By Allison Khoo, MS2, Baylor College of Medicine

The modern field of interventional radiology (IR) may still benefit from the words of Dr. Charles Dotter, who said in 1968, “If my fellow angiographers prove unwilling or unable to accept or secure for their patients the clinical responsibilities attendant on transluminal angioplasty, they will become high-priced plumbers facing forfeiture of territorial rights based solely on imaging equipment others can obtain and skill still others can learn.”1

A debate regarding the clinical responsibilities of interventional radiologists was the crux of a 2003 lawsuit against MedStar Washington Hospital Center.2 Neurointerventional radiologists there admitted a patient to the neuro ICU to prepare for a stent implantation without scheduling follow-up care by neurosurgery. The patient subsequently suffered a postprocedural stroke, and life-saving treatment was delayed. The 2007 settlement resulted in a stark policy change at MedStar stating, “members of the Department of Radiology are no longer credentialed to admit patients to the hospital.”3

Perhaps these are the “high priced plumbers” that Dotter predicted would come. Their arrival, however, raises important questions: What is the role of IR in the inpatient setting? Should IR personnel have hospital admitting privileges, or should they position themselves purely as a consultation service? How should we configure outpatient IR practices?

In an effort to address these uncertainties, the current practice guideline for Interventional Clinical Practice (ICP) provides a list of the types of patients that members of an IR service should admit “unless a medical condition exists or arises that is optimally managed by another service.”4 These include (i) patients seen in consultation for elective inpatient interventional therapeutic procedures, (ii) patients seen by interventionalists who develop complications warranting admission, (iii) patients admitted for diagnostic tests only, and (iv) urgent referrals from outpatient offices for IR services.5 Outpatient interventional radiologists are also widening their scope of care, focusing not only on the procedural encounter, but also on integral processes of the outpatient system such as generating referrals, managing medical records, and communicating with referring physicians.6
But the ICP guidelines stipulation “unless a medical condition exists” leaves room for confusion. As Mezrich pointed out in a 2013 commentary, interventional radiology can never be divorced from medical conditions.5 Patients receiving a TIPS procedure have portal hypertension and inevitable hepatic pathology. Patients scheduled for chemoembolization have a cancer diagnosis by definition. While the ICP guidelines have made it clear that IR practitioners will admit their own patients, further clarification of their clinical responsibilities is still necessary.
Change is already at hand. The field of IR is responding energetically to Dr. Dotter’s warnings, to MedStar’s neurointerventional radiology policies, and to the ICP guidelines by educating a new generation of IR physicians trained to manage both the medical and procedural needs of their patients. The new IR/DR primary certificate requires trainees to admit their own patients, make clinical decisions as the primary treating physicians, and provide follow-up care. This new educational policy will phase out “lines and tubes”-only practices and produce a more homogenous, clinically-sophisticated IR field.
References
1.Becker GJ. The future of interventional radiology. Radiology 2001; 220:281-292.

  1. HealthImaging.com. Missed radiology handoff sparks two lawsuits and policy change, December 2012.
  2. Millburg S. Settlement: radiologists can’t admit patients. Radiology Dailey, December 2012.
  3. ACR-SIR-SNIS Practice Guideline for Interventional Clinical Practice, Revised 2009 (Resolution 24).
  4. Mezrich JL. Hospital-admitting privileges in interventional radiology: how IR should reposition itself in the wake of one hospital’s policy change. J Vasc Interv Radiol 2013;24:1667-1669
  5. Siskin G. Outpatient Care of the Interventional Radiology Patient. Semin Intervent Radiol 2006; 23:337-346