Vascular Specialist

The Society for Vascular Surgery (SVS) Excellence in Community Service Award is an honor the SVS bestows on a member who has exhibited outstanding leadership within their community as a practicing vascular surgeon. Selection for this honor recognizes an individual’s sustained contributions to patients and their community, as well as exemplary professional practice and leadership.

Nominations are due February 1. More information is available here.

The Society for Vascular Surgery (SVS) Excellence in Community Service Award is an honor the SVS bestows on a member who has exhibited outstanding leadership within their community as a practicing vascular surgeon. Selection for this honor recognizes an individual’s sustained contributions to patients and their community, as well as exemplary professional practice and leadership.

Nominations are due February 1. More information is available here.

The Society for Vascular Surgery (SVS) Excellence in Community Service Award is an honor the SVS bestows on a member who has exhibited outstanding leadership within their community as a practicing vascular surgeon. Selection for this honor recognizes an individual’s sustained contributions to patients and their community, as well as exemplary professional practice and leadership.

Nominations are due February 1. More information is available here.

NEW YORK – Career burnout is common is common among physicians and surgeons, but vascular surgeons might be able to lower their risk simply by taking steps to improve their posture in the operating room, according to data presented at a symposium on vascular and endovascular issues on an evolution that is already underway.

“We looked at physical pain and we were able to demonstrate a correlation with burnout. More pain, more burnout,” said Samuel R. Money, MD, division of vascular surgery, Mayo Clinic, Phoenix, Arizona.

Pain was a reasonable focus for efforts to identify causes of burnout because it is so common among vascular surgeons. In data recently published by Dr. Money and his coinvestigators, 78.3% reported moderate to severe physical pain at the end of a day of surgery (J Vasc Surg 2018;70:913-920).

“Forty percent of vascular surgeons have chronic pain,” Dr. Money said at the symposium sponsored by the Cleveland Clinic Foundation.

Physical pain is not the only cause of burnout, which affects 30% of vascular surgeons, according to data recently presented at the annual meeting of the Society of Vascular Surgery (J Vasc Surg 2019;69[6]:e97.). In that survey, physical pain was joined by work hours, documentation tasks, on-call frequency, and conflicts between work and personal life as significant factors.

“The average vascular surgeon in North America works 63 hours per week,” noted Dr. Money, adding that his survey found nearly 90% of surgeons operate on 3 or more days of every week. This amount of time in the operating room is relevant because almost all surgeons report some degree of pain after a procedure. In the survey, the proportion was greater than 95%.

Yet, risk of pain is modifiable.

“Body position matters,” said Dr. Money, citing studies showing that open procedures are most closely associated with neck pain whereas endovascular procedures are more likely to produce back pain. Although there is a high risk of either type of pain with these procedures, the types of predominant pain are consistent with the demands on body positioning.

“The more you lean forward, the more stress is placed on your neck and back. When standing straight, your head weighs 10-12 pounds, but leaning forward, it can put 60 pounds of pressure on your neck,” he said.

The relative stress can be measured objectively. Dr. Money cited work with a device that measures the body force in inertial measurement units (IMU). According to Dr. Money, the neck is in a high stress position about 75% of the time spent performing typical vascular surgery.

“The trunk is placed in a high stress position approximately 40% of the time, while the other parts of the body that were measured were not generally that bad,” Dr. Money said.

To avoid postural pain, which is not often stressed in surgical training, Dr. Money had specific recommendations. Some are obvious, such as positioning the operating table to minimize the amount of time the head is inclined. He also recommended positioning display monitors no more than 10-20 degrees below and no higher than eye level.

“If you sit down to perform tasks during the procedure, use an adjustable chair so that you can optimize the height,” he said.

He identified loupes as a risk factor for bad posture, and he stressed the importance of wearing lead garments only when necessary and adjusted properly.

“Padded floor mats? They really help,” Dr. Money said. He also recommended appropriate footwear and support stocking.

“Microbreaks are being used in a lot of professions. This means stopping for a moment to stretch every 15-30 minutes,” Dr. Money said.

As a first step, Dr. Money recommended simply developing posture awareness. Many surgeons are simply ignoring the risk and failing to optimize the ways they can increase their comfort during surgery.

Even before entering the surgical suite, regular exercise, yoga, and stretching are all strategies that have the potential to make a difference, according to Dr. Money.

The immediate goal is to reduce the physical pain that is an important occupational hazard for vascular surgeons, but the ultimate goal is to improve job satisfaction, an important defense against professional burnout.

NEW YORK – Career burnout is common is common among physicians and surgeons, but vascular surgeons might be able to lower their risk simply by taking steps to improve their posture in the operating room, according to data presented at a symposium on vascular and endovascular issues on an evolution that is already underway.

“We looked at physical pain and we were able to demonstrate a correlation with burnout. More pain, more burnout,” said Samuel R. Money, MD, division of vascular surgery, Mayo Clinic, Phoenix, Arizona.

Pain was a reasonable focus for efforts to identify causes of burnout because it is so common among vascular surgeons. In data recently published by Dr. Money and his coinvestigators, 78.3% reported moderate to severe physical pain at the end of a day of surgery (J Vasc Surg 2018;70:913-920).

“Forty percent of vascular surgeons have chronic pain,” Dr. Money said at the symposium sponsored by the Cleveland Clinic Foundation.

Physical pain is not the only cause of burnout, which affects 30% of vascular surgeons, according to data recently presented at the annual meeting of the Society of Vascular Surgery (J Vasc Surg 2019;69[6]:e97.). In that survey, physical pain was joined by work hours, documentation tasks, on-call frequency, and conflicts between work and personal life as significant factors.

“The average vascular surgeon in North America works 63 hours per week,” noted Dr. Money, adding that his survey found nearly 90% of surgeons operate on 3 or more days of every week. This amount of time in the operating room is relevant because almost all surgeons report some degree of pain after a procedure. In the survey, the proportion was greater than 95%.

Yet, risk of pain is modifiable.

“Body position matters,” said Dr. Money, citing studies showing that open procedures are most closely associated with neck pain whereas endovascular procedures are more likely to produce back pain. Although there is a high risk of either type of pain with these procedures, the types of predominant pain are consistent with the demands on body positioning.

“The more you lean forward, the more stress is placed on your neck and back. When standing straight, your head weighs 10-12 pounds, but leaning forward, it can put 60 pounds of pressure on your neck,” he said.

The relative stress can be measured objectively. Dr. Money cited work with a device that measures the body force in inertial measurement units (IMU). According to Dr. Money, the neck is in a high stress position about 75% of the time spent performing typical vascular surgery.

“The trunk is placed in a high stress position approximately 40% of the time, while the other parts of the body that were measured were not generally that bad,” Dr. Money said.

To avoid postural pain, which is not often stressed in surgical training, Dr. Money had specific recommendations. Some are obvious, such as positioning the operating table to minimize the amount of time the head is inclined. He also recommended positioning display monitors no more than 10-20 degrees below and no higher than eye level.

“If you sit down to perform tasks during the procedure, use an adjustable chair so that you can optimize the height,” he said.

He identified loupes as a risk factor for bad posture, and he stressed the importance of wearing lead garments only when necessary and adjusted properly.

“Padded floor mats? They really help,” Dr. Money said. He also recommended appropriate footwear and support stocking.

“Microbreaks are being used in a lot of professions. This means stopping for a moment to stretch every 15-30 minutes,” Dr. Money said.

As a first step, Dr. Money recommended simply developing posture awareness. Many surgeons are simply ignoring the risk and failing to optimize the ways they can increase their comfort during surgery.

Even before entering the surgical suite, regular exercise, yoga, and stretching are all strategies that have the potential to make a difference, according to Dr. Money.

The immediate goal is to reduce the physical pain that is an important occupational hazard for vascular surgeons, but the ultimate goal is to improve job satisfaction, an important defense against professional burnout.

NEW YORK – Career burnout is common is common among physicians and surgeons, but vascular surgeons might be able to lower their risk simply by taking steps to improve their posture in the operating room, according to data presented at a symposium on vascular and endovascular issues on an evolution that is already underway.

“We looked at physical pain and we were able to demonstrate a correlation with burnout. More pain, more burnout,” said Samuel R. Money, MD, division of vascular surgery, Mayo Clinic, Phoenix, Arizona.

Pain was a reasonable focus for efforts to identify causes of burnout because it is so common among vascular surgeons. In data recently published by Dr. Money and his coinvestigators, 78.3% reported moderate to severe physical pain at the end of a day of surgery (J Vasc Surg 2018;70:913-920).

“Forty percent of vascular surgeons have chronic pain,” Dr. Money said at the symposium sponsored by the Cleveland Clinic Foundation.

Physical pain is not the only cause of burnout, which affects 30% of vascular surgeons, according to data recently presented at the annual meeting of the Society of Vascular Surgery (J Vasc Surg 2019;69[6]:e97.). In that survey, physical pain was joined by work hours, documentation tasks, on-call frequency, and conflicts between work and personal life as significant factors.

“The average vascular surgeon in North America works 63 hours per week,” noted Dr. Money, adding that his survey found nearly 90% of surgeons operate on 3 or more days of every week. This amount of time in the operating room is relevant because almost all surgeons report some degree of pain after a procedure. In the survey, the proportion was greater than 95%.

Yet, risk of pain is modifiable.

“Body position matters,” said Dr. Money, citing studies showing that open procedures are most closely associated with neck pain whereas endovascular procedures are more likely to produce back pain. Although there is a high risk of either type of pain with these procedures, the types of predominant pain are consistent with the demands on body positioning.

“The more you lean forward, the more stress is placed on your neck and back. When standing straight, your head weighs 10-12 pounds, but leaning forward, it can put 60 pounds of pressure on your neck,” he said.

