Vein and lymphatic medicine (VLM) fellowship after EM residency?

[EMhopeful987]

Incoming 1st year intern into a 4 year EM residency here. Given the doom and gloom surrounding the job market for EM I've been giving some considerable thought into fellowships. Problem is I literally have no interest in the typical EM fellowships (US, critical care, etc.). I recently took a family member to a vein clinic (to treat her varicose veins) and noticed a couple of the physicians there were EM board certified but practicing in the vein clinic. A bunch of them work part time in the clinic while also working in ERs part time as well. This is super appealing to me because I don't want to completely give up working in the ER but at the same time I want something else to lean on in case employment opportunities become super dire in the future. The vein docs seem to just do procedures all day which I like since I enjoy working with my hands and their work seems to be very well compensated (judging from the bill my family member received haha). Has anyone here gone through EM residency and then completed a VLM fellowship afterwards? I was hoping to get some perspective on how good the job opportunities are for vein medicine, splitting time between the ER and vein clinic, how well the pay is, etc.

I've been trying to do some research online but I've been reading some conflicting stuff. Some sites say how you don't really need to complete a VLM fellowship and can just take the VLM certification exam to be certified while others say its best to complete a formal fellowship (apparently they take applicants from all specialities like IM, FM, EM, surgery, etc.). I can't tell if this is a super new field that people are now getting into or something but I was hoping to get more insight. Thanks in advance.

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[skougess]

Honestly you have the right idea. Find short fellowships or certificates that can make you competent enough to practice half EM and half something else. These other fellowships like tox, ultrasound, etc are all academic traps imo.

 

[swamprat]

Option 2 - apply to other residency u alrdy drank the koolaid and are stuck in a 4 year one

 

[EMhopeful987]

Honestly you have the right idea. Find short fellowships or certificates that can make you competent enough to practice half EM and half something else. These other fellowships like tox, ultrasound, etc are all academic traps imo.

Yeah I'm not interested at all in those subspecialties like tox or EMS. I was looking into pain medicine because it offers a similar lifestyle to that of vein medicine and is quite lucrative. However from what I've researched pain medicine is something that you pretty much have to commit to as a full time job due the competitive nature of the speciality. I still have a genuine interest in EM and wanna be able to practice at least part time so pain wouldn't probably work for me. Vein medicine however seems to fit the bill for what I am looking for.

 

[EMhopeful987]

Option 2 - apply to other residency u alrdy drank the koolaid and are stuck in a 4 year one

To be honest the only other specialty I could see myself doing is general surgery. From the very beginning I've just never had my heart in other specialties like primary care, anesthesia, radiology, etc. I've done rotations as a medical student in all those specialities and honestly I hated it lol. The only other rotation outside of EM that I liked was general surgery. However switching from EM to general surgery would be extremely risky as I would pretty much have to drop out of my current residency and re-enter the match and frankly thats just not a risk I am comfortable taking. I would also need to somehow acquire surgery rec letters in order to apply (my last surgery rotation was almost 2 years ago during fall of 3rd year) so that would also pose a huge challenge.

 

[RuralEDDoc]

Vein medicine fellowship? Are you talking about a full year of training, or something less intensive? Sounds like a good fit for a two week course. Midlevels do this kind of stuff via on-the-job training, taking full salary.

 

[Franzd'Epinay]

I've been trying to do some research online but I've been reading some conflicting stuff. Some sites say how you don't really need to complete a VLM fellowship and can just take the VLM certification exam to be certified while others say its best to complete a formal fellowship (apparently they take applicants from all specialities like IM, FM, EM, surgery, etc.). I can't tell if this is a super new field that people are now getting into or something but I was hoping to get more insight. Thanks in advance.

I know nothing about this field. But generally speaking, if a fellowship isn't ACGME-accredited, then it's probably not necessary.

 

[Kryptocoin]

Vein fellowship? What's next, botox fellowship? Hint, if midlevels are doing it's means you can take a course somewhere.

 

[Birdstrike]

Incoming 1st year intern into a 4 year EM residency here. Given the doom and gloom surrounding the job market for EM I've been giving some considerable thought into fellowships. Problem is I literally have no interest in the typical EM fellowships (US, critical care, etc.). I recently took a family member to a vein clinic (to treat her varicose veins) and noticed a couple of the physicians there were EM board certified but practicing in the vein clinic. A bunch of them work part time in the clinic while also working in ERs part time as well. This is super appealing to me because I don't want to completely give up working in the ER but at the same time I want something else to lean on in case employment opportunities become super dire in the future. The vein docs seem to just do procedures all day which I like since I enjoy working with my hands and their work seems to be very well compensated (judging from the bill my family member received haha). Has anyone here gone through EM residency and then completed a VLM fellowship afterwards? I was hoping to get some perspective on how good the job opportunities are for vein medicine, splitting time between the ER and vein clinic, how well the pay is, etc.

