Marlin Schul, MD Challenges Us to Push the Boundaries

As the Congress Chair in charge of the 25th Annual American College Phlebology meeting this November, Dr. Marlin Schul has taken on the task of refocusing the content planned for attendees. VEIN Magazine Asked Dr. Schul for some insight into the program changes, as well as his daily duties as a practicing physician at the Lafayette Regional Vein Center.

VM: You’ve recently received some very positive feedback about the program you and the committee have planned for this year’s meeting. What did you do differently?

MS: A lot of times when you plan a program, you have to decide what to disseminate to the groups and what is going to be of interest – what are they going to get out of it, how is this going to help, is it worth your while and my while trying to put this together? These are questions that are essential for growth. If you are educating people, you have to push – you have to push the boundaries and the limits, and push it forward so that you’re actually learning new things.

The American College of Phlebology’s ACCME status, with the direction of Pam Beaton, forced us to add detail to program development. The process of identifying specific professional practice gaps has led to expanded content, essentially raising the bar with regards to this educational offering. I was told that this program was going to have my signature on it. It just so happens that the process and cooperation of the planning committee and faculty have allowed this to blossom into something special.

VM: What kinds of input have you been getting over the last several years about the education programming and meeting sessions that has led you to go with the deep vein issues?

MS: If you ask about the feedback over the couple of years, a recurring message involves some who share that they come to the conference every year and that they haven’t learned anything new in years. That perception resonated with me as both a problem and an opportunity.

The first place a shift is seen is in the pre-congress day program. The ‘big veins’ concept was spawned from the program development committee, and subsequently implemented as an advanced track and workshop. This was one of the areas where we thought we could offer more to our learners, but not the mix for the pre-congress day. Each committee member was charged with the task of thinking outside the box to identify fresh and pertinent topics in even the standard pre-congress tracks, e.g. practice management, ultrasonography, and basic phlebology.

The "big veins" track demonstrates how the ACP recognizes that this is a team effort for physicians to get the right care for their patients. There are so many different levels of vein care, and more people patients presenting problems that need solutions which require a better understanding of the deep venous system. Coupling a didactic session with a workshop involving IVC filters, stents, coils, etc., offers attendees insight to pathology and technologies they may not see on a regular basis in a private outpatient vein practice. This forum is will be limited in the number of people who may attend. Those who are interested may miss out if they don’t sign up early.

VM: Tell me about what the difficulties are with trying to fit all of this education into a format that has now been updated. Do you think you’ll get the feedback that attendees aren’t getting the essentials that they have gotten from earlier meetings?

MS: When it comes to content, there is truly something for everybody, every day, and every hour. Whether at pre-congress or the sessions, at any given time, there will be content for learners – basic, intermediate or advanced. The program handbook will label whether something is more basic or more advanced.

VM: So what can we look forward to with the ‘Big Veins’ track?

MS: To begin with, pre-congress day on Thursday is packed with education from leaders in the field. IVC filter placement, stent placement, mechanical thromboembolitic devices, balloons, coils, sclerosants, etc. It is a comprehensive deep vein symposium — Big Veins, Big Issues, Big Solutions.

We wanted to have something for that venous provider, or even someone like myself who may not do those procedures, to become more familiar with the indications and the application of those procedures. If you are a true vein specialist, you need to know more than just what you do in your office, because there are some things you just don’t do in an office. You need to know the right interventional radiologists, the right vascular surgeons and know what they are able to do to help the patient.

The program aims to do two things – it enhances the provider’s education in a given area with which they may not have had personal experience outside of journal articles, and it offers a hands-on approach through the afternoon workshops. If in fact a provider is learning about a particular procedure – let’s take stenting – and if we identify a patient with duplex findings suggestive of May-Thurner syndrome, by the end of this track, the attendee should be able to walk a patient confidently through the steps needed to address a specific deep vein concern. If an attendee is lacking knowledge in this area, they will be better prepared to identify the problem and make the appropriate referral. This simply leads to better patient care.

VM: Tell me about the ABPh Maintenance of Credential (MOC ) self-assessment modules.

