Vascular Lab 360: Are we losing control?

Transcription

1 From the Eastern Vascular Society PRESIDENTIAL ADDRESS Vascular Lab 360: Are we losing control? Ali F. AbuRahma, MD, Charleston, WV Only one who devotes himself to a cause with his whole strength and soul can be a true master. For this reason mastery demands all of a person Albert Einstein From the Robert C. Byrd Health Science Center of West Virginia University. Competition of interest: none. Presented at the Twenty-fifth Annual Meeting of the Eastern Vascular Society, National Harbor, MD, September 22-24, Reprint requests: Dr Ali F. AbuRahma, Robert C. Byrd Health Science Center of West Virginia University, 3110 MacCorkle Ave SE, Charleston, WV ( ali.aburahma@camc.org). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a competition of interest. J Vasc Surg 2012;55: /$36.00 Copyright 2012 by the Society for Vascular Surgery. doi: /j.jvs It is with the greatest honor that I stand before you today as president of the Eastern Vascular Society on this special 25th Anniversary of the society. This society has been very special to me since I joined 21 years ago, and I have not missed one single meeting since I joined in The Eastern Vascular Society was founded in 1987 by leaders in vascular surgery on the east coast of the United States, who have led the way in our society and played a prominent role in the leadership of our national Society for Vascular Surgery (SVS). In looking at the names of our past presidents, eight of them have served as president of the SVS/American Association for Vascular Surgery. It should also be noted that from the current officers of the Society for Vascular Surgery, the president, the vice-president, secretary, and the treasurer are current members of the Eastern Vascular Society. Over the past 25 years, our specialty has matured substantially. Today s vascular and endovascular surgeons provide the most comprehensive diagnosis and management of the entire spectrum of vascular disease, particularly in an era where several other specialists are engaging in treating patients with peripheral vascular disease. Today s vascular surgeons provide not only the best open vascular techniques but also the most modern endovascular therapy and comprehensive medical therapy. As vascular surgery has matured and expanded over the past 25 years, the Eastern Vascular Society has also expanded significantly. Today s Eastern Vascular Society is the largest regional vascular society in the United States, with approximately 600 members representing major academic medical centers and community hospitals in the eastern region of the United States and Canada. PERSONAL PERSPECTIVE I would not be standing here in front of you today without the assistance of many people who have had a huge impact on both my personal life and my professional career. I want to apologize in advance to anyone that I may miss who has influenced me, personally or professionally, but I must recognize those who have had special roles in my life. I would like to start by thanking my parents, who unfortunately cannot be with us today, since my father passed away 25 years ago and my mother 15 years ago. They would have been extremely proud of my achievements in the United States of America after their hesitancy regarding whether or not I should leave my native country and immigrate to the United States. Both parents instilled in me the importance of work ethics and integrity and taught me very important values regarding honesty, caring, and genuineness. Both were simple country people who would be proud of the achievements of their son on this occasion. My wife, Marion, has given me unwavering love, support, and understanding. She has been my companion for close to 30 years and has been, and always will be, my closest friend. I want to thank you, Marion, for the tremendous support you gave me in the early years when I barely had time to arrive home in time for dinner or for special occasions. As a surgical nurse, she always understood the duties and responsibilities that come with being a vascular surgeon. I also appreciate her hard work and dedication to our family. You are a loving mother and wife who has inspired all of us to be the best we can be. Thank you. I would also like to thank my three children, who have been patient and understanding, at least during the later stage of their life, regarding my duties as an academician and vascular surgeon. My two sons, Zachary and Joseph, and my daughter Chelsea, have given me a fulfillment that professional success alone could never have provided. My children provide me insights into my flaws. 571

2 572 AbuRahma JOURNAL OF VASCULAR SURGERY February 2012 Fig 1. Dr Boland: Professor and Chairman ( ), Department of Surgery, West Virginia University Charleston Division. On a professional level, I want to recognize a few important leaders who have had the greatest impact on my professional career, and I would like to start with the late Dr James Boland (Fig 1), who chaired the Department of Surgery at the Charleston Campus of West Virginia University/Charleston Area Medical Center (CAMC) for 35 years. Dr Boland fostered my interests in vascular surgery during my senior surgical residency and served as a talented and unselfish mentor during my early academic career, which continued until his death in April Dr Boland was an inspiring leader, master surgeon, and a man of few words who had the utmost integrity and dedication to surgical education. To me, he was a mentor, great friend, father figure, and my true hero. I wish he could have been with us today because he would have been very proud of my achievements. Dr Boland, we miss you. I would also like to acknowledge Dr Edward Diethrich, who taught me most of my vascular technical skills during my vascular fellowship. I also credit Dr Diethrich for my early career in endovascular intervention during several visits to the Arizona Heart Institute, where I learned many of the endovascular skills in the late 1980s and 1990s, such as percutaneous transluminal angioplasty and stenting. His visionary ideas and enthusiasm were highly motivating to me. Dr Diethrich is a powerful leader who has redirected the path of our specialty and kept us in the endovascular game when many people were denying our role in this new field. In my mind, I consider Dr Diethrich and Dr Frank Veith as the two most powerful leaders in our specialty and who kept endovascular procedures in the domain of our specialty. I would also like to acknowledge three national