASIL trial, now approaching its 10th anniversary.
Whatever the reasons in the past, I am convinced that we need to do a better job stratifying our patients and their disease on clinical grounds before we embark on selecting diagnostic studies and therapies. While there is no shortage of literature on the theory and practice of vascular intervention, I believe we lack a credible evidence base for much of what we do to patients. Such is not the case for cardiologists, however, for the management of triple vessel coronary disease in diabetics.
Academic cardiologists are standing in line to commend the recently completed FREEDOM trial. FREEDOM was many years in the planning and execution to answer the question "Should diabetic patients with multivessel coronary artery occlusive disease be treated with open or percutaneous intervention?" What were the limitations of prior trials that made it necessary to conduct this massive 8-year effort involving 136 centers in 20 countries? When surgical therapy appeared to best PCI catheter therapy the comparison was inapproriate; angioplasty needed to include stents. When newer trials yielded similar results indictating surgical superiority over stents the same line of reasoning was invoked; you’re comparing surgery to out-dated technology. It wasn’t a proper trial if it didn’t include drug-eluting stents. The surgeons couldn’t keep up because just around the corner there would always be the "new new thing" that would demonstrate PCI dominance. The same limitation also applied to surgical bypass; during the era of PCI hegemony the surgeons were actively improving their long-term outcomes by using better conduits for revascularization such as internal mammary and radial arteries and other operative improvements. Unfortunately, the matter remained unsettled because the studies were inadequately powered or failed to enroll enough diabetic patients. As a result, this large and important population eluded the generalizability of the trials. The FREEDOM trial addressed these limitations and concluded that diabetic patients with triple vessel disease were advised not to receive ad hoc PCI at the time of the "diagnostic coronary angiogram." No more "we’re already here, we may as well fix it;" "those other two arteries really aren’t so bad, let’s just do the LAD, etc., etc." Instead, the patient should either receive CABG and if uncertainty lingers, then come to a consensus under the auspices of a "multidisciplinary team". That all makes sense to me. Just because the catheter is positioned to do an angioplasty, that’s no reason to do the wrong procedure.
After hearing about the FREEDOM trial and then reading the paper and its supporting references, three questions nag at me. The first one is the simplest. In the dominion of cardiology, what is a multidisciplinary team? The cardiology conferences that I have attended center the discussion on which stent, how many stents, etc. When have we gone a stent too far rarely seems to come up. Although there is expressed interest in expanding the team approach, the main cardiac multidisciplinary teams seem to be those associated with implanting transcatheter aortic valves (TAVI), in which case they team up with thoracic surgeons.
The concept of a multidisciplinary team has been around for decades when dealing with the neuro-ischemic diabetic foot. The team approach has proven its effectiveness in preventing ulceration and healing feet in jeopardy of amputation. I’ll be on the look out for this new cardiac team in the hospitals where I practice.
Secondly, I wonder if arterial disease in the coronary circulation might have some lessons to teach us in the diabetic foot. The heart has three vessels with regionalized perfusion corresponding with myo-ischemic lesions in the three arterial territories. To me this suggests a similarity to the diabetic foot with its three runoff vessels that develop patterns of arterial occlusion that are cognate to the sites of foot ulceration. All three cardiac and leg vessels are in the 2- to 3-mm diameter range. I wonder if there might be a lesson in these parallels? And that’s not just because the overwhelming majority of the patients in the FREEDOM study had triple-vessel disease. And I’m not referring to the so-called angiosome theory. The majority of neuro-ischemic ulcerated diabetic feet have triple-vessel arterial disease, most with arterial calcification thrown in for good measure just to make things harder.
Of course not all diabetic foot ulcers are ischemic and many can achieve healing with skillful foot care by a diabetic podiatrist. My point is this. Three out of three vessel disease is as sign of aggressive arteriosclerosis and durable revascularization occurred in the cardiac setting only with bypass surgery. On average, each patient who underwent angioplasty needed three or four more additional interventions. This need for repeat intervention occurs all too commonly in the neuro-ischemic diabetic foot as well. I lack the data to support the policy of bypass first but by a similar token there is no evidence to recommend "angioplasty first."
Isn’t is about time that we, too, devise flexible and appropriate treatment paradigms to revascularize diabetic feet at risk and heal them in the shortest possible time? It is probably too much to hope for a trial as conclusive as the FREEDOM trial but we need to organize trials or a registry for ourselves before the tsunami of diabetic patients engulfs us.
Thirdly, I was unable to understand how so many patients were eligible for inclusion and so few were trial-eligible: 32,966 patients were considered possibly eligible by virtue of receiving a coronary arteriogram for angina pectoris/signs of myocardial ischemia; only 3,309 met the criteria for randomization. I wish that the trialist had provided more information on why the other 29,657 were excluded. What happened to those patients during the 7 years required to complete this study? Likewise, of the 3,309 patients eligible for randomization, 1,409 refused randomization; what happened to them? It was quite an undertaking to screen nearly 33,000 patients and end up with 1,900 – less than 6% trial-eligible patients that were randomized. That percentage is less than the BASIL trial. Having said all of that, congratulations to the investigators on their study and for getting someone to pay for it. The money was well spent.
Dr. Andros is the Medical Editor of Vascular Specialist.
