What are vascular deserts and why should we care? Vascular deserts are not just geographic but also socioeconomic barriers to care. Whether patients have to drive multiple hours to receive care or often cancel because they can’t schedule rides or have conflicting appointments, health outcomes are greatly impacted by patients’ ability to receive care.
Hi and welcome back to our last Sisterhood and surgery show. Before this summer, we're going to take a break and today we will be discussing vascular deserts, the team approach to expanding vascular care. You all know my co host Paul Maha and we have three great great guests today including the president of Dr Joseph Mills. Dr Travis Vowels who is a private surgeon in Amarilla, Texas, who graduated here from Houston Methodist and Dr Vivian Cho who is in Podia in Australia, which is 14 hours ahead of us. So a very exciting last show, Paula. Do you want to start with introductions? Oh, also I want to mention the join by web and join by text is acting up a little bit, but please try to send in your questions. They're going to try to figure it out during the show and the join the web is go to pole dot com. You enter to Bay, send in your question or by text text to Bay to 37607. Thank you so much Linda. It's really an honor and a pleasure to introduce doctor Joseph Mills who I've admired for so many years. Um, he's quite the leader in vascular surgery and in the field of uh, diabetic foot savage. Um, he's the lead professors in chief of the division of vascu surgery and end of vascular surgery at the, at the Michael DeBakey Department of Surgery at the Baylor College of Medicine in Houston, Texas. And the director of the BC M Step with the save extremity program was previously professor and chief of vascular surgery at the University of Arizona College of Medicine until 2015 and co director of the Southern Arizona Limb Salvage Alliance or SALSA. He has authored over 450 peer reviewed journal articles and book chapters. He's been COIT of the Rutherford Vascular Surgery text and is also a current vascular surgery section editor for up to date. He's been the principal investigator for over 45 clinical trials covering a wide spectrum of vascular disease with a focus on limb savage, chronically threatening ischemia and diabetic foot ulcers. He's the past president of the Peripherals Surgical Society and also served as treasurer of the SVS and chair of the SPS Distinguished fellows council and secretary treasurer of the Western Bass Society. Dr is the previous director of the American Board of Surgery, past chair of the vascular surgery board and just completed a seven year term on the RRC. He's also past president of the association of program directors in surgery and the Rocky Mountain Vask Society and Western Vascular Society. Most recently, he has led the SVSPP committee helping spearhead the SVS branding campaign. He has extensive clinical experience in multiple practice settings including the military, the VA County University and private hospitals in June of 2021. He was elected the vice president of the Society for Vascular Surgery and is its current president elect to start his term in June. Doctor Mills received both his BS and MD degrees from Georgetown University. Subsequently completed residency programs in general surgery at Wolford Hall USA F Medical Center, Lackland Air Force Base Vasco Surgery at the Oregon Health Science University in Portland, and a senior end of vascular surgery fellowship at Texas Tech University in Lubbock. He and his wife, Margaret Schneider Mills are the proud parents of three sons, Joseph Junior, Daniel and Andrew and five grandchildren, Edward Thomas Joseph the Third Lucas and Ruth. Welcome Joe. Thanks for coming. Thank you for that overly generous introduction. I'm looking forward to speaking with everybody here. Thank you. I'm honored. Is Ruth the favorite. She's the only girl. So she is the first girl on child on my father's side of the family in 125 years. Oh my God. So we just found out my youngest son and his wife were expecting now and, and we found out we reverted back to Mills, so that one's gonna be a boy again. So Ruth will be spoiled. She is. That's funny. Our next guest is Dr Travis vows. He is actually my mentee when he was here and we still, of course, keep in touch. He's a vascular surgeon in Amarillo Texas at the BSA Health System. He is one of the three vascular surgeons in his group and they cover a catchment area of 150 to 200 miles including Texas, New Mexico, Oklahoma and rural Kansas. He completed his medical school at the University of Texas Health Science Center in Houston across the street and he graduated, like I said from Houston Methodist. He's been really busy since he started over there doing some big cases in his spare time. He enjoys spending time with his wife Aubrey who is our nurse practitioner and we're very sad that she has left us as well and their baby boy Parker who is super cute and their dogs welcome Travis. Thank you for the induction doctor Lee. And it's my pleasure to introduce um Dr Vivian Tudor who's a professor of podia at the Western Sydney University in Australia. She leads a clinically based research program focusing on prevention and management of diabetes related foot disease in Aboriginal and Torres Strait Islander people and in non-indigenous Australians. This was developed as a living lab model incus clinical research and education elements. Vivian's research focuses on vascular complications of diabetes, physical activity interventions for diabetes related foot disease and cosign and diabetes foot care delivery. And I'm looking forward to working with her next week. In the Netherlands where we're doing a diabetic foot workshop where doctor will also be um running the one of the sessions. Thank you. Um So our topic, uh it's great to be here. Uh Thanks so much for the invitation and it's, you said it's 7 45. What, what time is it there now? It, it, it's 10 past eight in the morning now. So its a very decent time. Ok, good. Yeah, this is afternoon here, morning there. Ok, welcome, Vivian. So why do we care about a vascular desert? And what does that mean? And that really means to the lack of access to care of patients who have critical vascular diseases such as PD is one of the ones we'll be talking about today. But other diseases, karate disease, aneurysmal disease, it's lymphatic due to either geographic or socioeconomic barriers. And I mean, we see it actually in Houston a very large city, the socioeconomic barriers to care. And so why do we care about that? I mean, there's already going to be a shortage of vascular surgeons coming up in the future, let alone, you know, now what's going to happen to the rural and the urban areas? So Dr Mills, I don't know if you want to discuss why do we care about this? And you know, why has this been your focus these couple, you know, these years and now SVS President. Yeah, it's, it's always takes me a long time to start to figure things out. But I, I always started by trying to, to build a reputation and build a group practice. Try to pursue excellence, get patients sent to you. And I thought, and that's good. But what about all the patients