The Big Question: Four Perspectives on the Question of Whether Phlebology Should Include a Multidisciplinary Approach

It’s not a new topic. In fact, the discussion has loomed in phlebology for decades, likely since Raymond Tournay (widely associated with coining the term “phlebology”) helped found the Societe Francaise de Phlebologie with his colleagues in 1947. The simple question of who should practice phlebology has overtaken meetings and created divides among the subspecialty’s most respected doctors. It has also pushed phlebology toward new advancements, furthered the universal goal of better education in venous disease, and regardless of opinion, brought forward thinking leadership together in an effort to advance the treatment of venous disease despite any overall agenda.

We have heard many opinions on this topic over the years, and we want to vehemently stress that VEIN does not take a stance in, nor are we in a position to opine on this matter. We feel that is best left to the doctors and leadership who are practicing. Our job as your industry magazine is to cover relevant topics related to phlebology, and given that this hot button topic has reached a crescendo of late it would seem derelict of us not to address it in some manner.

The Questions

We asked each panel member four questions relevant to the current nature of this discussion:

1. What are your opinions on an exclusionary (surgeon only) versus inclusionary approach to the field of phlebology?

2. What is your opinion on the role of the ABPh as a professional standard for the field of phlebology? How do you think the ABPh is positioned with respect to future ABMS certification?

3. How do you feel the various medical societies perform at providing education and training for the phlebologist?

4. Do you feel that phlebology should only be practiced in a hospital setting? In your opinion, are there opportunities for tracking outcomes only in a hospital setting?

In addition, we also asked each doctor to add anything that they felt was relevant to this discussion. We wanted to gather a cross section of specialists who are recognized in the field of phlebology and, less the responses from an interventional radiologist we requested to participate, have done so. A brief biography of each will preclude their answers. Their answers are not intended to represent the opinions of any single group of physicians. Rather, they are intended to provide perspectives from various specialists whose views represent the crux of this discussion. Our intention is to provoke thought, not polarize attitudes. Because if we offer any opinion within the pages of this article, it is that the doctors we speak with are all incredibly passionate about advancing the education of venous disease and standard of patient care in the field of phlebology. We hope to hear your opinion on this discussion. Please email all comments to [email protected].

Stephen F. Daugherty, MD, FACS, RVT, RPhS, is the Medical Director of Veincare Centers of Tennessee. He is a diplomate of the American Board of Surgery and American Board of Phlebology. He is one of the representatives from the ACP to the IAC – Vein Center Division Board of Directors.

What are your opinions on an exclusionary (surgeon only) versus inclusionary approach to the field of phlebology?

Phlebology is the term utilized around the world for the medical specialty concerned with management of venous disorders. Some of the vascular surgical community view the term “phlebology” as a threat and suggest other terms for the specialty. The American Medical Association has recognized Phlebology as a medical sub-specialty since 2006.

Physicians who are experts in Phlebology come from a broad variety of backgrounds. Historically, general surgeons and vascular surgeons have been the primary physicians performing surgical procedures for venous disease as such procedures were developed over the past century. Few surgeons performed sclerotherapy until recently. Sclerotherapy was developed by physicians from mostly non-surgical backgrounds, and dermatologists once were the dominant sclerotherapists.

As the minimally-invasive procedures of microphlebectomy and endovenous thermal ablation were developed, it became possible for physicians of many different specialty backgrounds to perform these procedures in the office setting and, now, relatively few procedures for superficial vein disease are performed in the hospital setting in the United States.

Some general surgeons and vascular surgeons have learned the minimally-invasive procedures for treatment of superficial venous disease and some have also become very skilled at sclerotherapy. Many of us learned sclerotherapy, including ultrasound-guided foam sclerotherapy, from dermatologists, family practitioners, internists, anesthesiologists, or ER physicians who had become phlebologists, as well as from their sclerotherapy nurses.

