As the understanding of the discipline of cardiology has grown over time, cardiologists from all over the world have come to the realization that the heart is but one important component of the cardiovascular system. During the last decade, cardiologists have embraced several new disciplines within their traditional scope of service. The oversight of sleep-related disorders, diabetes, and weight control are now part of the mainstream cardiovascular practice, where it typically was not several years ago.

As the scope of today's cardiology practice continues to broaden, the most important additions might be the evaluation of peripheral vascular disease, also known as PAD, along with the study of venous circulation. In fact, many would now consider it malpractice if a physician suspects coronary heart disease but does not consider concomitant peripheral vascular disease as part of the evaluation process. As we know, the veins represent 50% of that system, yet are often underappreciated in the current cardiovascular training curriculum.

Recently, more and more progressive, talented cardiologists have embraced the practice of phlebology as an important addition to their armamentarium to help diagnose potentially preventable and treatable disorders. Interestingly, many have even said that adding phlebology to their practice has allowed them to enjoy the practice of cardiology again. This article hopes to explain how and why this important area of the field can help many patients and physicians by optimizing the success of today's physicians' practices.

HISTORY OF VEIN DISEASE AND PHLEBOLOGY

We have come a long way since Hippocrates affirmed that the liver is the “root” of all veins, and that the veins contained the body's nourishment. This misguided understanding of the complex venous system persisted until the 17th century, when William Harvey described his theory of blood circulation. Throughout the 20th century, surgery (stripping), as first propounded by Charles Mayo in 1904, remained the mainstay of treatment. 

However, in 1986, duplex scanning was first proposed for venous disorders and provided the impetus for the modern understanding of phlebology. Subsequently, at the beginning of the 21st century, catheter-based endovenous ablation or radiofrequency therapy became the treatment of choice. Most recently, longerwavelength lasers have been introduced with the goal of further reducing discomfort related to the endovenous procedure. Nevertheless, it was not until the end of this century's first decade that cardiologists began to embrace the importance of vein disease within their scope of practice.

HISTORY OF CARDIOLOGY

Simultaneous with the growth of phlebology was the explosion of knowledge within cardiology. Cardiologists the world over became proficient in catheter placement techniques and echocardiography. Pioneering work by Swan, Ganz, Diamond, and Feigenbaum on the use of catheters, ultrasound, and hemodynamics became the bedrock of cardiology.

These fundamental skills and knowledge, already inherent in most cardiology offices, leave today's cardiologists uniquely suited to utilize the advancements in phlebology to treat their venous-compromised patients. Essentially, this forms the “perfect storm” for a cardiology practice—a disease that is diagnosable in early form; curable with familiar, existing, inexpensive technology; and with patients that are already in their office or very enthusiastic to see them.

There are approximately 30,000 cardiologists nationwide that see more than 50 million patients per year. In sheer numbers alone, cardiologists are in a unique position to affect the future of venous disease. Not only do they have the patient contact and confidence necessary to get the practice of phlebology to the masses, but they often have the outpatient skills and experience necessary to make it successful. As one example, much of the current research on ultrasound-guided foam sclerotherapy centers on the issues regarding right-to-left cardiac shunting, a well-understood paradigm in cardiac literature. Thus, cardiologists might be able to impact phlebology in ways yet to be understood.

HOW A CARDIOLOGY PRACTICE CAN BENEFIT FROM A VEIN DIVISION

Dr. Hamsey is a 41-year-old, board-certified, solo, noninvasive cardiologist. He has recently seen his crucial diagnostic testing revenue reduced and is facing further challenges from pending changes in the health care industry. Dr. Hamsey's hospital responsibilities have made it more difficult to find time to spend with his family, and the hospital politics have become more cumbersome. He has an echocardiography machine in his office and one underused examination room that often is used for storage. However, he attended a seminar on vein disease and feels that many of his patients might benefit from therapy.

Dr. Hamsey subsequently attended a 2-day course in South Florida on vein disease given by active cardiologists on outpatient endovenous ablation techniques. This course also included everything necessary to begin the marketing, billing, and administration of a vein division within his practice. After he returned from the training course, he began adding a simple questionnaire to his normal office intake with questions such as: Do you have leg pain? Do you think you might have varicose veins?

After appropriate duplex scanning, his first few procedures were then scheduled, and he had seasoned vein ablation industry representatives helping him throughout the whole process. The vast experience of the representatives made Dr. Hamsey's first few cases go smoothly by being well prepared and confident, as did appropriate patient selection. He also had his mentor from his training site available via Skype (teleconferencing) during the first few cases.

