Integrating Multiple Specialties into Professional Training and Practice: A Vascular Surgeon’s Perspective John J. Ricotta MD FACS Harold Hawfield Chair of Surgery Washington Hospital Center

John J. Ricotta, MD DISCLOSURES I have no real or apparent conflicts of interest to report.

Vascular Disease: A Distinct Specialty 90 M Hypertensives / 23 M Diabetics 133,000 amputations annually 750,000 strokes annually 2.5% males over 50 have AAA 5% US adult population with “PAD” 10-30% adults have venous disease 4% of >65 have CVI with Ulcers

Vascular Disease: Poorly Taught, Poorly Practiced Dx and Mgmt of Vascular Diseases not a major focus of Core Residencies Most patients with PVD do not have recommended medical treatment Antiplatelet agents Statins ACE’s & ARB’s Smoking cessation Prevention / Rehab Programs are lacking

Vascular Disease: Too Many Interventions? > 80% of > 170,000 annual carotid interventions are for asymptomatic disease Impact of SFA intervention on life and limb is marginal No demonstrated benefit of intervention for AAA<5.5 cm, TAA <6 cm. Minimal benefit of Renal PTA

Vascular Disease: Need to Refocus Procedure / Intervention oriented Identify and treat asymptomatic or moderately symptomatic disease Prevention and Medical Management need improvement WHAT WILL HAPPEN IF (WHEN) THE INCENTIVES CHANGE?

Vascular Disease: The Future? Disease rather than procedure oriented Reward comprehensive management rather than episodes of care “VASCULAR HOME” Outcome driven Risk Adjusted Independently Audited

The Future Vascular Practitioner: A Vascular Surgeon’s Perspective Broad Knowledge of Vascular Disease Expertise in Vascular Imaging Evidence based Subspecialization – Intervention and Non Intervention Capable of Open and Endoluminal Interventions – reduce selection bias Regionalization for High end interventions?

Unified Model of Training

“Funnel” Model of Training

Current and Future Training Models in Vascular Surgery “5 + 2” – 2 years Vascular after 5 years GS “0 +5” – 24 months “Core” plus 36 months Vascular 60 months of clinical training 36 months dedicated to Vascular Care “0+7” – 24 months Core, 36 months Vascular , 24 months Thoracic

Essentials of a Common Training Pathway: Vascular Perspective 5 years of clinical training 3 years Vascular Training Interventionalists train in Open and Endovascular Techniques. Non Interventionalists focus on VM, VL, Venous Disease Certification through multiple Boards?

Integrating Specialties into Current Practice Much more difficult in current climate Different indications for intervention Lack of Common Outcome Reporting “Cherry picking” cases Lack of Financial Integration Money and Ego

Guidelines for Integration Common Practice Standards evidence based when possible different approaches require entry into a common database Transparent Outcomes Reporting Independent Audit Common Quality Review Commitment to comprehensive patient care – individual or practice group

Goals of Vascular Practice Integration: Disease rather than procedure oriented Provide comprehensive management rather than episodes of care “VASCULAR HOME” Outcome driven Risk Adjusted Independently Audited