This extensive interview which appears in the Spring/Summer 2020 issue of Vein Magazine appears here in two parts:
Be sure to check out part 1: Veith on VEITHsymposium
In this second part entitled "Embracing the New in an Imperfect World" -- Steve Elias and Frank Veith discuss current themes in their beliefs and explore the topics of education, quality of care and what's next for the field of vascular surgery.
by Dr. Steve Elias
Embracing the New in an Imperfect World
SE: I started off this discussion quoting famed music critic David Fick who postulated there are three essential commandments: “respect the elders, embrace the new, and encourage the improbable and impractical.” I think it is important for people in areas of influence, those who are respected, to not be dogmatic and pedantic. It is the responsibility of older people to encourage new people even though it may sound crazy. Because some of those things may turn out to be good.
FV: Right. This quote basically summarizes my attitude about professional life in general. You say that the elders should embrace these ideas. However, more often than not they don’t.
FV: The bottom line is that the elders, the so-called leaders of our specialty, even in vascular surgery, are just the opposite of what your theme and my thinking are. In general, the responsibility of leaders in a specialty is to promote and represent the needs of the specialty. That’s not what happens. Invariably, the majority of the time, the leaders promote what is good for them as individuals, self-aggrandizement, maintaining the status quo, rising in the world of prestige within surgery or radiology, whatever it is. It gets to one of my current themes and that is it’s an imperfect world. It’s imperfect because human nature is imperfect.
The idea of self-interest ruling most people’s motivation is really not a good thing, but it’s the way it is. It’s part of the imperfect world, whether it’s grasping for money, status, prestige, whatever, power. I gave a Homans Lecture a couple of years ago where I stated that surgery and medicine are caught up in this imperfect world where the lawyers don’t care whether what they’re suing for is right or wrong, they just want the money. Businessmen want the money. The politicians are all in some way or another corrupt, even in the United States. They are guided by their donations and often don’t represent what is good for the country. Of course, there are exceptions, but sadly not often in my opinion.
SE: Of course. Unfortunately, sooner or later it all comes down to money.
FV: In medicine, the imperfection is that even the leaders of medicine, the deans, the chairmen of departments, the presidents of hospitals, they may talk about the quality of what’s done in their institution, but most of the time they’re really driven by dollars, RVUs, and DRGs. Money, unfortunately, in our society is far too important in determining behavior.
It has always been that way. Wars start because of the egos, the false ego motivations of their leaders. It’s tragic. Look at our politics today. If we’re united as a country, we’d be so much better off than this ridiculous grabbing for power. It’s human nature.
SE: In the vein world, people were told, as you were told from an arterial viewpoint, this will never work. Radiofrequency, laser, this is crazy. You have to open up the groin. You need to ligate all the branches. For years, those in authority put down those who were coming up. Though that occurred, there still was progress and there continues to be progress. I do think though, in both the arterial and venous side of things, now we have a little change in attitude. I think those people who are in charge are not dismissive of anything new now. It’s a little more, hey, let’s take a look. Am I wrong?
FV: There’s a little bit of what you say I agree with, but I fear you’re mostly wrong. For example, we still advocate using PTFE grafts as bypasses to tibial arteries, which throughout the vascular world is regarded as an out of favor procedure even though it was described by me in 1978. It’s a no, no. I can tell because my granddaughter is applying for zero and five vascular residencies. She’s working with one of my ex-trainees on pulling together our recent data on PTFE tibial bypasses. When she goes to interviews and mentions that’s what she’s working on, she gets told that this is a ridiculous procedure. It turns out that we have patients that have survived with patent PTFE tibial bypasses for up to 13 years. Obviously, no other procedure was possible and the patients have had their limbs salvaged. We’re collecting that data because we think even now the standard of care is to dismiss these PTFE tibial bypasses as a possible limb salvage procedure. I think there’s still an element of resistance. Why are we able to get these long-term patencies with this far out procedure? Well, I guess there’s a way to do it right and there’s a way not to do it right.
There are certain little tricks that will make it work. If you don’t use those tricks, it doesn’t work. If you do a tibial anastomosis like you do an aortic anastomosis, it doesn’t work right. If you do it with great care, et cetera, under certain conditions, it can work. I think there’s a faddism in medicine and surgery that isn’t always right, but that most people think is right. One of the perfect examples is in situ bypasses as an arterial procedure. It used to be thought if you can’t do in situ bypass in a patient with a threatened limb, that amputation was the only alternative. Well, that’s obviously not true. It’s not true now and that’s accepted. There was a time when the faddism for in situ bypasses was controlling. I think it goes back to human nature. There’s always a resistance to change. Certainly, with endovascular the change was very threatening to people, and therefore the resistance was really quite massive.
