Program requirements for fellowship education in venous and lymphatic medicine

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DOI: 10.1177/0268355516664213
Cite this publication
Abstract
Background: In every field of medicine, comprehensive education should be delivered at the graduate level. Currently, no single specialty routinely provides a standardized comprehensive curriculum in venous and lymphatic disease. Method: The American Board of Venous & Lymphatic Medicine formed a task force, made up of experts from the specialties of dermatology, family practice, interventional radiology, interventional cardiology, phlebology, vascular medicine, and vascular surgery, to develop a consensus document describing the program requirements for fellowship medical education in venous and lymphatic medicine. Result: The Program Requirements for Fellowship Education in Venous and Lymphatic Medicine identify the knowledge and skills that physicians must master through the course of fellowship training in venous and lymphatic medicine. They also specify the requirements for venous and lymphatic training programs. The document is based on the Core Content for Training in Venous and Lymphatic Medicine and follows the ACGME format that all subspecialties in the United States use to specify the requirements for training program accreditation. The American Board of Venous & Lymphatic Medicine Board of Directors approved this document in May 2016. Conclusion: The pathway to a vein practice is diverse, and there is no standardized format available for physician education and training. The Program Requirements for Fellowship Education in Venous and Lymphatic Medicine establishes educational standards for teaching programs in venous and lymphatic medicine and will facilitate graduation of physicians who have had comprehensive training in the field.
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Original Article
Program requirements for
fellowship education in venous
and lymphatic medicine
Anthony J Comerota
1
, Robert J Min
2
, Suman W Rathbun
3
,
Neil Khilnani
2
, Thom Rooke
4
, Thomas W Wakefield
5
,
Teresa L Carman
6
, Fedor Lurie
1
, Suresh Vedantham
7
and Steven E Zimmet
8
Abstract
Background: In every field of medicine, comprehensive education should be delivered at the graduate level. Currently,
no single specialty routinely provides a standardized comprehensive curriculum in venous and lymphatic disease.
Method: The American Board of Venous & Lymphatic Medicine formed a task force, made up of experts from
the specialties of dermatology, family practice, interventional radiology, interventional cardiology, phlebology, vascular
medicine, and vascular surgery, to develop a consensus document describing the program requirements for fellowship
medical education in venous and lymphatic medicine.
Result: The Program Requirements for Fellowship Education in Venous and Lymphatic Medicine identify the knowledge
and skills that physicians must master through the course of fellowship training in venous and lymphatic medicine. They
also specify the requirements for venous and lymphatic training programs. The document is based on the Core Content
for Training in Venous and Lymphatic Medicine and follows the ACGME format that all subspecialties in the United States
use to specify the requirements for training program accreditation. The American Board of Venous & Lymphatic
Medicine Board of Directors approved this document in May 2016.
Conclusion: The pathway to a vein practice is diverse, and there is no standardized format available for physician educa-
tion and training. The Program Requirements for Fellowship Education in Venous and Lymphatic Medicine establishes
educational standards for teaching programs in venous and lymphatic medicine and will facilitate graduation of physicians
who have had comprehensive training in the field.
Keywords
Curriculum, professional education, medical education, venous medicine, lymphatic medicine, venous and lymphatic
medicine training, fellowship training, educational standards, specialization, clinical competence
Background
The major venous societies in the world share a common
mission to improve the standards of medical practi-
tioners, the educational goals for teaching and training
programs in venous disease, and the quality of patient
care related to the treatment of venous disorders. With
these goals in mind, a task force made up of experts from
the specialties of dermatology, family practice, interven-
tional radiology, interventional cardiology, phlebology,
vascular medicine, and vascular surgery was formed to
develop a consensus document describing the program
requirements for fellowship medical education in venous
and lymphatic medicine.
1
Jobst Vascular Institute, Toledo, USA
2
The Department of Radiology, Weill Cornell Medicine, New York, USA
3
Vascular Medicine, University of Oklahoma Health Sciences Center,
Oklahoma City, USA
4
Gonda Vascular Center, Mayo Clinic, Rochester, USA
5
Department of Surgery, Section of Vascular Surgery, University of
Michigan Health System, Ann Arbor, USA
6
Cardiovascular Medicine, University Hospitals Case Medical Center,
Cleveland, USA
7
Interventional Radiology Section, Mallinckrodt Institute of Radiology,
Washington University School of Medicine, St Louis, USA
8
Zimmet Vein & Dermatology, Austin, USA
Corresponding author:
Steven E Zimmet, Zimmet Vein & Dermatology, 1500 W. 34th Street,
Austin, TX 78703, USA.
Email: zimmet@drzimmet.com
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DOI: 10.1177/0268355516664213
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The Program Requirements for Fellowship Education
in Venous and Lymphatic Medicine identify the know-
ledge and skills that physicians must master through the
course of fellowship training in venous and lymphatic
medicine. They also specify the requirements for venous
and lymphatic training programs. The document is based
on the Core Content for Training in Venous and
Lymphatic Medicine
1
and follows the ACGME format
that all subspecialties in the United States use to specify
the requirements for training program accreditation.
2
This document is the result of a two-year national
development process initiated by the ABVLM and was
supported in part by the American College of Phlebology
Foundation. The ABVLM Board of Directors approved
this document in May 2016.
Program requirements (common
program requirements are in BOLD)
Introduction
Int. A. Residency and fellowship programs are essential
dimensions of the transformation of the medical
student to the independentpractitioneralongthe
continuum of medical education. They are phys-
ically, emotionally, and intellectually demanding
and require longitudinally concentrated eort on
the part of the resident or fellow.
The specialty education of physicians to practice
independently is experiential, and necessarily
occurs within the context of the health care deliv-
ery system. Developing the skills, knowledge, and
attitudes leading to proficiency in all the domains
of clinical competency requires the resident and
fellow physician to assume personal responsibility
for the care of individual patients. For the resi-
dent and fellow, the essential learning activity is
interaction with patients under the guidance and
supervision of faculty members who give value,
context, and meaning to those interactions. As
residents and fellows gain experience and demon-
strate growth in their ability to care for patients,
they assume roles that permit them to exercise
those skills with greater independence. This con-
cept—graded and progressive responsibility—is
one of the core tenets of American graduate med-
ical education. Supervision in the setting of
graduate medical education has the goals of
assuring the provision of safe and eective care
to the individual patient; assuring each resident’s
and fellow’s development of the skills, knowledge,
and attitudes required to enter the unsupervised
practice of medicine; and establishing a founda-
tion for continued professional growth.
Int. B. Definition and Scope of the Field
Venous and lymphatic medicine is the discip-
line that involves the diagnosis and treatment
of acute and chronic venous disease of the
superficial and deep systems and lymphatic dis-
orders. Included are telangiectasia, reticular
veins, varicose veins, venous edema, chronic
venous disease, chronic venous insuciency
with skin changes, venous leg ulcers, deep
venous disease, pelvic venous insuciency syn-
dromes, venous compression syndromes, con-
genital venous malformations, venous
thromboembolism, lymphedema, and other
disorders of venous, lymphatic, and mixed
origin. The Core Content for Training in
Venous and Lymphatic Medicine outlines the
content areas in the field.
1
Int. C. Duration and Scope of Education
The duration of a fellowship program in
venous and lymphatic medicine is 12 months.
Given the multispecialty nature of this
field, candidates will vary in their background
and level of preparation across the various
areas of the field. The program director
should assess knowledge and skills gaps
based on the areas of knowledge considered
essential in the field, as elucidated in the Core
Content for Training in Venous and
Lymphatic Medicine. The fellowship program
must be able to address the educational gaps of
each fellow, such that on completion of the
VLM training program fellows should be
able to demonstrate competence with sucient
expertise to act as independent care consult-
ants in the field.