that can't make it to you? And you know, we all have clinics. Uh, one of the types of patients that frequently is a no show for clinic is a dialysis patient, for example, or you get a patient's schedule for an angiogram and they don't show up and it messes your whole schedule up. But when you start looking into why that is we found one patient, for example, whose all his appointments were scheduled on his dialysis day because we had a clinic by the day. So his vascular surgeon had clinic on Monday. He dialy on Monday, he could never get a second ride to get from dialysis to his clinic. And the nurse practitioner actually just asked him, why were you always no showing? And he said, well, I can't make it very easily on Mondays. It's a real struggle. And she said, well, what about Tuesday? Would you mind seeing one of other bakers? Certain it was me. So anyway, that that's, but the desert thing is a great analogy, but I think it needs to be used figuratively. So when we think of desert, you think of this sprawling like Australia or parts of Texas or Arizona? And there's like I was, uh I actually went to first grade on the Navajo reservation 1st and 2nd grade. And um you're, you're geographically isolated so that geographic separates you, but you can have a desert like Linda was saying, within a city. So we actually tried to look at this. We looked at there's 100 and 45 zip codes in Houston, which is the fourth largest city in the country. Um, and it is 1800 square miles so it's spread out, but it's still a city. And of those 145 zip codes, almost a third of the amputations happen in 10 of those zip codes. That's pretty striking. That's, that's less than 10% of the zip codes account for almost a third. And if you look at socioeconomic disparities in Houston and overlap them with that heat map of amputation, they match up perfectly. So we've been trying, I've been working with Ben Tab and LBJ to try to figure out can we do something for the patients that are in our catchment area that should be in our system that have difficulty navigating through it and that it's very complex because there's lots of barriers to patients care. So when you're training and somebody doesn't show up, you figure, well, the patient didn't care enough to show up. Well, that's not the case at all. It's usually they can't get there for barriers that we haven't asked them about or try to help them. So I'd be interested to what the other people like. Travis. You're in a pretty remote area of the state. What's your experience? Yeah. I, I think my, my barriers are more, um, geographical rather than socioeconomic and then, you know, I, my, my catchment area is pretty big. I see people, half the people I see in, in clinic. Um, and, and in the hospital are from either New Mexico, Kansas, um, Oklahoma or, or Colorado. So they are kind of where all these states come together and, you know, I, I routinely have people drive 34 or five hours just to see me. Um So, you know, again, one of the ways that I've only been doing this for nine months, but one of the ways we've kind of been overcoming that a little bit is to give me or let me do clinic in the afternoons on two days of the week so that people can come in in the morning, get their studies done and then see me in the afternoon and then hopefully drive home and even, you know, even that doesn't overcome the barriers completely. Some people stop to get a hotel room, it's been denied and then they don't want to travel, you know, at, at, at night. So, uh you know, it can be a real big, a real big issue viv what about you? Can you comment about your practice in Australia? Uh Absolutely. Um And I completely agree with everything that Jo and Travis are saying about, you know, multiple barriers to um receiving care. I think what we see in Australia is we have really large geographic distances. I think the whole of Europe fits into Australia. Um So we're talking about big distances. So it wouldn't be uncommon for a patient to be looking at an 800 kilometer trip to, to a major hospital to get any kind of intervention. Um And I think probably that, that that's around 500 miles, I think. So it, it's quite a big difference um in terms of other barriers, we often see them clustering together. So we know in Australia that our populations in rural areas have worse health outcomes just generally. Um we have less um podiatrists, we have less specialist care in our rural and regional areas. Um And we also have uh poorer populations in those areas as well. So we have socioeconomic impacts in those areas. And then for our first nations communities, um they tend to have a, they, they are a higher proportion of the populations living in rural areas and they're really over represented in, in the, the amputation outcomes that we see. Um Our research says that the further you live from a high risk, good service, the more likely you I'd have an amputation. But that's also linked to the fact that you're also going to be, you know, living in a lower socioeconomic area. Um So there, there are those factors that all sit together. And then on top of that, you see, you know, the risk factors, the cardiovascular disease, risk factors that tend to cluster uh in those areas too. So it's, it's a really difficult um thing that we need to address because it's so multifaceted. So, so how do you feel the telehealth has improved or hurt the care? Is there a perfect balance or percentage or um in your practices? Do you see a patient one time and then agree to do telehealth the next time unless there's a concern or do you do repeated telehealth visit? Sometimes patients, they don't want to make the trip, they're kind of busy and they don't want to come in. But uh I usually like to see the patients at least every other visit. What are you doing? Yeah, we, we expanded that a lot during COVID and I hope that that would persist. So it helped us, we tried to use. So we, our hospital system was really only shut down for about six weeks. But even then it wasn't as bad as parts of Europe. So we were still allowed to do emergency cases and things that we could define as urgent. So we had to go through and come up with something that was urgent. So for our CLT I patients, we decided to use wifi. So if they had a lower stage wifi, they, I might get seen quickly in clinic and then be seen by telehealth and monitored and that worked pretty well. And then we saw a lot of post procedure visits by, um, you know, I always, I like to see my patients post op because especially when you have a clinic where you have a couple disastrous problems to contemplate. It's nice to see somebody that you did a procedure on a few weeks ago who is doing great. But then when you think that they had to drive three hours and wait an hour for you, because you're running behind for you to look at their incisions, which they could have sent you a picture of and showed you they were healed to get that warm fuzzy. Maybe it wasn't worth it. But anyway, long story short, it's falling off. Some the patients that can get, that are close enough that they can drive you. So you want to be seen in person. But for some of the ones that are further away, we still do that. It's really