War with Radiology?

Celiac Plexus said:

You seem to be saying, in a roundabout sort of way, that radiologists are greedy and don't care about patients. I disagree.

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Although I never said they are greedy...I think the salaries that they ask for(which BTW surpass what most other health care professionals make in the hospital) are rather steep. Do I think they don't care about patients, of course not. If it seemed that I implied that, I apologize.

Celiac Plexus said:

Blaming radiologists for turning down subpar job offers as a reason for compromised patient care is ridiculous.

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What is really compromised if physicians were properly trained to do the training than an average IR would be trained in as well. How much of a general radiology residency is devoted to learning IR techniques? No, really, I'm asking a genuine question. Would patient care suffer if Neuro and Cards were able to do the same fellowship program that was open to Rads grads?

Celiac Plexus said:

What exactly do you propose they do? Take a below-market job offer just because your hospital needs them? America doesn't work like that. At the moment, hospitals need radiologists more than radiologists need hospitals.

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If physicians continue to hold their standards akin to that of corporate America, then there is probably nothing more to discuss really. But you're right, we do need you more than you need us. Sad but true.

Celiac Plexus said:

If your hospital really needs an interventional radiologist to avoid compromising patient care, by your logic the CEO should be the one to take a pay cut.

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I don't disagree there. But if we are sitting here playing a game of chicken with the CEOs to see who budges first...I think the CEO won't have any problems waiting this out. His primary obligation is to make the hospital money. Our primary obligation is patient care.

This discussion I think highlights the problem in the growing field of interventional neurology (the most pc term for it IMHO).

The problem has to do with credentialing. It is a classic problem in economics and law. On the one hand, licensure/credentialing is important to maintain a certain level of industry quality. On the other hand, it can be easily abused to create restrictive practices (akin to monopolization), especially if much of the licensure/credential determination is done by selective members of the field. This is why the recent "guidelines" on credentials for carotid stenting is B.S. It is written by neuroradiologists, neurosurgeons, and neurologists to tell cardiologists and vascular surgeons what they need to do to be good enough to do carotid stents. If you don't believe me about this political intent, just read the adjoining commentary ("[the cardiologists] are coming...")

But the reason it is hard for a hospital to hire an INR doc is simply b/c there aren't enough fellowships out there yet to train enough of them. The reason this is the case is because of the stringent guidelines that they designed in the first place. So yes, these guidelines and credential requirements improve quality, but at a great cost to quantity thus limiting access of INR services only to those few major institutions that can afford them. So muse on this: are these guidelines really to the benefit of patients? What happens to innovations in the field? What happens to the hundereds of thousands of stroke patients that can't reach one of these major institutions in time?

The US govt doesn't like this, and so guess what happens now: when an INR doc is not available cardiologists do the carotid stents instead so that we can help prevent more than 40,000 out of the 700,000 strokes a year. And what happens next is that the cards people get good at the carotid stents, make innovations in the field (since there are 5000 of them vs the 400 in INR) and eventually, INR loses their turf. It is probably going to happen as it has in the past, and unless the INR/ESN folks seriously loosen their requirements for training, stroke is going to be taken care of by a team of stroke neurologists and interventional cardiologists in the future (if you don't believe me, check out much of the commentary on the topic from the other side...)

This will only happen if the cardiologists can convince the US govt/ACGME/ABMS that this is how it should go. Radiologists don't want to fight (they will make enough money anyhow), neurosurgeons have enough to handle and really should only do INR as an adjunct to cerebrovasc stuff (so carotid stents/thrombolysis really isn't their business if they want to still have time to maintain their neurosurg skills), and the neurologists are quite passive people. Cardiologists are aggressive, have a much larger lobby, have shown considerable success in making innovations for MI treatment, and are excellent interventionalists when it comes to those really small tortuous coronary arteries.

Who's gonna win?

B

> At our institution,we are also having problems with recruiting a
> IR(and mostly for financial reasons as it seems we just can't seem to
> make a worthy offer).
>
> Sure the hospital is being cheap, and sure the CEO of the hospital
> makes alot so he should just fork it over if they truly need a IR, but
> the people that lose out the most are the patients.

Why would the CEO's salary have anything to do with the offer for an IR ? I am pretty sure that there is more to the story than just salary. When recruiting an IR, issues other than money often play a more important role. (Access to patients, scope of practice, required off-hours coverage, equipment purchases, architectural changes, clinic space, administrative support, billing support, nursing/ambulatory surgery support etc etc.) The IR's salary wouldn't come from the hospital in the first place. Typically a radiology group pays the salary during the startup phase, once the volume is there patient care revenue should support the service. The hopitals role is in the areas mentioned above. Having an IR service is not only a big plus for patient care, a well run IR service generates a considerable 'leverage effect' for the hospital through technical fees and lucrative 23hr admissions. If they really wanted an IR to come there, they would make the necessary arrangements. Many places whine about not having suffient IR (or INR) services, but when you start asking questions you realize how much 'lip service' is involved. I repeat myself here: money alone is rarely the issue.

(I happen to be one of these 'greedy IRs' negotiating with a practice and hospital over the conditions of me going there. And it turns out that I (and probably most people who have interviewed for the job) have somewhat different ideas regarding the logistics and financials of the proposed service than they have. There is a reason why the local group stopped doing IR a couple of years ago.)

P.S.

-- How much of radiology residency training is devoted to IR anyway ?
Typically 4-6 months of diagnostic radiology residency are devoted to interventional training. That includes IR/angio rotations, body intervention and breast/thyroid procedures.