I. Institutions
I.A. Sponsoring Institution
One sponsoring institution must assume ultimate respon-
sibility for the program, as described in the Institutional
Requirements, and this responsibility extends to fellow
assignments at all participating sites.
The sponsoring institution and the program must ensure
that the program director has sucient protected time and
financial support for his or her educational and adminis-
trative responsibilities to the program.
I.B. Participating sites
I.B.1. There must be a program letter of agreement
(PLA) between the program and each participat-
ing site providing a required assignment. The
PLA must be renewed at least every five years.
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The PLA should:
I.B.1.a) identify the faculty who will assume both
educational and supervisory responsibilities
for fellows;
I.B.1.b) specify their responsibilities for teaching,
supervision, and formal evaluation of fel-
lows, as specified later in this document;
I.B.1.c) specify the duration and content of the edu-
cational experience; and
I.B.1.d) state the policies and procedures that will
govern fellow education during the
assignment.
I.B.2. The program director must submit any additions
or deletions of participating sites routinely pro-
viding an educational experience, required for all
fellows, of one month full time equivalent (FTE)
to the ABVLM.
I.B.3. Integrated Sites
A program that uses integrated sites must
ensure the provision of a unified educational
experience for all fellows. Each participating
site must oer significant educational opportu-
nities. Sites may be integrated with the spon-
soring institution through an integration
agreement specifying that the program director
must:
I.B.3.a) appoint the members of the faculty at the
integrated site;
I.B.3.b) appoint the chief or director of the teach-
ing service in the integrated site;
I.B.3.c) appoint all fellows in the program; and,
I.B.3.d) determine all rotations and assignments of
both fellows and members of the faculty
including duration of the experience as
well as educational and supervisory
responsibilities.
I.B.4. If integrated sites are in geographic proximity,
fellows will be permitted to attend joint confer-
ences, basic science lectures, and morbidity and
mortality reviews on a regular documented
basis at a central location. If the sites are geo-
graphically so remote that joint conferences
cannot be held, an equivalent educational pro-
gram of lectures and conferences at the inte-
grated site may be available and should be
documented.
I.B.5. State the policies and procedures that will
govern fellow education during the assignment.
II. Program Personnel and Resources
II.A. Program Director
II.A.1. There must be a single program director with
authority and accountability for the operation
of the program. The sponsoring institution’s
GMEC must approve a change in program
director.
II.A.1.a) The program director must submit this change
to the ABVLM.
II.A.2. Qualifications of the program director must
include:
II.A.2.a) requisite specialty expertise and documented
educational and administrative experience
acceptable to the Review Committee;
IIA.2.a).(1) demonstrated experience and expertise in
venous and lymphatic medicine as a
board certified physician in good
standing in a relevant medical/surgical
discipline.
IIA.2.a).(2) experience as a teacher in graduate
medical education of residents and/or
fellows in a relevant specialty; and
IIA.2.a).(3) an ongoing clinical practice in venous
and lymphatic medicine.
II.A.2.b) current certification by an ABMS recognized
specialty in which venous and lymphatic
medicine was part of the core curriculum, or
specialty qualifications that are acceptable to
the Review Committee; and,
II.A.2.c) current medical licensure and appropriate
medical staappointment.
II.A.2.c).(1) The program director must possess a
license in good standing in the state
in which the program exists.
II.A.2.c).(2) The program director must be based at
a teaching site that is encompassed
within the Program.
II.A.3. The program director must administer and
maintain an educational environment condu-
cive to educating the fellows in each of the
ACGME competency areas. The program dir-
ector must:
II.A.3.a) prepare and submit all information required
and requested by the ABVLM;
II.A.3.b) be familiar with and oversee compliance
with ABVLM Fellowship Accreditation
and Oversight (A&O) Committee policies
and procedures;
II.A.3.c) obtain review and approval of the sponsor-
ing institution’s GMEC/DIO before sub-
mitting information or requests to the
ABVLM, including:
II.A.3.c).(1) all applications for ABVLM
accreditation of new programs;
II.A.3.c).(2) changes in fellow complement;
II.A.3.c).(3) major changes in program structure
or length of training;
II.A.3.c).(4) progress reports requested by the
Review Committee;
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II.A.3.c).(5) responses to all proposed adverse
actions;
II.A.3.c).(6) requests for increases or any change
to fellow duty hours;
II.A.3.c).(7) voluntary withdrawals of accredited
programs;
II.A.3.c).(8) requests for appeal of an adverse
action; and,
II.A.3.c).(9) appeal presentations to a Board of
Appeal or the ABVLM.
II.A.3.d) obtain DIO review and co-signature on all
program information forms, as well as any
correspondence or document submitted to
the ABVLM that addresses:
II.A.3.d).(1) program citations, and/or
II.A.3.d).(2) request for changes in the program
that would have significant impact,
including financial, on the program
or institution.
II.A.3.e) devote sucient time to the administrative
and teaching tasks inherent in achieving
the goals of the program;
II.A.3.f) ensure that fellows’ service responsibilities
are limited to patients for whom the
teaching service has diagnostic and thera-
peutic responsibility;
II.A.3.g) be available and accessible to fellows at the
primary clinical site;
II.A.3.h) oversee and ensure the quality of didactic
and clinical education in all sites that par-
ticipate in the program;
II.A.3.i) approve a local director at each participating
site who is accountable for fellow education;
II.A.3.j) approve the selection of program faculty as
appropriate;
II.A.3.k) evaluate program faculty and approve the
continued participation of program faculty
based on evaluation;
II.A.3.l) monitor fellow supervision at all participat-
ing sites;
II.A.3.m) provide each fellow with documented quar-
terly evaluation and feedback of their
performance;
II.A.3.n) provide verification of fellowship education
with case documentation for all fellows,
including those who leave the program
prior to completion;
II.A.3.o) be responsible for monitoring fellow stress,
including mental or emotional conditions
inhibiting performance or learning, and
drug- or alcohol-related dysfunction.
II.A.3.o).(1) Both the program director and fac-
ulty should be sensitive to the need
for timely provision of confidential
counseling and psychological sup-
port services to fellows.
II.A.3.o).(2) Situations that demand excessive
service or that consistently produce
undesirable stress on fellows must
be evaluated and modified;
II.A.3.p) ensure that departmental clinical quality
improvement programs are integrated into
the fellowship program;
II.A.3.q) ensure that the fellowship does not place
excessive reliance on fellows for service as
opposed to education;
II.A.3.r) participate in academic societies and in edu-
cational programs designed to enhance his
or her educational and administrative skills.
II.B. Faculty
II.B.1. There must be a sucient number of faculty
with documented qualifications to instruct and
supervise all fellows.
II.B.1.a) The physician faculty must possess the
requisite specialty expertise and compe-
tence in clinical care and teaching abilities,
as well as documented educational and
administrative abilities and clinical experi-
ence in venous and lymphatic medicine.
II.B.1.b) While the expertise of any one faculty
member may be limited to a particular
aspect of venous and lymphatic medicine,
the training program must provide com-
prehensive experience in venous and
lymphatic medicine, including both tech-
nical aspects and clinical patient evalu-
ation and management.
II.B.1.c) In the short-term absence of the program
director, one member of the teaching sta
must assume the responsibility for the dir-
ection of the program.
II.B.2. The faculty must devote sucient time to the
educational program to fulfill their supervisory
and teaching responsibilities and demonstrate a
strong interest in the education of fellows.
II.B.2.a) The faculty must demonstrate a commit-
ment to the field of venous and lymphatic
medicine.
II.B.2.a).(1) Such commitment includes member-
ship in professional societies in this
field, publications in this field, and a
minimum of 30 hours of CME
Category I credit per year relevant
to venous and lymphatic medicine.
II.B.3. The physician faculty must have current certifi-
cation by the American Board of Medical
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Specialties or possess qualifications acceptable
to the Review Committee.