Welcome to our Online Edition and a New Voice
This issue's editorial is a calling card by our newest editorial board member, Dr. Joseph Mills of the University of Arizona. Demography is destiny. For a triad of reasons, Southern Arizona is at the epicenter of the global diabetes epidemic. The Arizona vascular surgery group led by Dr. Mills serves Native Americans, Americans of Hispanic heritage, and an increasing number of aging baby boomers and the already elderly that have relocated to or retired in the Sonoran desert.
Within Dr. Mills' patient catchment area is the Tohono O'odham Nation (Pima Indian Community) with perhaps the highest incidence of diabetes of any population in the world. When he talks about diabetic gangrene, he knows whereof he speaks. Recall that more than 80% of non-traumatic major leg amputations occur in diabetics. And diabetics aren't the only groups that have a complex pathogenesis of the foot lesions that lead to amputation.
Age, comorbidities such as renal failure, and multilevel, infrapopliteal and even intrapedal occlusive disease increase the challenge of selecting and performing the best revascularization procedures; remember that you may only get one chance.
Arterial calcification is more pervasive than ever and experienced surgeons are often defeated by it in their revascularization attempts; calcification unquestionably makes everything harder. Anyone who confronts these patients on a regular basis knows how difficult it is to get the feet healed and the patient back to an independent ambulatory life.
Dr. Mills sees the way forward through a better understanding of the interaction of arterial pathology, infection, severity of foot ulceration, patient comorbidities and selection of the right clinical treatment. Short of one or more large-scale prospective randomized trials to perfect our treatment paradigms, Dr. Mills suggests that a well-performed, all-inclusive registry, perhaps via the VQI, may be the best way forward.
I, for one, agree with him.
This issue's editorial is a calling card by our newest editorial board member, Dr. Joseph Mills of the University of Arizona. Demography is destiny. For a triad of reasons, Southern Arizona is at the epicenter of the global diabetes epidemic. The Arizona vascular surgery group led by Dr. Mills serves Native Americans, Americans of Hispanic heritage, and an increasing number of aging baby boomers and the already elderly that have relocated to or retired in the Sonoran desert.
Within Dr. Mills' patient catchment area is the Tohono O'odham Nation (Pima Indian Community) with perhaps the highest incidence of diabetes of any population in the world. When he talks about diabetic gangrene, he knows whereof he speaks. Recall that more than 80% of non-traumatic major leg amputations occur in diabetics. And diabetics aren't the only groups that have a complex pathogenesis of the foot lesions that lead to amputation.
Age, comorbidities such as renal failure, and multilevel, infrapopliteal and even intrapedal occlusive disease increase the challenge of selecting and performing the best revascularization procedures; remember that you may only get one chance.
Arterial calcification is more pervasive than ever and experienced surgeons are often defeated by it in their revascularization attempts; calcification unquestionably makes everything harder. Anyone who confronts these patients on a regular basis knows how difficult it is to get the feet healed and the patient back to an independent ambulatory life.
Dr. Mills sees the way forward through a better understanding of the interaction of arterial pathology, infection, severity of foot ulceration, patient comorbidities and selection of the right clinical treatment. Short of one or more large-scale prospective randomized trials to perfect our treatment paradigms, Dr. Mills suggests that a well-performed, all-inclusive registry, perhaps via the VQI, may be the best way forward.
I, for one, agree with him.
This issue's editorial is a calling card by our newest editorial board member, Dr. Joseph Mills of the University of Arizona. Demography is destiny. For a triad of reasons, Southern Arizona is at the epicenter of the global diabetes epidemic. The Arizona vascular surgery group led by Dr. Mills serves Native Americans, Americans of Hispanic heritage, and an increasing number of aging baby boomers and the already elderly that have relocated to or retired in the Sonoran desert.
Within Dr. Mills' patient catchment area is the Tohono O'odham Nation (Pima Indian Community) with perhaps the highest incidence of diabetes of any population in the world. When he talks about diabetic gangrene, he knows whereof he speaks. Recall that more than 80% of non-traumatic major leg amputations occur in diabetics. And diabetics aren't the only groups that have a complex pathogenesis of the foot lesions that lead to amputation.
Age, comorbidities such as renal failure, and multilevel, infrapopliteal and even intrapedal occlusive disease increase the challenge of selecting and performing the best revascularization procedures; remember that you may only get one chance.
Arterial calcification is more pervasive than ever and experienced surgeons are often defeated by it in their revascularization attempts; calcification unquestionably makes everything harder. Anyone who confronts these patients on a regular basis knows how difficult it is to get the feet healed and the patient back to an independent ambulatory life.
Dr. Mills sees the way forward through a better understanding of the interaction of arterial pathology, infection, severity of foot ulceration, patient comorbidities and selection of the right clinical treatment. Short of one or more large-scale prospective randomized trials to perfect our treatment paradigms, Dr. Mills suggests that a well-performed, all-inclusive registry, perhaps via the VQI, may be the best way forward.
I, for one, agree with him.
Who Gains, Who Pays?
Once you’ve read this month’s Veith’s Viewpoint, you will see it doesn’t shy away from topical and highly controversial realities that will come into sharper focus through the national election and for months and years to come. Americans demand, and believe that they are entitled to, health care whether or not they have paid generously into the Medicare health care funding scheme.
