As its visibility increases, the American Board of Phlebology (ABPh) has been the subject of debates at meetings of the American College of Phlebology and the American Venous Forum, with viewpoints offered by a member of the ABPh Board and by someone with an opposing view. Questions and concerns are now being raised and answered, but not always with commentary from the ABPh.

The ABPh continues to develop and evolve. For this reason, we would like to take this opportunity to review the background and goals of the ABPh and to discuss such issues as informing the public, educational standards and training programs, and patient care.

Why Was the ABPh Created?

The ABPh was created in response to concerns that the level of training in phlebology was very diverse across training programs in the medical specialties with a venous component. Many physicians within those specialties had little or no training in venous disease during their residency or fellowship. Put simply, there was no standardization or core curriculum in the existing training programs with regard to venous disease.

Given this, the ABPh, a wholly independent nonprofit organization, was established in 2007 to:

1. Improve the standards of medical practitioners and the quality of patient care related to the treatment of venous disorders and all aspects of venous disease;
2. Serve the public and the medical profession by establishing initial and continuing qualifications for certification and maintenance of certification as physician specialists in the practice of phlebology;
3. Examine physician candidates for certification and maintenance of certification in the practice of phlebology;
4. Award certifications in phlebology to candidates who meet the established requirements;
5. Maintain a registry of physicians who are Diplomates of the Board; and
6. Establish educational standards for teaching and training programs in phlebology.

Informing the Public: ABPh Adopts New Advertising Policy

We are all aware of the speed medicine is evolving. Much of the knowledge and many of today’s techniques regarding venous disease are just beginning to be incorporated into training programs. For the vast majority of physicians currently caring for venous disease patients, virtually all of their training in current knowledge and techniques was obtained at the postgraduate level.

In light of this, we have serious concerns about restricting disclosure of expertise in venous disease to physicians who are members of the specialty boards of the American Board of Medical Specialties (ABMS) or American Osteopathic Association Bureau of Osteopathic Specialties (AOABS). Limiting the ability to inform the public about expertise to only those certified by an ABMS board would unfairly restrict well-trained physicians from disclosing relevant, critical expertise, as well as objectively validated assessments of knowledge and competence.

With that said, after thorough discussion with consideration of our long-term goals, the ABPh Board of Directors approved a new advertising policy (see sidebar below) in November 2011. The policy is an attempt to carefully balance recognition of the efforts of our diplomates who have met the requirements to sit for and pass the exam, along with the need for transparency in properly informing the public.

There is a difference that must be recognized between those who have done a supervised training program with a standardized curriculum versus those with simply work experience and CME activities, regardless of how extensive such activities may be. There is a "gold standard" that has been set by the two primary U.S. certifying organizations, ABMS and AOABS, as well as the Royal College of Physicians and Surgeons of Canada. Becoming board certified by these organizations involves not only passing an exam, but also includes completing an approved supervised training program.

In the US, most laypersons do not differentiate between the ABMS/AOABS specialty boards and those board entities that are not affiliated with the ABMS or AOABS, such as the ABPh. In addition, a number of states prohibit physicians from advertising they are board certified unless they are certified by an ABMS/AOABS member specialty board or a specialty board with “equivalent” requirements approved by the state medical board. Equivalency typically requires satisfactory completion of a training program with training, documentation and clinical requirements similar in scope and complexity to ACGME- or AOA-approved programs. It should be noted that typically states have not prohibited advertising of specialization or the use of the term diplomate.

For these reasons, the ABPh advertising policy prohibits the use of the term “board certified” to avoid the perception that phlebology is a specialty recognized by the ABMS or AOABS. It is important to note that ABPh processes appear to meet other requirements regarding “equivalency,” which often include the following:

1. The organization requires all physicians who are seeking certification to successfully pass a written or oral examination, or both, which tests the applicant's knowledge and skills in the specialty or subspecialty area of medicine. All or part of the examination may be delegated to a testing organization. All examinations require a psychometric evaluation for validation;
2. The organization has written proof of a determination by the Internal Revenue Service that the certifying board is tax exempt under the Internal Revenue Code pursuant to Section 501(c);
3. The organization has a permanent headquarters and staff;
4. The organization has at least 100 duly licensedmembers, fellows, diplomates, or certificate holders from at least one-third of the states;
5. The organization provides an online resource for the consumer to verify the board certification of its members; and
6. The organization requires diplomates to recertify every ten years or less, and the recertification requires, at a minimum, passage of a written examination.

