Days of Future Past: Vein Specialists' Next Wave (Podcast Ep. 8)

Welcome to the VEIN Magazine Podcast with Dr. Steve Elias, where vein specialists sit around, have drinks and talk.

Dr. Steve Elias is joined by Drs. Angela Kokkosis and Pamela S. Kim, both of Stony Brook University Department of Surgery, to talk about what it's like to be young female vein physicians.

What are the unmet needs that women have in the vein world? When a woman comes to a vein specialist, is there something unique to her experience, anatomy or complaints that gets missed? Listen on.

Episode Transcript

Steve Elias: You guys are both at Stony Brook. Pam, why don't you tell us what you're doing at Stony Brook first.

Pam Kim: Okay. I just started. I've been at Stony Brook as an attending for about two months now.

Steve: When you say you started, started?

Pam: As a full-fledged attending.

Steve: As a real attending?

Pam: As a real-life attending, yes.

Steve: Okay. Where did you come from?

Pam: I have been at Stony Brook for about the past eight years. I did my general surgery residency at Stony Brook, and then I stayed for a phlebology fellowship there, then my vascular surgery fellowship, as well.

Steve: So, you did a phlebology fellowship and a vascular surgery fellowship?

Pam: Yes.

Steve: You may be the only. Do you think you're the only one?

Pam: Who's done both? Quite probably, yeah.

Angela: Yeah, it's not a common phenomenon.

Steve: If anyone says can you take care of veins, no one's going to question your credentials.

Pam: I hope not.

Steve: Right. They may credential mine or Angela's but not yours because you've done everything. We haven't done both of those things at all. Angela, she's been around for a while, though not so much of a while. The reason I have Angela and Pam here is because they're both relatively young and certainly younger than I, so I wanted to get their take on the vein world—a younger people's take. But, Angela, tell us how long you've been over there at Stony Brook.

Angela: I've been at Stony Brook now for four years. I did an integrated vascular training in the city at Mount Sinai, and then right afterward I was recruited to Stony Brook. My practice is a combination of venous procedures, outpatient veins, as well as some arterial stuff, as well.

Steve: Right. You're still doing arterial?

Angela: Yeah.

Steve: I think that's more the usual for younger people. Now, Pam, are you doing arterial, as well?

Pam: I am. I specialize in cold legs it seems like.

Steve: Do you specialize in cold legs and warming them up?

Pam: Yes, and warming them up.

Steve: Okay. You don't just get them cold and cut them off, you try to get them to warm up again?

Pam: Yes.

Steve: Okay.

Pam: That's the goal, right?

Angela: Absolutely.

Steve: That is our goal. Let's talk a little bit about the vein world. First of all, I mean, obviously, you're both women. We always, in vein, like to highlight the upcoming women in the vein specialist world, as well. Do you think there are more women practicing vein disease or, kind of, semi-specializing, whether it's a full-time thing or part-time with their practice?

Pam: I certainly think that's the trend. Do you agree?

Angela: I would agree subjectively, absolutely. Even just at the venous meetings, we definitely see more women there that are in practice.

Steve: That's what I'm thinking. The first wave, when we started just really doing vein disease as the minimally invasive stuff came on board in the late '90s and early 2000s, was mostly male because most of the people who were even doing vascular surgery were men. There are a few women who you could point to that are kind of in the second wave; meaning, in between my generation and your guys' generation. But now, I agree with you, I see a lot more. Do you think it makes sense, Angela?

Angela: I think so, absolutely.

Steve: Let's talk sense for me from the doctor side and sense from the patient side. Let's first talk about the doctor side.

Angela: Yeah, I think from the doctor side it makes sense. I mean, the lifestyle of current vein specialists is probably not what it was years ago. I would even go so far as to say a lot of the training pathways to be a vein specialist are not the same as it was years ago. I mean, now, because of the phlebology fellowships, we're seeing a lot of people who have different backgrounds. They're not just vascular surgeons that are getting into this field. I think that's also promoted more of the women who are entering the workforce.

Steve: And how about, Pam, from the patient's viewpoint? Do you think there's an advantage to the vein specialist being a woman when the patient comes to see the vein specialist, or is it not as impactful as we might think?

Pam: I do think there's certainly an advantage in being a woman vein specialist, especially since so many of our patients are women. I think just by default they feel more comfortable. I think they feel like they can relate a little bit better to a female surgeon.

Steve: Right. I don't know about you, Pam, but I know Angela, she'll tell us. You have a child now, right, Angela?

Angela: I do, on the way.

Steve: You're in that pregnancy state where women always say, "Oh, this vein came from my first child, this one came from my second."

Angela: Absolutely.

Steve: You certainly can relate a little bit better. Let's kind of go a little further down that road in terms of women. What do you think are the unmet needs that women may have in the vein world? What kind of things do you think we're not giving them that you think the patients may want? I have my own feelings about it, but is there anything? When a woman comes to a vein specialist, is there something unique to women's either experience, anatomy, complaints, that you think are underserved in the vein world?

