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Collaboration Between Vascular Surgeons and Interventional Radiologists: Reflections After Two Years

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Collaboration Between Vascular Surgeons and Interventional Radiologists: Reflections After Two Years View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector Collaboration between vascular surgeons and interventional radiologists: Reflections after two years Richard M. Green, MD, Rochester, NY Like the subject of Shel Silverstein’s provocative after previous efforts at collaboration broke down. children’s story, The Missing Piece,1 vascular sur- The Society for Vascular Medicine and Biology was geons think a piece is missing, that they are incom- invited to participate, and the program was orga- plete. They are not happy, and they are not alone. nized by Barry Katzen, MD (SCVIR), Alan Hirsch, There could not be any better evidence for this than MD (Society for Vascular Medicine and Biology), the unexpectedly large and broad-based attendance and me. The intent was to identify ways to collabo- at the Vascular Centers of Excellence Conference in rate more effectively. Every effort was made to bal- Chicago from April 30 to May 1, 1999. Vascular ance the program, and the premise that all the issues surgeons, along with many other people, came in should be discussed even if the participants walked search of their missing pieces. This story is an alle- away and agreed to disagree was accepted. goric rendition of the current rage for synergy that Conference organizers anticipated 200 attendees pervades the management of most large industries.2 and got 714 attendees (24% vascular surgery, 35% None of this would be occurring in the absence interventional radiology, 2% vascular medicine, 5% of the emerging technologies that transcend any one cardiology, and 15% hospital administration). A total specialty’s traditional expertise. It is not necessary to of $190,000 in corporate support was raised dwell on the massive paradigm shift underway in our although a parallel effort for the Research Initiatives treatment options for patients with vascular disease in Bethesda went unfunded. nor is it necessary to rehash our efforts at training Feedback from the participants clearly showed and access to interventional resources. Suffice it to that the “center” concept is merely a euphemism for say that sometimes we have all bumped into stone achieving individual agendas that have been well stat- walls. ed in the past.3 Surgeons came looking for a way into the endovascular sphere; 73% wanted to perform VASCULAR CENTERS OF EXCELLENCE: procedures that they were not currently perform- AN INTERDISCIPLINARY APPROACH TO ing, restricted by a lack of skills, access, or both. QUALITY PATIENT CARE Radiologists came to protect their involvement4; 83% The Chicago conference started out as an expressed frustration with access to patients, time, attempt to improve relations between the national and product availability. Vascular medical specialists vascular surgical societies and the Society for came to justify their existence: “. the need for med- Cardiovascular Interventional Radiology (SCIVR) ical specialists who are knowledgeable in the biology and natural history of vascular disease and can give long-term care to these high risk patients.”5 From the University of Rochester Medical Center. Cardiologists came to tell everyone else that periph- Competition of interest: nil. eral vascular disease was a component of their sphere. Based on a presentation given at the 1999 E. Stanley Crawford “There are compelling reasons for cardiologists to Critical Issues Symposium at the Annual Meeting of the Society undertake a more global approach to patients with for Vascular Surgery, Washington, DC. Reprint requests: Richard M. Green, MD, Box SURG, University atherosclerotic diseases . There are inherent advan- of Rochester Medical Center, 601 Elmwood Ave, Rochester, tages for patients when the interventionalist peform- NY 14642. ing the procedure is also the clinician responsible for J Vasc Surg 2000;31:826-30. the pre- and postprocedure care, analogous to the Copyright © 2000 by The Society for Vascular Surgery and vascular surgeon who cares for patients before and International Society for Cardiovascular Surgery, North 6 American Chapter. after surgical procedures.” Everyone spoke of col- 0741-5214/2000/$12.00 + 0 24/1/103795 laboration as a good thing (if only there were magic doi:10.1067/mva.2000.103795 formulas to achieve it). 