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The management of vascular disease requires knowledge of clinical assessment, pharmacotherapeutics, endovascular procedures and vascular surgery. In Canada, interventional cardiology, vascular surgery, interventional radiology and neurosurgery specialists may be involved in the care of patients with vascular disease, and they all claim to have expertise and an advantage in treating specific patients. The present article identifies the sources of the potential ‘turf war’ in vascular medicine, and proposes some possible solutions through reorganization of vascular care, with particular reference to the modern era of Canadian medicine.
La prise en charge de la maladie vasculaire requiert une connaissance de l’évaluation clinique, de la pharmacothérapeutique, des interventions endovasculaires et de la chirurgie vasculaire. Au Canada, les spécialistes de la cardiologie interventionnelle, de la chirurgie vasculaire, de la radiologie interventionnelle et de la neurochirurgie peuvent participer aux soins des patients atteints de maladie vasculaire et tous déclarent détenir une expertise et un avantage dans le traitement de patients spécifiques. Le présent article identifie les sources potentielles de guerres de territoire en médecine vasculaire et propose des pistes de solutions possibles par une réorganisation des soins vasculaires qui ferait particulièrement appel à la modernité de la médecine canadienne.
Vascular disease (peripheral arterial disease [PAD] and cerebrovascular disease) care has been facing a challenging time within the traditional Canadian health care system. For many years, vascular surgery was the dominant specialty in the management of patients with noncardiac vascular disease. The model used in cardiology and cardiac surgery (eg, having cardiologists and cardiac surgeons discuss cases in weekly rounds) did not seem to apply to other vascular disease. The advent of endovascular theraupeutics, our improved understanding of vascular biology and atherothrombosis, and the advancement in medical therapy, have all resulted in the evolution of vascular disease management so that it is not just simply dealt with by surgeons alone. Furthermore, the diagnosis and management of the affected organs (eg, brain, kidneys, gastrointestinal tract, etc) usually require other specialists’ assessments in addition to that of a vascular surgeon. When the responsibility of vascular care is not well defined, physicians from multiple disciplines would develop their own guidelines and acquire the necessary skills to become vascular care providers, particularly in performing endovascular procedures in different parts of the body (1–4). ‘Turf war’ has become a commonly used term among physicians dealing with cerebrovascular disease and PAD in the modern era of medicine (5–7).
The challenging dilemma of vascular disease care in Canada comes from various sources:
The competition among various departments illustrated above generally results in the provision of overlapping and competitive services within hospitals in other countries. In Canada, however, the turf war may also result in underuse of less invasive therapies that could have been offered to patients. Carotid stenting is a good example of this. Interventional cardiologists, vascular surgeons, interventional radiologists and neurosurgeons all claim to have advantages to the provision of therapy for carotid artery disease.
What should we do to resolve this problem? A reorganization of departments in the hospitals may be needed. This would require cooperation among personnel from multiple levels, including funding bodies, hospital administrators, department heads and staff physicians. Such a change may involve setting up a new department of vascular medicine that consists of physicians specialized in atherothrombosis care, diagnostic tests, endovascular procedures and surgical revascularization – a model similar to a cardiac services department in managing ischemic and valvular heart disease. Such an entity could be a stand-alone department in a hospital or a division of a cardiovascular institute. Physicians with an interest in vascular disease, including those from cardiology, vascular surgery, diagnostic and interventional radiology, neurosurgery, neurology, and nephrology, may be members of this department. A similar concept has developed between rheumatology and orthopedic surgery, neurology and neurosurgery, and respirology and thoracic surgery. In Canada, there are already examples of cardiac sciences departments that include cardiologists, cardiac and vascular surgeons, and others.
To break down the barriers, the first step is to improve communication among physicians; this can be accomplished by scheduling biweekly or monthly ‘case conferences’, where challenging, successful or unsuccessful cases can be discussed. This would allow physicians to bring their knowledge and particular skill set to discussions, so that the best decisions with regard to patients can be made. Through regular communication, it is hoped that the turf issues can be reduced and collaboration can be developed. Trainees interested in endovascular procedures might then receive multidisciplinary training within their home institutions.
Eventually, there will be a need for a new training program in vascular medicine. This may consist of several years of dedicated training in vascular medicine after graduation from medical schools, with an option for endovascular training during the last one to two years of the fellowship. Alternatively, vascular medicine could become a subspecialization of interventional cardiology, vascular surgery or interventional radiology (2).
This proposed change in vascular medicine in Canada will require a tremendous effort and dedication from the hospital administrators, hospital staff, and the fellowship training program directors. Initially, some physician groups may experience changes to their workload and therefore, their income. In the end, however, patients will be the ones who will benefit from the restructuring.