SE: The issue of quality of life improvement now both on the arterial and the venous side and just in general in medical interventions is really something that we are becoming so much more aware of. Even I remember my fellowship and reading about patency rates of bypasses or whatever, no one spoke about after you did the bypass, did the patient go back to their job? Were they able to take care of their spouse? It always was about did we save the leg? Did we save the life?
In general, if you do nothing about venous disease in a particular patient, nothing bad is going to happen. It’s not like they’re going to wake up the next day dead. I think quality of life is a theme that insurers, Medicare, and journals should think about. Should quality of life be our primary outcome when we do any venous or arterial intervention?
FV: It should be one of the primary outcomes, certainly with limb-salvage. I used to be criticized, Why not just do a quick, easy amputation? Well, there are no quick, easy major amputations. Maybe a young guy who loses his leg below the knee on the battlefield can be restored to a fairly normal life.
Older patients with arteriosclerosis, if they lose a leg through a major amputation, certainly above the knee, and probably below the knee, they do not regain an ambulatory status. For me, the question of whether it was worthwhile to do limb-salvage procedures was a no brainer and yet I was criticized. Critics questioned putting a patient through three or four-stage procedures to end up with an amputation. Well, the bottom line was most of the procedures we did worked and saved the leg, even if it was an imperfect limb with a few toes or transmetatarsal or even less of a foot. They could stay at home and be taken care of there. They could transfer from bed to the wheelchair. They were a lot better off with two legs than one leg, and even with one leg than no legs.
SE: Right. I think from the arterial side, you might take it relatively lightly amputating one leg. In general, you know if one leg is going, they may wind up pretty soon with the second.
FV: 45 percent end up with the second leg threatened. Going back to my early days, the standard treatment of all CLI, limb-threatening ischemia, gangrene, ulceration, or severe rest pain was an amputation. If a patient had one leg off, taking the second leg off was the standard of care. We, however, felt if a patient had one leg off already, that second leg was even more important to save because it allowed the patient to be taken care of at home. We went flat out to save everybody’s leg, which was a complete change from the standard of care at the time. For years, I was treated as a maverick.
Education and Quality of Care
SE: How do you get a good quality of care when people enter a specialty, vein care for instance, from multispecialty areas where they have been trained in something else — primary care, dermatology, general surgery, interventionional cardiology. How do you feel we can get a standard that wherever you have come from you need to enter that circle of vein care and show that you have the basics?
FV: That’s a tough one. There’s competition within medicine. There’s no question about competition for patients, competition for dollars, competition for space in an institution. Competition is part of life. When you talk about competition between specialists, it’s a reality because vascular lesions are fair game for just about any doctor. Putting aside that competitive nature, which was a big deal for me when I was in practice, from an educational point of view, there’s tremendous value in individuals from different disciplines all contributing to education. We’re trying to do that with our meeting.
About a third of our faculty is not vascular surgeons. They’re either cardiologists, radiologists, or even some neuroradiologists. From an educational point of view, there’s a great benefit to having multispecialty education. The same things that are valuable for vascular surgeons to learn are valuable for cardiologists treating non-cardiac vascular disease to learn and for interventional radiologists to learn. We help each other by having a multispecialty educational experience. The multispecialty idea can also determine standards for practice—again, trying to get away from the bias and turf issues that influence the other side of our personality.
Doing a better job for the patient is what it’s all about. Vascular surgeons can learn from cardiologists. VEITHsymposium is trying to have an alliance with TCT, which is a cardiology group and meeting because they can teach us things that make us better doctors. Radial access, for example. The cardiologists are pros with that procedure for the heart and for the periphery as well. They have the skills and technology that we as vascular surgeons don’t have. Joining with them in an educational effort may seem like a traitor’s behavior to other vascular surgeons, but it makes us as vascular surgeons better doctors, and the collaboration makes the cardiologists better doctors because they learn what procedures not to do from vascular surgeons who tend to be more conservative.
When I was at Montefiore, we learned a lot from our interventional radiology colleagues because we didn’t know much about catheter or guidewire technology. By making them partners for the purpose of learning how to do the procedures better, we learned from each other.
