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Future of Rads vs Ortho??

Discussion in 'Radiology' started by cbtk18, Mar 29, 2012.

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  1. johnnydrama

    johnnydrama I'm no Superman

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    VC doesn't need to be that expensive. It also should be very conducive to automatic detection.

    It will become more prevalent, but I'd wager it won't be so much a gain for radiology as a loss for GI. Real colonoscopies will still be required, but they won't be used for screening in almost everyone over 50.
  2. colbgw02

    colbgw02 Delightfully Tacky

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    Not to mention that the entire concept is predicated on the idea that VC will be reimbursed at a reasonable rate. Medicare - the 800 lbs. gorilla in the reimbursement room - has already nixed the idea, citing concerns about increasing overall costs of colon cancer screening. If anything, the current financial climate makes it more difficult to get VC approved for reimbursement. Taurus acts like it's a foregone conclusion.

    The whole idea isn't impossible as much as it's, well, stupid. I suppose it could work as a niche market, but the idea that radiologists are going to start opening colonoscopy clinics is highly improbable (read: stupid).
  3. MossPoh

    MossPoh Textures intrigue me

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    Never understimate stupidity because that is when it sneaks up and bites you.
  4. Taurus

    Taurus Paul Revere of Medicine

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    What you guys are forgetting is that procedures that were once soley by radiology are now done by others. In many cases, radiology does not do it anymore because it has been taken over completely.

    Heart stenting, cardiac nucs, echoes, PAD work, neurointerventional, ob u/s, etc.

    In Buffalo, NY, a neurology group reads their own brain MRI's. The Dent Institute.

    It doesn't happen overnight. It takes years. At my program years ago, vascular surgery residents rotated through IR for 3 months. At some IR fellowship programs, they were filling them with vascular surgery graduates because they couldn't fill them with radiology graduates. So why was anyone surprised that vascular surgeons one day realized that they were comfortable doing endovascular procedures on their own and didn't need IR? PAD work is gone. But the trend is more ominous than that. Neurosurgery and neurology will probably take over neurointerventional in the near future. At my hospital, GI and nephrology have been doing their own liver and kidney biopsies (at times, disastrously for the patient). I know that interventional nephrologists would love to do their own AV fistulas and perc neph's.

    I can go on and on.

    I think that radiology needs to recognize that one of its strengths is at the outpatient centers. There's a big difference between getting a referral between a specialist and a PCP. That specialist, ie, cardiology, GI, surgery, may decide that they want to do the procedures and read their own imaging. Because they control patient flow, they can pressure the hospitals to allow them to do that. That's how cardiology did it. That's how vascular surgery and neurosurgery do it now. Referrals from PCP's, especially for screening exams, are the sweet spot for radiology IMHO. Because that's the one area in radiology where you actually control patient flow. You can perform the imaging as well as the procedures. As these clinical services have shown, controlling patient flow is critical. Not only for your income, but it's for you to keep your job. The healthcare pool is contracting, not expanding. When imaging volume was expanding at 5% or more per year, maybe you didn't care if you lost cardiac nucs or ob u/s because you always had more than enough work to do. When the volume stagnates or decreases or reimbursements drop, you have to find new revenue sources for your practice to replace the lost revenue. If the practice cannot adapt with the times, there's a good chance you may lose your job or your practice may dissolve. I know of many people in those situations.

    That's why it's foolish to not look at every opportunity. VC is just one example. CT + heart screening is another. Personally, I would like to open a superoutpatient center that is a one stop shop for all your outpatient radiology needs. Mammo is the model that the rest of radiology needs to follow. Their setup is what I am envisioning.

    Like I said, it may sound preposterous for a radiologist to be doing colonoscopies. Heart stenting was created by radiology. PAD and neurointerventional was and still is done by radiology, but less so. In Japan, ERCP's are done mostly by radiology. It's always amusing to me when I tell lay people that radiology does procedures like TIPS and chemoembolizations.

    So don't underestimate what the profession can do. All it takes is one radiology group to prove it can be done and everyone will follow.
    Last edited: Apr 4, 2012
  5. Taurus

    Taurus Paul Revere of Medicine

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    ACR Backed Bill to Gain Medicare Coverage for Virtual Colonoscopy Introduced in House


    Do I think that this bill will pass? Probably not now. But the political pressure is building. Technology is improving. Radiation dose for all CT's is coming down. The research literature is more favorable. If I was a betting man, I would bet that it will eventually get Medicare coverage -- sooner than you think.

