IR-GS working relationship?

[ImmunoDude]

I'm a pre-med student, and I find both surgery and IR to be fascinating fields in their own way, and both complement each other very well. Without IR doing a pre-op PVE and/or TACE, a HBP surgeon couldn't do a hepatectomy for a large HCC and still leave the patient with enough remnant, and without that HBP surgeon, the IR wouldn't have a case.

I'm wondering about how IR and GS work in the post-op care of trauma patients. Like if the sole injuries are renal and splenic lacerations that were succesfully treated by angioembolization, would the IR be managing them post-op, or would the trauma surgeon? I know neuroIRs manage their emergency stroke and aneurysm patients post-op, and not the neurosurgeon. The one who does the procedure should be the one managing the patient.

Note: I'm assuming the IR is a modern clinically-focused one, not one of the old procedurally-focused ones who couldn't care less about patient care. The ones who graduate from a DIRECT pathway program would be excellent in a trauma team, as they have two years of GS training, two years of DR training, and two years of IR training, so they would be good at determining from H&P and imaging who can be observed, who needs surgery, and who needs radiologic intervention. And they could assist in the OR if their patient needs surgery. Theoretically.

---

Members don't see this ad.

 

[VisionaryTics]

Have fun, attendings and residents.

 

[ImmunoDude]

Have fun, attendings and residents.

It's just an honest question. If I'm absolutely wrong, I'm fine with it.

 

[LucidSplash]

I'm a pre-med student, and I find both surgery and IR to be fascinating fields in their own way, and both complement each other very well. Without IR doing a pre-op PVE and/or TACE, a HBP surgeon couldn't do a hepatectomy for a large HCC and still leave the patient with enough remnant, and without that HBP surgeon, the IR wouldn't have a case.

I'm wondering about how IR and GS work in the post-op care of trauma patients. Like if the sole injuries are renal and splenic lacerations that were succesfully treated by angioembolization, would the IR be managing them post-op, or would the trauma surgeon? I know neuroIRs manage their emergency stroke and aneurysm patients post-op, and not the neurosurgeon. The one who does the procedure should be the one managing the patient.

Note: I'm assuming the IR is a modern clinically-focused one, not one of the old procedurally-focused ones who couldn't care less about patient care. The ones who graduate from a DIRECT pathway program would be excellent in a trauma team, as they have two years of GS training, two years of DR training, and two years of IR training, so they would be good at determining from H&P and imaging who can be observed, who needs surgery, and who needs radiologic intervention. And they could assist in the OR if their patient needs surgery. Theoretically.

Gotta tell you, the IR guys where I am, who are nationally recognized for their stroke/aneurysm work and are amazing in their capabilities, don't manage those patients post op and neither do the neurosurgeons. Those patients are managed by the surgical critical care team. Truthfully I've never actually seen a model where the do manage these patients (or any patients) but my experience is limited to my current institution and the one where I went to medical school, so I suppose it could be out there somewhere.

They also definitely do not manage any patients who had a spleen or whatever embolized after trauma.

Maybe all this really will change once there start to be more of the direct-pathway guys out in the world, but right now, what you describe has not been my experience at all and frankly I'm very doubtful that such a seismic shift will occur. Don't get me wrong, I think IR interventions are great for patient care and the ones we have here are fantastic. But they don't manage any patients, ever.

 

[ImmunoDude]

Gotta tell you, the IR guys where I am, who are nationally recognized for their stroke/aneurysm work and are amazing in their capabilities, don't manage those patients post op and neither do the neurosurgeons. Those patients are managed by the surgical critical care team. Truthfully I've never actually seen a model where the do manage these patients (or any patients) but my experience is limited to my current institution and the one where I went to medical school, so I suppose it could be out there somewhere.

They also definitely do not manage any patients who had a spleen or whatever embolized after trauma.

Maybe all this really will change once there start to be more of the direct-pathway guys out in the world, but right now, what you describe has not been my experience at all and frankly I'm very doubtful that such a seismic shift will occur. Don't get me wrong, I think IR interventions are great for patient care and the ones we have here are fantastic. But they don't manage any patients, ever.

I bet it will change. IR won't get patients referred to them if they don't take the initiative to manage patients postop. And probably another reason is that a lot of IR patients are admitted by another service, like stroke/aneurysm cases are admitted by neurocritical care or neurosurgery, or trauma cases are admitted by surgery. And these are critical cases, and I really wouldn't want someone who is superb at image interpretation and manipulating wires and catheters but hasn't kept their clinical skills up to manage me after an accident.

From what I've seen in the elective world of IO is that IR will see a patient referred from the medical oncologist and determine if the procedure is necessary, order any pre-op imaging and labwork, and admit the patient for the procedure and 24 hours observation. Then regular follow-up imaging to determine if the procedure worked. This is from reading in the IR forum and reading some IR websites.

From what I see, IR is now what surgery was last century. Last century, surgeons were at the bottom of prestige and honor, they could only operate with a physician's permission, and they basically operated like this: physician asks surgeon to operate, surgeon operates, hands patient back to physician for management.


This paper could predict the evolution of IR, paralleling it with GS: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3036259/

 

[ESU_MD]

NeuroIR really shouldnt be trying to manage patients after the procedures. Similar to the concept that a surgeons time outside the OR is wasted.

 

[ImmunoDude]

NeuroIR really shouldnt be trying to manage patients after the procedures. Similar to the concept that a surgeons time outside the OR is wasted.

Probably, but then we could ask: why are surgeons managing their patients perioperatively? Because they saw themselves as physicians and not technical operators.

Based on this, surgeons should only operate and IR should only read images and operate. Leave all pre-op workup to IM and post-op management to anesthesia.

The primary job of a physician is to care for patients, not perform technical procedures. Any physician who operates or prescribes medication should be prepared to determine the necessity of said treatment and manage its complications s/p.

