Many suspect that medical tribalism is economically motivated and the most common answers from clinicians on why inter-speciality tension exists are “money” and “ego.” Rather, the primary driver of medical tribalism seems to be underappreciated value differences across specialities, write Eric J Keller and Robert L Vogelzang.
Uterine fibroid embolization was first described in 1995 and has been shown to be safe and effective with high patient satisfaction.1-4 Nevertheless, many interventional radiologists feel this less-invasive option is underutilised by gynaecologists despite extensive research and efforts to advertise the procedure. For example, we found that fibroid embolization referrals have remained constant at our institution over the last decade while the use of laparoscopic hysterectomy and myomectomy increased,5 and a recent study found that 38% of women who received a hysterectomy were not counselled on alternative treatments.6
However, these studies do not answer the critical question of why practice variation exists, only that it does. This is because “why” is more of a qualitative question than a quantitative one. As such, we embarked on a journey into the social sciences and found a well-validated technique called grounded theory that was initially designed in the 1960s to explore patients’ and providers’ perceptions of end-of-life care. We have now spent the last two years becoming budding medical anthropologists while using this method to answer long-standing questions such the one represented in this article’s title.
Many suspect that medical tribalism is economically motivated. In fact, the two most common answers we receive from clinicians for why inter-speciality tension exists are “money” and “ego.” Certainly these can exacerbate underlying tension, but we have found that tension persists across practice environments. Rather, the primary driver of medical tribalism seems to be underappreciated value differences across specialities.
When asked about their practices, interventional radiologists tend to define themselves by the procedures they offer. Patients are either candidates for procedures or not and treatments are valued primarily in terms of their non-invasiveness. Because of this, interventional radiologists tend to emphasise the high technical success rate of uterine fibroid embolization and shorter recovery times compared to hysterectomy. When a gynaecologist prioritises hysterectomy over embolization, this is viewed sceptically as subjecting patients to an unnecessarily invasive procedure, and since the interventional radiology professional identity is based on procedures, this choice not only implies that the gynaecologist devalues fibroid embolization but interventional radiology in general.
Gynaecologists however define themselves by their patient populations, eg, “I primarily treat women with fertility concerns.” As such, the value of treatments is primarily understood in terms of “definitiveness,” the ability to address the patient’s chief complaint(s) long-term. The choice of one procedure over another has little to do with gynaecologists’ professional identity, and as such, they tend not to perceive any tension. In fact, multiple gynaecologists have told us that studying medical tribalism may be fruitless because turf wars do not exist.
Where does this leave us? We are repetitively impressed by how distinct but underappreciated speciality value differences are in healthcare. Some may conclude that differences should be discouraged, but we disagree. As put by one interventional radiologist, “friction creates energy… We need people to think differently. We need people to challenge others”7. Practices where interventional radiologists and gynaecologists or cardiovascular radiologists and cardiologists collaborate more are not where there are less value differences but where clinicians are more aware and appreciative of such differences to better respond to them.
Thus, we have come to believe that better understanding speciality-specific values is critical for inter-specialty collaboration and better patient care. In regards to uterine fibroids, interventional radiologists could instead emphasise the definitiveness of uterine fibroid embolization and how it may address patients’ specific concerns. Gynaecologists could be more sensitive to the connotation communicated to interventional radiology if they continually choose hysterectomy or myomectomy over embolization. However, beyond this issue, we believe medical anthropology has much to offer the field of interventional radiology, helping interventional radiologists to grow shared territory with other specialists rather than competing for the same slice of the pie.
Eric J Keller is a medical student at Northwestern University, Chicago, USA. Robert L Vogelzang is the Albert Nemcek Education Professor of Radiology, Northwestern University, Chicago, USA. The authors have reported no disclosures pertaining to this article
References
1 Cain-Nielsen AH, Moriarty JP, Stewart EA, Borah BJ. Cost-effectiveness of uterine-preserving procedures for the treatment of uterine fibroid symptoms in the USA. Journal of Comparative Effectiveness Research. May 30 2014:1-12.
2 Gupta JK, Sinha A, Lumsden MA, Hickey M. Uterine artery embolization for symptomatic uterine fibroids. The Cochrane database of systematic reviews. 2012;5:CD005073.
3 Scheurig-Muenkler C, Koesters C, Powerski MJ, Grieser C, Froeling V, Kroencke TJ. Clinical long-term outcome after uterine artery embolization: sustained symptom control and improvement of quality of life. Journal of Vascular and Interventional Radiology Jun 2013;24(6):765-771.
4 Toor SS, Jaberi A, Macdonald DB, McInnes MD, Schweitzer ME, Rasuli P. Complication rates and effectiveness of uterine artery embolization in the treatment of symptomatic leiomyomas: a systematic review and meta-analysis. American Journal of Roentgenology. Nov 2012;199(5):1153-1163.
5 Keller E, Vogelzang R, Chrisman H. Fibroid treatment options: A ten year analysis of utilization and referral patterns. Society of Interventional Radiology Annual Scientific Meeting; 2015; Atlanta, USA.
6 Corona LE, Swenson CW, Sheetz KH, et al. Use of other treatments before hysterectomy for benign conditions in a statewide hospital collaborative. American Journal of Obstetrics and Gynecology. Mar 2015;212(3):304 e301-307.
7 Keller EJ, Vogelzang RL, Freed BH, Carr JC, Collins JD. Physicians’ professional identities: a roadmap to understanding “value” in cardiovascular imaging. Journal of Cardiovascular Magnetic Resonance 2016;18(1):52.