Pam: I think a big part of it is just broader education within the community that a lot of women, I think, just take a look at their legs and say, "Oh, I have some varicose veins. I have some veins that may not look so bad." But they don't necessarily think it would be an issue or something worse. Or, say if they have symptoms of their disease but they don't really think it's from that, they think it's just because, "oh, I've been running around with my four kids all day."

Steve: Right.

Pam: And that's their problem. I think just spreading the word is something that can help. An important factor is just broader education.

Angela: I'd say continuing in that same vein, that it's still underrecognized, the women who are experiencing the pelvic congestion syndromes and just having that knowledge of how many pregnancies a woman has had. Asking those questions may be, for some of our male counterparts, uncomfortable. I think that's a huge component.

Steve: Yeah, I think that the pelvic venous disease and pelvic venous issues are not as highlighted as they should be. It's becoming more highlighted now as we speak more about it. I think some male physicians maybe are not attuned to that because they haven't had significant pelvic pain. Even women who just go through their menstrual cycle have pelvic pain, and they know that can be debilitating, whether they have pelvic venous disease or not, so female vein specialists can certainly relate better.

I also think that there is a reluctance, like you say. Some men don't feel comfortable asking some of the questions that they should ask when they see a patient with vein disease and they suspect something further down. What do you think of the OBs and the gynecologists? Do you think that they're as attuned as they should be and are aware as to what we can do to help these people?

Pam: I don't really think so, no. It seems that whenever we speak to gynecologists about this issue, it seems new for them. Do you agree, Angela?

Angela: I totally agree.

Pam: Yeah. After a Lunch and Learn or a brief grand rounds or something like that, we do see an influx of these patients for consultation. I think that's really speaking to the fact that it's really not well known, not in the patient community or even in our own medical profession.

Angela: Absolutely.

Pam: Yeah, no, I agree with that. Now let's just go in a little different area, okay? How can we, or should we, get younger people involved? By this I mean, younger people who are in medical training, involved with considering a career in treating vein disease? Do we have enough already, too many, or not enough?

Angela: Well, I mean, if you look at the pathology from the standpoint of prevalence in the United States, we all know that venous disease is four times more prevalent than arterial disease. I would say there definitely must be an unmet need. There probably aren't enough skilled vein specialists to take care of all these patients.

Steve: Yeah. Now, there are some people practicing who would not want anyone else in the field because they think all of a sudden they're not going to have anybody to treat. So, Pam, you went from not being in the vein world at all, not even being in the vascular world, to deciding you wanted to do veins, and then deciding you also wanted to do vascular surgery. What made you decide? Do you know anyone else who's kind of gone that route as well in terms of the thought process?

Pam: I don't think in general surgery training nowadays that venous disease is highlighted very much. I think in general, within a traditional vascular fellowship, it's not highlighted that very much, as well. I think if you do have an interest in it, either you do vascular surgery fellowship and you try to do more cases, or you can do, now, this phlebology fellowship is available.

But having gone through the phlebology fellowship and gone to all the specialized meetings and conferences, it's made me realize how much of that education is lacking within either both general surgery and vascular. I'm very glad I actually did the fellowship. It makes me realize that it is a very specialized field, and you do need people who are specifically trained to be able to treat patients in the correct manner. It may seem simpler from a superficial point of view, but it can be quite a complex disease process.

Steve: Yeah, no, I mean, obviously, I believe, and that's all I do. I haven't done any arterial stuff.

Pam: Exactly.

Steve: In like 18 years. It's not that the procedures are so hard. I think sometimes the diagnosis of what to do when is a little more difficult than the arterial side of things. That to me is where I see the vein world going.

Pam: Exactly.

Angela: Just to clarify what I said earlier about needing more vein specialists, I think it's not that we don't have so many now, I think it's that we don't have enough comprehensive vein specialists.

Steve: Right.

Angela: Like Pam is suggesting, [vein specialists] who have gone through some sort of training that actually understand all superficial deep venous disease to really help these patients.

Steve: Yeah, I agree with you. Because, actually, all vein disease many times is interconnected. In other words, patients can have a combination of issues. It can just be below the inguinal ligament, it can be only above. But, in general, there's a combination. You got to kind of sort out where you may see the tip of the iceberg, and really the underlying pathology is somewhere else within the body and stuff.

Pam: Exactly.

Steve: I want to kind of finish up in a little bit. I want to think of if you guys could change some of the things in the teaching paradigm that we either do at the courses or in the training we already discussed that we should incorporate a little more in general surgery and vascular surgery. But in the courses, you see something that can be added or something more we should highlight in courses that, as you said, Pam, you come to special training programs. Angela, you teach at many of those programs. Is anything we should be highlighting more or adding that we don't have already?

Angela: Honestly, I think your courses are very comprehensive. I think the issue is that not everyone who should be attending them is attending them. Meaning, it kind of goes back to the training that the individuals went through. If you talk about vascular fellowships and residency programs, again, the emphasis on learning venous disease is not there.

