By Kartik Kansagra

Tell us a little about yourself.

First of all, thank you for the invitation to participate in this conversation and share my story with SIR and RFS. My name is Luka Novosel, and I am from Zagreb, Croatia, where I currently work as a radiology consultant at the Sisters of Mercy University Hospital. I am currently undergoing training to become an interventional radiologist, which is a 2-year subspecialty training here in Croatia. I also serve as the Croatian representative for the newly formed European Trainee Forum (ETF) committee under the Cardiovascular and Interventional Radiological Society of Europe (CIRSE), which is the European equivalent of RFS in the US.  The ETF committee is committed to promoting interventional radiology (IR) to trainees and young physicians interested in pursuing a lifelong career in this field.

How did you become interested in IR and what has your training been thus far?

Interestingly, I did not get introduced to IR during my radiology training in medical school. This was partly because IR was not a field that was well known to the medical community and it was not a part of the medical student curriculum in Croatia at the time. Luckily, I got involved in a student exchange program in Beirut, Lebanon where I met a colleague undergoing training for IR.  He repeatedly showed me procedures that he was involved in and boasted about how great of a field IR was.  He believed that IR was slowly but surely going to replace many of the open procedures and become the future of medicine. His infectious enthusiasm piqued my interest, which only grew since my days in Lebanon.  I came back to Croatia to find an open spot to train as a radiology resident at the Zagreb University Hospital. On my interview day, I openly told the interviewer that I applied to radiology because I wanted to become an IR physician. Fortunately, that year they were in search for an individual interested in pursuing IR, since most applicants were only interested in diagnostic radiology (DR).

The radiology residency curriculum in Croatia is a total of 5 years, with a couple of months of IR built into the schedule. However, the curriculum is very flexible, allowing many of the unwilling participants to avoid the angio suite, and in turn allowed me to spend much of my residency in the IR suite.  By the end of my residency I had performed most of the procedures that my training program offered. However, the interventions performed at my residency were limited to simple procedures and many of the complex interventions had not yet been introduced to Croatia.  Thus, the majority of my more advanced IR knowledge and skills had to be learnt from my studies abroad.

CIRSE helped me gain the experience that I so desired by providing me with visiting scholarship grants two years in a row, which allowed me to train in Canada, Spain, and France. I gained amazing mentors at the respective institutions who not only showed me the procedures, but gave me the hands on experience and tools to return to my own institution and readily perform what I learned from them.  It is during my study abroad that I was first introduced to vertebroplasty, CT guided ablation/biopsy and uterine fibroid embolization. All of these international experiences allowed me, as a newly graduated attending, to effectively introduce the newly learnt skills, some of which had never been performed in Croatia.

All of this IR training in Croatia and abroad demanded a great deal of sacrifice and effort, and a lot of road blocks had to be crossed. However, when we get good results from the interventions that we perform, and when we change the lives of the patients that we care for, I can happily say that it was worth it. It is for this very reason I firmly believe the ETF has a huge potential in helping young IR’s in obtaining the necessary international experience to expand their skill sets.

In the US there is an emphasis on clinical skills and comprehensive management of the patient which includes seeing them in clinic to discuss their condition, managing them conservatively as appropriate, and following them longitudinally in the office. It also entails admitting patients to our own VIR service as well as doing formal consultations on patients and not accepting orders for invasive procedures by other physicians.  What have you and other Interventionalists in Croatia done to adapt clinical IR to your practice and what options exist to obtain the necessary training to provide comprehensive clinical care?

All of us here in Europe have been observing what has been going on with IR and its new training paradigm in the US. And one of the things that we envy the most is the amount of clinical practice and patient care that the new IR training requires.  We envy the way it allows you to follow and treat the patients throughout their entire medical care instead of just serving as “the guys you call when a stent needs to be put in”.  Learning to become the patient’s primary clinician and not just a consulting proceduralist, is becoming ever more paramount, since other completing fields are adopting the minimally invasive procedures that IRs invented, but also adeptly taking care of the patient throughout their entire stay.

