Exhibition of Unknown Architects
Exhibition of Unknown Architects
by Steve Elias, M.D., FACS
walter Gropius, one of the found-
ers of the Bauhaus, proclaimed his
goal as being “to create a new guild of
craftsman, without the class distinc-
tions which raise an arrogant barrier
between craftsman and artist.” This
was written in a pamphlet of April 1919
describing an art exhibit entitled “ex-
hibition of Unknown Architects”. The
Bauhaus (House of Building) was founded with the idea
of integrating all forms of art and artists for the collective
good of all involved.
This issue’s roundtable discussion involves members from
The American College of Phlebology wrestling with the
methods and means of Phlebology education. How do we
educate both the beginning phlebologist and at the same
time, elevate learning by the experienced phlebologist?
Can we accomplish this while funds are becoming more
restrictive? And with an organization whose membership is
more diverse than the AvF or SiR?
Before we embark on the discussion, a passage from
Gropius’ lecture at Columbia University in 1961, entitled
“The Rule of the Architect in Modern Society” gives us the
mindset needed to maximize efforts within an organization
of the diverse specialties of the ACP (surgeons, vascular
surgeons, internists, dermatologists, etc.), “The Bauhaus
was not concerned with the formulation of time bound,
stylistic concepts, and its technical methods were not ends
in themselves. it was created to show how a multitude
of individuals, willing to work concertedly but without
losing their identity, could evolve a kinship of expression
in their response to the challenge of the day. its aim was
to give a basic demonstration of how to maintain unity in
diversity, and it did it with the materials, techniques, and
form concepts germane to its time.”
Let us see how members of the ACP (speaking as
individuals and not spokesmen for the ACP) confront the
“challenge of the day,” with concepts germane to this time.
Our roundtable participants include: Phillip A. Hertzman
MD, FACP, FACPh, FAAFP; Mel Rosenblatt, MD, FACPh;
Diana neuhardt, RvT and Helane Fronek MD, FACPh.
How would these architects, albeit not unknown, build
something new?
1. The ACP has a more heterogeneous group of
members compared to the AVF (vascular surgeons
and some interventional radiologists) or SIR
(interventional radiologists and some vascular
surgeons). How have you met the challenge of
educating people about Phlebology when they
bring such diversity of training to the field?
Mel: The ACP addresses people from all walks of the
medical field and consequently their educational challenges
are greater. They try to teach Phlebology in and of itself to
those that only manage vein disease and those that have
other aspects of their practice. They also need to teach
those areas that interact with Phlebology –in-
cluding dermatology, radiology, internal medicine
etc. This is really a challenge especially when the
Phlebology Board exam is out there for those who
have been practicing longer. everyone is coming to
the meeting with different levels of experience.
Diana: i agree with Mel. There is less common
ground – particularly for ultrasound. within
Phlebology, there are new users to ultrasound
which adds the complexity of teaching the
basic use of the ultrasound device. in addition,
teaching a non-standardized study such as venous
insufficiency presents some hurdles as well.
Conversely, one of the greatest aspects within
the ACP is that though there is a tremendous
variation in experience, it’s a unique community
because the environment is conducive to teaching
one another. Most of us realize that Phlebology is
an emerging specialty and we need to help each
other fill in the voids of our past training.
Phil: One important thing we need to highlight
is that there are new opportunities for licensing
and certification, and as a result, there are now
individuals who have studied and achieved these
goals. now, there are courses that aren’t as
interesting for those who have been involved
for a long period and demonstrated that they
know a certain amount – these courses are too
basic. How do you keep everyone interested and
motivated – when attendees are not just from
different specialties but also have different years
of phlebology experience?
Helane: The challenge of teaching phlebology
to people with such diverse backgrounds was
initially approached by presenting a one-day
course, either as a regional symposium or as
the pre-congress day. we recognized that many
practitioners with little knowledge of venous
anatomy, physiology, syndromes or therapeutic options
were entering the field and we wanted to provide a
background in the fundamentals of Phlebology. As research
expanded, our understanding grew, and new therapeutic
tools were developed, these programs have become more
sophisticated and specialized, but we need to continue to
offer the introductory information each year. in addition,
our textbook, The Fundamentals of Phlebology, is another
method that we have found useful in encouraging all of
our members to acquire a certain knowledge base. The
board exam is another vehicle with which we encourage the
attainment of a certain level of shared knowledge. i actually
feel that the varying specialties of our members brings a
richness to the discussion, as members trained in different
specialties are familiar with their literature and
may see things from a different vantage point that
affords fresh insights.
