Veith's Views

Adversity is part of life and everyone must deal with it. How one manages adversity matters, separates the winners from the losers, and is a major determinant of success. 

Adverse challenges may be minor, intermediate or major. Although everyone is faced with such challenges, they are particularly relevant in a vascular surgery career. This is because of the serious nature and consequences of vascular diseases which can threaten loss of life, limb, and neurological function, and because of the complicated administrative world in which vascular surgery functions.

Minor frustrations are almost daily occurrences in a busy vascular surgeon’s life. They occur in and out of the operating room or angio suite, and many of them relate to other coworkers and associates making errors that interfere with smooth work flow or even good patient care.  An angry response to these minor frustrations can exacerbate the problem and lead to strained, unpleasant working relationships and further errors. In contrast, a calm, measured response to these minor frustrations can minimize the damage caused and lead to a tranquil and effective work place.

Moreover, the individuals who control their responses are destined to be more effective and well liked. Equanimity when things go wrong during a stressful procedure in the operating room or angio suite is an even more valuable asset.  Such composed responses will usually yield a better outcome than will loud and angry expressions of blame. The more serious the situation, the greater will be the value of composure.

Intermediate adversity in a work environment can take the form of rejection of a paper, denial of a grant request, or failure to get a sought promotion or assignment to a particular area of one’s interest. The latter two failures can best be managed by quietly continuing to work and strive. Success should only be regarded as delayed not denied. Rejection of grants and articles is almost routine despite the amount of time and hard work required to prepare them. Calm persistence can overcome many of these adverse events.  Rewriting the paper or grant to correct the deficiencies detected by the reviewers followed by resubmission, even re-resubmission or submission to another journal, will ultimately result in publication of the work. To paraphrase Winston Churchill’s credo: Never, never, never, never, never, never give up.

A particularly challenging case can also be stressful and disheartening. It can appear at first to be an adverse event to the person faced with it. By staying calm and thinking clearly, it is sometimes possible to devise a new solution to the problem – one never described before. Thus, by meeting the challenge of this adversity, the vascular surgeon serendipitously turns adversity to his or her advantage and becomes an innovator. The seeming adversity becomes a creative opportunity.  Many new developments and progress in vascular surgery have begun this way.  No problem should be viewed as unsolvable despite so-called current wisdom.

More major adversity in a job setting can take the form of firing or termination. Such termination may be warranted or not.  Often it is totally unjustified and based on personality differences or ego issues. Jealousy or negative bias are often involved. Such firings may take the form of a witch hunt based on a clinical or administrative superior highlighting selective and unrepresentative bad outcomes in a few difficult cases – something every good vascular surgeon has because of the difficult nature of the diseases we treat.  

How should one deal with such a termination – unfair or not?  Do not seek revenge. Get over it. Get another job and move on. Fortunately other jobs are abundant in the United States. Moreover, the new job often turns out to be better than the one left behind. The termination actually becomes a blessing in disguise, although it may take time for this to become apparent. Interestingly, many first-line leaders or biggest names in vascular surgery have profited in this way from the apparent major adversity of a termination. As one door closes, another may open if one is alert to the possibilities that may arise from change. Furthermore, the best revenge for an unfair termination is gained by achieving great success in one’s next position.

Although the discussion about dealing with adversity has thus far dealt largely with professional issues, the same principles can be applied to dealing with other aspects of life in general. Vigorous and excessive responses to adversity often result in greater pain and enhancing the wealth of lawyers. Equanimity, minimizing reactivity, and succeeding in the new venture one is forced into – even if unfairly – usually produce the best long-term outcome. It is an imperfect world, and how one deals with the many adversities that are part of it can make it less imperfect.

Adversity is part of life and everyone must deal with it. How one manages adversity matters, separates the winners from the losers, and is a major determinant of success. 

Adverse challenges may be minor, intermediate or major. Although everyone is faced with such challenges, they are particularly relevant in a vascular surgery career. This is because of the serious nature and consequences of vascular diseases which can threaten loss of life, limb, and neurological function, and because of the complicated administrative world in which vascular surgery functions.

Minor frustrations are almost daily occurrences in a busy vascular surgeon’s life. They occur in and out of the operating room or angio suite, and many of them relate to other coworkers and associates making errors that interfere with smooth work flow or even good patient care.  An angry response to these minor frustrations can exacerbate the problem and lead to strained, unpleasant working relationships and further errors. In contrast, a calm, measured response to these minor frustrations can minimize the damage caused and lead to a tranquil and effective work place.

Moreover, the individuals who control their responses are destined to be more effective and well liked. Equanimity when things go wrong during a stressful procedure in the operating room or angio suite is an even more valuable asset.  Such composed responses will usually yield a better outcome than will loud and angry expressions of blame. The more serious the situation, the greater will be the value of composure.

Intermediate adversity in a work environment can take the form of rejection of a paper, denial of a grant request, or failure to get a sought promotion or assignment to a particular area of one’s interest. The latter two failures can best be managed by quietly continuing to work and strive. Success should only be regarded as delayed not denied. Rejection of grants and articles is almost routine despite the amount of time and hard work required to prepare them. Calm persistence can overcome many of these adverse events.  Rewriting the paper or grant to correct the deficiencies detected by the reviewers followed by resubmission, even re-resubmission or submission to another journal, will ultimately result in publication of the work. To paraphrase Winston Churchill’s credo: Never, never, never, never, never, never give up.

A particularly challenging case can also be stressful and disheartening. It can appear at first to be an adverse event to the person faced with it. By staying calm and thinking clearly, it is sometimes possible to devise a new solution to the problem – one never described before. Thus, by meeting the challenge of this adversity, the vascular surgeon serendipitously turns adversity to his or her advantage and becomes an innovator. The seeming adversity becomes a creative opportunity.  Many new developments and progress in vascular surgery have begun this way.  No problem should be viewed as unsolvable despite so-called current wisdom.

More major adversity in a job setting can take the form of firing or termination. Such termination may be warranted or not.  Often it is totally unjustified and based on personality differences or ego issues. Jealousy or negative bias are often involved. Such firings may take the form of a witch hunt based on a clinical or administrative superior highlighting selective and unrepresentative bad outcomes in a few difficult cases – something every good vascular surgeon has because of the difficult nature of the diseases we treat.  

How should one deal with such a termination – unfair or not?  Do not seek revenge. Get over it. Get another job and move on. Fortunately other jobs are abundant in the United States. Moreover, the new job often turns out to be better than the one left behind. The termination actually becomes a blessing in disguise, although it may take time for this to become apparent. Interestingly, many first-line leaders or biggest names in vascular surgery have profited in this way from the apparent major adversity of a termination. As one door closes, another may open if one is alert to the possibilities that may arise from change. Furthermore, the best revenge for an unfair termination is gained by achieving great success in one’s next position.

Although the discussion about dealing with adversity has thus far dealt largely with professional issues, the same principles can be applied to dealing with other aspects of life in general. Vigorous and excessive responses to adversity often result in greater pain and enhancing the wealth of lawyers. Equanimity, minimizing reactivity, and succeeding in the new venture one is forced into – even if unfairly – usually produce the best long-term outcome. It is an imperfect world, and how one deals with the many adversities that are part of it can make it less imperfect.

Adversity is part of life and everyone must deal with it. How one manages adversity matters, separates the winners from the losers, and is a major determinant of success. 

Adverse challenges may be minor, intermediate or major. Although everyone is faced with such challenges, they are particularly relevant in a vascular surgery career. This is because of the serious nature and consequences of vascular diseases which can threaten loss of life, limb, and neurological function, and because of the complicated administrative world in which vascular surgery functions.

Minor frustrations are almost daily occurrences in a busy vascular surgeon’s life. They occur in and out of the operating room or angio suite, and many of them relate to other coworkers and associates making errors that interfere with smooth work flow or even good patient care.  An angry response to these minor frustrations can exacerbate the problem and lead to strained, unpleasant working relationships and further errors. In contrast, a calm, measured response to these minor frustrations can minimize the damage caused and lead to a tranquil and effective work place.

Moreover, the individuals who control their responses are destined to be more effective and well liked. Equanimity when things go wrong during a stressful procedure in the operating room or angio suite is an even more valuable asset.  Such composed responses will usually yield a better outcome than will loud and angry expressions of blame. The more serious the situation, the greater will be the value of composure.

Intermediate adversity in a work environment can take the form of rejection of a paper, denial of a grant request, or failure to get a sought promotion or assignment to a particular area of one’s interest. The latter two failures can best be managed by quietly continuing to work and strive. Success should only be regarded as delayed not denied. Rejection of grants and articles is almost routine despite the amount of time and hard work required to prepare them. Calm persistence can overcome many of these adverse events.  Rewriting the paper or grant to correct the deficiencies detected by the reviewers followed by resubmission, even re-resubmission or submission to another journal, will ultimately result in publication of the work. To paraphrase Winston Churchill’s credo: Never, never, never, never, never, never give up.

A particularly challenging case can also be stressful and disheartening. It can appear at first to be an adverse event to the person faced with it. By staying calm and thinking clearly, it is sometimes possible to devise a new solution to the problem – one never described before. Thus, by meeting the challenge of this adversity, the vascular surgeon serendipitously turns adversity to his or her advantage and becomes an innovator. The seeming adversity becomes a creative opportunity.  Many new developments and progress in vascular surgery have begun this way.  No problem should be viewed as unsolvable despite so-called current wisdom.

More major adversity in a job setting can take the form of firing or termination. Such termination may be warranted or not.  Often it is totally unjustified and based on personality differences or ego issues. Jealousy or negative bias are often involved. Such firings may take the form of a witch hunt based on a clinical or administrative superior highlighting selective and unrepresentative bad outcomes in a few difficult cases – something every good vascular surgeon has because of the difficult nature of the diseases we treat.  

How should one deal with such a termination – unfair or not?  Do not seek revenge. Get over it. Get another job and move on. Fortunately other jobs are abundant in the United States. Moreover, the new job often turns out to be better than the one left behind. The termination actually becomes a blessing in disguise, although it may take time for this to become apparent. Interestingly, many first-line leaders or biggest names in vascular surgery have profited in this way from the apparent major adversity of a termination. As one door closes, another may open if one is alert to the possibilities that may arise from change. Furthermore, the best revenge for an unfair termination is gained by achieving great success in one’s next position.

Although the discussion about dealing with adversity has thus far dealt largely with professional issues, the same principles can be applied to dealing with other aspects of life in general. Vigorous and excessive responses to adversity often result in greater pain and enhancing the wealth of lawyers. Equanimity, minimizing reactivity, and succeeding in the new venture one is forced into – even if unfairly – usually produce the best long-term outcome. It is an imperfect world, and how one deals with the many adversities that are part of it can make it less imperfect.

Witch hunt: An intensive effort to discover and expose disloyalty, subversion, dishonesty or the like, usually based on slight, doubtful or irrelevant evidence, and to punish accordingly.
 - Merriam-Webster Dictionary

Over the years, several excellent vascular surgeons have either lost their jobs or been pressured to resign for reasons that are unclear – although in some instances a few particular cases with bad outcomes have been cited as a reason.

Vascular Surgery is a difficult specialty. If one takes on challenging cases that need treatment – patients with large complex AAAs, extensive foot gangrene, or high-risk symptomatic carotid disease, an occasional poor outcome can be expected even if everything the vascular surgeon does is correct. One, two, or three bad outcomes per year in a busy vascular practice are inevitable, and should not be a reason for a vascular surgeon’s termination. Something more must be involved. Likely it is a hidden agenda.

That something can best be summarized by the term “medical politics.” This term may sound benign. In fact, medical politics are anything but benign. In the case of vascular surgeons, they are often subject to the governance and direction of administrators or senior surgical leaders who have little understanding of the risks of complex vascular surgery, and are interested only in the money generated by vascular admissions and procedures. Quantity and dollars trumps quality most times in the eyes of these administrative leaders.