A general surgeon or vascular surgeon who desires to become an excellent phlebologist has a distinct advantage over a physician who has no surgical and catheter-based training, but surgical credentials alone do not qualify a physician to become a phlebologist. Neither should the lack of formal surgical training exclude appropriately-trained physicians from treating superficial venous disorders. There are too many very skilled physicians from non-surgical backgrounds practicing phlebology (many of whom have made major contributions to the specialty) for them to be excluded from the practice of phlebology.

Treatment of deep vein disorders is very different from treatment of superficial venous disorders and few physicians other than general surgeons, vascular surgeons, and interventional radiologists will become qualified to perform invasive procedures for deep vein disorders. However, all phlebologists should be knowledgeable and skilled at recognizing and working up deep vein disorders.

What is your opinion on the role of the ABPh as a professional standard for the field of phlebology? How do you think the ABPh is positioned with respect to future ABMS certification?

The American Board of Phlebology (ABPh) was founded to establish a curriculum in phlebology and to measure a candidate’s knowledge of the specialty. The goal to achieve American Board of Medical Specialties (ABMS) membership is a very long process for any new specialty. The ABPh has worked to meet the ABMS requirements, but residency/fellowships must be developed in sufficient numbers to provide a standard training track which will meet ABMS requirements. The ABPh examination is the only available measure of physician knowledge of phlebology for the purposes of credentialing.

While many surgeons may disagree, my opinion is that we should all support the ABPh by earning the diplomate status and by recognizing the ABPh as the accepted measure of phlebology knowledge while working to develop the standard training programs necessary to achieve ABMS membership. The curriculum established by the ABPh is quite extensive and includes venous disorders all over the body.

How do you feel the various medical societies perform at providing education and training for the phlebologist?

The American Venous Forum,, is a wonderful organization which provides academically-rigorous review and debate of important issues relative to venous disorders. The American College of Phlebology, www., is equally important in providing education for phlebologists, especially for treatment of superficial venous disorders. I commend both organizations for their efforts and recommend that physicians who practice phlebology become very involved with both organizations and their educational programs.

Do you feel that phlebology should only be practiced in a hospital setting? In your opinion, are there opportunities for tracking outcomes only in a hospital setting?

Treatment of superficial venous disorders generally should NOT be performed in a hospital setting. These procedures are much more efficiently performed in the office setting. The problem with minimally-invasive procedures being performed in the office setting is that there is no external professional oversight. There are more opportunities for poor quality care with inappropriate indications, poorly executed procedures, and unrecognized/unreported complications in the office setting. We all are aware of the tremendous variability of office practice from excellent to inadequate or worse.

The Intersocietal Accreditation Commission (the umbrella organization for vascular ultrasound accreditation) was approached by the American College of Phlebology with a request to develop an accreditation for vein treatment facilities. The new IAC —Vein Center Division Board of Directors includes 14 representatives from 9 medical societies including the American Academy of Dermatology, American College of Phlebology, American College of Surgeons, American Venous Forum, Society for Clinical Vascular Surgery, Society for Vascular Surgery, Society for Vascular Ultrasound, Society for Vascular Medicine, and the Society of Interventional Radiology. The organizational meeting of the Board of Directors was on June 5, 2012 and we hold telephone conferences every other week as we develop accreditation standards for vein centers which include standards for physician education and experience as well as facility standards. We anticipate three different accreditations—superficial vein disorders, deep vein disorders, and lymphatic disorders. While many differing perspectives come to the Board and are debated vigorously, we hope to achieve a consensus regarding accreditation standards which will assure appropriate training and performance by physicians and staff and appropriate equipment and protocols in accredited vein centers. I expect that accreditation eventually will be essential to the survival of a vein center.

Is there anything else you would like to add?

