Russell H. Samson, MD

This marks my last editorial as medical editor of Vascular Specialist. It has been more than a privilege to have been offered this position. After all, how lucky am I to be provided with an opportunity to rant about things that annoy me or laugh in print at some of the absurdities of our professional life.

Before I put down my pen, or should I more correctly say close my word processor, I would like to add an epithet that I have yet to coin publicly. I am suggesting that we lay to rest the term “Endoleak” and replace it with “Endofill.”

At the outset, I must commend doctors White, Yu, and May for recognizing and publicizing this important potential complication of aortic endografts (White GH, Yu W, May J., J Endovasc Surg. 1996.3:124-5). However, the term “Endoleak,” which they used to describe the continuation of free-flowing blood within the aneurysm sac, has created confusion amongst nonvascular surgeons and the lay public. Often such misunderstanding has resulted in deleterious consequences. I’m sure many vascular surgeons have been summoned to the emergency room after an emergency physician incorrectly interpreted a radiologist’s report of an Endoleak as a life-threatening rupture. Others may have had to explain to a referring physician that an Endoleak does not imply the vascular surgeon had performed an inadequate procedure. Further, patients have absolutely no concept of the meaning of this term and are often frightened when they learn they have an Endoleak. So prior to consenting them for an endograft, I always bring out a plastic model of an aneurysm with an endograft in place and go through a time-consuming explanation. Seldom do they remember this account. When I see patients back who have an Endoleak, I once again find myself placating terrified individuals who think they are about to die.

So that is why we should replace the alarming “Endoleak” with the less disturbing and more descriptive “Endofill.” After all, there is no “leak” but rather a “filling” of the sac with blood. Certainly, a Type 1 “Endofill” is still dangerous, but I doubt the uninitiated would consider it an immediate problem. “Endofill” may still take some explaining, but it is less likely to cause patient anxiety or an overzealous panic in a referring physician.

Let’s face it. Even the term “leak” has led to many errors in the treatment of patients with an abdominal aortic aneurysm. For example, it is not unusual that an emergency room physician, hospitalist, or internist will triage a “leaking” aneurysm as nonurgent because it has not “ruptured.”

I think we should ban “leaking” and “leak” from the medical vernacular. Let Washington politicians use the words. Rather, vascular surgeons and radiologists should describe exactly what is happening when a limited amount of blood escapes the wall of an aneurysm by using the term “contained rupture.” I’m sure that will get the nonvascular surgeon's attention!

I’m hopeful that you will also remember some of my other epithets and aphorisms from columns. Such as “Vascular surgeons Operate, Medicate and Dilate,” that TLR (Target Lesion Revascularization) should really be “The Least Relevant.” That a nervous surgeon will not be proficient so “The most important heart in the Operating room is the surgeon’s.” That vascular surgeons are all “Knights of the rectangular table,” and that rapacious doctors are committing “White Coat Crime.” That atheroembolism to the buttocks should be called “Trash Can.” That we should always ask for long-term outcomes before accepting new technologies otherwise, we would be encouraging “Premature congratulation.” That Societies that refuse to rein in their members by refusing to use the word “inappropriate” are being “Anti-semantic.” Further, that shared decision making is essential but that “Insecurity is the price patients must pay for sharing in the decision-making process.” And, of course, my request that we all join the SOS, the “Save Our Saphenous” society.

I am also hopeful that, with time, my exhortations will aid Vascular Surgery in getting the recognition that it deserves. I have suggested many ways we can expedite this goal including possibly changing the name of the Society to The American College of Vascular Surgery and offering members the opportunity to refer to themselves as Fellows of that College. I have encouraged all who are trying to achieve a separate Residency Review Committee, and I fully support an independent American Board of Vascular Surgery.

Over the last 5 years, I have penned almost all that I believe needs to be said about vascular surgery, vascular surgeons, our patients, and the Society for Vascular Surgery. However, although my contract still allows one more year as medical editor, I felt it was time for new insights from a new generation of surgeons.

It is with great pleasure, therefore, that I pass the reins to Malachi Sheahan III, MD. Vascular Specialist has become the primary news source for our Society, and its educational articles and news items offer learning experiences not found in peer-reviewed journals. I encourage all to submit interesting news items for print, add some unusual Tips and Tricks, write letters to the editor, and tell us about your accomplishments inside and out of vascular surgery.

Please also volunteer to write Point/Counter Point articles. Vascular Specialist is your resource, and it’s not only in print but also in all forms of electronic and social media. It is up to you to make sure that it continues to thrive as a valuable resource for all our members.

I want to publicly thank the Associate Editors for their many contributions. This magazine would not be the same without their insightful comments. However, in the background is the actual “hero,” Mark Lesney. Mark has been the editor who sends Mal and me news items to review, urges us to be punctual, and is responsible for putting Vascular Specialist together. He works tirelessly under the pressure of producing a monthly periodical. Vascular Specialist is indebted to his efforts.

Finally, I want to thank you all so much for bearing with my rantings these last few years. Your letters and emails of appreciation have been an inspiration. 

This marks my last editorial as medical editor of Vascular Specialist. It has been more than a privilege to have been offered this position. After all, how lucky am I to be provided with an opportunity to rant about things that annoy me or laugh in print at some of the absurdities of our professional life.

Before I put down my pen, or should I more correctly say close my word processor, I would like to add an epithet that I have yet to coin publicly. I am suggesting that we lay to rest the term “Endoleak” and replace it with “Endofill.”

At the outset, I must commend doctors White, Yu, and May for recognizing and publicizing this important potential complication of aortic endografts (White GH, Yu W, May J., J Endovasc Surg. 1996.3:124-5). However, the term “Endoleak,” which they used to describe the continuation of free-flowing blood within the aneurysm sac, has created confusion amongst nonvascular surgeons and the lay public. Often such misunderstanding has resulted in deleterious consequences. I’m sure many vascular surgeons have been summoned to the emergency room after an emergency physician incorrectly interpreted a radiologist’s report of an Endoleak as a life-threatening rupture. Others may have had to explain to a referring physician that an Endoleak does not imply the vascular surgeon had performed an inadequate procedure. Further, patients have absolutely no concept of the meaning of this term and are often frightened when they learn they have an Endoleak. So prior to consenting them for an endograft, I always bring out a plastic model of an aneurysm with an endograft in place and go through a time-consuming explanation. Seldom do they remember this account. When I see patients back who have an Endoleak, I once again find myself placating terrified individuals who think they are about to die.

So that is why we should replace the alarming “Endoleak” with the less disturbing and more descriptive “Endofill.” After all, there is no “leak” but rather a “filling” of the sac with blood. Certainly, a Type 1 “Endofill” is still dangerous, but I doubt the uninitiated would consider it an immediate problem. “Endofill” may still take some explaining, but it is less likely to cause patient anxiety or an overzealous panic in a referring physician.

Let’s face it. Even the term “leak” has led to many errors in the treatment of patients with an abdominal aortic aneurysm. For example, it is not unusual that an emergency room physician, hospitalist, or internist will triage a “leaking” aneurysm as nonurgent because it has not “ruptured.”

I think we should ban “leaking” and “leak” from the medical vernacular. Let Washington politicians use the words. Rather, vascular surgeons and radiologists should describe exactly what is happening when a limited amount of blood escapes the wall of an aneurysm by using the term “contained rupture.” I’m sure that will get the nonvascular surgeon's attention!

I’m hopeful that you will also remember some of my other epithets and aphorisms from columns. Such as “Vascular surgeons Operate, Medicate and Dilate,” that TLR (Target Lesion Revascularization) should really be “The Least Relevant.” That a nervous surgeon will not be proficient so “The most important heart in the Operating room is the surgeon’s.” That vascular surgeons are all “Knights of the rectangular table,” and that rapacious doctors are committing “White Coat Crime.” That atheroembolism to the buttocks should be called “Trash Can.” That we should always ask for long-term outcomes before accepting new technologies otherwise, we would be encouraging “Premature congratulation.” That Societies that refuse to rein in their members by refusing to use the word “inappropriate” are being “Anti-semantic.” Further, that shared decision making is essential but that “Insecurity is the price patients must pay for sharing in the decision-making process.” And, of course, my request that we all join the SOS, the “Save Our Saphenous” society.

I am also hopeful that, with time, my exhortations will aid Vascular Surgery in getting the recognition that it deserves. I have suggested many ways we can expedite this goal including possibly changing the name of the Society to The American College of Vascular Surgery and offering members the opportunity to refer to themselves as Fellows of that College. I have encouraged all who are trying to achieve a separate Residency Review Committee, and I fully support an independent American Board of Vascular Surgery.

Over the last 5 years, I have penned almost all that I believe needs to be said about vascular surgery, vascular surgeons, our patients, and the Society for Vascular Surgery. However, although my contract still allows one more year as medical editor, I felt it was time for new insights from a new generation of surgeons.

It is with great pleasure, therefore, that I pass the reins to Malachi Sheahan III, MD. Vascular Specialist has become the primary news source for our Society, and its educational articles and news items offer learning experiences not found in peer-reviewed journals. I encourage all to submit interesting news items for print, add some unusual Tips and Tricks, write letters to the editor, and tell us about your accomplishments inside and out of vascular surgery.

Please also volunteer to write Point/Counter Point articles. Vascular Specialist is your resource, and it’s not only in print but also in all forms of electronic and social media. It is up to you to make sure that it continues to thrive as a valuable resource for all our members.

I want to publicly thank the Associate Editors for their many contributions. This magazine would not be the same without their insightful comments. However, in the background is the actual “hero,” Mark Lesney. Mark has been the editor who sends Mal and me news items to review, urges us to be punctual, and is responsible for putting Vascular Specialist together. He works tirelessly under the pressure of producing a monthly periodical. Vascular Specialist is indebted to his efforts.

Finally, I want to thank you all so much for bearing with my rantings these last few years. Your letters and emails of appreciation have been an inspiration. 

This marks my last editorial as medical editor of Vascular Specialist. It has been more than a privilege to have been offered this position. After all, how lucky am I to be provided with an opportunity to rant about things that annoy me or laugh in print at some of the absurdities of our professional life.

Before I put down my pen, or should I more correctly say close my word processor, I would like to add an epithet that I have yet to coin publicly. I am suggesting that we lay to rest the term “Endoleak” and replace it with “Endofill.”

At the outset, I must commend doctors White, Yu, and May for recognizing and publicizing this important potential complication of aortic endografts (White GH, Yu W, May J., J Endovasc Surg. 1996.3:124-5). However, the term “Endoleak,” which they used to describe the continuation of free-flowing blood within the aneurysm sac, has created confusion amongst nonvascular surgeons and the lay public. Often such misunderstanding has resulted in deleterious consequences. I’m sure many vascular surgeons have been summoned to the emergency room after an emergency physician incorrectly interpreted a radiologist’s report of an Endoleak as a life-threatening rupture. Others may have had to explain to a referring physician that an Endoleak does not imply the vascular surgeon had performed an inadequate procedure. Further, patients have absolutely no concept of the meaning of this term and are often frightened when they learn they have an Endoleak. So prior to consenting them for an endograft, I always bring out a plastic model of an aneurysm with an endograft in place and go through a time-consuming explanation. Seldom do they remember this account. When I see patients back who have an Endoleak, I once again find myself placating terrified individuals who think they are about to die.

