A Brief History of Interventional Radiology
In 1953, Sven Ivar Seldinger transformed the practice of medicine when he described the simple but revolutionary consult of percutaneous vascular access. The Seldinger technique was an elegant way to essentially replace a procedure that once routinely required surgery. During the next decade, the field of angiography allowed radiologists to diagnose various conditions throughout the body. However, it was not until 1964, when Charles Theodore Dotter met Laura Shaw, that the field of vascular and interventional radiology (IR) began. Laura Shaw was an 82-year-old woman who had critical limb ischemia with gangrene in her left foot, and she was told by all her physicians that she needed an amputation. She absolutely refused, and Charles Dotter saved her leg on January 16, 1964, by performing percutaneous transluminal angioplasty on her superficial femoral artery. Shaw survived another three years walking on her own two feet. Despite tremendous opposition from competing providers (who called him “Crazy Charlie”), Dr. Dotter forged ahead, bringing percutaneous vascular intervention to the mainstream of modern medicine. He knew he was right, and patients benefited from it. With Dotter at the helm of this minimally invasive revolution, the nascent field of vascular and interventional radiology was born.
Since Dotter, vascular and interventional radiology has undergone a dramatic transformation marked by repeated innovation. A testament to that is that today, interventional radiologists can treat organ systems from head to toe, across every subspecialty in medicine. Although interventional radiologists may be seen as some of the most technically proficient and innovative physicians in medicine, establishing the role of interventional radiology in medicine has gone far too slowly.
Initially, with a field of radiologists performing angiography and then later “special procedures,” a majority of early interventionalists saw their role in medicine as performing interventions ordered by other providers. Rarely was the interventionalist asked about the appropriateness of a procedure—or, more important, his or her opinion about the disease process being managed. In this way, interventionalists were relegated to a pure technical role. The consequences of not being seen as consultants include interventional physicians not being consulted on patients who may have benefited from an interventional therapy, as well as potentially performing unwarranted procedures on patients at the behest of an “ordering” physician.
Charles Dotter saw the writing on the wall, realizing the importance of comprehensively managing a patient’s condition and acting as a true consultant. He professed the importance of working as a clinical consultant as early as the 1968 annual meeting of the American College of Surgery, when he said:
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.
Despite Dotter’s warnings, very few interventional radiologists initially took them to heart.
Over the following decades, interventional radiology continued to expand, based on innovation after innovation. Although technical advances allowed interventional radiology to perform increasingly complex life-saving interventions throughout the body, in most instances, interventionalists continued to function as technical experts rather than cognitive clinical experts. Since IR physicians treat some of the sickest patients in the hospital, this no longer can be considered the standard of care.
In September 11, 2012, the American Board of Medical Specialties recognized interventional radiology as the 37th primary specialty of medicine, a designation that acknowledged that no other specialists in medicine have the unique clinical, imaging, and technical skill set possessed by interventional radiologists. The new designation highlights the critical role that interventional radiology plays in patient care. International radiology is now an integral part of modern medicine, and as physicians with a unique skill set, it is up to all interventionalists to ensure that patients can benefit from minimally invasive therapies. The only way that this can happen is if this specialty becomes better integrated in guiding patient management via effective consultation.
While providing a consultation may seem intuitive, a lack of dedicated training in providing an effective consultation may lead to miscommunications among referring physicians, patients, and other consultants, which can potentially lead to worse outcomes. It is imperative that we provide consultations that are similar in nature to other consultants and valuable to our referring physicians. The purpose of this chapter is to provide a framework for interventionists that can used to provide a meaningful and effective consultation.
There was a joint document from the American College of Radiology (ACR), Society of Interventional Radiology (SIR), and the Society of Neurointerventional Surgery (SNIS) on Practice Guidelines for Interventional Practice that was initially published in 2005 and revised in 2009. This document lays down many of the requirements necessary to provide IR services. They discuss the importance of admitting patients to the IR service, an outpatient office, and an inpatient consultation service. In these guidelines, they recommend spending dedicated time on inpatient consultations and rounding, as well as outpatient clinic time that is separate from procedure time.
