Only eight doctors were qualified to perform the procedure in NSW - highly trained clinicians known as interventional neuroradiologists (INRs) whose first specialty was in radiology, neurology or neurosurgery. The explosion in clot retrieval cases would cast a redistribution of workflow, power and ultimately income. The old paradigm was fracturing in ways that would expose doctors at their most human. As they struggled to meet the demand in a way that benefited patients and themselves, they would be forced to examine what sacrifices they were prepared to make. 'Hot air and no real solutions' The INRs who met with Sydney Local Health District chief executive Teresa Anderson at the Kerry Packer Auditorium in 2016 were in a truculent frame of mind. The purpose of the meeting was to thrash out a mutually agreeable way of making clot retrieval available to all NSW residents 24 hours a day with a limited workforce. The INRs needed theatres, staff, software, a co-ordinated referral system and asked for a financial sweetener for the considerable after-hours work. Anderson leaned towards recruiting more doctors.

The doctors' original solution had been for six of them to quit their day jobs and form a private company contracted to supply INR services in NSW. But after three years of negotiations with the department, the chief executives of the local health districts baulked at the $20 million price tag. Dr Teresa Anderson, CEO of Sydney Local Health District. Credit:James Brickwood Now the doctors were smarting. Two had not even turned up to the meeting, a fact remarked upon by Anderson. Meanwhile, the system that had emerged was not serving patients. INR Rodney Allan, a neurosurgeon at RPA, says the private company contract included millions of dollars worth of equipment and clear arrangements for patient transfers. Its collapse left doctors rudderless.

"It would be naive to say money wasn't a part of it, but I actually earn more from neurosurgery than I would have done doing this," he says. INR Jason Wenderoth works at Prince of Wales and Liverpool Hospital. Credit:Spectrum Interventional Radiology South of the border, the system was operating efficiently. Two Melbourne hospitals had been endowed with extra resources to provide an around-the-clock clot retrieval service and doctors shared the on-call roster. But the mafioso-style clinician culture in Victoria (one neurologist is actually nicknamed "the Don") meant doctors accepted the pre-eminence of certain hospitals. In NSW, when plans for the private company were dashed, so too was the concept of teamwork. The INRs fell into factions around their own hospitals and nobody wanted to see empire building elsewhere. Jason Wenderoth, a radiologist who operates at Liverpool Hospital and Prince of Wales, feared that Anderson wanted to funnel all the work to her own hospital at RPA.

"It was pretty obvious to anyone from the INR side that the meetings weren't set up to find solutions, they were set up to make the whole thing collapse," he said recently. "All just hot air and no real solutions." A polarising figure, at the end of that meeting he spoke for everyone: "This is a waste of time." Anderson declined to comment for this story. The procedure Endovascular clot retrieval is the process of extracting a blood clot in the brain through a catheter inserted at the groin. A study by Royal Melbourne Hospital neurologist Bruce Campbell in 2015 found that it gave patients a 70 per cent chance of recovery compared to 40 per cent among those administered traditional clot-busting drugs.

"We presented those results in February at the International Stroke Conference and everybody was basically doing it from then on," Campbell says. In 2011-12, the clot retrieval was performed 47 times in NSW. Last year, 485 patients were treated. The scan shows regions of the brain already affected by stroke (pink) and those that remain at risk (green). Credit:Ischemaview It was, says Wenderoth, the "biggest change in medicine since penicillin". "It’s huge," he says. "This is taking stroke patients who have an 80 per cent chance of being disabled and enabling them to go back to work." Radiologists' first instinct was to feel threatened. Ischemic stroke treatment had been their bread-and-butter for decades while other specialists shunned it in favour of better paying conditions such as aneurysm. The risk now was that neurologists and neurosurgeons, who had the advantage of patient referrals unlike radiologists who were technicians, would seize all the work.

It was a pattern radiologists had seen previously in heart and vascular disease, and they were determined that it would not happen again. "The radiologists were pretty clever about that and headed it off at the pass," Wenderoth says. He feared that untrained doctors would attempt the procedure and leave the patients worse off. "The evidence repeatedly shows that operators with high volumes and centres with high volumes have better outcomes for patients." The first step was to establish a professional body, the CCINR, overseen by the colleges, that would set standards and supervise training - and restrict entry to the profession. New entrants would need to perform a minimum number of cases under certain supervision criteria to qualify as INRs, which are common preconditions to fellowship of a medical college. Doctors training to become INRs at the time suspected that the bar was being set more to control clinician numbers than case numbers. Those who inquired about training positions were often told by the existing INRs that there were no jobs available.

