Do’s and don’ts of starting a vascular practice

SAN DIEGO — Starting a vascular practice may be an uphill climb, but taking certain steps and avoiding common pitfalls can help pave a path to success, according to two speakers at the Society for Cardiovascular Angiography and Interventions Scientific Sessions.

During his presentation, Brian Kolski, MD, from St. Joseph Hospital in Orange, California, provided an early-career perspective aimed to help interventional cardiologists looking to perform vascular cases, providing tips to help define their goals, identify important sources of patient referrals, emphasize quality control and typical issues that may arise.

Nearly half of cardiologists will leave their first job within 3 years, Kolski said, which does not leave much room for trial and error. However, making an informed decision is paramount.

Interventionalists who are joining a large practice and want to perform vascular cases, for instance, should know how many physicians in the group already work in the vascular space, whether someone has already taken the lead in the group and case volume.

Building a practice

For interventionalists entering the vascular space, the first decision should be figuring out what kind of vascular doctor they want to be, Kolski said.

“My recommendation is that the broader the scope of your practice, the more successful you’ll be. Are you going to do abdominal aortic aneurysms? Are you going to do carotids? Are you going to do limb salvage?” he said.

Kolski also recommended establishing good relationships with other specialists, including specialists in wound care and podiatry, interventional radiologists and ED physicians, as well as seeing vascular medicine consults in hospitals.

According to Kolski, patients with critical limb ischemia will be the “bread and butter” of most vascular practices. Thus, it is important to develop a wound care team, which includes radiologists, infectious disease specialists and podiatrists, as well as developing a relationship with a wound and hyperbaric medicine center. Involving surgical colleagues can also be beneficial, he noted.

“If you can provide that level of comprehensive care to your patients, you’re not only doing your patients a service, but will be able to build your practice quickly,” he said.

The most important aspect of a practice, though, is the quality of work, especially in the first 2 years, Kolski said. Hiring experienced vascular technicians and controlling the nature of noninvasive vascular studies will help boost the accuracy of diagnosis and the quality of treatment.

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“The reports that you generate are from vascular technicians who are, by and large, the backbone of your practice and the backbone of the quality you put out there,” he said.

Clear communication with referring doctors is also essential, according to Kolski. They should receive the imaging studies, lab reports and details regarding follow-up for patients so they feel engaged in the process.

Finally, Kolski said it is important to find a mentor who can not only help with extremely complicated cases, especially early in an operator’s career, but also navigate hospital politics.

Avoiding landmines

Perhaps even more important than what to do when launching a vascular practice is what not to do, according to Christopher J. White, MD, chief of medical services and system chairman for cardiology at Ochsner Medical Center and professor and chairman of medicine at Ochsner Clinical School.

White, who offered a perspective from an interventional cardiologist with an established vascular practice, suggested using the first 100 cases as a landmark to assess performance and identify areas for improvement.

“At all costs, you want to avoid mortalities and minimize complications; you want to avoid the embarrassment of being proven wrong in public; and you want to avoid, most importantly, patient relationship catastrophes,” White, a member of the Cardiology Today’s Intervention Editorial Board, said during his presentation.

To achieve positive outcomes, including low mortality and complication rates, he encouraged early-career operators to “always think before you act.” Discussing cases with colleagues and a more experienced mentor will be especially beneficial.

In the same vein, White said, experience with a certain procedure or technique does not necessarily mean that it should be attempted, especially during an operator’s first few cases. Furthermore, the willingness not to pursue a particular treatment may be the best course of action.

“Don’t be afraid to say no. You can establish tremendous credibility with your interventional community and the others around you when you think of reasons why something is not a good idea,” White said. “We don’t say no because we’re afraid or think we can’t do something; we say no because maybe we need to step back and discuss the case and consider what the downstream ramifications are. Being deliberate is not a weakness. In fact, people will respect you for it.”

Another aspect of care that is often misunderstood is the role of nurses and technicians in the cath lab, according to White. Humility, respect and acknowledgment are key to fostering these relationships, which affect the quality of care provided, he noted.

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It is also important to not neglect the patient-physician relationship. White said physicians should be approachable, affable and available to answer questions from patients and their families without judgment and in a manner they will understand. By doing so, the operator will be more likely to hear about any issues or complaints that a patient has before their colleagues or hospital administration become involved.

Most importantly, White said there should be accountability, noting that early-career operators should take ownership of their patients and continue to grow.

“For those first 100 cases, take it slow and learn your craft. Your training doesn’t end when your fellowship ends. You want to be able to develop as mature practitioners and you get better as you develop those skills,” White said. “You’re going to dress for success, act for success and be what patients expect you to be if you want to be successful.” – by Melissa Foster

Reference:

Kolski B.

White CJ. How to start a vascular practice: A primer for fellows and early career members. Both presented at: Society for Cardiovascular Angiography and Interventions Scientific Sessions; April 25-28, 2018; San Diego.

Disclosures: Kolski and White report no relevant financial disclosures.