The new president of the British Society of Interventional Radiology, David Kessel, told Interventional News how interventional radiology has a growing role in major trauma cases, but is often overlooked due to being the “new kid on the block”. He also said interventional radiologists must start to take resposibility for 24/7 service provision because out-of-hours work is no longer “just nephrostomy and acute limb ischaemia”
As co-author of Interventional Radiology: A survival guide, what are your top three tips for a young interventional radiologist today?
The Survival Guide was written with my friend and colleague Iain Robertson. We began with the feeling that few books were written from the perspective of a reader who wants some straightforward tips on how to do procedures and what to do when things do not go exactly according to plan. We found it relatively easy to remember struggling with procedures and wishing for a few words of wisdom. “Keep it simple” has been our principle both in the text and the procedure. So with that ethos in mind, the top tips for an aspiring interventional radiologist would be:
- Put the patient first: imagine they were you or your family, what sort of treatment would you expect? As soon as I do this it is clear that there are implications for service provision, we need to ensure that there are arrangements for 24/7 cover for interventional radiology. This also guides us when considering whether we should attempt a particular procedure, what Jim Reekers calls “the me test”. If you would not want to have the procedure performed on yourself, then you should not be doing it to someone else. Collaborate with other IRs to ensure that there is a suitable service provision for the population you cover.
- Make sure that you are an expert in your chosen areas. This applies to whatever field of radiology you work in. All other clinicians have become increasingly specialised, in the UK radiologists remain trained as generalists with no subspecialty qualification. If interventional radiology is to prosper then we need to be masters of the conditions we treat and understand the prognosis, treatment options and expected outcomes. Without this level of knowledge and understanding we risk being seen as mere technicians. With expertise comes recognition of the contribution you can make to clinical decision making and patient management.
- Keep up to date with imaging relevant to your field. There is an adage that techniques change but diseases stay the same. This is particularly true in interventional radiology. The original “diagnostic interventional procedures” such as angiography and percutaneous cholangiography have largely disappeared and been replaced by non-invasive tests, ultrasound, computed tomography and magnetic resonance imaging. In some cases these tests are complex to assess, e.g. trauma imaging. It is crucial that IRs are able to interpret and manipulate this imaging both to make the diagnosis and also to plan the optimal route for treatment.
How do you think the formal set-up of interventional radiology on-call services is shaping up in the UK?
It is essential that interventional radiologists start to take responsibility for service provision, unfortunately 24/7 IR services are few and far between! Rather than playing a blame game we need to look to find solutions. Firstly, there is the issue of recognition of the importance of IR to modern acute medical practice. Out-of-hours is no longer just about doing a nephrostomy or treating acute limb ischaemia. If you have lower gastrointestinal bleeding or traumatic haemorrhage, we should be the first port of call. Sadly, our clinicians are often unaware of this, clinical management algorithms are obsolete and hospital managers do not recognise the need for a coherent service. To address these problems we need a “bottom-up” approach with IRs lobbying locally for proper service development. Secondly, there is a lack of political awareness at the levels of The Government, Department of Health and healthcare commissioners. If these people do not know who we are and what we do, then they are unlikely to promote the growth of the specialty! This is where we need a “top-down” approach, with societies such as CIRSE and BSIR actively promoting the specialty. Thirdly, there are our diagnostic radiology colleagues who often do not fully appreciate how different our role is from theirs. IRs can be viewed as non-productive as they report fewer cases. Obviously they will acknowledge that our cases take longer to perform but there is little will to consider that we may also need to see patients in clinics and on the ward both before and after cases. As IR becomes more complex, we spend more time at workstations planning procedures and ordering kit. This certainly is not recognised in many job plans.
Is there a growing role for interventional radiology in major trauma cases?
Major trauma is an important cause of mortality and morbidity, especially in the young. In simple, pragmatic terms, management revolves around rapid diagnosis and treatment: Firstly, stopping haemorrhage and secondly repairing damaged tissues. Interventional radiology is increasingly important when it comes to stopping bleeding either definitively by embolization or stent grafting, or temporarily by applying a “radiological tourniquet” in terms of a proximal occlusion balloon. The interventional radiologist will need to be rapidly available and able to interpret images, decide on the best management with other clinicians in the trauma team and perform the necessary treatments. This requires the sort of coordinated service I have referred to. Sadly evidence for most aspects of trauma management is limited. IR is handicapped both by being the “new kid on the block” and by the fact that diagnostic and interventional radiology are barely mentioned in the Advanced Trauma Life Support manual. Publications such as the National Confidential Enquiry into Patient Outcome and Death report “Trauma: Who Cares?” are starting to have an impact, but progress is slow.
