Views of an endovascular trainee

Created - 09.08.2009

It is just over three months since I took this job as a post-CCT endovascular fellow at Hull Royal Infirmary and surely enough as expected I received an email from my radiology consultant just the other day asking me to pen this article. From a radiology perspective, it is educating to get the views of an outsider such as a vascular surgeon on the interventional radiology training scheme. This has since got me thinking about the radiology work ethics and how this endovascular fellowship differs from that of a surgical job. 

To clarify, this is a Royal College of Surgeons post CCT fellowship which is for a fixed term of one year. There are no clinical commitments to this job and hence no on-calls. Yes, you’re right in assuming that there is no additional duty hours pay either, ouch! Too much to lose for a fellowship post; especially when you are in your late thirties, carrying a heavy baggage and the credit crunch is tightening its grip. However, I will over the course of this article hope to put forward some valid argument for this small sacrifice.

On my first day at work in the radiology department, I arrived a bit late; ten minutes past eight. Not an auspicious start, I thought to myself. Little did I realise that in the world of radiology, you do allow yourself some extra time in bed. However, that is where the perks end. It is a hard slog once your first patient has arrived in the radiology department from a “surgical ward” which is invariably 9.00 am or after. In most instances, work spills into the late evenings. In addition, when the surgeons are packing up for the weekend, they forget the tibial angioplasty for critical limb ischaemia that they happily handed over to their radiology colleague on friday evening to “sort out” over the weekend.

One of the prerequisites of an interventional radiologist is effective communication. They have respect for their surgical counterparts and critical clinical decisions are always made following discussions amongst themselves and the surgical team. This is an interesting and valuable lesson I have seen time and again and hope to have embedded in my brain by the end of this tenure. In addition there is a team working approach amongst the interventionists, tapping into the resources of individuals to deliver the most effective outcome. This is interesting, as reluctantly the surgeons are realising the virtues of team working as opposed to individual excellence.

An endovascular trainee in the radiology department does create a moral dilemma for the radiology trainer. Does he train up a vascular surgeon who can then render you redundant in the future? The lessons from the cardiologists are still fresh. In reality, interventional skills are not learnt by spending a few sessions in the catheter laboratory but require years of toil. Respect for these skills which have been fine-tuned over the years should see one safe in this environment. Open discussions often help clarify your stand and make your training a productive one.

Most interventional trainees are in competition with the radiology trainee for the limited case load and angiographic sessions. The fool proof method of safeguarding your training is to ensure that your weekly sessions are incorporated into the radiology trainee’s timetable. This way, everyone is allocated to specific areas without tredding on each other’s toes. By careful and tactical negotiations through supportive supervisors I have secured sessions in the angiography suite to suit my training needs. 

In addition to hands on experience in the catheter laboratory, I find the session allocated to cross sectional reporting and aortic stent graft planning extremely useful. It gives an insight into image reconstruction, image artefacts and manoeuvres to eliminate these and the limitations of imaging modalities. This aspect is as important, if surgeons are to get involved in endovascular therapy.

As with all new jobs, there is the issue with recognition and trust. This is inevitable and most registrars would have come across this at some point in their training career. Needless to say, we as doctors are capable of dealing with this effectively and I believe that time and patience are good attributes here. 

Outside the radiology department, my training involves sessions in vascular ultrasound. These are supervised sessions with an average of fifteen scanning episodes per week. I am currently working towards a post graduate certificate in vascular ultrasound at Leeds University. This is a skill which would be invaluable for the day to day working of a vascular surgeon with competence in assessing for peripheral arterial and carotid disease, venous disease and vascular access. I have allocated weekly sessions for minimally invasive venous surgery (endovenous laser therapy and foam sclerotherapy) which is another selling point of this job. 

To conclude, this is an opportunity to learn skills outside the remit of the current training curriculum for vascular surgeons. However these are skills that will be expected of the vascular specialist of the future. Although the coming years will see a change in the vascular training curriculum to coincide with the separation of vascular surgery from general surgery, it is early days to speculate how effective this will be. In my personal opinion, there will be a place for fellowships such as this to deliver targeted training. My initial impressions are that a fellowship program when well structured and supervised will deliver the most and hence I would recommend it to all trainees.

KJ Mylankal Chair FRCS Edin, FRCS Gen Surg