Postgraduate training in vascular medicine: proposed requirements and standards

Transcription

1 Postgraduate training in vascular medicine: proposed requirements and standards Mark A Creager a, Alan T Hirsch b, John P Cooke c, Jeffrey W Olin d, Michael R Jaff e, Thom Rooke f Jonathan L Halperin d Working Group on Fellowship Training in Vascular Medicine, The Society for Vascular Medicine and Biology The vascular medicine specialist Vascular diseases encompass pathological conditions and clinical syndromes involving all the arteries, veins and lymphatic vessels, and include such diverse processes as atherosclerosis, aneurysms, thrombosis, embolism, vasculitis, vasospasm, venous insuf ciency and lymphedema. These conditions are common and associated with considerable morbidity and mortality. Discoveries in vascular biology and clinical pharmacology and the technological advancement of percutaneous interventions have brought about a rapid evolution in the eld, and the pace is likely to accelerate. Translation of these scienti c achievements to improved care for patients with disorders of the vasculature requires consistent application of preventive strategies, careful choice of diagnostic methods, appropriate selection of therapeutic options and application of rehabilitative strategies based on training and experience. In the USA, vascular surgeons traditionally delivered care to patients with vascular diseases. The introduction of catheter-based endovascular interventions prompted specially trained radiologists and cardiologists to participate as well. The discipline of vascular medicine evolved early in the twentieth century from a foundation in vascular physiology, hemodynamics and thrombosis. A core of physicians with a background in internal medicine has also brought special expertise to the evaluation and management of patients with vascular diseases. Yet the number of vascular medicine specialists lagged behind other medical specialties because of several factors: the absence of subspecialty board certi cation in vascular medicine; a paucity of training programmes due to a lack of funding; a lack of faculty mentors in vascular medicine training programmes; misconceptions that blood vessels are mere conduits and that vascular disorders affect a single organ system; and the perception that there are few effective therapeutic options for patients with vascular diseases other than revascularization. Formal postgraduate education in vascular medicine began at a few programmes in the 1950s but the American Medical Association did not recognize vascular medicine a Harvard Medical School, Boston, MA, USA; b University of Minnesota Medical School, Minneapolis, MN, USA; c Stanford University School of Medicine, Palo Alto, CA, USA; d Mount Sinai School of Medicine, New York, NY, USA; e Vascular Ultrasound Core Laboratory, Morristown, NJ, USA; f Mayo Clinic, Rochester, MN, USA Address for correspondence: Jonathan L Halperin, The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Medical Center, Fifth Avenue at 100th Street, New York, NY , USA. Tel: ; Fax: ; jonathan.halperin@ msnyuhealth.org Ó Arnold 2003 as a self-de ned medical specialty until The American Board of Internal Medicine (ABIM) does not currently recognize vascular medicine as a subspecialty, and no certifying examination has been widely accepted as a benchmark of competency. Failure to establish certi cation may be viewed both as a cause and a consequence of the small number of vascular medicine specialists. Current staf ng considerations There are presently few physicians at academic centers across the nation quali ed to serve as mentors to trainees in vascular medicine and the number of vascular medicine specialists trained annually has fallen short of the minimum necessary to sustain current knowledge for the next generation. Compounding this shortage of personnel is a lack of funding to foster the growth of professional educational programmes in vascular medicine. Reductions in government support for advanced postgraduate medical training in general have contributed to the dissociation between scienti c advances and their effective clinical application. Declining clinical revenues over the past decade have further constrained efforts to create new postgraduate training programs. To reverse these trends, a national initiative to promote specialty training in vascular medicine is overdue. 