Advisory Board member and columnist David Schmiege interviews Stuart A. Harlin, MD, for this issue. Dr. Harlin is an associate professor and the director of outpatient vascular operations within the Department of Cardiothoracic and Vascular Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston.

Dr. Harlin is a board-certified vascular surgeon who specializes in minimally invasive treatment of vascular disease. He is active in several vascular research studies and has published articles in prominent medical journals such as the Journal of Vascular Surgery, American Journal of Surgery, Military Medicine, and Vascular Surgery. He is a decorated Air Force medical veteran where he served in the U.S. military from 1992 to 1999.

Schmiege:  Tell us how it all began. What made you decide to choose medicine in the first place? What was your path?

Harlin:  I was encouraged to choose medicine at an early age in my family, and after years of prodding in that direction, I guess it finally stuck at some point. Once in medical school, I thought I would pursue cardiology until I found out that you had to spend three years in Internal Medicine prior to specialization. Then I did a rotation in Vascular Surgery and the rest fell into place after that.

Schmiege:  Dr. Harlin, please share with our readers how you came to practice in the field of venous disease.

Harlin:  I was exposed to venous surgery from the first few weeks of my internship in General Surgery. I was fortunate to be exposed to the endovenous therapies early in my career in vascular surgery and really saw them as disruptive techniques that would revolutionize the care for patients with venous disease. I adopted RFA as soon as it was released commercially and really never looked back after that. I received remarkable support from them, and it really changed my perspective on vein treatment.

Schmiege:  What made you initially decide to go into private practice? Academics?

Harlin:  I initially began my practice in the military. I was set to join academia after leaving the military but that fell through and a pair of IR docs in Pensacola were looking to start a new joint venture. It seemed like a really cool idea and off I went into private practice.

Schmiege:  Thank You for your service

Schmiege:  What is it about your practice that sets it apart from others? Why should a patient visit your practice?

Harlin:  I think that my practice differs in that we offer a full spectrum of vein care and use most of the modalities without commercial preference. We try our best to individualize every patient’s care and use the best technologies for their individual situations rather than just focusing on RFA, laser, Varithena, and so on. We also offer a comprehensive service including treatment of all of the central vein issues, rather than just treating the GSV. Our ultrasound techs do a fantastic job imaging our patients and give us outstanding intel regarding each patient’s specific anatomy, which allows us to further customize each patient’s care.

Schmiege:  Arguably, one of the hottest topics in our community right now is about who is best qualified to do vein work. Who do you think is best qualified to do vein work and why? How do you think that will change in the next few years?

Harlin:  I think that Vascular Surgeons are the best qualified to do vein work because we have the most comprehensive training regarding those treatments. We remain the only specialty trained in all aspects of vein care – diagnosis, conservative therapies, and endovenous and open surgical techniques. I don’t see much of a change going forward, especially on the open surgical side.

Schmiege:  What role should vascular surgery take in the education of practitioners who treat vein disease?

Harlin:  I think that we should take the lead. Too many people treat vein disease because of the profit margin and not because they are passionate about vein care.

Schmiege:  What efforts have you been actively involved in for the advancement of the diagnosis and treatment of venous disease?

Harlin:  We participate in many trials for vein care and actively pursue research along several lines of vein care – including diagnosis and treatment modalities. We just received notice of acceptance from JVS regarding a paper on the relation between vein disease and lymphatic disorders.

Schmiege:  What technological advances are contributing to the quality of vein treatment that most excite you?

Harlin:  Ongoing improvement in diagnostics will lead our advancements in treatment – the more precisely we can see the problem, the better we can treat it.

Schmiege:  What is/are the biggest challenge(s) in your work?

Harlin:  Insurance companies & EMR – the ongoing avalanche of data entry

Schmiege:  How would you describe your Practice Philosophy?

Harlin:  Relentlessly pursuing the best care for our patients using the most innovative and progressive therapies available.

Schmiege:  What are some of the challenges of your profession?

Harlin:  COVID is the biggest issue today but it will fade soon, I hope. There continues to be issues with public knowledge of diseases we treat; we also see ongoing financial and social barricades that prevent us from delivering seamless care.