Moreover, these leaders are not immune from the frailties of bias and jealousy which motivate much of human behavior. Throughout my career I have seen many instances when such administrative leaders resented a vascular surgeon because he or she used many hospital resources for a large practice, was successful academically, but behaved “too independently” from the larger department or its leader. It was one reason, vascular surgery needed to be its own independent specialty rather than a part of general surgery.

In the case of the vascular surgeons facing termination for reasons that they cannot understand, there is usually an administrative superior who is involved. Perhaps the vascular surgeon has questioned the authority or judgment of the superior on the grounds that they do not understand a particular vascular surgery issue. The resulting anger of the superior prompts him to want to eliminate the vascular surgeon who is under his administrative control. The witch hunt begins and may be inflamed by other unjustified motives such as jealousy or other hidden agendas which may never be known.

Once the witch hunt has begun, if the vascular surgeon has one or a few cases with bad outcomes, they make him or her vulnerable to the unjustified attack leading to termination by those who do not understand the nature of vascular surgery. Other factors, e.g., a disgruntled or jealous competitor in vascular surgery, can exacerbate the situation and accelerate the termination. The few bad-outcome cases, however, are the excuse or smoking gun which is used as the reason for termination. What goes unrecognized is the fact that every competent vascular surgeon who treats sick patients has such cases which can be used if uninformed enemies wish to focus on them.

How can a vascular surgeon protect him or herself from such witch hunts? First, they must be aware that the nature of vascular surgery and its requirement for treating challenging patients makes them vulnerable if one or another superior dislikes them or is “out to get them.” Second, if one is dealing with a case likely to have a bad outcome, it should be discussed beforehand with superiors, and it is wise to get help from a colleague who can share responsibility if things go poorly.

Third, try not to make enemies of important administrative leaders by challenging their authority or judgment.

Share successes with them, rather than taking all the glory. It will help to neutralize their jealousy. If possible, be humble. Make as many friends in other specialties as possible. They can sometimes diffuse the intensity of a witch hunt. And lastly be aware that any vascular surgeon, particularly a good one, can be the subject of a damaging witch hunt in the imperfect world in which we function.

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

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

Witch hunt: An intensive effort to discover and expose disloyalty, subversion, dishonesty or the like, usually based on slight, doubtful or irrelevant evidence, and to punish accordingly.
 - Merriam-Webster Dictionary

Over the years, several excellent vascular surgeons have either lost their jobs or been pressured to resign for reasons that are unclear – although in some instances a few particular cases with bad outcomes have been cited as a reason.

Vascular Surgery is a difficult specialty. If one takes on challenging cases that need treatment – patients with large complex AAAs, extensive foot gangrene, or high-risk symptomatic carotid disease, an occasional poor outcome can be expected even if everything the vascular surgeon does is correct. One, two, or three bad outcomes per year in a busy vascular practice are inevitable, and should not be a reason for a vascular surgeon’s termination. Something more must be involved. Likely it is a hidden agenda.

That something can best be summarized by the term “medical politics.” This term may sound benign. In fact, medical politics are anything but benign. In the case of vascular surgeons, they are often subject to the governance and direction of administrators or senior surgical leaders who have little understanding of the risks of complex vascular surgery, and are interested only in the money generated by vascular admissions and procedures. Quantity and dollars trumps quality most times in the eyes of these administrative leaders.

Moreover, these leaders are not immune from the frailties of bias and jealousy which motivate much of human behavior. Throughout my career I have seen many instances when such administrative leaders resented a vascular surgeon because he or she used many hospital resources for a large practice, was successful academically, but behaved “too independently” from the larger department or its leader. It was one reason, vascular surgery needed to be its own independent specialty rather than a part of general surgery.

In the case of the vascular surgeons facing termination for reasons that they cannot understand, there is usually an administrative superior who is involved. Perhaps the vascular surgeon has questioned the authority or judgment of the superior on the grounds that they do not understand a particular vascular surgery issue. The resulting anger of the superior prompts him to want to eliminate the vascular surgeon who is under his administrative control. The witch hunt begins and may be inflamed by other unjustified motives such as jealousy or other hidden agendas which may never be known.

Once the witch hunt has begun, if the vascular surgeon has one or a few cases with bad outcomes, they make him or her vulnerable to the unjustified attack leading to termination by those who do not understand the nature of vascular surgery. Other factors, e.g., a disgruntled or jealous competitor in vascular surgery, can exacerbate the situation and accelerate the termination. The few bad-outcome cases, however, are the excuse or smoking gun which is used as the reason for termination. What goes unrecognized is the fact that every competent vascular surgeon who treats sick patients has such cases which can be used if uninformed enemies wish to focus on them.

How can a vascular surgeon protect him or herself from such witch hunts? First, they must be aware that the nature of vascular surgery and its requirement for treating challenging patients makes them vulnerable if one or another superior dislikes them or is “out to get them.” Second, if one is dealing with a case likely to have a bad outcome, it should be discussed beforehand with superiors, and it is wise to get help from a colleague who can share responsibility if things go poorly.

Third, try not to make enemies of important administrative leaders by challenging their authority or judgment.

Share successes with them, rather than taking all the glory. It will help to neutralize their jealousy. If possible, be humble. Make as many friends in other specialties as possible. They can sometimes diffuse the intensity of a witch hunt. And lastly be aware that any vascular surgeon, particularly a good one, can be the subject of a damaging witch hunt in the imperfect world in which we function.

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

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

Witch hunt: An intensive effort to discover and expose disloyalty, subversion, dishonesty or the like, usually based on slight, doubtful or irrelevant evidence, and to punish accordingly.
 - Merriam-Webster Dictionary

Over the years, several excellent vascular surgeons have either lost their jobs or been pressured to resign for reasons that are unclear – although in some instances a few particular cases with bad outcomes have been cited as a reason.

Vascular Surgery is a difficult specialty. If one takes on challenging cases that need treatment – patients with large complex AAAs, extensive foot gangrene, or high-risk symptomatic carotid disease, an occasional poor outcome can be expected even if everything the vascular surgeon does is correct. One, two, or three bad outcomes per year in a busy vascular practice are inevitable, and should not be a reason for a vascular surgeon’s termination. Something more must be involved. Likely it is a hidden agenda.

That something can best be summarized by the term “medical politics.” This term may sound benign. In fact, medical politics are anything but benign. In the case of vascular surgeons, they are often subject to the governance and direction of administrators or senior surgical leaders who have little understanding of the risks of complex vascular surgery, and are interested only in the money generated by vascular admissions and procedures. Quantity and dollars trumps quality most times in the eyes of these administrative leaders.

Moreover, these leaders are not immune from the frailties of bias and jealousy which motivate much of human behavior. Throughout my career I have seen many instances when such administrative leaders resented a vascular surgeon because he or she used many hospital resources for a large practice, was successful academically, but behaved “too independently” from the larger department or its leader. It was one reason, vascular surgery needed to be its own independent specialty rather than a part of general surgery.

In the case of the vascular surgeons facing termination for reasons that they cannot understand, there is usually an administrative superior who is involved. Perhaps the vascular surgeon has questioned the authority or judgment of the superior on the grounds that they do not understand a particular vascular surgery issue. The resulting anger of the superior prompts him to want to eliminate the vascular surgeon who is under his administrative control. The witch hunt begins and may be inflamed by other unjustified motives such as jealousy or other hidden agendas which may never be known.

Once the witch hunt has begun, if the vascular surgeon has one or a few cases with bad outcomes, they make him or her vulnerable to the unjustified attack leading to termination by those who do not understand the nature of vascular surgery. Other factors, e.g., a disgruntled or jealous competitor in vascular surgery, can exacerbate the situation and accelerate the termination. The few bad-outcome cases, however, are the excuse or smoking gun which is used as the reason for termination. What goes unrecognized is the fact that every competent vascular surgeon who treats sick patients has such cases which can be used if uninformed enemies wish to focus on them.

How can a vascular surgeon protect him or herself from such witch hunts? First, they must be aware that the nature of vascular surgery and its requirement for treating challenging patients makes them vulnerable if one or another superior dislikes them or is “out to get them.” Second, if one is dealing with a case likely to have a bad outcome, it should be discussed beforehand with superiors, and it is wise to get help from a colleague who can share responsibility if things go poorly.

Third, try not to make enemies of important administrative leaders by challenging their authority or judgment.

Share successes with them, rather than taking all the glory. It will help to neutralize their jealousy. If possible, be humble. Make as many friends in other specialties as possible. They can sometimes diffuse the intensity of a witch hunt. And lastly be aware that any vascular surgeon, particularly a good one, can be the subject of a damaging witch hunt in the imperfect world in which we function.

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

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

All vascular surgeons want to be good doctors and to take the best possible care of their patients. They, therefore, train diligently and strive to keep up with new developments by reading vascular journals and attending cutting edge vascular meetings. They seek to optimize their judgment, communicate well and honestly with patients, perform their procedures with care, and follow their patients closely.

However, doing all these things does not ensure ascendancy in the profession. There are other factors which go into being a successful vascular surgeon. Many of these are not taught in medical school or residency training, and failure to recognize their importance can derail an otherwise prominent career. It is, therefore, important to highlight some of these factors which can be pitfalls to even the best trained and most committed vascular surgeon.

Vascular surgeons exist in a professionally competitive environment. We compete for patients with several other specialists including interventional cardiologists, interventional radiologists, and some general and cardiac surgeons as well as other lesser competitors.

All are hungry for patients and all consider themselves expert in all or some of the things we do. We also face competition from other vascular surgeons, few of whom feel busy enough to turn away patients. Therefore, it is important that vascular surgeons consider the competitive landscape when they are choosing a location or institution in which to practice. Is there an empty niche for the particular skills one brings to the area or the institution, and will other physicians in the area recognize those skills? Even then they must compete effectively not only by providing superior care but also by engaging in appropriate public relations and marketing of their assets.

Recognizing the importance of professional relationships with nonphysicians and other physicians outside our specialty and cultivating these relationships are other keys to success. The need for good relationships with referring physicians is obvious. Not so obvious is the need to have good relationships with hospital administrators who control essential resources, with other specialists like anesthesiologists and intensivists who can optimize the care our patients receive, with industry representatives, and even with other vascular surgeons. To make these relationships work to our advantage it is crucial to make them mutually beneficial. People are much more inclined to be helpful if what they are doing also helps them. Mutual self-interest can even improve interactions with competitors.

It is also important to avoid making enemies. This is particularly hard to do in the competitive environment in which we work. It is even harder to do in the present health care setting in which others who we do not control are unreasonable or incompetent. This is particularly true with those in positions of administrative authority like hospital executives or operating room supervisors. Making enemies of these individuals can be disastrous since they often control resources that determine our destiny. Keeping such individuals supportive or at least neutral, despite their possible serious flaws, is worth the sometimes painful effort required.

One must also be aware that nothing elicits hostility like success. If a young vascular surgeon/specialist has introduced a new technique or is particularly charming and hard-working and therefore has a booming practice, rest assured that his or her competitors – or even non-competitors – will be covertly or overtly hostile and take every opportunity to damage or bring down the successful individual. It does not matter that the hostility is unjustified and based on jealousy. It can still be unfairly damaging. All should realize that jealousy and greed are among the most powerful motivators of human behavior.

In view of all these considerations, it is apparent that all vascular surgeons, especially talented and successful ones, will at various times in their careers face battles. All cannot be fought. So one has to decide which ones should be avoided and which ones to engage in. Battles to fight should be picked carefully because they will consume energy and leave scars, no matter the outcome.

Most battles are best avoided unless victory is certain. Multiple simultaneous battles should be avoided. Battles in which one faces numerous opponents at the same time should also be shunned. Ideally in unavoidable conflicts, one should have as many allies as possible, although the loyalty of allies cannot always be counted on. Self-interest will determine the loyalty of presumed allies.

