As cardiovascular specialists, we frequently manage and treat patients with peripheral arterial disease (PAD). Atherosclerosis is not limited to the coronaries and, when diagnosed, patients receive appropriate risk factor modification. Duplex ultrasound in the vascular lab is the primary means of screening and diagnosis of PAD. The following describe how to incorporate vascular imaging training into the cardiology fellowship curriculum.
In 2015, the Core Cardiovascular Training Statement (COCATS) 4 on vascular medicine was updated to include a focus on the non-invasive management of peripheral vascular diseases with a standardized Level I-III achievable. The expectation for fellows in an accredited cardiovascular training program is to achieve Level I certification for vascular medicine. This requires two months of exposure to vascular medicine with a focus on the history and physical examination as well as a basic understanding of vascular physiologic testing. Level I trainees should be able to understand the advantages and disadvantages of different testing modalities and when referral to a vascular specialist is indicated.
A Level II trainee should have a more detailed understanding of vascular medicine with an emphasis on non-invasive laboratory procedures. In particular, trainees should be able to perform and interpret vascular diagnostic studies. At the end of their requirements, trainees should be eligible for the Physicians’ Vascular Interpretation Examination (RPVI).
Unlike Level II, Level III training cannot be completed within a standard 24-month cardiovascular fellowship and requires an additional year of experience. The extra time builds on the prior clinical foundation and applies those skills to the broad spectrum of vascular diseases, emphasizing the complex treatment and management plans. Completion of this year fulfills the requirements to sit for the American Board of Vascular Medicine (ABVM) examination.
In 2016, the Alliance for Physician Certification & Advancement (APCA) joined with the American Registry for Diagnostic Medical Ultrasonography to preside over the RPVI examination. Beginning July 1, 2018, a new set of prerequisites are required prior to enrolling in the examination. Included in these changes is documentation of at least 500 vascular studies in the clinical diagnostic setting over a minimum of one month which must be completed within 36 months of application submission. Of the 500 studies, no more than 100 may be from didactic or simulated cases and no more than 50% of the cases can come from one type of examination.
There are three unique pathways to obtain the interpretation experience to fulfill the RPVI requirement. First, clinicians in an accredited residency or fellowship, on top of the minimum requirements listed above, must also participate in dedicated peripheral ultrasound didactics along with mentored training in the interpretation of these studies. Once complete, the trainee must obtain a letter signed by either a program director, vascular lab director, or RPVI certified affiliate. Second, if a trainee is part of a non-accredited program, he/she must complete at least 48 weeks of dedicated vascular clinical training, which must include 30 hours of didactic instruction and 40 hours of observed participation in the vascular lab. Once again a letter of completion must be signed prior to RPVI application submission. Lastly, for physicians in practice, clinical experience in a supervised setting can include hospitals, clinics, and private practices. In addition to the 500 study requirements, the physician must also complete 40 hours of AMA PRA category 1 CME pertaining to the vascular laboratory. A letter from either the medical director of the vascular lab or another qualified physician is again required. This option will expire at the end of 2022.
Our Institutional Experience
To adapt to the RPVI requirements, Emory University has piloted a vascular medicine rotation that focuses on the APCA criteria. We began the year with a dedicated day of ultrasound didactics and hands-on scanning led by our vascular medicine specialists and geared towards fellows at the beginning of their vascular training. The lectures were open to all post graduate levels and focused on the fundamental skills needed to interpret the studies done in our laboratory, which includes physiologic, carotid, visceral, and lower extremity arterial and venous studies. Simultaneously, we also created a vascular medicine rotation open to three-year clinical fellows, focusing on the three main pillars of COCATS Level II requirements; specifically, mentored ultrasound interpretation, outpatient experience in a vascular medicine clinic, and hands-on scanning with our vascular lab technologists. This fellow is expected to pre-read all vascular studies, evaluate and treat the outpatient vascular patients, and participate in hands-on scanning as the time permits. At the end of the rotation, we believe our fellows have the knowledge necessary for clinical care of vascular diseases and ultrasound interpretation needed for the RPVI examination.