-- Why is there a shortfall of radiologists ?
In the early 90s the length of the radiology residency was increased to 4 years to account for the growth in the field brought about by cross-sectional imaging. As the total number of medicare funded slots remained the same, the number of residents each program could admit every year had to be cut by about 1/3.
And yes, in 1992 US medicine switched into panic mode with the election of Hillary Clinton into the White House. Medical schools actively dissuaded their residents from going into 'dead end specialties' such as ophtho, gas and rads. Some of the community programs had trouble recruiting residents and closed down, freeing up the medicare funding for the 'en vogue' specialties such as gyn and IM. Similar trends could be seen in neurology. Look at the admission stats of your specialty.
In addition, in the late nineties, just like many other professionals, rads saw their retirement portfolios develop rather favourably. As a result, they could retire or cut back to per-diem work earlier than anticipated.

-- Is there a shortage of radiologists, or will there be one ?
The SAME authors that in 1994 projected an oversupply of approx 10.000 radiologists for 2000 are now projecting the astronomical deficits some people are kicking around here. Imho, they where wrong then, and they are wrong now.

There is no conspiracy at work here, just basic math and economics.

f_w said:

Why would the CEO's salary have anything to do with the offer for an IR ?

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Of course, I was being general and rather frivolous with that statement. But only because many people are quick to point out how much the management of the hospital is making and in not so many words, they want a piece of the pie too.

So...while you wait it out and refuse to accept the salary(or accomodations) that are available to you, what's wrong with allowing those who will accept those salary and accomodations to practice?

Once again, patient loses in the end.

> So...while you wait it out and refuse to accept the salary
> (or accomodations) that are available to you, what's wrong with
> allowing those who will accept those salary and accomodations
> to practice?

Nothing wrong with that. At this time, the cardiologists and the vascular surgeon are already doing some of the procedures falling into the realm of IR. It is actually the vascular/oncologic surgeon who is my best ally and keeps bugging the administration to make the necessary committments. He is the one loosing out if he has to send patients to the competing hospital accross town if he needs certain procedures done that go beyond his comfort level.
As for greedy: They made an average offer, and I took it. Not even a point of discussion in my negotiations.

This thread is a complete joke.

I just finished my neurology rotation. It was with a group that reads MR and CT in between patients. This was also a complete joke. The guy was reading CT looking for an acute bleed from the ER. You know what? He missed mastoiditis. Maybe that was the cause of the headache???

Neurologists - take care of your patients. Leave the imaging to radiologists. There are so many intricate things to look for even on a CT scan that neurologists won't see.

e.g. another neurologist was reading a head CT and said to me "these are just old ischemic changes in the cerebellum." WRONG. He was pointing to the shadowing/volume averaging affect due to the anatomy of the cerebellar surface. I almost laughed out loud but kept my composure. I'm a 4th yr med student and after 2 weeks in a neurorad rotation I KNEW THAT. The MR reports I read? Weak. With all the sequences, MRA, MRV, things were obviously missed. I had to review the MRA for a patient and I actually noticed things that the neurologist-cum-radiologist missed. This is sad. I am afraid for patients. Thank god I will most likely be going to a University/Academic residency program where EVERYONE knows their place and does what they do best, not what they THINK they can do halfway-decent-and-make-a-little-extra-cash.

samsoccer7 said:

This thread is a complete joke.

I just finished my neurology rotation. It was with a group that reads MR and CT in between patients. This was also a complete joke. The guy was reading CT looking for an acute bleed from the ER. You know what? He missed mastoiditis. Maybe that was the cause of the headache???

Neurologists - take care of your patients. Leave the imaging to radiologists. There are so many intricate things to look for even on a CT scan that neurologists won't see.

e.g. another neurologist was reading a head CT and said to me "these are just old ischemic changes in the cerebellum." WRONG. He was pointing to the shadowing/volume averaging affect due to the anatomy of the cerebellar surface. I almost laughed out loud but kept my composure. I'm a 4th yr med student and after 2 weeks in a neurorad rotation I KNEW THAT. The MR reports I read? Weak. With all the sequences, MRA, MRV, things were obviously missed. I had to review the MRA for a patient and I actually noticed things that the neurologist-cum-radiologist missed. This is sad. I am afraid for patients. Thank god I will most likely be going to a University/Academic residency program where EVERYONE knows their place and does what they do best, not what they THINK they can do halfway-decent-and-make-a-little-extra-cash.

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You are awesome! Your superior brain power is needed on the floors of the hospital RIGHT NOW. Please do not waste further time posting or surfing on the internet. Instead, go up to where your superior brain could be put to work saving mankind: the depths of the rad reading room, the ER, the floor. Please, the patients need you!

scared sh*tless said:

Hey everybody. Just spent like an hour reading all your posts and I thank everyone on both sides, because I learned a lot.

I disagree with one thing: I don't think this is a ******ed thread as evidenced by the many insightful things people have written here.

Secondly, if radiologists are paid so much because they are in short support supply; why are peds neurologists not paid more? As I understand, they are in even more short supply. (around here, they get paid like 80,000)

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Maybe you need to go back and read all those posts again:

Radiololgy = volume, volume, volume. for every ct or x-ray they spend 60 seconds reading, the cash register goes "Ka-ching!" for their highly reimbursed "procedure."

During time it takes for a radiogist to rack up a couple thousand bucks in interpretations, the peds neurologist has done what? Maybe spent like 2 hours trying to convice some poor Duchennes' kid's parents who are in complete denial that he's never gonna walk and he'll be dead by 20 and and we just can't do anything about that. And for that, the insurance company (if they even have any) pays like 90 bucks. You don't just "get paid" magically. You get paid based on the revenue you can generate. Does the world need more peds neurologists? Sure. Is it willing to pay them more for what they do? Nope. Hence both the shortage and the low salaries.

