Challenges in Phlebology

Two very important questions are being actively discussed by those with an interest in venous disorders. The first question is how best to assure that physicians now and in the future will be able to obtain comprehensive training in venous disorders so that patients can receive care from those well-trained in the field. The second question is how best to establish a threshold of knowledge and competence in venous disorders so that clinicians may strive to exceed that threshold and patients may recognize those who have done so.

The first of these questions raises some complex issues. To begin with, we know that physicians delivering medical care to patients with venous disease today come from a wide variety of specialty backgrounds.

We also know that physicians whose primary training was in a nonvascular field are treating many of these patients, and that many of these physicians have been delivering vein care for a long time.

We know that physicians whose original training was not in a vascular specialty have contributed significantly to our modern body of knowledge and capabilities, particularly with respect to advances in basic science, epidemiology, tumescent anesthesia, sclerotherapy, foam sclerotherapy, ultrasound-guided sclerotherapy, endovenous ablation, compression, and venous thromboembolism (VTE) management.

We know that well-respected leaders in the field of venous disease come from many different nations, traditions, specialties, and training programs.

While the wider availability of improved diagnostic and treatment techniques have greatly improved the outcomes we can achieve for a patient with venous disease, there remain many important challenges and opportunities with regards tofurther improving patient care.

Many of the important innovations and developments in the field of venous disease have come into common use without any opportunity for formal training for those already in practice, regardless of specialty background. Much of modern practice depends on skills and techniques that must be learned through conferences, peer-to-peer interactions and other individual postgraduate educational experiences.

However, similar challenges exist even for those currently enrolled in a formal training program, regardless of specialty. For example, in dermatology one must have instruction in sclerotherapy, but there is nothing in the curriculum about ultrasound, thermal ablation, phlebectomy or VTE. Such knowledge has to be obtained outside the standard dermatology training program.

In regards to vascular surgery, a review of the most recently available ACGME case logs (2011) reveals the following training experiences:

  • Sclerotherapy Average 1 case Median 0 cases
  • Endoluminal Ablation Average 11.2 Median 7
  • Operation for Varicose Veins Average 6.4 Median 4

Although case logs are not reported by vascular interventional radiology training programs, we know that no program currently offers a comprehensive venous curriculum.

It is clear is that no single specialty routinely provides a comprehensive curriculum to cover the full spectrum of venous and lymphatic disease. Most thoughtful and objective physicians would agree that the venous curriculum, even in vascular specialties, would benefit from being standardized and strengthened.

How do we engineer improvement? First, we must accept the reality that improvement means change. We cannot simultaneously seek improvement and embrace the status quo. To advance knowledge, skills, and outcomes in a meaningful way, we must think long term, with the objective to improve the venous curriculum at the medical school level as well as in residency and fellowship training programs.

Historically, change of this kind is best accomplished when the process seeks consensus through respectful professional conversation, is inclusive and values all potential contributors, and evaluates ideas based on merit.

The practice of venous medicine has many of the attributes often associated with a specialty or subspecialty. Venous medical societies exist in many countries. There are many medical and surgical conferences and multiple journals dedicated to venous disease. Many physicians’ practices focus mostly or primarily on venous disease. Given this reality, the fact that most practitioners have no opportunity to receive comprehensive formal training in the field represents both a challenge and an opportunity. It’s time to strengthen and standardize venous curricula and training in all relevant specialties, using a multidisciplinary consensus approach in order to develop qualified comprehensive specialists.

The American Board of Venous and Lymphatic Medicine (ABVLM), formerly the American Board of Phlebology, is using a collaborative, multispecialty consensus process to establish educational standards for training programs in venous disease. We have outlined the knowledge and skills considered essential in a Core Content document and are developing program requirements consistent with the Core Content. This will enable training programs interested in improving their venous education to adapt their curriculum consistent with the program requirements and Core Content.

The second of the important questions that occupy our minds at this moment represents a different and very particular challenge. Stated most bluntly, the question is: Should we seek to measure a physician’s knowledge base in the field of venous disorders? Some prominent leaders do not believe any form of certification can be a useful determinant of cognitive knowledge or a valid predictor of quality of care. Although the question is controversial and is not easy to study, there is literature to support the value of certification as a proxy for quality of training and quality of care.

But despite the controversy, we do know that adequate knowledge is essential to the development of medical expertise and effective clinical decision making. As previously discussed, we know that physicians from many different medical backgrounds are delivering vein care and that formal training in venous disease is generally recognized to be deficient across the full range of specialties. Given these facts, surely it is reasonable and useful to have some way of identifying those who possess a foundation of knowledge and experience in the management of venous disease.

Existing specialty board exams do not quite achieve the desired goal. For example, the Vascular Surgery Board exam allocates about 14% of its content to venous disease (~33 of 240 questions), with content categories consisting of thrombosis and venous insufficiency. Other areas of knowledge essential to the practice of venous medicine and surgery are not addressed in the exam. While not necessarily a criticism, it’s also interesting to note that candidates could likely get every question wrong and still easily pass the exam.

Similarly, the American Board of Radiology Vascular and Interventional Radiology exam includes content related to venous ablation, thrombolysis, filter placement, and venous ultrasound. However, other equally important areas are not included:

  • Clinical evaluation
  • Sclerotherapy
  • Phlebectomy
  • Compression

This information would lead most reasonable physicians to conclude there is no ABMS specialty exam that adequately tests knowledge in venous disease today. It is precisely this deficit that ABVLM certification attempts to bridge: The ABVLM certification process includes an extensive assessment of cognitive knowledge across all the foundational areas in venous disease, with about 200 items across six content categories. This provides the opportunity for much more extensive testing. As an example, the treatment/therapy section includes items on pharmacologic agents, wound care, compression, sclerotherapy, ultrasoundguided sclerotherapy, ambulatory phlebectomy, surgery, endovenous thermal ablation, deep venous insufficiency, deep vein obstruction, vascular malformations, management of recurrent varices, management of pelvic venous insufficiency, complications, VTE and other areas.

Category Weighting on Exam

  • Basic Science 16 items (8%)
  • Venous Diseases & Syndromes 40 items (20%)
  • Diagnostic Tools & Screening 20 items (10%)
  • Duplex U/S & Other Imaging 50 items (25%)
  • Treatment/Therapy 70 items (35%)
  • Professional Standards 4 items (2%)

It’s easy to understand the sentiment that no one wants to take another exam. However, this is an important pathway by which to achieve improvement in the quality of outcomes for patients with venous and lymphatic disorders: Preparation for a comprehensive exam helps build the examinee’s knowledge base, and the establishment of training and practice requirements to qualify for the certification process raises the bar for overall quality in the field.

Some have said that ABMS certification is about training not test taking, but if that were strictly true there would be no examinations required for ABMS board certification. In reality, the value of certification comes both from assessing a clinician’s training and from establishing a formal measure of a clinician’s knowledge base. Both of these are areas that need strengthening across today’s landscape of specialties in regards to venous disease. These improvements would get us much closer to true subspecialty/specialty status.