The Society for Vascular Surgery: Built to last
Article Outline
“It is not the strongest of the species that survive or the most intelligent, but the one most responsive to change.”
―Charles Darwin
We are all aware by now that organized vascular surgery as represented by the Society for Vascular Surgery (SVS) has undergone a major metamorphosis since the SVS merged with the American Association for Vascular Surgery (AAVS) to form the “new” SVS, a united organization with one mission and one set of organizational goals. With this metamorphosis, the SVS has evolved from an annual meeting-based organization, fragmented into two major entities, to become a unified and vibrant society that incorporated other organizations involved in the education and research as well as the clinical practice of vascular disease.
To accomplish its mission and strategic goals, the SVS relies on about 250 volunteer members who give their time, energy, and effort without expecting any tangible return; this represents 14% of SVS's active membership. What is more impressive than the number of volunteers involved is the number of members who apply each year to fill in the vacant positions on various councils, committees, and groups. Almost every appointment is now made through a request for appointment (RFA) process opening the Society to all members willing to help. This year, 91 members volunteered to fill in the available 75 positions.
And your volunteerism was not limited to the functions of the Society. In 2007, SVS members began answering a volunteer request to treat injured soldiers. By the end of 2010, 78 members had volunteered for the program, spending 2-week rotations at Landstuhl Medical Center in Germany, a noble and a worthy cause. Without your volunteerism, the engines of the Society will cease to churn.
Becky Maron and our Chicago office staff have displayed the skills and diligence required in organizing the efforts of these volunteers by staffing various groups and linking them together, so our clinical, educational, and research efforts are aligned and work in unison.
I have been attending this annual meeting uninterrupted since 1984 and watching this organization evolve; its transformation has been nothing less than miraculous. Over the last few decades, however, the Society and the speciality had to overcome obstacles, reinvent themselves, and take on major endeavors, and in doing so, we became stronger and we expanded our horizons to better serve patients with vascular disease. Throughout it all, the Society and the speciality remained true and faithful to our values of integrity, professionalism, and commitment to our members and our patients. But, how does this Society fare as a national organization, and more importantly, how does it relate to its members?
Stimulating progress
Over the years, I have become an avid reader of the writings of Jim Collins, who is considered one of the most thoughtful analysts of businesses and organizations in the United States and is published in several best sellers.1, 2, 3 In their book Built to Last, and in an attempt to understand what makes companies great, Collins and Porras compared the history of companies that maintained their success over decades, which they termed “visionary” companies, with others in similar industries that did not do as well, which they called “comparison” companies. They found, if one invested on January 1, 1926, in visionary companies that 65 years later, by December 31, 1990, the return would have been 6.6 times more than if invested in comparison companies and 15.3 times more compared with the general market.1 Their in-depth analysis showed that visionary companies differed partly by adopting goals that may seem unattainable. These companies relentlessly pursued such goals and in doing so stimulated their own progress. The authors dramatized these goals by calling them “Big Hairy Audacious Goals,” or BHAGs. An example of a BHAG was the decision by Boeing in 1965 to build the 747 Jumbo Jet, committing itself to achieving this goal, financially, psychologically, and publicly. McDonnell Douglas never caught up, even after building the DC-10.
Allow me to enumerate what I consider major BHAGs in the life of the SVS. Please recognize that I am not listing all SVS accomplishments over the years, it is far from it; these are milestones, which in my opinion, had a transformative effect on the speciality and they are what distinguishes vascular surgery from many other surgical and even nonsurgical specialities. They are:
As I put together this list, I am amazed at the magnitude of each one of these accomplishments and the amount of work that went into realizing them: they are BHAGs indeed. The leadership of the Society, guided by the needs of its members, not only envisioned these ideas and goals but was also persistent enough to see them to completion and, by doing so, moved the speciality further ahead in improving the care of our patients. And we are now recognized for them.
In a recent ABS retreat that included members of the Vascular Surgery Board and other component boards, vascular surgery was considered the thought leader by ABS. Two talks from the Chair and the Executive Director of the Vascular Surgery Board were dedicated to explaining to the rest of the specialities how vascular surgery accomplished its current status. Those of us who are aware of vascular surgery's history with the ABS were amazed at the turn of events; we have come a long way, indeed.