Never underestimate enemies, or overestimate allies. If the outcome of a battle is uncertain or to be determined by a board or other group, know how that group will vote before taking on the fight. Always remember the role of jealousy and greed in determining human behavior in battle. Defeated opponents do not forget and are forever dangerous.

Time is a vascular surgeon’s most important asset. Anything that one can do to enlist others to protect or expand this time is helpful. To this end, loyal nurses, physician’s assistants, or nonprofessional associates are invaluable. Their loyalty, which must be reciprocated, can be earned by recognizing their contributions and rewarding them intellectually and financially. This mutual loyalty is essential to success in practice and in the inevitable conflicts that will occur.

All these concepts and many others are not covered in medical school or residency training. Yet all are important in a vascular surgery career, whether it be in a practice or academic setting. Human nature is a constant and its elements may often work against one’s success. Being aware of some of these often noxious and little discussed elements will hopefully enable vascular surgeons to cope with them better and ultimately survive in what can be a difficult environment.

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

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

All vascular surgeons want to be good doctors and to take the best possible care of their patients. They, therefore, train diligently and strive to keep up with new developments by reading vascular journals and attending cutting edge vascular meetings. They seek to optimize their judgment, communicate well and honestly with patients, perform their procedures with care, and follow their patients closely.

However, doing all these things does not ensure ascendancy in the profession. There are other factors which go into being a successful vascular surgeon. Many of these are not taught in medical school or residency training, and failure to recognize their importance can derail an otherwise prominent career. It is, therefore, important to highlight some of these factors which can be pitfalls to even the best trained and most committed vascular surgeon.

Vascular surgeons exist in a professionally competitive environment. We compete for patients with several other specialists including interventional cardiologists, interventional radiologists, and some general and cardiac surgeons as well as other lesser competitors.

All are hungry for patients and all consider themselves expert in all or some of the things we do. We also face competition from other vascular surgeons, few of whom feel busy enough to turn away patients. Therefore, it is important that vascular surgeons consider the competitive landscape when they are choosing a location or institution in which to practice. Is there an empty niche for the particular skills one brings to the area or the institution, and will other physicians in the area recognize those skills? Even then they must compete effectively not only by providing superior care but also by engaging in appropriate public relations and marketing of their assets.

Recognizing the importance of professional relationships with nonphysicians and other physicians outside our specialty and cultivating these relationships are other keys to success. The need for good relationships with referring physicians is obvious. Not so obvious is the need to have good relationships with hospital administrators who control essential resources, with other specialists like anesthesiologists and intensivists who can optimize the care our patients receive, with industry representatives, and even with other vascular surgeons. To make these relationships work to our advantage it is crucial to make them mutually beneficial. People are much more inclined to be helpful if what they are doing also helps them. Mutual self-interest can even improve interactions with competitors.

It is also important to avoid making enemies. This is particularly hard to do in the competitive environment in which we work. It is even harder to do in the present health care setting in which others who we do not control are unreasonable or incompetent. This is particularly true with those in positions of administrative authority like hospital executives or operating room supervisors. Making enemies of these individuals can be disastrous since they often control resources that determine our destiny. Keeping such individuals supportive or at least neutral, despite their possible serious flaws, is worth the sometimes painful effort required.

One must also be aware that nothing elicits hostility like success. If a young vascular surgeon/specialist has introduced a new technique or is particularly charming and hard-working and therefore has a booming practice, rest assured that his or her competitors – or even non-competitors – will be covertly or overtly hostile and take every opportunity to damage or bring down the successful individual. It does not matter that the hostility is unjustified and based on jealousy. It can still be unfairly damaging. All should realize that jealousy and greed are among the most powerful motivators of human behavior.

In view of all these considerations, it is apparent that all vascular surgeons, especially talented and successful ones, will at various times in their careers face battles. All cannot be fought. So one has to decide which ones should be avoided and which ones to engage in. Battles to fight should be picked carefully because they will consume energy and leave scars, no matter the outcome.

Most battles are best avoided unless victory is certain. Multiple simultaneous battles should be avoided. Battles in which one faces numerous opponents at the same time should also be shunned. Ideally in unavoidable conflicts, one should have as many allies as possible, although the loyalty of allies cannot always be counted on. Self-interest will determine the loyalty of presumed allies.

Never underestimate enemies, or overestimate allies. If the outcome of a battle is uncertain or to be determined by a board or other group, know how that group will vote before taking on the fight. Always remember the role of jealousy and greed in determining human behavior in battle. Defeated opponents do not forget and are forever dangerous.

Time is a vascular surgeon’s most important asset. Anything that one can do to enlist others to protect or expand this time is helpful. To this end, loyal nurses, physician’s assistants, or nonprofessional associates are invaluable. Their loyalty, which must be reciprocated, can be earned by recognizing their contributions and rewarding them intellectually and financially. This mutual loyalty is essential to success in practice and in the inevitable conflicts that will occur.

All these concepts and many others are not covered in medical school or residency training. Yet all are important in a vascular surgery career, whether it be in a practice or academic setting. Human nature is a constant and its elements may often work against one’s success. Being aware of some of these often noxious and little discussed elements will hopefully enable vascular surgeons to cope with them better and ultimately survive in what can be a difficult environment.

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

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

All vascular surgeons want to be good doctors and to take the best possible care of their patients. They, therefore, train diligently and strive to keep up with new developments by reading vascular journals and attending cutting edge vascular meetings. They seek to optimize their judgment, communicate well and honestly with patients, perform their procedures with care, and follow their patients closely.

However, doing all these things does not ensure ascendancy in the profession. There are other factors which go into being a successful vascular surgeon. Many of these are not taught in medical school or residency training, and failure to recognize their importance can derail an otherwise prominent career. It is, therefore, important to highlight some of these factors which can be pitfalls to even the best trained and most committed vascular surgeon.

Vascular surgeons exist in a professionally competitive environment. We compete for patients with several other specialists including interventional cardiologists, interventional radiologists, and some general and cardiac surgeons as well as other lesser competitors.

All are hungry for patients and all consider themselves expert in all or some of the things we do. We also face competition from other vascular surgeons, few of whom feel busy enough to turn away patients. Therefore, it is important that vascular surgeons consider the competitive landscape when they are choosing a location or institution in which to practice. Is there an empty niche for the particular skills one brings to the area or the institution, and will other physicians in the area recognize those skills? Even then they must compete effectively not only by providing superior care but also by engaging in appropriate public relations and marketing of their assets.

Recognizing the importance of professional relationships with nonphysicians and other physicians outside our specialty and cultivating these relationships are other keys to success. The need for good relationships with referring physicians is obvious. Not so obvious is the need to have good relationships with hospital administrators who control essential resources, with other specialists like anesthesiologists and intensivists who can optimize the care our patients receive, with industry representatives, and even with other vascular surgeons. To make these relationships work to our advantage it is crucial to make them mutually beneficial. People are much more inclined to be helpful if what they are doing also helps them. Mutual self-interest can even improve interactions with competitors.

It is also important to avoid making enemies. This is particularly hard to do in the competitive environment in which we work. It is even harder to do in the present health care setting in which others who we do not control are unreasonable or incompetent. This is particularly true with those in positions of administrative authority like hospital executives or operating room supervisors. Making enemies of these individuals can be disastrous since they often control resources that determine our destiny. Keeping such individuals supportive or at least neutral, despite their possible serious flaws, is worth the sometimes painful effort required.

One must also be aware that nothing elicits hostility like success. If a young vascular surgeon/specialist has introduced a new technique or is particularly charming and hard-working and therefore has a booming practice, rest assured that his or her competitors – or even non-competitors – will be covertly or overtly hostile and take every opportunity to damage or bring down the successful individual. It does not matter that the hostility is unjustified and based on jealousy. It can still be unfairly damaging. All should realize that jealousy and greed are among the most powerful motivators of human behavior.

In view of all these considerations, it is apparent that all vascular surgeons, especially talented and successful ones, will at various times in their careers face battles. All cannot be fought. So one has to decide which ones should be avoided and which ones to engage in. Battles to fight should be picked carefully because they will consume energy and leave scars, no matter the outcome.

Most battles are best avoided unless victory is certain. Multiple simultaneous battles should be avoided. Battles in which one faces numerous opponents at the same time should also be shunned. Ideally in unavoidable conflicts, one should have as many allies as possible, although the loyalty of allies cannot always be counted on. Self-interest will determine the loyalty of presumed allies.

Never underestimate enemies, or overestimate allies. If the outcome of a battle is uncertain or to be determined by a board or other group, know how that group will vote before taking on the fight. Always remember the role of jealousy and greed in determining human behavior in battle. Defeated opponents do not forget and are forever dangerous.

Time is a vascular surgeon’s most important asset. Anything that one can do to enlist others to protect or expand this time is helpful. To this end, loyal nurses, physician’s assistants, or nonprofessional associates are invaluable. Their loyalty, which must be reciprocated, can be earned by recognizing their contributions and rewarding them intellectually and financially. This mutual loyalty is essential to success in practice and in the inevitable conflicts that will occur.

All these concepts and many others are not covered in medical school or residency training. Yet all are important in a vascular surgery career, whether it be in a practice or academic setting. Human nature is a constant and its elements may often work against one’s success. Being aware of some of these often noxious and little discussed elements will hopefully enable vascular surgeons to cope with them better and ultimately survive in what can be a difficult environment.

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

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

Although some vascular surgeons are convinced that endovascular aneurysm repair (EVAR) is superior to open repair for the treatment of ruptured abdominal aortic aneurysms (rAAAs), the issue remains controversial. The naysayers for the superiority of EVAR in this setting claim that all data showing superior outcomes for EVAR are flawed by patient selection, and they demand level 1 evidence from randomized comparisons of EVAR and open repair.

Three such randomized controlled trials (RCTs) have recently been published or have had their results presented: the AJAX or Amsterdam (Dutch) trial,¹ the ECAR or French trial,² and the IMPROVE or U.K. trial.³ All three trials concluded that 30-day mortality outcomes after EVAR are no better than those after open repair. However, in these three trials, this conclusion is rendered unjustified or misleading because of serious flaws or misinterpretation of the trial data. Let us examine the specifics.

The AJAX and ECAR trials randomized small numbers (116 and 107, respectively) of patients and had the serious flaw of excluding hypotensive or unstable rAAA patients. Such high-risk patients are precisely the ones who are most likely to have better outcomes with EVAR than with open repair. Therefore, exclusion of these high-risk patients precludes these trials from demonstrating the advantage that EVAR might have in the overall population of patients with rAAAs. In addition, both these trials may have used, in a suboptimal fashion, three adjuncts generally believed to improve EVAR outcomes.

Better usage of fluid restriction (hypotensive hemostasis), supra-aortic balloon control and open abdomen treatment of abdominal compartment syndrome might have further improved the EVAR outcomes in both trials.

In contrast to these two smaller RCTs, the larger U.K. IMPROVE trial was conducted in 30 high-volume centers. Although 652 possible rAAA patients were excluded for various reasons, the trialists did randomize 613 patients with a diagnosis of rAAA to either an endovascular strategy (316 patients) or open repair (297 patients).

Patients were randomized before CT scans were performed. The 30-day mortality in the endovascular strategy group was 35%; in the open repair group, it was 37%. Obviously, there was no significant difference, and a primary conclusion of the main IMPROVE trial article was “A strategy of endovascular repair was not associated with significant reduction in 30-day mortality.” This was paraphrased in various news report headlines as, “No Difference Between Endovascular and Open Repair.”

However, the detailed data from the IMPROVE trial must be examined closely to see why these conclusions are misleading. Of the patients randomized to the endovascular strategy group, only 154 (about half) actually underwent EVAR; 112 had an open repair and 17 had no treatment. The 30-day mortality in this group was 27% for those treated by EVAR and 38% for those treated by open repair. Of the patients randomized to the open repair group, 36 actually had EVAR, 220 had open repair, and 19 had no treatment.