826 JOURNAL OF VASCULAR SURGERY Volume 31, Number 4 Green 827 MODELS OF COLLABORATION BETWEEN Albany Medical Center, and Washington University VASCULAR SURGEONS AND are three examples of evolving collaborative agree- INTERVENTIONAL RADIOLOGISTS ments.11 Our agreement was not reached easily or quickly. The dialogue started in a way similar to that A variety of current models of collaboration in The Missing Piece: between vascular surgeons and interventional radiolo- I am not your missing piece. gists may provide excellent care in the short term, but I am nobody’s missing piece. none is a widely applicable solution as endovascular I am my own piece. therapies that transcend specialty borders become And even if I were someone’s missing piece, I don’t more available. There are those who think collabora- think I’d be yours.1 tion means sharing know-how. Surgeons have been But local circumstances that included a long, allowed to observe catheter-based interventions, and successful working relationship between the two radiologists have watched vascular surgical operations. groups, a supportive Chair of Radiology, and the This means “why don’t you come down and see emergence of endografts for aortic aneurysms shep- where I live…but don’t touch anything.” These rela- herded this agreement to fruition. And just as in the tionships only breed hostility because watching does story, the pieces seemed to fit. not teach anyone how to cross the iliac bifurcation or Why? Let me pose two situations. You have how to manage claudication. deployed an aortic endograft, and the 1-month A number of centers have emerged with support computed tomography scan shows an endoleak. At from academic awards provided by the National 6 months the aneurysm has grown 7 mm in diame- Institutes of Health. These efforts have been quite ter, and the endoleak persists. An angiogram reveals successful in promoting basic research initiatives, mul- the source as a large patent inferior mesenteric tidisciplinary care, and training in vascular medicine7 artery. The solution is a coil. How do you get it but are unsuccessful in promoting cross-training in there? The solution requires access through the catheter-guidewire skills and economic integration. superior mesenteric artery. If you are a surgeon and These centers have for the most part developed an you can do this, you do not need a collaborator. infrastructure that may yet facilitate the development On the other hand, if you are a radiologist and of true collaborative efforts as the needs for cross- you retrieve a piece of the iliac artery as you remove training and fiscal integration become more obvious. the deployment device, you need collaboration. And Some think collaboration means moving into a so we moved ahead. We designed a system to share shared physical space where each specialty does what revenues based on previous compensation levels, to it does best. These models are usually attempted share extra income, to train each other’s fellows and where there is great strength in multiple disciplines.8 each other, to discuss case management, and to Although there is a free flow of patients among spe- share in the newly created endovascular program. cialties, there is little sharing of resources. In this Like the story, we shared the optimism of achieving model, vascular surgeons continue to perform oper- a long-sought union with our missing piece: ations, and radiologists perform interventions, and It fit! the referring physicians and patients decide what It fit perfectly! 9 treatment is appropriate. Each participant is at risk At last! At last!1 to become an endangered species if the skills pos- sessed by their space-mates become dominant at Collaboration has up sides and down sides. their expense, and for that reason, each must acquire But, after 2 years, this turns out not to be a per- whatever skills are necessary for survival. Others fect fit. We now recognize that it is an illusion to have collaborated in centers where one specialty think that achieving synergy with interventional dominates the other, usually because it is the princi- radiology does not have a potential down side to ple source of referrals.10 This is a serious handicap both parties. In our enthusiasm to make a deal, we over the long-term for the stronger group, unless an overemphasized the upside potential and minimized effort is made to strengthen the weaker party. It is the risks. This miscalculation caused a good deal of not in anyone’s best interest to collaborate with a strain on the relationship that might have been weak partner. avoided had it been anticipated and is a common True collaboration, which I will define as eco- error in many attempts at synergy. We forgot our nomic integration and cross training, occurs at only cardinal rule: first, do no harm. a few institutions. The University of Rochester, Our top-down strategy has failed to eliminate the JOURNAL OF VASCULAR SURGERY 828 Green April 2000 tensions at the grass roots level. Although we once disease and apply a variety of techniques to that end; thought otherwise, money issues (although very they possess technical skills and resources to provide real) are not the main stumbling blocks to achieving one form of therapy. In addition, they do other non- a meaningful synergy: achieving professional gratifi- vascular procedures that are necessary for their sus- cation for each member of every groups is. When tenance, which have no appeal to us. The piece does negotiations began, we thought that guaranteeing not fit. salaries for the radiologists would mitigate the reali- Second, financial considerations are an impor- ty of vascular surgeons doing interventions.
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