Russell Samson, MD

Who in their right mind would organize the main event of a surgeons’ convention around the topic of unnecessary procedures? Surely this would almost certainly guarantee an empty auditorium. But Dr. Peter F. Lawrence, President of the Society for Vascular Surgery, had the wisdom and courage to do just that when he organized the Stanley Crawford Symposium at the recent Vascular Annual Meeting. Amazingly, he was rewarded not with approbation but rather with a standing-room turnout and congratulatory remarks. For Dr. Lawrence had the foresight to realize that vascular surgeons acknowledge that it is not only physicians from other specialties who are guilty of performing unnecessary procedures but also some of our own. Further, he had the insight that the attendees would share his desire to discuss what, in prior years, may have been a taboo subject.

When he first approached me to present at that symposium on the ethics of unnecessary procedures I thought I would produce a talk that would point out how the SVS could help its members reach an ethical high ground. But I soon realized that the SVS cannot be responsible for its members’ ethics. Ethics is, after all, an individual matter. Yes, I am certain that the vast majority of our members are indeed ethical and place their patients’ interests ahead of their own.

However, as in any large group, there will be individuals who value "I" in the word "Individual" as being more important than the "i" in the word "Ethics." "I" becomes "Me" and, unfortunately, "Me" becomes the defining factor in the equation that describes the doctor and patient relationship.

In preparing the talk I was struck that the word Individual provides clues to unethical behavior. The word contains three I’s, and three words that begin with the letter I are primarily responsible for unethical and unnecessary procedures. They are Indifference, Ignorance, and Incompetence. Perhaps the most unethical is the physician who is Indifferent: Indifferent to data, indifferent to results, indifferent to complaints, indifferent to patient suffering. This physician has no moral compass and will do whatever he or she pleases.

However, let’s start with Ignorance. I don’t want to come across as biased against other specialties, but I will not step away from a position I have frequently stated: Some of our colleagues in other specialties are not sufficiently educated in vascular diseases to be able to recognize that they do not have the judgment or skills to offer appropriate treatment. Nor do they recognize when they should refer to a vascular surgeon rather than attempt a procedure they should not be doing. How else can we explain the full metal jacket superficial femoral artery in a patient who was not even complaining of anything but was found to have a stenotic artery on routine testing?

Well, I’ll give the physician the benefit of the doubt. Perhaps the physician is uneducated about the natural history of peripheral arterial disease and believes that he or she was preventing an amputation. However, with some physicians I believe ignorance is not only a choice but an excuse!

Similarly, Incompetence is an individual problem. It seems it is a little-appreciated fact that surgery and endovascular procedures are not generic. Just as not every golfer can play scratch golf and join the professional circuit, not every surgeon or interventionalist is proficient. Rather, some will have bad results and bad results cause more procedures.

By coincidence, there are other factors that begin with the letter I that may promote unnecessary procedures and that are not necessarily related to individual mischief. Perhaps the most important I word is Insensitivity. It is the inability to recognize that one actually is ignorant, incompetent, or lacking in strength of character to the point of being indifferent to the effects of unethical behavior; that one is indifferent to the suffering of others or the moral responsibility of being an ethical physician.

But it’s not only self-driven issues that promote unethical procedures. It’s those other I’s, and first amongst all must be Income, or rather, lack of it. As long as our government does not adequately reimburse us for our work, some physicians will see volume as the only method to rectify the disparity. I believe that there were fewer inappropriate procedures when there were not as many surgeons, cardiologists, and radiologists and when they were all paid more appropriately. Related to Income is the I of Insurance reimbursement, which also drives procedures. We have only to see what happened to atherectomy after it was finally reimbursed. I am not necessarily implying that the tremendous increase in volume is inappropriate but surely it can be explained only by the fact that we are now being paid for a procedure that previously was not being compensated.

I was consulted on a patient who exemplified this point. He had no complaints whatsoever but during a cardiac evaluation was found to have an absent dorsalis pedis pulse. For no apparent reason, he was taken to the privately-owned angiography suite where he had a pedal access procedure to atherectomize an occluded anterior tibial artery. This resulted in an anterior compartment syndrome, yet the interventionalist was still enriched by many thousands of dollars. Of course, Innovations such as atherectomy may be important clinically but they invariably spur increased utilization. There is pressure to be the first to bring a new advance to the community. This may be entirely ethical if one is well trained in the procedure, but is not so if the physician jumps on the bandwagon with minimal instruction. Furthermore, Industry may also be guilty in promoting overuse by advertising benefits beyond what is known about these new procedures and by encouraging adoption with minimal oversight as to credentials. I may be overly cynical but why should Industry care who uses its device as long as it is used?

Inefficient treatments with unacceptable long-term outcomes also pose an ethical dilemma. Perform a highly compensated atherectomy, angioplasty, and stent of a totally occluded tibial artery knowing that one will be back for the next procedure in the not-too-distant future? Alternatively, bypass the blocked artery with a less well paid and time-consuming autogenous vein graft that may last for years?

Further, at first glance you may wonder how I consider Indications as driving unnecessary procedures. But consider a procedure such as renal artery denervation for treatment of hypertension that has, as yet, not proved to be worthwhile.

Couldn’t a physician justify performing it until such time as it is shown to be inappropriate even if that physician may not have much faith in its benefits?

Dr. Lawrence also charged me with evaluating whether there were differences in ethical issues between employed physicians (at universities, for example) and those in community practice who are self-employed. I would suggest that there is such a difference, especially when we evaluate the I of Incentives. And here I refer specifically to relative-value units and academic promotion.

Although I do not have a better method of evaluating work, I believe that institutions that reward employed physicians based on RVUs cause a perverse incentive to do more. Certainly the single physician is not going to be enticed by this manufactured number. Academic promotion may also incentivize a surgeon to do more, especially if it is in the area of research for which the surgeon is renowned. The surgeon who has made a reputation studying surgery for small aneurysms may find the need to operate on ever smaller ones!

Perhaps one of the most important causes of ethical lapses is the absence of oversight in Independent outpatient environments separate from hospitals. This is where most bad things are happening. Here anyone can do anything and the intervention occurs only when a major complication sends the patient to a hospital or a negligent act results in a malpractice suit. As long as the government refuses to credential who can do what in the outpatient setting we may have poorly qualified, immoral doctors let loose on their unsuspecting prey. Physicians from almost every medical specialty are ablating saphenous veins in so-called "vein centers."

Further, some cardiologists without vascular training – and even some surgeons – with little indication are lasering tibials or inserting stents into every known artery in outpatient cath labs.

Fortunately, although the three I’s in the word Individual may explain unnecessary procedures, there is one I word derived from the single I in Ethics that denotes why almost all of us will do what is right. That word is Integrity – the quality of being honest and having strong moral principles – that will prevent us from doing what we know is wrong.

So this leads to Dr. Lawrence’s final charge to the speakers: to come up with three suggestions to help reduce unethical procedures. Although there must be many more, I would suggest the three most important would be the following:

• Only physicians who are board certified by a recognized specialty and who have been appropriately trained and credentialed should be allowed to perform procedures in hospitals and independent facilities.

• Payment must ultimately be based on outcomes where not only the result but also the indication needs to be taken into consideration.

• Medical schools need to provide courses in ethical behavior, which must be conceived as being equally as important as anatomy and physiology.

In conclusion, I congratulate Dr. Lawrence and the SVS VAM organizing committee under the leadership of Dr. Ronald M. Fairman for putting this potentially contentious subject on the program. For by so doing, vascular surgeons demonstrate that we have the courage and ethics to acknowledge some of our shortcomings. At the same time we prove our leadership as the specialty most suited to treat and protect patients with vascular disease.

Who in their right mind would organize the main event of a surgeons’ convention around the topic of unnecessary procedures? Surely this would almost certainly guarantee an empty auditorium. But Dr. Peter F. Lawrence, President of the Society for Vascular Surgery, had the wisdom and courage to do just that when he organized the Stanley Crawford Symposium at the recent Vascular Annual Meeting. Amazingly, he was rewarded not with approbation but rather with a standing-room turnout and congratulatory remarks. For Dr. Lawrence had the foresight to realize that vascular surgeons acknowledge that it is not only physicians from other specialties who are guilty of performing unnecessary procedures but also some of our own. Further, he had the insight that the attendees would share his desire to discuss what, in prior years, may have been a taboo subject.

When he first approached me to present at that symposium on the ethics of unnecessary procedures I thought I would produce a talk that would point out how the SVS could help its members reach an ethical high ground. But I soon realized that the SVS cannot be responsible for its members’ ethics. Ethics is, after all, an individual matter. Yes, I am certain that the vast majority of our members are indeed ethical and place their patients’ interests ahead of their own.

However, as in any large group, there will be individuals who value "I" in the word "Individual" as being more important than the "i" in the word "Ethics." "I" becomes "Me" and, unfortunately, "Me" becomes the defining factor in the equation that describes the doctor and patient relationship.

In preparing the talk I was struck that the word Individual provides clues to unethical behavior. The word contains three I’s, and three words that begin with the letter I are primarily responsible for unethical and unnecessary procedures. They are Indifference, Ignorance, and Incompetence. Perhaps the most unethical is the physician who is Indifferent: Indifferent to data, indifferent to results, indifferent to complaints, indifferent to patient suffering. This physician has no moral compass and will do whatever he or she pleases.

However, let’s start with Ignorance. I don’t want to come across as biased against other specialties, but I will not step away from a position I have frequently stated: Some of our colleagues in other specialties are not sufficiently educated in vascular diseases to be able to recognize that they do not have the judgment or skills to offer appropriate treatment. Nor do they recognize when they should refer to a vascular surgeon rather than attempt a procedure they should not be doing. How else can we explain the full metal jacket superficial femoral artery in a patient who was not even complaining of anything but was found to have a stenotic artery on routine testing?

Well, I’ll give the physician the benefit of the doubt. Perhaps the physician is uneducated about the natural history of peripheral arterial disease and believes that he or she was preventing an amputation. However, with some physicians I believe ignorance is not only a choice but an excuse!

Similarly, Incompetence is an individual problem. It seems it is a little-appreciated fact that surgery and endovascular procedures are not generic. Just as not every golfer can play scratch golf and join the professional circuit, not every surgeon or interventionalist is proficient. Rather, some will have bad results and bad results cause more procedures.

By coincidence, there are other factors that begin with the letter I that may promote unnecessary procedures and that are not necessarily related to individual mischief. Perhaps the most important I word is Insensitivity. It is the inability to recognize that one actually is ignorant, incompetent, or lacking in strength of character to the point of being indifferent to the effects of unethical behavior; that one is indifferent to the suffering of others or the moral responsibility of being an ethical physician.

But it’s not only self-driven issues that promote unethical procedures. It’s those other I’s, and first amongst all must be Income, or rather, lack of it. As long as our government does not adequately reimburse us for our work, some physicians will see volume as the only method to rectify the disparity. I believe that there were fewer inappropriate procedures when there were not as many surgeons, cardiologists, and radiologists and when they were all paid more appropriately. Related to Income is the I of Insurance reimbursement, which also drives procedures. We have only to see what happened to atherectomy after it was finally reimbursed. I am not necessarily implying that the tremendous increase in volume is inappropriate but surely it can be explained only by the fact that we are now being paid for a procedure that previously was not being compensated.

I was consulted on a patient who exemplified this point. He had no complaints whatsoever but during a cardiac evaluation was found to have an absent dorsalis pedis pulse. For no apparent reason, he was taken to the privately-owned angiography suite where he had a pedal access procedure to atherectomize an occluded anterior tibial artery. This resulted in an anterior compartment syndrome, yet the interventionalist was still enriched by many thousands of dollars. Of course, Innovations such as atherectomy may be important clinically but they invariably spur increased utilization. There is pressure to be the first to bring a new advance to the community. This may be entirely ethical if one is well trained in the procedure, but is not so if the physician jumps on the bandwagon with minimal instruction. Furthermore, Industry may also be guilty in promoting overuse by advertising benefits beyond what is known about these new procedures and by encouraging adoption with minimal oversight as to credentials. I may be overly cynical but why should Industry care who uses its device as long as it is used?

Inefficient treatments with unacceptable long-term outcomes also pose an ethical dilemma. Perform a highly compensated atherectomy, angioplasty, and stent of a totally occluded tibial artery knowing that one will be back for the next procedure in the not-too-distant future? Alternatively, bypass the blocked artery with a less well paid and time-consuming autogenous vein graft that may last for years?

Further, at first glance you may wonder how I consider Indications as driving unnecessary procedures. But consider a procedure such as renal artery denervation for treatment of hypertension that has, as yet, not proved to be worthwhile.

Couldn’t a physician justify performing it until such time as it is shown to be inappropriate even if that physician may not have much faith in its benefits?

Dr. Lawrence also charged me with evaluating whether there were differences in ethical issues between employed physicians (at universities, for example) and those in community practice who are self-employed. I would suggest that there is such a difference, especially when we evaluate the I of Incentives. And here I refer specifically to relative-value units and academic promotion.

