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3. Distinguish the role of a research and education foun­dation in defining the future of a specialty.

4:35 p.m. What Will You be Doing in 10 Years? Panelists: Gmy}. Becker, MD

Miami Cardiac & Vascular Institute

Miami, PL

Robert L. Vogelzang, MD

Northwestern Memorial Hospital

Chicago, IL

Peter R. Nluelfer, MD

Massachusetts Geneml Hospital

Boston, MA

Gary}. Becl?er, MD

Miami Cardiac & Vascular Institute

Miami, PL

We physicians are most comfortable when we feel in control. All of our lives, we plan, we anticipate, we strive to attain our educational goals, and we organize our personal and professional lives. All this we do to achieve predictable results: acceptance into the medical school and residency of our choice, happy marriage and family, the job of our dreams in a choice location, and profes­sional satisfaction. In truth , this utopian ideal has be­come increasingly difficult to achieve. Reasons include mounting governmental regulation , competition be­tween specialties, the malpractice insurance criSis, man­aged care dominance, and erosion in the public's confi­dence in phYSiCians, to mention just a few. Nevertheless, we try. As we reach for the ideal in our work, the internal compass that guides us is influenced by our profession­alism, our education and training, and Ollr experience.

After we leave the safe haven of medical school and postgraduate training, we all encounter cases, disorders, medicines, procedures, and situations that are unfamil­iar. We interpret them through the prism of our own professionalism, education and training. As the years pass, our early education and training recede into the distance. In order to avoid what former Dean Walter Daly of the Indiana University School of Medicine used to call "creeping obsolescence", each of us must bolste r his/ her foundation with new knowledge and new expe­riences. Yet surprisingly, for people who should be re­sponsible clinicians and scientists with an objective view of new information, we phYSicians obdurately adhere to dated dogma and seek refuge in the familiar, even as we shun the very new knowledge that is essential to both our professional futures and the well-being of our pa­tients. There are many reasons; however, central among them is the fact that change forces us out of our comfort zone, where we are (relatively) happily in control of our lives and our professional practices. Are there other reasons? Indeed there are. We haven't enough time or energy, we fail to recognize the relevance of certain new

knowledge, and we are so overwhelmed with the sheer volume of new information that we fail to sort and prioritize. Yet embrace change we must, because today's accelerating pace of development just in molecular im­aging, genomics, proteomics, bioinformatics, image­guided intervention (IGI), and evidence-based medicine threatens us, not with creeping, but rather with "gallop­ing obsolescence". Indeed, the rapid pace of develop­ment is outstripping ollr capacity for accommodatiml and for timely appropriate responses in the areas of lawmaking, ethical discourse, research study design and methodology, and updating of educational content in postgraduate residency training programs.

Yet with all of the aforementioned as a warning, it still remains clear that we physicians who subspecialize in Interventional Radiology (IR) can justly claim bragging rights as some of the most innovative and adaptable of all physicians. After all, our young subspecialty com­prises a diverse array of procedures that have evolved as minimally-invasive alternatives to conventional surgelY, with the aid of both rapid advances in imaging and catheter-based technologies and the ingenuity of re­searchers and practitioners. Examine a week's worth of daily procedure schedules at your institution. Compare the schedules with those of a decade ago. How many similarities do you see? How many differences? Were you placing port catheters a decade ago? Were you doing UFEsl Were you involved in endografting? Radio­frequency ablation? Carotid stenting?

Future IR will demand of us even greater innovation and adaptability. What will you be doing ten years from nowl That will depend upon: 1) who you are and what you are doing today, 2) how well you keep pace with the biological and technological advances that will both shape our field and intersect with various other disci­plines in clinical medicine , and 3) a number of external forces, including the national healthcare agenda, access to care and our nation's acceptance or rejection of the single payer model (national health insurance), account­ability to the public, the rise of evidence-based medi­cine, the available workforce, competition between clin­ical diSCiplines, the influence of pharmaceutical and medical device manufacturers, practice group size and philosophy, local politics, and Web-empowerment of patients. In the pages that follow, I will predict what you will be doing in ten years by analyzing you and your practice according to each of the aforementioned three factors. Each of the following sections is organized ac­cording to factor 1, "who you are and what you are doing today".

Academician·Basic Researcher If you are an academician whose primary emphasis is basic research, then you will not only experience, but will likely be on the forefront of landmark changes that will occur in the next ten years.

