Vascular Medicine After IM Training

Vascular medicine as a subspecialty following internal medicine training is not a well-known pathway. Most vascular medicine specialists have a unique experience that led them to vascular medicine and inspired them to pursue this subspecialty. Some may have come across it when facing an anticoagulation dilemma during their internal medicine rotations, while others may have researched career paths after internal medicine residency or while looking for academic research opportunities. One thing is for sure: vascular medicine specialists address a lot of "grey zone" consults and conditions in medicine, which makes vascular medicine an interesting and challenging subspecialty. Vascular medicine specialists play a key role in the multidisciplinary management of patients with complex vascular disorders such as critical limb ischemia who will benefit from a comprehensive approach to treatment.

There are 24 vascular medicine training programs in the U.S., and they accept 1-4 fellows for each recruitment cycle. The duration of the fellowship is 1-2 years depending on the program's curriculum with some programs offering an optional year for research in vascular medicine.

The structure of each vascular medicine fellowship program is unique. Some programs are focused on the outpatient setting, some include both outpatient and inpatient rotations, and others are more focused on the procedural aspects of vascular medicine. Vascular medicine fellows are exposed to various pathologies including acute aortic syndromes, atherosclerotic vascular disease including peripheral artery disease and carotid disease, acute and critical limb ischemia, venous thromboembolism, vascular wounds, and lymphatic disease. Some programs provide further exposure and training in vasculitis, blood disorders such as heparin-induced thrombocytopenia, pulmonary embolism, and pulmonary hypertension.

Vascular medicine fellows play an important role in the Pulmonary Embolism Response Team (PERT). This involvement promotes skills in assessing critically ill patients with pulmonary embolism and navigating safe treatments through immediate multidisciplinary action, bedside examination, and echocardiogram training. In addition, the vascular medicine team is responsible for running post-PERT clinic follow-ups, where patients are reassessed for long-term complications of pulmonary embolism. The broad exposure to a variety of pathologies helps vascular medicine trainees gain the expertise needed to improve the quality of care provided to patients and ultimately improves the overall outcomes of our patients.

Some programs provide extensive training on venous procedures and wound care including endovascular laser ablation, pseudoaneurysm treatment, venous phlebectomy, and sclerotherapy. Vascular diagnostic laboratory training is an essential part of most vascular medicine programs, where fellows learn the interpretation of vascular imaging. Additionally, some programs offer training in multimodality imaging (CT/MR) for vascular disorders.

Training in vascular medicine is comprehensive and creates physicians well-versed in the management of complex vascular conditions. The community in vascular medicine is very passionate and supportive via meetings, conferences, online forums, and social media. The ACC organizes many events and discussions for vascular medicine where experts can join, meet, and exchange experiences through its Vascular Disease Member Section.

The field of vascular medicine is rapidly evolving and there is a great need for research to better understand the mechanisms behind vascular pathologies and develop novel therapies for the treatment of vascular disorders. Research is an important aspect of vascular medicine training and academic career. Fellowship programs support fellows to conduct research in their areas of interest including vascular biology, vascular epidemiology, and translational and clinical vascular medicine.

Upon completion of vascular medicine training, trainees are eligible to sit for the American Board of Vascular Medicine, American Board of Endovascular Medicine, and American Board of Venous and Lymphatic Medicine and apply to be a Registered Physician in Vascular Interpretation. After fellowship, some may focus exclusively on practicing outpatient vascular medicine, others may focus on inpatient vascular medicine or a combination of both. Some may decide to work in vein centers, where they have varying levels of procedural involvement.  Others may pursue further training in cardiovascular medicine, interventional cardiology, hematology/oncology, neurology, or pulmonary medicine.

Many trainees develop the desire to learn more about the role of cardiac diseases in vascular medicine during their training and decide to pursue a cardiovascular medicine fellowship where they can apply modalities such as echocardiography and angiography to patient care. Also, they can confidently assess and treat cardio-pulmonary diseases and broaden their toolset to help patients.

There is a large burden of vascular disease worldwide, therefore more vascular medicine experts are needed. We highly encourage those interested to apply for vascular medicine fellowship to learn more.

This article was written by Batool Abuhalimeh, MD, a vascular medicine fellow at the Cleveland Clinic Foundation; Leili Behrooz, MD, MPH, a vascular medicine fellow at Boston Medical Center; Adithya Peruri, MD, a cardiology fellow at Parkview Hospital in Pueblo, CO; Christopher J. Regan MD, FACC; and Carlos Mena-Hurtado, MD, FACC

Twitter: @LeiliBehrooz and @MDPeruri

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