The 30-day mortality in this open repair group was 22% for those undergoing EVAR and 37% for those undergoing open repair. Overall in the two randomized groups, taken together, the 30-day mortality for rAAA patients actually treated by EVAR was 25% and for those actually treated by Open Repair, it was 38%.

Clearly the conclusion of the IMPROVE trial should have been, in patients with an rAAA, if they can be treated by EVAR, their 30-day survival will be superior. If one adds to this the fact that patients undergoing EVAR are less likely to receive no treatment, the conclusion is inescapable: EVAR is superior to open repair for the treatment of patients with rAAAs.

Thus, those treating rAAA patients must learn how to do EVAR in this setting, including acquiring expertise in all the adjuncts and strategies that can improve EVAR outcomes in such patients. We do not need further RCTs to confuse the issue any more.

References

1. Ann. Surg. 2013;258:248-56.

2. www.veithondemand.com/2013.

3. BMJ 2014;348:f7661.

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

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

Although some vascular surgeons are convinced that endovascular aneurysm repair (EVAR) is superior to open repair for the treatment of ruptured abdominal aortic aneurysms (rAAAs), the issue remains controversial. The naysayers for the superiority of EVAR in this setting claim that all data showing superior outcomes for EVAR are flawed by patient selection, and they demand level 1 evidence from randomized comparisons of EVAR and open repair.

Three such randomized controlled trials (RCTs) have recently been published or have had their results presented: the AJAX or Amsterdam (Dutch) trial,¹ the ECAR or French trial,² and the IMPROVE or U.K. trial.³ All three trials concluded that 30-day mortality outcomes after EVAR are no better than those after open repair. However, in these three trials, this conclusion is rendered unjustified or misleading because of serious flaws or misinterpretation of the trial data. Let us examine the specifics.

The AJAX and ECAR trials randomized small numbers (116 and 107, respectively) of patients and had the serious flaw of excluding hypotensive or unstable rAAA patients. Such high-risk patients are precisely the ones who are most likely to have better outcomes with EVAR than with open repair. Therefore, exclusion of these high-risk patients precludes these trials from demonstrating the advantage that EVAR might have in the overall population of patients with rAAAs. In addition, both these trials may have used, in a suboptimal fashion, three adjuncts generally believed to improve EVAR outcomes.

Better usage of fluid restriction (hypotensive hemostasis), supra-aortic balloon control and open abdomen treatment of abdominal compartment syndrome might have further improved the EVAR outcomes in both trials.

In contrast to these two smaller RCTs, the larger U.K. IMPROVE trial was conducted in 30 high-volume centers. Although 652 possible rAAA patients were excluded for various reasons, the trialists did randomize 613 patients with a diagnosis of rAAA to either an endovascular strategy (316 patients) or open repair (297 patients).

Patients were randomized before CT scans were performed. The 30-day mortality in the endovascular strategy group was 35%; in the open repair group, it was 37%. Obviously, there was no significant difference, and a primary conclusion of the main IMPROVE trial article was “A strategy of endovascular repair was not associated with significant reduction in 30-day mortality.” This was paraphrased in various news report headlines as, “No Difference Between Endovascular and Open Repair.”

However, the detailed data from the IMPROVE trial must be examined closely to see why these conclusions are misleading. Of the patients randomized to the endovascular strategy group, only 154 (about half) actually underwent EVAR; 112 had an open repair and 17 had no treatment. The 30-day mortality in this group was 27% for those treated by EVAR and 38% for those treated by open repair. Of the patients randomized to the open repair group, 36 actually had EVAR, 220 had open repair, and 19 had no treatment.

The 30-day mortality in this open repair group was 22% for those undergoing EVAR and 37% for those undergoing open repair. Overall in the two randomized groups, taken together, the 30-day mortality for rAAA patients actually treated by EVAR was 25% and for those actually treated by Open Repair, it was 38%.

Clearly the conclusion of the IMPROVE trial should have been, in patients with an rAAA, if they can be treated by EVAR, their 30-day survival will be superior. If one adds to this the fact that patients undergoing EVAR are less likely to receive no treatment, the conclusion is inescapable: EVAR is superior to open repair for the treatment of patients with rAAAs.

Thus, those treating rAAA patients must learn how to do EVAR in this setting, including acquiring expertise in all the adjuncts and strategies that can improve EVAR outcomes in such patients. We do not need further RCTs to confuse the issue any more.

References

1. Ann. Surg. 2013;258:248-56.

2. www.veithondemand.com/2013.

3. BMJ 2014;348:f7661.

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

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

Although some vascular surgeons are convinced that endovascular aneurysm repair (EVAR) is superior to open repair for the treatment of ruptured abdominal aortic aneurysms (rAAAs), the issue remains controversial. The naysayers for the superiority of EVAR in this setting claim that all data showing superior outcomes for EVAR are flawed by patient selection, and they demand level 1 evidence from randomized comparisons of EVAR and open repair.

Three such randomized controlled trials (RCTs) have recently been published or have had their results presented: the AJAX or Amsterdam (Dutch) trial,¹ the ECAR or French trial,² and the IMPROVE or U.K. trial.³ All three trials concluded that 30-day mortality outcomes after EVAR are no better than those after open repair. However, in these three trials, this conclusion is rendered unjustified or misleading because of serious flaws or misinterpretation of the trial data. Let us examine the specifics.

The AJAX and ECAR trials randomized small numbers (116 and 107, respectively) of patients and had the serious flaw of excluding hypotensive or unstable rAAA patients. Such high-risk patients are precisely the ones who are most likely to have better outcomes with EVAR than with open repair. Therefore, exclusion of these high-risk patients precludes these trials from demonstrating the advantage that EVAR might have in the overall population of patients with rAAAs. In addition, both these trials may have used, in a suboptimal fashion, three adjuncts generally believed to improve EVAR outcomes.

Better usage of fluid restriction (hypotensive hemostasis), supra-aortic balloon control and open abdomen treatment of abdominal compartment syndrome might have further improved the EVAR outcomes in both trials.

In contrast to these two smaller RCTs, the larger U.K. IMPROVE trial was conducted in 30 high-volume centers. Although 652 possible rAAA patients were excluded for various reasons, the trialists did randomize 613 patients with a diagnosis of rAAA to either an endovascular strategy (316 patients) or open repair (297 patients).

Patients were randomized before CT scans were performed. The 30-day mortality in the endovascular strategy group was 35%; in the open repair group, it was 37%. Obviously, there was no significant difference, and a primary conclusion of the main IMPROVE trial article was “A strategy of endovascular repair was not associated with significant reduction in 30-day mortality.” This was paraphrased in various news report headlines as, “No Difference Between Endovascular and Open Repair.”

However, the detailed data from the IMPROVE trial must be examined closely to see why these conclusions are misleading. Of the patients randomized to the endovascular strategy group, only 154 (about half) actually underwent EVAR; 112 had an open repair and 17 had no treatment. The 30-day mortality in this group was 27% for those treated by EVAR and 38% for those treated by open repair. Of the patients randomized to the open repair group, 36 actually had EVAR, 220 had open repair, and 19 had no treatment.

The 30-day mortality in this open repair group was 22% for those undergoing EVAR and 37% for those undergoing open repair. Overall in the two randomized groups, taken together, the 30-day mortality for rAAA patients actually treated by EVAR was 25% and for those actually treated by Open Repair, it was 38%.

Clearly the conclusion of the IMPROVE trial should have been, in patients with an rAAA, if they can be treated by EVAR, their 30-day survival will be superior. If one adds to this the fact that patients undergoing EVAR are less likely to receive no treatment, the conclusion is inescapable: EVAR is superior to open repair for the treatment of patients with rAAAs.

Thus, those treating rAAA patients must learn how to do EVAR in this setting, including acquiring expertise in all the adjuncts and strategies that can improve EVAR outcomes in such patients. We do not need further RCTs to confuse the issue any more.

References

1. Ann. Surg. 2013;258:248-56.

2. www.veithondemand.com/2013.

3. BMJ 2014;348:f7661.

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

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

Vascular surgery has evolved from a limited subspecialty of general and thoracic surgery into a complex and well-defined specialty. The introduction of endovascular treatments and their adoption and embrace by vascular surgeons has made our specialty exciting and attractive.

However, the increasing importance of these endovascular treatments also poses some dangers to vascular surgery. By using these endovascular techniques, other specialists have the tools to treat vascular lesions in vascular patients who previously could be treated by vascular surgeons only.

Some of these other specialists have contributed to the development of endovascular treatment techniques and therefore have a legitimate claim to use these techniques on vascular patients. This certainly applies to interventional radiologists (IRs) and to some extent to interventional cardiologists (ICs).

More recently, cardiac surgeons, whose practices have been diminished by the development of better coronary stents and now transcatheter valves, are venturing more into the treatment of noncardiac vascular lesions and are trying, somewhat belatedly, to become expert in endovascular skills and methods and are using them to treat a panoply of noncardiac vascular lesions. To facilitate this, combined training programs have been proposed.

What is the impact of all this multispecialty outreach, and what is its effect on vascular patients and vascular surgeons? To the extent that different specialists can learn from each other’s skills and techniques and can cross train each other, it is probably a good thing for doctors and patients.

However, this multispecialty interest in noncardiac vascular lesions and patients has some serious potential downsides. When specialists expand their scope of practice to new areas as an add-on to their primary practice, they run the risk of becoming dabblers.

They may be able to use techniques without the appropriate knowledge base to know when the techniques should be used. As a result, they may do more harm than good, and health care costs will rise. In addition, the pool of patients justifiably needing treatment is limited. Thus, if more specialists consider themselves capable of treating a given lesion, it will surely increase the number of unnecessary procedures and complications. All these effects will be bad for patients and the health care system.

In 1996, in an SVS presidential address titled "Charles Darwin and Vascular Surgery" ( J. Vasc. Surg. 1997;25:8-18), I predicted the increasing importance of endovascular treatments and how they would replace most open surgical procedures. My predictions then, thought by most to be too high, have proven actually to be too low.

In that presidential address, I advised vascular surgeons to become endo-competent to avoid extinction. Thankfully they have done so. Because of this, our specialty survives in the endovascular era. I also advocated that vascular surgeons work together with other specialists (IRs and ICs) in vascular centers for the betterment of patient care.

With a few exceptions this has not happened for many reasons which can best be summarized as due to human nature with its tendencies to tribalism, self-interest, and competition for patients and dollars.

Undoubtedly these tendencies will continue to have negative consequences on the care of vascular patients. Nevertheless, vascular surgery, IR, and IC currently exist in the United States in a state of stable equilibrium in the provision of noncardiac vascular care. What will happen in the future remains uncertain.

What does all this have to do with Charles Darwin? Darwin in his classic book, The Origin of Species, hypothesized that there is a relationship between extinct and contemporary species of plants and animals, that there is a competitive struggle for life between species, and that preservation of favored species occurs through a process of evolution and natural selection.

In a Utopian world in which food and resources are unlimited, all species will flourish and prosper. However, the reality is that food and resources are not unlimited. So, in the struggle for life, there is intense competition between species for the available food, resources, and space. The species that are best evolved and adapted to win this competition will flourish and survive. The species that are least well adapted will wither and become extinct.

There are many analogies between medical specialties and species. Patients for a medical specialty are analogous to food for a species. Other resources and space for a species are analogous to access to patients, the workplace, and its resources for a specialty.

For vascular surgeons to prosper and flourish, they must have access to vascular disease patients and the resources to care for them optimally. These resources include the necessary skills. They also include the facilities such as noninvasive laboratories, operating rooms, angiography suites, and postprocedural care areas – with all the necessary permanent and disposable instrumentation and equipment to care for vascular patients and their lesions.

In the Darwinian sense, vascular surgeons are competing with IRs and ICs for scarce food and resources. The likelihood is that we will soon be competing with cardiac surgeons whose food source (patients needing open procedures) is going away.

Vascular surgeons have certain assets such as specialized training and a focus on noncardiac vascular disease, knowledge of its medical treatment and natural history, and the ability to do open vascular operations when needed.

