Specialities must work together


The first session of this year’s Charing Cross International Symposium began with a lively debate regarding the future of vascular surgery and interventional radiology. Kim Hodgson, Springfield, USA, said that the issues surrounding the management of vascular disease has come to the forefront owing to the rise of endovascular technologies and the decline of surgery. For example, he stated, in the US from 2001-2005 there was a huge increase in the number of endovascular procedures, while open surgery procedures declined. In addition, vascular trainees undergoing their fellowships now spend 50% of their time learning endovascular skills. He concluded by stating that despite the developments in endovascular technologies “the specialists of the future should be defined by the anatomy, not technique – and provide unbiased vascular care”.

Michael Wyatt, Newcastle, UK, discussed the mounting pressures on the vascular and interventional radiology specialities. He showed US figures that demonstrated the escalation of endovascular procedures from 340,000 in 1996 to 750,000 in 2005. He commented that that these are very political times, emphasising that patients now have a ‘choice and a voice’ and are aware of, and will demand, a less-invasive treatment. Such changes have added to the pressure of a vascular surgeon, and for the trainee vascular surgeon, vascular surgery is not an attractive career option. As a result this has created a situation where only 10% of general surgery trainees specialise in vascular surgery. For interventional radiologists, Wyatt said that they have difficulty coping with the vascular interventional workload, with only one in three hospitals having an interventional radiology on-call rota. Furthermore, more than half of interventional radiologists are involved in non-vascular treatments (GI, urology, etc). He said “we must change”.

Cliff Shearman, Southampton, UK, said that the problem with having interventional radiologists deal with vascular disease was that they had “an obsession with intervention”, despite 70% of vascular treatments needing non-interventional treatments. Shearman asked, “What would the role of the vascular surgeon be? Would they just cover emergency procedures?” He claimed that if interventional radiologists were to command the domain of vascular diseases, this would have a disastrous effect and “send peripheral arterial disease to the wilderness”.

However, Tony Nicholson, Leeds, UK, claimed that he would not want to be treated by a vascular surgeon who was ‘part surgeon, part radiologist’, meaning “part man, part monkey – only interested in doing little bits”. Only an interventional radiologist can deliver the standard of care we would all expect. He added that an additional problem was a poor retention rate among interventional radiologists, with only 10 out of 88 trainees becoming interventional radiologists.

Robin Williams, Newcastle, UK, and Robert Fisher, The Rouleaux Club, both made valuable contributions to the discussion by highlighting current trainee thinking. In his research, Williams discovered that a small majority of trainee interventional radiologists wanted to acquire vascular surgery skills. In addition, Fisher reported that a huge majority of trainee vascular surgeons wanted to acquire interventional radiology skills. Both reported that trainees believed that cardiologist should stay away from non-cardiac endovascular procedures.

Therefore, it would seem that vascular surgeons and interventional radiologists agree that the situation cannot continue. Both recognise the threat posed by interventional cardiologists, but are wary of combining a mixture of interventional and vascular skills.

Chairing the session, Geoffrey Gilling-Smith, Liverpool, UK, proposed the creation of a hybrid specialist. He said that the vascular specialist off the future would organise many management areas, both emergency and elective. In order to provide a high quality service, meet the requirements of the European Working Tine Directive and offer trainees an attractive and flexible career, Gilling-Smith proposed a common training pathway for the “Pluripotential (Vascular) Specialist” (he noted that some of interventional radiologists renamed this term, ‘lowbrid’), with fellows reaching a standard of care when performing elective and emergency care and then specialising in complex elective interventions/open surgery.

The subsequent audience discussion raised some interesting points, with Professor Roger Greenhalgh, London, UK, stating that any hybrid speciality must not lose interventional radiology skills, while Nicholson commented that he thought there was a lot of ‘surplus’ knowledge involved in interventional radiology. Speaking to Interventional News, Gilling-Smith commented, “I think we must get together, before there is nothing left to fight over.”

Training requirements

The trouble with talking about vascular specialists of the future is that the definition of skills is getting broader than simply technical expertise “and now includes certain desirable behaviours, attitudes, dispositions and personal characteristics”, said Dr Sumaira Macdonald, consultant vascular radiologist (Newcastle-upon-Tyne, UK). “Despite the fact that most people here will have type A personalities by definition, humility is a very important quality!” It is her belief that any future specialisation within the vascular system must be disease-based, to include every aspect of the process such as managing the risk factors and overseeing pharmacology as well as operating and/or intervening.

Adding his voice to the interventional radiology argument was Dr Barry Katzen, founder and medical director of the Baptist Cardiac and Vascular Institute (Miami, FL). Training of the vascular specialist of the future proved to be a contentious issue as he claimed that current vascular surgery training was “the worst of both worlds”.

Katzen predicted that in the future, vascular specialists will receive support from three or four boards: vascular surgery, radiology and cardiology. He added that radiologists currently see in two dimensions but have to think in three. “Maybe in the future we will have a virtual three-dimensional environment, but simulators are still in early stages of development.”

That view was echoed by David Kessel (Leeds, UK), who said that relying on simulator technology raised a “serious risk of hurting patients”. While it is likely that virtual reality will provide certain aspects of training for the vascular specialist of the future, this will not happen any time soon, and nor will it comprehensively replace other forms of training.

Kessel observed that there is no proof that simulator experience leads to improved performance on anything other than the simulator. At present, the best use for simulators is to allow a trainee to rehearse sequences of steps involved in a procedure. In future, training on simulators may become an integral part of a formal curriculum. “But we can’t get them to work on simple cases; we’re light years away from complex ones,” he concluded.

However, Mr John Wolfe, president of the Vascular Society, raised an interesting point, that simulators can play a vital role in crisis training. While they may not necessarily be totally accurate at replicating the scenario, they at least force the trainees to consider that such a situation might arise.

Dr Jonathan Beard (Sheffield, UK), wrapped up the endovascular session with a talk focusing primarily on technical skills. He commented that it is vital for us “to get cleverer at how we train doctors”. With the European working time directive limiting hours that trainees can work, as well as ongoing career-path changes, the old apprenticeship model of training is not keeping pace. “As Charles Mayo said, ‘Experience can mean doing the wrong thing over and over again’,” he explained. While being careful not to belittle the importance of experience, Beard called for a curriculum based on assessment of competency instead.

Mixed feelings

After listening to the facts the audience was asked, “Will there be a hybrid vascular specialist in the future?” 78% of the audience voted yes. The audience was also asked “Will the specialities would go their own way?” And, confusingly, on this point 51% of the audience voted yes.