leaders who have had a significant impact on my professional career, and I give them credit for many advances in my academic career and national recognition. These leaders are John Bergan, Frank Veith, and Robert Rutherford. My contact and personal communication with these three vascular surgeons extended over 20 years through visits to my institution and assisting me in establishing my annual West Virginia Vascular/Endovascular Symposium for over 20 years in both Charleston and at the famous Greenbrier Resort in West Virginia. In fact, Dr John Bergan assisted me in establishing my first symposium 21 years ago, and he continued as a partner in this endeavor for 20 years. Similarly, Frank Veith has been a powerful leader in our specialty and has tirelessly fought to establish our specialty as an independent vascular specialty. Frank redirected the path of the vascular specialty and kept us from extinction. I cannot resist reminding our members of the 50th Presidential Address by Frank Veith, Charles Darwin and Vascular Surgery, who likened the evolution of vascular surgery to the observations of Charles Darwin on the evolution of the species. At that time, Frank felt that we, too, were evolving, but that we must be aggressively proactive in what is now a very rapid evolution; in Darwin s terms, we have to be the fittest if we are to survive. Perhaps, most of the members remember Frank Veith s statement over a decade ago: Become endo-competent or become extinct. 1 I learned, through my communications with these leaders, the wisdom of critical thinking. I don t want to finish this portion of my presentation without recognizing the friendship, support, and guidance that I received from several of the past presidents of our society with whom I worked closely during my tenure on the executive council or as an officer: Anton Sidawy, Bruce Perler, Enrico Ascher, Dhiraj Shah, Bill Flinn, Clem Darling, Keith Calligaro, and Michel Makaroun. Thanks to all of you. Finally, I am indebted to my associates at the Charleston Division of West Virginia University and all of the members of our team at the Vascular Center of Excellence at Charleston Area Medical Center (Fig 2), who have been very supportive of me, particularly over the past decade. They tolerated my excessive absence, mostly for academic purposes, both nationally and internationally. They also relieved me of the duties of taking call for the past few years, and more often than they think, they taught me so much. Specifically, I want to thank one of my associates, Dr Mark Bates, who helped me in this regard. I give credit to Mark, who helped me during my first carotid stenting in the 1990s and continued until I had mastered this technique. He was instrumental in teaching me advanced and complicated endovascular skills. I also want to thank Mark for standing with me, along with our late chairman, in developing our Vascular Center of Excellence almost 15 years ago, which is now considered the most outstanding facility for vascular care in the state of West Virginia. For those of you who may not know much about West Virginia, I would like to take this opportunity to let you know that several years ago we opened a modern Heart and Vascular Center of Excellence ($80 million), which has a joint medical directorship between Dr Bates and me. We also believed that having a multidisciplinary team would be beneficial to patient care and also to our success. Today, our Vascular Center of Excellence has 10 full-time faculty members, consisting of 6 board-certified vascular surgeons, 2 interventional cardiologists who completed an extra year

3 JOURNAL OF VASCULAR SURGERY Volume 55, Number 2 AbuRahma 573 Fig 2. Vascular Center Of Excellence at Charleston Area Medical Center/West Virginia University, Charleston Campus Team and Facility. of dedicated vascular intervention fellowship and have expertise and interest in vascular surgery, 1 vascular medicine/vascular interventionist with 2 years of a vascular intervention fellowship, and 1 physician who is dedicated to preventive vascular medicine. I also want to thank Dr Patrick Stone for returning to Charleston, after completing his vascular fellowship in Florida, to join Dr Boland, Dr Bates, and I in establishing our accredited vascular fellowship several years ago. I strongly believe that with this nucleus we were able to recruit several young talented physicians: Aravinda Nanjundappa, Stephen Hass, John Campbell, Albeir Mousa, James Campbell, Shadi Abu-Halimah, and Mohit Srivastava. VASCULAR LAB 360: ARE WE LOSING CONTROL? Over the past several months, as I reflected on a topic for the presidential address, I reviewed more than two dozen previous presidential addresses of both regional and national vascular societies. I also discussed this with several of our past presidents to elicit their ideas. One thing I realized is that our members don t need another lecture on endovascular surgery or another state of the union address from another president. After looking into the main component of our specialty, which includes open vascular surgery, endovascular surgery, venous diagnosis and intervention, and vascular laboratory and imaging, I would like to remind you that nationwide, we perform 70% of the endovascular aneurysm repairs and about one-third of peripheral and carotid stent procedures, while numbering less than 20% of physicians who lay claim to vascular care. 2-4 After a lengthy debate, I realized that covering the present topic related to vascular laboratories would be of great interest based on the evolution of the vascular laboratory over the last 30 years and the present abuse of vascular laboratories all over the country. I am not here today to expound on politics and what should be done regarding endovascular procedures. However, you can t help but notice that for peripheral endovascular procedures, close to 70% are performed by nonvascular surgeons, and I don t want this trend continued for vascular laboratory dominance also. Therefore, this is why I chose to speak on Vascular Lab 360: Are We Losing Control? HISTORICAL PERSPECTIVE OF THE VASCULAR LABORATORY Noninvasive testing has its roots in the early research laboratories over 50 years ago. The first laboratory was established at Massachusetts General Hospital in These early efforts of objective assessment of vascular disease date to the days when sympathectomy was the only surgical treatment for vascular insufficiency. Measurements of changes in skin temperatures or vascular resistance was used to demonstrate changes in the sympathetic activity. These led to the introduction of plethysmographic devices to record pulse pressure waveforms. Several methods included application of a variety of pneumatic and straingauge sensors. Some of these were the Windsor pneumatic plethysmograph, followed by the pulse volume recorder, which continues to be used today. Further applications of pneumatic plethysmography were the Cranley phleborheograph, Gee s ocular pneumoplethysmography, Kartchner s plethysmography, and more recently, air plethysmography by Nicolaides. Other innovations include recording and analysis of vascular bruits (carotid phonoangiography), electrical impedence plethysmography of Wheeler for

