What is Ethical Vein Treatment?
- Faisal Siddiqi, MD, FACC
- Claudia Rios-Datta, MD, ABVLM
There has been a deviation from evidence-based clinical practice and appropriateness regarding vein treatment, and this has led to an exponential growth in venous procedural volume and unqualified practitioners performing venous interventions. In our opinion, there are several likely explanations to the increase in vein procedures:
Of the currently recognized American Board of Medical Specialties (ABMS) and subspecialties, only vascular surgery, interventional radiology, and cardiology have specific venous training. While some physicians are providing excellent venous care independent of their speciality designation, a critical gap exists between the training level and scope of practice for certain practitioners.
This can lead to serious consequences for both the patient and physician performing vascular procedures out of their depth. ABVLM is a pathway for non-traditional vein specialists to demonstrate clinical competence through certification.
VSC is investing regularly into technologies that aid the comfort of procedures and efficacy. A few examples include.
Cardiologists, Radiologists and Vascular Surgeons are formally trained in understanding vascular imaging and providing accurate interpretation. Vascular imaging is essential to the proper diagnosis and treatment of venous insufficiency.
It is simply outside the scope of an internist or pain management physician to interpret vascular ultrasounds. Despite any assurances that the images are sent to an independent third party for interpretation, we advise patients to approach with caution!
An ultrasound can often detect early signs of venous insufficiency even in individuals with simple spider veins. This alone does not justify medical interventions, but assists doctors with understanding how treatment will be impacted. However, it needs to be emphasized that spider veins are not cured or entirely prevented by medical vein treatments despite certain promises. A vein specialist should help you navigate your options guided by your treatment goals.
In practice today, there are an incredible number of untrained physicians inflating their experience as vein specialists without ever completing any vascular training or board certification. This is especially true of many newly formed vein centers provided by pain management doctors, internists, and physiatrists. Unknowing patients seeing pain specialists for leg pain are commonly worked up for vein disease despite a lack of clinical or physical signs of varicose veins. An undelivered promise to cure leg pain with minimally-invasive vein treatments. Having found lucrative reimbursements, many clinics employ aggressive tactics to gain referrals from closely associated practices.
We specifically ask patients to be wary of referrals to vein specialists without vascular training from Podiatry and Physical Therapy. This is a concerning trend and should be scrutinized carefully before proceeding with treatment.
We would invite patients to be aware of the financial incentives referring doctors might have with particular vein specialists. This can include ownership in surgical centers where patients are taken for procedures. In general, any doctor is obliged to share their financial disclosure with a surgical center, but this does not apply to referring colleagues.
At VSC, our vein doctors all have undergone intense procedural training for minimally invasive vein procedures. Each doctor is hand-selected based on their background training and maintenance of board certification in a vascular specific field.
Dr. Alissa Brotman is currently the President of The Vascular Society of New Jersey. Dr. Claudia Rios is a veteran in the field of phlebology and is a diplomate of the American Board of Vascular and Lymphatic Medicine (ABVLM). Drs. Faisal Siddiqi and Simon Smith are both board-certified cardiovascular specialists with interventional training.
Many pop-up vein centers do not employ their vascular techs as a cost-saving measure. Instead, technicians are brought in on a weekly basis as “hired-guns” incentivized to find abnormal studies. What Else To Look Out For:
Non-credentialed techs are directly performing the procedures and are incentivized to fill in the role of the doctor. This is both dangerous and unprofessional, whether it’s a physician assistant, nurse practitioner, or ultrasound technician. Many of these individuals will tout incredible numbers of procedures and experience, however only a properly trained physician can be responsible for the success and ethical performance of a procedure. Most importantly, only a properly trained physician can understand the individual risk of each procedure. Unknowing patients sedated for minimally-invasive procedures otherwise performed under simple local anesthetics by skilled vein doctors are especially vulnerable to this practice.
Our talented doctors honor their commitment to providing the highest quality of care. Dr. Alissa Brotman was recently appointed as President of the Vascular Society of New Jersey. The independent organization is dedicated to the establishing standards of proficiency in the recognition and care of vascular disease (including vein treatment). We fully support this objective!
Cosmetic sclerotherapy should not be billed to insurance and threatens the integrity of our specialty. Sclerotherapy is covered under medical necessity for large varicose veins close to the skin or in some cases neovascularization.
It is inappropriate for use with spider vein treatment and any potential cost-savings are not likely associated with high quality treatment.
As a minimally invasive procedure, vein ablation and varithena do not routinely require conscious sedation or anesthesia. For most doctors comfortable with the procedure, vein ablation can be performed with little or no discomfort using simple local anesthetics. Some patients with an extreme sensitivity or apprehension, an oral sedative can provide the necessary relaxation when needed. Rarely, a patient may require conscious sedation and the risks and benefits of this approach should be discussed ahead of time. We believe that anesthesia provides an unnecessary risk usually by inexperienced providers uncomfortable with their technique.
The Vein Specialist Centers is entirely dedicated to the treatment of spider veins and varicose veins. Conversely, some non-vascular doctors have found vein treatment an opportunity to expand their services.
We feel strongly that vein treatment requires the utmost dedication and attention to achieve high quality results and patient satisfaction.
In some clinics, health extenders including Nurse Practitioners and Physician Assistants are performing vein ablations and medical sclerotherapy in place of the doctor. Despite assurances that these procedures are supervised by the attending, this is far from the case. Many times, the physician is at a remote location providing zero support or supervision. The primary intention is to provide as many treatments as possible in a single day. We refer to this as “Fast-Food” medicine. Vascular procedures are not intended to be performed by health extenders and any deviation from this practice is a serious concern.
Our mission at VSC is to provide modern medical treatments for vein insufficiency with clinical integrity and competence with the utmost respect for each patient’s individual goals. We empower patients through knowledge to be active participants in their treatments. Regardless of the changes in the practice of medicine and the challenges presented, VSC is committed to ethical vein treatment.