So that is why we should replace the alarming “Endoleak” with the less disturbing and more descriptive “Endofill.” After all, there is no “leak” but rather a “filling” of the sac with blood. Certainly, a Type 1 “Endofill” is still dangerous, but I doubt the uninitiated would consider it an immediate problem. “Endofill” may still take some explaining, but it is less likely to cause patient anxiety or an overzealous panic in a referring physician.

Let’s face it. Even the term “leak” has led to many errors in the treatment of patients with an abdominal aortic aneurysm. For example, it is not unusual that an emergency room physician, hospitalist, or internist will triage a “leaking” aneurysm as nonurgent because it has not “ruptured.”

I think we should ban “leaking” and “leak” from the medical vernacular. Let Washington politicians use the words. Rather, vascular surgeons and radiologists should describe exactly what is happening when a limited amount of blood escapes the wall of an aneurysm by using the term “contained rupture.” I’m sure that will get the nonvascular surgeon's attention!

I’m hopeful that you will also remember some of my other epithets and aphorisms from columns. Such as “Vascular surgeons Operate, Medicate and Dilate,” that TLR (Target Lesion Revascularization) should really be “The Least Relevant.” That a nervous surgeon will not be proficient so “The most important heart in the Operating room is the surgeon’s.” That vascular surgeons are all “Knights of the rectangular table,” and that rapacious doctors are committing “White Coat Crime.” That atheroembolism to the buttocks should be called “Trash Can.” That we should always ask for long-term outcomes before accepting new technologies otherwise, we would be encouraging “Premature congratulation.” That Societies that refuse to rein in their members by refusing to use the word “inappropriate” are being “Anti-semantic.” Further, that shared decision making is essential but that “Insecurity is the price patients must pay for sharing in the decision-making process.” And, of course, my request that we all join the SOS, the “Save Our Saphenous” society.

I am also hopeful that, with time, my exhortations will aid Vascular Surgery in getting the recognition that it deserves. I have suggested many ways we can expedite this goal including possibly changing the name of the Society to The American College of Vascular Surgery and offering members the opportunity to refer to themselves as Fellows of that College. I have encouraged all who are trying to achieve a separate Residency Review Committee, and I fully support an independent American Board of Vascular Surgery.

Over the last 5 years, I have penned almost all that I believe needs to be said about vascular surgery, vascular surgeons, our patients, and the Society for Vascular Surgery. However, although my contract still allows one more year as medical editor, I felt it was time for new insights from a new generation of surgeons.

It is with great pleasure, therefore, that I pass the reins to Malachi Sheahan III, MD. Vascular Specialist has become the primary news source for our Society, and its educational articles and news items offer learning experiences not found in peer-reviewed journals. I encourage all to submit interesting news items for print, add some unusual Tips and Tricks, write letters to the editor, and tell us about your accomplishments inside and out of vascular surgery.

Please also volunteer to write Point/Counter Point articles. Vascular Specialist is your resource, and it’s not only in print but also in all forms of electronic and social media. It is up to you to make sure that it continues to thrive as a valuable resource for all our members.

I want to publicly thank the Associate Editors for their many contributions. This magazine would not be the same without their insightful comments. However, in the background is the actual “hero,” Mark Lesney. Mark has been the editor who sends Mal and me news items to review, urges us to be punctual, and is responsible for putting Vascular Specialist together. He works tirelessly under the pressure of producing a monthly periodical. Vascular Specialist is indebted to his efforts.

Finally, I want to thank you all so much for bearing with my rantings these last few years. Your letters and emails of appreciation have been an inspiration. 

The day had gone very well. The vascular surgeon woke early excited for a morning in the OR and then an afternoon in the office. Driving to the hospital, he had planned out his day. A patient with a fempop at 7:30, an AV fistula at 10:30 am, a quick bite in the doctor’s lounge, and then to the office for two phlebectomies, a few new consults, as well as some returning patients.

Fortunately, he had purchased an advanced electronic medical record so that reviewing old records and inputting new data went smoothly. He had been on call for the local hospital’s ER, but he received no calls, so his day was not impacted. After a dinner with his wife, also a surgeon, he helped put their youngest baby to sleep, played with his older children, took the dog out for a walk, read the latest JVS and went to sleep. Despite being on call, the phone never rang, and he had an uninterrupted sleep.

Now, what really happened!

The vascular surgeon woke early in preparation for a day in the OR and office. Traffic slowed him down, but he still arrived at the hospital just before his 7:30 start time. He expected his patient to be on the table prepped and ready for the procedure. But the OR supervisor informed him that new regulations required him to personally mark the site of surgery, update the H&P, and date and time the consent.

He was nonplussed. He had marked the patient last night and had signed the consent too. His PA had dictated a three-page H&P that was in the chart. However, the patient was still in the holding room. The surgeon rushed over, marked the leg again, and completed the required documentation.

“Well,” he thought, “I’ll run upstairs, discharge my carotid from yesterday, and by the time that’s done and I’ve changed into scrubs, my patient will be ready.” Impatiently he waited 5 minutes for the elevator, but it never arrived. So he elected to run up 10 floors and across to the other side of the hospital where the administrators had inconveniently placed the postop vascular patients. The patient was eager to leave. The vascular surgeon dictated the discharge note and signed into the hospital electronic medical record.

But the software insisted that he had to comply with numerous “safety” regulations before signing off. These required reviewing every medication and all discharge instructions. The patient was on 15 drugs, and the surgeon was unfamiliar with most. After 10 minutes of unsuccessfully trying to enter the relevant orders, he called a medical student over to help.

The patient was going to a skilled nursing facility. This required completing two more electronic forms. The software stubbornly refused to close the discharge section till he assigned the appropriate ICD-10 codes. After a few more frustrating minutes he finally clicked the proper boxes and completed the discharge.
 

It was 8:15 by the time he made the skin incision. The case went smoothly. He relaxed a little knowing that he probably would not run too late for the rest of his day. Finishing ahead of schedule, he dictated the note, spoke to the patient’s family, and went to preop his AV fistula scheduled for 10:30. Then back to the wards to complete rounds.

The first two patients were uncomplicated. The third had a fever requiring multiple orders in the EMR. Then heated conversations with the pharmacist and head of infection control, since the EMR would not allow him to prescribe the antibiotic of his choice. Back across the entire length of the hospital to see a patient with renal failure. But she was in dialysis at another distant location in the hospital.

At 10:30 he ran down to the OR ready to scrub. Again, this patient was still in the holding area. The patient’s potassium was 5.6, and the anesthesiologist wanted to run another blood test. Then the nurse had to go on break. Now there was confusion about whether a room would be available as another surgeon had a bump case.

Ultimately, he started at 11:30. During the procedure, his beeper went off constantly. There were already two consults in the ER. The fistula took a mere 30 minutes, but he had waited 90 minutes since finishing the fempop.

“Medicare should pay me for the time between cases, and I’ll do the procedure for free” he complained to a colleague as he passed her on the way to the ER to see the consults.

He sent the patient with the DVT home, but the patient with the infected foot would require later debridement. He admitted her and booked the OR for after office hours.

By the time he got to the doctors’ lounge all that was left was a half-eaten pack of Doritos and burned coffee.

He thought he would have a brief respite driving to the office. Then his surgeon wife called him in the car asking him to field a call from their son’s school since she was stuck in the OR.

He arrived late to the office. The waiting room was filled with hostile-looking patients one of whom made a point of holding up her watch as if to reinforce his tardiness. There were already three additions to his schedule. Further, his nurse told him that there was some issue with the internet connection to the server. Thus, despite his expensive EMR, no records were available. She had informed the patients that there would be a “little” delay.

While they were waiting she brought in reams of documents that had come in the prior day and needed his signatures. He also used the time “productively” to answer emails. When the EMR was back online, he returned to his patients who by now were seething.

A patient brought in a CD of a CTA. He loaded it up on a computer, but the disc kept spinning relentlessly. Cursing, he loaded it on a second computer. The instructions were indecipherable. He could get a picture up but could not scroll through the images. The program froze. By the time he had evaluated the disc, he had wasted over 20 minutes. He was running even further behind.

The next patient was a second opinion from a physician in another state. She brought in over 200 pages of medical records describing a multitude of prior procedures. Politely he explained he would need to read them first and rescheduled her.

The ER called again with a patient with a cold leg. He canceled the rest of the office and snuck out through a back door, afraid to witness the consternation in the waiting room.

At the hospital, he argued briefly with the anesthesiologist who was reluctant to anesthetize the patient who had eaten 5 hours before. So the harried surgeon read some vascular labs, and visited a few less stable patients. Then back to the OR to revascularize the ER patient’s leg and later to debride the earlier patient’s foot.

He got home at 8:30 pm. His wife had also been delayed by a long surgery. They put the baby to bed. There was no time to play with the other children. The surgical couple barely had the energy left to microwave leftovers for dinner. He was too tired to take the dog out for its nocturnal pee. He went to his study, picked up the JVS, and fell asleep in his chair. He woke up with a start as he felt the dog urinate on his leg.

Exhausted he climbed into bed. It had been a good day, he told himself. After all the ER had not been too disruptive. He drifted off into a deep sleep. And then the phone rang. Ruptured AAA in the ER.

The day had gone very well. The vascular surgeon woke early excited for a morning in the OR and then an afternoon in the office. Driving to the hospital, he had planned out his day. A patient with a fempop at 7:30, an AV fistula at 10:30 am, a quick bite in the doctor’s lounge, and then to the office for two phlebectomies, a few new consults, as well as some returning patients.

Fortunately, he had purchased an advanced electronic medical record so that reviewing old records and inputting new data went smoothly. He had been on call for the local hospital’s ER, but he received no calls, so his day was not impacted. After a dinner with his wife, also a surgeon, he helped put their youngest baby to sleep, played with his older children, took the dog out for a walk, read the latest JVS and went to sleep. Despite being on call, the phone never rang, and he had an uninterrupted sleep.

Now, what really happened!

The vascular surgeon woke early in preparation for a day in the OR and office. Traffic slowed him down, but he still arrived at the hospital just before his 7:30 start time. He expected his patient to be on the table prepped and ready for the procedure. But the OR supervisor informed him that new regulations required him to personally mark the site of surgery, update the H&P, and date and time the consent.