The Registered Phlebology Sonographer (RPhS) certification was established by Cardiovascular Credentialing International in 2010 to certify both physicians and technologists who perform ultrasound in a vein practice. This is the only ultrasound credential specific to venous ultrasound and may be a better measure of venous ultrasound knowledge than the RPVI , RVT , or RV S certifications. I believe all physicians treating venous disorders should earn one of the four certifications, ideally the RPhS. I encourage all phlebologists (of all specialty backgrounds) to earn ABPh diplomate status and to work toward IAC -Vein Center accreditation once the standards are published next year.

Michael Richman M.D., F.A.C.S. is President/ CEO of The Elite Laser Vein Center of Los Angeles, a diplomate in The American Board of Surgery, and also a diplomate in the American Board Thoracic Surgery.

What are your opinions on an exclusionary (surgeon only) versus inclusionary approach to the field of phlebology?

The notion that training in any specialty can lead to a physician becoming a board certified phlebologist is extremely distressing and dangerous in light of the fact that most of the ACGME -recognized specialties are medical and not surgical, and these medical specialties provide no mechanism in which to operate and train in phlebology. I think it is naive and irresponsible to believe that phlebology can be performed by any doctor who can provide the correct documentation and pass a written test. The harsh reality is that board certification in phlebology is not real and should not convey to the public this means the physician has had proper training.

My intent is not to inflame physicians. My intent is to outline to patients that practitioners who call themselves board certified phlebologists, who have not had adequate training in a specialty that is surgical or invasive in nature, and cannot manage independently any problem that may arise during the patient’s care. These practitioners, for the most part, do not hold hospital privileges.

With the constitutionality of The Affordable Health Care Act being upheld by the US Supreme Court, I speak as one of the few physicians who have had formal training in one of the surgical specialties treating venous diseases. We as a group should stand up and confront the unpleasant reality of who could and should care for patients with venous disease. Doing so will exclude many of those inadequately trained board certified phlebologists from this field in order to protect the integrity of those surgeons who are trained in vascular surgery, arterial and venous disease. It will assure the public that this field is not a “wide open free-for-all” that allows any physician to use the label “phlebologist” just because he or she took several weekend courses and passed a written exam.

I will elaborate on several of these points that I have raised. First, the three surgical specialties that include formal training in operative management and the medical care of these patients with diseases of the blood vessels are general surgery, vascular surgery, and cardiothoracic surgery. Board certification in general surgery has been a prerequisite in order to gain board certification in the other two specialties after an additional two or three years of additional training. It is often forgotten that starting in medical school and later in surgical training, we are taught that a surgeon/physician should not be performing a procedure if they are incapable of providing complete post-opcare including being able to deal with any potential complication that might have occurred as a direct result of the procedure performed. Thus, given the fact that these three surgical disciplines are the only specialties that train the residents to master the expertise in performing the technical aspects of each vascular/venous procedure and post operative management, which on a rare occasion may require hospitalization, should make complete sense to both physicians and those with no medical background that no other specialty has the qualifications to treat these sometimes complex and often misunderstood diseases of the venous system. Clearly a neurosurgeon, one of the most highly trained surgical specialists who deals with some of the most critically ill patients, does not practice phlebology. Any physician, however, who has performed a residency in any one of the recognized specialties can call him or herself a phlebologists and say they are board certified if they pass a written test and have additional documentation of having some experience dealing with venous disease.

What is your opinion on the role of the ABPh as a professional standard for the field of phlebology? How do you think the ABPh is positioned with respect to future ABMS certification?

Nearly one year ago, I wrote an article for WebMD regarding the medical training that interns and residents must endure on their journey to gain board certification as a physician or a surgeon. This was in response to regulations implemented in 2003 by the Accreditation Council for Graduate Medical Education (ACGME ). While the intent was to create a more humane residency training, I felt that the changes in training hampered the ability of new doctors to deal with real world medicine after residency. Required residency hours were lengthy and medical professional communities recognized the potential dangers that excessive work hours under stressful situations posed on several levels, including sleep deprivation and the resulting increased rates of medical errors due to fatigue. The ACGME then looked at the current residency programs. This included studying time requirements spent at the hospital, patient safety issues, resident wellness, and the resident training experience. In 2007 regulations were restricted to 80 hours per week for medical residents in training, overnight call frequency of no more than one overnight every third day, 30-hour maximum straight shift, and 10 hours off between shifts; albeit voluntary, adherence had been mandated for the purposes of accreditation of the residency. Moreover, first year residents, also called interns, were limited to shifts no longer than 16 hours straight due to these newly regulated standards effective on July 1, 2011.