A consultation, in simplest terms, is a physician or other healthcare provider asking another physician for assistance in the care of a patient. Consultations are generally made to help guide patient management, whether it involves setting an unknown diagnosis, the need for an interventional or surgical procedure, or other treatment recommendations. The hallmarks of the formal consultation are a specific clinical question; a bedside visit to the patient; performance of a history, physical, and review of systems; and review of the available laboratory and imaging data, followed by a documented assessment and recommendations. The proverbial curbside consult should be avoided. A general surgeon will evaluate patients thoroughly prior to bringing them to the operative suite for an appendectomy or gallbladder surgery, and an IR physician should act in a similar fashion. This enables the consultant to evaluate the situation thoroughly and make sure that all potential issues are addressed and that the patient, patient’s family, and referring physician are well informed about the plan.
Curbside consultations are fraught with the potential for error. All too frequently, they result in communicating incorrect information or incompletely conveying relevant information. In fact, this phenomenon has been formally evaluated in the literature. One study found that of the information provided to the consultant during a curbside consultation, 51% of it was incomplete or inaccurate. Furthermore, when a formal consultation was performed after a curbside consultation, management recommendations changed 60% of the time. That is an incredible discrepancy when considering how frequently recommendations are given over the phone, without a conversation with the patient or a thorough review of the patient’s medical history.
The consultation should be for the evaluation and management of a condition, not a procedure. For example, with a patient with deep vein thrombosis (DVT), he or she should be evaluated to see if urgent thrombectomy/thrombolysis, inferior vena cava (IVC) filter, anticoagulation type, and duration are required, and the patient may also require a follow-up in an IR clinic. A consultation is an opportunity to educate, guide, and counsel patients, patients’ families, and the referring providers about the conditions that we manage. As IR physicians, we should move away from answering whether we can technically perform a procedure, and instead first ask whether we should perform a procedure. In order to provide guidance and be able to counsel a patient, it is imperative that we discuss the risks of the various procedures, benefits of our interventions, and most important, all alternatives, including medical therapy, surgical options, and no treatment at all.
It is also important to understand where patients are in their care to determine what information has to be gleaned. Critically ill patients and/or those in intensive care units (ICUs) are often seen by a host of consultants in an attempt to manage an acute or life-threatening condition. As such, consultants must have a solid foundation in critical care medicine, which will enable them to become effective partners in the intensive care and trauma settings. For example, the management of a massive pulmonary embolus may require a multidisciplinary approach, which includes pharmacologic adjuncts such as inhaled nitrous oxide, intravenous tissue plasminogen activator, catheter-based thrombectomy or thrombolysis, extracorporeal membrane oxygenation, or even surgical embolectomy. This requires multiple disciplines, including the critical care physician, interventional physician, and cardiovascular surgeon, in order to be able to have a multidisciplinary approach to attack these processes. The interventional radiologist often makes important management decisions after emergent consultation and thus must have an appropriate knowledge base, supporting staff, facilities, and equipment to manage critically ill patients.
There is a growing use of technology to communicate with patients, such as telemedicine. Patients should have an easy way to reach their consultants, and this can be via telephone, email, or televideo. All these should be compliant with the Health Insurance Portability and Accountability Act (HIPPA), and it is mandatory that the discussion is documented in the medical records. It is always preferred to have face-to-face communication, with the patient and the family present. Many things can be lost in translation via telephone or email that can be better addressed during face-to-face communication. Also, the physical examination and the eyeball test are difficult to do without being in the same room.
Elements of an Effective Consultation
The formal consultation has to have a few key elements that will allow the consultants to organize their thoughts and get a global understanding of the patient’s condition and the potential impact that an intervention may have on the patient. The following template is a good example:
Vascular and Interventional Specialists:
DATE OF CONSULTATION: *******
REFERRING PHYSICIAN: *******
CONSULTING PHYSICIAN: ********************
REASON FOR CONSULTATION: **************
Social History: **********
Family Medical History:*********
Review of Systems:**********
Physical Exam/Oxygenation/Vitals: **********
(outpatient follow-up, etc.)
