Addressing the changes in academic IR

Interventional radiology (IR) has in many ways dramatically revolutionised the practice of medicine, the standard of care and the patient outcomes achieved for many disease processes. However, in the United States over the past decade academic IR in particular has faced many challenges, such as difficulties in filling fellowship places and the ever present 'turf war'. Moreover, there has also been a significant shift in clinical practice. As image-guided interventions have assumed greater importance in the care of patients, IRs have assumed an ever-increasing role in the clinical management of these patients. In the same period there has also been a shift in practice away from academic IR to private practices as the latter have become more sophisticated and attractive.

All of these issues have resulted in a dramatic re-think as to how academia can attract and retain new recruits. Interventional News talked to three prominent IRs; Drs Robert White (Yale University), William Rilling, Education Division Councilor (Medical College of Wisconsin) of the SIR, and John Kaufman, Secretary of the SIR (Dotter Interventional Institute, Oregon) about the causes and the mechanisms in place to re-address the balance.

White believes that the problems with recruitment do not stem from a 'turf war', although he acknowledges that it is a problem. He claims the real issue is the organisation of radiology in the US. "The traditional theory behind this is that many residents in diagnostic radiology (DR) are concerned about turf issues. But I think that is a bit fallacious, because quite honestly the major reason we have had a decline in qualified applicants is because of the way radiology is organised in the US," commented White. "At Yale University we have no problem attracting medical students who want to do patient care. They want to go into IR and have clinics and admit patients. But when it comes to applying for that pathway they have to go through a DR residency."

Residency programmes
It is this aspect of the DR residency White claims deters students from applying for places because they want to be clinicians, to be associated with patient care. He said that the current IR residency programme does not make it easy on medical students who want to go into the field nor give them enough training. "If you want to be a cardiologist or a surgeon you are going to do three years of this work including research - we give them one year - and it is not enough."

Moreover, he said that the residents who enter DR are not really interested in patient care. "I think that parts of the DR are a must for an IR residency, but I think that it has to be reduced in length, and a greater emphasis placed on IR training and patient care. I think that this view is shared by many fellowship directors in the United States," added White.

He said that the current programmes offered by the American Board of Radiology (ABR), in which people from other specialties can go into IR, are not fully utilised and in his view will not make an impact in addressing the shortfall in recruitment.

According to White what is needed is a special pathway through the programme. For example, a medical student would apply for one of the 1,000 available positions in the first year of radiology residency, 100 of those would be dedicated to IR. All students would take an internship and then a three-year radiology programme, with two years of IR. He added IR needs to stay within the house of radiology and maintain its strong links with DR, but suggested that IR should be more like radiation oncology and become a separate room within the house of radiology, "We all use diagnostic imaging all the time and have to be trained in it. So the links with DR will remain."

Changes in practice
According to Rilling, it is not just the issue of training but also how the role of the IR academic has changed and been de-emphasised as medicine has turned into a business from a profession. "Our productivity is measured predominately by our clinical productivity - and that's what hospitals look at before giving us resources. We must be much more clinically productive on a day to day basis, so in reality we have become much more like a private physician," he commented. The consequences are that with ever-decreasing academic time, IRs have less time to teach residents and fellows.

However, it is not only the academic profession that has witnessed changes in practice, there have also been significant changes in private clinics that have contributed to the problem. "If you look back ten or 15 years the only place you could do sophisticated radiology was in an academic centre," commented Rilling. "But as the clinics have become more sophisticated the difference between the way you could practice IR in academics and private practice has become smaller. When I came out into private practice ten years ago there were very few private practices where you could be a full time IR and practice it to the degree that I wanted to, whereas now there are a lot of private practices groups that have a lot of full time IRs who are practising at a very high level - and of course the salaries in private practice have always been much higher."



