When did you decide that you wanted a career in medicine?
My desire to go into medicine started as early as junior high school. My father encouraged me to follow this career path through a very close friend of his who was a very successful physician. I was fascinated by stories he used to tell me regarding difficult medical conditions he successfully managed. He was able to care for sick patients and with appropriate diagnosis and treatment, they were cured and back to active life. His gratification was almost immediate and the reward was very thankful patients; the perfect career path.
Why did you decide to specialise in vascular surgery?
In the seventies, while in medical school, I read an article about Michael DeBakey treating abdominal aortic aneurysms using a synthetic graft. I was really fascinated how a patient suffering from this potentially lethal condition can lead a normal life after having the abdominal aortic aneurysm repaired. This article got me interested in vascular surgery; I felt it would be great to be in a specialty that would have such an impact on life or limb. So, I entered a surgical residency then I applied to a “Vascular Surgery Fellowship”.
Who have you been greatly influenced by?
The beautiful thing about being active in our specialty is that we come across many thoughtful and interesting people that we can learn from and be influenced by, not only clinically, but academically and administratively as well. Specifically, I was delighted to be accepted in the vascular fellowship at Boston University and train under Frank LoGerfo and James Menzoian, where I did not only learn vascular surgery but fell in love with academic surgery.
How has vascular surgery evolved since you began your career?
When I started my training, the new big thing at the time was the in-situ bypass and the technology related to it; such as various valvulotomes and ways to detect valvular structures. However, fast forward about 25 years, and as I stated in my presidential address to the Society for Vascular Surgery, the metamorphosis of vascular surgery from an open surgery-based specialty into a specialty that uses endovascular as well as open surgical means was nothing less than miraculous. It is actually very encouraging how the specialty and the society came together to implement endovascular therapy in the armamentarium of the vascular surgeon. Although the SVS and other national, international, and regional societies provided the impetus, the credit should go to the individual vascular surgeons who took the initiative, made the effort, and learned the new technology to offer it to their patients.
What are your current areas of research?
Since I was in fellowship training at Boston University Hospital, I continue to be highly interested in the pathology of diabetic vascular disease, the diabetic foot, and their management. With the number of diabetics ever increasing, any productive research in this area will have a considerable impact on limb salvage in this patient population. My research in this area has progressed over the years from basic science to, more recently, the clinical area.
What have been your proudest moments?
Professionally, in the vascular area, I am most proud of serving as president of the Society for Vascular Surgery and as the editor of the Journal of Vascular Surgery. I have been involved in organised vascular surgery in the United States for many years and, in 2003, I was part of the group that worked on merging the two national societies, the Society for Vascular Surgery and the American Association for Vascular Surgery into one united organisation representing the specialty in the United States. Since then the society has evolved from an annual meeting based organisation into an active and vibrant society that represents the specialty and its practicing physicians 24/7/365. I am proud I was fortunate enough to play a part in the evolution of the society. Needless to say being selected as one of the editors of the Journal is a distinct honour that has been bestowed on lucky few vascular surgeons over the 25 year history of the journal. The JVS helped in establishing the Society for Vascular Surgery as the premier academic authority in this field and it has been a very successful enterprise for the society ascending to the eleventh position out of 148 surgical journals worldwide based on 2008 impact factor and the first among its peers using the same parameter. To be chosen as one of its editors to lead it into the second quarter century was indeed a proud moment for me.
Increasing the number of patients screened for abdominal aortic aneurysms is one of the challenges in the vascular field. What can be done to broaden screening?
The Society for Vascular Surgery spearheaded the National Aneurysm Alliance (NAA) that was able to successfully pass the SAAAVE (Screening Abdominal Aortic Aneurysm Very Effectively) bill. However, since abdominal aortic aneurysm screening was linked to the “Welcome to Medicare” exam, not many potential aneurysm patients were screened. Now, the NAA remains active in the hopes of removing the obstacles to screening, such as de-linking abdominal aortic aneurysm screening from the “Welcome to Medicare” exam. The society is also a sponsor of AAAnswers Coalition, which is leading a campaign to increase aneurysm screening and awareness in the United States.
