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EDITORIAL
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Volume 22	January March 2006	Number 1
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Identity Crisis: Who is a Vascular Surgeon?

Davender Singh1 and Shaukat Ali Jawaid 2

While the answers to the few problems in vascular surgery are slowly emerging i.e. the refinement of diagnostic techniques and the development of biologically better small arterial substitutes, from the work of laboratory and clinical research, some problems, far away from this scientific effort, have recently intruded into the daily life of the vascular surgeon… WHO IS A VASCULAR SURGEON?

By definition a vascular surgeon is a specialty-trained physician who performs surgery on blood vessels. Surgery can include removing the plaque from an artery, bypassing the area of obstruction with a graft, performing endovascular procedures etc. A vascular surgeon can also be involved in the medical treatment of vascular disease.1

Vascular surgery is the branch of surgery that occupies itself with surgical interventions of arteries, veins and lymphatics as well as conservative therapies for disease of the peripheral vascular system. Surgery of the heart is the specialty of the cardiothoracic surgeon, and is effectively a branch of vascular surgery.2

In a historical perspective, these problems of identity crisis are not unexpected. For centuries, even millennia, medicine was an undivided unitary segment of humanity’s interaction with the hostility of nature. There was no conceivable reason to parcel out the meager factual cargo that encompassed the knowledge of diseases and the (usually fruitless) attempts to deal with them. A physician was a person whose identity was sharply defined within an unchanging circle of activity. It was only in relatively recent times (some 300 years ago) that the first dichotomy appeared in this image: the recognition of a new type of physician who used his or her hands in treating disease, that is, the surgeon. A veritable deluge of change came as medicine assumed the aspects of science no more than 100 years ago. Internal medicine and surgery assumed sharply distinguished silhouettes; during the last 50 years, their further fragmentation has resembled a chain reaction.

This process has forced each subdivision of the large entity of medicine to face the same problem of defining its identity, as we now see in vascular surgery. Elemental and vitally important questions arose: Is the existence of the new subdivision justified by the goal it seeks to achieve? What exactly is the scope of its legitimate interest? Who is entitled to enter it? How does one acquire this entitlement?

The difficulties do not lie only at the clinical level; a mundane concern also enters the picture. The practitioners of the parent discipline instinctively resent the contraction of their territory. The interests of the new specialty often conflict with the aspirations of other fields that have been newly created. The need for the very existence of new branches is often questioned. All these historical conflicts have afflicted the birth and growth of vascular surgery.

Everyone knows about "heart disease", but very few know about vascular diseases. In fact vascular disease kills and cripples almost as many people as heart disease or cancer. The sheer magnitude of the problem of vascular disease in this part of the world is staggering. Although there is no accurate vascular registry, the fact that there are over 25 million Diabetics in India alone and ever increasing prevalence of diabetes mellitus in Pakistan is just a small pointer to the vast numbers of the undiagnosed vascular cases. Patients of severe vascular disease have been treated for low backache and arthritis for years. It is only the onset of peripheral gangrene which brings to light the fact that arterial pulsations have been absent for long periods of time hitherto unnoticed. After diagnosis also the only treatment of these unfortunate cases has been amputations leaving the primary vascular problem unsolved. The lack of awareness of the disease is so acute, that even some cardio-vascular surgeons have never heard of a separate, independent vascular surgery department or a vascular surgeon. A truly tragic situation indeed!

From the beginning, the existence of independent vascular surgery as a specialty was challenged by the Medical Council of India, as in India it is still considered to be the part of the broad specialty of "cardio-thoracic-vascular surgery’ (CTVS). A similar situation exists in Pakistan as well as in many other developing Third World countries. However there is an exception whereby Medical Council of India has granted Madras Medical College, Chennai to start the MCh training programme in vascular surgery, but unfortunately the facility can only be availed by the surgeons of the State, thereby denying valuable training opportunity to the surgeons from rest of the country. However, all the hope is not lost for the vascular patients of India. Thanks to the effort of National Board of Examination, New Delhi, which understood and realized the magnitude of the problem. With a vision and mission in 2001, the National Board of Examination started a two years fellowship programme in peripheral vascular surgery and hence giving a separate independent recognition to this subject. Presently this course is available in only three major cities and needs further expansion in future to cover the entire country. As regards Pakistan, no special training programme in vascular surgery recognized by Pakistan Medical and Dental Council (PM&DC) exists nor the College of Physicians and Surgeons Pakistan (CPSP) or Universities the bodies involved with postgraduate medical education, have recognized vascular surgery as a separate discipline.

In spite of this still the picture is not clear. Cardiac surgeons in India still claim themselves to be the best vascular surgeons also. No matter, as in reality their operative vascular work is less than 2% and there CTVS training is skewed only towards cardiac surgery. In fact the approach, diagnosis and therapy of vascular diseases is very much different from approach to a patient with heart disease. No doubt that cardiac surgeon is technically very competent to perform vascular operations, but they are universally burdened with coronary bypasses and valve replacement. So no reason to blame them, in fact what is required is a separate recognized vascular surgeon who can take care of the peripheral vascular system.

Not only that, to confuse and complicate the issue further we now have general surgeons, thoracic surgeons, general surgeons with some experience in vascular surgery and general surgeons with added qualifications in vascular surgery all performing the full assortment of vascular operations. This conceptual puzzle kept many hundreds of surgeons in resentful confusion for years. Time, however, slowly but surely is beginning to sort out this confusion: hospitals concerned with their professional standing are increasingly inclined to grant vascular privileges to new staff members only if they are certified by the Medical Council of India or National Board of Examination as having special or added qualifications in general vascular surgery.

The image of the vascular surgeon is gradually acquiring formal recognition, but the limits of the legitimate participation of the general surgeon in treating vascular diseases in actual practice, is still very high in the real scenario.

As this problem of identity is yet to be solved, vascular surgeons face other problems that impinge on their practice. Now even cardiologists and radiologists are also claiming themselves in the race of treating and eliminating vascular diseases. A real challenge indeed for the vascular surgeons!

As with other sub-specialties in major disciplines, vascular surgery as a separate discipline, a sub-specialty of surgery will eventually emerge in the developing Third World countries as well. No one can stop this progress but it may take some more time before we have full fledged vascular surgery departments headed by qualified and trained vascular surgeons in major healthcare facilities in general and teaching hospitals in particular. Units imparting postgraduate training in vascular surgery must have one surgeon faculty member in addition to the supervisor of the vascular surgery programme who must be a certified vascular surgeon. It is also important that the faculty members are appointed for a period long enough to ensure adequate continuity in the supervision of these postgraduates. It is high time that development of vascular surgery as a separate discipline is given a serious thought by all those concerned.

Educational programme in vascular surgery should provide educational resources appropriate for the development of proficiency in diagnosis and treatment of diseases of the arterial venous, lymphatic circulatory systems, exclusive of those components intrinsic to the heart and intracranial vessels. After completing their training, these vascular surgeons should function as qualified practitioners of vascular surgery. The educational programme can be of twelve months duration exclusively devoted to vascular surgery in addition to the education required for certification in general surgery or thoracic surgery. This programme can be initiated in teaching hospitals with facilities for postgraduate training.

References

1. www.romabhansali.com/oconnor/glossary.htm (accessed on October 19, 2005).

2. http://encylopedia.laborlawtalk.com/vascular_surgery (accessed on October 19, 2005)

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