good. It's good for a complex patient where you're trying to gather information first. They don't come all the way and you find out they're missing half the stuff they need. And it's good for a follow up. Like you saw them, they needed a couple of tests and you're going to go over what the plan might be and they don't want to drive all the way back. But I hope that can be expanded. That's one exciting way. I think we could try to expand centers, influence and not influence as much as help to people that in small areas so that patients they're worried about that. They could be reassured about that could be kept there and people that actually need to be sent could be sent sooner and that would be the holy grail. I think Travis is your practice in a similar pattern at this time. Uh We, we actually don't do any telehealth here and I, you know, I talked to my partners, I don't think they did any telehealth even in the height of COVID. We, we did a course a ton in, in Houston during all this uh while this was happening. Uh My, you know, my wife just took a, a wound care job. So one day a week, she's gonna be going to skilled nursing facilities here in town and the other day she's gonna be driving to three sniffs, uh total, you know, total mileage or total hours like three hours in a car for her. Um But she's also gonna be doing telehealth one of those days to, to, to reach out to school nursing facilities and a couple other surrounding towns that are about two hours away from here. So I she, she will be doing it and, and I know it, it, it is possible but it, it's not that common. Um At least out here if you give an interesting description of how you've used this differently in Australia. Can you go into that? Yeah, absolutely. Uh So telehealth is really important to us uh mainly because of, of those large geographic distances that we have to deal with. Um But what we find is really effective, particularly in relation to foot disease is actually telehealth that supports practitioners so often in rural and remote areas, we will have aboriginal health workers and nurses that we can support uh you know, as podiatrists uh in terms of wound healing and offloading. Um So we can actually provide care. Uh that's, that's via another health practitioner to the patient. So, patient to practitioner works well for us and in some circumstances that works well in podiatry for us, but also that practitioner to practitioner telehealth is what is really effective in terms of care delivery. And I think that's something that we can really work on expanding in Australia because you know, we know that where there's not good communication between health professionals that our patients, health care suffers and their outcomes are worse. So using telehealth to support that side of patient care is a really important thing that we need to develop moving forward. That brings us nicely into what is the team approach and what does that stand for? So, I don't know Dr Mills, if you want to, I know that's you've had one in Arizona as well as here. So would you like to expand on that? Yeah, our our team concept is pretty simple. Actually, I think if the team gets too big, it gets too complicated. Um, so our team functionally consists mostly of podia and vascular surgery, their vas site, we did this in Arizona and, but I decided to hire a podiatrist or didn't want it. But when I told him that they were only gonna do diabetic foot problems, they said fine. And then the chair said, well, I don't know what to do with the podiatrist. So I'll put him in your division, you figure it out. And so we, we got a clinic space from transplant. That was two parallel hallways. We had Vascor in one hallway, podia in the other, in the vascular lab in between. And we just saw patients together and um I did the same thing when I came to Houston. So our, our, our system is built on the toe and flow model. So basically, whichever service they're referred to as an outpatient, they automatically get perfusion assessments. And then if they need joint care, they get that. If it's mostly neuropathy offloading minor infection, the podiatrist takes care of that. If the flow is OK. And if they're in between, then we work out a plan about how long we're going to treat this less conservatively before we do more than that. And then the hospital same thing. So they usually call us and podia at the same time from the ed or the consultants. But if they don't, then the other service automatically gets involved. And within 24 hours you have a plan. So we tried to add ID, I was, wanted to look at antibiotic resistance patterns and I wanted to make sure our patients were being discharged on the right antibiotics and actually finish their course. That's worked. Ok. Um, but we actually have, we have a private, um, at ST Luke's, we have a private, um ID group and also Baylor, but they alternate call and they're very, they're probably some of the best doctors in the hospital. So when we started monitoring duration of antibiotics and everything, we found that they were kind of all over it. Um But ultimately, you need orthotics, you need, um you might need orthopedics. There's, it can be, it can expand. But I think the bare minimum is high end podiatrists who are dedicated to diabetic foot care and they have to be surgical podiatrists, at least some of them. And then not just any vascular surgeon, but somebody who wants to take care of limps and has, and then your group has to have expertise in open and end up because I think patients often need both. I don't like the either argument so much and some groups have been able to incorporate either IIR or cardiology in the end up part of that. And I'm not against that either. As long as it's all run in a coordinated way. I do. You have anything differently at your uh well, we, you know, we have a couple of podiatrists that we work closely with both on the inpatient and the outpatient side. But one of the things that, that BS A has really done well at is, is creating a know their own advanced wound care center uh with, with three wound care doctors, um who, who only only see wounds and they, they run the hyperbaric oxygen uh therapy there as well. So that's who I get. Uh the majority of my pe D and, and Venus consults uh from. And then I of course, send them when I see a patient first from uh from, from a family medicine physician or to refer them to me and they have a wound, I typically send them uh to our wound care center as well. And again, you know, the idea, yeah, people are coming from so far away, but because all of our offices are, are on the same street and they can just set up a clinic appointment with, with each person individually on, on the same day to kind of prevent having to come back and forth, you know, hundreds of miles when I was at bu uh when I came into practice, I was very fortunate to join Gary Gibbons and Jeff Haber, who was a well known podiatrist at the time. And it was, we were co located in the same clinic office and worked very well together. And they really provided the highest level of care. And I did some of the open and the endovascular uh stuff and we did all the wound care. We did a graph training and all of these things