He was nonplussed. He had marked the patient last night and had signed the consent too. His PA had dictated a three-page H&P that was in the chart. However, the patient was still in the holding room. The surgeon rushed over, marked the leg again, and completed the required documentation.

“Well,” he thought, “I’ll run upstairs, discharge my carotid from yesterday, and by the time that’s done and I’ve changed into scrubs, my patient will be ready.” Impatiently he waited 5 minutes for the elevator, but it never arrived. So he elected to run up 10 floors and across to the other side of the hospital where the administrators had inconveniently placed the postop vascular patients. The patient was eager to leave. The vascular surgeon dictated the discharge note and signed into the hospital electronic medical record.

But the software insisted that he had to comply with numerous “safety” regulations before signing off. These required reviewing every medication and all discharge instructions. The patient was on 15 drugs, and the surgeon was unfamiliar with most. After 10 minutes of unsuccessfully trying to enter the relevant orders, he called a medical student over to help.

The patient was going to a skilled nursing facility. This required completing two more electronic forms. The software stubbornly refused to close the discharge section till he assigned the appropriate ICD-10 codes. After a few more frustrating minutes he finally clicked the proper boxes and completed the discharge.
 

It was 8:15 by the time he made the skin incision. The case went smoothly. He relaxed a little knowing that he probably would not run too late for the rest of his day. Finishing ahead of schedule, he dictated the note, spoke to the patient’s family, and went to preop his AV fistula scheduled for 10:30. Then back to the wards to complete rounds.

The first two patients were uncomplicated. The third had a fever requiring multiple orders in the EMR. Then heated conversations with the pharmacist and head of infection control, since the EMR would not allow him to prescribe the antibiotic of his choice. Back across the entire length of the hospital to see a patient with renal failure. But she was in dialysis at another distant location in the hospital.

At 10:30 he ran down to the OR ready to scrub. Again, this patient was still in the holding area. The patient’s potassium was 5.6, and the anesthesiologist wanted to run another blood test. Then the nurse had to go on break. Now there was confusion about whether a room would be available as another surgeon had a bump case.

Ultimately, he started at 11:30. During the procedure, his beeper went off constantly. There were already two consults in the ER. The fistula took a mere 30 minutes, but he had waited 90 minutes since finishing the fempop.

“Medicare should pay me for the time between cases, and I’ll do the procedure for free” he complained to a colleague as he passed her on the way to the ER to see the consults.

He sent the patient with the DVT home, but the patient with the infected foot would require later debridement. He admitted her and booked the OR for after office hours.

By the time he got to the doctors’ lounge all that was left was a half-eaten pack of Doritos and burned coffee.

He thought he would have a brief respite driving to the office. Then his surgeon wife called him in the car asking him to field a call from their son’s school since she was stuck in the OR.

He arrived late to the office. The waiting room was filled with hostile-looking patients one of whom made a point of holding up her watch as if to reinforce his tardiness. There were already three additions to his schedule. Further, his nurse told him that there was some issue with the internet connection to the server. Thus, despite his expensive EMR, no records were available. She had informed the patients that there would be a “little” delay.

While they were waiting she brought in reams of documents that had come in the prior day and needed his signatures. He also used the time “productively” to answer emails. When the EMR was back online, he returned to his patients who by now were seething.

A patient brought in a CD of a CTA. He loaded it up on a computer, but the disc kept spinning relentlessly. Cursing, he loaded it on a second computer. The instructions were indecipherable. He could get a picture up but could not scroll through the images. The program froze. By the time he had evaluated the disc, he had wasted over 20 minutes. He was running even further behind.

The next patient was a second opinion from a physician in another state. She brought in over 200 pages of medical records describing a multitude of prior procedures. Politely he explained he would need to read them first and rescheduled her.

The ER called again with a patient with a cold leg. He canceled the rest of the office and snuck out through a back door, afraid to witness the consternation in the waiting room.

At the hospital, he argued briefly with the anesthesiologist who was reluctant to anesthetize the patient who had eaten 5 hours before. So the harried surgeon read some vascular labs, and visited a few less stable patients. Then back to the OR to revascularize the ER patient’s leg and later to debride the earlier patient’s foot.

He got home at 8:30 pm. His wife had also been delayed by a long surgery. They put the baby to bed. There was no time to play with the other children. The surgical couple barely had the energy left to microwave leftovers for dinner. He was too tired to take the dog out for its nocturnal pee. He went to his study, picked up the JVS, and fell asleep in his chair. He woke up with a start as he felt the dog urinate on his leg.

Exhausted he climbed into bed. It had been a good day, he told himself. After all the ER had not been too disruptive. He drifted off into a deep sleep. And then the phone rang. Ruptured AAA in the ER.

The day had gone very well. The vascular surgeon woke early excited for a morning in the OR and then an afternoon in the office. Driving to the hospital, he had planned out his day. A patient with a fempop at 7:30, an AV fistula at 10:30 am, a quick bite in the doctor’s lounge, and then to the office for two phlebectomies, a few new consults, as well as some returning patients.

Fortunately, he had purchased an advanced electronic medical record so that reviewing old records and inputting new data went smoothly. He had been on call for the local hospital’s ER, but he received no calls, so his day was not impacted. After a dinner with his wife, also a surgeon, he helped put their youngest baby to sleep, played with his older children, took the dog out for a walk, read the latest JVS and went to sleep. Despite being on call, the phone never rang, and he had an uninterrupted sleep.

Now, what really happened!

The vascular surgeon woke early in preparation for a day in the OR and office. Traffic slowed him down, but he still arrived at the hospital just before his 7:30 start time. He expected his patient to be on the table prepped and ready for the procedure. But the OR supervisor informed him that new regulations required him to personally mark the site of surgery, update the H&P, and date and time the consent.

He was nonplussed. He had marked the patient last night and had signed the consent too. His PA had dictated a three-page H&P that was in the chart. However, the patient was still in the holding room. The surgeon rushed over, marked the leg again, and completed the required documentation.

“Well,” he thought, “I’ll run upstairs, discharge my carotid from yesterday, and by the time that’s done and I’ve changed into scrubs, my patient will be ready.” Impatiently he waited 5 minutes for the elevator, but it never arrived. So he elected to run up 10 floors and across to the other side of the hospital where the administrators had inconveniently placed the postop vascular patients. The patient was eager to leave. The vascular surgeon dictated the discharge note and signed into the hospital electronic medical record.

But the software insisted that he had to comply with numerous “safety” regulations before signing off. These required reviewing every medication and all discharge instructions. The patient was on 15 drugs, and the surgeon was unfamiliar with most. After 10 minutes of unsuccessfully trying to enter the relevant orders, he called a medical student over to help.

The patient was going to a skilled nursing facility. This required completing two more electronic forms. The software stubbornly refused to close the discharge section till he assigned the appropriate ICD-10 codes. After a few more frustrating minutes he finally clicked the proper boxes and completed the discharge.
 

It was 8:15 by the time he made the skin incision. The case went smoothly. He relaxed a little knowing that he probably would not run too late for the rest of his day. Finishing ahead of schedule, he dictated the note, spoke to the patient’s family, and went to preop his AV fistula scheduled for 10:30. Then back to the wards to complete rounds.

The first two patients were uncomplicated. The third had a fever requiring multiple orders in the EMR. Then heated conversations with the pharmacist and head of infection control, since the EMR would not allow him to prescribe the antibiotic of his choice. Back across the entire length of the hospital to see a patient with renal failure. But she was in dialysis at another distant location in the hospital.

At 10:30 he ran down to the OR ready to scrub. Again, this patient was still in the holding area. The patient’s potassium was 5.6, and the anesthesiologist wanted to run another blood test. Then the nurse had to go on break. Now there was confusion about whether a room would be available as another surgeon had a bump case.

Ultimately, he started at 11:30. During the procedure, his beeper went off constantly. There were already two consults in the ER. The fistula took a mere 30 minutes, but he had waited 90 minutes since finishing the fempop.

“Medicare should pay me for the time between cases, and I’ll do the procedure for free” he complained to a colleague as he passed her on the way to the ER to see the consults.

He sent the patient with the DVT home, but the patient with the infected foot would require later debridement. He admitted her and booked the OR for after office hours.

By the time he got to the doctors’ lounge all that was left was a half-eaten pack of Doritos and burned coffee.

He thought he would have a brief respite driving to the office. Then his surgeon wife called him in the car asking him to field a call from their son’s school since she was stuck in the OR.

He arrived late to the office. The waiting room was filled with hostile-looking patients one of whom made a point of holding up her watch as if to reinforce his tardiness. There were already three additions to his schedule. Further, his nurse told him that there was some issue with the internet connection to the server. Thus, despite his expensive EMR, no records were available. She had informed the patients that there would be a “little” delay.

While they were waiting she brought in reams of documents that had come in the prior day and needed his signatures. He also used the time “productively” to answer emails. When the EMR was back online, he returned to his patients who by now were seething.

A patient brought in a CD of a CTA. He loaded it up on a computer, but the disc kept spinning relentlessly. Cursing, he loaded it on a second computer. The instructions were indecipherable. He could get a picture up but could not scroll through the images. The program froze. By the time he had evaluated the disc, he had wasted over 20 minutes. He was running even further behind.

The next patient was a second opinion from a physician in another state. She brought in over 200 pages of medical records describing a multitude of prior procedures. Politely he explained he would need to read them first and rescheduled her.

The ER called again with a patient with a cold leg. He canceled the rest of the office and snuck out through a back door, afraid to witness the consternation in the waiting room.

At the hospital, he argued briefly with the anesthesiologist who was reluctant to anesthetize the patient who had eaten 5 hours before. So the harried surgeon read some vascular labs, and visited a few less stable patients. Then back to the OR to revascularize the ER patient’s leg and later to debride the earlier patient’s foot.

He got home at 8:30 pm. His wife had also been delayed by a long surgery. They put the baby to bed. There was no time to play with the other children. The surgical couple barely had the energy left to microwave leftovers for dinner. He was too tired to take the dog out for its nocturnal pee. He went to his study, picked up the JVS, and fell asleep in his chair. He woke up with a start as he felt the dog urinate on his leg.

Exhausted he climbed into bed. It had been a good day, he told himself. After all the ER had not been too disruptive. He drifted off into a deep sleep. And then the phone rang. Ruptured AAA in the ER.

From the Editor

Recent news events have detailed the many humiliations and abuses, both verbal and physical, that women, and some men, have to endure in the workforce. It would not surprise me if some vascular surgeons admit that they have heard of similar instances of egregious behavior occurring in our workplaces. The people that have been impacted have predominantly been women and have come from all walks of life. They have been patients, colleagues, our employees or those of the many institutions in which we work. Unfortunately, the demands of our profession and the pace of our lives may diminish our relationships with these persons. This facelessness and disconnection may allow some surgeons to justify their poor behavior whereas others may not realize that they are negatively impacting these individuals’ lives. The fact that these injustices persist is made more upsetting because we are so indebted for all that these nurses, technologists, office personnel, and even patients, do for us.

