Vascular medicine and phlebology: Where do we intersect?

As we begin the new year, the societies representing vascular medicine and phlebology embrace new opportunities while facing the existing challenges of growth and recognition. This issue of Vascular Medicine is devoted solely to venous disease, a core area of vascular medicine training. As the field of phlebology also relates to venous disease, the question arises, what is the relationship between vascular medicine and phlebology and are vascular medicine specialists also phlebologists?

If you search a most trusted source (and yes I say this with sarcasm), Wikipedia, for the definitions of vascular medicine and phlebology you will find that vascular medicine, aka angiology, is the “medical specialty which studies the diseases of the circulatory system and of the lymphatic system, i.e., arteries, veins and lymphatic vessels, and its vessels” while a phlebologist is a “medical specialist in the diagnosis of disorders of venous origin.”^1,2 If you agree with these categorizations, it would seem that vascular medicine specialists indeed are also phlebologists. However, some might argue that the depth and knowledge of the phlebologist surpasses vascular medicine core training in venous disease. With this background, let’s take a closer look at key areas that may help distinguish vascular medicine from phlebology.

First, who are practicing vascular medicine specialists? In general, these include physicians (MD or DO) who have completed internal medicine training and have sought additional formal fellowship training or practice-based experience in vascular medicine and are eligible to sit for the American Board of Vascular Medicine certifying examination. ³ This group includes a substantial membership of cardiology trained specialists including interventional cardiologists. In contrast, providers practicing phlebology come from numerous specialties and training pathways including general and vascular surgery, family medicine, internal medicine, dermatology, obstetrics and gynecology, emergency medicine, interventional radiology, cardiology and of course, vascular medicine. Most have practice-based training in venous diseases or training through vascular surgery, and can choose to certify through the American Board of Venous and Lymphatic Medicine (ABVLM), formerly known as the American Board of Phlebology. ⁴

A document entitled “Postgraduate training in vascular medicine: proposed requirements and standards” outlining fellowship training guidelines was published in Vascular Medicine in 2003. ⁵ This document, now somewhat outdated, details a one-year training plan for those who have completed an internal medicine residency with core rotations incorporating study of venous disorders, including venous thromboembolic disease, hypercoagulable states, chronic venous diseases, lymphatics diseases as well as imaging related to the aforementioned diseases. The plan includes rotations in peripheral angiography, catheter-based endovascular intervention and vascular surgery for the purposes of exposing trainees to the indications, interpretation, potential complications, limitations and quality assessment of these interventions, but not performance of interventions. ⁵ More recently, the American College of Cardiology plans to publish the core competencies in vascular medicine within cardiovascular medicine fellowship training under the new Accreditation Council for Graduate Medical Education (ACGME) format, to include medical knowledge of the anatomy, pathology, pathophysiology and differential diagnosis of venous disease, pharmacological and interventional treatments for venous disease, laboratory tests to assess for thrombophilia, causes and treatment of lymphedema, interpretation of duplex testing for venous disease and evaluation and management of risk of venous thromboembolism. ⁶

In 2014, the American Board of Venous and Lymphatic Medicine published the core content for training in venous and lymphatic medicine. ⁴ Notably, lymphatic disease was added as a specific area of knowledge. The core content is composed of five major categories: basic science, diagnostic evaluation, knowledge, procedures and skills integral to the practice of venous and lymphatic medicine, clinical sciences and other components and core competencies of the practice of venous and lymphatic medicine. The strength of this document is its provision of a comprehensive and extensive description of specific areas of core knowledge and expertise developed with input from key specialty stakeholders. A core focus area of the ABVLM training content is interventional treatments of venous disease including endovenous ablation, surgery for venous incompetence, ambulatory phlebectomy, sclerotherapy, and interventional treatment modalities for deep venous thrombosis and obstruction. Clearly, the emphasis on provision of endovascular and surgical treatments for venous disease may be inherent to phlebology training. Traditionally, vascular medicine training is solely cognitive, although many vascular medicine specialists have sought additional training in venous intervention and have incorporated these treatments as part of their routine vascular medicine practice.

