SVMB Presidential address

Vascular Medicine 2007; 12: 215–218

SVMB Presidential address Vascular medicine: past, present and future

Preamble It is my great pleasure to address this 18th Annual Meeting of the Society for Vascular Medicine as the outgoing President. It will be your greater pleasure to know that in this address, I will follow the advice of the seventeenth-century Catalan philosopher Baltasar Gracián who said, “What is good, is doubly so if it be short; and in like manner, what is bad, is less so if there be little of it.” Let me begin by thanking Drs Michael Bacharach and Thom Rooke for their superb work in producing an educational event of high value. Dr Bacharach’s Scientific Organizing Committee included Drs Annex, Creager, Hirsch, Jaff and Mohler. Dr Rooke was assisted by Dr Timothy Sullivan. Both the scientific session and the board review course have a spectacular faculty providing topical content. Dr Michael Jaff deserves special mention for his outstanding leadership of the Finance Subcommittee which raised funds for the meeting. I am grateful to our corporate sponsors, who have helped to make possible this educational effort. Founding of the Society, and its first President, Jay Coffman The first annual meeting of our Society took place on March 19, 1989 in Anaheim CA, when 13 physicians founded the Society for Vascular Medicine and Biology. One of those founders, Jay Coffman, became the first President of our Society. Jay was professor and head of the section of vascular medicine at Boston’s University Hospital. He was an internationally recognized physician-scientist, and made many important contributions to our understanding of the regulation of cutaneous blood flow and the pathophysiology of Raynaud’s disease.1,2 Jay passed away this year, and in recognition of his contributions to our field, the Scientific Organizing Committee has named the Young Investigators Competition after him. Jay would have enjoyed the superb presentations that we heard yesterday. It is wonderful to see that the future of our field is in the hands of such promising young investigators, and that Dr Coffman’s legacy will continue.

Jay would also be delighted to see the continued growth and influence of our Society. In the last 2 years, the Society has grown by 76% from 376 to 663 fellows, members and associates. I am grateful for the hard work of Dr Joshua Beckman and his Membership Committee (Drs Jim Froehlich, Alain Drooz, Pavel Levy and Suman Rathbun) who vetted each of the new applications. The increased interest in our Society and growth of our field is attributable to a number of developments. Developments driving the emergence of vascular medicine Vascular diseases account for most of the morbidity and mortality in the USA.3 In addition to the major vascular diseases causing cerebrovascular and myocardial infarction as well as venous thromboembolism, there is a broad spectrum of arterial, venous, and lymphatic diseases, as well as associated medical disorders. This diversity and complexity of vascular diseases requires knowledgeable vascular internists to provide care in a cost-effective manner.4 Currently, there is a great shortage of vascular internists in the USA. To address this manpower need, the NHLBI has announced this year that it will fund five new training programs in vascular medicine at Stanford University, University of Pennsylvania, Northwestern University, Wake Forest University, and Boston University. This allocation brings to seven the number of NHLBIfunded training programs in vascular medicine (which include the Mayo Clinic and the Brigham and Women’s Hospital). This unprecedented NIH support for a clinical training program was in no small part due to the lobbying efforts and persistent hard work of Society leadership, most notably Dr Mark Creager, who was assisted by Drs Jeffrey Olin and Christopher White. It is very exciting for me to witness the accelerated activity in research and education in vascular medicine and biology in the past few years. I am proud of the major contributions that our SVMB fellows have made, and are continuing to make, in advancing knowledge and clinical care in vascular medicine. The academic vascular internists expected to come from these programs are desperately needed to train a new

© 2007 SAGE Publications, Los Angeles, London, New Delhi and Singapore

Downloaded from vmj.sagepub.com by guest on January 8, 2016

10.1177/1358863x07082376

216

JP Cooke

generation of vascular specialists, who can deal with the epidemic of vascular disease in this country. Additional developments driving the growth of our field include the rapid advances in peripheral imaging and intervention. These developments have stimulated great interest in endovascular medicine, which is beneficial to our field. Many of our new members and fellows have entered the field by this intravascular route. Nevertheless, there remains much work to be done to establish best practices in the application of peripheral imaging and intervention. We need more randomized clinical trials of endovascular interventions, such as CLEVER, to strengthen the scientific foundation for clinical practice.5 Furthermore, our medical system needs vascular specialists who understand the natural history of vascular diseases, who are knowledgeable in the medical management of these disorders, and who are involved in the evaluation and application of endovascular technologies. Certification for vascular medicine specialists Also, boosting the expansion of our field has been the creation of a certifying process for specialists in vascular medicine. Soon after founding the Society, there was discussion and ultimately a broad consensus regarding the need for certification. The Society leadership formulated a plan for a certifying entity, the American Board of Vascular Medicine,6 and the Society funded its development. The ABVM held its first certifying exams in September 2005 and again in 2006. Over 500 individuals have taken these national examinations in general vascular medicine or endovascular medicine. The successful launch of the ABVM represents a watershed moment for vascular medicine, as our discipline emerges as a distinct subspecialty. In days hence, when we are gathered round the hearth and remembering times gone by, glasses will be raised to the name of Bruce Gray. I believe that the inception of the ABVM will be seen as an inflection point in the growth and influence of the Society. Bruce Gray has worked tirelessly to organize the ABVM, to oversee its administration, and to execute the certifying examinations in vascular and endovascular medicine. Of course, Bruce Gray had a band of brothers assisting him in this great effort. Individuals that deserve accolades for their contribution to the success of the ABVM include Past President Dr Michael Jaff, who played a primary role in the founding of ABVM. A number of fellows labored long and hard to make the examination a success, investing many hours of thought and discussion in the development of test questions. These dedicated physicians included Drs Michael Bacharach, Mark Creager, Jon Halperin, Jeffrey Olin, Kenneth Rosenfield, Christopher White, and Krishna Rocha-Singh.

