Subspecialisation: resist evolution at your peril


Tony Nicholson says current attitudes towards subspecialisation leave interventional radiology stuck in the 20th century.

In the latter part of the 20th century there were tremendous advances in technology, materials, and therapeutics that demanded and enabled increasingly accurate diagnoses to be made, and ever more effective treatments to be given. The total knowledge base increased rapidly to a point where it became increasingly difficult for any one doctor to deliver top-class care in every medical or surgical specialty.

More recently, social and political demands to reduce the length of postgraduate medical training have exacerbated the difficulties of delivering training to a sufficiently high standard in all aspects of medicine and surgery. Whilst medical school education continues to provide, in four to six years, a good general understanding of basic medical sciences, outside of primary care, postgraduate medical education tries to deliver some general (core) skills/competencies, but increasingly concentrates on specialist skills.

Most responsible training bodies, recognising the trend, have slowly moved with these developments, though medicine has moved faster than surgery. In radiology, parallel developments have happened slowly and unofficially, though noted by the authorities that deliver radiology training. The perceived wisdom has been that a radiology department has to provide service for a multitude of specialties and subspecialties, as well as primary care, and that an impartial nonspecialist opinion from a radiologist with a broad spectrum of knowledge is of value to the subspecialist who may not be able to see the wood for the trees.

In addition, many radiologists consider that the lack of exposure to radiology during medical school years leaves new radiology trainees unable to make a decision as to whether they would like to specialise and in what area.

Such opinions and attitudes are part of 20th century thinking and in some countries are underpinned by the financial arrangements for healthcare. They leave 21st century radiology stuck in the 20th century where departments must deliver a complete general curriculum in which all aspects of radiology are covered. If specialist training is required, it has to occur outside the official training years.

However, in reality many radiology trainees and consultants recognise that the complexities of modern imaging require that the service they offer has to provide the specialist physician or surgeon with both a diagnostic and interventional service which complements the complexity of management. Whist the merits of thinking and seeing outside the specialty are undeniable, the recognition of what is normal and what isn’t has become more important to many radiologists than specific diagnosis outside their chosen field.

It is probable that there are now no large hospitals that do not have specialist groups of musculoskeletal radiologists, breast radiologists, neuroradiologsists, interventional radiologists, and cross-sectional imagers in organ-based subspecialties.

Interventional radiology resists such evolution at its peril. By recognising the move to subspecialisation, altering policy, and embracing the change now, it does so from a position of current strength. If it then grabs the opportunities and is unafraid of the perceived threats it can establish itself alongside other specialties and subspecialties.

By the time this is published, I hope UEMS (The European Union of Medical Specialists) will have approved a bid to make interventional radiology a subspecialty of radiology.

Look out for an expanded version of this article in the June 2009 issue of Interventional News. Don’t miss your copy: subscribe here.