SE: Both you and I didn’t grow up being trained in endovascular procedures; we either learned it on our own or learned it from our friends who were interventional radiologists, and then hopefully we were good enough. We got better on our own. I think you’re right; we need to recognize what each specialty brings to the care of a particular disease and instead of putting those other people down, let’s all contribute together and learn from each other, as you say. Let’s talk about abuse in the vascular world. There is abuse of procedures by certain people.
FV: Lots of people of all specialties.
SE: Exactly. It’s the nature of the beast as you have said. First of all, I want to ask you, why do people do something that’s not right or do something for the wrong reasons? Why have we failed in training to emphasize this or is it just nature and there’s nothing we can do about it?
FV: In general, the tendency in America is to grow wealth. Whether you’re on Wall Street or a politician, you strive to make your children rich. There’s a lot of imperfection in the world because human nature is imperfect. In medicine, there’s a tendency to do procedures and to rationalize the doing of them because they augment one’s income. That is driving a lot of the outpatient facilities because the amount of money that one can generate is great and because the oversight in an outpatient facility is nil. It goes on in preeminent major institutions as well, where the head of the institution tells the workers, the doctors, the providers to accumulate RVUs, get more patients into the hospital and that motivation sometimes comes from the highest level.
I do have one possible solution and that is to educate patients in the nature and righteous requirements for treatment in vascular disease. Vascular surgery is really an unrecognized, unappreciated specialty. Why? For one thing, because we’re subordinate, which is controversial even now. I believe we need to educate the public—they go online, they read. We need to educate the public that not every varicose vein needs to be treated. Not every pain on walking or claudication needs to be treated. Some conditions are benign. Not every asymptomatic carotid needs to be intervened upon. If you educate the public, they will seek out specialists who are ethical and aren’t inclined to do a procedure on every patient they see.
The Society for Vascular Surgery (SVS) talks about educating referring doctors. That’s important because most of them don’t know beans about vascular disease. It’s more important though to educate the public as to what we do, what we should be doing, what we can do, and what we shouldn’t be doing. Just as an educated public is the answer to corruption in our government, an educated public is an answer to all these unnecessary procedures. A doctor tells a patient, You have a blockage in your carotid, it should be fixed. The patient says, Oh God, I have a blockage in my carotid, it should be fixed. Well, in many instances, it shouldn’t be fixed.
SE: Right. As the population ages and those people who are younger become older, there is a greater percentage of people in the population that are very comfortable with gathering information online. I think we have an opportunity now to jump into this early rather than waiting until we missed the boat. More than 50 percent of the people, if they’re going to go see Frank Veith or Steve Elias as a doctor, at least half the people have already Googled us, see what we’re doing, see where our specialties are, what reviews we’ve received, et cetera. As you said, we should have good places where patients can go to get information.
FV: My plea is that the SVS and other vascular societies that are supposed to represent us as vascular surgeons should make a major PR effort to the public. It’s going to cost millions of dollars. We should pay for it. Why? Because vascular surgeons are totally unrecognized and unappreciated as experts, and the public needs to know. How are you going to tell them? You pay millions of dollars, which we should contribute to having a PR campaign which tells the public what a vascular surgeon is, how they’re trained, what they do, and how the disease should and shouldn’t be treated. The vascular societies have money in their treasuries. This should be one of their prime objectives. I don’t believe that it is.
SE: No, it probably is not, but it would be a great investment in the future of vascular surgeons.
FV: Advertising works. We need to make it known to the public what it is that vascular surgeons do. If I go to a cocktail party and people ask me what I do or what I did, I’d say, I’m a vascular surgeon. They say, Oh, you’re a heart doctor.
SE: Right, that’s what they always say.
FV: Or they’d say, You operate on varicose veins. I’d say, Yes, I do operate on varicose veins, but I do many other things that are also substantively improving the quality of life. Nobody knows that. As a result, one of the reasons that we can lose our patients to other specialists is because nobody realizes what vascular surgeons do, that we’re the doctors who take care of all sorts of vascular disease in terms of conservative treatment, indications for operation, interventional treatment, and open surgery when needed. Nobody knows about us.
Our society is raising money for our PAC, the public action committee. We should contribute to that, but it’s far more important that we contribute money as a specialty to informing the public about how we vascular surgeons care for those with vascular disease. We haven’t done that.
A Look Ahead
SE: What is the biggest issue involving patient care from the artery side? What disease or type of problem have we not solved yet?