Just think how much we owe the nurses on the hospital floors. It is to nurses that we entrust the postoperative care of our patients. They make sure to call us when they detect that a pulse is weakening or suddenly absent, or that a neck is expanding as a hematoma threatens breathing. They timely diagnose a retroperitoneal bleed that may endanger the patient’s life. Dialysis nurses notify us that a puncture looks like it may suddenly bleed out. Our patients’ lives are often entirely dependent on the astute observation of an accomplished nurse.

And what about the operating nurses and scrub technicians? They lay out our surgical tray perfectly with all the tools that we are wont to use. They are there to assist when a sudden event requires the steady hand of an observant nurse who knows just what instrument we need without us having to ask. When you are in a difficult area, an encouraging word will often inspire the confidence required to accomplish a successful outcome. When a procedure is going poorly and tension mounts, their silence accepts our sometimes curt requests. There is a bond that develops between two professionals who recognize each other’s expertise.

Vascular technologists work tirelessly, often in darkened rooms, frequently under challenging positions straining eyes and limbs to detect pathology that may be life or limb saving. Their diagnostic acumen can be the difference between a subsequent procedure’s success or failure. Indeed, the vascular surgeon has to make the final interpretation, but if the technologist fails to show the pathology, even the most erudite physician may miss the diagnosis.

Front-desk personnel who sit at check-in and check-out in an office are the face of our practice. Their friendly attitude welcomes our patients and reassures them that they have come to a well-run, professional workplace. A smiling, personal greeting will calm even the most worried patient. Of course, their attention to detail assures that collections will not be misplaced.

Our office nurses exude compassion for the many patients who face immense hurdles in living with vascular disease. They assist in teaching wound care, explain medications, and help in arranging social services. They cry with those that have recently lost a spouse or child and get excited to hear of the birth of a patient’s grandchild. Without their organizational skills, office hours would be interminable, and patients who are kept waiting would complain, or worse, leave the practice. They have learned to laugh at the same joke that they have heard us tell innumerable times, and to ignore the sometimes lousy mood we may bring into the office after a brutal night on call.

The spouses or significant others of our patients also play an important role since it is often from them that we get the most accurate history. They will ask to speak to us privately to make sure we do not cause despair when we discuss treatment options or to ensure that we firmly admonish their loved one to stop smoking, exercise or watch their weight. Unfortunately, they will sometimes have to accept a disparaging remark or gesture from their “spouse” to make sure that we are supplied all the necessary information to come to an appropriate diagnosis.

I can go on about other medical personnel that contribute to our success, but I believe I have made the point. The men and women with whom we interact as vascular surgeons deserve the same respect we grant ourselves. Any insult to them demeans not only the recipient but more so the abuser and those of us who stand by silently.

Finally, there are many female colleagues whose interest and drive has allowed them to not only break into but achieve leadership positions in a specialty that was almost uniformly male and unwelcoming. Their aptitudes and attitudes have broadened the specialty’s ability to help our patients. However, recently the news has been replete with evidence that women have been abused as they tried to enter other male-dominated professions and so it is likely that this has happened in ours.

Other recent news items suggest that these physical and emotional abuses are inflicted not only on women but also men. We may never know the scope of this mistreatment, but we must assure that it stops immediately.

Ethical behavior must be gender neutral. Further, condescending attitudes, cruel language, and a lack of appreciation sometimes can be as damaging as physical or sexual abuse and must be abolished from our workplace. ■

From the Editor

Recent news events have detailed the many humiliations and abuses, both verbal and physical, that women, and some men, have to endure in the workforce. It would not surprise me if some vascular surgeons admit that they have heard of similar instances of egregious behavior occurring in our workplaces. The people that have been impacted have predominantly been women and have come from all walks of life. They have been patients, colleagues, our employees or those of the many institutions in which we work. Unfortunately, the demands of our profession and the pace of our lives may diminish our relationships with these persons. This facelessness and disconnection may allow some surgeons to justify their poor behavior whereas others may not realize that they are negatively impacting these individuals’ lives. The fact that these injustices persist is made more upsetting because we are so indebted for all that these nurses, technologists, office personnel, and even patients, do for us.

Just think how much we owe the nurses on the hospital floors. It is to nurses that we entrust the postoperative care of our patients. They make sure to call us when they detect that a pulse is weakening or suddenly absent, or that a neck is expanding as a hematoma threatens breathing. They timely diagnose a retroperitoneal bleed that may endanger the patient’s life. Dialysis nurses notify us that a puncture looks like it may suddenly bleed out. Our patients’ lives are often entirely dependent on the astute observation of an accomplished nurse.

And what about the operating nurses and scrub technicians? They lay out our surgical tray perfectly with all the tools that we are wont to use. They are there to assist when a sudden event requires the steady hand of an observant nurse who knows just what instrument we need without us having to ask. When you are in a difficult area, an encouraging word will often inspire the confidence required to accomplish a successful outcome. When a procedure is going poorly and tension mounts, their silence accepts our sometimes curt requests. There is a bond that develops between two professionals who recognize each other’s expertise.

Vascular technologists work tirelessly, often in darkened rooms, frequently under challenging positions straining eyes and limbs to detect pathology that may be life or limb saving. Their diagnostic acumen can be the difference between a subsequent procedure’s success or failure. Indeed, the vascular surgeon has to make the final interpretation, but if the technologist fails to show the pathology, even the most erudite physician may miss the diagnosis.

Front-desk personnel who sit at check-in and check-out in an office are the face of our practice. Their friendly attitude welcomes our patients and reassures them that they have come to a well-run, professional workplace. A smiling, personal greeting will calm even the most worried patient. Of course, their attention to detail assures that collections will not be misplaced.

Our office nurses exude compassion for the many patients who face immense hurdles in living with vascular disease. They assist in teaching wound care, explain medications, and help in arranging social services. They cry with those that have recently lost a spouse or child and get excited to hear of the birth of a patient’s grandchild. Without their organizational skills, office hours would be interminable, and patients who are kept waiting would complain, or worse, leave the practice. They have learned to laugh at the same joke that they have heard us tell innumerable times, and to ignore the sometimes lousy mood we may bring into the office after a brutal night on call.

The spouses or significant others of our patients also play an important role since it is often from them that we get the most accurate history. They will ask to speak to us privately to make sure we do not cause despair when we discuss treatment options or to ensure that we firmly admonish their loved one to stop smoking, exercise or watch their weight. Unfortunately, they will sometimes have to accept a disparaging remark or gesture from their “spouse” to make sure that we are supplied all the necessary information to come to an appropriate diagnosis.

I can go on about other medical personnel that contribute to our success, but I believe I have made the point. The men and women with whom we interact as vascular surgeons deserve the same respect we grant ourselves. Any insult to them demeans not only the recipient but more so the abuser and those of us who stand by silently.

Finally, there are many female colleagues whose interest and drive has allowed them to not only break into but achieve leadership positions in a specialty that was almost uniformly male and unwelcoming. Their aptitudes and attitudes have broadened the specialty’s ability to help our patients. However, recently the news has been replete with evidence that women have been abused as they tried to enter other male-dominated professions and so it is likely that this has happened in ours.

Other recent news items suggest that these physical and emotional abuses are inflicted not only on women but also men. We may never know the scope of this mistreatment, but we must assure that it stops immediately.

Ethical behavior must be gender neutral. Further, condescending attitudes, cruel language, and a lack of appreciation sometimes can be as damaging as physical or sexual abuse and must be abolished from our workplace. ■

From the Editor

Recent news events have detailed the many humiliations and abuses, both verbal and physical, that women, and some men, have to endure in the workforce. It would not surprise me if some vascular surgeons admit that they have heard of similar instances of egregious behavior occurring in our workplaces. The people that have been impacted have predominantly been women and have come from all walks of life. They have been patients, colleagues, our employees or those of the many institutions in which we work. Unfortunately, the demands of our profession and the pace of our lives may diminish our relationships with these persons. This facelessness and disconnection may allow some surgeons to justify their poor behavior whereas others may not realize that they are negatively impacting these individuals’ lives. The fact that these injustices persist is made more upsetting because we are so indebted for all that these nurses, technologists, office personnel, and even patients, do for us.

Just think how much we owe the nurses on the hospital floors. It is to nurses that we entrust the postoperative care of our patients. They make sure to call us when they detect that a pulse is weakening or suddenly absent, or that a neck is expanding as a hematoma threatens breathing. They timely diagnose a retroperitoneal bleed that may endanger the patient’s life. Dialysis nurses notify us that a puncture looks like it may suddenly bleed out. Our patients’ lives are often entirely dependent on the astute observation of an accomplished nurse.

And what about the operating nurses and scrub technicians? They lay out our surgical tray perfectly with all the tools that we are wont to use. They are there to assist when a sudden event requires the steady hand of an observant nurse who knows just what instrument we need without us having to ask. When you are in a difficult area, an encouraging word will often inspire the confidence required to accomplish a successful outcome. When a procedure is going poorly and tension mounts, their silence accepts our sometimes curt requests. There is a bond that develops between two professionals who recognize each other’s expertise.

Vascular technologists work tirelessly, often in darkened rooms, frequently under challenging positions straining eyes and limbs to detect pathology that may be life or limb saving. Their diagnostic acumen can be the difference between a subsequent procedure’s success or failure. Indeed, the vascular surgeon has to make the final interpretation, but if the technologist fails to show the pathology, even the most erudite physician may miss the diagnosis.

Front-desk personnel who sit at check-in and check-out in an office are the face of our practice. Their friendly attitude welcomes our patients and reassures them that they have come to a well-run, professional workplace. A smiling, personal greeting will calm even the most worried patient. Of course, their attention to detail assures that collections will not be misplaced.

Our office nurses exude compassion for the many patients who face immense hurdles in living with vascular disease. They assist in teaching wound care, explain medications, and help in arranging social services. They cry with those that have recently lost a spouse or child and get excited to hear of the birth of a patient’s grandchild. Without their organizational skills, office hours would be interminable, and patients who are kept waiting would complain, or worse, leave the practice. They have learned to laugh at the same joke that they have heard us tell innumerable times, and to ignore the sometimes lousy mood we may bring into the office after a brutal night on call.

The spouses or significant others of our patients also play an important role since it is often from them that we get the most accurate history. They will ask to speak to us privately to make sure we do not cause despair when we discuss treatment options or to ensure that we firmly admonish their loved one to stop smoking, exercise or watch their weight. Unfortunately, they will sometimes have to accept a disparaging remark or gesture from their “spouse” to make sure that we are supplied all the necessary information to come to an appropriate diagnosis.

I can go on about other medical personnel that contribute to our success, but I believe I have made the point. The men and women with whom we interact as vascular surgeons deserve the same respect we grant ourselves. Any insult to them demeans not only the recipient but more so the abuser and those of us who stand by silently.

