INTERNATIONAL REPORT

For the inauguration of this new column, Vein Magazine recently caught up with renowned phlebology expert Eberhard Rabe, M.D., to get an inside perspective of European phlebology practice as well as an update on the German Society of Phlebology.


What is the history of phlebology in Germany?

Rabe: The first phlebological organisation in Germany was the “Association of specialists for leg diseases” between 1909 and 1934. It was founded by Dr. Bertold Lasker, first husband of the famous writer Else Lasker-Schueler and by Dr. Nathan Brann. After the Second World War the German Society of Phlebology was founded in Frankfurt the 23rd March 1957. The first president was Erich Krieg who was also the first president of the Union Internationale de Phlébologie (UIP), which was founded 10 years later in 1967. Since then the society has grown steadily and now has about 1.300 members.

What are the key initiatives-goals of the German Society of Phlebology in the next five years?

Rabe: In the last two decades phlebology has changed from “experience based medicine” to “evidence based medicine” but there are still a lot steps to go. This is one of the main goals of the German Society of Phlebology. We are encouraging and funding scientific studies and projects in diagnosis and treatment of venous diseases. This includes new less invasive treatments options for varicose veins, genetics of varicose veins, venous ulcer treatment, deep venous thrombosis, phlebitis and epidemiological studies. At the same time we have to improve education not only of new phlebologists but also of established colleagues in the meaning of continuous education. We also have to encourage young physicians to take the option of phlebological training.

Who delivers phlebology care in Germany?

Rabe: Different medical specialists like dermatologists, internal medical doctors, surgeons and vascular surgeons perform phlebology as a subspecialty.

How do most doctors get training in phlebology?

Rabe: As phlebology is a certified subspecialisation in the medical system in Germany there is an official education program of one to five years duration since 1992 in addition to specialisation in dermatology, internal medicine or surgery. Before 1992 most doctors learned phlebology in continuous education and self-established training programs. In 1985 the German Society of Phlebology established a Collegium of Quality Control, which was a predecessor of the current official subspecialisation.

What training opportunities are available?

Rabe: There are officially certified institutions in hospitals and private practices which are certified by the health organisations for training in phlebology.

Do your colleagues in other areas of medicine recognize phlebology as a specialty?

Rabe: Yes, this is the case. Vascular medicine in Germany is performed by vascular surgeons, angiology is a speciality in internal medicine and phlebology is a subspecialisation in the above-mentioned specialities. The competition between these groups has diminished in the last years and we are working together quite well. This is partly due to the fact that the members of the German Society of Phlebology belong to different specialty groups including dermatologists, vascular surgeons and internal medical specialists. Phlebology in Germany is an interdisciplinary matter as represented in our society.

Is phlebology taught in medical school and residency programs?

Rabe: Phlebology is not one of the main specialities. The education in medical school differs from university to university. It is usually integrated in the dermatological, surgical or internal medical lectures but in most cases there is no phlebological lecture covering the whole field.

Is there a certification program in Germany?

Rabe: As phlebology is a certified subspecialisation there is an official certification program lasting one to five years of theoretical and practical education in a residency programme. This includes clinical, duplex and functional investigations of the superficial and deep venous system, conservative and invasive treatment (sclerotherapy, surgery) of superficial venous diseases and diagnosis and treatment of lymphedema.

Does insurance cover phlebology procedures? What is the process?

Rabe: Health insurance covers the majority of phlebology procedures in Germany. This only excludes treatment for cosmetic reasons like sclerotherapy of spider veins. Compression treatment, sclerotherapy and surgery are reimbursed. There is only a discussion concerning new treatment options like endovenous procedures and foam sclerotherapy, which are not yet integrated in the official reimbursement system.

Which are the trends in phlebology in Germany?

Rabe: Concerning varicose veins, as everywhere in the world, less invasive systems like endovenous laser treatment or radiofrequency treatment of varicose veins is of growing interest. The same is true for foam sclerotherapy which has already reduced the number of operations for instance in recurrent varicose veins. Concerning deep venous diseases, ambulatory treatment of deep venous thrombosis has been established for 10 years ago and we are looking forward to new anticoagulation drugs.

You are current president of the International Union of Phlebology. Can you discuss the UIP and what the goals of the organisation are?

Rabe: The Union International de Phlébologie is the union of about 40 national societies all over the world. The aims of the UIP are to strengthen the links between the societies or associations, either existing or to be created, which have a special interest in the study and the therapy of venous disorders; to create recommendations regarding the teaching of phlebology as well as the training and continuing medical education of phlebologists, to promote consensus on all aspects of venous disorders and to encourage studies and research on disorders of venous origin. The goal is also to promote joint meetings and international congresses, to encourage the creation and activities of national societies or associations and to encourage them to join the International Union of Phlebology.
In summary the three goals of the UIP are:
1. To improve scientific work in phlebology;
2. To improve education in phlebology and
3. To improve communication between the phlebological and with other vascular societies.
The UIP organizes world congresses every 4 years and supranational chapter meetings between these periods. Until 2009 we are building up a curriculum in phlebology, which should be the basis for national curricula and education systems. For this reason we are organizing several consensus documents in all fields of phlebology. We are also developing a communication platform with a worldwide newsletter service.
The next UIP World Congress will be organized by the German Society of Phlebology and the French Society of Phlebology together in Monaco 31st August until 4th September 2009.

What are the trends that you see internationally?

Rabe: Internationally phlebology gains more and more interest which leads to the formation of new phlebological societies. In former decades phlebologists usually belonged to a small subgroup in other societies in fields like cardiovascular surgery or dermatology. As a consequence phlebological topics were integrated in the national congresses of these societies more or less intensively. In some countries, like the USA, Germany, France or Italy societies dedicated only to phlebology were created from the beginning. Now more and more young societies are developing with this goal. This is also caused by the fact that populations are changing in the western countries towards a higher proportion of aged people with a higher prevalence of venous diseases. In other countries prosperity increases with a higher income in the general population and consequently a better chance to finance the treatment of diseases that are not life threatening. At the same time phlebology has become more and more evidence-based in its diagnostic and therapeutic options. Treatment of varicose veins has become much less invasive and in many countries treatment of venous diseases has changed from vascular surgical procedures towards endovascular treatment. But we still have to solve many questions. We still don’t know why varicose veins develop and which genetic changes predispose for this disease.