Steve: Should we have meetings that address
the baseline knowledge needs which would help
people focus on a common goal (for example, in
ultrasound or sclerotherapy)?
Mel: The width and breath of the field makes this
a challenge. is it appropriate for phlebologists to
know about dermatologic cancers because they may
see them in their practice? There are certain areas
of the specialties that may overlap. The challenge is
to give people what they need when their practice
touches on multiple subspecialty areas.
what constitutes the core knowledge of
Phlebology? That should be reflected in the
Phlebology exam. we are witnessing the breakdown
of subspecialties to various other specialties that
have knowledge or ownership of one aspect of
it. As a consequence, people come to meetings
with only partial knowledge, looking for a more
common baseline of phlebology knowledge.
2. Educational challenges are more
difficult now with restrictive funding since
the new AdvaMed and PhRMA changes. If
we only have money for one (maybe two)
educational objectives, what would you
consider paramount for Phlebology?
Mel: There is a challenge to get the general
medical community (non-Phlebologists) to agree
as to what venous insufficiency is and to realize
that it can be treated. This is not taught by ACP
or AvF. The general medical community needs to
understand what this specialty is today and what
it can do compared to what could be done 15-20
years ago. Perhaps we need to spend time and
money getting the rest of the medical community
to understand what Phlebology is and what we
can now do to help people. This would be the best way to
spend our time and money.
Phil: The onus is on primary care physicians to provide
their patients with the best quality care. And the onus is also
on the physician to refer to a specialist for those conditions
that warrant them. The educational dollars to educate the
internist versus educating the phlebologist is vastly different
--- and different vendors/manufacturers will want to be
involved in supporting a meeting based on who the audience
is that is actually attending. what aspects of Phlebology do
you teach, and are you going to deliver it in a traditional
way as a meeting or in a non-traditional way such as a DvD
that can be posted online? Or will there still be enough
money to have people go to meetings and interact and build
connections in person?
Helane: informing primary care physicians and potential
patients that venous disease is not benign and that it is
now more easily and effectively treated than ever before
is a crucial goal. Given that educational (and all) dollars are
shrinking, i think that we have to be smarter than ever and
use our resources in clever ways. For instance, vendors
who call on primary care physicians or who exhibit at their
meetings can be enlisted to deliver this message. when
the ACP first created its textbook, we also created a
companion power point presentation and speaker’s bureau.
we contacted 100 medical schools/primary care residency
training programs and offered to present this information
and none of the institutions responded. we need to find a
way to convince our primary care colleagues that we can
help them understand this very common disorder and learn
to help their patients – without requiring a great deal of
their time.
3. You are leaving out the patients themselves as
a target for education. One of my pet peeves is
that venous disease is primarily a self-diagnosed
disease. Patients need only to look at their legs
to know if they have abnormal veins. Should we
reach out to patients directly, similar to the Viagra
approach or the PAD campaign, to drive patients
directly to a vein specialist?
Diana: There is a fair bit of money from foundations
to address public awareness. The problem is that many
of the varying educational teaching methods have failed
to help them or answer specific questions. i currently
serve as chair on the ACP public awareness task force and,
as a committee, we have identified that patients do not
know who a vein specialist is. A goal this year is to assist
in educating the public about two words - Phlebology and
Phlebologist. we hope to encourage patients to seek care
by medical professionals who are specifically trained to treat
vein disease.
Phil: Somehow, physicians that want to do Phlebology
have to become competent. A second issue is that
patients must understand what competent physicians can
accomplish. You can’t have one and not the other. if we
educate patients about venous disease, we need to make
sure there are enough phlebologists out there who can fill
that need of care.
Helane: Many years ago, Medi USA held a series of
focus groups and determined that the most effective way to
encourage potential patients to buy stockings was not with
an advertising piece that directly mentioned the benefits of
stockings, but with a list of eight signs of venous disease that
they put in poster form. involvement of a public relations/
marketing group might be helpful in finding better ways of
getting the information directly to potential patients. i think
that this approach should not be ignored. Patients then
return to their primary care physicians and drive the interest
in venous disease.
4. How do we best get young physicians and medical
students interested in Phlebology? How do we build
for the future and get people to make this a career
choice? Are we destined to have physicians enter
Phlebology from diverse fields forever?
