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premature aging/cancer

Discussion in 'Interventional Radiology' started by Dumb, Dec 23, 2011.

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  1. Dumb

    Dumb USMLE Tutor - PM me for info

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    This may seem like a silly question but is there any evidence or data on whether a career in Interventional Radiology leads to premature aging or worse...like cancer?
  2. shark2000

    shark2000

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    Nobody knows the definite answer to your question. At least till 5-10 years ago, the interventionist (both rads and cards) were not as busy as these days. Nobody has really followed up them for a long time to see what happens.
    But generally speaking, the risk of cancer should not be more than general population. It has been shown that your risk of cataract is higher.

    If you are an MS please just think about my advice. Medical students are really interested about interventional radiology or interventional cardiology. I do not want to disappoint you, but these are not as lucrative and as exciting as you think. Putting on a 5 pound lead at 2am and embolizing a splenic rupture is not as rewarding as you think. IMO, if you are interested in procedures, at least consider something with controllable life style, better hours and healthier patients. Something that does not deal with life and death. Procedures will become pain in the neck after a few years. The last thing that you need is dealing with a dying patient. There are bunch of other procedural specialties with more lucrative procedures. These include both light and heavy procedures. Have you ever thought about urology? Mohs surgery? Ortho? ENT? Ophtho.

    Despite what medical students think, as you advance in your medical education, you will find out that you are neither god, nor a magician. That large saddle PE that you want to take a brave action on by doing an embolectomy , is nothing but a pain in the neck. The best you can do is to rescue yourself out of all the BS.

    If you are really passionate about it (And I still do not know how can a medical student be passionate about IR) go for it. But just be aware that it is neither the best job in medicine (as some people want to make it), nor a comfortable life. And be aware that one day you will be 40 or 50 with all the family around you and while many other doctors are not working on the Christmas Eve, you have to come to the hospital to embolize the ESLD Cirrhotic GI bleeder that will die 2 days later despite all your efforts.
  3. officedepot

    officedepot

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  4. shark2000

    shark2000

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    Probably I exaggerated it. But my point is that many medical specialties are unknown to medical students. Don't take me wrong. IR is a great field, but there are many other great fields in medicine that MS do not even think about them. For an MS4, his hero is the hospitalist or the IR guy. Medical students almost see the hospital based specialties. And almost always it is in an educational center with less work and a lot of residents. To them IR is a 9-3 specialty as it is the schedule for attending in university setting.
    I don't want to paint a disappointing picture. It is a great field. But you never ever see a urologist, ortho_joint replacement, derm, ophtho, ENT, plastics, rad oncologist working on weekend or Christmas.
    Your post is the best example. FYI, a lot of surgeons (breast, plastics, ...) only work in outpatient setting which is equal to not working on holidays. The same for many IM docs.

    My most important point : Patient contact sucks. Thanks Radiology. MS love patient contact. For junior residents it is OK. Attendings hate it and constantly looking for a setting to skip it. The general trend is that as you advance through medical education your preference goes from critical care to ER to inpatient to outpatient. By the time you finish residency you hate it and you just want an outpatient setting. If you are lucky you are a radiologist that you are able to escape it other than more than enough brief encounters during mamo.
    Most people who choose radiology for IR, will not pursue it. As you become the senior resident, you will find out yourself. That is the reason that when the job market was good, very few people wanted to do IR. in 2004 it was 90 applicants for 200 spots. Funny.
    Then when the job market became tight, it is obvious that radiologists start to fill the jobs from the most lucrative ones which is Neuro and MSK. Those spots filled and the BS of radiology which is IR remained. Now everybody expressed their interest in IR. Last year it was 220 applicants for 200 spots. I can not believe that the interest of residents changed so fast in less than 5 years.

    The summary of my long post is that Diagnostic radiology beats most if not all medical fields . I think it is not wise to ruin it by doing IR. If you do not like DR, do not do radiology. If you are surgical type, go for some other procedural field. DR is very rewarding compared to most or even all fields. But IR is not as rewarding as many other procedural fields in the long run.
  5. Dumb

    Dumb USMLE Tutor - PM me for info

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    Hmm...which fellowships do you think are worth pursuing (or are most lucrative) at this time? Still MSK or mammo?
  6. davidjones

    davidjones

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    First to the OP: you are not likely to get cancer from doing IR procedures, the thing most people worry about is cataracts, if you wear leaded glasses you'll be fine. And you wear a radiation badge to monitory how much you're gettting.

    As far as IR not being all it's cracked up to be, well to be frank it is. The most novel therapies come from IR, the biggest advances in medical care in the last 40 years have been thanks to interventional radiologists. Seldinger, was a radiologist, and every doctor under the sun has used the techniques he developed. IRs are by far the most innovative physicians of any other specialty out there.

    The schedule can be hard, if you're in trauma center, or large hospital with lots of GI stuff; but I've been in residency for 2 years now and only rarely do my attendings come in on overnight to do calls; seldom is there a true emergency that needs to be dealt with right away; of course if you are not in a place with residents you would have to come to evaluate every overnight consult; Neuro IR is a different story; there you will be on call.