While patient safety advocates and surgeons themselves felt trepidation about these drastic changes that would alter the way residents would be trained, still the ACGME implemented the new standards in an effort to protect residents from sleep deprivation, fatigue, and the medical errors that can follow from longer work hours. Second year resident schedules allowed up to 24 straight hours, with 4 additional hours permitted to ensure proper patient handoff,as opposed to the previous standards whereby 24 hour shifts were the maximum for all residents, with 6 additional hours for patient hand-off.

With this as a background, I want to discuss board certification and clarify what it is and why it is so important, and then talk about the current state of the medical specialty know as phlebology.

First of all, many doctors and most laypersons are unaware that there are only 24 approved medical specialties. The American Board of Medical Specialties (ABMS) was created to assist these 24 medical specialty boards in the development and use of standards in the ongoing evaluation and certification of physicians. The ABMS, recognized as the “gold standard” in doctor certification, believes that better trained physicians means better care for patients.

Unfortunately, phlebology is not one of the 24 recognized medical specialties and there are no formal university-based training programs in existence today. The American Board of Phlebology was formed in 2007 with the goal of setting standards of practice, establishing training programs in venous disease, and to promote excellence in treatment by “credentialing” doctors who can pass a written exam, have trained in one of the 24 ABMS recognized specialties and have letter documentation of confirmation that they have trained in phlebology in some way. The different ways to achieve “board certification” in phlebology by the American Board of Phlebology is listed on their website.

In fact, the ABPh states clearly on its website that “It is not the purpose of the Board to define requirements for membership on hospital staffs, to gain special recognition of privileges for its diplomates in the practice of Phlebology or to define the scope of Phlebology practice. The Board does not define who may or may not practice Phlebology. It is neither a source of censure, nor an entity for the resolution of ethical or medico-legal issues.” This basically says the Board is not responsible for who does what, what their training is, or where they do it at.

In contrast, I use The American Board of Thoracic Surgery as an example. It maintains the standards and provides certification only to those cardiothoracic surgeons who have gone through a rigorous training program that includes a vascular component. It is only after successful completion of training, attainment of certain operative requirements, and the ability to provide complete care for these seriously ill patients, that one can be accepted to sit for the written board examination. If successful, he may be accepted to sit for a very difficult oral examination. Once each requirement is completed, a person can call himself board certified in thoracic surgery.

The requirements to maintain board certification in the three surgical specialties I have mentioned that are uniquely trained to diagnose and treat venous disease include having active privileges at a JCA HO accredited hospital and soon will require all diplomates be approved and then mandate participation in a well established outcome database. Unfortunately, board certification in phlebology does not require the physician to have hospital privileges, allows any physician of any specialty to perform these office based procedures, and then if a problem arises they often have to send the patient to the hospital and have a qualified physician treat their patient and deal with the complication that may have not occurred had a truly qualified doctor cared for the patient from the onset. Once again, I will state that a physician should not perform any procedure, in the event that a problem should arise, that their training did not prepare them to diagnosis and treat. That is just not how I was trained in my surgical programs and I do not know another surgeon who trained in the same specialty who will not echo this same sentiment.

How do you feel the various medical societies perform at providing education and training for the phlebologist?

Although the American Venous Forum does have a new database and should be applauded at their hard work to form the first venous registry in the United States, currently any physician who practices phlebology can participate and submit their results. Why is this a problem?