IR subspecialty training is somewhat of a rarity in Europe, and most countries with specific IR training do not require specific clinical rotations (e.g. ICU, hepatology, vascular surgery, etc.). I voluntarily opted to spend 6 months in the wards and 2 months in ICU, but no trainee prior to me has attempted to do so.  I strongly believe that the management of the patient before and after the IR procedure is equally as important as the intervention itself, and something that we do not emphasize enough in our training here in Europe. After witnessing how the IRs can serve as true clinicians to their patients, and realizing the necessity of implementing it into my own practice, my colleagues and I have implemented a comprehensive IR consultation service, organized adequate follow ups, and meticulously tracked the results of our work and attempt to improve upon it. We also try to be a part of the decision making process in deciding the patient’s treatment, even if a noninvasive route is sought with no intervention performed.

Are there any specific changes or additions that you’d like to see done to the current training methods to better prepare future trainees for the necessary clinical skills?

Fundamental changes to the approach and mindset towards our training is of paramount importance. To elaborate, it is crucial that our more traditional colleagues, who did not participate in a clinically based training  accept the new training paradigm as a necessity.  It is also necessary for the new trainees to accept the change as an inevitability in the process of becoming a good IR physician. As for more specific changes, the national IR curriculum should be written so that it specifies the exact procedures that each trainee must perform during training, how much time should be spent on clinical rotations, and what skills an IR must acquire before graduating. As a member on the National Croatian IR Committee, I am currently trying to implement the European Board of Interventional Radiology (EBIR) exam as the official board exam for all the interventional radiologists at the end of the 2 year program here in Croatia. This push is in the hopes that the IR curriculum will inherently become a more clinically based training model since clinical knowledge is a large part of the EBIR exam.

Do you feel like your experience as a trainee thus far has prepared you to provide comparable clinical care with other interventional and vascular specialists like vascular surgery and interventional cardiology?

As I have eluded on my previous answers, I believe that the education and training that I have gotten thus far as a resident and IR trainee did not meet the standards of what I believe a modern IR must strive to be. I, however, find comfort in the fact that I am still in the training process and that I still have the chance and the choice to to become a more clinically oriented IR physician. There are still areas I want to continue to perfect including clinical care, pharmacotherapy, anesthesia, and management of complications. I am realizing on a daily basis how important these ‘empty spots’ in our IR education are.

I strive to take ownership of my patients from the moment they step foot into my hospital.  I continue to follow up on their medical conditions and get involved in all aspects of their care. This often times means that I collaborate with the other clinical services also spend many afternoons and evenings brushing up on my medical knowledge beyond IR. I am hopeful all of this work will culminate a more clinically oriented IR physician.  I am hopefully that the IR training model will begin to adopt a more structured and diverse training that makes this process an easier and more concrete one for the succeeding trainees.

You have accomplished some extraordinary things as a trainee such as bringing RFA and vertebral augmentation to Croatia. Can you tell us a little about what it took to make that happen? I am sure you met many roadblocks along the way. How did you overcome these and not get discouraged?

I must admit it was not easy, but my advice is to stay persistent and follow what you believe is right.   Although the road was arduous, if I had the chance, I would do it all over again at a drop of a hat. First step was putting myself out there and applying for the grant from CIRSE, two years in a row, despite the competition from all other european countries.  Once I was granted the opportunity, I had was lucky enough to encounter great leaders of IR, such as Drs. Lanciego and Ciampi in Toledo, Spain and Dr. Le Dref in Paris.  Despite my status as a foreign resident, they provided me with ample opportunities to perform IR procedures as the primary operator. It was during these opportunities, also supplemented by additional training in Strasbourg, where I got the necessary knowledge and skils to perform IR.

There were three areas that were of particular interest to me, especially since I knew how they would benefit our patients back in croatia; these were CT guided biopsies and thermal ablations, vertebroplasties, and uterine fibroid embolizations (UFE).

However, just having the knowledge and the skill sets to perform the IR procedures was only the beginning of a long climb. It took at least two years to get any procedure up and running at our institution. First, it took multiple lectures and meetings with the other services and heads of departments to introduce them to the details of the new intervention and how the patients and their services could benefit from the procedure.  Then we had to address the organizational details amongst many different services. The struggle was even more apparent when dealing with other surgical specialties, especially since we were proposing a minimally invasive approach to a more traditional, and often times more invasive surgical approach.