This is a quote ripped from someone's dad, sorry I don't remember who.

"Pediatrics: little people, little money and little respect."

Unfortunately, as recently as a few years ago, the government reimburses less for clinic visits and procedures across the board for kids compared to adults.

Medicine is far from a free market.
There is artificial supply ala dermatology. There are market forces at work that determine fee for service procedures like plastic surgery.
However for everything else that is actually medically indicated, fees are not determined by the free market but by whatever arbitrary amount medicare decides to reimburse.

> sorry I started a flame war

No, just a 'spirited discussion'. Unfortunately the usual cast of knuckleheads on both sides of the discussion goes a bit over the line at times. My '******ed thread' comment came at a point when people were getting personal over this.

Going back to your original post: Nobody is going to take anything away from you. There are neurologists who provide imaging services now, and there will be some in the future. As long as you guys can find malpractice carriers to underwrite this extension of your practice, you are fine.

AAN will do their thing to expand self-referred clinician imaging, ACR will do their part to curtail it. It is a play of forces, nothing else.

To paraphrase a line from Forest Gump: 'Remember, anytime somebody starts to talk about 'quality of care' and the 'interest of the patient', hold on to your wallet and run.'

scared sh*tless said:

Yeah I get the 'procedure bit' but it was posited by one person here that radiologists are paid more because there is a short supply. BUt as you and Hans19 have pointed out, there is more at play here than supply and demand economics. We, as a society, have decided we want to pay someone the same amount of moolah to read a body CT scan in 5 mins as to take 2 hours, as you have said, to deliver some bad news to a patient's family.

But then again the peds neurolgist at my institution is a lot happier than the neuroradiologist... I actually think that if you look at your profession as a 'job' .. i.e. how many films can you read in 8 hours, then go home and SPEND YOUR MONEY, vs. a calling to service -- i.e. I'm not getting paid for this but this family needs my counsel right now, I think you end up valuing what you do more.

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1. You can't compare what a radiologist values in life and what a peds neurologist values in life. Apples and oranges.

scared sh*tless said:

let's pay them less, and increase the pay to peds neurologists.

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2. Good luck getting radiologists to accept lesser pay unless a major overhaul in reimbursement occured and it was imposed on them. And as far as increasing the pay for peds neurologist, this is something that peds neuro or the neurology community in general will have to lobby for. Maybe they can
1. Start doing a procedures or specialized test
2. Make it a standard of care for every live birth
3. Tell every er, peds or ob/gyn doc that sees a child that if they don't order this test/procedure they are violating standard of care, and the child is being under worked up.
4. Inform lawyers that if er,peds and ob/gyn docs do not order this test/procedure and some adverse event happens they can sue for millions of dollars
5. Tell other specialties that only they(peds neurologist) are qualified to do this procedure or test(or interpret it).

THEN peds neuro will start seeing some bank rolls.

P.S. I'm not a neurologist...

And please, please spare me that sobstory about the peds neurologists not making money. For every duchenne's that you have to spend 2 hours on counseling the parents, you will see 5 febrile seizures and 10 medication refills that you can pump out in 25minutes and 10 minutes respectively.

There is a wide bandwith in the incomes of peds neuros. I have worked with one guy who did workmans comp back pain including EMG (->$$$) 3 days a week (hey, you are boarded in general neuro, aren't you) and saw pedi patients on the other 2 days. Also, he had streamlined everything into standard workups, bc he had realized that no matter how you call that seizure syndrome, the treatment is still valproate.
It depends on where and how you set up your practice. The country is wide open for peds neuro. But of course, if you put your office in a downtown area with 80% medicaid HMO's, you are going to starve. If you put your office in the suburbs to treat the children of the worried well, you will look at decent money (not interventional cardiology money, more like run of the mill adult neuro money).

But wait a second. Isn't it evil to even think about money if you are a physician ?

(If the US wanted a medical system where everybody makes the same amount of money regardless of specialty and physicians are distributed according to a master plan, they would have elected Dean to become the president.)

eddieberetta said:

The problem with specialists reporting their own studies as has been suggested by two of the neurology people here is

1. when all you have are hammers, everything looks like a nail. Specialists deal with a certain range of pathology relevant to their own specialty and do not have experience with other lesions. How many cholesterol granulomas have you seen? How many traumatic ossicular disruptions? How many retropharyngeal abscesses? How many chondrosarcomas of the skull? How many meningoencephaloceles? These are picked up on head imaging all the time. Do you propose to send every study to a neurologist, neurosurgeon, ENT, orthopod? Or will a 2- week refresher course in Hawaii prepare you?

2. it is impossible to predict when lesions outside your scope of knowledge will arise. Since you have no training in dealing with them, it is not necessarily the case that you will even identify them, let alone diagnose / refer correctly.

3. it is incorrect to think that you have more experience with the imaging findings of diseases you treat regularly compared to a radiologist. your entire days clinic would flow through a single radiologist in the time of 1-2 of your clinical encounters. radiologists have orders of magnitude more image volume exposure than clinicians.

4 along the same lines, radiologists have more knowledge of imaging physics, artifacts, troubleshooting imaging problems etc. etc. that are everyday issues in the radiology department that you are completely shielded from when you drop by.

5 Yet a further issue is, by "cherry picking" cases as you propose to do, only referring when you have a question, you will reduce the case volume the radiologist sees, which would not allow him to maintain profiency. As a result you will not have specialist radiologists to turn to.

We can all list times our colleagues have made mistakes on both sides of the fence. But come on, it is simply not true that a freshly trained neurologist is safe to practice as a radiologist. The reason we have specialties is to better serve patients by training MDs to have special proficiencies in particular aspects of medicine. Like radiology. And clinical neurology.