4 574 AbuRahma JOURNAL OF VASCULAR SURGERY February 2012 detection of deep vein thrombosis, and photoplethysmography. The application of ultrasound techniques for vascular diagnosis has played a major role in this field. Satomura used Doppler signal processing for transcutaneous detection of blood flow, which led to the development of the early nondirectional continuous-wave detectors. Technical improvements in this initial discovery included the design of directional detectors and, later, the evolution of processors to measure the frequency characteristic of the Dopplershift signals. The continuous-wave Doppler velocity detector was responsible for the rapid growth in noninvasive testing in the 1970s. A parallel development was achieved in the ultrasound imaging of blood vessels. Initially, this equipment provided static, low-resolution images; however, technologic improvements provided realtime images that helped to advance this field. Perhaps one of the most important advances was noticed after 1972, when Strandness and his associates at the University of Washington developed duplex scanning, combining flow and image information in the same examination. By the early 1980s, the duplex scanner became widely used in clinical practice. Its initial application was for the noninvasive examination of the carotid artery, followed by its application in the peripheral arterial and venous systems and later into the abdominal visceral vessels. This was followed by the development of color-flow encoding, which has simplified and shortened many of the difficult examinations. VASCULAR SURGEONS AS INITIAL LEADERS IN THE NONINVASIVE VASCULAR REVOLUTION As indicated earlier, the first laboratory designated for the study of human peripheral circulation was established by Linton at Massachusetts General Hospital in Other laboratories that followed in the 1950s and 1960s included those of John Cranley at Good Samaritan Hospital in Cincinnati, Ohio, and the blood flow laboratory of Professor W. T. Irvin at St Mary s Hospital in London, England. In the 1970s, vascular laboratories and noninvasive testing became the focus of many vascular surgeons. In 1971, using the pulse volume recorder, R. Clement Darling and Jeff Raines reopened the vascular laboratory at Massachusetts General Hospital for clinical use. Other vascular laboratories were established soon after that at Northwestern University Medical School in Chicago, Illinois (John Bergan and Jim Yao); Good Samaritan Hospital in Cincinnati, Ohio (Cranley); the VA Hospital at the University of Washington in Seattle, Washington (Gene Strandness); Scripps Clinic in San Diego, California (Eugene Bernstein); the University of Colorado, Denver, Colorado (Bob Rutherford and Richard Kempczinski); and the Arizona Heart Institute, Phoenix, Arizona (Edward Diethrich). Our noninvasive vascular laboratory at CAMC was started in 1978 as one of the early vascular laboratories in the mid-atlantic region. In 1976, the TransAtlantic Inter-Society Consensus task force of the American Heart Association, the Inter- Society Commission for Heart Disease Resources, published their report on testing for peripheral arterial disease (PAD). 6 The group concluded that a clinical vascular laboratory was desirable in institutions treating vascular disease, including venous thromboembolism. They recommended the establishment of a clinical laboratory in a hospital was desirable to provide studies vital to preoperative and postoperative management of patients undergoing arterial reconstruction and to provide services to patients suffering from venous thromboembolic disease. This document provided the blueprint for many hospitals in the United States to establish a fee-for-service vascular laboratory. This development could not have been achieved without the assistance of vascular technologists. In 1977, the Society of Vascular Technology was established during a noninvasive diagnostic symposium organized by Gene Bernstein in San Diego. This cooperative work between vascular technologists and vascular surgeons has fully developed the vascular laboratory as it is known today. Most techniques used during the early stages were indirect testing: supraorbital Doppler or ocular plethysmography for carotid stenosis, or impedence plethysmography or phlebogram for venous thrombosis. However, with the introduction of duplex scanning in 1979 by Gene Strandness and David Phillips of the University of Washington, the evolution of the modern vascular laboratory was created. Perhaps the two most important events that popularized noninvasive vascular technologies in the late 1970s and through the 1980s were the vascular symposium of noninvasive diagnostic techniques by Gene Bernstein in San Diego and the annual international noninvasive cardiovascular congress sponsored by the Arizona Heart Institute in Phoenix, which was conducted for over 10 years. Several hundred people attended these meetings and eventually spread this technology both nationally and internationally. The growth in noninvasive vascular testing has required trained people to carry out these examinations. Much of the original work was performed by the doctors, primarily vascular surgeons, who developed this kind of testing. With time, other physicians studied and duplicated the work reported by the early pioneers, but the problem came when clinicians decided to create a new testing facility without going through learning-curve experience by the researchers. In some cases, interested physicians visited established laboratories for brief periods to learn techniques and to pick up the practical tips. Lectures and dedicated courses helped to school many in the basic components of this new field. With the growth of the complexity of noninvasive testing and the time required for examinations exceeding the time that physicians could dedicate to these studies, technologists were increasingly recruited from a variety of backgrounds, including nurses, physician assistants, catheterization laboratory or operating room technicians, and a variety of research assistants. By the 1980s, almost all vascular