Meeting manpower needs in vascular medicine This Society has had an influx of interventional cardiologists with a special interest in vascular and endovascular medicine, and this is a very welcome development. Indeed, about half of the growth in our Society in the last 2 years has been due to the entry of these new colleagues. We welcome them and acknowledge the energy and knowledge that they bring to our field and to our Society. However, there remains a global need for vascular internists who are fully trained in all aspects of arterial, venous and lymphatic diseases and the associated medical disorders. Certification in vascular medicine will encourage more physicians to seek training; will stimulate training programs in vascular medicine; will promote the codification of a lexicon for vascular specialists; and will enhance patient care. In addition, certification in endovascular medicine provides the first multidisciplinary process to provide credentialing in peripheral endovascular procedures. The work of the ABVM will help to increase the number of vascular specialists. These specialists are needed to meet the growing demands of an aging US population where vascular diseases will remain the greatest cause of morbidity and mortality in the future. This is all very hopeful but I remain concerned regarding the manpower needs in vascular medicine. The new NHLBI-funded training programs are limited in number (seven) and limited in the number of years that they will be funded (5).7 There are also a handful of self-funded training programs. The existing programs are not sufficient to meet the manpower needs of this field. Furthermore, there is not sufficient economic incentive for the extended training that many of our fellows undergo. Many of our trainees have undergone 3 years of internal medicine training and 3 years of subspecialty training. After 6 years of extensive training, we ask them to undergo an additional 1–2 years of training in vascular and/or endovascular medicine. The problem is especially acute for academic physicians, who need to incorporate into their training at least 2 years of research to acquire the tools to be successful clinician-investigators. As a result, young faculty members on average obtain their assistant professor position at the age of 40, and their first major NIH funding at the age of 44.8 I believe that radical changes in training are necessary to reduce the excessive prolongation of training, which has become an obstacle for meeting manpower needs for vascular internists, particularly those in academic medicine.9 One approach is to introduce medical students to the concept of vascular medicine during their first year in medical school, so that they can begin to imagine themselves in this field of specialty. In addition, students would be recruited out of medical school to train in this specialty. The first 2 years would be composed of



Vascular medicine: past, present and future

internal medicine rotations directly applicable to vascular medicine (for example, the hematology/ oncology rotation would focus on thrombosis rather than chemotherapy regimens). The next 2 years might be within a division of cardiovascular medicine, again with rotations directly applicable to vascular medicine (for example, non-invasive imaging of cardiac and vascular structures would receive emphasis over electrophysiology). One year of vascular investigation (clinical, translational or basic) would also be mandatory, together with journal clubs and other mechanisms to train the fellow in evaluation of the literature for continuing lifelong education. At the end of this training, the fellow would be board eligible in internal medicine, vascular medicine and cardiology (once vascular medicine is recognized as a separate subspecialty by third party payors, board eligibility in cardiology may be less of a necessity). An additional year or more of training would be necessary for those fellows who wish to become facile with vascular intervention or plan to become independent investigators. The Society for Vascular Medicine To reflect the changes taking place in the field, and within our Society, we have elected to change the name of the Society to reflect its changing role. The Society membership was strongly in favor of the change, with about 80% responding positively in a recent survey. The trustees were unanimous in their support for the name change, and a clear majority of the fellows voted to approve. Dropping ‘Biology’ from the title is by no means a retreat from the research mission of the Society. More to the point, it is to recognize that vascular medicine includes all aspects of research, including clinical, translational as well as basic vascular biology. Research areas include arterial, venous and lymphatic disease; associated medical disorders of metabolism, coagulation, and hemodynamics; a broad spectrum of imaging and diagnostic tools; and intervention with lifestyle changes, pharmacotherapy and endovascular devices. The broad scope of research activities now being performed by our Society members may not be best characterized as ‘Biology’. Another reason to drop the ‘B’ is to acknowledge the changing composition of our constituency, who are largely endovascular and general vascular practitioners. Nevertheless, there will always be biologists among us; I count myself as one. But I am happy to be in this diverse congregation that includes many types of investigators, educators, and clinicians, all united in their dedication to the field of vascular medicine. Advocating for the field and our patients Our Society is engaged at a national level to improve the care of patients with vascular disease. Dr Heather