What do you hope to achieve in your term as president of BSIR?
First of all, to survive intact! Any society presidency is a relatively short time – in the case of BSIR it is two years. The most a president can hope to achieve is to set a course for the society in the medium- to long-term. This has been agreed by the Society’s officers and council, and will be pursued by Iain Robertson, the vice president, during his term in office. In broad terms, the key societal aims are to raise the profile of interventional radiology amongst the public, doctors and politicians. Professor Anna Belli (our CIRSE representative on the council) met UK MPs in November 2009, for just this purpose. We must pursue our ambition to achieve subspecialty status for IR in the UK and also prepare our members and potential recruits to the specialty for the changes this will start to bring about. These will include the need to solve the perennial problem of out-of-hours service provision. There is no “one size fits all” solution for this but a variety of options exist which might suit different localities. An issue for interventional radiology is that it is a small specialty, that is, there is insufficient work in most hospitals to occupy enough interventional radiologists to deliver an on-call service. Hence, it is obvious that some form of strategy is necessary in each region, reflecting population, geographical and resource issues. This is no different to the situation in some other specialties such as cardiothoracic surgery, neurosurgery and specialist cancer and liver services. Co-operation can work and need not be painful as long as doctors are prepared to set aside the concept that they belong to a particular hospital, but rather are employed to serve the healthcare needs within a population. This is well illustrated by the acute coronary intervention service in Yorkshire where I am based. Cardiologists from many centres join in with a central service provision in Leeds. This means that the out-of-hours work is less frequent. This in turn means that the service is sustainable and the career more attractive.
On my last weekend on call, I spent 17 hours in the hospital, much of it at night, performing embolization for a variety of patients (adults and children) with trauma, gastrointestinal bleeding and haemoptysis. This is possible because we are one of the few trusts with 24/7 IR service provision. Our average commitment is 3.5 hours per call. Our service is 1:6 with prospective cover, the cardiologists are 1:11. If we are to attract doctors into our specialty, we must ensure that working conditions are attractive, especially for those with families. At present this is not the case. Only by raising awareness of the importance of a co-ordinated IR service in every region will this be achieved. Once again, I would invoke the “me” test and challenge all IRs to ask the question whether their local service provision meets a standard that they would expect for themselves or their family? If the answer is no, then change is needed!
Why did you decide to study medicine? And what drew you to becoming an interventional radiologist?
I was a late developer and when I left school I worked as a laboratory technician. Ann Mather, my girlfriend at the time, encouraged me to make some plans and get an education. With that in mind I went back to college to get some qualifications and was fortunate enough to be offered a place to study medicine at Cambridge. I would not be so lucky nowadays! The choice of medicine was relatively easy as my father was a doctor and it was clear that this was a rewarding career. Although these are turbulent times for medicine in the UK, I would still remind doctors that they are relatively wealthy, have immense job security and opportunities to develop different interests throughout their careers which are not available to those working in industry.
As for the choice of IR, that was relatively easy. I have always believed that there are two types of people – those who enjoy performing procedures (lines, drains, lumbar punctures etc) and those who step back whenever a procedure is in the offing. I was in the former category. I think this still applies today, most trainees who enjoy and are reasonably good at performing procedures will fit into IR. Those who do not enjoy them are unlikely to enjoy IR. Also, those who enjoy them but are not any good are unlikely to be good at IR.
In the early years of your career, who are the people who influenced you, and what advice of theirs do you carry with you, even today?
Alan Findlay, my director of studies, always told me that if you want something done you should give it to a busy man. I never understood the truth hidden in this until recently. Latterly, I have come to recognise having a lot on my plate has made me relatively efficient. Alan Cuthbert, professor of pharmacology was my guru in my final undergraduate year. He knew everything that went on in the department and taught me always to keep my ear to the ground. If you can avoid having people treading on your head, the insight this offers is incredibly useful. After house jobs I started a medical rotation. Chris Mallinson, a consultant physician, taught me that, “It looks thoughtful and even intelligent to pause and reflect for a few seconds before answering, but this effect wears off after about 10 seconds and then you will appear intellectually destitute.” I try never to remain silent for more than three seconds!
Throughout my career the clinicians who have impressed me always demonstrated three attributes: Compassion, attention to detail and economy of effort. I hope that I carry these with me in my practice today.
Can you describe one of the most memorable cases you have ever treated?
