Phlebology International

VEIN Editor Claudia Schou recently caught up with highly acclaimed phlebology expert Kurosh Parsi, M.D., FACD, FACP, who is serving a tenure as conjoint senior lecturer at the University of New South Wales and as president of the Australasian College of Phlebology.

What is the history of phlebology in Australia?

The Australasian College of Phlebology was established in 1993 as a nonprofit organization founded to improve the standard of care related to venous disease. The discipline has grown over time, and the college has clinicians, practitioners and researchers in all states and territories in Australia and New Zealand. The profession is particularly strong in Sydney and Melbourne, with the chancellor of the college, Professor Ken Myers, being a leader of the Victorian faculty.

The early days of what we might call phlebology in Australia, the 1950s to the mid-1960s, saw the dominance of the general surgeon—with general agreement that outcomes were poor in a relative sense. During this early era, Peter Halliday and John Loewenthal developed the vascular unit at the Royal Prince Alfred Hospital with expertise in arterial surgery twinned to investigative venograms, and Australians such as Professor John Ludbrook conducted landmark studies on venous physiology. The Fagan period saw George Fagan of Rotunda Hospital, Dublin, influence the Australian scene incredibly. The huge move to compression sclerotherapy was supported by numerous trainee surgeons studying under Fagan in Ireland. Peter Conrad’s paper in the Medical Journal of Australia [1967:1:1011] on the topic and a flurry of correspondence saw informal networks develop into the Australian and New Zealand Society of Phlebology, with key leaders being William Campbell Sr. [of Brisbane], Peter Conrad [of Sydney], and John Royle [of Melbourne].

In the last 20 years, Australian practices have grown much more international in nature and character. More-accurate noninvasive investigations have been introduced at the same time as key research findings on the Doppler and duplex ultrasound by figures such as Large, Myers, Richardson and Beckwith. Non-surgical interventions gained massive popularity in this period thanks to the early efforts of Paul Thibault [of Newcastle], who introduced ultrasound-guided sclerotherapy (UGS) to Australia in 1989 and founded the Sclerotherapy Society of Australia in 1993. Catheter-guided sclerotherapy technique [was invented by me] in 1997, and foam sclerosants were introduced to Australia by a friend of the college, Attilio Cavezzi of Italy, in 1999. Ken Myers [of Melbourne] introduced endovenous laser ablation (EVLA) in 2001. The Australasian College of Phlebology was founded in 1999. The first presidents of the college, Paul Thibault and David Jenkins, were followed by [me]. Professor Ken Myers was elected chancellor of the college in 2007, and Professor Andre van Rij [of Dunedin, New Zealand] as Deputy Chancellor. The college inauguration ceremony in 2007 was a milestone in the history of phlebology in Australasia.

An initiative of the college, The ANZ Journal of Phlebology, began publishing in 1999. The standing of the journal and its articles is critical to providing practitioners, in particular those who are not able to avail themselves of the conference or symposium opportunities either domestically or internationally, with key reference points to alert them to trends and research impacting day-to-day clinical environments. Two examples of journal articles that generated significant interest were 1999 and 2001 papers on hot topics. The November 1999 Cavezzi and Frullini paper on the role of sclerosing foam in ultrasound-guided sclerotherapy of the saphenous veins and of recurrent varicose veins exposed Australian practitioners to European expertise hard to access from Adelaide, the Barrier Reef or Canberra. The June 2001 paper on traveler’s venous thromboembolism, by authors and colleagues Michael McGrath and Reg Lord, was on a topic that had caught and still retains both patient and clinician interest.

The college’s training program, introduced in 2000, is well regarded both domestically and internationally. A flexible and highly workplace-relevant preceptorship with the college is a valued commencement towards a rigorous fellowship program.

What are your key initiatives and goals for the next five years?

The college has grown into a standalone professional body with offices close to the Sydney [Central Business District], a functioning training program and a desire to obtain specialty recognition within the foreseeable future.