1 To meet this challenge, academic institutions must be encouraged to develop postgraduate training programmes in vascular medicine and to establish new funding mechanisms to support them. Delivery of care for patients with vascular disease is distributed among a disparate array of internists, cardiologists, hematologists, nephrologists, neurologists, radiologists and vascular surgeons, among others, varying with the organ affected and regional differences in practice patterns. A concerted national effort to develop vascular medicine training programmes must be organized around objective standards of competency. Formal accreditation of training programmes and certi cation of practitioners by the ABIM could enhance this effort, as could programmatic nancial support from the National Institutes of Health or nonpro t organizations. Even without these stimuli, there is a pressing demand in the health care marketplace for physicians with the cognitive and clinical skills to evaluate and effectively treat patients with vascular disease. A key controversy is whether to vest training and certi - cation in a separate medical discipline or under an existing rubric, as de ned by the Subspecialty Board of Cardiovascular Diseases. Given the prevalence of atherosclerosis and thrombotic disorders in the population, vascular medi / x03vm468xx

2 48 MA Creager et al cine is unquestionably an important component of cardiovascular training. Expertise in vascular medicine, however, requires special training analogous to that required for electrophysiology, cardiac failure and transplantation, nuclear cardiology or echocardiography. 2 Board certi cation in cardiovascular diseases documents successful completion of a fellowship programme and tested knowledge according to an objective standard. Despite the potential economy of utilizing existing resources, few academic centers have integrated vascular medicine into cardiovascular fellowship training and it remains uncertain whether existing programmes will be able to accomplish this successfully. Vascular medicine training guidelines for cardiologists The American College of Cardiology (ACC) Core Cardiology Guidelines for Training in Adult Cardiovascular Medicine 3 describe three levels of vascular training for cardiovascular fellows: Level I training, which applies to all cardiology trainees, calls for two months of exposure to patients with peripheral vascular disorders during the standard three-year cardiovascular fellowship (two of which involve clinical rotations). No accurate survey has determined how effectively training programmes in cardiology presently provide trainees with this level of exposure. Level II training is intended to prepare fellows for careers as vascular specialists, exclusive of performing interventional catheterization or surgical procedures. Toward this end, a 12-month exposure is outlined beyond the conventional training of the cardiologist, which can be offered during the third year of standard cardiovascular fellowship. The training guidelines are similar to those recommended above for all cardiovascular trainees. At least three months should be spent in the noninvasive peripheral vascular laboratory, two to three months on an inpatient vascular medicine consultation service, one to two months in a catheterization laboratory or angiographic suite performing peripheral arterial and venous angiography and interventions and a half to one day per week in a longitudinal outpatient vascular medicine clinic. Additional time should be allocated to elective rotations in vascular surgery, hematology, neurology, rheumatology or magnetic resonance imaging. The training standards call for physicians seeking special expertise in evaluation and management of patients with vascular disease to complete an approved internal medicine residency (generally 36 months) leading to the certifying examination, 24 months of cardiovascular fellowship and 12 months devoted to vascular medicine, which could be completed during a third or fourth year, to enable the fellow to become an expert in vascular medicine. 3 Additional training is required to develop special pro- ciency in catheter-based endovascular interventions. Upon successful completion of level II training as speci- ed by the ACC, a physician would be eligible for certi - cation in cardiovascular diseases. Certi cation by the ABIM Subspecialty Board on Cardiovascular Disease requires three years of accredited training, of which a minimum of 24 months is clinical training, in the diagnosis and management of a broad spectrum of cardiovascular diseases. In an extended cardiovascular fellowship programme, training in vascular medicine supplements 24 months of core cardiovascular training, meeting (in aggregate) the eligibility requirements for the cardiovascular board examination. 