The time is now for vascular medicine

Vascular disease represents the number one cause of morbidity and mortality in the United States. The burden of vascular disease is enormous, and its manifestations are broad, ranging from acrocyanosis to aortic aneurysm, pernio to peripheral artery disease, venous thromboembolism to vasculitis. Indeed, vascular disease has occupied this ignominious position for decades and currently lacks a holistic medical home.

In a 1990 Annals of Internal Medicine editorial, SVM founding members John Cooke and Victor Dzau declared ‘The time has come for vascular medicine’, and predicted that a growing workforce of clinicians with advanced specialized training would expand the pool of physicians able to care for the growing population of patients with vascular disease. ¹ They envisioned that this vascular medicine workforce would collaborate with others on multidisciplinary care teams, ‘forming a bridge with vascular biologists to bring therapeutic advances to clinical fruition’ and would ‘apply the latest therapeutic and diagnostic tools to give optimum care to patients suffering from vascular disease . . . and will appropriately refer these patients for invasive interventions’. ¹ Unfortunately, though this call for vascular medicine has occurred on multiple occasions, it has yet to come to fruition more than 30 years later. ² Despite the exhaustive efforts of many in our community, the subspecialty of vascular medicine is not yet recognized by the American Board of Medical Specialties (ABMS), and our vascular medicine training programs are still not accredited by the American College of Graduate Medical Education (ACGME).

The Society for Vascular Medicine (SVM) has created a significant foundation upon which to build a certified specialty. The tripartite mission of a mature medical field includes a clinical corpus, an educational program to continually recreate and augment the work-force, and a research enterprise to understand the mechanisms of disease and devise new treatments. Despite the failure to achieve certification, our field has had great successes in the years since Cooke and Dzau’s editorial. Standardization of the key body of knowledge recognized by a multispecialty panel of societies and certification as an expert in vascular medicine (as well as endovascular medicine) has been available through the American Board of Vascular Medicine (ABVM) for almost two decades and is now administered by the Alliance for Physician Certification & Advancement (APCA). There are approximately two dozen vascular medicine training programs in North America listed on the SVM website, ³ and broadly endorsed training standards in our field have been published. ⁴ In 2023, the membership of SVM surpassed 700 members for the first time as the field expands its reach to people and places formerly unaware of our discipline. Vascular medicine specialists have held leadership positions in major cardiovascular organizations in the United States and have an impact on vascular care through their active involvement in clinical trials, guideline development, scientific investigation, advocacy, and education. Each year brings new clinical vascular medicine programs into existence at institutions across North America.

The value of a medical specialty is generally represented by not only its impact on individual patients in the office, but on systems of care, quality improvement, clinician education, and scientific advance. Patients see the value directly in 1:1 interactions when speaking with a clinician with topic-specific expertise. Physicians see the value in referral to vascular colleagues who can assist with diagnosis, management, and patient education. Hospital administrators see the value in efficient, appropriate, cost-effective care delivered in both acute and chronic settings. Leveraging the value of our field is the pathway to our mandatory goal of certification.

In applications to various bodies for subspecialty recognition over more than a decade, some have suggested that our subspecialty has not adequately demonstrated its incremental value with a unique body of knowledge extending beyond internal medicine or cardiovascular medicine or by its potential impact on patient care and clinical outcomes. We recognize the unique skillset vascular medicine specialists bring to the health care setting, but we have not demonstrated it sufficiently to others. We have observed mixed messaging in this space marked by groups who endorse our expertise in word but not deed. ⁵

To address this gap, the SVM Subspecialty Recognition Taskforce issued a call for proposals to study the impact of vascular medicine in common health care settings. In this issue of Vascular Medicine, three of these SVM-funded studies are published, and each provides evidence to support the value of the skillset that vascular medicine specialists bring to bear to enhance the quality of care for patients with vascular disease.

