Recognizing Expertise: Obtaining Certification by the American Board of Vascular Medicine

Why do you think this board is of value to the field of endovascular medicine?

Right now, there aren’t enough experts in vascular medicine to care for the masses of patients who have systemic atherosclerosis. So many different specialists are involved in the care of these patients that it’s hard to know who really has expertise in the overall management of patients with vascular disease. The concept behind the creation of the American Board of Vascular Medicine is to set a standard level so that people who have really dedicated themselves to the management of these patients and to this field can demonstrate their expertise with board certification. The ultimate goal, obviously, is to gain recognition for ABVM by the American Board of Medical Specialties, as a boarded subspecialty under internal medicine, surgery or radiology.

There’s been a lot of discussion about appropriate training pathways to vascular practice. Can you discuss how the ABVM requirements came about?

This was a challenging issue. First of all, we developed two different exams. One is a general vascular medicine exam (ABVM-GE), and the second is an endovascular exam (ABVM-EE). We needed to recognize the number of different pathways that people might have in order to get to the point of sitting for a certification exam. For example, a vascular surgeon may have completed a formal training program in vascular surgery, whereas a general surgeon performs vascular surgery in his or her practice. It could be that an interventional radiologist was formally trained in vascular intervention. A fellowship-trained interventional cardiologist may have gained some “on-the-job” experience after training, because the formal training didn't include much vascular disease management. The ABVM actually approached this in a manner that will allow people who have truly demonstrated training or experience in the field to be eligible for the exam. The goal is not to include physicians who “dabble” in this field to be eligible for the exam, because frankly, they would have a difficult time passing the exam. The goal is to establish a level of expertise that demonstrates commitment to the field.

Can you discuss the differences between the two exams?

The general vascular medicine exam includes issues regarding epidemiology, natural history, methods of diagnosis, and options for therapy for all non-coronary vascular diseases. This will include atherosclerotic arterial diseases, like carotid disease, innominate/brachiocephalic arterial disease, aortic diseases, mesenteric and renal artery diseases, and peripheral arterial disease. It will include venous thromboembolic disease, both the acute and the chronic manifestations. It will include lymphedema and other less common causes of limb swelling. It will include vasculitis and inflammatory vascular disorders, environmental and occupational vascular disorders, hypercoagulability, and limb ulcerations. In other words, the whole gamut of knowledge that a true vascular medicine specialist ought to possess in order to manage these patients will be included in the examination. The endovascular exam will specifically deal with issues regarding diagnosis, patient selection, and endovascular treatment. It will have questions regarding endovascular techniques, potential complications, management of those complications, durability, alternatives for therapy and outcomes in regard to endovascular approaches to the management of vascular disease. This will include any disorder outside of the coronary arteries in which an intervention may be performed. There will certainly be some questions on the exam about vascular surgical therapy, not questioning the details of a vascular surgical procedure, but more asking about when you would choose surgery over an endovascular approach, or vice versa.

Who should take which exam? Is there any benefit to taking both?

I think the guide for that ought to be where the physician feels their expertise lies. Don’t take the exams just to say that you’ve got a piece of parchment on your wall. If you truly feel that you manage the entire spectrum of vascular disease, from arterial to venous to lymphatic to vasculitis to hypercoagulability, then you ought to sit for the general exam. If manage patients with vascular disease from an endovascular approach as a routine part of your practice, you ought to sit for the endovascular exam. Quite frankly, I suspect that there will be relatively few physicians who will sit for both.

What is the exam fee?

It’s not quite finalized yet, but it will be comparable and competitive with any other certifying exam fee.

You are a member of the ABVM board of directors. What has been (and what will be) the function of this group?

The Board of Directors is charged with developing and implementing a scientifically sound certification pathway in vascular and endovascular medicine. The process taken by the Board to get to our current position is quite impressive. The first thing we did was to investigate how to go about creating a board certification, as there were two major options. One was to set up a freestanding, not-for-profit board certification group; the other was to try to move the process through the American Board of Medical Specialties. It turns out that the latter takes a very long time (potentially five to ten years), with no guarantee that it will happen. So we opted to set up our own independent board. We actually hired an attorney who has helped other non-vascular medical specialties develop board certification in the past, and who helped form the American Board of Vascular Medicine. The board has a charter, a series of bylaws and a board of directors. The next thing we did was hire a professional, well-regarded testing company to help us develop a validated test which could withstand the muster of criticism and external review. We reviewed all of the major professional testing companies, narrowed it down to three, then we did a formal interview of those three companies. We ultimately chose ACT, located in Iowa. ACT is known to many people because they also provide the ACT exam for college entrance; it’s the alternative to the SAT taken by many people, particularly in the Midwest and West. As a company, ACT has been around a long time. They’ve got a lot of experience in medical board certification exam development and administration. They’re a very progressive testing company. Their exams are given on computers in testing sites all around the United States, so it’s very convenient, and they’ve been outstanding to work with. After we hired them, we had several face-to-face meetings where we developed a syllabus for the exam, and then divided up who is responsible for specific aspects of the exam questions. Those people were then charged with identifying subject matter experts in the field who would provide testing units for the exam. We are collecting test questions now, and then we are going to meet to validate those questions and put the exam together.