He also added that the 'turf war' had had a negative affect on academia and highlighted certain programmes were there have been defections from IR, because the vascular/cardiologists have taken over all of the peripheral vascular business. It is a view partly shared by White who agreed that IR is losing vascular work to cardiologists etc, but added that it is because the profession has depended for so many years on a 'roller coaster' of patients through deferral. "I think once we change our practice patterns it become academic whether we have competition, because there are many other areas of medicine where there is competition. But right now it does hurt us because in the US we do not have clinics and we do not have mid-level practitioners to assist us."

Reversing the trend
Rilling commented that the situation five or six years ago was a real concern and cited that the reasons for the manpower shortage and the difficulty in filling fellowship places was that people were unhappy in their jobs, under-appreciated and under-paid, therefore there was no incentive for people to enter the specialty. But over the past couple of years the situation has been reversed as the academic departments have realised that in order to retain the young talent (in academic departments) they have had to look at salary structures and new ways to emphasise and reward research and teaching.

But it is not just the academic institutions that have responded to the problem. "At a Societal level we are working hard to try and improve the satisfaction of IRs at an academic level," he noted. "There is only so much a Society can do and a lot of it has to do with local politics and with chairman who have a lot of control. But we realise the importance of academia as far as the future of the specialty is concerned. There is no question that in order for IR to stay at the forefront of minimally-invasive medicine we have to be major players in research and that cannot happen without strong academic departments."

Rilling said there were also changes needed in training to stabilise and improve the health of academic IR. "The problem is the specialty has moved forward so quickly and the training pathways take so long to adjust - we are sort of reacting to what's happening clinically. We are playing catch up and there is no question that some aspects of training are not the optimal method of training the IRs of the future," he added.

"It is very difficult, because you see these changes happening clinically but by the time you recognise the problem five years have gone by. So by the time the training pathways start to make an impact another five years have gone by - its very difficult to be proactive with these things," he said.

DIRECT Pathway
In July 2004, the SIR responded by implementing the DIRECT (Diagnostic and Interventional Radiology Enhanced Clinical Training) Pathway. The essential purpose of the pathway is to allow up to two years of clinical training to count toward the Diagnostic Radiology certificate and subspecialty VIR (Vascular Interventional Radiology) certificate. It was the first time the ABR has permitted more than one year of credit for non-radiology clinical years. The aim is to reduce the barrier of 'lost time' for those residents who become interested in the IR specialty, but have already completed clinical time in another specialty.

"The DIRECT Pathway is a start along the road to revolutionising the way we train our fellows and trainees - it's a definite step in the right direction," commented Rilling. "We are also in the process of proposing an IR pathway where medical students can directly match into an IR residency which would have much more clinical training and much more dedicated IR training and much less DR training in the future."

While acknowledging that the changes will take a time to have an impact, Rilling said that that the DIRECT Pathway had already started to gain a foothold. "We still train 90% of our trainees in the traditional pathways. But we are starting to make a dent. I think there are now 15 or 16 programmes that have Direct Pathway positions approved by the ABR."

Rilling added that there has been a lot of discussion concerning about sub-specialisation in IR - "In the future there is no question that there will be programmes that will focus on different disease processes and people will sub specialise to a very extensive degree; I think that will be a natural evolution." However, at this moment in time he concluded that the focus is not interventional oncology, peripheral disease or women's health, but pathways that will simply prepare trainees in general to be better clinicians and to be able to follow patients, like any other surgeon sub-specialists, allowing IR to get on a level playing field.

"To paraphrase Mark Twain," said Kaufman "'The reports of our death have been greatly exaggerated'. We were very lucky for a long time in that we had almost exclusive control over imaging modalities. The rest of the world lived and lives in a competitive environment and we avoided it until now." However, despite the pressure of the 'turf war' and shortages in recruitment, he is confident the tide has turned. "The training programmes are on the mend, but we have a long way to go before we get to where we were seven years ago. But the shortfall (in fellows) has allowed us to utilise our residents more," he added.

