Mina S. Makary, MD

Interventional Radiology has grown exponentially in recent years. Embolization procedures were first performed in 1970. Three years later, balloon angioplasties were being performed. Then, in the 1980s, complex interventions, such as Transjugular Intrahepatic Portosystemic Shunt (TIPS) placements were introduced

. These therapies are now offered in nearly every hospital. Such growth has been facilitated by advances in technology, combined with the creativity of practitioners. Evolving advances in augmented reality, artificial intelligence (AI), imaging modalities, robotics, and procedural techniques will play a big role in the future and facilitate further exponential growth.

In augmented reality, virtual images can be seen alongside real images. In contrast to virtual reality where the field of vision includes no real images, augmented reality offers the ability to maneuver objects and interact with the real world. This powerful development has wide-ranging applications for image-guided interventions. For example, an interventional radiologist could visualize vital signs within the same field of vision, overlying the patient during a critical intervention. These numbers could potentially appear on command when performing a key step of a procedure or when the radiologist has a concern.

Augmented and Virtual Reality – Radiology at the Center of Medical Technology

Needle placement or a procedure with an image-guided device is another application. For instance, the operator could also view a fused ultrasound image, during simultaneous visualization of needle insertion and ultrasound probe manipulations. Augmented reality can also be used to visualize anatomy underneath procedural drapes to guide an intervention when there is poor sonographic penetration or fluoroscopic guidance is insufficient. For example, a projected 3D hologram, recreated from a pre-programmed CT scan, can help the radiologist identify – and avoid – key structures during a percutaneous intervention, which may otherwise be invisible.

Recent developments in AI represent additional revolutionary opportunities of growth in the current and future practice of image-guided interventions. Utilizing AI, outcomes of interventions can be more accurately and quickly predicted, improving patient outcomes. Machine learning algorithms will be able to augment the interventional radiologist in guiding treatment decisions and selecting patient populations that would benefit most from interventions in areas, such as interventional oncology, where multimodal therapies abound.

Other future applications will include intraprocedural augmentation for the interventional radiologist. AI will enhance image guidance through anatomical recognition, to facilitate interventions and guide the operator through complex anatomy. Lastly, promising applications exist in the treatment of patients requiring time-sensitive interventions. Conditions, such as strokes and pulmonary embolisms, have been described to benefit from AI’s impact on expediting recognition and throughput to improve patient outcomes

Furthermore, continued enhancement of current image-guidance modalities and development of new ones will enhance future procedural practice. Limitations of current imaging modalities in interventional radiology include two-dimensionality and, oftentimes, radiation exposure. One new imaging guidance modality currently being pioneered is Fiber Optic RealShape (FORS)

. This imaging technology utilizes catheters embedded with light sensing technology. Currently, physicians are challenged by tortuous and diseased vasculature, which is difficult to visualize in 2D and often presents technical challenges to operators driving the catheter. Technologies, such as FORS and other evolving modalities, could optimize vascular imaging guidance, drastically decrease the procedural time, and radiation exposure for interventions, drastically increasing the safety for patients and practitioners alike in the future.

Another area with future potential in imaging-guided interventions is robotics, which has already been integrated into many fields of medicine. Oftentimes, in order for robotic systems to flourish in utilization, there must be a proven clinical benefit. For example, the DaVinci Surgical System results in smaller incision sites and higher surgical accuracy. These factors justify the cost.

Robotics have been applied to many endovascular procedures. Uterine artery embolization, cardiac ablation, and aneurysm repair have all been successfully performed with robotic navigation systems. Radiographic procedures are uniquely positioned to benefit from robotics due to added benefits to the operators. The interventionalists can work in a separate room from the procedural suite, thereby shielding them from radiation exposure and musculoskeletal injury from heavy protective aprons. More research, however, is needed to justify the cost of such systems, but it is expected that robotics will become more prominent in interventional suites. It is essential that benefits to the operator safety will not compromise patient outcomes, and quality-control studies continue to be rigorously applied and performed.