Often times the struggle was against my own DR colleagues due to lack of understanding of the changes proposed. Many IR departments operate under the auspice of a larger DR department headed by a DR. I have learned that without the collaboration between the DR and IRs alike, implementation of potentially beneficial IR procedures may be brought to a staggering halt, or even completely abandoned.

Today, we stand as one of the only centers in Croatia, who systematically perform vertebroplasties, UFEs, and CT guided tumor ablations.  Despite our status, our struggles still remain since there is a constant “turf war” between completing fields.   The perception of IR in Croatia remains as the more costly alternative to classical surgical methods, since the healthcare system focuses only on the initial cost of the IR technology, and turns a blind eye to the decreased hospital stays, complication rates, personnel required for minimally invasive versus open surgeries, etc. This is a battle we fight every day in the hopes that one day, the system will realize the cost-effectiveness of IR, and more importantly, the tremendous benefit it will bring our patients.

It’s amazing that you are performing acute stroke thrombectomy! How did you go about getting training to have that level of comfort performing such an advanced procedure alone as a trainee?

At my new hospital, I got the chance to meet and work with two great colleagues, Drs. Kalousek and Čulo, who are only two years ahead of me in training.  Couple of years ago, they went through a similar process abroad and similar or greater struggles and roadblocks to implement IR into the hospital.  At the time I joined their practice, their main focus was neurointerventional procedures.

Among many other procedures, they managed to introduce mechanical thrombectomy for stroke patients into our hospital, which is now only one of two centers to perform these procedures in Croatia. The idea was to organize a 24/7 on-call team to perform the interventions. They graciously invited me to join their endeavor, and I gladly accepted.

So I got intensive training from them and also abroad in an animal lab in Sweden to perform the neurointerventional procedures. Now I work with them as part of the stroke intervention team. They truly exemplify physicians who love their jobs and are willing to spend time, energy, and a lot of hard work to provide the care their patients deserve.

Mechanical thrombectomy in setting of acute stroke has the most profound results for a patient in all currently available IR Procedures.  And I strongly believe that all efforts should be made to make it available to all patients, independent of where they reside.

What advice would you have for new trainees on how to be a successful, clinical IR?

My main advice is to be persistent and patient. IR is the medical field of the future and nothing can stop its growth. However, it is still not at the level of some of its competing fields, such as surgery and cardiology, when it comes to history, public awareness and patient population.

So the natural course of becoming a good IR in this era will be lengthy, arduous, and seemingly discouraging at first; however, if you persevere and never lose hunger for knowledge and acceptance, it will undoubtedly bring you lots of joy and the results you so desire.

Key to obtaining a great, diverse IR training is going to centers in different countries. Whenever possible, use every opportunity to learn from your more experienced and successful predecessors. This will take you further than simply learning from only your own mistakes and anecdotal experiences. It will not come to you on a silver platter; you will find yourself having to reach out to experts and organize your own journey abroad.  But from my own experience, a vast majority of these experts are very open to help, answer your emails, and offer you an opportunity to come learn from them.

You are a pretty active member of the European Trainee Forum. What are some things you are hoping to accomplish through the forum? What sort of collaborative effort would you like to see done on the international level to help foster the growth of IR internationally?

To ensure the continued growth of IR in the next decades, CIRSE has recognized the need for a comprehensive strategy to engage medical students and IRs in training and thereby secure a steady stream of fresh minds into the discipline.  In order to better support these doctors on their way to becoming full medical professionals and to supplement other educational activities, ETF was established, consisting of representatives from all European countries. Its main purpose is to enhance and encourage the participation of young physicians in scientific and educational activities internationally and to create a space within CIRSE for IR trainees to further their careers through networking opportunities.

We are actually a younger, still developing version of the SIR RFS; however through collaboration with your representatives, we already managed to get and implement some experiences. We are currently mainly involved in three projects – opening an online resource under CIRSE and tailoring material that is more suitable to young doctors, residents, and trainees.  Secondly, we are trying to establish a network through which all trainees will be able to communicate, gather experiences, and more easily establish international mobility. Last but not least, we are trying to approach students in our own countries and introduce them to IR early, so that their first encounter with IR is not abroad at a foreign country.