The relative stress can be measured objectively. Dr. Money cited work with a device that measures the body force in inertial measurement units (IMU). According to Dr. Money, the neck is in a high stress position about 75% of the time spent performing typical vascular surgery.

“The trunk is placed in a high stress position approximately 40% of the time, while the other parts of the body that were measured were not generally that bad,” Dr. Money said.

To avoid postural pain, which is not often stressed in surgical training, Dr. Money had specific recommendations. Some are obvious, such as positioning the operating table to minimize the amount of time the head is inclined. He also recommended positioning display monitors no more than 10-20 degrees below and no higher than eye level.

“If you sit down to perform tasks during the procedure, use an adjustable chair so that you can optimize the height,” he said.

He identified loupes as a risk factor for bad posture, and he stressed the importance of wearing lead garments only when necessary and adjusted properly.

“Padded floor mats? They really help,” Dr. Money said. He also recommended appropriate footwear and support stocking.

“Microbreaks are being used in a lot of professions. This means stopping for a moment to stretch every 15-30 minutes,” Dr. Money said.

As a first step, Dr. Money recommended simply developing posture awareness. Many surgeons are simply ignoring the risk and failing to optimize the ways they can increase their comfort during surgery.

Even before entering the surgical suite, regular exercise, yoga, and stretching are all strategies that have the potential to make a difference, according to Dr. Money.

The immediate goal is to reduce the physical pain that is an important occupational hazard for vascular surgeons, but the ultimate goal is to improve job satisfaction, an important defense against professional burnout.

NEW YORK – Published 12 months apart, guidelines on management of abdominal aortic aneurysm (AAA) from the European Society for Vascular Surgery are similar but diverged in instructive ways from those of the Society for Vascular Surgery, according to a critical review at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation. “Some of the differences were almost unavoidable in the sense that the ESVS guidelines represent multiple idiosyncratic health care systems across Europe,” reported Ronald L. Dalman, MD, chief of vascular surgery, Stanford (Calif.) University.

Ted Bosworth/MDedge News

As a result, the ESVS guidelines provide very little specificity about pharmacologic options because of the differences in availability of these treatments within specific health systems. In addition, both open and endovascular aneurysm repair (EVAR) are given similar emphasis because of the limited availability of EVAR in some parts of Europe.

“The ESVS guidelines specifically recommend repair of an aneurysm within 8 weeks when repair is indicated, but there are not many aneurysms that go 8 weeks in the U.S. without being fixed by a fee-for-service surgeon,” Dr. Dalman observed.

The SVS AAA guidelines were published in January 2018 (J Vasc Surg 2018;67:2-77) and the ESVS guidelines followed 1 year later (Eur J Vasc Surg 2019;57:8-93).

The differences in the guidelines, although modest, are interesting because each set of guidelines was based largely on the same set of trials and published studies, according to Dr. Dalman, who was a coauthor of the SVS guidelines and an external reviewer for the ESVS guidelines.

In the lag between completion of the two guidelines, new information led to three ESVS additions not found in the SVS guidelines, according to Dr. Dalman. They involved the importance of considering aneurysm diameter as a prognostic factor, new understanding of the limitations on endovascular aneurysm sealing (EVAS), and new information about how aneurysm size should affect frequency of surveillance.

Overall, the U.S. guidelines contain 111 recommendations based on 177 references, while the ESVS guidelines contain 125 guidelines based on 189 references. In retrospect, Dr. Dalman believes both sets of guidelines omitted some clinically meaningful information, such as the risk of large-diameter devices for causing endoleaks.

The authors of the ESVS guidelines did have an opportunity to review of a draft of the SVS guidelines, so differences can be interpreted as intentional. For example, the SVS guidelines recommend risk calculators, but Dr. Dalman suggested that the authors of the ESVS guidelines were less convinced that their utility was established.

The decision not to recommend a door-to-treatment time for ruptured aneurysms, as in the SVS recommendations, might have been in deference to disparate practice across European countries, Dr. Dalman suggested.

Ultimately, the guidelines are “substantially similar,” according to Dr. Dalman, but he expressed concerned that neither guideline is accompanied by a specific mechanism or recommended strategy to ensure implementation.

Many of the SVS recommendations are likely to be translated into quality metrics at U.S. institutions, but “there are implementation issues” for ensuring that each guideline is applied, Dr. Dalman said.

Given the agreement on the vast majority of the recommendations, Dr. Dalman suggested that “it might be time to consider global guidelines” for management of AAA and other vascular diseases. Some type of language might be required to accommodate divergent resources or practices across borders, but Dr. Dalman questioned the need to review the same literature to arrive at mostly the same conclusions.

NEW YORK – Published 12 months apart, guidelines on management of abdominal aortic aneurysm (AAA) from the European Society for Vascular Surgery are similar but diverged in instructive ways from those of the Society for Vascular Surgery, according to a critical review at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation. “Some of the differences were almost unavoidable in the sense that the ESVS guidelines represent multiple idiosyncratic health care systems across Europe,” reported Ronald L. Dalman, MD, chief of vascular surgery, Stanford (Calif.) University.

Ted Bosworth/MDedge News

As a result, the ESVS guidelines provide very little specificity about pharmacologic options because of the differences in availability of these treatments within specific health systems. In addition, both open and endovascular aneurysm repair (EVAR) are given similar emphasis because of the limited availability of EVAR in some parts of Europe.

“The ESVS guidelines specifically recommend repair of an aneurysm within 8 weeks when repair is indicated, but there are not many aneurysms that go 8 weeks in the U.S. without being fixed by a fee-for-service surgeon,” Dr. Dalman observed.

The SVS AAA guidelines were published in January 2018 (J Vasc Surg 2018;67:2-77) and the ESVS guidelines followed 1 year later (Eur J Vasc Surg 2019;57:8-93).

The differences in the guidelines, although modest, are interesting because each set of guidelines was based largely on the same set of trials and published studies, according to Dr. Dalman, who was a coauthor of the SVS guidelines and an external reviewer for the ESVS guidelines.

In the lag between completion of the two guidelines, new information led to three ESVS additions not found in the SVS guidelines, according to Dr. Dalman. They involved the importance of considering aneurysm diameter as a prognostic factor, new understanding of the limitations on endovascular aneurysm sealing (EVAS), and new information about how aneurysm size should affect frequency of surveillance.

Overall, the U.S. guidelines contain 111 recommendations based on 177 references, while the ESVS guidelines contain 125 guidelines based on 189 references. In retrospect, Dr. Dalman believes both sets of guidelines omitted some clinically meaningful information, such as the risk of large-diameter devices for causing endoleaks.

The authors of the ESVS guidelines did have an opportunity to review of a draft of the SVS guidelines, so differences can be interpreted as intentional. For example, the SVS guidelines recommend risk calculators, but Dr. Dalman suggested that the authors of the ESVS guidelines were less convinced that their utility was established.

The decision not to recommend a door-to-treatment time for ruptured aneurysms, as in the SVS recommendations, might have been in deference to disparate practice across European countries, Dr. Dalman suggested.

Ultimately, the guidelines are “substantially similar,” according to Dr. Dalman, but he expressed concerned that neither guideline is accompanied by a specific mechanism or recommended strategy to ensure implementation.

Many of the SVS recommendations are likely to be translated into quality metrics at U.S. institutions, but “there are implementation issues” for ensuring that each guideline is applied, Dr. Dalman said.

Given the agreement on the vast majority of the recommendations, Dr. Dalman suggested that “it might be time to consider global guidelines” for management of AAA and other vascular diseases. Some type of language might be required to accommodate divergent resources or practices across borders, but Dr. Dalman questioned the need to review the same literature to arrive at mostly the same conclusions.

NEW YORK – Published 12 months apart, guidelines on management of abdominal aortic aneurysm (AAA) from the European Society for Vascular Surgery are similar but diverged in instructive ways from those of the Society for Vascular Surgery, according to a critical review at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation. “Some of the differences were almost unavoidable in the sense that the ESVS guidelines represent multiple idiosyncratic health care systems across Europe,” reported Ronald L. Dalman, MD, chief of vascular surgery, Stanford (Calif.) University.

Ted Bosworth/MDedge News

As a result, the ESVS guidelines provide very little specificity about pharmacologic options because of the differences in availability of these treatments within specific health systems. In addition, both open and endovascular aneurysm repair (EVAR) are given similar emphasis because of the limited availability of EVAR in some parts of Europe.

“The ESVS guidelines specifically recommend repair of an aneurysm within 8 weeks when repair is indicated, but there are not many aneurysms that go 8 weeks in the U.S. without being fixed by a fee-for-service surgeon,” Dr. Dalman observed.

The SVS AAA guidelines were published in January 2018 (J Vasc Surg 2018;67:2-77) and the ESVS guidelines followed 1 year later (Eur J Vasc Surg 2019;57:8-93).

The differences in the guidelines, although modest, are interesting because each set of guidelines was based largely on the same set of trials and published studies, according to Dr. Dalman, who was a coauthor of the SVS guidelines and an external reviewer for the ESVS guidelines.

In the lag between completion of the two guidelines, new information led to three ESVS additions not found in the SVS guidelines, according to Dr. Dalman. They involved the importance of considering aneurysm diameter as a prognostic factor, new understanding of the limitations on endovascular aneurysm sealing (EVAS), and new information about how aneurysm size should affect frequency of surveillance.

Overall, the U.S. guidelines contain 111 recommendations based on 177 references, while the ESVS guidelines contain 125 guidelines based on 189 references. In retrospect, Dr. Dalman believes both sets of guidelines omitted some clinically meaningful information, such as the risk of large-diameter devices for causing endoleaks.

The authors of the ESVS guidelines did have an opportunity to review of a draft of the SVS guidelines, so differences can be interpreted as intentional. For example, the SVS guidelines recommend risk calculators, but Dr. Dalman suggested that the authors of the ESVS guidelines were less convinced that their utility was established.