II.B.4. The physician faculty must possess current med-
ical licensure and appropriate medical sta
appointment.
II.B.4.a) Faculty must possess a license in good
standing in the state in which the program
exists.
II.B.5. The faculty must establish and maintain an
environment of inquiry and scholarship,
which would ideally include an active research
component.
II.B.5.a) The faculty must regularly participate in
organized clinical discussions, rounds,
journal clubs, and conferences.
II.B.5.b) Some members of the faculty should also
demonstrate scholarship by one or more
of the following:
II.B.5.b).(1) peer-reviewed funding;
II.B.5.b).(2) publication of original research or
review articles in peer reviewed jour-
nals, or chapters in textbooks;
II.B.5.b).(3) publication or presentation of case
reports or clinical series at local,
regional, or national professional
and scientific society meetings; and/
or
II.B.5.b).(4) participation in national committees
or educational organizations.
II.B.5.c) There must be education on the basic prin-
ciples of research, study design, and evalu-
ation of published literature.
II.B.6. Nonphysician faculty must be appropri-
ately qualified and credentialed in their field
and must hold appropriate institutional
appointments.
II.B.7. Faculty members should participate in faculty
development programs to enhance the eect-
iveness of their teaching.
II.B.8. For programs not aliated with a medical
school, all physician faculty should be mem-
bers of the medical staof at least one of the
participating sites.
II.B.9. Faculty members must always be available for
back-up when fellows are on night, weekend,
or holiday call.
II.B.10. Faculty members must review all diagnostic
images and sign all fellows reports within 24
hours.
II.B.11. Faculty members must provide didactic
teaching and direct supervision of fellow per-
formance in peri-procedural patient manage-
ment and of the procedural, interpretative,
and consultative aspects of VLM.
II.B.12. Faculty members must supervise all invasive
procedures.
II.B.12.a) Faculty members should determine
the appropriate level of direct or indirect
supervision for the following proced-
ures: diagnostic ultrasound, application
of bandaging and compression, and
sclerotherapy.
II.B.12.b) All other percutaneous image-guided
invasive procedures must be directly
supervised by faculty members.
II.C. Other Program Personnel
The institution and the program must jointly ensure the
availability of all necessary professional, technical, and
clerical personnel for the eective administration of the
program.
II.C.1. Fellows should have an opportunity to work
with health care personnel and receive timely
and appropriate consultation, when appropri-
ate, from other specialties such as radiology,
interventional radiology, vascular surgery,
vascular medicine, anesthesiology, dermatol-
ogy, and others.
II.D. Resources
The institution and the program must jointly ensure the
availability of adequate resources for fellow education, as
defined in the specialty program requirements.
II.D.1. Adequate space, clinical patient volume, and
administrative support stamust be available
to enable every fellowship trainee access to the
following key training opportunities:
II.D.1.a) A diverse population of patients with
venous and lymphatic disorders must be
available, from which a broad experience
in venous care can be obtained.
II.D.1.b) A sucient number of patients must be
available to enable each fellow to achieve
the required educational outcomes.
II.D.1.c) A clinic in which to practice clinical
patient assessment (history and physical)
of venous and lymphatic diagnosis is
required. Exposure to a wound care
clinic or center is highly desired.
II.D.1.d) An adequately staed and equipped
accredited vascular ultrasound laboratory
is required.
II.D.1.e) Program laboratories should be in com-
pliance with all federal, state, and local
regulations regarding a work environment
(e.g. OSHA)
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II.D.1.f) Adequate space dedicated to the perform-
ance of vein procedures is required. It is
desirable for this to include facilities for
oce-based procedures, outpatient proced-
ures that utilize fluoroscopy, and hospital-
based procedures that utilize fluoroscopy.
II.D.1.g) Inpatient and outpatient systems must be in
place to prevent fellows from routinely per-
forming clerical functions, including but
not limited to scheduling tests and appoint-
ments, and retrieving records and letters.
II.D.1.h) There should be adequate space and equip-
ment including meeting rooms, examin-
ation rooms, computers, visual and other
educational aids, and work/study space.
II.D.1.i) It is highly desirable for the institution to
provide laboratory and ancillary facilities
to support research projects.
II.D.1.j) Access to an electronic health record
should be provided. In the absence of an
existing electronic health record, institu-
tions must demonstrate institutional com-
mitment to its development and progress
toward its implementation.
II.D.1.k) If needed, aliations with other institu-
tions may be utilized to ensure that fel-
lowship trainees have access to the
above mentioned key resources.
II.E. Medical Information Access
Fellows must have ready access to specialty-specific and
other appropriate reference material in print or electronic
format. Electronic medical literature databases with
search capabilities should be available.
III. Fellow Appointments
III.A. Eligibility Criteria
All required clinical education for entry into the fellow-
ship program must be completed in an ACGME-accre-
dited residency program, or in an RCPSC-accredited
or CFPC-accredited residency program located in
Canada, and/or meet other eligibility criteria as specified
by the Review Committee.
III.A.1. The program must document that each fellow
has met the eligibility criteria.
III.B. Number of Fellows
The program’s educational resources must be adequate to
support the number of fellows appointed to the program.
III.B.1. The program director may not appoint more fel-
lows than approved by the Review Committee,
unless otherwise stated in the specialty-specific
requirements.
III.B.2. The Review Committee will approve the
number of fellows based upon established
written criteria that include the adequacy of
resources for fellow education (e.g., the qual-
ity and volume of patients and related clinical
material available for education), faculty-
fellow ratio, institutional funding, and the
quality of faculty teaching.
III.B.3. Fellow Transfers: To determine the appro-
priate level of education for fellows who are
transferring from another program, the pro-
gram director must receive written verifica-
tion of previous educational experiences
and a statement regarding the performance
evaluation of the transferring fellow prior to
their acceptance into the program. A pro-
gram director is required to provide verifi-
cation of education for fellows who may
leave the program prior to completion of
their education.
III.B.4. Appointment of Other Students: The
appointment of fellows from other pro-
grams, residents or students must not dilute
or detract from the educational opportu-
nities available to regularly appointed fel-
lows. Prior approval for changes in the
approved resident/fellow complement must
be obtained by the Review Committee.
IV. Educational Program
IV.A. The curriculum must contain the fol-
lowing educational components
IV.A.1. Skills and competencies the fellow will be able
to demonstrate at the conclusion of the pro-
gram. The program must distribute these
skills and competencies to fellows and faculty
annually, in either written or electronic form.
IV.A.1.a) These skills and competencies should be
reviewed by the fellow at the start of each
rotation;
IV.A.2. ACGME Competencies
The program must integrate the following ACGME com-
petencies into the curriculum:
IV.A.2.a) Patient Care and Procedural Skills
IV.A.2.a).(1) Fellows must be able to provide
patient care that is compassionate,
appropriate, and eective for the
treatment of health problems and
the promotion of health. Fellows:
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IV.A.2.a).(2) Fellows must be able to competently
perform all medical, diagnostic,
and surgical procedures considered
essential for the area of practice.
(See Appendix 1 for specific proced-
ural requirements)
Fellows:
IV.A.2.a).(2).(a.) must demonstrate manual dexter-
ity appropriate for the procedures
they perform;
IV.A.2.a).(2).(b.) must develop and execute appro-
priate patient care plans;
IV.A.2.a).(2).(c.) must have technical skills essential
for practitioners that can be
acquired only through personal
experience and education. The
program must provide sucient
clinical and operative experience
to educate competent practi-
tioners. A sucient number and
distribution of venous and lymph-
atic cases must be provided for
the achievement of adequate pro-
cedural skill and clinical judgment.
