Early Sunday Morning
by Steve Elias, MD, FACS
Edward Hopper knew. “Early Sunday Morning” has nothing happening (Fig. A). No movement, no action, no people.
But it is early on a Sunday morning and a lot could be happening. That is the advantage of nothing happening, it encourages us to make something happen. It begs for something to happen. We are free to let our mind make something from nothing. This painting subliminally asks us to supply the narrative, our own personal narrative. The painting becomes ours for the moment. What does this have to do with venous education? Perhaps absolutely nothing. I just like the painting. It is at the Whitney Museum in New York City.
Of course it has something to do with venous education, otherwise why waste time writing about it? Traditional venous education has been anything but “Early Sunday Morning”. Rather it has been more akin to what James McMurtry sings in the song “Painting By Numbers”:
Cause you’re painting by numbers, connecting the dots.
They don’t have to tell you, you don’t call the shots.
For the great majority of our education, annual society meetings, journals, textbooks, and non societal meetings (IVC, Veith etc.) serve our needs well. There is predictability and comfort like connecting the dots. However, different times require something more than business as usual. In light of recent changes in the economy, societal funding, physician free time and industry contribution rules, we need to look at a different picture, such as “Early Sunday Morning” that challenges us to have some new thoughts and create our own narrative. To this end we started at the American Venous Forum (AVF) meeting in February with a group of AVF members and posed many of the questions that I listed in the last issue of VEIN magazine. These members spoke as individuals who happen to be AVF members and not as official spokesmen for the AVF. The disclaimer has been stated; now to some of their thoughts.
Question 1: With limited time and limited resources and a busy practice, if a physician wants to remain current in his education but only wants to attend one meeting, what should he do?
MD #1 – This can be a problem. Much of the content may overlap at various meetings but each meeting has its own “personality”. We all know that the AVF meeting is different from an ACP meeting and from the IVC meeting.
MD #2 – Pick one meeting per year and alternate between meetings over a two to three year cycle. Some new information comes out each year but a lot of that can be obtained from journals.
MD #3 – What about those that do not attend but want to access papers and talks presented at a meeting? I think ACP, Veith and the IVC have some of this data online. We at AVF don’t have that yet. I am not sure if you needed to attend the meeting or you can pay a separate fee to get it.
MD #4 – I think you had to have attended the meeting to get the information. How about purchasing a thumb drive or online information even if you didn’t attend the meeting? This could be less expensive than going to the meeting but it would be a more efficient use of a physician’s time and money.
MD #5 – Societies could then disseminate information to non attendees, but do you think this would have a big impact on meeting attendance?
MD #3 – I don’t think so. More importantly, a larger audience could be reached. It may even bring in more members to AVF if you make it a requisite that non-members need to apply for membership before they can get the meeting presentations.
Summary from Elias – A lot of this is already being done by other societies. We don’t know to what success. As our time becomes more important and the economy continues as is, this may become more popular. A huge number of patients and physicians get information online; these ideas are another piece in that big puzzle. You could even purchase part of a meeting. For instance, what if you could not attend the “Great Debates” segment of the post graduate course this year due to time constraints, you could purchase that segment at a reduced price. A lot of that segment was very interesting. Members could get educated on their own time at home, in the car, etc.
Question 2: What percentage of our time, efforts and money should we spend educating physicians who have been in practice 20-30 years and now want to get involved in treating vein disease? Contrast this with the time we should spend educating fellows, residents, medical students and younger practitioners. Assume we have limited resources, especially with increasing restrictions on industry.
MD #2 – Investing in the long term future of younger surgeons gives us a better “return on investment”. Having said that, our society probably should not dismiss that 54 year old who wants to now manage venous disease. It is my impression though that the majority of our new AVF members are younger and come from an academic training background.
MD #4 – I agree. It seems that other societies are enrolling a greater percentage of older established practitioners who now want to treat vein disease.
MD #5– Perhaps our role and focus at AVF should be on younger academically trained surgeons who can continue the work of our founding members. Maybe we shouldn’t try to be all things to all physicians. We should narrow our focus.
MD #6 – Steve, that is what you have done in terms of the Fellows Course in Venous Disease.