The decision not to recommend a door-to-treatment time for ruptured aneurysms, as in the SVS recommendations, might have been in deference to disparate practice across European countries, Dr. Dalman suggested.

Ultimately, the guidelines are “substantially similar,” according to Dr. Dalman, but he expressed concerned that neither guideline is accompanied by a specific mechanism or recommended strategy to ensure implementation.

Many of the SVS recommendations are likely to be translated into quality metrics at U.S. institutions, but “there are implementation issues” for ensuring that each guideline is applied, Dr. Dalman said.

Given the agreement on the vast majority of the recommendations, Dr. Dalman suggested that “it might be time to consider global guidelines” for management of AAA and other vascular diseases. Some type of language might be required to accommodate divergent resources or practices across borders, but Dr. Dalman questioned the need to review the same literature to arrive at mostly the same conclusions.

NEW YORK – The dual challenges of teaching open vascular surgery techniques when few are performed and reaching a generation that has a different attitude to absorbing information requires new and innovative approaches, according to an academic surgeon speaking at symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

Ted Bosworth/MDedge News

“The see one, do one, teach one approach to surgical training is no longer possible,” explained R. Clement Darling III, MD, chief of the division of vascular surgery at Albany (N.Y.) Medical Center Hospital.

For open procedures, the problem is a rapidly declining number of cases in the era of endovascular surgery, but Dr. Darling also recommended adjusting training to the outlook and expectations of a new generation. First observed in the millennial generation, an attitude of firm work-related boundaries is also being seen in generation Z. Generation Z, characterized by birth after 1995, is just now beginning to reach residency programs.

“The approach to work-life balance is extremely different for these individuals than it was for my generation,” Dr. Darling said. While previous generations were often motivated by fear and pressure, newer generations appear to respond less well to anxiety.

“People learn differently. Some from their tactile sense, some intellectually, and some from fear or pressure, but mostly, particularly those who are younger, now learn from positive reinforcement,” Dr. Darling said.

For teaching open procedures at his own institution, Dr. Darling has switched from the traditional model of one-on-one instruction undertaken in the surgical suite to a group approach. The limited number of open cases was the impetus, but group instruction now extends beyond the operating room.

“We have a meeting before the case, when we go over the technical aspects,” Dr. Darling explained. Fellows are asked to envision and describe potential problems and potential solutions.

“We try to make them visualize as well as verbalize exactly what will be done in the operating room,” Dr. Darling said. The plans are outlined carefully “so no one does any thinking in the OR. All the thinking is done in advance.”

Videos and simulators are teaching aids, but a great deal of learning can be accomplished independent of doing, according to Dr. Darling. Moreover, understanding the anatomy, which comes before developing surgical skills, is the same for open and endovascular procedures, so each is relevant to the other.

After witnessing an open case, all of the trainees along with the nurses and attending physicians go through a debriefing to consider the potential lessons. At Dr. Darling’s center, open procedures increasingly involve sicker and older patients, conferring case analysis with a particularly vital learning function in the curriculum.

Because of the diminishing number of open cases and the diminishing open skills, even among experienced vascular surgeons, residents in an increasing number of training programs “graduate without any open experience, which is a little shocking,” Dr. Darling said.

Importantly, group instruction, although valuable and necessary for exposing residents and fellows to open vascular surgery, has its own lessons to impart even if it was born out of necessity.

“We always emphasize that it is not the sewing that counts, it is the setup that counts,” said Dr. Darling, indicating that this is a clear message when the group is assembled for case planning. The group planning also emphasizes that surgery is a team sport.

“All of us is smarter than one of us,” said Dr. Darling, articulating the implicit message of group training.

Although this is a departure from a bygone era where infallible surgeons ruled the OR, it is fits nicely with changing attitudes about the best attributes of a competent surgeon.

NEW YORK – The dual challenges of teaching open vascular surgery techniques when few are performed and reaching a generation that has a different attitude to absorbing information requires new and innovative approaches, according to an academic surgeon speaking at symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

Ted Bosworth/MDedge News

“The see one, do one, teach one approach to surgical training is no longer possible,” explained R. Clement Darling III, MD, chief of the division of vascular surgery at Albany (N.Y.) Medical Center Hospital.

For open procedures, the problem is a rapidly declining number of cases in the era of endovascular surgery, but Dr. Darling also recommended adjusting training to the outlook and expectations of a new generation. First observed in the millennial generation, an attitude of firm work-related boundaries is also being seen in generation Z. Generation Z, characterized by birth after 1995, is just now beginning to reach residency programs.

“The approach to work-life balance is extremely different for these individuals than it was for my generation,” Dr. Darling said. While previous generations were often motivated by fear and pressure, newer generations appear to respond less well to anxiety.

“People learn differently. Some from their tactile sense, some intellectually, and some from fear or pressure, but mostly, particularly those who are younger, now learn from positive reinforcement,” Dr. Darling said.

For teaching open procedures at his own institution, Dr. Darling has switched from the traditional model of one-on-one instruction undertaken in the surgical suite to a group approach. The limited number of open cases was the impetus, but group instruction now extends beyond the operating room.

“We have a meeting before the case, when we go over the technical aspects,” Dr. Darling explained. Fellows are asked to envision and describe potential problems and potential solutions.

“We try to make them visualize as well as verbalize exactly what will be done in the operating room,” Dr. Darling said. The plans are outlined carefully “so no one does any thinking in the OR. All the thinking is done in advance.”

Videos and simulators are teaching aids, but a great deal of learning can be accomplished independent of doing, according to Dr. Darling. Moreover, understanding the anatomy, which comes before developing surgical skills, is the same for open and endovascular procedures, so each is relevant to the other.

After witnessing an open case, all of the trainees along with the nurses and attending physicians go through a debriefing to consider the potential lessons. At Dr. Darling’s center, open procedures increasingly involve sicker and older patients, conferring case analysis with a particularly vital learning function in the curriculum.

Because of the diminishing number of open cases and the diminishing open skills, even among experienced vascular surgeons, residents in an increasing number of training programs “graduate without any open experience, which is a little shocking,” Dr. Darling said.

Importantly, group instruction, although valuable and necessary for exposing residents and fellows to open vascular surgery, has its own lessons to impart even if it was born out of necessity.

“We always emphasize that it is not the sewing that counts, it is the setup that counts,” said Dr. Darling, indicating that this is a clear message when the group is assembled for case planning. The group planning also emphasizes that surgery is a team sport.

“All of us is smarter than one of us,” said Dr. Darling, articulating the implicit message of group training.

Although this is a departure from a bygone era where infallible surgeons ruled the OR, it is fits nicely with changing attitudes about the best attributes of a competent surgeon.

NEW YORK – The dual challenges of teaching open vascular surgery techniques when few are performed and reaching a generation that has a different attitude to absorbing information requires new and innovative approaches, according to an academic surgeon speaking at symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

Ted Bosworth/MDedge News

“The see one, do one, teach one approach to surgical training is no longer possible,” explained R. Clement Darling III, MD, chief of the division of vascular surgery at Albany (N.Y.) Medical Center Hospital.

For open procedures, the problem is a rapidly declining number of cases in the era of endovascular surgery, but Dr. Darling also recommended adjusting training to the outlook and expectations of a new generation. First observed in the millennial generation, an attitude of firm work-related boundaries is also being seen in generation Z. Generation Z, characterized by birth after 1995, is just now beginning to reach residency programs.

“The approach to work-life balance is extremely different for these individuals than it was for my generation,” Dr. Darling said. While previous generations were often motivated by fear and pressure, newer generations appear to respond less well to anxiety.

“People learn differently. Some from their tactile sense, some intellectually, and some from fear or pressure, but mostly, particularly those who are younger, now learn from positive reinforcement,” Dr. Darling said.

For teaching open procedures at his own institution, Dr. Darling has switched from the traditional model of one-on-one instruction undertaken in the surgical suite to a group approach. The limited number of open cases was the impetus, but group instruction now extends beyond the operating room.

“We have a meeting before the case, when we go over the technical aspects,” Dr. Darling explained. Fellows are asked to envision and describe potential problems and potential solutions.

“We try to make them visualize as well as verbalize exactly what will be done in the operating room,” Dr. Darling said. The plans are outlined carefully “so no one does any thinking in the OR. All the thinking is done in advance.”

Videos and simulators are teaching aids, but a great deal of learning can be accomplished independent of doing, according to Dr. Darling. Moreover, understanding the anatomy, which comes before developing surgical skills, is the same for open and endovascular procedures, so each is relevant to the other.

After witnessing an open case, all of the trainees along with the nurses and attending physicians go through a debriefing to consider the potential lessons. At Dr. Darling’s center, open procedures increasingly involve sicker and older patients, conferring case analysis with a particularly vital learning function in the curriculum.

Because of the diminishing number of open cases and the diminishing open skills, even among experienced vascular surgeons, residents in an increasing number of training programs “graduate without any open experience, which is a little shocking,” Dr. Darling said.

Importantly, group instruction, although valuable and necessary for exposing residents and fellows to open vascular surgery, has its own lessons to impart even if it was born out of necessity.

“We always emphasize that it is not the sewing that counts, it is the setup that counts,” said Dr. Darling, indicating that this is a clear message when the group is assembled for case planning. The group planning also emphasizes that surgery is a team sport.

“All of us is smarter than one of us,” said Dr. Darling, articulating the implicit message of group training.

Although this is a departure from a bygone era where infallible surgeons ruled the OR, it is fits nicely with changing attitudes about the best attributes of a competent surgeon.

NEW YORK – Numerous experts, including a past president of the Society for Clinical Vascular Surgery, lined up at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation to explain why there is a critical need for a separate vascular surgery board with membership on the American Board of Medical Specialties.

