As a professor of surgery at the University of Washington, Dr. Mark Meissner leads the pack when it comes to research on chronic venous disease, vascular trauma, acute deep venous thrombosis and pharmacological treatment of venous leg ulcers. He has been recognized as one of VEIN Magazine’s 25 Most Influential, as a Top Doctor in the field of vascular surgery and research by US News and World Report, has served in leading positions with both the American Board of Phlebology and the American Venous Forum, and has dedicated many hours to the advancement of the field (even while on the slopes or stranded on the side of the road on the Sea to Sky Highway in British Columbia). Thus, Mark serves as an excellent mentor to his students and peers alike. We jumped right in and asked about his views on the current state of venous disease research and management, as well as what he has planned as an integral member in the field of phlebology.
V: If money and logistics were not an issue, what clinical trial needs to be done?
MM: I think it important to recognize that a randomized clinical trial may not be the best approach to every question in the clinical management of venous disease, and even with the best methodology, randomized trials will never be available for every question confronting the clinician. A more important question is, “What are the important questions for which adequate evidence is currently lacking?”
In the case of acute deep venous thrombosis, important questions include the role of pharmacomechanical thrombolysis in the management of iliofemoral deep venous thrombosis, the optimal management of isolated calf vein thrombosis in different patient populations, and the comparative effectiveness of new anticoagulants in the management of DVT . For chronic venous disease, important questions include the optimal management of venous ulceration, the comparative effectiveness of different modalities of managing C2 disease (compression, pharmacologic treatment, different ablative technologies), and the role of intervention for the treatment of CC SVI in multiple sclerosis.
V: How should we balance decisions about patient care taking into account societal guidelines and clinical experience?
MM: We should all strive to practice evidence-based medicine, which involves integrating three components of clinical practice: the best available clinical evidence, the physician’s clinical expertise, and a consideration of the patient’s and health care system’s values and preferences. The first component requires knowledge of the evidence regarding a specific clinical question, how this evidence was collected, and what are its underlying limitations. This may be the easiest part of patient care, as most physicians have the interest and motivation to stay current in their field. The more difficult part may be deciding how this information, if available, applies to the individual patient. This is the clinical judgment component that defines thoughtful clinicians. Good medicine is not cookbook medicine based upon strictly following published guidelines. Good medicine requires an understanding the guidelines, the limitations of the data they are based on and the judgment as to whether or not they are appropriate for the individual patient. The third, and perhaps most difficult part, is being a good citizen.
We currently live in an era where advancing technology has outpaced our medical resources. Although there are those that make the counterargument that innovation is stifled by excessive concern regarding costs, we no longer practice in an economic environment where the costs of validating a new technology can be borne by the health care system. In fields where technology is rapidly advancing, it is incumbent upon us all to demand clinical evidence of efficacy before adopting any new technology. This is perhaps the most difficult aspect of evidence-based practice in rapidly evolving fields such as venous disease. The desire for ourselves and our patients to adopt new technology prior to any clinical data often conflicts with our job of being good stewards of the health care system.
V: You are involved as faculty for the Fellow’s Course in Venous Disease. What aspect is most beneficial to the educational experience of the fellows?
MM: Most vascular surgery training programs in the United States are focused on arterial disease and most do a very good job teaching its management. Training in the management of venous disease is more variable and often limited. Dr. Joann Lohr surveyed the attendees at a fellow’s course a few years ago and found that only 45% had vein clinic experience, only 30% could adequately assess iliac venous stenosis, and only 10% could accurately categorize patients using the CEA P classification.
The American Venous Forum’s Fellow’s Course in Venous Disease aims to address some of these deficiencies. A fundamental aspect of the course is close, personal interaction with experts who have made venous disease a focus of their careers. This is important in demonstrating to the fellows that venous disease can be a valid and personally rewarding part of their practice. The course is also important in introducing the fellows to the entire spectrum of venous disease, from the management of acute deep venous thrombosis through sclerotherapy, the management of vascular malformations, and advanced venous reconstruction.
V: In your opinion, are there too many venous societies or not enough?
MM: I believe the two primary societies devoted to venous disease, the American Venous Forum and the American College of Phlebology, meet the needs of venous practitioners very well and in different ways. The vision statements of the two organizations are subtly different with the American Venous Forum’s mission being to “promote venous and lymphatic health through innovative research, education and technology,” and the American College of Phlebology’s vision beginning with the goal of being “an indispensible resource for education, knowledge exchange, and practice management.” The American Venous Forum accordingly excels at the clinical and basic science research produced by its members, as well as being the voice of evidence-based vein practice through its guidelines and initiatives such as the Pacific Vascular Symposium. Similarly, the American College of Phlebology’s educational offerings are superb and the organization has done a very good job being an advocate for venous practitioners.
Both societies, therefore, have important roles and are increasingly working together to advance the care of patients with venous disease. This is evidenced by recent efforts to collaborate on reimbursement issues, to participation in the American Venous Registry, and to support intersocietal efforts to accredit vein centers.
V: Should more practitioners manage pelvic venous insufficiency or should “centers of excellence” be identified and used?
MM: The technical aspects of managing pelvic venous insufficiency, as well as many other advanced venous disorders, are within the skill sets of most vascular surgeons and interventional radiologists. However, many aspects of diagnosis and management do require some degree of expertise in the overall management of venous disease. Management by centers and programs that are expert in the management of venous disease is probably far more important than management by a group with a particular skill set but little interest in venous disease. Looking to the future, I believe that management of pelvic venous disorders, as well as all aspects of advanced venous disease, is something that must be incorporated into residency and fellowship training programs in venous disease.
V: We are products of our mentors when training. Who were some of yours?
MM: Although as a vascular surgeon I have great respect for physicians with exceptional technical skills, my personal mentors have been those with excellent critical thinking, data synthesis, and judgment skills. My original mentor was Dr. D. Eugene Strandness, who many would consider the father of duplex ultrasonography. Dr. Strandness was among the most innovative, original thinkers I have known and was singularly responsible for my interest in venous disease. Others have included vascular surgeons such as Drs. Kevin Burnand, Thomas O’Donnell, and Peter Gloviczki, as well as several individuals from epidemiology. All have an ability to discern
those issues that are at the heart of any clinical question, effectively separate meaningful data from the background noise, and generate a thoughtful response.
V: What does your week look like? Where do you spend your time and efforts within the scope of your job(s) in the venous community?
MM: My work week is probably typical for an academic vascular surgeon – two days in the operating room, one day in the angio suite, and one day in clinic. My current practice is approximately 60% arterial and 40% venous disease. Perhaps more importantly, much of my clinical time is spent teaching medical students, residents, and fellows about venous disease and mentoring them in venous research projects. Efforts in the venous community over the past few years have included participation in the generation of evidence-based practice guidelines, participating in the Fellow’s Course in Venous Disease, and serving on the faculty of educational program in venous disease.
V: What positions do you hold currently and have you held recently within the societies and organizations in the venous community?
MM: I have had diverse roles in the major venous organizations, including being a past president of the American Venous Forum and a member of the board of Directors of the American College of Phlebology. I am currently helping with the scientific committee for the 2013 International Union of Phlebology (UIP) meeting in Boston and will be serving as the American Venous Forum’s representative to Intersocietal Accreditation Commission’s program to accredit vein care centers. Perhaps more than any other imitative over the past several years, I think this program will significantly improve the care of patients with venous disorders.
by Jana Acciacca