    Assuming that coverage is passed, the question will be, what's the best economic model to run a VC clinic? Is it radiology/GI team? Is it radiology only where the radiologists does the scoping only? Or, the radiologist reads the VC and has an experienced FP or PA do the scoping? In an outpatient setting, I doubt that the radiology/Gi team model would work simply because if for example you find a polyp in only 10% of your patients then what is the GI guy going to do with the rest of the time? You'll be paying some guy a lot of money doing nothing until he gets called to do a scoping. It makes more sense if the radiologist to do the scoping as needed. If not looking at VC's, the radiologist can read other studies from other body parts and modalities. You can even pipe in teleradiology into your outpatient so that you are always working. A GI guy in a VC clinic who's not scoping is not doing much at all.

    It goes without saying that any radiologist or physician should not scope unless they had the proper training and felt comfortable with it. It won't be easy for the first few people who want to go down that path. After they do it, it will get easier for those who follow.

    I know that GI is terrified of VC. They lobby hard so that it doesn't get Medicare coverage. But don't kid yourself into thinking that GI doesn't want to control VC too. Some GI's have begun to try to read VC's. If GI can say that they can confidently read VC as well as the abdominal CT without radiology (extremely unlikely given how complex the abdomen is), then you can consider abdominal CT as another endangered piece of radiology.
    Last edited: Apr 4, 2012
  6. officedepot

    officedepot

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  7. Taurus

    Taurus Paul Revere of Medicine

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    I am only focusing on one facet of radiology - the outpatient setting. I am not talking about other areas like inpatient and ED. I have my thoughts on those too, but I don't want to write a book.

    Like I said, I think that radiology has a bright future. You just have to be smart on how you approach it. Like most of medicine, it's changing. However, it's different from most of medicine because it's under assault from not one but two fronts. 1) Reimbursements are being cut, like they are for most of medicine. 2) Subspecialists clamoring to do their own imaging and procedures because they want to increase or maintain their incomes. Subspecialists have the advantage most of the time because they control patient flow, especially inpatient and academic settings. In these settings, the subspecialists won't encroach on a study if 1) has too many "extra" stuff or high litigation risk (mammo, lungs, abdomen) 2) too difficult to master (mammo, high-end IR for now). Reimbursement levels don't seem to deter academic subspecialists too much from what I've seen, ie, ED docs trying to read their own chest x-rays (only get $5 each). However, that is not true in the outpatient setting for screening exams. In fact, the reverse is true. With VC, CT lung + heart screenings, mammo, etc, radiology is probably the strongest there and radiologists need to take advantage of it.

    If I have to choose residency again, would I still chose radiology knowing what I know today? Yes, because the residency is tolerable and the specialty fits my interests and personality the best. Would I choose medicine again? Probably not.
    Last edited: Apr 4, 2012
  8. officedepot

    officedepot

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  9. Taurus

    Taurus Paul Revere of Medicine

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    More specific imaging is actually bad for radiology. If you make something so obvious that a non-radiologist can read it, then you don't need a radiologist.

    Chest x-rays are great example. It can be very subtle and life-threatening conditions can be missed if you're not trained. On chest CT, anyone can see the obvious pneumothorax, mass, bleeds, etc.

    PACS was the best and worst thing that ever happened to radiology. Now everyone from any location can look at the images, often times they make their clinical decisions before you even look at the images!

    Anyways, I'll stop posting on this topic. I've learned a lot over the years and I thought I would share with people some of what I have found. People need to know what they're getting themselves into.
  10. shark2000

    shark2000

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    You have a chance of 0.6 % of being happy in radiology in the future. Your ideas are unrealistic (= stupid).
    You are a medical student who has not even took one radiology call, despite claiming to be a residents. Otherwise, you are a really stupid resident walking on the clouds.
    Just calrify something. If you are really deep into colonoscopy, do yourself a favor and go to GI.
    1-Radiologists never have done coronary stenting. They did coronary angiography in 80s.
    2-Cardiac Nucs belonged to Nuclear medicine doctors, not radiologist. So if we steal it from Nucs doctors, that is totally fine, but cardiologists should not.
    3- Mammo is not difficult to master at all. That is other reason I bet you are not a resident. You have read some BS online about mammo, but have not done even one rotation.
    4- If you even know a little about current health care economics, you will figure out that not only in radiology, but almost across all specialties the out patient medicine is going bankrupt.
    5- Who says nephrologists doing kidney biopsy is disastrous. In 80s they used to do it all the time. We encroached on their turf and now they are taking it back.

    Again do yourself a favor and do not do radiology. You are looking for a procedural specialty with least patient care. GI appears to be the best fit for you.

    GOOD LUCK.
  11. DoctwoB

    DoctwoB

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    Agreed w/above. Rads taking over scopes is just as unlikely as rads taking over cardiac caths. Both are their respective fields bread and butter and they will fight tooth and nail to hold on to them, and they control the patient flow, not the rads docs.
  12. Taurus

    Taurus Paul Revere of Medicine

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    So what part of "high litigation risk" did you not understand?

    Reading a mammo is not hard. Neither is reading chest or abdominal radiographs.