Lastly, the scope of practice of interventional radiology itself is expanding, as well. In addition to advancements in existing procedures and techniques, interventional radiologists are developing new procedures to address conditions, such as arthritis, obesity, and benign prostatic hypertrophy. Many of these procedures have been validated in small scale clinical trials. Chronic arthritis pain is being managed through embolization of hyperemic synovial tissue

. The left gastric artery has been embolized to decrease fundus blood flow, thereby restricting growth of ghrelin-producing cells and decreasing appetite

. Radiologists can also treat lower urinary tract symptoms through decreasing the size of the prostate with embolization

. Endovascular approaches continue to be identified as a way to treat conditions formerly managed with invasive surgeries and medication therapies. The future is bright as the value proposition of interventional radiology offering minimally invasive, high-quality, low-complication, cost-effective therapies aligns extremely well with the future of medicine and healthcare.

In summary, advancements in technology will foster improvements in efficiency, efficacy, and safety for interventional radiology and image-guided interventions. The degree of innovation and changing practice patterns will continue to be exponential, alongside exponential growth in technology. Interventional radiologists will be presented with ample opportunity to adapt and invent. This is an exciting challenge, and will mean a brighter future for patients.

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Articles

From augmented reality to virtual reality to robotics to new procedural techniques – the future of interventional radiology is bright.

Future Trends and Technologies in Interventional Radiology: What to Expect

Maintaining personal wellness and preventing professional burnout have an established role in the modern medical theater. The World Health Organization differentiates personal wellness from health as it involves fulfilment and realization of that person both as an individual “physically, psychologically, socially, spiritually and economically” and their perceived role in their social circles.

This heady definition attempts to simplify esoteric components of an extremely personal idea of mental health and satisfaction that really can only be identified by that individual. Burnout on the other hand is a more specific syndrome: emotional exhaustion from stress on the job, de-personalization and detachment from patients, and a demarcated shift in projections of professional self-worth and competence

. Physicians are particularly vulnerable to experiencing burnout and sacrificing their personal wellness for their job, with radiologists facing challenges unique from their colleagues.

These vulnerabilities have only been stressed by recent accommodations necessitated by the COVID-19 pandemic’s strain on the healthcare system. Recent surges in radiologist burnout have raised alarms concerning compromised patient care and deteriorating provider wellness

. Despite these challenges, there are simple practices that the individual can take to help combat the decline of their personal wellness and stave off burnout even with the added stress of the current health emergency.

There are many factors contributing to the rise in work fatigue and declined wellness in radiology. Institutionally, the paradigm of patient-centered physician values and the growing push for productivity and cost/revenue control by the hospital and insurance industries can produce cognitive dissonance

. Specific to radiologists, an increasing emphasis on reading speed and studies per day has resulted in an accumulation of more burnout than ever with rates of burnout symptoms hovering around 50 percent by some measures

Additionally, as patient care and quality control measures get more complex, the burden of work for physicians before care can be performed has become somewhat daunting. Some may feel that more of their time is spent maneuvering bureaucratic tape than performing radiology and medicine

. As more is expected out of radiologists during the workday, the corners that are cut can frequently be those that preserve wellness, such as lunch breaks and diverse time for academics or research. Radiology inherently lends itself poorly to much meaningful personal interaction on the day-to-day with either patients or other faculty. For some, this can be a source of fatigue and should be addressed. With these challenges in the forefront, a radiologist’s risk of facing deteriorating personal motivation and wellness in the modern age of medicine is substantial.

Radiology residents face different challenges from their full-fledged attending physician counterparts and suffer from substantially increased rates of burnout ranging from 40 percent to 80 percent – a level greater than either medical students or physicians

. They still have to deal with all the same issues that practicing radiologists do, but with the added stressors of being in the middle of a chain of educators -- being both student and teacher and being expected to internalize great amounts of information and balance that learning and teaching with their patient responsibilities.

Radiology residents have some of the worst rates of burnout of all fields. Nearly 85 percent of trainees experience some decline in emotional wellness, feelings of personal accomplishment, and other affects consistent with burnout

. This article by Mendoza and Bertino cites tedious training modules, long hours, and low levels of social interaction responsible for producing this number. Residents are also more vulnerable to feelings of inadequacy due to imagined and actual perceptions of being inexperienced.