FV: I believe that the next big advances will come in medical treatment, which I think is the right way to go. What has happened with the statins, with the PCSK-9 inhibitors is awesome. It threatens vascular surgeons and proceduralists because some of their procedures won’t be necessary.
Aneurysms are another area—we’ll ultimately be able to slow the development of aneurysms. Medical treatment for prevention and treatment of vascular diseases is a huge area for advancement.
SE: On the vein side?
FV: Better and simpler interventions for veins. I’ve been wrong about varicose veins in the past. I used to say nobody ever dies from varicose veins. You have all these big veins, who cares? Wear long pants.
But in our modern world where beauty and cosmetic stuff are important, I think people deserve to be treated. And there will be less invasive, safer, simpler ways to do it. And I’m all for them. Also, better treatment for edema and venous ulcers.
SE: That’s what I think. In the vein world, it is both extremes we need to get better at. One extreme, the end-stage disease, like you said. Ulcers things like that. We got to get better with that because it’s a huge burden on the patient and society. And we haven’t done that good of a job in decreasing the recurrence of ulcers or healing ulcers that well. And then, in the opposite direction, we’re doing the same thing today we’ve been doing forever to treat cosmetic spider veins.
FV: There have to be better ways.
SE: Technology as we all know just keeps getting better and better. No matter what age you are, no matter where you are in your training, you need to look to new things and you need to also encourage things that don’t make sense because they may wind up making sense.
FV: And things that didn't work in the past. In other words, the first airplanes all crashed.
When I have a young fellow or trainee ask what area to go into, I tell them to go into something that nobody else wants, that doesn’t seem attractive or that hasn’t worked. Everybody wants to do fenestrated and branched endografts. They are for a select few, and the leaders are already defined. There are 20 doctors in the world that are really experts in fenestrated and branched grafts. They are not going to be replaced. So, my advice is to go into something that hasn’t worked and try and make it work.
Critical limb ischemia is a huge area of opportunity. I tell young surgeons to go somewhere and learn all the endo techniques from the cardiologists or angiologists like Ferraresi or Schmidt. Learn the vascular surgery part from somebody who is still doing these procedures well. Because today, few can do these distal bypasses that we once did because they don’t do enough of them. You have to do 100, 200 to get good at it. My past trainees are still very good at them because they did more than 100 during their fellowship.
But when I go to other places I see critical limb ischemia is often not well handled by vascular surgeons because they’re all interested in doing 100 other things.
If we had our own specialty board we could have sub-specialization in venous disease, we could have sub-specialization in critical limb ischemia, we could have sub-specialization in open aneurysm repair, which nobody is any good at anymore because they don’t do adequate numbers of such cases. Those are areas I think our Society for Vascular Surgery needs to address, but I do not know whether they will or not.
SE: All right, lastly, I give you the final word. Anything we did not discuss that you want to make sure everybody who’s going to read this knows about?
FV: Vascular surgery is a great area of opportunity and we’re unrecognized as a specialty. We’re unappreciated. When somebody gets in trouble in the operating room, we’re the people who are called to put out the fire and stop the bleeding. Also, we have great value in providing care in serious vascular disease and in making patients better. But as a specialty in the hierarchy of medicine, we’re totally unrecognized and that is disappointing. It’s sad, but that’s the way it is. Having an extensive public education program that touts vascular surgery is something that is worth doing because so many people have vascular disease and the lesions are fair game for anybody who wants to address them. And if they’re good at it, they should be addressing them. But if they’re not good at it, they shouldn’t be doing it as an adjunct to another specialty.
Vascular surgeons should be able to promote their specialty. And yet, we haven’t done that well. I’ve talked to some of the SVS leaders and they basically have said what’s more important is educating referring physicians. Here is why that is not enough. I have a neighbor. When he wanted my advice because he was having some cardiac symptoms, I told him he should go and see a cardiologist, and I gave him the name of a good cardiologist to see. He did not take my advice, but went on the internet, read about his problem and found another cardiologist to go to. That shows how important the internet is and how we must educate the public about vascular diseases and what vascular surgeons do. Patients so often make the decision as to what doctor they go to. Therefore we need to educate them about our specialty.
SE: Make sure the education is right. So, I think that’s a good thing to end on. The correct education, not just of doctors but of patients. I want to thank you Frank, it was an enlightened pleasure for me. I hope you enjoyed it.