I've been trying to do some research online but I've been reading some conflicting stuff. Some sites say how you don't really need to complete a VLM fellowship and can just take the VLM certification exam to be certified while others say its best to complete a formal fellowship (apparently they take applicants from all specialities like IM, FM, EM, surgery, etc.). I can't tell if this is a super new field that people are now getting into or something but I was hoping to get more insight. Thanks in advance.

A guy I did Pain fellowship with does these vein ablations. We do radiofrequency nerve ablations in Pain, but we never learned vein ablations in fellowship. I haven't bothered to learn it, since it's usually cosmetic and non-Pain related. But it apparently was easy enough to learn for a Pain fellowship-trained person without much additional effort. At the time he started doing these, I think it was a procedure that paid well in a surgery center setting, so he learned it. I'm not sure if it still does.

So, to answer your question, yes, an EM physician could potential do EM + Pain fellowship then learn vein ablations with a tiny bit of extra training. But as far as making vein and lymphatics your whole focus, it seems super narrow, narrow enough that if the reimbursement was cut (like it often is for various procedures over time) then you might not have anything. I definitely think it's worth looking into, as is anything that decouples you from having to work in a hospital-based EM to live, but I'm not sure that by itself its a career in and of itself. I could be wrong.

 

[Birdstrike]

Here's your "fellowship" side by side with "many MD and RN." Looks like a pay-to-play weekend course by people with terrible grammar and bad punctuation. Looks like you can get your certificate without even attending anything. You just swipe your card, get a set of books, powerpoint slides and you're "certified."

 

[Birdstrike]

Unfortunately, there are many of these types of courses in Pain (spine injections), Plastics (botox and fillers) and other specialties where they try to train non-physicians to do physician jobs. Welcome to Medicine in 2021.

My opinion is it's best to stick with formal board certification pathways and ACGME accreditation. Unfortunately, that opens us up to being cannibalized by untrained people that masquerade as properly qualified. They give Medicine a bad name and are part of why no one respects doctors anymore. People have a bad outcome or hear of someone who has and they just conclude "modern medicine is a scam." They don't know how to distinguish who's legit and who isn't so they just conclude all providers are frauds and end up not caring whether they're taken seen by a doctor with residency and two fellowships or some fly-by-night fraudster with little to no training at all.

Do it right, so you can sleep at night.

 

[GonnaBeADoc2222]

Unfortunately, there are many of these types of courses in Pain (spine injections), Plastics (botox and fillers) and other specialties where they try to train non-physicians to do physician jobs. Welcome to Medicine in 2021.

My opinion is it's best to stick with formal board certification pathways and ACGME accreditation. Unfortunately, that opens us up to being cannibalized by untrained people that masquerade as properly qualified. They give Medicine a bad name and are part of why no one respects doctors anymore. People have a bad outcome or hear of someone who has and they just conclude "modern medicine is a scam." They don't know how to distinguish who's legit and who isn't so they just conclude all providers are frauds and end up not caring whether they're taken seen by a doctor with residency and two fellowships or some fly-by-night fraudster with little to no training at all.

Do it right, so you can sleep at night.p

I mean it's not like you're going to change the system with this attitude. We have the fine motor skills as EM docs to learn these procedures. Why do a fellowship and take a 300k income hit? We already give charlatans like naturopaths, chiropractors and NPs the legal freedom to do this stuff, why not actual doctors?

 

[Birdstrike]

I mean it's not like you're going to change the system with this attitude. We have the fine motor skills as EM docs to learn these procedures. Why do a fellowship and take a 300k income hit? We already give charlatans like naturopaths, chiropractors and NPs the legal freedom to do this stuff, why not actual doctors?

Why do a fellowship and take the $300K hit?

Because somethings are more important than money. I did an ACGME accredited Pain Fellowship. Getting in as an EM doc was climbing Mt. Everest. But I did it and now I’m ABMS board certified. I’m truly a sub specialist and an expert.

If you want to join the ranks of the charlatans, scammers, snake-oil salesmen and shamans by doing a weekend course and calling yourself an “expert,” then have at it. That’s not changing the system, that’s burning it to the ground.

 

[Apollyon]

When I saw this, I thought of a new fellowship from over 10 years ago for "vascular medicine" that one of the IM residents did, and it wasn't some casual thing. Now, just Googling, I see MGH, UMich, the WFCCF, and others, and the VM are a subset of Vascular Surgery. And, VM and VSx are like ortho is op, and PM&R is non-op ortho, or neuro and NSx are medical and surgical, or renal and uro are medical and surgical.