Much has been written about the hallmarks of an effective consultation, but there is a dearth of instruction on this topic in the IR literature. Given the technical origins of our specialty, dedicated education on how to provide an effective clinical consultation is critical. In that vein, looking to our colleagues and their literature is helpful because a series of common themes emerge. Goldman et al. write about the 10 commandments of an effective medical consult, and similar pearls of advice are found in the surgical literature. These can be readily adapted to apply to interventional radiology. As young trainees learn to take care of patients in a new clinical paradigm and more senior interventional physicians adapt to modern interventional radiology, the following pieces of information can help interventional radiologists in all stages of their career provide better consultations (and therefore better patient care).
The Commandments of the Effective IR Consultation
Be Available and Affable
Availability and affability are prerequisites to developing a strong consultative practice. Remember that referring physicians are constantly under pressure from administrators to reduce inpatient length of stay, decide dispositions, or improve patient satisfaction measures. As such, seeing a patient promptly often trumps clinical prowess. Establish a time frame: is the consult emergent, urgent, or routine? All parties, including the patient, should know when to expect the consultant to appear at the bedside.
In addition, evaluate your own practice for hidden bottlenecks. If you are the consultant and you are scrubbed in a procedure, it is important that someone is carrying the pager and can respond in a timely fashion. Referring physicians should have an easy and quick way to contact you about consults. Make yourself visible in daily medical practice. Being seen on the floors, ICUs, and outpatient settings by other physicians and healthcare providers builds rapport and often leads to new consults. Always carry a business card and offer your cellphone so that other providers have a quick and easy way to contact you if needed.
It is important to get a consultation for the management of a condition or disease, as opposed to a procedure request. For instance, an internist may ask an interventional radiologist to help manage a patient with ascites by asking her or him to perform a paracentesis. In this case, the reason for the consult would be paracentesis, but the clinical problem is abdominal ascites. By seeing a patient for the clinical problem of ascites, the interventionalist can provide more meaningful recommendations, be they related to medical or interventional management. Often, other providers may not be familiar with interventional options, thereby depriving patients of beneficial interventions. Other times, the wrong procedure is requested based on false premises. In the case of abdominal ascites, instead of a paracentesis procedure, perhaps the patient with underlying cirrhosis would benefit from an aldosterone antagonist, a peritoneovenous shunt, or even a transjugular intrahepatic portosystemic shunt. Perhaps the ascites needs to be worked up for malignancy based on the serum ascites albumin gradient, nature of the fluid aspirated, or available imaging findings that are incompletely reported or misunderstood. If the ascites is malignant and the patient is not a chemotherapy candidate, perhaps a tunneled peritoneal catheter, rather than a temporizing paracentesis, is what the patient will ultimately require.
Look for Yourself, Decide for Yourself
Once you understand the chief complaint and reason for consultation, it is critical to evaluate the patient and available data independently. As was mentioned, getting a brief history from the referring physician is appropriate to gain an appreciation for the clinical context, but it is imperative to speak directly with the patient and patient’s family, and perform your own physical exam and review the available laboratory and imaging data. Relying exclusively on the referring physician’s judgment may result in misunderstanding the nuances of a clinical problem. Furthermore, since interventional radiologists have unique expertise, they can often gather additional information from the same data by reviewing it independently. After having done this, the clinical interventionalist should be able to arrive at an independent conclusion of how to proceed with a patient’s care.
Working in what historically has been a technical specialty, interventional radiologists must now strengthen their own clinical abilities and decide the appropriate next step in patient management. It is vital that interventionalists have a firm understanding of the clinical conditions that they are asked to intervene in and accept responsibility for what happens to the patient. It is entirely appropriate to push for their particular point of view, especially if their reasoning is clinically sound, and the patient is amenable toward their suggested next step.
