Keys to Elevating Awareness of Interventional Radiology Among Referring Physicians and Patients

Interventional radiology (IR) is an exciting, evolving discipline, which offers minimally-invasive therapies that carry the benefits of decreased morbidity, mortality, and cost in comparison to its invasive, surgical counterparts.¹ Despite these benefits and high clinical impact, under-awareness of IR remains prevalent along referring and primary care physicians (PCPs).^2-4

Improving IR under-awareness appears one-dimensional at first glance. However, educating physicians, trainees, and the public offers a synergistic solution to increase referrals and improve health-care outcomes in applicable situations. Additionally, tackling all three domains can help stimulate conversation not only in the medical setting, but also in the public for a more efficient and effective strategy to increase IR awareness.

Recognizing Where IR Can Have an Impact in Treating Patients

Primary care providers are exposed to the greatest variety of pathology, which can require further evaluation from specialists. For example, diabetes (and the related development of peripheral artery disease) is a commonly treated disease in the primary care setting.⁵ Often, patients with diabetes have a need for revascularization therapies in patients with diabetes. While revascularization may be performed via open surgical techniques, these procedures have high risks.6 New endovascular techniques performed by interventional radiologists are preferred in appropriate cases due to a higher safety profile and efficacy.⁶ Therefore, PCP awareness of IR can help facilitate better health-care outcomes in this patient population.

Another example includes interventions for women’s health. Uterine fibroids are traditionally treated with myomectomies and hysterectomies, both of which have risks of adverse complications and significant recovery period. However, in IR, uterine artery embolization is a minimally-invasive approach that can shrink fibroids and improve symptoms while preserving fertility and reducing risks and recovery time.⁷

Interventional radiology can also provide oncological treatments for patients who are not surgical candidates for various types of primary and metastatic disease including lung, renal, hepatic, and other cancers.⁸ Moreover, IR can provide venous solutions for patients suffering from chronic venous insufficiency, congenital venous malformations, and fertility issues due to testicular varicoceles.⁹

These existing interventions can provide great efficacy for a large patient population seen by PCPs. Constant innovation in this field has the potential to provide even more solutions, creating a necessity for a reliable relationship between referring specialties and IR in addition to having general awareness regarding procedures that IR can perform.

Current Status of IR Awareness in Health Care: Where Things Stand

Current awareness of IR is unfortunately low.^2-4 However, large, multi-center studies that assess this are scarce. One study conducted at a large academic center surveyed primary care physicians on their awareness of IR. Of the 234 physicians who responded, 137 physicians (56.9 percent) stated they had adequate knowledge of IR, 49 respondents (20.3 percent) noted a poor knowledge of IR and only 2.5 percent of respondents said they had excellent knowledge.³

A gap of this size may be attributable to lack of communication and a strong relationship between referring specialties and IR. This gap may be even more detrimental in an academic setting, where innovative procedures are first trialed and could have been offered to patients.

Even more alarmingly, researchers have suggested that there is even a larger knowledge gap in the private practice setting where IR physicians often split their time between treatment procedures and diagnostic duties.¹⁰ Concerningly, the study further states that 42 (17.65 percent) physicians never offered IR procedures as an alternative to surgery, which contrasts to only eight (3.35 percent) physicians who offered IR as an alternative every time.³ This highlights many missed opportunities in which a safer, less costly alternative could have been provided for patients that would in turn decrease the burden of complications and cost of more invasive options.

Referrals for IR procedures seem to mirror the lack of awareness. Therefore, it would seem logical to conclude that once awareness of IR services increases, the amount of times IR is offered as an alternative will increase as well.

Under-awareness of IR is an issue that starts upstream. A lack of formal didactics and exposure of IR in medical school curriculum is partly responsible for the current unfamiliarity. One systematic review evaluating perceptions and knowledge regarding IR among medical students, mostly in the United States, concluded that in nine of 17 studies, student knowledge and interest were both poor.¹¹ The same medical students enter residencies and eventually attending-level positions in hospital/private practice environments that may not be conducive to IR exposure and education. This causes the complete miss of an opportunity to learn and provide options for future patients.

Two studies suggest the problem is not exclusive to the United States. One study conducted in Saudi Arabia revealed that half of the senior medical students and first-year residents subjectively believed their IR knowledge was poor.¹² Similarly, a study conducted in India reported that 60 percent of their medical students had poor or very poor knowledge of IR.¹³ Albaqawi and colleagues found that among medical students and interns, 45 percent of the students agreed that their knowledge and information regarding IR was poor with 72.5 percent of respondents not having been exposed to IR clinical work.¹⁴

It can be assumed that countries that are even less resourceful may experience greater under-awareness, prohibiting any chance for providing much needed IR interventions in those populations. Evidence of IR under-awareness across the globe can help tailor educational solutions to options that can be easily accessible to the public and physicians across the globe.

