PAD eval and managment

[badasshairday]

Interesting study in JVIR. Not a new article, but new to me. It is about primary referrals from primary care to VIR for PAD management.

http://www.ncbi.nlm.nih.gov/pubmed/18440449

I think it just reaffirms that PAD is something that can and will remain in the realm of VIR as long as a clinical role is maintained.

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[shark2000]

If you truly want to do endovascular work do either vascular surgery or cardiology.
Vascular work is done on a Vasculopath patient which needs endless care round the clock. You may end up in a group that does not do vascular work at all and you are the only one. In that situation you have to cover the patients round the clock everyday for the rest of your life.

Man, I don't know what you want to prove by some random article somewhere. As I mentioned many times before doing Radiology solely for IR is stupid. It is just doing cardiology just for reading Echos.
PVD for IR, is like comparing the volume of prostate US in a urologist office to our volume of imaging. OK, still you can get some referrals from here and there. But it is never comparable to the volume of a vascular surgeon or even a cardiologist. Take a look at them. There is a telemetry unit, which is filled automatically with 40 patients with chest pain all of them vasculopath. Half of them will have cardiac cath eventually at some point. They even do not need to look for patients as the patients are admitted automatically to their service. On the contrary, you have to beg for patients from here and there.

I still do not understand why someone who wants to admit patients, run inpatient service, take care of sick patients constantly esp vasculopath patients who have lots of complications any time, run clinics and ...is doing radiology? You can do a lot of other patient based fields which are challenging by themselves, have better hours and have much more secure turf than IR.

Good Luck.

 

[IRneuroIR]

I disagree with this sentiment. If you are interested in running a clinical IR practice, then you are more than qualified to admit patients, run an inpatient service, take care of sick patients (including medical management), and have your clinic. There are many of us in IR who enjoy doing this and are equal clinicians in the care of these patients and viewed as such by referring clinicians. Moreover, there is so much PAD out there that there are not enough clinicians to take care of them all -- even combining cardiology, vascular surgery, and IR.

And how is "doing radiology solely for IR stupid"? Couldn't a similar argument be made for doing general surgery just to do vascular surgery (or, more specifically nowadays, endovascular surgery)? Ultimately, you can do in life and in your career what interests you. I started into radiology not knowing that I would enjoy IR and neuroIR so much but this is what I do now and truly enjoy it. Yes, it is a busier lifestyle but I enjoy it more than reading chest x-rays.

In medicine, I feel you truly have the ability to control a lot of your destiny but you have to be willing to work for it. But if you enjoy what you are doing, then it hardly seems like work and if you take good care of patients, both they and referring clinicians will recognize it. Best of luck.

 

[duckie99]

http://www.ncbi.nlm.nih.gov/pubmed?term=21785058

This is a newer article. I think radiology is losing or has already lost PAD almost completely. Maybe not in large teaching hospitals but I think as a whole they essentially have.



I go to a program (upper level med student) with a large IR program. I think those guys have a clinic but it is mostly onc if anything. The thing is that they are so busy with other stuff they don't have time for PAD. Also procedures like biopsy's, etc that other rads do here (abdominal and even NPs) may have to be done by IR in the real world.

By in large IR is procedures with little management beyond that from what I have seen. Even in onc patients I'd imagine they really just need the scans and can make decisions purely off them.

Essentially I don't think IR has or will change the way some of you guys want it. People have been saying the same things for years and years and nothing has changed. It's hard to do it in the real world when you haven't really done any medical management of patients since intern year. It' s just not IR's role. I however am sure there is other endovascular work out there beyond pvd that cards and vasc surgery don't touch (like thrombosis of venous fistulas for dialysis).

But IR is not seen as a clinical field by the great majority of physicians and they're biggest referrers (IM docs) will always refer to cards or surgery first. It's just in their nature. Example that isn't pad: should GI or IR do the Gtube - young new attending said GI because the patient may need to be followed to an extent (may have GI bleed) and that IR is good if pt going to nursing home and does not need any further f/u. This illustrates the attitude other physicians have towards IR.