If you just look a patient over, operate, and hand them back to the referrer, you're not a physician, you're a highly-paid technician.

All physicians who directly deal with patients, like medicine, surgery, and IR, should be required to manage their patients pre and postop. Medicine and surgery have the skillset, and IR is gaining it.

When a DR's tru-cut biopsy diagnoses a patient with HCC, the oncologist and IR should get together and decide whether the tumor is ablatable. If it's not either and the group decides the IR should perform SIRT and the oncologist should prescribe sorafenib, the oncologist and IR should both follow the patient, and have regular meetings to review imaging until the tumor becomes ablatable. And if the tumor is invading a vital structure, the HPB surgeon should be invited to the meeting as well.

 

[HopesandDreams]

Probably, but then we could ask: why are surgeons managing their patients perioperatively? Because they saw themselves as physicians and not technical operators.

Based on this, surgeons should only operate and IR should only read images and operate. Leave all pre-op workup to IM and post-op management to anesthesia.

The primary job of a physician is to care for patients, not perform technical procedures. Any physician who operates or prescribes medication should be prepared to determine the necessity of said treatment and manage its complications s/p.

If you just look a patient over, operate, and hand them back to the referrer, you're not a physician, you're a highly-paid technician.

All physicians who directly deal with patients, like medicine, surgery, and IR, should be required to manage their patients pre and postop. Medicine and surgery have the skillset, and IR is gaining it.

When a DR's tru-cut biopsy diagnoses a patient with HCC, the oncologist and IR should get together and decide whether the tumor is ablatable. If it's not either and the group decides the IR should perform SIRT and the oncologist should prescribe sorafenib, the oncologist and IR should both follow the patient, and have regular meetings to review imaging until the tumor becomes ablatable. And if the tumor is invading a vital structure, the HPB surgeon should be invited to the meeting as well.

Do you not understand the principle of specialization of labor? Your theory might work ok for one single patient, but how about thousands or hundreds of thousands? Highly paid technician, seriously? The word you are looking for is SURGEON. Surely you grasp the fact that in order to perform surgery you need not only knowledge and skill, but also the judgement to make life altering decisions for a patient at any moment. Just sit back and think about the fact that you are trying to denigrate the entire field of surgery and how ridiculous that sounds right now.

You say the primary job of the physician is to care for patient, that is true. But what you are missing is that physicians operate as part of a TEAM to get that job done. Should physicians change bedsheets, bathe and feed patients as well? The answer is obviously no, because those jobs can be delegated to people who lack the advanced/ specialized training that physicians have, and in fact those people perform those jobs more efficiently because that is their role day in and day out. It's an extreme example but it's the same concept at work.

What would you prefer, the single physician who works alone and treats 100 patients, or the team of 20 people who treats 10,000 patients in the same time frame with the same standard of care?

 

[ImmunoDude]

Do you not understand the principle of specialization of labor? Your theory might work ok for one single patient, but how about thousands or hundreds of thousands? Highly paid technician, seriously? The word you are looking for is SURGEON. Surely you grasp the fact that in order to perform surgery you need not only knowledge and skill, but also the judgement to make life altering decisions for a patient at any moment. Just sit back and think about the fact that you are trying to denigrate the entire field of surgery and how ridiculous that sounds right now.

You say the primary job of the physician is to care for patient, that is true. But what you are missing is that physicians operate as part of a TEAM to get that job done. Should physicians change bedsheets, bathe and feed patients as well? The answer is obviously no, because those jobs can be delegated to people who lack the advanced/ specialized training that physicians have, and in fact those people perform those jobs more efficiently because that is their role day in and day out. It's an extreme example but it's the same concept at work.

What would you prefer, the single physician who works alone and treats 100 patients, or the team of 20 people who treats 10,000 patients in the same time frame with the same standard of care?

The team of 20 who treats 10,000. I want the oncologist to be prescribing meds according to the recommendations of the pharmacist, the IR to interpret imaging and provide image-guided treatments, and the surgeon to operate. And all of them should collaborate on every step.

I never intended to denigrate surgery at all. Surgery is the model IR should be following: IRs need to be experts in patient and disease management like surgeons are, and NOT practice like highly-paid technicians as they are now.

As I said before IR now is surgery 200 years ago, and this needs to, and is changing.

And my comments about being highly-paid technicians were a response to ESU_MD's comment about the concept of a surgeon's time outside of the OR is wasted, and I was refuting it.

 

[neb85]

My n=8 in terms of hospitals I have spent significant time at as a med student and resident. At only one of these hospitals do any of the IR guys admit to their own service; I heard about this one only because it was one of our chronic pts undergoing a particularly difficult lumbar approach TDC placement. Apparently this was an extremely rare occurrence even there.

The IR attendings have clinic at several of these hospitals but they only see new patients/new problems, not follow ups. Everywhere else they just meet the patients for the first time in the holding room.

At the places I've been, the IR guys will admit to the most relevant specialty (ie splenic embos to trauma, liver RFAs or TACE to liver surgery or surg onc) since the patients are either already followed outpt by that service, and/or they tend to have more experience diagnosing and managing post procedure complications.

Interestingly, an academic VA I rotated at had all the peripheral thrombolysis done by IR physicians but admitted to vascular surgery for post/peri procedure management - needless to say the residents and vascular staff there weren't particularly happy about that.

Obviously this will differ from hospital to hospital and I'd be interested to see what other peoples' experiences are like.

 

[neb85]

When a DR's tru-cut biopsy diagnoses a patient with HCC, the oncologist and IR should get together and decide whether the tumor is ablatable. If it's not either and the group decides the IR should perform SIRT and the oncologist should prescribe sorafenib, the oncologist and IR should both follow the patient, and have regular meetings to review imaging until the tumor becomes ablatable. And if the tumor is invading a vital structure, the HPB surgeon should be invited to the meeting as well.

