By Saundra S. Spruiell, DO, FACPh

The recognition of Phlebology as a bona fide specialty within the United States is in a dynamic state. Although it more widely recognized today than even 10 years ago, continued progress is essential to move phlebology toward the specialty recognition that is needed – by the lay public, medical colleagues, organized medicine, governmental agencies and health insurers.

Today, phlebology, which deals with the diagnosis and treatment of venous disorders, is experiencing tremendous growth. The reasons are primarily threefold: venous disease is very common; major advancements in the understanding and treatment of venous disease have led to a large number of medical professionals flocking to the field; and both patients and insurance carriers are increasingly familiar with the benefits of treatment provided by specialized practitioners with phlebology expertise.

From a growth standpoint, phlebology has clearly moved out of its infancy and is a thriving field. Many milestones mark its maturation (Table 1), including a peer reviewed journal dedicated solely to phlebology; multiple text books dedicated to the treatment of venous disease; the development of the American College of Phlebology Foundation, dedicated to advancing the specialty by investment in education and research; the creation of the American Board of Phlebology to improve the base of knowledge and experience of medical practitioners and thus the care of patients related to venous disorders through rigorous testing, reliable certification, and improved educational standards; and the establishment of fellowship and preceptorship programs to train future generations. These milestones mark significant progress and are clearly the reflection of an organized specialty.

What, then, does it mean to be “recognized” as a specialty? This can be interpreted a number of different ways. It may mean the ability to be listed as a phlebologist in a hospital staff directory, insurance directory or as an attendee at a local CME event. It can also be reflected in a hospital delineating core privileges in phlebology or a multi-specialty group adding a phlebology division. without a doubt, acceptance of a recognized need to organize is indicative that a special subset of knowledge exists for patients who require unique answers to specific health problems.

Another view of specialty recognition addresses the adoption of phlebology as a practice category in listings by state medical boards and state medical associations. Currently, a combination of 18 states and U.S. territories allow physicians to designate phlebology (PHL) as an area to which their practice is dedicated either in whole or in part. Five state licensure boards have indicated the possibility of listing phlebology if the request comes from a current licensee. Thirteen states list only D.O. or M.D. designations, while another seven states recognize only American Board of Medical Specialties (ABMS) categories. Only three states that track the area of medicine practiced by their constituents have declined to list phlebology (PHL) as a field of practice code, though an additional seven states and two territories have been unresponsive to multiple official requests to add phlebology to their list of designated practice areas.

Charged with protecting the public, the regulatory agencies that have yet to list phlebology have inadvertently set themselves up to countermand their primary missive. Their stance is particularly myopic considering both the AMA, in 2005 and the AOA, in 2007 acknowledged phlebology as a self-designated practice area. Additionally, in April 2007, the Center for Medicare and Medicaid Services (CMS) assigned a taxonomy code for phlebologists to obtain their National Provider Identification (NPI) numbers. PHL may be listed as a primary, secondary or tertiary area of practice with the CMS.

To many physicians, the most desirable form of specialty recognition will be achieved when phlebology is recognized by the ABMS. Dating back to 1934, medical specialty boards have been approved jointly by action of the ABMS and the American Medical Association Council on Medical Education (AMA/CME).(1) The organization currently sanctions twenty four primary member boards that continually meet stringent requirements. The most recent document guiding the process, The Twelfth Revision of Essentials for Approval of Examining Boards in Medical Specialties, effective November 2005, details rigorous qualifications. Phlebology will not experience difficulty meeting many of the criteria, thanks to the foresight of its leadership.

The development of criteria and content for a Phlebology Board examination is an historic milestone in phlebology in the US. Patterned after ABMS exam criteria, the exam sets a valuable standard for education, experience and evaluation but is not currently recognized by either the American Board of Medical Specialties or the American Osteopathic Association’s Bureau of Osteopathic Specialists (A0A-BOS). The Bureau of Osteopathic Specialists dates to 1939 and certifies 18 member boards or specialty colleges.2 Government, medical facilities, insurance carriers and the public all look primarily to ABMS and BOS to serve the valuable function of uniform standard identification. Their recognition is a primary sign of physician quality and competence.(2, 3)

ABMS recognition of phlebology is an achievable but lofty goal. Time and politics may, however, play key roles impacting the likelihood of a successful application to become an ABMS
member board. The process for recognition often takes 10 to 15 years for a subspecialty board and a lifetime or more for a primary board. There are a number of requirements that must be met to achieve ABMS recognition including but not limited to: 1) the training needed to meet requirements for certification by an applicant board must be sufficiently distinct from training required for certification by approved ABMS Boards and sufficiently complex or extended so that it is not feasible for it to be included in established training programs leading to certification by approved AMBS Boards, 2) the required graduate medical education programs must be accredited by the Accreditation Council for Graduate Medical Education (ACGME), or a plan must be presented for the interim approval of training programs, until ACGME approved training programs are established, and 3) the applicant medical specialty board must demonstrate support from the relevant field of medical practice and broad professional support.(1)

Mechanisms for accreditation by these agencies require navigating a complex labyrinth. The intricacies encountered generate multiple questions:

• What defines a specialty and is it defined by the authority traditionally entrusted to these accreditation entities?
• Should recognition as a primary specialty be sought?
• Is subspecialty recognition a viable option under a current ABMS-member board?
• Is there a similar mechanism within the BOS?
• Are conjoint certifications possible?
• What are the best strategies to achieve formal recognition?