Resident radiologists are set up to burn out during their training and carry that vulnerability into their working careers. Reinforcing the wellness of their trainees should be a high priority for programs not simply to encourage enrollment or placate concerns of overworking, but to facilitate learning and promote good practices for burnout resilience during and after residency.

While burnout and wellness statistics among radiologists, both attendings and trainees, have been morbid in recent years, the onset of practices to combat COVID-19 has disrupted even those with otherwise stable personal wellness. With long work hours and limited personal interaction already being the cause of much of the burnout radiologists currently experience, the social isolation and increased need for personnel that the pandemic brought on has surely only made this worse.

Studies looking at previous endemics and pandemics have revealed that not only is the populace at large exposed to increased mental stress, but physicians have increased rates of mental distress and even post-traumatic stress disorder following participation in managing these outbreaks

. Between the looming threat of infection and the increased scrutiny by the public and public health officials, stress levels are at an all-time high. Even though much of the public sentiment is positive regarding “healthcare heroes,” those that feel that the title is unwarranted or unfulfilled may have their self-worth damaged by the additional expectations.

Additionally, harassment by social media conspiracy activists claiming mask exemption, pandemic hoaxes, and other similar falsities may exacerbate feelings of not being able to effectively control the outbreak while individuals refuse to follow guidelines. While the focus is appropriately on patient care and increased demands during the ongoing outbreak, attention should still be directed towards maintaining wellness.

Addressing burnout and maintaining wellness can be targeted either at the institutional level or by the individual. Institutions have a vested interest in keeping their workforce healthy and fully functional. Constant interruptions and long hours lead to burned-out physicians and overlooked mistakes

As for residents, while many programs may try to implement mandatory wellness lectures or provide meditation services and other such at-will avenues to increase burnout resilience, only work-hour limits have been strongly associated with improvement in emotional exhaustion and burnout

On the individual level, many small practices can be integrated into daily life to preserve wellness and prevent oneself from being burned out. Drs. Fessell and Cherniss suggest a small list of “micropractices” to help strengthen resilience to burnout and keep wellness balanced

. These are things like diaphragmatic breathing and taking a “moment for mindfulness:” this means taking a moment to reflect inwards when doing something like hand washing, centering oneself, and analyzing their current state. This allows a chance to address feelings from the last case or make sure that personal needs are met.

Another such micropractice involves naming complex emotions as they are experienced to aid self-awareness and facilitate a return to calm. Lastly, sharing cases and frustrations with peers is a great way to acknowledge that others are facing similar problems and get practical tips to internalize

. These are things that must be consciously done regularly to keep wellness a priority during a complex and hectic workday.

Maintaining wellness can be a challenge even under ideal circumstances, let alone during a world-wide health emergency. Maneuvering the modern medical landscape of high demands, impersonal patient interactions, and complicated infectious precautions has produced a large burden of burned-out physicians. The challenges that radiologists face are different from their colleagues and require specific and deliberate attention.

Every radiologist should try to be more aware of the state of their personal wellness and take steps to remedy shortcomings and reinforce resilience to burnout. Sacrificing mental health and wellness in the name of patient care, dedication, or monetary gains in reality is harmful to both the physician and the patient. Burnout is not a burden that has to be borne, but it takes deliberate effort and acknowledgement by institutions and individuals.

1. Maslach, C., Jackson, S. E., & Leiter, M. P. (2018). 

2. Shah K, Kamrai D, Mekala H, Mann B, Desai K, Patel RS. Focus on Mental Health During the Coronavirus (COVID-19) Pandemic: Applying Learnings from the Past Outbreaks. Cureus. 2020;12(3):e7405. Published 2020 Mar 25. doi:10.7759/cureus.7405

3. Berg, S. (2020, May 28). The 12 factors that drive up physician burnout. Retrieved June 07, 2020, from https://www.ama-assn.org/practice-management/physician-health/12-factors-drive-physician-burnout

4. Cohan RH, Davenport MS. Productivity, Meet Burnout. 

. 2018;25(12):1513‐1514. doi:10.1016/j.acra.2018.08.001

5. Busireddy KR, Miller JA, Ellison K, Ren V, Qayyum R, Panda M. Efficacy of Interventions to Reduce Resident Physician Burnout: A Systematic Review. 