MS: This year marks the first that diplomates of the American Board of Phlebology will be required to begin accruing maintenance of certification (MOC ) hours. The annual congress has programmed content consistent with that required for the ABPh self-assessment modules (SAM ). Sessions approved for MOC at this event include the following: Preparing for a phlebology emergencies; solutions and small veins; enhancing communication and ethics; and Journal Club. This is a huge leap forward. Just by attending the congress, attendees may elect to kill two birds with one stone.

VM: What stands out to you? What programming is being offered that you are most excited about?

MS: Where do I stop?! We have two general sessions that are, I think, very timely. We have The Great Venous Ulcer Debate and the Timing of Treatment for Superficial Venous insufficiency. There’s a story behind this.

During an ulcer symposium at the 2009 World Congress of Phlebology in Monaco, a retiring vascular surgeon reported that he would rather skin graft an ulcer verses treat the underlying venous disease in a patient with a venous ulcer. He touted results of the ESCHAR trial and was not challenged. I was truly surprised. In contrast to this, the final session at the AFV meeting this year in San Diego, it was apparent that controversy continues on as to when to treat SVI in the face of patients with venous ulcers. Despite the merits of the ESCHAR study, it was done in a day without thermal or comprehensive control of superficial venous insufficiency. I think that what came out of that was a consensus that maybe it is time to repeat the ESCHAR trial with the new toys. Drs. Marston and O’Donnell will provide a lively debate on the timing of treatment of SVI in patients with VLU as a spicy start to this year’s event.

The general session on Saturday morning is called Capturing the Patient’s Voice: Navigating This Time in Critical Medicine. Dr. David Flum is the director of patient outcome research at University of Washington and Washington State University. David has been appointed to the methodology committee for the Patient-Centered Outcomes Research Institute. That is essentially the nuts and bolts of identifying what benefit there is for surgery or treatment. As it pertains to phlebology, nobody knows.

The ACP, as well as the American Venous Forum and the Society for Interventional Radiologists, and anyone else who wants to play a role in identifying what it is that we do, have an obligation, if not just an outright requirement to do so. Nobody knows what national healthcare is going to do to venous disease. Dr. Flum believes that compared to any other specialty that he’s looked at, Phlebology has tremendous opportunity. The greatest opportunity meaning that if you just capture the patient’s voice, you can show the benefit. Nobody is actively capturing quality of life data on a large scale. I have patients every week telling me that they cannot describe how much better their legs feel or look, but do I capture that in a quality of life assessment? No, I haven’t.

Dr. Flum understands what we do in regards to managing patients. He’s an interesting guy and he has a unique perspective as to the specialty and what opportunities we have to move forward. It is my personal belief that we cannot take a reactive stance, rather, we must be proactive. Collectively we are on the cusp of being able to convince insurance companies in that what we do is important. Our procedures should be covered benefits, and this is why. The outcomes and efficacy, when coupled with quality of life data, could really build a story. This is critical topic and Dr. Flum’s credentials speak for themselves. So those two items were of utmost importance to me as the centerpiece of this educational forum.

As for the remainder of the program, there really is something for everyone and intriguing topics at every turn. What is truly amazing is how much goes into building a quality program. Volunteers of the program planning committee, the program development committee, the CME committee, the education standing committee, and AC P HQ staff have worked toward the common goal of bringing a tremendous opportunity to learn. It is my sincere hope that all attendees not only take something of value back to their respective practice, but they also have fun in the process.

VM: In addition to all of the AC P planning, you’ve been helping with VEIN Magazine, crafting manuscripts or book chapters, among many other things. What does your week look like and how do you fit everything into your schedule?

MS: It’s truly isn’t easy! The reality is that I enjoy every aspect of what I do to help patients, and to promote and support the specialty of phlebology. No matter what’s going on, faith and family come first. Everything clinically is focused on providing our patients the best possible experience. Our practice mission serves to deliver pure excellence in customer service leading to superior clinical outcomes. We have so many tools that truly help change the quality of life for our patients. The key to me is finding balance, and this year has proven a greater challenge than in years past.