The program director must ensure
that the procedural and clinical
experience of the individual fel-
lows in the same program is
comparable;
IV.A.2.a).(2).(d.) are considered to be accomplished
practitioners when they can docu-
ment a significant role in the fol-
lowing aspects of patient
management: determination or
confirmation of the diagnosis; pro-
vision of pre-procedure care; selec-
tion and performance of the
appropriate procedure; direction
of post-procedure care; and per-
forming sucient follow-up which
demonstrates knowledge of the dis-
ease and the anticipated outcome
of its treatment. Participation in
procedure only, without pre-
procedure and post-procedure
care, is inadequate;
IV.A.2.a).(2).(e.) must have continuity of primary
responsibility for patient care.
This must be taught in a longitu-
dinal way, and must include
ambulatory care, inpatient care,
referral and consultation, and
utilization of community
resources when appropriate;
IV.A.2.a).(2).(f.) must be provided with clinical
responsibilities for the total care of
patients, including preoperative
evaluation, appropriate use of diag-
nostic tests, therapeutic decision-
making, procedural and clinical
experience, and post-procedure
management;
IV.A.2.a).(2).(g.) must have the opportunity to pro-
vide consultation with faculty
supervision. They should have
clearly defined educational
responsibilities for other resi-
dents, medical students, and pro-
fessional personnel participating
in their clinical program. These
teaching experiences should cor-
relate basic anatomic, physio-
logic, pathophysiologic, and
biomedical knowledge with the
clinical aspects of patients with
venous and lymphatic disease;
IV.A.2.a).(2).(h.) should act as teaching assistants,
when clinical and procedural
experience justifies a teaching
role and should report such
cases to the Review Committee
residency;
IV.A.2.a).(2).(i.) must receive education on the spe-
cific diagnostic techniques for the
management of venous and lymph-
atic disease. It is essential that
fellows understand the methods
and techniques of venous duplex
ultrasound. Fellows must be cap-
able of performing venous duplex
ultrasound when acute DVT is sus-
pected. They must be capable of
performing and interpreting tests
for venous reflux of the superficial
and deep venous systems and per-
forating veins. In addition, general
knowledge and skills in the assess-
ment of pelvic veins, inferior vena
cava, renal veins, gonadal veins,
and upper extremity veins is
required. Fellows must have a
working knowledge of physiologic
testing of the venous system, which
includes audible venous Doppler,
photoplethysmography, air
plethysmography, venous outflow
studies, and venous pressure
measurements.
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IV.A.2.a).(2).(j.) must be knowledgeable about com-
puted tomographic venography
(CTV) and magnetic resonance
venography (MRV) and their arter-
ial counterparts. That includes the
risks and benefits of the procedures,
their strengths and weaknesses and
in particular how to best apply
these techniques to patients with
venous and lymphatic disease.
IV.A.2.a).(2).(k.) must be knowledgeable with the
proper indications of and inter-
pretation of ascending and des-
cending phlebography and the
indications for and role of arteri-
ography for evaluating patients
with vascular malformations and
selected patients with venous dis-
ease. In addition, knowledge, skill
set, and interpretation of veno-
graphic studies including pelvic
veins and the inferior vena cava,
renal veins and gonadal veins is
expected.
IV.A.2.a).(2).(l.) must have experience with out-
patient activities, as these consti-
tute an essential component of the
care of patients with venous and
lymphatic disease. Three days per
week, on average, should be
devoted to outpatient activities.
IV.A.2.a).(2).(m.) must be knowledgeable about
diagnostic tests for lymphedema
and proper interpretation; specif-
ically, the proper performance,
and interpretation of
lymphoscintigraphy.
IV.A.2.b) Medical Knowledge
Fellows must demonstrate knowledge of established and
evolving biomedical, clinical, epidemiological, and social-
behavioral sciences, as well as the application of this
knowledge to patient care. Fellows:
IV.A.2.b).(1) must be able to critically evaluate and
demonstrate knowledge of pertinent
scientific information;
IV.A.2.b).(2) should have education in the entire
venous and lymphatic system.
Instruction in each area should be asso-
ciated with relevant patient exposure. If
this is not possible, instructional mater-
ials must be provided to ensure ade-
quate education for unusual
conditions, such as congenital disorders.
IV.A.2.b).(3) must have instruction and become
knowledgeable in the fundamental
sciences, including anatomy, embry-
ology, microbiology, physiology, and
pathology as they relate to the patho-
physiology, diagnosis, and treatment
of venous and lymphatic diseases, as
delineated in the ‘‘Core content for
training in venous and lymphatic
medicine’’ document
1
;
IV.A.2.b).(4) must have instruction in critical
thinking, design of clinical trials,
evaluation of data, as well as in the
technological advances that relate to
the care of patients with venous
and lymphatic diseases. The program
should encourage the participation
of fellows in clinical and/or
laboratory research and make
appropriate facilities available includ-
ing the ability to submit abstracts,
presenting original work, and publi-
cations; and,
IV.A.2.b).(5) will have educational conferences
that are adequate in quality and
quantity to provide a review of
venous and lymphatic diseases as
well as recent advances. The confer-
ences should be scheduled to permit
the fellows to attend on a regular
basis. Participation by fellows and
faculty must be documented. Active
participation by venous and
lymphatic fellows in the planning
and production of these conferences
is essential. The following types of
conferences must exist within a
program:
IV.A.2.b).(5).(a) a review, held at least quarterly, of
all significant complications,
including radiological and patho-
logical correlation.
IV.A.2.b).(5).(b) a course or a structured series
of conferences to ensure cover-
age of the basic and clinical sci-
ences fundamental to venous
and lymphatic diseases (a sole
reliance on textbook review is
inadequate);
IV.A.2.b).(5).(c) regular organized clinical teach-
ing, such as ward rounds and
clinical conferences; and,
IV.A.2.b).(5).(d) a regular review of recent litera-
ture, such as a journal club
format.
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IV.A.2.c) Practice-based Learning and Improvement
Fellows are expected to develop skills and habits to be
able to meet the following goals:
IV.A.2.c).(1) systematically analyze practice using
quality improvement methods and
implement changes with the goal of
practice improvement, and
IV.A.2.c).(2) locate, appraise, and assimilate evi-
dence from scientific studies related to
their patients’ health problems;
IV.A.2.c).(3) critique personal practice outcomes;
IV.A.2.c).(4) demonstrate a recognition of the
importance of and process for lifelong
learning in practice.
IV.A.2.d) Interpersonal and Communication Skills
Fellows must demonstrate interpersonal and communica-
tion skills that result in the eective exchange of infor-
mation and collaboration with patients, their families,
and health professionals, including the ability to:
IV.A.2.d).(1) counsel and educate patients and
families; and
IV.A.2.d).(2) eectively document practice activities.
IV.A.2.e) Professionalism
Fellows must demonstrate a commitment to carrying out
professional responsibilities and an adherence to ethical
principles, and display:
IV.A.2.e).(1) high standards of ethical behavior;
IV.A.2.e).(2) a commitment to continuity of patient
care; and
IV.A.2.e).(3) sensitivity to age, gender, and culture
of other health care professionals.
IV.A.2.f) Systems-based Practice
Fellows must demonstrate an awareness of and responsive-
ness to the larger context and system of health care, as
well as the ability to call eectively on other resources in
the system to provide optimal health care, and:
IV.A.2.f).(1) practice high quality, cost eective
patient care;
IV.A.2.f).(2) demonstrate a knowledge of risk-ben-
efit analysis; and,
IV.A.2.f).(3) demonstrate an understanding of the
role of dierent specialists and other
health care professionals in overall
patient management.
IV.B. Fellows’ Scholarly Activities
IV.B.1. The curriculum must advance fellows’ know-
ledge of the basic principles of research,
including how research is conducted, evalu-
ated, explained to patients, and applied to
patient care.