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It's good to see this thread has gotten a little more civil. I think what we're seeing is that this is a discourse that needs to be played out, it is pretty prominent in the mids of both fields.

I have thought about EB's post, and have gotten the idea that it fairly well sums up most of the major tenets of the arguments rads puts out against clinicians reading films. Also thought it was overlooked in this thread. Specifically points 1 and 2 have not been addressed - they're kind of 2 parts of the same point. 3, 4, and 5 have been dealt with elsewhere and I think the arguments against them are more played out already.

But 1 and 2 present a solid argument: Neurologists probably would not suggest that they could function more proficiently than general radiologists on non-neuro cases. So, how can we be equally as prepared as a general radiologist (or a neuroradiologist) to handle non-neuro incidental findings on head/brain imaging?

I have 2 questions in response:

1. What would be examples of such incidental findings on a brain MRI or head CT, which would be outside the scope of training of a neurologist? The ENT findings you mention do not really qualify, these could involve neuro function and structure, so they should be within our sphere of knowledge and experience. I also challenge radiologists everywhere to answer your "how many" question about these particular findings. In general pathology within or around the close quarters of the brain and spinal cord should be within the grasp of a neurologist - they are likely relevant to neurology.

2. Functional MRI is essentially a focused exam - there are not incidental findings per se. I think this is an excellent prospect as a diagnostic procedure that neurologists are very well equipped to handle when it begins to be used in a clinical capacity. Neuroradiologists are as well, certainly - but insofar as it is a functional exam, a neurologist is the prime candidate to interpret the results.

In response to 3: Neurologists I have worked with have a policy of reading every neuro film on every patient that comes through their service, keeping up with all previous readings of those films, plus keeping abreast of their clinical case history, etc. In other words every neurologist on my service intends to read every neuro film, and sees exactly the image volume the neuroradiologists do. When do they fit this in? In my hospital, it's often after 4PM ( ).

suburbanite said:

So, how can we be equally as prepared as a general radiologist (or a neuroradiologist) to handle non-neuro incidental findings on head/brain imaging?

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Well, the obviouss answer is that the length of training required would approach that of a radiology residency -- about 3-4 yrs. If you want to have the same expertise you will have to undertake similar training. Your question is like asking what it would take for a GP or perhaps a general surgeon to acquire expertise in management of seizure, eeg, and stroke.

1. What would be examples of such incidental findings on a brain MRI or head CT, which would be outside the scope of training of a neurologist? The ENT findings you mention do not really qualify, these could involve neuro function and structure...they are likely relevant to neurology.

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Neurologists are not whole brain physicians -- they focus in a subset of brain and nerve pathology let alone ent and osseous pathology as listed. I am not sure if you are a resident or not -- these lesions and many others are not covered in depth in neurology residency, let alone their imaging findings. You would need to do a residency as I noted above. I think the onus is on you -- what makes you think neurologists have any expertise in all of the myriad anatomic pathologies of the brain, head neck and spine that they do not manage or treat?

Radiology residency and board exams are very grueling [in my biased opinion] and uncommon lesions are carefully studied and we are examined extensively on them because the expectation is that we are the "last line"

2. Functional MRI is essentially a focused exam.

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Insofar as fMRI includes an anatomic scan dataset, many feel an obligation to have the images reviewed at least once. In the hospitals I have worked at, a set of anatomic images are interpreted by neurorad, for free I might add as it is not possible to bill for this. This is because of a collegial research relationship which may not occur everywhere.

Interpretation of the fMRI data is often for research; when it is for surgical planning the lab people, and surgeon can combine the fmri data with other tests to decide where to cut. fMRI is not a major issue.

In response to 3: Neurologists I have worked with have a policy of reading every neuro film on every patient that comes through their service.
.

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Your radiologist reads all those films and the many fold more ordered by neurosurgery, ent, outside gps, rheumatologists, orthopods, oncologists, etc etc etc. One neurologist reviewing his own scans is not enough to maintain a modicum of competence. In addition, the radiologist spends all of his time maintaining expertise and updating his knowledge in the imaging findings of disease. This is a specialized area.

I welcome your comments but I truly believe that it is in the best interests of patients and providers that imaging specialists interpret imaging studies. If you propose that some neurologists enter imaging, after a comprehensive [multi-year] training program, and then maintain their expertise by devoting a majority of their time to imaging, then I propose that that is very similar to training as a radiologist anyway.

While your motives may be genuine, what is being proposed by most is that with no more training that the standard neuro residency, neurologists read a smattering of scans that they order for their own patients [just re-read some of the arrogant posts at the start of this thread]. I feel that this will provide substandard care.

There are already training programs for the 'ueber-neurologist'. They combine neuro/neurorad/general rads in a 7 year program. The original idea was to create that mythical creature able to diagnose and treat the neuro patient A-Z. They didn't get far.

The problem is that many of the neurologists interested in getting into the imaging business largely see this as such: a business. The idea is to become able to self-refer and to cherry pick the high-reimbursement studies. While there are pure imaging center based radiology groups, most have some sort of hospital attachment requiring them to offer call coverage. If you want to take the $1400 easy to read 'follow up MS' MRI, you should also be ready to read the unreimbursed 3 am 'drunk, fell over' head-CT.

The main issue with self-referred clinician imaging is the skyrocketing utilization that it brings along (not only in the US, this has been shown in other countries, greed is univerrsal).
Try to get a well-insured female in and out of a gyn's office without a pelvic ultrasound. Ever been to a cardiologist ? The only question is whether you are younger than 45 (---> ECHO only) or whether you are older than 45 (---> ECHO and nuclear stress test). The indications get 'bent' appropriately to give the ripoff a semblance of legality.

