Reflections of an interventional radiologist

Created - 10.07.2016

1st October 1985 I remember the day well. I had just changed from a career in General Surgery to one in Diagnostic radiology. I’d spent the previous night removing a spleen from a patient who’d been in an RTA. He survived and I felt good. On my first day in radiology, I sat next to a consultant and watched as he reported about 100 plain films in an hour. I had never felt so low I couldn’t believe what I had done and I experienced that surge of sympathetic activity that’s a part of the flight and fight response!

However this was 1985 and the darkest hours come just before the dawn, Interventional radiology from an embryonic state suddenly burst to life and wow we were on a rollercoast ride which would last (for me) 30 years and its still rolling. Along came stents, covered stents , TIPSS, EVAR, TEVAR, embolisation to name but a few. Industry was developing gear so quickly we sometimes had to think of a procedure to fit around the device ! Think back to Bill Gore showing a surgeon on a golf course a tube of Goretex. Of course it was an open field completely unregulated, limited simply by the enthusiasm of the interventional radiologist. I remember my colleague Richard Edwards on hearing of Richters success with a first in man TIPSS deciding to have a go at one in Glasgow, I believe the first attempt in the U.K. and he was a senior registrar at the time ! The specialty grew. In Glasgow we went from one (myself) to 10 consultants , radiographers and nurses appeared and we grew up , even setting up an on call rota with full nursing and radiographic support. Extended role was just around the corner and against some in house resistance persuaded colleagues that nurses could do procedures we had held sacrosanct e.g. Hickman lines. However when on the crest of the wave you either ride it out or you fall and slowly but surely we had to prove to the system that what we did actually benefitted patients and latterly good value for money.

Research is a lonely road often poorly paved and frequently taking you down a cul-de-sac. I started to engage with this process and learnt the value of a strong team. The REST and ASTRAL trials illustrated this involving notable champions as the likes of Tony Nicholson and Nick Chalmers. Trials aim to tell the truth and perhaps we weren’t ready for some negative results. ASTRAL, CORAL, Symplicity HTN-3, ICSS, vertebroplasty and SUPER to name but a few. However we gained respect for honest quality research and of course ever stretched healthcare resources which could be placed into more fruitful areas.

In contrast the fibroid and aneurysm trials paved the way for procedures which now sit comfortably in the IR armamentarium. 

When I did surgery we used to speak to patients. Call me old fashioned but its good to do so. They like it. It was almost a complete anathema to our diagnostic colleagues however who simply didn’t understand. How could they? They look at pictures all day long ! So the clinics started and for me it was the highlight of the week. You had control. You were out of the radiology department. You were a real doctor again. We gained visibility and respect from the other specialties. 

When I gave the Andreas Gruntzig lecture at CIRSE my title was “not how but if and when “. They asked me to change the title saying people wouldn’t understand. I was simply trying to say doing a procedure is one thing but clinical judgment is needed first and foremost. The first class surgeon knows when not to operate and we should take heed.

So what for the future ? For me it’s a clear break from diagnostic radiology , I have never thought the two sit comfortably together. We need more people. We need to attract young doctors into IR and in my view they don’t necessarily need to come from the diagnostic radiology specialty. Surgeons and others look increasingly interested in what we are doing or indeed failing to do because of staff shortages. We should embrace that and breakdown the barriers between specialties. The Middle East needs re-drawn , IR should follow suit.

I wish you all well. Doors close and new ones open. IR remains a fast moving game. Keep your minds open, and remember talk to the patient.

Jon Moss