5 JOURNAL OF VASCULAR SURGERY Volume 55, Number 2 AbuRahma 575 laboratory testing in the United States was being done by technologists under the direction of physicians. As indicated earlier, most of the developments of early physiologic testing were carried out by vascular surgeons and other researchers in the field of vascular disease. As technologic improvement made ultrasound imaging a clinical reality, there came an increasing interest by radiologists. There was an explosion in noninvasive testing by the mid- 1980s, and other specialties became involved, including neurology, neurosurgery, cardiology, and even urology. Noninvasive testing is currently performed in a wide variety of settings, ranging from solo practitioners doing the tests themselves in their offices to large hospitals, vascular centers, and vascular mobile units. Presently, noninvasive vascular laboratories are an integral part of the fee-for-service diagnostic services in any hospital providing care to patients dealing with vascular disease. It is estimated that close to 10,000 vascular laboratories exist in the United States, and only 2400 of these are accredited. 7 Recognizing the importance of the noninvasive vascular laboratory is now designated, along with open vascular surgery, endovascular surgery, medical management, and critical care, as one of the five components of training requirements and credentials for hospital privileges in vascular surgery. 8 THE ORIGIN OF VASCULAR LABORATORY ACCREDITATION In the late 1980s, there was growing concern among the leaders in noninvasive vascular testing about the call from the medical insurance companies for the regulation of all noninvasive testing and for elimination of payment for vascular testing. Isolated cases of highly fraudulent operations were well publicized and caught the attention of many payors. Leaders in the field voiced the need for better self-policing of this entity. There was also concern that some specialty organizations might take the initiative to create standards for vascular laboratories. Finally, in 1989, an informal meeting of leaders in the field of noninvasive testing proposed studying the possibility of establishing a voluntary accreditation process. This initial group included vascular surgeons, radiologists, and vascular technologists. Support and financial sponsorship were sought from a variety of professional societies whose members at that time were involved in noninvasive vascular testing. The initial meeting was dedicated to defining the scope of the noninvasive vascular laboratory accreditation and the minimum guidelines necessary for quality assurance. The overall objective was to ensure high-quality patient care by providing a mechanism that recognized laboratories providing quality vascular diagnostic techniques through the process of voluntary accreditation. Earlier, the accreditation was felt to be as inclusive as possible, something that could be achieved by even the smallest laboratory that was doing quality work. Another important principle that was adopted was that accreditation would not require specific medical specialty training but would evaluate the particular education and expertise of the doctors Fig 3. Number of laboratories accredited by the Intersocietal Commission for the Accreditation Vascular Laboratories. and technologists in each laboratory, which I personally felt was abused in the later stages of vascular accreditation. In March 1990, a group adopted the constitution and bylaws for the Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL), and in November 1990, ICAVL was incorporated as a nonprofit corporation in Maryland. The members of the ad hoc work group became the original board of directors, and Brian Thiele, who had chaired the work group (the SVS secretary later), became the first president of the ICAVL. In January 1991, Sandra Katanick, RN, RVT, was selected as the executive director and charged with creating the administrative structure for the commission. The initial group of 36 laboratories was accredited in January Presently, approximately 2000 vascular laboratories are accredited by the ICAVL (Fig 3). ARE WE LOSING CONTROL OF THE VASCULAR LABORATORY? It is not uncommon for many of our vascular surgeon colleagues to see patients for a vascular evaluation who have already undergone noninvasive testing, whether in a nonaccredited vascular laboratory or even an accredited one, which has already been interpreted by physicians who are not qualified to read the tests. Many of these tests are done by unqualified technicians or are interpreted by physicians who lack the vascular training background to qualify them to properly interpret these tests, giving either falsely positive or negative results, with major clinical implications. Many of us would then be facing the dilemma of whether to order further imaging, which may be associated with excessive costs, or ordering another vascular laboratory test in a more qualified vascular laboratory, which unfortunately, would end up not being paid for by insurance companies, thus raising a major dilemma for physicians, patients, and hospitals alike. This trend is becoming so frequent that my own estimate at our institution is that more than 50% of

6 576 AbuRahma JOURNAL OF VASCULAR SURGERY February 2012 Table I. Current specialties in laboratories accredited by the Intersocietal Commission for the Accreditation of Vascular Laboratories Specialties No. (%) Medical director Vascular surgery 293 (47) Cardiology 139 (22) Radiology/interventional radiology 71 (10) Vascular medicine 37 (6) General surgery 28 (4) Neurology/neurosurgery 27 (4) Internal medicine 13 (2) Cardiovascular and thoracic surgery 3 (1) Family practice 2 (1) Medical staff Radiology/interventional radiology 808 (41) Vascular surgery 549 (27) Cardiology 353 (17) Neurology/neurosurgery 82 (4) General surgery 78 (3) Vascular medicine 48 (2) Cardiovascular and thoracic surgery 7 (1) Family practice 5 (1) Phlebology 1 (1) patients referred to us will fall under this description. The increasing number of nonaccredited vascular laboratories and an increasing number of physicians (nonvascular surgeons or vascular specialists) who may not be qualified in vascular laboratory interpretations, as reflected