Saumya Gurbani, G1, MD/PhD Program, Emory University
In early 2012, JVIR published an article on how interventional radiology can play a role in the paradigm of patient-centered care – a model of healthcare that many institutions are aiming to implement to improve the value that patients (and the healthcare system as a whole) receive. It has been an important topic in the shifting landscape of healthcare. In a report on healthcare for the 21st century, the Institute of Medicine defined patient-centered care as a model that:
“[provides] care that is respectful of and responsive to individual patient preferences, needs, and values, and ensures that patient values guide all clinical decisions.”
The SIR response, as highlighted in the JVIR article, is that push to this paradigm “offers an opportunity for interventional radiology (IR) to showcase its value—specifically, to demonstrate that IR often offers the better, safer, faster, and less expensive treatment option for various clinical scenarios.”
In this blog post, we’re going to try a more anecdotal approach to address Steele’s thesis —better, safer, faster, and more affordable treatment options – and how IR sits in a unique niche amongst medical specialties. I’ve had the great pleasure of interviewing four interventional radiologists from across the spectrum of medical practices:
- Geogy Vatakencherry works for Kaiser Permanente in Southern California, an HMO that runs a large nationwide network of hospitals.
- Gary Siskin work in a hybrid private/academic group affiliated with Albany Medical Center in New York.
- Jim Benenati runs a private group – Miami Vascular – that is also a teaching facility for residents and fellows.
- Gail Peters is the director of the IR Fellowship at Emory University in Atlanta, GA.
Each of these four physicians presents a unique perspective on patient centered care and how they use it within their practice.
“The goal is to take charge of the patient condition.”
While IR is a procedure-focused specialty, it is more than just a consult service, and care for the patient does not transfer to another physician when he or she leaves the OR. “We manage a portion of the patient’s care, not the entire care of the patient,” says Dr. Peters, “but trainees need to care about pre-procedure work-up and follow-up.” A common theme amongst all four physicians is that interventional radiologists should step up to take responsibility of the patient’s care beyond the operating room. This naturally varies by patient and the type of procedure being done – a port placement may not require much pre-op or follow up, but a uterine fibroid ablation can require many months of follow-up care. The physician must understand what the patient’s needs are and appropriately approach the responsibility for the patient’s condition. “[Primary care providers] will ask you to ‘answer a question,’ not ‘do a procedure,’” says Dr. Siskin. If you have a patient with diverticulitis, for example, the question you need to answer is “how can we improve this patient’s condition” – and that will likely involve working with a medical team to consider the best approach for the patient, whether it’s a surgical intervention or encouraging lifestyle changes. Throughout the entire process, the patient should be in your care, in spirit if not also technically. Take charge of the patient, not of the procedure.
“We need to change the culture of what IR is.”
In many ways, interventional radiology in the 21st century is analogous to the general surgeons of the mid-20th century – interventionalists who are not tied to a specific organ, but to a specific approach to care. Within an IR practice, you can see patients holistically without limiting yourself to just a single type of procedure. And that broad foundation is important – it gives you the clinical insight into the big picture of the patient’s health, and as a result can lead to better value for the patient. Dr. Vatakencherry gives a great example of this: “While in the IR clinic, if a patient comes in for a procedure and you know from the patient’s chart that she is a diabetic or has risk factors for coronary artery disease, why not go ahead any take an A1C or LDL while they’re in the clinic? It saves time and money to both the patient and the health system, but most importantly, puts the patient’s overall health as the priority.” Certainly, this involves having the courage to step beyond the traditional paradigm, but can truly benefit our patients. IR exists as a “marriage of imaging and clinical medicine” according to Dr. Peters, and the latter part of that relationship is arguably the more important. Dr. V pushes for a holistic approach, and argues that we have the “unique opportunity, and unique responsibility, to be the general interventionalists” of the next paradigm shift in medicine.
“Overcome logistical and communication hurdles”
Of course, to expand the role of the IR physician requires a great deal of effort and collaboration with everyone in the healthcare system. A large part of this is effective communication with the primary care team. Miami Vascular is a large private clinic (affiliated with a 7-hospital health system) and sees tens of thousands of consults a year at its inpatient and outpatient offices. Over a third of their patients are external referrals, however, which certainly raises many challenges in terms of information transfer and inter-office communication. Dr. Benenati says that the responsibility is on IR physicians to facilitate this. We must “communicate thoroughly with the referring physician” to get a holistic view of the patient condition, especially (but not only) if the patient’s medical records aren’t readily available. This puts the burden on the already heavy shoulders of physicians, and is not easy to accomplish, but is something that is necessary if IR is to step outside the shadow of an order-based service.
And this is something that needs to be taught to the next generation of students. With the new IR residencies coming onto the scene over the next few years, programs are structuring themselves to incorporate a strong clinical culture. At Emory, Dr. Peters is trying to make the radiology-focused post-graduate years as clinically focused as possible, with rotations in the transplant service, critical care unit, vascular surgery, and hematology/oncology. Regardless of if a resident ends up pursuing a career in any of these sub-specialties, they will have broadened the scope of their training and learned to collaborate with these services.
“Develop a culture of responsibility in the next generation of IR physicians.”
Developing this “culture of responsibility,” as Dr. Benenati calls it, begins right now while we’re in medical school. The focus is on clinical management of a patient, and those skills are what we learn while on the wards and during residency. It was unanimous from all the physicians that it’s incredibly important to take advantage of these opportunities. Some advice they had for medical students include:
- Get a strong 4th year experience in medicine and surgery
- Consider doing electives in diagnostic radiology and, if offered, interventional radiology during your fourth year. (SIR offers a database of hospitals and programs which offer IR electives to visiting students, if your home program doesn’t have one in place.)
- Try an away rotation during 4th year to see how other institutions approach clinical care
- Apply for residencies where clinical care outside of the OR is part of the curriculum
- While many programs recommend a surgery internship, consider doing an intern / transition year in medicine; while surgical skills are important, that year is a great opportunity to focus on patient management
- Try and gauge the philosophy of an institution or practice – do they approach IR holistically and with the patient in mind at all times?
- R. Steele, et. al., “Quality Improvement in Interventional Radiology: An Opportunity to Demonstrate Value and Improve Patient-centered Care,” J. Vasc. Interv. Radiol. (2012).