I hope that I haven't given the impression that I think neurologists are just as good at reading neurorad films as radiologists(especially neuroradiologists).

My comment was simply at trying to establish why exactly rads would be so against a neurologist reading films and doing interventional techniques(IF PROPERLY TRAINED).

If a neurologist was apt to do a 2-3 interventional neuro fellowship, I don't see why they couldn't. Unless you are specifically saying that in no way shape or form a general neurologist, who has a rather good knowledge of clinical/anatomical neuroanatomy is fathoms behind a general radiology 4th year resident(who does not BTW spend all his time in neuro-rad).

Am I wrong in this assumption?

> My comment was simply at trying to establish why exactly rads
> would be so against a neurologist reading films

There is already enough self-referred clinician imaging, the experience in these areas has shown that:
- utilization goes up, way up.
- quality goes down
- accountability goes down (many gyns don't print films, images are not available for follow-up)
- revenue streams for the local hospitals dry up
- yes, it takes money out of our pockets

> If a neurologist was apt to do a 2-3 interventional neuro fellowship,

I believe they already do. NIR fellowships admit neuro residency graduates.

> Unless you are specifically saying that in no way shape or form
> a general neurologist, who has a rather good knowledge of
> clinical/anatomical neuroanatomy is fathoms behind a general
> radiology 4th year resident

Except for some of our enthusiastic rads-to-be interns here, nobody would seriously say that.
When radiologists enter NIR fellowship they have 4-6 monts of neuro, 4-6months of angio/IR during residency and 12months of diagnostic neuro fellowship behind them, that is probably worth a couple of feet (fathoms, I don't know).
I am sure that neuro residents can make this up if they don't have two left hands (as the ones around here seem to have).

Some folks here keep throwing in cardiology 20 years ago as an example as to how a specialty can develop a skill (in this case angio). I submit that a neuro resident (4 years training) to an interventional neuroradiologist (7-8 years of training) is the same as as an internist (3 years) to an interventional cardiologist (7 years training). (Internists don't stent small vessels fresh out of PGY-3, and I don't know why some of the kids here think neuro residents should)

PS
The server here seems to make posts disappear if you leave the reply window open for too long, hence the 'empty posting'.

Whodathunkit said:

My comment was simply at trying to establish why exactly rads would be so against a neurologist reading films and doing interventional techniques(IF PROPERLY TRAINED).

If a neurologist was apt to do a 2-3 interventional neuro fellowship, I don't see why they couldn't.

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I think you are mixing up some issues here. On one hand you are talking about reading films, on the other about interventional training.

I feel that several years of additional training are needed for a neurologist to pick up the skill needed to be a diagnostic neuroradiologist [i.e. head neck and spine imager capable of being a solo neuroradiologist in a radiology practice]. Such a direct path is not available, but you could always do a radiology residency, and would probably get credit for 1-2 years and need to do 3-4 yrs, which is similar to the amount of training I think would be needed. This would also give you the skill needed to be a radiologist on call, a prerequisite to working in small-medium size groups.

There is already a path for neurologists and neurosurgeons to do INR -- apply to fellowship. But that training will not suffice for diagnostic N.R.

What has been proposed by the earlier posters is that clinical neurologists look at the Cts and MRs they order [often with report in hand and a neuroradiologist standing nearby], and this gives them the expertise to read on their own and squirt the odd angio.

Addendum: regarding the amount of time spent during residency on neurorads, the time-block estimates are not realistic. In our call nights and rounds we see hundreds more cases throughout every year of training. The neuro rotation is just a part of that.

The work of a neuroradiologist will be very diferent from a neurologist/neurosurgeon with INR training. The neurologist/neurosurgeon cannot completely evaluate CT/MRIs of head/neck/spine with regards to soft tissues,sinuses,etc and neuroradiologists cannot do clinical and intensive care management.
The interventional neurologists/nsurgeons would evaluate films with respect to their immediate clinical utility and apart from the procedures would also take care of critical care issues and management which is also extremely important. This definiely needs extra 3 yrs training after neuro residency. The adequate clinical management of patients after intervention or neurosurgical procedures is one of the most important pre-requisites for good outcomes.

> neuroradiologists cannot do clinical and intensive care management.

If you are talking about you a regular diagnostic neuroradiologist, that is probably true.
If you are talking about a ASITN trained interventional neuroradiologist, this statement is incorrect. A good part of neuroIR training is devoted to post procedure management.

Most elective NIR patients might get housed in the ICU just bc they have an indwelling arterial sheath. If you didn't mess up during the procedure, they shouldn't need much more than someone to watch the gauges and to empty the foley bag every once in a while. Acute patients, such as SAHs and strokes are hopefully managed in an interdisciplinary team. I don't have to be an expert on vent management if I have an experienced intensivist to take care of that aspect of care.

> The adequate clinical management of patients after intervention or
> neurosurgical procedures is one of the most important pre-requisites
> for good outcomes.

The most important pre-requisites for successful endovascular therapy are:
- adequate patient selection
- that that little catheter thingi goes right where it belongs
- meticulous technique
- no bubbles, no clots
And for that, you want to have the person with the best catheter skills and the most endovascular experience.

You can diddle around with the electrolytes or vent settings all you want afterwards, if brain is dead, it's dead.

(If I need my skull cracked, I will go to the best neurosurgeon money can buy. If I need an aneurysm coiled, I'll go to someone who does that for a living. If I need that spontaneous twitch of my left hand looked at, I will be glad to see a good neurologist.)