IV.B.2. Fellows should participate in scholarly activity
and include submission of abstracts, presenta-
tions, and publishing in peer-reviewed journals.
IV.B.3. The sponsoring institution and program
should allocate adequate educational resources
to facilitate fellow involvement in scholarly
activities.
V. Evaluation
V.A. Fellow Evaluation
V.A.1. The program director must appoint the Clinical
Competency Committee.
V.A.1.a) At a minimum the Clinical Competency
Committee must be composed of three
members of the program faculty.
V.A.1.a).(1) The program director may appoint
additional members of the Clinical
Competency Committee.
V.A.1.a).(1).(a) These additional members
must be physician faculty
members from the same pro-
gram or other programs, or
other health professionals
who have extensive contact
and experience with the pro-
gram’s fellows in patient care
and other health care settings.
V.A.1.a).(1).(b) Chief residents who have
completed core residency
programs in their specialty
and are eligible for specialty
board certification may be
members of the Clinical
Competency Committee.
V.A.1.b) There must be a written description of the
responsibilities of the Clinical Competency
Committee.
V.A.1.b).(1) The Clinical Competency Committee
should:
V.A.1.b).(1).(a) review all fellow evaluations semi-
annually;
V.A.1.b).(1).(b) prepare and assure the reporting
of Milestones evaluations of each
fellow semi-annually; and,
V.A.1.b).(1).(c) advise the program director regard-
ing fellow progress, including pro-
motion, remediation, and dismissal.
V.A.2. Formative Evaluation
V.A.2.a) The faculty must evaluate fellow performance
in a timely manner.
This evaluation should be made for each rotation
or similar educational assignment and written documen-
tation should be provided at completion of the
assignment.
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V.A.2.b) The program must:
V.A.2.b).(1) provide objective assessments of com-
petence in patient care, medical know-
ledge, practice-based learning and
improvement, interpersonal and com-
munication skills, professionalism,
and systems-based practice based on
the specialty-specific Milestones (see
supplementary online material for
Venous and Lymphatic Medicine
Fellowship Milestones, available
online with this article, http://
phl.sagepub.com);
V.A.2.b).(2) use multiple evaluators (e.g., faculty,
peers, patients, self, and other profes-
sional sta); and,
V.A.2.b).(3) provide each fellow with documented
semiannual evaluation of perform-
ance with feedback.
V.A.2.c) The evaluations of fellow performance must
be accessible for review by the fellow, in
accordance with institutional policy.
V.A.3. Summative Evaluation
V.A.3.a) The specialty-specific Milestones must be used
as one of the tools to ensure fellows are able to
practice core professional activities without
supervision upon completion of the program.
V.A.3.b) The program director must provide a summa-
tive evaluation for each fellow upon comple-
tion of the program.
This evaluation must:
V.A.3.b).(1) become part of the fellow’s permanent
record maintained by the institution and
must be accessible for review by the fellow
in accordance with institutional policy.
V.A.3.b).(2) document the fellow’s performance
during their education; and,
V.A.3.b).(3) verify that the fellow has demonstrated
sucient competence to enter practice
without direct supervision.
V.B. Faculty Evaluation
V.B.1. At least annually, the program will evaluate fac-
ulty performance as it relates to the educational
program.
V.B.2. These evaluations should include a review of the
faculty’s clinical teaching abilities, commitment to
the educational program, clinical knowledge, pro-
fessionalism, and scholarly activities.
These evaluations must include at least semiannual
written confidential evaluations by the fellows of the
faculty and program overall.
V.C. Program Evaluation and Improvement
V.C.1. The program director must appoint the
Program Evaluation Committee (PEC).
V.C.1.a) The Program Evaluation Committee:
V.C.1.a).(1) must be composed of at least two program
faculty members and should include at
least one fellow;
V.C.1.a).(2) must have a written description of its
responsibilities; and,
V.C.1.a).(3) should participate actively in:
V.C.1.a).(3).(a) planning, developing, implementing,
and evaluating educational activities
of the program;
V.C.1.a).(3).(b) reviewing and making recommenda-
tions for revision of competency-
based curriculum goals and
objectives;
V.C.1.a).(3).(c) addressing areas of non-compliance
with ACGME standards; and,
V.C.1.a).(3).(d) reviewing the program annually using
evaluations of faculty, fellows, and
others, as specified below.
V.C.2. The program, through the PEC, must document
formal, systematic evaluation of the curriculum
at least annually, and is responsible for render-
ing a written and Annual Program Evaluation
(APE).
The program must monitor and track each of the follow-
ing areas:
V.C.2.a) fellow performance;
V.C.2.b) faculty development; and,
V.C.2.c) progress on the previous year’s action
plan(s).
V.C.3. The PEC must prepare a written plan of action
to document initiatives to improve performance
in one or more of the areas listed in section
V.C.2., as well as delineate how they will be
measured and monitored.
V.C.3.a) The action plan should be reviewed and
approved by the teaching faculty and docu-
mented in meeting minutes.
VI. Fellow Duty Hours in the Learning
and Working Environment
VI.A. Professionalism, Personal
Responsibility, and Patient Safety
VI.A.1. Programs and sponsoring institutions must
educate fellows and faculty members con-
cerning the professional responsibilities of
physicians to appear for duty appropriately
rested and fit to provide the services required
by their patients.
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VI.A.2. The program must be committed to and
responsible for promoting patient safety
and fellow well-being in a supportive educa-
tional environment.
VI.A.3. The program director must ensure that fel-
lows are integrated and actively participate
in interdisciplinary clinical quality improve-
ment and patient safety programs.
VI.A.4. The learning objectives of the program must:
VI.A.4.a) be accomplished through an appropriate
blend of supervised patient care respon-
sibilities, clinical teaching, and didactic
educational events, and
VI.A.4.b) not be compromised by excessive reli-
ance on fellows to fulfill non-physician
service obligations.
VI.A.5. The program director and sponsoring institu-
tion must ensure a culture of professionalism
that supports patient safety and personal
responsibility.
VI.A.6. Fellows and faculty members must demonstrate
an understanding and acceptance of their per-
sonal role in the following:
VI.A.6.a) assurance of the safety and welfare of
patients entrusted to their care;
VI.A.6.b) provision of patient- and family centered
care;
VI.A.6.c) assurance of their fitness for duty;
VI.A.6.d) management of their time before, during,
and after clinical assignments;
VI.A.6.e) recognition of impairment, including illness
and fatigue, in themselves and in their peers;
VI.A.6.f) attention to lifelong learning;
VI.A.6.g) the monitoring of their patient care per-
formance improvement indicators; and,
VI.A.6.h) honest and accurate reporting of duty
hours, patient outcomes, and clinical
experience data.
VI.A.7. All fellows and faculty members must dem-
onstrate responsiveness to patient needs that
supersedes self-interest. Physicians must rec-
ognize that under certain circumstances, the
best interests of the patient may be served
by transitioning that patient’s care to
another qualified and rested provider.
VI.B. Transitions of Care
VI.B.1. Programs must design clinical assignments to
minimize the number of transitions in patient
care.
VI.B.2. Sponsoring institutions and programs must
ensure and monitor eective, structured hand-
over processes to facilitate both continuity of
care and patient safety.
VI.B.3. Programs must ensure that fellows are compe-
tent in communicating with team members in
the hand-over process.
VI.B.4. The sponsoring institution must ensure the
availability of schedules that inform all mem-
bers of the health care team of attending phys-
icians and fellows currently responsible for
each patient’s care.
VI.C. Alertness Management/Fatigue
Mitigation
VI.C.1. The program must:
VI.C.1.a) educate all faculty members and fellows to
recognize the signs of fatigue and sleep
deprivation;
VI.C.1.b) educate all faculty members and fellows in
alertness management and fatigue mitiga-
tion processes; and,
VI.C.1.c) adopt fatigue mitigation processes to
manage the potential negative eects of
fatigue on patient care and learning, such
as naps or back-up call schedules.
