Novosti - News

Should interventional radiologists admit their own patients?

An important discussion ensued at the session titled “Strategic plan for interventional
radiology” at the CIRSE annual meeting in Munich, Germany, on 10 September. The
question, “Should interventional radiologists get the necessary training to be completely
in-charge of patients, including having ownership of beds and wards?” generated
interesting debate and differing points of view.

Dierk Vorwerk, Ingolstadt, Germany, who outlined the challenges facing interventional
radiology in Europe, said that it was important to usher in an era of interdisciplinary medicine
that would keep factors like ego and money at bay when offering patients treatment
options. “The way doctors [currently] do business is not fair for the patients, and is not
transparent. If we can establish that self-dealing is not appropriate for the patients, society or
economy because it makes medicine expensive, we can make the public see that multiple
control is needed. Interventional radiologists can help to achieve this as we have no beds and
no control over the patient. […] A multiple control principle is needed and interventional
radiologists are the ideal partners to guarantee multiple control systems because we have no
free patient access and no beds,” he said. Responding to this, John Kaufman, Portland, USA,
one of the moderators of the session, clarified that he understood “access to beds to mean the
ability to admit patients to a hospital to an interventional radiology service. In the USA, this
has been a focal point in our trying to expand our influence and get some control over the
referral and managing of patients, at least for the short-term afterwards. Do you see this
important? Vorwerk replied: “Ten years ago, I would have said we need access to beds, now I
believe that it is not necessary anymore. Beds are a burden too, they are expensive and you
need to keep them busy with a flow of patients and manage the economics of it. In most areas
we have to face competing disciplines, for instance in the area of vascular interventions,
nearly 80% of these can be performed on an outpatient basis, so it is not necessary to have
beds. Just as other specialties like vascular surgery are performing interventions without the
proper training, if radiologists run wards, we lack the proper training to do this. We do not
have knowledge in internal medicine, or ECG and antibiotics, etc. So we would be operating
beyond our knowledge. I think that we should treat the patients as outpatients as far as
possible,” he said.

M F Reiser, Munich, Germany, also a moderator of the session, stated that in his hospital and
elsewhere, beds were no longer dedicated to one department and there were instead “pooled”
beds. “This might make it easier to have access to beds and admit interventional patients into
these pooled beds which can be taken care of by an interdisciplinary team,” he stated.

Later in the session Andy Adam, London, UK, and one of the editors-in-chief
of Interventional News spoke on the topic “Do we want to become a clinical subspecialty?
Pros and cons”. He emphasised that a key activity for any practical discipline was the
clinical control of patients. He quoted Charles Dotter who had warned about this in 1968
who said: “If... unwilling or unable to accept clinical responsibilities... they face forfeiture
of territorial rights based solely on imaging equipment others can obtain and skills that
others can learn”. “If we remain a technical discipline within radiology without subspecialty
status, we will continue to have inadequate clinical training, insufficient time for clinical
care and will see a continued loss of ground to competitors. This has been shown in the last
few decades, where we keep coming up with procedures which others then take from us, at
least in some cases,” he said. Adam noted that clinical practice in interventional radiology
was essential for correct patient care, to obtain true informed consent, prepare patients for
procedures and anticipate and treat complications. “It also increases our credibility and
secures our referral base and in most countries there are no institutional obstacles to prevent
interventional radiologists undertaking primary clinical responsibility for their patients,” he
said. Adam responded to a question to say: “I think it is essential to look after our patients
and I do not see ownership of beds as an obstacle. I admit all my own patients and they come
under my care and nobody else’s. It is possible to do that. I think that if you do not do that,
you cannot really be responsible from the beginning to the end in the care of that patient. I
know that Dierk [Vorwerk] talked about the challenge of [acquiring] clinical knowledge that
you need to have, in order to look after those patients, but there are ways to achieve this. You
can integrate it into training or forge collaborative relationships with other teams, but the
important thing is to assume primary responsibility for the patient and if you do not do that,
you do not have control.”

Vorwerk responded by saying, “I agree with almost everything Andy [Adam] said, but we
need a paradigm shift, because in medicine we think about ‘owning the patient’. Yet the
patient is not owned by anybody. We have to explain to the patient that he/she is responsible
for the decision and that the best possible care is provided by an interdisciplinary group of
physicians. We should not make the same mistake that surgeons and cardiologists make, of
trying to ‘own’ the patient. We are now coming into a society that is educated and has access
to several sources of information. We should train the patients to ask the doctor, ‘what other
options do I have?’ Then we have a friend, the patient [who can help bring about this
change]. “We should be the motor of integrated, interdisciplinary practice in medicine. Our
thinking as doctors is very old, from the Middle Ages. We think the patient is an object that
we can work on and that does not hold true today. We have to educate the patients and that is
our only chance. If we want to have training in clinical knowledge, this will take a long time,
and there are a lot of obstacles, including negativity from other specialties, but by educating
patients, this paradigm shift can take place much more quickly,” he said. Adam agreed for the
most part, but noted that there was a fine, but real line between the two positions. “I do
believe that educating the patient is important. Actually in the UK, we are probably further
than just about anywhere in having the patient as part of the decision-making. I completely
agree with you that the thinking about owning the patient is old fashioned; the patient should
decide what to have done and that is quite right. “But, when you discuss the care of the
patient and if there is disagreement between the surgeon, oncologist and radiologist or
whoever, there is, in the end someone who will influence that decision more than anybody
else. It is perhaps the person who will present those options to the patient. If you say that I
think the patient should be stented and a surgeon thinks they should be operated on, in theory
the patient completely independently makes that decision [about what treatment to have], in
practice there is a person who presents the patients with the options available, and that is the
person I am talking about. If we are not that person, we are not undertaking primary clinical

responsibility. The only way to do that is to give antibiotics, give drugs and do all the things
that we need to do. It is not difficult to gain the necessary clinical knowledge. For example
you can stipulate that before you go into interventional radiology, you have to have two years
of clinical training. Clinical training is a requisite before going into radiology in the UK, and I
am sure it can be done elsewhere. There is no way around that, if you do not learn how to
look after patients, they are not yours.”

Interventional News also spoke to Barry Katzen, Miami, USA, who attended the session. He
said, “I do not think that in the long-term, interventional radiology can reach its full potential
without being a clinical discipline. My concept has been that interventional radiology should
be an equal partner in the delivery of healthcare in the care of a patient. The only way to be an
equal partner in a true sense is to have clinical standing and clinical credibility about clinical
decision making. This means going beyond how to do procedures or when to do them. We
need to be knowledgeable about our own procedures but also about disease processes and
be fully engaged in the decision-making. We all started out as physicians first... so it is not
like we were never trained. When people enter radiology, they get oriented towards imaging
and they abandon whatever clinical skills and clinical interests they had. What we are saying
is keep developing those along with the imaging and interventional skills needed. “The
concept of ‘owning’ a patient is a little crude, but that being said, different disciplines are in
the position of owning the patient in the sense that they are the key decision makers. Why is
that? It is because they are the ones who have established the relationship with the patient.
So in the end, the patient wants the physician to give them the best possible direction. And if
the interventional radiologist only comes in at the end of the period of discussion, then you
have a very narrow perspective. If you are involved from the beginning, your position in the
decision-making tree is totally different. I have been a big advocate of multidisciplinary teams
and that is how we work, but in the end somebody has to be the captain of a ship for a specific
patient. Is the interventional radiologist willing to be the captain of a ship? If so, how do you
get into that position? The only way is to be a clinical individual,” he said.