These meetings exist at many hospitals, happen once or more per week, and are called tumor boards or tumor conferences. Although, I have never seen them include interventional radiology. I can see how it might be worth the IR physician's time, but only if he/she is an onc specialist.

Sorry for the double post.

neb

 

[badasshairday]

At our academic hospital IR admits and serves as primary for their oncology patients after oncologic procedures such as TACE as well as patients post uterine fibroid embos. So they deal with typical inpatient issues like blood pressure and pain.

They do formal consults and notes for throbolysis, bronchial artery embo, billiary drains, renal artery angioplasty/stent, TIPS, kyphoplasty, and pretty much every procedure besides basic things. They round on these patients daily and manage their specific piece of patient care as needed.

For more basic things like chest tubes, venous access. For some of these procedures, such as a pigtail chest tube, that is referred by medicine (or basically anyone non-pulmonology or surgery) they will round on these patients and manage the tube.

IR holds clinic for new oncology patients as well as follow up patients. They will also see self referrals for things like uterine artery embo. They also have a vein clinic. They take part in tumor board with rad/onc, med/onc, surg/onc. They also take part in vascular board with vasc surgery.

 

[Chakrabs]

I'm going into neurosurgery so I can only speak for the academic institutions that I have personally rotated through. The vast majority of places I've been, its has been a combined team with the neuro-IR guys working in the neurosurgery department. They typically admit their patients to the neuro-ICU where the patients are cared for by the neuro-critical team, which consists of fellowship trained neuro intensivists and neurosurgery residents. Also, at most academic centers that I've been to, there are more and more neurosurgeons doing endovascular and other interventional procedures. Just from my perspective it seems that neurosurgeons are taking over the more complex endovascular procedures done at the bigger academic centers while neuro-IR folks are in the community hospitals handling bread and butter cases; referring overly complex cases to the bigger academic centers where the dual-trained neurosurgeons can offer either surgical or further endovascular treatment.

 

[Winged Scapula]

At our academic hospital IR admits and serves as primary for their oncology patients after oncologic procedures such as TACE as well as patients post uterine fibroid embos. So they deal with typical inpatient issues like blood pressure and pain.

I have not experienced this model either in training or out in practice so what follows is a completely innocent (i.e., not designed to criticize) question:

what training do these IR guys have to handle "typical inpatient issues" having neither the benefit of IM or Surgery residencies, or any inpatient care since their intern year?

 

[igap]

Where I trained, the IR was handled by a group of guys who covered several hospitals in town. They did not have admitting privileges at our hospitals, and I suspect that they did not have them at the other hospitals as well.

Typically IR guys make a tremendous amount of money by doing procedures every day. They are not encumbered by clniic, or rounding, and they like it that way. I cannot imagine any of the IR guys I know all of a sudden wanting to give up a big percentage of their income for the added responsibility of managing inpatients, and having clinic. There is no financial incentive for this.

 

[badasshairday]

I have not experienced this model either in training or out in practice so what follows is a completely innocent (i.e., not designed to criticize) question:

what training do these IR guys have to handle "typical inpatient issues" having neither the benefit of IM or Surgery residencies, or any inpatient care since their intern year?

Legit question. Full disclosure (probably obvious based on my avatar) I'm going into radiology and went to med school associated with a very highly regarded IR fellowship.

Well, the threshold to consult IM is low. They aren't managing hypertensive emergencies or anything. Nor or are they managing ventilated patients in the unit. But giving a dose of beta blocker or hydralazine on the floor post-angio probably does not require a full IM/surgery residency (PA/NP's do it immediately after school with the knowledge equivalent of a 3th year med student).

Pain is definitely in the realm of IR as post-embolization syndrome is very common cause of pain in hepatic embolization procedures and uterine artery embolization. Also during procedures the IR is ultimately in charge of the sedation RN. Most IR inpatients status post UAE or interventional oncology procedure are usually inpatients for 24-48 hours max due to the minimally invasive nature of the procedures. So besides the pain management since intern year, they have the experience of floor pain management on their IR rotation during residency and during their fellowship.

 

[cpants]

I have not experienced this model either in training or out in practice so what follows is a completely innocent (i.e., not designed to criticize) question:

what training do these IR guys have to handle "typical inpatient issues" having neither the benefit of IM or Surgery residencies, or any inpatient care since their intern year?

Exactly. IR rarely has admitting privileges, and for good reason. When those surgeons were spending years of residency on the wards and in the ICU, the IR docs were sitting in a dark room reading CT scans. It can make for some annoyed vascular surgery residents as mentioned above, but when you look at the situation objectively, there is no way in hell a radiologist should be managing your standard vasculopath.

The IR guys often get pissed about what the admitting docs (especially surgeons) do as well. Surgeons generally do whatever the hell we want with drains, tubes, anticoagulation, etc.

 

[Winged Scapula]

Legit question. Full disclosure (probably obvious based on my avatar) I'm going into radiology and went to med school associated with a very highly regarded IR fellowship.

Well, the threshold to consult IM is low. They aren't managing hypertensive emergencies or anything. Nor or are they managing ventilated patients in the unit. But giving a dose of beta blocker or hydralazine on the floor post-angio probably does not require a full IM/surgery residency (PA/NP's do it immediately after school with the knowledge equivalent of a 3th year med student).

Pain is definitely in the realm of IR as post-embolization syndrome is very common cause of pain in hepatic embolization procedures and uterine artery embolization. Also during procedures the IR is ultimately in charge of the sedation RN. Most IR inpatients status post UAE or interventional oncology procedure are usually inpatients for 24-48 hours max due to the minimally invasive nature of the procedures. So besides the pain management since intern year, they have the experience of floor pain management on their IR rotation during residency and during their fellowship.