for the patients. And I learned a lot of the foot receptions from them. So then when I went and came to Syracuse, the first thing I did was find the Jocelin Center and the podiatrist and befriend them right away. And then I joined the Wound care Center and I worked there as well. So I tried to recreate what I had in Boston, but I really felt that um I needed that team. I, I think I can take the best care of patients with that type of support, particularly critical in threatening ischemia and, and diabetic foot. Maybe it has a relationship with uh the vascu surgeons there. I, I know a few. I love them. They're just great to uh work with uh at least from a societal perspective. But absolutely, uh um I think to um they're a great bunch, but I think for us in Australia, it really depends the on the situation that you're working in. Uh So we have high risk foot services uh that are really effective and fantastic. And they are based in our major hospitals in our major cities. Uh And they are usually led by a vascular surgeon or led by an endocrinologist. Uh and they tend to have really well established teams and vast referral um processes through the hospitals. Uh And they're, they're an effective form of, of managing patients who are in trouble um where it becomes more difficult is uh in the rural and regional areas. Um I work now outside of high risk foot clinics. I work in a community clinic but we have aboriginal foot health services. So, services or Aboriginal health services that are uh specifically for our first nations people who, who run these services um and are really involved in the way they're developed. Um But because they tend to sit in more rural and regional areas, uh we are working often with a foot that should be in a high risk foot service, but having to work in a community based setting uh in and in those areas, it is really difficult to make sure that you get those referrals uh done at the speed that you need them to be done. Uh It's hard, you work with a, a whole range of practitioners in all different areas. You'll, you can be dealing with a vascular surgeon who's in a major city, who is 800 kilometers away, organizing something for your patient. There is a lot of responsibility on single practitioners um that can be quite stressful. Um So it can be a situation where you can feel quite isolated as a practitioner because you deal with very high risk patients. Uh without necessarily the support that we see uh in a large uh tertiary hospital. Um So they, it's a, it's a situation that I think requires a lot of experience. We often have practitioners out there who are inexperienced uh and are working by themselves, which creates further difficulty in those circumstancess. Uh And we're heavily reliant on local medical services to try and support what we're doing. Um So those kind of situations can be very challenging and I think it's those uh kind of situation we're trying to address, you know, when we're developing new guidelines and things where we look at what are alternate ways to better deliver this care. How can we get that support, that specialist support we need, um you know, across the country. Uh And that's, that's not, you know, based only in Australia, that's not relevant only to Australia that's relevant to, to, to many countries, including the US where you've got those really large distances that you have to try and cover. So I think that there's in my head, there's an ideal team of what I would love to be able to work with in a, in a rural area, in a, in a setting where I often find myself and then there's the reality and they're not, not the same things unfortunately, but having um support to set up rapid referral processes uh with the necessary providers and having using practitioners to practitioner telehealth with specialists is something that's really important and something that we really need to, to further develop and rely on, I think, uh to actually um improve care outcomes in those areas. Well, it's interesting, it's uh working with the World Federation of vast societies. I've had a lot of insight into these different global areas. And our colleagues in South Africa, the VASA group is really a small group of Vasa surgeons. And they told me that they rely heavily on midlevels and podia um to service South Africa. So it's, it's very interesting. So, um, you bring up a good point about education, how are we going to use Midlevels advanced practice providers who can obtain the skill? I mean, I've been practicing for almost 20 years. How do I tell a patient that my newly hired nurse practitioner has the same experience as I do to render the same care? I mean, as, as hard as they try, you just can't make up 20 years of experience. So I'm, I'm interested in hearing from all of you how you've managed that in your practice, educating them, bringing them up to speed with oversight. Uh What other ways you did that? And my, my other comment, Paul is, it's only going to get worse, right? Because we had the nursing shortage show where now there's a huge nursing shortage. And so therefore, that's eventually going to lead to a nurse practitioner shortage. And so even though we as physicians are moving more toward mid level providers, they may not be that in the future to even obtain, to help us, you know, provide care. Maybe you can comment about the SPS S approach to the team in which they have the SPN, the P A section and how they, they're really working towards building this. I know the executive board is working on this right now. But there's been a lot, I mean, if you've done this anywhere, it's not just podia and vascular surgery, even if that's how your model is set up. There's a lot of, we have the vascular lab people. And it's funny when I got to Houston. So in Arizona, we did all our own wound care, didn't go anywhere. It stayed at our clinic. And if they needed Doctor Tori, they came to the hospital and either vascular or podia increasingly did it. Then when I showed up in Houston, after I did a couple like procedures and they had like an open foot wound, I'd ask for like dressing supplies and there weren't any. And I said, well, what do you do with patients post up with CLT I that need wound care. And we sent them to the wound center. I said, where's that? It was like five miles away. And I said, well, who are they? And it was just this, this didn't make any sense. So it's funny. And initially the first couple of ma we hired, didn't want to even look at wounds. They were kind of aghast at some of the stuff that we see and increasingly we've gotten them really well trained. So, um, they do a lot of the, I mean, I'll see the patient but the actual, some of the debris is even done by the MP and not ma, but ps, um, so they, they, they've adopted, you got to teach them. It takes time and we, uh, I still try to see my own follow ups but I might add them on to my clinic and have the NP go in and say hi and do the paperwork and tell me if everything's great and if it's great, I just run in and say hi real quick. And if there's a problem I'm still around and then they do see patients, like if you travel, they're really good about working a patient and it doesn't sound right and then