Of these major goals, however, I believe the most transformative of all was the decision made by the speciality and the Society to adopt endovascular therapy as equal and complementary to open surgical techniques. Just 15 years ago we were discussing on the floor of this annual meeting and in the hallways of hotels and convention centers whether endovascular therapy was a passing fad or here to stay. Some visionary vascular surgeons predicted that most vascular procedures would be done by endovascular means,4 while others felt outcomes would limit the use of this technology.5
At the persistent urging of younger members, the Society committed the necessary resources and developed plans not only to educate fellows in training in endovascular techniques but also to train practicing vascular surgeons through sponsored postgraduate courses. The Society established the Endovascular Program Evaluation and Endorsement Committee to evaluate and approve mini-fellowships used by practicing surgeons who are now experts at endovascular therapy. Younger surgeons trained their more senior partners. The results were impressive.
An analysis of peripheral vascular Medicare claims is quite telling. From 1998 to 2008, vascular surgery's share of endovascular procedures has been steadily increasing. Specifically, the usage of peripheral stents by vascular surgeons has been increasing, while interventional cardiology's share has remained stable and the share of interventional radiology has steadily decreased. Indeed, volume growth or percent annual increase in peripheral vascular stent usage by vascular surgeons has been the highest among the three specialities every year from 1999 to 2008.6
We take now for granted the full adoption of endovascular techniques in the armamentarium of the vascular surgeon, but to appreciate fully the magnitude of this accomplishment, contrast it with general surgery losing upper and lower endoscopy and cardiothoracic surgery's current struggle trying to recapture thoracic endovascular aortic aneurysm repair and percutaneous valves, not to mention coronary angioplasty and stenting, lost to that speciality many years ago.
Program assessment
Like any other active society, SVS enacts many programs in many areas of clinical practice, education, and research. Although the leadership of the Society feels that these programs meet the needs of the membership, the question remains, do they? In this regard, the book 7 Measures of Success: What Remarkable Associations Do That Others Don't detailed the results of a study commissioned by the American Society of Association Executives, and for which Jim Collins served as a consultant. Associations such as the American Association of Retired Persons, the American College of Cardiology, the American Dental Association, and the Radiological Society of North America were studied using the same “matched-pair” methodology used by Collins and Porras to study major corporations in Built to Last. The match-pair analysis method showed that the main factor that mattered in differentiating remarkable associations from the average was for an organization to be “obsessively data-driven, combined with the creativity and discipline to act on that data in ways that meets your members' needs better than any other organization.”3 This program analysis helps in developing “stop doing” lists of programs that are not successful or do not meet the membership's need, which would allow an organization like ours to allocate its budget wisely.2
In an attempt to evaluate SVS programs, gather data, and develop priorities for budget allocation, the Board of Directors held a retreat about 3 years ago in which various programs already funded by the Society were scored by Board members. In making their scoring assignments, Board members considered (1) their perception of the importance of a program to the members, (2) the profitability of a program, or lack thereof, and (3) the usability of a program, such as the level of attendance at a meeting or a course. Of the 16 programs analyzed, the top programs that were assigned the highest scores by Board members were government relations, publications to include the Journal of Vascular Surgery (JVS), the Annual Meeting, and communications.
Although the list was informative and helpful, program assessment should not be based solely on evaluation by Board members. Indeed, our members' opinion of Society's programs designed to benefit them assumes a paramount importance; to that end, we recently sent members a survey asking for their evaluation and assessment of various programs and functions sponsored by the Society. Of the respondents, 44% identified themselves as being in an academic setting, the rest described themselves as private practitioners with or without teaching responsibilities. Specifically, the members' most favorite SVS benefit is the JVS, 89% of the respondents ranked it as highly important. The JVS is followed by the Vascular Annual Meeting (81%), government relations and lobbying (81%), and improving the public's awareness in vascular surgery (74%). Of note, the rankings are very similar to those of the Board members; all are benefits that the leadership of the Society has considered as top priorities (Table I).