Examining the Depth of Public Misperceptions About IR

Interventional radiology under-awareness is not limited to referring physicians. In a lecture titled “Public Perception of Interventional Radiology: a Call to Action,” Frederick Keller, M.D., FSIR, one of the pillars of IR, noted that only 2 percent of the general public recognized IR as a medical specialty at the time.¹⁵ In fact, in one single-center prospective study, 80 patients were surveyed in a hospital radiology waiting room, revealing that 65 percent of the patients did not have prior knowledge of IR.² In the same study, a separate Internet-based survey was administered to the general public and 100 responses were collected. Only 28 percent of the respondents correctly identified interventional radiologists as physicians compared to 83 percent of the respondents identifying urologists as physicians.²

On the other hand, newer studies suggest that now 40 percent of the general population recognizes IR as a medical specialty but less than 50 percent of those respondents recognized IR as a procedural specialty.⁴ Although IR is starting to become more recognized, its role in medicine and the value it provides still appear to be unclear to the public. Further, this lack of awareness generates mistrust in patients as they are opting to have the same procedure performed by a surgeon. This speaks to the necessity to raise awareness among physicians and the general public.⁴

The Pros and Cons of Social Media To Raise IR Awareness

One method to increase awareness of IR among referring physicians and the public is the use of the Internet. Currently, X (formerly known as Twitter) is the most popular form of social media used for health-care communication.¹⁶ Specifically, social media platforms can be pivotal in increasing awareness of IR as there are many interventional radiologists in the X space.^17,18 One author suggests that utilization of X can not only increase awareness, but also spark interest among medical students to explore the field further.¹⁹

Social media is a tool that can be utilized further in connecting and educating referring physicians on the platform. Secondly, it can also be used a poster board to display new, cutting-edge procedures. Social media may also provide a platform for medical students and the public to directly communicate with IR physicians and inquire about procedures.

Apart from social media, there are comprehensive websites tailored to IR, such as the Interventional Initiative (theii.org) and The Society of Interventional Radiology (sirweb.org). Websites like these provide educational patient pamphlets, infographics, video documentaries, and decision aids to guide patients.

While the Internet can be an effective medium for increasing awareness about IR, there are several drawbacks. Information on social media platforms and websites is often not peer-reviewed, which creates a potential to mislead patients. Additionally, not every physician or medical professional has a social media account, limiting who accesses the posted information. Lastly, the social media presence of elderly patients, who may require these procedures, is alarmingly low, creating another potential barrier to access.²⁰

Can Traditional Lectures Have an Impact?

Apart from informal online education, formal didactics also appear to be a desired and effective way of increasing IR awareness. In one study looking at a series of two, 60-minute-long lectures on IR presented at emergency and internal medicine didactic conferences with pre- and post-lecture assessments, researchers noted significant increases in mean scores from 32 to 82 percent for the first lecture and 44 to 65 percent for the second lecture.²¹

Along the same lines, IR symposiums have not only proved to be successful in educating future physicians, they also can generate interest in the field. In an observational study, researchers administered a scaled survey before and after an IR symposium held at a major academic center in Ohio to assess audience awareness of IR as a specialty, understanding of the current training pathways, and level of interest in IR. The results revealed increased interest in IR and no-surgical specialties after the symposium while interest in surgical fields did not show a significant increase.²²

A Mixture of Strategies to Elevate Awareness Among Referring Physicians and Patients Alike

The benefit of didactics and symposiums can include direct opportunities for referring physicians and medical students to network and interact with physicians and staff representing IR. However, limitations include difficulty scheduling didactic sessions within a busy work schedule, time and traveling barriers to attending symposiums, and cost associated with facilitating these sessions. That said, Emin and colleagues concluded that symposiums, elective courses, electronic learning platforms, lectures, and surveys were all able to not only increase knowledge of IR but also generate interest in the field.¹¹

Therefore, it would be reasonable to assume that a combination of online education with in-person events can be effective in offering longitudinal education for medical professionals and, in turn, increase IR awareness.