    There are two huge deterrence to anyone but radiologists doing mammo's:
    1) Lawsuits. Have fun convincing a jury why you missed that breast cancer if you're a nonradiologist. Also have fun explaining why you missed that mediastinal bleed or peritoneal free air (that's why nonradiologists love CT's because they can't competently read radiographs without missing something important.)

    2) MQSA (look it up).

    Besides, people who go into mammo fellowship do it because they want to learn how to do breast procedures like ultrasound, sterotactic, CT and MR guided biopsies.

    I'm not convinced that you're a radiologist. I shouldn't have to point that out to you. If you are one hard as it to believe, you're most likely one of those lazy ones who only wants to work 8-5, no call, no procedures, don't want to see patients. You may even be doing teleradiology only. Your type needs to retire and get out of the field.

    Honestly, I don't care what you are.

    While I'm less than impressed by your business acumen, we can finally agree on something. Outpatient medicine is hurting right now. Medicare has skewed reimbursements toward hospitals (thanks to their lobbying). For example, many cardiology practices are selling out to hospitals and becoming hospital employees.

    But practicing medicine is most expensive in the hospital setting and it's cheaper at the outpatient centers. Do you really believe that all outpatient medicine such as radiology, cardiology, GI, etc will move to the hospital? If you believe that, I have a bridge to sell you too. The bean counters in Washington will eventually wake up to this and change the reimbursement formula. The pendulum will swing once again.

    The beauty of radiology is that it is very flexible. I can go from outpatient to inpatient to ED with little difficulty. Isn't that one of my earlier points? Be flexible. Adapt to the changes. Take advantage of opportunities.
  13. fun8stuff

    fun8stuff *hiding from patients*

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    regarding mammo- i don't know if "master" is the right word... "easy" to "practice" may be true... you can easily read the birads and mammo text in a month and get everything you need to know. however, If you've ever done mammo tumor board then i'm sure you've realized that there are a good number of cases where the cancers were visible on the prior mammograms. Not always easy to make "correct" diagnostic decisions.
  14. colbgw02

    colbgw02 Delightfully Tacky

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    Yeah, I'm not sure people are using the right verbiage to describe these studies. Mammograms and chest radiographs are hardly easy to read. The people that are truly great at reading screening mammos can't even really teach it. They just know it, as if they're reading with their mind's eye. It's really humbling to be around someone that can do that. In any case, if you think they're easy, then you're either Ben Felson or you're seriously over-confident. Maybe straightforward is a better the way, as in hitting a golf ball is straightforward, but I can't do it reliably to save my life.
  15. Taurus

    Taurus Paul Revere of Medicine

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    I agree. I was being facetious with my remarks about mammo's and chest radiographs.

    It's truly amazing the abilities of some of the older radiologists who trained entirely on radiographs before CT and MRI.

    The ability to read radiographs of the chest, abdomen, MSK, mammo is a spectrum from novice to true master.

    Because you can kill someone if you don't pick up on a subtlety on a chest radiograph or get easily sued for missing a breast cancer, they will always remain the domain of radiology.
  16. Taurus

    Taurus Paul Revere of Medicine

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    Let me clarify again. I'm not saying that radiology will take colonoscopies completely away from GI. What I am saying is, if you are qualified, have the facilities, and can do it profitably, then the radiologist should do it at the VC clinic. Why leave money on the table? You did all the hard work to find that polyp and read the rest of the abdomen. Why send the patient away to GI to fetch that polyp? Do it yourself. All this means is that radiology will be another player in the colonoscopy game, in addition to GI, FP, and surgeons. What % of colonoscopies will be done by radiology in the future? Who knows. Maybe 5-10%. Maybe less, maybe higher. I think there is a business case for radiology to colonoscopies in the future. If colonoscopies weren't profitable, GI's wouldn't be one of the best paid subspecialists out there. Once VC becomes more popular, I think that other radiologists will independently come to the same conclusion as I have. All it takes is one radiology practice to demonstrate that it can be done and at a good profit then others will follow.

    Don't stop there though. If in the future you have the opportunity to do other procedures such as angios, stenting, or embo for PVD, cardiac, or neuro work or some other high end procedures and you have good control of patient flow, then get the training so that you can offer the service yourself or hire an IR guy to do it. This is highly unlikely scenario because these other subspecialists have done a super job of shutting out radiology and it requires extensive training. But remember that there are still many places where PVD is done by radiology. Miami Vascular is a well-known one. You can always do an IR fellowship to get skills. Of course, I wouldn't do this unless I had solid control of the patient flow. Unfortunately, that means you have to become a clinician, ie, have clinic, admit, follow them in the hospital, d/c, etc. That turns off a lot of IR guys, especially the older guys.
    Last edited: Apr 5, 2012
  17. shark2000

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    Though there is no point in arguing with stupidity, I give some comments:

    1- Mammo is very separate from the rest of radiology. A lot of mammo is read by non-fellowship trained rads.
    By doing 3 months of mamo rotation and 6 months of fellowship (FYI who is not a radiologist, most mammo fellowships are 6 months) you are entitled to have monopoly over reading mammo. But GIs who do 3 years of fellowship to learn to scope should let you scope people. Then my question is: How can you convince the jury that you are qualified to do colonoscopy while there are GI doctors trained to do it at least 3 years (or some 4 years)?

