Lessons from the Peloton

Any bike race starts with the peloton. The peloton is the mass of riders racing. From the peloton, there emerge leaders and, ultimately, a winner. Nobody can win staying with the peloton, but they can’t win without the peloton. I will explain.

One lone rider is not as strong as many riders working together. If someone breaks away and tries to go it alone, the peloton can recapture him. Riders can take turns leading the peloton. The front rider of the peloton breaks the wind, and others draft him; this requires less effort. When the lead rider tires, someone else in the peloton takes his place in front and “pulls” the rest of the peloton along. This way, someone is always fresh. Eventually, they recapture the lone rider attempting to break away. He cannot maintain the speed the peloton can.

A bike race is made up of separate teams, each with a designated leader. But one team cannot usually race ahead of other teams consistently. Therefore, the teams that are competing with each other must work together within the peloton to keep any one team from breaking away. Ultimately, nearer to the end of the race, this cooperation stops and it is every team for itself. But nobody could get to this point without their rivals’ help and everyone acting as one big team.

For most of the race, riders put individual agendas, egos and needs aside for the greater good of all, knowing this cooperation may ultimately benefit the individual.

Venous education is finally morphing into the peloton mentality. Early on, from 2000 to 2005 or so, it was every man for himself, similar to an individual time trial in bike racing. Every professional organization (the American Venous Forum, American College of Phlebology, Society of Interventional Radiology, etc.) and industry had its own educational agenda. They wound up duplicating services, efforts and monies spent. Many of us worked with various organizations and industries, developing their educational goals and plans. Most of the discussions and conclusions were the same no matter with whom you were working. Essentially, five major conclusions arose regarding education:

  1. The field of venous disease was exploding with new ideas, new techniques and new technologies.
  2. Education of physicians treating vein disease would ensure quality care.
  3. Education of referring physicians would heighten awareness of vein disease and increase the number of patients referred for management.
  4. Education of the public would help people obtain modern, minimally invasive management of their vein disease.
  5. Education would ensure the best-quality growth with the best-quality care over time.

Yet the methods used to attain these five conclusions were individual. Various societies ran their own courses, asking the same companies for support. How many post-graduate, hands-on, advanced-training, breakout, how-to and case-presentation educational programs were really needed? Some, for sure, but maybe there were a few too many. Venous education experienced growing pains during those early years. Industry felt compelled to be fair (and rightly so), so each company wound up supporting many programs. Much money was spent duplicating services. Everyone was jockeying for position within the race and expending a lot of energy in the process.

Those were fun times as we tried to educate everyone who was interested in vein disease. They were also trying times. Industry and professional organizations tried to attract physicians interested in vein disease to their particular group, at times with the concept of exclusivity. Not a good thing in the long run, although maybe it seemed good in the short run.

Then around 2005, the peloton concept started. I am not sure why. Maybe most involved with venous disease and venous education got tired of duplicating services, attempting to achieve exclusivity and spending extra money toward education—of trying to be that lone bike rider. A number of things happened:

  1. The ACP and AVF started to run educational sessions at each other’s meetings.
  2. Robert Kistner, M.D., organized the invitation-only Pacific Vascular Meeting, held in January 2006, with international faculty and attendees to discuss the future of vein disease.
  3. The ACP Foundation was started in 2006 with the support of industry, physicians and allied health-care professionals.
  4. The International Vein Congress, conceived by Jose Almeida, M.D., arose as the premier non-societal venous education program.
  5. The VEITH Vascular meeting in 2007 had a separate venous program involving members of the AVF, ACP and SIR. It was another non-societal multidisciplinary meeting.
  6. The Venous Disease Coalition was organized.
  7. The American Medical Association and American Osteopathic Association recognized phlebology as a specialty.
  8. The first academic fellowship in phlebology was offered in 2007 at the University of California, San Diego.
  9. The journal Phlebology was accepted for MEDLINE indexing in 2007.
  10. The first boards in phlebology were given in May 2008.

These events allowed for a narrower focus and a concentrated effort regarding venous education. Industry now has more knowledge of who the major players are and where to direct efforts and funding.

In no way, however, should the above be construed as a “complete” list. Rather it highlights the striking positive change that has occurred. Everyone is being much more inclusive as far as education is concerned. This can only be a good thing for all.

The future challenge is to construct a core curriculum that all involved in venous education agree upon. In this way, everyone can support three to four meetings per year that cover this curriculum. Separate societies and industries can then focus on the next level of education specific to their specialty or their particular technology. Why duplicate efforts to teach the agreed-upon basics? The above deals with physicians already in practice; for those in training (fellows or residents), the various societies that agree on the core curriculum can incorporate it into their training programs. Therefore, by the time a resident or fellow finishes, he or she will have gone over the core curriculum and need only enhance his or her knowledge with the more advanced training offered by societies and industry. This concept requires “ buy in” by the leaders in the vein field. They have already moved in that direction.

By happenstance or coincidence, the leaders in the vein world have bought into the peloton model. It allows for both significant cooperation and individual achievement. These two concepts are intertwined; each exists because of the other and cannot exist alone.

Bicycle racing as a specialty has been around for more than 100 years. Phlebology as a specialty is just beginning. Let us continue to learn some things from another established specialty. I am confident we will achieve our mutual educational goals.

Steve Elias, M.D., FACS, is a member of the American Venous Forum, the American College of Phlebology, the Society for Clinical Vascular Surgery and the International Society of Cardiovascular Surgery. He currently serves as director of The Center for Vein Disease at Mount Sinai MedicalCenter in New York and director of the Center for Vein Disease at Englewood Hospital and Medical Center.