VI.C.2. Each program must have a process to ensure
continuity of patient care in the event that a
fellow may be unable to perform his/her patient
care duties.
VI.C.3. The sponsoring institution must provide ade-
quate sleep facilities and/or safe transportation
options for fellows who may be too fatigued to
safely return home.
VI.D. Supervision of Fellows
VI.D.1. In the clinical learning environment, each
patient must have an identifiable, appropriately
credentialed, and privileged attending phys-
ician (or licensed independent practitioner as
approved by each Review Committee) who is
ultimately responsible for that patient’s care.
VI.D.1.a) This information should be available to fel-
lows, faculty members, and patients.
VI.D.1.b) Fellows and faculty members should
inform patients of their respective roles in
each patient’s care.
VI.D.2. The program must demonstrate that the appro-
priate level of supervision is in place for all
fellows who care for patients.
Supervision may be exercised through a variety of meth-
ods. Some activities require the physical presence of the
supervising faculty member. For many aspects of patient
care, the supervising physician may be a more advanced
fellow. Other portions of care provided by the fellow can
be adequately supervised by the immediate availability of
the supervising faculty member or fellow physician, either
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in the institution, or by means of telephonic and/or elec-
tronic modalities. In some circumstances, supervision
may include post-hoc review of fellow-delivered care
with feedback as to the appropriateness of that care.
VI.D.3. Levels of Supervision
To ensure oversight of fellow supervision and graded
authority and responsibility, the program must use the
following classification of supervision:
VI.D.3.a) Direct Supervision – the supervising phys-
ician is physically present with the fellow
and patient.
VI.D.3.b) Indirect Supervision:
VI.D.3.b).(1) with direct supervision immediately
available – the supervising physician
is physically within the hospital or
other site of patient care and is imme-
diately available to provide Direct
Supervision.
VI.D.3.b).(2) with direct supervision available – the
supervising physician is not physically
present within the hospital or other
site of patient care, but is immediately
available by means of telephonic and/or
electronic modalities, and is available to
provide Direct Supervision.
VI.D.3.c) Oversight – the supervising physician is
available to provide review of procedures/
encounters with feedback provided after
care is delivered.
VI.D.4. The privilege of progressive authority and
responsibility, conditional independence, and a
supervisory role in patient care delegated to
each fellow must be assigned by the program
director and faculty members.
VI.D.4.a) The program director must evaluate each fel-
low’s abilities based on specific criteria.
When available, evaluation should be
guided by specific national standards-based
criteria.
VI.D.4.b) Faculty members functioning as supervising
physicians should delegate portions of care to
fellows, based on the needs of the patient and
the skills of the fellows.
VI.D.4.c) Fellows should serve in a supervisory role of
residents or junior fellows in recognition of
their progress toward independence, based
on the needs of each patient and the skills
of the individual fellow.
VI.D.5. Programs must set guidelines for circumstances
and events in which fellows must communicate
with appropriate supervising faculty members,
such as the transfer of a patient to an intensive
care unit, or end-of-life decisions.
VI.D.5.a) Each fellow must know the limits of his/her
scope of authority, and the circumstances
under which he/she is permitted to act with
conditional independence.
VI.D.6. Faculty supervision assignments should be of
sucient duration to assess the knowledge
and skills of each fellow and delegate to him/
her the appropriate level of patient care author-
ity and responsibility.
VI.E. Clinical Responsibilities
The clinical responsibilities for each fellow must be based
on PGY-level, patient safety, fellow education, severity,
and complexity of patient illness/condition and available
support services.
VI.E.1. An optimal clinical workload allows fellows
to develop the required competencies in
patient care with a focus on learning over
meeting service obligations.
VI.E.2. The work of the caregiver team should be
assigned to team members based on each
member’s level of education, experience, and
competence.
VI.E.3. As fellows progress through levels of increas-
ing competence and responsibility, it is
expected that work assignments will keep
pace with their advancement.
VI.F. Teamwork
Fellows must care for patients in an environment that
maximizes eective communication. This must include
the opportunity to work as a member of eective inter-
professional teams that are appropriate to the delivery of
care in the specialty.
VI.F.1. Eective practices entail the involvement of
members with a mix of complementary skills
and attributes (physicians, nurses, and other
sta). Success requires both an unwavering
mutual respect for those skills and contribu-
tions, and a shared commitment to the pro-
cess of patient care.
VI.F.2. Fellows must collaborate with fellow residents,
and especially with faculty, other physicians
outside of their specialty, and non-traditional
health care providers, to best formulate treat-
ment plans for an increasingly diverse patient
population.
VI.F.3. Fellows must assume personal responsibility
to complete all tasks to which they are
assigned (or which they voluntarily assume)
in a timely fashion. These tasks must be com-
pleted in the hours assigned, or, if that is
not possible, fellows must learn and utilize
the established methods for handing o
remaining tasks to another member of the
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caregiver team so that patient care is not
compromised.
VI.F.4. Lines of authority should be defined by the
programs, and all fellows must have a work-
ing knowledge of these expected reporting
relationships to maximize quality care and
patient safety.
VI.G. Fellow Duty Hours
VI.G.1. Maximum Hours of Work per Week
Duty hours must be limited to 80 hours per week, aver-
aged over a four-week period, inclusive of all in-house call
activities and all moonlighting.
VI.G.1.a) Duty Hour Exceptions
A Review Committee may grant exceptions for up to
10% or a maximum of 88 hours to individual programs
based on a sound educational rationale.
VI.G.1.a).(1) In preparing a request for an exception the
program director must follow the duty hour
exception policy from the ACGME Manual
on Policies and Procedures.
VI.G.1.a).(2) Prior to submitting the request to the
Review Committee, the program director
must obtain approval of the institution’s
GMEC and DIO.
VI.G.2. Moonlighting
VI.G.2.a) Moonlighting must not interfere with the
ability of the fellow to achieve the goals
and objectives of the educational program.
VI.G.2.b) Time spent by fellows in Internal and
External Moonlighting (as defined in the
ACGME Glossary of Terms) must be
counted towards the 80-hour Maximum
Weekly Hour Limit.
VI.G.3. Mandatory Time Free of Duty
Fellows must be scheduled for a minimum of one day free of
duty every week (when averaged over four weeks). At-home
call cannot be assigned on these free days.
VI.G.4. Maximum Duty Period Length
Duty periods of fellows may be scheduled to a maximum
of 24 hours of continuous duty in the hospital.
VI.G.4.a) Programs must encourage fellows to use alert-
ness management strategies in the context of
patient care responsibilities. Strategic nap-
ping, especially after 16 hours of continuous
duty and between the hours of 10:00 p.m. and
8:00 a.m., is strongly suggested.
VI.G.4.b) It is essential for patient safety and fellow
education that eective transitions in care
occur. Fellows may be allowed to remain
on-site in order to accomplish these tasks;
however, this period of time must be no
longer than an additional four hours.
VI.G.4.c) Fellows must not be assigned additional clin-
ical responsibilities after 24 hours of continu-
ous in-house duty.
VI.G.4.d) In unusual circumstances, fellows, on their
own initiative, may remain beyond their
scheduled period of duty to continue to pro-
vide care to a single patient. Justifications for
such extensions of duty are limited to reasons
of required continuity for a severely ill or
unstable patient, academic importance of the
events transpiring, or humanistic attention to
the needs of a patient or family.
VI.G.4.d).(1) Under those circumstances, the fellow
must:
VI.G.4.d).(1).(a) appropriately hand over the care of all
other patients to the team responsible
for their continuing care, and
VI.G.4.d).(1).(b) document the reasons for remaining to
care for the patient in question and
submit that documentation in every cir-
cumstance to the program director.