Ted Bosworth/MDedge News

Not least of the reasons is, “We need to control our destiny by training more residents and fellows in vascular surgery,” said Alan M. Dietzek, MD, who served as SCVS president in 2018 and is an active vascular surgeon in Danbury, Conn.

According to Dr. Dietzek, the American Board of Surgeons recently rejected an application for a vascular resident review committee (RRC), which develops and controls training within a specialty.

“A vascular surgery RRC would facilitate more applications [for training] as well as innovations in specialized programs, which we could certainly use in aortic and venous fellowships,” Dr. Dietzek said. “All ABMS-recognized boards have their own RRC.”

Other speakers, including Timothy M. Sullivan, MD, a professor of surgery at the University of Minnesota, Minneapolis, made the same point. He also believes that a vascular surgery RRC is pivotal in establishing recognition for the specialty and what it offers.

From his perspective, O. William Brown, MD, a vascular surgeon from Bingham Falls, Minn., believes that creating a vascular surgery board will increase recognition in general. Like the others, he maintained that an independent board could draw attention to the specific skills of vascular surgeons, creating a basis for attracting patients, advocating for their needs, and lobbying for resources.

Many experts, including Dr. Brown, believe that the specialty of vascular surgery already meets the qualifications for creating an independent board. However, Dr. Dietzek said that membership in ABMS is dependent on support from the Society of Vascular Surgeons, “and we don’t have that yet.”

In the title of his talk on creating a vascular surgery board, Dr. Brown called for the SVS Executive Committee to “recognize this need and go after it with full force.”

Dr. Dietzek believes the SVS should survey the membership. If there is support for an independent board, it should move ahead with the appropriate support.

“Can we afford it? Other small boards have done just fine,” said Dr. Dietzek, citing the American Board of Colorectal Surgery and the American Board of Thoracic Surgery. He said both are doing well financially, and he provided estimates suggesting that a vascular surgery board would also achieve firm financial footing.

The value of an independent board in exercising control over training programs is part of a larger issue of self-determination, according to Dr. Dietzek. For example, vascular surgeons have “little or no control over the priorities or the budget” at most institutions where they work. An established and recognized vascular surgery board could help these specialists define their identity and separate from other surgical specialties to create their own divisions or departments.

Others who spoke on this topic agreed. Many expressed concern about marginalization by hospital administrators who are often unclear on what vascular surgeons do. A vascular surgery board has the potential to provide a degree of stature that is now lacking.

“We need to build relationships with hospital administrators, politicians, and the insurance industry. This is critical,” Dr. Dietzek said. He believes a vascular surgery board offers an opportunity to achieve these goals and “help us control our own destiny.”

Dr. Dietzek and the other participants report no financial conflicts of interest relevant to this topic.

NEW YORK – Numerous experts, including a past president of the Society for Clinical Vascular Surgery, lined up at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation to explain why there is a critical need for a separate vascular surgery board with membership on the American Board of Medical Specialties.

Ted Bosworth/MDedge News

Not least of the reasons is, “We need to control our destiny by training more residents and fellows in vascular surgery,” said Alan M. Dietzek, MD, who served as SCVS president in 2018 and is an active vascular surgeon in Danbury, Conn.

According to Dr. Dietzek, the American Board of Surgeons recently rejected an application for a vascular resident review committee (RRC), which develops and controls training within a specialty.

“A vascular surgery RRC would facilitate more applications [for training] as well as innovations in specialized programs, which we could certainly use in aortic and venous fellowships,” Dr. Dietzek said. “All ABMS-recognized boards have their own RRC.”

Other speakers, including Timothy M. Sullivan, MD, a professor of surgery at the University of Minnesota, Minneapolis, made the same point. He also believes that a vascular surgery RRC is pivotal in establishing recognition for the specialty and what it offers.

From his perspective, O. William Brown, MD, a vascular surgeon from Bingham Falls, Minn., believes that creating a vascular surgery board will increase recognition in general. Like the others, he maintained that an independent board could draw attention to the specific skills of vascular surgeons, creating a basis for attracting patients, advocating for their needs, and lobbying for resources.

Many experts, including Dr. Brown, believe that the specialty of vascular surgery already meets the qualifications for creating an independent board. However, Dr. Dietzek said that membership in ABMS is dependent on support from the Society of Vascular Surgeons, “and we don’t have that yet.”

In the title of his talk on creating a vascular surgery board, Dr. Brown called for the SVS Executive Committee to “recognize this need and go after it with full force.”

Dr. Dietzek believes the SVS should survey the membership. If there is support for an independent board, it should move ahead with the appropriate support.

“Can we afford it? Other small boards have done just fine,” said Dr. Dietzek, citing the American Board of Colorectal Surgery and the American Board of Thoracic Surgery. He said both are doing well financially, and he provided estimates suggesting that a vascular surgery board would also achieve firm financial footing.

The value of an independent board in exercising control over training programs is part of a larger issue of self-determination, according to Dr. Dietzek. For example, vascular surgeons have “little or no control over the priorities or the budget” at most institutions where they work. An established and recognized vascular surgery board could help these specialists define their identity and separate from other surgical specialties to create their own divisions or departments.

Others who spoke on this topic agreed. Many expressed concern about marginalization by hospital administrators who are often unclear on what vascular surgeons do. A vascular surgery board has the potential to provide a degree of stature that is now lacking.

“We need to build relationships with hospital administrators, politicians, and the insurance industry. This is critical,” Dr. Dietzek said. He believes a vascular surgery board offers an opportunity to achieve these goals and “help us control our own destiny.”

Dr. Dietzek and the other participants report no financial conflicts of interest relevant to this topic.

NEW YORK – Numerous experts, including a past president of the Society for Clinical Vascular Surgery, lined up at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation to explain why there is a critical need for a separate vascular surgery board with membership on the American Board of Medical Specialties.

Ted Bosworth/MDedge News

Not least of the reasons is, “We need to control our destiny by training more residents and fellows in vascular surgery,” said Alan M. Dietzek, MD, who served as SCVS president in 2018 and is an active vascular surgeon in Danbury, Conn.

According to Dr. Dietzek, the American Board of Surgeons recently rejected an application for a vascular resident review committee (RRC), which develops and controls training within a specialty.

“A vascular surgery RRC would facilitate more applications [for training] as well as innovations in specialized programs, which we could certainly use in aortic and venous fellowships,” Dr. Dietzek said. “All ABMS-recognized boards have their own RRC.”

Other speakers, including Timothy M. Sullivan, MD, a professor of surgery at the University of Minnesota, Minneapolis, made the same point. He also believes that a vascular surgery RRC is pivotal in establishing recognition for the specialty and what it offers.

From his perspective, O. William Brown, MD, a vascular surgeon from Bingham Falls, Minn., believes that creating a vascular surgery board will increase recognition in general. Like the others, he maintained that an independent board could draw attention to the specific skills of vascular surgeons, creating a basis for attracting patients, advocating for their needs, and lobbying for resources.

Many experts, including Dr. Brown, believe that the specialty of vascular surgery already meets the qualifications for creating an independent board. However, Dr. Dietzek said that membership in ABMS is dependent on support from the Society of Vascular Surgeons, “and we don’t have that yet.”

In the title of his talk on creating a vascular surgery board, Dr. Brown called for the SVS Executive Committee to “recognize this need and go after it with full force.”

Dr. Dietzek believes the SVS should survey the membership. If there is support for an independent board, it should move ahead with the appropriate support.

“Can we afford it? Other small boards have done just fine,” said Dr. Dietzek, citing the American Board of Colorectal Surgery and the American Board of Thoracic Surgery. He said both are doing well financially, and he provided estimates suggesting that a vascular surgery board would also achieve firm financial footing.

The value of an independent board in exercising control over training programs is part of a larger issue of self-determination, according to Dr. Dietzek. For example, vascular surgeons have “little or no control over the priorities or the budget” at most institutions where they work. An established and recognized vascular surgery board could help these specialists define their identity and separate from other surgical specialties to create their own divisions or departments.

Others who spoke on this topic agreed. Many expressed concern about marginalization by hospital administrators who are often unclear on what vascular surgeons do. A vascular surgery board has the potential to provide a degree of stature that is now lacking.

“We need to build relationships with hospital administrators, politicians, and the insurance industry. This is critical,” Dr. Dietzek said. He believes a vascular surgery board offers an opportunity to achieve these goals and “help us control our own destiny.”

Dr. Dietzek and the other participants report no financial conflicts of interest relevant to this topic.

Off-label device use is common in vascular surgery, but few studies address off-label uses through both surgical and legal perspectives, according to Wei Li, MD, of the University of Maryland School of Medicine, Baltimore. Dr. Li will discuss the medical-legal landscape of off-label device use in her presentation on Friday morning.

She and her colleagues assessed the publicly accessible LexisNexis legal database and Manufacturer and User Facility Device Experience (MAUDE) from January 2012 to December 2017. Jury verdict and case law searches within the LexisNexis were performed in order to identify representative cases and related legal doctrines for entries related to three (off-label) stents deployed in the superficial femoral artery.

They categorized and compared the reported adverse events for all three stents.

Although off-label device use is both legal and unregulated, it can carry potential legal implications on billing practices and subsequent medical malpractice liability, according to the researchers.

They found that off-label device use was more widespread in the pediatric patient population because of an unmet demand that can require Humanitarian Device Exemption. Among 497 total entries of reportable adverse events in MAUDE, for the three stents, they found significant differences, and they also found that the highest malfunction was associated with stent delivery. No deaths were reported with off-label use.

Dr. Li will discuss how vascular specialists need to have more in-depth knowledge about the off-label devices they use to minimize the chance of complications. Their investigation found no evidence reportable adverse events bear a direct relationship with Food and Drug Administration–approved indications related to the three superficial femoral artery stents in question.