And it isn’t just senior citizens but those with ESRD on HD but also those on disability who receive Medicare benefits before age 65. There isn’t enough money to pay for the services and the costs as a percentage of the GDP are expensive and unsustainable. So where do we cut? Who will receive fewer OR MORE services and who will be paid more OR LESS for providing them?
Veith argues that it is the specialists who get the patients well and should not be forced to accept less compensation, especially if the extra money goes to GPs. This is the stuff of inter-specialty conflict. More importantly, because it is part of legislation that has withstood Supreme Court scrutiny, it weaves government regulation tighter into the fabric of medical care. Which decisions in the practice of medicine, its ethics, morals and values, are appropriately promulgated inside the Beltway? To what extent should winners and losers be decided by the federal government and Congress, especially one as fractious and dysfunctional as ours is currently?
There will be no simple answers to the dilemmas that this month’s Veith’s Viewpoint raises but we all need to be engaged in the discussion. Write and tell us what you think. And, of course, feel free to share it with your colleagues – including the GPs.
Dr. Andros is the Medical Editor of Vascular Specialist. He is medical director, Amputation Prevention Center at Valley Presbyterian Hospital andfounding partner, Los Angeles Vascular Specialists, Los Angeles, Calif.
Once you’ve read this month’s Veith’s Viewpoint, you will see it doesn’t shy away from topical and highly controversial realities that will come into sharper focus through the national election and for months and years to come. Americans demand, and believe that they are entitled to, health care whether or not they have paid generously into the Medicare health care funding scheme.
And it isn’t just senior citizens but those with ESRD on HD but also those on disability who receive Medicare benefits before age 65. There isn’t enough money to pay for the services and the costs as a percentage of the GDP are expensive and unsustainable. So where do we cut? Who will receive fewer OR MORE services and who will be paid more OR LESS for providing them?
Veith argues that it is the specialists who get the patients well and should not be forced to accept less compensation, especially if the extra money goes to GPs. This is the stuff of inter-specialty conflict. More importantly, because it is part of legislation that has withstood Supreme Court scrutiny, it weaves government regulation tighter into the fabric of medical care. Which decisions in the practice of medicine, its ethics, morals and values, are appropriately promulgated inside the Beltway? To what extent should winners and losers be decided by the federal government and Congress, especially one as fractious and dysfunctional as ours is currently?
There will be no simple answers to the dilemmas that this month’s Veith’s Viewpoint raises but we all need to be engaged in the discussion. Write and tell us what you think. And, of course, feel free to share it with your colleagues – including the GPs.
Dr. Andros is the Medical Editor of Vascular Specialist. He is medical director, Amputation Prevention Center at Valley Presbyterian Hospital andfounding partner, Los Angeles Vascular Specialists, Los Angeles, Calif.
Once you’ve read this month’s Veith’s Viewpoint, you will see it doesn’t shy away from topical and highly controversial realities that will come into sharper focus through the national election and for months and years to come. Americans demand, and believe that they are entitled to, health care whether or not they have paid generously into the Medicare health care funding scheme.
And it isn’t just senior citizens but those with ESRD on HD but also those on disability who receive Medicare benefits before age 65. There isn’t enough money to pay for the services and the costs as a percentage of the GDP are expensive and unsustainable. So where do we cut? Who will receive fewer OR MORE services and who will be paid more OR LESS for providing them?
Veith argues that it is the specialists who get the patients well and should not be forced to accept less compensation, especially if the extra money goes to GPs. This is the stuff of inter-specialty conflict. More importantly, because it is part of legislation that has withstood Supreme Court scrutiny, it weaves government regulation tighter into the fabric of medical care. Which decisions in the practice of medicine, its ethics, morals and values, are appropriately promulgated inside the Beltway? To what extent should winners and losers be decided by the federal government and Congress, especially one as fractious and dysfunctional as ours is currently?
There will be no simple answers to the dilemmas that this month’s Veith’s Viewpoint raises but we all need to be engaged in the discussion. Write and tell us what you think. And, of course, feel free to share it with your colleagues – including the GPs.
Dr. Andros is the Medical Editor of Vascular Specialist. He is medical director, Amputation Prevention Center at Valley Presbyterian Hospital andfounding partner, Los Angeles Vascular Specialists, Los Angeles, Calif.
Welcome to the August Online Issue: Take the SVS Survey
When the Society for Vascular Surgery (SVS) was approached to become involved in assessing vascular out-patient centers (OEC) the Clinical Practices Committee (CPC) convened to examine this topic that was arousing so much interest and concern among providers and patients.
After reviewing the preliminary CPC assessment, the SVS leadership asked two of the committee to develop an editorial for publication in Vascular Specialist. The intent is to survey the SVS membership on this increasingly relevant issue.
So click on the editorial. Read it. And take the easy online, interactive survey at the bottom.
Your views ARE important. They will help shape how SVS deals with this important issue going forward. Let us know your opinions about OECs. There is room for comment after each survey question, but if you have a lengthier opinion, please take the survey and then e-mail us your in-depth comments at vascularspecialist@elsevier.com.
When the Society for Vascular Surgery (SVS) was approached to become involved in assessing vascular out-patient centers (OEC) the Clinical Practices Committee (CPC) convened to examine this topic that was arousing so much interest and concern among providers and patients.