4 Level III training for those cardiovascular fellows who will perform catheter-based endovascular diagnostic and therapeutic procedures involves at least one year beyond the standard three-year clinical cardiology fellowship. This level of training for peripheral interventional procedures does not entail the comprehensive training in vascular medicine that comprises level II training, but does build the cognitive skills necessary to evaluate and manage patients referred for catheter-based endovascular intervention. Trainees seeking comprehensive training in vascular medicine should complete level II training. The ACC recommends that cardiologists performing catheter-based peripheral vascular procedures complete three years cardiovascular fellowship, including at least eight months of training in diagnostic cardiac catheterization, plus at least one year of additional specialized training in coronary intervention and at least six months additional specialized training in peripheral vascular intervention. Level III training for peripheral interventions can be undertaken concurrently with training in coronary interventional procedures. Speci c training pathways in vascular medicine Several related medical specialties, among them hematology and nephrology, provide foundations upon which to build vascular medicine training. A graduate of one of these fellowships might be a candidate for a vascular medicine fellowship programme tailored to complement previous training by providing a comprehensive approach to vascular disease management. Currently, no subspecialty board designation exists to recognize competency in vascular medicine beyond cardiovascular board certi cation. 5 Furthermore, there is no designated pathway to certi cation for individuals with internal medicine training who complete a vascular medicine fellowship. We encourage the cardiovascular board to establish a certi cate of special competency in vascular medicine, but recognize that this may not be feasible in the short term. Certi cation in clinical vascular medicine should be made available to candidates who pass a standardized, written examination upon completion of the 12-month postgraduate curriculum. (Note: A precedent exists for the cardiovascular board to issue a certi cate of special competency in vascular medicine based on procedures for the certi cation in cardiac electrophysiology and interventional cardiology. Independent not-for-pro- t corporations established to develop and administer practice-related examinations and credentialing, offer certi cation in nuclear cardiology 6 and adult echocardiography, 7 and a similar model is proposed for clinical vascular medicine.) The ABIM recognizes alternative paths to certi- cation for trainees completing combined training in Internal Medicine and either Dermatology, Emergency Medicine, Family Practice, Neurology, Nuclear Medicine, Pediatrics, Physical Medicine and Rehabilitation, Preventive Medicine, or Psychiatry and endorses admission to the examination in Internal Medicine and the respective specialty board. Combined training includes the components of separate internal medicine residencies and residencies in the

3 Postgraduate training in vascular medicine: proposed requirements and standards 49 respective discipline. While the Accreditation Council does not accredit combined programmes for Graduate Medical Education, there are currently some 155 active combined programmes training approximately 2000 residents in various subspecialties. In lieu of or until certi cation is provided by the ABIM, review of credentials and administration of the qualifying examination could be administered under the aegis of an independent organization developed for this purpose by the Society for Vascular Medicine and Biology and the National Board of Medical Examiners. The working group envisions such a training path in vascular medicine, beginning with an approved internal medicine residency programme and proceeding through an additional fellowship year in vascular medicine in an approved programme. This is based on the vascular medicine curriculum speci ed below in this document and analogous to level II supplementary training in vascular medicine in a cardiovascular fellowship. A discussion of the speci c training and procedural experience appropriate to qualify an individual to perform peripheral vascular interventions is beyond the scope of this document. Vascular medicine specialists planning research careers should complete an approved internal medicine residency plus one year of clinical vascular medicine and two years of either basic or clinical research. The curriculum in vascular medicine Training in vascular medicine requires at least one year of clinical training devoted to the following topics, with a onemonth allowance for vacation: Hospital consultative vascular medicine (three months) Outpatient vascular medicine (a half to one day per week) Vascular diagnostic laboratory and imaging (three to four months) Peripheral angiography and catheter-based endovascular intervention (one to two months) Vascular surgery (one to two months) Elective rotations in vascular pathology, thrombosis, dermatology, rheumatology, or advanced imaging (e.g., magnetic resonance angiography) (one to two months) Scienti c meetings and congresses (one to two