Filling the Holes: Challenges of Vein Care for Interventional Radiologists

Vein Magazine’s Medical Director, Dr. Steve Elias, got together with four leading vein specialists who have backgrounds in interventional radiology for a robust conversation about what holes exist in the Interventional Radiologist’s training and practice style as it pertains to vein care. Here we hear from Drs. Carl Black of Intermountain Vein Center, John Rundback of Advanced Interventional Radiology Services, LLP, Mel Rosenblatt of Connecticut Image and Mark Garcia of EndoVascular Consultants to find out what’s missing from the young IR’s training as well as mid-career IRs who are transitioning into a vein practice. See their insights below, and have a look at the video recording at YouTube.

Steve Elias: Let’s talk a little bit first about some of the challenges or holes you all needed to fill in when you started to go into vein disease. All of you were already in practice. You didn’t get much training in vein disease as a fellow or resident. You came to vein treatment with a great skill set, but where did you need to fill in?

Carl Black: My training gave me a lot of experience and confidence from a technical perspective, and that included imaging, understanding anatomy, and a skillset that included most things endovascular with respect to deep and superficial vein disease. There were probably some limitations in my own personal fellowship training in superficial vein disease. It wasn’t as heavily emphasized as deep venous disease.

The biggest obstacle already having been in practice, was basically changing my mindset that I needed to now be responsible for a clinic and that I needed to provide outpatient continuity of care, pre-procedure and post-procedure; that I see a patient in consultation, formulate a plan, and provide continuity to the whole clinical picture.

That may sound very basic for someone coming from a vascular surgery background or from another practice background, but for an interventional radiologist, the concept of running a clinic with staff, mid-levels and sonographers was a little bit foreign to me. I wouldn’t say that it was insurmountable at all.

It actually seemed to be natural evolution for me into that side of medicine. But as I look at my the deficiencies following training, my main deficiency was in understanding the logistics of running an outpatient the clinical practice, and in making sure that I could provide the same outpatient standard of care from pre-procedure to post-procedure that my colleagues in vascular surgery would provide.

From a training perspective, I’m speculating but I think filling gaps in venous training really depends on an IR fellow’s interventional training mentors. Are IR fellows being mentored by individuals who have an outpatient practice, who have a clinic, who see patients in consultation and are not just proceduralists? That’s really where interventional radiology needs to go and is going. Our success as a specialty really hinges on that long term.

John Rundback: My experience is a little bit different from Carl’s. I’ve been in practice for 25 years and during that time, I’ve done complex peripheral arterial disease with a very robust office-based practice from day one. So my vein practice actually grew as an offshoot of the arterial practice where it became obvious to us that many of these wounds we were treating and many of these patients had venous disease—actually just as much, if not more than arterial disease. So there was a hole to fill in our own practice which obviously we’ve built up considerably.

So we do the full spectrum, both deep and superficial venous disease. I tell interventional radiologists who want to get into the peripheral arterial disease field, to start from the bottom up. And what I mean from that is, don’t try to cherry pick the easy iliac or femoral cases. Those are going to be highly competitive. Offer your services for the more complex conditions such as tibial, pedal, occlusive disease, critical ischemia. The reason that’s relevant to veins is that if you build an arterial practice that way, you’ll come across a lot of wounds, a lot of combined arterial and venous insufficiency, and naturally, you’ll migrate to a vein practice.

Steve Elias: What are things IRs can learn from your experience to be ready on day one to change from a hospital-based consult to what you set up?

John Rundback: There are several routes you could take. One is to go to a traditional diagnostic group where you do some interventional and you make a good case and a good business plan around getting the time you need for office hours and to do vein procedures, preferably in an outpatient setting. That’s very challenging because diagnostic groups also are strained and need the extra workforce. The other group you can join someday to get experience, is like the people on this call who already have established practices.

We have a new associate who came on and already we have him in the office, and he’s doing quite a few vein procedures. So you can organically come into this. And the third thing is to get your experience working for a VCA or someplace like that where there is established infrastructure if that’s where your interests lie. Each of these paths reflects the most difficult to the easiest but also reflects the greatest potential upside through to the least.

Steve Elias: Mel, you’ve been in your own practice for a long time. You went from Yale and then you Carl Black, MD John Rundback, MD decided to start your own place. Any variations on the themes that you heard from Carl or John?

