During the Society of Interventional Radiology (SIR) annual scientific meeting (23–28 March, Salt Lake City, USA), interventional radiology (IR) societies from nations worldwide sat around a table to consider the status of IR in their geographies. The Global Society Summit—the first meeting of its kind—heard international IR leaders discuss and define common challenges, to track a path for multinational collaboration and sustain a unified voice for IR in an increasingly competitive global healthcare environment.
Thirteen panellists in attendance, representing IR societies from every global continent, stood and updated the room on the status of IR in their country. “It’s heartening to hear that many of our challenges and thought processes are very similar worldwide,” said Alda Tam (MD Anderson Cancer Center, Houston, USA), SIR president and co-coordinator of the summit. Although at different stages down the path to subspecialty and specialty status, each society reported strikingly similar challenges, namely the recognition of the importance of clinical care in IR, difficulties with standardisation and training, practice economics and specialty distinction.
The IR clinical practice model was first to be dissected by the panel. SIR international division councillor and panel moderator Constantinos T Sofocleous (Weill Cornell Medical College Memorial Sloan-Kettering Cancer Center, New York, USA) began by discussing the value of routine outpatient IR clinical practice with longitudinal care for patients. Taking a poll, the majority of the panel agreed on the value of IR clinics and indicated that they offer this service.
“I think that in the USA,” said Parag Patel (Medical College of Wisconsin, Milwaukee, USA) following this poll, “one of the critical aspects for our recognition as a specialty and from other specialties was the recognition that we take care of patients with the diseases that we manage.” Until the American Board of Medical Specialties recognised the important role that interventional radiologists play in the “longitudinal management of disease going forward”, he said, there was “no path to specialty”. However, he added that a young trainee who wants to take care of patients and do procedures will likely pursue an IR-dedicated training pathway that “involves or invokes” clinical practice as “mandatory”, Patel noted. This, however, is a highly streamlined training modality that is not frequently offered worldwide.
Adding to this point, Robert Lookstein (Icahn School of Medicine at Mount Sinai, New York, USA) noted that these direct training pathways are “critical to the success of [IR] at a global level”. Yet, in an effort to “refocus”, he shared data from a survey his centre carried out which asked US IR chiefs or clinical leads whether or not they provide outpatient clinical services. They found that 76% said yes and 24% said no, and these figures were similar when the same question was asked for inpatient services. “I share these because there are clearly opportunities for improvement, to meet the goal that we’re all stiving for here. We all want IR to have a singular focus on longitudinal clinical care to achieve clinical excellence. Is the distribution of clinical services similar in other countries?” Lookstein asked.
“In Europe, I think that the numbers are much lower,” said Christoph Binkert (Kantonsspital, Winterthur, Switzerland), “but heterogeneity is much higher, not just across Europe but even within my country.” Although Binkert noted that Switzerland is not entirely representative of Europe, he explained that outpatient clinics have become the norm. “All of the big players do it—if you’re not offering outpatient clinical care, patients will not come to you.”
In the UK, Robert Morgan (St George’s Hospital NHS Foundation Trust, London, UK)—British Society of Interventional Radiology (BSIR) president and co-coordinator of the summit—shared that being given “permission” to provide outpatient clinics is not always given in UK hospitals for interventional radiologists. He believes that there is “much to be done” to increase recognition by UK Hospital Trusts of dedicated, protected time, within work hours to see patients before procedures and at follow up in outpatient clinics.
In Denis Szejnfeld’s (Certa Hospital, São Paulo, Brazil) view, issues arise as interventional radiologists often do not specialise early in training. Confirming this statement, Ethel Rivas Zuleta (Universidad Dr José Matías Delgado, La Libertad, El Salvador) commented that in Latin America, graduates must choose between two paths early in their training—private practice or institutional national practice, also referred to as academic hospitals, which leaves little room for deviation.
In other nations worldwide, training can be limited due to a lack of resources, as audience member Chidubem Ugwueze (Icahn School of Medicine at Mount Sinai, New York, USA) conveyed. Addressing the panel, he explained his involvement with a training programme in Nigeria which provides a well-rounded IR course preparing trainees for the European Board of Interventional Radiology (EBIR) examination.
He referenced one of his trainees who he says has all of the clinical requirements he would need to pass the EBIR examination—this is not the issue in these African nations, he said. “The biggest obstacle is that trainees can have all of the technical skills to do the procedures, but they don’t have reliable access to the devices needed to perform these,” Ugwueze said. “I see a lot of big names in this room who can move mountains and change these circumstances. I also see people who have already solved these problems elsewhere—how would you go about changing this?” he asked.
In response to Ugwueze, interventional radiologist Sangjoon Park (Seoul National University Hospital, Seoul, South Korea) shared his experience in Ethiopia and recounted difficulties in transporting enough lipiodol to the centre there. Park averred that trainee interventional radiologists there should not be trained in these procedures if they have no access to the devices/therapeutic agents. “Bottom line, there’s some things that you can do and some things that you can’t—so you have to decide on what procedures you can do to the best of your ability.”
“I did not want to touch on the lack of materials,” Rivas Zuleta commented. “Coming from Latin America, these disparities are ingrained, and what we must focus on is these materials come from companies who earn millions of dollars/euros in Europe and the USA. They aren’t going to give us free products, so we have to focus on what we can do.”
Referencing a previous session that day—Extreme IR—Rivas Zuleta noted that her first thoughts were “oh my god, what an expensive case”. In this session, one particular case reported the use of 12 coils for a single patient. “All I was thinking was, ‘I wouldn’t be able to use coils for the rest of the year’. Coming from relatively low-income countries means that we have to focus on what procedures are possible for us,” she said.
Another voice from the audience was past president of the Society of Interventional Radiology (SIR) Brian Stainken—interventional radiologist and current co-editor-in-chief of Interventional News—who stated he was “a little disappointed” more speakers had not addressed a glaringly obvious issue. “I’m old enough now to know it’s all about the dollars. Practice economics is something that isn’t much talked about on the international stage but it’s very real. There are lots of reasons given to why these medical device companies aren’t selling in these countries, but the big one is there’s no market. There’s no market because the market hasn’t been made.”
Wael Saad (University of Utah, Salt Lake City, USA)—representing the Society of African Interventional Radiology and Endovascular Therapy (SAFIRE)—responded that each society can help to “push in the right direction” in terms of moving mountains for countries requiring resources. “It’s very impactful for physicians in Africa to be able to help patients in need with minimal equipment and there is a lot of need there. An advantage of progressing from behind is that you learn from others’ mistakes and misfortunes,” Saad added.
Closing the summit, Morgan asked the panel how they believe the forum should go forward, to which Patel added that, yes, although their needs are varied, how can they “identify and prioritise support needed in each region?” Patel continued that the forum is intended to be a “continued effort in partnership with SIR and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE)”, holding global summits at each of their respective meetings to “continue conversations, identify society needs and maintain collaboration to elevate IR, so that it is recognised universally as a distinct specialty that can provide exquisite care”. Sofocleous indicated that on behalf of SIR alongside Patel and Morgan, the summit will prioritise the described international IR needs for the next agenda to be discussed at CIRSE 2024 (14–18 September, Lisbon, Portugal). The coordinators stated that this inaugural summit is the “first of many” that will help to empower local interventional radiologists. In doing so, they hope to join international forces to increase IR outreach in each corner of the globe.
