Education: The Aristocrats

The Aristocrats

Comedian # 1: “The punch line is ‘The Aristocrats.’”

Comedian # 2: “The punch line is ‘The Aristocrats’?”

Comedian # 1: “Yes, that’s right. The punch line is ‘The Aristocrats.’”

Comedian # 2: “I don’t get it.”

Comedian # 1: “Of course you don’t get it, but that is the punch line with which you finish the joke. And it should be funny.”

Comedian # 2: “But you know the punch line already, how can I make it funny?”

Comedian # 1: “Why should that stop you from telling the joke?”

“The Aristocrats” is purported to be the funniest joke ever told by many famous comedians. It is their right of passage. There is even a movie about this legendary joke called, of course, “The Aristocrats.” The premise is that it is more about the creative process of telling the joke than the punch line since everyone knows the punch line before the joke begins. The humor is derived from how each comedian arrives at the punch line. There is but one catch: it must be the dirtiest, most disgusting, repulsive joke each comedian has ever told. This is where the similarity to venous education ends.

The comedian’s task is to take his own path and somehow get to the already known end. Anyone who wants to treat venous disease needs to do the same thing. The end is obvious enough: obtain an education regarding venous disease and become a phlebologist. It sounds easy. You just start, go through it and arrive at the end. But, surprisingly enough, “The Aristocrats” bit parallels just how different each path to the “punch line” might be.
During the movie of the same name, comedians give us insight into how they started, what they went through, and how much work it took to get to the end of “The Aristocrats.” They each made unique choices to tell the joke their own way, and maximize the results of their effort. Isn’t that what we should do when we educate ourselves in venous disease? Each specialty and each individual will take a different tack when getting to the stated end of phlebology education.

Just as each comedian uses his strengths to create his unique “Aristocrat” joke, anyone wanting to become a phlebologist must do the same. Assess and write down your strengths. What do you already bring to the table? What unique training, skill sets, and knowledge about phlebology do you already possess? Build on this base. Then think about the type of phlebology practice you want.

Examples are:

  • Treat mostly cosmetic and mildly symptomatic (C1, C2, C3) patients
  • Treat advanced (C4, C5, C6) patients
  • Office-based practice
  • Hospital-based or a combination
  • Your own vascular lab
  • All-encompassing practices

Obviously, the type of practice targeted defines the training and skills you need, and that brings several categories to the forefront for consideration. Decide which categories already harbor your strengths, and which ones need to be developed to build the type of practice you desire.

Categories include:

  • Venous anatomy, physiology, pathology
  • Imaging skills - ultrasound, venography, IVUS
  • Technical skills - endovenous ablation, phlebectomy, PAPS, deep venous lysis, angioplasty and stenting, sclerotherapy - all types
  • Interpersonal skills - yourself and office staff
  • Office environment - both physical and attitudinal
  • Insurance participation, fee for service, other variations

I am sure there are other categories that are more specific but the above are some key ones to think about. Below are some generalized - and I do mean generalized - thoughts as to what each specialty brings to phlebology education and, conversely, what they don’t, based on traditional training programs. These concepts should in no way be misinterpreted to mean that any one specialty has more skill sets than another, just different.

Vascular Surgeons:

  • Have seen, touched, sewn, dissected the veins
  • Have pulled, ripped, cut the veins
  • Need to realize veins are also important, not just arteries
  • Need to treat vein patients differently than arterial patients
  • May need training in catheter skills
  • Have some training about venous pathophysiology
  • Need to learn sclerotherapy

Interventional Radiologists:

  • Can get a wire/catheter into any blood vessel
  • Most have never seen a real live vein
  • Have accessed and infused a lot of things into a lot of blood vessels
  • Don’t usually have an office practice
  • Need to learn that just because there is an anatomic abnormality it doesn’t always need treatment
  • Have excellent imaging skills
  • Have an understanding of pelvic venous anatomy


  • See a lot of patients with vein disease
  • See the skin manifestations of vein disease
  • Understand spider/reticular disease
  • Have a large, well-organized office practice
  • Need to learn catheter skills
  • Understand the cosmetic concerns of venous patients
  • Need imaging skills


  • Have a lot of patients with advanced venous disease
  • Have excellent catheter skills
  • Need to better understand venous pathophysiology
  • Need to realize veins can be as important to patients as the heart
  • Need venous imaging education
  • Are well respected by most of their patients


  • Have a lot of patients with C1-C3 disease
  • Have a lot of young women patients who want to look and feel better
  • Have some ultrasound skills, but these are non-specific to venous disease
  • Need to better understand venous pathophysiology
  • Have some appreciation of pelvic venous disease
  • Have a well-organized office practice

Plastic Surgeons:

  • Understand how to address the cosmetic needs of patient
  • Have a cohesive office staff working towards a common goal
  • Understand doing procedures for self-pay patients
  • Need to understand venous pathophysiology
  • Have experience with tumescent anesthesia
  • Need to learn access and catheter skills

Other Internists, Cardiac Surgeons, General Surgeons:

  • Too diverse a group to list strengths and weaknesses
  • The points listed regarding the specialties above cross over into these specialty practices as well

So now the punch line is not “The Aristocrats” but rather “The Phlebologist.” Your route to the punch line “The Phlebologist” will be unique. What do you already possess? What do you need to acquire for the type of practice you want? By making a list you can better guide your education and be more efficient when you decide how to spend your time.

Do you go to every vein-oriented meeting? Do you go to specialty training courses? Do you attend industry-sponsored programs? Do you employ companies to “set up a vein practice?” Do you visit individual phlebologists that can teach you unique skills? Many questions to answer, but each answer brings you closer with less wasted effort to the universal punch line “The Phlebologist.”

By the way, according to legend - and comedian consensus - the best told “The Aristocrats” jokes are by Bob Saget, Gilbert Gottfried, and George Carlin. If you are not easily offended, see the movie.