annually) These rotations should provide experience with the following vascular diseases: aortic diseases, peripheral arterial diseases, aneurysmal disease, thromboangiitis obliterans, bromuscular dysplasia, renal and visceral artery disease, cerebrovascular disease, hypertension, hyperlipidemia and risk factor modi cation, venous thromboembolic disease, hypercoagulable states, chronic venous diseases, lymphatic diseases, leg ulcers, vasospastic diseases, thoracic outlet syndromes, vasculitis, vascular trauma, and less common vascular diseases such as pernio, erythromelalgia and re ex sympathetic dystrophy. Clinical exposure should be accompanied by didactic teaching supplemented by study of major textbooks of vascular medicine, selected original scienti c articles and critical reviews and course work in biostatistics and interpretation of medical literature. Descriptions of each component follow. Consultative vascular medicine in hospitalized patients To become an effective consultant, the fellow should be adept at the primary medical management of hospitalized patients with each of the vascular disorders listed above and consultative management of vascular surgical patients. Emphasis should be placed on vascular problems that occur frequently in the hospital setting, including but not limited to venous thrombosis and pulmonary embolism, pulmonary hypertension, limb ischemia, atheromatous embolism, aortic and arterial dissection, vasospasm and vasculitis. This rotation typically serves as an avenue to honing skills as an educator, whereby the fellow imparts knowledge of vascular care to residents in internal medicine and to primary physicians. In each case, direct supervision of the fellow by a member of the vascular medicine faculty should be documented in the medical record. Evaluation and management of ambulatory patients with vascular disease The art and science of vascular medicine is applied on a longitudinal basis under the supervision of attending vascular specialists in an ambulatory setting. Diagnosis and treatment of such conditions that usually require predominantly outpatient management, such as peripheral arterial disease, chronic venous insuf ciency, lymphedema, other causes of leg swelling, vasospastic diseases, vasculitis, thoracic outlet syndromes, procoagulant disorders, hypertension and hyperlipidemia are emphasized. Competence must be developed in the assessment and control of atherosclerosis risk factors and management of prothrombotic states. The fellow will also perform preoperative assessments of patients requiring cardiovascular surgical and revascularization procedures and plan both diagnostic testing and longterm, integrative postoperative care. Noninvasive vascular diagnostic laboratory and imaging A structured vascular laboratory module should be provided to expose each trainee to the following diagnostic modalities: 1) Physiological diagnostic studies of the upper and lower extremities at rest and after exercise or provocative maneuvers: pulse volume recordings segmental blood pressure measurements Doppler waveform analysis. 2) Exercise testing in conjunction with Doppler owmetry to evaluate limb hemodynamic responses and other factors that may contribute to functional impairment. 3) Duplex ultrasound of the upper and lower extremities to evaluate: venous thrombosis and insuf ciency obstructive disease of peripheral arteries and bypass grafts aortic and peripheral aneurysms, masses and tumors arteriovenous stulas and access grafts preoperative venous and arterial mapping pseudoaneurysms and their obliteration by compression maneuvers and/or thrombin injections. 4) Duplex ultrasound examination of the deep abdominal vessels to evaluate:

4 50 MA Creager et al aortic aneurysms renal and mesenteric arteries and veins. 5) Duplex ultrasound examination of the carotid and intracranial arteries. 6) Hemodynamic and imaging studies for diagnosis of neurovascular compression/entrapment syndromes, including those of the thoracic outlet. Training in each modality has four cornerstones: A rm foundation in the relevant vascular pathophysiology Ability to perform standard vascular laboratory procedures with pro ciency comparable to that of a registered vascular technologist 8 Interpretation of results under the tutelage of a faculty expert Application of knowledge gained from the literature as it pertains to the indications for and limitations of vascular diagnostic laboratory data. Requisite training ensures at least three months during which the trainee s work is dedicated exclusively in a vascular diagnostic laboratory that is accredited by the Intersocietal Commission on the Accreditation of Vascular Laboratories (ICAVL). All tests and procedures should be supervised and interpreted by a physician with specialized training and experience in vascular diseases 9 and the