In 2007, the American Registry of Diagnostic Medical Sonographers (ARDMS) introduced the Registered Physician in Vascular Interpretation (RPVI) credential responding to requests of physicians in vascular surgery and vascular medicine. This was a giant step in the right direction – requiring physicians who interpret a very complex study to demonstrate that they know what they are doing. What’s not to like?
As of 2014, the American Board of Surgery requires that all physicians who want to be boarded in Vascular Surgery have the RPVI credential. Again, in my opinion, this is another giant step in improving patient outcomes. This is great for the physicians who have a formal training program and rotation through a vascular lab that provides a broad array of vascular testing.
The ARDMS has experience pathways as prerequisites for taking the RPVI, including physicians with the Registered Vascular Technologist (RVT) credential (Prerequisite A1), physicians currently on staff in an accredited vascular lab (Prerequisite A2), physicians who have formal training (Prerequisite B1 and C1), or physicians who have informal training (Prerequisite B2 and C2). The prerequisite for physicians who have the RVT credential makes sense since the reason many physicians obtained the RVT credential was to prove to people that they knew what they were doing. The accreditation pathway makes some sense, but there is a loophole related to how many studies someone with informal training has to read –that’s another topic for another day. Let’s focus on the formal and informal training pathways.
Earlier in this year, the ARDMS put out a statement regarding the required cases for the informal training pathways: “All 500 required clinical studies, noted in the PVI examination application prerequisites B2 and C2, must be completed through employment as an interpreting physician in a clinical diagnostic setting (limited to hospitals, clinics and private practices). This can include vascular studies billed by the applicant for contracted interpretation. Interpretation of cases outside of a clinical setting, such as online or in-person courses/seminars, do not meet the experience requirement.”
Thomas D. Shipp, MD, RDMS, Chair, ARDMS Board of Directors is quoted as saying, “The growing proliferation of non-clinical setting case review courses targeted to PVI applicants to meet their application clinical case requirements, does not satisfy the rigorous standards set forth by ARDMS education and clinical experience requirements to ensure public safety.”
I’m pretty sure that I understand the intent behind these statements. The ARDMS intended that physicians learn how to interpret vascular studies through hands-on learning with someone who has the experience interpreting these studies. They want them interpreted in a clinical setting, which I assume means in a setting where the decision about treatment or follow-up is made. They want to ensure public safety by having the RPVI candidate be exposed to normal and abnormal evaluations so that they can properly handle the patient. The bottom line is that the ARDMS wants physicians who interpret studies, and get paid for them, to prove that they know what they are looking at and that they understand what they are looking at, and how that what they are looking at is applied to the clinical decision making process.
Notice how I kept saying “looking at”? I emphasize this because over the years many physicians have interpreted vascular studies based on the preliminary impression of the technologist or sonographer without ever looking at an image or a waveform. Please understand that I am not saying that every physician has done this, but the anecdotes from colleagues and my own observations suggest that this happened more often than not. The RPVI credentialing process now requires that physicians be able to recognize normal and abnormal pathology in ultrasound images and waveforms, perhaps in a setting where RPVI candidates are being mentored by physicians who have limited experience interpreting images or waveforms. I’m sure that this is not the case, but one can only hope.
So, how are other physicians with a vested interest in caring for or treating patients with risk factors or symptoms of vascular disease supposed to gain experience reading these studies? How are they supposed to learn to read and then validate their knowledge by taking a credentialing exam? I’m talking about physicians in Cardiovascular Fellowship programs who are not granted access to vascular studies for interpretation for numerous reasons, and those who have been in practice for years who have not had the advantage of going through a Fellowship with vascular interpretation. We could get into how cardiovascular interventionalists are performing the majority of vascular interventions, and how they should be including vascular testing in their Fellowships, and how unless they’re in the Vascular Diagnostic Lab or Radiology they’ll never be exposed to the exams, but we don’t have time to discuss all of that here. Put it in the comments.
I fully understand the meaning behind Dr. Shipp’s statements. There are courses and seminars out there that offer case interpretation as a way of gaining experience. As a matter of fact, NAVIX offers a Preceptorship in Vascular Interpretation, which presents entire patient studies, including a history, images, and review of interpretations, giving the entire clinical scenario including discussions about treatment and follow-up options. The Preceptorship offers normal and abnormal cases, presenting a wide spectrum of disease states that physicians may or may not encounter in their Fellowship, or in their accredited lab. I don’t know the other courses that are out there and how they are set up, so I can’t really comment on them, but it sounds to me like this is exactly what the ARDMS intended.
I know that the ARDMS would like to be inclusive of all specialties and all physician groups and ensure that non-invasive vascular ultrasound studies are interpreted properly. I also know that there are folks out there that would like to take advantage of loopholes in the system to circumvent the rigorous standards established by credentialing and accrediting organizations. But I also know that there are folks out there who want to exceed the standards set by organizations and take patient care to a higher level. Maybe the classroom setting was not the “intent” to gain experience, but sometimes the difference between what was intended and what actually happens exceeds the intent.
Perhaps the ARDMS should take a look at these alternative ways of gaining experience and not exclude them out of hand. There can’t be that many, can there? Set some standards. Review some content. Sit in on the course and see how this can work within the rigorous standards for education and clinical experience. Can experience be gained in course or in an accelerated program? Sure it can. Come see how it works.