Mel: The best way to introduce the concept of Phlebology
is at the medical school level. There is the residency
program as well, where they should also be teaching it.
My experience is that some are and some aren’t. in some
programs, superficial venous disease is getting addressed
and in others, the residents have no exposure. Steve, you
saw a need years ago when you started The Fellows Course
in venous Disease. The problem is that Phlebology is a
multidisciplinary pathway while medical school is filled with
traditional pathways and Phlebology doesn’t fit into any of
these boxes neatly.
Medical schools need to introduce it and teach it: if
medical students want to go into this field, there is no formal
pathway at this time.
Helane: i agree with Mel that your question is a bit
premature at this point, since there still is no formal
Phlebology curriculum in medical schools and we don’t have
specific training programs. Once Phlebology fellowships are
in place, it will be more reasonable to approach medical
students. At this time, the ACP offers scholarships for
trainees (medical students and residents) to attend our
congress, which is an excellent idea. i believe that the AvF
offers research grants for trainees as well. encouraging
our members to present papers and lectures at their
primary specialty meetings is another effective avenue for
encouraging interest in Phlebology.
Steve: You can change the educational paradigm: you
can go from medical school into a Phlebology program or
fellowship. i don’t think our goal should be to continue to rely on our traditional ways of educating people from all
specialties and then transitioning them into Phlebology. it’s
not a very efficient process.
5. Should the annual meeting be used for more
educational tracks or should we change focus
and let the annual meeting primarily address
new research and papers and the business side of
Phlebology, using other more focused meetings
during the year for educational/workshop venues?
Should we stop trying to educate everyone at the
same time at the annual meeting?
Phil: it needs to stay exciting and stimulating. Both the
most exciting sessions at ACP and AvF are where there are
issues addressed in a panel forum with audience participation.
These need to be nurtured and offered more broadly. very
similar to the session you moderated at the meeting this
year Steve called “Give Us Your Best Shot”.
Mel: we all need to have a certain number of CMe
credits so we can renew our board certification. it’s not so
easy for average practitioner or even a busy practitioner
to stay away from their practice due to the decreasing
reimbursement associated with treating anyone today.
As a consequence, to keep these meetings going, there has
to be a critical mass of people invited to assure that enough
will show up. There is a huge challenge with these meetings
to meet the many different demands of people interested
in attending.
Helane: Although not a perfect solution, i like the fact
that the annual congress has something for everyone. it is,
however, always a difficult challenge to fit it all in!
6. With travel more expensive and inconvenient
and many of us not able to leave our practices as
often as before, should we explore other ways to
educate our members (i.e., internet) in 2010 which
don’t require you to physically leave your office?
Mel: Distance learning maybe the next step in learning,
since it eliminates the cost of travel.
Diana: The ACP, among other societies, are further
developing distance learning. The problem is still time
management – and at home, you can commit to learn, but
you can easily become distracted. when you go away to a
meeting, you interact with others, talk with others, make
contacts and share stories. To discount the impact that
this has on true learning and contributing to the base of
knowledge in Phlebology is probably a little short sighted.
That is one reason why we have medical advancement --
through interaction between individuals with differing skills
and experience.
Phil: i agree with Diana. when you look at attendance
at ACP and AvF, it’s increasing. i just got my DvD from the
ACP meeting. if you choose your sessions well, you can
benefit from what you missed in person by reviewing the
DvD. i would hate to give up that interaction component
though. i think both are critical.
Mel: i echo both comments. The interaction on the
personal level is invaluable. i’m just raising a concern that
the AdvaMed and other rules may make it cost-prohibitive
for anyone to go to these courses. if these rules continue,
we may have no other alternative but to educate remotely.
Steve: i think these rules may become more stringent
over the next few years, but then the government may find
that they have been overzealous and things will settle out.
But i agree it’s going to be tougher in the short term to be
supported by industry. And industry is truly interested in
advancing education; their support of these meetings is not
devious in the way the regulations portray it.
7. You have all been involved with venous education,
what type of educational activity do you think we
should NOT continue on a going forward basis?
Phil: i have to reiterate what i stated already. You’ve got
to keep the learning intellectually stimulating. There has to
be interactive discussion, case-based learning. The way we
were taught in medical school is not as effective as some
of these newer methods. i would decrease the amount of
didactic sessions and increase the interactive ones.
Steve: i think we agree that we need to get rid of some of
the didactic methods of learning. what newer ways should
we invest in to approach education to keep it more exciting
even with fewer dollars?