Although I do not have a better method of evaluating work, I believe that institutions that reward employed physicians based on RVUs cause a perverse incentive to do more. Certainly the single physician is not going to be enticed by this manufactured number. Academic promotion may also incentivize a surgeon to do more, especially if it is in the area of research for which the surgeon is renowned. The surgeon who has made a reputation studying surgery for small aneurysms may find the need to operate on ever smaller ones!

Perhaps one of the most important causes of ethical lapses is the absence of oversight in Independent outpatient environments separate from hospitals. This is where most bad things are happening. Here anyone can do anything and the intervention occurs only when a major complication sends the patient to a hospital or a negligent act results in a malpractice suit. As long as the government refuses to credential who can do what in the outpatient setting we may have poorly qualified, immoral doctors let loose on their unsuspecting prey. Physicians from almost every medical specialty are ablating saphenous veins in so-called "vein centers."

Further, some cardiologists without vascular training – and even some surgeons – with little indication are lasering tibials or inserting stents into every known artery in outpatient cath labs.

Fortunately, although the three I’s in the word Individual may explain unnecessary procedures, there is one I word derived from the single I in Ethics that denotes why almost all of us will do what is right. That word is Integrity – the quality of being honest and having strong moral principles – that will prevent us from doing what we know is wrong.

So this leads to Dr. Lawrence’s final charge to the speakers: to come up with three suggestions to help reduce unethical procedures. Although there must be many more, I would suggest the three most important would be the following:

• Only physicians who are board certified by a recognized specialty and who have been appropriately trained and credentialed should be allowed to perform procedures in hospitals and independent facilities.

• Payment must ultimately be based on outcomes where not only the result but also the indication needs to be taken into consideration.

• Medical schools need to provide courses in ethical behavior, which must be conceived as being equally as important as anatomy and physiology.

In conclusion, I congratulate Dr. Lawrence and the SVS VAM organizing committee under the leadership of Dr. Ronald M. Fairman for putting this potentially contentious subject on the program. For by so doing, vascular surgeons demonstrate that we have the courage and ethics to acknowledge some of our shortcomings. At the same time we prove our leadership as the specialty most suited to treat and protect patients with vascular disease.

Who in their right mind would organize the main event of a surgeons’ convention around the topic of unnecessary procedures? Surely this would almost certainly guarantee an empty auditorium. But Dr. Peter F. Lawrence, President of the Society for Vascular Surgery, had the wisdom and courage to do just that when he organized the Stanley Crawford Symposium at the recent Vascular Annual Meeting. Amazingly, he was rewarded not with approbation but rather with a standing-room turnout and congratulatory remarks. For Dr. Lawrence had the foresight to realize that vascular surgeons acknowledge that it is not only physicians from other specialties who are guilty of performing unnecessary procedures but also some of our own. Further, he had the insight that the attendees would share his desire to discuss what, in prior years, may have been a taboo subject.

When he first approached me to present at that symposium on the ethics of unnecessary procedures I thought I would produce a talk that would point out how the SVS could help its members reach an ethical high ground. But I soon realized that the SVS cannot be responsible for its members’ ethics. Ethics is, after all, an individual matter. Yes, I am certain that the vast majority of our members are indeed ethical and place their patients’ interests ahead of their own.

However, as in any large group, there will be individuals who value "I" in the word "Individual" as being more important than the "i" in the word "Ethics." "I" becomes "Me" and, unfortunately, "Me" becomes the defining factor in the equation that describes the doctor and patient relationship.

In preparing the talk I was struck that the word Individual provides clues to unethical behavior. The word contains three I’s, and three words that begin with the letter I are primarily responsible for unethical and unnecessary procedures. They are Indifference, Ignorance, and Incompetence. Perhaps the most unethical is the physician who is Indifferent: Indifferent to data, indifferent to results, indifferent to complaints, indifferent to patient suffering. This physician has no moral compass and will do whatever he or she pleases.

However, let’s start with Ignorance. I don’t want to come across as biased against other specialties, but I will not step away from a position I have frequently stated: Some of our colleagues in other specialties are not sufficiently educated in vascular diseases to be able to recognize that they do not have the judgment or skills to offer appropriate treatment. Nor do they recognize when they should refer to a vascular surgeon rather than attempt a procedure they should not be doing. How else can we explain the full metal jacket superficial femoral artery in a patient who was not even complaining of anything but was found to have a stenotic artery on routine testing?

Well, I’ll give the physician the benefit of the doubt. Perhaps the physician is uneducated about the natural history of peripheral arterial disease and believes that he or she was preventing an amputation. However, with some physicians I believe ignorance is not only a choice but an excuse!

Similarly, Incompetence is an individual problem. It seems it is a little-appreciated fact that surgery and endovascular procedures are not generic. Just as not every golfer can play scratch golf and join the professional circuit, not every surgeon or interventionalist is proficient. Rather, some will have bad results and bad results cause more procedures.

By coincidence, there are other factors that begin with the letter I that may promote unnecessary procedures and that are not necessarily related to individual mischief. Perhaps the most important I word is Insensitivity. It is the inability to recognize that one actually is ignorant, incompetent, or lacking in strength of character to the point of being indifferent to the effects of unethical behavior; that one is indifferent to the suffering of others or the moral responsibility of being an ethical physician.

But it’s not only self-driven issues that promote unethical procedures. It’s those other I’s, and first amongst all must be Income, or rather, lack of it. As long as our government does not adequately reimburse us for our work, some physicians will see volume as the only method to rectify the disparity. I believe that there were fewer inappropriate procedures when there were not as many surgeons, cardiologists, and radiologists and when they were all paid more appropriately. Related to Income is the I of Insurance reimbursement, which also drives procedures. We have only to see what happened to atherectomy after it was finally reimbursed. I am not necessarily implying that the tremendous increase in volume is inappropriate but surely it can be explained only by the fact that we are now being paid for a procedure that previously was not being compensated.

I was consulted on a patient who exemplified this point. He had no complaints whatsoever but during a cardiac evaluation was found to have an absent dorsalis pedis pulse. For no apparent reason, he was taken to the privately-owned angiography suite where he had a pedal access procedure to atherectomize an occluded anterior tibial artery. This resulted in an anterior compartment syndrome, yet the interventionalist was still enriched by many thousands of dollars. Of course, Innovations such as atherectomy may be important clinically but they invariably spur increased utilization. There is pressure to be the first to bring a new advance to the community. This may be entirely ethical if one is well trained in the procedure, but is not so if the physician jumps on the bandwagon with minimal instruction. Furthermore, Industry may also be guilty in promoting overuse by advertising benefits beyond what is known about these new procedures and by encouraging adoption with minimal oversight as to credentials. I may be overly cynical but why should Industry care who uses its device as long as it is used?

Inefficient treatments with unacceptable long-term outcomes also pose an ethical dilemma. Perform a highly compensated atherectomy, angioplasty, and stent of a totally occluded tibial artery knowing that one will be back for the next procedure in the not-too-distant future? Alternatively, bypass the blocked artery with a less well paid and time-consuming autogenous vein graft that may last for years?

Further, at first glance you may wonder how I consider Indications as driving unnecessary procedures. But consider a procedure such as renal artery denervation for treatment of hypertension that has, as yet, not proved to be worthwhile.

Couldn’t a physician justify performing it until such time as it is shown to be inappropriate even if that physician may not have much faith in its benefits?

Dr. Lawrence also charged me with evaluating whether there were differences in ethical issues between employed physicians (at universities, for example) and those in community practice who are self-employed. I would suggest that there is such a difference, especially when we evaluate the I of Incentives. And here I refer specifically to relative-value units and academic promotion.

Although I do not have a better method of evaluating work, I believe that institutions that reward employed physicians based on RVUs cause a perverse incentive to do more. Certainly the single physician is not going to be enticed by this manufactured number. Academic promotion may also incentivize a surgeon to do more, especially if it is in the area of research for which the surgeon is renowned. The surgeon who has made a reputation studying surgery for small aneurysms may find the need to operate on ever smaller ones!

Perhaps one of the most important causes of ethical lapses is the absence of oversight in Independent outpatient environments separate from hospitals. This is where most bad things are happening. Here anyone can do anything and the intervention occurs only when a major complication sends the patient to a hospital or a negligent act results in a malpractice suit. As long as the government refuses to credential who can do what in the outpatient setting we may have poorly qualified, immoral doctors let loose on their unsuspecting prey. Physicians from almost every medical specialty are ablating saphenous veins in so-called "vein centers."

Further, some cardiologists without vascular training – and even some surgeons – with little indication are lasering tibials or inserting stents into every known artery in outpatient cath labs.

Fortunately, although the three I’s in the word Individual may explain unnecessary procedures, there is one I word derived from the single I in Ethics that denotes why almost all of us will do what is right. That word is Integrity – the quality of being honest and having strong moral principles – that will prevent us from doing what we know is wrong.

So this leads to Dr. Lawrence’s final charge to the speakers: to come up with three suggestions to help reduce unethical procedures. Although there must be many more, I would suggest the three most important would be the following:

• Only physicians who are board certified by a recognized specialty and who have been appropriately trained and credentialed should be allowed to perform procedures in hospitals and independent facilities.

• Payment must ultimately be based on outcomes where not only the result but also the indication needs to be taken into consideration.

• Medical schools need to provide courses in ethical behavior, which must be conceived as being equally as important as anatomy and physiology.

In conclusion, I congratulate Dr. Lawrence and the SVS VAM organizing committee under the leadership of Dr. Ronald M. Fairman for putting this potentially contentious subject on the program. For by so doing, vascular surgeons demonstrate that we have the courage and ethics to acknowledge some of our shortcomings. At the same time we prove our leadership as the specialty most suited to treat and protect patients with vascular disease.

I must admit that Shakespeare was not one of my favorite subjects at school. However, his words have relevance to some of my thoughts about vascular surgical issues. In a previous editorial I adopted his words to describe how, with the increasing representation of women and minorities, we have matured from a "Band of Brothers" to a "Band of Brothers and Sisters." Now, Shakespeare once again resonates with Hamlet’s inward-looking and existential "To be or not to be?"

For vascular surgeons are in an introspective mood as we re-evaluate our collaboration with other specialties to determine the best treatments for our patients. Increasingly we are developing our own guidelines, white papers, and position papers rather than appending our insights to initiatives originated by the American College of Cardiology. Whereas we were fundamental in the formation of the original "Trans-Atlantic Societal Consensus (TASC)¹," SVS as well as the European Society for Vascular Surgery (ESVS) and the World Federation of Vascular Societies (WFVS) have declined participation in further TASC iterations.

The fracturing of TASC began with controversy and strong differences of opinions raised by TASC IIb. Fundamental issues of process, governance, conflict of interest (COI), evidence base, and appropriate representation were raised and debated. In the end the SVS and other international vascular societies determined the TASC construct was not workable, and a new Global Vascular Guidelines initiative was born.

Under the co-leadership of Mike Conte (SVS), Andrew Bradbury (WFVS), and Philippe Kolh (ESVS), our surgical societies are developing practice guidelines reflecting the international consensus of vascular surgeons as well as other specialists directly involved in the care of vascular patients. This group is committed to an evidence-based approach and a strong COI policy that will hopefully insulate treatment algorithms from what many believed was the excessive influence of industry and "market forces" reflected in TASC IIb.

The proposed guidelines will no longer simply be lesion based. Rather, they will evaluate the patient and disease process, taking into account the potential benefit of both endo and open vascular procedures. It’s not that vascular surgeons are unsupportive of endo techniques. In fact many endo procedures have emerged from the inventive minds of vascular surgeons from all over the world. But only surgeons who can offer all treatment modalities can fully appreciate when an open procedure is still the best option, or that the disease process may be more benign than the planned treatment.

What we have gained and what have we lost by our withdrawal from communal involvement with other specialists is not altogether clear. Vascular surgeons have pioneered many of the major advances in our understanding and treatment of vascular diseases from the various bypass operations, through vascular lab testing to advances in endovascular therapy.

Nonetheless, we should not discount the contributions of our medical colleagues. Physicians from other disciplines pioneered endovascular therapies that many of our vascular surgeon predecessors claimed would never work. Medical management prevents thrombosis, keeps our patients alive and our bypasses and stents open. We must also acknowledge that there are many highly qualified physicians in other specialties who are equally devoted to improving the care of patients with vascular disease.

At present there are almost 5,000 U.S. vascular surgeons, and even more globally. Almost every developed nation has a vascular surgical society, and some even have a designated specialty of vascular surgery. Yet it seems we still do not have the numbers to be universally recognized for our expertise. However, our comprehensive training and knowledge have given us the self-assurance and confidence to claim that our specialty is uniquely qualified to take the leadership position in the management of vascular conditions.

So, "IIb, unquestionably, will not be" but, unlike Hamlet, we need not despair. TASC may have failed but we will not!

1) Eur. J. Vasc. Endovasc. Surg. 2007;33 Suppl 1:S1-75.

I must admit that Shakespeare was not one of my favorite subjects at school. However, his words have relevance to some of my thoughts about vascular surgical issues. In a previous editorial I adopted his words to describe how, with the increasing representation of women and minorities, we have matured from a "Band of Brothers" to a "Band of Brothers and Sisters." Now, Shakespeare once again resonates with Hamlet’s inward-looking and existential "To be or not to be?"