reaching out to you to help. So I think it takes a whole team and I think, um, trying to figure out how to incorporate nurse practitioners to provide some other care. Um, but I still think that one of the problems I have with wound care clinics is they tend to just put stuff on wounds. And what you really need is an actual correct diagnosis and a management plan. And if you have the right diagnosis and management plan and sequence, then you can use other providers to help you carry that out just like in the hospital, right? Like think about surgeons, we see our patients probably less than the nurses on the ward do by far. Right. And a lot of the care is delivered by them. But the plan for what operation they had and what's expected to happen afterwards and all is all, there's a plan. Right. So, I think the same thing needs to happen for outpatient care. But I think we're going to have to figure out how to incorporate more and more people in this process, but it needs to be structured and not just random because I'm concerned if we have, if the level of care that is the initial consultation for patients is not someone who's really well trained, we're going to get on the wrong pathway. Travis. How many uh midlevels do you have in your group? Yeah, we, you know, we're kind of experiencing the, the same issue now. So we have, we have 77 surgeons and we just hired three nurse practitioners probably within the last three months. Uh two of them specifically for a clinic and then, and one of them for the hospital and, and that may, that may switch kind of depending on our needs. We, we're still trying to figure out um you know, exactly how we're gonna utilize them. But for, you know, for the past month, I've, I've just been having the, the uh clinic and nurse practitioner shadow me. Um and, and, you know, again, if there's time go in and see the patient before me and, and, and kind of come out and tell me uh their assessment and, and go, we go in together. So it, it's, it's, it's a long road and I think it, it's just about um experience and, and, and teaching first hand. Do you have mid levels? And pory is that a thing? Uh It, it kind of is a thing, farmer. Uh We have, uh in some circumstances we have put care assistants, allied health assistants, um and Aboriginal health workers who work with us and support what we do. Uh which is fantastic. And I think, you know, I've worked in um a service where that model worked very well where we provided an initial oversight, which is, I agree with Joe. It's really important that at some point, you know, at the initial point there is um the experience to actually determine the pathway for, for care for that patient. And then there's, there's regular check ins. Um So even, you know, at the level of podia, it's quite effective to do it that way because um we are still faced with, with shortages in terms of not enough podiatrists, aging population. And I think that's only gonna get worse over the next couple of decades. So it's something that we actually have to look at. And I think in terms of patient perspectives, uh it's always interesting because patients are often expect what we set them up to expect. Um So I think in terms of educating a patient, if you educate them from the outset of this is how it works. This is what you can expect. Um, then, then that can be, uh a very effective way of, uh, I guess, um, making sure that they, their expectations of, of what is gonna happen are consistent with, with what you can deliver. And I think when we're talking about patients who are in rural areas, uh it can actually be of benefit to the patient and they, they will see the benefit uh if they don't have to travel as much. If there's, there's options for them to seek local care for us in Australia. Uh with a lot of our uh first nations people living uh in rural and regional areas. Uh It's great where they can act access culturally safe care. So if we can work with um first nations health organizations to, to facilitate that, that's a really good thing. And that's something that would be their preference uh rather than the traveler and seeing the, the the specialist. Uh So patient education is important. And then also, yeah, actually triaging because we are going to have to manage situations that are arising where there are not enough of um vascular surgeons, there are not enough podiatrists and we need to, to find ways to make this work better. And that doesn't necessarily mean training more practitioners, it means using them more effectively. Um And actually, uh facilitating, I guess a more multi skilled workforce in, in healthcare. I think you hit a good point is the education. Uh, we say we're educating patients. Are we really educating the patients? Are they just nodding and agreeing with us? And you tell them 100 times, don't put weight on your foot, don't smoke and this and that or, or whatever you're telling them to do because there have been some articles I've reviewed recently that really from Britain Great Britain that assessed, um you know, from practitioners, whether the, what they're telling the patients or whether the patients are actually really understanding and is there a better way for us for the practitioners to communicate with the different cultures and the different patients to be more effective? And we have to take some ownership here, right. It's not just the patient didn't care, right? I mean, they do care, right? Nobody wants to lose their leg right after the fact they're all sorry. And then we feel bad, but maybe we could have all done better. I think the education piece is really complicated, right? Because it's, you have to educate patients, but you have to educate patients before they even realize they have a problem. Right. So the analogy I've thought about is there was a program I think it was in Los Angeles to try to call attention to the problem of hypertension in black men and they ran it through barbershops because black men would, would, would congregate there. They trusted the environment and that was a place they could be reached. And I thought about that in Houston. So the biggest community we have difficulty reaching is the Hispanic community. But you would have to go through churches or um neighborhood groups or Spanish radio stations, TV stations. I mean to reach people in a place that they're normally going to be comfortable. So that that part is difficult then just educating the health care system and everybody that comes in contact with these patients that, you know, you see two extremes. 