What I'm saying is that it is much deeper than just sclero on varicosities. And, who are average vascular pts? Obese, diabetic, heavy smokers, combinations of all. What I don't know is, who is the first call? Does VM refer to VSx, or the other way - does the surgeon say, "we can't help, see this doc instead"?

 

[GonnaBeADoc2222]

Why do a fellowship and take the $300K hit?

Because somethings are more important than money. I did an ACGME accredited Pain Fellowship. Getting in as an EM doc was climbing Mt. Everest. But I did it and now I’m ABMS board certified. I’m truly a sub specialist and an expert.

If you want to join the ranks of the charlatans, scammers, snake-oil salesmen and shamans by doing a weekend course and calling yourself an “expert,” then have at it. That’s not changing the system, that’s burning it to the ground.

The system is already burnt bruh. You think "customers" care where they get their botox/fillers from? They don't care if they an MD, ND, NP, whatever for their spine injection or z pack.

I agree with you that board certification and actual training is the way to do it, but no one care what me or you think.

They only care about satisfying "what they want" at the ideal "Speed + Convenience" / "Cost" ratio.

 

[Birdstrike]

The system is already burnt bruh.

Yes, the system is burnt. I saw that over a decade ago and have been telling everyone on this forum about it for 10 years. You're preaching to the choir. The question is: What to do about it?

I read the tea leaves others ignored while they called me a negative doomsayer and I did the hard work despite the haters that knew better. Now I have a 4.5 day per week, no nights, no weekends, no holidays, no call, low stress job. I'm part owner with substantial and growing share value and on the Board of Directors of a 140 employee physician-owned group. Hospital CEOs try to buy us out all the time and we tell 'em to **** off.

How about you?

 

[MechEDoc]

How about you?

I'm envious, extra crispy, employed below my potential, commuting 5 states away to make a living while supporting my little one at home...

 

[Birdstrike]

I'm envious, extra crispy, employed below my potential, commuting 5 states away to make a living while supporting my little one at home...

I been there. Hang in there.

 

[Franzd'Epinay]

When I saw this, I thought of a new fellowship from over 10 years ago for "vascular medicine" that one of the IM residents did, and it wasn't some casual thing. Now, just Googling, I see MGH, UMich, the WFCCF, and others, and the VM are a subset of Vascular Surgery. And, VM and VSx are like ortho is op, and PM&R is non-op ortho, or neuro and NSx are medical and surgical, or renal and uro are medical and surgical.

What I'm saying is that it is much deeper than just sclero on varicosities. And, who are average vascular pts? Obese, diabetic, heavy smokers, combinations of all. What I don't know is, who is the first call? Does VM refer to VSx, or the other way - does the surgeon say, "we can't help, see this doc instead"?

Are these "vein medicine" fellowships the same as the "vascular medicine" fellowships you describe? It doesn't look like it to me from a brief search.

 

[Apollyon]

Are these "vein medicine" fellowships the same as the "vascular medicine" fellowships you describe? It doesn't look like it to me from a brief search.

I don't know. To me, "vascular medicine" is legit.

 

[EMhopeful987]

I mean it's not like you're going to change the system with this attitude. We have the fine motor skills as EM docs to learn these procedures. Why do a fellowship and take a 300k income hit? We already give charlatans like naturopaths, chiropractors and NPs the legal freedom to do this stuff, why not actual doctors?

Do you think it might be worth it to do the fellowship so that you could use it as a marketing technique to show how you're better and more qualified as opposed to other vein medicine providers that aren't "fellowship" trained? Or do patients really not care at all about that kind of stuff lol

I was also thinking what if they change vein medicine in the future so that it does require fellowship training in order to practice? The reason for thinking this is because I was reading online on how there's a push for vein and lymphatic medicine fellowships to be ACGME accredited

 

[Birdstrike]

...there's a push for vein and lymphatic medicine fellowships to be ACGME accredited

Before I even replied on this thread, I should have asked, "What does a vein and lymphatic specialist do?"

 

[EMhopeful987]

A guy I did Pain fellowship with does these vein ablations. We do radiofrequency nerve ablations in Pain, but we never learned vein ablations in fellowship. I haven't bothered to learn it, since it's usually cosmetic and non-Pain related. But it apparently was easy enough to learn for a Pain fellowship-trained person without much additional effort. At the time he started doing these, I think it was a procedure that paid well in a surgery center setting, so he learned it. I'm not sure if it still does.