While I agree that having a low threshold for consulting IM/Surg is important, I'm afraid that your example of "PA/NPs/3rd year medical students" being able to manage hypertension or an arrhythmia doesn't cut it.

You certainly have your biases, but you must allow me and others more senior to you, to posit that sometimes these things are much more complicated than they seem, something that PAs/NPs/3rd year medical students don't often appreciate, sometimes with disastrous results. And I'm talking about things that seem basic, not hypertensive crisis, impending stroke, MI etc.

IMHO having IR manage any medical/surgical problems would be akin to having the intern managing those problems without someone more senior supervising them. Vasculopaths in particular are known to drop very very quickly. The lack of any experience at seeing that means that patients often get under treated until its too late. This is the problem with junior residents and allied health professionals; they don't know what they don't know and they often don't call for help soon enough.

I respect my IR colleagues immensely and worked closely with them in residency, however, I think they have their place on the team, but managing any medical/surgical problems doesn't seem to be their place, IMHO.

 

[omarsaleh66]

Where I trained, the IR was handled by a group of guys who covered several hospitals in town. They did not have admitting privileges at our hospitals, and I suspect that they did not have them at the other hospitals as well.

Typically IR guys make a tremendous amount of money by doing procedures every day. They are not encumbered by clniic, or rounding, and they like it that way. I cannot imagine any of the IR guys I know all of a sudden wanting to give up a big percentage of their income for the added responsibility of managing inpatients, and having clinic. There is no financial incentive for this.

Agree. Also in private practice, IR are expected to read studies between cases so clinic or any type of followup will eat into the PP radiology groups RVU. However, this is the very reason IR loses procedures to other specialities who actually see and manage the patients.

 

[omarsaleh66]

While I agree that having a low threshold for consulting IM/Surg is important, I'm afraid that your example of "PA/NPs/3rd year medical students" being able to manage hypertension or an arrhythmia doesn't cut it.

You certainly have your biases, but you must allow me and others more senior to you, to posit that sometimes these things are much more complicated than they seem, something that PAs/NPs/3rd year medical students don't often appreciate, sometimes with disastrous results. And I'm talking about things that seem basic, not hypertensive crisis, impending stroke, MI etc.

IMHO having IR manage any medical/surgical problems would be akin to having the intern managing those problems without someone more senior supervising them. Vasculopaths in particular are known to drop very very quickly. The lack of any experience at seeing that means that patients often get under treated until its too late. This is the problem with junior residents and allied health professionals; they don't know what they don't know and they often don't call for help soon enough.

I respect my IR colleagues immensely and worked closely with them in residency, however, I think they have their place on the team, but managing any medical/surgical problems doesn't seem to be their place, IMHO.

Agree. Just as surgery, nephrology and other specialties are evolving and getting more sophisticated to do endovascular procedures. IR is trying to evolve and become more clinical. There are pathways such as the DIRECT to do that. Will it equal a surgeon's 5+ year clinical skills? No. I dont know the best answer, IR has its advantages in being adept with the imaging and techical skills. We put wires and needles into everything, not just vascular so I see that as an advantage. The big WEAKNESS is clinical which needs to be addressed either with its own residency or all the endovascular will be done by a bunch of other subspecialties. IR still has cancer work, but what is stopping heme onc, surg onc in the next 20 years? Anyone who wants to do these types of procedures will just have to compete as more and more stuff will continue to get minimally invasive.

 

[Dr.LeoSpaceman]

Perhaps I could see IR managing those TACE patients who stay overnight, or other fairly straightforward stuff. But I don't think it would ever be a good idea to ahve them managing those trauma patients who get something embolized. Trauma patients are best managed by the trauma team since you're often dealing with multiple injuries. And not only that, but what happens if the embolization fails? You need a surgeon on board to definitively handle the problem.

 

[badasshairday]

Perhaps I could see IR managing those TACE patients who stay overnight, or other fairly straightforward stuff. But I don't think it would ever be a good idea to ahve them managing those trauma patients who get something embolized. Trauma patients are best managed by the trauma team since you're often dealing with multiple injuries. And not only that, but what happens if the embolization fails? You need a surgeon on board to definitively handle the problem.

Agreed, they should be managed by trauma. I also agree that scheduled oncologic interventions can and should be managed by IR as these are their patients and due to the minimally invasive nature require short inpatient stays.

As of right now, oncologic interventions are inpatient procedures that usually require only a short stay. Patients tend to stay 24 hours to monitor for any complications and for pain control. I think dumping these patients onto a hospitalist, GI/hepatology, or surgery service is not the right thing to do.

Right now the best clinical training for IR is the DIRECT pathway which ensures certification in IR in 6 years. During this time the physician in training does 2 years of surgery or IM, 2 years of diagnostic radiology, and 2 years of interventional radiology including ICU rotations.

I also agree with omarsaleeh, this does not come close to the 5 years of surgical training that surgeons have. But it is a start and I believe it at least affords straightforward inpatient management when needed. Again, obviously not the management of ICU patients or trauma patients.

Winged Scapula, I appreciate your perspective and you are right about what you say. However I think, some clinical management for certain procedures, especially those consulted in an outpatient clinic; such as oncologic interventions, pain procedures, women's health procedures should be clnically taken care of by IR. As someone eluded to earlier, the vascular surgery service was not happy about having to take care of a post-IR procedure. To avoid this and to keep procedures in the realm of IR, they need to take care of patients.

 

[igap]

I know an IR guy who does most of the angios and stents for a couple of medium-sized vascular groups, and he is purely a technician. If he were to suddenly have clinic and make rounds on the patients he works on, he would have to take a serious pay cut.

Furthermore, in private practice you are not "dumping" on the hospitalists, or other services by asking them to admit your patient. They will get reimbursed for the admission and probably will not mind the extra cash for minimal effort on their part. Conversely your suggestion that IR admits the easy patients only, and saves the challenging patients for other services to admit... well that is not a private practice recipe for success either.