The college is positioned to make a major contribution to the development of depth and expertise in the profession by the provision of training programs that meet the needs of a diverse set of stakeholders. Australian medicine exhibits an ageing demographic with respect to its doctor workforce, and the desire of many regional/rural medical practitioners to undertake specialist training that would allow them room to grow their practices is acknowledged. At the moment, the majority of inquiries for training are being received from doctors in the northern and smaller states of Queensland and South Australia.

With a professional secretariat and a board following more-corporate strategies for the organization, there is scope for greater direct government-to-sector involvement. The current board has initiated projects that reach the key areas of defense health recruitment, regional/rural city-service provision and student awareness of phlebology.

The rollout of faculty leadership teams [with onsite educational and training commitments] is a natural goal for the period of 2008 through 2013.

Who delivers phlebology care in Australia?

About 30 percent of Australian vascular surgeons and practically all vascular physicians in Australia and New Zealand are fellows of the college. Given that not all vascular surgeons are interested in treating venous disease, this is an impressive figure. Phlebology is also practiced by medical practitioners with a background in dermatology, interventional radiology or general practice. A number of hematologists with a special interest in thrombosis and hemostasis are affiliate fellows of the college. Sonographers, coagulation scientists, phlebology nurses and other allied health professionals are affiliate members of the college. A significant number of fellows are providing teaching leadership at key Australian medical schools.

In terms of provision of patient care, vascular physicians, dermatologists and general practitioners run ulcer clinics in public hospitals. Community nurses play a major role in looking after ulcer patients. Very few vascular surgeons have an interest in management of leg ulcers. General surgeons and some vascular surgeons continue to strip veins in the public or private hospitals. Fellows of the college and some non-fellows provide non-surgical treatment options for varicose veins such as ultrasound-guided foam sclerotherapy, radiofrequency ablation (RFA) and endovenous laser ablation (EVLA). Very few college fellows and a handful of surgeons offer ambulatory phlebectomy. Some fellows, such as myself, treat vascular anomalies both privately and within the public system. Clotting disorders, deep-vein thrombosis and thrombophilia is managed by most college fellows as well as other hematologists and surgeons. Lymphedema is managed by occupational therapists, physiotherapists and very few medical practitioners. Certified members of the college, trained cosmetic general practitioners, very few nurse injectors as well as beauticians and non-trained GPs offer direct vision sclerotherapy. Vascular laser therapy, including IPL [intense pulsed light laser], is offered by dermatologists, GPs, nurses, plastic surgeons, beauticians and more.

How do most doctors get their training?

Common to Australian standards, medical practitioners complete a rigorous university-level period of training in medicine, followed by two years of internship and residency in the public hospital system. Following this, they may apply to the college to pursue preceptorships and/or formal training. The formal training to achieve college fellowship takes four years to complete. This is compatible with most other specialties.

What training opportunities are available?

The college offers preceptorships which are akin to initial training exposures to the full run of clinical practices. For further training, there is a basic phlebology training of one-year duration that certifies the practitioner in sclerotherapy and an advanced three-year training which certifies the practitioner in phlebology and more-advanced procedures. The training is done under a regime of log books, formal examinations and supervision. Those completing the four-year training program gain fellowship of the college. This is complemented by regular workshops and annual refresher courses.

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

I strongly believe that phlebology, in its true sense, should be recognized as an independent medical specialty. A phlebologist should be able to manage any vein-related disorder of any nature in patients of any age group. The phlebologist should be the specialist to treat and manage clotting disorders of any kind: pelvic, upper limb and truncal venous pathology; vascular malformations; vascular tumors; lymphedema and lymphatic malformations; leg ulcers; dermatological conditions with underlying venous pathophysiology such as acroangiodermatitis; pigmented purpuric dermatoses; reticulate eruptions; and pediatric syndromes such as Cobb and Proteus should be easily diagnosed and managed by phlebologists. The basic science research in phlebology expands into coagulation disorders; vascular biology; genetics; biophysics; and, of course, fluid dynamics.

The key message is that for phlebology to be recognized as a medical specialty, it cannot have a narrow focus. Although phlebology overlaps with some other specialties, no specialty on its own can cover the range of conditions that a true phlebologist may come across. Despite what some colleagues think, phlebology is not all about treating varicose veins. Similarly, you cannot be called a “dermatologist” if all you know about dermatology is treating skin cancers. This is why our training curriculum is comprehensive and inclusive and reflects the width and depth required by our training standards.