Off-label device use is common in vascular surgery, but few studies address off-label uses through both surgical and legal perspectives, according to Wei Li, MD, of the University of Maryland School of Medicine, Baltimore. Dr. Li will discuss the medical-legal landscape of off-label device use in her presentation on Friday morning.

She and her colleagues assessed the publicly accessible LexisNexis legal database and Manufacturer and User Facility Device Experience (MAUDE) from January 2012 to December 2017. Jury verdict and case law searches within the LexisNexis were performed in order to identify representative cases and related legal doctrines for entries related to three (off-label) stents deployed in the superficial femoral artery.

They categorized and compared the reported adverse events for all three stents.

Although off-label device use is both legal and unregulated, it can carry potential legal implications on billing practices and subsequent medical malpractice liability, according to the researchers.

They found that off-label device use was more widespread in the pediatric patient population because of an unmet demand that can require Humanitarian Device Exemption. Among 497 total entries of reportable adverse events in MAUDE, for the three stents, they found significant differences, and they also found that the highest malfunction was associated with stent delivery. No deaths were reported with off-label use.

Dr. Li will discuss how vascular specialists need to have more in-depth knowledge about the off-label devices they use to minimize the chance of complications. Their investigation found no evidence reportable adverse events bear a direct relationship with Food and Drug Administration–approved indications related to the three superficial femoral artery stents in question.

Off-label device use is common in vascular surgery, but few studies address off-label uses through both surgical and legal perspectives, according to Wei Li, MD, of the University of Maryland School of Medicine, Baltimore. Dr. Li will discuss the medical-legal landscape of off-label device use in her presentation on Friday morning.

She and her colleagues assessed the publicly accessible LexisNexis legal database and Manufacturer and User Facility Device Experience (MAUDE) from January 2012 to December 2017. Jury verdict and case law searches within the LexisNexis were performed in order to identify representative cases and related legal doctrines for entries related to three (off-label) stents deployed in the superficial femoral artery.

They categorized and compared the reported adverse events for all three stents.

Although off-label device use is both legal and unregulated, it can carry potential legal implications on billing practices and subsequent medical malpractice liability, according to the researchers.

They found that off-label device use was more widespread in the pediatric patient population because of an unmet demand that can require Humanitarian Device Exemption. Among 497 total entries of reportable adverse events in MAUDE, for the three stents, they found significant differences, and they also found that the highest malfunction was associated with stent delivery. No deaths were reported with off-label use.

Dr. Li will discuss how vascular specialists need to have more in-depth knowledge about the off-label devices they use to minimize the chance of complications. Their investigation found no evidence reportable adverse events bear a direct relationship with Food and Drug Administration–approved indications related to the three superficial femoral artery stents in question.

An unexpected prevalence of chronic lower back pain (CLBP) was found among patients with proximal venous outflow obstruction (PVOO), according to Windsor Ting, MD, of the Icahn School of Medicine at Mount Sinai, New York and colleagues.

On Friday morning, Dr. Ting will present a study they performed to assess 168 consecutive patients (59% women; mean age 63 years) with PVOO who underwent iliac vein stent placement. PVOO was confirmed with venography and/or IVUS. The patients were queried regarding preoperative and postoperative CLBP, defined as consistent low back pain of a minimum 3-month duration.

They collected data on demographics, venous-related symptomatology, pain scores (0-10) as determined by a visual analog scale (VAS), characteristics of the CLBP. In addition, details of the vein stent procedure were collected.

The mean postoperative duration among the patients was 526 days. Preoperative CLBP was present in 104 (62%) patients; 29 (28%) used analgesics and 38 (37%) had a prior visit with a CLBP specialist. Standing (44%) and sitting (43%) were the two most common factors associated with CLBP pain exacerbation.

Dr. Ting will discuss how CLBP was unexpectedly prevalent among patients with PVOO prior to their iliac vein stent placement, and how their pain was significantly improved after iliac vein stent placement, with 32% of the patients reporting complete symptom resolution. This study is the first to report these unexpected findings, according to the researchers, but the pathophysiology of CLBP in PVOO is unclear.

An unexpected prevalence of chronic lower back pain (CLBP) was found among patients with proximal venous outflow obstruction (PVOO), according to Windsor Ting, MD, of the Icahn School of Medicine at Mount Sinai, New York and colleagues.

On Friday morning, Dr. Ting will present a study they performed to assess 168 consecutive patients (59% women; mean age 63 years) with PVOO who underwent iliac vein stent placement. PVOO was confirmed with venography and/or IVUS. The patients were queried regarding preoperative and postoperative CLBP, defined as consistent low back pain of a minimum 3-month duration.

They collected data on demographics, venous-related symptomatology, pain scores (0-10) as determined by a visual analog scale (VAS), characteristics of the CLBP. In addition, details of the vein stent procedure were collected.

The mean postoperative duration among the patients was 526 days. Preoperative CLBP was present in 104 (62%) patients; 29 (28%) used analgesics and 38 (37%) had a prior visit with a CLBP specialist. Standing (44%) and sitting (43%) were the two most common factors associated with CLBP pain exacerbation.

Dr. Ting will discuss how CLBP was unexpectedly prevalent among patients with PVOO prior to their iliac vein stent placement, and how their pain was significantly improved after iliac vein stent placement, with 32% of the patients reporting complete symptom resolution. This study is the first to report these unexpected findings, according to the researchers, but the pathophysiology of CLBP in PVOO is unclear.

An unexpected prevalence of chronic lower back pain (CLBP) was found among patients with proximal venous outflow obstruction (PVOO), according to Windsor Ting, MD, of the Icahn School of Medicine at Mount Sinai, New York and colleagues.

On Friday morning, Dr. Ting will present a study they performed to assess 168 consecutive patients (59% women; mean age 63 years) with PVOO who underwent iliac vein stent placement. PVOO was confirmed with venography and/or IVUS. The patients were queried regarding preoperative and postoperative CLBP, defined as consistent low back pain of a minimum 3-month duration.

They collected data on demographics, venous-related symptomatology, pain scores (0-10) as determined by a visual analog scale (VAS), characteristics of the CLBP. In addition, details of the vein stent procedure were collected.

The mean postoperative duration among the patients was 526 days. Preoperative CLBP was present in 104 (62%) patients; 29 (28%) used analgesics and 38 (37%) had a prior visit with a CLBP specialist. Standing (44%) and sitting (43%) were the two most common factors associated with CLBP pain exacerbation.

Dr. Ting will discuss how CLBP was unexpectedly prevalent among patients with PVOO prior to their iliac vein stent placement, and how their pain was significantly improved after iliac vein stent placement, with 32% of the patients reporting complete symptom resolution. This study is the first to report these unexpected findings, according to the researchers, but the pathophysiology of CLBP in PVOO is unclear.

Stephen Hahn, MD, President Trump’s pick to head the Food and Drug Administration, faced questions from both sides of the aisle on youth vaping, but came up short when asked to commit to taking action, particularly on banning flavored vaping products.

Speaking at a Nov. 20 confirmation hearing before the Senate Health, Education, Labor, and Pensions Committee, Dr. Hahn said that youth vaping and e-cigarette use is “an important, urgent crisis in this country. I do not want to see another generation of Americans become addicted to tobacco and nicotine and I believe that we need to take aggressive to stop that.”

Sen. Patty Murray (D-Wash), the committee’s ranking member, asked Dr. Hahn whether he would work to finalize a ban flavored e-cigarette products, first proposed but then backed away from, by the president in September.

“I understand that the final compliance policy is under consideration by the administration, and I look forward to their decision,” Dr. Hahn said. “I am not privy to those decision-making processes, but I very much agree and support that aggressive action needs to be taken to protect our children.”

When pressed by Sen. Murray as to whether he told President Trump that he disagrees with the decision to back away the proposed ban, Dr. Hahn revealed that he has “not had a conversation with the president.”

Dr. Hahn, a radiation oncologist who currently serves as chief medical executive at MD Anderson Cancer Center, Houston, held firm to just coming up short of making that commitment when questioned by senators from both parties.

Sen. Mitt Romney (R-Utah) warned Dr. Hahn that the playing of politics would be unlike anything he has seen and is already being played out in the lobbying of the administration to change its stance on flavored e-cigarette products, which can run counter to the science about the harmful effects of these products.

“The question is how you will balance those things in which you put forward,” Sen. Romney asked. “How you will deal with this issue is a pretty good test case for how you would deal with this issue on an ongoing basis on matters not just related to vaping.”

He also brought up President Trump’s September announcement on a flavor ban and the administration’s signaling they are moving away from a flavor ban. “Is the FDA, under your leadership, able and willing to take action which will protect our kids, whether or not the White House wants you to take that action?”

Dr. Hahn cited his pledge as a doctor to always put the patient first and reiterated that “I take that pledge very seriously and I think if you ask anyone who has worked with me, they will tell you that I have upheld that pledge.”

But he fell short of saying that he would take actions that would oppose the White House, saying only that “patients need to come first and the decisions that we make need to be guided by science and data, congruent with the law.”

When asked by Sen. Romney if he saw any reason for holding off on a flavor ban, given the evidence that suggests flavored e-cigarette products are the gateway to youths nicotine addiction, Dr. Hahn said that he has seen the same evidence and that it requires “bold action,” but did not commit to a flavor ban. “I will use science and data to guide the decisions if I am fortunate enough to be confirmed, and I won’t back away from that.”

Sen. Doug Jones (D-Ala.) expressed concern about Dr. Hahn’s answers.

“I was less than happy with many of the answers you gave to members of this committee with regard to vaping and the potential ban on flavored e-cigarettes,” Sen. Jones said. “I think you can tell from the questions of so many senators that is one of the biggest issues that the United States Senate and Congress is facing right now. It is with this committee.”

