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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 4  |  Issue : 2  |  Page : 96-101

Foundation doctors' exposure to interventional radiology in two large teaching hospitals in the United Kingdom


1 Department of Imaging, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
2 Department of Radiology, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom

Date of Submission11-Jun-2020
Date of Acceptance30-Jun-2020
Date of Web Publication07-Aug-2020

Correspondence Address:
Dr. Zaid Alsafi
Department of Imaging, Imperial College Healthcare Nhs Trust, Hammersmith Hospital, Du Cane Road, London, W12 0hs
United Kingdom
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AJIR.AJIR_27_20

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  Abstract 

Background: Significant efforts have been made to improve medical students' exposure to interventional radiology (IR). Foundation doctors in the UK, however, are a neglected group, with little being done engage these doctors who are at a crucial juncture in their training.
Objectives: The objective of the study is to assess Foundation Year 1 (FY1) doctors' understanding of and exposure to IR.
Methods: FY1s from two teaching hospitals in the UK at the end of their first year of Foundation training were invited to take part in an 18-question survey, including 14 single-best-answer (SBA) questions. The questions examined knowledge of IR and other specialties. The SBAs were scored out 14 and the Student's t-test was used to compare IR and non-IR scores.
Results: Questionnaires were given to 72 FY1 doctors and 52 (72.2%) were completed. The median score was 9/14 (64.3%) [4.5/14–12/14]. Questions relating to coronary intervention and neurosurgery scored best (96.2% and 94.3%, respectively). The mean score for IR-related questions was significantly lower than that for non-IR questions (51.5% vs. 81.1%, respectively, P < 0.0001). Participants who referred patients to IR at least once per month scored higher than those who rarely referred (60.5% vs. 47.2%, respectively, P < 0.0084). Nearly 83.0% of participants expressed a desire to gain more exposure to IR.
Conclusion: Although Foundation doctors have some understanding of IR, reflecting some exposure to the specialty, this remains deficient when compared with their knowledge of other specialties. This may be improved by the introduction of IR specific teaching during the Foundation program.

Keywords: Foundation program, interventional radiology, medical education, radiology, training


How to cite this article:
Alsafi Z, Ramachandran S, Bhrugubanda V, Graham A, Alsafi A. Foundation doctors' exposure to interventional radiology in two large teaching hospitals in the United Kingdom. Arab J Intervent Radiol 2020;4:96-101

How to cite this URL:
Alsafi Z, Ramachandran S, Bhrugubanda V, Graham A, Alsafi A. Foundation doctors' exposure to interventional radiology in two large teaching hospitals in the United Kingdom. Arab J Intervent Radiol [serial online] 2020 [cited 2020 Sep 27];4:96-101. Available from: http://www.arabjir.com/text.asp?2020/4/2/96/291727


  Introduction Top


As technology advances, the scope of interventional radiology (IR) continues to rapidly expand, forming a key part of modern patient care in the elective and emergency settings[1],[2] The supply of Interventional radiologists has, however, failed to meet the demand, with the Royal College of Radiologists' census in 2017 showing that 39 consultant posts remain unfilled.[3] In addition, over two-thirds of hospitals in the UK employ fewer than four Interventional radiologists despite evidence suggesting that a minimum of six consultants is required to run an effective and sustainable service[2],[4] Attempts have been made to encourage medical students to pursue a career in IR with varying success,[5],[6],[7] but little has been done to appeal to Foundation doctors (equivalent to interns in many European countries and the United States) who are about to embark on their specialist training (residency). With few radiology rotations on offer within the Foundation program in the UK, very few Foundation doctors are exposed sufficiently to radiology and its subspecialties.

Due to the growth in the number and complexity of treatments offered by IR, nonradiologists may not be familiar with its scope.[8] While there are published undergraduate medical curricula[9],[10] there is a distinct lack of postgraduate education relating to IR except for those pursuing radiology training. Foundation doctors in the UK are often the front-line physicians referring patients for consideration of IR treatment. These doctors, like some of their more experienced colleagues, often have little understanding of IR, which can lead to patients not being referred for the appropriate treatment.