The simple answer is that a registry that is open to any “vein doctor”, whether qualified or not, who can submit their results is quite different from the Society of Thoracic Surgeons database. The STS database is only open to selected surgeons and their results are heavily scrutinized by independent medical personnel in order to assure the accuracy and veracity of data input since the outcomes are often used to generate new practice standards of care. The American Venous Forum Registry does not and cannot assure accuracy of data input and thus conclusions must be regarded with much caution.

The next question that one may ask is why the AV F Registry matters anyway? The brief answer is that the Affordable Health Care Act assures us that government regulators and insurance company analysts will look at these databases and decide on the universal acceptance of certain procedures by looking at cost versus benefits model and obviously the outcomes generated. If the registry is allowed to continue in its present state, the results from endovenous ablative procedures cannot be trusted and could be outstanding due to inaccurate data input or dreadful because an unqualified, poorly trained doctor who has the lack of integrity to input his true results can make this outstanding procedure appear dangerous and lead to poor outcomes. This will allow government health agencies and private insurance companies to have complete justification to deem it dangerous and no longer pay for this non-invasive procedure which has become the gold standard in the treatment of venous reflux disease in the superficial venous system of the legs. This could require the antiquated and barbaric vein stripping, which must be done at a hospital or surgical center, to once again become the standard of care. This would propel the treatment of venous disease backwards and exclude patients that are now “too sick” to have their lower extremity venous disease treated surgically and any subsequent complications to be treated conservatively which would result in lost work days and increased medical costs.

Is there anything else you would like to add? /strong>

Since I am a board certified in both general surgery and cardiothoracic surgery, I will discuss training from my perspective as a surgeon. After 4 years of medical school and 9 more years of surgical training after that, I went into private practice as a heart surgeon in 1999. I did my general surgery training at Los Angeles County-USC Medical Center, which is probably the busiest hospital in the US. I performed over 1300 cases as the primary surgeon in 4 years and often spent 130 hours a week at the hospital. I did my heart surgery training at University of Miami-Jackson Memorial Hospital, which also is one of the busiest hospitals in the United States. Today, the graduating residents from the same general surgery program I trained at finish with around half the number of cases that I performed in the same time frame of training.

There is a reason that surgical training is extensive and complex. The first reason is to purge those doctors that can’t perform under such extreme conditions. The second reason is that in order to develop an excellent technical skill set in the operating room, there needs to be a graded approach to learn how to operate such that residents can operate and care for patients independently at the end of residency. Today, in most residency programs, many residents are only allowed to do a portion of the case, because the attending surgeon completes the surgical procedure. After graduation, how are these surgeons going to face a sick patient “alone” if they haven’t successfully performed the required procedures for board certification with great frequency and without being taught all the techniques? Indeed, if surgeons cannot perform invasive procedure and manage patients appropriately, how can the American Board of Phlebology continue their present stance and allow any doctor trained in an accredited specialty by the ABMS to have a chance at board certification in phlebology? If changes are not rapidly implemented, I fear the field is doomed to extinction.

The importance of what I have stated cannot be overlooked or brushed under the rug. General surgical residents who are one of the few physicians who learn vascular surgery during their training felt that the current training will probably not prepare them adequately with the skill set to operate and treat patients independently and with the confidence that graduates of the same programs until training changed in the early 2000s. If our future general surgeons leave training not well prepared unless they sub-specialize, how can we allow anybody to call himself or herself a phlebologist and treat patients? Clearly, if the trend is that surgical training programs appear to be falling short, is it fair to those of us properly trained in surgical specialties that deal with arterial and venous disease to have to sit back and watch a field implode by allowing all non-surgical specialties to perform invasive procedures without formal training? A weekend course is not sufficient to teach a procedure that if done wrongly can potentially lead to the death of a patient. At present, there is one non-accredited training program in phlebology taught by a surgeon in an academic setting. There are several “weekend” courses given on the treatment of venous disease at different locations that can be quite costly to attend. Clearly, those physicians without a surgical background cannot learn the technical aspects about how to perform a procedure by taking a course and therefore, the motives of those physicians teaching these courses should be suspect. If a board certified vascular surgeon was to perform endovascular arterial procedures, they are required to spend several months learning the proper techniques ataccredited high volume programs and indeed they already have all the skills and board certification in vascular surgery. This standard does not apply to a non-surgical physician who wants to learn phlebology, and as of now it appears only a few surgeons are willing to speak up and talk the about reality of future healthcare and how it relates to the practice of phlebology. Taking a written exam or several courses should not be allowed to suffice to meet the requirements to allow any doctor to call themselves a board certified phlebologist. Those of us surgeons who have the skills and knowledge base to deal with any venous problem and any