Table I. Society for Vascular Surgery program assessment
(data from 2010 members survey)| Board of directors | Members survey respondents |
|---|---|
| 1. Government relations | 1. JVS |
| 2. Publications to include JVS | 2. Vascular Annual Meeting |
| 3. Vascular Annual Meeting | 3. Government relations |
| 4. Communications | 4. Communications |
More specifically, you believe that it is highly important to improve the specialty's influence and credibility in the eyes of Congress, the public, and referring physicians (Fig 1). Indeed, our efforts to date have borne positive results. Although any examples I give of SVS's accomplishments in this area or any other area, for that matter, will not do the Society justice, I will mention some highlights to make specific points:
Fig 1.
Importance of activities to increase the credibility of the Society for Vascular Surgery.
(data from 2010 member survey)
The SVS spearheaded the National Aneurysm Alliance, and we were rewarded with the passage of the SAAAVE (Screening Abdominal Aortic Aneurysm Very Efficiently) Act, the only preventive measure included in the Deficit Reduction Act of 2006. The National Aneurysm Alliance remains active, working on removing obstacles to abdominal aortic aneurysm screening as called for by SAAAVE.
SVS lobbying was the main reason noninvasive physiologic vascular diagnostic studies were removed from the Deficit Reduction Act, by persuading 18 members of Congress to write to the Administrator of the Centers for Medicare and Medicaid Services (CMS) requesting to do so. SVS staff has also been successful in keeping vascular ultrasound off of every proposed cut in imaging reimbursement since the Deficit Reduction Act.
Our exposure to the public has also taken a positive turn. In the last 12 months, we documented >3.3 million hits on VascularWeb, >41,000 Podcast downloads from VascularWeb, >10,000 Podcast views on YouTube, and about 60,000 Podcast downloads on iTunes. Encouraged by such numbers, the Society has invested in improving VascularWeb to make it more user-friendly and easier to navigate by the public. The new VascularWeb is being rolled out during this meeting.
Membership also strongly favored development of practice guidelines, effectiveness research, and an SVS-sponsored registry for tracking patient outcomes (Fig 2). All these are areas that the Society is investing in and pursuing actively. Specifically, SVS has commissioned the Knowledge and Encounter Research (KER) Unit of the Mayo Clinic to study the development of practice guidelines. Guidelines in areas such as arteriovenous dialysis access, AAA, and carotid interventions have been published, and guidelines in multiple other areas are in the works. In addition, a group of SVS members produced and published in JVS last December an Objective Performance Goals document in chronic limb ischemia,7 accompanied by a commentary from the Food and Drug Administration.8 In addition to being useful to our members, such documents raise our standing in the eyes of governmental agencies and other organizations.
Fig 2.
Importance of Society for Vascular Surgery activities to its members.
(data from 2010 member survey)
The membership supports the development of vascular registries. In addition to our own carotid registry, SVS has been working with the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) to develop a vascular component that would allow data development if you practice in an institution in which NSQIP is available. This new NSQIP vascular component will have expanded granularity, including technical details, specific perioperative variables, and data collection on 100% of index vascular procedures. For those members who prefer the “regional” model popularized by the Vascular Study Group of New England, SVS has started discussions with the leadership of this registry in the hopes of supporting a regional concept for use by SVS members.
The membership also endorsed the Vascular Annual Meeting and meetings of regional societies as a preferred source of continuing medical education (CME), specifically, 83% and 70%, respectively (Fig 3). To provide American Medical Association category 1 CME credits, the Society invested, last year, staff time and resources under the leadership of the late Jim Seeger to go through the laborious and intensive process of securing Accreditation Council for Continuing Medical Education accreditation, a valuable asset to SVS members.
Fig 3.
Value of continuing medical education (CME) activities to Society for Vascular Surgery members (data from 2010 members survey). JVS, Journal of Vascular Surgery; VAM, Vascular Annual Meeting.
In contrast, for example, you rated hands-on skills training low (30%, Fig 3); of note, the Board of Directors ranked it the lowest on their list. This is understandable because the vast majority of our members are now endovascular-proficient. The Society already reduced considerably hands-on skill training programs; however, we continue to monitor the trend and possible growth of carotid artery stenting and will offer postgraduate courses to retrain our members in this technology if this mode of carotid disease therapy expands.