The aim of this study is to evaluate Foundation Year 1 (FY1) doctors' understanding of the scope of IR by assessing their grasp of common IR procedures in everyday clinical scenarios and compare this to their knowledge of other clinical specialties.


  Methods Top


An anonymous paper-based survey composed of eighteen questions was handed out to FY1 doctors from two teaching hospitals in the UK (West Suffolk NHS Foundation Trust and The Royal Preston Hospital). The survey was adapted from one used previously to assess medical students' understanding of IR although with more clinically relevant questions.[11] The survey was given to FY1 doctors during their last month of training in July 2018 before progression to their FY2. This is a critical period when doctors are preparing to apply for specialty training. The questionnaire included fourteen clinically relevant single-best-answer (SBA) questions [Appendix 1]. One question assessed the FY1 doctors' current exposure to IR, while two questions asked the participants about their interest in gaining more experience in the field and undertaking part of their Foundation training in an IR department. The last question assessed where the participant's undergraduate medical education was undertaken. The SBA questions were designed to assess clinicians' ability to make appropriate IR and other minimally invasive non-IR referrals in commonly encountered clinical scenarios. For each clinical scenario, the participants were given a list of possible referral pathways/interventions and were asked to choose the most appropriate referral.

Correct answers scored one mark with no negative marking. We accepted two possible correct answers for question seven and gave half a mark if the answer (a) was given for question 12 recognizing clinical flexibility in some scenarios. All the questions were equally weighted and the questionnaires were marked out of 14.

GraphPad Prism 6.0 for Mac OS (GraphPad Software Inc., San Diego, CA, USA) was used for the statistical analysis. The results were evaluated using descriptive statistics as well as paired two-tailed Student's t-test. All results are expressed as mean or median and interquartile range. P < 0.05 was considered statistically significant.

Ethics

Ethics approval was not require to conduct this anonymized survey. Consent was obtained from the study participants to use their anonymized survey data.


  Results Top


Questionnaires were handed out to 72 FY1 doctors and 52 (72.2%) were completed. The median score was 9/14 (64.3%) [7.5/14-10/14]. Questions relating to coronary intervention and neurosurgical procedures scored best, with 96.2% and 94.3% of participants answering these correctly, respectively. Three (5.8%) participants knew of the role of IR in managing hemorrhage in trauma, with the average score for trauma embolization scenarios being 33.3%. The mean score for IR related questions was 51.5% which was significantly lower than that of non-IR questions, 81.1%.(P < 0.0001, paired two-tailed Student's t-test) [Figure 1].
Figure 1: Scatter plot of the individual scores for interventional radiology and noninterventional radiology questions. *: P < 0.0001, paired Student's t-test

Click here to view


Foundation doctors who referred patients to IR once or more per month scored significantly higher than those who rarely or never referred patients to IR with a mean score of 60.5% [50.0–69.4], n = 17 compared with 47.2% [36.1–55.6], n = 36, respectively (P < 0.0084, unpaired two-tailed Student's t-test). Nearly 83.7% of participants indicated that they would like more exposure to IR during their Foundation training, whereas 67.3% said that they would apply for a Foundation training post which had an IR rotation.


  Discussion Top


A number of studies have assessed medical students' understanding of and exposure to IR with a number of recommendations and published undergraduate IR curricula.[5],[7],[9],[10],[12] Despite this, IR remains significantly under-represented within undergraduate medical education, with few medical schools adopting some form of IR teaching. This could explain why medical students' knowledge of IR remains poor.[11] When compared to studies conducted on undergraduates, our results demonstrate that the knowledge of IR among FY1 doctors is better than that of medical students.[11] This is to be expected; however, as the majority of FY1 doctors have some contact with the specialty. Foundation trainees who referred patients to IR once or more per month scored significantly higher than those who rarely referred. This is not surprising as with more exposure, junior doctors make more appropriate referrals to IR and develop a better understanding of the role of IR in their patients' pathways.

82.7% of FY1 doctors who participated in this study expressed a desire to gain more exposure to IR during their Foundation training, wheras 67.3% said that they would apply for a Foundation training post which had an IR rotation. Despite this interest, there are no rotations on offer during the Foundation program that expose FY1 doctors to IR.

