About three years ago, one of the cardiologists at Cape Cod Hospital in Hyannis, MA, asked interventional radiologist Philip Dombrowski to teach him how to do peripheral vascular work. Dombrowski's reaction: Over my dead body.
Over the next year-and-a-half the cardiologist took patients with peripheral vascular disease to interventional radiology programs in Boston, where he performed 150 supervised procedures to fulfill American College of Cardiology and Society of Cardiovascular and Interventional Radiology credentialing requirements.
Despite Dombrowski's opposition, the cardiologist obtained privileges to perform peripheral vascular procedures at Cape Cod Hospital, and, irony of ironies, the medical staff assigned Dombrowski to oversee the cardiologist's first 20 cases.
After seeing that the cardiologist did a pretty good job, Dombrowski decided to team with him to manage challenging cases, such as high-risk carotid stent placements and laser-assisted angioplasty in the superior femoral and popliteal arteries, and to carry out procedures that mesh cardiac catheter skills with traditional interventional techniques.
Now Dombrowski is forming a multidisciplinary center of vascular excellence that will include cardiologists, vascular surgeons, and interventional radiologists. It will offer complex cardiac procedures, such as aortic stent grafting. The aim is to create a program that will attract referring physicians and patients with vascular disease from all over Cape Cod.
"Working in a combined way, we've been able to do things we probably would be years away from doing, if ever, in a small community hospital," Dombrowski said. "We're getting involved with procedures that traditionally have been centered more in a teaching hospital setting or a larger community hospital. We've been able to accomplish more, working together in the last couple of years, than we would have if we had been trying to do it separately."
Cardiovascular imaging and treatment programs across the country are beginning to forge working relationships among cardiovascular subspecialists because they don't have any other choice, said Dr. Dieter Enzmann, chairman of radiology at Northwestern Memorial Hospital in Chicago.
"This is an inexorable trend, driven by the market and by science," Enzmann said. "Physicians from several specialties have to work out these collaborative efforts because no one specialty has the needed fount of knowledge and the extent of infrastructure."
Since healthcare, like politics, is local, there is no magic formula, no universal solution for overcoming turf issues. Each program has to find its way past the eddies of conflicting credentialing, training, and reimbursement concerns. Each program has to experiment on its own, relying on local leadership, culture, and a desire to make something happen, Enzmann said.
But if there is anything successful programs have in common, it is their history of collaboration and their ability to build bridges over specialty turf issues, via their common research activities.
HEART CENTER
The departments of cardiology and radiology at the University of Iowa in Iowa City have long collaborated closely in pioneering research on cardiac echocardiography, MRI, PET, and electron-beam CT. The joint research efforts generated a rapport and trust that led to a multidisciplinary heart center, which will be entrusted to handle diagnostic and therapeutic procedures, establish uniform standards for monitoring the performance and outcomes of cardiovascular procedures, unify subspecialist training, and foster new research.
For example, radiologists, cardiologists, and cardiac electrophysiologists at the University of Iowa are installing new technology that will produce maps of the cardiac conduction system and identify autonomous tissue that may be the activation site for arrhythmias. Research in cardiac MR will enable them to build exquisite cardiac anatomic models and clearly see venous drainage from the lungs and other related anatomy.
"In the future, we will have much more complete and robust computer graphic models of cardiac anatomy," said Dr. Michael Vannier, chairman of radiology.
Next January, Emory University in Atlanta plans to launch a cooperative vascular center involving vascular surgeons, interventional radiologists, and interventional cardiologists. The center will handle all vascular interventions from the base of the skull to the tips of the toes, excluding the heart. Cardiovascular specialists want to be able to do carotid angioplasty and stenting, renal angioplasty, endovascular procedures in the legs, and aortic stent grafting, said Dr. Louis G. Martin, director of interventional radiology.
Although vascular surgeons and cardiologists will be performing procedures that once fell almost exclusively to the interventional radiologist, still a nearly insurmountable turf issue at many institutions, radiologists at Emory see opportunities.
Radiologists will take clinical rotations in interventional cardiology and vascular surgery and as a result will be expanding their practice to include direct patient care in vascular clinics, in consultation with other cardiovascular specialists.
The multidisciplinary vascular center also will try to bring more vascular patients to Emory-for the benefit of radiologists as well as vascular surgeons and cardiologists, Martin said.
"The program we're instituting will make our presence known to physicians and patients throughout the Southeast. So the pot will grow, and we will share in the growth. We also will be sharing corporate funding and government grants for research projects that could not be done alone," Martin said.
NIH FACTOR
Cooperation between cardiologists and radiologists at Johns Hopkins University dates back to 1987 when physicians from the two specialties started conducting joint research projects on cardiac function. Although tension between clinicians and researchers was not unheard of, the researchers ignored their differences as they gained expertise in cardiology, radiology, and cardiac physiology.
The department of radiology collaborated with cardiac medical specialists, basic scientists, and biomedical engineers in a series of clinical trials to compare echocardiography and cardiac MR in the assessment of mechaical function, and to pit nuclear medicine techniques against contrast-enhanced MR.
As Dr. Elias A. Zerhouni, chairman of radiology at Johns Hopkins, points out, these trials set the stage for other joint activities.
"Isolated research doesn't hold water. To get a grant from the National Institutes of Health you need to have teams that work together. Then you're ready to start training and mentoring young doctors and post-doctoral fellows. So you create a joint education program. By the time you get to clinical practice, you've developed ways of collaborating that are almost second-nature," he said.
Nonetheless, forging relationships among specialties is tricky. Successful partnerships take time and patience, and require more than politics to get a foot in the door. Each group must add value to the effort with their personalities and skills, Enzmann said.
Financial issues can be a stumbling block.
"The problems involved in getting this kind of integrated service going are enormous, and not just on the physician side. Huge barriers rise up on the reimbursement side, which spill over onto the physician side, because you have to figure out a way to split payment in a fair way," Enzmann said.
Collaboration among cardiac subspecialists, like those in Iowa, Georgia, and Maryland, doesn't happen in a vacuum.
"These are not ad hoc snapshot situations; they are part of a dynamic process that relates to the cycle of technology and medicine in general," Zerhouni said.
When a new technology challenges the conventional way of treating patients, at first it is considered to be disruptive or even risky, and its use is highly restricted. But gradually, it becomes more refined and acceptable, and new techniques start confronting older ones and pushing them aside.
"When an established clinical field is threatened, its practitioners protest. 'Wait a minute,' they say. 'If I can't do this, I'm going to be irrelevant in the next 12 or 15 years.' So physicians redirect their attention to emerging technology and start figuring out ways to handle it," Zerhouni said.
For example, an endovascular center employs new specialists, called angiologists, who take care of patients, while surgeons perform procedures. But everybody works together as a team and shares the risks and the rewards, Zerhouni said.
"There still is some paranoia," he said. "People in radiology say cardiology is going to take over everything, and the cardiology people say the opposite. But we have to keep that under control. The collegial approach is the better way to go."
And if the focus cannot always be on collegiality, then it should at least be on professional survival.
"There may be a struggle for a while, but in the end healthcare needs to respond to the market," Enzmann said. "If the market demands these integrated services, physicians will have to find a way to provide them, no matter now much they dislike the prospects."
MS. SANDRICK is a contributing editor to Diagnostic Imaging.