by the statistics that will be shown later, is a significant challenge to us all. ICAVL VASCULAR LABORATORY STATISTICS Recent ICAVL statistics (March 2011) show that the percentage of vascular laboratory medical director qualifications was as follows: 47% vascular surgery, 22% cardiology, 10% radiology, 6% vascular medicine, 4% neurology, 4% general surgery, 2% internal medicine, and 1% family medicine. The percentage of medical staff specialties were radiology as the dominant medical staff, constituting 41%, followed by vascular surgery at 27% and cardiology at 17%; however, other noted specialties who interpret vascular laboratory tests include cardiovascular and thoracic surgery, family medicine, general surgery, and even phlebology (Table I and Fig 4). What is more interesting is the trend in the dwindling number of vascular surgeons as the dominant percentage of vascular laboratory directors, or even as physicians interpreting studies in the vascular laboratory. As noted in Table II, there was a decreasing trend in the number of vascular surgeons as medical directors for the vascular laboratory, dropping from 76% in 1993 to 51% in In contrast, the number of cardiologists rose from 2% in 1993 to 27% in This is very clearly shown in Fig 5, which shows the significant drop in the number of vascular surgeons and the significant increase in the number of cardiologists as medical directors of these laboratories. These numbers can even be misleading if you take into consideration the majority of Fig 4. Percentages of (A) vascular laboratory medical directors and (B) medical staff specialties (from the 2011 Intersocietal Commission for the Accreditation of Vascular Laboratories). IR, Interventional radiology. laboratories that are not accredited in the United States because many of these are located in cardiology offices. I believe that the proliferation of nonvascular surgeons as medical directors or as physicians in general interpreting vascular laboratory tests can be explained by several reasons: 1. the market share of the cardiology group, which far exceeded the number of vascular surgeons or other vascular specialists in this field; 2. concern for increased revenue, at least in some practices; 3. many others believe the present standard of the ICAVL in regards to the minimal physician qualifications for physicians to interpret vascular laboratory testing would only encourage many physicians, regardless of their background, to qualify to interpret these tests, particularly in the informal training pathways; and

7 JOURNAL OF VASCULAR SURGERY Volume 55, Number 2 AbuRahma 577 Table II. Percentage of specialties of medical directors in laboratories accredited by the Intersocietal Commission for the Accreditation of Vascular Laboratories from 1993 to 2011 Years Vascular surgeon (%) Radiologist (%) Internal medicine (%) Cardiologist (%) Neurologist (%) the American Registry for Diagnostic Medical Sonography (ARDMS) standards in granting physicians to qualify in taking the examination of the Registered Physicians Vascular Interpretation (RPVI) are somewhat similar. ICAVL STANDARDS The present standards of ICAVL are summarized in the following: Standard for Medical Director A. Medical Director qualifications B. Training and experience requirements 1. The Medical Director must demonstrate an appropriate level of training and experience by meeting one or more of the following: a. Formal Training Completion of a residency or fellowship that includes appropriate didactic and clinical vascular laboratory experience as an integral part of the program. For those testing areas in which training is provided, the physician must have experience in interpreting the following minimum number of diagnostic studies under supervision: Carotid duplex ultrasound 100 cases Transcranial Doppler 100 cases Peripheral arterial physiological 100 cases Peripheral arterial duplex 100 cases Venous duplex ultrasound 100 cases Visceral vascular duplex ultrasound 75 cases b. Informal Training Appropriate training and experience for proper qualifications to interpret noninvasive vascular laboratory studies can be achieved through formal accredited post graduate education i. A minimum of 40 hours of relevant category 1 CME credits must be acquired within the 3-year period prior to the initial application. Twenty (20) hours must be courses specifically designed to provide knowledge of the techniques, limitations, accuracies and methods of interpretations of noninvasive vascular laboratory examinations the physician will interpret. Twenty (20) hours may be dedicated to appropriate clinical topics relevant to vascular testing. Eight (8) of the 40 hours must be specific to each testing area the physician will interpret. ii. The physician must acquire a minimum of 8 hours supervised practical experience for each testing area to be interpreted; observing or participating in testing procedures in an accredited laboratory. iii. For those examinations the physician will interpret, there must be documentation of interpretation for the following minimum number of studies while under the supervision of a physician who has already met the ICAVL standard. Carotid duplex ultrasound 100 cases Transcranial Doppler 100 cases Peripheral arterial physiologic 100 cases Peripheral arterial duplex 100 cases Venous duplex ultrasound 100 cases Visceral vascular duplex ultrasound 75 cases c. Established Practice Current training and current experience will be considered appropriate for a physician who has met the qualifications of and has worked in a vascular laboratory for at least the past 3 years and has interpreted the following minimum number of diagnostic studies in the specific areas that will be interpreted. Carotid duplex ultrasound 300 cases Transcranial Doppler 300 cases Peripheral arterial physiological 300 cases Peripheral arterial duplex 300 cases Venous duplex ultrasound 300 cases Visceral vascular duplex ultrasound 225 cases d. Physician Credential for Vascular Interpretation i. Registered Physician in Vascular Interpretation (RPVI) ii. Neurosonology credential (ASN) from the American Society of Neuroimaging (for physicians who interpret extracranial and intracranial examinations only). ARDMS STANDARDS FOR RPVI Prerequisite A1: MD or DO with RVT (active status): Physicians who currently hold the RVT credential with