Fellowship training in vascular medicine dates back to the 1930s and 1940s at the Mayo and Cleveland Clinics. There have been recent NIH-sponsored training programs in vascular medicine as the National Heart Lung and Blood Institute (NHLBI) recognizes the critical need for these specialists. Currently, there are at least 16 vascular medicine training programs across the United States with additional sites in development. ⁷ The American College of Phlebology provides financial support and guidelines for fellowship training in phlebology and currently there is one active training program at New York University (NYU). The ABVLM has taken on the task of expanding fellowship training in venous and lymphatic medicine and has developed a comprehensive fellowship curriculum with input from over 30 experts from six separate specialties including cardiology, dermatology, family medicine, interventional radiology, vascular medicine and vascular surgery. The ABVLM core curriculum document is expansive. However, the ABVLM recognizes that not all training programs will have the same curriculum as their circumstances and resources differ, but will be able to adapt this core curriculum as model content for instruction.

Another area of scrutiny is the evaluation and treatment of lymphatic diseases. While this area has been included in vascular medicine training and practice since inception, this skill set represents a new addition to both the name of the phlebology certification examination, now known as the American Board of Venous AND LYMPHATIC medicine, as well as to the core content described above. Some in vascular medicine, as well as specifically practicing lymphologists, have questioned this addition as there has been little mention of this at meetings of the American College of Phlebology and no previous guidelines for training. The challenge for phlebology going forward will be in providing training in this area and encouraging currently practicing phlebologists to incorporate this specialty as part of their core practice.

A key area of vascular medicine training and practice is non-invasive vascular diagnostic imaging. This expertise represents an important and core area of training in vascular medicine and distinguishes vascular specialists from their general internal medicine trained colleagues. Those who complete fellowship training in vascular medicine are eligible to sit for the Registered Physician in Vascular Interpretation (RPVI) certification examination administered through the American Registry for Diagnostic Medical Sonography (ARDMS); an examination which certifies competencies in interpretation of imaging of all vascular arterial and venous beds (www.ardms.org). Indeed, many vascular medicine specialists including those here at the University of Oklahoma Health Sciences Center (as well as at the Cleveland Clinic and other institutions) are responsible for the operation and accreditation of the vascular diagnostic laboratory as well as for the interpretation of the studies performed. For phlebologists, there is no current certification for venous imaging through the ARDMS, although a specific venous imaging interpretation credential is in discussion. Currently, the organization Cardiovascular Credentialing International (CCI) provides a Registered Phlebology Sonographer (RPhS) credential for which physicians who perform venous ultrasound are eligible to apply (www.cci-online.org).

Finally, the most important area of effort for both vascular medicine specialists and phlebologists is sub-specialty certification. The Society for Vascular Medicine is currently working towards recognition by the American Board of Internal Medicine (ABIM) since nearly all its trainees hail from an internal medicine background. This is an arduous and highly political process, but its success is crucial to the growth of the specialty and most importantly to the care of patients with vascular disease. Both the American College of Phlebology and the ABVLM have a similar goal in mind. Identification of a sponsoring board is less clear since phlebologists come from diverse practice backgrounds, and ultimately the American Board of Medical Specialties (ABMS) may be involved in this process. The American Medical Association and the American Osteopathic Association have added phlebology to their list of self-designated practice specialties. It is important to note that the ABVLM has recognized the important role that vascular medicine plays in the care of patients with venous and lymphatic disorders, and it has included vascular medicine specialists in these endeavors.

So, to answer the question whether vascular medicine specialists are also phlebologists, I would say yes to those who have completed fellowship training or who care for patients with venous disease in their practice. But, this is really a distraction to the larger question. Are there opportunities for vascular medicine specialists and phlebologists to work together both for education and recognition? And, to that I would answer a resounding YES! Both groups have the ultimate goal of improving the care of patients with venous disease. In the spirit of collaboration, the American College of Phlebology’s annual meeting includes a session organized by the Society for Vascular Medicine. In addition, there is discussion regarding the incorporation of the venous and lymphatic disease curriculum developed by the ABVLM into vascular medicine fellowship training. Steven Zimmet, president of the ABVLM, has written in an editorial in VEIN that “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…”. ⁸ I agree wholeheartedly with Dr Zimmet. As I get older, and hopefully a little wiser as my vanity wanes, I have learned it is not really about what name you give yourself, but more about what you strive to change. So, go forward vascular medicine specialists, and enthusiastically embrace your inner phlebologist!