VI.G.4.d).(2) The program director must review each
submission of additional service, and
track both individual fellow and pro-
gram-wide episodes of additional duty.
VI.G.5. Minimum Time Obetween Scheduled Duty
Periods
VI.G.5.a) Fellows PGY4 and above must be prepared
to enter the unsupervised practice of medi-
cine and care for patients over irregular or
extended periods.
VI.G.5.a).(1) This preparation must occur within the
context of the 80-hour, maximum duty
period length, and one-day-o-in-seven
standards. While it is desirable that fellows
have eight hours free of duty between
scheduled duty periods, there may be cir-
cumstances when these fellows must stay
on duty to care for their patients or
return to the hospital with fewer than
eight hours free of duty. The Review
Committee defines such circumstances
as: required continuity of care for a
severely ill or unstable patient, or a com-
plex patient with whom the fellow has
been involved; events of exceptional
educational value; or, humanistic
attention to the needs of a patient or
family.
VI.G.5.a).(1).(a) Circumstances of return-to-hospital
activities with fewer than eight hours
away from the hospital by fellows
must be monitored by the program
director.
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VI.G.6. Maximum Frequency of In-House Night Float
Fellows must not be scheduled for more than six consecu-
tive nights of night float.
VI.G.6.a) Any rotation that requires fellows to work
nights in succession, is considered a night
float rotation, and the total time on nights
is counted toward the maximum allowable
time for each resident over the one-year
fellowship.
VI.G.6.b) Night float rotations must not exceed two
months.
VI.G.6.c) There must be at least two months between
each night float rotation.
VI.G.7. Maximum In-House On-Call Frequency
Fellows must be scheduled for in-house call no more fre-
quently than every-third-night (when averaged over a
four-week period).
VI.G.8. At-Home Call
VI.G.8.a) Time spent in the hospital by fellows on at-
home call must count towards the 80-hour
maximum weekly hour limit. The fre-
quency of at-home call is not subject to the
every-third-night limitation, but must satisfy
the requirement for one-day-in-seven free of
duty, when averaged over four weeks.
VI.G.8.a).(1) At-home call must not be so frequent or
taxing as to preclude rest or reasonable
personal time for each fellow.
VI.G.8.b) Fellows are permitted to return to the hos-
pital while on at-home call to care for new or
established patients. Each episode of this
type of care, while it must be included in
the 80-hour weekly maximum, will not initi-
ate a new ‘‘o-duty period.’’
Acknowledgements
The Program Requirements for Fellowship Education in
Venous and Lymphatic Medicine is an initiative of the
American Board of Venous & Lymphatic Medicine. The mem-
bers of the Program Requirements Task Force were as follows:
Lisa Amatangelo, Riyaz Bashir, James Benenati, Ruth Bush,
Teresa Carman, Emily Cummings, Anthony Comerota, Steve
Elias, Bruce Gray, Michael R Ja, Lowell Kabnick, Julie
Karen, Neil Khilnani, Ted King, Raghu Kolluri, Peter
Lawrence, Fedor Lurie, Mark Meissner, Robert Min, Girish
Munavalli, Benson S Munger, PhD, Tri Nguyen, Joseph
Raetto, Suman Rathbun, Thom Rooke, Mel Rosenblatt,
Marcus Stanbro, Julianne Stoughton, Suresh Vedantham,
Thomas Wakefield, and Steven E Zimmet (chair). We thank
Christopher Freed, CAE, Executive Director of the ABVLM,
for his outstanding administrative support.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) disclosed receipt of the following financial sup-
port for the research, authorship, and/or publication of this
article: The American Board of Venous & Lymphatic
Medicine (ABVLM) covered costs related to teleconference
calls and administrative tasks. The American College of
Phlebology Foundation provided a grant to the ABVLM,
which was used to fund a face-to-face meeting of the
Program Requirements Task Force.
References
1. Zimmet SE, Min RJ, Comerota AJ, et al. Core content for
training in venous and lymphatic medicine. Phlebology
2014; 29: 587–593.
2. ACGME Common program requirements for one-year
fellowships, http://www.acgme.org/Portals/0/PFAssets/
ProgramRequirements/One_Year_CPRs_07012015.pdf
(accessed 2 May 2016).
Appendix 1
Fellowship in venous and lymphatic
medicine
Scope of procedures
It is expected that graduates of a Venous and
Lymphatic Fellowship will be capable of treating all
aspects of superficial venous disease. Graduates must
be knowledgeable about the diagnosis of superficial and
deep venous disease and lymphatic disease. The suc-
cessful candidate must be comfortable managing
patients with infrainguinal DVT, and knowledgeable
about management of all cases of VTE.
Graduates of this fellowship are not necessarily
expected to perform deep venous or pelvic vein inter-
ventions; however, they should have enough exposure
to these procedures to understand their proper place in
patient management.
Candidates should perform a minimum number of
diagnostic studies to understand the important elem-
ents of anatomy and physiology and the technical
aspects important for good quality examinations.
Importantly, candidates should interpret a minimal
number of diagnostic studies under the supervision of
an attending physician, with the goal of integrating the
observed pathology/pathophysiology with patient pres-
entation. Graduates of this fellowship are not expected
to provide ocial interpretations for the medical
record. Fellows may read and sign the reports, but an
attending must sign oas well. In addition, fellows
should leave the program with enough experience to
meet the ultrasound requirements to serve as a medical
director in a Intersocietal Accreditation Commission
(IAC) accredited ‘‘Vein Center,’’ currently minimum
of 100 cases of focused, limited or complete diagnostic
14 Phlebology 0(0)
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venous duplex ultrasound examinations performed
during the previous three years prior to application.
The numbers listed were derived from a consensus of
25 experts in venous and lymphatic medicine, spanning
the disciplines of vascular surgery, vascular medicine,
interventional radiology, dermatology, cardiology,
interventional cardiology, and family practice.
The appendix lists the minimum number of studies
and procedures which must be performed (and inter-
preted) for successful graduation. These are considered
essential for the safe and eective care of patients fol-
lowing program completion.
Minimal requirements
for patient care by trainee
Imaging
Cumulative DUS volume minimums by graduation
include performance and interpretation of diagnostic
ultrasound, with creation of an accurate, organized
venous map and report, with sign oby credentialed
physician (200 limbs). This should include a minimum
of 20 patients with suspected deep vein thrombosis.
Physically performs Ankle Brachial Index in 15
patients (with indirect supervision by faculty);
In simulated environments, interprets venous find-
ings of computed tomography and magnetic resonance
(15 patients, with documentation of interpretation and
review by faculty);
Observation of the use of intravascular ultrasound
should include at least five cases, including interpret-
ation of the venous findings and creation of a written
report.
Technical skills-core superficial procedures
(Compression, visual sclerotherapy of spider, reticular
and varicose veins, microphlebectomy, tumescent
anesthesia, endovenous thermal and non-thermal
ablation of saphenous veins)
Must log total number of directly and indirectly super-
vised procedures in a case log.
Cumulative core superficial vein case volume min-
imums by graduation include:
Compression for chronic venous disorder (50 patients)
Total procedures, (200) which must include at a
minimum:
Visual sclerotherapy (75 limbs)
Microphlebectomy (25 limbs)
Endovenous ablation of saphenous veins (75 veins).
This must include a mix of GSV and SSV, and
should include thermal, and may include non-thermal
techniques. Must include tumescent anesthesia in a
minimum of 20 cases.
Technical Skills-Advanced superficial procedures
(Ultrasound-guided sclerotherapy, perforator
ablation, ulcer debridement and care, inelastic
compression application)
Must log the number of directly and indirectly super-
vised procedures in a case log.