Finally, there are many female colleagues whose interest and drive has allowed them to not only break into but achieve leadership positions in a specialty that was almost uniformly male and unwelcoming. Their aptitudes and attitudes have broadened the specialty’s ability to help our patients. However, recently the news has been replete with evidence that women have been abused as they tried to enter other male-dominated professions and so it is likely that this has happened in ours.

Other recent news items suggest that these physical and emotional abuses are inflicted not only on women but also men. We may never know the scope of this mistreatment, but we must assure that it stops immediately.

Ethical behavior must be gender neutral. Further, condescending attitudes, cruel language, and a lack of appreciation sometimes can be as damaging as physical or sexual abuse and must be abolished from our workplace. ■

In 1999, two psychologists, David Dunning and his student Justin Kruger, published a paper that demonstrated people who are really bad at something tend to believe that they are really good (J Pers Soc Psychol. 1999;77:1121-34). They also posited that most competent people underestimate their abilities while the rest of us overestimate them, and the worse we are, the more we overestimate our capabilities. In essence, they postulate that one needs a degree of skill in performing an activity in order to assess one's aptitude. In other words, it’s impossible to tell if you are bad at something if you’re too bad to know that you’re bad.

No, I’m not writing another diatribe about cardiologists (although this surely applies to some!). Rather this is a semi-apology to the vascular fellow who I featured in my last editorial, wherein I bemoaned that the endo-revolution resulted in some younger surgeons lacking open skills. That young man is an example of a highly competent trainee who probably underestimates his abilities to perform complex open procedures. In fact, an honest self-evaluation of my own clinical experience has made me realize that there is a corollary to newly minted vascular surgeons having limited open experience … rather, that some older surgeons, well versed in open surgery, may be inexperienced in some complex endo-procedures. The implications for the practice of vascular surgery are significant and warrant discussion. Perhaps my personal experience in learning endovascular methods will be revealing.

I performed my vascular fellowship at Montefiore with Frank Veith, MD, in 1980. At the time, Dr. Veith was a principal investigator in a multicenter, randomized trial to evaluate whether PTFE could be an acceptable substitute for saphenous vein in infra-inguinal bypass. As his fellow, I gained an enormous experience in these procedures. I stayed on in academic vascular surgery for another 6years honing my techniques in other forms of open surgery. In 1986 I moved to Sarasota, Fla., to start a private practice. Here, vascular surgery was performed by general surgeons who, although competent in the vascular procedures of that time, treated most infrapopliteal disease with an amputation. My calling card was my ability to do a distal bypass. What an anachronism! Of course, I still do a fair number of tibial bypasses, but femoropopliteal bypass is almost ready for the museum. The reason is that the tidal force of the endo-tsunami had just begun to wash up on the sunny beaches of Sarasota.

While at Montefiore I had witnessed the beginning of the endovascular wave. I realized that if I didn’t learn this new technology, I might well have become a surgical dinosaur. Accordingly, soon after arriving in Sarasota, I left town to spend a week with a pioneering radiologist who allowed me to observe his team’s early experience with aortic endografts. I left my practice a second time to visit with a very busy invasive cardiologist where I had hands-on experience with balloon angioplasty and early Palmaz stents. On my return, I cautiously started performing diagnostic arteriograms in the operating room using early C-arms. Eventually, my partner, David Showalter, MD, and I convinced the hospital to outfit a room as a semi “hybrid” suite, a fixed sliding X-ray table coupled with the most advanced C-arm of the time. Over the objections of local radiologists and cardiologists, we ultimately obtained privileges to perform our endo cases in their radiology suites and cath labs. This allowed us to expand our endovascular experience, first by improving our proficiency as diagnostic arteriographers, then by advancing our angioplasty and, ultimately, stent techniques. In the interim, however, endovascular technology had flourished with the introduction of TEVAR, FEVAR, chimneys and snorkels, rotor-rooters, lasers, drills, drug-eluting balloons and stents, radial and tibial access. Unfortunately, I must not have read Dale Carnegie’s book on how to win friends and influence people since by then I had alienated some of the general surgeons and all the radiologists and cardiologists. Accordingly, we had to train ourselves on these new devices and indications. Fortunately, training programs were by then producing endo-competent vascular surgeons and we were able to incorporate, and learn from, two of these younger surgeons, Michael Lepore, MD, and Deepak Nair, MD, who had joined our practice.

I suspect that many vascular surgeons who trained in the early eighties, and perhaps even nineties, were similarly self-taught. In fact, I suggest that some program directors, who now teach endovascular procedures, also had to learn on the job. This does not imply that we are all less skilled. Rather, that our generation of vascular surgeons come to the endo table with prejudices that favor open surgery and which may prevent us from fully embracing new technologies. Further, the host of new equipment alternatives makes it almost impossible to gain a global experience unless one has an extensive clinical practice or works within a large group or academic program. Thus, if we are not exposed to these devices and are not aware of their pluses and minuses, we might not be as good at them as we think we are.

An even more unfortunate repercussion of the endo-tsunami drowning open skills of young surgeons is that it may be having a similar effect on their more senior colleagues. Surgeons over the age of 50 are now in the majority and most have appropriately embraced endovascular procedures. However, in so doing their open volume falls and their expertise in this segment of their practice must diminish. I realize that there are many surgeons of my generation who are masters of all techniques, and I applaud their resilience. However, some may need to acknowledge that they may be just a little less proficient in the operating room. Accordingly, we need to be careful not to cast too many stones at our junior colleagues.

So, there are young vascular surgeons who may have lesser open skills, older surgeons who may have lesser endo skills, and some senior surgeons who may not be totally expert at either skill. I propose that it is now up to those of you, in the middle of your careers, to make sure that you keep up with changing paradigms, never lose your hard-earned skills, teach the new graduates all you can and, even more importantly, always remain aware of your inadequacies.

Russell Samson, MD, is a physician in the practice of Sarasota Vascular Specialists and clinical professor of surgery, Florida State University, Tallahassee. He is also the medical editor of Vascular Specialist.

In 1999, two psychologists, David Dunning and his student Justin Kruger, published a paper that demonstrated people who are really bad at something tend to believe that they are really good (J Pers Soc Psychol. 1999;77:1121-34). They also posited that most competent people underestimate their abilities while the rest of us overestimate them, and the worse we are, the more we overestimate our capabilities. In essence, they postulate that one needs a degree of skill in performing an activity in order to assess one's aptitude. In other words, it’s impossible to tell if you are bad at something if you’re too bad to know that you’re bad.

No, I’m not writing another diatribe about cardiologists (although this surely applies to some!). Rather this is a semi-apology to the vascular fellow who I featured in my last editorial, wherein I bemoaned that the endo-revolution resulted in some younger surgeons lacking open skills. That young man is an example of a highly competent trainee who probably underestimates his abilities to perform complex open procedures. In fact, an honest self-evaluation of my own clinical experience has made me realize that there is a corollary to newly minted vascular surgeons having limited open experience … rather, that some older surgeons, well versed in open surgery, may be inexperienced in some complex endo-procedures. The implications for the practice of vascular surgery are significant and warrant discussion. Perhaps my personal experience in learning endovascular methods will be revealing.

I performed my vascular fellowship at Montefiore with Frank Veith, MD, in 1980. At the time, Dr. Veith was a principal investigator in a multicenter, randomized trial to evaluate whether PTFE could be an acceptable substitute for saphenous vein in infra-inguinal bypass. As his fellow, I gained an enormous experience in these procedures. I stayed on in academic vascular surgery for another 6years honing my techniques in other forms of open surgery. In 1986 I moved to Sarasota, Fla., to start a private practice. Here, vascular surgery was performed by general surgeons who, although competent in the vascular procedures of that time, treated most infrapopliteal disease with an amputation. My calling card was my ability to do a distal bypass. What an anachronism! Of course, I still do a fair number of tibial bypasses, but femoropopliteal bypass is almost ready for the museum. The reason is that the tidal force of the endo-tsunami had just begun to wash up on the sunny beaches of Sarasota.

While at Montefiore I had witnessed the beginning of the endovascular wave. I realized that if I didn’t learn this new technology, I might well have become a surgical dinosaur. Accordingly, soon after arriving in Sarasota, I left town to spend a week with a pioneering radiologist who allowed me to observe his team’s early experience with aortic endografts. I left my practice a second time to visit with a very busy invasive cardiologist where I had hands-on experience with balloon angioplasty and early Palmaz stents. On my return, I cautiously started performing diagnostic arteriograms in the operating room using early C-arms. Eventually, my partner, David Showalter, MD, and I convinced the hospital to outfit a room as a semi “hybrid” suite, a fixed sliding X-ray table coupled with the most advanced C-arm of the time. Over the objections of local radiologists and cardiologists, we ultimately obtained privileges to perform our endo cases in their radiology suites and cath labs. This allowed us to expand our endovascular experience, first by improving our proficiency as diagnostic arteriographers, then by advancing our angioplasty and, ultimately, stent techniques. In the interim, however, endovascular technology had flourished with the introduction of TEVAR, FEVAR, chimneys and snorkels, rotor-rooters, lasers, drills, drug-eluting balloons and stents, radial and tibial access. Unfortunately, I must not have read Dale Carnegie’s book on how to win friends and influence people since by then I had alienated some of the general surgeons and all the radiologists and cardiologists. Accordingly, we had to train ourselves on these new devices and indications. Fortunately, training programs were by then producing endo-competent vascular surgeons and we were able to incorporate, and learn from, two of these younger surgeons, Michael Lepore, MD, and Deepak Nair, MD, who had joined our practice.

I suspect that many vascular surgeons who trained in the early eighties, and perhaps even nineties, were similarly self-taught. In fact, I suggest that some program directors, who now teach endovascular procedures, also had to learn on the job. This does not imply that we are all less skilled. Rather, that our generation of vascular surgeons come to the endo table with prejudices that favor open surgery and which may prevent us from fully embracing new technologies. Further, the host of new equipment alternatives makes it almost impossible to gain a global experience unless one has an extensive clinical practice or works within a large group or academic program. Thus, if we are not exposed to these devices and are not aware of their pluses and minuses, we might not be as good at them as we think we are.

An even more unfortunate repercussion of the endo-tsunami drowning open skills of young surgeons is that it may be having a similar effect on their more senior colleagues. Surgeons over the age of 50 are now in the majority and most have appropriately embraced endovascular procedures. However, in so doing their open volume falls and their expertise in this segment of their practice must diminish. I realize that there are many surgeons of my generation who are masters of all techniques, and I applaud their resilience. However, some may need to acknowledge that they may be just a little less proficient in the operating room. Accordingly, we need to be careful not to cast too many stones at our junior colleagues.