    The same can be said of any other procedural specialty; I know a derm resident, who, when we go out to dinner with other friends (consisting of anesthesia, urology, ortho and IR) is constantly late because she is seeing consults, at 6 pm, (who needs a derm consult at 6 pm??!!!);

    The cool think about IR is you do get to deal with critically ill people, and often are the only reason they survive or don't have to go for a much more morbid surgery: examples I can think of within the next 10 seconds include: TIPS for esophageal varices; UAE for post-partum hemorrhage, foreign body retrievals from the vessels, GI bleed embolization; not to mention all the novel cancer therapies and therapies for benign conditions like BPH and fibroids.

    While Shark makes a relatively good point about not going into DR to just do IR, I want to tweek it a little; you should at least understand that you will have to DR for a large portion of your training (which may change when the dual certificate IR/DR, and will cut down DR training for people by 1 year); you don't have to picture yourself sitting on your butt and reading scans all day for the rest of your life, just view it as another hoop to jump through to get to where you need. Additionally the knowledge you get in DR is quite useful to an IR; particularly if you're part of a tumor board or are treating cancer patients; and it makes you very marketable to both multi-specialty and radiology practices.

    Finally, I get excited every time I go to the angio suite (CT/US procedures are fine to pay the bills, but not all that fun for me); even if it's 3 AM; I see wearing the lead as just a part of my workout routine; and patient contact does not suck; while that is the general attitude of some, not just in radiology; it is very very gratifying to have a patient thank you even after something as trivial as draining an abscess; because while it's trivial for us, it is very scary and traumatizing for them.
  7. Dumb

    Dumb USMLE Tutor - PM me for info

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    Do you mean that cancer is unlikely with or without irradiation or that risk of cancer is not increased at all by being an IR?

    With great respect, while the innovations were remarkable indeed, it seems that the capacity to privatize and monopolize the market has been lacking. Out of the original pie of interventional procedures done solely by IRs, a good chunk of market share was effectively stolen by encroaching fields. These turf wars do not seem to be over, either. If anything, it seems more marketshare will probably be stolen since there is no clear way to protect against it. Do you agree?



    I am not sure I follow your logic. You state that IR is an awesomely innovative field for which you have no buyer's remorse, but then acknowledge Shark's comment as a good point?

    It's great to see that people are still passionate about IR; however, quite frankly, there are many IR guys out there with buyer's remorse. They resent the turf wars with vascular and cardio enough to make it an almost daily complaint. They also resent the hours they work, even at top private IR practices.
  8. shark2000

    shark2000

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    The problem with IR or vascular work in general, whether it is vasc surgery, cardiology or NeuroIR is its nature. It is less related to turf war.
    On the other side of the story vascular surgeons and cardiologists are constantly nagging.
    The type of you patients are diabetic, vasculopathic with ESRD. Vascular diseases are one of the most emergent ones in medicine. As a result you will end up with the most emergent procedures in a patient that will come back to you chronically till he dies, and many times in an emergent setting. Once a vas surgeon told me that he hates his job because whatever he does will end up in amputation. You can develop 100 techniques for angio/stenting, however sooner or later patient will come back in the ED at 2 am with a cold leg. It is a whole different from a cataract surgery, stapedial implant, Mohs surgery, or knee replacement. Even if you dislike these, they are least likely to end up in ED at Christmas Eve.

    The practice in academic center is a whole different from pp. Do not compare them. In academic center you can have a 9-4 job even as a trauma surgeon. There is always residents, fellows and junior attendings.

    That is the reason that most interventional radiologists that I know quit their job after 8-10 years of practice and shift back to DR. Almost every cardiologist that I know kiss intervention goodbye after 10 years and go back to general cardiology with some imaging. And I am talking about pp. In academic setting, you can survive because after a few years the junior attendings will cover the call. Vascular surgeons do not have any other option. Most of these people were more passionate than you, when they were resident.
  9. davidjones

    davidjones

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    1)You're risk of cancer goes up a minimal amount with regard to working with radiation. I'm too tired to look up the actual papers, but a great deal of work goes into protecting people who work with it. So that's not a reason to not go into IR. If anything vascular surgery and cards have greater risks, because they stay in the room when they do runs, don't even bother putting shield between them and the source.

    2)Perhaps the greatest failing of IR training is it's lack of accountability with regard to patient care; which is the reason a lot of vascular work has been lost. There was ample opportunity to go about a different training pathway to allow for that accountability but the first generation of IRs did not do it because referrals kept coming in; notably Dotter warned against this and that's exactly what happened.

    There has been a great shift within the field, particularly with regard to patient ownership, particularly in the arena of cancer therapy; I am hard pressed to think of a department (and I'm familiar with quite a few) where cancer therapy is performed by IR (chemo/radioembolization, ablation, bone stuff etc) and the patient is not seen in the IR clinic or admitted to the hospital. The IRs at my institution always go to tumor board. We have a fibroid clinic run by IR/Gyn. There is a push to have a different training pathway for IR, which will likely take another 10 years to get pushed through, but it will happen.