Prince of Wales Hospital, Randwick. Credit:AAP "If I were in your position, I would be looking for a place to practise before looking for a training job," one hopeful INR was told in an email seen by the Herald. "However, we would consider taking on an overseas trainee in 2016." Other doctors, who had completed the minimum two years training were informed at the end of that period that there were technical deficiencies associated with their training sites. Their applications were declined on these grounds despite meeting individual training requirements. In most cases, their training was only recognised after months of contesting, appeals or even complaints. Allan, the chair of the CCINR, says the only reason people were not approved was because they had not met the criteria. “The criteria are pretty simple. You just have to get a certain number of cases in a certain period of time.” Next, Wenderoth and his colleagues at Prince of Wales and Liverpool set up a centralised call service and distributed it to hospital emergency departments around NSW to feed them stroke patients. They also set up web-based referral, devised protocols and organised the system for patients to be transferred to their sites.

Victims of their own success Loading The Prince of Wales/Liverpool team had now positioned themselves in the box seat for patient referrals, but were becoming victims of their own success. Although clot retrieval was useful in drawing patients who might also need elective procedures, unless NSW Health could be persuaded to give them a financial incentive they were barely worth the crippling on-call demands. When called out after hours, INRs receive $200 per hour for public patients, or more than $5000 for private patients. At each hospital where the procedure was performed, the INRs lobbied their managers for the nurses, anaesthetists, theatres and software they needed to run the service. At Prince of Wales, Wenderoth found it to be an exercise in "buck passing". The chief executive would say that the money was the general manager's to allocate, while the general manager would argue there was not enough funding to allocate.

The radiology nurse manager at Prince of Wales - a dominant personality and fierce protector of her staff's working rights - had enough. She refused to roster nursing staff for the procedure after 8pm. When the issue came to the attention of the media, the then health minister Jillian Skinner was forced to declare that the service was available 24 hours, and the doctors and nurses who worked in INR at Prince of Wales were hauled into a meeting. "The minister said we are 24/7 so unless we are 24/7 heads will roll," they were told. They have been running a 24-hour service ever since. The INRs who worked across Royal North Shore and Westmead hospitals took a hardline approach. Until the procedure was properly resourced, they would only do clot retrieval within the hours of 8am and 3pm on weekdays, or 10am to 3pm on weekends. "The North Shore guys will hold out until all the resources come that everyone else has been pushing for," Wenderoth says. "It's a tactical manouevre. So far ours hasn't worked."

Only at RPA, where Anderson made it her mission to build the service, have resources been forthcoming. But in many cases her efforts served to stoke existing divisions. She guaranteed that no patient suitable for clot retrieval would be turned away, but this meant that those who arrived for other treatments had to be transferred to other hospitals, creating unrest among clinicians. She created favourable contracts and working conditions that allowed her to employ four new INRs - bringing the total number in NSW to 14 including new hires at Prince of Wales and John Hunter - but some of them are under-deployed, even while there is no after-hours service at Royal North Shore or Westmead. The neurologists, neurosurgeons and radiologists who work at RPA suspect each other of hoarding resources and cases. "There is quite a spectrum of personalities in medicine," one INR says. "We are all very separate," says another.

'We could all co-operate ...' More recently, Wenderoth approached the RPA administration to sound out a quid pro quo arrangement where the Prince of Wales/Liverpool INRs could share the after-hours roster with RPA on some nights of the week. "We were asking for a few concessions on their part to make it palatable for us ... ICU beds, being paid properly to do it, teams to do it," Wenderoth says. He heard nothing back. Now he says he plans to quit as soon as it's financially possible to do so. He says they’re receiving the same pay ‘‘for three times the work and it’s completely changed our life-work balance’’.

"We’re up all night every night without fail, getting calls from everywhere. If we get sick the system will fall over." Last week he got a speeding fine for doing 51km/hour on the on-ramp to the emergency department at 3am. That clot retrieval will end up costing him $80. INRs and administrators agree that most people are getting serviced, but the workforce is so poorly distributed that many are getting delayed care. Allan says if he were in charge of health in NSW, he would concentrate stroke services at three sites in Sydney with all INRs sharing the after-hours roster. But this would mean neurologists who worked at the hospitals where stroke services were stripped would lose patients, and chief executives would lose the cachet and funding that comes with a comprehensive stroke centre. "There's no real co-ordinated stroke care in NSW," Allan says. "We could all work co-operatively, that would be an answer. But I don't think that's going to happen once you get chief executives involved, with the exception of Teresa Anderson."