Case volume minimums include:
Ultrasound guided sclerotherapy (10)
Perforator ablation (3)
Management of venous ulcer patients (15)
Ulcer debridement (2 sessions)
Inelastic compression application (10 limbs)
Manual lymphatic massage (observation in clinical
setting with appropriately credentialed sta)
Technical Skills-Core deep procedures (IVC filter
placement and removal, venous stenting, venous
thrombectomy and thrombolysis, evaluation and/or
management of pelvic venous insufficiency, evalua-
tion and/or management of vascular malformations)
Must log total number of observed, assisted, and
directly supervised procedures in a case log.
Case volume minimums* should include:
Evaluation and management of infrainguinal DVT (10)
IVC filter decision making (5)
IVC filter placement (2) and removal (1)
Vascular malformation evaluation and/or treatment (2)
Venous stenting (5)
Venous thrombectomy and or thrombolysis (5)
Pelvic venous insuciency evaluation and/or man-
agement (2)
*50% of the case volume may be met through the
use of simulation. These procedures are not skills that
the trainees need to be credentialed to perform at the
completion of their training, but reflect the clinical
experiences that the trainees need to have had to be
able to advise and appropriately refer patients.
Patient safety
Must be BLS certified
Must complete a course in laser safety in medicine
Comerota et al. 15
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Supplementary resource

  • ... [18][19][20] In addition, there are other specialists, including cardiologists, dermatologists, and interventional radiologists, who often absorb a large proportion of an institution's venous disease practice. 4,21 Consistent with this notion, vascular surgery trainees do see competition with other specialists as a major challenge to the future of vascular surgery, and 71% have suggested that vascular privileges be restricted to board-certified surgeons. 4 It is also possible that, especially in academic practices, venous disease training is often overlooked in favor of faculty members' niche interests. ...
    ... In 2014, the American Venous Forum and the American College of Phlebology endorsed a core content for venous and lymphatic medicine that was designed to improve the standards of medical practitioners and to improve the quality of patient care related to the treatment of venous disorders. 21,27 In 2016, the American Board of Venous & Lymphatic Medicine (ABVLM) published a new set of guidelines defining program requirements for fellowship education in venous and lymphatic medicine. 21,27 Recognizing that no current ACGMEaccredited fellowships provide comprehensive training in venous education, the ABVLM sought to develop a consensus document describing educational standards for teaching programs in venous and lymphatic medicine. ...
    ... 21,27 In 2016, the American Board of Venous & Lymphatic Medicine (ABVLM) published a new set of guidelines defining program requirements for fellowship education in venous and lymphatic medicine. 21,27 Recognizing that no current ACGMEaccredited fellowships provide comprehensive training in venous education, the ABVLM sought to develop a consensus document describing educational standards for teaching programs in venous and lymphatic medicine. Based on input from physicians in dermatology, family practice, interventional radiology, interventional cardiology, phlebology, vascular medicine, and vascular surgery, these guidelines outline the pertinent knowledge and skills that physicians should master through the course of their fellowship training to achieve comprehensive training in venous and lymphatic medicine. ...
    Article
    Full-text available
    Objective: The objective of this study was to characterize U.S. vascular surgery trainees' perceptions, case numbers, and attitudes toward venous disease education, as well as their intent to incorporate it into future practice. These data will provide us with a current snapshot of postgraduate venous education from a resident's perspective. Methods: Institutional Review Board approval was obtained. A 13-question survey was created and distributed to all vascular surgery residents in the United States by SurveyMonkey. Formal electronic distribution remained deidentified as the surveys were e-mailed to residents from the Association of Program Directors in Vascular Surgery. Results: Of 464 vascular surgery trainees queried, 104 (22%) responded to the survey. The majority of responders (80%) were between 25 and 34 years of age, 60% were male, and 72% were white; 91% reported that they were in an academic training program, and 57% were enrolled in an integrated vascular surgery residency program. Postgraduate years (PGYs) of training among respondents were well represented: PGY 1, 14%; PGY 2, 8%; PGY 3, 14%; PGY 4, 12%; PGY 5, 9%; PGY 6, 18%; and PGY 7, 25%. Vascular resident training experience with venous disease revealed the following: 63% performed <10 inferior vena cava stents, 64% performed <10 vein stripping/ligation procedures, and 50% performed <10 iliac stents; 92% of responders reported having performed <10 venous bypasses during their training. Experience with endothermal ablations was slightly better, with 74% of responders reporting having performed up to 20 cases. Case volumes for endothermal ablation, vein stripping/ligation, inferior vena cava stenting, and iliac stenting increased progressively by clinical training year among integrated vascular residents (P ≤ .02) but were relatively stable for classic 5 + 2 vascular fellows (P ≥ .67). Integrated residents reported having received more didactic venous education than the 5 + 2 vascular surgery fellows (P = .01). There were no differences in overall reported venous procedure volumes between groups (P ≥ .28). The majority of trainees (82%) acknowledged that treating venous disease is part of a standard vascular surgery practice, and many (75%) indicated a desire to have increased venous training. Despite this, 59% of responders reported plans to dedicate <25% of their future vascular surgery practice to venous disease. Conclusions: In this national survey-based study of vascular surgery trainees, we demonstrate a perceived weakness in venous disease case volumes and didactic education in residency. This training deficit is apparent in both integrated (0 + 5) and traditional (5 + 2) training pathways. Our data suggest that expansion of the venous disease curriculum with clear training standards is warranted and that trainees would welcome such a change.
  • ... [18][19][20] In addition, there are other specialists, including cardiologists, dermatologists, and interventional radiologists, who often absorb a large proportion of an institution's venous disease practice. 4,21 Consistent with this notion, vascular surgery trainees do see competition with other specialists as a major challenge to the future of vascular surgery, and 71% have suggested that vascular privileges be restricted to board-certified surgeons. 4 It is also possible that, especially in academic practices, venous disease training is often overlooked in favor of faculty members' niche interests. ...
    ... In 2014, the American Venous Forum and the American College of Phlebology endorsed a core content for venous and lymphatic medicine that was designed to improve the standards of medical practitioners and to improve the quality of patient care related to the treatment of venous disorders. 21,27 In 2016, the American Board of Venous & Lymphatic Medicine (ABVLM) published a new set of guidelines defining program requirements for fellowship education in venous and lymphatic medicine. 21,27 Recognizing that no current ACGMEaccredited fellowships provide comprehensive training in venous education, the ABVLM sought to develop a consensus document describing educational standards for teaching programs in venous and lymphatic medicine. ...
    ... 21,27 In 2016, the American Board of Venous & Lymphatic Medicine (ABVLM) published a new set of guidelines defining program requirements for fellowship education in venous and lymphatic medicine. 21,27 Recognizing that no current ACGMEaccredited fellowships provide comprehensive training in venous education, the ABVLM sought to develop a consensus document describing educational standards for teaching programs in venous and lymphatic medicine. Based on input from physicians in dermatology, family practice, interventional radiology, interventional cardiology, phlebology, vascular medicine, and vascular surgery, these guidelines outline the pertinent knowledge and skills that physicians should master through the course of their fellowship training to achieve comprehensive training in venous and lymphatic medicine. ...
  • Article
    Full-text available
    The major venous societies in the United States share a common mission to improve the standards of medical practitioners, the educational goals for teaching and training programs in venous disease, and the quality of patient care related to the treatment of venous disorders. With these important goals in mind, a task force made up of experts from the specialties of dermatology, interventional radiology, phlebology, vascular medicine, and vascular surgery was formed to develop a consensus document describing the Core Content for venous and lymphatic medicine and to develop a core educational content outline for training. This outline describes the areas of knowledge considered essential for practice in the field, which encompasses the study, diagnosis, and treatment of patients with acute and chronic venous and lymphatic disorders. The American Venous Forum and the American College of Phlebology have endorsed the Core Content.