The best-answered question related to coronary intervention, reflecting participants' exposure to cardiology either during cardiology rotations or during general medical or surgical on-calls. The second best-answered question was one relating to the management of hydrocephalus, highlighting awareness of the condition and prior exposure. Our findings are in line with studies focused on medical students where cardiology and neurology/neurosurgery knowledge scored highest, while IR knowledge was significantly lower.[11] Unsurprisingly, junior doctors' scores for these topics were higher than senior medical students, which reflects their ongoing practical exposure to these acute specialties.

This is the first study to assess the knowledge of IR among junior doctors in the UK. Despite our sample size of 52 from only two hospitals, our results highlight the lack of FY1 doctors' exposure to IR compared with other specialties. This is particularly concerning as FY1 doctors often did not appreciate the role IR plays in the management of haemorrhage. Those with more frequent exposure to IR scored best, suggesting that IR rotations or IR-related teaching during the Foundation program may be of benefit, with over half of those surveyed expressing a desire to gain more exposure to IR during their rotations.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


  Appendix Top


Appendix 1: Questionnaire sent to medical students. The accepted answers are at the end of the appendix

Foundation Trainee Referrals.

For each of the scenarios below what procedure/referral is most appropriate for your patient? Only tick one answer.

  1. A 55-year-old man with a history of diabetes presents with chest pain. No ST-elevation was demonstrated on his ECG but he had an elevated troponin.What is the most appropriate initial referral?


    1. □ Cardiothoracics for a CABG (Coronary Artery bypass graft)
    2. □Vascular Surgery for a CABG with a (LIMA) left internal mammary artery graft
    3. □Interventional Radiologists for a TEVAR (Thoracic EndoVascular Aortic aneurysm Repair)
    4. □Cardiology for coronary angiography +/- stenting


  2. A 25-year-old cyclist present to the emergency department with multiple injuries following a road traffic accident (RTA). A CT shows a descending thoracic aortic transection with a surrounding haematoma but no active bleeding. The patient is stable. His other injuries are not life threatening.What is the most appropriate definitive management?


    1. □Cardiothoracics for aortic repair
    2. □Vascular Surgery for an open aortic repair
    3. □Interventional Radiology for a TEVAR (Thoracic endovascular aortic repair)
    4. □Cardiologists for best medical management with blood pressure control


  3. Following a fall from a ladder, a 45-year-old builder presents to A&E with multiple pelvic fractures and active bleeding in the pelvis.What is the most appropriate initial management after initial resuscitation?


    1. □General Surgery for an explorative laparotomy
    2. □Trauma Surgery for pelvic fixation and bleeding control
    3. □Vascular Surgery to control pelvic bleeding
    4. □Interventional Radiology for internal iliac artery embolization


  4. A 38 year old woman presents to your outpatient gynaecology clinic with pelvic pain, urinary frequency, heavy periods. Her pelvic ultrasound demonstrated three large subserosal and mural fibroids. She has had a Mirena® coil and OCP previously with little effects on symptoms.What is the most appropriate next management step?


    1. □Refer back to GP for medical management.
    2. □Benign gynaecology team for a myomectomy or hysterectomy.
    3. □Interventional Radiology for assessment for uterine artery embolization.
    4. □Vascular Surgery for uterine artery ligation


  5. Who do you refer a patient to after the liver MDT decides that the best treatment for a patient's HCC is Trans-arterial Hepatic Chemo-embolization (TACE)?


    1. □Medical Oncology
    2. □Clinical Oncology
    3. □Interventional Radiology
    4. □Hepatobiliary surgery


  6. A 38-year-old patient with cervical cancer has a staging CT, which showed bilateral moderate hydronephrosis. Her creatinine is mildly elevated at 110mmol/l but remains well.Prior to surgery/chemotherapy you refer her to?


