Turf wars are nothing new in medicine. But a gathering of specialists to resolve their differences is rare.
That was the aim of a conference in Chicago organized by specialty societies to promote the development of multidisciplinary vascular centers (See chart).
There are about 20 vascular centers in the U.S., and some observers believe the number could grow tenfold within a few years. Vascular disease outside the heart, known as peripheral arterial disease, is a growing problem, affecting an estimated 10 million Americans.
Vascular disease is an early indicator of heart disease, making vascular centers a logical companion to cardiac services. But resolving the turf battles among cardiologists, interventional radiologists and vascular surgeons is a high hurdle.
Paul Pomerantz, executive director of the Society of Cardiovascular and Interventional Radiology, says conference organizers didn't know what to expect when rivals from the three specialties met face-to-face. "In some ways, I was worried this was going to be like a Jerry Springer show," he says.
New noninvasive techniques have ignited the wars. Increasingly, vascular surgeons are swapping their scalpels for catheters, encroaching on procedures that were under the sole purview of interventional radiologists.
Cardiologists threaten both vascular specialties because they control many referrals and perform about 10% of vascular procedures, says Barry Katzen, M.D., past president of the society. Although some heart doctors attended the conference, the American College of Cardiology was not a sponsor.
Despite some verbal bashing, the overall tenor of the event was positive, organizers say. Attendance was 714 people, nearly triple expectations. "We obviously hit a major nerve," Pomerantz says.
New therapies such as endovascular stent grafts to repair aneurysms require teams of surgeons and interventional specialists, which are essential to attract lucrative clinical trials. In addition, vascular centers eliminate duplication and streamline care.
"In most institutions the various services are spread out all over the place because they've historically developed as little fiefdoms," says Katzen, medical director of Baptist Health Systems' Miami (Fla.) Cardiac and Vascular Institute.
There's also a public health angle. Vascular centers offer services that private practices often don't, such as accredited diagnostic labs, disease prevention and smoking cessation programs, exercise rehabilitation, and access to the latest technology, says Alan Hirsch, M.D., president of the Society for Vascular Medicine and Biology, whose members focus on long-term care and prevention.
About 100 hospital administrators attended the conference, and 80% of all attendees were associated with community hospitals as opposed to large teaching institutions.
Many institutions clearly have a long road ahead. Only 21% of attendees work at established vascular centers. A whopping 85% of all attendees reported having no business plan, and 87% lacked a marketing plan-meaning that even some established vascular centers lack essential business tools.
Many hospitals are looking at vascular centers to cement physician loyalty and make hospital and physician services more visible. This month, New York's Lenox Hill Hospital announced the establishment of the Lenox Hill Heart and Vascular Institute of New York. The hospital has committed about $25 million to renovate hospital space that will house the institute, agreed to hire an administrator/physician management team and launched a marketing campaign.
The hospital's interventional cardiology chief, Jeffrey Moses, M.D., says the creation of the center was a "seminal issue" in his decision to keep his thriving practice at the hospital rather than accept an offer at competing New York (N.Y.) Presbyterian Hospital.
A large capital commitment isn't always required. According to Hirsch, reconfiguring patient-care space typically requires a "relatively small but definitive capital buy-in," with marketing being another major expense.
But physician leadership is a bigger obstacle than money. "It won't be possible for everyone to have a vascular center because of the political hurdles," Katzen says.
Asked to identify a barrier to the development of vascular centers, 52% of conference attendees cited politics and personal agendas, while 27% pointed to a lack of multidisciplinary cooperation.
Integrating cardiac and vascular care, as Lenox is trying to do, can be especially difficult. Vascular specialists fear losing their identities by merging with more numerous cardiologists, Katzen says. For example, they reject the moniker "cardiovascular center" in favor of "cardiac and vascular." Similar issues block the creation of a new hybrid specialty with unified standards for training and credentialing.
The societies have talked to the American College of Cardiology about future collaboration, Pomerantz says. Meanwhile, they plan to hold another conference next year and to continue the dialogue with newsletters and a World Wide Web site, he says.