Clinical interventional radiology: serving the patient.

INTERVENTIONAL radiology (IR) has roots in diagnostic radiology, which began as a hospital-based specialty to provide vital medical information based on imaging examinations to ordering physicians. Historically, radiologists did not interact directly with patients and communicated results of diagnostic tests to the ordering doctor (1,2). However, courts have long recognized that a physician-patient relationship exists when radiologists perform diagnostic tests and also recognized is the radiologist’s responsibility for directly communicating some abnormal test results to the ordering physician and in some instances, such as screening mammography, to the patient (3,4). However, diagnostic radiologists rarely interact with patients and for the most part do not determine and execute management plans directly with patients (5). That is the background in which IR developed. Interventional radiologists have recognized that their services differ considerably from those of diagnostic radiologists and the specialty has evolved considerably because of that reality. IR has become an important therapeutic specialty for a variety of disease processes and the practice of IR always entails consideration of percutaneous treatment options rather than simply diagnosis. This has mandated that interventionalists welcome patient contact, including preprocedure evaluations and long-term follow-up after therapeutic procedures. The realization that IR would become a bona fide clinical specialty occurred long ago and interventionalists have been exhorted on a number of occasions to that end (6–9). There is evidence that many interventionalists have embraced clinical responsibilities in their practices, such as admitting patients to IR services, conducting outpatient office hours for evaluation and management, employing nurse practitioners and physician assistants, joining traditionally clinical departments, and working with other clinical specialists in joint clinical ventures (10). But has the doctor–patient relationship in IR evolved to one that is consistent with clinical medicine? Unfortunately, most interventionalists have eschewed the accountability and responsibility to their patients required by the profession of medicine, regardless of the trappings of clinical practice they have developed. Most interventionalists do not answer primarily to their patient but, like diagnostic radiologists, believe that their primary duty is to the referring or “ordering” physicians (5). Although the interventionalist may see a patient in an outpatient setting before invasive therapeutic procedures are performed, take a history and perform a physical examination, and obtain informed consent that includes all of the therapeutic options, it is often the referring doctor who directs care. If there is disagreement about the implementation of standard interventional therapies, it is my belief that the vast majority of interventionalists defer to the referring physician in routine medical decision-making, without further consultation or explanation to the patient. Indeed, it is common practice among interventionalists to break scrub and call the referring physician to ask “permission” to provide standard and clearly indicated interventional therapies, even after they have informed the patient of the treatment options and obtained their consent. It is also common for the patient and interventionalist to agree on a standard treatment and for the ideal treatment situation to exist after the diagnostic part of the procedure, but for the service to not be provided if the “ordering” doctor does not want it. Why is that so? Radiologists traditionally have depended on referring doctors for their access to patients and, therefore, their livelihood. Interventionalists, like diagnostic radiologists, in most cases practice as though they serve the referring doctor first and the patient second. This is a conflict of interest. There are numerous conflicts of interests in medicine, such as physician financial interest in their research, payments to physicians for “education” of drug company representatives who are permitted to see patients with the physician, payments for the enrollment of patients on new medications as part of corporate pseudo-studies, vacations for “consultants” meetings that often include honoraria, and financial inducements by managed care organizations to reduce access to expensive care. Unfortunately, all such conflicts From the Division of Vascular & Interventional Radiology, Department of Diagnostic Imaging, Rhode Island Hospital, 593 Eddy Street, Providence, Rhode Island 02903. Received and accepted November 18, 2002. Address correspondence to T.P.M.; E-mail: tmurphy@lifespan.org