10, it's just a foot ulcer diabetics get those all the time. No big deal. Doesn't look that bad. Or, um, the, the opposite extreme where they over admit patients and some had a clean neuropathic ulcer and they're admitted to the hospital, they've had their wound swabbed and the Mr scheduled and you go see the patient and it's actually been healing. So anyway, you have to educate all the providers that, um, come in contact with these patients. It's really, that's why I've chosen it at Harris Health. Not to try to do that yet. It's just because it's too complicated, it would probably take a lot of money. So we've been trying to fix at least the part of what happens to the patient when they get in our system. Right. So that's where we're, most of our focus is, at least we should have more control over that because at least we can control the people that come in contact with the patient and try to have a system that is not random. So, what do you think? Uh I know Joe and if you're basically just rewrote the guidelines for diabetic foot and we eagerly, and I've reviewed them for the Document Oversight Committee. But what uh key changes have you made from the last set of guidelines? I mean, are there? I mean, maybe now you're recommending Plavis instead of Aspirin. I don't know. I mean, there's, but there's got to be some changes that are different. Do you have any thoughts on that? You wanna go there? You want me to, you can go. Well, I can't, I can't give them all away because they're not gonna come up till next week, but there's some subtle changes. There's, there's some new data, what, what we find actually, I don't know, this is my third time through this. So it's every five years and um, we find similar gaps almost every time, the same kind of, there's some new data, but it has the same limitations as before. So it's quite frustrating. Actually, part of it is around nomenclature and part of it is the vascular literature. The diabetic foot literature is a little bit, it's separate. I mean, they're related languages but they're, it's kind of like French and Spanish. I mean, theoretically, if you saw it all written down and had a good background, you could figure a lot of it out, but it's just the communication is not very good. So, but there are, there are new trials, for example, the, the basil just came out which conflicts with it seemed like the best cli trial was gonna add some clarity and then that lasted a few months and then best uh basil comes out and at least on the surface has a different conclusion. So we'll probably be discussing that at the hague. But um there's a big lack of, of granularity about definitions of things. So there's, I think it's new this time around, there's actually going to be agreed upon definitions that were run by the chairs and the groups of all the different working groups. So offloading infection, um the group, the P AD group, all of them, we came up with commonly used terms and tried to reach, you know, what should this mean when you see it written in the paper? So I think that will be helpful. There's a lot of different terms get thrown around and they, they're not totally accurate. I think that'll be helpful. Um Now we have a lot of recommendations. So, you know, we use the grade methodology that's a whole several courses to go into. But people say, well, I know that's not true because of this paper. It's like, well, OK, but we couldn't include that paper because it didn't meet the inclusion criteria for the following five reasons, right. So it doesn't mean in practice, you ignore other sources of information, but when you actually has done a great job with this, but when you actually methodically go through, so we're going to look at this topic. So what does it have to have in this study for us to be able to assess the outcomes we want to look at? Right. So you have a question and then some outcome you want to measure. So they have to, they have to have looked at that question and they have to have measured some outcome that you think is important and then how do they measure that outcome? Right. And so you and then did they separate out? For example, since this is a diabetic foot group, basically, if they lumped in all patients with foot wounds and didn't separate out the patients with diabetes from those without, then they get excluded. Basically because you can't tell one from the other, right? And they probably are different. So anyway, it becomes frustrating. If you try to be, on the one hand, you have to have scientific methodology to do these assessments. Right. On the other hand, if you're too rigid, you can end up not being able to say anything because if you apply strict criteria to most of what we do, a lot of it is not very well supported. It's a bit frustrating. I'm hoping with the global guidelines and these definitions and we have more multidisciplinary interactions. So this is the first time the SS, the SS and the working group are doing this jointly for the diabetic foot and PD. So, rather than us having overlapping guidelines every 2 to 3 years that don't really add up, they are all three societies together, which I think that's a huge undertaking because they all have different um they have different steps that have to be progressed through to get approved and they don't always know the steps don't line up so you can be ready with one group and the other group is not back yet. So that's been a bigger headache than I would have thought. But I think it's worth the effort because it actually has multiple specialties now involved and it's more likely to represent everybody's viewpoint. We all get in our little microcosm, right? You kind of think you understand what you do when you work in your little world every day. But there's other people working in the same world or parallel worlds that look at things a little bit differently. Set park has been fun and Vivian has done a great job. She's, um, she doesn't want to, I don't think I want to brag on her in public too much, but she's unbelievably patient. And like when we have to do something all over again, there's like, never a complaint. But these are really tedious. I think the average person thinks, well, these guys just sit around and make this stuff up. Um A lot of work goes through and you know, there's arguments over the wording for a particular recommendation and then people don't always realize the type of language you have to use. If you're trying to follow a great methodology, you can't just say it probably OK, or you can't just make up your terminology. It has to follow specific terminology. It gets to be complicated. What, what is your perspective, Viv is the foot doctor. So, on our group, you're the only foot doctor, there's Rob Hinchliffe. So there's Rob H because we have two Robs. So Rob H is from the UK, he's in Bristol now and Rob is uh still in Adelaide, I believe. And then Viv is the only podiatrist and then me from the SVS. So what's your podiatric perspective on the group? Well, I will agree. It was a lot of work. Um So going through the pro the grade process, I think uh has been good in that. It's really identified where we have gaps in the literature and what we need to do in terms of research moving forward. Um Working with the multidiscipline group has been, has been great. Uh It's really uh the different perspectives you get when you're developing recommendations, when you've got that group working together um is really interesting, really important uh and has really uh influenced the way we've developed those recommendations. Uh So I think uh it, it the the new guidelines and the recommendations will reflect the multidisciplinary nature of the care we need to deliver to people with diabetic foot disease. So I I think that's a really important outcome. Uh from the process. I think we have managed to include patient perspectives a lot