8 578 AbuRahma JOURNAL OF VASCULAR SURGERY February 2012 Fig 5. Comparing numbers of medical directors according to specialty (from 2011 Intersocietal Commission for the Accreditation of Vascular Laboratories statistics) active status may apply directly for the RPVI credential examination. Prerequisite A2: MD or DO, current ICAVL or American College of Radiology (ACR) laboratory accreditation: MD or DO degree with current, valid medical license to practice in the U.S. or Canada, and current ICAVL or ACR vascular ultrasound accreditation. Prerequisite B1: Formal training (U.S. and Canada). Licensure: MD or DO degree earned in the U.S. or Canada. Training: Attendance of an Accreditation Council for Graduate Medical Education (ACGME) or Royal College of Physicians and Surgeons of Canada (RCPSC) accredited residency or fellowship that includes didactic and clinical vascular laboratory/ultrasound interpretation experience as an integral part of the program. Interpretation Experience: The applicant must be able to document interpretation experience with a minimum of 500 vascular laboratory studies. These studies should be distributed over the following testing areas: carotid duplex ultrasound, transcranial Doppler, peripheral arterial physiological testing, peripheral arterial duplex ultrasound, venous duplex ultrasound, and visceral vascular duplex ultrasound. Prerequisite B2: Informal training (U.S. and Canada). Licensure: MD or DO degree earned in the U.S. or Canada. Interpretation Experience: The applicant must be able to document interpretation experience with a minimum of 500 vascular laboratory studies. These studies should be distributed over the following testing area: carotid duplex ultrasound, transcranial Doppler, peripheral arterial physiological testing, peripheral arterial duplex ultrasound, venous duplex ultrasound, and visceral vascular duplex ultrasound. As noted from the ICAVL standards and the RPVI, under formal training, it does not specify the specialty of the physicians who can interpret, it just simply says completion of residency or fellowship that includes appropriate didactic and clinical vascular laboratory/ ultrasound interpretation experience, without any reference to training in vascular medicine and/or surgery or related fields, which allows practically any physician with any background to be able to claim formal or informal training. It should also be noted in the RPVI prerequisite B2, the applicant can write his or her own letter if no other physician is around to write that letter. EASTERN VASCULAR SOCIETY VASCULAR LAB SURVEY A recent survey of active members of the Eastern Vascular Society related to vascular laboratories was conducted during the months of May and June The survey included 20 questions covering various demographics (age, specialty), years of experience, presence of a laboratory in the member s main hospital, presence of outpatient vascular laboratories, status of accreditation of these laboratories, and specialty of the medical director and medical staff who interpret the vascular ultrasounds at their institution or in their own laboratories. Members were asked whether they interpret vascular ultrasound in their affiliated hospitals or in an outpatient vascular laboratory, and in what department these vascular laboratories belong. They were asked to share their opinions about recent requirements of the vascular surgery board of the American Board of Surgery, which mandated that all future candidates for the vascular surgery board must pass the RPVI examination before taking the vascular surgery board, and whether they themselves presently carry this certificate. They were asked for their input or opinion

9 JOURNAL OF VASCULAR SURGERY Volume 55, Number 2 AbuRahma 579 Table III. A and B, 2011 Eastern Vascular Society Vascular Laboratory Survey Table III. C, 2011 Eastern Vascular Society-Vascular Laboratory Survey Responses (No.) Response ratio (%) Responses (No.) Response ratio (%) A, Specialty Vascular surgeon General surgeon Other 4 3 Vascular lab in main hospital ICAVL accredited Accreditation by ACR B, Vascular lab medical director s specialty Vascular surgeon General radiologist/interventional radiologist Cardiologist 4 3 Vascular medicine 3 2 General surgeon 3 2 Others/unspecified 12 9 Medical staff specialties interpreting vascular US Vascular surgeon General radiologist/interventional radiologist Cardiologist Neurologist/neurosurgeon 16 7 General surgeon 12 5 Vascular medicine 11 5 ACR, American College of Radiology; ICAVL, Intersocietal Commission for the Accreditation of Vascular Laboratories; US, ultrasound. about the specific ARDMS prerequisite to take the RPVI examination, including their opinion on prerequisite B1, which is the formal training pathway, and prerequisite B2, the informal training pathway. They were also asked if they agree with the ARDMS position that allows any physician, regardless of their background training, to take the RPVI examination and allows applicants to write their own recommendation letters. Overall, 135 active members responded (which constitutes around 25% of the members). Table III summarizes these findings. As noted, 87% of the responding members were board-certified or eligible vascular surgeons, 10% were general surgeons, and 3% were others. Ninety-three percent responded positively for having a vascular laboratory at their main affiliated hospital, of which 70% were ICAVL accredited, and 14% were American College of Radiology accredited. Also, as expected, 67% of the respondents indicated that the medical director specialty was a vascular surgeon, and 16% were radiologists. When it comes to the specialties of medical staff that interpret vascular ultrasound at their institution, 43% of these physicians were vascular surgeons, followed by a significant number of radiologists (29%), and cardiologists (11%). It was surprising to me that only 67% of the responding members indicated that they interpret vascular ultrasound images at their main institutions. Meanwhile, 81% said their institution has an outpatient vascular laboratory facility. It is also interesting to note that 24% of the respondents indicated that there is more than one Do you interpret vascular ultrasounds in your hospital? Yes Do you have an outpatient vascular laboratory facility? Yes Number of vascular labs at your institution What departments do they belong to? Vascular division Radiology Cardiology Neurology/neurosurgery 8 4 General surgery 3 2 Vascular medicine 2 1 Other 6 3 Other vascular laboratories in your region? Yes Who interprets these tests? General/interventional radiologist Vascular surgeon Cardiologist General surgeon 30 7 Neurologist/neurosurgeon 28 7 Internal