    2- you are stupid if you think that a general surgeon or even a trauma surgeon can not pick up free peritoneal air or mediastinal hematoma as good as a radiologist.

    3- Somebody who talks about CT guided breast biopsy, should STFU and study for his step 1.

    4- You are not a resident so I do not expect you to know. Other than MR guided biopsy, US guided and sterotactic biopsy can be easily done by a general radiologist. You can train a monkey to do it in 2-3 months.

    5- Being a master in everything is very tough. That includes mammo, CXR and CT. But also it includes doing colonoscopy, neurological exam, chemotherapy, ...
    That was my whole point. There is somebody who is trained for 3 years to do that ****.

    6- Whoever thinks DR is an easy or lazy job has not done one day of radiology. Your perception of radiology is limited to your rotation as a medical student.

    7- Most radiologist see lack of patient contact the main advantage of the field. It is at the same time the Achilles heel of the field. If you are really deep into seeing patients and doing procedures go and do some surgical field.

    And at the end FYI, CT guided breast biopsy does not exist. You can google it while you are doing kaplan for step1.
    Also have fun convincing a jury that you perforated a colon doing colonoscopy if you are not a GI doctor or a surgeon.
  18. shark2000

    shark2000

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    And also cardiologists, neurosurgeons. neurologists, nephrologists, ... are not criminals.
    Most of them are much more responsible that you and serve society much better than you.
    You have to prove that cardiologists doing angio, vascular surgeons doing PVD or GIs doing colonoscopies are disservice to the patient.
    At least many of them take care of people. Most of your last posts was about "making money " and law suits.
    I hope you change your mind and choose another specialty before you apply for residency in 1 or 2 years.
  19. Dumb

    Dumb USMLE Tutor - PM me for info

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  20. shark2000

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    After you finish your CT guided breast biopsy, start doing your embo for PVD.
    You are right. You are changing the whole picture of radiology. I have not seen any radiologist doing CT guided breast biopsy or any IR doing embolization for PVD. But you are right, why leave money on the table. Offer these services in your future outpatient center besides colonoscopy.
  21. Radonkulous

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    jack of all trades, master of none.
  22. officedepot

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    Last edited: Apr 12, 2012
  23. colbgw02

    colbgw02 Delightfully Tacky

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    Compare the incidence/prevalence of PVD to tumors amenable to chemoembolization and you'll have your answer.

    In other words, $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$.
  24. Taurus

    Taurus Paul Revere of Medicine

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    Again to clarify. VC is a 3D reconstruction of the colon from cross-sectional axial images using some fancy software. In lay terms, you take the axial CT images and construct a 3D rendering of the colon from it. So that means that the reader is responsible not only for the VC component but also the entire study (ie, liver, kidneys, pancreas, vessels). The VC may be normal but the person may have a honking liver or kidney tumor. Because of how CT technology works, you cannot exclude the rest of the abdomen except for the colon. That's why if GI wants to do VC they will need a radiologist to read the rest of the abdomen if they want to only read the VC component and scope. If the radiologist knows how to scope, he can both read the study and scope without involving GI.

    It's akin to CTA of any part of the body, ie, heart, brain, abdomen, extremities. For example, cardiac CTA captures not only the heart but the lungs and everything else in the chest. So the cardiologist who wants to read the cardiac CTA better feel comfortable reading the whole chest if he wants to bill for it. Majority do not because they don't want the legal liability of missing something non-cardiac. That's why many cardiologist will have a setup where they read the cardiac part and have a radiologist read everything else.

    As I said in one of my earlier posts, cardiac CTA will explode in utilization in the near future after that NEJM study. The ED and floors will begin to order cardiac CTA's for chest pain in low-risk cardiac patients. Right now, most cardiac CTA's are ordered by cardiology who have been trying very hard to keep cardiac CTA's to themselves (it goes back to what I've saying about the difference between an order from a PCP vs. a subspecialist). Radiology will definitively be the biggest winner when cardiac CTA's are ordered by ED and floors because 1) radiology can read the entire study so we can put out a final read of the entire study in minutes (important because Medicare is changing reimbursement rules for imaging where they want final reads before patient is d/c; this is why many academic radiology departments are going 24/7) 2) who's going to put out a final read for a cardiac CTA done at 1 AM but radiology? I am at an academic center and I can tell you that discussions have begun on beginning coverage for cardiac CTA's from the ED. I've heard other centers are also looking at it. After feeling comfortable ordering cardiac CTA's from the ED and floors, it's just a matter of time before PCP's also order cardiac CTA's as an outpatient for their low-risk cardiac patients who complain of chest pain.
    Last edited: Apr 6, 2012
  25. officedepot

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  26. shark2000

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    The future of cardiac imaging is not bad for radiologists. Currently almost half of cardiologists are hospital employees. It means they are not bringing money to the hospital anymore.
    Regarding coronary CTA there are some issues I want to clarify for you. It seems that you do not have a lot of experience.

