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Dr Enrico Ascher (Brooklyn, NY). Is competition from other surgical and nonsurgical specialties of concern to the Australian vascular surgeons?

Dr Philip J. Walker. Yes, I think, as I alluded to, one of the major issues in terms of practice in Australia and New Zealand is political. Other specialties are trying to move into our area, particularly cardiologists, less so radiologists; but other groups, for example vascular sonographers, show now some movement for independence, where previously they have worked in concert with vascular surgeons. Also, podiatric surgeons are attempting to move into the management of diabetic foot disease. Additionally, there is a big push from the universities and from government for a role substitution across medicine and not just in the vascular area.

I suppose cardiologists are perceived as the biggest threat in Australia in that they have access to patients who have a similar disease profile, they have catheter skills, and they have access to facilities. Radiologists in Australia aren't primary care physicians. They don't have admitting rights in hospitals, so they actually work on a referral basis; so they are seen as less of a threat.

I suppose having had an independent board and independent flexible training system that has been able to evolve, Australian vascular surgeons now are extremely well trained in endovascular techniques and really we see ourselves in good position to withstand these pressures as they arise.

Dr Henrik Sillesen (Copenhagen, Denmark). I guess the issue of the cardiologists is something that everybody knows about. I just recently heard a good answer to give a cardiologist when they ask if you need help with something, with balloons, you just ask them back if they need help with the coronaries; and then it kind of stops there, I think.