After reviewing the preliminary CPC assessment, the SVS leadership asked two of the committee to develop an editorial for publication in Vascular Specialist. The intent is to survey the SVS membership on this increasingly relevant issue.
So click on the editorial. Read it. And take the easy online, interactive survey at the bottom.
Your views ARE important. They will help shape how SVS deals with this important issue going forward. Let us know your opinions about OECs. There is room for comment after each survey question, but if you have a lengthier opinion, please take the survey and then e-mail us your in-depth comments at vascularspecialist@elsevier.com.
When the Society for Vascular Surgery (SVS) was approached to become involved in assessing vascular out-patient centers (OEC) the Clinical Practices Committee (CPC) convened to examine this topic that was arousing so much interest and concern among providers and patients.
After reviewing the preliminary CPC assessment, the SVS leadership asked two of the committee to develop an editorial for publication in Vascular Specialist. The intent is to survey the SVS membership on this increasingly relevant issue.
So click on the editorial. Read it. And take the easy online, interactive survey at the bottom.
Your views ARE important. They will help shape how SVS deals with this important issue going forward. Let us know your opinions about OECs. There is room for comment after each survey question, but if you have a lengthier opinion, please take the survey and then e-mail us your in-depth comments at vascularspecialist@elsevier.com.
February Fix-Up
Welcome to the February online edition of Vascular Specialist.
We all had hoped for more but had to settle for another temporary fix to the SGR, this time for 10 months until December 31, 2012. Our SGR story gives the details. When Congress takes it up again the possible cut in our Medicare reimbursement will be 32% instead of 27 and the resolve finally to correct the problem will be harder than ever to muster. There is a strange connection from this dispiriting lack of legislative courage to the memory that it conjured up when I read the story at breakfast.
By my senior year of medical school I had pretty much decided to go into surgery and got an invitation to observe an operation from an outstanding Chicago heart surgeon who, like many in those days, also did some vascular cases. The day I attended I recall vividly that he performed a "bucket-handle" saphenous vein bypass of an adductor occlusion of the superficial femoral artery. Endovascular intervention has made that procedure, a bypass from just above the adductor tendon to the popliteal artery above the knee, a passé operation. He was a wonderful surgeon; direct and focused, gentle with tissue, and fast as only an efficient surgeon can be. Before he closed, he turned to me and said, "we’ll take a few extra minutes to be certain that we’re dry and the graft is perfect. No sense to wasting that time in the surgeons’ lounge just drinking another cup of coffee."
But what he said next I think explains why the failure to solve the SGR problem made me recall this experience from decades ago. As he meticulously closed the skin he remarked, "Remember, George, don’t ever rush. You may think that there is never time to do it right, but there is always time to do it over." Why that remark came so quickly to mind this morning is because I always silently repeat it to myself before I close any case. That surgeon’s advice is as true as ever today for the management of complex OR cases and for challenging legislative matters as well. Soon the SGR will recede from the Congressional consciousness but when it returns let’s all hope that there will still be time to do it over – and that, just maybe, they get it right.
Welcome to the February online edition of Vascular Specialist.
We all had hoped for more but had to settle for another temporary fix to the SGR, this time for 10 months until December 31, 2012. Our SGR story gives the details. When Congress takes it up again the possible cut in our Medicare reimbursement will be 32% instead of 27 and the resolve finally to correct the problem will be harder than ever to muster. There is a strange connection from this dispiriting lack of legislative courage to the memory that it conjured up when I read the story at breakfast.
By my senior year of medical school I had pretty much decided to go into surgery and got an invitation to observe an operation from an outstanding Chicago heart surgeon who, like many in those days, also did some vascular cases. The day I attended I recall vividly that he performed a "bucket-handle" saphenous vein bypass of an adductor occlusion of the superficial femoral artery. Endovascular intervention has made that procedure, a bypass from just above the adductor tendon to the popliteal artery above the knee, a passé operation. He was a wonderful surgeon; direct and focused, gentle with tissue, and fast as only an efficient surgeon can be. Before he closed, he turned to me and said, "we’ll take a few extra minutes to be certain that we’re dry and the graft is perfect. No sense to wasting that time in the surgeons’ lounge just drinking another cup of coffee."
But what he said next I think explains why the failure to solve the SGR problem made me recall this experience from decades ago. As he meticulously closed the skin he remarked, "Remember, George, don’t ever rush. You may think that there is never time to do it right, but there is always time to do it over." Why that remark came so quickly to mind this morning is because I always silently repeat it to myself before I close any case. That surgeon’s advice is as true as ever today for the management of complex OR cases and for challenging legislative matters as well. Soon the SGR will recede from the Congressional consciousness but when it returns let’s all hope that there will still be time to do it over – and that, just maybe, they get it right.
Welcome to the February online edition of Vascular Specialist.
We all had hoped for more but had to settle for another temporary fix to the SGR, this time for 10 months until December 31, 2012. Our SGR story gives the details. When Congress takes it up again the possible cut in our Medicare reimbursement will be 32% instead of 27 and the resolve finally to correct the problem will be harder than ever to muster. There is a strange connection from this dispiriting lack of legislative courage to the memory that it conjured up when I read the story at breakfast.