As the President of this organization, I am particularly delighted that those members who responded to the survey felt very positively about of the benefits provided to them by the Society. The SVS has been quick to provide programs and services in response to the members' needs. In response to CMS National Coverage Decision regarding carotid stenting, the Outcomes Committee was quick to develop the SVS Carotid Registry. Other societies felt the need to develop such a registry, also in response to the National Coverage Decision, but the SVS registry was the first out there and is now the most successful. The Society was also quick to respond to the self-assessment evaluation portion of the Maintenance of Certification program of the American Boards of Medical Specialties and developed the Vascular Education and Self-Assessment Program (VESAP-1), and now it is in the process of developing the second edition of this successful program.
Alliance building
To improve the care of our patients and the practice environment of our members, the leadership of the Society has moved to strengthen our relationships with organizations whose goals and missions intersect with ours. Indeed, alliance building was one of the “7 Measures of Success” that make an association remarkable. We have markedly improved the collaboration with the Society for Vascular Ultrasound; the SVS has worked and continues to work with the Society for Vascular Ultrasound on advocacy and vascular laboratory reimbursement issues. We are working on forming tighter relations with the Society for Vascular Medicine. We recently formed a new alliance with the American Podiatric Medical Association (APMA). For years, podiatrists and vascular surgeons worked closely together in the care of the ischemic foot in general and the diabetic foot in particular.
The leaderships of SVS and APMA met on August 23, 2009, and discussed in details the issues faced by podiatrists and vascular surgeons while caring for patients with foot ischemia and diabetes. This resulted in specific goals that the two organizations implemented. A joint statement on the multidisciplinary team approach to the care of diabetic foot was published in the June issue of JVS,9 and a supplement on the care of diabetic foot with authors from both organizations will soon be jointly published in the Journal of Vascular Surgery and the Journal of the American Podiatric Medical Association. The two organizations are also collaborating on advocacy issues.
Both leaderships felt that these initial steps would help to launch a collaborative working relationship that would not only satisfy its main goal, improving the care of diabetic foot, but would also help improve the practice environment of the members of both organizations by streamlining the care of this very important condition.
I strongly believe that we belong to one of the most exciting specialities and the most dynamic field in medicine today. The Vascular Annual Meeting has been improving year after year, with excellent new features added to meet the needs of the practicing vascular surgeon. Last week's registration numbers for this meeting were up by 30% compared with last year's meeting at the same time.
This year, 449 abstracts were submitted, an exciting new record. The topics cover every aspect of our speciality, confirming that we are the “vascular specialists” that can provide the total and comprehensive care of patients with vascular disease: medically, surgically, and endovascularly. We are uniquely trained in and we can use the full spectrum of diagnostic methodology as well as perioperative care. Membership growth is also exciting. Since the year after the merger, our total membership increased by 44%, and our active membership increased by 60% over the same time period, measures of excellence in any organization (Fig 4).
Fig 4.
Growth of Society for Vascular Surgery membership since the year after the merger with the American Association for Vascular Surgery.
Indeed, our Society, by any comparative measure, meets all the requirements of a remarkable organization: we have stimulated our progress while preserving our core values and purpose, our programs have been member-centric, and we have been building alliances and partnerships to improve the practice environment of our members. However, I believe our successes have been tempered by our inability to increase our ranks to meet future demands. Our number is very small, there are fewer vascular surgeons per capita than any other surgical or medical speciality; we rank on top of all specialities in that regard (Fig 5).10
Fig 5.
Number of people per active physician by specialty.
© 2006 Association of American Medical Colleges. All rights reserved. Reproduced with permission.
In my 2003 Presidential Address to the Eastern Vascular Society, I discussed this very issue.11 With the explosive growth in aging baby boomers, it was estimated then that we needed to train about 160 vascular surgeons a year to meet demand. With the full adoption of endovascular techniques by vascular surgeons, the full impact of maturing baby boomers that is expected to hit in 2020 to 2030, and the aging physician workforce, we will need to train even more vascular surgeons than the estimated 160 a year to meet future demands. This year, we had available 113 certified traditional training positions in the match, only 10 positions more than 2003. In addition, the demand remains modest, with 113 applicants certified, which resulted in applicant-to-position ratio of 1.0, and 9% of the positions went unmatched (Table II). In contrast, the demand for the integrated training positions has been much better, with an applicant-to-position ratio about 7 to 8 times that of the traditional pathway. Expansion of the integrated programs has been slow, however, and we are still likely to come up short.