However, these may not be enough to ensure our specialty’s survival, since the other specialties interested in the same patients and lesions as we do also have assets that may counteract their intrinsic liability of not being focused primarily on these patients or lesions.

So what about the often-heard recommendation that we collaborate with these other specialties interested in caring for vascular patients – that we cooperate and help them in their training and practice on their vascular disease patients? In an ideal Utopian world, we should do so, and all interested specialties should work together harmoniously as I suggested in 1996.

But here is what Charles Darwin, if he were alive today, would likely say about this. The real world is not such a Kumbaya place. Experience has shown over and over that human nature with its affinity for competition, tribalism, and self-interest works against Kumbaya. These traits, especially self-interest, which accounts for problems in our politics, our legal profession, and Wall Street, also causes problems for our specialty.

Darwin would also say that our patients, a target of opportunity for other specialties, are limited. So are the resources to take care of them optimally, like dollars, vascular laboratories, angiography suites, hybrid operating rooms, hospital beds, etc.

So regarding our relationship with other specialties interested in caring for vascular patients, especially cardiac surgery, Darwin would say: Vascular surgeons and cardiac surgeons are closely related specialties (species) that are competing for limited resources and space. Vascular surgery adapted more quickly than cardiac surgery to the endovascular revolution and will likely survive and prosper. However cardiac surgeons are aggressive and talented and have open skills.

They can learn endovascular techniques as we did. We should not train them and give away our current competitive advantage.

Vascular surgery must maintain and enhance its niche, possibly by increasing its recognition as a separate specialty. Lastly Darwin would say: Vascular surgery should never forget that it is in a struggle to survive. It should do everything it can to maintain and enhance its competitive edge.

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

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

Vascular surgery has evolved from a limited subspecialty of general and thoracic surgery into a complex and well-defined specialty. The introduction of endovascular treatments and their adoption and embrace by vascular surgeons has made our specialty exciting and attractive.

However, the increasing importance of these endovascular treatments also poses some dangers to vascular surgery. By using these endovascular techniques, other specialists have the tools to treat vascular lesions in vascular patients who previously could be treated by vascular surgeons only.

Some of these other specialists have contributed to the development of endovascular treatment techniques and therefore have a legitimate claim to use these techniques on vascular patients. This certainly applies to interventional radiologists (IRs) and to some extent to interventional cardiologists (ICs).

More recently, cardiac surgeons, whose practices have been diminished by the development of better coronary stents and now transcatheter valves, are venturing more into the treatment of noncardiac vascular lesions and are trying, somewhat belatedly, to become expert in endovascular skills and methods and are using them to treat a panoply of noncardiac vascular lesions. To facilitate this, combined training programs have been proposed.

What is the impact of all this multispecialty outreach, and what is its effect on vascular patients and vascular surgeons? To the extent that different specialists can learn from each other’s skills and techniques and can cross train each other, it is probably a good thing for doctors and patients.

However, this multispecialty interest in noncardiac vascular lesions and patients has some serious potential downsides. When specialists expand their scope of practice to new areas as an add-on to their primary practice, they run the risk of becoming dabblers.

They may be able to use techniques without the appropriate knowledge base to know when the techniques should be used. As a result, they may do more harm than good, and health care costs will rise. In addition, the pool of patients justifiably needing treatment is limited. Thus, if more specialists consider themselves capable of treating a given lesion, it will surely increase the number of unnecessary procedures and complications. All these effects will be bad for patients and the health care system.

In 1996, in an SVS presidential address titled "Charles Darwin and Vascular Surgery" ( J. Vasc. Surg. 1997;25:8-18), I predicted the increasing importance of endovascular treatments and how they would replace most open surgical procedures. My predictions then, thought by most to be too high, have proven actually to be too low.

In that presidential address, I advised vascular surgeons to become endo-competent to avoid extinction. Thankfully they have done so. Because of this, our specialty survives in the endovascular era. I also advocated that vascular surgeons work together with other specialists (IRs and ICs) in vascular centers for the betterment of patient care.

With a few exceptions this has not happened for many reasons which can best be summarized as due to human nature with its tendencies to tribalism, self-interest, and competition for patients and dollars.

Undoubtedly these tendencies will continue to have negative consequences on the care of vascular patients. Nevertheless, vascular surgery, IR, and IC currently exist in the United States in a state of stable equilibrium in the provision of noncardiac vascular care. What will happen in the future remains uncertain.

What does all this have to do with Charles Darwin? Darwin in his classic book, The Origin of Species, hypothesized that there is a relationship between extinct and contemporary species of plants and animals, that there is a competitive struggle for life between species, and that preservation of favored species occurs through a process of evolution and natural selection.

In a Utopian world in which food and resources are unlimited, all species will flourish and prosper. However, the reality is that food and resources are not unlimited. So, in the struggle for life, there is intense competition between species for the available food, resources, and space. The species that are best evolved and adapted to win this competition will flourish and survive. The species that are least well adapted will wither and become extinct.

There are many analogies between medical specialties and species. Patients for a medical specialty are analogous to food for a species. Other resources and space for a species are analogous to access to patients, the workplace, and its resources for a specialty.

For vascular surgeons to prosper and flourish, they must have access to vascular disease patients and the resources to care for them optimally. These resources include the necessary skills. They also include the facilities such as noninvasive laboratories, operating rooms, angiography suites, and postprocedural care areas – with all the necessary permanent and disposable instrumentation and equipment to care for vascular patients and their lesions.

In the Darwinian sense, vascular surgeons are competing with IRs and ICs for scarce food and resources. The likelihood is that we will soon be competing with cardiac surgeons whose food source (patients needing open procedures) is going away.

Vascular surgeons have certain assets such as specialized training and a focus on noncardiac vascular disease, knowledge of its medical treatment and natural history, and the ability to do open vascular operations when needed.

However, these may not be enough to ensure our specialty’s survival, since the other specialties interested in the same patients and lesions as we do also have assets that may counteract their intrinsic liability of not being focused primarily on these patients or lesions.

So what about the often-heard recommendation that we collaborate with these other specialties interested in caring for vascular patients – that we cooperate and help them in their training and practice on their vascular disease patients? In an ideal Utopian world, we should do so, and all interested specialties should work together harmoniously as I suggested in 1996.

But here is what Charles Darwin, if he were alive today, would likely say about this. The real world is not such a Kumbaya place. Experience has shown over and over that human nature with its affinity for competition, tribalism, and self-interest works against Kumbaya. These traits, especially self-interest, which accounts for problems in our politics, our legal profession, and Wall Street, also causes problems for our specialty.

Darwin would also say that our patients, a target of opportunity for other specialties, are limited. So are the resources to take care of them optimally, like dollars, vascular laboratories, angiography suites, hybrid operating rooms, hospital beds, etc.

So regarding our relationship with other specialties interested in caring for vascular patients, especially cardiac surgery, Darwin would say: Vascular surgeons and cardiac surgeons are closely related specialties (species) that are competing for limited resources and space. Vascular surgery adapted more quickly than cardiac surgery to the endovascular revolution and will likely survive and prosper. However cardiac surgeons are aggressive and talented and have open skills.

They can learn endovascular techniques as we did. We should not train them and give away our current competitive advantage.

Vascular surgery must maintain and enhance its niche, possibly by increasing its recognition as a separate specialty. Lastly Darwin would say: Vascular surgery should never forget that it is in a struggle to survive. It should do everything it can to maintain and enhance its competitive edge.

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

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

Vascular surgery has evolved from a limited subspecialty of general and thoracic surgery into a complex and well-defined specialty. The introduction of endovascular treatments and their adoption and embrace by vascular surgeons has made our specialty exciting and attractive.

However, the increasing importance of these endovascular treatments also poses some dangers to vascular surgery. By using these endovascular techniques, other specialists have the tools to treat vascular lesions in vascular patients who previously could be treated by vascular surgeons only.

Some of these other specialists have contributed to the development of endovascular treatment techniques and therefore have a legitimate claim to use these techniques on vascular patients. This certainly applies to interventional radiologists (IRs) and to some extent to interventional cardiologists (ICs).

More recently, cardiac surgeons, whose practices have been diminished by the development of better coronary stents and now transcatheter valves, are venturing more into the treatment of noncardiac vascular lesions and are trying, somewhat belatedly, to become expert in endovascular skills and methods and are using them to treat a panoply of noncardiac vascular lesions. To facilitate this, combined training programs have been proposed.

What is the impact of all this multispecialty outreach, and what is its effect on vascular patients and vascular surgeons? To the extent that different specialists can learn from each other’s skills and techniques and can cross train each other, it is probably a good thing for doctors and patients.

However, this multispecialty interest in noncardiac vascular lesions and patients has some serious potential downsides. When specialists expand their scope of practice to new areas as an add-on to their primary practice, they run the risk of becoming dabblers.

They may be able to use techniques without the appropriate knowledge base to know when the techniques should be used. As a result, they may do more harm than good, and health care costs will rise. In addition, the pool of patients justifiably needing treatment is limited. Thus, if more specialists consider themselves capable of treating a given lesion, it will surely increase the number of unnecessary procedures and complications. All these effects will be bad for patients and the health care system.

In 1996, in an SVS presidential address titled "Charles Darwin and Vascular Surgery" ( J. Vasc. Surg. 1997;25:8-18), I predicted the increasing importance of endovascular treatments and how they would replace most open surgical procedures. My predictions then, thought by most to be too high, have proven actually to be too low.

In that presidential address, I advised vascular surgeons to become endo-competent to avoid extinction. Thankfully they have done so. Because of this, our specialty survives in the endovascular era. I also advocated that vascular surgeons work together with other specialists (IRs and ICs) in vascular centers for the betterment of patient care.

With a few exceptions this has not happened for many reasons which can best be summarized as due to human nature with its tendencies to tribalism, self-interest, and competition for patients and dollars.

Undoubtedly these tendencies will continue to have negative consequences on the care of vascular patients. Nevertheless, vascular surgery, IR, and IC currently exist in the United States in a state of stable equilibrium in the provision of noncardiac vascular care. What will happen in the future remains uncertain.

What does all this have to do with Charles Darwin? Darwin in his classic book, The Origin of Species, hypothesized that there is a relationship between extinct and contemporary species of plants and animals, that there is a competitive struggle for life between species, and that preservation of favored species occurs through a process of evolution and natural selection.

In a Utopian world in which food and resources are unlimited, all species will flourish and prosper. However, the reality is that food and resources are not unlimited. So, in the struggle for life, there is intense competition between species for the available food, resources, and space. The species that are best evolved and adapted to win this competition will flourish and survive. The species that are least well adapted will wither and become extinct.

There are many analogies between medical specialties and species. Patients for a medical specialty are analogous to food for a species. Other resources and space for a species are analogous to access to patients, the workplace, and its resources for a specialty.

For vascular surgeons to prosper and flourish, they must have access to vascular disease patients and the resources to care for them optimally. These resources include the necessary skills. They also include the facilities such as noninvasive laboratories, operating rooms, angiography suites, and postprocedural care areas – with all the necessary permanent and disposable instrumentation and equipment to care for vascular patients and their lesions.

In the Darwinian sense, vascular surgeons are competing with IRs and ICs for scarce food and resources. The likelihood is that we will soon be competing with cardiac surgeons whose food source (patients needing open procedures) is going away.

Vascular surgeons have certain assets such as specialized training and a focus on noncardiac vascular disease, knowledge of its medical treatment and natural history, and the ability to do open vascular operations when needed.

However, these may not be enough to ensure our specialty’s survival, since the other specialties interested in the same patients and lesions as we do also have assets that may counteract their intrinsic liability of not being focused primarily on these patients or lesions.

So what about the often-heard recommendation that we collaborate with these other specialties interested in caring for vascular patients – that we cooperate and help them in their training and practice on their vascular disease patients? In an ideal Utopian world, we should do so, and all interested specialties should work together harmoniously as I suggested in 1996.