more. Uh So it's been done in the past, but we've increased that inclusion of patient perspectives in developing these recommendations. And for me, from a personal perspective, it's been a great process in terms of developing recommendations and then having the opportunity to try and apply them to practice along the way because it really identifies to you where a recommendation may or may not work clinically or may need to be tweaked uh to make it uh more uh applicable and adaptable across a wider range of situations. So, I it's been a great experience. It's been great working with, with three societies. It's been great working with um you know, specialists from all over the world. Uh And yeah, it's I I've definitely learned a lot in the process, Joe, do you think in terms of the these, you know, the limb preservation programs are we, you know, I mean, insurance Medicare, there's so many funding cuts. I know even now the new change or the recent changes, new amputees Medicare won't pay for rehab and certain commercial insurances won't pay for rehab. And so they go home with home health, but that's, you know, physical therapy three times a week. I mean, how do you expect that person to walk again? Right. Without aggressive post rehabilitation. So, how would we, I guess in terms of a funding issue, you know, get these programs paid for and lobby to do so because they, well, as far as lobbying, one thing, the SVS is gonna have a huge presence in DC. So a lot of us are gonna go downtown DC the day before the meeting and try to lobby for um our specialty and for our patients especially and you know, the with the, the offer symposium this year will partly be addressing this. But how do we get good vascular care for all patients who need it? And we're way behind in doing that. And so we need to figure out a way to a probably train more of us and then b how do we work together better with each other and with other specialties to try to address those needs because there's a lot of patients that we all see this, that get what care they could get until they show up with something that's much more complicated. But I think the reimbursement thing is a huge issue. I mean, it's um that's the problem with trying to do, I've been trying to figure out how to try to do some regional work in Texas, but there are some insurance barriers um that you can't overcome. Um And those are the alternative is a single care system, which single health care system which should work better. But then depending on how it's funded, they may also be very strained. Also this happening in the UK, they're having difficulty seeing patients in a timely fashion. Supposedly happens in Canada. I don't have personal experience with that and we know it happens in our va every va is different but they can be overwhelmed sometimes and have trouble getting patients quickly through the system. So there is no perfect system. What is your opinion about artificial intelligence? It's really quite the buzz even on the news recently. But uh a lot of some hospitals are incorporating its use and some radiology systems are we, they've used it in our radiology system to identify etic aneurysms and in wound care it's being used in podia, it's gonna be used. Um I mean, I think we can it, but how are we going to use it? Have you thought about that Joe Travis? Uh from, from my perspective, I'm, I'm dealing with it on a daily basis at a university level in terms of training. Uh because trying to, I guess future proof training courses to, to limit the um uh influence of A I on on student assessments and things like that, that is a real challenge. Um And then on the flip side, I can see how effective it's going to be in health care from the point of view of reducing administrative burden and freeing up patient time, uh uh bring up practitioner time for patients, it could really improve patient care. And you know, it's such a continuum of what could actually happen with A I. Uh I think one of the biggest challenges will be overcoming cultural barriers. So within the medical profession of, of how do we deal with this as practitioners, how do we, you know, change the way we work to actually make better use of, of what A I can do. Um So I think in terms of how it's used, the obvious one to start with is administration and reducing administrative burden because there is going to be, I'm sure every health practitioner would love that. And that is something where, you know, changing workplace culture to accommodate, that will be something that can easily be achieved and that that's a really good, I guess uh springboard for, for actually integrating it into, to other areas of health care. Yeah, I know it's used for stroke and for aortic dissection and for that, it seems to be really effective. Um and there's talk of using it for pe si don't know if people are doing that yet. So I think for emergency triage, it may end up being really good because some of the neuro radiologists now they can look, we have two neuro radiologists that cover a large part of Houston for stroke call. So they need to know where they need to be. And if they really need to be there or somewhere else and they can look on their phone on this app and basically look at the images and decide right then. So that's a huge, like at least in our epic system in Haiku, we can't see the actual images. It's very frustrating. And when we get patients transferred from our own system, they often have to come with a disk um for wound care, it should be again if you had it set up. So the working group actually recommends the International Working Group on the diabetic foot, three levels of care for diabetic foot ulcers. So something you'd have in a smaller area, medium sized area and then tertiary quinary care. And there is a paper that's about to come out in the European from one of the provinces in the Netherlands where they actually implemented that and reduced their amputation rate significantly. So that kind of thing could possibly work. But it's, it's sort of a chronic slow emergency, right? It's different than an aortic dissection or a stroke where you only have minutes to hours. These patients, you have a little more time. But we frequently see we all heard the term right time is tissue and in the UK, now you're supposed to get people revascularized within two weeks. I think that's pretty impractical because we, we could, we'd have to stay open 24 hours a day and do nothing but rev ask if we actually tried to do that. But the question is how do you organize all these wound images and stuff and what other information you need? And somebody's gonna have to look at them. Right. Um Maybe a I can do some of that. But how often have anybody on this call seen a patient that was supposedly not very sick and you go by and you walk in the room and you know, right away it's not what was advertised or the opposite. Right. There was an A I one floating around on the internet looking at, um, I think PETA commented on it trying to decide if a wound was ischemic infected or, or neuropathic and wounds are off in all three. Right? And so, um, some of the wounds didn't look obviously anything. So I don't know how that part works anyway. I