For vascular surgeons are in an introspective mood as we re-evaluate our collaboration with other specialties to determine the best treatments for our patients. Increasingly we are developing our own guidelines, white papers, and position papers rather than appending our insights to initiatives originated by the American College of Cardiology. Whereas we were fundamental in the formation of the original "Trans-Atlantic Societal Consensus (TASC)¹," SVS as well as the European Society for Vascular Surgery (ESVS) and the World Federation of Vascular Societies (WFVS) have declined participation in further TASC iterations.

The fracturing of TASC began with controversy and strong differences of opinions raised by TASC IIb. Fundamental issues of process, governance, conflict of interest (COI), evidence base, and appropriate representation were raised and debated. In the end the SVS and other international vascular societies determined the TASC construct was not workable, and a new Global Vascular Guidelines initiative was born.

Under the co-leadership of Mike Conte (SVS), Andrew Bradbury (WFVS), and Philippe Kolh (ESVS), our surgical societies are developing practice guidelines reflecting the international consensus of vascular surgeons as well as other specialists directly involved in the care of vascular patients. This group is committed to an evidence-based approach and a strong COI policy that will hopefully insulate treatment algorithms from what many believed was the excessive influence of industry and "market forces" reflected in TASC IIb.

The proposed guidelines will no longer simply be lesion based. Rather, they will evaluate the patient and disease process, taking into account the potential benefit of both endo and open vascular procedures. It’s not that vascular surgeons are unsupportive of endo techniques. In fact many endo procedures have emerged from the inventive minds of vascular surgeons from all over the world. But only surgeons who can offer all treatment modalities can fully appreciate when an open procedure is still the best option, or that the disease process may be more benign than the planned treatment.

What we have gained and what have we lost by our withdrawal from communal involvement with other specialists is not altogether clear. Vascular surgeons have pioneered many of the major advances in our understanding and treatment of vascular diseases from the various bypass operations, through vascular lab testing to advances in endovascular therapy.

Nonetheless, we should not discount the contributions of our medical colleagues. Physicians from other disciplines pioneered endovascular therapies that many of our vascular surgeon predecessors claimed would never work. Medical management prevents thrombosis, keeps our patients alive and our bypasses and stents open. We must also acknowledge that there are many highly qualified physicians in other specialties who are equally devoted to improving the care of patients with vascular disease.

At present there are almost 5,000 U.S. vascular surgeons, and even more globally. Almost every developed nation has a vascular surgical society, and some even have a designated specialty of vascular surgery. Yet it seems we still do not have the numbers to be universally recognized for our expertise. However, our comprehensive training and knowledge have given us the self-assurance and confidence to claim that our specialty is uniquely qualified to take the leadership position in the management of vascular conditions.

So, "IIb, unquestionably, will not be" but, unlike Hamlet, we need not despair. TASC may have failed but we will not!

1) Eur. J. Vasc. Endovasc. Surg. 2007;33 Suppl 1:S1-75.

I must admit that Shakespeare was not one of my favorite subjects at school. However, his words have relevance to some of my thoughts about vascular surgical issues. In a previous editorial I adopted his words to describe how, with the increasing representation of women and minorities, we have matured from a "Band of Brothers" to a "Band of Brothers and Sisters." Now, Shakespeare once again resonates with Hamlet’s inward-looking and existential "To be or not to be?"

For vascular surgeons are in an introspective mood as we re-evaluate our collaboration with other specialties to determine the best treatments for our patients. Increasingly we are developing our own guidelines, white papers, and position papers rather than appending our insights to initiatives originated by the American College of Cardiology. Whereas we were fundamental in the formation of the original "Trans-Atlantic Societal Consensus (TASC)¹," SVS as well as the European Society for Vascular Surgery (ESVS) and the World Federation of Vascular Societies (WFVS) have declined participation in further TASC iterations.

The fracturing of TASC began with controversy and strong differences of opinions raised by TASC IIb. Fundamental issues of process, governance, conflict of interest (COI), evidence base, and appropriate representation were raised and debated. In the end the SVS and other international vascular societies determined the TASC construct was not workable, and a new Global Vascular Guidelines initiative was born.

Under the co-leadership of Mike Conte (SVS), Andrew Bradbury (WFVS), and Philippe Kolh (ESVS), our surgical societies are developing practice guidelines reflecting the international consensus of vascular surgeons as well as other specialists directly involved in the care of vascular patients. This group is committed to an evidence-based approach and a strong COI policy that will hopefully insulate treatment algorithms from what many believed was the excessive influence of industry and "market forces" reflected in TASC IIb.

The proposed guidelines will no longer simply be lesion based. Rather, they will evaluate the patient and disease process, taking into account the potential benefit of both endo and open vascular procedures. It’s not that vascular surgeons are unsupportive of endo techniques. In fact many endo procedures have emerged from the inventive minds of vascular surgeons from all over the world. But only surgeons who can offer all treatment modalities can fully appreciate when an open procedure is still the best option, or that the disease process may be more benign than the planned treatment.

What we have gained and what have we lost by our withdrawal from communal involvement with other specialists is not altogether clear. Vascular surgeons have pioneered many of the major advances in our understanding and treatment of vascular diseases from the various bypass operations, through vascular lab testing to advances in endovascular therapy.

Nonetheless, we should not discount the contributions of our medical colleagues. Physicians from other disciplines pioneered endovascular therapies that many of our vascular surgeon predecessors claimed would never work. Medical management prevents thrombosis, keeps our patients alive and our bypasses and stents open. We must also acknowledge that there are many highly qualified physicians in other specialties who are equally devoted to improving the care of patients with vascular disease.

At present there are almost 5,000 U.S. vascular surgeons, and even more globally. Almost every developed nation has a vascular surgical society, and some even have a designated specialty of vascular surgery. Yet it seems we still do not have the numbers to be universally recognized for our expertise. However, our comprehensive training and knowledge have given us the self-assurance and confidence to claim that our specialty is uniquely qualified to take the leadership position in the management of vascular conditions.

So, "IIb, unquestionably, will not be" but, unlike Hamlet, we need not despair. TASC may have failed but we will not!

1) Eur. J. Vasc. Endovasc. Surg. 2007;33 Suppl 1:S1-75.

I recently returned from Professor Roger Greenhalgh's excellent Charing Cross meeting in London. A plethora of exciting new developments was presented to almost 4,000 attendees from all over the world. As impressive as these presentations may have been, I became acutely aware that most of what was presented consisted of short-term data. Perhaps I am dating myself, but before the advent of endovascular technology, one could hardly get a presentation accepted at a major meeting without long-term, preferably 5-year-data.

Dr. D. Emerick Szilagyi, a pioneer of vascular surgery and former editor of the Journal of Vascular Surgery, having experienced the early failure of homografts, was renowned for stating that a new treatment required a 5-year track record before it could be deemed beneficial. Perhaps 5 years was chosen because that was an average life span for patients undergoing what was then major vascular surgery. Or was it because we knew that, at least in the short term, most vascular procedures worked but needed multiple revisions. Who would have anticipated that after aortic endografts were first inserted, we would soon be dealing with a new "condition," which we now refer to as an endoleak?

Regardless, at recent symposia and in our journals, we seem to receive predominately premature information. It is now commonplace to be presented with 1-year outcomes but more often with 90-, 30-, or even 7-day results. An even shorter interval is described in reports detailing "technical success."

It is as if we have won a victory of sorts when we do something that actually works until the end of the procedure! It appears that the announcement of every new product or treatment is accompanied by a proclamation of a new "breakthrough," a "paradigm shift," or a new major addition to our armamentarium. I wonder if we have succumbed to an embarrassing new malady that I will euphemistically describe as "premature congratulation."

I find these reports particularly common in cardiology and interventional radiology journals. They are also appearing with increasing frequency in our vascular literature and at scientific meetings. In fact, my own presentation at this year?s Charing Cross meeting was only a 4-year comparison of heparin bonded ePTFE vs. standard ePTFE. Perhaps even this could be considered to be too short a follow-up. Furthermore, can we forget how our popular press touted the advent of carotid stents when the original SAPPHIRE paper was presented? Using premature data, the newspaper USA Today announced the demise of carotid endarterectomy. Another example is how ezetimibe became a best-selling drug to treat hypercholesterolemia, and it still has yet to show any clinical benefit (JAMA 2014;311:11279 [doi:10.1001/jama.2014.2896]).

Admittedly, it may be important for new technologies or methods to be announced before they have been proven to be helpful, since these new "advances" may inspire more fruitful modifications to established procedures. On occasion, they may also uncover new avenues of investigation which may lead to new inventions or techniques. The question remains: how should we as vascular physicians respond to short-term data? Should we embrace new devices before they have stood the test of time? Or should we avoid their use, perhaps preventing a patient from receiving a life- or limb-saving procedure simply because we are unsure of its longevity or unforeseeable complication?

This is a quandary that our meeting organizers and journal editors must also face. Should they reject new material until it has been proven to have lasting benefit? I believe that the answer is no, but would interject a cautionary note in the general adoption of new methods until more definitive data are available. I have had personal experience with premature adoption of new technology when I was guilty of publishing excellent 1-year data with a balloon system only to later publish disappointing 2-year results. Of course, there is a benefit to having to retract earlier reports -- you become the author of two peer-reviewed manuscripts. Sarcasm aside, we do need to be kept informed about all new developments in our field. But it may be beneficial for proponents and experts to emphasize the true potential as well as possible drawbacks and complications of the new methods. It is also our responsibility to maintain an open mind.

While we can be cautiously optimistic, it is inadvisable to rush headlong into performing every new modality. Early adopters should be reminded that there is little to celebrate when a procedure?s benefits are brief. To avoid "premature congratulation," follow the slow and steady mantra that has served us well in other areas of life.

I recently returned from Professor Roger Greenhalgh's excellent Charing Cross meeting in London. A plethora of exciting new developments was presented to almost 4,000 attendees from all over the world. As impressive as these presentations may have been, I became acutely aware that most of what was presented consisted of short-term data. Perhaps I am dating myself, but before the advent of endovascular technology, one could hardly get a presentation accepted at a major meeting without long-term, preferably 5-year-data.

Dr. D. Emerick Szilagyi, a pioneer of vascular surgery and former editor of the Journal of Vascular Surgery, having experienced the early failure of homografts, was renowned for stating that a new treatment required a 5-year track record before it could be deemed beneficial. Perhaps 5 years was chosen because that was an average life span for patients undergoing what was then major vascular surgery. Or was it because we knew that, at least in the short term, most vascular procedures worked but needed multiple revisions. Who would have anticipated that after aortic endografts were first inserted, we would soon be dealing with a new "condition," which we now refer to as an endoleak?

Regardless, at recent symposia and in our journals, we seem to receive predominately premature information. It is now commonplace to be presented with 1-year outcomes but more often with 90-, 30-, or even 7-day results. An even shorter interval is described in reports detailing "technical success."

It is as if we have won a victory of sorts when we do something that actually works until the end of the procedure! It appears that the announcement of every new product or treatment is accompanied by a proclamation of a new "breakthrough," a "paradigm shift," or a new major addition to our armamentarium. I wonder if we have succumbed to an embarrassing new malady that I will euphemistically describe as "premature congratulation."

I find these reports particularly common in cardiology and interventional radiology journals. They are also appearing with increasing frequency in our vascular literature and at scientific meetings. In fact, my own presentation at this year?s Charing Cross meeting was only a 4-year comparison of heparin bonded ePTFE vs. standard ePTFE. Perhaps even this could be considered to be too short a follow-up. Furthermore, can we forget how our popular press touted the advent of carotid stents when the original SAPPHIRE paper was presented? Using premature data, the newspaper USA Today announced the demise of carotid endarterectomy. Another example is how ezetimibe became a best-selling drug to treat hypercholesterolemia, and it still has yet to show any clinical benefit (JAMA 2014;311:11279 [doi:10.1001/jama.2014.2896]).

Admittedly, it may be important for new technologies or methods to be announced before they have been proven to be helpful, since these new "advances" may inspire more fruitful modifications to established procedures. On occasion, they may also uncover new avenues of investigation which may lead to new inventions or techniques. The question remains: how should we as vascular physicians respond to short-term data? Should we embrace new devices before they have stood the test of time? Or should we avoid their use, perhaps preventing a patient from receiving a life- or limb-saving procedure simply because we are unsure of its longevity or unforeseeable complication?

This is a quandary that our meeting organizers and journal editors must also face. Should they reject new material until it has been proven to have lasting benefit? I believe that the answer is no, but would interject a cautionary note in the general adoption of new methods until more definitive data are available. I have had personal experience with premature adoption of new technology when I was guilty of publishing excellent 1-year data with a balloon system only to later publish disappointing 2-year results. Of course, there is a benefit to having to retract earlier reports -- you become the author of two peer-reviewed manuscripts. Sarcasm aside, we do need to be kept informed about all new developments in our field. But it may be beneficial for proponents and experts to emphasize the true potential as well as possible drawbacks and complications of the new methods. It is also our responsibility to maintain an open mind.

