Learning from the past to innovate our future
Interventional radiology must learn from its past in order to succeed in the future, according to William S. Rilling, MD, FSIR, the 2023 Dr. Charles T. Dotter Lecturer.
Dr. Rilling’s lecture took a critical look at the history of IR, from Dr. Dotter’s early landmarks—like the first transluminal dilation of peripheral arterial stenosis in 1964 and his 1978 Nobel Prize nomination—to the challenges IR faced in the early 2000s and subsequent expansion the field is experiencing today.
In the late 1990s and early 2000s, which Dr. Rilling described as IR’s “awkward teenage years and existential crisis,” there was a prevailing sentiment of doom, Dr. Rilling said. He pulled select Dotter lectures that showcased this feeling, citing lectures with titles like “Will IR survive into the next millennium?” and “IR: Veni, Vidi, Vanished.”
“Time passed and IR did not fall into the abyss or fade into obscurity,” Dr. Rilling said. The tenor of lectures began to change to subjects like evolution, messages of cooperation, encouraging competition and pursuing IR training and excellence.
Dr. Rilling attributed IR’s survival and subsequent success to six factors:
- Embracing collaboration in multidisciplinary teams
- Shifting from perfectionism to healthy competition
- Creating and putting into practice a clinical care infrastructure and mindset
- Offering foundational services in hospital settings that are depended on by programs such as trauma and transplant departments
- Growing a research infrastructure to generate data that supports IR therapies, and learning to run NIH-sponsored trials
- Honing a valuable skillset that is unique, and can’t be acquired with a weekend course
“I believe that the current time period of IR can best be described as an embarrassment of riches,” Dr. Rilling said.
Dr. Dotter once said, “Further improvement seems inevitable.” Dr. Rilling proved how correct this prediction was by tracking the veritable explosion of IR procedures and areas that have originated just from 1996 to 2023. He showed the expansion of IR CPT codes and the trends in their utilization and listed the numerous other specialties that have adopted interventional methods, such as interventional cardiology, pulmonology, pain management and more.
But with great expansion comes great challenges, Dr. Rilling said. Keeping up with the increasing body of knowledge generated by IR and general medical advancements every day is almost impossible.
“Doctors would need to read for almost 21 hours a day in order to stay current with the primary care literature,” Dr. Rilling said. “Every day we wake up more behind on the literature than we were the day before.”
Perhaps the solution, he suggested, is to acknowledge that keeping up with evidence-based medicine is becoming unrealistic, and to begin teaching information management.
Another way to keep up with the pace of expansion, he said, is specialization, subspecialization and subsubspecialization.
There are pros and cons to this approach though—while it has benefits to the patients and makes it easier for physicians to stay abreast of relevant medical knowledge, it can lead to the continued fragmentation of care and create practical issues surrounding certification or continuing medical education.
Dr. Rilling does ultimately believe that specialization is beneficial. “It’s a good thing for patients that the surgeon taking out a gallbladder one day isn’t working on a carotid artery the next.”
This is something that SIR has already begun to embrace, he says, pointing to the eight clinical specialty councils that SIR has set up. Subspecialization is part of the normal evolution of IR, Dr. Rilling said, and is required to develop multidisciplinary relationships, and stay competitive. No one size fits all, but subspecialists and the therapies they create—such as tumor ablation, Y-90, limb salvage, lymphatic or spine interventions—drive innovation, Dr. Rilling said. And IR is built on innovation.
But there should be checks on this expansion, he said, returning to IR’s past once more. He referenced the sudden explosion of venous angioplasty and stenting in 2009, after it was suggested that it may offer relief to patients with multiple sclerosis. But it was soon established that chronic cerebrospinal venous insufficiency (CCSVI) therapies weren’t effective and even had negative impacts on patients.
“Innovation outpaced data, and we learned that all expansion isn’t good expansion,” Dr. Rilling said. But he believes the specialty has learned its lesson, and pointed toward prostate artery embolization (PAE) as an example of innovation done “the right way in the right order.”
He documented a timeline of studies, publications and trials, citing 48 trials that have studied safety and efficacy of PAE.
“I don’t think specialization equals separation,” Dr. Rilling said. “There are fears of fragmenting our specialty, but we’re all still IRs and SIR is our umbrella organization. And I think we’re hitting our prime.”
Read an earlier SIR Today interview with Dr. Rilling previewing his Dotter Lecture.