" If I need an aneurysm coiled, I'll go to someone who does that for a living."
This could be a neuroradiologist or nsurgeon or neurologist with endovascular training. People from these 3 streams would have to train for the same number of years to perform these procedures.

eddieberetta said:

ummm..yes. Beacuse radiologists, unlike neurologists receive extensive training in intracranial, extracranial, osseous and soft tissue lesions that are seen on routine "neuro" exams, I propose that radiologists should read films. Do you think mere "general" neurologists should treat MS?


do neurology residents make prelim diagnoses overnight? Do you prescribe meds? I guess we shouldn't allow that.

...(Obviously neurology is no different)

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Sorry, I've been going through these useless posts and realized I never repied.

Anyway, just wanted to point out that you agree with me: while a subspecialty opinion is valuable, so is a general doctor's opinion. Even a resident can manage these cases: rads or neuro. General neurologists and primary care doctors can and do diagnose and treat MS. Nothing wrong with that. It's a matter of comfort, experience, and skill sets.

When I'm asking clinical question: "does stroke or hemorrhage explain acute right hemiplegia?" I can figure it out. In fact, I do, since spending any time with radiology on that point is wasted time. Just like a rehab doctor can figure out that increased latency through the median nerve at the wrist is CTS.

So I'm glad you fell for my questions. Now we agree: neurology can do spine surgeries. Kidding obviously. I'll stick to my comfort level: brain and high spine for the clinical questions that I want answered.

neglect said:

When I'm asking clinical question: "does stroke or hemorrhage explain acute right hemiplegia?" I can figure it out. ... I'll stick to my comfort level: brain and high spine for the clinical questions that I want answered.

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What about any significant findings that do not answer the clinical questions that you want answered? Yes, it is true that you can probably exclude hemorrhage but you are talking about providing the FINAL interpretation (the one that gets billed for), not the PRELIM. One must deal with all findings relevant to the clinical context and not. [Yes, we are talking about the lung nodule on the ct-c-spine; the chordoma on head MR, the Mondini malformation in the corner of the Facial Bones CT]. Neurologists do not have that training, and radiologists do -- that is our job.

There is no doubt that you are`right. There are findings on head CTs/MRIs that neurologists are not trained to detect. I believe neurologists should not have the final say on the 'entire film', but certainly their opinion on findings in the neuraxis
is relevant. But doing interventonal procedures and managing patient is entirely different. Neurologists are trained in intensive care, cerebrovasc disease and all other aspects of neurologic care. With additional training they can also do interventional procedures. There are different neurology subspecialities, this will be one of them, actually a part of stroke/neuro ICU.

> There are different neurology subspecialities, this will be one of
> them, actually a part of stroke/neuro ICU.

And this is what worries me. People who did a couple of months of catheter training during their ICU fellowship as opposed to folks who went through a 3 year dedicated training period to do only NIR.

f_w said:

> There are different neurology subspecialities, this will be one of
> them, actually a part of stroke/neuro ICU.

And this is what worries me. People who did a couple of months of catheter training during their ICU fellowship as opposed to folks who went through a 3 year dedicated training period to do only NIR.

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No. Neurologists will not be doing caths after only a couple of months of training. They are required to do a 2 year dedicated program for NIR after they have already spent 1 year doing a vascular neurology. The point is that they will have a full 2 years of training doing cerebral angio's and interventions in the brain. This is exactly how much training a neuroradiologist or a neurosurgeon will be getting if they want to do NIR. The only difference is that neuroradiologists might have more training with fluoroscopic technique and reading CT/MRIs. Neurosurgeons will be better at managing aneurysms and brain tumors (e.g. can decide whether to take to angio suite or OR) and neurologists will be better at the diagnosis and ICU management.

Besides, remember that we have far fewer INR people than we need. Why the bitter arguments? If a vascular neurologist, neuroradiologist, or a neurosurgeon wants to spend an additional 2 years for INR... I say let them!!!

B

If someone indeed did his 2 years of NIR after the stroke fellowship, all power to him. I am scared of folks who did 15 angios during their ICU fellowship and set up shop in a community hospital doing IA lysis or thrombectomy (this is how many vascular surgeons got into peripheral intervention. Buckets of infarcted kidneys are testament to this concept.)

f_w said:

If someone indeed did his 2 years of NIR after the stroke fellowship, all power to him. I am scared of folks who did 15 angios during their ICU fellowship and set up shop in a community hospital doing IA lysis or thrombectomy (this is how many vascular surgeons got into peripheral intervention. Buckets of infarcted kidneys are testament to this concept.)

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I fully agree! Intracranial angiography is far more risky than peripheral interventions even and requires that somebody be exceptionally well trained with the procedures (as well as the pre- and post-procedure management of stroke simply because of 24/7 call requirements). For peripheral interventions, though, I think the cards guys will take over. This is simply because of their personality, number, and ability to refer atherosclerotic patients to themselves. This includes carotid stenting. Fortunately, most of the cards people doing peripheral work focus on the peripheral work only, so I believe that they will be well trained to do the carotid, renal, and femoral artery stenting. Vasc surgeons need to split their procedure time btw surgery and IR, so will never be quite as proficient (similar to neurosurgeons wanting to do INR).

B

There is no denying the fact that anyone with a plain neuro ICU fellowship would be grossly undertrained to do intracranial interventions. For any neurologist to do these procedures would take a dedicated INR fellowship after stroke and neuro ICU.
All i am saying is that it would take the same number of years in training for neurologists to practice intervention, but their work profiles would be different.
Both neurologists and neurorads would do intervention. Neurologists would also manage neuro icu, but would not be completely trained to read entire head CT/MRIs. They would be able to read these films only pertaining to their clinical requirement. Neurorads would be masters of neuroimaging, would also do intervention , but would not clinically manage patients in the neuro ICU ( which include not only ishemic/hemorrhagic strokes, but also status epilepticus, myasthenic crisis, comatose patients, encephalitis and so on)
I sincerely admire the skills of neuroradiologists at interpretations of neuro films, but neurology residents also have to work hard to build the clinical concepts of neurologic disease including electrophysiology and management.