medicine 23 6 Vascular medicine 18 4 Family practice 11 3 Cardiothoracic surgeon 7 2 Others 6 1 vascular laboratory at their institution and 16% have two or more vascular laboratories in the same institution. Of these laboratories, 46% are located in the vascular surgery division, 32% in the department of radiology, and 12% in the department of cardiology. Eighty-eight percent of the respondents indicated the presence of more than one laboratory outside their facility within a 10- to 20-mile radius of their main affiliated hospital. The specialty of physicians who interpret these outpatient vascular laboratory tests is reported in Table III, C: 19% were cardiologists, 28% radiologists, 7% general surgeons, 7% neurologists, and 3% family practitioners. These were somewhat similar to what is seen in the ICAVL statistics. What is also surprising is that only 18% of our members carry the RPVI credential; meanwhile, 39% have the RVT credential. When members were asked to give their opinion regarding whether they agree with prerequisite B2 (informal training) of the ARDMS to take the RPVI examination, 53% disagreed, and 70% felt very strongly against the ARDMS allowing physicians, regardless of their background training, to take the RPVI examination. In an astoundingly negative response, 85% of the respondents expressed that applicants should not be allowed to write

10 580 AbuRahma JOURNAL OF VASCULAR SURGERY February 2012 Table III. D, 2011 Eastern Vascular Society Vascular Laboratory Survey: Credentials Responses (No.) Response ratio (%) RPVI credential? Yes RVT credential? Yes Do you agree with prerequisite B-2 for RPVI? Yes No Do you agree with ARDMS, which allows any physician regardless of their background of training, to take RPVI examination? Yes No Do you agree that applicant can write own letter? No ARDMS, American Registry for Diagnostic Medical Sonography; RPVI, Registered Physician in Vascular Interpretation. their own letter of recommendation in order to sit for the examination. It is noteworthy to include some of the comments that were given frequently by the respondents: 1. It seems like everyone has a vascular laboratory. 2. Many internists, and almost every cardiologist, have a vascular laboratory in their office in our area. This may only reflect the proliferation of vascular laboratories in many of the physician s offices, particularly cardiologists. 3. Several indicated that they repeated many of the vascular laboratory studies brought to their offices with totally different results, unfortunately, with no reimbursement for these repeated tests. 4. Several indicated that for the vascular surgery board to require applicants to take the RPVI examination before their vascular surgery boards would indicate that the vascular boards are insufficient to properly interpret vascular studies. 5. On the same issue, several also indicated that having that requirement would only make it easier for nonvascular surgeons to achieve parity with vascular surgeons in regards to credentialing. 6. Many indicated that ICAVL qualifications for physicians interpreting testing or the ARDMS prerequisite for taking the RPVI examination should be confined to physicians who practice vascular surgery, vascular medicine, radiology, or cardiology if they have a specific rotation in the vascular laboratory. These physicians must demonstrate understanding of the vascular disease processes. 7. Similarly, several indicated a thorough understanding of hemodynamics, blood flow, physics, and vascular disease is paramount in their ability to correctly interpret vascular testing. Although physicians may occasionally have some or all of this, they generally do not. Even cardiologists who have vascular laboratories do not really understand peripheral vascular disease. 8. In regards to writing their own letter to take the RPVI examination, several others also wrote that anyone could write such a letter with no proof that they know anything about vascular laboratory studies. On the same issue, a letter is too easy to fudge and does not imply an understanding of vascular disease and proper vascular laboratory interpretation. 9. Several others indicated that these individuals may possess the book knowledge but do not live with these case problems on a continual daily basis. 10. Others indicated that physicians can learn to interpret testing, just as vascular surgeons can learn to interpret electrocardiograms or echoes, but it does qualify them to properly interpret vascular tests. 11. Some indicated that it is high time that vascular societies take the bull by the horns: if every Tom, Dick, and Harry is doing imaging studies, many of them are unnecessary. RECOMMENDATIONS The vascular laboratory used to be considered the domain of vascular surgery; however, management of the noninvasive vascular laboratory has been increasingly assumed by radiology and cardiology. A survey by the Society of Clinical Vascular Surgery in 2000 showed that vascular surgeons reported an average income drop of 16% from the vascular laboratory, whereas 40% of the vascular surgeons reported no relationship with a noninvasive laboratory. This is an extremely alarming percentage. Vascular surgeons must regain control of our laboratories and maintain our leadership in this rapidly evolving technology. It is an absolute necessity that the vascular fellow must obtain a formal rotation in an accredited vascular laboratory that will provide hands-on skills and the performance of various noninvasive vascular testing and interpretations. In our own laboratory, our junior vascular fellows spend a 1-month rotation working with the vascular laboratory technologists under the supervision of the chief vascular laboratory technologist to gain an understanding of keyboard operation of the duplex scanning equipment, proper probe handling, configuration, and selection of appropriate frequency ranges. They also learn the appropriate application of image and hemodynamic measurements. They are given didactic lectures on various vascular testing, including vascular hemodynamics and related topics. During their junior year rotation, they will also be exposed to the general principles of interpretation of these tests, which will be followed with another month of rotation during their senior year where they will be supervised in reading the necessary number of duplex ultrasounds, which will qualify them to sit for the RPVI examination. They will also be exposed to a specific number of physiologic testing techniques, including segmental Doppler pressures, anklebrachial index, and plethysmography. National forecasts of peripheral arterial procedures indicate that because of early treatment of these diseases and