While we can be cautiously optimistic, it is inadvisable to rush headlong into performing every new modality. Early adopters should be reminded that there is little to celebrate when a procedure?s benefits are brief. To avoid "premature congratulation," follow the slow and steady mantra that has served us well in other areas of life.

I recently returned from Professor Roger Greenhalgh's excellent Charing Cross meeting in London. A plethora of exciting new developments was presented to almost 4,000 attendees from all over the world. As impressive as these presentations may have been, I became acutely aware that most of what was presented consisted of short-term data. Perhaps I am dating myself, but before the advent of endovascular technology, one could hardly get a presentation accepted at a major meeting without long-term, preferably 5-year-data.

Dr. D. Emerick Szilagyi, a pioneer of vascular surgery and former editor of the Journal of Vascular Surgery, having experienced the early failure of homografts, was renowned for stating that a new treatment required a 5-year track record before it could be deemed beneficial. Perhaps 5 years was chosen because that was an average life span for patients undergoing what was then major vascular surgery. Or was it because we knew that, at least in the short term, most vascular procedures worked but needed multiple revisions. Who would have anticipated that after aortic endografts were first inserted, we would soon be dealing with a new "condition," which we now refer to as an endoleak?

Regardless, at recent symposia and in our journals, we seem to receive predominately premature information. It is now commonplace to be presented with 1-year outcomes but more often with 90-, 30-, or even 7-day results. An even shorter interval is described in reports detailing "technical success."

It is as if we have won a victory of sorts when we do something that actually works until the end of the procedure! It appears that the announcement of every new product or treatment is accompanied by a proclamation of a new "breakthrough," a "paradigm shift," or a new major addition to our armamentarium. I wonder if we have succumbed to an embarrassing new malady that I will euphemistically describe as "premature congratulation."

I find these reports particularly common in cardiology and interventional radiology journals. They are also appearing with increasing frequency in our vascular literature and at scientific meetings. In fact, my own presentation at this year?s Charing Cross meeting was only a 4-year comparison of heparin bonded ePTFE vs. standard ePTFE. Perhaps even this could be considered to be too short a follow-up. Furthermore, can we forget how our popular press touted the advent of carotid stents when the original SAPPHIRE paper was presented? Using premature data, the newspaper USA Today announced the demise of carotid endarterectomy. Another example is how ezetimibe became a best-selling drug to treat hypercholesterolemia, and it still has yet to show any clinical benefit (JAMA 2014;311:11279 [doi:10.1001/jama.2014.2896]).

Admittedly, it may be important for new technologies or methods to be announced before they have been proven to be helpful, since these new "advances" may inspire more fruitful modifications to established procedures. On occasion, they may also uncover new avenues of investigation which may lead to new inventions or techniques. The question remains: how should we as vascular physicians respond to short-term data? Should we embrace new devices before they have stood the test of time? Or should we avoid their use, perhaps preventing a patient from receiving a life- or limb-saving procedure simply because we are unsure of its longevity or unforeseeable complication?

This is a quandary that our meeting organizers and journal editors must also face. Should they reject new material until it has been proven to have lasting benefit? I believe that the answer is no, but would interject a cautionary note in the general adoption of new methods until more definitive data are available. I have had personal experience with premature adoption of new technology when I was guilty of publishing excellent 1-year data with a balloon system only to later publish disappointing 2-year results. Of course, there is a benefit to having to retract earlier reports -- you become the author of two peer-reviewed manuscripts. Sarcasm aside, we do need to be kept informed about all new developments in our field. But it may be beneficial for proponents and experts to emphasize the true potential as well as possible drawbacks and complications of the new methods. It is also our responsibility to maintain an open mind.

While we can be cautiously optimistic, it is inadvisable to rush headlong into performing every new modality. Early adopters should be reminded that there is little to celebrate when a procedure?s benefits are brief. To avoid "premature congratulation," follow the slow and steady mantra that has served us well in other areas of life.

I am ashamed to admit this, but I think I am becoming an "anti-semantic!" Surely it is scandalous that an editor is beginning to find some ordinary words and phrases obnoxious? But consider the following excerpt from an Oct. 30 Bloomberg News article by Peter Waldman: "The American College of Cardiology is changing its guidelines for when implanting coronary stents is appropriate – by banishing the term ‘Inappropriate’ (replacing it with ‘Rarely Appropriate’). Another category in cases in which there is medical doubt will switch from ‘Uncertain’ to ‘May Be Appropriate’"

So with the sweep of the pen or rather the delete key on the computer, thousands of coronary stents with no valid indication may suddenly be justified. I assume that these heart specialists also believe that peripheral stents placed in asymptomatic patients with normal arteries may be appropriate.

It’s not surprising that the specialty that pioneered endovascular procedures for anyone with a heart or leg would also adopt euphemisms to justify unsupported interventions. Remember, this is the same group that popularized the words "high-risk" in order to promote the widespread adoption of carotid stenting.

According to the Bloomberg News article (titled, Doctors Use Euphemism for $2.4 Billion in Needless Stents), Dr. Robert Hendel, a cardiologist at the University of Miami, stated that "A lot of regulators and payers were saying if it’s inappropriate why should we pay for it and why should it be done at all?" I must admit I agree with the regulators and payers. Why should an insurance company or Medicare pay for a procedure that was completely unjustified?

Like most vascular surgeons, I have seen countless patients with stents up and down their lower extremity arteries, all occluded and now with limb-threatening ischemia. Invariably the patients were asymptomatic before the first stent but told that if they did not have the stent they would require an amputation. Now because of their "Rarely Appropriate" treatment they will actually lose their leg.

Dr. Hendel stated that the word "inappropriate" caused a "visceral response" which I presume implied that cardiologists didn’t like being told that what they may be doing in some cases was "wrong" (they haven’t banned that word yet!). I recently had a similar visceral response when called at midnight to fix a pseudo-aneurysm after a heart specialist attempted to open an occluded popliteal in a 90-year-old wheelchair-bound Alzheimer’s patient.

In case I sound prejudiced, let me say that I can sympathize with some of the cardiologists’ misgivings. Sometimes society or specialty guidelines can be too restrictive and will prevent the patient from getting a treatment that is really needed. Our writing groups need to be adroit in developing these recommendations. Clearly every clinical situation cannot be anticipated, but surely certain scenarios can be identified where interventions should never be performed.

I also believe Dr. Hendel correctly implied that the terms "inappropriate" and "uncertain" were fodder for hungry malpractice lawyers. Vascular surgeons don’t want to feed these litigators’ avarice either. But is that reason enough to allow wordsmiths to manipulate language with the unintended result that we condone bad medicine?

As vascular specialists whose primary interest is the preservation of life and limb, shouldn’t we admit that it’s "appropriate" that some treatments are just "inappropriate"?

Dr. Samson is a clinical professor of surgery (vascular), Florida State University Medical School, a member of Sarasota Vascular Specialists, Sarasota, Fla., and the medical editor of Vascular Specialist.

I am ashamed to admit this, but I think I am becoming an "anti-semantic!" Surely it is scandalous that an editor is beginning to find some ordinary words and phrases obnoxious? But consider the following excerpt from an Oct. 30 Bloomberg News article by Peter Waldman: "The American College of Cardiology is changing its guidelines for when implanting coronary stents is appropriate – by banishing the term ‘Inappropriate’ (replacing it with ‘Rarely Appropriate’). Another category in cases in which there is medical doubt will switch from ‘Uncertain’ to ‘May Be Appropriate’"

So with the sweep of the pen or rather the delete key on the computer, thousands of coronary stents with no valid indication may suddenly be justified. I assume that these heart specialists also believe that peripheral stents placed in asymptomatic patients with normal arteries may be appropriate.

It’s not surprising that the specialty that pioneered endovascular procedures for anyone with a heart or leg would also adopt euphemisms to justify unsupported interventions. Remember, this is the same group that popularized the words "high-risk" in order to promote the widespread adoption of carotid stenting.

According to the Bloomberg News article (titled, Doctors Use Euphemism for $2.4 Billion in Needless Stents), Dr. Robert Hendel, a cardiologist at the University of Miami, stated that "A lot of regulators and payers were saying if it’s inappropriate why should we pay for it and why should it be done at all?" I must admit I agree with the regulators and payers. Why should an insurance company or Medicare pay for a procedure that was completely unjustified?

Like most vascular surgeons, I have seen countless patients with stents up and down their lower extremity arteries, all occluded and now with limb-threatening ischemia. Invariably the patients were asymptomatic before the first stent but told that if they did not have the stent they would require an amputation. Now because of their "Rarely Appropriate" treatment they will actually lose their leg.

Dr. Hendel stated that the word "inappropriate" caused a "visceral response" which I presume implied that cardiologists didn’t like being told that what they may be doing in some cases was "wrong" (they haven’t banned that word yet!). I recently had a similar visceral response when called at midnight to fix a pseudo-aneurysm after a heart specialist attempted to open an occluded popliteal in a 90-year-old wheelchair-bound Alzheimer’s patient.

In case I sound prejudiced, let me say that I can sympathize with some of the cardiologists’ misgivings. Sometimes society or specialty guidelines can be too restrictive and will prevent the patient from getting a treatment that is really needed. Our writing groups need to be adroit in developing these recommendations. Clearly every clinical situation cannot be anticipated, but surely certain scenarios can be identified where interventions should never be performed.

I also believe Dr. Hendel correctly implied that the terms "inappropriate" and "uncertain" were fodder for hungry malpractice lawyers. Vascular surgeons don’t want to feed these litigators’ avarice either. But is that reason enough to allow wordsmiths to manipulate language with the unintended result that we condone bad medicine?

As vascular specialists whose primary interest is the preservation of life and limb, shouldn’t we admit that it’s "appropriate" that some treatments are just "inappropriate"?

Dr. Samson is a clinical professor of surgery (vascular), Florida State University Medical School, a member of Sarasota Vascular Specialists, Sarasota, Fla., and the medical editor of Vascular Specialist.

I am ashamed to admit this, but I think I am becoming an "anti-semantic!" Surely it is scandalous that an editor is beginning to find some ordinary words and phrases obnoxious? But consider the following excerpt from an Oct. 30 Bloomberg News article by Peter Waldman: "The American College of Cardiology is changing its guidelines for when implanting coronary stents is appropriate – by banishing the term ‘Inappropriate’ (replacing it with ‘Rarely Appropriate’). Another category in cases in which there is medical doubt will switch from ‘Uncertain’ to ‘May Be Appropriate’"

So with the sweep of the pen or rather the delete key on the computer, thousands of coronary stents with no valid indication may suddenly be justified. I assume that these heart specialists also believe that peripheral stents placed in asymptomatic patients with normal arteries may be appropriate.

It’s not surprising that the specialty that pioneered endovascular procedures for anyone with a heart or leg would also adopt euphemisms to justify unsupported interventions. Remember, this is the same group that popularized the words "high-risk" in order to promote the widespread adoption of carotid stenting.

According to the Bloomberg News article (titled, Doctors Use Euphemism for $2.4 Billion in Needless Stents), Dr. Robert Hendel, a cardiologist at the University of Miami, stated that "A lot of regulators and payers were saying if it’s inappropriate why should we pay for it and why should it be done at all?" I must admit I agree with the regulators and payers. Why should an insurance company or Medicare pay for a procedure that was completely unjustified?

Like most vascular surgeons, I have seen countless patients with stents up and down their lower extremity arteries, all occluded and now with limb-threatening ischemia. Invariably the patients were asymptomatic before the first stent but told that if they did not have the stent they would require an amputation. Now because of their "Rarely Appropriate" treatment they will actually lose their leg.

Dr. Hendel stated that the word "inappropriate" caused a "visceral response" which I presume implied that cardiologists didn’t like being told that what they may be doing in some cases was "wrong" (they haven’t banned that word yet!). I recently had a similar visceral response when called at midnight to fix a pseudo-aneurysm after a heart specialist attempted to open an occluded popliteal in a 90-year-old wheelchair-bound Alzheimer’s patient.

In case I sound prejudiced, let me say that I can sympathize with some of the cardiologists’ misgivings. Sometimes society or specialty guidelines can be too restrictive and will prevent the patient from getting a treatment that is really needed. Our writing groups need to be adroit in developing these recommendations. Clearly every clinical situation cannot be anticipated, but surely certain scenarios can be identified where interventions should never be performed.

I also believe Dr. Hendel correctly implied that the terms "inappropriate" and "uncertain" were fodder for hungry malpractice lawyers. Vascular surgeons don’t want to feed these litigators’ avarice either. But is that reason enough to allow wordsmiths to manipulate language with the unintended result that we condone bad medicine?

As vascular specialists whose primary interest is the preservation of life and limb, shouldn’t we admit that it’s "appropriate" that some treatments are just "inappropriate"?

Dr. Samson is a clinical professor of surgery (vascular), Florida State University Medical School, a member of Sarasota Vascular Specialists, Sarasota, Fla., and the medical editor of Vascular Specialist.

Sometimes I feel like I am writing in invisible ink. I write these editorials but I have a feeling no one is actually reading them. It's a little bit like the old adage that if a tree falls in the forest and no one sees or hears it fall, did it really fall?