Schmiege:  What is something about you that would surprise your colleagues?

Harlin:  I hated basic science in medical school

Schmiege:  What type of medical trends do you feel are going to make a difference in the future?

Harlin:   The same trends that shape the world today. Ongoing advancements in technology that allow faster and better care. Artificial intelligence; big data – a collection of data sets so large and complex that it becomes difficult to process using on-hand database management tools or traditional data processing applications; and the like will continue to shape medicine more vigorously over time.

Schmiege:  Is there any one particular case from your career which stands out in your mind?

Harlin:  I tend to focus on things that did not turn out perfectly rather than success stories. Surgical training suggests that an outcome that is not perfect is your fault, and I guess that stuck with me over time.

Schmiege:  Have you read any recent medical studies which intrigued you? If so, what were they?

Harlin:  A lot of papers now seem to be self-explanatory – i.e., like sicker do worse than healthy patients with the same problems. It seems also like we are seeing more and more large data mining efforts rather than seeking original answers to problems.

Schmiege:  A decade ago, few would have foreseen the crossover in types of vein treatments being offered at other specialty practices. Where do you think the next big movement is going to be and how will it affect vein practice?

Harlin:  I think that the insurance companies will exert more pressure on practitioners to demonstrate a true expertise in vein treatment rather than attending a weekend class and declaring yourself fit to ablate GSV’s. More pressure will be placed to ensure patients have actually been compliant with conservative care before allowing interventions. The explosive growth in vein treatments will be in some way detrimental to its growth going forward.

There will be more emphasis on precise diagnosis prior to intervention. It will me mandatory that you are IAC accredited. Similarly, more emphasis will be placed on compliance with conservative care rather than a rush to intervention. This will drive out many of the profiteers currently treating veins.

Schmiege:  In your opinion, which area of research is yielding the most advancement in the field?

Harlin:  Randomized trials pitting one treatment vs another will continue to be the most important source of information. As more folks enter the field, this will generate more of these types of results, which will define care options going forward. Basic science will also yield more advancement, especially in the treatment of venous ulcers.

Schmiege:  You are well-known in your field of work. What is something about you that would surprise your colleagues?

Harlin:  I guess that I am not entirely driven by the bottom line, but rather the focus on the humanity of our patients and how frequently we fail them in that regard.

Schmiege:  What Schmiege did I not ask that I should? Now answer it!

Harlin:  I think a key question for venous treatments is where they will go physically. I think you will see an ongoing exodus of cases out of the hospitals into outpatient centers – especially for issues like DVT and PE. The new thrombectomy devices lend themselves very readily to outpatient utilization and it is only a matter of time before these largely leave the hospitals.

Schmiege:  Tell us about any publications or research you are currently working on or recently finished.

Harlin:  We recently had a paper on the relation of venous disease and lymphatic disease accepted by JVS. We have submitted a large number of articles on the new thrombectomy techniques for DVT and PE. We have started trials comparing the thrombectomy devices with other modalities such as CDT for DVT and PE. We have started trials on the effects of right heart failure and other right heart issues such as Afib on peripheral venous disease and their treatments. We just concluded a trial for Varithena on the treatment of patients with venous ulcers.

Schmiege:  How does the current state of health insurance affect your practice and what are the pitfalls?

Harlin:  The insurance companies continue to pursue a more conservative approach to vein intervention which is good. The explosion in vein interventions is partly due unscrupulous overutilization by providers, which makes it harder for all providers to obtain authorization for interventions.

Schmiege:  Who or what inspires you the most?

Harlin:  Mainly my patients for their dignity and grace. I see folks with truly rotten situations who are upbeat despite all of that – and they are offering me comfort.

Schmiege:  If you could do anything else for a living, what would it be? Why?

Harlin:  Honestly, at this point in my life and career, I’d rather pursue a career in racing age-group triathlons. Not that I would expect to win or dominate, but rather that I truly miss the mental discipline it takes to compete at that level. There is so much noise in the world today – tweets, texts, etc. that just don’t serve a purpose. I would just as soon throw away my phone! VTN