The challenge for the future of IR is to somehow control the flow of patients so that they can be "captured", and not be lost to other specialties. The problem is that the other specialties see the patients far upstream, and IR is dependent on referrals for their work. Since reimbursement is so much higher for percutaneous interventions, other fields are now competing for those interventions. Hence, the move by vascular surgery to incorporate endovascular skills into their training.

It is much easier for a specialty like vascular and CT surgery to add EVARs and TEVARs to their training, or vascular to add peripheral vessel angioplasty/stenting to their skill sets, than it is for IR to somehow learn everything that a vascular surgery or CT surgeon knows about managing patients.

I see IR as being at high risk for being cut off at the knees when it comes to vascular, and oncologic interventions. Surgeons are agressive, and as waves of newer grads come out of training with their field-specific set of interventional skills, the referrals to IR will cease. Why would a vascular surgeon refer out a tremendously well-paying intervention to IR when they can do the procedure themselves? One only has to look at the rapid subjugation of the CT surgeon at the hands of big cardiology groups to see how IR guys could be affected. It is only a matter of time before vascular groups start adding "endovascular" guys to their practices. Or general surgeons comfortable with RFA of liver mets, or percutaneous placement of intra-abdominal catheters... the list goes on. I don't think a pathway that has an internship, 1 year of surgery or medicine residency, 2 years of rads, and 2 years of IR is any better than the current pathway. Actually I think it is worse. The traditional pathway at least provides the IR guy with a full radiology residency to fall back on in case IR gets too competitive or the compensation drops down to everyone else's level. The "DIRECT" pathway adds nothing really in surgery or medicine training (one year of junior resident training), and only 2 years of radiology training (instead of 4 in a full residency). Seems to me like watered down radiology training with very little clinical education added. It will be interesting in the coming years to see how everything plays out.

 

[ImmunoDude]

I know an IR guy who does most of the angios and stents for a couple of medium-sized vascular groups, and he is purely a technician. If he were to suddenly have clinic and make rounds on the patients he works on, he would have to take a serious pay cut.

Furthermore, in private practice you are not "dumping" on the hospitalists, or other services by asking them to admit your patient. They will get reimbursed for the admission and probably will not mind the extra cash for minimal effort on their part. Conversely your suggestion that IR admits the easy patients only, and saves the challenging patients for other services to admit... well that is not a private practice recipe for success either.

The challenge for the future of IR is to somehow control the flow of patients so that they can be "captured", and not be lost to other specialties. The problem is that the other specialties see the patients far upstream, and IR is dependent on referrals for their work. Since reimbursement is so much higher for percutaneous interventions, other fields are now competing for those interventions. Hence, the move by vascular surgery to incorporate endovascular skills into their training.

It is much easier for a specialty like vascular and CT surgery to add EVARs and TEVARs to their training, or vascular to add peripheral vessel angioplasty/stenting to their skill sets, than it is for IR to somehow learn everything that a vascular surgery or CT surgeon knows about managing patients.

I see IR as being at high risk for being cut off at the knees when it comes to vascular, and oncologic interventions. Surgeons are agressive, and as waves of newer grads come out of training with their field-specific set of interventional skills, the referrals to IR will cease. Why would a vascular surgeon refer out a tremendously well-paying intervention to IR when they can do the procedure themselves? One only has to look at the rapid subjugation of the CT surgeon at the hands of big cardiology groups to see how IR guys could be affected. It is only a matter of time before vascular groups start adding "endovascular" guys to their practices. Or general surgeons comfortable with RFA of liver mets, or percutaneous placement of intra-abdominal catheters... the list goes on. I don't think a pathway that has an internship, 1 year of surgery or medicine residency, 2 years of rads, and 2 years of IR is any better than the current pathway. Actually I think it is worse. The traditional pathway at least provides the IR guy with a full radiology residency to fall back on in case IR gets too competitive or the compensation drops down to everyone else's level. The "DIRECT" pathway adds nothing really in surgery or medicine training (one year of junior resident training), and only 2 years of radiology training (instead of 4 in a full residency). Seems to me like watered down radiology training with very little clinical education added. It will be interesting in the coming years to see how everything plays out.

Not to interrupt this interesting discussion, but...

Since most IRs also practice some DR, and DR is often the first to know if a patient has cancer, couldn't they just call the patient up and say "Hey, Mr Jones, I just read the CT scan Dr Smith ordered for your weight loss and abdominal pain, and I really would like to discuss the results with you, as I found a suspicious mass in your liver." Then the IR can discuss the CT scan's findings with the patient, and do a biopsy. Once he has the pathology report, he can then convene a tumor board of himself, an HPB surgeon, and a GI oncologist, and they can discuss appropriate management.

The patient wins because he gets informed of the possibility of cancer as soon as the radiologist reads the scan, and not when the PCP gets the report. The IR wins because he gets a new patient.

IR needs to make use of their valuable diagnostic role, and be proactive in seeking out patients by scheduling clinic appointments to discuss imaging.

I'd rather have the doctor who actually read the scan to tell me I have cancer, rather than someone who's just repeating what the radiologist tells them.

DRs are the patient's doctor as well, not just the doctor's doctor.

You guys are way further up in medical experience than me, so if this idea is stupid, tell me.

 

[ZagDoc]

Interestingly, an academic VA I rotated at had all the peripheral thrombolysis done by IR physicians but admitted to vascular surgery for post/peri procedure management - needless to say the residents and vascular staff there weren't particularly happy about that.

That is how things are done at my institution. At night, the nurses are supposed to page the IR fellow first with any issues, but they never respond to pages, so its the in-house vascular resident who ends up managing them.