Even though most newspapers are moving to tablet and smartphone apps, and Gen X doesn’t know what a typewriter is, it is apparent that many vascular surgeons are not reading the electronic version of Vascular Specialist. Despite the move to electronic media most of us like to have paper delivered to our desk. I believe that is because we are constantly inundated with emails, texts and tweets. Every day I seem to have a new friend on Facebook or a new acquaintance on LinkedIn.

I have a Nigerian prince who wants to send me gold and a hitherto unknown cousin who lost her wallet while traveling abroad and now she needs me to send money immediately. There are constantly people that want to update my website and sales representatives that want me to read the latest and greatest data on their product.

Recruiters are "tempting" me with new job opportunities in Saudi Arabia and I am being implored to present a manuscript on anything I like at a meeting in a remote part of China. If I didn't know better, I would think I was the most important person on this planet (actually I am, but that is not germane to this problem).

When an innocent email arrives notifying me that the latest edition of Vascular Specialist is online I, like many others, may disregard it in this morass of emails and automatically send the notification to my trash file without thinking – and I'm the editor!

Accordingly, this month my editorial asks you to answer a brief survey... so help me out here. Please take our simple poll below. Choose from one of the responses. It will not take long.

If you haven’t read this editorial, choose response D. Now I realize this may be an existential question since how can you choose a response that states that you didn’t read the editorial? Clearly you can’t! But then I have my own existential question which is "are you readers even out there?" Hello! Anybody there?

Oh well, back to the forest.

Dr. Samson is a clinical professor of surgery (vascular), Florida State University Medical School, a member of Sarasota Vascular Specialists, Sarasota, Fla., and the medical editor of Vascular Specialist.

Sometimes I feel like I am writing in invisible ink. I write these editorials but I have a feeling no one is actually reading them. It's a little bit like the old adage that if a tree falls in the forest and no one sees or hears it fall, did it really fall?

Even though most newspapers are moving to tablet and smartphone apps, and Gen X doesn’t know what a typewriter is, it is apparent that many vascular surgeons are not reading the electronic version of Vascular Specialist. Despite the move to electronic media most of us like to have paper delivered to our desk. I believe that is because we are constantly inundated with emails, texts and tweets. Every day I seem to have a new friend on Facebook or a new acquaintance on LinkedIn.

I have a Nigerian prince who wants to send me gold and a hitherto unknown cousin who lost her wallet while traveling abroad and now she needs me to send money immediately. There are constantly people that want to update my website and sales representatives that want me to read the latest and greatest data on their product.

Recruiters are "tempting" me with new job opportunities in Saudi Arabia and I am being implored to present a manuscript on anything I like at a meeting in a remote part of China. If I didn't know better, I would think I was the most important person on this planet (actually I am, but that is not germane to this problem).

When an innocent email arrives notifying me that the latest edition of Vascular Specialist is online I, like many others, may disregard it in this morass of emails and automatically send the notification to my trash file without thinking – and I'm the editor!

Accordingly, this month my editorial asks you to answer a brief survey... so help me out here. Please take our simple poll below. Choose from one of the responses. It will not take long.

If you haven’t read this editorial, choose response D. Now I realize this may be an existential question since how can you choose a response that states that you didn’t read the editorial? Clearly you can’t! But then I have my own existential question which is "are you readers even out there?" Hello! Anybody there?

Oh well, back to the forest.

Dr. Samson is a clinical professor of surgery (vascular), Florida State University Medical School, a member of Sarasota Vascular Specialists, Sarasota, Fla., and the medical editor of Vascular Specialist.

Sometimes I feel like I am writing in invisible ink. I write these editorials but I have a feeling no one is actually reading them. It's a little bit like the old adage that if a tree falls in the forest and no one sees or hears it fall, did it really fall?

Even though most newspapers are moving to tablet and smartphone apps, and Gen X doesn’t know what a typewriter is, it is apparent that many vascular surgeons are not reading the electronic version of Vascular Specialist. Despite the move to electronic media most of us like to have paper delivered to our desk. I believe that is because we are constantly inundated with emails, texts and tweets. Every day I seem to have a new friend on Facebook or a new acquaintance on LinkedIn.

I have a Nigerian prince who wants to send me gold and a hitherto unknown cousin who lost her wallet while traveling abroad and now she needs me to send money immediately. There are constantly people that want to update my website and sales representatives that want me to read the latest and greatest data on their product.

Recruiters are "tempting" me with new job opportunities in Saudi Arabia and I am being implored to present a manuscript on anything I like at a meeting in a remote part of China. If I didn't know better, I would think I was the most important person on this planet (actually I am, but that is not germane to this problem).

When an innocent email arrives notifying me that the latest edition of Vascular Specialist is online I, like many others, may disregard it in this morass of emails and automatically send the notification to my trash file without thinking – and I'm the editor!

Accordingly, this month my editorial asks you to answer a brief survey... so help me out here. Please take our simple poll below. Choose from one of the responses. It will not take long.

If you haven’t read this editorial, choose response D. Now I realize this may be an existential question since how can you choose a response that states that you didn’t read the editorial? Clearly you can’t! But then I have my own existential question which is "are you readers even out there?" Hello! Anybody there?

Oh well, back to the forest.

Dr. Samson is a clinical professor of surgery (vascular), Florida State University Medical School, a member of Sarasota Vascular Specialists, Sarasota, Fla., and the medical editor of Vascular Specialist.

For a specialty with less than 5,000 members in the United States, vascular surgery certainly has an abundance of societies – SVS, SAVS, ISVS, SCVS, etc. However, I am proposing a new one, the SOS (Save Our Saphenous) devoted to saving the saphenous vein.

At the outset, I know that ablation of the saphenous has a definite role in the management of venous disease. I have ablated many myself – but must every human being on this planet have theirs removed? Has it become the appendix of the venous system, a redundant vestigial organ with no apparent reason for existence, placed in the leg simply to provide an income for starving physicians?

I believe all of us have been horrified seeing some unfortunate young woman who initially went to a "Vain" Clinic for a single spider vein and had the great and small saphenous veins ablated from both legs. Thousands of dollars out of pocket, often with legs scarred or burned and still with a spider vein, she shows up wondering why the magic laser did not eradicate her red spot.

And what about the elderly patient with a longstanding cardiac history who, while in her cardiologist's office, was told that she needed her asymptomatic varicose veins removed and her saphenous obliterated? We have all seen patients who were told they need their vein ablated after a duplex scan performed by some fly by night lab, yet when we repeat the study it's completely normal. Are those physicians simply uneducated or are they committing fraud, and even more seriously, physically abusing the patient?

It seems that ablation of the saphenous vein has become an industrialized initiative. Vein clinics and vein specialists are being established faster than Starbucks. Soon there will be one on every street corner -- perhaps even in the airport. Moreover, they are run by entrepreneurial doctors from virtually every walk of life irrespective of their training or education in venous disease.

They include anesthesiologists, gynecologists, and even podiatrists. Why, even retired cardiac surgeons who spent their whole professional lives saving their patients by using the saphenous are now advertising themselves as board-certified vein specialists and are destroying normal veins as fast as they can say the word "Dollar."

Will we soon be seeing veterinarians also climbing on the vein bandwagon? Go to a weekend meeting, learn from a company rep, and then advertise yourself as a vein expert. It's easy! And worse still, are some of our own also to blame?

Insurance carriers are just beginning to realize that there is something fishy going on. Now even the truly symptomatic are required to wear stockings, exercise, and lose weight before they can undergo appropriate treatment. I foresee a time when our symptomatic patients will have to provide photographic evidence that they spent at least part of everyday walking on their hands with their feet in the air.

Moreover, what's up with patients who go to vein screenings? What do they really think those ugly blue tubes up and down their legs are an alien's tentacles? And why do they need to be screened -- don't they own a mirror?

Venous disorder screenings offered through the auspices of the American Venous Forum are designed to educate patients about treatment options, risks for VTE, chronic venous insufficiency, etc., and have a true benefit. But the "doc-in-a-box" varicose vein screening is simply a come on to induce patients to have an unnecessary ablation.

So I think it is time for vascular surgeons to become the white knights and join the noble SOS. Take the time to educate our patients and medical colleagues that they may need to reconsider who they use for vein treatment and refer to vascular surgeons who are specifically trained to know about venous disorders.

A knowledgeable vascular surgeon will treat the vein because it needs to be treated and not because its removal helps pay the doctor's mortgage. Someone who knows that unnecessarily ablating a normal vein will not improve the patient's cosmetics or symptoms; that ablating the vein may at some later time limit their patient's chance to have a functional leg or coronary bypass. Who knows that patients may even die because they had their vein destroyed. For what specialty of physician knows more than vascular surgeons about the importance of the saphenous as a potential conduit for life- or limb-saving surgeries? What other specialty can fully appreciate when it is really necessary to sacrifice the vein?

So I encourage all vascular surgeons to join the SOS. However, as a disclaimer, I would like to point out that I am the Founder, Secretary, Treasurer, and President-for-Life of the SOS. I expect to receive no financial remuneration since I am spending most of my time saving the saphenous vein.

Dr. Samson is a clinical associate professor of surgery (vascular), Florida State University Medical School, a member of Sarasota Vascular Specialists, Sarasota, Fla., and the medical editor o Vascular Specialist.

For a specialty with less than 5,000 members in the United States, vascular surgery certainly has an abundance of societies – SVS, SAVS, ISVS, SCVS, etc. However, I am proposing a new one, the SOS (Save Our Saphenous) devoted to saving the saphenous vein.

At the outset, I know that ablation of the saphenous has a definite role in the management of venous disease. I have ablated many myself – but must every human being on this planet have theirs removed? Has it become the appendix of the venous system, a redundant vestigial organ with no apparent reason for existence, placed in the leg simply to provide an income for starving physicians?

I believe all of us have been horrified seeing some unfortunate young woman who initially went to a "Vain" Clinic for a single spider vein and had the great and small saphenous veins ablated from both legs. Thousands of dollars out of pocket, often with legs scarred or burned and still with a spider vein, she shows up wondering why the magic laser did not eradicate her red spot.

And what about the elderly patient with a longstanding cardiac history who, while in her cardiologist's office, was told that she needed her asymptomatic varicose veins removed and her saphenous obliterated? We have all seen patients who were told they need their vein ablated after a duplex scan performed by some fly by night lab, yet when we repeat the study it's completely normal. Are those physicians simply uneducated or are they committing fraud, and even more seriously, physically abusing the patient?

It seems that ablation of the saphenous vein has become an industrialized initiative. Vein clinics and vein specialists are being established faster than Starbucks. Soon there will be one on every street corner -- perhaps even in the airport. Moreover, they are run by entrepreneurial doctors from virtually every walk of life irrespective of their training or education in venous disease.

They include anesthesiologists, gynecologists, and even podiatrists. Why, even retired cardiac surgeons who spent their whole professional lives saving their patients by using the saphenous are now advertising themselves as board-certified vein specialists and are destroying normal veins as fast as they can say the word "Dollar."

Will we soon be seeing veterinarians also climbing on the vein bandwagon? Go to a weekend meeting, learn from a company rep, and then advertise yourself as a vein expert. It's easy! And worse still, are some of our own also to blame?

Insurance carriers are just beginning to realize that there is something fishy going on. Now even the truly symptomatic are required to wear stockings, exercise, and lose weight before they can undergo appropriate treatment. I foresee a time when our symptomatic patients will have to provide photographic evidence that they spent at least part of everyday walking on their hands with their feet in the air.

Moreover, what's up with patients who go to vein screenings? What do they really think those ugly blue tubes up and down their legs are an alien's tentacles? And why do they need to be screened -- don't they own a mirror?

Venous disorder screenings offered through the auspices of the American Venous Forum are designed to educate patients about treatment options, risks for VTE, chronic venous insufficiency, etc., and have a true benefit. But the "doc-in-a-box" varicose vein screening is simply a come on to induce patients to have an unnecessary ablation.

So I think it is time for vascular surgeons to become the white knights and join the noble SOS. Take the time to educate our patients and medical colleagues that they may need to reconsider who they use for vein treatment and refer to vascular surgeons who are specifically trained to know about venous disorders.

A knowledgeable vascular surgeon will treat the vein because it needs to be treated and not because its removal helps pay the doctor's mortgage. Someone who knows that unnecessarily ablating a normal vein will not improve the patient's cosmetics or symptoms; that ablating the vein may at some later time limit their patient's chance to have a functional leg or coronary bypass. Who knows that patients may even die because they had their vein destroyed. For what specialty of physician knows more than vascular surgeons about the importance of the saphenous as a potential conduit for life- or limb-saving surgeries? What other specialty can fully appreciate when it is really necessary to sacrifice the vein?

So I encourage all vascular surgeons to join the SOS. However, as a disclaimer, I would like to point out that I am the Founder, Secretary, Treasurer, and President-for-Life of the SOS. I expect to receive no financial remuneration since I am spending most of my time saving the saphenous vein.

Dr. Samson is a clinical associate professor of surgery (vascular), Florida State University Medical School, a member of Sarasota Vascular Specialists, Sarasota, Fla., and the medical editor o Vascular Specialist.