So, there are young vascular surgeons who may have lesser open skills, older surgeons who may have lesser endo skills, and some senior surgeons who may not be totally expert at either skill. I propose that it is now up to those of you, in the middle of your careers, to make sure that you keep up with changing paradigms, never lose your hard-earned skills, teach the new graduates all you can and, even more importantly, always remain aware of your inadequacies.

Russell Samson, MD, is a physician in the practice of Sarasota Vascular Specialists and clinical professor of surgery, Florida State University, Tallahassee. He is also the medical editor of Vascular Specialist.

In 1999, two psychologists, David Dunning and his student Justin Kruger, published a paper that demonstrated people who are really bad at something tend to believe that they are really good (J Pers Soc Psychol. 1999;77:1121-34). They also posited that most competent people underestimate their abilities while the rest of us overestimate them, and the worse we are, the more we overestimate our capabilities. In essence, they postulate that one needs a degree of skill in performing an activity in order to assess one's aptitude. In other words, it’s impossible to tell if you are bad at something if you’re too bad to know that you’re bad.

No, I’m not writing another diatribe about cardiologists (although this surely applies to some!). Rather this is a semi-apology to the vascular fellow who I featured in my last editorial, wherein I bemoaned that the endo-revolution resulted in some younger surgeons lacking open skills. That young man is an example of a highly competent trainee who probably underestimates his abilities to perform complex open procedures. In fact, an honest self-evaluation of my own clinical experience has made me realize that there is a corollary to newly minted vascular surgeons having limited open experience … rather, that some older surgeons, well versed in open surgery, may be inexperienced in some complex endo-procedures. The implications for the practice of vascular surgery are significant and warrant discussion. Perhaps my personal experience in learning endovascular methods will be revealing.

I performed my vascular fellowship at Montefiore with Frank Veith, MD, in 1980. At the time, Dr. Veith was a principal investigator in a multicenter, randomized trial to evaluate whether PTFE could be an acceptable substitute for saphenous vein in infra-inguinal bypass. As his fellow, I gained an enormous experience in these procedures. I stayed on in academic vascular surgery for another 6years honing my techniques in other forms of open surgery. In 1986 I moved to Sarasota, Fla., to start a private practice. Here, vascular surgery was performed by general surgeons who, although competent in the vascular procedures of that time, treated most infrapopliteal disease with an amputation. My calling card was my ability to do a distal bypass. What an anachronism! Of course, I still do a fair number of tibial bypasses, but femoropopliteal bypass is almost ready for the museum. The reason is that the tidal force of the endo-tsunami had just begun to wash up on the sunny beaches of Sarasota.

While at Montefiore I had witnessed the beginning of the endovascular wave. I realized that if I didn’t learn this new technology, I might well have become a surgical dinosaur. Accordingly, soon after arriving in Sarasota, I left town to spend a week with a pioneering radiologist who allowed me to observe his team’s early experience with aortic endografts. I left my practice a second time to visit with a very busy invasive cardiologist where I had hands-on experience with balloon angioplasty and early Palmaz stents. On my return, I cautiously started performing diagnostic arteriograms in the operating room using early C-arms. Eventually, my partner, David Showalter, MD, and I convinced the hospital to outfit a room as a semi “hybrid” suite, a fixed sliding X-ray table coupled with the most advanced C-arm of the time. Over the objections of local radiologists and cardiologists, we ultimately obtained privileges to perform our endo cases in their radiology suites and cath labs. This allowed us to expand our endovascular experience, first by improving our proficiency as diagnostic arteriographers, then by advancing our angioplasty and, ultimately, stent techniques. In the interim, however, endovascular technology had flourished with the introduction of TEVAR, FEVAR, chimneys and snorkels, rotor-rooters, lasers, drills, drug-eluting balloons and stents, radial and tibial access. Unfortunately, I must not have read Dale Carnegie’s book on how to win friends and influence people since by then I had alienated some of the general surgeons and all the radiologists and cardiologists. Accordingly, we had to train ourselves on these new devices and indications. Fortunately, training programs were by then producing endo-competent vascular surgeons and we were able to incorporate, and learn from, two of these younger surgeons, Michael Lepore, MD, and Deepak Nair, MD, who had joined our practice.

I suspect that many vascular surgeons who trained in the early eighties, and perhaps even nineties, were similarly self-taught. In fact, I suggest that some program directors, who now teach endovascular procedures, also had to learn on the job. This does not imply that we are all less skilled. Rather, that our generation of vascular surgeons come to the endo table with prejudices that favor open surgery and which may prevent us from fully embracing new technologies. Further, the host of new equipment alternatives makes it almost impossible to gain a global experience unless one has an extensive clinical practice or works within a large group or academic program. Thus, if we are not exposed to these devices and are not aware of their pluses and minuses, we might not be as good at them as we think we are.

An even more unfortunate repercussion of the endo-tsunami drowning open skills of young surgeons is that it may be having a similar effect on their more senior colleagues. Surgeons over the age of 50 are now in the majority and most have appropriately embraced endovascular procedures. However, in so doing their open volume falls and their expertise in this segment of their practice must diminish. I realize that there are many surgeons of my generation who are masters of all techniques, and I applaud their resilience. However, some may need to acknowledge that they may be just a little less proficient in the operating room. Accordingly, we need to be careful not to cast too many stones at our junior colleagues.

So, there are young vascular surgeons who may have lesser open skills, older surgeons who may have lesser endo skills, and some senior surgeons who may not be totally expert at either skill. I propose that it is now up to those of you, in the middle of your careers, to make sure that you keep up with changing paradigms, never lose your hard-earned skills, teach the new graduates all you can and, even more importantly, always remain aware of your inadequacies.

Russell Samson, MD, is a physician in the practice of Sarasota Vascular Specialists and clinical professor of surgery, Florida State University, Tallahassee. He is also the medical editor of Vascular Specialist.

On behalf of the SVS Publications Committee I am delighted to announce the appointment of Malachi Sheahan, III, M.D., as Associate Medical Editor of Vascular Specialist. I am sure readers will realize this official newspaper of the Society for Vascular Surgery has grown substantially over the last few years. With the help of generous advertisers we now “publish” Vascular Specialist not only in print but in multiple formats. These include electronic versions on the Web, Facebook, and Twitter, as well as mobile versions for smartphones and tablets. The print version is now published monthly and most often as 20 pages.

Further, www.vascularspecialistonline.com includes many articles not found in the print edition. Articles can be searched based on subject and author and the print version can be seen in PDF version. The web version also allows readers to answer polls posed in the print edition. These are archived for review.

A recent survey of 250 members of the SVS confirmed that Vascular Specialist is now the most widely read vascular news publication. More importantly, it was considered by far the most authoritative.

This expansion requires a significant expenditure of time by the Associate Editors and the Medical Editor in particular. Accordingly, it is essential that the medical editorial staff be supplemented by an Associate Medical Editor. This will also allow the smooth transition when the Medical Editor’s appointment terminates.

Mal has already proven to be an excellent writer, and his commitment to the SVS, resident/fellow training, and his sense of humor make him an outstanding choice to assume this position. Mal completed his vascular surgery training at the Beth Israel Deaconess program in 2003. Shortly thereafter he joined the faculty at the Louisiana State University Health Sciences Center in New Orleans. He currently serves as the program director for both their integrated and independent vascular training programs. In 2014, he was named the Claude C. Craighead Jr. Professor and Chair of the Division of Vascular and Endovascular Surgery.

I have previously requested that all members consider themselves not only readers but also contributors. Once again I encourage you to send Mal and me opinion pieces or letters to the editor. We also welcome Tips and Tricks. These can be quite short and do not require any references. They are meant to highlight a technique that you have found to be helpful in performing an open or endovascular procedure. One or two photos often help the piece but they must be in .jpg format and at least 124kb. If you are so inclined we will also print your photo and affiliation alongside. However, we regret you cannot submit your high school photo or substitute one of Tom Cruise or Beyoncé! Don’t worry that you may not be a Pulitzer Prize journalist since we have professional writers who will tidy up your writing as necessary. We also welcome suggestions about news items that we may have missed or overlooked. These may be news items from the lay press or a manuscript you read in a journal other than the JVS. Again, our professional reporters will turn the item into a news article. You can also send us a comment and, if appropriate, we will print it as a sidebar to the article.

Further, we encourage news about your comings and goings which we can publish in the “From the community” section. Executive members of the various regional Societies can also utilize this section to bring us news about their Societies activities.

In order to keep the commentaries fresh, we do need to rotate the members of the editorial board. So, if you would like to be considered for such a position, please send us a short biography and your area of interest. This could be related to a disease process, treatment, or socioeconomic issues. Associate Editors will be required to read short news items about 12 times a year and to provide commentary when requested. Even if you are not selected we may occasionally turn to you to write a comment on a news item related to your stated interest.

The SVS wants Vascular Specialist to be YOUR newspaper. Please help us achieve that goal as we continue to make Vascular Specialist the most read and respected supplier of news and opinions about vascular surgery and vascular surgeons.

You can contact me at [email protected] and Dr. Sheahan at [email protected].

On behalf of the SVS Publications Committee I am delighted to announce the appointment of Malachi Sheahan, III, M.D., as Associate Medical Editor of Vascular Specialist. I am sure readers will realize this official newspaper of the Society for Vascular Surgery has grown substantially over the last few years. With the help of generous advertisers we now “publish” Vascular Specialist not only in print but in multiple formats. These include electronic versions on the Web, Facebook, and Twitter, as well as mobile versions for smartphones and tablets. The print version is now published monthly and most often as 20 pages.

Further, www.vascularspecialistonline.com includes many articles not found in the print edition. Articles can be searched based on subject and author and the print version can be seen in PDF version. The web version also allows readers to answer polls posed in the print edition. These are archived for review.

A recent survey of 250 members of the SVS confirmed that Vascular Specialist is now the most widely read vascular news publication. More importantly, it was considered by far the most authoritative.

This expansion requires a significant expenditure of time by the Associate Editors and the Medical Editor in particular. Accordingly, it is essential that the medical editorial staff be supplemented by an Associate Medical Editor. This will also allow the smooth transition when the Medical Editor’s appointment terminates.

Mal has already proven to be an excellent writer, and his commitment to the SVS, resident/fellow training, and his sense of humor make him an outstanding choice to assume this position. Mal completed his vascular surgery training at the Beth Israel Deaconess program in 2003. Shortly thereafter he joined the faculty at the Louisiana State University Health Sciences Center in New Orleans. He currently serves as the program director for both their integrated and independent vascular training programs. In 2014, he was named the Claude C. Craighead Jr. Professor and Chair of the Division of Vascular and Endovascular Surgery.