Educating patients and the public is an additional avenue to explore for increasing overall awareness. In a 2023 study, nearly 46 percent of 1,000 survey respondents wanted to learn more about the IR specialty, and the best way to do this was to communicate with short educational videos and information provided by their primary care physician.⁴

Baerlocher and colleagues have recommened a variety of strategies to help educate the public on IR.²³ They suggested that discussing the field with the patients before in-patient procedures can be an organic way to spread information. Providing referring physicians and patients with physical resources about the procedure/field in the pre-procedural clinic visit is another common way to educate in the medical setting.

From an academic perspective, publishing relevant scientific articles in journals read by the referring physicians can help increase awareness. Further, writing articles outlining common IR procedures for the public in popular magazines and media can help stimulate conversation within communities, which may lead to conversations with their PCPs as well. Baerlocher and colleagues also noted that reaching out to other physicians about the struggles regarding IR awareness and incorporating their feedback may pay dividends.

Should Rebranding be Considered to Help Elevate the Profile of Interventional Radiology?

In addition to didactics, rebranding how the specialty is marketed may help boost the public’s awareness and familiarity among referring physicians. Several studies suggest that under-awareness of IR may be a product of its name. Specifically, in a recent survey of 1,000 members of the general public regarding their awareness of IR, over half of the respondents said IR was ambiguous.⁴ Interventional radiology’s branding may be contributing to not only the lack of public awareness, but also lower interest amongst prospective trainees.

A suggested title for IR physicians includes minimally invasive radiologists and perhaps referring to their work as “image‐guided surgery,” “endovascular surgery,” and “minimally invasive surgery.”4,24 These names may provide a clearer definition and be more self-explanatory, akin to how the general public typically knows what work a cardiologist or endocrinologist does. Iwai and colleagues also suggested that interventional radiology is a reductive term that does not convey the complex dynamic between procedures, imaging, and direct patient care, which would further add to the confusion around the specialty’s clinical value.²⁵

Lastly, transitioning IR into a clinical specialty can also help contribute to increasing awareness. The approval by the American Board of Medical Specialties (ABMS) for IR to be a primary specialty, combined with the American College of Radiology encouraging a clinical practice model for IR, were both major steps forward for the awareness of the specialty. However, still, the typical IR model often lacks a complete clinical practice (only accounting for 1.4 percent of the billed services), which is critical for facilitating referrals from non-IR physicians.26,27 Having a clinical presence allows for referring physicians to have a strong and direct relationship with the interventional radiologist. This strong relationship further transcends to the patient level, allowing for PCPs and other referring physicians to covey gathered information for their patient population.

Final Notes

In conclusion, although large, multicenter studies assessing the level of awareness of IR among PCPs, referring physicians, and the public are scarce, the current literature suggests a low awareness. Under-awareness of IR has direct consequences to patient care as treatments performed by interventional radiologists often can help decrease morbidity, mortality, and health-care costs. There are several media in place to spread IR awareness, including online platforms, in-person didactics and conferences. Additional measures for bolstering IR awareness include improved marketing and an increased clinical presence. Nonetheless, ongoing efforts to educate and expose referring physicians, future physicians, and the public regarding IR is necessary for the specialty to reach its full impact for patients everywhere.

References

1. Jamil H, Tariq W, Ameer MA, et al. Interventional radiology in low- and middle-income countries. Ann Med Surg (Lond). 2022;77:103594.

2.Heister D, Jackson S, Doherty-Simor M, Newton I. An evaluation of trends in patient and public awareness of IR. J Vasc Interv Radiol. 2018;29(5):661-668.

3. Makary MS, Gage D, Elliott ED, Dowell JD. Primary care provider awareness of IR: a single-center analysis. J Vasc Interv Radiol. 2019;30(9):1420-1427.

4. Rodgers B, Rodgers KA, Chick JFB, Makary MS. Public awareness of interventional radiology: population-based analysis of the current state of and pathways for improvement. J Vasc Interv Radiol. 2023;34(6):960-967.e6.

5. Aldhafery BF. What family physicians should know about interventional radiology? J Family Community Med. 2020;27(2):85-90.

6. Tang QH, Chen J, Hu CF, Zhang XL. Comparison between endovascular and open surgery for the treatment of peripheral artery diseases: a meta-analysis. Ann Vasc Surg. 2020;62:484-495.

7. Mailli L, Patel S, Das R, et al. Uterine artery embolisation: fertility, adenomyosis and size – what is the evidence? CVIR Endovascular. 2023/02/27 2023;6(1):8. doi:10.1186/s42155-023-00353-2

8. Iezzi R, Gangi A, Posa A, et al. Emerging indications for interventional oncology: expert discussion on new locoregional treatments. Cancers (Basel). 2023;15(1). doi:10.3390/cancers15010308

9. Arnold MJ, Keung JJ, McCarragher B. Interventional radiology: indications and best practices. Am Fam Physician. 2019;99(9):547-556.