For a specialty with less than 5,000 members in the United States, vascular surgery certainly has an abundance of societies – SVS, SAVS, ISVS, SCVS, etc. However, I am proposing a new one, the SOS (Save Our Saphenous) devoted to saving the saphenous vein.

At the outset, I know that ablation of the saphenous has a definite role in the management of venous disease. I have ablated many myself – but must every human being on this planet have theirs removed? Has it become the appendix of the venous system, a redundant vestigial organ with no apparent reason for existence, placed in the leg simply to provide an income for starving physicians?

I believe all of us have been horrified seeing some unfortunate young woman who initially went to a "Vain" Clinic for a single spider vein and had the great and small saphenous veins ablated from both legs. Thousands of dollars out of pocket, often with legs scarred or burned and still with a spider vein, she shows up wondering why the magic laser did not eradicate her red spot.

And what about the elderly patient with a longstanding cardiac history who, while in her cardiologist's office, was told that she needed her asymptomatic varicose veins removed and her saphenous obliterated? We have all seen patients who were told they need their vein ablated after a duplex scan performed by some fly by night lab, yet when we repeat the study it's completely normal. Are those physicians simply uneducated or are they committing fraud, and even more seriously, physically abusing the patient?

It seems that ablation of the saphenous vein has become an industrialized initiative. Vein clinics and vein specialists are being established faster than Starbucks. Soon there will be one on every street corner -- perhaps even in the airport. Moreover, they are run by entrepreneurial doctors from virtually every walk of life irrespective of their training or education in venous disease.

They include anesthesiologists, gynecologists, and even podiatrists. Why, even retired cardiac surgeons who spent their whole professional lives saving their patients by using the saphenous are now advertising themselves as board-certified vein specialists and are destroying normal veins as fast as they can say the word "Dollar."

Will we soon be seeing veterinarians also climbing on the vein bandwagon? Go to a weekend meeting, learn from a company rep, and then advertise yourself as a vein expert. It's easy! And worse still, are some of our own also to blame?

Insurance carriers are just beginning to realize that there is something fishy going on. Now even the truly symptomatic are required to wear stockings, exercise, and lose weight before they can undergo appropriate treatment. I foresee a time when our symptomatic patients will have to provide photographic evidence that they spent at least part of everyday walking on their hands with their feet in the air.

Moreover, what's up with patients who go to vein screenings? What do they really think those ugly blue tubes up and down their legs are an alien's tentacles? And why do they need to be screened -- don't they own a mirror?

Venous disorder screenings offered through the auspices of the American Venous Forum are designed to educate patients about treatment options, risks for VTE, chronic venous insufficiency, etc., and have a true benefit. But the "doc-in-a-box" varicose vein screening is simply a come on to induce patients to have an unnecessary ablation.

So I think it is time for vascular surgeons to become the white knights and join the noble SOS. Take the time to educate our patients and medical colleagues that they may need to reconsider who they use for vein treatment and refer to vascular surgeons who are specifically trained to know about venous disorders.

A knowledgeable vascular surgeon will treat the vein because it needs to be treated and not because its removal helps pay the doctor's mortgage. Someone who knows that unnecessarily ablating a normal vein will not improve the patient's cosmetics or symptoms; that ablating the vein may at some later time limit their patient's chance to have a functional leg or coronary bypass. Who knows that patients may even die because they had their vein destroyed. For what specialty of physician knows more than vascular surgeons about the importance of the saphenous as a potential conduit for life- or limb-saving surgeries? What other specialty can fully appreciate when it is really necessary to sacrifice the vein?

So I encourage all vascular surgeons to join the SOS. However, as a disclaimer, I would like to point out that I am the Founder, Secretary, Treasurer, and President-for-Life of the SOS. I expect to receive no financial remuneration since I am spending most of my time saving the saphenous vein.

Dr. Samson is a clinical associate professor of surgery (vascular), Florida State University Medical School, a member of Sarasota Vascular Specialists, Sarasota, Fla., and the medical editor o Vascular Specialist.

On a recent flight back from Europe I had a most unsettling but thought provoking experience when I watched the Oscar-winning foreign movie "Amour."

You may ask why this film had such a profound effect. It was because it aroused an emotion I had submerged for many years - the sense of dread that I might cause severe harm to a patient with my surgery.

Now, for those of you who haven’t seen it yet, don’t worry -- I am not going to give away the whole story, so no spoiler alert is necessary. The premise of this extraordinary film revolves around an elderly French couple. The wife is a retired piano teacher who undergoes a carotid endarterectomy following a TIA. When she returns from hospital, her right side is paralyzed, but she can still speak. From then on we watch the gradual decline of this lovely woman and the consequences her stroke has on their lives. Her loss of self, her struggles to complete the basics of life, and even the ability to hold and read a book. Her loving and dedicated husband struggles with his own dwindling abilities to care for her, to help her bathe, and to eat.

Her daughter asks the husband what happened. He replies in a defeated but matter of fact tone ... "The surgery was unsuccessful. You know, it's that 5% thing."

That 5% thing! Our journals are full of similar statistics about the bad things that can happen to our patients and we use these statistics all the time. We reassure our patients that in our hands the stroke rate or the amputation rate or the mortality rate is 5%, or 1%, or whatever percent. Sometimes we do it with a sense of pride. Sometimes we discuss these statistics to avoid a malpractice suit. Sometimes we don't even know for a fact what our statistics are. But most of the time we give out this information glibly. There is little thought for what it will mean to our patients if they are the unlucky one who suffers the event we describe with these percentages.

So what makes us forget that our actions that can have such life changing outcomes? I believe there are many reasons. Perhaps the most common would be confidence in our technical skills, past excellent results and the rarity of the complications. But having been reminded by the film "Amour" I think it is because we do not see our patients living their daily lives when afflicted by a life changing complication.

We don’t go into their homes and watch them try to feed themselves with one hand. We don’t place a diaper on the bedridden lying in a bed saturated with urine. We don’t see the husband struggling to take care of his now handicapped spouse. What about some of our interventional colleagues? Do they come to the operating room to watch us try to save the life or limb of a patient after one of their procedures went amiss? How many of us go to the rehab hospital to check on our newly paralyzed patient? How many of us visit the dialysis unit and sit for three hours with our patient who is now in renal failure? How many of us are there when our patient is learning to walk again with an artificial leg? How many of us attend the funeral of a patient that succumbed following an unsuccessful procedure?

Of course we don't. It's not that we are heartless or uncaring, but our lives are complicated and enormously stressful and time is precious. So we continue with our busy schedule, trying to do the best we can while our patients become yet another statistic.

But then, what if we did spend time with our unfortunate outcomes? Would we become so emotionally handicapped ourselves that we could not continue doing our necessary interventions? Would we become so scarred that we could never again lift a knife or insert a catheter?

I believe that would be the case because after the film I turned to my wife and said "I don't want to do this anymore. I don't want to be the cause of such misery." Fortunately she replied that I "should remember all the people I had saved from such a fate" -- the 95%! And then the reassuring platitude that if I couldn't save the patient then who could?

As we flew on, I had time to ruminate, and my misgivings diminished. For it is a fact that as vascular surgeons we are well aware of the extraordinary responsibility that we shoulder when patients hand us their bodies. We know what the disease will do to our patients if we do not intervene, and we also know when we should leave the patient alone. We are aware of the magnitude of a decision to perform surgery or an endovascular procedure, and we are aware of our own abilities.

So even though we are not infallible we can still continue to strive for the 95% and pray that we are not the cause of "that 5% thing."

On a recent flight back from Europe I had a most unsettling but thought provoking experience when I watched the Oscar-winning foreign movie "Amour."

You may ask why this film had such a profound effect. It was because it aroused an emotion I had submerged for many years - the sense of dread that I might cause severe harm to a patient with my surgery.

Now, for those of you who haven’t seen it yet, don’t worry -- I am not going to give away the whole story, so no spoiler alert is necessary. The premise of this extraordinary film revolves around an elderly French couple. The wife is a retired piano teacher who undergoes a carotid endarterectomy following a TIA. When she returns from hospital, her right side is paralyzed, but she can still speak. From then on we watch the gradual decline of this lovely woman and the consequences her stroke has on their lives. Her loss of self, her struggles to complete the basics of life, and even the ability to hold and read a book. Her loving and dedicated husband struggles with his own dwindling abilities to care for her, to help her bathe, and to eat.

Her daughter asks the husband what happened. He replies in a defeated but matter of fact tone ... "The surgery was unsuccessful. You know, it's that 5% thing."

That 5% thing! Our journals are full of similar statistics about the bad things that can happen to our patients and we use these statistics all the time. We reassure our patients that in our hands the stroke rate or the amputation rate or the mortality rate is 5%, or 1%, or whatever percent. Sometimes we do it with a sense of pride. Sometimes we discuss these statistics to avoid a malpractice suit. Sometimes we don't even know for a fact what our statistics are. But most of the time we give out this information glibly. There is little thought for what it will mean to our patients if they are the unlucky one who suffers the event we describe with these percentages.

So what makes us forget that our actions that can have such life changing outcomes? I believe there are many reasons. Perhaps the most common would be confidence in our technical skills, past excellent results and the rarity of the complications. But having been reminded by the film "Amour" I think it is because we do not see our patients living their daily lives when afflicted by a life changing complication.

We don’t go into their homes and watch them try to feed themselves with one hand. We don’t place a diaper on the bedridden lying in a bed saturated with urine. We don’t see the husband struggling to take care of his now handicapped spouse. What about some of our interventional colleagues? Do they come to the operating room to watch us try to save the life or limb of a patient after one of their procedures went amiss? How many of us go to the rehab hospital to check on our newly paralyzed patient? How many of us visit the dialysis unit and sit for three hours with our patient who is now in renal failure? How many of us are there when our patient is learning to walk again with an artificial leg? How many of us attend the funeral of a patient that succumbed following an unsuccessful procedure?

Of course we don't. It's not that we are heartless or uncaring, but our lives are complicated and enormously stressful and time is precious. So we continue with our busy schedule, trying to do the best we can while our patients become yet another statistic.

But then, what if we did spend time with our unfortunate outcomes? Would we become so emotionally handicapped ourselves that we could not continue doing our necessary interventions? Would we become so scarred that we could never again lift a knife or insert a catheter?

I believe that would be the case because after the film I turned to my wife and said "I don't want to do this anymore. I don't want to be the cause of such misery." Fortunately she replied that I "should remember all the people I had saved from such a fate" -- the 95%! And then the reassuring platitude that if I couldn't save the patient then who could?

As we flew on, I had time to ruminate, and my misgivings diminished. For it is a fact that as vascular surgeons we are well aware of the extraordinary responsibility that we shoulder when patients hand us their bodies. We know what the disease will do to our patients if we do not intervene, and we also know when we should leave the patient alone. We are aware of the magnitude of a decision to perform surgery or an endovascular procedure, and we are aware of our own abilities.

So even though we are not infallible we can still continue to strive for the 95% and pray that we are not the cause of "that 5% thing."

On a recent flight back from Europe I had a most unsettling but thought provoking experience when I watched the Oscar-winning foreign movie "Amour."

You may ask why this film had such a profound effect. It was because it aroused an emotion I had submerged for many years - the sense of dread that I might cause severe harm to a patient with my surgery.

Now, for those of you who haven’t seen it yet, don’t worry -- I am not going to give away the whole story, so no spoiler alert is necessary. The premise of this extraordinary film revolves around an elderly French couple. The wife is a retired piano teacher who undergoes a carotid endarterectomy following a TIA. When she returns from hospital, her right side is paralyzed, but she can still speak. From then on we watch the gradual decline of this lovely woman and the consequences her stroke has on their lives. Her loss of self, her struggles to complete the basics of life, and even the ability to hold and read a book. Her loving and dedicated husband struggles with his own dwindling abilities to care for her, to help her bathe, and to eat.

Her daughter asks the husband what happened. He replies in a defeated but matter of fact tone ... "The surgery was unsuccessful. You know, it's that 5% thing."

That 5% thing! Our journals are full of similar statistics about the bad things that can happen to our patients and we use these statistics all the time. We reassure our patients that in our hands the stroke rate or the amputation rate or the mortality rate is 5%, or 1%, or whatever percent. Sometimes we do it with a sense of pride. Sometimes we discuss these statistics to avoid a malpractice suit. Sometimes we don't even know for a fact what our statistics are. But most of the time we give out this information glibly. There is little thought for what it will mean to our patients if they are the unlucky one who suffers the event we describe with these percentages.

So what makes us forget that our actions that can have such life changing outcomes? I believe there are many reasons. Perhaps the most common would be confidence in our technical skills, past excellent results and the rarity of the complications. But having been reminded by the film "Amour" I think it is because we do not see our patients living their daily lives when afflicted by a life changing complication.