For basic research in JR, opportunities will abound in the pre-clinical study of 1) image-gUided application of

radiofrequency (RF), microwave (MW) , and high-inten­sity focused ultrasound (HIFU) energies for the ablation of neoplasms; 2) chemoembolization; 3) combination therapies; 4) molecular imaging and molecular image­guided intervention; 5) genomics; 6) proteomics; 7) bioinformatics; and 8) new interventional methods for targeted gene therapy and tissue engineering in vascular disease, cancer, diabetes, dyslipidemias, blood disor­ders, neurological diseases, and a variety of inherited deficiency syndromes. It will be important for research­ers with roots in diagnostic imaging to keep abreast of these changes, as effective therapies will be increasingly determined by molecular signatures of disease. More­over, novel strategies to combat them will draw on elements of molecular biology, imaging, proteomics, and artificial intelligence.

The most important actions basic IR researchers can take to remain on the forefront of the dramatic changes of the coming decade will be to actively involve them­selves in collaborative research with investigators from other disciplines and to support initiatives aimed at ex­panding federal funding for biomedical research. Con­cerning the former, interdisciplinary collaboration is cen­tral to Director Zerhouni's new NIH Roadmap for Biomedical Research. Basic IR researchers should aim not only for supportive roles in the research of others, but also for primary investigatorships. Concerning the latter, since external pressures continue to force upon academic medical centers (AMCs) the establishment of a more clinically competitive orientation and thereby threaten the academic mission, federal research funding of basic researchers will increase in importance. In this regard, the recent major increase in the budget of the National Institute of Biomedical Imaging and Bioengi­neering should help. In addition, grantsmanship work­shops and new programs to teach research methodology and to promote mentoring will be provided by profes­sional radiological societies in the coming decade, both alone and in cooperation with experts from other disci­plines. These efforts should help to increase the success of federal grant applicants.

Academician-Clinical Researcher If you are a clinical researcher in IR, then chances are you are also heavily involved in the clinical care of IR patients at your institution. It will come as no surprise to you, then, that I predict your "practice mix" in ten years will comprise vanishingly little in the way of atheroscle­rotic vascular disease and a predominance of cancer. That intervefltional cardiologists and vascular surgeons have launched a major offensive in the peripheral and non-coronary vasculature is not exactly cause for a me­dia alert. Both the AAVS-SVS 0, 2) and the ACC have taken steps to formalize their involvement in "endovas­cular surgery" (peripheral or non-coronary vascular in­terventions). The casualties being inflicted on IR pro­grams are monumental. In the end, vascular intervention will be a clinical endeavor involving a heterogeneous

bunch of practitioners with backgrounds in Vascular SurgelY, Interventional Cardiology, IR, and Vascular Medicine. A diminishing role for IR is unavoidable. These changes have been fueled by the medical device industly, which views IR as a discipline that innovates and Interventional Cardiology as the discipline that makes markets.

But don't despair. Remember that ours is a diSCipline fueled by innovation and new frontiers. That cancer is the new frontier should be evident to all by now. For­tunately, the stars are aligning to make for great suc­cesses among clinical IR cancer researchers in the next decade. The Institute of Medicine has been hosting a series of workshOps aimed at addressing the challenges facing the clinical research enterprise. They have ad­dressed specific stakeholders, including government and non-government funding agencies, AMCs, professional societies, healthcare purchasers and payers, and health­care delivery systems (public and private), contract re­search organizations (CROs), practice-based researchers and networks, public health departments, manufacturers of pharmaceuticals and medical devices, community health centers, investigators, subjects, and regulatOlY en­tities (3). The aim is to overcome two translational blocks: 1) impediments to the translation of basic science into clinical study, and 2) impediments to the translation of clinical studies into medical practice and health deci­sion making. Within NIH, workshops have been held (4) and others are being planned to address methodological issues that are unique to the study of image-guided interventions (IGO (5). In addition, there are plans either to add clinical IGI studies to ACRIN or to initiate ACRlN­

like studies of IGIs within the Cancer Imaging Program (CIP) of NCI. On the negative side, history tells us that clinical research is under-funded by NIH. Here again, don't despair. There are several initiatives are underway to address this problem. The 10M workshops are one. Zerhouni's roadmap is an important second. Addition­ally, radiologic societies are launching initiatives to cre­ate a database of clinical researchers willing to serve on NIH study sections. They are also making plans to initi­ate and/or participate in workshops aimed at teaching fellows and young faculty about clinical oncology trials and how to design them. In summalY, the outlook is rosy for clinical IR investigators who desire a future in onco­logic intervention.

