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Should interventional radiologists admit their own patients?


Friday, 25 Nov 2011 12:27
Dierk Vorwerk
Dierk Vorwerk


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.

 



Andy Adam
Andy Adam

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.”

 

Barry Katzen
Barry Katzen

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.




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