Mel Rosenblatt: Slight. All of the points that were made are all valid and good points. It’s interesting. I started my superficial vein practice in a university setting, in a hospital setting. At that time, the reimbursements were favorable to do so. When the reimbursements shifted, they forced a lot of the physicians to exit the hospital and to go into outpatients environments. Now, many radiology practices don’t have that established, and that is, as Carl had said, a bit of a foreign element to them. It’s not something that they’re comfortable with, whereas a lot of other specialists might feel very comfortable creating outpatient environments where they can do minor or moderate procedures.

Starting out in the hospital environment, I had to transition to the outpatient environment, and I did so. We were always clinically focused at Yale, so we always had a clinic, but establishing something that’s completely disconnected from the hospital is a lot more challenging for the average interventional radiologist. When we reflect on what holes or what gaps exist for radiologists, that’s probably the biggest in my opinion. Those radiologists who are working for large radiology groups at university practices may not have the infrastructure to go out and do procedures outside of their hospital-based environment. They may even have outpatient imaging centers, but those imaging centers are not geared for doing procedures, and they don’t have the nursing infrastructure as well as the ancillary staff infrastructure to do that because all of that exists in the hospital, and it’s very difficult for them to know how to take it out of the hospital.

Steve Elias: Let’s get a little bit into training the people who are already in training. Of all the IR training programs, what percentage of training programs do you think allow graduates to be able to manage superficial disease from day one?

John Rundback: Well, day one, coming out of training to do this, I think you’re going to have to find a mentor and somebody with whom you can work and go out and get the appropriate training. The companies are very good at providing this. And something else which we didn’t mention is that, if you’re in an environment where they give you the resources and time, you’ll always find that these companies will go out and help you do some marketing and practice development. We shouldn’t give up the idea that you need to give the ground rounds, and you need to, go out and give the community talks. Working it that way, I think you can get a combination of the skillset and the access.

Carl Black: I would be speculating, on the percentage of current trainees that are actually getting sufficient superficial experience to step right in a practice and provide comprehensive vein care, but I would say that it’s a lower percentage. I agree that deep venous is probably adequately covered during fellowship, but I think with superficial venous disease, you have to really be broad in your scope of how you approach vein disease if you’re going to do it correctly. You have to understand everything from coagulopathies and anticoagulation, how to manage patients medically and interface with an interdisciplinary group of caregivers.

In certain cases you may collaborate with a vascular surgeon, wound care specialists, physical therapist, or an internist. There’s a group of providers that are going to work together, and I think that in and of itself is a skill set. You have to think outward of how you’re going to tie the expertise in your community together to get best outcomes.

There’s a global deficiency, I would say, in providing comprehensive vein care, and I think it goes beyond interventional radiology, but since our focus is on interventional radiology, I would say that yes, there are some deficiencies. We share some of the same limitations a lot of practitioners in this area might have. And some of them are going to lack things that IR’s have. But I guess the bottom line is that a smaller than optimal percentage of IR fellows are coming out fully trained in comprehensive vein care.

Mel Rosenblatt: I think there’s a direct correlation between a training program and its access to an outpatient vein center or vascular center and the degree of experience the fellows get. If you look at Cornell for example, the fellows have an outpatient facility on the west side of Manhattan. I don’t know how often they get out there. Unfortunately, there may be programs out there that don’t have that opportunity, and I would venture to guess that in those programs, the fellows and trainees don’t get the experience in superficial venous disease to any significant degree. They certainly get the deep vein training because that is part in part of their basic in-hospital activities.

Steve Elias: What do you think Society of Interventional Radiology’s (SIR’s) role is in filling in the gaps?

Mel Rosenblatt: SIR’s role, almost like the American College of Phlebology’s (ACP’s) role and the American Venous Forum’s (AVF’s) role, is to provide training so there is a didactic component to this besides the experiential component. Those societies are there to educate. That’s one of their primary goals. And so they’re trying to educate those who want to learn about venous disease, both superficial and deep, and they can provide that. What they can’t provide is the hands-on aspect—the ability to actually do cases and to do punctures and to do what needs to be done and to do sclerotherapy.

As we all know, sclerotherapy is an art form and while you may be able to interact with a plastic trainer model, it’s not the same as doing it and understanding the complications and outcomes and what concentrations to use and the like. That comes with experience of watching physicians doing it who know what they’re doing and having the opportunity to do it yourself. So there’s no question that a didactic experience is certainly available to them, but that experiential component is certainly lacking.