The ABPh Exam The mission of the ABPh is to advance the care of patients with venous disorders by improving the quality of practitioners treating them. We are pursuing this goal by offering a rigorous exam process, a commitment to lifelong learning and assessment, and the development of standardized comprehensive training in venous disease.

The ABPh Exam is open to licensed physicians in the U.S or Canada who meet rigorous prerequisite qualifications. There are three pathways to qualification:

• Fellowship
• Residency
• Practice

It should be noted that every new medical specialty has an early but limited period in which doctors can become certified through a practice track.

Detailed criteria are available online at: http://www. americanboardofphlebology.org/files/pdfs/ABPh_Criteria.pdf.

The ABPh examination was developed using the Standards for Educational and Psychological Testing, which establishes procedures for exam development to ensure valid interpretation of score results. Standards are published and adopted by the American Educational Research Association, the American Psychological Association, and the National Council on Measurement in Education.

Exam items are written, reviewed and approved by an item writer committee, consisting of experts of the subject matter and psychometricians. The committee goes through a rigorous process, with the input of psychometricians, to add new items each year. The committee then selects items to be in that year’s exam, with a content weighting based on the ABPh board-approved content document. The computer-based examination is comprised of approximately 200 multiple-choice questions in the following categories:

• Basic Science (8%)
• Venous Diseases and Syndromes (20%)
• Diagnostic Tools and Screening (10%)
• Duplex Ultrasound and other
• Imaging Modalities (25%)
• Treatment (35%)
• Professional Standards (2%)

Psychometricians analyze every item after they are presented on a test. Statistical analysis is done to assess how well the item yielded useful information about candidate ability. Items that fail to perform properly increase the error of the exam and therefore do not contribute to the precision of the pass/fail decision made about candidates. Any item that performs poorly is flagged for possible deletion. All comments from examinees are reviewed and considered. The reliability and standard error of measurement are carefully evaluated for each exam. To date, each of the ABPh exams has performed very well on these measures, with results comparable with the exam performance of established ABMS boards.

The ABPh exam follows the criterion-referenced testing model. This model holds that the level of performance required to pass a credentialing test should depend on the knowledge and skills necessary for acceptable performance and should not be adjusted to regulate the number or proportion of persons passing the test. The ABPh pass point was determined by careful analysis and judgment of practicing physicians who established an acceptable performance in consultation with the ABPh’s psychometrical consultants.

Each exam is equated to a benchmark scale initially established in 2008, with a new benchmark established every five years. A test equating process is designed to calculate differences in the difficulty of examinations among administrations and then adjust the scale of the current test administration so that the same criterion standard can be used. By accounting for differences in difficulty across years, all candidates
have a comparable opportunity to pass the examination, regardless of when they take the test. For example, if the test administered in a particular year was found to be more difficult relative to other years' tests, the percent correct necessary to pass would be lowered to be equivalent to the criterion standard. On the other hand, if a test administration were easier, the percent correct necessary to pass would be higher to be equivalent to the criterion standard.

Lifelong Learning and Assessment

The guiding principle of maintenance of certification (MOC) programs is to continually foster excellence in patient care through its commitment to lifelong learning and assessment. Since its inception, the ABPh has recognized the importance of MOC. In January, we witnessed the commencement of the ABPh PHLEB-MOC program.

Educational Standards In a major effort involving representatives from societies around the country and around the world, the ABPh convened a Curriculum Task Force in 2011 with the charge of standardizing training in phlebology. The Task Force is comprised of 24 leaders in venous disease from phlebology, vascular surgery, interventional radiology, vascular medicine and dermatology. The charge was to use a collaborative approach to develop a consensus for a comprehensive curriculum in phlebology. Ultimately, the ABPh seeks to improve patient outcomes on a national and international scale. But to achieve this, formal training standards in venous disease must be established.

