Introduction
Interventional radiology (IR) has evolved significantly since 1964 when Chares Dotter salvaged an ischaemic leg of a patient who refused amputation by dilating her stenosed femoral artery. Since then, the number and complexity of IR procedures have grown, ranging from diagnostic angiography to therapeutic embolization. Many of the procedures demonstrate lower mortality and complication rates allowing for faster recovery plus shorter hospital stays. A notable example would be NHS England’s clinical commissioning policy regarding mechanical thrombectomy for ischaemic strokes [1]. It has highlighted the evidence of patients having a significant improvement in disability-free survival and quality of life in comparison to patients who were treated with medical therapy alone. Yet with all these developments, IR still remains a sub-specialty within the Royal College of Radiologists (RCR). We explore the reasons why IR should gain specialty status and perhaps why they haven’t.
Reasons for
To increase the number of applicants for recruitment
IR needs specialty status from the Department of Health and Social Care to gain recognition for recruitment. There is a shortage of IR consultants nationwide (specifically 386 from the Clinical radiology workforce census 2019 report) to meet the minimum standards of 6 consultants per Trust/Health Board and to provide a sufficient 24 hours service [2]. One of the main reasons cited is a lack of suitable or sufficiently trained candidates. With IR establishing itself as a specialty, medical students and junior doctors may be more familiar with the specialty, prompting their interest in it at an earlier stage [3]. This contrasts with the current environment where medical students are only exposed to it very briefly if they select it for their student-selected units, or when junior doctors organize a taster in the department. With medical trainees familiarizing themselves with the specialty, this may hopefully increase the number of candidates applying for the program.
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To develop its own training program
Undoubtedly, a radiologist trainee needs to learn the core fundamentals of diagnostic radiology prior to performing any intervention. Interventional radiologists however have additional responsibilities such as pre-intervention assessment, consent, outpatient clinics, follow up and ward activities [4]. Without discounting the current curriculum, IR trainees need earlier exposure to technical skills, clinical experience, accepting referrals, and working as a part of a multidisciplinary team (MDT) as expected from a consultant interventional radiologist [5]. With IR becoming a specialty, it would provide the Royal College of Radiologists (RCR) with the opportunity to address these training requirements[6].
To have primary clinical responsibility for patients
Becoming a recognized specialty may grant IR admitting privileges as well as the development of intervention facilities in hospitals that don’t already have them. They may also be allocated more space to manage their patients. This includes access to inpatient day beds, clinic slots, wards, and elective lists in addition to an intervention suite with the appropriate facilities. By being the named primary clinical physician plus having the physical space to manage them, one can ensure patient safety and the delivery of appropriate care [6] . Moreover, patients are entitled to have follow-ups post-procedure and the opportunity to be referred should they require the service. Having these commodities would allow the consultant the opportunity in advising and providing optimal clinical management [7].
Reasons against
It is difficult to define IR as a specialty
IR was initially rejected by the Royal College of Physicians and Surgeons of Canada Committee on Specialties in 2004 for application for sub-specialty. The reasons are other specialties are able to offer services offered by IR, and IR recognized as a field based on technical competence alone was not justifiable. The Canadian Association of Interventional Radiology reapplied in 2011 with more support on this occasion from other specialties, eventually gaining its subspecialty status in 2013 [8,9]. Until today it is still difficult to pinpoint what IR does specifically as a field. A medical specialty is defined as a branch of medical practice that focuses on a defined group of patients, diseases, skills, or philosophy[10]. It is particularly challenging with IR as they encounter a variety of patients, and perform procedures on nearly all organ systems, in addition to the fact it provides both diagnostic and therapeutic intervention. As mentioned, there is a considerable overlap of procedures that other specialties are capable of providing from IR, particularly vascular surgery.
There are not enough resources to train diagnostic and interventional radiologists simultaneously
Although there is a demand for more clinical plus IR consultants, there may not be sufficient resources to accommodate double the trainees should there be simultaneous training pathways for clinical radiologists and interventional radiologists [11]. Radiology is currently stuck in a vicious cycle where understaffed departments are unable to provide teaching to the current trainees, resulting in difficulty recruiting new doctors into the program and so on[2]. A single PACS station can cost from 30,000-50,000 pounds[12]. An increase in trainees would increase the demand for workstations, clinical/educational supervisors, and rivalry for experience in performing procedures just to name a few. Given the current shortage of consultants, it is highly unlikely they would take on additional teaching responsibilities given their workload.
Clinical radiology is integral to intervention radiology
The RCR has stated the interventional radiology curriculum is to be used as a supplement to the clinical radiology curriculum. The curriculum also highlights clinical radiology trainees are expected to provide basic image-guided diagnostic and therapeutic intervention regardless of the availability of IR services in their location[13]. Understandably, the procedures in IR are much more complex however, radiologists must first achieve competencies in the practical procedures for clinical radiology prior to advancing[ 5] . This makes it impossible to progress to IR without first completing clinical radiology’s capabilities in practice. The United States has recognized this educational requirement hence they integrated the diagnostic radiology syllabus into all 3 of their IR residency pathways [14]. IR residents in America are required to undergo residency in diagnostic radiology despite IR being recognized as a specialty there [15].
Conclusion
In summary, it is important we acknowledge the advantages and disadvantages of IR becoming a specialty. Given how the British Society of Interventional Radiology has recently voted in favor of IR becoming a specialty, it is plausible that it may become so in the near future. With that said, we need to anticipate the implications of this development. Unlike IR, breast, gastrointestinal, and neuroradiology concentrate on specific organs. Would these sub-specialties then want specialty status as well given their defined focus? Ultimately, it is crucial that the benefits and risks associated with specialization are considered as a whole before making any further decisions.
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