“The only constant in life is change.”—Heraclitus.
The field of pediatric interventional radiology has evolved and expanded immensely over just a few decades and continues to do so at an ever-increasing pace. Richard B. Towbin, MD, FSIR, the director of pediatric radiology at Phoenix Children’s Hospital, and James S. Donaldson, MD, professor of radiology at Northwestern University Feinberg School of Medicine, have observed and been key participants in this evolution.
In this interview, Drs. Towbin and Donaldson spoke with IRQ on how pediatric IR has come into its own as a subspecialty, the role of pediatric IRs in multidisciplinary care and how to approach training the next generation.
Richard B. Towbin, MD, FSIR, (top) and James S. Davidson, MD (bottom).
Lisa Kang, MD: You were both involved in the early days of pediatric IR. How has the field evolved?
Richard B. Towbin, MD, FSIR
Richard B. Towbin, MD, FSIR: I started in pediatric radiology in the 1970s after finishing my training as a pediatrician. On the adult patient side, interventional radiology was already taking hold, but not in pediatrics. We began trying to improve on the interventional procedures the adult side was pioneering and were focused on designing equipment specifically for younger patients. There was nothing designed that would work in children at the time, so we were innovating with sedation and catheters.
We had some new inventions, but mostly we adapted existing tools, watched the adult IRs and tried to do the procedures in kids. The first therapies we did were aspiration, drainage and biopsies. Everything morphed when good CT and MR came out, because the imaging was fast and we were then able to guide procedures using imaging. Once we could better guide the procedures, we could copy the procedures performed on adult patients but also innovate. We started with 20–30 cases a year and, by the mid-’80s, we finally broke 1,000, which was a milestone I never thought we would reach.
James S. Donaldson, MD: I was exposed to IR earlier in my career because I trained in the ’80s at a residency that had some Charles Dotter proteges and a rich special services program on the adult patient side. But when I started working at a children’s hospital, there was almost no IR. Phillip Stanley, MD, FACR, FSIR, was there doing a few things, but it was nothing compared to what had been done on the adult side. Then I went to Chicago as a diagnostic pediatric radiologist and saw even less IR—so there was no IR going on in at least two major children’s hospitals.
Children’s hospitals isolate themselves a bit in their training, so I was working at facilities where all the surgeons had trained at other children’s hospitals, presumably without IR, and they only knew one thing: A chance to cut is a chance to cure.
It was hard to convince people, intellectually—we knew what was being done on the adult patient side and knew these techniques worked, but I didn’t have the techniques or skills to prove it at the time, and I had to convince them to trust me and trust the technique. And with pediatric surgeons and staff, they treat these young patients like their own kids. If they don’t trust you, they won’t let you try. It took a long time to change the culture. We faced the same barriers that the pioneers of IR faced—we just faced it a little bit later because of the isolated culture of children’s hospitals. Today, we’ve gotten past that cultural barrier, and now our largest challenges are training and recruitment.
LK: What are some of the key differences between pediatric and adult IR?
James S. Donaldson, MD
JD: Mostly it’s technical. There is the concern over radiation levels for imaging. In addition, our small patients have to be put to sleep even for relatively simple procedures, which raises the difficulty. Some pediatric procedures are difficult because of smaller areas and organs, and some tools aren’t appropriately sized for this population.
RT: Young children are unique, and their disease spectrum is totally different. Their differential diagnoses and sensitivities are different. Neonates, for example, can’t get cold or wet. They’re only 700 grams—the size of a big mac. And there isn’t much space to work with in smaller patients, so you have to be extremely good at ultrasound guidance and very precise with sizing, because many sheaths are bigger than the blood vessels we work in.
JD: Also, I will work on a neonate, and then switch to a teenager as big as I am.
RT: Exactly. Weight is the key difference. We know the whole body and have a command over all disease states and procedures at various ages and weights. There aren’t many pediatric IRs, so we don’t focus on organs or certain procedures—we have to be generalists, which is why our training pathways are so important.
LK: What does training look like for a pediatric IR?
