The benefits to patients and hospitals of the early discharge lung biopsy pathway and using the Heimlich valve chest drain (HVCD) to treat post-procedural pneumothorax in an ambulatory fashion are obvious.
I would like to talk about how the approach also benefits trainees, providing a superior training environment to learn what to my mind was previously an inherently "risky" procedure.
Whilst passing through Barnet as part of my rotational radiology training I was asked if I wanted to learn how to perform lung biopsies. I was somewhat surprised given I was a relatively junior registrar. In other centres I had rotated through, lung biopsy was regarded as quite an advanced procedure rarely performed by even more senior trainees. I think part of this stems from standard U.K. practice where a pneumothorax, the most common complication, would mean a call to a respiratory physician colleague and inpatient admission for underwater seal drainage.
Fundamentally, when learning procedural skills there is only so far you can go by watching: at some point you have to get hands on and move the needle yourself
One needs to understand the psychology of radiologists - we spend a fair chunk of time doing diagnostic and interventional procedures addressing clinical colleagues' complications so it is unusual and a little uncomfortable when the situation is reversed and you have to call someone to "bail you out."
Radiology is one of the best specialties for training, with lots of one to one time spent with enthusiastic, knowledgeable and motivated supervising consultants. However my perception is that having to call a colleague to admit the patient and the resultant inconvenience for the patient means that people are less willing than with other radiological procedures to let registrars learn and practice. Fundamentally, when learning procedural skills there is only so far you can go by watching: at some point you have to get hands on and move the needle yourself; with appropriate supervision of course.
The ambulatory HVCD approach is a game changer for training as the negative effects of a pneumothorax are largely mitigated. If the patient develops one, they can still go home with a HVCD in situ and minimal fuss. This means the extra time with the needle in the lung or slightly imprecise movements you might make as a trainee do not negatively impact the patient, whilst allowing you to build your biopsy skills. It also means the supervising consultant also has reassurance that a pneumothorax will not be catastrophic.
There is a tension between patient outcomes and training in procedural skills; the unspoken truth is that no one is born a great proceduralist and every clinician once had to hone their skills through practice.
There is likely to be a growing need for lung biopsy over the next few years. Oncologists want more and more tissue for the plethora of molecular and genetic markers; want to patients to undergo repeat biopsy when patients' disease progresses to look for new treatable mutations; and as screening will probably be introduced many more nodules will need sampling. All these mean effective training in lung biopsy skills will be more important than ever.
There is a tension between patient outcomes and training in procedural skills; the unspoken truth is that no one is born a great proceduralist and every clinician once had to hone their skills through practice. The Barnet model allows trainees, whether registrars or consultants, to do this in the best possible way, most importantly with minimal negative consequences for patients.
Read our interview with Sam, A common-sense, practical innovation that improves patient care, and his follow-up guest blog about why the ambulatory lung biopsy method should be rolled out across the NHS
Aniket is specialist registrar in radiology at the Royal Free London NHS Foundation Trust. He studied medicine at St. John's College Oxford, graduating with distinction. Prior to radiology training he spent a year working as a clinical fellow to Prof Sir Bruce Keogh, NHS medical director; and as a clinical fellow to Dr Fiona Godlee, editor in chief of the BMJ Group. Alongside clinical practice and research he is interested in healthcare innovation and the organisation and delivery of healthcare services.