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Florida Vein Doctors: Who’s treating who?

The Kimmel Institute Featured in The Sun Sentinel

On Monday April 2nd, the South Florida newspaper The Sun-Sentinel, published a front page article on vein procedures done by Florida doctors.  (See http://www.sun-sentinel.com/health/fl-hk-varicose-vein-laser-20120401,0,5822457.story ).  While this was factually accurate for the most part, it was clearly written in a way to emphasize the “dark side” of doctors who include the treatment of veins in their practice.  So let’s get all the facts out in the open. To begin, any fully licensed physician in the State of Florida can buy a laser and treat varicose veins.  The question here becomes, just because one is legally allowed to do this procedure, is the physician appropriately trained and experienced enough to manage all aspects of the disease?  Based on Residency training and board certification, there is really only one specialty that meets the highest criteria for this: vascular surgeons. Who are these other doctors who are doing the procedures?  In addition to vascular surgeons, there are a number of other specialists who claim to be “phlebologists” or “cardiovascular specialists”.  These include family practitioners, dermatologists, cardiologists, general surgeons, interventional radiologists, gynecologists, emergency medicine doctors and more.  Again, all of these specialists are “legally” able to treat vein problems, but none of them have the depth of experience and clinical expertise of a vascular surgeon (or equivalently trained cardiovascular surgeon).  Why is this important?  Well, many people can be trained to actually do the procedure (there are actually a number of nurse practitioners and physician assistants doing this), but few have the training and experience to comprehensively manage complicated or difficult cases and the potential complications that can arise. Interestingly, one other group of doctors should be mentioned, that is the Podiatrists.  The State of Florida allows a licensed Podiatrist to practice medicine and surgery below the tibial tuberosity (essentially just below the knee).  Yet despite this clear demarcation of the scope of their privileges, there are some Podiatrists who have begun to perform laser vein closures in the thigh area.  They justify this by saying that the laser is inserted in the leg, below the knee, so it is ok.  To even make the diagnosis of an incompetent saphenous vein in the thigh is beyond their scope of practice, so to then treat above the knee without any legal support or clinical justification simply reflects their primary indication: money.  While this is clearly beyond their training and experience, I have personally been informed of many such persons throughout the state who do this to unsuspecting patients.  So while there are many highly regarded Podiatrists who provide excellent care to their patients, beware of the few who try to practice beyond what their license allows. The next consideration should be: is the vein doctor that I’m seeing able to take care of all my vein problems?  Too often, it is the less experienced and insufficiently trained group of doctors who only want to do the laser vein ablations, and not any of the other vein procedures that often are needed.  Why?  Because the laser ablation is not usually too difficult (technically) to perform, and it pays well compared to the other things that these doctors are used to doing.  In addition, the comprehensive management of venous disease requires both an understanding of the vascular system and the surgical skills to perform the necessary treatments that are indicated.  Simply put, vascular surgeons are the best trained and most skilled to mange venous disease. The bigger problem here is that if you only do part of the treatment, you are doing a disservice to the patient and this will often result in further complications.  Poor decisions are made by this group of doctors (who are not vascular surgeons), and this casts a dark shadow on all of us who treat vein disease. It also leads them to poor decisions to treat simply based on financial reimbursement (as indicated in the newspaper article). The good news with this is that there are a lot of highly skilled and experienced vein doctors in Florida who do a very good job and who have a high level of both academic and professional integrity.  Many of us who have performed open heart surgeries, who have used the saphenous vein for bypasses and who have been trained for 5-8 years in Residency programs to treat the vascular system, have busy and successful vein practices with results that are equal to those anywhere in the world.  We understand that just because we have the equipment and the skills, we do not always need to treat every patient.  But for those patients who should have treatment, we also know that we can offer a comprehensive skill set and deal with any problems that arise.  We don’t deceive patients into having unnecessary procedures because we are usually busy enough treating the patients who need us. We don’t treat “normal veins” because we truly do understand that these veins may be needed in the future for the patient’s other medical problems.  And we (vascular surgeons) are also experienced enough to understand (unlike one of the doctors quoted in the article suggests) that a diseased dilated vein will not be an acceptable conduit for future open heart surgery, and if the patient is symptomatic and meets standard acceptable criteria, this vein should be removed. As far as the costs go, the article misrepresents the actual reimbursement for the procedure.  While it stated that doctors can make up to $2000 per procedure, this is grossly inflated and does not account for the cost of the equipment, supplies, staff time and other overhead that all offices have.  Never the less, compared to the reimbursement for a routine office visit of less than $100, it’s no wonder that primary care doctors and others want to “cash in” on this procedure, and it is for this reason, that many vein centers are popping up all over the area. Concerning certification of the center, the two most important things to consider are if the ultrasound technologists are trained and certified as vascular ultrasonographers and if the physician is a board certified vascular/cardiovascular surgeon.  The intersocietal certification that was referenced is often needed for radiological facilities or hospitals, and is not required for a highly specialized vein practice.  However, the state of Massachusetts has taken the bold step of recognizing that only vascular specialists should be doing these vascular procedures.  (You wouldn’t go to an orthopedic surgeon if you were having a heart attack, or ask an electrician to fix your leaking water pipes, right?) The following summary should help you decide who you can trust:
  • Is the doctor a board certified vascular or cardiovascular surgeon?
  • Does the doctor have vascular surgical privileges at a local hospital?
  • Does the office have registered vascular ultrasound technologists
  • Is the vein center treating patients with vein problems as the majority of their practice?
  • Have the recommendations for your treatment been explained in detail and is the center able to treat all complications?  Are they willing and able to answer your questions to your complete satisfaction?