Enmeshed throughout most global training curricula, dual certification in diagnostic radiology (DR) and interventional radiology (IR) is commonplace, but is an extensive knowledge of DR necessary to operate as a competent interventional radiologist? This was among questions raised during a poignant session at this year’s Cardiovascular and Interventional Radiological Society of Europe (CIRSE) annual congress (13–17 September, Barcelona, Spain).
In a Q&A-style discussion, moderator Gerry O’Sullivan (University Hospital Galway, Galway, Ireland) posed a series of audience queries to panellists Liz Kenny (Royal Brisbane and Women’s Hospital, Brisbane, Australia), Bulent Arslan (Rush University, Chicago, USA), John Kaufman (Oregon Health and Science University, Oregon, USA) and Andy Adam (King’s College London, London, UK) who debated whether it’s high time for a velvet divorce.
O’Sullivan: Have you faced resistance from other clinical specialties or higher management in your own hospital while becoming more clinical? And how did you combat that?
Arslan: I haven’t faced resistance from other specialties. We have a very good relationship with them, and I think that’s essential in IR—working with everybody. Anytime another specialist needed something, we would always entertain the idea and see what the best solution was for the patient and that created a lot of supporters for us.
One aggressive question I was asked in the process was: “So, cardiology is bigger than you. Why aren’t they becoming a department and you are?” I answered that by showing our clinical numbers, procedures, and growth over 10 years. I explained that IR is a clinical specialty, whereas DR is diagnostic. Cardiology is also a clinical specialty, but the medicine chair will never tell a cardiology chief they don’t need a clinic. However, I was told that three times, because DR chairs don’t understand how we operate as a therapeutic specialty. That answer settled the issue.
Kaufman: I’ll share an anecdote. We were an institute separate from DR for almost 30 years before moving to true academic departmental status. The operational questions about funding and such were easy to resolve because we already had one of the busiest consult services in the hospital.
As part of the process I met with every single department chair, explained our plan, and asked for their concerns and support. Their most common question was: “What does the chair of DR think about this?” despite our having been separate for decades. This highlights the point that identity remains a critical issue. Luckily, the chair DR was fully on board and supported our transition from institute to department.
Adam: Another anecdote; we didn’t face vehement opposition, but there were ripples. For example, after renal ablations, one young urologist wrote to me complaining that it was wasteful for patients to be seen in both urology and IR clinics. I wrote back agreeing, and suggested she stop seeing them.
O’Sullivan: That’s what we want to hear! Let me ask another question. Do you think other specialists should get basic DR training, like surgeons and cardiologists do, to improve their 3D anatomical vision? Just a yes or no.
Kenny: Yes. For me it’s essential, it’s a core part of our training.
Kaufman: A little training is great, no problem. But competency is different. That’s where Andy [Adam] and I may differ on what the DR part should mean.
Adam: I completely agree.
Kenny: Our department has its own computed tomography [CT] and magnetic resonance imaging [MRI] scanners. Some even have positron emission tomography [PET]-CTs. But we don’t report, we don’t provide diagnostic advice. That’s the key difference between DR and how we use imaging in radiation oncology.
O’Sullivan: Interesting. The transition is towards a more clinical specialty, but will DR knowledge change with that transition?
Adam: In the UK, training is three plus three, so six years. Some may see that as unattractive, but in my view, it’s necessary.
O’Sullivan: Do you see a pathway where IR residents drop DR certification altogether? If not, why not? John and Bulent—this is to you.
Arslan: In the USA, everything is controlled by hospitals. That’s how turf wars started. Surgeons could observe a few cases, take a short course, then apply for credentialing. Hospitals often don’t check competency properly. Complications get reviewed, but not always by an interventional radiologist. The chair of surgery signs off their financial position and prospects procedures (FPPP) documentation and problems cannot then be unmasked. That’s the unfortunate reality. Having said that, interventional radiologists can easily do image readings without a formal DR certification. Cardiologists are already doing that in the USA.
O’Sullivan: Yes, I’ve seen low-level IR services block access for specialists wanting to provide higher-level care. John, what’s your take?
Kaufman: Things are changing. Many DR practices now want independent interventional radiologists to take over that part of the practice. But all politics are local. In rural areas, 100% IR isn’t feasible, and we know a large percentage of IRs choose to practice some DR, so combined training and certification remain important.
Looking forward, we must maintain DR competency as part of our training. Almost everything we do is based on sophisticated image interpretation. If we lose that, we lose one of the most important skills that we bring to our patients. So, DR competency as part of training is non-negotiable.
Adam: I agree. Separation of DR and IR could have been effected decades ago, but not now. The real question is: how do we increase the clinical element of IR?
For me, the best route is through interventional oncology [IO]. It provides a referral base, and it’s too risky not to follow-up your own patients. That’s the difference between vascular and cancer.
Arslan: I agree with the importance of IO, but in the USA we follow all of our patients. Every patient, whether for vascular disease, embolization, transjugular intrahepatic portosystemic shunt [TIPS], biopsy, or other procedures, comes through our clinic. I believe, we need to build clinicians across everything we do, not just oncology.
O’Sullivan: Good point. Another question: how do we deal with resistance from the Royal College of Radiologists [RCR] in the UK? Andy?
Adam: Creating a subspecialty was the first step. Now, we need to pressure the RCR to form a faculty of IR. Radiation oncology and DR have one, why not IR? The college claims it would cost a million pounds, but I don’t buy that. The British Society of Interventional Radiology [BSIR] should push hard for this.
O’Sullivan: Next—IR involvement in multidisciplinary tumour boards. Do you attend as clinicians or diagnosticians?
Kenny: As clinicians. Bottom line.
O’Sullivan: Absolutely. Otherwise, you risk being dragged into diagnostic work just to get IR cases.
Kaufman: Agree. Tunnel vision is a danger if you’re both the treating IR and the diagnostic interpreter. Having separate, objective input is critical.
Arslan: I agree. When I was at Moffitt Cancer Center [Tampa, USA], I refused to run the tumour board as a DR. Instead, we ran it as IR clinicians. At Rush [Chicago, USA], we run the liver tumour board, and our residents present every case. We also join other tumour boards (gastrointestinal, spine, sarcoma) as IR clinicians alongside a DR who does image interpretation, which we sometimes have to correct, I might add.
O’Sullivan: Final question: should IR residents rotate through internal medicine wards, surgery, and intensive care unit to increase clinical skills?
O’Sullivan (answering his own question): Unequivocally yes—it has to happen.