Table II. Match results for independent (5
+2) vascular surgery training pathway
| 2003 | 2010 |
|---|---|
•103 certified positions | •113 certified positions |
•108 certified applicants | •113 certified applicants |
•12 unfilled positions (11.6%) | •10 unfilled positions (9%) |
Now that all vascular educational groups, the Association of Program Directors in Vascular Surgery, the Vascular Surgery Board, and the Education Council of the SVS are working in unison, and with the SVS leadership, we can face this challenge head on. It is incumbent upon us as a speciality and a Society to use our well-earned momentum and come together again to make sure that we are producing the next well-trained generation of vascular surgeons, not only in the quality and breadth of training we have become accustomed to but also in the necessary numbers needed to meet future demands. If we do not, we will risk abdicating the care of vascular disease to other specialities; several are eager to capture the caseload. We have the ability and the means to do so ourselves. Let this be our next BHAG.
Dear colleagues, if I sound optimistic about our speciality and Society that is because I am. Vascular surgery is doing well today not because of some governmental mandate or a sudden increase in reimbursement that favored our speciality over others. Vascular surgery is doing well today not because of its size; it is, after all, one of the smallest specialities. But vascular surgery is doing well today because the speciality came together, represented by this Society, and made the difficult decision every step of the way. The SVS is a vibrant society today because of its young members who with vision and energy will develop the next graft, the next stent, or the next training opportunity. The SVS is doing well today because despite its small size, it is highly respected by governmental agencies, industry partners, and other professional organizations.
But most of all, this speciality and Society are doing well today because of you, dependable and hard-working vascular surgeons; whether you are in private practice, academic practice, solo practice, or group practice, you wake up every day and you go about the business of taking care of patients with vascular disease. Your patients expect the best and you give them your best.
This Society is successful today because every step of the way and for every decision the leadership makes and before every program it intends to initiate it asks this specific question: would it benefit our members and our patients?
This is why, despite the economic gloom and doom, the membership of the Society continues to expand with record number of new members.
This is why, despite your busy practices, you continue to volunteer and dedicate your time and effort to the speciality and the Society.
And, this is why the SVS is built to last, as a remarkable organization, because it is a Society of its members, by its members, and for its members.
Thank you very much for the privilege of having me as your President. You have honored me, I am extremely grateful.
References
- . Built to last: successful habits of visionary companies. New York: HarperCollins; 1997;
- In: Collins JC editors. Good to great: why some companies make the leap… and others don't. New York: HarperCollins; 2001;
- . Foreword to 7 measures of success. Washington, DC: American Society of Association Executive and the Center for Association Leadership; 2006;
- . Presidential address: Charles Darwin and vascular surgery. J Vasc Surg. 1997;245:8–18
- . Presidential address-reflections. J Vasc Surg. 2001;33:213–219
- Personal communication, Mr. John Brumleve.
- Suggested objective performance goals and clinical trial design for evaluating catheter-based treatment of critical limb ischemia. J Vasc Surg. 2009;50:1462–1473
- . FDA perspective on objective performance goals and clinical trial design for evaluating catheter-based treatment of critical limb ischemia. J Vasc Surg. 2009;50:1474–1476
- . The role of interdisciplinary team approach in the management of the diabetic foot: A joint statement from the Society for Vascular Surgery and the American Podiatric Medical Association. J Vasc Surg. 2010;51:1504–1506
- . Physician specialty data: A chart book. Washington, DC: AAMC; 2006;
- . Presidential address: generations apart—bridging the generational divide in vascular surgery. J Vasc Surg. 2003;38:1147–1153
Competition of interest: none.
Presented at the 2010 Vascular Annual Meeting of the Society for Vascular Surgery, June 10-13, 2010, Boston, Mass.
The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a competition of interest.
PII: S0741-5214(10)02847-8
doi:10.1016/j.jvs.2010.12.002
© 2011 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