But here is what Charles Darwin, if he were alive today, would likely say about this. The real world is not such a Kumbaya place. Experience has shown over and over that human nature with its affinity for competition, tribalism, and self-interest works against Kumbaya. These traits, especially self-interest, which accounts for problems in our politics, our legal profession, and Wall Street, also causes problems for our specialty.

Darwin would also say that our patients, a target of opportunity for other specialties, are limited. So are the resources to take care of them optimally, like dollars, vascular laboratories, angiography suites, hybrid operating rooms, hospital beds, etc.

So regarding our relationship with other specialties interested in caring for vascular patients, especially cardiac surgery, Darwin would say: Vascular surgeons and cardiac surgeons are closely related specialties (species) that are competing for limited resources and space. Vascular surgery adapted more quickly than cardiac surgery to the endovascular revolution and will likely survive and prosper. However cardiac surgeons are aggressive and talented and have open skills.

They can learn endovascular techniques as we did. We should not train them and give away our current competitive advantage.

Vascular surgery must maintain and enhance its niche, possibly by increasing its recognition as a separate specialty. Lastly Darwin would say: Vascular surgery should never forget that it is in a struggle to survive. It should do everything it can to maintain and enhance its competitive edge.

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

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

The question of whether or not to give more healthy patients statin drugs is one of considerable interest to the public and much debate in both the medical community and the lay press.

In Nov. 12, 2013, the American College of Cardiology and the American Heart Association (ACC/AHA) released their long-awaited new guideline on the treatment of blood cholesterol to reduce the risk of adult atherosclerosis.

This guideline, among other recommendations, guided physicians to expand the number of patients being treated with statin drugs. This ACC/AHA guideline was greeted with many objections in both the medical community and the lay press. Most notable was a Nov. 14 New York Times Op Ed by two respected experts, Dr. John Abramson and Dr. Rita Redberg, entitled "Don’t Give More Patients Statins."

Other New York Times articles by Gina Kolata on Nov. 18 and 26 (citing Dr. Paul Ridker, Dr. Nancy Cook, and others) expressed similar reservations about the ACC/AHA guideline recommendation to broaden statin administration. Thus, this guideline and its recommendations are controversial and of great interest and importance to physicians and the public.

The Op Ed by Dr. Abramson and Dr. Redberg makes the case that the recent ACC/AHA cholesterol guideline is incorrect to advocate expansion of statin usage to more patients because such expansion "will benefit the pharmaceutical industry more than anyone else." They state that the guideline’s authors were not "free of conflicts of interest." In addition, they claim that "18% or more" of statin recipients "experience side effects" and that the increase in statin administration will largely be in "healthy people" who do not benefit and who would be better served by an improved diet and lifestyle.

While the latter is true for everyone, Dr. Abramson and Dr. Redberg convey the wrong message. Statins are the miracle drug of our era. They have proven repeatedly and dramatically to lower the disabling and common consequences of arteriosclerosis – most prominently heart attacks, strokes, and deaths in patients at risk. Statins avoid these vascular catastrophes not only by lowering bad blood lipids but also by a number of other beneficial effects that stabilize arterial plaques.

They have minimal side effects, most of which are benign. In several controlled studies, the patients who did not receive statins had an incidence of "side effects" equal to those who received them. Serious side effects are rare and manageable. Moreover, healthy patients are healthy only until they get sick. Many individuals over 40 take a daily aspirin. Statins are far more effective than aspirin in preventing heart attacks and strokes which often occur unexpectedly in previously "healthy people."

Clearly it would be worthwhile for such healthy people to take a daily statin pill with few side effects if it would lower their risk of such vascular catastrophes and premature death. In contrast to what is implied in the Abramson–Redberg Op Ed, these drugs are an easy way for people to live longer and live better, and statins cannot be replaced with a healthy life style and diet – although combining the latter with statins is a good thing.

Lastly, regarding the comments about the pharmaceutical industry benefitting and guideline authors’ conflicts of interest, both are less important than patient benefit, which has been demonstrated dramatically and consistently in many controlled statin trials. Moreover, most statins are now generic so the cost for obtaining these miraculous drugs need not be prohibitive, and the guideline’s authors are experts who are eminently qualified to write them.

More patients should be on statin medication.

Dr. Veith is professor of vascular surgery, Langone New York University Medical Center and The Cleveland Clinic. He is an associate medical editor for VASCULAR SPECIALIST. He has no financial conflicts of interest.

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

The question of whether or not to give more healthy patients statin drugs is one of considerable interest to the public and much debate in both the medical community and the lay press.

In Nov. 12, 2013, the American College of Cardiology and the American Heart Association (ACC/AHA) released their long-awaited new guideline on the treatment of blood cholesterol to reduce the risk of adult atherosclerosis.

This guideline, among other recommendations, guided physicians to expand the number of patients being treated with statin drugs. This ACC/AHA guideline was greeted with many objections in both the medical community and the lay press. Most notable was a Nov. 14 New York Times Op Ed by two respected experts, Dr. John Abramson and Dr. Rita Redberg, entitled "Don’t Give More Patients Statins."

Other New York Times articles by Gina Kolata on Nov. 18 and 26 (citing Dr. Paul Ridker, Dr. Nancy Cook, and others) expressed similar reservations about the ACC/AHA guideline recommendation to broaden statin administration. Thus, this guideline and its recommendations are controversial and of great interest and importance to physicians and the public.

The Op Ed by Dr. Abramson and Dr. Redberg makes the case that the recent ACC/AHA cholesterol guideline is incorrect to advocate expansion of statin usage to more patients because such expansion "will benefit the pharmaceutical industry more than anyone else." They state that the guideline’s authors were not "free of conflicts of interest." In addition, they claim that "18% or more" of statin recipients "experience side effects" and that the increase in statin administration will largely be in "healthy people" who do not benefit and who would be better served by an improved diet and lifestyle.

While the latter is true for everyone, Dr. Abramson and Dr. Redberg convey the wrong message. Statins are the miracle drug of our era. They have proven repeatedly and dramatically to lower the disabling and common consequences of arteriosclerosis – most prominently heart attacks, strokes, and deaths in patients at risk. Statins avoid these vascular catastrophes not only by lowering bad blood lipids but also by a number of other beneficial effects that stabilize arterial plaques.

They have minimal side effects, most of which are benign. In several controlled studies, the patients who did not receive statins had an incidence of "side effects" equal to those who received them. Serious side effects are rare and manageable. Moreover, healthy patients are healthy only until they get sick. Many individuals over 40 take a daily aspirin. Statins are far more effective than aspirin in preventing heart attacks and strokes which often occur unexpectedly in previously "healthy people."

Clearly it would be worthwhile for such healthy people to take a daily statin pill with few side effects if it would lower their risk of such vascular catastrophes and premature death. In contrast to what is implied in the Abramson–Redberg Op Ed, these drugs are an easy way for people to live longer and live better, and statins cannot be replaced with a healthy life style and diet – although combining the latter with statins is a good thing.

Lastly, regarding the comments about the pharmaceutical industry benefitting and guideline authors’ conflicts of interest, both are less important than patient benefit, which has been demonstrated dramatically and consistently in many controlled statin trials. Moreover, most statins are now generic so the cost for obtaining these miraculous drugs need not be prohibitive, and the guideline’s authors are experts who are eminently qualified to write them.

More patients should be on statin medication.

Dr. Veith is professor of vascular surgery, Langone New York University Medical Center and The Cleveland Clinic. He is an associate medical editor for VASCULAR SPECIALIST. He has no financial conflicts of interest.

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

The question of whether or not to give more healthy patients statin drugs is one of considerable interest to the public and much debate in both the medical community and the lay press.

In Nov. 12, 2013, the American College of Cardiology and the American Heart Association (ACC/AHA) released their long-awaited new guideline on the treatment of blood cholesterol to reduce the risk of adult atherosclerosis.

This guideline, among other recommendations, guided physicians to expand the number of patients being treated with statin drugs. This ACC/AHA guideline was greeted with many objections in both the medical community and the lay press. Most notable was a Nov. 14 New York Times Op Ed by two respected experts, Dr. John Abramson and Dr. Rita Redberg, entitled "Don’t Give More Patients Statins."

Other New York Times articles by Gina Kolata on Nov. 18 and 26 (citing Dr. Paul Ridker, Dr. Nancy Cook, and others) expressed similar reservations about the ACC/AHA guideline recommendation to broaden statin administration. Thus, this guideline and its recommendations are controversial and of great interest and importance to physicians and the public.

The Op Ed by Dr. Abramson and Dr. Redberg makes the case that the recent ACC/AHA cholesterol guideline is incorrect to advocate expansion of statin usage to more patients because such expansion "will benefit the pharmaceutical industry more than anyone else." They state that the guideline’s authors were not "free of conflicts of interest." In addition, they claim that "18% or more" of statin recipients "experience side effects" and that the increase in statin administration will largely be in "healthy people" who do not benefit and who would be better served by an improved diet and lifestyle.

While the latter is true for everyone, Dr. Abramson and Dr. Redberg convey the wrong message. Statins are the miracle drug of our era. They have proven repeatedly and dramatically to lower the disabling and common consequences of arteriosclerosis – most prominently heart attacks, strokes, and deaths in patients at risk. Statins avoid these vascular catastrophes not only by lowering bad blood lipids but also by a number of other beneficial effects that stabilize arterial plaques.

They have minimal side effects, most of which are benign. In several controlled studies, the patients who did not receive statins had an incidence of "side effects" equal to those who received them. Serious side effects are rare and manageable. Moreover, healthy patients are healthy only until they get sick. Many individuals over 40 take a daily aspirin. Statins are far more effective than aspirin in preventing heart attacks and strokes which often occur unexpectedly in previously "healthy people."

Clearly it would be worthwhile for such healthy people to take a daily statin pill with few side effects if it would lower their risk of such vascular catastrophes and premature death. In contrast to what is implied in the Abramson–Redberg Op Ed, these drugs are an easy way for people to live longer and live better, and statins cannot be replaced with a healthy life style and diet – although combining the latter with statins is a good thing.

Lastly, regarding the comments about the pharmaceutical industry benefitting and guideline authors’ conflicts of interest, both are less important than patient benefit, which has been demonstrated dramatically and consistently in many controlled statin trials. Moreover, most statins are now generic so the cost for obtaining these miraculous drugs need not be prohibitive, and the guideline’s authors are experts who are eminently qualified to write them.

More patients should be on statin medication.

Dr. Veith is professor of vascular surgery, Langone New York University Medical Center and The Cleveland Clinic. He is an associate medical editor for VASCULAR SPECIALIST. He has no financial conflicts of interest.

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

Two young men went camping in the wilderness. One of them went off to gather firewood. He returned an hour later, staggering, badly battered, very bloody and with his clothes in tatters. His friend asked what happened. "I ran into a blacksnake" was the reply. "Everyone knows that blacksnakes are harmless," his friend retorted. "They are not so harmless if they make you jump off a cliff."

How does this story apply to vascular surgery and vascular disease patients? It is very relevant to the management of asymptomatic carotid stenosis, small aneurysms, or nondisabling intermittent claudication -- all conditions that are not dangerous and in most cases cause no serious harm.

Let's look first at asymptomatic carotid stenosis. A healthy, totally asymptomatic 58-year-old man with no cardiovascular risk factors undergoes a carotid screening exam by a commercial mobile laboratory service. He is told that he has a moderate carotid stenosis and a proper carotid duplex is recommended. This is obtained in the office of a "vascular specialist," and it shows that the patient has a "50%-60% narrowing of his left internal carotid artery." The vascular specialist advises him to have a "minimally invasive" carotid stent placed. This is performed in the local hospital by the vascular specialist. The patient has a "minor stroke" with near complete recovery within 2 months except for some persistent difficulty with fine movements of his right hand and some difficulty finding words. Although the man is able to keep his job, he is not as skilled at it as he was.