    1- It is a very good test for ruling out. It is a very crappy study when there is relatively extensive calcification of coronary arteries. It is almost only diagnostic in low risk patients (read overutilization). If it will become popular it will be over-utilized by ED doctors on 25 year old girl with chest pain or by cardiologists for making money (scanning whoever passes in front of their office).

    2- If you get only heart it is easier for the cardiologist to read.
    Please let me know how can you just get the heart. You are irradiating the whole chest. If you want to post-processing it, still there will be some tissue around. You can not draw a very clear line around the pericardium in a beating heart.

    3- Do not forget that the patient is coming for chest pain and not for heart pain. That is the reason you do 3 years of IM to be a cardiologist. While you have the information, you need to look at any reason for chest pain if you want to practice reasonable medicine. The last time I checked there is a whole lot of differential diagnosis for chest pain in cardiology literature. Why you need to learn it?

    4- It is not just a nodule. Our CTA service is split between us and cardiology. One of our cardiologists who has written text book of cardiac imaging, got sued recently because he missed an esophageal cancer on a scan. It caused chest pain because on the scan it invaded the mediastinum. After that our cardiologists start to talk about being over-read by radiology, though it is not official yet. They constantly send their fellows to our chest room for some advice!!!

    5- I assume you are a cardiologist or interested in doing it. From a cardiologist stand point it takes 6 years to read an echo, but a reading chest CT can be learned in a weekend course.

    There is no doubt that you need extra-cardiac images. It is the same reason why you have to do 3 years of IM and why you have to read all about reasons of chest pain in cardiology fellowship. Also it is not easy to read extra-cardiac parts. It is not only a small nodule, though even a nodule is not also as easy as you think (you can check round atelectasis and scarring which are constantly called nodules/masses by cardiologists).
    However, it may eventually turn out to go to the wrong way by a lot of lobbying from cardiology. They have not been successful so far.

    Doing it the way that cardiology want it to be done is like scanning only bowel when the patient come with abdominal pain. So next time when the ED orders a CT for abdominal pain, We can only include the bowel (I don't know how, but we will find a way) and will cut the rest.
    If there is chest pain then they have to tell us which organ they want. If it is heart, we will do a coronary CTA. If it is lungs we will scan lungs and exclude the rest. If it is mediastinum we will exclude the rest. Even we can divide mediastinum to vascular (if they are interested in aorta) or non-vascular.

    Just interestingly, one of the recent coronary CTAs I read, turned out to be a PE. Can it cause chest pain? Is is important? The answer depends on your financial incentive. It is not important if you are a cardiologist want to read CTs.
    Also one of the last chest CTAs I read for PE, turned out to be acute pathologic fracture of rib with small pneumo. Can it cause pleuritic chest pain? The ED doctor could ask me to exclude chest wall and ribs. It would make it easier for many to read it.
  27. shark2000

    shark2000

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    the reason most IRs are not running clinic is not lack of skill. It is just they are not interested. Let's be honest. Even most clinician's are tired of patient contact. Despite what people say in medical school a lot of clinicians do not like it.
    In the current environment you need a clinic to be able to run a productive IR service.
    We have a very clinically oriented IR department. Clinician's want to exaggerate it. You do not 10 years to do it. I don't say it is easy, but can be easily done by a radiologist.
    Don't forget that new generation of clinicians do not have clinical skills more than us!!
    Cardiologists and vascular surgeons are constantly doing carotid stenting. Other than acute hemodynac instability, they do not know that much clinically about it. It causes neurological symptoms and the understanding of them are even less than us. At least we see head CTs and MRs constantly. When was the last time a vascular surgeon saw a TIA? Can an average cardiologist tell you where does this carotid go up to ?
    The only reason they are doing it is that they have patients and clinic. It is not because of their clinical skill or any other magical reason. If you start a clinic you can compete with them.
  28. fun8stuff

    fun8stuff *hiding from patients*

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    exactly
  29. Taurus

    Taurus Paul Revere of Medicine

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    This is a gross oversimplification of chest CT and cross-sectional exams in general. If it was that easy, you wouldn't need radiologists. If it was that simple, don't you think that the cardiologists would have figured that out? There are many non-cardiac diseases of the chest. You have to look at the lymph nodes because metastases is very common there. Many diseases occur in the anterior and posterior mediastinum. You have your bones and muscles of the thorax. Many diseases affect the lungs, not just tumors. You have processes that may be infectious, metabolic, neoplastic, vascular, etc. There's a good reason why body cross-sectional studies including chest, abdomen, pelivs using CT and MR are the domain of radiology and why nobody is going to take it away. The litigation risk would be way too high.

