Unconventional thinking could win the day

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James F Benenati, medical director, Baptist Cardiac and Vascular Institute’s, Peripheral Vascular Laboratory, Miami, USA, delivered the 2014 Charles T Dotter Lecture on 23 March at the opening plenary of SIR’s 39th Annual Scientific Meeting in San Diego, USA.

Benenati used an example from history, cited by historians as one of the biggest military mismatches from World War II, the Battle off Samar, to illustrate how doing things differently and responding to disadvantaged situations in unusual ways, can result in a small group triumphing over a much more powerful adversary.

In the Battle off Samar, a two-and-a-half-hour sea battle fought on 25 October 1944, the US Navy task unit of “jeep carriers” and their “tin can” escorts took on and succeeded in the near-impossible feat of beating back an overwhelming force of Japanese battleships and cruisers.

Benenati told delegates of how the current time in the history of interventional radiology, is for most interventional radiologists “a career defining” moment with the Affordable Care Act coming into force just as interventional radiology in the USA is getting to grips with becoming a specialty. “This kind of raging change was probably last seen in 1966, when Medicare came into force and is a once-in-a-lifetime event for most interventional radiologists,” Benenati said.

He referred to some of the key points of pressure on the specialty: Research and development activities moving offshore especially given the tight link between industry and innovation in interventional radiology; the rising debt to income ratio for new trainees in interventional radiology; the importance of defining training so that interventional radiologists are able to maintain their scope of work without infringement by other specialties.

“I submit to you that any challenges that we face can be overcome with the right training, the right tools and clear understanding of the clinical landscape we live in. We need to look at lessons learned from the past. We need to use unconventional methods to transform enormously disadvantageous situations into advantage,” he said.

Speaking about the divide between interventional radiologists who carry out peripheral vascular work and embolization, he told delegates that the way the market was broken down in the United States was that radiologists are doing  about 30% of the peripheral vascular work. “If you look at embolization, the actual percentage growth has tripled since 2003, and it is something we should pursue, but should we expose our flank? Should we put ourselves in a position where we are not training our fellows to certain things (ie vascular procedures)? We stand to lose the turf because trainees are coming out ill-prepared to deal with clinical problems. In surveys, we see that a number of our trainees are gaining their training from vascular surgeons and cardiologists. This was a great stopgap arrangement, but I suggest that this is a mistake. We need to train our own people and we should take this on,” he said.

He also alluded to the fact that hospitals have to meet or exceed federal mandated performance targets. “It is not just clinical quality—efficiency and outcomes are going to be measured. This is an excellent opportunity to think a little bit differently—not just to do a lot of cases, but to improve our outcomes; decrease hospital stays and prove efficiency. We as interventional radiologists can become great assets and add value to the healthcare systems. Given the minimally invasive nature of our work, of all the specialties, we are the most ideally suited to adapt than anybody else. Other specialties are already measuring door to balloon time, assessing the median time from emergency department arrival to time of departure from the emergency room. We should be capturing this type of data.

“In other strategies, we see medical imaging growing and growing. However, I suggest to you that that is not really where our future is going to be. We ought to look at some strategies that show value in decreasing unnecessary imaging and decreasing unnecessary procedures and demonstrating value to healthcare providers by doing only what is indicated and appropriate. This might seem misaligned with the way we are reimbursed, but it is something that we will have to do in the future,” he said.


Importance of unity

Benenati highlighted the importance of interventional radiology being “a unified group” to maintain a certain clout with the industry and government. “Fragmentation and splintering is a huge mistake, we need to be a unified group under our society’s roof and our society should be broad enough to accommodate everyone’s service line. Nationwide, lower extremity revascularisation is growing by 67%, venous ablation by 400% and embolization 52%. But just getting this work and doing it is not enough. We have to participate in trials; the only voice that is going to be heard by the government is data. As a society we need to examine different practice models and it might be that working with diagnostic radiology in the future is not the answer. We need to be open to all types of practice models,” he said.

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