By my senior year of medical school I had pretty much decided to go into surgery and got an invitation to observe an operation from an outstanding Chicago heart surgeon who, like many in those days, also did some vascular cases. The day I attended I recall vividly that he performed a "bucket-handle" saphenous vein bypass of an adductor occlusion of the superficial femoral artery. Endovascular intervention has made that procedure, a bypass from just above the adductor tendon to the popliteal artery above the knee, a passé operation. He was a wonderful surgeon; direct and focused, gentle with tissue, and fast as only an efficient surgeon can be. Before he closed, he turned to me and said, "we’ll take a few extra minutes to be certain that we’re dry and the graft is perfect. No sense to wasting that time in the surgeons’ lounge just drinking another cup of coffee."
But what he said next I think explains why the failure to solve the SGR problem made me recall this experience from decades ago. As he meticulously closed the skin he remarked, "Remember, George, don’t ever rush. You may think that there is never time to do it right, but there is always time to do it over." Why that remark came so quickly to mind this morning is because I always silently repeat it to myself before I close any case. That surgeon’s advice is as true as ever today for the management of complex OR cases and for challenging legislative matters as well. Soon the SGR will recede from the Congressional consciousness but when it returns let’s all hope that there will still be time to do it over – and that, just maybe, they get it right.
A Thoughtful December
Welcome to our December Online issue. I hope you all have a happy holiday season and as prosperous a new year as Congress will allow.
We have some very interesting articles this month. In particular, I call your attention to the article on the American College of Surgeons' response to new changes in resident work hours, and its very apt commentary by Dr. Cynthia Shortell.
Those of us who are not directly involved in the post-graduate education of residents and fellows are nevertheless affected by the flux in work hours that Dr. Shortell has commented upon. These matters are important to us all, as these are the future vascular surgeons who will be taking care of our patients and ourselves. They are our future partners and leaders of our specialty.
In his typically thought-provoking book "The Outliers," author Malcolm Gladwell reminds us what it takes to excel, maybe not how to be the absolute best, but how to be the best that your talent will allow.
Besides luck it takes being around at the right time, and for young vascular surgeons the time has never been better. The vascular surgical tent is big and diverse. No one can perform our specialty as well as we can. But will the next generation of trainees be up to the opportunity offered to them because it also takes time on the job? As Gladwell tells us it takes 10,000 hours to be really good at something. Will the current work hours allow for the development of this kind of excellence? Can we afford to allow some of that time to be misdirected away from training to moonlighting? Dr. Shortell finds the issue to be astonishing and I cannot disagree.
If you have any opinions that you would like to express on this subject, I invite you to weigh in by writing me care of vascularspecialist@elsevier.com
Also, be sure to note our other stories, especially the one on the potential dangers of an office visit by a recovery audit contractor and Dr. Russell Samson's insightful comments on its direct relevance to vascular surgeons. Opinions on this and other stories are also welcome.
Sincerely,
George Andros, M.D.
Medical Editor
Welcome to our December Online issue. I hope you all have a happy holiday season and as prosperous a new year as Congress will allow.
We have some very interesting articles this month. In particular, I call your attention to the article on the American College of Surgeons' response to new changes in resident work hours, and its very apt commentary by Dr. Cynthia Shortell.
Those of us who are not directly involved in the post-graduate education of residents and fellows are nevertheless affected by the flux in work hours that Dr. Shortell has commented upon. These matters are important to us all, as these are the future vascular surgeons who will be taking care of our patients and ourselves. They are our future partners and leaders of our specialty.
In his typically thought-provoking book "The Outliers," author Malcolm Gladwell reminds us what it takes to excel, maybe not how to be the absolute best, but how to be the best that your talent will allow.
Besides luck it takes being around at the right time, and for young vascular surgeons the time has never been better. The vascular surgical tent is big and diverse. No one can perform our specialty as well as we can. But will the next generation of trainees be up to the opportunity offered to them because it also takes time on the job? As Gladwell tells us it takes 10,000 hours to be really good at something. Will the current work hours allow for the development of this kind of excellence? Can we afford to allow some of that time to be misdirected away from training to moonlighting? Dr. Shortell finds the issue to be astonishing and I cannot disagree.
If you have any opinions that you would like to express on this subject, I invite you to weigh in by writing me care of vascularspecialist@elsevier.com
Also, be sure to note our other stories, especially the one on the potential dangers of an office visit by a recovery audit contractor and Dr. Russell Samson's insightful comments on its direct relevance to vascular surgeons. Opinions on this and other stories are also welcome.
Sincerely,
George Andros, M.D.
Medical Editor
Welcome to our December Online issue. I hope you all have a happy holiday season and as prosperous a new year as Congress will allow.
We have some very interesting articles this month. In particular, I call your attention to the article on the American College of Surgeons' response to new changes in resident work hours, and its very apt commentary by Dr. Cynthia Shortell.
Those of us who are not directly involved in the post-graduate education of residents and fellows are nevertheless affected by the flux in work hours that Dr. Shortell has commented upon. These matters are important to us all, as these are the future vascular surgeons who will be taking care of our patients and ourselves. They are our future partners and leaders of our specialty.
In his typically thought-provoking book "The Outliers," author Malcolm Gladwell reminds us what it takes to excel, maybe not how to be the absolute best, but how to be the best that your talent will allow.