I think IR is awesome but their niche and role is not really in managing vascular patients.

 

[badasshairday]

http://www.ncbi.nlm.nih.gov/pubmed?term=21785058

This is a newer article. I think radiology is losing or has already lost PAD almost completely. Maybe not in large teaching hospitals but I think as a whole they essentially have.

Whoa, how did you take that leap and state radiology has almost completely lost PAD? Table 3 shows that there has been a 13% decrease in peripheral angioplasty/stenting between 2000-2007. They didn't say a 90% decrease. The paper mostly just showed how cardiologists are screening all their patients and vascular surgeons are performing more endovascular work. Basically it is showing a large growth in endovascular work by cards and vasc surgery and a minimal decrease in radiology endovascular work.

Table 3
http://www.ajronline.org.proxy.lib.mcw.edu/content/197/2/W314/T3.large.jpg

 

[badasshairday]

Man, I don't know what you want to prove...

Not trying to prove anything. If IR loses PAD, they still will be busy with a ton of other procedures. I just think it is short sighted and for lack of a better word, lame, to give up on PAD because other specialists are doing it. That is the mentality that allows other fields to encroach on IR. I don't know how many times I heard from other radiology applicants when I was at programs doing PAD, "well it doesn't matter that they do peripherals here because its not like we will be doing it in practice." It is that passive mentality that allows these "turf wars" to happen.

Is it really that hard to do ADCVANDISML? If other specialties can learn endovascular work, surely we can (re)learn how to prescribe statins and basic management of inpatient blood pressure (as we all will have done during internship).

 

[duckie99]

Whoa, how did you take that leap and state radiology has almost completely lost PAD? Table 3 shows that there has been a 13% decrease in peripheral angioplasty/stenting between 2000-2007. They didn't say a 90% decrease. The paper mostly just showed how cardiologists are screening all their patients and vascular surgeons are performing more endovascular work. Basically it is showing a large growth in endovascular work by cards and vasc surgery and a minimal decrease in radiology endovascular work.

Table 3
http://www.ajronline.org.proxy.lib.mcw.edu/content/197/2/W314/T3.large.jpg

yeah but the article's data ended in 2007 (5 years ago) where the trend was down for IR. If you continue to extrapolate out by the time you finish fellowship (6 years from now) it will likely be even less but it's hard to predict.

Regardless if cards and vasc surgery are increasing that dramatically they'll get even more patients because of how IM docs practice. As I said in my previous post if an internist has a patient with PAD they'll send them to the cardiologist or surgeon first before IR. That's just my experience on IM's attitudes toward IR - good for procedures but if a patient will need medical followup he/she needs cards or surgery. Also it is part of the work up for any CAD patient to be screened for PAD. So cards I think has the edge in the end if they want it.

As I said I think IR will still do plenty of endovascular stuff (onc, trauma, diagnostic studies, etc). It just won't be PAD. There's plenty to do because there are not enough cardiologists or vascular surgeons to do all that needs to be done. Also there are things (splenic emobolization, fistula thrombolysis, etc) that I think cards and surg don't want to do so IR will continue to. The scope of practice for IR is narrowing in my opinion and this isn't necessarily a bad thing. If anything they'll get a stronger foothold on certain areas/procedures which is good for the field.

 

[shark2000]

I disagree with this sentiment. If you are interested in running a clinical IR practice, then you are more than qualified to admit patients, run an inpatient service, take care of sick patients (including medical management), and have your clinic. There are many of us in IR who enjoy doing this and are equal clinicians in the care of these patients and viewed as such by referring clinicians. Moreover, there is so much PAD out there that there are not enough clinicians to take care of them all -- even combining cardiology, vascular surgery, and IR.