So, to answer your question, yes, an EM physician could potential do EM + Pain fellowship then learn vein ablations with a tiny bit of extra training. But as far as making vein and lymphatics your whole focus, it seems super narrow, narrow enough that if the reimbursement was cut (like it often is for various procedures over time) then you might not have anything. I definitely think it's worth looking into, as is anything that decouples you from having to work in a hospital-based EM to live, but I'm not sure that by itself its a career in and of itself. I could be wrong.

Yeah I was actually really interested in pain medicine as it provides a great lifestyle and disassociates you from hospital dependency while still satisfying that craving for procedural based work. However I was looking into it with intention of wanting to practice pain medicine part time as I am genuinely passionate about EM and would still want to work in the ER if I could. From what I've read and researched pain medicine (please correct me if I'm wrong lol) seems to be a field that you need to go all into and commit to as a full time job. The whole point of pursuing the pain medicine fellowship for me would be to solely keep it as a back up plan if the whole field of EM truly does go crashing down and I need a good exit plan in order to keep food on the table.

Vein medicine caught my eye because it is very similar to pain in terms of lifestyle and procedural work while seeming considerably less competitive to get into. My plan would be to continue working part time in the ER but also work as a part time partner or something in one of these corporate clinics (ex: Vein Clinics of America). If the field of EM does end up truly crashing down and I start making considerable less money working ERs then maybe I could transition into vein medicine completely by opening up my vein clinic or something (I figure by then I would have years of experience working part time in a vein clinic so I would know the ins and outs of the business game in relation to vein medicine)

I'm not sure if I'm getting way ahead of myself here and am better off just focusing for now on doing my absolute best in EM residency lol I guess this whole doom and gloom thing for EM has got me super paranoid.

 

[EMhopeful987]

Before I even replied on this thread, I should have asked, "What does a vein and lymphatic specialist do?"

From what I understand they primarily treat spider and varicose veins using imaging/treatment modalities such as venous US, venous ablation, sclerotherapy. However they can also manage deep venous/pelvic venous malformations with treatments such as thrombectomy, thrombolysis, venous stenting, IVC filter placement, deep venous reconstruction, surgical therapy, embolization, and chemical ablation.

These are my sources that I am getting all this from:

ABVLM | The American Board of Venous & Lymphatic Medicine

https://www.abvlm.org/files/pdfs/ABVLM_Criteria.pdf

 

[Birdstrike]

Yeah I was actually really interested in pain medicine as it provides a great lifestyle and disassociates you from hospital dependency while still satisfying that craving for procedural based work. However I was looking into it with intention of wanting to practice pain medicine part time as I am genuinely passionate about EM and would still want to work in the ER if I could. From what I've read and researched pain medicine (please correct me if I'm wrong lol) seems to be a field that you need to go all into and commit to as a full time job. The whole point of pursuing the pain medicine fellowship for me would be to solely keep it as a back up plan if the whole field of EM truly does go crashing down and I need a good exit plan in order to keep food on the table.

Vein medicine caught my eye because it is very similar to pain in terms of lifestyle and procedural work while seeming considerably less competitive to get into. My plan would be to continue working part time in the ER but also work as a part time partner or something in one of these corporate clinics (ex: Vein Clinics of America). If the field of EM does end up truly crashing down and I start making considerable less money working ERs then maybe I could transition into vein medicine completely by opening up my vein clinic or something (I figure by then I would have years of experience working part time in a vein clinic so I would know the ins and outs of the business game in relation to vein medicine)

I'm not sure if I'm getting way ahead of myself here and am better off just focusing for now on doing my absolute best in EM residency lol I guess this whole doom and gloom thing for EM has got me super paranoid.

From what I understand they primarily treat spider and varicose veins using imaging/treatment modalities such as venous US, venous ablation, sclerotherapy. However they can also manage deep venous/pelvic venous malformations with treatments such as thrombectomy, thrombolysis, venous stenting, IVC filter placement, deep venous reconstruction, surgical therapy, embolization, and chemical ablation.

These are my sources that I am getting all this from:

ABVLM | The American Board of Venous & Lymphatic Medicine

https://www.abvlm.org/files/pdfs/ABVLM_Criteria.pdf

1) When I looked into doing a Pain fellowship, 10 years ago, it was similar to this, in that almost no one in or outside of EM knew or thought an EM person could do it. That is, until I found someone who had done it. So I commend you for looking into this. You might be onto something.

2) Although in my opinion it's best to pick one or the other, you can combine Pain and EM. I know an EM guy who did a Pain fellowship then worked at Kaiser doing 50/50 EM and Pain. So, it can be done, but easiest in a huge group like that, or academics. Less likely at a small or medium group where they shun part-time anything.