. 2017;9(3):294‐301. doi:10.4300/JGME-D-16-00372.1

6. Mendoza, D., & Bertino, F. J. (2019). Why Radiology Residents Experience Burnout and How to Fix It. 

(4), 555-558. doi:10.1016/j.acra.2018.08.009

7. Fessell D, Cherniss C. Coronavirus Disease 2019 (COVID-19) and Beyond: Micropractices for Burnout Prevention and Emotional Wellness. 

. 2020;17(6):746‐748. doi:10.1016/j.jacr.2020.03.013

The role of the pandemic and what radiology can do to mitigate its burnout effect.

Radiologist Wellness and Burnout in the COVID-19 Era

Medical errors are the third most common cause of patient mortality in the United States, following cancer and cardiovascular disease, affecting more than 251,000 patients annually

Errors in diagnostic interpretative imaging are a key contributor with an estimated day-to-day error rate of 3 percent-to-5 percent for all studies reported

. With 1 billion radiographic examinations performed annually worldwide, this would translate into 30 million-to-50 million interpretative errors per year. Given the significant patient implications, it is imperative that we continually attempt to identify and eliminate diagnostic errors as best as possible.

A common diagnostic error is termed “satisfaction of search.” With this error, a radiologist fails to continue to search for additional abnormalities after finding the first one.

 This error accounts for 22 percent of radiologic errors.

Using checklists is the classic remedy. A helpful checklist is well encompassing, but not too lengthy. It can reduce errors of omission by reminding the radiologist to take a second look at certain imaging features, particularly for “do-not-miss” diagnoses

. Additionally, working smarter by simply being mindful of diagnoses that oftentimes present in combination, such as multiple fractures, foreign bodies or vascular occlusions, can help reduce the likelihood of finishing a report too early before all of the abnormalities have been identified

Under-reading is another common diagnostic error, constituting up to 42 percent or more of all radiologist errors

. It occurs when an abnormality is present on the image but is missed and not recorded in the final report. Often, the abnormality is easily identifiable in retrospect, but it was simply not perceived at the time of primary image interpretation

While there is no definitive solution, several strategies can help reduce the frequency of this type of error. For example, image enhancement and post-processing tools can help optimize images and aid in reducing under-reading errors. An example of this is bone subtraction software being used to reduce anatomic noise and help visualize pulmonary nodules on chest radiographs. In addition to enhancing the image and reducing anatomic noise, artificial intelligence is becoming increasingly more useful at identifying abnormalities in the image itself. Computer-aided detection can help reduce the likelihood of missing some radiologic abnormalities, particularly in mammography and lung nodule detection on CT

The third key error that affects imaging care is failure of effective communication, which is often a key driver of patient adverse outcomes. Effective communication between the radiologist and the referring physician relies on clear and concise reports delivered in an appropriate and timely manner.

To improve the overall structure of the report, the American College of Radiology (ACR) Reporting and Data Systems (RADS) provides a standardized framework for reporting on imaging findings. This framework can reduce the variability between reports on a diverse range of disease processes. In addition to the content of the report itself, optimal time frame for communication is also an important aspect to consider as a source of error

. To this end, the ACR Actionable Reporting Work Group categorized findings in terms of optimal time frame for communication from most-to-least urgent, which provide guidance regarding the response times to improve interdisciplinary communication and patient outcomes.

Identifying major diagnostic errors and potential strategies to reduce their occurrence is a key step towards improving radiologic care. However, perhaps the most important factor to consider is the inclusion of meta-awareness in the education of future radiologists. Providing the next generation of radiologists with an understanding of their own limitations and biases may have the greatest long-term impact on reducing the frequency of diagnostic errors.

We must never lose sight of the fact that, as humans, we are prone to error despite our best intentions, and by acknowledging our fallibility and working diligently to change them, we will continue to improve.

