When I started my career in Charleston, West Virginia, I was the only interventional radiologist in a community of 50,000 people. I was already somewhat familiar with the challenges faced by patients in remote communities, having previously worked in emergency departments in rural East Tennessee. I knew there is often a gap in the quality of care that rural patients receive, but my tenure in West Virginia underscored that phenomenon. Many of my patients lived in communities with no health care infrastructure and were required to travel great distances to receive basic services. Even when they traveled hours to reach our hospital, many of these patients had needs that we could not meet and, for some disorders, had to travel to another state to receive subspecialty care.
My experience in Charleston was not unique—except, perhaps, in that that the local community actually had IR services while I lived there. Data have demonstrated that individuals living in many parts of the country not only lack access to an IR but also lack access to any radiologist with image-guided procedural skills. These “IR deserts” highlight a major public health concern and a startling inequality in access to care.
Today’s standard of care
IR therapies have become a standard of care for many disease states, to such an extent that some of us may take them for granted. When I was in surgical training, if someone had an abdominal abscess, we would take them to the operating room, open them up and wash them out. That was something we did routinely—but now one would rarely think to do that when an IR can place a CT-guided drain. Draining pus may not be a sexy procedure, and it’s not something a lot of IRs latch onto as their purpose in life, but avoiding an open surgery in favor of a CT-guided procedure with local anesthesia and sedation can significantly improve outcomes for the patient.
Alternatively, consider management of a bleeding patient. IRs have become critical partners in treating bleeding. Before image-guided therapies for GI bleed became the standard, the physician would transfuse as needed, try to assess from which side of the colon the bleed was arising and then take the patient to the OR for hemicolectomy—trusting the side of the colon removed was the side with the bleed. Now, the medical community largely takes for granted that IRs can stop a colonic bleed in a minimally invasive manner most of the time.
Draining pus may not be a sexy procedure, and it’s not something a lot of IRs latch onto as their purpose in life, but avoiding an open surgery in favor of a CT-guided procedure with local anesthesia and sedation can significantly improve outcomes for the patients.
When a patient presents with these and other disorders in a community that does not have an IR, paradigm-changing therapies are not an option. Even procedures viewed by the IR community as simple and straightforward are unavailable. Procedures like nephrostomy placement, cholecystostomy, image-guided biopsy or percutaneous gastrostomy are out of scope of many radiologists. In communities without IRs, people are subject to excess morbidity and avoidable mortality.
Addressing the deserts
There are many reasons why these IR deserts exist. About 82% of counties classified as rural are also considered “medically underserved.” 1 Data show that rural hospitals have been closing at unprecedented rate: 134 rural hospitals in the United States have closed since 2010.2 As a result of this and other financial strains, medical specialists are becoming rare in these areas. While there is a general paucity of all medical specialists, IR physicians are often one of the first specialties to leave, or the last to enter. Several reasons for this phenomenon have been proposed. First, IRs are relatively few and the care we provide, when cost of the procedure is considered in isolation, is expensive compared with non-procedural services. Second, many IRs struggle with radiology group practice models, and there continues to be discussion about the optimal practice structure for the successful practice of IR. This appears to be particularly relevant to communities’ ability to recruit and retain interventional radiologists. Third, it is not emphasized enough to trainees why they would want to consider practice in smaller communities, many of which offer a high quality of life.
Addressing the IR desert phenomenon will require collaboration and education. SIR has joined forces with the American College of Radiology’s Commission on General, Small, Emergency and Rural Practices and the Commission on Interventional and Cardiovascular Radiology to evaluate and navigate the challenges that are creating barriers to recruitment and retention of IRs to practices in smaller communities. We have also established an SIR Small and Rural Practices Advisory Group and have begun discussions with APDIR and APDR about how to raise residents’ awareness of smaller communities. In recent years, as IR has increasingly become one of the most competitive specialties in the residency match, there has been a focus in social media on the cool, high-tech procedures we perform; however, there has been little mention of the community wellness and public health elements of our impact. SIR, ACR, and APDIR are assessing opportunities to raise awareness among trainees of life and practice in smaller communities, which are often great places to live with blue-ocean opportunities. In small communities with the proper balance of other medical specialties and hospital infrastructure, IRs can develop sophisticated practices with less competition around areas like PAD, oncology or pain management.
Finally, SIR has also started exploring the best way to influence the direction of DR residencies and encourage them to remember that many of the graduates from DR programs will locate in communities without IRs. We want to be certain that graduates have basic procedural skills and a comfort level with CT-guided or ultrasound-guided procedures. This requires finding a balance in the provision of care between DR and IR that will be dependent on specific community needs and on defining procedural competencies to be achieved in a DR residency.
Conclusion
For many IRs in urban practices or academic medical centers, IR deserts are virtually invisible. It is important to raise awareness of the fact that in our society there is not uniform availability to specialty care. Vulnerable populations may suffer preventable harm or death without access to IR services. It’s time for us, as interventional radiologists, to determine what we can do structurally and personally to improve care not just directly for our own patients, but for all communities.
References:
- National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Roundtable on the Promotion of Health Equity; Roundtable on Population Health Improvement. Achieving Rural Health Equity and Well-Being: Proceedings of a Workshop. National Academies Press; 2018
- University of North Carolina, Cecil G. Sheps Center for Health Services Research, N.C. Rural Health Research Program, 176 Rural Hospital Closures: January 2005–present.