think there's a role for it. Yeah, I think we still have a job. I think he's not going to replace us, put us out of business. No, we need more of us actually. It might make us more efficient. But, um, yeah, that's the thing that, you know, there was, um, I don't remember where she, I heard Amy Reed give a talk and it was at the, um, Texas basket and I asked her to talk at the Crawford this year, but she couldn't make it because she'd be in Europe. But the question was, are there enough vascular surgeons or not enough or are we just now distributed. And so Travis is a little unusual because he's really well trained and he goes to a smaller area to make an impact. And we had a fellow that ended up in Wyoming that ends up doing everything. He's got a huge practice. Now when he went there, all their patients used to go to Denver, but a lot of younger people when they finish training don't want to do that. They would like to be part of a big group. So they have less call and also make sure they get all the high-end cases which don't always come to the smaller places, at least in a lot of volume. So we need people. Um, like Travis, where are, where are you from originally? Uh, Travis, I grew up in the DFW area so I've been in big cities my whole life. Yeah, it's interesting. So I've always tried to figure out if you could entice people. So I thought one way to try to recruit for these areas is to, is to consciously select students and residents who are from areas like that in the hope that they'll go back. And possibly if you could link it up with some governmental loan forgiveness or support, people might be willing to do that. There are some people who get tired of the big city and just decide I've had it with all this stuff and I want to go somewhere more manageable so that sounds like what Travis did. But that was my experience. You, um, I mean, but usually going to, like smaller cities you actually get paid more than being in a big city. I mean, I sure know Travis is. Yeah. But then the downside of that is you're on call war too, right. If you're in a 10 person group, you might get hammered when you're on. But you're one and 10 if you're in a two or three man group, and if you're, especially if you're in a group where you're the main vascular person, the other people are kind of like general plus vascular. You can bet all the really complicated vascular they're gonna call the vascular guy for. So you end up wearing that person out. That's the thing that I think there's two issues with the rural, rural type practice or small area practices not burning the poor person out who's going to be on call all the time. And then how do you get support if they need help and be able to transfer a patient in some organized way and then other activities depending on what the family wants to do. Um, in the school systems, in the area you choose and so forth. Haven't enough to do for the family. But I think we need to figure out how to do this because it's, it's a huge problem. I think we just have a few minutes left. I don't know if you want to make any, uh, closing comments that went quickly. Certainly a lot to talk about Travis. Why don't you sell being in a smaller town to the audience? Because you, I mean, you do love it and the cases you've talked about are pretty good. I mean, very good. I feel like sometimes when you start off as a junior faculty in the bigger cities, you know, all the older faculty are taking all the good stuff and you're left with, you know, whatever it is. But I mean, it seems like you've been doing great cases and your partners are really awesome. So, yeah. No, I, I mean, I, I've picked up quite quickly and I'm, I'm pretty clinically busy now. Uh, my partners are, are more than happy to give me everything. In fact, one of them just text me for, for to do a Leg Angio tomorrow, but I don't have time. Um, so you do take AAA bit of a hit in going to a smaller city, you lose a lot of conveniences of a, of a big town and that's very, um, it turns a lot of people off and, uh, you know, I don't think I fully appreciated that, that aspect of, of everything. And then, then of course, there's the family aspect too. We just had a kid. Uh, Amarillo is pretty kid friendly. Um, but it's still gonna take a year and a half to get him into daycare somewhere and my wife, you know, is, is just now going back to work. So, and, and, and, you know, there, there's certainly not a lot to do here. Uh, relative, relatively speaking to Houston. We don't have, you know, Galveston an hour away and in New Orleans and Austin all within a short drive. So you, you do take a big hit. I will say the call responsibility in a small town is much, even though I'm on call for a week at a time, every third week, week, I, I will say it's much less um, uh difficult uh, of a call week than, than say, being on call at a large tertiary hospital. I, I do get to sleep the night, probably three or four nights a week. I do maybe one emergency in the middle of the night, a week, one emergency during the, the day and uh per week that I'm on call. So, um, I, for me it's, I, I love my job. Um, I love this place and I'm, I'm really trying to convince my, my wife now to, to, to kind of stay here for, for a long time because, you know, she does get to see me at two or three o'clock. Uh a lot of days, the, the days that I don't have a clinic in the afternoon or that I'm not reading ultrasounds. Um, so for, for me and for us right now it's a great, um, situation and II, I really encourage a lot of people to, to give it a try because honestly, when I got the postcard in the mail before I graduated, um II I was not very sold until I came out here and talked to the guys in the group. Um Well, that's great. Any closing comments? Shower a bit? Oh, I, I'm sorry, sorry joke. Um I need to say thank you for having me. It's been really fascinating uh to, to listen to as well as be a part of. It's been great. Thank you. I've learned a lot from. You really crossed the pond way across. It's the most fun thing about what we do I think is when you get to meet people who practice in different places and you end up finding out a lot of our difficulties are very similar, but you find some subtle, you'll get little nuggets of, of somebody who's found a better way to do something or a more innovative way or a way to make something less frustrating. But it's really fun to see people in all different parts of the world, kind of tap on the same thing. But thanks for putting this together. This has been a good thing of COVID. It's actually a lot of our education now can be done by and if you have a family or other obligations, not having to travel to do something educational and it's also stored. So people that couldn't make the time that you chose can pretend that that's a big plus. I think that's probably the one good thing about COVID. Well, this is tape. So what it's gonna be on youtube as soon as we finish and anybody can watch. But, uh, thank you so much. I'll see you too next week. Take us with you. I've never been, I heard it's nice. We'll post pictures. All right, perfect. Well, thank you. Thanks. Thanks very much. Good luck Travis. Thank you. Thank you. I'll see you in then.