Outside of vaping, much of the senators’ questioning was nonconfrontational, with questions spanning a gamut of issues facing the FDA.

Dr. Hahn offered his commitment to working with Congress to address drug shortages, noting nonspecifically that, “there are things that we can do to help.”

He also pledged to work with Congress on addressing patent reform to get more biosimilars to market in an effort to help drive down drug prices.

Regarding opioids, Dr. Hahn was asked about balancing the needs of those who legitimately need access to opioids against abuse and diversion.

“When I first went to medical school and started taking care of cancer patients, the teaching was that cancer patients should be treated liberally with opioids and that they don’t become addicted to pain medications,” he said. “We found out that wasn’t the case – and in some instances – with tragic consequences.”

He noted that pain therapy has evolved and that his institution now takes a multidisciplinary approach employing both opioid and nonopioid medications.

“I am very much a supporter of the multidisciplinary approach to treating pain,” he said. “I think it is something that we need to more of and if I am fortunate enough to be confirmed as commissioner of [FDA], I look forward to furthering the education efforts for providers and patients.”

Other areas he committed to included helping to improve clinical trial design for psychiatric medications and improving development of therapies for rare diseases.

Committee Chairman Lamar Alexander (R-Tenn.) said he plans to schedule a Dec. 3 vote to advance Dr. Hahn’s nomination to the full Senate for its consideration.

[email protected]

Stephen Hahn, MD, President Trump’s pick to head the Food and Drug Administration, faced questions from both sides of the aisle on youth vaping, but came up short when asked to commit to taking action, particularly on banning flavored vaping products.

Speaking at a Nov. 20 confirmation hearing before the Senate Health, Education, Labor, and Pensions Committee, Dr. Hahn said that youth vaping and e-cigarette use is “an important, urgent crisis in this country. I do not want to see another generation of Americans become addicted to tobacco and nicotine and I believe that we need to take aggressive to stop that.”

Sen. Patty Murray (D-Wash), the committee’s ranking member, asked Dr. Hahn whether he would work to finalize a ban flavored e-cigarette products, first proposed but then backed away from, by the president in September.

“I understand that the final compliance policy is under consideration by the administration, and I look forward to their decision,” Dr. Hahn said. “I am not privy to those decision-making processes, but I very much agree and support that aggressive action needs to be taken to protect our children.”

When pressed by Sen. Murray as to whether he told President Trump that he disagrees with the decision to back away the proposed ban, Dr. Hahn revealed that he has “not had a conversation with the president.”

Dr. Hahn, a radiation oncologist who currently serves as chief medical executive at MD Anderson Cancer Center, Houston, held firm to just coming up short of making that commitment when questioned by senators from both parties.

Sen. Mitt Romney (R-Utah) warned Dr. Hahn that the playing of politics would be unlike anything he has seen and is already being played out in the lobbying of the administration to change its stance on flavored e-cigarette products, which can run counter to the science about the harmful effects of these products.

“The question is how you will balance those things in which you put forward,” Sen. Romney asked. “How you will deal with this issue is a pretty good test case for how you would deal with this issue on an ongoing basis on matters not just related to vaping.”

He also brought up President Trump’s September announcement on a flavor ban and the administration’s signaling they are moving away from a flavor ban. “Is the FDA, under your leadership, able and willing to take action which will protect our kids, whether or not the White House wants you to take that action?”

Dr. Hahn cited his pledge as a doctor to always put the patient first and reiterated that “I take that pledge very seriously and I think if you ask anyone who has worked with me, they will tell you that I have upheld that pledge.”

But he fell short of saying that he would take actions that would oppose the White House, saying only that “patients need to come first and the decisions that we make need to be guided by science and data, congruent with the law.”

When asked by Sen. Romney if he saw any reason for holding off on a flavor ban, given the evidence that suggests flavored e-cigarette products are the gateway to youths nicotine addiction, Dr. Hahn said that he has seen the same evidence and that it requires “bold action,” but did not commit to a flavor ban. “I will use science and data to guide the decisions if I am fortunate enough to be confirmed, and I won’t back away from that.”

Sen. Doug Jones (D-Ala.) expressed concern about Dr. Hahn’s answers.

“I was less than happy with many of the answers you gave to members of this committee with regard to vaping and the potential ban on flavored e-cigarettes,” Sen. Jones said. “I think you can tell from the questions of so many senators that is one of the biggest issues that the United States Senate and Congress is facing right now. It is with this committee.”

Outside of vaping, much of the senators’ questioning was nonconfrontational, with questions spanning a gamut of issues facing the FDA.

Dr. Hahn offered his commitment to working with Congress to address drug shortages, noting nonspecifically that, “there are things that we can do to help.”

He also pledged to work with Congress on addressing patent reform to get more biosimilars to market in an effort to help drive down drug prices.

Regarding opioids, Dr. Hahn was asked about balancing the needs of those who legitimately need access to opioids against abuse and diversion.

“When I first went to medical school and started taking care of cancer patients, the teaching was that cancer patients should be treated liberally with opioids and that they don’t become addicted to pain medications,” he said. “We found out that wasn’t the case – and in some instances – with tragic consequences.”

He noted that pain therapy has evolved and that his institution now takes a multidisciplinary approach employing both opioid and nonopioid medications.

“I am very much a supporter of the multidisciplinary approach to treating pain,” he said. “I think it is something that we need to more of and if I am fortunate enough to be confirmed as commissioner of [FDA], I look forward to furthering the education efforts for providers and patients.”

Other areas he committed to included helping to improve clinical trial design for psychiatric medications and improving development of therapies for rare diseases.

Committee Chairman Lamar Alexander (R-Tenn.) said he plans to schedule a Dec. 3 vote to advance Dr. Hahn’s nomination to the full Senate for its consideration.

[email protected]

Stephen Hahn, MD, President Trump’s pick to head the Food and Drug Administration, faced questions from both sides of the aisle on youth vaping, but came up short when asked to commit to taking action, particularly on banning flavored vaping products.

Speaking at a Nov. 20 confirmation hearing before the Senate Health, Education, Labor, and Pensions Committee, Dr. Hahn said that youth vaping and e-cigarette use is “an important, urgent crisis in this country. I do not want to see another generation of Americans become addicted to tobacco and nicotine and I believe that we need to take aggressive to stop that.”

Sen. Patty Murray (D-Wash), the committee’s ranking member, asked Dr. Hahn whether he would work to finalize a ban flavored e-cigarette products, first proposed but then backed away from, by the president in September.

“I understand that the final compliance policy is under consideration by the administration, and I look forward to their decision,” Dr. Hahn said. “I am not privy to those decision-making processes, but I very much agree and support that aggressive action needs to be taken to protect our children.”

When pressed by Sen. Murray as to whether he told President Trump that he disagrees with the decision to back away the proposed ban, Dr. Hahn revealed that he has “not had a conversation with the president.”

Dr. Hahn, a radiation oncologist who currently serves as chief medical executive at MD Anderson Cancer Center, Houston, held firm to just coming up short of making that commitment when questioned by senators from both parties.

Sen. Mitt Romney (R-Utah) warned Dr. Hahn that the playing of politics would be unlike anything he has seen and is already being played out in the lobbying of the administration to change its stance on flavored e-cigarette products, which can run counter to the science about the harmful effects of these products.

“The question is how you will balance those things in which you put forward,” Sen. Romney asked. “How you will deal with this issue is a pretty good test case for how you would deal with this issue on an ongoing basis on matters not just related to vaping.”

He also brought up President Trump’s September announcement on a flavor ban and the administration’s signaling they are moving away from a flavor ban. “Is the FDA, under your leadership, able and willing to take action which will protect our kids, whether or not the White House wants you to take that action?”

Dr. Hahn cited his pledge as a doctor to always put the patient first and reiterated that “I take that pledge very seriously and I think if you ask anyone who has worked with me, they will tell you that I have upheld that pledge.”

But he fell short of saying that he would take actions that would oppose the White House, saying only that “patients need to come first and the decisions that we make need to be guided by science and data, congruent with the law.”

When asked by Sen. Romney if he saw any reason for holding off on a flavor ban, given the evidence that suggests flavored e-cigarette products are the gateway to youths nicotine addiction, Dr. Hahn said that he has seen the same evidence and that it requires “bold action,” but did not commit to a flavor ban. “I will use science and data to guide the decisions if I am fortunate enough to be confirmed, and I won’t back away from that.”

Sen. Doug Jones (D-Ala.) expressed concern about Dr. Hahn’s answers.

“I was less than happy with many of the answers you gave to members of this committee with regard to vaping and the potential ban on flavored e-cigarettes,” Sen. Jones said. “I think you can tell from the questions of so many senators that is one of the biggest issues that the United States Senate and Congress is facing right now. It is with this committee.”

Outside of vaping, much of the senators’ questioning was nonconfrontational, with questions spanning a gamut of issues facing the FDA.

Dr. Hahn offered his commitment to working with Congress to address drug shortages, noting nonspecifically that, “there are things that we can do to help.”

He also pledged to work with Congress on addressing patent reform to get more biosimilars to market in an effort to help drive down drug prices.

Regarding opioids, Dr. Hahn was asked about balancing the needs of those who legitimately need access to opioids against abuse and diversion.

“When I first went to medical school and started taking care of cancer patients, the teaching was that cancer patients should be treated liberally with opioids and that they don’t become addicted to pain medications,” he said. “We found out that wasn’t the case – and in some instances – with tragic consequences.”

He noted that pain therapy has evolved and that his institution now takes a multidisciplinary approach employing both opioid and nonopioid medications.

“I am very much a supporter of the multidisciplinary approach to treating pain,” he said. “I think it is something that we need to more of and if I am fortunate enough to be confirmed as commissioner of [FDA], I look forward to furthering the education efforts for providers and patients.”