Steve Elias: I think if anyone has good technical skillsets in terms of training nowadays, it’s both IR trainees and now vascular trainees because of all the endovascular stuff. Sclerotherapy in and of itself can be a difficult procedure because, you’re talking about little veins and an awake patient with high expectations versus taking care of an iliac compression syndrome, big veins, not a problem. But I personally think IR from a skilled technical viewpoint probably has the best skillsets, and in general, these vein procedures are not that hard technically. It’s more the, “What should I do when?” kind of thing. It’s more that cognitive side that is the issue.

Mel Rosenblatt: Certainly the use of ultrasound and ultrasound guidance is something that IR fellows have a lot of exposure to, so you’re absolutely correct when you say that the raw talent is there, and the skillsets are certainly things that can carry over.

John Rundback: The decision making is such a big part of it. You get that at SIR or at a dedicated vein course. The skillset is there. But you know, there is a very, very large part that is about making the right decisions and performing the right surveillance and follow up and counseling patients according to the right expectations. Handling the expectations, knowing the adverse events and how to deal with those is as large a part of this as the actual skillset.
Steve Elias: That’s something that people outside of the IR world and vascular world think: you’re proceduralists and not cognitive. Are there people doing procedures just because they can do them rather than thinking about, whether it’s the right thing to do for a particular patient?

John Rundback: You could always get individuals in any specialty, in any domain, who abuse their privileges and perform things not necessarily for the best reasons. I know one IR—not to be named— who on every patient does bilateral staged greater and smaller saphenous ablations. Every single patient. Now that may be necessary, but clearly individuals like that don’t necessarily have the right motives. Cream floats and at the end of the day, if you recognize the responsibility you have, and if you embrace the emerging data which has very much changed the way we focus on vein disease, then you’re going to be a responsible practitioner, and you need to be.

In the old days, maybe there was a merit to just sort of putting needles into fixing them. We didn’t know the outcomes, and we didn’t have the science behind it, but now we have a lot of science and a growing, robust scientific base regarding both treatment of DVT and superficial disease. You need to know all facets of the science as well as the technique. And that’s going to be the new evolution.

Steve Elias: Mark, now that you have joined us, what do you think are the important points that an IR fellow or trainee needs to take away when they’re going to treat vein disease? Is it a procedural, technical aspect? Is it more of a cognitive, understanding disease aspect? Where do you think they shine, and where do you think there are some deficiencies?

Mark Garcia: Up to now, I think we’ve done a good job, but I think we still have a long way to go in educating IRs to be true clinicians. The problem is that unless you come from the primary pathway, or one of the pathways that were more clinically oriented, you are at a disadvantage when you come from the original diagnostic pathway that most of us here tonight have. You really had to take it upon yourself to educate yourself and be engaged as a clinician.

I think that’s the hardest part of our subspecialty. For the other subspecialties, it’s innate that they learn their clinical medicine. But for us, diagnostic radiology is not a hands-on, patient-to-patient oriented daily contact. It’s only in IR rotations that you get most of that. As we educate trainees coming up to be clinicians, they learn the science and skill, they learn the data, they become more engaged in participating in clinical trials and understanding what IR medicine is all about. And it kind of goes into what your question to John was.

I think that when we truly understand the disease from the top down we can all do a better job. Our colleagues on the call tonight, we believe it’s not about padding the wallet. It’s truly about taking care of the patient and doing the right thing. I think it starts with education, and hopefully the new primary certificate trainees will be educated on true patient care.

Carl Black: I think part of the evolution that I have seen with organized IR (SIR) and with those who treat vein disease, is that we are becoming much more interdisciplinary. And Steve, to your credit, I think you have facilitated that. I’ve known you for a lot of years, and you have been at the forefront, of bringing a specialists together to have interdisciplinary dialogue. I know less about lymphatics, but have been forced to learn more. I would say the same about wound care. And I think that we are in a critical evolution of becoming better at interacting with other specialists and feeling more comfortable with learning from each other.

Steve Elias: We all bring to the management of vein disease our own subset of what we’re good at and what we’re not good at, and collaboration is probably a good thing for us, and obviously, for patients as well. But our goal should be that if an IR wants to treat vein disease or if a vascular person wants to treat vein disease that they should almost have 95 percent of the skillsets to treat vein disease, and those very specific areas that maybe vascular has a little bit more or IR has a little bit more, but I think our goal, personally, we should always collaborate. But yet anyone who’s treating vein disease should really be able to treat the big, big spectrum of vein disease. And if they’re not going to do it, they should get somebody into their practice who does.