After the second month, he had exceeded all of his projections. In month 3, he decided to add a part-time nurse practitioner to his practice, whose sole purpose was to perform the sclerotherapy injections that many patients began asking for as a cosmetic adjunct. In addition to adding income to his practice, these cosmetic procedures performed by his part-time nurse practitioner added a new type of patient to his existing practice and made his practice the buzz around town. In fact, popular Saturday hours were used by his nurse practitioner to augment her income and further reduce his overhead.

By month 6, his vein practice was bringing in more revenue than his cardiology practice, and his cardiology practice was growing due to the cross referral potential. All of the nurses in the local hospital were coming to his office for vein evaluations as they began to hear his local lectures and satisfied patient testimonials, and the new exposure allowed him to update his Web site and refresh his office décor. This, in turn, led to patients scheduling online, and by the ninth month, he opened up a satellite office in a nearby region.

Dr. Hamsey used what he had learned in his vein training marketing program and harnessed the power of digital social media to advertise his program. He began seeing patients asking for cash-based options and added a financing option to his front desk operations. For the first time in his career, 25% of his revenue was independent of any insurance carrier, and patients often had no accounts receivable because his staff was able to collect in advance. He subsequently limited his responsibilities in the hospital to only his existing patients, stopped taking nighttime and weekend emergency department calls, and was able to reconnect with his family and work on his golf game. Dr. Hamsey joined the American College of Phlebology to add to his cardiology credentials and is a soughtafter speaker in his area.

HOW TO GET STARTED

Although cardiologists are relatively new in this space, there are a few easy ways to get started and/or evaluate if a phlebology practice can potentially work for you. To start, simply ask a local colleague, such as a vascular surgeon to whom you might already be sending patients, if they would permit you to “scrub in” to a case or two; it is a great way to pique your curiosity. Often, they will be more than happy to oblige because the vascular surgeons generally do not find your interests to be competitive to theirs, because they usually have plenty of work, and they also realize that additional referrals may stem from your observation of them.

After this, if you are still interested in moving forward, attendance at a formal course should be the next step. There are a variety of formal courses available from companies selling the laser consoles. Additionally, look for a 1- to 2-day training course because a course of any longer duration is usually not necessary and cumbersome on your staff. You should make sure that it is a cardiologist-oriented training program, as anything else will not optimally synergize with your practice. Also, be sure that sclerotherapy is emphasized in any formal course or training session because this is an important adjunct to any vein practice and improves general patient satisfaction.

Finally, if you feel that hands-on experience is absolutely necessary, then there are a few international programs available for this purpose. The Masters Practicum, offered by Dr. Jose Almeida biannually in the Dominican Republic, offers a week of active procedures, including sclerotherapy, thermal ablation techniques, and even phlebectomy. It is a unique experience that can be very valuable. Because it is not an inexpensive option, we suggest this might be done after taking an introductory training course.

Once trained, comfortable, and working closely with your endovenous ablation industry representative, you should implement an awareness campaign within your practice. By making your staff aware and amending the focus of your practice to include phlebology, it will lead to patients being sent to ultrasound and, ultimately, being identified as appropriate endovenous ablation candidates. When the first few good and obvious candidates are identified, they should then be properly consented and scheduled.

An examination room is prepared (most regular examination rooms will suffice), and the first case is performed with the representatives at the bedside. The staff should be instructed on proper postprocedure draping and patient education. Additionally, the billing staff should be made aware of the proper coding and authorization. Once the first few cases are finished, the patients will come back raving about their experience, the billing office will complement you on the substantial reimbursement received, the office will be comfortable with the happy patients coming through, and your practice will be well on its way to success.

CONCLUSION

In the face of rapidly declining professional satisfaction and reimbursement in cardiology, the practice of phlebology might be a useful adjunct. The skill set necessary to diagnose and treat venous disease is well within many cardiologists' training and background. Optimizing vascular health is no longer just about the coronary arteries, and the inclusion of venous disease has added a dimension useful for a wider and more appreciative patient base. As many prominent cardiologists have shown, the addition of vein treatment can be very satisfying, lucrative, and fulfilling.

Ariel D. Soffer, MD, FACC, is Clinical Assistant Professor of Medicine at Florida International University in Miami, Florida, and at Nova Southeastern University in Fort Lauderdale-Davie, Florida. He is also the Chief Executive Officer of the Soffer Heart & Vein Institute and Training Facility in Miami, Florida. He has disclosed that he holds no financial interest related to this article. Dr. Soffer may be reached at (305) 792-0555; as@sofferheart.com.