Great, so we finally agree and can hug each other. Henceforth we will abstain from insulting each other and work for the good of the patient evermore )

good way to conclude.

eddieberetta said:

What about any significant findings that do not answer the clinical questions that you want answered? Yes, it is true that you can probably exclude hemorrhage but you are talking about providing the FINAL interpretation (the one that gets billed for), not the PRELIM. One must deal with all findings relevant to the clinical context and not. [Yes, we are talking about the lung nodule on the ct-c-spine; the chordoma on head MR, the Mondini malformation in the corner of the Facial Bones CT]. Neurologists do not have that training, and radiologists do -- that is our job.

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Look, first of all, I'm sorry to even be posting. This is a useless conversation, because it'll be settled by regulation and the market (as much of a market as medicine has), not by us. Turf wars demeen both fields, but the fact is simply that neurologists can read films as well as radiologists.

I'm sure you have some anecdotes on the stupidity of the neurologists at your hospital. I've seen some reports that were dictated while looking at another film during a power outtage.

Your point seems to be that neurologists will make mistakes. If that is your requirement for the ability to read films, then the only person who should ever read a film is someone subspecialized within the area. No general radiologists should read anything. Except that, of course, specialists make mistakes reading films. Where does that lead us?

Having to dig into the medical trivia so deeply that you come up with the Mondini malformation is telling. Let's consider the medical mission: the best outcomes possible. . Does anyone miss a chordoma? I've actually seen radiology miss several mets to the same region because they actually didn't know what the history was telling them, even when it was simplified into: CA, now with left R 6th and 7th. Those were picked up by your ever helpful neurologist. Bad radiologists? No. Things sometimes just get missed. Should these radiologists continue to read films? Sure. Just like the ER should continue to treat migraines.

tum said:

that's EXACTLY it. it's not as bad as derm, but there's definitely a hint of artifice when you read these news reports about the "national shortage" like we can't pump out grads fast enough because the field is so daunting or some crap like that..

one thing that does worry me, and i've mentioned this before, is whether managed care will try to reduce reimbursements for foreign reads from us trained radiologists. i'm not sure how they'd justify it, and it would sure look bad in court if something happened, but still..

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The comparison is innaccurate. Please read my post after the post you quoted for a better explanation. Expanding residency spots just doesn't happen overnight. The reason for the shortage is due to a variety of factors, including immense increase in volume for the past 10 years.

I do predict a decrease in reimbursement and radiology salaries in the near future, but not due to foreign rads, which will likely be a small factor, if at all. It will have more to do with the government deciding too much is spent on imaging and unilaterally cutting reimbursement.

Bump

salmonella said:

Bump

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iatrosB said:

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IMGforNeuro said:

The work of a neuroradiologist will be very diferent from a neurologist/neurosurgeon with INR training. The neurologist/neurosurgeon cannot completely evaluate CT/MRIs of head/neck/spine with regards to soft tissues,sinuses,etc and neuroradiologists cannot do clinical and intensive care management.
The interventional neurologists/nsurgeons would evaluate films with respect to their immediate clinical utility and apart from the procedures would also take care of critical care issues and management which is also extremely important. This definiely needs extra 3 yrs training after neuro residency. The adequate clinical management of patients after intervention or neurosurgical procedures is one of the most important pre-requisites for good outcomes.

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When was the last time a Neurology resident matched into Interventional Neuroradiology fellowship (unless he was a resident at Johns Hopkins, UCSF or Mass General)???

Interventional Neuro (IVN) is now Neurosurgery/Radiology territory. And that is a fact. Politically the senior neurologists have revolted against 'interventional' hypothesizing that its not part of traditional neurology. That was observable at the recent AAN and ANA meetings that distanced themselves from IVN. Infact the best seminars and presentations on IVN this year were at the Congress for Neurological Surgeons meeting at Chicago.

Dont ask me , ask any neurologist.

Onco said:

When was the last time a Neurology resident matched into Interventional Neuroradiology fellowship (unless he was a resident at Johns Hopkins, UCSF or Mass General)???

Interventional Neuro (IVN) is now Neurosurgery/Radiology territory. And that is a fact. Politically the senior neurologists have revolted against 'interventional' hypothesizing that its not part of traditional neurology. That was observable at the recent AAN and ANA meetings that distanced themselves from IVN. Infact the best seminars and presentations on IVN this year were at the Congress for Neurological Surgeons meeting at Chicago.

Dont ask me , ask any neurologist.

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There are several residents (and now fellows) who are in or will begin an interventional fellowships that come from programs such a U. Miami, Mayo, Cleveland Clinic, Jefferson, to name a few.

... Northwestern, University of Chicago, Washington University...

Endovascular approaches to stroke is a hot topic at the upcoming AAN meeting.

B

Onco said:

When was the last time a Neurology resident matched into Interventional Neuroradiology fellowship (unless he was a resident at Johns Hopkins, UCSF or Mass General)???

Interventional Neuro (IVN) is now Neurosurgery/Radiology territory. And that is a fact. Politically the senior neurologists have revolted against 'interventional' hypothesizing that its not part of traditional neurology. That was observable at the recent AAN and ANA meetings that distanced themselves from IVN. Infact the best seminars and presentations on IVN this year were at the Congress for Neurological Surgeons meeting at Chicago.

Dont ask me , ask any neurologist.

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It's called interventional/vascular neurology fellowship, targeting neurology grads. They are popping up everywhere.