I have previously requested that all members consider themselves not only readers but also contributors. Once again I encourage you to send Mal and me opinion pieces or letters to the editor. We also welcome Tips and Tricks. These can be quite short and do not require any references. They are meant to highlight a technique that you have found to be helpful in performing an open or endovascular procedure. One or two photos often help the piece but they must be in .jpg format and at least 124kb. If you are so inclined we will also print your photo and affiliation alongside. However, we regret you cannot submit your high school photo or substitute one of Tom Cruise or Beyoncé! Don’t worry that you may not be a Pulitzer Prize journalist since we have professional writers who will tidy up your writing as necessary. We also welcome suggestions about news items that we may have missed or overlooked. These may be news items from the lay press or a manuscript you read in a journal other than the JVS. Again, our professional reporters will turn the item into a news article. You can also send us a comment and, if appropriate, we will print it as a sidebar to the article.

Further, we encourage news about your comings and goings which we can publish in the “From the community” section. Executive members of the various regional Societies can also utilize this section to bring us news about their Societies activities.

In order to keep the commentaries fresh, we do need to rotate the members of the editorial board. So, if you would like to be considered for such a position, please send us a short biography and your area of interest. This could be related to a disease process, treatment, or socioeconomic issues. Associate Editors will be required to read short news items about 12 times a year and to provide commentary when requested. Even if you are not selected we may occasionally turn to you to write a comment on a news item related to your stated interest.

The SVS wants Vascular Specialist to be YOUR newspaper. Please help us achieve that goal as we continue to make Vascular Specialist the most read and respected supplier of news and opinions about vascular surgery and vascular surgeons.

You can contact me at [email protected] and Dr. Sheahan at [email protected].

On behalf of the SVS Publications Committee I am delighted to announce the appointment of Malachi Sheahan, III, M.D., as Associate Medical Editor of Vascular Specialist. I am sure readers will realize this official newspaper of the Society for Vascular Surgery has grown substantially over the last few years. With the help of generous advertisers we now “publish” Vascular Specialist not only in print but in multiple formats. These include electronic versions on the Web, Facebook, and Twitter, as well as mobile versions for smartphones and tablets. The print version is now published monthly and most often as 20 pages.

Further, www.vascularspecialistonline.com includes many articles not found in the print edition. Articles can be searched based on subject and author and the print version can be seen in PDF version. The web version also allows readers to answer polls posed in the print edition. These are archived for review.

A recent survey of 250 members of the SVS confirmed that Vascular Specialist is now the most widely read vascular news publication. More importantly, it was considered by far the most authoritative.

This expansion requires a significant expenditure of time by the Associate Editors and the Medical Editor in particular. Accordingly, it is essential that the medical editorial staff be supplemented by an Associate Medical Editor. This will also allow the smooth transition when the Medical Editor’s appointment terminates.

Mal has already proven to be an excellent writer, and his commitment to the SVS, resident/fellow training, and his sense of humor make him an outstanding choice to assume this position. Mal completed his vascular surgery training at the Beth Israel Deaconess program in 2003. Shortly thereafter he joined the faculty at the Louisiana State University Health Sciences Center in New Orleans. He currently serves as the program director for both their integrated and independent vascular training programs. In 2014, he was named the Claude C. Craighead Jr. Professor and Chair of the Division of Vascular and Endovascular Surgery.

I have previously requested that all members consider themselves not only readers but also contributors. Once again I encourage you to send Mal and me opinion pieces or letters to the editor. We also welcome Tips and Tricks. These can be quite short and do not require any references. They are meant to highlight a technique that you have found to be helpful in performing an open or endovascular procedure. One or two photos often help the piece but they must be in .jpg format and at least 124kb. If you are so inclined we will also print your photo and affiliation alongside. However, we regret you cannot submit your high school photo or substitute one of Tom Cruise or Beyoncé! Don’t worry that you may not be a Pulitzer Prize journalist since we have professional writers who will tidy up your writing as necessary. We also welcome suggestions about news items that we may have missed or overlooked. These may be news items from the lay press or a manuscript you read in a journal other than the JVS. Again, our professional reporters will turn the item into a news article. You can also send us a comment and, if appropriate, we will print it as a sidebar to the article.

Further, we encourage news about your comings and goings which we can publish in the “From the community” section. Executive members of the various regional Societies can also utilize this section to bring us news about their Societies activities.

In order to keep the commentaries fresh, we do need to rotate the members of the editorial board. So, if you would like to be considered for such a position, please send us a short biography and your area of interest. This could be related to a disease process, treatment, or socioeconomic issues. Associate Editors will be required to read short news items about 12 times a year and to provide commentary when requested. Even if you are not selected we may occasionally turn to you to write a comment on a news item related to your stated interest.

The SVS wants Vascular Specialist to be YOUR newspaper. Please help us achieve that goal as we continue to make Vascular Specialist the most read and respected supplier of news and opinions about vascular surgery and vascular surgeons.

You can contact me at [email protected] and Dr. Sheahan at [email protected].

This edition of Vascular Specialist is being published early to coincide with the VAM. Since medical students will be attending the meeting I thought this would be a good opportunity to describe an often overlooked reason why, after all my years in practice, I still enjoy being a vascular surgeon. By doing so I hope to encourage these young people to consider a career in vascular surgery.

Some vascular surgeons, with the same goal, have volunteered to mentor these students at the VAM. I suspect most mentors would extoll vascular surgery as unique amongst surgical specialties. They will describe the variety of complex operations as well as advanced endovascular procedures that we perform. Proudly, some mentors will mention that other practitioners turn to us for help when they encounter uncontrollable hemorrhage. They will emphasize that we are the one specialty that covers the gamut of vascular interventions from open surgery and endovascular procedures to medical management. Perhaps some mentors will incorporate my mantra that vascular surgeons “Operate, Dilate, and Medicate.”

However, I suggest that the most satisfying aspect of our profession is not the procedures that we perform but rather the interaction we have with our patients. After all, most of us entered the medical profession to take care of patients, and vascular patients are very special indeed. However, sometimes we established vascular surgeons become too enthralled by technical advances to remember the more humanistic reasons for our being. Also, changes in medical practice and reimbursement have resulted in many being so overworked that we do not have time to enjoy relationships with our patients. Perhaps those who are so burdened should take heed from the stories mentors will relate to inspire these students.

Based on my personal experience I suspect the mentors will say something along the following lines: “Vascular conditions are chronic and are wont to afflict more than one part of the body. Accordingly, we are required to follow most patients for their whole lives (or ours!). Not only do we treat these patients but we also become intimately involved with their families, often treating them as well. Often our ‘treatment’ will not be procedural but rather will involve emotional support of these relatives as they deal with their recuperating or debilitated spouse, sibling, or parent. Those of us who have been in practice for many years will fondly recall patients who have become an integral part of our lives. The patient who undergoes a vascular procedure will return every 6 or 12 months to have their bypass checked or their other carotid assessed.

“We follow asymptomatic small abdominal aneurysms and claudicants. A venous ulcer often recurs and a dialysis patient may require a new intervention. Some patients come to the office so they can be made more secure that their condition has not deteriorated, and the lonely just because we are the only human they interact with on a regular basis. They bring with them their varied life stories and these vignettes become a part of our own fiction. Perhaps we will share with them our own life story. Contrast that to the general surgeon who repairs a hernia and after a few post op visits may never see the patient again.

“Vascular patients may be very young or more commonly very old and come from all walks of life. So the vascular surgeon will learn to calm the crying infant. She will provide careful optimism to allay the fears of a mother who brings in her daughter scarred by a cavernous hemangioma. He or she will reassure the young girl, mortified by embarrassing spider veins, that she will be able to wear a dress to her high school prom. Together with the obstetrician, the vascular surgeon will guide a pregnant woman with a DVT through her entire pregnancy assuring her that both she and her baby will be safe.”

The mentor will re-count how special it was to get a hug from an old lady who he operated on 25 years previously when he was a young surgeon. Or the gratification one gets when a father, after a successful limb revascularization, shows a video of himself walking down the aisle at his daughter’s wedding. Perhaps the mentor will confide her sense of dismay every time a young dialysis patient is admitted for revision of a fistula and the joy she feels when told that her patient has finally received a viable transplant. Year after year the vascular surgeon will follow a patient with early onset, widespread vascular disease whose parents died young from the ravages of familial hyperlipidemia.

He will provide encouragement to help the patient stop smoking and commiserate when a sibling dies from a heart attack. The mentor might relate how she felt when she saved the leg of a soldier injured by a land mine or how she was amazed by the 80-year-old ballroom dancer who danced a few weeks after a below knee amputation.

Mentors will also describe getting to know a patient’s daily routine so they can informatively advise a patient whether it is worth having a procedure to improve quality of life. Or the thrill we get when that patient thanks us for relieving the claudication that prevented gainful employment. We are relieved when a longstanding patient wakes up neurologically intact from an endarterectomy.

However, we are filled with remorse when we inform a family that they have lost their loved one who died from a ruptured aneurysm. Of course, our failures may be devastating but they reinforce our humility when we acknowledge that we have been defeated by a disease that resisted our every effort.

The mentor may also share that “Every Xmas you will collect cards thanking you for saving a life or, out of the blue, receive a carton of fruit from the orchard of a farmer who finally was able to walk amongst her crop. You will pass tissues to the sobbing husband whose wife always accompanied him to his yearly physical, but who recently passed from incurable cancer. You will listen to stories from veterans of past wars. You will see pictures of patients’ children and you will remark how they have grown through the years. A patient will make you look admiringly at their latest puppy or prize-winning pig. You will be given stock advice by a millionaire and you will pay for a taxi for the indigent to get home from your office. You may keep patients waiting while you hear intriguing gossip or wonder just how you can stop the little old lady rambling on about lost loves. You will be charmed by the 98-year-old who makes sure that she has her hair and makeup done prior to coming to see you, and how her face lights up when you pronounce her more beautiful than ever.

“Dear student, the technical aspects of vascular surgery are indeed demanding and exciting. We are invigorated by the knowledge that our expertise saved a life or limb, prevented a stroke or provided the nephrotic with a working fistula. Even the more simple cosmetic procedures give us pleasure. If you still need inspiration to embark on a vascular surgical career I encourage you to read the Presidential address Dr. Bruce J. Brener gave to the Society for Clinical Vascular Surgery in March 1996. His eloquent portrayal of the vascular surgical experience is unmatched (Amer J Surg, 1996; 172:97-9). However, it is our daily and often lifelong interaction with our wonderful patients that so intimately reinforces our humanity and makes this profession so uniquely satisfying.”

This edition of Vascular Specialist is being published early to coincide with the VAM. Since medical students will be attending the meeting I thought this would be a good opportunity to describe an often overlooked reason why, after all my years in practice, I still enjoy being a vascular surgeon. By doing so I hope to encourage these young people to consider a career in vascular surgery.