The whole field of IR is very interesting and an area I think surgeons should have been more aggressive staking claim to early on, but as stated above are slowly starting to reclaim (our vascular attendings to EVARs/TEVARs and peripheral stuff and one of our hepatobiliary staff does RFA ablations of liver mets). But what we have is what we have. My field doesn't interact with IR a great deal, but my 2 cents is that if you want to be treated like a surgeon you need to act like one and care for your patient before and after your "surgery" - hell or high water, any hour of the day. But the IR proceduralists I have interacted with to this point have been coddled and protected from that, and frankly, enjoy coming in, running the cash register, then going home at 6pm for the day while someone else manages their patients. And frankly, with the pathway of training to IR as it exists now, they shouldn't be managing their patients, as their only formal post-op clinical training came from a prelim year in the distant past.

 

[Dr.LeoSpaceman]

Not to interrupt this interesting discussion, but...

Since most IRs also practice some DR, and DR is often the first to know if a patient has cancer, couldn't they just call the patient up and say "Hey, Mr Jones, I just read the CT scan Dr Smith ordered for your weight loss and abdominal pain, and I really would like to discuss the results with you, as I found a suspicious mass in your liver." Then the IR can discuss the CT scan's findings with the patient, and do a biopsy. Once he has the pathology report, he can then convene a tumor board of himself, an HPB surgeon, and a GI oncologist, and they can discuss appropriate management.

The patient wins because he gets informed of the possibility of cancer as soon as the radiologist reads the scan, and not when the PCP gets the report. The IR wins because he gets a new patient.

IR needs to make use of their valuable diagnostic role, and be proactive in seeking out patients by scheduling clinic appointments to discuss imaging.

I'd rather have the doctor who actually read the scan to tell me I have cancer, rather than someone who's just repeating what the radiologist tells them.

DRs are the patient's doctor as well, not just the doctor's doctor.

You guys are way further up in medical experience than me, so if this idea is stupid, tell me.

Because you often don't need a tumor board to make the decision of how to proceed. In fact, only a small percentage of cases actually make it to those multidisciplinary meetings. And the person that should be telling the patient he has cancer is the one who understands and can describe the general treatment for it, and what may be the likely course of treatment for that patient. That's not the diagnostic radiologist or the interventional radiologist. In fact, I think there is little worse than walking into a room with a patient who has been told "You have cancer", but has had to wait hours or days to talk with someone who can actually explain what it means for them. It's like psychologic torture for the patient.

 

[Winged Scapula]

I'd rather have the doctor who actually read the scan to tell me I have cancer, rather than someone who's just repeating what the radiologist tells them.

No you wouldn't. You are presumably young, and probably have not established a long term relationship with a physician, And what makes you think that the radiologist would know more about management of the particular problem than the ordering physician? Patients are not satisfied with "hey you've got a mass on your liver, call your doctor" type of response, which is what you get.

I can tell you from *years* of experience that patients do NOT want to hear information from their radiologist. They want to hear it from someone they have a professional relationship with and someone who can tell them "what's next" rather than someone who simply says, "call your <ordering> doctor" or makes recommendations which are outside the realm of their practice/or without understanding all the issues (such as patient medical history, family history, etc). Like FaytIND says, that's torture for the patient, and for the practitioner, sometimes trying to undo the damage a non-clinician has done to the patient (with either incorrect, or outdated information or simply not understanding all the issues), is torture for us.

 

[SLUser11]

I'd rather have the doctor who actually read the scan to tell me I have cancer, rather than someone who's just repeating what the radiologist tells them.

You guys are way further up in medical experience than me, so if this idea is stupid, tell me.

This idea is stupid....and extremely unprofessional. If a radiologist had the habit of telling patients they have cancer as a way of poaching possible interventional business, he/she better have a backup career plan.

Radiologists are not trained to have this long, difficult discussion with patients and families, nor are they trained to offer recommendations regarding care.

I'm trying my hardest to even imagine a radiologist committing on a diagnosis of cancer based on a CT scan. In the real world, radiographic findings are non-specific and "clinical correlation is recommended."

 

[doc05]

You guys are way further up in medical experience than me, so if this idea is stupid, tell me.

yes it is

 

[omarsaleh66]

This whole situation is reminding me of that HBO show Game of Thrones. Everybody wants a piece of the pie. haha

One interesting thought is why does it have to be VS vs Cards vs IR? Its way more complicated atleast as a radiologist there is a lot of IR vs Diagnostic, and Rads vs Rads, or IR vs IR (from different groups). As Im sure surgery has to deal with competition from other surgeons?

Are scenarios where IR +vascular from the same hospital can make more money together and compete with other local hospitals and groups. I have seen this type of setup in some places and would like to hear your thoughts. It doesnt have to be this way but these types of alliances Im sure are occuring alot but we dont hear about it as much as the turf battles and competition.

For example, if a vascular group gets so busy and they have to hire another surgeon and pay him 300-400k, why not save that and get the IR to do some of the PAD work and cut costs? Both parties win except the guy who doesnt get the job, of course. Obviously IR cant do any of the open stuff so vascular call setup would be complicated. There are IR groups out there who hire their own vascular surgeon or nephrologists or vice versa. Just an interesting thought for discussion.

 

[ImmunoDude]

Let me explain what I meant, since that original idea was stupid.

In order for the patient to understand the results of his imaging better, the reporting DR should send them an annotated copy of the report, explaining what they found and what it could mean, and what this means for them. There's a pathology group that does just this with path reports. http://www.thedoctorsdoctor.com/f_translating.html

Like this:

Study: Abdominal CT with and without IV contrast.