Academician-Health Services Researcher Of you , there are sparingly few. However, your impor­tance is expected to increase in the next decade. Out­comes research and technology assessment will find a comfortable future in the era of evidence-based medi­cine. Therefore, I anticipate and predict that you will be thriving ten years from now as you have never thrived before. The aforementioned 10M initiative and other initiatives of the NIH and the radiologiC societies will create important roles for health services research in IR and in all of Radiology.

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Academician-Educator The year is 2014. You are the Program Director of an ACGME-accredited IR fellowship training program in your institution. Ten years ago your program of four slots matched only two trainees. At that time, your department chairmanship was filled by an interim chairperson, and the search was on. The national workforce in Radiology was still behind 6-7% and IR fellowships elsewhere were not filling either. The chairman of the Department of Surgery at your institution managed to convince the dean that you had to offer training in non-coronary endovascular interventions to the fellows in Vascular Surgery. To support that position, the Surgery chairman cited current ACGME language that requires Vascular Surgery trainees to have endovascular experience (1).

He also presented the endovascular training program endorsement essentials of the SVS/AAVS (2). You fought that decision on the basis that the Vascular SurgelY fellows have a complete lack of foundation in imaging. In the end, your pleas were not heard, and you were forced, against your will, to do as the dean demanded. Now on days when you are training the vascular surgical fellows, you have a scowl on your face. At the same time in your department, similar problems were unfolding in the training of neurologists in the field of Endovascular Surgical Neuroradiology. You have a medical student serving a one-month rotation on your service. Even in that short month, she has developed a distaste for the turf struggle between IR and Vascular Surgery. She says she will not be inclined to consider IR or Vascular Sur­gery for a career. Sadly, there is not enough time to show her all that is still interesting and exciting about Inter­ventional Radiology.

Community Practitioner of ffi-Large Practice with Subspecialization The year is 2014. You arrive at work in the morning, and your schedule is as follows:

0700 Tumor Board conference

0800 Robotic-assisted biopsy of PET-CT hot area of lung nodule

0900 Renal artery stents for bilateral ostial stenoses and creatinine = 2.4

0945 RFA, 2 cm renal cell carcinoma

1100 Port catheter placement in patient with non­small cell lung CA

1200 Chemoembolization for recurrent hepatocellular carcinoma

1345 HIFU for 1 cm prostate CA identified by PET-MR

1515 HIFU of uterine fibroids

1430 Medical liver biopsy for Hepatitis C

Your add-on unscheduled procedures for the day are: 1) an IVC filter in a patient with iliofemoral deep vein thrombosis and a glioblastoma multiforme, and 2) an emergency angiogram and micro coil embolization for

colonic hemorrhage following colonoscopic polypec­tomy.

You are successful for a number of reasons. First, your group practice is committed to a subspecialty phi­losophy, in which the infrastructure required to succeed in IR is understood by all partners. You have clinic hours two afternoons per week, and you have the space and personnel to conduct your clinical activities with ease and confidence. You and your interventional colleagues run your own clinical coverage schedule and call sched­ule. You've deliberately involved yourself in all of the new treatment modalities through your program of life­long learning and self-assessment. You have completed all your requirements for maintenance of certification (MOC), passed your ABR MOC cognitive examination in IR, and received your new certificate. You have stayed current with the literature. Web-surfing patients and their families often find you on the Internet, where you are listed among other specialists who treat cancer, uterine fibroids, venous insufficiency, renovascular hyperten­sion, and claudication due to peripheral arterial disease (PAD). The patients and families are also able to view your treatment results in an online database.

Six years ago, you lost a credentialing battle with tme vascular surgeons at your hospital, in which they SU'C­

ceeded in obtaining endovascular privileges to perform most of the procedures that used to occupy your days 10-15 years ago. As a result of that loss, the Radiology contract with the hospital has been modified. Vascular surgeons are now permitted to schedule and perform elective procedures in the IR department. Shortly after that, a few of the interventional cardiologists applied for and received delineation of privileges to perform non­coronary vascular interventions. You still do endovascu­lar arterial work for several of the internists, and for a few of the noninvasive cardiologists and nephrologists. You are involved in very few clinical trials of new vascular devices and interventions. In your daily practice, you are able to meet other new patients who present to the depaltment for MRA or peripheral arterial noninvasive studies (PVRs and Doppler). Typically, you speak with their primary physicians at the time of the visit, and educate the patients as to their condition and treatment options. Often the result is a scheduled office consulta­tion and possible renovascular or peripheral vascular intervention.