complication which might arise are the only hope to insure that the field of phlebology continues to expand, have excellent patient outcomes using new minimally invasiveprocedures, and maintain the highest ethical standards thatare instilled during surgical training.

E.J. Sanchez, M.D., F.A.C.C., R.V.T., R.P.V.I., C.C.R.P., practices at the Cardiovascular & Vein Center of Florida. He is a diplomate of the American Board of Internal Medicine and Cardiovascular Disease, and a member of the American Society of Nuclear Cardiology, Society of Nuclear Medicine and the American College of Physicians.

What are your opinions on an exclusionary (surgeon only) versus inclusionary approach to the field of phlebology?

To give preferential exclusionary privileges to any group solely on the basis of being part of a group is “group and egocentric bias” or for a better word “deformation professionelle”. The advancement in the treatment of venous disease today is the contribution of many different fields of medicine and surgery. These include dermatology, general medicine, radiology, and surgery.

Lately, there has been a lot said about the treatment of deep venous disorders being exclusive to surgeons. Some of the reasons mentioned are that the procedures being performed are invasive procedures and a surgeon would be more capable to treat any complication that might arise. Another is that self-proclaimed interventional nephrologist performing outpatient peripheral interventions (venous or arterial) may encourage other non-fellowship trained physicians already treating veins to do the same. At present, in order for a non-fellowship vascular physician to be able to perform these procedures he might attend one or several observational course(s) usually sponsored by a device company or colleague. These courses range from teaching basic angiography skills to performing complex interventions. It is left to the trainee when to proclaim himself as a trained interventional physician competent to perform the procedures of his choice, sometimes performing these procedures in an outpatient procedure lab in which he or she gets to participate in both the professional and technical component.

I suspect that this training track should raise issues of concern in the medical community if it continues to become common practice and include other specialties. I hope that we can be honest and use our common sense. Deep venous interventions require advanced knowledge and training which are acquired in a formal fellowship program. Perhaps a solution when it comes to treating deep disease is assuring they are performed in a hospital setting. This will allow for peer review and credentialing committees to assess safety and competency. The only way that a self proclaimed interventionalist gets to perform these procedures is by operating within an outpatient procedure lab because no hospital would ever allow it. In an era of scarce resources and skyrocketing health care costs the last thing we need is more outpatient procedure labs. Shut down the outpatient procedure labs and this would no longer be a concern. Is this something our legislative branch of government might want to address?

What is your opinion on the role of the ABPh as a professional standard for the field of phlebology? How do you think the ABPh is positioned with respect to future ABMS certification?

The ABPh has contributed to the field of phlebology. It has created the platform in which different fields could share and integrate their knowledge of venous disorders. It has always been inclusive to all specialties willing to contribute to the field of phlebology. It has converted this consensus knowledge into suggestions and possible guidelines in the treatment of venous disorders.

It created a process of certification for its members to demonstrate a minimal knowledge in the field of phlebology. This certification process is not a “board certification” and is not intended to be misleading.

How do you feel the various medical societies perform at providing education and training for the phlebologist?

Most medical and surgical societies have their own source of information in the field of venous disorders. However, most of them still list vein stripping as optimal and claim