3) My opinion is, if you're going to be a specialist in something, commit to it and truly be an expert in it. This is where I diverge with EM people. They all ask me, "Are you still doing EM? Aren't you afraid you'll lose your skills? You know, so you can still do some EM?" My answer is, "Uhhh....what? Do cardiologists hang on and do General IM clinic to 'keep their skills up'? Do Plastic surgeons do rotten gall bladders now and then to 'keep their skills up'? The concept is absurd to me.

What skills are you keeping up? You're a subspecialist now, with skills more specialized, refined and more unique than your base/general specialty with a perfect lifestyle, yet the more common, less unique skills with the brutal lifestyle are the ones you want to keep up?

I never understood it. But yes, you can do it, if you wanted to.

4) I don't know much about this Vein and Lymphatic stuff, but I can tell you, with EM as it is, I can tell you it's definitely worth looking into. Whether you do it, don't do it, or split it 50/50, is for you to decide in the future. But I think it's worth looking into, as is anything that decouples an EM physician from having to be at the mercy of chronic circadian rhythm depression and dysphoria, and PTEDSD.

 

[IRattending2021]

From what I understand they primarily treat spider and varicose veins using imaging/treatment modalities such as venous US, venous ablation, sclerotherapy. However they can also manage deep venous/pelvic venous malformations with treatments such as thrombectomy, thrombolysis, venous stenting, IVC filter placement, deep venous reconstruction, surgical therapy, embolization, and chemical ablation.

These are my sources that I am getting all this from:

ABVLM | The American Board of Venous & Lymphatic Medicine

https://www.abvlm.org/files/pdfs/ABVLM_Criteria.pdf

what you are describing is an interventional radiologist or a vascular surgeon with their respective ACGME fellowship/residency

This is like to carve out the lower acuity patients for ED and push to make an ACGME fellowship for urgent care.

it will only pollute the physician job market.

 

[Franzd'Epinay]

I don't know. To me, "vascular medicine" is legit.

Oh, I'm sure it is. I was merely commenting that vascular medicine is likely different from the vein medicine OP is looking into.

 

[Apollyon]

Oh, I'm sure it is. I was merely commenting that vascular medicine is likely different from the vein medicine OP is looking into.

That's fair enough.

 

[IRattending2021]

Vein medicine is kinda similar to “general practioner” where every doc can kind of do it after a weekend course but actual deep vein reconstruction can be extremely skill and equipment intensive and mostly remain the turf of IR.

People have been seriously disabled or killed with inappropriate venous treatment. I can recall a case where venous stent migrated into the heart and retrivial became complicated with a bad outcome, as well as erroneous ablation of bilateral GSV which precluded CABG option with vein graft.

 

[sylvanthus]

Do you think it might be worth it to do the fellowship so that you could use it as a marketing technique to show how you're better and more qualified as opposed to other vein medicine providers that aren't "fellowship" trained? Or do patients really not care at all about that kind of stuff lol

I was also thinking what if they change vein medicine in the future so that it does require fellowship training in order to practice? The reason for thinking this is because I was reading online on how there's a push for vein and lymphatic medicine fellowships to be ACGME accredited

Were already more qualified and are being replaced by cheaper alternatives. Noone cares about how well trained anyone is, just “can they save us money by halfassing the job.”

 

[whatsthepoint]

Are these "vein medicine" fellowships the same as the "vascular medicine" fellowships you describe? It doesn't look like it to me from a brief search.

Does anyone know the difference between vascular medicine fellowships and vein and lymphatics fellowship?

 

[HemorrhagicShock]

With this necrobump I'm deeply interested in seeing how our OP @EMhopeful987 is doing in residency

And also to see if anybody is actually doing this as a way of escaping EM and/or a reasonable clinical side hustle. Seems like it's too easy for any PA/NP or basically anybody with a license/pulse to do vein stuff, and thus no real moat with which you can be competitive.

 

[BoardingDoc]

With this necrobump I'm deeply interested in seeing how our OP @EMhopeful987 is doing in residency

And also to see if anybody is actually doing this as a way of escaping EM and/or a reasonable clinical side hustle. Seems like it's too easy for any PA/NP or basically anybody with a license/pulse to do vein stuff, and thus no real moat with which you can be competitive.

EMhopeful987 hasn't been on SDN since 2021, so it's not impossible, but somewhat unlikely that you'll get an update.

 

[Doctor_Strange]

Another necro-bump -- anybody end up pursuing ABLVM fellowship? Do you join a private practice or what? Seems some practices overlap with medical necessity and cosmetic.