Besides luck it takes being around at the right time, and for young vascular surgeons the time has never been better. The vascular surgical tent is big and diverse. No one can perform our specialty as well as we can. But will the next generation of trainees be up to the opportunity offered to them because it also takes time on the job? As Gladwell tells us it takes 10,000 hours to be really good at something. Will the current work hours allow for the development of this kind of excellence? Can we afford to allow some of that time to be misdirected away from training to moonlighting? Dr. Shortell finds the issue to be astonishing and I cannot disagree.
If you have any opinions that you would like to express on this subject, I invite you to weigh in by writing me care of vascularspecialist@elsevier.com
Also, be sure to note our other stories, especially the one on the potential dangers of an office visit by a recovery audit contractor and Dr. Russell Samson's insightful comments on its direct relevance to vascular surgeons. Opinions on this and other stories are also welcome.
Sincerely,
George Andros, M.D.
Medical Editor
Editor's Diary
A vascular surgeon friend from the Midwest recently stopped by my office here in Southern California. His visit gave me a chance to compare our hospitals.
Like many private practitioners, I work at several community hospitals. My primary hospital has 250 beds with 85%–90% occupancy. My visitor’s main hospital, by contrast, is a magnificent nearly brand-spanking-new university hospital, which treats a mix of community patients and tertiary referrals, as well as esoterica that seldom come my way.
I asked him many questions about his hospital, but I was especially curious about the following: When he went on the wards, was it easy to find a place to sit and write his notes, or were all of the chairs taken by nurses writing their notes, as occurs in the community hospitals in which I practice?
Subjects like this can be difficult to raise, lest you be seen as one of the reminiscing old guard. But as soon as I asked, I realized that I had misspoken. The nurses at his hospital, no doubt, entered their notes into an equally brand-spanking-new EMR system, and he, or his house officer, presumably did likewise. But my colleague astonished me by saying that not only were places to sit in short supply, but also that access to the computers was extremely limited.
At my own hospital, the computer "shortage" has been addressed lately with an army of WOWs – workstations on wheels – but their appearance, so often the case with technology, has unintended consequences. Moreover, their advent has exacerbated a longstanding problem. Over the past several years I have found it increasingly difficult to pry a nurse away from the nursing station to make rounds with me; the WOWS (even when the WOW is positioned outside the patient’s door) have only made it worse.
I remind the nurses that there could be no better time to discuss the patient than when we are shoulder-to-shoulder at the bedside, but their reluctance remains in the "unmodified behavior" category. More often than not, the minute I leave the floor the nurse reads my (handwritten) orders and pages me to discuss exactly what it was that I wanted for the patient. I have given up explaining that the post-visit telephone page would have been entirely avoidable if we had seen the patient together. I took scant reassurance when my colleague confirmed that nurses’ attachment to their computers and their resistance to making rounds were, to his knowledge, common phenomena. Why is it that we all appear so purposeful and engaged in important work when we lean earnestly toward our computer screens and type?
It is assumed that having fewer patients to care for may free up nurses to spend more time with those patients – and with doctors – but I confess I am dubious. In 2004, California passed a law mandating a reduction in the patient/nurse ratio from 6 to 5. Then-Governor Schwarzenegger attempted to return the ratio to 6 to control costs but his action was overturned in the courts. Indeed, in the past few years, the gulf between doctors and nurses seems to have widened, and I doubt that adding more nurses to the ranks will enhance those interactions.
Personally, I see more food trays uneaten, and fewer patients being ambulated ("That’s physical therapy’s job") than ever before. Assuming that an increase in the number of nurses will improve the quantity and quality of nursing care and reduce adverse events, the current limitations on health care spending make it unlikely that such an increase will ever occur.
Some experts have estimated the there will be a shortage of 800,000 nurses by 2020. The chronic lack of money puts that number beyond our reach. However, if I were given the power to make it happen, I would make a request.
Let all the new nurses, if possible, be drawn somehow from the ranks of the unemployed. There are many able, and in fact overqualified people, who are unemployed but could be made "patient-ready" in 18 months. Let’s identify those who might be interested in a nursing career and re-train them for these rewarding jobs.
Despite the advent of the paperless chart, I still troop regularly to the Medical Records Room to "do my charts" and lately I have taken to reviewing the nursing portion of the chart. This section is impressive not only for the sheer multitude of individual nursing entries but also for their stunningly meager clinical relevance.
It is as if the chart were being compiled to assuage a vague but menacing Leviathan. Most of the nursing entries are not part of the paper record. But when I bring up the electronic portion, I find that it is composed of preselected pull-down menus, vast notations of vital signs, lab work-ups, and a jaw-dropping array of additional computer-dictated form-filling.
For example, if hourly urine outputs are ordered, the computer complicates and bloats what is otherwise a straightforward, patient-centered exercise. That is, rather than simply note the output and vitals on a chart, the nurse checks the output, retreats to the computer, logs in, finds the patient’s file, scrolls through screen after screen, and finally plugs in the data.
With so many data to enter, is it any wonder that ICU nurses appear to spend more time serving the computers than the patients? Could this proliferation of nursing entries all be the result of the fine print in "the regulations"?
Nowadays, many aortic procedures, such as open aneurysm repair and aorto-bifemoral bypass, have ceded their role to endovascular therapy. As a result, aortic procedures are vanishing from the skill sets of many vascular surgeons, especially the younger ones.