According to Kaufman, this has resulted in residents getting better exposure to IR while on service; they get excited about the specialty and decide to stay. Some programmes that were in trouble a couple of years ago with no fellowship applicants are now getting internal residents to stay with great enthusiasm. He also said that the SIR has made great efforts to attract new recruits with a big outreach effort directly to medical students and DR residents.

He acknowledged that there are a lot of academic interventionalists who are faced with demands to be more clinically productive at the expense of research time. "But there are some positive things that are happening in IR academics. Dr Timothy Murphy at Rhode Island Hospital (Brown University, Providence, Rhode Island) has had two different multi-institutional interventional PVD clinical trials funded by the National Institutes of Health (NIH) grants, which is a huge step for IR as a specialty. Also Dr Jeff Geschwind at John Hopkins University Hospital (Baltimore, Maryland) has basic science NIH grants for oncology research. So academically, we are stronger than we were just 5 years ago."

Primary Certificate
Kaufman also revealed that the SIR is currently preparing a proposal for a Primary Certificate in Interventional Radiology, which would be a completely different training pathway. A medical student would go directly into IR and when they completed their fellowship their Board of Certification would only be in interventional radiology. The rationale for creating a new primary certificate in IR is the transformation of the specialty that has occurred as interventions have come to dominate daily pratice. "Essentially, Bob White is correct. In the past the two basic pillars of the specialty were imaging and technical skills. Patients were sent to us for invasive diagnostic procedures after having been evaluated by other physicians, we would do our procedure, and then send them back."

Now, Kaufman claims there is a third pillar of equal importance - direct patient care. IR practice now includes non-imaging non-procedural patient care in offices, clinics, and hospitals. This occurs before, after, and sometimes instead of a procedure. This vital component must be elevated in training to a level of emphasis equivalent to imaging and technical skills, and not viewed as just an ancillary skill. Currently, direct patient care is not taught during the four years of diagnostic radiology. "A primary certificate in IR would attract a different group of residents to the specialty. What we are seeing now are medical students who are considering surgery or another specialty where they could have direct patient care looking at IR as an option. They see image-guided interventions as the future. A primary certificate in IR, by emphasizing direct patient care as well as imaging and technical skills, is a very attractive proposition to them. Patient care is why they entered medicine in the first place," he added.

The Society is also working very hard at stimulating research through the SIR Foundation (SIRF). Under the direction of Drs Joseph Bonn (Lankenau Hospital, Pennsylvania) and James Spies (Georgetown University Hospital, Washingon, DC) and Keith Hume, SIRF Executive Director, an over-arching research agenda for has been developed and implemented. One of the benefits of increased research is to ensure that IR continues to have a major role in the intellectual content of the specialty. "If all we do is perform procedures and do not investigate them scientifically at basic and clinical levels, then we will not have intellectual ownership of our specialty." He cited the very high percentage of endovascular based articles currently in the Journal of Vascular Surgery (JVS) as an example. "Fifteen years ago this was not where one turned for published research on peripheral arterial interventions. Now, every month this journal features endovascular and imaging articles. So we recognise that we need to push forward with our own research in all areas of IR and publish in or own journals as well as in major non-radiology journals."

The future
According to Kaufman when surgery first started there were a limited number of operations that a single person could learn to perform on all patients. Gradually, as operations increased in number and complexity, surgical specialties developed with separate training programs. "So if you look at IR right now we are in a paradigm shift -we were initially technique-based and applied a few procedures to a few conditions in a wide variety of patients." However, he claims that over time, the specialty has developed such a diverse and complex set of procedures that IRs can focus on specific patient groups and/or pathologies. "The natural evolution is from generalisation to specialisation and that is what our future may be. We are an enthusiastic, optimistic, inventive group, on the cusp of a major transformation. It's a very exciting time. So despite all the pressures we have faced recently, I believe that we are a healthier profession because of it: stronger, more self-respect, looking to the future, and as dynamic and creative as ever."