11 JOURNAL OF VASCULAR SURGERY Volume 55, Number 2 AbuRahma 581 the advancing age population, the number of peripheral arterial procedures will increase by 25% in 5 years. Most of this increase will probably be due to an increase in percutaneous vascular intervention. To deal with this future demand of an aging population and diabetes epidemic, we need to train more vascular surgeons or we will end up losing the care of these patients to other specialists, as we have seen over the past decade or so, specifically in noninvasive vascular laboratories and in endovascular intervention. In his presidential address, Jim Stanley 9 indicated that to meet the demand projection for the year 2030, we should be graduating approximately 160 vascular surgery residents every year. Filling this manpower gap has been a top priority for our SVS leaders over the past several years, as manifested by several presidential addresses that have addressed this issue by Dr Richard Green Dr Sidawy specifically addressed this issue in his presidential address to our society in 2003, 11 where he pointed out several factors that discourage medical students from considering surgical specialties in particular, including lifestyle issues, inability to attract women to vascular surgery, diminished reimbursement, long residency, and debt accumulation. Addressing the manpower issues in vascular surgery. Some of these issues have been addressed over the past few years, specifically in March 2005; the American Board of Medical Specialties approved a primary certificate in vascular surgery, effectively eliminating the requirement for residents to obtain board certification in general surgery before beginning their vascular surgery training. By reducing the time spent in general surgery rotations, the primary certificate will result in a shortened training period for junior residents or medical students who choose vascular surgery as their career. We must attract women when choosing vascular residency or fellowship. It has been estimated that the number of women choosing a vascular fellowship is one of the lowest in any specialty. We must also encourage the best of our international foreign medical graduates to enroll in our specialty to fill this gap. 14 There is an increasing percentage of international medical graduates among our vascular fellowship applicant pool, which reflects contemporary health care demographics. Redefining the prerequisite for the RPVI examination and for physician qualifications in interpreting vascular laboratory ultrasound testing by the accredited body (ICAVL). The Eastern Vascular Society and other regional societies, in conjunction with our national society (SVS), must work hand-in-hand to refine these requirements and perhaps make them clearer to minimize the number of physicians of limited vascular background from qualifying for these examinations or qualifying for interpretation of tests without proper and solid credentialing. The time of grandfathering, which has been used over the past 30 years, in my judgment, has passed, except, perhaps, for vascular surgeons or physicians with a background in vascular medicine or radiology who might not have been exposed to noninvasive vascular testing over the past 2 to 3 decades, which is extremely rare. I propose for both the prerequisite for the RPVI examination and for physician qualifications in reading in an accredited vascular laboratory, that under the formal training pathway, the physician s specialty must clearly state that completion of a residency or fellowship in the four main areas of medicine that deal with vascular medicine/surgery (ie, vascular surgery), which includes a vascular fellowship after general surgery or 0 5 vascular residency, vascular medicine, radiology, and cardiology, with the stipulation that these specialties should have a designated rotation in the vascular laboratory during their fellowship or residency, or both. An exception must be given to neurologists and neurosurgeons who have proper didactic and clinical vascular laboratory experience in reading transcranial Doppler and carotid duplex ultrasound images. I also believe that under informal training, a similar background of these specialties needs to be added under this section. I also believe similar requirements are needed for physicians in an established practice; otherwise, we will end up having a two-class tier of physicians reading in the vascular laboratory. As I indicated earlier, physicians with an established practice in vascular surgery, radiology, or vascular medicine may be grandfathered in if they complete a refresher course in noninvasive vascular testing, as indicated in the requirements by the RPVI examination or the ICAVL. However, this must be a rarity because the vascular laboratories are more than 30 years old. In closing, I hope this presentation will shed better light on the need to improve the quality of vascular laboratories nationwide. You were the early leaders of this technology and we must continue to lead, not only for our sake but also for the sake of better patient care. I would like to close with the following quote from Leonardo da Vinci. The artist sees what others only catch a glimpse of. I want to thank all of you for giving me the distinct privilege to serve as your president. Thank you. REFERENCES 1. Veith FJ. Presidential address: Charles Darwin and vascular surgery. J Vasc Surg 1997;25: Centers for Medicare & Medicaid Services: Part B physician/supplier procedure summary public use file. PSP, Aug 3, Steppacher R, Csikesz N, Eslami M, Arous E, Messina L, Schanzer A. An analysis of carotid artery stenting procedures performed in New York and Florida ( ): procedure indication, stroke rate, and mortality rate are equivalent for vascular surgeons and non-vascular surgeons. J Vasc Surg 2009;49: Vogel TR, Dombrovskiy VY, Haser PB, Graham AM. Carotid artery stenting: impact of practitioner specialty and volume on outcomes and resource utilization. J Vasc Surg 2009;49: Cranley JJ, Lohr JM. Evolution of the vascular laboratory. J Vasc Technol 2001;25: Bergan JJ, Darling RC, DeWolfe VG, Raines JK, Strandness DE Jr, Yao JS. Report of the Inter-Society Commission for Heart Disease Resources. Medical instrumentation in peripheral vascular disease. Resource and planning guidelines for the hospital and physician. Circulation 1976;54:A1-9.