As a result of your loss of the endovascular exclusive at your hospital, you are no longer obligated to automat­ically accept every call or consult for a PICC line or central line. Instead, you turn down procedures you don't want to do or more often simply don't have the time or resources to do. That's one small freedom in which you now bask that others have basked in for years. It seems an important freedom, though, since the counby is now headed toward approval of a single­payer system of national health insurance, under which most, if not all financial incentives to do procedures will soon disappear. The inpatient consults you accept are

usually seen first by your physician's assistant. The case

history, physical findings, laboratory results and imaging

findings are reviewed with you. A disposition is then

made. You have two other totally dedicated IR partners, with whom you share call and clinical service responsi­bilities. Life is good.

Community Practitioner of ffi-Medium-Size Practice without Subspecialization The year is 2014. You arrive at work in the morning, and

your schedule is as follows:

0700 PICC line for antibiotics in patient with osteo­

myelitis

0745 Diverticular abscess drainage

0845 Port catheter check; possible lysis

0930 Lysis (mechanical or chemical) of a thrombosed

dialysis access

1100 FNA lung biopsy in patient with COPD and

solitary 1.5 em nodule

1200 PICC line for antibiotics in patient with infective

endocarditis

1300 Percutaneous gastrostomy in obese patient with

previous stomach surgery

1415 Uldall dialysis catheter placement following failed attempt in OR

1530 PICC line for antibiotics in a patient with pneu­

monia

You are finding it difficult to succeed in IR for several

reasons. First, your eight-person group has not yet em­

braced a philosophy of subspecialization. Not only don't

you have an IR partner among them, but you 're not even doing full-time IR. The group has permitted you to in­

crease your percentage of time committed to IR each

year and you are now up to 60%. You don't have office 'hours or any physician extenders. You are required to take general Diagnostic Radiology call, in addition to your IR call, so you are exhausted most of the time. You are too tired to do your lifelong learning and self-assess­

ment activities, and you haven't studied for your MOC

examination in IR, even though the date is rapidly ap­proaching.

You don't have admitting privileges. You have lost all

of the vascular interventional credentialing batdes to the

cardiologists and vascular surgeons. Your number of

arterial interventions per month is now approaching

zero. You have no direct line of communication with the

hospital administration. Although you are in need of

new imaging eqUipment, your department chairman was

unsuccessful in getting it onto the budget. Meanwhile, a

fixed angiography stand with digital roadmapping and

the latest post-processing software, just like the one

installed last year in the cardiac catheterization labora­

tory, is now being installed in the operating room.

Summary In the decade ahead, both academicians and clinical practi tioners of IR must embrace major changes in order to succeed in their endeavors, achieve professional sat­isfaction , and continue advancing the subspecialty. All IR professionals must recognize that in the future , vascular interventions will be performed by physicians from sev­eral disciplines. The major new growth area is in IR is interventional oncology. Basic and clinical researchers must pursue collaborative interdisciplinary investigation, in order to stay abreast of new advances, follow the new NIH roadmap for biomedical research , and garner the necessary research funds. For IR to thrive in the commu­nity, practices must adopt a philosophy of subspecial­ization; support their IRs with clinic time, space, and personnel; hire physician extenders; and encourage in­dependent responsibility for IR scheduling and call cov­erage. IRs must stay current in all of the newest treatment modalities, and fulfill the requirements of the ABR's MOC program.

References 1. Program requirements for residency education in Vas­

cular Surgery. Effective January 1, 2000. ftp :!/www. acgme.org/RRCprogReq/450pr100.pdf. Accessed 09-29-2003.

2. Endovascular training program endorsement essentials of the SVSI AA VS Endovascular Program Evaluation &

Endorsement Committee (EV-PEEC). http://www. vascularweb.org/file/EV-PEEC_1-11. pdf. Accessed 09-29-2003.

3. Sung NS, Crowley WF Jr, Genel M et al. Central challenges faCing the national clinical research enter­prise. JAJ\lIA 2003;289:1278-1296.

4. Vannier M. Final report of an NIH/NSF workshop on image-guided interventions, Sept. 12-13, 2002, Be­thesda, MD. http://www.nibib1.nih.gov/ events/ IGII IGIWorkshop2002JINALReport.pdf. Accessed 09-29-2003

5. Dorfman GS, Sullivan DC. Personal communication.

5:05 p.m. Debate

5:20 p.rn. Nanotechnology Julio C. Palmaz, MD The University of Texas Health Science Center San Antonia, Texas

The term nanotechnology is perhaps a misnomer in this context, because it refe rs to fabrication in the nanometer scale (10- 9 m). Perhaps more accurately, these tech­niques should be described as microtechnology, since they deal with dimensions in the micron scale (10-6 m). However, the term has been popularized as technology related with microscopic electromechanical systems and has been widely adopted in this area.

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