Your abdomen was scanned before and after a special dye was injected to make blood flow easier to see

Indication: Referring physician suspects liver disease based on clinical history and findings per radiology request form

This is why your doctor wanted you to have this scan, to determine why you have upper abdominal pain, yellowing of the skin and eyes, and nausea and vomiting

Findings: There is a 500 mL hypodense mass in segment 1 and 4 of the cirrhosed liver.
Mild ascites is present. There is cavernous transformation of the thrombosed portal vein. The mass and thrombus are continuous with each other and enhance with contrast. Gastric and esophageal varices are present. Remainder of study is normal.

There is a large mass present in the middle of your liver. The mass has invaded the portal vein, which takes nutrient-rich blood from your digestive system to the liver for processing. The portal vein became obstructed because of this, so your body is bypassing the obstruction with many collaterals to relieve the high pressure in it. But this was not enough, so the blood is backing up in the veins in your esophagus and stomach.The high pressure led to scarring and fluid build up around the liver. After the dye was injected, the mass and obstruction became bright, which shows that the mass is perfused with blood. Otherwise, everything else appears normal.

Impression: Possible hepatocellular carcinoma leading to hepatic cirrhosis and failure. Biopsy highly recommended. GI oncology consult advised if biopsy shows malignancy.

I believe that this mass could be a type of liver cancer. The mass is damaging your liver, which is causing your symptoms, and I urge your doctor to request me to perform a percutaneous biopsy of it so a pathologist can examine the cells to determine whether or not this mass is indeed cancer, and you and your doctor can refer you to a cancer specialist for appropriate treatment. Hopefully the mass is not cancer, but if it is, I provide a full spectrum of non-surgical cancer treatment if medication alone is not enough to get you healthy again.

That's not poaching patients, that's a radiologist doing his job in educating their patient. Clinicians should do everything they can to help radiologists make a final diagnosis, instead of not giving them a detailed reason for why they want a scan done. "Clinical correlation required" on a report means the radiologist is telling the clinician they didn't give them enough info to make a definitive diagnosis.

In the UK, you have to have three years of clinical training before entering radiology, because they realize how important it is.

 

[igap]

Let me explain what I meant, since that original idea was stupid.

Just let this idea go... it is a non-starter anyway you present it. You don't need to "clarify" the idea any further. It will still be a "stupid" idea.

Though I do think you should maintain your "think outside the box" frame of mind. There is always room to improve how we do things and the way we do them today is not always the best way. It will be people coming through the system like you with fresh perspectives who can help break outdated practice patterns, an hopefully improve the way we do things.

 

[cpants]

This whole situation is reminding me of that HBO show Game of Thrones. Everybody wants a piece of the pie. haha

One interesting thought is why does it have to be VS vs Cards vs IR? Its way more complicated atleast as a radiologist there is a lot of IR vs Diagnostic, and Rads vs Rads, or IR vs IR (from different groups). As Im sure surgery has to deal with competition from other surgeons?

Are scenarios where IR +vascular from the same hospital can make more money together and compete with other local hospitals and groups. I have seen this type of setup in some places and would like to hear your thoughts. It doesnt have to be this way but these types of alliances Im sure are occuring alot but we dont hear about it as much as the turf battles and competition.

For example, if a vascular group gets so busy and they have to hire another surgeon and pay him 300-400k, why not save that and get the IR to do some of the PAD work and cut costs? Both parties win except the guy who doesnt get the job, of course. Obviously IR cant do any of the open stuff so vascular call setup would be complicated. There are IR groups out there who hire their own vascular surgeon or nephrologists or vice versa. Just an interesting thought for discussion.

Your example doesn't make sense. If the group is so busy they can support another surgeon, why wouldn't they want to expand? They will make a lot more money in the long run by adding a partner or associate physician to their team.

 

[ImmunoDude]

Just let this idea go... it is a non-starter anyway you present it. You don't need to "clarify" the idea any further. It will still be a "stupid" idea.

Though I do think you should maintain your "think outside the box" frame of mind. There is always room to improve how we do things and the way we do them today is not always the best way. It will be people coming through the system like you with fresh perspectives who can help break outdated practice patterns, an hopefully improve the way we do things.

Thank you. I'd just like to know why exactly this would be bad, as it seems perfectly reasonable for a DR to help the patient understand his role in their care.

I've had to think outside of the box for undergrad due to being homeschooled, and I'm now attending a top UK research uni. I'm likely going to have to go to an Irish or UK medical school due to this, but I discovered something interesting from a friend on ValueMD: ND, OK, and ME accept GMC-UK or GMC-I registration as an alternative to residency requirements for licensure. And since I'll have an EU medical degree, if I don't get into a residency here, I can do my internship or Foundation training, then do basic surgical training and pass the Membership of the Royal College of Surgeons exam, and radiology training in Ireland, UK, or Australia, get Fellowship of the Royal College of Radiologists and registered, and then come back to those states. And if I do an IR fellowship at medical school here and spend three years as a faculty member, I can then take the ABR boards. Although doing three other, different, ACGME-accredited fellowships would be better, as then I can also fulfill the postgraduate training requirements to get licensed back in my home state of California.

There's a urologist in Maine who did just that. He was born here, went to Cambridge for medical school, did urology training and research in Ireland, UK, and Australia, got GMC-registered, and then came back to his home state of Maine. He got privileges due to his FRCS(Urol).

So I have two options to become a practicing IR in the US. The good thing about the Commonwealth system of GME is that you're not forced to commit to a specialty right after graduation. You can spend up to four years figuring out what you're good at and what you like.

If I do finally decide on IR, I'm going to commit myself to becoming just as expert on cancer as surgical oncologists. If I didn't become a disease expert, I wouldn't be a physician, just a film reader and wire+catheter-pusher.

An old surgeon once said "a surgeon is an internist who can offer definitive treatment." Someday, that will be true of IR as well. They are developing minimally-invasive and minimally-disruptive ways of treating HPB, GU, CNS, pulmonary disease, and trauma.