    1. □Urology for retrograde ureteric stenting
    2. □General Surgery for adhesiolysis
    3. □Interventional Radiology for bilateral nephrostomies and antegrade stents
    4. □Nephrology for medical management and followup


  7. An 85-year-old woman presents to A&E with right-sided loin to groin pain and urinary sepsis. She is started on antibiotics and fluid resuscitated. She has a CT showing a large right-sided proximal ureteric calculus causing severe hydronephrosis.What is the most appropriate initial referral/management?


    1. □Urology for retrograde stenting
    2. □General Surgery with a Urology review
    3. □Interventional Radiology for nephrostomy insertion
    4. □Nephrology for medical management.


  8. A 48-year-old man presents with painless jaundice. His CT shows a pancreatic head mass. He has an unsuccessful ERCP (Endoscopic retrograde cholangiopancreatogrphy).What is the most ppropriate next step in his management?


    1. □Repeat ERCP
    2. □Pancreatic head resection
    3. □PTC (Percutaneous transhepatic cholangiopancreatography).
    4. □Wipple's procedure


  9. Following recovery from a recent MI, a 75-yearold man complains in clinic about pain in his right buttock, thigh and calf when he walks 50 meters. This has been worsening over the passed year. His right leg Duplex scan which shows mild SFA disease but no significant stenosis. It suggests an upstream stenosis.You then arrange a CTA, which shows an 80% right common iliac artery stenosis. You then refer the patient to:


    1. □Cardiology for a pacemaker insertion to improve his cardiac output.
    2. □Vascular Surgery for aorto-femoral bypass
    3. □Interventional Radiology for iliac stenting
    4. □Back to the GP for lifestyle modification and medical management


  10. A 22-year-old woman presents with a grade 1 subarachnoid haemorrhage, which is managed well medically. She subsequently develops hydrocephalus.What is the most appropriate next step in her management?


    1. □Refer to Neurosurgery for an EVD (external ventricular drain) insertion
    2. □Neuro-interventional Radiology for aneurysm coiling
    3. □Neurologist for optimal medical management
    4. □Neurophysiology for an EEG (Electroencephalography)


  11. You see a 50-year-old man with previous MIs and several documented runs of ventricular tachycardia on your ward round. He has no ischaemic changes and no chest pain.You refer to:


    1. □Cardiology for coronary angiography and stenting
    2. □ardiology for ICD (Implantable cardioverter defibrillator) insertion
    3. □Cardiothoracics for revascularization
    4. □Cardiac scientists for rhythm assessment


  12. A35 year-old-woman with recurrent headaches has and MRI showing a left MCA (Middle cerebral artery) aneurysm measuring 18 mm in size with narrow neck.You refer her to:


    1. □Neurosurgery for an aneurysm clip
    2. □clinical pharmacology for blood pressure control
    3. □Neuro-interventional radiology for coiling
    4. □Neurology for follow-up


  13. A 68-year-old man with known gallstones presents with RUQ pain. His BP is 110/70, HR 95 bpm. His bilirubin is mildly elevated with a raised white cell count. His MRCP shows two calculi in the CBD with mild intra-hepatic bile duct dilatation.What is the most appropriate next intervention?


    1. □General surgery for a hot Cholecystectomy.
    2. □Gastroenterology for an ERCP (Endoscopic Retrograde Cholangiopancreatography).
    3. □Hepatobiliary surgery for a cholecystectomy and CBD exploration
    4. □Interventional Radiology for a PTC.(Percutaneous Cholangiopancreatogrphy)


  14. A 12-yeal-old girl is brought in to A&E by ambulance following a fall from a horse. She has a fractured ulna and radius and left upper quadrant pain. Her BP is 92/45 mmHg and HR is 98. She has a CT showing a grade 2 splenic laceration with active bleeding.What is the most appropriate next step in management/referral following resuscitation?