What type of questions are they?

They will all be multiple-choice. About 40% of the test questions will have images associated with them.

Can you talk about plans for the ABVM Certification Review Course? It is scheduled for June 16–19, 2005.

Obviously one of the things that people are concerned about is preparation for this exams. Under the auspices of the Society for Vascular Medicine and Biology, the first board review course will be in June, in Chicago. Thom Rooke, MD, director of the Gonda Vascular Center at the Mayo Clinic, is the course director. This is going to be an intensive, three-day board review course that will cover the entire syllabus for the general and endovascular exam. More information about how to register will soon be available on both the Society for Vascular Medicine and Biology website (www.svmb.org), the ABVM website (www.vascularboard.org) and also through brochures sent via mail to interested parties. ABVM is also supported by the Society of Angiography & Interventions (SCA&I). We actually approached all of the other major vascular professional societies to see if they were interested in collaborating. The SCA&I has also been an excellent partner with us on the endovascular exam in particular. A member of the ABVM board is and SCA&I member. They’ve greatly contributed to the test-writing process and will be involved in helping us market the exam to their membership.

Is there a computer simulation element to the endovascular exam?

We feel quite strongly that if metrics can be developed to actually provide some quantitative feedback on a simulator, that would be a critical component to the endovascular exam. It’s one thing to ask people questions and put them in scenarios, but another to actually make them perform a procedure and have them be scored on that procedure. For example, how long does it take you to realize that there is a perforation from the guidewire to the kidney? Did you use the wrong stent? Have you overdilated the lesion? Did you recognize the symptoms of a complication? We’re actually in the process of trying to figure out if we can get standard metrics put onto a simulator. My suspicion is that we’ll either have this as an experimental part of the first exam, or only include it in the second exam in 2006. We want to make sure that it is validated, so that an examinee being tested on a simulator receives a score commensurate with their skill.

Are there any plans for non-U.S. physicians to be able to become ABVM-certified?

We actually opted to limit this to United States physicians for the first year. There is no route currently for foreign physicians, but I’m hopeful that this will expand in future years.

Will there eventually be any enduring materials or textbook offered by ABVM?

There will be a syllabus handed out at the board review course that will be very extensive. It is not going to be just PowerPoint slides. Dr. Rooke has mandated that each section is going to yield a very extensive study manual. The syllabus has been created in preparation for an actual board review textbook, which will be available for the 2006 exam, or the second cycle. The first cycle will have the actual syllabus available at the time people come to the June board review course.

If people can’t make the board review course, is there any option open to them?

Yes, they’ll be able to purchase the syllabus after the meeting. As the course textbook is finished, they’ll be able to purchase that as well.

How does the ABVM position itself in regard to any statements or guidelines from the American College of Cardiology/American Heart Association (ACC/AHA) about vascular medicine training?

The recently published peripheral vascular disease consensus document1 was chaired by Mark Creager, MD, who is actually the co-chair of the ABVM. Everything that we are addressing at the American Board of Vascular Medicine for certification is parallel to the consensus document guidelines. We were very careful to make sure that what we required met the standards for those guidelines.

What are the benefits of becoming ABVM-certified?

There are a number of obvious benefits. First and foremost, the physician who has successfully obtained ABVM certification is able to provide a level of reassurance, not only to local community physicians and referring doctors, but to patients. Certification demonstrates that a physician has dedicated his or her career to becoming an expert in the diagnosis and management of patients with vascular disease, both from a clinical standpoint and from an interventional standpoint. It helps to expand the opportunities for physicians to provide care to the increased number of patients with vascular disease. I really believe that it will increase the opportunities for research, because there will be more experts in the field who will want to further the field, and improve the science and knowledge base in patients with non-coronary vascular disease. The “mid-term” goals of the ABVM are to improve reimbursement rates for practicing physicians with expertise, because as you know, many third-party payors won’t reimburse a doctor who is not a board-certified specialist. If there is no board certification, you cannot say you are a board-certified specialist. The long-term goal of ABVM is to become an American Board of Medical Specialties-recognized board certification, which will add a new level of increased credibility.