Some vascular surgeons, with the same goal, have volunteered to mentor these students at the VAM. I suspect most mentors would extoll vascular surgery as unique amongst surgical specialties. They will describe the variety of complex operations as well as advanced endovascular procedures that we perform. Proudly, some mentors will mention that other practitioners turn to us for help when they encounter uncontrollable hemorrhage. They will emphasize that we are the one specialty that covers the gamut of vascular interventions from open surgery and endovascular procedures to medical management. Perhaps some mentors will incorporate my mantra that vascular surgeons “Operate, Dilate, and Medicate.”

However, I suggest that the most satisfying aspect of our profession is not the procedures that we perform but rather the interaction we have with our patients. After all, most of us entered the medical profession to take care of patients, and vascular patients are very special indeed. However, sometimes we established vascular surgeons become too enthralled by technical advances to remember the more humanistic reasons for our being. Also, changes in medical practice and reimbursement have resulted in many being so overworked that we do not have time to enjoy relationships with our patients. Perhaps those who are so burdened should take heed from the stories mentors will relate to inspire these students.

Based on my personal experience I suspect the mentors will say something along the following lines: “Vascular conditions are chronic and are wont to afflict more than one part of the body. Accordingly, we are required to follow most patients for their whole lives (or ours!). Not only do we treat these patients but we also become intimately involved with their families, often treating them as well. Often our ‘treatment’ will not be procedural but rather will involve emotional support of these relatives as they deal with their recuperating or debilitated spouse, sibling, or parent. Those of us who have been in practice for many years will fondly recall patients who have become an integral part of our lives. The patient who undergoes a vascular procedure will return every 6 or 12 months to have their bypass checked or their other carotid assessed.

“We follow asymptomatic small abdominal aneurysms and claudicants. A venous ulcer often recurs and a dialysis patient may require a new intervention. Some patients come to the office so they can be made more secure that their condition has not deteriorated, and the lonely just because we are the only human they interact with on a regular basis. They bring with them their varied life stories and these vignettes become a part of our own fiction. Perhaps we will share with them our own life story. Contrast that to the general surgeon who repairs a hernia and after a few post op visits may never see the patient again.

“Vascular patients may be very young or more commonly very old and come from all walks of life. So the vascular surgeon will learn to calm the crying infant. She will provide careful optimism to allay the fears of a mother who brings in her daughter scarred by a cavernous hemangioma. He or she will reassure the young girl, mortified by embarrassing spider veins, that she will be able to wear a dress to her high school prom. Together with the obstetrician, the vascular surgeon will guide a pregnant woman with a DVT through her entire pregnancy assuring her that both she and her baby will be safe.”

The mentor will re-count how special it was to get a hug from an old lady who he operated on 25 years previously when he was a young surgeon. Or the gratification one gets when a father, after a successful limb revascularization, shows a video of himself walking down the aisle at his daughter’s wedding. Perhaps the mentor will confide her sense of dismay every time a young dialysis patient is admitted for revision of a fistula and the joy she feels when told that her patient has finally received a viable transplant. Year after year the vascular surgeon will follow a patient with early onset, widespread vascular disease whose parents died young from the ravages of familial hyperlipidemia.

He will provide encouragement to help the patient stop smoking and commiserate when a sibling dies from a heart attack. The mentor might relate how she felt when she saved the leg of a soldier injured by a land mine or how she was amazed by the 80-year-old ballroom dancer who danced a few weeks after a below knee amputation.

Mentors will also describe getting to know a patient’s daily routine so they can informatively advise a patient whether it is worth having a procedure to improve quality of life. Or the thrill we get when that patient thanks us for relieving the claudication that prevented gainful employment. We are relieved when a longstanding patient wakes up neurologically intact from an endarterectomy.

However, we are filled with remorse when we inform a family that they have lost their loved one who died from a ruptured aneurysm. Of course, our failures may be devastating but they reinforce our humility when we acknowledge that we have been defeated by a disease that resisted our every effort.

The mentor may also share that “Every Xmas you will collect cards thanking you for saving a life or, out of the blue, receive a carton of fruit from the orchard of a farmer who finally was able to walk amongst her crop. You will pass tissues to the sobbing husband whose wife always accompanied him to his yearly physical, but who recently passed from incurable cancer. You will listen to stories from veterans of past wars. You will see pictures of patients’ children and you will remark how they have grown through the years. A patient will make you look admiringly at their latest puppy or prize-winning pig. You will be given stock advice by a millionaire and you will pay for a taxi for the indigent to get home from your office. You may keep patients waiting while you hear intriguing gossip or wonder just how you can stop the little old lady rambling on about lost loves. You will be charmed by the 98-year-old who makes sure that she has her hair and makeup done prior to coming to see you, and how her face lights up when you pronounce her more beautiful than ever.

“Dear student, the technical aspects of vascular surgery are indeed demanding and exciting. We are invigorated by the knowledge that our expertise saved a life or limb, prevented a stroke or provided the nephrotic with a working fistula. Even the more simple cosmetic procedures give us pleasure. If you still need inspiration to embark on a vascular surgical career I encourage you to read the Presidential address Dr. Bruce J. Brener gave to the Society for Clinical Vascular Surgery in March 1996. His eloquent portrayal of the vascular surgical experience is unmatched (Amer J Surg, 1996; 172:97-9). However, it is our daily and often lifelong interaction with our wonderful patients that so intimately reinforces our humanity and makes this profession so uniquely satisfying.”

This edition of Vascular Specialist is being published early to coincide with the VAM. Since medical students will be attending the meeting I thought this would be a good opportunity to describe an often overlooked reason why, after all my years in practice, I still enjoy being a vascular surgeon. By doing so I hope to encourage these young people to consider a career in vascular surgery.

Some vascular surgeons, with the same goal, have volunteered to mentor these students at the VAM. I suspect most mentors would extoll vascular surgery as unique amongst surgical specialties. They will describe the variety of complex operations as well as advanced endovascular procedures that we perform. Proudly, some mentors will mention that other practitioners turn to us for help when they encounter uncontrollable hemorrhage. They will emphasize that we are the one specialty that covers the gamut of vascular interventions from open surgery and endovascular procedures to medical management. Perhaps some mentors will incorporate my mantra that vascular surgeons “Operate, Dilate, and Medicate.”

However, I suggest that the most satisfying aspect of our profession is not the procedures that we perform but rather the interaction we have with our patients. After all, most of us entered the medical profession to take care of patients, and vascular patients are very special indeed. However, sometimes we established vascular surgeons become too enthralled by technical advances to remember the more humanistic reasons for our being. Also, changes in medical practice and reimbursement have resulted in many being so overworked that we do not have time to enjoy relationships with our patients. Perhaps those who are so burdened should take heed from the stories mentors will relate to inspire these students.

Based on my personal experience I suspect the mentors will say something along the following lines: “Vascular conditions are chronic and are wont to afflict more than one part of the body. Accordingly, we are required to follow most patients for their whole lives (or ours!). Not only do we treat these patients but we also become intimately involved with their families, often treating them as well. Often our ‘treatment’ will not be procedural but rather will involve emotional support of these relatives as they deal with their recuperating or debilitated spouse, sibling, or parent. Those of us who have been in practice for many years will fondly recall patients who have become an integral part of our lives. The patient who undergoes a vascular procedure will return every 6 or 12 months to have their bypass checked or their other carotid assessed.

“We follow asymptomatic small abdominal aneurysms and claudicants. A venous ulcer often recurs and a dialysis patient may require a new intervention. Some patients come to the office so they can be made more secure that their condition has not deteriorated, and the lonely just because we are the only human they interact with on a regular basis. They bring with them their varied life stories and these vignettes become a part of our own fiction. Perhaps we will share with them our own life story. Contrast that to the general surgeon who repairs a hernia and after a few post op visits may never see the patient again.

“Vascular patients may be very young or more commonly very old and come from all walks of life. So the vascular surgeon will learn to calm the crying infant. She will provide careful optimism to allay the fears of a mother who brings in her daughter scarred by a cavernous hemangioma. He or she will reassure the young girl, mortified by embarrassing spider veins, that she will be able to wear a dress to her high school prom. Together with the obstetrician, the vascular surgeon will guide a pregnant woman with a DVT through her entire pregnancy assuring her that both she and her baby will be safe.”

The mentor will re-count how special it was to get a hug from an old lady who he operated on 25 years previously when he was a young surgeon. Or the gratification one gets when a father, after a successful limb revascularization, shows a video of himself walking down the aisle at his daughter’s wedding. Perhaps the mentor will confide her sense of dismay every time a young dialysis patient is admitted for revision of a fistula and the joy she feels when told that her patient has finally received a viable transplant. Year after year the vascular surgeon will follow a patient with early onset, widespread vascular disease whose parents died young from the ravages of familial hyperlipidemia.

He will provide encouragement to help the patient stop smoking and commiserate when a sibling dies from a heart attack. The mentor might relate how she felt when she saved the leg of a soldier injured by a land mine or how she was amazed by the 80-year-old ballroom dancer who danced a few weeks after a below knee amputation.

Mentors will also describe getting to know a patient’s daily routine so they can informatively advise a patient whether it is worth having a procedure to improve quality of life. Or the thrill we get when that patient thanks us for relieving the claudication that prevented gainful employment. We are relieved when a longstanding patient wakes up neurologically intact from an endarterectomy.

However, we are filled with remorse when we inform a family that they have lost their loved one who died from a ruptured aneurysm. Of course, our failures may be devastating but they reinforce our humility when we acknowledge that we have been defeated by a disease that resisted our every effort.

The mentor may also share that “Every Xmas you will collect cards thanking you for saving a life or, out of the blue, receive a carton of fruit from the orchard of a farmer who finally was able to walk amongst her crop. You will pass tissues to the sobbing husband whose wife always accompanied him to his yearly physical, but who recently passed from incurable cancer. You will listen to stories from veterans of past wars. You will see pictures of patients’ children and you will remark how they have grown through the years. A patient will make you look admiringly at their latest puppy or prize-winning pig. You will be given stock advice by a millionaire and you will pay for a taxi for the indigent to get home from your office. You may keep patients waiting while you hear intriguing gossip or wonder just how you can stop the little old lady rambling on about lost loves. You will be charmed by the 98-year-old who makes sure that she has her hair and makeup done prior to coming to see you, and how her face lights up when you pronounce her more beautiful than ever.

“Dear student, the technical aspects of vascular surgery are indeed demanding and exciting. We are invigorated by the knowledge that our expertise saved a life or limb, prevented a stroke or provided the nephrotic with a working fistula. Even the more simple cosmetic procedures give us pleasure. If you still need inspiration to embark on a vascular surgical career I encourage you to read the Presidential address Dr. Bruce J. Brener gave to the Society for Clinical Vascular Surgery in March 1996. His eloquent portrayal of the vascular surgical experience is unmatched (Amer J Surg, 1996; 172:97-9). However, it is our daily and often lifelong interaction with our wonderful patients that so intimately reinforces our humanity and makes this profession so uniquely satisfying.”