    I think that they will lose this battle because they can't and don't want to provide 24/7 coverage. Is cardiology going to read that CTA at 3 AM? Heck no. Radiology will because we will be there already reading everything that comes out of the ED. Furthermore, if a CTA comes across my queue, am I supposed to read the non-cardiac portion and leave the rest to cardiology? Heck no. I'm putting out a full final report of the entire study. If cardiology wants to be part of the action, they can sit next to me at 3 AM.

    With that said, I think that cardiology will initially try to keep a toehold in cardiac CTA by requesting that the cardiac component be left to them for the am. But the unwieldly workflow this creates and pushback from radiology and ED will I think mean that this arrangement will short-lived. After a while, radiology will read the entire study. I'm sure that cardiology interest and participation will never die out completely especially in the outpatient setting but they will definitely see a large decline in their reading the studies.

    Finally, remember that chest pain is very nonspecific complaint. It could be due to CAD but it could be due to PE, aortic dissection, pneumothorax, pneumonia, pulmonary infarction, etc. That means that if we do the study we need to be able to rule out as many of those conditions as possible in one visit to the CT scanner. You don't want to send the patient back to the scanner to first rule out CAD, then PE, then dissection, etc. You want the most bang for your buck first time around. The ED of course will also want this. Therefore, we are working on developing protocols to do this. Again, cardiology can't provide the depth of reading the chest that radiology can and that's why they will lose this.

    This new development is good news for radiology because it puts some cardiac imaging back in play. Maybe some new study will show that cardiac MR should be ordered from the ED too. Cardiac MR is another area where cardiology is trying its best to take from radiology. The vast majority of providers ordering cardiac MR as you guessed it is cardiology.
    Last edited: Apr 6, 2012
  30. johnnydrama

    johnnydrama I'm no Superman

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    Something like mammography may be relatively simple to learn, but that doesn't mean it's simple to master.

    The difference between getting it right 95% of the time and getting it right 99.9% of the time might seem trivial, but that gap can be hard to cross and the space in between is where lawsuits happen.
  31. remote

    remote

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    what do you guys think about the future of urology compared to rads/ortho??
  32. shark2000

    shark2000

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    The more I read your posts the more I am convinced that you are not a radiology resident and the more BS I find in them.

    Do you know anything about cardiac MR or you have just read about it in some random forum?
    Do you know its indications?
    Could you please name one indication why at 3 am a cardiac MR should be ordered from ED?
    Do you have any idea how long it takes to have a cardiac MRI done?

    Good luck with your step 1 .
  33. shark2000

    shark2000

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    Urology need its own personality.
    Has tough residency, but as attending it is almost a 8-5 job unless you want to kill yourself working.
    Barely you see a urologist in the hospital after 7-8 pm. No weekends, light calls. Very few if any emergencies.
    Currently for the amount of work it is a good gig.
    IMO, its future is no different that other similar fields. It is on safer side than GI as they have more than 1 or 2 money making procedures.
    Do it only if you like it. I'd rather be jobless than be a urologist.
  34. Radonkulous

    Radonkulous

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    shark2000, which fields in medicine do you think will be better off in the future, both job demand wise and reimbursement wise? Throw in the controllable hour aspect. Dermatology is already a given.
  35. Frazier

    Frazier turtle in a rabbit race Lifetime Donor

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    thoughts on how the field will change in the reform-riddled-future, given the older patient population on medicare?
  36. shark2000

    shark2000

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    The major issue is despite all the speculations, even the policy makers do not even have a rough estimation about the reforms, their impacts and the future.
    The only think that they are talking about is decreasing costs. On the other hand they are talking about kind of insurance for everybody which adds about 50 mil to the medicare pool.
    Whatever people say is more guts feeling rather than based on evidence because nobody knows about the practical aspect of the changes.

    I dislike the field personally. However, as an external observer it is a very good if you like it,. Relatively diverse with balance of surgery and minimally invasive procedures, less patient contact than an average clinical field and very minimal admission BS.
    Regarding future it will be on the same boat with other fields.
    Some points:
    1- Prostate cancer: is a failure for the field. They still make money out of it. 10 years ago they were very optimistic about its future. They wanted to start screening programs similar to mammo or colonoscopy (PSA screening and then biopsy). Then it turned out to be useless and is not implemented anymore. Still there are places who do it. But not going to be in large scale. Also there were studies showed similar outcomes with radiation vs surgery. They lose some of their job to rad oncs though many urologists try to take it from rad onc.

