Veerendra Chadachan MD, MRCP, FAMS, Diplomate (ABVM), RPVI

Vascular diseases are the leading cause of morbidity and mortality all over the world. Most of these disorders have common pathophysiology with similar mechanisms, irrespective of the site of the disease. Despite this, in most countries, the vascular diseases are managed differently by different specialties. In the U.S. and many European countries there is growing recognition of the need for dedicated vascular medical services. However, this is not yet true in most other countries. Although the specialty recognition of vascular medicine is yet far off in most Asian countries, we in Singapore have realized the importance of this specialty. The life expectancy of the Singapore population is one of the highest in the world, and, with an ageing population, the prevalence of vascular diseases is rapidly increasing. The need has arisen for implementing a comprehensive holistic approach to the management of these patients. Since different specialists with different skills are required, the evolving concept here is that the care of patients with vascular diseases should be coordinated, in close collaboration with other disciplines, by a dedicated physician such as a vascular medicine specialist.

Unfortunately, we do not have formal training programs in vascular medicine in our part of the world. Recognizing the importance of dedicated clinical vascular medicine services, some of the institutions, along with the Ministry of Health of Singapore, have started sponsoring interested physicians overseas in countries such as Australia, the U.S. and Canada. As part of this program, I was supported to train in the vascular medicine program at Boston University Medical Center. I was fortunate to be able to train in the U.S. in an excellent program. The training I received has enabled me to expand the vascular medicine services within our institution. With more trained physicians returning from other countries, the future for development of vascular medicine appears promising. As most of us come from internal medicine backgrounds, vascular medicine is being established as a specific clinical service under the department of general medicine. Various surgical and medical disciplines have started making inter-disciplinary referrals directly to vascular medicine, as do some of the community physicians and general practitioners at the primary care level.

The role of vascular medicine in Singapore encompasses clinical services provided for venous disorders (venous thrombo-embolism, venous insufficiency disorders), arterial disorders (medical management of peripheral vascular diseases, risk factor control, vasculitides), hypertension, and lymphatic disorders (lymphedema). While some of the services, such as venous thrombo-embolism, risk factor control, and management of hypertension, are primarily served by vascular medicine, others are carried out in collaboration with vascular surgeons, interventional radiologists, cardiologists, rheumatologists, physiotherapists, and pharmacists. Unlike in the U.S., where vascular medicine specialists, along with cardiologists, assist in perioperative management of vascular diseases, in Singapore, the perioperative management is primarily served by cardiologists and not by vascular medicine specialists. The other areas of involvement of vascular medicine specialists include vascular biology and hypertension-related research, and reporting of vascular laboratory studies in some institutions.

Noninvasive vascular studies were traditionally performed by vascular technicians, and reported by either radiologists or vascular surgeons. In most institutions there are two vascular study units: a diagnostic noninvasive vascular unit managed by the radiologists, and a non-invasive vascular laboratory which is run and directed by the vascular surgeons. Unlike the vascular units run by the radiologists, most of the physiological studies, such as ankle brachial index, venous incompetency studies, etc are only performed at the vascular laboratory units run by vascular surgeons. Of late, with more vascular physicians being trained, the vascular laboratory workload is also shared by some of the vascular physicians.

While the services of vascular medicine specialists and vascular laboratory studies are expanding, what is lacking here is the national accreditation of these services. Hence, there are no specific CME requirements specific to vascular medicine or vascular laboratory testing. Most laboratories have vascular technicians who, after completing training curricula, have obtained credentials such as Registered Vascular Technologists (RVT) from the American Registry for Diagnostic Medical Sonography (ARDMS), and vascular surgeons are accredited to interpret and report the studies by virtue of their vascular ultrasound training during their residency and fellowship programs. Vascular physicians with the credentials of RPVI do interpret the studies, but there are not many physicians with these credentials. We do not have formal national vascular laboratory accreditation bodies/procedures in place, although there are institutional regulatory committees which provide professional oversight for clinical policies, oversee the standard of vascular diagnostic laboratory function, and ensure conformity to international standards. There are also efforts to guide training and credentialing of the vascular laboratory and personnel with international agencies.

On the other hand, credentialing of the vascular medicine specialists has a long way to go in Singapore. Development of national credentialing examinations is ideal, but this is possible only when the specialty gets recognition at the national level. The U.S. and European countries have been struggling for more than a decade to obtain the specialty recognition within their countries. Many of the European countries have still not accepted and are not recognizing the specialty. Moving forward, it would be very useful for the international community to have the American and European credentialing bodies, such as American Board of Vascular Medicine or European Board of Angiology/Vascular Medicine open up their credentialing examinations internationally. Formal credentialing will encourage more physicians to acquire the skills and join the marathon of dealing with these common and dreadful diseases. However, the vascular medicine community will not last long unless the role of the vascular physicians is also expanded to include participation in dedicated research, education and mentoring of like-minded physicians, and development of processes to audit and evaluate the outcome of clinical care. Development of a new vascular medicine specialty with subsequent world-wide standardization of care of patients with vascular diseases will not only improve patient care, but will also be economical for the entire international community.