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Editorials |
1 From the Brady Urologic Institute, Johns Hopkins Medical Institutions, Baltimore, Md (L.R.K., M.N.); and Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021 (S.B.S.). Received June 10, 2005; accepted June 14. Address correspondence to: S.B.S. (e-mail: solomons{at}mskcc.org).
Editor's Note: A similar version of this editorial was published in the July 2005 issue of the Journal of Urology. It is being published here to also reach the readers of Radiology.
Early renal cancer detection, advances in imaging technology, and the development of reliable needle-based ablative therapies have given birth to a new paradigm in the evaluation and treatment of renal neoplasms. This nascent approach has been used primarily in patients at risk for medical complications of traditional surgery, and preliminary therapeutic results from multiple institutions are encouraging. If these suggested benefits continue to be borne out, there is a real possibility that ablative technology will become the standard of care in the majority of patients with small solid renal masses.
The potential advantages of ablative therapy are substantial. This technique can be performed on an outpatient basis with sedation, postprocedural pain is minimal, and most patients do not require administration of narcotics. Normal activity can be resumed within a day, as opposed to weeks of convalescence after conventional approaches. Patients who are unable to undergo general anesthesia can now be treated, and those with compromised renal function face a much lower risk of requiring dialysis. These benefits translate into cost reductions, as there are potential collateral advantages to payors, employers, and the economy as a whole. While the arguments for percutaneous ablative therapy are quite cogent, there is a major obstacle to their widespread adoption: turf.
This colloquial concept has great historical relevance in all professions, including medicine. It is ingrained in medical students that urologists treat the kidney, the gall bladder is under the purview of the general surgeon, and radiologists interpret images. The rigorous, lengthy, and often rigid preparation involved in the process of postgraduate specialty training serves to reinforce such distinctions. However, innovation continually disrupts these accepted, albeit artificial, domains. With advances in both technique and technology, various providers have retooled themselves to provide novel services to patients. For example, we have witnessed a change in the standard of care for breast biopsy, which has traditionally been an open surgical procedure. With the advent of stereotactic image-guided approaches, radiologists now perform the majority of breast biopsy procedures. Conversely, ultrasonographically (US) guided prostate biopsy, which was introduced by radiologists, has become a standard part of the urologist's armamentarium. Analogous situations abound across all specialties, with burgeoning growth in endovascular, endoscopic, and radiation oncologic approaches in particular, leading to changes in the management landscape and the principal providers of that management for an entire population of patients.
Inherent to many discussions of evolving systems of care is an often skeptical and sometimes adversarial hubris of providers from disciplines competing for the right to provide a novel service. Specialists adopt the position of defending the garrison of their practice from a perceived attack at the gates (1). In this particular case of renal tumor ablation, urologists, who are experts in the biology of renal tumors, are at odds with radiologists, who are experts in the field of imaging. The domains of expertise themselves are dynamic, with the pace of change in our understanding of the relevant disease processes at the molecular level matched by rapidly evolving capabilities of new interventional instrumentation and real-time imaging capabilities. Occasionally, the conflict over ownership of a new modality may play out within a specialty. For example, in the field of radiology, diagnostic radiologists have led the adoption of image-guided ablation in some hospitals, whereas interventional radiologists have led the charge in other institutions. As numerous factions clamor to stake claims of legitimacy in these shifting sands, it is imperative that we maintain a vigilant focus on the goal of maximizing the delivery of the highest standard of service to our patients, advancing both the scientific and the technical sophistication of our practice.
In this vein, we would do well to keep in mind that with rapidly evolving knowledge and technology, very few individuals possess all the skills necessary to provide complete care to patients. Thus, cooperation is mandatory. For traditionally individualistic enterprises, such as clinical practice or medical research, this statement may seem somewhat naive to the reality of daily life. In contrast to widely held perceptions, however, there are a number of accepted standards in contemporary practice that show that a receptive approach to collaborative ventures, rather than a subversion of the security of established patterns of care, may provide opportunities for substantial added value. Successful cross-disciplinary paradigms have flourished with collaboration, proving that innovation is not necessarily a zero-sum game. Prostate brachytherapy provides one such example of how turf issues can be assuaged through a symbiotic approach. The urologist contributes anatomic expertise with US-guided prostate procedures, while the radiation oncologist contributes knowledge of dosimetry and delivery of radioactive isotopes. Working together, these specialists have come to offer appropriately selected patients an alternative to prostatectomy or conventional radiation therapy.
In the field of percutaneous image-guided renal procedures, urologists contribute expertise in tumor biology and clinical management, whereas radiologists offer experience in image guidance and needle manipulation. To this end, jointly performed procedures have added value relative to procedures performed alone by physicians of either specialty. Furthermore, as the field is in its scientific and clinical infancy, the potential for basic discovery and technical refinement is clearly enhanced when individuals bring complementary but different skill sets and mind-sets to the table. The need to better characterize appropriate patient selection, follow-up regimens, and definitions of clinical success are clearly no less important than refining technique and service delivery at the point of care. Future reimbursement should reflect the benefits to patients when these procedures are jointly performed, as is presently the case in prostate brachytherapy. Indeed, reimbursement codes that can reflect the distinct work of both the radiologist and the urologist are being developed.
Durable innovations in medicine can improve patient care, but they can also disrupt preexisting physician practice patterns. For percutaneous image-guided procedures, a collaborative relationship between the fields of urology and radiology will ultimately lead to better patient care by drawing on the complementary expertise of both specialties. With increasing technical complexity, openness to new approaches requires interest and imagination, as well as a spirit of cooperation. We urge the American College of Radiology and the American Urological Association to jointly develop a rational approach that includes establishment of nontraditional training paradigms to ensure optimal patient outcomes.
There is a reason why the barber surgeon of yore is an anachronism for which there is little nostalgia. The concurrent trends of increasing subspecialization in medicine and burgeoning technologic advances in treatment have yielded palpable and profound benefits for patients and practitioners alike. As such, it is incumbent on individual providers and the leadership of relevant specialty organizations to nurture emerging technology.
This discussion provides an opportunity to consider evolution in the organization of medicine. Perhaps it is time to move away from traditional models and form new paradigms based on advances in our understanding of medicine and technology. For instance, radiologists may need to have clinics and provide longitudinal care, whereas urologists may need to have an increased knowledge of imaging (2,3). These changes may markedly transform and even eliminate time-honored expectations of certain disciplines; collectively, they may be the ultimate route that allows medicine to best address modern disease.
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