"Radiologists must make up their collective minds: Do they wish
to become members of the [clinical] team with all the
responsibilities and credibility that come with it or do they
prefer to remain outsiders and, sooner or later, lose much of their
clinical work [and income] to cardiologists and "
"We have to teach different attitudes. If radiologists wish to
be treated as real docs, then let them first be real docs. We must
also consider changing the duration of the residency and the
relative emphasis awarded each sub-specialty. Perhaps it is also
time to split radiology and its education into two disciplines,
namely, radiologic imaging and surgical radiology."
- Yoram Ben-Menachem, MD, RSNA Categorical Course, 1990
People say and write the darndest things. Sometimes they even
make sense, perhaps even more so ten years later. As the collective
monetary pie in medicine shrinks, the decision of which specialist
is to do what procedure is becoming less well defined. Radiologists
can no longer claim to be "the owners" of a procedure simply
because it requires the use of an image-guided modality.
Organ-based specialists are performing more and more of these
procedures that were traditionally done by radiologists.
More than ever, interventional radiology has become a clinical
subspecialty. For this reason, procedures are being lost by
radiologists who are unwilling to act like "real docs". We should
realize that by assuming more clinical responsibility, we position
ourselves higher in the "food chain" and may enact a greater impact
on referral patterns. In certain practice situations, a physician
assistant or nurse practitioner can help with the practical aspects
of patient care. Some interventional radiologists may also need to
invest time and effort to re-learn the basic aspects of clinical
medicine, keeping in mind that it is alright to request a consult
if a clinical dilemma is encountered. Indeed, by requesting a
consult, we become a "referring clinician", and will be viewed as
"more equal" in the clinical arena.
In general, interventional radiologists work longer hours in
more stressful conditions than diagnostic radiologists. The
wear-and-tear on the body and the radiation exposure make it
unlikely that most interventional radiologists will be able to
continue to practice at their current pace for the same duration as
most diagnostic radiologists. Therefore, practices must also become
more flexible and adjust remuneration and call schedules. Indeed, a
number of interventional radiologists have already become
frustrated with "traditional" radiology practice patterns and have
teamed with interventional cardiologists and vascular surgeons. In
this setting, interventional radiologists are finding the work
ethic and philosophy of practice to be more consistent with their
own. Unfortunately, this migration of services to non-radiology
groups will eventually lead to greater losses for radiology as a
whole.
Having stated all of the above, radiology residency and
interventional radiology fellowship training programs, in general,
provide a relatively weak foundation upon which to base a clinical
practice. It is, therefore, important for the field of radiology to
develop a better, long-term solution to this basic educational
dilemma.
For those individuals interested in becoming an interventional
radiologist, a training program incorporating two years of clinical
medicine, two years of diagnostic radiology, and two years of
subspecialty training in vascular and interventional radiology
should be created. Individuals completing this six-year program
should then be eligible for board certification in both diagnostic
radiology and internal medicine, as well as for the Certificate of
Added Qualifications (CAQs) in vascular and interventional
radiology. This type of training program is quite feasible,
especially given the training model already established by
neurology, radiology, and neuroradiology: Individuals completing
this six-year training program are board eligible for neurology and
radiology, and are able to sit for the CAQs in neuroradiology.
Although close to ten years have passed since Dr. Ben-Menachem
gave his presentation at the RSNA, his statements are perhaps more
applicable than ever. It is time for radiology to take a collective
look at itself and recognize that the traditional paradigm for
training and practice patterns needs to be modified in order for
interventional radiology to survive and remain under the auspices
of diagnostic radiology.
Interventional radiology is now a clinical practice. In the
short term, interventional radiologists must assume a greater
presence in the clinical arena, and radiology groups must provide
them the flexibility and support necessary to establish their
clinical practice. In the long term, the American Board of
Radiology will need to create a clinically-oriented, six-year
interventional radiology training program to allow students the
opportunity to acquire the necessary experience to become a "real
doc" and perform image-guided procedures. Otherwise, the practice
of interventional radiology as we know it will cease to exist.
Dr. Matsumoto is Director of Vascular and Interventional
Radiology at the University of Virginia Health Science System in
Charlottesville, VA. He is also a member of the editorial
advisory board of this journal.