The Australian Medical Council (AMC), representative of the government and key health stakeholders, does not at this stage recognize phlebology as a specialty discipline; however, the Australian Medical Association has accepted phlebology as a section interest in its NSW structure as a precursor to further developments. The college is in the process of gaining recognition of its training program and, ultimately, phlebology as a specialty. It is noteworthy that the announcement by the American Medical Association to add phlebology as a self-designated practice specialty has been very much noticed on this side of the Pacific.

As Dr. Paul Thibault, a former president of the college, noted in December 2005, the pathway in Australia to specialty recognition is long, complex and somewhat frustrating. The AMC is the gatekeeper and is given strong riding instructions from the national government. The three key criteria appear to place most emphasis on improvement of safety of health care; improvements to health care per se and data analysis; and, finally, cost-effective health-care delivery. With Australians having elected a new government after 10 years of a conservative administration, with new ideas facing Prime Minister Kevin Rudd, there is some ambiguity as to what to expect from any new body that may replace the AMC.

The data collection and core health preventative strategies advocated and implemented by the college are making some inroads on the pathway to specialty recognition. However, readers in various jurisdictions would recognize the speed and care that health regulators display with similar liberal democratic systems of check and balance. The Australian context is also very much influenced by recent community data that shows very strong voter preference for government- or substantially government-endorsed, delivered or funded medicine.

Is phlebology taught in medical school and residency programs?

Undergraduate teaching of phlebology is slight in the current medical school curricula; however, the college is seeking to establish greater awareness amongst senior medical students through scholarship programs and via presentations at key professional events in all major capital cities. The launch of the Victorian faculty of the college, to be conducted in Melbourne in late 2008, is an opportunity for the governor of Victoria—His Excellency Professor David de Kretser AC (Companion in the Order of Australia), himself a noted medical leader in his previous professional life—to announce the very first outreach to senior medical students. If phlebologists can get to key fifth-year students before they are seduced by the other areas of medicine, we may find the transition from undergraduate to fellow-in-training less arduous and more natural.

The college offers postgraduate teaching in phlebology. Related sub-specialties, such as vascular surgery, only offer limited exposure to venous disease, and the modern non-surgical techniques of management are nonexistent in these training programs. Our approach to postgraduate teaching of phlebology is unique in the sense that we offer a mutually inclusive training in all allied and related fields such as hematology and dermatology.

Is there a certification program in Australia?

The college certifies practitioners who have completed the basic training program in sclerotherapy and those who complete the advanced training program in phlebology.

Does insurance cover phlebology procedures? What is the process?

Medicare Australia covers most procedures aimed at treating venous disease. EVLA has just recently received endorsement by the Medical Services Advisory Committee and will be covered by Medicare. There is no government funding in New Zealand.

What are the trends in phlebology in Australia?

There is a strong trend in Australia and New Zealand towards the non-surgical interventions for the treatment of varicose veins. With new procedures such as UGS, RFA and EVLA, stripping of varicose veins is rapidly becoming of historical interest. More surgeons and non-surgeons are training in these noninvasive procedures, and patients are enjoying the benefits. The college has had a leading role in the introduction of these new procedures and maintaining high standards of care. All college fellows practicing these procedures are required to submit their safety data to the college on a monthly basis. This is part of the continuous professional development program of the college, which was introduced two years ago.

What are the trends that you see internationally?

Phlebology is becoming more and more accepted as an independent specialty, and the profession is gaining more respect in the medical community. The 50th celebration of the Union International de Phlébologie (UIP) in Monaco in 2009 is a fitting benchmark for a profession that has made leaps and bounds in terms of technology, patient care and clinical innovation. As Professor [Eberhard] Rabe, the current UIP president, has made clear in his UIP manual message, the three foundation stones of phlebology are scienc , education and communication. The Australasian college is committed to making these vital and obvious features the cornerstones of our efforts in a region that offers high-level research opportunities, affordable education in medicine and clear communication pathways.