Sources:
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	2. Brady AP. Error and discrepancy in radiology: inevitable or avoidable? Insights into Imaging. 2016;8:171–82.
	3. Bruno MA, Walker EA, Abujudeh HH. Understanding and Confronting Our Mistakes: The Epidemiology of Error in Radiology and Strategies for Error Reduction. RadioGraphics 2015;35:1668–76. doi:10.1148/rg.2015150023.
	4. Lee CS, Nagy PG, Weaver SJ, Newman-Toker DE. Cognitive and System Factors Contributing to Diagnostic Errors in Radiology. American Journal of Roentgenology 2013;201:611–7. doi:10.2214/ajr.12.10375.
	5. Waite S, Scott JM, Drexler I, Martino J, Legasto A, Gale B, et al. Communication errors in radiology – Pitfalls and how to avoid them. Clinical Imaging 2018;51:266–72. doi:10.1016/j.clinimag.2018.05.025.

Three causes of errors and three potential solutions to improve diagnostic accuracy.

Diagnostic Errors: Lessons Learned and Mitigation Strategies 

Augmented and virtual reality are among some of the newest technologies to reach a sophistication viable for medical use. Augmented reality (AR) is the integration of virtual components onto the background of reality, while virtual reality (VR) is a complete and isolated virtual display.

The most popular utilization of AR and VR is in entertainment devices, such as video games, but the versatility and responsiveness of the technologies have allowed for exciting developments in healthcare, as well. In some ways, it can be said that interventional radiologists have been using these techniques for their entire existence. In essence, anytime a fluoroscopic projection is used during a procedure, that is technically an augmentation of reality used to help visualize internal structures in real time.

Utilizing recent AR and VR technological advances, radiographic data can now be used to create a display with more integration and interaction. In addition to its utility in image-guided procedures, AR and VR have also found niche roles in the education of trainees and for direct benefits to patients, as well, though the technology is not without its drawbacks.
	
	One of the most promising uses of AR technology, specifically, is procedural planning and guidance. In the operating room, AR displays are generated using advanced algorithms that interpret CT data into a 3D map of structures delineated by density (Tang et al.). This map can, then, be displayed in several ways, such as on a screen nearby, through a headset, or projected onto the patient themselves depending on the needs of the procedure. Then, a plan can be drawn onto the augmented surgical field before the first cut.

Not only can structures, such as vessels and tumors, be overlaid onto a display of the surgical field, but organ movements and deformations can be accounted for in real time to update the display. This gives some compensation for the lack of tactile feedback during laparoscopic procedures and allows for a better real-time visualization of underlying structures. Tang and colleagues demonstrated the value of these displays for hepatobiliary surgery, but these techniques can be applied to just about any surgical procedure that can be planned far enough in advance.

AR projectors can already integrate navigation aids in MRI-guided procedures to assist in carrying out the procedure such as Mewes et al. describes. Wherever radiographic information exists before or during a procedure, AR stands to improve the integration of that information in the OR, and radiologists are the gatekeepers of this technology with their knowledge of medical informatics and mastery of radiologic anatomy.

With AR and VR already in the public consciousness as powerful tools of media consumption, it should come as no surprise that they have been quickly modified to work as compelling interactive forms of education. Progress has been made in developing AR tools for the advance of “tele-mentoring,” the use of displays to mentor trainees at long distance (Andersen et al.). AR allows for mentors to annotate directly on the student’s display so the trainee is no longer required to shift attention between a separate screen and their work and the training procedure can be done collaboratively. This system would also allow a more experienced interventional radiologist or surgeon to assist one doing an unfamiliar procedure without the need for transportation of the expert to the patient.

VR works as a training tool similarly to how it is used to consume media: allowing for a virtual simulation of a subject rather than just a video. New software allows for VR headsets to display a procedure to trainees to observe from anywhere. These students can see the surgical field from a 360-degree view or from the surgeon’s own perspective as each step is narrated, providing more immersion and detail than any 2D animation or lecture could. Interventional radiologist Dr. Ziv Haskal is pioneering this technique to teach complicated trans-jugular intrahepatic portosystemic shunt (TIPS) placement surgery (Barney). He demonstrates that even the most complicated and difficult-to-shadow surgeries could be shared nationwide and simulated through simple VR sets as a powerful teaching aid.