    2- BPH: More common than moles. TURP is a relatively uncomplicated procedure and easy procedure. Is a huge revenue for them.

    3- Renal Stone: very lucrative. The BS is covered by ED doctor (Fluid and pain medication). Diagnosis is made by radiology. If need immediate action they ask IR for per-cut nephrostomy. Then it will an elective outpatient procedure.

    4- Bladder cancer: not common itself, but good revenue as they scope everybody with hematuria. Easy bedside procedure. I have read tons of IVPs in patients with renal stones who had bladder endoscopy prior to CT, that was not indicated.

    5- Tons of other outpatient small procedures like vasectomy, Varicocele, ....

    6- The field has a very good diversity that is not typically done by average urologist including high end oncology, Pediatrics, renal transplant, male infertility , ....

    A comment: Read about screening of prostate cancer. That was supposed to be a huge money maker that did not turned out to be what predicted. However the field did not hurt as it is very diverse. That is the problem I have with GI itself. I hate GI myself, though agree it is a good gig these days. But the Achille's heel of GI is its huge dependence on one disease entity and that is colon cancer. Screening colonoscopy makes almost 60-70% of GI revenue. If some time in the future they find a better screening modality or do not find it cost-effective then the whole field will get a bad hit.
    Radiology is pretty safe in this regard. You can see despite loosing some turfs and some procedures going absolete the field is thriving well. At 70s and 80s barium work was 50% of radiology. It is almost obsolete now, but the field did not hurt at all as we do not deal with single technology and single disease.

    GOOD LUCK.
  37. Frazier

    Frazier turtle in a rabbit race Lifetime Donor

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    thanks for the detailed insight :thumbup:
  38. Dumb

    Dumb USMLE Tutor - PM me for info

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    .
    Last edited: Jun 1, 2012
  39. johnnydrama

    johnnydrama I'm no Superman

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    Well that seems dumb. I can understand cutting the technical component for someone getting scanned repeatedly, but exactly where is the added efficiency in reading multiple scans on the same person? Not having to read what little information is provided with the images twice?
  40. Taurus

    Taurus Paul Revere of Medicine

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    All specialties will be hit, even derm. All of the surgical specialties like ortho, ENT, and uro will too. Choose a field based on your interests and not necessarily on reimbursement because it will change.

    Dermatologists Will Be Targeted in Healthcare Reform
    By Kate Johnson

    March 17, 2012 (San Diego, California) — Regardless of the fate of the Affordable Care Act, physicians in general, and dermatologists in particular, will be targeted as healthcare reform proceeds, Jack Resneck Jr., MD, told a packed audience here at the American Academy of Dermatology 70th Annual Meeting.

    "Whatever you think about the Affordable Care Act...dermatology will be a target in the next few years," said Dr. Resneck, who has joint appointments as associate professor of clinical dermatology at the University of California at San Francisco and the San Francisco Institute for Health Policy Studies.

    Dermatologists account for just 1% of physicians in the United States but 3.5% of Medicare expenditures, so they face growing attention from policy makers, he said.

    "With the skin cancer epidemic, there may be incredibly good reasons for this, but it puts us on the radar screen."

    The attention has led to "a perception problem in the eyes of other physicians who...probably don't have realistic ideas about what most of us actually do in our practices on a daily basis," he said.

    Skin cancer is now the sixteenth mostly costly Medicare diagnosis, accounting for $2.9 billion annually. This is almost half of the $6.8 billion spent on cardiology. The rate of growth of some procedures, such as Mohs surgery, has increased by 400% over the past 15 years, said Dr. Resneck.

    "This may be entirely justified [because] we have a massive skin cancer epidemic...[but] it gets people's attention in policy circles on the hill and at Medicare, and they tend to come after you."

    As a result, the Relative Value Update Committee (RUC) has been assigned to review, among other dermatology codes, Mohs codes, pathology codes, and actinic keratosis codes in the next year. "And we know what happens when codes go to RUC — they do not get increased.... If you happen to be surveyed on how much work you do for these codes, do not ignore those surveys," he said.

    Additionally, "we have seen efforts by other specialties over the past couple of years that substantially could impact our practices," he told Medscape Medical News. A coalition group, known as the Alliance for Integrity in Medicine, even suggested to the deficit super committee that the Stark exemption for in-office ancillary services be eliminated, he explained. "This effort, which would alter our ability to provide dermatopathology services in our offices, may be a sign of things to come."

    It is not just dermatology but medicine in general that is "in trouble in terms of figuring out how to fund what we do in years to come," said Dr. Resneck.