This patient is a victim of the blacksnake phenomenon. Although his carotid stenosis had more than a 95% chance of causing him no future harm, he suffered a somewhat disabling stroke that he would not have had if he had not undergone the screening exam. In other words the detection of the lesion and its unnecessary invasive treatment lead to a problem that otherwise would not have occurred.

Another example of a potential blacksnake phenomenon occurred in a 74-year-old retired hand surgeon with a 4.1-cm (diameter) abdominal aortic aneurysm. In 2004 this patient saw a vascular surgeon who was then chief of service at a major university center that was just beginning to perform EVAR. The patient had favorable anatomy for EVAR, and the vascular surgeon apparently wished to increase his limited experience with the procedure. The patient was advised to have the EVAR procedure "as soon as possible." He sought a second opinion and was advised to have his aneurysm observed periodically. Ten years later the patient remains well, and the aneurysm still has a diameter of 4.1 cm. If this patient had had an urgent EVAR in 2004 and had had any complication, it would have been a clear example of the blacksnake phenomenon. The fact-based second opinion and the patient's willingness to follow the appropriately conservative option spared him any exposure to the risk of treating a largely harmless condition. Harm from the blacksnake phenomenon was avoided.

Another patient who was spared exposure to the blacksnake phenomenon was a 58-year-old hypertensive hyperlipidemic smoker who had had a coronary artery bypass and who sought a second opinion for treatment of two block left calf claudication. The patient had had three endovascular procedures by a "vascular specialist" for a long superficial femoral artery occlusion which was causing the same symptom. All three interventions had failed, and a bypass had been suggested by the same specialist. The second opinion work-up revealed that the patient shockingly had not been placed on statins, had not been advised to stop smoking, and was not being treated for his hypertension by his intervening vascular specialist or the cardiologist who had referred the patient for his three interventions. Nor had he been told that his uncorrected femoral artery occlusion posed little risk to his limb or his life. The vascular surgeon providing the second opinion advised no treatment for the femoral occlusion, but placed the patient on statins, anti-hypertensives, and other medical measures. Had the patient undergone a fourth intervention or a bypass for the femoral occlusion, his risks would have been substantial. Avoiding these risks spared the patient the likelihood of being victimized by the blacksnake phenomenon.

All these cases are real. Yet all are examples of an actual or potential blacksnake phenomenon which can and does occur commonly in our system of vascular care. These cases emphasize that patients can be harmed by the blacksnake phenomenon, which results from the benign natural history of many vascular lesions which are better left uncorrected. Fixing such lesions simply because they exist and are detected causes more harm than benefit to patients. Many self-appointed vascular specialists are not fully aware of this benign natural history. Others, it seems, choose to ignore it, perhaps for bad motives. However, it behooves all specialists that treat non-coronary vascular disease to be aware of the natural history of various lesions and conditions, so that they do not treat patients with them unnecessarily or for the wrong reasons.

Moreover, they must be aware of and utilize optimal medical treatments for these lesions and conditions. In that way patients can be spared exposure to the blacksnake phenomenon, and real vascular specialists can provide the best overall care for their patients.

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

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

Two young men went camping in the wilderness. One of them went off to gather firewood. He returned an hour later, staggering, badly battered, very bloody and with his clothes in tatters. His friend asked what happened. "I ran into a blacksnake" was the reply. "Everyone knows that blacksnakes are harmless," his friend retorted. "They are not so harmless if they make you jump off a cliff."

How does this story apply to vascular surgery and vascular disease patients? It is very relevant to the management of asymptomatic carotid stenosis, small aneurysms, or nondisabling intermittent claudication -- all conditions that are not dangerous and in most cases cause no serious harm.

Let's look first at asymptomatic carotid stenosis. A healthy, totally asymptomatic 58-year-old man with no cardiovascular risk factors undergoes a carotid screening exam by a commercial mobile laboratory service. He is told that he has a moderate carotid stenosis and a proper carotid duplex is recommended. This is obtained in the office of a "vascular specialist," and it shows that the patient has a "50%-60% narrowing of his left internal carotid artery." The vascular specialist advises him to have a "minimally invasive" carotid stent placed. This is performed in the local hospital by the vascular specialist. The patient has a "minor stroke" with near complete recovery within 2 months except for some persistent difficulty with fine movements of his right hand and some difficulty finding words. Although the man is able to keep his job, he is not as skilled at it as he was.

This patient is a victim of the blacksnake phenomenon. Although his carotid stenosis had more than a 95% chance of causing him no future harm, he suffered a somewhat disabling stroke that he would not have had if he had not undergone the screening exam. In other words the detection of the lesion and its unnecessary invasive treatment lead to a problem that otherwise would not have occurred.

Another example of a potential blacksnake phenomenon occurred in a 74-year-old retired hand surgeon with a 4.1-cm (diameter) abdominal aortic aneurysm. In 2004 this patient saw a vascular surgeon who was then chief of service at a major university center that was just beginning to perform EVAR. The patient had favorable anatomy for EVAR, and the vascular surgeon apparently wished to increase his limited experience with the procedure. The patient was advised to have the EVAR procedure "as soon as possible." He sought a second opinion and was advised to have his aneurysm observed periodically. Ten years later the patient remains well, and the aneurysm still has a diameter of 4.1 cm. If this patient had had an urgent EVAR in 2004 and had had any complication, it would have been a clear example of the blacksnake phenomenon. The fact-based second opinion and the patient's willingness to follow the appropriately conservative option spared him any exposure to the risk of treating a largely harmless condition. Harm from the blacksnake phenomenon was avoided.

Another patient who was spared exposure to the blacksnake phenomenon was a 58-year-old hypertensive hyperlipidemic smoker who had had a coronary artery bypass and who sought a second opinion for treatment of two block left calf claudication. The patient had had three endovascular procedures by a "vascular specialist" for a long superficial femoral artery occlusion which was causing the same symptom. All three interventions had failed, and a bypass had been suggested by the same specialist. The second opinion work-up revealed that the patient shockingly had not been placed on statins, had not been advised to stop smoking, and was not being treated for his hypertension by his intervening vascular specialist or the cardiologist who had referred the patient for his three interventions. Nor had he been told that his uncorrected femoral artery occlusion posed little risk to his limb or his life. The vascular surgeon providing the second opinion advised no treatment for the femoral occlusion, but placed the patient on statins, anti-hypertensives, and other medical measures. Had the patient undergone a fourth intervention or a bypass for the femoral occlusion, his risks would have been substantial. Avoiding these risks spared the patient the likelihood of being victimized by the blacksnake phenomenon.

All these cases are real. Yet all are examples of an actual or potential blacksnake phenomenon which can and does occur commonly in our system of vascular care. These cases emphasize that patients can be harmed by the blacksnake phenomenon, which results from the benign natural history of many vascular lesions which are better left uncorrected. Fixing such lesions simply because they exist and are detected causes more harm than benefit to patients. Many self-appointed vascular specialists are not fully aware of this benign natural history. Others, it seems, choose to ignore it, perhaps for bad motives. However, it behooves all specialists that treat non-coronary vascular disease to be aware of the natural history of various lesions and conditions, so that they do not treat patients with them unnecessarily or for the wrong reasons.

Moreover, they must be aware of and utilize optimal medical treatments for these lesions and conditions. In that way patients can be spared exposure to the blacksnake phenomenon, and real vascular specialists can provide the best overall care for their patients.

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

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

Two young men went camping in the wilderness. One of them went off to gather firewood. He returned an hour later, staggering, badly battered, very bloody and with his clothes in tatters. His friend asked what happened. "I ran into a blacksnake" was the reply. "Everyone knows that blacksnakes are harmless," his friend retorted. "They are not so harmless if they make you jump off a cliff."

How does this story apply to vascular surgery and vascular disease patients? It is very relevant to the management of asymptomatic carotid stenosis, small aneurysms, or nondisabling intermittent claudication -- all conditions that are not dangerous and in most cases cause no serious harm.

Let's look first at asymptomatic carotid stenosis. A healthy, totally asymptomatic 58-year-old man with no cardiovascular risk factors undergoes a carotid screening exam by a commercial mobile laboratory service. He is told that he has a moderate carotid stenosis and a proper carotid duplex is recommended. This is obtained in the office of a "vascular specialist," and it shows that the patient has a "50%-60% narrowing of his left internal carotid artery." The vascular specialist advises him to have a "minimally invasive" carotid stent placed. This is performed in the local hospital by the vascular specialist. The patient has a "minor stroke" with near complete recovery within 2 months except for some persistent difficulty with fine movements of his right hand and some difficulty finding words. Although the man is able to keep his job, he is not as skilled at it as he was.

This patient is a victim of the blacksnake phenomenon. Although his carotid stenosis had more than a 95% chance of causing him no future harm, he suffered a somewhat disabling stroke that he would not have had if he had not undergone the screening exam. In other words the detection of the lesion and its unnecessary invasive treatment lead to a problem that otherwise would not have occurred.

Another example of a potential blacksnake phenomenon occurred in a 74-year-old retired hand surgeon with a 4.1-cm (diameter) abdominal aortic aneurysm. In 2004 this patient saw a vascular surgeon who was then chief of service at a major university center that was just beginning to perform EVAR. The patient had favorable anatomy for EVAR, and the vascular surgeon apparently wished to increase his limited experience with the procedure. The patient was advised to have the EVAR procedure "as soon as possible." He sought a second opinion and was advised to have his aneurysm observed periodically. Ten years later the patient remains well, and the aneurysm still has a diameter of 4.1 cm. If this patient had had an urgent EVAR in 2004 and had had any complication, it would have been a clear example of the blacksnake phenomenon. The fact-based second opinion and the patient's willingness to follow the appropriately conservative option spared him any exposure to the risk of treating a largely harmless condition. Harm from the blacksnake phenomenon was avoided.

Another patient who was spared exposure to the blacksnake phenomenon was a 58-year-old hypertensive hyperlipidemic smoker who had had a coronary artery bypass and who sought a second opinion for treatment of two block left calf claudication. The patient had had three endovascular procedures by a "vascular specialist" for a long superficial femoral artery occlusion which was causing the same symptom. All three interventions had failed, and a bypass had been suggested by the same specialist. The second opinion work-up revealed that the patient shockingly had not been placed on statins, had not been advised to stop smoking, and was not being treated for his hypertension by his intervening vascular specialist or the cardiologist who had referred the patient for his three interventions. Nor had he been told that his uncorrected femoral artery occlusion posed little risk to his limb or his life. The vascular surgeon providing the second opinion advised no treatment for the femoral occlusion, but placed the patient on statins, anti-hypertensives, and other medical measures. Had the patient undergone a fourth intervention or a bypass for the femoral occlusion, his risks would have been substantial. Avoiding these risks spared the patient the likelihood of being victimized by the blacksnake phenomenon.

All these cases are real. Yet all are examples of an actual or potential blacksnake phenomenon which can and does occur commonly in our system of vascular care. These cases emphasize that patients can be harmed by the blacksnake phenomenon, which results from the benign natural history of many vascular lesions which are better left uncorrected. Fixing such lesions simply because they exist and are detected causes more harm than benefit to patients. Many self-appointed vascular specialists are not fully aware of this benign natural history. Others, it seems, choose to ignore it, perhaps for bad motives. However, it behooves all specialists that treat non-coronary vascular disease to be aware of the natural history of various lesions and conditions, so that they do not treat patients with them unnecessarily or for the wrong reasons.

Moreover, they must be aware of and utilize optimal medical treatments for these lesions and conditions. In that way patients can be spared exposure to the blacksnake phenomenon, and real vascular specialists can provide the best overall care for their patients.

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

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

A stated goal of the United States is to support and promote democracy throughout the world. This seems reasonable, because democracy has often worked well in our own and other Western countries, and because no other form of government has consistently been better. So is democracy the best form of government? I submit that it is the best only if certain conditions are met.

