Vascular Surgery: Time For Recognition

Dr Devender Singh

Answers to problems in vascular surgery, like the refinement of diagnostic techniques and the development of biologically better small arterial substitutes, are slowly emerging. But what has so far eluded is independent recognition of vascular surgery as a separate specialty.

In a historical perspective, these problems are not unexpected. For centuries, even millennia, medicine was an undivided unitary segment of human interaction with the hostility of nature. There was no conceivable reason to parcel out the meager factual cargo that encompassed the knowledge of diseases and the (usually fruitless) attempts to deal with them.

A physician was a person whose identity was sharply defined within an unchanging circle of activity. It was only in relatively recent times (some 300 years ago), that the first dichotomy appeared in this image: the recognition of a new type of physician who used his or her hands in treating disease, that is, the surgeon. A veritable deluge of change came as medicine assumed the aspects of science no more than 100 years ago. Internal medicine and surgery assumed sharply distinguished silhouettes during the last 50 years; their further fragmentation has resembled a chain reaction.

This process has forced each subdivision of the large entity of medicine to face the same problem of defining its identity, as we now see in vascular surgery. Elemental and vitally important questions arose: Is the existence of the new subdivision justified by the goal it seeks to achieve? What exactly is the scope of its legitimate interest? Who is entitled to enter it? How does one acquire this entitlement?

The difficulties do not lie only at clinical level; a mundane concern also enters the picture. The practitioners of the parent discipline instinctively resent the contraction of their territory. The interests of the new specialty often conflict with the aspirations of other fields that have been newly created.

The need for the very existence of new branches is often questioned. All these historical conflicts have afflicted the birth and growth of vascular surgery.

Everyone knows about heart diseases, but very few know about vascular diseases. In fact, vascular disease kills and cripples almost as many Indians as does a heart disease or cancer. The sheer magnitude of the problem of vascular disease in India is staggering.

Although there is no accurate vascular registry, the fact that there are over 25 million diabetics in the country is just a small pointer to the vast numbers of the undiagnosed vascular cases. Patients having severe vascular diseases have been treated for low backache and arthritis for years.

It is only the onset of peripheral gangrene which brings to light the fact that arterial pulsations have been absent for long periods of time hitherto unnoticed. Even after diagnosis, the only treatment for these unfortunate cases has been amputations, which leaves the primary vascular problem unsolved. The lack of awareness of the disease is so acute, that even some cardio-vascular surgeons have never heard of a separate, independent vascular surgery department or a vascular surgeon. A truly tragic situation indeed!

From the beginning, the existence of independent vascular surgery as a specialty was challenged by the Medical Council of India (MCI), as in India it is still considered to be a part of the broad speciality of cardio-thoracic-vascular surgery (CTVS). To the exception MCI has granted Madras Medical College, Chennai to start the MCh training programme in vascular surgery, but unfortunately the facility can only be availed by the surgeons of the state, thereby denying valuable training opportunity to the surgeons from rest of the country.

However, all the hope is not lost for vascular patients in India. Thanks to the effort of National Board of Examination (NBE), New Delhi, which understood and realised the magnitude of the problem. With a vision and mission in 2001, the NBE started a two-year fellowship programme in peripheral vascular surgery and hence giving a separate independent recognition to this subject. Presently, this course is available in only three major cities and needs further expansion in future to cover the entire country.

Inspite this, the picture is not clear. Cardiac surgeons in India still claim themselves to be the best vascular surgeons also. No matter, as in reality there operative vascular work is less than two per cent and their CTVS training is skewed only towards cardiac surgery. Infact the approach, diagnosis and therapy of vascular diseases is very much different from the approach to a patient with heart disease.

No doubt that cardiac surgeon is technically very competent to perform vascular operations, but they are universally burdened with coronary bypasses and valve replacement. So no reason to blame them, infact what is required is a separate recognised, independent vascular surgery department, which can take care of peripheral vascular system.

Not only that, to confuse and complicate the issue further we now have general surgeons, thoracic surgeons and general surgeons with some experience in vascular surgery, and general surgeons with added qualifications in vascular surgery; all performing the full assortment of vascular operations.

This conceptual puzzle kept many hundreds of surgeons in resentful confusion for years. Time, however, slowly but surely has begin to sort out this confusion. Hospitals concerned with their professional standing are increasingly inclined to grant vascular privileges to new staff members, only if they are certified by the MCI or NBE as having special or added qualifications in general vascular surgery.

The image of the vascular surgery is gradually acquiring formal recognition, but the limits of legitimate participation of the general surgeon in treating vascular diseases in actual practice, is still very high in real scenario.

As this problem of existence is yet to be solved, vascular surgeons face other problems that impinge on their practice. Now even cardiologists and radiologists are claiming themselves in the race of treating and eliminating vascular diseases.

A real challenge indeed for vascular surgeons and vascular surgery!

The writer is Assistant Professor, Department of Vascular surgery at Nizam's Institute Of Medical Sciences, Hyderabad.
Email: drdevendersingh@hotmail.com