NHLBI Vascular Medicine Training Program Working Group
Executive Summary

March 30, 2004

Vascular Medicine is a medical specialty devoted to the evaluation and management of patients with arterial, venous, and lymphatic diseases. Arterial diseases include: atherosclerosis and its clinical manifestations, peripheral arterial diseases, aortic diseases, renal artery disease, mesenteric vascular disease, and cerebrovascular disease; arterial thrombosis and embolism; vasculitides; and vasospastic disorders. Venous diseases include venous thrombosis, chronic venous insufficiency, and varicose veins. Lymphatic diseases include primary and secondary forms of lymphedema. Also, Vascular Medicine encompasses risk factors that contribute to atherosclerosis such as dyslipidemia, hypertension and diabetes, and disorders of coagulation that lead to thrombosis. Expertise in caring for patients with vascular disease requires skills in patient evaluation, vascular diagnostic testing and knowledge of the therapies that are available to treat these patients. Vascular Medicine physicians who perform endovascular interventions also must have the knowledge as well as the clinical and technical skills requisite for performing catheter-based vascular interventional procedures.

Vascular diseases are the major causes of death and disability in the United States, affecting over 25 million people. The prevalence of vascular disease will increase as the population ages. Novel technologies provide opportunities for earlier and more accurate diagnosis. New discoveries in vascular biology and pathophysiology have increased our understanding of atherosclerosis, thrombosis and vasculitis and are being translated to therapeutics at a rapid pace. Hence, substantial opportunities now exist for early diagnosis and effective treatment of many vascular diseases. Yet, there is only a small cadre of vascular specialists in the United States that has the expertise to integrate and apply the rapidly advancing diagnostic tools and treatment options to manage patients most effectively.

Despite the magnitude of the problem, only a few programs are available to train physicians in Vascular Medicine. Training programs do exist for vascular surgery and interventional radiology. For many years, vascular surgeons have functioned as principal care providers for patients with vascular disease, but by the nature of their specialty, they focus primarily on patients with late manifestations of the diseases. Interventional radiologists are trained to perform endovascular interventions, but generally do not evaluate, medically manage, and provide longitudinal care for patients with vascular diseases. As a result, much of the care of patients with vascular disease is distributed among other specialties including general internal medicine, cardiology, hematology, rheumatology, and neurology, depending in large part on which end organ is predominantly affected by the vascular disorder. The treatment of patients at risk for vascular disease or who have manifestations of vascular disease requires a more comprehensive knowledge base. By possessing the comprehensive skills for patient evaluation, diagnosis and treatment, the Vascular Medicine physician can provide a level of expertise that is not feasible for most primary care physicians and can interface more effectively with other vascular specialists, such as vascular surgeons. In this respect, an analogy can be drawn with other medical specialties and their surgical counterparts, such as cardiology and cardiac surgery, neurology and neurosurgery, and medical and surgical oncology .

Need for and Characteristics of a Vascular Medicine Training Program

Vascular Medicine has not sufficiently developed as a specialty area for several reasons. Foremost, there are only a few Vascular Medicine training programs in the United States. In large part, this results from a lack of funding to support such training. Also, the recognition of vascular diseases as an important and dynamic area of specialization is not realized by many trainees since formal education in these diseases is very limited in most medical schools and residency training programs. Among those physicians who have developed an interest in Vascular Medicine, there are concerns that no formal certification process exists to confer recognition of competency and expertise. Establishment of a Vascular Medicine Training Award by the NHLBI would address each of these issues by providing funds for training, increasing awareness of Vascular Medicine among trainees and academic programs, and giving the discipline the recognition and implicit credibility required to develop a formal certification process.

The ideal program for training in Vascular Medicine will occur in the context of an integrated multidisciplinary approach to the management of vascular diseases. Training in the diagnosis and therapy of vascular diseases will require the participation of faculty with expertise in the wide spectrum of arterial, venous and lymphatic diseases; in the associated disorders of dyslipidemia, diabetes, hypertension, tobacco dependency, hypercoagulability, and vascular inflammatory syndromes; in the non-invasive and invasive diagnostic approaches; in preventive and interventional therapeutic approaches. Faculty involved in such a program will come from diverse specialties including cardiology, endocrinology, hematology, pulmonary medicine, vascular surgery, and vascular radiology. An integrated approach, and the education of Vascular Medicine specialists, can be enhanced by multidisciplinary conferences for clinical case presentations. These clinical conferences should be supplemented by didactic sessions or journal clubs for review of the relevant literature.

In addition to training Vascular Medicine fellows, the ideal program will also expose medical students, residents, and nurse practitioners to the basic fundamentals of Vascular Medicine. The ideal center would also have an active educational outreach to community physicians, providing postgraduate education in vascular disease. The program may also have opportunities for summer research for undergraduates, and would particularly encourage the participation of students from racial and ethnic minorities.

Clinician-educators trained in such programs will be able to educate the next generation of vascular specialists. In addition, these clinician-educators are likely to have interest and expertise in a particular field of Vascular Medicine. For example, they may provide specialized care (e.g. catheter-based therapies) or diagnostic services (e.g. vascular magnetic resonance). Or they may lead a clinical or translational research effort in an aspect of Vascular Medicine. Most importantly, they will provide sustained leadership at their institution for continued training in Vascular Medicine.

Working Group Recommendation

The Working Group's primary recommendation is to establish National Programs of Excellence for training in Vascular Medicine. These centers will train the next generation of clinician-educators in Vascular Medicine, in a multidisciplinary milieu that provides exposure to all aspects of vascular diagnostics and therapeutics. The expected outcomes from the activity of such centers will be: an increase in the number of Vascular Medicine specialists who can provide training in this subspecialty; an increase in the number of individuals who can develop and lead translational research programs in Vascular Medicine; and an increase in the number of vascular clinicians who can provide expert care of patients with vascular disease. Each of these outcomes will contribute to the improved vascular health of the nation.

Working Group Members

Chair: Marc A. Creager, M.D. (Chair), Bringham and Women's Hospital, Boston, MA

Participants:

• John Cooke, MD, Stanford University, School of Medicine, Stanford, CA
• Victor Dzau, MD, Bringham and Women's Hospital, Boston, MA
• William R. Hiatt, MD, University of Colorado School of Medicine, Denver, CO
• Jeffrey W. Olin, D.O., Mt Sinai Medical Center, New York, NY
• Christopher J. White, MD, Ochner Heart and Vascular Institute

NHLBI Staff:

• Barbara Alving, MD, National Heart Lung and Blood Institute, Bethesda, MD
• Diane Reid, MD, National Heart Lung and Blood Institute, Bethesda, MD
• Sonia I. Skarlatos, Ph.D., National Heart Lung and Blood Institute, Bethesda, MD
• Beth Schucker, MA, National Heart Lung and Blood Institute, Bethesda, MD