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.
Overview of Vascular Medicine in the USA
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
June 2004
|