Summary from Elias – That is true. The course is designed to serve a specific need in a defined population. Industry has been very supportive because they believe in education, an educational objective that will hold true over time. You all realize that the future of venous disease care and our society is not just dependent on gross numbers but also on the long term commitment of younger academically oriented vein specialists.
Question 3: What do you think is the most underserved population by AVF in 2009?
MD #4 – Medical students and residents.
MD #6 – You are right. This will become even more important as many vascular training programs become integrated and medical students will be making career decisions much earlier than now.
MD #2 – Talk about investing time, effort and money early. This certainly could give us a larger base. Remember we will not be the only specialty or society vying for medical student commitment
Question 4: As a follow up, should the AVF be more aggressive in terms of educational opportunities for medical students and residents and bring them to our meetings? You know the ACP Foundation supports a significant number of medical students/residents to attend their meeting.
MD #1 – As a medical student, I was fortunate to have a surgical attending bring me to an American College of Surgeons meeting. This had a major influence on me choosing surgery as a career.
MD #3 – Perhaps we should consider allowing AVF members to bring a medical student or resident either for free or at a reduced fee.
MD #5 – Medicine still comes down to where it started: you spent time with someone, you got to know what they did, you liked it, you then did it. Our training is really one continuous mentoring process.
MD #4- At our annual meeting, vascular fellows do attend but this is usually if they are presenting a paper. We should have more attend and have a luncheon or reception for them with some of the leaders in the field. The American College of Surgeons does that.
MD #2 – This would reinforce what the Fellows Course in Venous Disease does. It is their time to discuss their needs.
Summary from Elias – Great thoughts. A narrow focus on our future will serve us best in the long run. You all have expressed strong feelings that personal mentoring and small groups go a long pay to fulfill the goal of venous education.
Question 4: Phlebology Boards – an educational opportunity or a waste of time? Let’s not answer this from the “political” aspect but rather from an educational viewpoint.
MD #6 - From a purely educational perspective, the Phlebology Boards do encompass some basic knowledge of venous disease. Passing them doesn’t necessarily mean one is “credentialed” to practice phlebology.
MD #4 - I don’t think that was ever the intent.
MD #3 - This may at best be an educational opportunity for non vascular surgeons. It is a way of standardizing a knowledge base.
MD #2 – It can fill a void that traditional training programs can’t at the moment under their current curriculums. As a society, the AVF has already identified needs even within vascular fellowship training regarding venous disease.
MD #5 – I don’t think the solution for vascular fellows is the Phlebology Boards. We should and are focusing our attention on improving fellowship and resident training in venous disease.
MD #1 – Perhaps Tom Wakefield at the University of Michigan has the answer. He had family practitioners that were interested in practicing phlebology take the boards. He felt comfortable that they now had a good knowledge base in phlebology.
Question 5: As I have said before, we need “to hold the monkeys” such as when you order a drink. Don’t give me cherries, umbrellas, or plastic monkeys; just give me the drink. Shouldn’t we work together with other societies and industry to hold our monkeys and cut out unnecessary or duplicated expense and effort when developing our educational goals?
MD #2 – There is some overlap between many society meetings. A lot of the workshops and postgraduate courses seem to cover similar topics in similar ways.
MD #5 – We could benefit from joint meetings that cover certain topics that members from two or three societies can attend. This would cut each society’s cost of education.
MD #1 – It would also cut industry costs. This is becoming more important as travel costs increase and guidelines come out restricting industry’s role in education.
Summary from Elias – This has been my suggestion: Have disease specific meetings sponsored by a few societies. For example, “The Sclerotherapy Meeting” or “The Venous Ulcer Meeting”. The annual meetings of each separate society could then be directed towards more scientific papers and the business of that society. Remember, we have more limits on our resources now due to many factors: industry restrictions, time constraints, a poor economy etc. Cooperation can cut costs, egos can increase costs.
We’ve looked at venous education from the “Early Sunday Morning” perspective and filled in some of our own narrative. We should be able to make a better something out of almost anything if we work together. Marcel Duchamp knew that all he needed was a bicycle wheel and a stool (Fig. B) to make something. We should strive as venous societies to take our existing resources to develop new ways of looking at venous education. Ways which build a very solid future. In future issues, we will hear from members of industry and from members of the American College of Phlebology to gain their views on this topic.