Other areas he committed to included helping to improve clinical trial design for psychiatric medications and improving development of therapies for rare diseases.

Committee Chairman Lamar Alexander (R-Tenn.) said he plans to schedule a Dec. 3 vote to advance Dr. Hahn’s nomination to the full Senate for its consideration.

[email protected]

NEW YORK – Telehealth should be embraced by vascular surgeons for their own self-interest independent of the evidence that it is well accepted and more convenient for patients, according to an update on an evolution that is already underway.

“One of the great advantages of telehealth is the efficacy of time for the clinician,” John W. Hallett, MD, professor of vascular surgery at the Medical University of South Carolina, Charleston, said at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

This efficiency is purchased with no loss of revenue, he added. He said that many clinicians are unaware of the opportunity this affords.

“Almost every payer reimburses telehealth visit at the same rate as that of an office visit,” Dr. Hallett explained. The only additional step is adding a “GT” modifier when billing Medicare or a “95” modifier when billing private payers.

Telemedicine is not a new concept. Published studies date back decades, but this interaction is increasingly understood to be the future. Along with an increasing array of sensors employing smartphone technology to allow physicians remote access to vital signs and other clinical data, patient attitudes have changed.

“Patients like telemedicine. It is convenient for them,” said Dr. Hallett, who noted that many providers are recognizing telemedicine as a potential marketing tool.

“On my way in from the airport yesterday, there was an advertisement for telemedicine from NYU on the television in the cab,” said Dr. Hallett, referring to the New York University health system.

The data supporting the benefits of telemedicine even include studies undertaken in vascular surgery patients. In one recent retrospective study cited by Dr. Hallett, substantial time and travel costs were saved for every vascular surgery consult conducted by telemedicine rather than in an office visit (Paquette S et al. Ann Vasc Surg. 2019;59:167-172).

“There was no difference in the rate of complications, and 94% of the patients considered the telehealth consultation adequate,” Dr. Hallett said.

He said there is urgency for vascular surgeons to pursue telemedicine. With the number of individuals over the age of 65 growing by thousands in the United States every day, there will be increasing pressure on the relatively fixed pool of vascular surgeons to improve their efficiency.

In addition, telemedicine is coming whether vascular surgeons like it or not.

“Patients are becoming more interested in looking at an app on their smartphone than coming to the office,” said Tony S. Das, MD, an interventional cardiologist who practices in Dallas. Dr. Das also spoke about the value of telemedicine for the vascular and cardiovascular surgeon at the VIETHsymposium.

In his overview, Dr. Das spoke about telehealth in the context of the estimated $12 billion dollars that will be spent on digital health in vascular medicine by 2021. The growth in digital health in vascular medicine is a reflection of a global change in clinical care. According to Dr. Das, there were more than 600 vendors of wearable sensors to monitor disease and health at a recent consumer electronics convention.

“This technology is here to stay,” said Dr. Das, who, appropriately, was not present at the symposium but delivered his presentation remotely.

Both the Centers for Medicare and Medicaid Services and the Food and Drug Administration have digital health action plans, according to Dr. Das. The CMS has already developed reimbursement codes to pay for remote monitoring services and more are expected.

Calling this type of telehealth “untethered vascular care,” Dr. Das agreed with Dr. Hallett that an evolution is coming whether vascular surgeons choose to get on board now or are forced to take action later.

SOURCE: VIETHsymposium

NEW YORK – Telehealth should be embraced by vascular surgeons for their own self-interest independent of the evidence that it is well accepted and more convenient for patients, according to an update on an evolution that is already underway.

“One of the great advantages of telehealth is the efficacy of time for the clinician,” John W. Hallett, MD, professor of vascular surgery at the Medical University of South Carolina, Charleston, said at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

This efficiency is purchased with no loss of revenue, he added. He said that many clinicians are unaware of the opportunity this affords.

“Almost every payer reimburses telehealth visit at the same rate as that of an office visit,” Dr. Hallett explained. The only additional step is adding a “GT” modifier when billing Medicare or a “95” modifier when billing private payers.

Telemedicine is not a new concept. Published studies date back decades, but this interaction is increasingly understood to be the future. Along with an increasing array of sensors employing smartphone technology to allow physicians remote access to vital signs and other clinical data, patient attitudes have changed.

“Patients like telemedicine. It is convenient for them,” said Dr. Hallett, who noted that many providers are recognizing telemedicine as a potential marketing tool.

“On my way in from the airport yesterday, there was an advertisement for telemedicine from NYU on the television in the cab,” said Dr. Hallett, referring to the New York University health system.

The data supporting the benefits of telemedicine even include studies undertaken in vascular surgery patients. In one recent retrospective study cited by Dr. Hallett, substantial time and travel costs were saved for every vascular surgery consult conducted by telemedicine rather than in an office visit (Paquette S et al. Ann Vasc Surg. 2019;59:167-172).

“There was no difference in the rate of complications, and 94% of the patients considered the telehealth consultation adequate,” Dr. Hallett said.

He said there is urgency for vascular surgeons to pursue telemedicine. With the number of individuals over the age of 65 growing by thousands in the United States every day, there will be increasing pressure on the relatively fixed pool of vascular surgeons to improve their efficiency.

In addition, telemedicine is coming whether vascular surgeons like it or not.

“Patients are becoming more interested in looking at an app on their smartphone than coming to the office,” said Tony S. Das, MD, an interventional cardiologist who practices in Dallas. Dr. Das also spoke about the value of telemedicine for the vascular and cardiovascular surgeon at the VIETHsymposium.

In his overview, Dr. Das spoke about telehealth in the context of the estimated $12 billion dollars that will be spent on digital health in vascular medicine by 2021. The growth in digital health in vascular medicine is a reflection of a global change in clinical care. According to Dr. Das, there were more than 600 vendors of wearable sensors to monitor disease and health at a recent consumer electronics convention.

“This technology is here to stay,” said Dr. Das, who, appropriately, was not present at the symposium but delivered his presentation remotely.

Both the Centers for Medicare and Medicaid Services and the Food and Drug Administration have digital health action plans, according to Dr. Das. The CMS has already developed reimbursement codes to pay for remote monitoring services and more are expected.

Calling this type of telehealth “untethered vascular care,” Dr. Das agreed with Dr. Hallett that an evolution is coming whether vascular surgeons choose to get on board now or are forced to take action later.

SOURCE: VIETHsymposium

NEW YORK – Telehealth should be embraced by vascular surgeons for their own self-interest independent of the evidence that it is well accepted and more convenient for patients, according to an update on an evolution that is already underway.

“One of the great advantages of telehealth is the efficacy of time for the clinician,” John W. Hallett, MD, professor of vascular surgery at the Medical University of South Carolina, Charleston, said at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

This efficiency is purchased with no loss of revenue, he added. He said that many clinicians are unaware of the opportunity this affords.

“Almost every payer reimburses telehealth visit at the same rate as that of an office visit,” Dr. Hallett explained. The only additional step is adding a “GT” modifier when billing Medicare or a “95” modifier when billing private payers.

Telemedicine is not a new concept. Published studies date back decades, but this interaction is increasingly understood to be the future. Along with an increasing array of sensors employing smartphone technology to allow physicians remote access to vital signs and other clinical data, patient attitudes have changed.

“Patients like telemedicine. It is convenient for them,” said Dr. Hallett, who noted that many providers are recognizing telemedicine as a potential marketing tool.

“On my way in from the airport yesterday, there was an advertisement for telemedicine from NYU on the television in the cab,” said Dr. Hallett, referring to the New York University health system.

The data supporting the benefits of telemedicine even include studies undertaken in vascular surgery patients. In one recent retrospective study cited by Dr. Hallett, substantial time and travel costs were saved for every vascular surgery consult conducted by telemedicine rather than in an office visit (Paquette S et al. Ann Vasc Surg. 2019;59:167-172).

“There was no difference in the rate of complications, and 94% of the patients considered the telehealth consultation adequate,” Dr. Hallett said.

He said there is urgency for vascular surgeons to pursue telemedicine. With the number of individuals over the age of 65 growing by thousands in the United States every day, there will be increasing pressure on the relatively fixed pool of vascular surgeons to improve their efficiency.

In addition, telemedicine is coming whether vascular surgeons like it or not.

“Patients are becoming more interested in looking at an app on their smartphone than coming to the office,” said Tony S. Das, MD, an interventional cardiologist who practices in Dallas. Dr. Das also spoke about the value of telemedicine for the vascular and cardiovascular surgeon at the VIETHsymposium.

In his overview, Dr. Das spoke about telehealth in the context of the estimated $12 billion dollars that will be spent on digital health in vascular medicine by 2021. The growth in digital health in vascular medicine is a reflection of a global change in clinical care. According to Dr. Das, there were more than 600 vendors of wearable sensors to monitor disease and health at a recent consumer electronics convention.

“This technology is here to stay,” said Dr. Das, who, appropriately, was not present at the symposium but delivered his presentation remotely.

Both the Centers for Medicare and Medicaid Services and the Food and Drug Administration have digital health action plans, according to Dr. Das. The CMS has already developed reimbursement codes to pay for remote monitoring services and more are expected.

Calling this type of telehealth “untethered vascular care,” Dr. Das agreed with Dr. Hallett that an evolution is coming whether vascular surgeons choose to get on board now or are forced to take action later.

SOURCE: VIETHsymposium

NEW YORK – Seven years after the formation of the first pulmonary embolism response team (PERT), more than 100 institutions have joined the PERT Consortium, which was created to guide care and research for this thrombotic complication, according to a status report at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

Ted Bosworth/MDedge News

“Why are PERTs needed? Pulmonary embolism patients are like snowflakes. No two are the same,” explained Richard Channick, MD, director of the pulmonary vascular disease program, University of California, Los Angeles.

