Helping interventional radiology patients through a culture of clinical research
By Suresh Vedantham, MD, FSIR Summer 2017
Interventional radiologists uniquely evaluate each patient’s distinctive anatomy, physiology and clinical phenotype and target our intervention to what that one person needs. If personalized medicine is the future, well, we got there first. The “interventional mindset” is inherently experience-based—we improve clinical care through a process of leveraging that experience, and sometimes those of trusted colleagues, to find new ways to individualize care.
This flexibility constitutes a crucial value-added dimension that IR contributes to the health care system. However, we are sometimes at a loss on how to integrate evidence-based medicine into our clinical decision-making. We know that rigorously designed studies minimize bias and enhance the statistical precision of our estimates of the effect of IR treatments. But our interventional minds naturally split and lump our patient populations into infinite microcategories that may each require different approaches. We can feel frustrated when data seems to contradict our observations.
With that tension in mind, I offer a few ideas that may support our ability to use research to benefit IR patients and improve our clinical practices.
First, we must be sufficiently humble and self-aware to recognize that our observations are not always objective. Both explicit and implicit forms of bias can enter into play when we self-evaluate our own impact upon patient care.
Second, clinical trial results and clinical practice guidelines are like traffic rules and street signs. Generally, you stop at a stop sign . . . but not if an oncoming bus swerves toward you. Trial results and guidelines should always be interpreted in light of an individual patient’s situation, and deviations are certainly appropriate in some situations. Questions to be asked: Was the trial really evaluating the same indication for therapy as my current patient? Did it use a similar intervention? Did the trial patients differ in some important way? That said, we certainly should not tie ourselves in knots trying to find ways to explain away disappointing or unexpected trial results.
Third, the best way to become comfortable with evidence-based medicine is to actively participate in developing that evidence. SIR has so many talented members doing terrific clinical work in diverse practice settings, and it is crucial for their results to be included in the clinical trials that will represent IR care to the world. Some members present their work at meetings, but relatively few publish the work in medical journals. IR is also underrepresented in obtaining research grants from NIH and other major sponsors.
Fortunately, there are now more opportunities than ever for us to address these challenges. SIR Foundation has a diverse portfolio of grant opportunities for young investigators and continues to seek new mentorship models to develop the investigators of the future. The IR Registry provides an easy way for clinicians to efficiently have their clinical outcomes counted in quality and research initiatives. It is so important that practicing IRs participate in the Registry to enable us to objectively show our value to others.
Just as “more speech” is the best way to reduce the impact of offensive speech, doing more studies reduces the chance that one unexpected finding/study will carry the day in influencing physician and patient treatment preferences. Consider endovascular stroke therapy. Three negative pivotal trials (including a large NIH trial) prompted new technology and created a better understanding of the optimal target population, resulting in three subsequent positive trials that made endovascular stroke therapy the standard of care for acute stroke. More studies = better patient care.
Fourth, start using published IR research as an integral tool in your own practice-building efforts. The SIR website has a number of important resources to help you, including clinical practice guidelines, evidence summaries, toolkits and references to pivotal clinical trials.
Finally, let’s all agree to evolve toward a strong pan-IR culture of clinical investigation, spanning academic and nonacademic practices. If our cardiology and oncology colleagues can do it, why can’t we? The IR Residency will be bringing us a host of young investigators with bright clinical research ideas and hopefully also more formal research training from which to execute them. But, training aside, nothing will be as impactful to their efforts as the community and culture that stand behind them.
IR has come so far in developing a clinical care culture, let’s shoot for the stars and see our patients benefit both from our innovative, experience-based mindset and from our outstanding research accomplishments.