And how is "doing radiology solely for IR stupid"? Couldn't a similar argument be made for doing general surgery just to do vascular surgery (or, more specifically nowadays, endovascular surgery)? Ultimately, you can do in life and in your career what interests you. I started into radiology not knowing that I would enjoy IR and neuroIR so much but this is what I do now and truly enjoy it. Yes, it is a busier lifestyle but I enjoy it more than reading chest x-rays.

In medicine, I feel you truly have the ability to control a lot of your destiny but you have to be willing to work for it. But if you enjoy what you are doing, then it hardly seems like work and if you take good care of patients, both they and referring clinicians will recognize it. Best of luck.

I never said admitting patients is stupid. For sure there are people who may like it. Whether this is more exciting or reading a CXR is a different story and very personal. You may enjoy it, I may not.
But still I think doing Radiology solely for IR is stupid. Do not get insulted. You are spending 6 years of your life, but your IR training is around one year and half at most. Or better to say, your clinical training is around 1 year and half. On the other hand vascular surgery is 2 years or so above 5 years of surgery all clinical.
You spend 5 years managing sick people, SICU, ER, OR, ....
When was the last time you managed an unstable patient in ICU ?
Also vascular surgeons have more skills than catheter including open surgery. Even the most aggressive cardiologists, still respect vascular surgeons because they need them as back up. As a result they can never be out of the game. This is the most important winning card for them. On the other hand, IR in many places is out of the game.
I don't say you can not do it. For sure you can do it and by effort you will be busier than you can manage. But the question is while you can do it in other secure ways, what is the point of doing it through this route?
I can guarantee you if you go for vascular surgery you will do PAD, but for IR I do not know. You may or may not.
The whole concept of radiology is that it is cool and diverse. If you want to do solely PAD there is no point in doing it. But if you want to have a mixture of everything including DR, light procedures and some high end procedures that is a great balanced field.

 

[shark2000]

Not trying to prove anything. If IR loses PAD, they still will be busy with a ton of other procedures. I just think it is short sighted and for lack of a better word, lame, to give up on PAD because other specialists are doing it. That is the mentality that allows other fields to encroach on IR. I don't know how many times I heard from other radiology applicants when I was at programs doing PAD, "well it doesn't matter that they do peripherals here because its not like we will be doing it in practice." It is that passive mentality that allows these "turf wars" to happen.

Is it really that hard to do ADCVANDISML? If other specialties can learn endovascular work, surely we can (re)learn how to prescribe statins and basic management of inpatient blood pressure (as we all will have done during internship).

It is not about learning to manage the patient. You can learn whatever you like.
It is about having an organized department with all the needed infra-structure for that.
So take a look at our DR department. We cover the hospital for 7/24. Every minute that a stroke comes to ER, the report or prelim result is ready in half an hour. We cover all the hospital. We do not tell them at 3 am that sorry we do not have a neuroradiologist to read the brain MRI.

On the other hand, just show me a radiology department that can provide 7/24 hours of coverage clinically and procedurally of possible PAD. It means if the patient comes with leg pain to ED, then they call IR. I bet in 99% if not all cases, IR will not be called. Leg pain may be vascular or not. Then they may put surgery consult. Then the surgery sees the patient and decides this is for example a leg abscess or baker's cyst and not arterial problem or DVT.
Let's be honest. IR does not have infra-structure. The infra-structure of vascular surgery is general surgery, nurses, surgery wards, ORs and inpatient, Surgical ICU, ....
Which of these belong to IR? which do we have?
For example take a look at cards. For every 10 chest pain they work up, 1 will be a cardiac. But they get constantly called for it.
You may be able to overcome all these problems, but it is very difficult.

You are right, IR have many other procedures to do, though with a lot of turf battles with DR people. In my medical center most of these are done by DR people. Even internally there is turf battle between DR and IR. In the case of biopsies, Body or chest people find the lesion first. They call the referring doctor (primary doctor or oncologist) and recommend biopsy and take it. This way they bypass everybody else including surgeons and IR people. The same for MSK people esp for pain management. The same for Neuro people.

Good Luck