minimum laboratory case volume for each procedure should adhere to ICAVL guidelines. (Note: These currently include interpretation of 100 venous, 100 extracranial carotid, 100 limb arterial, 75 visceral vascular duplex ultrasound and 100 physiological arterial examinations. The Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL) is af liated with the Intersocietal Accreditation Commission along with the Intersocietal Commission for the Accreditation of Echocardiography Laboratories, the Intersocietal Commission for the Accreditation of Nuclear Medicine Laboratories and the Intersocietal Commission for the Accreditation of Magnetic Resonance Laboratories. ICAVL, 8840 Stanford Boulevard, Suite 4900, Columbia, MD 21045, USA.) Fellows should be exposed to the administrative and s- cal aspects of vascular laboratory operation including ongoing quality assurance, but how this is best accomplished is left, initially, to the discretion of individual training program directors. The evaluation process for noninvasive vascular laboratory skills is the same for all areas of the vascular medicine fellowship, as discussed below. Those seeking academic careers in advanced vascular imaging will generally require additional training to hone technical skills or undertake independent investigation. Peripheral angiography and catheter-based endovascular intervention The purpose of this one to two month rotation is to expose each fellow to noncardiac angiography with emphasis upon indications, interpretation, potential complications, limitations and quality assessment. It is not designed to prepare trainees to perform diagnostic angiography, phlebography, lymphangiography or catheter-based vascular interventions. Catheter-based therapeutic procedures should be observed and complemented by discussion to teach the array of available procedures, their indications, limitations and compli- cations, with emphasis upon risk/bene t analysis and alternatives to percutaneous therapy. Appropriate exposure would include angioplasty, intravascular stents, stent grafts, lters, embolic occlusion and protection devices, use of thrombolytic agents and mechanical thrombectomy devices, access site care and management of complications. Each trainee should be exposed to the full spectrum of peripheral diagnostic angiograms and interventional procedures. Vascular surgery In parallel with the recommended experience in endovascular catheter-based interventions, fellowship training in vascular medicine requires observational exposure in the operating room to commonly performed vascular surgical procedures. Emphasis is placed on indications, contraindications, potential complications and risks, perioperative diagnostic evaluation, and comprehensive pre- and postoperative care of vascular surgical patients. The relative advantages and limitations of common surgical methods, and the application of these techniques in conjunction with pharmacotherapy and endovascular procedures should be discussed. Rounds and conferences The vascular medicine curriculum requires regular attendance at a variety of intramural rounds and conferences, as well as annual participation in an established national or international symposium or congress. The number and variety of conferences may differ based upon the volume of patients and services and upon the resources available at each programme. Minimum frequencies for conference attendance are indicated below. 1) Daily supervised clinical rounds with a member of the vascular medicine faculty for consultation and inpatient hospital patient care, documented by entries in the medical record by both the fellow and faculty. 2) Clinicopathological grand rounds in vascular medicine conducted at least once monthly at an hour when both trainees and faculty can attend. Case material should be selected for discussion based upon a core curriculum related to vascular diseases. 3) Conferences at least twice monthly devoted to the review and discussion of vascular imaging procedures, including ultrasound, scintigraphy, computed tomography, magnetic resonance imaging and angiography, with emphasis upon clinical diagnosis and patient management. 4) A monthly conference focused on critical review of the emerging scienti c literature, emphasizing judicious trial methodology and application of statistical methods. Fellows not otherwise engaged in medical scienti c writing should be required periodically to prepare a scholarly review of the paper or topic under discussion. 5) A monthly quality assurance or morbidity and mortality review conference, ideally multidisciplinary, in which vascular surgeons, radiologists, cardiologists and vascular medicine physicians participate. Methods to improve patient care should be discussed with the goal of limiting procedure-related complications and disease-mediated morbid and mortal events.