Similarly, electronic dropdowns and radio buttons appear to be supplanting – or at the very least, diverting – the concrete nursing skills required to care for these patients. We protest that that open and endotherapy are complementary, but it cannot be so unless the infrastructure to provide care for both treatment paradigms remains viable and intact.
Today’s nurses seem to spend so much time making sure the computer has what it needs that I fear for those of the patients. Indeed, the loss of hands-on nursing skills may be an unintended consequence of the endotherapy revolution.
Would people laugh if I started carrying a folding chair on rounds?
Dr. Andros is the medical editor of Vascular Specialist.
A vascular surgeon friend from the Midwest recently stopped by my office here in Southern California. His visit gave me a chance to compare our hospitals.
Like many private practitioners, I work at several community hospitals. My primary hospital has 250 beds with 85%–90% occupancy. My visitor’s main hospital, by contrast, is a magnificent nearly brand-spanking-new university hospital, which treats a mix of community patients and tertiary referrals, as well as esoterica that seldom come my way.
I asked him many questions about his hospital, but I was especially curious about the following: When he went on the wards, was it easy to find a place to sit and write his notes, or were all of the chairs taken by nurses writing their notes, as occurs in the community hospitals in which I practice?
Subjects like this can be difficult to raise, lest you be seen as one of the reminiscing old guard. But as soon as I asked, I realized that I had misspoken. The nurses at his hospital, no doubt, entered their notes into an equally brand-spanking-new EMR system, and he, or his house officer, presumably did likewise. But my colleague astonished me by saying that not only were places to sit in short supply, but also that access to the computers was extremely limited.
At my own hospital, the computer "shortage" has been addressed lately with an army of WOWs – workstations on wheels – but their appearance, so often the case with technology, has unintended consequences. Moreover, their advent has exacerbated a longstanding problem. Over the past several years I have found it increasingly difficult to pry a nurse away from the nursing station to make rounds with me; the WOWS (even when the WOW is positioned outside the patient’s door) have only made it worse.
I remind the nurses that there could be no better time to discuss the patient than when we are shoulder-to-shoulder at the bedside, but their reluctance remains in the "unmodified behavior" category. More often than not, the minute I leave the floor the nurse reads my (handwritten) orders and pages me to discuss exactly what it was that I wanted for the patient. I have given up explaining that the post-visit telephone page would have been entirely avoidable if we had seen the patient together. I took scant reassurance when my colleague confirmed that nurses’ attachment to their computers and their resistance to making rounds were, to his knowledge, common phenomena. Why is it that we all appear so purposeful and engaged in important work when we lean earnestly toward our computer screens and type?
It is assumed that having fewer patients to care for may free up nurses to spend more time with those patients – and with doctors – but I confess I am dubious. In 2004, California passed a law mandating a reduction in the patient/nurse ratio from 6 to 5. Then-Governor Schwarzenegger attempted to return the ratio to 6 to control costs but his action was overturned in the courts. Indeed, in the past few years, the gulf between doctors and nurses seems to have widened, and I doubt that adding more nurses to the ranks will enhance those interactions.
Personally, I see more food trays uneaten, and fewer patients being ambulated ("That’s physical therapy’s job") than ever before. Assuming that an increase in the number of nurses will improve the quantity and quality of nursing care and reduce adverse events, the current limitations on health care spending make it unlikely that such an increase will ever occur.
Some experts have estimated the there will be a shortage of 800,000 nurses by 2020. The chronic lack of money puts that number beyond our reach. However, if I were given the power to make it happen, I would make a request.
Let all the new nurses, if possible, be drawn somehow from the ranks of the unemployed. There are many able, and in fact overqualified people, who are unemployed but could be made "patient-ready" in 18 months. Let’s identify those who might be interested in a nursing career and re-train them for these rewarding jobs.
Despite the advent of the paperless chart, I still troop regularly to the Medical Records Room to "do my charts" and lately I have taken to reviewing the nursing portion of the chart. This section is impressive not only for the sheer multitude of individual nursing entries but also for their stunningly meager clinical relevance.
It is as if the chart were being compiled to assuage a vague but menacing Leviathan. Most of the nursing entries are not part of the paper record. But when I bring up the electronic portion, I find that it is composed of preselected pull-down menus, vast notations of vital signs, lab work-ups, and a jaw-dropping array of additional computer-dictated form-filling.
For example, if hourly urine outputs are ordered, the computer complicates and bloats what is otherwise a straightforward, patient-centered exercise. That is, rather than simply note the output and vitals on a chart, the nurse checks the output, retreats to the computer, logs in, finds the patient’s file, scrolls through screen after screen, and finally plugs in the data.
With so many data to enter, is it any wonder that ICU nurses appear to spend more time serving the computers than the patients? Could this proliferation of nursing entries all be the result of the fine print in "the regulations"?
Nowadays, many aortic procedures, such as open aneurysm repair and aorto-bifemoral bypass, have ceded their role to endovascular therapy. As a result, aortic procedures are vanishing from the skill sets of many vascular surgeons, especially the younger ones.
Similarly, electronic dropdowns and radio buttons appear to be supplanting – or at the very least, diverting – the concrete nursing skills required to care for these patients. We protest that that open and endotherapy are complementary, but it cannot be so unless the infrastructure to provide care for both treatment paradigms remains viable and intact.