10. Andrews RT. Raising awareness of IR: addressing an old challenge with new tools. J Vasc Interv Radiol. 2019;30(9):1428-1429. doi:10.1016/j.jvir.2019.05.011

11. Emin EI, Ruhomauly Z, Theodoulou I, et al. Are interventional radiology and allied specialities neglected in undergraduate medical education? A systematic review. Ann Med Surg (Lond). 2019;40:22-30.

12. Alshumrani GA. Awareness of interventional radiology among final-year medical students and medical interns at a university in Southwestern Saudi Arabia. Saudi Med J. 2013;34(8):841-7.

13. Agrawal D, Renfrew MA, Singhal S, Bhansali Y. Awareness and knowledge of interventional radiology among medical students at an Indian institution. CVIR Endovascular. 2019;2(1):45.

14. Albaqawi R, Alreshidi M, Alshubrami D, Alrasheedi H, Alreshidi F, Alrashidi I. Awareness of interventional radiology among clinical years’ medical students and medical interns at University of Hail. Arab J Intervent Radiol. 2019;3(02):58-64.

15. Keller FS. Public perception of interventional radiology. J Vasc Interv Radiol. 2002;2(13):P96-P97.

16. Pershad Y, Hangge PT, Albadawi H, Oklu R. Social medicine: Twitter in healthcare. J Clin Med. 2018;7(6). doi:10.3390/jcm7060121

17. Wadhwa V, Brandis A, Madassery K, et al. #TwittIR: Understanding and establishing a Twitter ecosystem for interventional radiologists and their practices. J Am Coll Radiol. 2018;15(1 Pt B):218-223.

18. Kassin MT, Ukeh I, Bunch PM, Sabri SS. Social media considerations for the interventional radiologist. Radiographics. 2022;42(6):E165-E166. doi:10.1148/rg.220157

19. Kesselman A, Dani H, Bergen M, Gallo V, Vazquez Y, Walsh J. Leveraging social media to foster interventional radiology awareness and improve education. J Vasc Interv Radiol. 2016;27:S268.

20. Mikal JP, Wurtz R, Grande SW. Older adults' computer-mediated communication (CMC) engagement following COVID-19 and its impact on access to community, information, and resource exchange: a longitudinal, qualitative study. Gerontol Geriatr Med. 2021;7:23337214211052201. doi:10.1177/23337214211052201

21. Sweeney AM, Wadhwa V, Farrell JJ, Makary MS. Interventional radiology education for improving primary care provider awareness. Curr Probl Diagn Radiol. 2022;51(3):308-312.

22. Makary MS, Rajan A, Miller RJ, Elliott ED, Spain JW, Guy GE. Institutional interventional radiology symposium increases medical student interest and identifies target recruitment candidates. Curr Probl Diagn Radiol. 2019;48(4):363-367.

23. Baerlocher MO, Asch MR, Puri G, Vellahottam A, Myers A, Andrews K. Awareness of interventional radiology among patients referred to the interventional radiology department: a survey of patients in a large Canadian community hospital. J Vasc Interv Radiol. 2007;18(5):633-7.

24. Chong CCW, Chennapragada SM, Schick C, et al. The 'Sic Vos non Vobis' of interventional radiology - rebranding and modernising the interventional specialities of radiology in Australia and New Zealand. J Med Imaging Radiat Oncol. 2022;66(3):423-427.

25. Iwai Y, Erinjeri JP. What's in a name: Is "Interventional Radiology" too reductive? J Vasc Interv Radiol. 2019;30(9):1430-1431.

26. Balthazar P, Hawkins CM, Vijayasarathi A, Loehfelm TW, Duszak R. Current clinical practice patterns of self-identified interventional radiologists. AJR Am J Roentgenol. 2018;210(3):663-668.

27. Swischuk JL, Sacks D, Pentecost MJ, et al. Clinical practice of interventional and cardiovascular radiology: current status, guidelines for resource allocation, future directions. J Am Coll Radiol. 2004;1(10):720-7.

Additional Reference

28. American College of Radiology, Society of Interventional Radiology, Society of Neurointerventional Surgery, Society of Pediatric Radiology. J Vasc Interv Radiol. 2015;26(8):1197-204.