5 Postgraduate training in vascular medicine: proposed requirements and standards 51 Programme administration The vascular medicine fellowship programme should be organized and supervised by a single attending physician designated as the programme director, whose responsibilities include the following: 1) Providing a structure for the fellowship, including written curriculum material, a schedule of rotations, rounds and conferences that meet the requirements set forth above. 2) Selecting faculty responsible for mentoring, teaching various aspects of vascular medicine to fellows and serving as role models. 3) Providing an atmosphere conducive to scholarly activity and high-quality patient care. 4) Mentoring and constructive evaluation of fellows based upon comments from faculty, mastery of the curriculum and personal interaction. 5) Mentoring and constructive evaluation of faculty based upon comments from fellows, adherence to the curriculum and personal interaction. 6) Soliciting and reviewing applicants for admission to the programme. Review of programme performance Training programmes should provide an enriched environment conducive to learning, and emphasize the translation of research ndings to clinical patient care and the epidemiological underpinnings of practice guidelines, where they exist. Both internal and external review processes are used to determine how successfully a training programme meets these goals and provides the elements of curriculum delineated above. An internal advisory committee composed of the programme director and members of the faculty should meet regularly to review the progress of individual trainees and evaluate the programme as a whole. This should be supplemented by periodic review by established clinicians and educators from outside the programme to provide fellows, members of the teaching faculty, and the programme director with information regarding current training standards and evaluation processes. One or more visiting reviewers should meet with representative trainees to exchange perceptions about the quality of the curriculum and discuss ongoing change within the specialty. The les of current trainees with problem performance should be reviewed to assess the adequacy of problem identi cation and remedial action. There should be a summary meeting with the program director to discuss any identi ed de ciencies, and this should be followed by a report containing recommendations for the future development of the programme. Training for a career in academic vascular medicine Many trainees anticipating an academic career nd research opportunities during medical school, residency or fellowship. Guided by a training programme director or other faculty, they may choose a career involving basic or clinical research, teaching or clinical activities. Training for an academic career (1) engenders familiarity with current issues and controversies in vascular medicine; (2) fosters the ability to create cogent, testable hypotheses, as well as rigorous application of the scienti c method and critical analysis; (3) exposes the fellow to a broad range of ideas and techniques of investigation; (4) faithfully transmits a commitment to conducting ethically responsible research; (5) focuses individual effort on a eld of research that can serve as a springboard for future investigation and independent grant support; and (6) enhances skills in oral and written communication. Meeting these objectives requires the guidance of experienced faculty mentors enhanced by opportunities for interdisciplinary collaboration. A period of two years is generally needed to transmit knowledge suf- cient to serve as a foundation for direct contributions, and to clarify the boundaries that separate what is known from what is not known in this eld. Faculty mentoring Each fellow should have a strong mentor to provide the guidance and opportunities necessary to launch an academic career. This mentor should meet weekly with the trainee to develop experimental protocols and review data, emphasizing rigorous education in the scienti c method, to assure the trainee becomes facile with the lexicon and techniques of a focused area of research and skillful in communicating scienti c ideas. Optimally, the mentor should provide the trainee with a syllabus of landmark articles, help direct further reading and help select scienti c meetings for the trainee to attend. Peer-reviewed publications Publication of the results of well-conceived and wellexecuted investigations in peer-reviewed journals is an enduring contribution to the eld and serves as a benchmark of academic productivity. The trainee should be taught how to write and present an abstract for communication at a scienti c meeting, how to author a review of the literature, and how to compose an original research report. Ethical principles of scienti c research and reporting include criteria for authorship, appropriate citations of previous work and disclosure of potential con ict of interest. The trainee s publication record is re ective of the mentor s guidance and the trainee s productivity. The trainee should publish at least one paper per year of research training, the quality and substance of which will be examined when the trainee competes for funding, or applies for a junior faculty position. Extramural research funding Grants and contracts fuel academic activity. A successful academician knows how to obtain funding to support the growth of teaching, research or new clinical programmes. Academic training should include exposure to the funding process. There are multiple opportunities for the trainee to gain this experience, including competitive grants and awards from the National Institutes of Health, nonpro t agencies and societies. The trainee should seek out such funding opportunities and, with the mentor s assistance, apply for fellowship stipends and awards. Through the process of applying for funding, the trainee will learn the importance of reviewing the literature, formulating hypoth-