Currently, leadership of the ACP and ABPh are working to seek answers to these questions. As standard-driven organizations, both the ACP, through venous education, and the ABPh, through creation of an examination and certification process, understand that standards are critical to improve the base of knowledge and experience of medical practitioners and thus the care of patients related to venous disorders. Established standards also serve to guide the way as physicians adopt phlebology as a new field of practice. The latter statement has particular relevance because a comprehensive phlebology curriculum does not exist within current ABMS and BOS-approved training programs. Likewise, vascular ultrasound specific to the superficial venous system is not available in traditional sonography training. Thus, the educational opportunities created through the ACP and the evaluation offered through the ABPh serve even greater significance.

Phlebology has proven it is a standard-driven field, as evidenced by myriad accomplishments marking its profound growth and progress referenced earlier in this article. Phlebology is deserving of an official seat in accreditation board rooms and may see this come to fruition if time and politics don’t get in the way.

Our future holds bright promise as the third anniversary of the American College of Phlebology’s acceptance into the American Medical Association’s Specialty Service Section, November 2010, draws near. As this article was going to press, the ACP just learned it is eligible for entrance into the House of Delegates (HOD) if it has reflected an active commitment through participation of a) a delegate to biannual HOD meetings and b) if 25% of ACP members hold dual AMA membership. Additional guidelines for admission are listed in Table 2. As the largest policy making body influencing matters of U.S. healthcare, the ability to gain voting rights within the HOD is no small privilege. In fact, this is a privilege that can go a long way toward positively influencing phlebology’s future.

From its inception, U.S. phlebology has experienced exemplary leaders who have brought both foresight and vision. They are to be lauded. However, they are undeniably in need of our assistance. As phlebology practitioners in the field, we are each leaders, of a sort. After all, we have adopted a new discipline and made it available within our communities. It is time for phlebologists to unite regardless of specialty of origin. Band together and avoid turf battles that have marred other specialties. Turn a deaf ear to exclusionary, pious thinking. Elevate current standards and inspire each other to adhere to them. Participate and let our collective voice be heard with such a roar there is no denying its presence as the voice of expertise…the voice of our specialty, phlebology.

Saundra S. Spruiell, DO is the Chair of the Specialty Recognition Committee of the American College of Phlebology, a Fellow of the American College of Phlebology, and a Diplomat of the American Board of Phlebology. She is the Director of Oklahoma Vein Specialists and has been a practicing phlebologist in Oklahoma City for more than ten years.

REFERENCES
1 Twelfth Revision of the American Board of Medical Specialties Essentials for Approval of Examining Boards in Medical Specialties.
2 Ramirez AF, The Journal of the American Osteopathic Association, November 2004, Vol 104, No 11
3 eMedicineHealth. Practical Guide to Health. Doctors: Specialties and Training. http://www.emedicinehealth.com/doctors_specialties_ and_training/page6_em.htm; (accessed 15 July, 2009).
4 American Medical Association, Specialty Service Society Caucus Guidelines for Admission. http://www.ama-assn.org/ama/pub/aboutama/ our-people/house-delegates/the-delegates/specialty-servicesociety- caucus/guidelines-admission.shtml; (accessed 07 July, 2009).

Table 2
Guidelines for Admission of a Specialty Society to the
American Medical Association House of Delegates.4
A. The organization must not be in conflict with the constitution and bylaws of the American Medical Association by discriminating in membership on the basis of sex, color, creed, religion, disability, ethnic origin, sexual orientation, or age, or for any other reason unrelated to character or competence.
B. The organization must have a voluntary membership and must report as members only those who are current in payment of dues, have full voting privileges and are eligible to hold office.
C. The organization must be active within its field of medicine and hold at least one meeting of its members per year.
D. The organization must be national in scope. It must not restrict its membership geographically and must have members from a majority of the states.
E. The organization must submit a resolution or other official statement to show that the request is approved by the governing body of the organization.
F. If international, the organization must have a U.S. branch or chapter, and this chapter must be reviewed in terms of all of the above guidelines.
G. The organization must represent a field of medicine that has recognized scientific validity; not have board certification as its primary focus, and not require membership in the specialty organization as a requisite for board certification.
H. An SSS applicant society must meet 50% of the current AMA membership requirement for Delegate status in the AMA House of Delegates in order to be granted or to maintain representation in the SSS. The society must be able to demonstrate active recruitment for AMA membership to meet the House of Delegates requirement for representation.
I. The organization must be established and stable; therefore it must have been in existence for at least 5 years prior to submitting its application to the AMA House of Delegates.
J. To be eligible for membership status, physicians should comprise the majority of the voting membership of the organization.