What I want to know to help our readers is, a young IR says, “Hey. I want to get involved with vein disease.” None of us on this call are working at a big academic center. Yet, I think any of us could and some of us did work at big academic centers. The reason many of us who are dealing with vein disease and, do it, is not the procedural aspect of it but the ability to relate to patients and treat them. Where in that paradigm do the trainees learn this? Because I don’t think they’re going to learn it during their academic career when they’re being trained.

Mel Rosenblatt: It depends on the program. When I was at Hopkins, when I was at Yale, we had very clinically active programs, thanks to Bob White who was present at Hopkins and then at Yale. There were a lot of the early IR physicians who really strongly believed that having a direct patient interaction, not just a referral patient, do a procedure, never see them again approach, was something very beneficial. Now clearly programs don’t follow that modality, but we’re talking about fellowship training programs, and many of the fellowship programs that I’m aware of do kind of have that approach, at least in the IR programs that I’m aware of.

During the diagnostic radiology portion of their residencies, that’s probably where they lack that experience. So they don’t get it as, let’s say a vascular surgeon, would get during their five years of residency training. It’s at their fellowship that they get it. So clearly there is a slight disadvantage, but most of the IR fellows do have some clinical background and, you know, have the opportunity to go to the clinic, maybe not as much as other specialties for sure, but it is there in most programs.

There was some allusion to the fact that maybe physicians might be doing things in a routine fashion, basically if they have a hammer, everything’s a nail. I think it’s a diagnostic element that we might be neglecting to talk about. The ultrasound diagnosis is critical and guides therapy and everything. In some programs, when the ultrasound department is somewhat separated from, let’s say, the IR training program, I think that one of the deficiencies that maybe interventional radiology fellows have is that they don’t really have a good experience with making the appropriate diagnosis. I’ve seen some young IR fellows come out of practice, and while they know how to do procedures very well, and they know how to see patients in the clinic, there’s still an educational gap of how to really evaluate a patient with an ultrasound machine and understand what it is they have to do.

Mark Garcia: I think though one of the issues that we all are going to face going forward, speaking about physicians that may do things that may be unnecessary or would be looked upon by most of us as questionable is that, you know, CMS is aware that there is an astronomical increase in the number of vein procedures in the outpatient facility. There has to be some oversight. ASCs and hospitals have oversight. There’s going to be a need for oversight (indication and outcomes) in the OBL world. That’s coming. It’s going to have to happen.

Rather than being what and how things can be treated, somehow we, going back to the collaborative model, ought to partner together in our societies and figure out what these should be and be very forceful about it. I think we need be very opinionated about doing the right thing for the patient. Otherwise, we’re going to be stuck in a situation in which we have no control. We’re going to be taken to the cleaners because of the abuse that’s going on, so people better wise up and start to play the game a little bit cleaner.

Steve Elias: Let me pivot a little bit. Typically in a vascular practice, the new hire, so to speak, is the one who becomes the “vein person.” Vein treatment in the vascular world, until recently, has been the low-end of the spectrum. Is this the same type of thing in the IR world? When you take on another partner, do you say to them, “you’re going to be the person doing veins in our practice, and we’re going to take care of the complex arterial issues?” Or is it thought of differently at this point?

John Rundback: While the easy way is to bring on a junior associate and let him do the things you don’t want to do, the better way is to bring him or her in and have them do everything you do. Obviously sort of starting slow, working with them, watching how they approach disease, discussing cases, but you know to immediately integrate them into a practice where they’re doing both venous and arterial disease if that’s part of your practice.

That’s hard. That’s a challenge. That requires good mature partners who are sort of comfortable in what they do and comfortable relinquishing some relationships they built with referring physicians to somebody who is new and who potentially will struggle through some initial cases. But it’s the right way. It’s important so we build a broad foundation for the future.

Carl Black: We’ve brought on a couple younger partners in the last several years, and we follow the same pattern that John described. In our practice we want to be a 24/7 service where all of us provide a very uniform standard of care, where it doesn’t matter who’s on a rotation - whether they happen to be in our vein clinic or on the inpatient service, the standard of care and the spectrum of disease we treat is the same.

We have never carved out specific roles for vein or arterial disease. Some IR’s will have an affinity towards perhaps interventional oncology, or maybe they have a particular interest in more complex arterial cases, but that tends to be a process of self-selection. For the core offering, we try to be on a fairly equal level and give everybody equal experience.

