SVM Communications: Interview with writing committee of Advanced Training Statement on vascular medicine and talking points from Paclitaxel Coalition

How does this consensus statement further vascular medicine training?

The document is a joint effort from the SVM, ACC, AHA, and ACP. We had representation in the writing group from other professional organizations including the Association of Black Cardiologists (ABC), Society for Cardiovascular Angiography and Intervention (SCAI), Society for Vascular Nursing (SVN), and Society for Vascular Surgery (SVS). It truly demonstrates the breadth of practitioners engaged in the care of patients with vascular disease; we appreciate their collaboration and input greatly.

This statement provides structure and goals for vascular medicine training; it does so in a way that allows us to have a common framework for vascular medicine training. Additionally, it underscores the notion that additional training beyond internal medicine and core cardiovascular fellowship training is a requisite to become a competent physician in noninvasive management across the breadth of vascular disorders. The document also includes competencies in recognizing vascular health disparities and treating vascular disease across sex, race, and ethnicity to promote strategies for improved health outcomes and equity.

Do you see this document advancing our endeavor towards ABIM recognition and certification as an advanced specialty?

This statement provides a framework for vascular medicine training programs, demonstrating to the ABIM that vascular medicine is an established advanced specialty. The six core competencies of training (medical knowledge, patient and procedural skills, system-based practice, practice-based learning, professionalism, and interpersonal and communication skills) outlined by the ACGME and endorsed by ABIM are discussed for trainees completing an advanced vascular medicine fellowship. Moreover, it is important to enhance the number of vascular medicine specialists to ensure its viability as a distinct medical specialty and provide optimal care of patients with a breadth of vascular diseases. The ATS reviews the competencies to be achieved with advanced training. We hope that this statement will support the growth of vascular medicine training programs.

How does this statement differ from the latest Core Cardiovascular Training Statement (COCATS 4)?

COCATS is a guideline for competency in training for general cardiovascular medicine. ² It includes multiple chapters on the competencies that cardiovascular medicine trainees are expected to achieve over 3 years of training (e.g. ambulatory and longitudinal cardiovascular care, arrhythmia management, echocardiography, other advanced imaging, cardiac catheterization, critical care cardiology); vascular medicine is one of the chapters. The vascular medicine chapter in COCATS 4 outlines and discusses the core competencies for what should be acquired during a 3-year cardiovascular medicine fellowship. During core cardiovascular fellowship training, it is expected that all fellows would achieve Level I training in vascular medicine. Level II training may be achieved by some fellows with additional time and training in the noninvasive vascular laboratory and would allow for Registered Physician in Vascular Interpretation (RPVI) candidacy and certification. The ATS outlines the Level III competencies achieved during an advanced fellowship dedicated to vascular medicine.

Not all training programs have access to vascular medicine specialists with Level III training. How does the document address this challenge to meet standards of training in vascular medicine?

More vascular medicine training programs are needed to reach a critical mass of vascular medicine experts. Until then, training programs need to be flexible and engage experts in vascular disease and related specialties (e.g. vascular surgery, hematology, rheumatology, radiology) to provide the necessary expertise for trainees. Thus, those experts do not have to be (nor is it feasible that they would be) exclusively vascular medicine experts. For example, hematologists with knowledge of venous thromboembolism or vascular surgeons who care for patients with critical limb ischemia may contribute to comprehensive training. Additionally, the vascular lab may sit within another area like vascular surgery or radiology. The ATS writing committee envisions a multidisciplinary team approach to training vascular medicine specialists in a parallel fashion to team-based approaches to treat and prevent vascular disease.

What specific resources should vascular medicine fellowship programs have for trainees in vascular and cardiovascular medicine?

Several elements need to be available and accessible, including personnel with expertise (as discussed above), appropriate facilities, including the vascular laboratory and other advanced imaging, as well as access to catheter- or surgical-based interventions. To gain exposure in these areas, training activities may take place at the primary location or another site. The statement permits flexibility for training across institutions if required to achieve all elements of competency.

Some ATS competencies are optional (notated in Table 1 as an added Milestone in the ATS document) ¹ , like performing superficial venous intervention or pseudoaneurysm injections. These represent training pathways that may be available and achieved by some, but not all, vascular medicine specialists.

For trainees pursuing peripheral intervention, do you envision that they would have vascular medicine training with intervention? Should that be a requisite?

In the 2004 Clinic Competency Statement on Vascular Medicine and Catheter-based Peripheral Vascular Interventions document, we recommended that cardiovascular interventionalists should have both inpatient and outpatient consultative vascular medicine exposure and experience in the noninvasive vascular diagnostic laboratory in addition to the required interventional training, so they would have the cognitive skills to care for the patients they are treating. ³ Vascular intervention is not included in the 2021 ATS. Intervention will likely be included in a future advanced training statement on cardiovascular intervention.

Other professional bodies, including SVS, include pathways and endovascular and surgical training for obtaining cognitive skills, expertise in the noninvasive vascular laboratory, and other competencies to manage patients with vascular disease. The Intersocietal Accreditation Commission (IAC) supports that reading physicians attain RPVI certification to read vascular diagnostic studies.

Do you have anything additional you would like to share with the SVM community?

This is an extremely important document for our profession. We are delighted SVM collaborated with the ACC, which is the home for these competency statements, along with the AHA, ACP, and other professional organizations, in this endeavor. This ATS should serve as a foundation for vascular medicine training programs and encourage more training programs to become available. We need to train more vascular medicine specialists to serve patients with vascular disease and contribute expertise to our professional community.