We don’t go into their homes and watch them try to feed themselves with one hand. We don’t place a diaper on the bedridden lying in a bed saturated with urine. We don’t see the husband struggling to take care of his now handicapped spouse. What about some of our interventional colleagues? Do they come to the operating room to watch us try to save the life or limb of a patient after one of their procedures went amiss? How many of us go to the rehab hospital to check on our newly paralyzed patient? How many of us visit the dialysis unit and sit for three hours with our patient who is now in renal failure? How many of us are there when our patient is learning to walk again with an artificial leg? How many of us attend the funeral of a patient that succumbed following an unsuccessful procedure?

Of course we don't. It's not that we are heartless or uncaring, but our lives are complicated and enormously stressful and time is precious. So we continue with our busy schedule, trying to do the best we can while our patients become yet another statistic.

But then, what if we did spend time with our unfortunate outcomes? Would we become so emotionally handicapped ourselves that we could not continue doing our necessary interventions? Would we become so scarred that we could never again lift a knife or insert a catheter?

I believe that would be the case because after the film I turned to my wife and said "I don't want to do this anymore. I don't want to be the cause of such misery." Fortunately she replied that I "should remember all the people I had saved from such a fate" -- the 95%! And then the reassuring platitude that if I couldn't save the patient then who could?

As we flew on, I had time to ruminate, and my misgivings diminished. For it is a fact that as vascular surgeons we are well aware of the extraordinary responsibility that we shoulder when patients hand us their bodies. We know what the disease will do to our patients if we do not intervene, and we also know when we should leave the patient alone. We are aware of the magnitude of a decision to perform surgery or an endovascular procedure, and we are aware of our own abilities.

So even though we are not infallible we can still continue to strive for the 95% and pray that we are not the cause of "that 5% thing."

The Physician Payment Sunshine Act is now in place, and I’m concerned that it may become the "Sunset Act" since it may be another reason for doctors to consider leaving the profession. As of August, manufacturers of drugs, devices, biologicals, or medical supplies are obliged to report annually to the Secretary of Health and Human Services certain payments or other transfers of value to physicians and teaching hospitals. According to the Centers for Medicare and Medicaid Services (CMS) this bit of regulatory burden is going to cost industry $269 million the first year and $180 million annually thereafter.

What is the purpose of this "Sunshine Act"? Congress implied that this process is not designed to stop, chill, or call into question beneficial interactions between physicians and industry, but to ensure that they are transparent. Although CMS did not use harsh or derogatory language, what I think is "transparent" is the implication that making these financial interactions public will prevent industry from having undue influence over physicians. In less euphemistic terms I believe CMS thinks it will prevent physicians from taking industry bribes.

James Barrie once said, "Those that bring sunshine into the lives of others cannot keep it from themselves" – yet I note that our politicians have not passed similar legislation for themselves.

So what does this Sunshine Act mean for vascular surgeons? In short, any amount of money paid directly or in kind (such as a free meal) in an amount exceeding $10, or if less than $10 amounting to more than $100 over a year, has to be reported by these companies to a national database. This will be made public for all our patients to see. I think it’s actually quite comical that CMS set the level of $10 for reporting. They clearly think this amount is enough to influence us. That’s probably because they realize that Medicare has reduced our income so dramatically that we would be willing to sell our mothers for $10!

Now, like every other law enacted by the government, it took CMS 287 pages to describe how to interpret this supposedly simple law. Despite the length, I would urge everyone to read the final rule – but a good dose of Maalox should help. For in this extensive document CMS outlines rules such as how companies will determine how to report food a physician consumes at a national convention.

The final rule determines how research monies should be accounted for and describes regulations for reporting payment for talks given to groups of referring physicians. I was especially intrigued by the convoluted mathematics that CMS invented to determine the dollar amount a company needs to report for the food provided by their representative for lunch for physicians and their staff. It goes something like this: If the food cost $180 and two of the four partners and three staff eat the food, then the per person food cost would be $36. That then becomes the amount that would be reported for each of the two doctors who got diarrhea from the bad food!

Now, just to prove that CMS is not manned by a group of old fogies, they have even created an app for our smartphones so that we can track what is being reported. But we are obliged to enter the data ourselves, and we can’t use this as proof that an incorrect report was made. So, while physicians will have a minimum of 45 days to challenge information before it is public, and can dispute inaccurate reports and seek corrections during a 2-year period, it is advisable to review and correct all information before it is published. To not do this would be the same as asking the government to do our taxes rather than having our accountant do them!

It is certainly true that abuses have occurred where unreasonable amounts of money have been paid to doctors to promote the use of drugs and medical products, and where research may have been tainted by profit motives. Furthermore, travel junkets thinly disguised as educational meetings have caused many to look askance at the relationship between industry and physicians. Improprieties have occurred by physicians on hospital purchasing committees because of undue influence from industry. And yes, some doctors would sell their mothers for 10 bucks. But, on the whole, we remain one of the most honest of professions. So was it really necessary to add another impediment to the doctor-patient relationship?

When our patients eventually look at this database, will they really be able to differentiate between monies for research or those used to provide lunch to an office? Will they regard physicians as crooks just because they were reimbursed for lecturing at a scientific meeting? Maybe! Actually, I suspect my patients won’t bother to look at the database but those that do will just be confused. Regardless, I suspect we will now be spending time explaining ourselves rather than explaining treatments. So much for Sunshine!

Dr. Russell Samson is the Medical Editor of Vascular Specialist.

The Physician Payment Sunshine Act is now in place, and I’m concerned that it may become the "Sunset Act" since it may be another reason for doctors to consider leaving the profession. As of August, manufacturers of drugs, devices, biologicals, or medical supplies are obliged to report annually to the Secretary of Health and Human Services certain payments or other transfers of value to physicians and teaching hospitals. According to the Centers for Medicare and Medicaid Services (CMS) this bit of regulatory burden is going to cost industry $269 million the first year and $180 million annually thereafter.

What is the purpose of this "Sunshine Act"? Congress implied that this process is not designed to stop, chill, or call into question beneficial interactions between physicians and industry, but to ensure that they are transparent. Although CMS did not use harsh or derogatory language, what I think is "transparent" is the implication that making these financial interactions public will prevent industry from having undue influence over physicians. In less euphemistic terms I believe CMS thinks it will prevent physicians from taking industry bribes.

James Barrie once said, "Those that bring sunshine into the lives of others cannot keep it from themselves" – yet I note that our politicians have not passed similar legislation for themselves.

So what does this Sunshine Act mean for vascular surgeons? In short, any amount of money paid directly or in kind (such as a free meal) in an amount exceeding $10, or if less than $10 amounting to more than $100 over a year, has to be reported by these companies to a national database. This will be made public for all our patients to see. I think it’s actually quite comical that CMS set the level of $10 for reporting. They clearly think this amount is enough to influence us. That’s probably because they realize that Medicare has reduced our income so dramatically that we would be willing to sell our mothers for $10!

Now, like every other law enacted by the government, it took CMS 287 pages to describe how to interpret this supposedly simple law. Despite the length, I would urge everyone to read the final rule – but a good dose of Maalox should help. For in this extensive document CMS outlines rules such as how companies will determine how to report food a physician consumes at a national convention.

The final rule determines how research monies should be accounted for and describes regulations for reporting payment for talks given to groups of referring physicians. I was especially intrigued by the convoluted mathematics that CMS invented to determine the dollar amount a company needs to report for the food provided by their representative for lunch for physicians and their staff. It goes something like this: If the food cost $180 and two of the four partners and three staff eat the food, then the per person food cost would be $36. That then becomes the amount that would be reported for each of the two doctors who got diarrhea from the bad food!

Now, just to prove that CMS is not manned by a group of old fogies, they have even created an app for our smartphones so that we can track what is being reported. But we are obliged to enter the data ourselves, and we can’t use this as proof that an incorrect report was made. So, while physicians will have a minimum of 45 days to challenge information before it is public, and can dispute inaccurate reports and seek corrections during a 2-year period, it is advisable to review and correct all information before it is published. To not do this would be the same as asking the government to do our taxes rather than having our accountant do them!

It is certainly true that abuses have occurred where unreasonable amounts of money have been paid to doctors to promote the use of drugs and medical products, and where research may have been tainted by profit motives. Furthermore, travel junkets thinly disguised as educational meetings have caused many to look askance at the relationship between industry and physicians. Improprieties have occurred by physicians on hospital purchasing committees because of undue influence from industry. And yes, some doctors would sell their mothers for 10 bucks. But, on the whole, we remain one of the most honest of professions. So was it really necessary to add another impediment to the doctor-patient relationship?

When our patients eventually look at this database, will they really be able to differentiate between monies for research or those used to provide lunch to an office? Will they regard physicians as crooks just because they were reimbursed for lecturing at a scientific meeting? Maybe! Actually, I suspect my patients won’t bother to look at the database but those that do will just be confused. Regardless, I suspect we will now be spending time explaining ourselves rather than explaining treatments. So much for Sunshine!

Dr. Russell Samson is the Medical Editor of Vascular Specialist.

The Physician Payment Sunshine Act is now in place, and I’m concerned that it may become the "Sunset Act" since it may be another reason for doctors to consider leaving the profession. As of August, manufacturers of drugs, devices, biologicals, or medical supplies are obliged to report annually to the Secretary of Health and Human Services certain payments or other transfers of value to physicians and teaching hospitals. According to the Centers for Medicare and Medicaid Services (CMS) this bit of regulatory burden is going to cost industry $269 million the first year and $180 million annually thereafter.

What is the purpose of this "Sunshine Act"? Congress implied that this process is not designed to stop, chill, or call into question beneficial interactions between physicians and industry, but to ensure that they are transparent. Although CMS did not use harsh or derogatory language, what I think is "transparent" is the implication that making these financial interactions public will prevent industry from having undue influence over physicians. In less euphemistic terms I believe CMS thinks it will prevent physicians from taking industry bribes.

James Barrie once said, "Those that bring sunshine into the lives of others cannot keep it from themselves" – yet I note that our politicians have not passed similar legislation for themselves.

So what does this Sunshine Act mean for vascular surgeons? In short, any amount of money paid directly or in kind (such as a free meal) in an amount exceeding $10, or if less than $10 amounting to more than $100 over a year, has to be reported by these companies to a national database. This will be made public for all our patients to see. I think it’s actually quite comical that CMS set the level of $10 for reporting. They clearly think this amount is enough to influence us. That’s probably because they realize that Medicare has reduced our income so dramatically that we would be willing to sell our mothers for $10!

Now, like every other law enacted by the government, it took CMS 287 pages to describe how to interpret this supposedly simple law. Despite the length, I would urge everyone to read the final rule – but a good dose of Maalox should help. For in this extensive document CMS outlines rules such as how companies will determine how to report food a physician consumes at a national convention.

The final rule determines how research monies should be accounted for and describes regulations for reporting payment for talks given to groups of referring physicians. I was especially intrigued by the convoluted mathematics that CMS invented to determine the dollar amount a company needs to report for the food provided by their representative for lunch for physicians and their staff. It goes something like this: If the food cost $180 and two of the four partners and three staff eat the food, then the per person food cost would be $36. That then becomes the amount that would be reported for each of the two doctors who got diarrhea from the bad food!

Now, just to prove that CMS is not manned by a group of old fogies, they have even created an app for our smartphones so that we can track what is being reported. But we are obliged to enter the data ourselves, and we can’t use this as proof that an incorrect report was made. So, while physicians will have a minimum of 45 days to challenge information before it is public, and can dispute inaccurate reports and seek corrections during a 2-year period, it is advisable to review and correct all information before it is published. To not do this would be the same as asking the government to do our taxes rather than having our accountant do them!

It is certainly true that abuses have occurred where unreasonable amounts of money have been paid to doctors to promote the use of drugs and medical products, and where research may have been tainted by profit motives. Furthermore, travel junkets thinly disguised as educational meetings have caused many to look askance at the relationship between industry and physicians. Improprieties have occurred by physicians on hospital purchasing committees because of undue influence from industry. And yes, some doctors would sell their mothers for 10 bucks. But, on the whole, we remain one of the most honest of professions. So was it really necessary to add another impediment to the doctor-patient relationship?

When our patients eventually look at this database, will they really be able to differentiate between monies for research or those used to provide lunch to an office? Will they regard physicians as crooks just because they were reimbursed for lecturing at a scientific meeting? Maybe! Actually, I suspect my patients won’t bother to look at the database but those that do will just be confused. Regardless, I suspect we will now be spending time explaining ourselves rather than explaining treatments. So much for Sunshine!

Dr. Russell Samson is the Medical Editor of Vascular Specialist.

In July, the Society for Vascular Surgery sent requests to its members to complete surveys regarding the work involved with creation, revision, and thrombectomy of hemodialysis access. These surveys form the basis of data used by the American Medical Association/Relative Value Scale Update Committee (also known as the RUC) to make recommendations to the Centers for Medicare and Medicaid Services (CMS) regarding the relative value of these procedures. It is surprising, then, that some members do not respond to these requests nor fully comprehend the importance of diligently completing the surveys. This could result in vascular surgeons being reimbursed too little or too much (for vascular surgery the latter is obviously very infrequent!)