Today’s nurses seem to spend so much time making sure the computer has what it needs that I fear for those of the patients. Indeed, the loss of hands-on nursing skills may be an unintended consequence of the endotherapy revolution.
Would people laugh if I started carrying a folding chair on rounds?
Dr. Andros is the medical editor of Vascular Specialist.
A vascular surgeon friend from the Midwest recently stopped by my office here in Southern California. His visit gave me a chance to compare our hospitals.
Like many private practitioners, I work at several community hospitals. My primary hospital has 250 beds with 85%–90% occupancy. My visitor’s main hospital, by contrast, is a magnificent nearly brand-spanking-new university hospital, which treats a mix of community patients and tertiary referrals, as well as esoterica that seldom come my way.
I asked him many questions about his hospital, but I was especially curious about the following: When he went on the wards, was it easy to find a place to sit and write his notes, or were all of the chairs taken by nurses writing their notes, as occurs in the community hospitals in which I practice?
Subjects like this can be difficult to raise, lest you be seen as one of the reminiscing old guard. But as soon as I asked, I realized that I had misspoken. The nurses at his hospital, no doubt, entered their notes into an equally brand-spanking-new EMR system, and he, or his house officer, presumably did likewise. But my colleague astonished me by saying that not only were places to sit in short supply, but also that access to the computers was extremely limited.
At my own hospital, the computer "shortage" has been addressed lately with an army of WOWs – workstations on wheels – but their appearance, so often the case with technology, has unintended consequences. Moreover, their advent has exacerbated a longstanding problem. Over the past several years I have found it increasingly difficult to pry a nurse away from the nursing station to make rounds with me; the WOWS (even when the WOW is positioned outside the patient’s door) have only made it worse.
I remind the nurses that there could be no better time to discuss the patient than when we are shoulder-to-shoulder at the bedside, but their reluctance remains in the "unmodified behavior" category. More often than not, the minute I leave the floor the nurse reads my (handwritten) orders and pages me to discuss exactly what it was that I wanted for the patient. I have given up explaining that the post-visit telephone page would have been entirely avoidable if we had seen the patient together. I took scant reassurance when my colleague confirmed that nurses’ attachment to their computers and their resistance to making rounds were, to his knowledge, common phenomena. Why is it that we all appear so purposeful and engaged in important work when we lean earnestly toward our computer screens and type?
It is assumed that having fewer patients to care for may free up nurses to spend more time with those patients – and with doctors – but I confess I am dubious. In 2004, California passed a law mandating a reduction in the patient/nurse ratio from 6 to 5. Then-Governor Schwarzenegger attempted to return the ratio to 6 to control costs but his action was overturned in the courts. Indeed, in the past few years, the gulf between doctors and nurses seems to have widened, and I doubt that adding more nurses to the ranks will enhance those interactions.
Personally, I see more food trays uneaten, and fewer patients being ambulated ("That’s physical therapy’s job") than ever before. Assuming that an increase in the number of nurses will improve the quantity and quality of nursing care and reduce adverse events, the current limitations on health care spending make it unlikely that such an increase will ever occur.
Some experts have estimated the there will be a shortage of 800,000 nurses by 2020. The chronic lack of money puts that number beyond our reach. However, if I were given the power to make it happen, I would make a request.
Let all the new nurses, if possible, be drawn somehow from the ranks of the unemployed. There are many able, and in fact overqualified people, who are unemployed but could be made "patient-ready" in 18 months. Let’s identify those who might be interested in a nursing career and re-train them for these rewarding jobs.
Despite the advent of the paperless chart, I still troop regularly to the Medical Records Room to "do my charts" and lately I have taken to reviewing the nursing portion of the chart. This section is impressive not only for the sheer multitude of individual nursing entries but also for their stunningly meager clinical relevance.
It is as if the chart were being compiled to assuage a vague but menacing Leviathan. Most of the nursing entries are not part of the paper record. But when I bring up the electronic portion, I find that it is composed of preselected pull-down menus, vast notations of vital signs, lab work-ups, and a jaw-dropping array of additional computer-dictated form-filling.
For example, if hourly urine outputs are ordered, the computer complicates and bloats what is otherwise a straightforward, patient-centered exercise. That is, rather than simply note the output and vitals on a chart, the nurse checks the output, retreats to the computer, logs in, finds the patient’s file, scrolls through screen after screen, and finally plugs in the data.
With so many data to enter, is it any wonder that ICU nurses appear to spend more time serving the computers than the patients? Could this proliferation of nursing entries all be the result of the fine print in "the regulations"?
Nowadays, many aortic procedures, such as open aneurysm repair and aorto-bifemoral bypass, have ceded their role to endovascular therapy. As a result, aortic procedures are vanishing from the skill sets of many vascular surgeons, especially the younger ones.
Similarly, electronic dropdowns and radio buttons appear to be supplanting – or at the very least, diverting – the concrete nursing skills required to care for these patients. We protest that that open and endotherapy are complementary, but it cannot be so unless the infrastructure to provide care for both treatment paradigms remains viable and intact.
Today’s nurses seem to spend so much time making sure the computer has what it needs that I fear for those of the patients. Indeed, the loss of hands-on nursing skills may be an unintended consequence of the endotherapy revolution.
Would people laugh if I started carrying a folding chair on rounds?
Dr. Andros is the medical editor of Vascular Specialist.