In a similar way that we're now mandated to take the RPVI and be certified in ultrasound interpretation, I think there should be some mandate as to how to treat venous disease. It's actually not even part of the case logs. I think if there was a little more push at the front end, getting more of these individuals to actually reach out to these courses that are clearly available and they're very comprehensive, I think we would see more, again, educated vein specialists out there.

Pam: I agree. I have seen that over the years. The ACP and the AVF have been quite obviously starving-

Steve: Pam, it's not the ACP anymore.

Pam: Oh, I'm sorry, I'm sorry.

Steve: The name, we just changed the name last week. It's the American Vein and Lymphatic Society.

Pam: Okay, the American Vein-

Steve: The AVLS. You heard it first here on this podcast.

Pam: Yes.

Angela: We've been informed.

Steve: Yes.

Pam: The AVLS and the AVF have been doing a lot to get the courses out there to all physicians, not just surgeons, involved in the education. I think that's a huge step in the right direction.

Steve: Now, my final thought about what we should do for the courses. At a lot of the main meetings, we have a separate segment for fellows, or medical students, residents. Obviously, we have a separate course from the American Venous Forum, the fellows' course in venous disease. Do you think we should look to find, just like in the arterial world, young surgeons courses so to speak?

The people who've been in practice for one to five years or so, their needs perhaps, the younger person's needs, are a little bit different than someone like me who's been practicing for 30 something years? What do you think about adding that segment to some of the courses? Or, do you feel that young people just starting out are not necessarily any different than people who have been practicing?

Pam: I, personally, would take any extra education that's offered to me.

Steve: That's all you got to do. It's also for a networking kind of thing.

Angela: Absolutely.

Pam: Absolutely. I think it's a great opportunity overall.

Angela: Yeah, I think, when you're already in practice, tips, tricks, and things like that are always great because there are always new things to learn from a technology standpoint and research. I think that absolutely would be a good idea.

Pam: Especially with all the new, as Angela said, technologies that are coming out. The coding, the CPT codes, all of that changes by the year.

Steve: I know but those are things every vein specialist would want to know about. I want to know...

Angela: Like a training course?

Steve: Either training, a philosophical aspect to it, an approach to developing your practice kind of. Are there any needs that younger people who are just starting out in the vein world need and would like to meet with others like them rather than in the big main meeting? Do you think that we should gear things toward people like you, Pam? Angela's almost moving out of that time slot that I named.

Angela: Almost an old dog now.

Pam: I agree, yes. I don't know exactly what you're trying to get at.

Angela: I think what he's saying is, if you'll let me interject.

Steve: Go ahead.

Angela: Let's say that they set up a young phlebologists course.

Steve: No, we call them vein specialists.

Angela: A young vein specialist. This is good, I'm learning. So young vein specialist sort of training or session, and it was not at any national meeting, it was at some location convenient in the United States, and there were about 20 of these vein specialists, would you go, two or three years out from your training?

Pam: Yeah, definitely.

Steve: To talk with your fellow young people as to what's going on. We always see, the reason I'm doing the podcast, we always like to come up with some conclusion decision. We've come up with some: Are there too many meetings? That has been one thing. How do we make meetings more interesting? That was another thing. Oh, yes, the name change. What goes into changing a name?

So here, now if you don't agree, you don't have to agree with me just because I'm the one running the podcast. You can say, "No, Steve, we really don't need that. We're fine the way we are." But I was asking you if you thought some unique meeting or get together with people who are around your practice level might be helpful going forward. The other reason I think would be helpful is you, hopefully, will become the leaders in the future. It's good early on to have connections with those of your peers who are the same age so that you grow together.

Angela: Absolutely.

Steve: You then, like me, can name all of those friends at your level. We all hang around together and stuff. It's the same idea I'm thinking of younger people. You got to hang around for the next 20 or 25 years together.

Angela: Exactly.

Steve: Doing what we're doing now.

Angela: Right. It's the next generation, yeah.

Steve: I'm not always going to be here and everybody else that's been doing it as long as me are not going to be here, but we need to identify the upcoming people. You are identified as the upcoming people. Are you willing to take that mantle, that moniker?

Angela: The charge has been implemented.

Pam: It's most welcome.

Steve: Okay, good. But when you become the people, there's kind of the rules to live by. My rules to live by are respect the elders, embrace the new, encourage the improbable and impractical without bias. When you guys have become leaders, always remember you do still have to respect the elders, those who came before.

Angela: I accept those criteria.

Steve: Okay, good.

Pam: I agree.

Steve: All right. Let's wrap it up here at the VEITH meeting since usually at the VEITH meeting, no lecture or talk or anything takes more than three to five minutes. We've been talking for much longer. So in the spirit of VEITH, we will end now. But I want to thank both of you very much, and we'll see everybody next time on the podcast.

Pam: Thank you.

Angela: Thank you.