In the first article, Whipple and colleagues provide data regarding the utilization of supervised exercise therapy (SET) among 5320 patients with PAD cared for at the University of Minnesota over a 5-year period. ⁶ Among the 415 patients who ultimately enrolled in SET, vascular medicine specialists accounted for 31% of referrals, well beyond the proportion of physicians who see these patients. These data demonstrate that vascular medicine specialists are effective in applying guideline-recommended, efficacious, and cost-effective noninvasive therapies for their patients with vascular disease.

In the second article, Vlazny and Houghton describe the effectiveness of vascular medicine consultation on an inferior vena cava (IVC) filter retrieval initiative at Mayo Clinic from 2018 to 2022. ⁷ They report a 42% increase in IVC filter retrieval when patients were seen at follow up in vascular medicine compared to those without vascular medicine involvement. Further, they report that initial vascular medicine consultation for consideration of IVC filter placement resulted in 68–74% of patients avoiding IVC filter insertion altogether, instead managed with alternative strategies. This study highlights the role vascular medicine specialists can play in determining appropriate use of interventional therapies/devices. The question is not whether a filter can be placed, but whether there is a benefit to that placement. Vlazny and Houghton’s work shows that initiatives to address the appropriate use of a low-value therapy right-sizes its usage.

Finally, in a third article, Kaushik and colleagues report on how vascular medicine specialists can lead multispecialty programs to care for diseases that lack a definitive medical home. ⁸ They recount the outcomes of a coordinated care program for patients with severe Raynaud’s phenomenon requiring inpatient hospital admission. The vascular medicine consultative service implemented a tailored therapeutic plan to these significantly impaired patients, including intravenous vasodilators and chemical sympathectomy performed by partnering with hand surgeons. The aggregation of expertise within a coordinated care program created an effective strategy with improved outcomes for patients with this difficult to treat condition.

In aggregate, these three publications provide the first salvo of evidence of the many ‘value adds’ vascular medicine specialists bring to the health care system: prescription of guideline-recommended medical therapies; increased referral for therapeutic procedures when clinically indicated (and avoidance when not); collaboration with partnering specialists in the care of patients with vascular disease; and leadership in the multispecialty care of patients with rare or orphan diseases that lack a medical home. Further, these manuscripts highlight work from programs with longstanding clinical vascular medicine programs (Mayo Clinic, University of Minnesota) and a newer kid on the block (Beth Israel Deaconess). Taken together, these studies represent the beginning of an effort to stockpile published, peer-reviewed evidence that verifies the value of our specialty and the favorable impact vascular medicine has on patient outcomes.

Although these three investigations validate the value of vascular medicine, they represent only a fraction of the ongoing work in our field at many medical centers and practices across the United States. To make the case for vascular medicine certification, we must publish more data to demonstrate our unique body of knowledge and impact on patient care. We want to hear from you. Vascular Medicine, as the primary outlet for vascular medicine clinicians and written voice of the SVM, can now announce a permanent call for papers demonstrating the value of vascular medicine in practice.

The work to show our value does not require changing behaviors or career modifications. It only requires that we report what we are doing every day, in every office and hospital floor, for every patient. We no longer have the luxury of ‘just doing our job’ and toiling in obscurity. We need to show our wares. We need to continually expand our efforts to improve patient care and report our work. These efforts will always find a home in this journal.

The SVM Vascular Medicine Subspecialty Recognition Taskforce, in its various incarnations, has been working toward its goal for more than 15 years. Navigating the waters of certification is neither simple nor straightforward. That said, the work of the Society, our interactions with other practitioners in the vascular space, our participation in the creation of guidelines, the presence of our members at the highest leadership levels of many organizations, our collaborations with regulatory agencies and industry, and our expansion across the United States in one hospital after another are collectively bringing us closer than ever to subspecialty recognition. Changes in the certification environment may soon create circumstances favorable to our goal. The Taskforce will continue to work on our field’s behalf until we have achieved our objective.

The endgame is in reach. Now really is the time for vascular medicine!