Terror, Terroir


I am trying to avoid dying while driving around in a bulletproof car avoiding mosquitoes and admiring bad graffiti. I have never experienced this trifecta of terror or terroir. Having traveled 4778 miles for this experience makes the event so much more meaningful. What is more of the threat: bullets, mosquitoes or bad graffiti? Depends on your point of view.

You see there is a yellow fever alert in Sao Paulo Brazil. You see there is a need for bulletproof cars in São Paulo Brazil. You see there is a lot of bad graffiti in Sao Paulo Brazil. I am in São Paulo Brazil. Didn’t make it here last year, the case of the missing visa which was well documented in last year’s VEIN magazine. But I am here now avoiding bullets, mosquitoes, and graffiti.Mosquito

I am at the Science III Meeting. Last year no one told me about the need for a visa. This year no one told me about the yellow fever alert. And I guess it was assumed that I knew bulletproof cars are de riguer in Sao Paulo. And the bad graffiti? Why even mention it when there are bigger things you could die from. Bad graffiti really only affects one’s quality of life but it doesn’t usually kill you. Bullets and yellow fever can.

Terror and Terroir. They sort of melded together as I sat in the car that picked me up from the airport that services São Paulo, not even in São Paulo. Even the airport doesn’t want to be there. We all know what terror is. Terroir is a type of melding and melting of local, indigenous, environmental factors that give a wine or food their unique properties. It is a positive term.

Triple cream cheese from Normandy, FranceI was experiencing both terror and terroir as I was being driven from the airport to my final resting place, the hotel. The terroir I sought was that similar to the experience of eating local cheeses in Normandy, France. Especially the fabled triple crème. There are not many cheeses left in Normandy that are infused with the local terroir of the region. The elusive triple crème, Brillat-Savarin may still exist but confirmation is still debated according to local Normandy lore.

Created in the late 1800s by the Dubuc family, it is as elusive as understanding the Heisenberg Uncertainty Principle: one cannot know the exact speed and location of an atomic particle at exactly the same time. Perhaps this concept is only appreciated by those individuals who have read and understand Herman Hesse’s book, Magister Ludi: The Glass Bead Game.

I have tried to complete reading this esoteric, monumental work 3 times. Only to be confronted with the terror of the terroir he describes. Sometimes one needs to accept his limitations. This book is way beyond my intelligence.

It remains on my bookshelf as a reminder of what Billy Wilder the Hollywood producer once said in response to Morley Safer asking him, “Where are all the Academy Awards you received, they are not on your bookshelf?”. Wilder’s response, “If I need to see them every day it merely says to me: So what have you done lately?” Limitations.

In VEIN this issue we go beyond limitations and explore possibilities. The terror and terroir of vein disease are explored. The first possibility we explore is how can a mobile phone be used to better communicate and help patients? The mobile phone is ubiquitous even with our older patients. The Chatbots article by Carl Black et al. let’s us know what is out there and how this technology is being used to increase patient compliance. AI is invading the vein world in a good way. Read what they have created.

The limitations of in-person learning are described in an article by Julie Cardoso and ….. Getting on a flight to some distant destination, paying for a hotel and taking time away from work is not always the best learning method, sometimes alternatives can be used. They have utilized online learning in an efficient and innovative way. Read about what’s here now and what the possibilities are. No limitations.

Our entire issue is patient-centric. It is rare that we include patient stories for the obvious reason that before and after pictures are silly. Do you really think that some device company is going to put a before and after picture in their brochure that shows poor results? On the contrary, we have 2 patient stories that bring us closer to a better understanding of the terror patients encounter when they have a problem that goes unrecognized.

The terroir of vein disease is highlighted in the articles having to do with past and future meetings. We have articles addressing different aspects of venous terroir: AVF, NCVH, VIVA, and SIR. They come from different outlooks but the goal of all is physician education and optimal patient care. Pay special attention to SIR’s diversity program. A laudable, conscious effort.

Finally, we have articles addressing some niche issues: Thom Rooke’s Bodybuilding and Veins. This to me takes a look at the potential benefit of bulging, visible veins as only Thom can. Clearly one of the more obtuse but intense thinkers we have. The benefits of compression are well known in vein disease and anything that can make it more effective is welcome. Juzo has a relatively straightforward, simple way of evaluating adequate compression in patients.

Lastly, to answer some questions about “How are we doing?”, we have 2 articles addressing the use of data and how it can be leveraged to change vein specialists treatment paradigm and increase appropriate patient care. ACP’s article regarding their Improving Wisely campaign will help practitioners see how they measure up to peers. Hopefully, the outliers will think, “Gee, maybe I should rethink what I am doing?”

Our cover article, the roundtable discussion entitled: Big Data, Little Data, More Data with Jack Cronenwett, Marlin Schul, Jens Jorgensen, and myself as moderator explores how data can lead to better, appropriate patient care. It also moves the discussion into the area of collaboration between the various societies that harbor data.

There is a terror about overuse and abuse about the terroir of overuse and abuse that is being fomented in the vein world. It needs to be vetted and discussed. The outliers need to be identified and dealt with. Without cover. Enough is enough. Data will be our divine salvation. No shelter.

Graffiti in Sao Paulo, Brazil

We do not shelter our readers from the reality of the vein world. We bring you the terroir of our specialty. We want you to experience and embrace the terroir without any terror. Enjoy the vein world. I have led my life thus far not concerned with yellow fever, mosquitoes, bullets or graffiti. I have lived a sheltered life. Sitting in a bulletproof car at night avoiding mosquitoes and staring at bad graffiti in São Paulo is not the scenario I expected.


As Vo Nguyen Giap a compatriot of Ho Chi Minh when asked about his strategy to defeat the French in Vietnam said, “My armies will be everywhere and nowhere”. He had studied the theories of Napoleon, Sun Tzu and Lawrence of Arabia as to how to fight a war. By the way, he won. The French left.

To avoid bullets, mosquitoes, and graffiti in Sao Paulo, I decided to take Vo Nguyen Giap’s advice and be everywhere and nowhere to avoid the bullets, mosquitoes and graffiti. They never got me. Was the terroir worth the terror? Hmm…