By John Daake, MD

Current educational opportunities in phlebology range from multifunctional congresses, such as the American Venous Forum or American College of Phlebology, to single instructor seminars for small groups. The former aim to provide topics of interest to a broad spectrum of attendees; the latter usually focus on a specific topic such as EVLA or advanced sclerotherapy. Rarest, outside of a fellowship, is a true hands-on experience — live patients, one-on-one mentoring and the chance to use the equipment with your own hands.

This article is a description of the planning and formation of one example of hands-on education. Such a course requires a good deal of effort and maintenance; but, in addition to the rewarding goal of advancing the skills of members of the profession, this instruction is an excellent form of marketing. There is no better advertisement for a clinic or practitioner than a “graduate” who is excited about his or her skills and where and how they were honed.

The design of a curriculum has to appeal to a variety of “students;” the practice of phlebology includes professionals from many types of clinical background. A hands-on experience requires basic knowledge and skills already acquired by an attendee from other sources; it is not intended to show, for instance, how to acquire an image with an ultrasound or learn the basics of laser safety. There are three primary requirements to develop a hands-on opportunity:

1. An educator with the experience, depth of knowledge and ability to teach that will together make a worthwhile experience.
2. Access to patients who have sufficient confidence and trust in the educator and the facility that they will participate in a training experience.
3. Equally important, the state licensing board must be satisfied with the level of supervision, the qualifications of prospective attendees, the experience and reputation of the educator and the facility. The approval of the state board is essential to conducting a teaching program with real patients.
It goes without saying that adequate insurance coverage for the facility and the attendee should be in place before any patient contact. Regulations may vary by state and by individual contract regarding the portability of a physician’s insurance as he participates in hands on training outside of his normal realm. Regardless of that, the facility will likely incur some increase in required liability coverage from their insurance vendor.

In addition to the faculty, the facility ideally should have:

1. The ability to record the teaching experience on a CD or DVD — each attendee should be able to review at home just what he did and compare that to the approach of the instructor.
2. A library of sonograms of unusual anatomy encountered, photos of clinical conditions treated or complications seen, and so on. This sort of data is acquired over years of clinical practice, though reproductions from journals and other sources can be gathered also.
3. Scheduling expertise that will allow for customizing the time a student will spend in the program — for example, more time for laser usage, more sclerotherapy, or a strictly operating room experience, etc., to suit the needs of the attendee.

The attendees must bring certain skill levels to a hands-on course. If someone wants to apply lasers to leg veins or telangiectasias, he or she must document attendance at an appropriate laser safety and basics course. If an attendee’s background is not primarily surgical, he or she must have adequate experience in operating room technique and instruments. If a nurse practitioner or physician’s assistant seeks training in advanced sclerotherapy, a collaborative agreement with a supervising physician must be in place. In our specific case, almost all attendees should have adequate experience in using ultrasound techniques to diagnose and map venous conditions.

A sample of our curriculum is shown below. The venues can be adjusted into single-day, two- or three-day courses according to the requests made in advance for specific content.

Agenda
Education Center Curriculum:
1. Pre-visit mailing (Goals and Expectations)
a) Overview of your visit
b) Basic information to review prior to your visit
c) Your expectations and goals — return form enclosed

2. Day one of curriculum:
8 a.m.: Introductions, review of basic information, review of expectations and goals
9-noon: Participation in clinic activities — new patient consultations, ultrasound examinations, sclerotherapy
Noon-1:15 p.m.: Lunch with physicians
1:30-4:30 p.m.: clinic activities — laser applications, sclerotherapy, patient consultations
4:30-5:00 p.m.: review of day’s activities, questions and comments

3. Day two of curriculum:
7:30 a.m.: discussion of surgical patients, operative techniques and equipment
8:30-noon: surgical procedures (first assist)
Noon-1:00 p.m.: lunch with operating personnel
1-4 p.m.: surgical procedures (hands on)
4-5 p.m.: review of day’s activities

4. Day three of curriculum:
 8 a.m.-noon: postoperative patient evaluations including ultrasound exams, clinic activities
Noon-1:15 p.m.: lunch with physician and office manager
1:15-4:00 p.m.: options
a) Discussions of coding, insurance, pricing with office manager
b) Adjunctive products — line of compression stockings, laser skin care, sclerotherapy solutions (FDA, suppliers, and alternatives)
c) Ultrasound exam recordings — unusual anatomy, perforators, difficult cases
d) Additional laser time
4:00 p.m.: summary with physicians

Finally, our intent of meeting the educational needs of those involved in various aspects of phlebology has resulted in the development of this curriculum and the facility within which it can work.

But there is a second intent at Reno Vein Clinic: to meet the needs of those patients we see who do not have adequate insurance or funds to pay for the care they require. The Northern Nevada Vein Foundation has been incorporated and is supervised by an independent board of directors representative of the community and with no ties to the Reno Vein Clinic.

The task of the Foundation is twofold. First, seek the necessary funding through industry grants, charitable contributions, and government grants or other resources available; and official nonprofit status is being sought from the IRS for the Foundation. Second, the board decides on a case-by-case basis which applicants will have their care funded and by how much. All facilities within our geographic area that provide the more expensive venous interventions and are state licensed are qualified to receive funds from the Foundation. Physician or professional fees are not reimbursed by the Foundation; this is made clear in advance to the provider who refers a case for consideration so an agreement can be reached with the patient on that issue.

The American College of Phlebology is currently taking the lead in developing a phlebology preceptorship program. They are “defining learning objectives, preceptor selection criteria, preceptor requirements, guidelines and responsibilities, and quality assurance aspects of the preceptor program (phlebology.org).” Their guidelines can be of benefit to anyone considering the establishment of a teaching program.

John W. Daake, MD and a vascular surgeon dedicated solely to the treatment and correction of vein disorders, is with the Reno Vein Clinic (RenoVeinClinic.com), which claims the distinction of being the the first vein clinic west of the Mississippi to perform Radiofrequency Closure.