    Although this pressure is largely due to the federal budget deficit, there is also pressure from business over the amount it is having to pay insurance companies. Private insurance has become unmanageable for many low-income employers such as Walmart or Target, which face employee health-insurance premiums that exceed the amount they pay in salaries, he said.

    Tax revenue and discretionary spending are currently garnering the most attention, and blame, but future projections show that Medicare and healthcare spending are on the trajectory to become the overwhelming driver in spending growth. "This is not a sustainable course; and it makes the Social Security crisis look very meager," he said.

    Dermatologists "have to take some responsibility for figuring out where savings are going to come from, "because if we keep sticking our heads in the sand, as we have tended to do in the past, somebody else is going to reshape the system without our input," Dr. Resneck explained.

    http://forums.studentdoctor.net/showthread.php?t=898416
  41. barebones

    barebones

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    xx
    Last edited: Apr 13, 2013
  42. shark2000

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    DERM is a different animal. You can not put it on par with radiology, ortho, IM, surgery, ...
    It is out of pocket CASH for a lot of procedures. Mohs surgery is paid by insurance but the caveat is they can always maintain relative shortage because there is nothing emergent about it.
    Every hospital based field with emergencies is doomed to relative surplus.
    You may argue that DERM job market is bad now. yes, it is. But it is less amenable to pay cuts. That is stupid to think they will get hit badly. In fact, government encourages increased reimbursements for out of pocket procedures.

    DERM vs Radiology:
    1- Rads is much more challenging, at least to me. To me it is more scientific and exciting.
    2- Hours: Derm beats rads any time.
    3- Diversity: Rads beat Derm any time.
    4- Income: Derm has more potential. Less amenable to pay cuts.
    5- Study material : radiculous for rads. Pretty light in Derm.
    6- Worst part of DERM: you have to deal with crazy histrionic personalities. Though, still better than doing IR screwing your life.
  43. yappy

    yappy

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    What do you mean by this?


  44. johnnydrama

    johnnydrama I'm no Superman

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    I'm guessing he means dealing with people who obsess over every wrinkle/pimple. They're probably about as fun to deal with as chronic pain patients.
  45. cbtk18

    cbtk18

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    What does this mean? Are you implying that IR sucks?


    Sent from my ADR6300 using SDN Mobile
  46. officedepot

    officedepot

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    .
    Last edited: Apr 12, 2012
  47. johnnydrama

    johnnydrama I'm no Superman

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    I think the issue is that IR cannot be done from home without pants.
  48. yappy

    yappy

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    I was trying to pry about his statement because I wonder if he was speaking to the radiation exposure that you get from operating in a field being bombarded with X-rays... Is there an exposure danger to IR?
  49. johnnydrama

    johnnydrama I'm no Superman

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    There is, but the long term effects with proper shielding seem innocuous enough but need to be studied further.

    In the early days, there were increased cases of leukemia etc, and I think there's still an increased risk of cataracts since not everyone wears proper eye protection.

    If I go into IR, maybe I'd bank some sperm out of paranoia, but I wouldn't worry about my own health too much as long as I have appropriate protection.
  50. shark2000

    shark2000

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    About DERM, I meant dealing with people who are over-obsessed with a dimple. You can check body dysmorphic disorder. I assume a good number of derm and plastics patients have at least some traits of this disorder.

    Between 2000-2005 IR was one of the least competitive sub-specialties. They could barely fill half of their spots. Even in those times, its job market was good. Then all of a sudden when job market turned around, we see all "IR lovers" and "IR passionate" personalities. I can not believe in less than 5 years the mindset or the interest of radiology residents changes so fast.

    Take whatever I say with a grain of salt as everybody is biased towards his interests:

    Not getting off the track, IR can be cool for its personality, but not a whole lot different than many surgical subspecialties, albeit with worse hours. I do not say it is bad, but one of the greatest advantages of doing radiology is minimal patient contact and the diagnostic challenge of the field. I do not see the same benefits in IR. IR is in the same nature of work as ENT, GI, Surgery, ....
    Some guy in this forum said that I am lazy that do not want to see patients and want to hide in the dark room or something similar. To me, If you like patient contact and you like doing procedures there are a lot of options that IR is one of them. It is funny to claim you only Love IR and can not see yourself doing anything else especially with the new model of IR.

    When I say screw your life I mean it. I am a senior resident, but older than many of you because I have done a lot of other things in life before doing medicine. You have to think what you want to do at the age of 50 and 60. It may seem challenging to you now, but is it sustainable for 30 years ? I understand some people may like it, but IMO you are screwing your life. My best evidence is that MOST SURGEONS are chronically exhausted with a very malignant abnormal personality after a certain age (like 50). You do not see the same in family medicine, IM, Peds, Rads, Patho, DERM, .... For sure there are exceptions.

    Good Luck.

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