After leading the implementation of a Picture Archiving and Communication System (PACS) to dramatically improve access to medical imaging in his home country of Tanzania, Dr. Frank Minja at Yale School of Medicine (YSM) is working alongside residents and faculty from Yale and other institutions to establish a three-year longitudinal program in Tanzania geared at training radiology residents, nurses, and technologists in interventional radiology.
Interventional radiology (IR) is a versatile and minimally invasive procedure that allows doctors to treat complex medical conditions and diseases through a tiny incision in the skin. IR was initially developed as a subspecialty of diagnostic radiology and has been an established clinical specialty in the United States, Europe, and East Asia since the 1960s, with an estimated 3,000-4,000 practicing IR physicians in the United States alone. However, in most of the world, especially in countries with limited resources like Tanzania, there is little to no access to the numerous benefits of IR because few doctors in those countries have been trained to use it.
“The need for IR in a country like Tanzania could not be greater,” said Minja, an assistant professor of radiology and biomedical imaging at YSM. “With interventional radiology, physicians can not only identify an area of the body where something is wrong, but they actually have the ability to do something about the healthcare issue on the spot in real-time and in a minimally invasive way. It can be used to provide a broad range of treatments such as draining abscesses, treating strokes, embolizing arteries, or sampling tissue.”
In IR, a needle or catheter can be inserted directly into a lesion or area of the body that requires examination or treatment. For example, an IR catheter can be used to drain an abscess caused by a ruptured appendix, avoiding a large surgical incision. IR can also be conducted intravascularly by maneuvering catheters over thin wires inside blood vessels. Patients who have undergone IR procedures heal much more quickly than they would after traditional surgical interventions.
These techniques also allow doctors to easily sample human tissue including tumors. It can help them determine the type of tumor and then personalize treatment for individual patients. A catheter could also be used to deliver treatment directly into the tumor, allowing for more targeted delivery of the chemotherapeutic agent with decreased side effects.
“Interventional radiology provides minimally invasive state-of-the-art personalized care. Utilizing advanced imaging techniques, we are able to precisely deliver treatments including chemotherapy for cancers, remove tissue for diagnosis and planning, and provide care often without even a skin incision. This enables faster recovery and less pain than conventional surgery” says Dr. Douglas Silin, assistant professor of radiology and biomedical imaging, and director of Yale’s Interventional Radiology Residency Program. Silin will travel to Tanzania this fall to help inaugurate the Tanzania IR training program.
Tanzania ready for interventional radiology
In late 2017, Minja travelled to Tanzania with Drs. Fabian Laage Gaupp and Kenedy Foryoung, radiology residents in the Department of Radiology and Biomedical Imaging at YSM. There they conducted a thorough IR readiness assessment at the Muhimbili National Hospital (MNH) in Dar es Salaam. “The IR readiness assessment tool provides a structured format for initial assessment of all resources needed to start IR training at a given site,” says Laage Gaupp. “In Tanzania, we found that nearly all the key components are already in place, including access to imaging equipment and availability of radiology trainees. The only missing component are motivated IR experts from Yale and other parts of the world who are willing to travel to Tanzania and share their expertise.”
“The technology is there. Hospitals have CT scanners. They have ultrasound machines. They have fluoroscopy, angiography, and MRI machines,” said Minja. “Adoption and use of interventional radiology simply helps them get much more use out of the equipment and infrastructure they already have. Training staff on using IR enables hospitals gain more return on investment from capital expenditures; it helps doctors improve medical diagnostic procedures, and increase the volume and quality of patient care they provide; and most importantly, patients get better medical treatment and heal faster.”
In addition to improved patient care, Minja says, another significant benefit to adopting IR is that it requires little additional investment beyond the cost of training radiologists and disposable equipment such as catheters and biopsy needles. He says the minor investment is more than offset by cost savings due to decreased hospitalization length and lower complication rates.
Dr. Flora Lwakatare, head of the Radiology Department at MNH, says the hospital urgently needs enhanced IR capability.
“Presently we practice very basic IR procedures such as ultrasound-guided fine needle aspiration of lesions for cytology,” Lwakatare said. “The benefits of IR, which include the reduction of costs, make this radiology specialty very important in a hospital with limited resources. We welcome and are very grateful for the IR program coordinated by Yale University, which will also ensure the training of IR specialists.”
Dr. Mechris Mango, head of the Radiology Department at Tanzania’s Muhimbili Orthopaedic Institute (MOI), says adoption of IR will allow the county’s hospitals to offer patients less risky and painful procedures with shorter recovery times, which translates to shorter hospital stays.
“Working with the Yale Radiology Global Outreach IR Team, our doctors will have a chance to learn and transfer this important knowledge for the betterment of our patient’s healthcare,” Mango said.
Dr. Lulu Fundikira, head of Radiology Department at the Muhimbili University of Health and Allied Sciences (MUHAS), says she is excited to implement a robust IR training program, noting, “The IR program could not have come at a better time, we are more than ready!”
Lwakatare, Fundikira, and Mango are collaborating closely on supervising the training of radiology residents at the Muhimbili campus.
Implementing IR as a team
Minja and his colleagues are assembling multi-disciplinary teams of IR physicians, nurses, and technologists to implement this longitudinal IR training program. IR teams typically comprise, at bare minimum, an IR physician, nurse, and technologist. Each one of these team members serves a specific role in conducting IR procedures. The IR physician determines the indication, manages the , and performs the actual procedure. The technologist is responsible for providing the necessary tools and assists in operating the imaging equipment, and the nurse ensures that the patient is adequately sedated and that the patient’s blood pressure and other vital signs remain stable during the IR procedure.
According to Minja the IR training is being done in close collaboration with the Yale School of Nursing and RAD-AID, a non-profit organization with the mission to improve and optimize access to medical imaging in poor and developing regions of the world. Specifically, RAD-AID is helping to coordinate and mobilize volunteer IR physicians, nurses and technologists for the IR training program in Tanzania.
“From the start, we want to simulate and emphasize the multi-disciplinary nature of IR, and the urgent need to also train the nurses and IR technologists who will assist the Tanzanian IR physicians,” Minja said. “Therefore, assembling multi-disciplinary training teams is essential. ”
Each year the program will send 10 expert IR faculty from Yale and other institutions around the world to Tanzania where they will train three Tanzanian radiology residents per year in the use of IR. While the mainstay of their training is in Tanzania, these IR trainees will also travel to Yale and other U.S. institutions to observe IR procedures and conduct research projects. A competency-based IR curriculum will be implemented over time, which will eventually result in a self-sustaining IR training program in Tanzania. Study resources are already being provided to the IR trainees in Tanzania, including access to online resources as well as e-books and live-streaming of IR lectures.
Conducting IR training in Tanzania also has the unique benefit of providing immediate access to IR procedures for Tanzanian patients, without the patients having to wait until the trainees complete their training overseas, notes Minja.
“Most of the world’s population does not have any access to the incredible benefits of IR.
Our IR readiness assessment in Tanzania found that the key remaining gap is the lack of IR training opportunities. We have an amazing opportunity to immediately begin in-country training of the first generation of Tanzanian IR physicians, nurses and technologists. We are
so excited for Yale to be leading this effort, with the help of many other institutions and our generous supporters.” says Minja.
Visit this website to learn more about Yale’s work to support Interventional Radiology outreach and training. Also on the site is an overview of the work being conducted and options for getting involved, including an outreach calendar showcasing all dates for 2018-2019 IR outreach trips to Tanzania. Information on other Yale Radiology global outreach efforts can also be found by visiting the Yale Radiology & Biomedical Imaging website or viewing this video.