Affability: Educate Without Berating—Be Professional
Other healthcare providers do not possess the imaging, technical, and clinical skills of the modern interventional radiologist. Just as there is no such thing as a stupid question, there is no such thing as a bad consult. While many consults may seem basic or frivolous to the interventionalist who has six years of specialized training, this sentiment should never be communicated to the referring provider. The consultant’s job is to educate and assist, never to admonish. No matter how basic or simple a consult may seem, remember that referring providers consult only when they really need assistance. It is not the referring physician’s job to know the details about diseases and procedures performed by interventionalists, and in many instances, common knowledge to interventional radiologists is not common knowledge to the referring physician. It should be considered a privilege to be consulted, and that indicates that you are seen as a valuable contributor in your hospital setting. Always be grateful for the consults, no matter how big or small, and consider ending the consult by saying something like “Thank you for allowing us to participate in the care of this patient.”
Documentation is critical for the complete consultation. Not only will it help as a reference for the referring physician, it is the only medical-legal record of your recommendations in your own words. Allowing another provider to document your recommendations second-hand leaves room for error and misinterpretation, which could have poor consequences for the patient. Thorough documentation also shows your referring physician that you are engaged and are adding value to the case. Appropriate documentation also helps facilitate transitions of care. If the interventional radiologist who consults on a patient switches off service, the consult note will help the incoming interventionalist understand the discussions that have already taken place. Finally, thorough documentation is also important for billing and coding; make sure to provide adequate documentation (patient acuity, physical exam, review of symptoms, etc.) for appropriate-level billing.
Be Specific with Your Recommendations
When making recommendations, ensure that they are detailed and concise and leave no room for misinterpretation. Providers do not want to make an extra phone call just to ask follow-up questions on drug doses, durations, and timing of imaging studies. This should all be clearly outlined in the initial consultation. In addition, if any interventions are recommended, details about timing of the procedure and how the primary team should help optimize the patient for the procedure should be clarified. It is imperative to discuss timing of nil per os (NPO) status, holding anticoagulation or antiplatelets.
Communicate Both with the Referring Team and the IR Team
Communication is an essential element of providing a good consultation; this concept refers to communication with the patient, referring provider, and the rest of the IR team. Once the assessment and recommendations have been documented for the medical record, the referring physician should be apprised of the plan in person or over the phone. Relying on the referring provider to follow up on the consult note leads to unnecessary delays in care and can lead to misunderstandings about how to proceed. In addition, conveying the nuances in a consultation note can be difficult, and thus a phone call to the referring physician is more personal and helpful for clarifying any remaining issues. It is extremely important to keep the patient and the patient’s family in the loop on what the plans are and what to expect.
The final decision to proceed or not to proceed with a course of action is ultimately up to the patient and the patient alone. Allowing a noninterventionalist to explain the nuances of a procedure can lead to confusion on the patient’s part and contribute to a patient’s sense of dissatisfaction and abandonment. Most important, open communication with the patient is an important component of informed consent and is essential to fostering a strong doctor-patient relationship.
Finally, there should be dedicated communication with any covering physicians via a dedicated sign-out during nights, weekends, and holidays. A good sign-out is performed physician to physician and includes the names of patients on the service, active issues that may come up when the primary physician is not available, and things that the covering doctor should perform or monitor during the time of coverage. This should also be documented in the electronic medical records.
Follow-up—Both in the Hospital and Outside
A consultation rarely ends after the initial patient interaction. The patient should be followed until the underlying problem is resolved or until the interventionalist communicates to the referring provider and the patient that there is nothing more that the interventionalist can offer. Importantly, even if a procedure is not recommended, follow-up is often still indicated. Consider the following: If a percutaneous drain is placed to treat an abscess, the patient should be followed until the abscess has resolved and the drain can be removed. In situations like this, the physician removing the drain should also be the interventional radiologist, not a surgeon or another provider. If the patient has had an implant placed, such as an IVC filter or an endograft for aneurysm repair, it is best if this is followed for the life of the patient by the implanting physician. Failing to provide care on a longitudinal basis may even be seen as abandonment by the patient and referring team.