    1. □Paediatrics for monitoring and transfusion
    2. □General surgery for a splenectomy
    3. □Interventional Radiology for embolization
    4. □Paediatric surgery for a laparoscopic splenectomy


  15. How often do you refer a patient to Interventional Radiology?


  16. ≥1 per day

    ≥1 per week

    ≥1 per week and ≥1 per month

    Rarely

    Never

  17. Given the opportunity, would you like some exposure to Interventional Radiology during your foundation training?

    Yes No
    (Circle please)


  18. Would you apply for a FY1/FY2 job that has a clinical and interventional radiology rotation allowing to develop some ultrasound scanning skills (e.g. FAST scanning – identifying hydronephrosis…) as well some ultrasound guided procedural skills (e.g. drain insertion, vascular access, arterial puncture)


  19. Yes No (Circle please)

  20. Where did you undertake your undergraduate medical education?


…………………………………………………………………

Accepted answers:

1 d

2 c

3 d

4 c

5 c

6 a

7 a and c

8 c

9 c

10 a

11 b

12 c (1/2 mark given for a)

13 b

14 c



 
  References Top

1.
Rösch J, Keller FS, Kaufman JA. The birth, early years, and future of interventional radiology. J Vasc Interv Radiol 2003;14:841-53.  Back to cited text no. 1
    
2.
The Royal College of Radiologists. Investing in the Interventional Radiology Workforce: The Quality and Efficiency Case; 2014. Available from: https://www.rcr.ac.uk/publication/investing-interventional-radiology-workforce-quality-and-efficiency-case. [Last accessed on 2016 Aug 12].  Back to cited text no. 2
    
3.
The Royal College of Radiologists. Clinical Radiology UK WORKFORCE Census 2017 Report; 2017. Available from: https://www.rcr.ac.uk/system/files/publication/field_publication_files/bfcr185_cr_census_2017.pdf. [Last accessed on 2019 Feb 03, Last cited on 2019 Feb 03].  Back to cited text no. 3
    
4.
The Royal College of Radiologists. Provision of Interventional Radiology Services; 2014. Available from: https://www.rcr.ac.uk/publication/provision-interventional-radiology-services. [Last accessed on 2016 Aug 12].  Back to cited text no. 4
    
5.
Emin EI, Ruhomauly Z, Theodoulou I, Hanrahan JG, Staikoglou N, Nicolaides M, et al. Are interventional radiology and allied specialities neglected in undergraduate medical education? A systematic review. Ann Med Surg (Lond) 2019;40:22-30.  Back to cited text no. 5
    
6.
de Gregorio MA, Guirola JA, Sierre S, Serrano-Casorran C, Gimeno MJ, Urbano J. Interventional radiology and Spanish medical students: A survey of knowledge and interests in preclinical and clinical courses. Cardiovasc Intervent Radiol 2018;41:1590-8.  Back to cited text no. 6
    
7.
Lee AM, Lee MJ. Teaching IR to medical students: A call to action. Cardiovasc Intervent Radiol 2018;41:203-5.  Back to cited text no. 7
    
8.
Shaikh M, Shaygi B, Asadi H, Thanaratnam P, Pennycooke K, Mirza M, et al. The introduction of an undergraduate interventional radiology (IR) curriculum: Impact on medical student knowledge and interest in IR. Cardiovasc Intervent Radiol 2016;39:514-21.  Back to cited text no. 8
    
9.
British Society of Interventional Radiology. Undergraduate IR Curriculum; 2016. Available from: http://www.bsir.org/bsirt/undergraduate-ir-curriculum/. [Last accessed on 2019 Feb 09].  Back to cited text no. 9
    
10.
Cardiovascular and Interventional Radiological Society of Europe. Interventional Radiology Curriculum for Medical Students 2019. Available from: https://www.cirse.org/students/ir-curriculum-for-students/. [Last accessed on 2020 Jul 16; Last updated on 2019 May 14].  Back to cited text no. 10
    
11.
Alsafi Z, Bhrugubanda V, Ramachandran S, Alsafi A, Hamady M. Is it Time for a Specific Undergraduate Interventional Radiology Curriculum? Cardiovasc Intervent Radiol 2017;40:1062-9.  Back to cited text no. 11
    
12.
Goldman DT, Magnowski A, Rochon PJ, Bream PR Jr, Kondo KL, Peters G, et al. The state of medical student teaching of interventional radiology: Implications for the future. J Am Coll Radiol 2018;15:1761-4.  Back to cited text no. 12
    


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