Patient variability is an issue because algorithms for pulmonary embolism (PE) often differ at the point of diagnosis, such as the emergency department or intensive are unit, according to Dr. Channick, who was present when the first PERT was created in 2012 at Massachusetts General Hospital (MGH) in Boston. In addition, treatment algorithms can seem complex at a time when patients are deteriorating quickly.

“The treatment algorithms always say consider this or consider that, and then you get a recommendation with a 2B grade of evidence. So what do you do?” Dr. Channick asked, “This has really been crying for an organized approach.”

PERTs were created to fill this need. In most centers, PERTs are organized to respond to a diagnosis of PE wherever it occurs in the hospital. The goal is rapid activation of a team of experts who can reach a single consensus recommendation.

At MGH and UCLA, a similar relatively simple scheme has been created to guide physicians on how to activate the PERT and which situations make this appropriate.

“A big part of the PERT value has been our ability to conduct a real-time virtual consultation where we leverage online technology to look at images together in order to agree on a strategy,” Dr. Channick explained.

Although frequently asked what specialists are needed for an effective PERT, Dr. Channick said it depends on institutional structures, the types of specialists available, and, in some cases, the specific characteristics of the patient. In many situations, a pulmonary vascular specialist and an interventional radiologist might be sufficient. In others, team members might include some combination of an interventional cardiologist, a cardiac surgeon, and a hematologist.

It is also appropriate to include clinicians likely to participate in care following acute treatment of the PE. “One of the most critical values to PERT is the ability to systematically follow patients” after the PE is treated, Dr. Channick said.

So far, there are no data to confirm patients managed with PERT achieve better outcomes than those who are not. Reductions in mortality, length of stay, and costs are reasonably anticipated and might eventually be demonstrated, but Dr. Channick said that PERTs already have value.

“I think the efficiency of care is important,”he said. He called PERT a “one-stop shopping” approach to ensuring that multiple strategies are considered systematically.

There are many anecdotal examples of the benefits of shared decision-making for PE treatment. In one, a pulmonary specialist in a PERT team narrowly averted a planned thrombolysis in a patient diagnosed with PE who was actually found to have severe pulmonary fibrosis, according to Dr. Channick.

Not least important, the shared decision-making of a PERT could relieve the burden of difficult choices in complex situations. Bad outcomes in PE can be unavoidable even with optimal therapy.

“To me personally, a very important benefit of being part of a PERT is the feeling that we are all in it together,” Dr. Channick said. “Patients can go from being pretty stable to being dead very quickly.”

The PERT Consortium has sponsored an annual meeting on PE since 2015. It also maintains an ongoing registry for PE data from member institutions. These data are expected to have increasing value for comparing the impact of patient characteristics, treatment strategies, and other variables on outcomes.

For clinicians who are uncertain whether the PE incidence at their institution justifies a PERT, Dr. Channick had some advice. “If you build it, they will clot,” he said, meaning that due to the frequency of PE, a PERT will generally have plenty of work once created.

SOURCE: VEITHSYMPOSIUM

NEW YORK – Seven years after the formation of the first pulmonary embolism response team (PERT), more than 100 institutions have joined the PERT Consortium, which was created to guide care and research for this thrombotic complication, according to a status report at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

Ted Bosworth/MDedge News

“Why are PERTs needed? Pulmonary embolism patients are like snowflakes. No two are the same,” explained Richard Channick, MD, director of the pulmonary vascular disease program, University of California, Los Angeles.

Patient variability is an issue because algorithms for pulmonary embolism (PE) often differ at the point of diagnosis, such as the emergency department or intensive are unit, according to Dr. Channick, who was present when the first PERT was created in 2012 at Massachusetts General Hospital (MGH) in Boston. In addition, treatment algorithms can seem complex at a time when patients are deteriorating quickly.

“The treatment algorithms always say consider this or consider that, and then you get a recommendation with a 2B grade of evidence. So what do you do?” Dr. Channick asked, “This has really been crying for an organized approach.”

PERTs were created to fill this need. In most centers, PERTs are organized to respond to a diagnosis of PE wherever it occurs in the hospital. The goal is rapid activation of a team of experts who can reach a single consensus recommendation.

At MGH and UCLA, a similar relatively simple scheme has been created to guide physicians on how to activate the PERT and which situations make this appropriate.

“A big part of the PERT value has been our ability to conduct a real-time virtual consultation where we leverage online technology to look at images together in order to agree on a strategy,” Dr. Channick explained.

Although frequently asked what specialists are needed for an effective PERT, Dr. Channick said it depends on institutional structures, the types of specialists available, and, in some cases, the specific characteristics of the patient. In many situations, a pulmonary vascular specialist and an interventional radiologist might be sufficient. In others, team members might include some combination of an interventional cardiologist, a cardiac surgeon, and a hematologist.

It is also appropriate to include clinicians likely to participate in care following acute treatment of the PE. “One of the most critical values to PERT is the ability to systematically follow patients” after the PE is treated, Dr. Channick said.

So far, there are no data to confirm patients managed with PERT achieve better outcomes than those who are not. Reductions in mortality, length of stay, and costs are reasonably anticipated and might eventually be demonstrated, but Dr. Channick said that PERTs already have value.

“I think the efficiency of care is important,”he said. He called PERT a “one-stop shopping” approach to ensuring that multiple strategies are considered systematically.

There are many anecdotal examples of the benefits of shared decision-making for PE treatment. In one, a pulmonary specialist in a PERT team narrowly averted a planned thrombolysis in a patient diagnosed with PE who was actually found to have severe pulmonary fibrosis, according to Dr. Channick.

Not least important, the shared decision-making of a PERT could relieve the burden of difficult choices in complex situations. Bad outcomes in PE can be unavoidable even with optimal therapy.

“To me personally, a very important benefit of being part of a PERT is the feeling that we are all in it together,” Dr. Channick said. “Patients can go from being pretty stable to being dead very quickly.”

The PERT Consortium has sponsored an annual meeting on PE since 2015. It also maintains an ongoing registry for PE data from member institutions. These data are expected to have increasing value for comparing the impact of patient characteristics, treatment strategies, and other variables on outcomes.

For clinicians who are uncertain whether the PE incidence at their institution justifies a PERT, Dr. Channick had some advice. “If you build it, they will clot,” he said, meaning that due to the frequency of PE, a PERT will generally have plenty of work once created.

SOURCE: VEITHSYMPOSIUM

NEW YORK – Seven years after the formation of the first pulmonary embolism response team (PERT), more than 100 institutions have joined the PERT Consortium, which was created to guide care and research for this thrombotic complication, according to a status report at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

Ted Bosworth/MDedge News

“Why are PERTs needed? Pulmonary embolism patients are like snowflakes. No two are the same,” explained Richard Channick, MD, director of the pulmonary vascular disease program, University of California, Los Angeles.

Patient variability is an issue because algorithms for pulmonary embolism (PE) often differ at the point of diagnosis, such as the emergency department or intensive are unit, according to Dr. Channick, who was present when the first PERT was created in 2012 at Massachusetts General Hospital (MGH) in Boston. In addition, treatment algorithms can seem complex at a time when patients are deteriorating quickly.

“The treatment algorithms always say consider this or consider that, and then you get a recommendation with a 2B grade of evidence. So what do you do?” Dr. Channick asked, “This has really been crying for an organized approach.”

PERTs were created to fill this need. In most centers, PERTs are organized to respond to a diagnosis of PE wherever it occurs in the hospital. The goal is rapid activation of a team of experts who can reach a single consensus recommendation.

At MGH and UCLA, a similar relatively simple scheme has been created to guide physicians on how to activate the PERT and which situations make this appropriate.

“A big part of the PERT value has been our ability to conduct a real-time virtual consultation where we leverage online technology to look at images together in order to agree on a strategy,” Dr. Channick explained.

Although frequently asked what specialists are needed for an effective PERT, Dr. Channick said it depends on institutional structures, the types of specialists available, and, in some cases, the specific characteristics of the patient. In many situations, a pulmonary vascular specialist and an interventional radiologist might be sufficient. In others, team members might include some combination of an interventional cardiologist, a cardiac surgeon, and a hematologist.

It is also appropriate to include clinicians likely to participate in care following acute treatment of the PE. “One of the most critical values to PERT is the ability to systematically follow patients” after the PE is treated, Dr. Channick said.

So far, there are no data to confirm patients managed with PERT achieve better outcomes than those who are not. Reductions in mortality, length of stay, and costs are reasonably anticipated and might eventually be demonstrated, but Dr. Channick said that PERTs already have value.

“I think the efficiency of care is important,”he said. He called PERT a “one-stop shopping” approach to ensuring that multiple strategies are considered systematically.

There are many anecdotal examples of the benefits of shared decision-making for PE treatment. In one, a pulmonary specialist in a PERT team narrowly averted a planned thrombolysis in a patient diagnosed with PE who was actually found to have severe pulmonary fibrosis, according to Dr. Channick.

Not least important, the shared decision-making of a PERT could relieve the burden of difficult choices in complex situations. Bad outcomes in PE can be unavoidable even with optimal therapy.

“To me personally, a very important benefit of being part of a PERT is the feeling that we are all in it together,” Dr. Channick said. “Patients can go from being pretty stable to being dead very quickly.”

The PERT Consortium has sponsored an annual meeting on PE since 2015. It also maintains an ongoing registry for PE data from member institutions. These data are expected to have increasing value for comparing the impact of patient characteristics, treatment strategies, and other variables on outcomes.

For clinicians who are uncertain whether the PE incidence at their institution justifies a PERT, Dr. Channick had some advice. “If you build it, they will clot,” he said, meaning that due to the frequency of PE, a PERT will generally have plenty of work once created.

SOURCE: VEITHSYMPOSIUM