If a consultation is requested for lower-extremity claudication and the interventionalist decides to treat it with medical management and an exercise regimen, that patient should be followed by the interventional radiologist even though no intervention has been performed. Also, the patient should be started on appropriate life-saving pharmacologic adjuncts such as ace inhibitors, statin therapy, and antiplatelet regimens. Although an intervention may not initially be necessary, medical management may cease being effective, at which time an intervention may be beneficial to the patient. It is up to the interventionalist to ensure that the patient is being screened appropriately and that the disease does not progress in a manner where more drastic interventions become the patient’s only option.
Knowledge of the Disease: Own the Disease
Stay up to date, active, and involved in all facets of a disease process. To be a disease expert requires contributing more to a patient’s care than just the procedure. This includes counseling the patient on the epidemiology, natural history, risk factors, prognosis, and all treatment options. It is important to offer all alternatives, including medical management, surgical techniques, and minimally invasive treatments. One must learn and use guidelines, protocols, and scores that are commonly used by other providers, such as CHA₂DS₂-VASc, SOFA, and the Model for End-Stage Liver Disease (MELD). Fundamentally, if you are viewed as a disease expert, the number of consults that you provide should vastly outnumber the interventions that you perform. If this is the reality of your practice, you can be sure that referring providers value your clinical judgment as much as, if not more than, your technical prowess.
As interventional radiology is a relatively new field, many referring providers do not understand the scope and breadth of what we can offer to our patients. It is important to frequently give grand rounds and talks on the conditions that we treat to primary care providers, hospitalists, emergency room (ER) physicians and other healthcare providers. Multidisciplinary conferences are another area where we can educate healthcare providers about when we can help them with their patients.
A Job Well Done? Getting Feedback on How You Did Your Job as a Consultant
Besides simply asking referring physicians their perceptions about the IR consultative practice, other metrics that can be used to measure the performance of the IR consultant. Objectively, the end of each consult should end with a mental check: “Was the clinical question answered?” Whether the consult was initiated for an undifferentiated clinical process or a specific procedure, the assessment and plan should directly address the referring provider’s questions and concerns. Checking to see if the provided recommendations were implemented is another way to get feedback about both the effectiveness of the consultation and the trust that referring providers place on the consultant’s clinical judgment.
Over time, providing consultations that are viewed as valuable will inevitably result in more referrals. For instance, rather than getting consulted for chemoembolization or ablation, a clinical interventional radiologist will be asked to evaluate a patient with hepatocellular carcinoma or a liver mass and recommend the best course of action. Instead of consulting a clinical interventionalist for a paracentesis, the interventional radiologist will be asked to help manage the patient’s ascites. In essence, the best feedback that a consultant can obtain is:
• An increasing number of referrals over time
• Implementation of the provided recommendations
• Consultations that are made for broad clinical issues rather than specific procedures
As important as it is to note where you are doing well, make sure to also pay attention when your recommendations are ignored. It is important to stay attuned to this, not only because it may reflect on your performance, but if poor consultations are the perceived norm, referring physicians will begin to look elsewhere for answers and patients may not benefit from your expertise. The most common reasons for referring providers to ignore the consultant are (Rosenberg):
• Poor communication
• Delayed response to the consultation request
• Failure to address the key clinical question
• Prematurely ending the involvement of the consultant in the patient’s care
• Infrequent follow-up visits
Avoiding these pitfalls can ensure that a consultative interventional practice can thrive.
Interventional radiology has existed for over five decades, but the specialty is at an exciting turning point in its history. In the days of “special procedures,” interventional radiologists were almost exclusively technicians. Then, interventional radiologists evolved into the ultimate curbside consultants. For years, there remained a reluctance to see patients directly prior to interventions. Opinions would be rendered without a patient visit, a history and physical, or any documentation in the medical record.
However, as a specialty, interventional radiology is at a point where that level of interaction with patients and referring providers is no longer enough. A truly consultative practice is mandatory for both improved patient outcomes and the future of the specialty. If interventionalists can improve patient outcomes in this manner, the specialty and all of medicine will only continue to thrive.