6 52 MA Creager et al esis-driven speci c aims, obtaining preliminary data, and developing experimental protocols to test hypotheses. Professional interaction Research and education are communal activities. Progress in a eld is typically incremental, and requires knowledge of who has done what, and when, and by which means. It is important to communicate with other investigators to remain current in the eld and to promote productive collaboration. The mentor should provide opportunities for trainees to meet and to review data with investigators at other research centers. Conclusions Over the past decade, advances in vascular biology, new technologies for diagnosis and imaging, drug discovery and novel catheter-based therapies have advanced vascular medicine to a new level of importance. Just as specialization in other elds of medicine has both accelerated diagnostic and therapeutic advances and brought about improvements in diagnosis and treatment, opportunities to achieve this in vascular medicine abound. Few fellowship programmes presently offer formal training in peripheral vascular diseases and those that provide the breadth required for comprehensive expertise are rare. Most adult cardiology training programmes do not provide advanced training in the pathophysiology of vascular conditions, clinical evaluation of the patient with vascular disease, noninvasive vascular laboratory diagnostic techniques, peripheral angiography or intervention. A major impediment is an insuf cient supply of academic vascular medicine teachers. National trends in postgraduate medical education in the USA have critically narrowed the avenues through which vascular expertise might be passed to a new generation of physicians. Mainstream cardiology training programmes have neither fostered role models in vascular medicine nor created settings conducive to postgraduate training in vascular medicine. This document represents a proposal for speci c training in vascular medicine based on didactic training, scienti c mentoring and clinical experience in the care of patients with peripheral vascular disorders. A curriculum has been designed to assure that the vascular medicine specialist can integrate knowledge with clinical skills to complement the surgeon and catheter interventionist. This curriculum would be appropriate either in conjunction with cardiology fellowship or after completion of residency training in internal medicine for those seeking more advanced clinical mastery of vascular diseases. A career in academic vascular medicine derived from rigorous training integrates all aspects of vascular biology and encourages the translation of discoveries in basic science to clinical practice. The US health care system has reached a critical juncture, as an expanding population of individuals with vascular disease confronts a diminishing supply of specialized caregivers. The future of vascular medicine depends on the successful integration of multiple disciplines and the cultivation of a new generation of leaders who have a broad and cohesive view of vascular biology. Training recommendations alone are insuf cient to preserve the current knowledge base or provide opportunities for optimum clinical application. Development of educational programmes faces numerous challenges, including the identi cation of faculty, sources of funding and the creation of enriched training environments. Implementation of these standards for postgraduate training in vascular medicine must be accompanied by appropriate recognition of special competency and by a commitment of resources on a national scale. Acknowledgements The Trustees of the Society for Vascular Medicine and Biology and the members of the Working Group on Fellowship Training in Vascular Medicine gratefully acknowledge the efforts of the following individuals, whose thoughtful advice and review contributed to the formulation of this document: J Michael Bacharach, Bruce Gray, William R Hiatt, Emile R Mohler, III, David Naide and Judith R Regensteiner. References 1 Cooke JP, Dzau VJ. The time has come for vascular medicine. Ann Intern Med 1990; 112: Olin JW, Young JR, Graor RA, Ruschhaupt WF, Bartholomew JR, Gray BH. Role of the cardiologist in peripheral vascular disease. J Am Coll Cardiol 1991; 19: Beller GA, Bonow RO, Fuster V. Core Cardiology Training Symposium (COCATS). ACC revised recommendations for training in adult cardiovascular medicine. Core Cardiology Training II (COCATS 2). (Revision of the 1995 COCATS training statement). J Am Coll Cardiol 2002; 39: ( 4 American Board of Internal Medicine. Policies and procedures for certi cation, Olin JW. Is vascular medicine a viable specialty? Vasc Med 2001; 6: Certi cation Board of Nuclear Cardiology (CBNC) National Board of Echocardiography (NBE). 8 Intersocietal Commission for the Accreditation of Vascular Laboratories. Essentials and standards for accreditation in noninvasive vascular testing Abbott WM. Training vascular surgery residents in the noninvasive vascular laboratory. Semin Vasc Surg 1994; 4: