AMERICAN BOARD OF VENOUS & LYMPHATIC MEDICINE Update: November 2016 Sunday: Nov 6, 2016 Presentation Title: OC16A-6 - ABVLM Update Type: Concurrent Session Time: 8:50 AM - 9:00 AM Presented During: Research, Registry and Accreditation Presented During Time: 8:00 AM - 9:00 AM Location: Anaheim Marriott, Orange County 1 - 3 Role: Speaker Steven E. Zimmet, MD RPVI RVT FACPh President, ABVLM

Disclosures President, ABVLM

Testing of Foundational Knowledge in VLM ABMS Specialties

Vascular Surgery Qualifying Exam “To determine if candidate has adequate cognitive knowledge” Venous Disease: 8% 24/300 questions* Candidate could get every question wrong and still easily pass the exam While not necessarily a criticism it’s interesting to note that a candidate could get every single venous question wrong and still easily pass the exam. The point is just that being certified in vascular surgery does not necessarily imply comprehensive training in the management of the full spectrum of venous disease. *Based on exam content document updated Jan 2015 http://www.absurgery.org/default.jsp?certvsqe Accessed June 29, 2015

American Board of Surgery General Surgery Recertification Exam (2013) Over 300 questions Two related to venous disease Very general question about PE Purpose of thrombolysis Steve, I recently took the American Board of Surgery recertification exam for my third recertification.  The exam which consisted of over 300 questions contained two questions related to venous disease.  One question expected me to recognize that shortness of breath in a post-op patient might be due to pulmonary embolism and the other expected me to know that the purpose of iliofemoral thrombolysis is to preserve deep venous valves.  Sad.   Stephen F. Daugherty, MD, FACS, RVT, RPhS Medical Director, VeinCare Centers of Tennessee Tennessee Vascular Center Clarksville Surgical Associates, PLC 647 Dunlop Lane, Suite 100 Clarksville, Tennessee  37040 Voice 931-551-8991 Fax 931-551-4053 sdaugherty@clarksvillesurgical.com

Other equally important areas not included Exam includes content related to venous ablation, thrombolysis, filter placement, venous ultrasound Other equally important areas not included Clinical evaluation Sclerotherapy Phlebectomy Compression Most would agree that no ABMS specialty exam adequately tests knowledge in venous disease http://www.theabr.org/ic-vir-study

ABVLM Certification Process Licensing & Training Requirements Full unrestricted license: N. American physicians Residency program: approved by ACGME, AOA, Royal College of Physicians and Surgeons of Canada (RCPSC) or the Collège des Médecins du Québec in Canada Board certification: Must be or have been board certified by an ABMS, AOA or Canadian-recognized board CME: in VLM 45 hours relevant CME over last 3 year period References Discussions regarding opportunities for international certification Royal College of Physicians and Surgeons of Canada (RCPSC) or the Collège des Médecins du Québec in Canada

Residency/Fellowship Track Approved program completed w/in 5 years of application Venous disease, venous interventional treatment & venous ultrasound training was included in the core curriculum Director attests to competency ACGME, AOA, Royal College of Physicians and Surgeons of Canada, or Collège des Médecins du Québec or Phlebology Fellowship ABVLM Case Log (100 cases) Outcomes, documenting direct participation in cases over the prior 3 yrs Cases performed as part of a fellowship/residency may be included must have completed Residency training in a program approved by the Approved by recognized enitity or ACP approved phlebology fellowship Accreditation Council of Graduate Medical Education (ACGME) or American Osteopathic Association (AOA) in the United States, or the Royal College of Physicians and Surgeons of Canada (RCPSC) or the Collège des Médecins du Québec.

ExperienceTrack ABVLM Case Log (200 cases) Outcomes, documenting direct participation in cases over the prior 3 years Venous Duplex Ultrasound (1 of the following): Credential: RVT, RVS, RPVI or RPhs Document peripheral venous duplex ultrasound training in an ACGME-, RCPSC- or AOA- accredited Residency or Fellowship Case log: 100 cases of focused or complete diagnostic u/s over period not to exceed 3 years Description phlebology training references

ABVLM Certification Exam Content 200 Multiple Choice items across 6 Content Categories Category % Weighting on Exam Basic Science 8 Venous Diseases & Syndromes 20 Diagnostic Tools & Screening 10 Duplex U/S & Other Imaging 25 Treatment/Therapy 35 Professional Standards 2 Likely the comprehensive exam of knowledge of venous disease in the world

Exam Performance: Comparison with ABMS Boards Extensive psychometric analysis every item & exam as a whole Exam # of Items CSR SEM 1 226 .92 .17 2 220 .91 .15 3 309 .89 ABVLM (2008-2014) 188 4 200 .88 .16 5 205 .87 .225 6 321 .86 Extensive analysis by psychometricians of every item on the exam and the exam on the whole Comparison with 6 mature ABMS boards CSR: How well does the examination distinguishes between candidate abilities Our exam performs very well and in line with mature ABMS board exams Year N items CSR SEM 2008 192 .86 0.21 2009 185 .89 0.17 2010 186 .88 0.17 2011 183 .91 0.17 2012 192 .89 0.16 2013 181 .87 0.17 2014 194 .90 0.17 2008-2014 188 .886 0.17 CSR: Candidate Separation Reliability SEM: Standard Error of Measurement Data provided by Measurement Research Associates

ABVLM Exam: Pass Rate Exam Pass rate 87% 15 ABIM subspecialties (2008) 78-94% (median 87%)

Diplomate Specialty Background 754 diplomates + 12 board eligible Surgery 42% (General 29% & Vascular 13%) FP/IM 26% Radiology 9%

MOC 2.0 Part I: Professional Standing Part II: Life Long-Learning Part III: 10 year re-certification exam will be replaced by annual online process, with immediate feedback, references, information Annual MOC fee

The Future of Venous Disease: Where ARE We Going? Mark Meissner’s excellent key note at ACP Congress on Future of Venous Disease Mark H. Meissner, MD University of Washington School of Medicine Seattle, WA

Do We Need Venous Specialists? YES Do We Need Venous Specialists? There is some evidence for this Focus in the future should probably be on developing standardly trained venous specialists Large patient population 15 years of technological advances Inadequate training- Cognitive, Procedural Few training opportunities encompass the whole spectrum Courtesy of Mark Meissner

SIR Task Force develped guidelines for training in IR ACGME requirements for IR vague Inconsistencies in time on service, clinical training, and procedural experience have led to a wide variation in the knowledge base & technical skill of IR fellowship trainees Goals Train well-rounded interventional radiologists Covers range of percutaneous image-guided minimally invasive interventional procedures There is evidence of this JVIR 2013;24(11);1609–1612

IR Procedures Included 1. Imaging-guided biopsy and drainages; 2. Venous access placement; 3. Diagnostic peripheral angiography; 4. Peripheral arterial revascularization techniques; 5. Endovascular repair of abdominal and thoracic aneurysms; 6. Visceral/renal arteriography; 7. Diagnostic neuroangiography; 8. Embolization techniques (to treat traumatic bleeding, gastrointestinal bleeding, portal vein embolization, or fibroid tumors) 9. Percutaneous transhepatic cholangiography, biliary drainage, and biliary stent placement; 10. Nephrostomy tube placement; 11. Gastrostomy tube placements; 12. Dialysis fistula/graft evaluation and intervention; 13. IVC filter placements; 14. Vascular thrombolysis and thrombectomy techniques; and 15. Interventional oncology therapies such as ablative and transcatheter therapies. DOES NOT INCLUDE MANY OF COMMON VENOUS PROCEDURES IN USE TODAY Sclerotherapy, compression, phlebectomy, endovenous thermal ablation JVIR 2013;24(11);1609–1612

Vascular Surgery: ACGME Case Logs Procedure Mean # Cases (2011) Mean # Cases (2014) Mean # Cases (2015) Sclerotherapy 1 1.8 0.7 Endoluminal Ablation 11.2 13.9 11.4 Operation for VVs 6.4 6.1 5.7 Operation for venous ulcer 0.2 0.1 Venous reconstruction 1.3 1.7 1.6 Embolectomy/Thrombectomy (venous) 0.4 0.5 0.6 Transluminal mechanical thrombectomy 2.1 2.6 2.9 IVUS 1.5 Average VS trainee finishes training having done almost no sclerotherapy, <15 endovenous ablations, and 6 open surgeries, and surprisingly inadequate experience in deep venous procedures. And these numbers are not improving 2014-2015 ACGME Case logs: http://www.acgme.org/Portals/0/PDFs/450_National_Report_Program_Version.pdf 2013-2014 Case Logs: https://www.acgme.org/acgmeweb/Portals/0/SurgeryVascular_National_Report_Program_Version.pdf May do lot aortic reconstructions, but very low case volume for some aspects venous disease In the United States, a survey of vascular residents attending the American Venous Forum (AVF) Fellow’s course in 2007-2008 found that, prior to the course, less than ten percent of their time was devoted to venous disease, and less than one-half had access to a “vein specialist” or vein clinic experience.2 “The average duration of vascular laboratory training was five weeks with only thirty-five percent having education in vascular laboratory interpretation of venous studies.” Only 10% correctly classified patients using the CEAP system, and only 10% could define pathologic venous reflux. Lohr JM, Dalsing MA, Wakefield TW et al. Knowledge Deficit in Venous Disease Remarkable in Current Vascular Trainees. J Vasc Surg. 2009;49(5), Supplement:S21. http://www.acgme.org/Portals/0/PDFs/450_National_Report_Program_Version.pdf

“And Outcomes Reflect Inadequate Training” Presented by Mark Meissner ACP Keynote, Nov 2015 Review of UW data 5/13 – 5/14 26 patients undergoing chronic iliocaval stenting Mean Age – 45.8 ± 14.7 Female:Male – 15 (58%):11 (42%) Post-thrombotic – 21 (81%) Successful crossing in 24 (92.3%) Pre-existing stent failure – 5 (19%) Improper stent selection / sizing Improper overlap Failure to stent all disease “All of these failures could be avoided with good training, formal education rather than dabbling in venous disease” In his keynote Mark suggested that outcomes seem to reflect lack of training He reviewed a year of UW experience (5/13-5/14) complex chronic ileocaval occlusions- did 26 patients- successful 92%, ~ 20% of volume was on patients intervened on before (and this continues through today)- 100% of these are preventable- can always identify some reason stenting went wrong- usually because of inadequate training- my experience 3 reasons (see slide)- improper stent selection/sizing improper overlap of stent failure to stent all the disease all these failures could be overcome with good training- rather than dabbling in treating venous disease really having formal education

Bottom Line No specialty routinely provides comprehensive curriculum These gaps suggest the need for standardized training

ABVLM Education Initiative Multi-specialty consensus process to establish standards for VLM training Three steps Core Content Program Requirements Promote/support development of fellowships Three step With this in mind

Step One: Core Content VLM Core Content Basic Sciences Diagnostic Evaluation Treatment Modalities Clinical Sciences Other Components & Competencies Won’t bore you with the details, but it’s very granular within each category

Step Two: Program Requirements Graduate Medical Education in VLM Multi-disciplinary 2 year effort Serve as a guide for one-year fellowships Based on the ACGME template Defines the structure & requirements Identifies the knowledge and skills that must be mastered Aligned with the Core Content Milestones Putting finishing touches on this document Defines requirements for sponsoring institution, participating sites Program Director and Faculty- requirements, roles Resource requirements Fellow appointments- eligibility requirements Educational Program- curriculum patient care, competencies, medical knowledge, procedural requirements, scholarly activity Thirty experts from 6 specialties Cardiology, dermatology, family medicine, interventional radiology, vascular medicine & vascular surgery Core Superficial Procedures Compression, visual sclerotherapy, AP, tumescent anesthesia, thermal and NT ablation saphenous veins Advanced Superficial Procedures UGS, perforator ablation, ulcer debridement and care, inelastic compression application, Pelvic VI Core Deep Procedures IVC filer placement and removal, vascular malformations, IVUS, venous stenting, venous thrombectomy and thrombolysis, Program Requirements & Milestones published in Phlebology Sept 2016

Step Three Promote and support development of one-year fellowships Accreditation & Oversight Committee Fellowship Development Committee Toolkit Identify potential program directors and institutions Goal of fostering interest in offering fellowships Provide information and resources to potential program directors and programs Develop a list of potential program directors and institutions, and anticipates hosting F2F meetings with potential PDs

Value of VLM Fellowships Standardize training Graduate better educated physicians Foster academic development Young physicians can stimulate scientific inquiry Development of future faculty & leaders Increase credibility, representation, recognition Improve healthcare system & patient care Fellowships- increased credibility, visibility, increase meaning of certification to insurance and governmental agencies Important benefits regardless of quest for ABMS recognition Fellowship positions have been increasing since 2000, outpacing growth rate of residency positions, according to ACGME CEO Thomas J. Nasca, MD The ongoing professional responsibility to protect the public by defining who is qualified to practice remains a core part of medicine’s social contract (3) 2006: The Fellowship Program Committee simultaneously defined a Phlebology Fellowship Program patterned after an Accreditation Council for Graduate Medical Education (ACGME) post-graduate medical training program. Value of Fellowships: Add benefit for patients- reduction of piecemeal/fragmented care. Referring docs would better know who to refer to.

Goals Minimum of 5 one-year fellowship positions by 2020 Target of 10 positions by 2025 Once a few programs are in place, it will be useful to help create a PD association Passion

Subspecialty Recognition Recent examples of subspecialties that are now ABMS recognized that initially had a freestanding board Hospice & Palliative Medicine Sleep Medicine Addiction Medicine- application pending Addiction medicine- application submitted by American Bd Preventive Medicine

ABMS Recognition Historical Perspective Specialty AMA Recognition # Society Members Yrs Since 1st Exam # Fellowships Sleep Medicine 12 4000 29 40 Hospice/Palliative ? 3000 10 (22 after accred) 57 Addiction Medicine 25 3400 33 Vascular Medicine 18 400 7 16 Venous/Lymphatic 2000 1 Add Addiction Medicine- 25 fellowships, plan to get more http://journalofethics.ama-assn.org/2011/12/mhst1-1112.html

Birth of a Specialty VLM has many of the attributes associated with a subspecialty Distinct and well defined field of practice Many physicians’ practices focus on venous disease Venous medical societies exist around the world Numerous conferences devoted to venous disease Multiple journals dedicated to venous disease Reasonable to have a method to assess foundational knowledge Time to strengthen and standardize venous curricula and training in order to develop qualified comprehensive specialists Critical to achieving true subspecialty status Critical to achieving true subspecialty status Practice of venous medicine has many of the attributes associated with a subspecialty Venous medical societies exist in many countries Many conferences devoted to venous disease Multiple journals dedicated to venous disease Many physicians’ practices focus on venous disease Time to strengthen and standardize venous curricula and training in order to develop qualified comprehensive specialists Reasonable to have a method to assess foundational knowledge These improvements would get us much closer to true subspecialty status Birth of a true specialty Tremendous growth- many conferences devoted to vein care, many societies, journals, research, techniques. Standardized curriculum, training programs and accepted certification process as a way to demonstrate who has foundational knowledge in the field.

Let’s focus on the future and the opportunity we have to shape it