Updated: Feb 4, 2019
Building a vein practice requires knowledge and skills beyond the treatment of venous disease. Vein expert Dr. Brooke Spencer discusses where to start when treating patients with venous disease, when to take charge as a diagnostician, and why interventional radiologists need to start managing their patients perioperatively.
The BackTable Brief
Treating patients with superficial venous disease may be the best place to start when building a vein practice, says Dr. Brooke Spencer.
Patients with superficial venous disease frequently have deep venous system pathology, pelvic venous problems, and additional venous complications; initial superficial venous work may help to expand a physician’s practice to include deep venous treatments.
Understanding the intricacies of the venous system helps the physician to minimize interventions and resolve venous pathology.
The perioperative and clinical management of patients with venous disease consists of understanding anticoagulation regimens, compression therapies, and available treatment options. Dr. Brooke Spencer believes being a comprehensive clinician is inherent to becoming a venous expert.
Disclaimer: The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
What is a good starting point for building a vein practice?
When building a vein practice, Dr. Brooke Spencer suggests that treating the superficial venous system is the easiest place to start. Patients with superficial venous system problems may have subsequent pathology of the deep venous system. By starting with the superficial system, the physician can expand their work to encompass the entire venous system. [Isabel Newton] What would be a really good place to start for someone who's just trying to build this practice? Would it be varicose veins or maybe interacting with referring physicians or setting up the infrastructure? Where's a good starting point?
[Brooke Spencer] Starting a superficial vein practice is definitely the easiest place to start because you're not going to have trouble accomplishing treatment of those patients in a successful and low complication way. If you start to treat superficial venous patients, you're going to realize that a lot of these patients have deep venous problems, pelvic venous problems, and things you can treat as well. It will help you expand your practice from there going forward if you start in that location.
This may sound the opposite of what most of the advice is out there today, but there are journals like Endovascular Today and other journals that have techniques in vascular interventional radiology, seminars in interventional radiology. They're not as level A clinical medicine oriented, but they are practice oriented, and they tell you, "Here's how you set up a practice. Here's how you treat these patients from the start to the finish. Here's all the things that you should consider in doing this." You still need to practice evidence-based medicine, but hopefully you're trained in that. What you're not trained is the nuances or the details of how you do this.
I think the other thing is that starting a vein practice is an excellent way for a young interventional radiologist to be able to develop a clinical practice. So there are a lot of impediments to doing that, right? But then you can also see your uterine fibroid patients there. You can also see your cancer patients there. You can slowly build and grow.
And then going and visiting someone who has an established clinic or a practice, even if you think it's obvious that you know kind of how to do a clinic, is always a good option. I think there's a lot of partners in industry who will help support that and who know who's out there doing that and willing to train and help.
Understanding the Ins and Outs of Venous Disease
Training your ultrasonographer to understand your thought process is crucial for diagnosing venous disease. The final diagnosis, however, comes from the physician’s ability to integrate imaging findings with the pathophysiology of venous disease. Understanding the entirety of your patient’s venous disease leads to improved treatment outcomes.
… Part of that is also training your sonographer. So if you're going to start a vein practice, you have to be hands-on, and you have to personally train your ultrasound technologist to understand how you think.
Here’s an example from just this week in clinic. I have a new partner that didn't do a lot of superficial vein stuff. He's been working with me on these patients to learn that part of it. I have an excellent sonographer. We had a patient with a deep venous system that's re-cannulized. The patient was never intervened on [and] had a massive pulmonary embolism. We had done a thrombolysis on his pulmonary arteries and he was coming back in for follow up. He has a re-cannulized channel of flow in his femoral and popliteal vein, but he's not having pain in his leg or massive swelling or something that would require going through the process of putting him on Lovenox, doing a re-cannulization of his deep veins, bringing him back, following him, and doing all that because he was doing well except he has a large patch of venous eczema on the posterolateral aspect of his calf.
So I looked at my partner, and I said, "Okay, he has a large perforator underneath leading to a varix that's then going to be emptying back into the small saph or back into the distal gastroc at the end of the venous eczema patch." I then grabbed my handheld ultrasound, stuck it on his leg, there's a big perforator, and there's a varix running under his venous eczema patch and emptying back into his small saphenous vein, which was not incompetent beyond that point.
My sonographer missed that. So if you're counting on the results of an ultrasound technologist or someone else to understand and know what's happening in your patient, and they have all these problems, and they're not getting better, you really need to understand where the problems are probably coming from, and you need to make the diagnosis, which sometimes means picking up an ultrasound probe and looking yourself. I think that it does make a difference between the person who's just the average vein clinic and the one who's not.
The Importance of Perioperative Management
Successful treatment of venous disease goes beyond treating the problem acutely. It’s important to understand anticoagulation regimens, compression therapies, and all treatment options, says Dr. Brooke Spencer. Being a clinician and managing patients from start to finish is inherent to establish yourself as a venous expert.
[Brooke Spencer] The place that not all interventional radiologists are as comfortable with yet, sometimes, is the clinical management of these patients. I think that my personal belief is that the inherent key to all of this is that interventional radiologists need to start seeing themselves of clinicians in the sense that they own the patient, which means it's their job to take care of every portion of the patient's venous care from the start to the finish.
So that means knowing, learning, and understanding anticoagulation regimens. It means knowing, learning, and understanding compression therapy, lymphedema physical therapists, what all the options are for treatment even if it's not an intervention. That's something I think most interventionalists are less comfortable with, but if you want to establish yourself as a true venous expert, you need to not only learn about these things, but you need to own them and manage your patients preoperatively, intraoperatively, and postoperatively in all of these areas. If you're not comfortable with one of those areas, and you want to start a vein practice, then I think going and training or getting that information or advice or learning over time is really helpful.
Podcast Participants: Dr. Brooke Spencer is a practicing interventional radiologist at the Minimally Invasive Procedure Specialists group in Denver, CO. Dr. Isabel Newton is a practicing interventional radiologist at UC San Diego Health in San Diego, CA.
Cite this podcast: BackTable, LLC (Producer). (2018, October 9). Ep 33 – Building a Comprehensive Vein Practice [Audio podcast]. Retrieved from http://www.backtable.com/podcasts Medical Disclaimer: The Materials available on the BackTable Blog are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable. Disclosures: None.