Training, Experience, and Evidence Matter

When all is said and done, more is usually said than done.

Winston Churchill

Knowing is not enough; we must apply.Willing is not enough; we must do.

Johann Wolfgang von Goethe

This issue includes a consensus statement from a coalition of seven professional societies—the American Academy of Neurology, the American Association of Neurologic Surgeons (AANS), the American Society of Interventional and Therapeutic Neuroradiology, the American Society of Neuroradiology, the Congress of Neurologic Surgeons (CNS), the AANS/CNS Cerebrovascular Section, and the Society of Interventional Radiology—representing most of the physicians in North America who specialize in the diagnosis and treatment of diseases of the brain and spinal cord. In this statement, the societies propose standards for training, competency, and credentialing in the performance of diagnostic cervicocerebral angiography, carotid stent placement, and cerebrovascular interventions. Based on a concern for patient safety, this statement is an attempt to address what seems likely to become the rampant performance of some of these procedures by physicians who, because they are not properly trained, cannot be considered competent in this area.

At no time in the history of medicine has growth in knowledge and technologies been so great. As one whose early practice in neuroradiology included pneumoencephalography, gas myelography, and plain-film angiography to monitor the positioning and detachment of balloons manually tied on the end of a catheter, I am awed by both the power of the diagnostic and therapeutic tools that I now use daily and by the potential harm and cost that the improper application of these tools can bring to patients and their families. To use these appropriately and safely, specialized training and expertise are required.

This consensus statement is not a demand for a utopia, but rather, a realistic and reasoned call to physicians wishing to do these procedures that they obtain and then maintain the proper skills to protect their patients from undue harm. Reports from the Institute of Medicine have documented frequent and unnecessary injury to patients, as well as a failure of the healthcare system to deliver the quality of care that patients deserve and expect (1, 2). The statement published in this issue is one attempt to improve and ultimately eliminate this deficiency. While no injury is acceptable, damage to the nervous system is especially serious. In the face of strong evidence that training matters in preventing adverse events and also in minimizing injury when it does occur, it is unacceptable for individuals to take or institutions to offer “shortcuts” to aid physicians in obtaining skill in these procedures.

Those having proper training are obligated to be certain that the potential benefits of the procedures they perform outweigh the potential risks. In large part, this entails using and understanding the concepts of evidence-based practice. Fundamental to such practice is the integration of the best research evidence with clinical expertise and patient values (1). In this definition, clinical expertise means “the ability to use clinical skills and past experience to rapidly identify each patient’s unique health state and diagnosis, individual risks and benefits of potential interventions, and personal values and expectations” (1). Such skills cannot be acquired quickly, easily, or informally. Maintenance of these skills demands ongoing education.

Finally, it is emphasized that this call is not one that seeks to carve out or protect “turf.” Healthcare will increasingly be delivered by teams that work in complex and novel arrangements. The concept of physicians with varied training and experiences working together should be welcomed and adopted, as traditional alliances are shown to be no longer productive or rational. An amalgamation of specialties with different skills and experiences offers the potential for huge improvements, as it is often on the edge of disciplines where the really significant advances occur. These alliances should, however, be focused on patient well-being and not on efficiencies of personnel or on economic gain.

I applaud the effort of these societies to ensure that all patients receive the quality of care and protection that they deserve.

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