“Embolisation requires a different skill set from peripheral arterial and venous disease work. Currently, this skill set lies in the domain of interventional radiology. No other specialty really has the ability to train physicians to do this type of work,” James F Benenati, current president of the Society of Interventional Radiology (SIR), told delegates at GEST USA 2010, San Francisco, USA.
He began his talk by saying, “The last of my disclosures is that if you are not an interventional radiologist, and you are listening to this, you might not like some of the things that you are going to hear.” Benenati told delegates that the position SIR took was that, unlike in peripheral arterial disease, embolisation was a very different skill set. “Right now, in 2010, I think it is fairly safe to say that that skill set lies within the domain of interventional radiology. With the exception of one or two areas, such as the embolisation of the internal iliac arteries with endografts, which is performed by a variety of specialists, the knowledge of embolics, the knowledge of visceral catheter skills, imaging expertise, radiation training, procedural management skills are really exclusive to interventional radiology. I do not think this is debatable, and it is fundamentally true,” he said.
He emphasised the importance of relevant training in order to perform this procedure safely and effectively. “While talking about embolisation, we have to ask ourselves what are we really encompassing, how do we want to do it and what are the skill sets required. When you look at this list, it becomes evident that this encompasses a lot more than one type of procedure. There is a wide variety of procedures that we call embolisation. Some of the skill sets may be the same, but there are skill sets and interventional needs that are different for each of these areas and it would be a huge mistake to lump all of this under one type of procedure.” Benenati asked: “Who can do this? Well, within IR, does a fellowship-trained interventional radiologist have the ability to do all those procedures under embolisation? There is a wide variety of fellowships, we do not learn to do all of these procedures with equal expertise in all fellowships.
“The question is what types of skill sets can transfer from one procedure to another. We also need to look at how we can develop standards of practice that will allow qualified MDs to do this work. Better stated, we need to ensure patient safety by making sure that only those who are adequately trained are able to perform these procedures. We are seeing more and more non-IR specialists dabbling in areas of embolisation. This tells me, in some cases at least, that training in embolisation is taking place more on the fly rather than in sanctioned training programmes. Attending a meeting and obtaining a document that one has completed a course in, is simply not sufficient to allow one to begin working in the embolisation field. This is not in the best interest of patient safety or quality.”
Benenati urged interventional radiologists to be active in establishing credentialing early and enforcing it. He said that while the SIR can establish standards and policy documents, it cannot be relied on to fight local battles. He also said that the SIR would collaborate with all specialties in the advancement of patient care, but would not compromise on the embolisation issue. “We do not want to be isolationists, we want to collaborate with other specialties, but we feel strongly in this area that we are the specialists to do this: No one else has demonstrated competence in this area. There are no training programmes other than in IR, which cover the skills associated with embolisation.”
He drew attention to the fact that some vascular surgeons were stepping beyond their levels of organ competencies in order to expand the scope of their practice. “There are cases of other specialties advertising that they are able to embolise fibroids, and this skill has possibly been gained from reading journal articles, attending courses like this and yet they are advertising that they can do this. But they do not have the credentials to do this,” he said.
Benenati also said that the SIR was internally re-evaluating existing training standards in order to deal with the wide scope of procedures that fall under the umbrella of embolisation. Finally, he said, “We must remember lessons learned in the past. Think back 10 years–the water got very bloodied with peripheral arterial interventions. We lost a lot of our turf, partly due to our own fault. At this point, many of us jumped into blue waters, we got into oncology and other areas. But now those blue waters may be threatened. We must be able to clinically manage our patients, understand the disease processes we are treating, and be able to demonstrate our value to referring physicians and administrators. Being an excellent interventionalist is simply not enough. It takes more,” he said.
Ziv Haskal, one of the directors of GEST USA 2010, agreed: “Patients should not be served upon the sacrifical altar of embolotherapy amateurism. This procedure is not a weekend or dilletantish addition to one’s practice, but one, that at GEST USA 2010, we have tried to show, is a complex, diverse, and highly demanding area to specialise in.”