Presumably the less than desirable response to these requests is because like me, some of us may not fully understand the RUC and how this committee is involved in physician payment. I am indebted to Sean Roddy, Bob Zwolak, David Han and Matt Sideman for helping me provide the following background information. In 1992, Medicare transitioned to a physician payment system based on the Resource-Based Relative Value Scale. The American Medical Association convened the multispecialty committee known as the RUC and in May of 1992 the RUC considered the first relative value recommendation from a specialty society. In the years since, thousands of codes have been presented to the RUC by specialty societies such as ours, with recommendations for each code’s relative value made to CMS for their final decision.

It is important to understand that the RUC does not set prices. That is up to CMS. The RUC is a multispecialty committee that analyzes and reviews data on new and existing Current Procedural Terminology (CPT) codes, specifically looking at the practice expense and relative effort of physician work and intensity. All new codes are reviewed; existing codes that are potentially misvalued are also reviewed. By law, all existing relative values are reviewed at least every five years (Section 1848 (C) 2 (B) of the Omnibus Budget Reconciliation Act of 1990).

RUC recommendations for relative values are based on data supplied by one or more specialty societies. SVS works closely with other specialty societies including the American College of Surgeons, Society for Interventional Radiology, and the American College of Cardiology especially when discussing codes that are performed by physicians from multiple disciplines. Specialty societies such as ours collect data from surveys that assess the time and intensity associated with the pre-, intra-, and postoperative care of our patients. Based on these data, expert panels from each society submit proposals for the time and relative value units (RVUs) associated with each procedure. These proposals are then subject to assessment and adjustment by the RUC, with final recommendations determined by vote of the RUC members. As part of the rule making process, CMS is open to public comment and accepts input from the RUC, just as it accepts input from the public. It is important to reiterate that the RUC does not set prices. Total Medicare payments for physician-provided services are determined by Congress and CMS each year. The RUC’s sole purpose is to serve as a volunteer expert advisory body to help determine relativity between very different services performed by all of the specialties throughout medicine. SVS believes that the RUC has performed objectively in this role since its inception.

However, recently, the activity of the RUC has been the subject of scrutiny and criticism by the media, including several articles and editorials in Washington Monthly, The Washington Post, and USA Today.

The gist of these articles is that in order to gain financially doctors who respond to the surveys and their specialty societies exaggerate the time taken to perform the procedures. The Washington Post’s reporter cynically proposed it would appear that some doctors are working 26 hours in a 10-hour paid day.

The AMA has responded that in many cases the RUC has actually resulted in devalued procedures. To quote a letter from the AMA to the Washington Post "In recent years, the committee has taken the initiative to identify overvalued medical services to help drive cost reduction. To date, they reviewed about 1,300 potentially misvalued services and recommended reductions to 500 previously overvalued services." More importantly to us as vascular surgeons is the fact that the Medicare physician payment system is ultimately budget-neutral. Let me explain my concern. In other words there is no financial impact to overall Medicare spending if the government accepts a recommendation for increasing a medical service value. This is because any increase is automatically offset by decreasing values assigned to all other services. So if members of other specialty societies exaggerate the relative value of their services and the RUC and CMS agrees with these excessive RVU’s then they have to reduce other RVUs. So, if vascular surgeons don’t supply realistic data for our procedures we are likely to have our fees reduced.

THE AMA claims to have redistributed $2.5 billion to primary care and other services. It is this latter claim that makes me hopeful that our members will take these surveys seriously since I am sure we have not been the beneficiaries of this multibillion dollar redistribution. If we don’t complete the surveys it is likely that our procedures will be devalued and the monies CMS saves will simply be passed on to our primary care colleagues or other specialists.

Accordingly, I urge members of the SVS to take seriously these requests to fill out the RUC surveys. Do not under play how long it takes you to do the procedure but do not exaggerate either. An honest survey serves us and our patients best. SVS representatives have spent countless hours ensuring that the work of our members is fairly and accurately represented. The role of RUC advisor has been held for the last 20 years by Gary Seabrook, and beginning this year is being taken up by Matt Sideman. The next time you see either of them, be sure to give Gary your thanks, and wish Matt the best.

In July, the Society for Vascular Surgery sent requests to its members to complete surveys regarding the work involved with creation, revision, and thrombectomy of hemodialysis access. These surveys form the basis of data used by the American Medical Association/Relative Value Scale Update Committee (also known as the RUC) to make recommendations to the Centers for Medicare and Medicaid Services (CMS) regarding the relative value of these procedures. It is surprising, then, that some members do not respond to these requests nor fully comprehend the importance of diligently completing the surveys. This could result in vascular surgeons being reimbursed too little or too much (for vascular surgery the latter is obviously very infrequent!)

Presumably the less than desirable response to these requests is because like me, some of us may not fully understand the RUC and how this committee is involved in physician payment. I am indebted to Sean Roddy, Bob Zwolak, David Han and Matt Sideman for helping me provide the following background information. In 1992, Medicare transitioned to a physician payment system based on the Resource-Based Relative Value Scale. The American Medical Association convened the multispecialty committee known as the RUC and in May of 1992 the RUC considered the first relative value recommendation from a specialty society. In the years since, thousands of codes have been presented to the RUC by specialty societies such as ours, with recommendations for each code’s relative value made to CMS for their final decision.

It is important to understand that the RUC does not set prices. That is up to CMS. The RUC is a multispecialty committee that analyzes and reviews data on new and existing Current Procedural Terminology (CPT) codes, specifically looking at the practice expense and relative effort of physician work and intensity. All new codes are reviewed; existing codes that are potentially misvalued are also reviewed. By law, all existing relative values are reviewed at least every five years (Section 1848 (C) 2 (B) of the Omnibus Budget Reconciliation Act of 1990).

RUC recommendations for relative values are based on data supplied by one or more specialty societies. SVS works closely with other specialty societies including the American College of Surgeons, Society for Interventional Radiology, and the American College of Cardiology especially when discussing codes that are performed by physicians from multiple disciplines. Specialty societies such as ours collect data from surveys that assess the time and intensity associated with the pre-, intra-, and postoperative care of our patients. Based on these data, expert panels from each society submit proposals for the time and relative value units (RVUs) associated with each procedure. These proposals are then subject to assessment and adjustment by the RUC, with final recommendations determined by vote of the RUC members. As part of the rule making process, CMS is open to public comment and accepts input from the RUC, just as it accepts input from the public. It is important to reiterate that the RUC does not set prices. Total Medicare payments for physician-provided services are determined by Congress and CMS each year. The RUC’s sole purpose is to serve as a volunteer expert advisory body to help determine relativity between very different services performed by all of the specialties throughout medicine. SVS believes that the RUC has performed objectively in this role since its inception.

However, recently, the activity of the RUC has been the subject of scrutiny and criticism by the media, including several articles and editorials in Washington Monthly, The Washington Post, and USA Today.

The gist of these articles is that in order to gain financially doctors who respond to the surveys and their specialty societies exaggerate the time taken to perform the procedures. The Washington Post’s reporter cynically proposed it would appear that some doctors are working 26 hours in a 10-hour paid day.

The AMA has responded that in many cases the RUC has actually resulted in devalued procedures. To quote a letter from the AMA to the Washington Post "In recent years, the committee has taken the initiative to identify overvalued medical services to help drive cost reduction. To date, they reviewed about 1,300 potentially misvalued services and recommended reductions to 500 previously overvalued services." More importantly to us as vascular surgeons is the fact that the Medicare physician payment system is ultimately budget-neutral. Let me explain my concern. In other words there is no financial impact to overall Medicare spending if the government accepts a recommendation for increasing a medical service value. This is because any increase is automatically offset by decreasing values assigned to all other services. So if members of other specialty societies exaggerate the relative value of their services and the RUC and CMS agrees with these excessive RVU’s then they have to reduce other RVUs. So, if vascular surgeons don’t supply realistic data for our procedures we are likely to have our fees reduced.

THE AMA claims to have redistributed $2.5 billion to primary care and other services. It is this latter claim that makes me hopeful that our members will take these surveys seriously since I am sure we have not been the beneficiaries of this multibillion dollar redistribution. If we don’t complete the surveys it is likely that our procedures will be devalued and the monies CMS saves will simply be passed on to our primary care colleagues or other specialists.

Accordingly, I urge members of the SVS to take seriously these requests to fill out the RUC surveys. Do not under play how long it takes you to do the procedure but do not exaggerate either. An honest survey serves us and our patients best. SVS representatives have spent countless hours ensuring that the work of our members is fairly and accurately represented. The role of RUC advisor has been held for the last 20 years by Gary Seabrook, and beginning this year is being taken up by Matt Sideman. The next time you see either of them, be sure to give Gary your thanks, and wish Matt the best.

In July, the Society for Vascular Surgery sent requests to its members to complete surveys regarding the work involved with creation, revision, and thrombectomy of hemodialysis access. These surveys form the basis of data used by the American Medical Association/Relative Value Scale Update Committee (also known as the RUC) to make recommendations to the Centers for Medicare and Medicaid Services (CMS) regarding the relative value of these procedures. It is surprising, then, that some members do not respond to these requests nor fully comprehend the importance of diligently completing the surveys. This could result in vascular surgeons being reimbursed too little or too much (for vascular surgery the latter is obviously very infrequent!)

Presumably the less than desirable response to these requests is because like me, some of us may not fully understand the RUC and how this committee is involved in physician payment. I am indebted to Sean Roddy, Bob Zwolak, David Han and Matt Sideman for helping me provide the following background information. In 1992, Medicare transitioned to a physician payment system based on the Resource-Based Relative Value Scale. The American Medical Association convened the multispecialty committee known as the RUC and in May of 1992 the RUC considered the first relative value recommendation from a specialty society. In the years since, thousands of codes have been presented to the RUC by specialty societies such as ours, with recommendations for each code’s relative value made to CMS for their final decision.

It is important to understand that the RUC does not set prices. That is up to CMS. The RUC is a multispecialty committee that analyzes and reviews data on new and existing Current Procedural Terminology (CPT) codes, specifically looking at the practice expense and relative effort of physician work and intensity. All new codes are reviewed; existing codes that are potentially misvalued are also reviewed. By law, all existing relative values are reviewed at least every five years (Section 1848 (C) 2 (B) of the Omnibus Budget Reconciliation Act of 1990).

RUC recommendations for relative values are based on data supplied by one or more specialty societies. SVS works closely with other specialty societies including the American College of Surgeons, Society for Interventional Radiology, and the American College of Cardiology especially when discussing codes that are performed by physicians from multiple disciplines. Specialty societies such as ours collect data from surveys that assess the time and intensity associated with the pre-, intra-, and postoperative care of our patients. Based on these data, expert panels from each society submit proposals for the time and relative value units (RVUs) associated with each procedure. These proposals are then subject to assessment and adjustment by the RUC, with final recommendations determined by vote of the RUC members. As part of the rule making process, CMS is open to public comment and accepts input from the RUC, just as it accepts input from the public. It is important to reiterate that the RUC does not set prices. Total Medicare payments for physician-provided services are determined by Congress and CMS each year. The RUC’s sole purpose is to serve as a volunteer expert advisory body to help determine relativity between very different services performed by all of the specialties throughout medicine. SVS believes that the RUC has performed objectively in this role since its inception.

However, recently, the activity of the RUC has been the subject of scrutiny and criticism by the media, including several articles and editorials in Washington Monthly, The Washington Post, and USA Today.

The gist of these articles is that in order to gain financially doctors who respond to the surveys and their specialty societies exaggerate the time taken to perform the procedures. The Washington Post’s reporter cynically proposed it would appear that some doctors are working 26 hours in a 10-hour paid day.

The AMA has responded that in many cases the RUC has actually resulted in devalued procedures. To quote a letter from the AMA to the Washington Post "In recent years, the committee has taken the initiative to identify overvalued medical services to help drive cost reduction. To date, they reviewed about 1,300 potentially misvalued services and recommended reductions to 500 previously overvalued services." More importantly to us as vascular surgeons is the fact that the Medicare physician payment system is ultimately budget-neutral. Let me explain my concern. In other words there is no financial impact to overall Medicare spending if the government accepts a recommendation for increasing a medical service value. This is because any increase is automatically offset by decreasing values assigned to all other services. So if members of other specialty societies exaggerate the relative value of their services and the RUC and CMS agrees with these excessive RVU’s then they have to reduce other RVUs. So, if vascular surgeons don’t supply realistic data for our procedures we are likely to have our fees reduced.

THE AMA claims to have redistributed $2.5 billion to primary care and other services. It is this latter claim that makes me hopeful that our members will take these surveys seriously since I am sure we have not been the beneficiaries of this multibillion dollar redistribution. If we don’t complete the surveys it is likely that our procedures will be devalued and the monies CMS saves will simply be passed on to our primary care colleagues or other specialists.

Accordingly, I urge members of the SVS to take seriously these requests to fill out the RUC surveys. Do not under play how long it takes you to do the procedure but do not exaggerate either. An honest survey serves us and our patients best. SVS representatives have spent countless hours ensuring that the work of our members is fairly and accurately represented. The role of RUC advisor has been held for the last 20 years by Gary Seabrook, and beginning this year is being taken up by Matt Sideman. The next time you see either of them, be sure to give Gary your thanks, and wish Matt the best.