JD: Pediatric specialists in general—beyond even IR—do not work on adults or get trained in adult medicine. That doesn’t always hold true for IR. We need to do what those other specialties have done and get at medical students early. When we’re able to talk to medical students about what we do, we’ve then had students get to their radiology training and know they want to focus on pediatric IR. If students get interested early enough in the training program, we can modify the path they take to make sure they’re getting a pediatric-focused education. For example, if we have one fellow interested in pediatrics, we can adjust rotations so they’re getting more pediatric IR than the rest of their classmates, and I feel they come out very well trained. They get the breadth and scope of an adult-patient IR practice, but can work in the pediatric world.
RT: At my institution we’ve been able to have one program filled with pediatric students. We do a year of pediatric diagnostics followed by a year of IR. You can’t be an IR if you don’t know the diseases, and the best way to get that knowledge is to see repetition. Diagnostic radiology offers that. On neonate or ward rounds, a student will see 500 kids with respiratory distress, for example, and when they leave that immersion they know the difference between a neonate and a 6-year-old and what respiratory distress looks like in all ages. Our training also puts an emphasis on ultrasound for guidance—if an IR isn’t skilled in ultrasound, they can’t do pediatrics.
LK: What do you think is the solution to these recruitment and training difficulties?
RT: It is my hope that in the future there will be a dedicated pediatric IR fellowship. IR has so many subspecialties that require in-depth knowledge and specialized training, and pediatrics is absolutely one of those. I think people would be willing to do another year.
JD: If we can get people interested, we can figure out the pathway to get them there. Pediatric IR is so interesting right now. We’re not just doing aspiration drainages and biopsies or acting as a PICC line service. Except for oncology or stent grafting, we do pretty much everything an adult-patient IR does, and we have an interesting practice that isn’t confined to baseline procedures.
LK: Tell us about the work. What makes IR a crucial part of pediatric care?
JD: Just like IR changed the adult health system, so too has pediatric IR. One place we’re truly integral is vascular anomalies and lesions. When we review lesion cases every month at my institution, I’d say that two-thirds of the cases that come through get referred into IR, because it offers an option for difficult vascular lesions. Without IR there’s no option but to cut, which means cutting things and places you shouldn’t.
RT: Our goal is to make open surgery go away. That won’t happen, but the fact remains that image-guided, minimally invasive procedures are better for your health. IR is not the only specialty to understand that, and it’s only a matter of time until no one will choose an open procedure if there is a minimally invasive procedure available that is just as effective.
We have, in pediatric IR, effected this change many times over—we’ve changed the approach to vascular malformations and now treat malformations by the hundreds. Blunt trauma is now largely treated with minimal invasion. We’re now seeing certain kinds of tumors, like osteoid osteomas, which we can remove or kill them with image-guided techniques. When you compare today to the 1970s, it’s so different that it just makes you want to smile. It’s a good thing.
LK: Where do you think pediatric IR needs to go next?
RT: I think the next step is entering the era of multidisciplinary therapies in an organized way. In general, the medical and surgical specialties have done a wonderful job of evolving, so if we want to evolve to solve the next generation of problems, we need an augmented toolbox to deal with the residual problems that haven’t been solved.
For example, a few years ago we worked with orthopedic surgeons to put a pin in a very specific location to reduce a complex pelvic fracture dislocation. On their own, surgeons would perform an operation and open the person up around the pelvis. My team did this without an operation and put a pin in the right spot, as guided by the orthopedist, and with one pin we reduced the fracture dislocation. The technical procedure was easy for me—but I couldn’t have done it as smoothly without the orthopedist pointing where to go.
JD: In my opinion, we do advanced procedures and have bridged the gap with our adult-patient colleagues, but a lot of practices aren’t as clinical as they ought to be. We need to behave like a surgical service where we consult on patients, see them in clinics, round on them and have a team of supporters—a whole staff that takes ownership of our patients. We have to be an active clinical service, because it raises the visibility and credibility of the IR service when you are treated like a clinical colleague who has primary care of the patient.
RT: I agree. Patient and clinician care is key, because we have caught up with the medical advances. We’re an uncontainable force at this point.
Additional resources:
Youth meets experience: Taking an educated approach to the pediatric patient: bit.ly/irqyouth
Society of Pediatric Interventional Radiology: spir.org
Society of Interventional Radiology pediatric guidelines: bit.ly/2hTKweH
