Interventional radiology has evolved into an indispensible branch of modern medicine, offering a growing number of minimally invasive procedures in a broad range of therapeutic areas. This reach has been the discipline's strength as well as its Achilles heel; with no specific disease state, organ system, or patient group to exclusively call its own, IR often struggles for recognition while other specialties threaten to take on the procedures it has pioneered. However, in the changing world of medicine the organisation of patient care is no longer constrained within the classic collegial divisions, but depends upon interdisciplinary collaboration and the pooling of various competencies and expertise.
In 2009 a milestone was reached on the journey to recognition in Europe. Interventional radiology gained UEMS (European Union of Medical Specialists) subspecialty status within the division of radiology. This is a clear message to medical colleagues, patients and hospital administrators alike that IR, as a unique discipline, is here to stay, and that the most appropriate experts to carry out IR procedures are appropriately trained and credentialed doctors. Even so, in increasingly competitive and cost-constrained times, IR must position itself wisely for the future if it is to be an equal member of the medical family. Through constant discovery of novel procedures and technical innovation IR enables many new treatments with fewer complications, shorter hospital stays, faster recovery, improved patient comfort, and lower costs.
Given these advantages, it is surprising to see IR existing in many hospitals as an under-utilised resource, performing a one-dimensional technical role providing procedures at the request of referring physicians. More and more IRs are actively changing this situation, however, proving their professional worth by playing a collaborative role in clinical patient care and raising awareness of what they have to offer.
Laying the Groundwork
In supporting the cause of IR, the work of national and supra-national organisations is vital in ensuring an environment exists in which individual IRs can excel in their specialty. A first step is its universal recognition and it is with this in mind that CIRSE and SIR collaborated on the publication of the 'Global Statement Defining Interventional Radiology'. Endorsed by 42 professional societies in 39 countries, the Statement was published concurrently in CVIR (Cardiovascular and Interventional Radiology) and JVIR (Journal of Vascular and Interventional Radiology), and provides a unified and accurate picture of IR, as distinct from other specialties and subspecialties.
As well as defining the clinical scope and required training for the discipline, the clinical practitioner status of those who belong to it is strongly asserted, to counter the detrimental view that IRs are nothing more than technical experts. The statement informs health authorities and political decision makers of the resources IR requires to provide proper clinical interventional care as a complete clinical practicing specialty in the context of multidisciplinary collaboration.
Another significant achievement has been UEMS recognition of IR as a defined medical subspecialty. As well as being an excellent way of raising IR in the consciousness of influential European policy makers, subspecialty status will catalyse the Europe-wide standardisation of IR training through syllabus development, to make specialised training pathways a reality and guarantee dedicated time for clinical practice during speciality training.
Furthermore, it has become vital for the future growth of IR that medical students at the undergraduate level gain more exposure to the specialty. This is essential, not only to guarantee a steady recruitment stream but also to raise awareness and make a positive impression on the referring doctors of tomorrow. It is disappointing that when IR procedures are taught in schools of medicine, it is often by non-interventionalists. Given the increasing reliance on imaging to teach anatomy, as well as the existing inclusion of radiology in undergraduate curricula, the opportunity is ripe for IRs to become more engaged in teaching what is no longer a set of novelties, but an essential part of modern medicine.
A further benefit of UEMS recognition is that the organisation will accredit examinations and assessments. It has already endorsed the European Board of Interventional Radiology (EBIR), which is an international hallmark of excellence in IR, certifying expertise and validating training. This qualification indicates that those who have attained it are highly competent in performing interventional procedures effectively and to the required standards of safety. The EBIR is administered by CIRSE and endorsed by ESR, two organisations that are also strongly supporting further scientific research in the field through involvement in the European Institute for Biomedical Imaging Research (EIBIR).
All of these steps will support IR in education and training, as well as teaching and research: the foundations upon which a clinical specialty is built. The final requirement of a true medical specialty is professionalism in clinical practice that has been promoted by CIRSE with the publication of 'Clinical Practice in Interventional Radiology'. This reference manual explains how to set up a clinical IR practice and details the resources required to do so, with a view to providing complete care for patients.
An Indispensable Part of the Clinical Pathway
The factors above have created the structures and support for IRs to excel within their own local working environments. The time has come when it is no longer enough for an IR to see the referred patient only on the day of the intervention. Indeed, patients as well as referring physicians expect more than just technical procedure provision, and want to be sure that the specialist to whom they refer takes responsibility for full clinical care. Patients who undergo an IR procedure should be seen by the IR for initial evaluation, including consideration of options prior to obtaining informed consent, work-up, therapy, and follow-up. This policy of longitudinal care is normal practice for other specialties so is essential to full professional recognition from all sides.
IRs should make themselves visible: writing on patient charts during ward rounds, offering a 24-hour service and communicating with primary care doctors upon patient discharge are all crucial in this regard. Primary care should also be engaged through attendance at meetings and continuing education events, where IRs can present their specialty. In this way referrals are gained, as personal contacts are made and primary care doctors are assured that full clinical care is provided for those patients they refer to IR. Such development of clinical practice requires the full support of diagnostic radiologists as well as chairs of radiology departments. The imaging skills necessary to perform IR procedures are housed within diagnostic radiology and will continue to be so, making harmony between colleagues in the interventional and diagnostic branches vital.
Greater Access Required
Despite an enthusiasm for clinical practice and a strong will for change, the number of IRs that have access to outpatients and control over dedicated beds is still too small. Even IRs that actively seek to establish a clinical practice may find obstacles in their way, especially when faced with hospital management tasked with efficient allocation of limited resources. This inertia may be compounded further through extra-disciplinary suspicion or concern over a rising source of competition.
In bidding for clinical practice resources IRs should highlight the financial benefits, in that IR adds well-reimbursed and complex interventional procedures, as well as sophisticated ancillary imaging work, to the group case-load. In terms of the wider healthcare market, a clinical IR practice positions a hospital for growth in the expanding area of minimally invasive procedures. IR is also a traditional source of innovation and progress in the clinic, and is highly marketable as a cutting-edge field of medicine.
Many IR procedures are unique alternatives to other more invasive surgical procedures, have great clinical value, and are preferred by patients. These interventions are now integral to modern medicine and in the face of rising patient demand must be offered as part of a complete clinical care package delivered by IR. Good patient-doctor relationships are based on trust that is established through full patient contact and clinical care. This is vital to risk management: in the case of a patient who knows and trusts their doctor, litigation is less likely to follow any complications that might arise from an intervention.
IRs are the ideal specialists with the complete skill set necessary for image-guided minimally invasive interventions and are just as qualified to provide the associated clinical care. Thanks to their own good work and the continuing support of their professional organisations IRs can be proud to make themselves heard in striving towards a bright future, not only for their own specialty but also for wider professional collaboration and improved patient care.