We always remember our first cases, cases that we learned important lessons from, often because they went suboptimally, and cases which have an emotional effect on us. A number of years ago Barry Katzen came over to watch the second human deployment of a novel SFA stent graft. The case was performed in the operating theatre in case surgery was required, but against the odds, went surprisingly well. Seconds after the graft was deployed, my scrub trousers fell down. My immediate reaction was to step out of them. After the case Barry said to me “I can’t wait to do that!” “A femoral stent graft?” I asked, “No” he said, “a case without my trousers on”. Clearly not a giant leap for mankind!
Much to my surprise, I often remember cases performed out of hours. This is not a perverse pleasure derived from sleep deprivation but a knowledge that this is when interventional radiology can be at its very best, patients most grateful and everyone recognises the important contribution they have made. It is not uncommon for bleary-eyed smiles and an exchange of high fives at the end of such a procedure!
I continue to learn important lessons on an almost daily basis, and patients never stop surprising me with their sense of humour and stoicism in the face of adversity. I am always delighted when a patient manages to laugh during a procedure and says how much better the procedure was than they had expected.
You have worked on the production of a comprehensive training syllabus in interventional radiology, which was approved by the Royal College of Radiologists. Could you tell us what the aims and challenges were?
I have been involved in medical education for a long time both locally, within the BSIR and in the RCR. My belief is that radiology training needs to evolve if the specialty is to survive. All radiologists need to be able to have high level dialogue with their clinical colleagues if they are to maintain credibility. This means that radiologists must mirror clinicians in being expert in their field rather than performing at a lower level across many areas. Hence, I have used IR as an exemplar of what might be achieved in any subspecialty area in radiology rather than trying to make IR a special case. Defining a syllabus was my ambition whilst chairman of the BSIR education subcommittee. I hasten to add that this is not all my own work! We started with the SIR syllabus and checked content for omissions, and then set out a framework based on the CANMEDS exemplar and UK guidelines for construction of syllabus and curriculum. We subsequently consulted widely with other special interest groups to ensure that many interests were represented so that this was not a BSIR stand alone document. Many people worked long and hard to contribute and the project was only finished when Derek Gould succeeded me as chair. The completed syllabus was then presented to and approved by the RCR education board. It was subsequently adapted to become the CIRSE syllabus. My belief is that work such as this has helped establish the credibility of IR and the need for recognition for special training. I am most proud of my small contribution to this change in radiology practice.
Which developing techniques and technologies are you watching closely?
Interventional radiology remains a vibrant and innovative field of medical practice. I hope that it remains so in the future and see no problem with IR remaining at the forefront of minimally invasive therapy as we move progressively from keyhole towards pinhole therapy. I would however caution interventional radiologists to keep abreast of changes in drug and molecular therapies as there will be limits to what “mechanical therapy” can achieve. This will be particularly important in cancer therapies where the delivery of therapeutic agents may well become more important than ablative treatment. We must not rest on our laurels and need only to look at the way medical and surgical treatments evolve to recognise that this will be the case.
Outside of medicine, what are your other interests?
It would be tragic to have nothing to do outside medicine! Besides three children (Jamie, 13, Ross, 10 and Anna, 7), there are still a few waking hours to pursue other interests. We are all keen travelers and have been lucky enough to travel abroad as a family to some great places such as Borneo, New York, Canada, Egypt, France, Spain, the Caribbean. When we are not doing this we may be found camping in Northumberland. As well as writing books, I love to read for pleasure – mainly novels but occasionally technical books on photography in the hope that something will rub off. I would describe myself as an enthusiastic but amateur photographer of limited talent, but I still enjoy photography both on land and underwater. This leads on to another passion, scuba diving: My wife and I are divemasters and Jamie has already taken the plunge. We are fortunate to have dived in a wide range of exotic locations. (Diving in the UK is not for me as I get cold in the bath). I have also been a lifelong supporter of Manchester United football club, and despite the typical profile of an MU fan, I was a regular spectator in the Stretford End. Worryingly, my first memories of Old Trafford involve George Best, Bobby Charlton, Dennis Law et al…starts to hint at my age!
– Current Appointment:
Consultant Vascular Radiologist
Leeds Teaching Hospitals Trust
– British Society of Interventional Radiology President 2009
– Elected member Royal College of Radiologists Education Board 2004-2008.
– Member Interventional Radiology Subcommittee 2006 onwards
– Member of RCR / RCS working group on joint training pathway for vascular specialists 2005 onwards
– Member of CIRSE Simulation Task Force 2006 onwards