For patients with asymptomatic carotid disease, what treatment options do you think will prevail, stenting or surgery?
My answer may surprise the reader. I think over the next 10 years we will be intervening less and less on asymptomatic carotid disease surgically or endovascularly. I think this disease will be managed medically. I believe that medical management of asymptomatic carotid artery disease will be shown to be as effective as surgical or interventional techniques.
What have been your greatest achievements as president of the Society for Vascular Surgery (2009–2010)?
The SVS has become bigger than any one person involved in its management including the President. It is now an around the year functioning society with many programmes that benefit its members. These programmes are carried from year to year by various committees and councils staffed by mature administrative structure. So all the great things SVS has accomplished have really been because of sustained efforts that span the term of more than one president. However, if I were to single out accomplishments for my tenure, it would be the relationship with the American Podiatric Medical Association (APMA) and all the good things that have/will come out of that; such as joint education, diabetic foot practice guidelines, joint statement on the benefits of team approach to the management of diabetic foot, and the diabetic foot supplement that will be published jointly in the Journal of Vascular Surgery and the Journal of the American Podiatric Medical Association. In addition, I worked hard last year to keep the members informed of what the Society is doing for them and of SVS programmes they can take advantage of.
The Society for Vascular Surgery was among the medical societies that criticised the healthcare reform in the USA. What is your evaluation of the approved reform?
Although there are some positive provisions for both vascular surgeons and our patients in the Patient Protection and Affordable Care Act of 2009 that was passed by Congress and signed into law by the President in March, there are other provisions that fall short of addressing serious problems, including the following:
The flawed sustainable growth rate (SGR) formula, which is used to determine Medicare physician payment, was not repealed.
Medical liability reform that would put reasonable limits on non-economic damages is not included.
An unelected, unaccountable Independent Payment Advisory Board (IPAB) with minimal
Congressional oversight was included.
Quality improvement initiatives are not well-designed and tested.
It does little to address surgical workforce shortages.
However, the law has some positive provisions that will benefit vascular surgeons and their patients:
There is an emphasis on preventive services, including ultrasound screening for abdominal aortic aneurysms.
SVS supports annual transparency reports from manufacturers of covered drugs, devices, and biological or medical supplies.
SVS supports insurance regulations in the law such as the exclusion of pre-existing conditions and caps on benefits.
Expanding insurance coverage to the uninsured.
One of the Vascular Disease Foundation’s aims is to increase patient awareness. How can this be achieved?
The Vascular Disease Foundation (VDF) is the only national multidisciplinary non-profit committed to reducing death and disability from vascular disease for all Americans. There are over 54 million Americans with vascular disease and providing them with scientific and trustworthy education is key. VDF accomplishes this through a variety of methods, including a free quarterly magazine for the public, audio HealthCasts, “Ask the Expert Live Chat”, educational videos, interactive vein and artery map, educational pamphlets and brochures, and an extensive website that provide patient education. We also promote patient awareness through media campaigns with radio, television, print and billboard advertisements, as well as articles for newspapers and magazines, to call attention to vascular disease. VDF conducts two initiatives through its P.A.D. Coalition and Venous Disease Coalition who have partnered with government agencies such as the Centers for Disease Control and Prevention (CDC) to educate women about deep vein thrombosis and with the National Heart, Lung and Blood Institute to increase awareness about peripheral arterial disease. VDF and its coalitions focus not only on patient education, but also on educating healthcare providers about vascular disease so that they may better educate their patients.
Outside of medicine, what other interests do you have?
My outside interests have been rather limited due to the heavy schedule related to my job, involvement in the national society, and the Journal of Vascular Surgery. However, I always manage to read books related to the history of the United States and its founding fathers. It is fascinating how a group of thoughtful people got together in Philadelphia in the heat of summer and produced the template upon which this nation was built. In addition, I have been most interested in the history and archeology of the Middle East. This historically rich area continues to play an important role in world’s geopolitics until this day. However, my greatest interest outside medicine is to watch my children grow and become mature adults planning their own futures; in a way reliving my life through theirs.