217

Gornik leads our Advocacy Committee. Current objectives include increasing the public awareness of PAD, as well as securing third party coverage for ABI screening, and supervised exercise rehabilitation. Dr Gornik and our Advocacy Committee, working with Dr Alan Hirsch and the PAD Coalition, have had some major victories in the past year. Most notably, on August 3 2006, the Senate passed a resolution designating Sept 18–22, 2006 as National Peripheral Arterial Disease Awareness Week (to lobby for legislation to make this an annually recurring event, Dr Gornik will soon be asking you to write to your congressmen). Passage of this resolution launched the first national awareness campaign (the ‘Stay in Circulation’ campaign) to increase public and health care provider awareness about PAD. A major mechanism for influencing the field is through the creation of scholarly and thoughtful documents regarding guidelines and best practices. An excellent example is the paper last year by Beckman and colleagues10 to refute the United States Preventive Services Task Force recommendation statement on screening for peripheral arterial disease. The USPSTF recommended against PAD screening, and implied that screening may lead to unnecessary tests, including increased risk associated with use of contrast angiographic studies. Beckman and colleagues provided a compelling rebuttal of the Task Force’s recommendation. They point out that the USPSTF statement omitted key peer-reviewed data on the prevalence, screening efficacy, and short-term adverse prognosis of patients with PAD and failed to consider the beneficial outcomes that would result from timely diagnosis and medical therapy. This article should encourage the USPSTF to re-evaluate the data, and reconsider its recommendation. Parting thoughts Our field and our Society will continue to grow and to evolve. As the SVM grows, it will be important to preserve the original mission of the Society. Our mission has been and will be, to improve the recognition and care of vascular diseases; to foster education and research in vascular medicine; and to provide leadership to government, industry and the profession regarding issues related to vascular health. The mission has been served very well indeed by individuals, and it will continue to be the commitment and initiative of individuals that drives the Society. However, to channel that energy in a way that preserves the mission of the Society, I have introduced some additional structure. A committee structure has been formalized, and is operating very well indeed, thanks to the inspired work of the committee chairs and members. If you aspire to involve yourself in the intellectual life and leadership of the Society, please let the



218

JP Cooke

leadership know. In particular, you may be interested to become a member of the Emerging Leaders Committee, chaired by Dr Robert Eberhardt. The role of this committee is to introduce emerging leaders to the ongoing activities and operations of the Society, and to integrate these individuals into projects that support the mission of the SVM. In preparing this address, I am struck by how far we have come. So much has been achieved, so quickly, and by so few. Yet, for continued and future success, we must diversify and expand the leadership. Thank you in advance for answering the call, and joining the effort, as we innovate, expand, and advance the discipline of vascular medicine.

5

6 7 8

9

10

vascular medicine: proposed requirements and standards. Vasc Med 2003; 8: 47–52. Hirsch AT. Treatment of peripheral arterial disease – extending ‘intervention’ to ‘therapeutic choice’. N Engl J Med 2006; 354: 1944–47. http://www.vascularboard.org/about.cfm http://grants2.nih.gov/grants/guide/rfa-files/RFA-HL-05002.html Landis S, Bravo NR. New Investigators Committee Update. Dec 1, 2005. URL: http://grants.nih.gov/grants/new_investigators/20051201_New_Investigator_Advisory.ppt#278,1 Zemlo TR, Garrison HH, Partridge NC, Ley TJ. The physician scientist: career issues and challenges at the year 2000. FASEB J 2000; 14: 221–30. Beckman JA, Jaff MR, Creager MA. The United States Preventive Services Task Force recommendation statement on screening for peripheral arterial disease: more harm than benefit? Circulation 2006; 114: 861–66.

References 1 Khan F, Coffman JD. Enhanced cholinergic cutaneous vasodilation in Raynaud’s phenomenon. Circulation 1994; 89: 1183–88. 2 Coffman JD. The enigma of primary Raynaud’s disease. Circulation 1989; 80: 1089–90. 3 Heart Disease and Stroke Statistics – 2007 Update. A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2007; 115: e69–e171. 4 Creager MA, Hirsch AT, Cooke JP et al. Working Group on Fellowship Training in Vascular Medicine, The Society for Vascular Medicine and Biology. Postgraduate training in

John P Cooke President, Society for Vascular Medicine Director, Section of Vascular Medicine Division of Cardiovascular Medicine Stanford University School of Medicine 300 Pasteur Drive, Falk Cardiovascular Research Center Stanford, CA 94305-5046 USA Tel: ⫹1 650 725 3778 Fax: ⫹1 650 725 1599 E-mail: [email protected]