VR sets also have the potential to directly benefit the patient through simulated education and therapeutic benefit. Amazingly, therapeutic VR simulations have been found to reduce a self-reported pain score especially among those with more severe initial pain (Spiegel et al.). This represents an alternative to pharmacological therapy thought to work by distracting from nociceptive perception by fully engaging the other senses. Furthermore, VR can be used to walk a patient through their day at the hospital from check-in to procedure.

Dr. Haskal demonstrated how VR can be used to prep a patient for the same procedure he was teaching before -- a TIPS placement -- with the viewer getting checked in, visiting with their doctor, and being taught the procedure through the VR medium (Davis). Simple VR simulations like these can be programmed into a smartphone that many patients already have and viewed with the addition of a foldable cardboard headset, allowing for these sessions to be conducted in the patient’s own home.

Unfortunately, a technology this new to the field comes with some limitations. AR specifically requires a more robust framework in place compared to VR. The tele-mentoring system suffers from a few significant draw backs: a frame rate which limits the system’s ability to accept annotations from a proctor, the current model can only relay still frames for communication, and audio communication was not integrated (Andersen et al.). Additionally, processing power is a constraining factor especially if a projection is desired due to the increased demand necessary to account for the changes in topography when the field distorts (Tang et al.). And with any additional piece of machinery comes the opportunity for malfunctions and the need for supplementary technical staff and funding.

There is also a significant buy-in in terms of costs and burden of learning for the software. Improvements are needed to make the systems more user-friendly before AR and VR are appealing to the less technologically inclined. There are also limitations to haptic realism in the programs and some develop motion sickness and cannot even use them. Despite all this, as the software becomes more robust and user-friendly, the versatility of AR and VR will quickly overcome its weaknesses.

AR and VR are the future of technology-integrated medicine. Using projectors or headsets to simulate internal structures or peek into a procedure in VR are things that seem in place in a science fiction novel, but that reality is closer than ever. The sheer utility of AR annotation in procedural planning and visualization of radiologic information in real-time is something that will drive the technology forward despite its current drawbacks. The field of radiology has many avenues to apply these technologies, with its wealth of procedures using radiographic displays and the benefit of AR displays to non-invasive surgeries.

With a variety of current applications including patient and trainee education, as well as procedural planning and guidance, the future directions that AR and VR can take medicine in are as varied as remote-assisted home treatments for patients and VR curriculums over specific chronic diseases for patients and students alike. The technology has the potential to integrate with many aspects of the daily medical procedures and medical education, and radiologists are in a position to take those steps first.

1. Andersen D, Popescu V, Cabrera ME, et al. Virtual annotations of the surgical field through an augmented reality transparent display. The Vis Comp. 2015;32(11):1481-1498.

2. Barney J. Virtual Reality Puts Physicians, Trainees – Even You – Right in the Operating Room. 2018, October 19 Retrieved from https://news.virginia.edu/content/virtual-reality-puts-physicians-trainees-even-you-right-operating-room

3. Davis J. Going virtual: How VR is guiding interventional radiology. 2018, September 18  Retrieved from https://www.elsevier.com/connect/going-virtual-how-vr-is-guiding-interventional-radiology

4. Mewes A, Heinrich F, Hensen B, et al. Concepts for augmented reality visualisation to support needle guidance inside the MRI. Health Tech Let. 2018;5(5):172-176.
	5. Spiegel B, Fuller G, Lopez M, et al. Virtual reality for management of pain in hospitalized patients: A randomized comparative effectiveness trial. Plos One. 2019;14(8).

6. Tang R, Ma LF, Rong ZX, et al. Augmented reality technology for preoperative planning and intraoperative navigation during hepatobiliary surgery: A review of current methods. Hepat & Panc Dis Intl. 2018;17(2):101-112.

Radiology is in position to lead the integration of AR and VR into medical procedures and medical education.

Author | Mina S. Makary, MD

Articles

Future Trends and Technologies in Interventional Radiology: What to Expect

Radiologist Wellness and Burnout in the COVID-19 Era

Diagnostic Errors: Lessons Learned and Mitigation Strategies

Augmented and Virtual Reality – Radiology at the Center of Medical Technology