As the first step towards achieving these goals, a draft of the “Core Content in Phlebology” was written by the multispecialty based ABPh Curriculum Task Force, outlining the areas of knowledge and competency considered essential for its practice. Seventy advisors, key leaders from various disciplines, were invited to review and critique the Core Content draft. A stakeholder’s comments phase was held from January 16 to February 29, 2012. All comments, concerns and suggestions were considered as ABPh finalized this document.

The outcomes we seek are to:

1. Outline the knowledge necessary to identify and manage venous, arteriovenous, and venolymphatic conditions and their sequelae;
2. Improve the standards, consistency and dependability of training across all the different specialties that treat venous disease; and
3. Provide a benchmark against which to assess the knowledge of practitioners of venous medicine and surgery.

Letter of Support from the AMA

We have received a letter from the AMA in support of ABPh efforts. Dr. Jeremy Lazarus, President-elect of the AMA, stated his support in a letter dated October 3, 2011:

I wanted to send this note of congratulations, as both a physician and President-elect of the AMA, to you and
the leadership of the American Board of Phlebology. I am impressed with the effort to establish a core content document in venous disease. Efforts to increase professional standards in medicine are something both the AMA and I vigorously support… I wish you all the best in the pursuit of your goal - the elevation of professional standards of care for venous disease patients.

The ABPh Board of Directors believes development of the “Core Content in Phlebology” will pave the way to improve educational standards and standardize comprehensive training in venous disease. These improvements are critical to achieving our goal of improving patient care.

Who Benefits? Improving Patient Care Medical boards share a common mission and purpose. They promote excellence in the practice of a given medical discipline to better serve patient and public interests. There are important and relevant non-ABMS boards that use legitimate and accepted processes and standards to identify competent and capable physicians in areas ABMS may never be willing to recognize.

Advances in medicine have naturally led to greater specialization. No specialty or specialty board has ever launched as an ABMS-recognized board. This process takes many years and is a difficult and very political. In the meantime, advances continue to be made from which patients can and should gain benefit. The goal of the ABMS is to improve the standards of medical practitioners and the quality of patient care related to a particular discipline. ABPh is pursuing this same goal by offering legitimate and accepted methods that include a rigorous exam process, a commitment to lifelong learning and assessment, and the development of standardized comprehensive training in venous disease.

A subset of the many physicians who have added phlebology services to their practice have taken the time, expense and effort to properly educate themselves. The ABPh feels it is imperative to offer the public some way to differentiate between those physicians who have a serious interest in phlebology and those who do not.

The ABPh administered its first certification exam in phlebology in 2008. Since the conclusion of the 2011 exam cycle, there are now 520 diplomates of the ABPh. These individuals come from a variety of specialty backgrounds including vascular surgery, general surgery, vascular medicine, interventional radiology, emergency medicine, dermatology, gynecology, anesthesiology, internal medicine and family practice. The interest and expertise of the physician and the quality of care given to the patient are far more important factors than the primary specialty background of the physician.

ABPh Advertising Policy

Diplomates of the American Board of Phlebology (ABPh) must comply with the guidelines of the Board with respect to publicity and advertising, as follows:

• Diplomates may identify themselves in letterhead and in educational and promotional materials as “Diplomate of the American Board of Phlebology” and may use the abbreviation ABPh. Because of the potential for confusion, this appellation should not be abbreviated as “Board certified in Phlebology.”
• Diplomates may not claim or imply that Diplomate status is a certification of special skills, expertise, or competence not possessed by other clinicians.
• Diplomates may not use the ABPh logo in any documents, websites, or promotional ma erials.
• Diplomates may not make claims of regional exclusivity with respect to their status as a Diplomate of the ABPh.
• Diplomates must comply with all federal, state, and local laws governing professional advertising and the use of certifications in advertising materials.
• Diplomates must comply with all policies of state medical boards with respect to advertisements of certification in a specialty.

These guidelines may be amended periodically; Diplomates may request a copy of the current guidelines from the ABPh at any time.