And what's so special about JH/UCSF/MG? Are you trying to say that neuro grads from other programs are not up to the standards of radiology/NSGY?

What's this 'revolting' business you speak of? Give me a break.

Mind sharing what you are smoking? I like to escape from reality for a while too.

No offence but you are perhaps not aware of the severe internal revolt in neurology against 'IVN'..

And dont tell me about these IVN fellowships.. they are a joke. At my program both IVN fellows are former neurosurgery residents. Almost 70 - 80% of all IVN fellows dont have a background of neurology... 'Endovascular Neurosurgery' is now the official 8th sub-speciality of Neurosurgery... Read Kassam et al.

I know this all sounds skeptical and you dont want to believe it.. sorry

Please enlighten us more about this "internal revolt" against IVN. I am aware of the reservation by many top stroke physicians against the use of carotid stenting. This is data driven and ongoing studies will continue to change thoughts on this matter. Aneurysms and AVM's, the two conditions that receive the most interventional care are in the domain of neurosurgeons and neurointensivists. Cerebral angiography is giving way to CTA and in some places where it is done properly, to MRA as well. So to a neurologist, interventional procedures don't matter much.

If this is what you mean by "revolt", then yes, there is one. But if you mean to say that neurology does not want to deal with IVN, then while there might be a few against, it seems overall neurology has accepted that some neurologists will want to become interventionalists. Why else have an IVN section in the AAN?

Neurosurgeons have clearly accepted this is a specialty, as neuroradiologists continue to do so. Neurologists only make 20-25% of the fellows currently (though this is rising). This makes sense since except for carotid stenting (which is mostly done by cardiologists and vascular surgeons), there is no intervention that makes a difference for conditions that are typically treated by neurologists. Even carotid stenting is only useful in select circumstances. However, this might all change very soon. If intracranial stenting, intraarterial delivery of thrombolytics or neuroprotective agents, or even other as yet unexplored agents (e.g. stem cells) becomes a proven therapy for stroke, then you better believe that neurologists will embrace the field.

So I stand by what I have said before: if your main interest lies in the interventional treatment of stroke, neurology is by far and away, the best path for this. Others in the field will accept this since you--and not the radiologists or neurosurgeons--have experience giving thrombolytics, managing their antiplatelet and antihypertensive agents afterwards, in the setting of a large amount of growing data. If you want to do interventional for the aneurysms and AVM's, do neurosurgery. If you want to do it for the money, do radiology (okay, if you are interested in head and neck issues also, then radiology is far superior to neurosurgery and neurology).

B

Bonobo said:

Neurosurgeons have clearly accepted this is a specialty, as neuroradiologists continue to do so. Neurologists only make 20-25% of the fellows currently (though this is rising).


B

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I think the numbers are 15% (and most probably declining) My source is a newsletter from a recent meeting in Radiology.
As I said, I know of two neurosurgery residents in IV fellowships.. The field is being controlled by Radiologists currently however, the new 'Endovascular neurosurgeons' will take over within next 10-15 years. I told you guys to check Kassam Its only natural that neurosurgeons do it because they spend 7 years of their lives training to operate on the brain and know the neuroanatomy inside out. With endovascular neurosurgery, everything will be done IV.. from brain tumor removal to clot busting..

I am a Neurology resident interested in both Diagnostic Neuroradiology and Interventional Neurology, and have found Neurosurgery and Radiology attendings to be both helpful and very encouraging of Neurologists accepting fellowship positions in both of these areas.

And so I went and got me a popcorn bag and went through the entire thread *no for real, I did get a popcorn bag, I didn't have lunch*.

Comments...

1) I am a self declared radiologist hater *heh*

2) Still I know neurorads know more about head CT/MRI than neurologists BECAUSE not every head CT/MRI is ordered by a neurologist or has a neurologist involved. In terms of raw number cases, neurorads win.

3) Just because #2 is true, it doesn't mean neurologists are NOT ENOUGH for a brain MRI/CT for the neuro cases... After all, they do order those and that's all they look at as well. I mean if you are doing 300 a week and I am doing 100 a week... who are you to say that 10 years from now you will be so much better that you will _ALWAYS_ make a difference... what about a neurologist with 10 years experience vs a neurorad with 1 year experience? Can't claim that the neurorad has had more MRI/CT scans to look at than the neurologist. Please don't give me the symphony about the training being different... I already admitted #2 but that doesn't mean it's enough... If I echo every single patient that comes to the ER with chest pain.. of course it will be better than just plain EKG but that doesn't mean it's the right thing to do. Same with neurorad vs neurologists reading the CT/MRI.

4) I am sick and tired of hearing comparisons of clinical aspect vs film/test aspect. The clinical picture AND the radiology test ARE BOTH IMPORTANT BECAUSE NEITHER IS NINTY FIVE PERCENT CONFIDENT in their diagnosis. Both have correlations of correctness and when added together they produce a better curve fit to diagnose a problem. I'm sure everyone knows cases where the clinical aspect was garbage and I am sure everyone knows cases where the radiological assessment was garbage.

5) Radiology SHOULD be worried about outsourcing because currently the way the stupid system is designed... it forces the residents who are on J-1 visa to leave the country for 2 years. That means they will go back to India or wherever and try get back in the country... meaning they CAN be board certified and end up going to their country. Radiology should try and limit their residents to people with green cards or US citizens because you know those are the most likely people to stick around in the US (yes I will get flamed for this but it is the truth). But hey, if the radiologists want to ignore the huge money incentive in having radiologists read the films from outside the US for less cost... then so be it.. it's their profession that they put at risk. I advise against denial... and as the saying goes.... Just because I'm paranoid, it doesn't mean they aren't out to get me.

Lets kill this thread please. It's useless.