With newer partners, I think it’s a matter of making sure they all having the same rotation experience, and that is how we distribute our schedule. We pretty much all get the same spectrum of opportunity.

Mark Garcia: Part of the reason this occurs, is that many IR programs, particularly where most of us came from (even though we’re starting to branch out and do officebased labs), practice in the hospital. It’s very difficult to bring on a young doctor who may be hired into a Level 1 trauma center or complicated IR program, and ask them to perform procedures they don’t know how to when they’re on-call. And you can’t really have that.

You have to have everybody on the team have skill and expertise for everything that is performed in that practice. This is why in many IR programs, people don’t necessarily specialize. One thing that we do is to have one IR take the lead position for certain diseases, i.e. arterial disease, venous disease interventional oncology, and so on, but that doesn’t mean that all members are left out. It was just that someone was really responsible to interact and collaborate with the other subspecialties, to try to drive that practice. Othe than that, everybody still had to perform all IR procedures so they could do them when they were on-call.

Steve Elias: From all of you, give me two or three meetings or experiences that are going to give vein specialists a pretty good idea about how to manage venous disease.

Mel Rosenblatt: I just had that question asked me today interestingly enough and had an opportunity to think about that. I personally think, and this is the recommendation I made, is that the first thing they should do is take a basic review course. The ACP has a day before their meeting where you have a basic phlebology course where they review the basics, and then of course, they can go onto advanced courses. And there are other courses out there. This really doesn’t have to be the ACP. Have a full period of time where they review the entire elements, at least in superficial venous disease. And that’s probably step one.

Step two, in my opinion, would be if they had the opportunity to go maybe to act as a volunteer in South America where they have the chance to treat maybe hundreds of patients who are in need. Do something charitable while at the same time getting a tremendous education. I think that would be an invaluable experience in hands-on and learning something about the disease in an environment where making the correct decision is not about money, but it’s about taking care of the patient.

If there were two activities that I would recommend, I would recommend a basic training course. Get as much as you can. Maybe some advanced. And then try to spend a week on one of these charitable missions to South America to get some hands-on training.

John Rundback: Certainly, the American College of Phlebology runs a good course, and that’s a very robust and full curriculum. I’m partial to Raghu Kolluri’s course at VIVA every year. That Veins course is fabulous, and you can stay on for the extra day and get exposure to some of the complex arterial stuff in live cases, so it makes it a little bit more rounded. And of course, if you’re in the tristate area, this guy Steve Elias runs a course, and you can go to his shop, and he’ll sort of give you some hands-on stuff as well.

My junior partner came out and did some work with you with and learned a great deal. So if you have that resource, whether it be you, Steve Elias, or somebody else in the community that you can approach who’s doing this sort of work and ask if you can come in and watch and do some cases, I think that’s probably a very good thing to do.

Carl Black: I can speak firsthand on the humanitarian mission. I’ve gone to Honduras with the Hackett Hemwell Patterson Foundation for several years, and that’s been a tremendous experience. You see a wide spectrum of pathology - the worst of the worst. I would fully support that as a combined educational and a service opportunity.

I am also very impressed with the initiatives of the American Board of Venous and Lymphatic Medicine (ABVLM). This organization is in its infancy, but has a lot of potential to improve standards of care in vein disease across many specialties. It gets back to what you were saying, Steve, that if we’re going to be in this business, we need to be able to all treat the 95th percentile of everything. There may be some outliers we refer out.

I think we’re getting closer and closer to establishing uniformity in what we all need to understand. If you prepare for ABVLM exam, you will learn a ton of material. I think preparing for and taking the ABVLM exam would be a useful additional learning opportunity to round out an interventional radiologist’s experience as they enter into this field.

Mark Garcia: What has been stated is great advice. We’ve talked and heard a lot about superficial venous disease. I think there’s a lot of chronic deep venous disease work that has to be done. The AVF is probably what turned it around for me. I think the American Venous Forum has been fantastic and is a very scientific meeting. I’ve learned more science about venous disease from you and your colleagues. I also like the idea of doing mini fellowship training at very busy centers. There’s just a tremendous amount to learn in one-on-one, small group training that’s invaluable.

Steve Elias: I think we’ve come to some ideas and conclusions that people can take something away from this if they want to fill in the holes, and the holes, it doesn’t necessarily just have to be IR holes. It could be anybody who wants to get involved with vein disease. So I thank you all.