Diana: interactive case study is the best strategy for
ultrasound teaching and we will continue to expand on this
aspect. Case-based learning, i’ll call it visual versus book
learning. when you visualize the ultrasound, it appears to
be the most useful in understanding.
Mel: i believe that case based learning is the best way for
me to learn things as well --- but it’s the least efficient way of
learning. it needs to be some type of blend. Sometimes you
are observing cases that you are watching for a longer time
than you are actually learning. Should the case be showed
in a video instead? Should we show an entire procedure
in video or just air video segments that focus on the key
aspects of the case?
Phil: Didactic learning is an educational dilemma: it’s more
efficient but results in less retention. At ACP, there is no more
sclerotherapy hands-on training because there is no longer a
simple way to do this in our current legal environment.
Helane: People are always asking for sessions that include
clinical cases – i agree with Phil that we have a huge resource
within our membership of both great cases and people with
excellent clinical problem solving skills. we used to have
clinical case discussions at each ACP meeting, presented
in a CPC format, and these were always favorites of the
attendees. Understanding how a practiced phlebologist
assesses, exams, reassesses and treats is very educational.
when it comes to the acquisition of skills, there is no better
format than hands on practice, followed by immediate
feedback and the opportunity to do it again, better. without
formal training programs, this is difficult to offer.
Steve: Learning on a case basis is more fun, but it implies
that attendees have a certain basic level of knowledge.
People need the knowledge base. At least, at this point, for
general Phlebology practitioners, they are at a different place
than ten years ago. They want that case based learning, the
controversial sessions. But there are still those that are newer
that need the basics. Yet i do think there are more people
each year that are looking for the next level of learning.
Diana: The ACP is offering an advanced Phlebology
ultrasound symposium in March. we have tremendous
material but soon realized that cost efficiency wasn’t
there. So we had to be efficient and eliminate the option of
offering attendees hands on scanning. instead, we developed
a strategy to include live patients with a known “specific”
teaching point who will be scanned live by “experts.” The
course will be interactive with the sonologist pointing out
key aspects within the exam. Additionally, we are exploring
other ways to offer the material but in “fast forward” in
favor of both time and cost-efficiency.
Mel: i have been asked to teach Phlebology to those
that don’t have this as part of their practice. i’ve been a
little put off by this. why are they asking – just to add one
more procedure to their practice or because they want
to learn about this area? i told them to get a book. They
ask where else they can go to get this basic information.
i tell them to go to a meeting. Sometimes the available
meetings are too advanced, but they are going to have to
get the basics somewhere. As the sophisticated practitioner
group increases, the needs for the basic attendees may
diminish. Balance is going to constantly be altered based
on the educational interests of the specific meetings and
attendees. we do this each year at ACP and the balance
does shift based on who is attending.
Helane: Trying to satisfy the needs of learners of all
levels is what makes planning a meeting fun and challenging.
Having been to all of the annual congresses, i can attest
to the fact that the level has definitely risen dramatically.
Mixing up the presentation formats makes it worthwhile to
continue to attend each year. if the meeting were the same
each year, why would anyone bother coming? For instance,
this year there were several new sessions, many interactive,
that were very exciting to listen to and excellent.
we have some things to think about. we are talking about educational concepts we didn’t even consider five to ten
years ago when Phlebology started to grow. Some priorities
we have identified include: public and referring physician
awareness; the need to continue teaching basic Phlebology;
and incorporating Phlebology into the education of younger
medical students and resident/ fellows.
You have all expressed the need to keep our annual
meetings as a focus where ideas can be exchanged. Continue
to offer basic courses but add more interactive case based
sessions which are more interesting for the experienced
phlebologist. walter Gropius in his essay, “The Bauhaus
Manifesto” of 1919 emphasizes how growth comes from
first learning the basic principles of one’s art or profession.
“Architects, painters, sculptors, we must all return to the
crafts. There is no such thing as ‘professional art.’ There is
no essential difference between the artist and the craftsman.
The artist is an exalted craftsman. By the grace of Heaven
and in rare moments of inspiration which transcended the
will, art may unconsciously blossom from the labor of his
hand, but a base in handicrafts is essential to every artist. it
is there that the original source of creativity lies”
Finally, we need to be cognizant of where we’ve come from
to have a better idea of where we are going. Sometimes a
walk on the beach in the winter helps. (See Fig 1, photograph
entitled: “Where I’ve Been? Where I’m Going?”).