And based on what you've been saying, why exactly are neurosurgeons even bothering to learn neuroIR; they still have to do open surgery to remain certified. And the neurointensivists don't have the neuroradiology training. The neurosurgeon should stick to operating, the neurointensivist should stick to postop care, and the neuroIR should stick to image interpretation and image-guided interventions. They shouldn't be messing around in each other's areas of expertise.

And all neuroIRs should get the training needed to do craniostomies so they can place an EVD if needed, instead of bothering a neurosurgeon. The neurointensivists already do their own.

And here's something really odd: why don't neuroIRs do stereotactic procedures? They have the imaging expertise that's absolutely required to do the procedure successfully, and already do the majority of the planning. An iatrogenic epidural bleed can be managed endovascularly. Other bleeds can be managed with thrombin. And the hematoma can be aspirated stereotactically. Post-op abscesses can be drained that way as well.

 

[cpants]

If I do finally decide on IR, I'm going to commit myself to becoming just as expert on cancer as surgical oncologists. If I didn't become a disease expert, I wouldn't be a physician, just a film reader and wire+catheter-pusher.

Good luck with that. It's kind of hard to become just as expert as someone who has done a fellowship in cancer treatment and now treats cancer full time, when you have trained in radiology/IR and do that stuff full time. There are only so many hours in the day.

An old surgeon once said "a surgeon is an internist who can offer definitive treatment." Someday, that will be true of IR as well.

No it won't.

 

[ImmunoDude]

you're not explaining what you meant...you are back peddling and restating a modified idea since we all said your last one was dumb. Everyone understood what you meant originally.

The idea of radiologists drafting an annotated report explaining their read in lay terms is actually a very good one. I've seen patients walk into clinic holding a copy of their mammography report who thought they had "stage 4" cancer because the read said BIRADS 4.

But there is no real incentive for a radiologist to do this because it would just take time and would be unbillable. And using the final line of it as a sales pitch for all your other "services" would be unseemly and would again upset your referral base



No, you won't. It's just not feasible. Surgical oncologists spend an entire fellowship solely devoted to cancer care, then spend a career 100% focused on it. There is no way to do that in an IR training pathway because the main focus of that training is on learning those catheter/wire skills which (rightly) takes a ton of time and effort in and of itself.

Still, if you do an IR fellowship at MSKCC or somewhere with a large oncology patient list, you should come out with a good deal of oncology knowledge. And I want to be an academic, and do IO research.

All physicians should educate their patients, even if it costs them a bit. And since radiologists make so much money from the sheer volume of scans they do (even with cuts, if you read a 50 CTs/day at $100 a piece, 5 days/week, 48 weeks/year, that's $480,000/year after a 60% overhead), or from the technical fee of the scan if they own their own scanner and rent it out to other docs, spending an extra hour or two drafting a plain-English interpretation of the reports after all the day's work is done shouldn't eat into profit that much.

And how exactly are patients supposed to get care, or physicians get patients, if physicians don't advertise? I see ads on TV from medical groups all the time, including a few cancer centers. It's simply telling the patient options, and that you're available.

 

[cpants]

Still, if you do an IR fellowship at MSKCC or somewhere with a large oncology patient list, you should come out with a good deal of oncology knowledge. And I want to be an academic, and do IO research.

All physicians should educate their patients, even if it costs them a bit. And since radiologists make so much money from the sheer volume of scans they do (even with cuts, if you read a 50 CTs/day at $100 a piece, 5 days/week, 48 weeks/year, that's $480,000/year after a 60% overhead), or from the technical fee of the scan if they own their own scanner and rent it out to other docs, spending an extra hour or two drafting a plain-English interpretation of the reports after all the day's work is done shouldn't eat into profit that much.

And how exactly are patients supposed to get care, or physicians get patients, if physicians don't advertise? I see ads on TV from medical groups all the time, including a few cancer centers. It's simply telling the patient options, and that you're available.

Ok, so if you do IR at MSKCC you might know enough about cancer treatment to be the main oncologist and point of contact for a cancer patient. How many IR fellowship spots do you think there are at MSKCC? 2? By the way, IR seeing newly diagnosed cancer patients before a surgeon/medical/radiation oncologist is not a model MSK or any other hospital embraces. It makes no sense. IR does not offer definitive treatment for any cancer.

Some advice: Go to med school and find out what you are really interested in before you start imagining what your future practice will be like and how you are going to break the mold. It's obvious you don't even know what the mold is yet.

 

[ImmunoDude]

Ok, so if you do IR at MSKCC you might know enough about cancer treatment to be the main oncologist and point of contact for a cancer patient. How many IR fellowship spots do you think there are at MSKCC? 2? By the way, IR seeing newly diagnosed cancer patients before a surgeon/medical/radiation oncologist is not a model MSK or any other hospital embraces. It makes no sense. IR does not offer definitive treatment for any cancer.

Some advice: Go to med school and find out what you are really interested in before you start imagining what your future practice will be like and how you are going to break the mold. It's obvious you don't even know what the mold is yet.

You're right.

 

[neb85]

I don't necessarily think that you should stop thinking of what an ideal practice would be like for you. As you get more experience it will constantly change but having a goal in mind is always good.

That being said, you have to be realistic about things, and that is what experience teaches. In my brief medical career I've found that all manners of practice exist, and there are probably IR physicians somewhere who are able to structure their practice in the way you describe. The problem is that if they do exist, they are most definitely a rarity and probably only exist because when the rare opportunity came along, they were somehow able to aggressively carve out a niche for themselves, and had very supportive referring physicians. Everyone else will practice the "traditional" way, either because that is what they want/most bang for the buck, or is what they are forced to do by the general medical model and referral patterns.

I think that people will always have an ideal of what they want; this is a good thing. Finding out how to evolve it and fit it into the realities of the way medicine works is difficult. It is something I think about often.