For democracy to work, the public must be well informed and willing to consider, at least to some extent, the country’s interests in addition to their own self-interests. If a major fraction of the public does not care about or know what is good for the country or is totally motivated by self-interest, the government and the country will fail. Sadly this appears to be the case in the U.S. today as evidenced by Jay Leno’s "JayWalking Segments" in which most young people interviewed – even college graduates – have no idea about issues important to our country. They appear to be more interested in sports and their social life and more knowledgeable about TV sitcoms and reality shows.

How can such individuals be relied upon to pick government leaders who will take care of our country’s interests in the trying times it faces politically and economically? An ill-informed and non-caring public is more likely to pick leaders who are the slickest talkers and who promise the most despite the impossibility or negative effects of keeping these promises. This know-nothing or self-interested nature of our electorate contributes importantly to the ever expanding entitlement culture in the U.S. and the resulting dangerous expansion of our national debt.

Another related requirement for democracy to be an effective form of government is the need for an honest and objective media and press. A controlled or biased source of information contributes hugely to an ill-informed public. Whoever controls the media and the press controls the minds of the voters. For democracy to work effectively, the public must not only want to be informed, they must also be given the necessary objective facts to make valid judgments. The press has a vital responsibility to provide such facts with minimal bias. There is considerable doubt about whether or not this is occurring today in the U.S.

Of even greater importance to a successful democracy is the ethical stature of its leaders and their motivation – once elected – to act in the best interests of the country. Many forces act upon our leaders and are counter to these interests. These include obligations to those who helped elect them, ideology, personal gain, a desire to be re-elected, and most importantly the corrupting requirement to solicit campaign financing. In the U.S. currently, the need to finance expensive campaigns is a major flaw in our democracy, and is really a veiled form of bribery.

For a democratic leader to be successful in terms of doing a good job of leading the country, all these forces must be overridden by the desire to do what is right and best for the whole country. This means the leader must not serve solely special or self-interests, and must have the courage and inner strength to do what may at the moment be unpopular with his or her electoral base. He or she must unite the country rather than divide it for short-term political or parochial gain. Unfortunately many of our recently elected U.S. leaders have not met any of these requirements. If this trend continues, our democracy will serve the country’s interests poorly, and the U.S. will decline rather than gain in stature and strength.

Efforts at democracy in the Middle East and elsewhere have failed because some or all of the requirements discussed here have not been met. A similar decline awaits our U.S. democracy if the current flaws in the underlying system cannot be corrected.

So far this discussion has largely been related to the U.S. federal government. However, the same considerations apply to effective governments at the county, state, and city levels, and to governing bodies of other entities which purport to be managed in a democratic fashion. This even applies to our vascular societies. The ethics and character of the leaders and those choosing them are important to effective governance and the success of the organization. If special interests, financial conflicts, and self-interest prevail over the needs of the organization, the latter will fail and decline.

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

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

A stated goal of the United States is to support and promote democracy throughout the world. This seems reasonable, because democracy has often worked well in our own and other Western countries, and because no other form of government has consistently been better. So is democracy the best form of government? I submit that it is the best only if certain conditions are met.

For democracy to work, the public must be well informed and willing to consider, at least to some extent, the country’s interests in addition to their own self-interests. If a major fraction of the public does not care about or know what is good for the country or is totally motivated by self-interest, the government and the country will fail. Sadly this appears to be the case in the U.S. today as evidenced by Jay Leno’s "JayWalking Segments" in which most young people interviewed – even college graduates – have no idea about issues important to our country. They appear to be more interested in sports and their social life and more knowledgeable about TV sitcoms and reality shows.

How can such individuals be relied upon to pick government leaders who will take care of our country’s interests in the trying times it faces politically and economically? An ill-informed and non-caring public is more likely to pick leaders who are the slickest talkers and who promise the most despite the impossibility or negative effects of keeping these promises. This know-nothing or self-interested nature of our electorate contributes importantly to the ever expanding entitlement culture in the U.S. and the resulting dangerous expansion of our national debt.

Another related requirement for democracy to be an effective form of government is the need for an honest and objective media and press. A controlled or biased source of information contributes hugely to an ill-informed public. Whoever controls the media and the press controls the minds of the voters. For democracy to work effectively, the public must not only want to be informed, they must also be given the necessary objective facts to make valid judgments. The press has a vital responsibility to provide such facts with minimal bias. There is considerable doubt about whether or not this is occurring today in the U.S.

Of even greater importance to a successful democracy is the ethical stature of its leaders and their motivation – once elected – to act in the best interests of the country. Many forces act upon our leaders and are counter to these interests. These include obligations to those who helped elect them, ideology, personal gain, a desire to be re-elected, and most importantly the corrupting requirement to solicit campaign financing. In the U.S. currently, the need to finance expensive campaigns is a major flaw in our democracy, and is really a veiled form of bribery.

For a democratic leader to be successful in terms of doing a good job of leading the country, all these forces must be overridden by the desire to do what is right and best for the whole country. This means the leader must not serve solely special or self-interests, and must have the courage and inner strength to do what may at the moment be unpopular with his or her electoral base. He or she must unite the country rather than divide it for short-term political or parochial gain. Unfortunately many of our recently elected U.S. leaders have not met any of these requirements. If this trend continues, our democracy will serve the country’s interests poorly, and the U.S. will decline rather than gain in stature and strength.

Efforts at democracy in the Middle East and elsewhere have failed because some or all of the requirements discussed here have not been met. A similar decline awaits our U.S. democracy if the current flaws in the underlying system cannot be corrected.

So far this discussion has largely been related to the U.S. federal government. However, the same considerations apply to effective governments at the county, state, and city levels, and to governing bodies of other entities which purport to be managed in a democratic fashion. This even applies to our vascular societies. The ethics and character of the leaders and those choosing them are important to effective governance and the success of the organization. If special interests, financial conflicts, and self-interest prevail over the needs of the organization, the latter will fail and decline.

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

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

A stated goal of the United States is to support and promote democracy throughout the world. This seems reasonable, because democracy has often worked well in our own and other Western countries, and because no other form of government has consistently been better. So is democracy the best form of government? I submit that it is the best only if certain conditions are met.

For democracy to work, the public must be well informed and willing to consider, at least to some extent, the country’s interests in addition to their own self-interests. If a major fraction of the public does not care about or know what is good for the country or is totally motivated by self-interest, the government and the country will fail. Sadly this appears to be the case in the U.S. today as evidenced by Jay Leno’s "JayWalking Segments" in which most young people interviewed – even college graduates – have no idea about issues important to our country. They appear to be more interested in sports and their social life and more knowledgeable about TV sitcoms and reality shows.

How can such individuals be relied upon to pick government leaders who will take care of our country’s interests in the trying times it faces politically and economically? An ill-informed and non-caring public is more likely to pick leaders who are the slickest talkers and who promise the most despite the impossibility or negative effects of keeping these promises. This know-nothing or self-interested nature of our electorate contributes importantly to the ever expanding entitlement culture in the U.S. and the resulting dangerous expansion of our national debt.

Another related requirement for democracy to be an effective form of government is the need for an honest and objective media and press. A controlled or biased source of information contributes hugely to an ill-informed public. Whoever controls the media and the press controls the minds of the voters. For democracy to work effectively, the public must not only want to be informed, they must also be given the necessary objective facts to make valid judgments. The press has a vital responsibility to provide such facts with minimal bias. There is considerable doubt about whether or not this is occurring today in the U.S.

Of even greater importance to a successful democracy is the ethical stature of its leaders and their motivation – once elected – to act in the best interests of the country. Many forces act upon our leaders and are counter to these interests. These include obligations to those who helped elect them, ideology, personal gain, a desire to be re-elected, and most importantly the corrupting requirement to solicit campaign financing. In the U.S. currently, the need to finance expensive campaigns is a major flaw in our democracy, and is really a veiled form of bribery.

For a democratic leader to be successful in terms of doing a good job of leading the country, all these forces must be overridden by the desire to do what is right and best for the whole country. This means the leader must not serve solely special or self-interests, and must have the courage and inner strength to do what may at the moment be unpopular with his or her electoral base. He or she must unite the country rather than divide it for short-term political or parochial gain. Unfortunately many of our recently elected U.S. leaders have not met any of these requirements. If this trend continues, our democracy will serve the country’s interests poorly, and the U.S. will decline rather than gain in stature and strength.

Efforts at democracy in the Middle East and elsewhere have failed because some or all of the requirements discussed here have not been met. A similar decline awaits our U.S. democracy if the current flaws in the underlying system cannot be corrected.

So far this discussion has largely been related to the U.S. federal government. However, the same considerations apply to effective governments at the county, state, and city levels, and to governing bodies of other entities which purport to be managed in a democratic fashion. This even applies to our vascular societies. The ethics and character of the leaders and those choosing them are important to effective governance and the success of the organization. If special interests, financial conflicts, and self-interest prevail over the needs of the organization, the latter will fail and decline.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dr. George Andros, departing Medical Editor of Vascular Specialist, was presented with a Presidential Citation Award by Dr. Peter Gloviczki in recognition of his exemplary service to the Society for Vascular Surgery for outstanding editorial leadership of Vascular Specialist. He received the award during the SVS Business Meeting May 31 at the Vascular Annual Meeting.

Dr. Andros succeeded Dr. K. Wayne Johnston as only the second medical editor of Vascular Specialist. Under his esteemed leadership over the past years, Vascular Specialist has widened its coverage of vascular surgery and  entered the online world with online-only editions, e-newsletters, and a website.

He installed a stellar board of editorial advisors from across the United States and the world and inspired them to provide the insightful commentaries that have so enhanced our pages.

As managing editor, I would personally like to thank Dr. Andros for his commitment, professionalism, and friendship throughout this time.

Dr. Andros will be succeeded by Dr. Russell Samson, who will begin his medical editor duties with the August print edition of Vascular Specialist.

Mark Lesney

Managing Editor, Vascular Specialist

mlesney@frontlinemedcom.com

Dr. George Andros, departing Medical Editor of Vascular Specialist, was presented with a Presidential Citation Award by Dr. Peter Gloviczki in recognition of his exemplary service to the Society for Vascular Surgery for outstanding editorial leadership of Vascular Specialist. He received the award during the SVS Business Meeting May 31 at the Vascular Annual Meeting.

Dr. Andros succeeded Dr. K. Wayne Johnston as only the second medical editor of Vascular Specialist. Under his esteemed leadership over the past years, Vascular Specialist has widened its coverage of vascular surgery and  entered the online world with online-only editions, e-newsletters, and a website.

He installed a stellar board of editorial advisors from across the United States and the world and inspired them to provide the insightful commentaries that have so enhanced our pages.

As managing editor, I would personally like to thank Dr. Andros for his commitment, professionalism, and friendship throughout this time.

Dr. Andros will be succeeded by Dr. Russell Samson, who will begin his medical editor duties with the August print edition of Vascular Specialist.

Mark Lesney

Managing Editor, Vascular Specialist

mlesney@frontlinemedcom.com

Dr. George Andros, departing Medical Editor of Vascular Specialist, was presented with a Presidential Citation Award by Dr. Peter Gloviczki in recognition of his exemplary service to the Society for Vascular Surgery for outstanding editorial leadership of Vascular Specialist. He received the award during the SVS Business Meeting May 31 at the Vascular Annual Meeting.

Dr. Andros succeeded Dr. K. Wayne Johnston as only the second medical editor of Vascular Specialist. Under his esteemed leadership over the past years, Vascular Specialist has widened its coverage of vascular surgery and  entered the online world with online-only editions, e-newsletters, and a website.

He installed a stellar board of editorial advisors from across the United States and the world and inspired them to provide the insightful commentaries that have so enhanced our pages.

As managing editor, I would personally like to thank Dr. Andros for his commitment, professionalism, and friendship throughout this time.

Dr. Andros will be succeeded by Dr. Russell Samson, who will begin his medical editor duties with the August print edition of Vascular Specialist.

Mark Lesney

Managing Editor, Vascular Specialist

mlesney@frontlinemedcom.com