    Additionally only arterial disease and to a lesser extent venous disease and vascular access is the turf in question. Oncology, hepatobiliary (including TIPS), ablations, PCNs, foreign body retrievals, visceral aneurysm therapy, women's therapy (pelvic pain syndrome, UFE) embolotherapy for any reason are all firmly within the purvue of interventional radiology and just because someone is skilled in endovascular intervention does not mean they will attempt these simply because no IR anywhere will teach them having learned from the events of the past. There was a fairly well publicized case done at MGH where a vascular surgeon tried to embolize an RCC prior to surgery and they screwed up and IR refused to come in and help them. Vascular surgery no longer does embolizations of tumors there needless to say.

    Oncology and surgical oncology will not go into the realm of interventional oncology 1)no one will teach them 2)in an era of sub-specialization you just can't know and do everything.

    So actually a good deal of stuff is being done to keep these within our specialty. Also if vascular surgery didn't "steal" these procedures, they wouldn't really have a field anymore, so their backs were up against a wall, just like IRs was a few years ago.

    3)If you think the innovations are in the past you are mistaken, even now there are new techniques being developed for cancer therapy, there is an intra-arterial treatment for BPH, a flouroscopic guided breast implant is being developed just to name a few.

    4) A lot of the guys who are complaining are the ones who practiced before the turf wars, and they lost the work because they refused to own up to the problem with the field, i.e. no patient ownership. Our very own Dr. Vatakencherry (Gvataken) admits about 300 patients a year, sees around 30 in clinic/week and rounds on his own ICU patients. The guys coming into the field now are not complaining about turf wars, but are fighting them and well. Instead waiting for referrals from sub-specialits we get them from primary care, it's just that easy. IR people write articles in FP journals and IM journals, give talks to PCPs and the general public; there are multi-specialty groups where you can work as well.


    With regard to me agreeing with Shark's statement. I mean that you should not do IR if you only like IR because as of now you need to do 4 years of DR residency, and if you truly don't like DR then those 4 years will be unbearable and you are unlikely to do well as there is a great breadth/depth of knowledge to learn in DR and you're tested on it all the time. I myself can only tolerate DR and it is pretty miserable in the reading for me, though I do get enough time on IR to compensate.


    With regard to Shark's comments: I know a fair share of IRs and many of them practice well into their 60s; just like any procedural field you get tired and may want to do something less grueling, at least with IR you have the option of doing diagnostic work when you get burnt out, surgeons don't really have that option. I have an attending in his 50s who is not really showing signs of slowing down: he takes less call, and doesn't do things like TIPS but does a lot of vascular access/PCNs/Hepatobiliary stuff and staffs the UFE clinic. The younger guys do the more grueling procedures, just like you would seen in a surgical practice.

    Also as a coincidence, I am on call tonight (christmas eve) and no IR emergencies came in, but 2 ophtho emergencies are here both of which needed to go to the OR. NeuroIR had 2 cases but those were during the day, and it's a whole different animal.

    Just do what you love. If you're passionate about something you won't let the negative things get you down but fight through it. There are plenty of fields with turf issues urology/urogyn; neurosurg/ortho, hand surgery: plastics/ortho/gen surgery (who still do it); facial plastics (omfs/ent/plastics) so on and so forth; anywhere you have lucrative procedures you're going to have turf wars. The most important advice anyone can give you is do not go into a field for money or lifestyle, both are unpredictable.
  10. shark2000

    shark2000

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    Agree with most of what you say. But you ignored my post. I did not talk about turf wars at all. Turf war is exaggerated. It you want you can have more than enough work to do.
    As I mentioned before do not compare academic practice with pp. They are the whole different type of practices. The reason that your ophtho emergency is busy is because all of the ophtho clinics in your neighborhood (I think you are at UCLA) are closed and the patients shift towards your center.

    Radiology is one the best and yet one of the most flexible fields in medicine, IMO. If you hate seeing patients you can do DR which is one of the most challenging fields by itself. If you want to see patients, do mamo. You will run a busy clinic with less hassle compared to other clinics.
    If you want to procedures, still you can do a lot of spine injections, nerve blocks, biopsies, ... even without IR fellowship. If you want to do lots of procedures you can go for IR. BUT, if you are really passionate about procedures, IR is not the way to go. You have to like DR, otherwise you will be miserable. A lot of IR practices require you to do at least 30-40% of DR.
    So my main point is choosing IR because you are procedural type is not the best way to go. There are a lot of other procedural fields with better balance.
  11. IRGuru

    IRGuru

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    Respect :thumbup:

    IR is awesome
  12. Dumb

    Dumb USMLE Tutor - PM me for info

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    That was a very insightful and thorough post. While all of this makes sense and all, how difficult would it be for vascular or cardio to simply hire an IR guy at a premium to teach them? Also, sometimes IR is not given a choice. At several hospitals, I have been witness to IR guys being forced to teach vascular by the hospital admin itself. I do not know the details of the case you mentioned, but having spent a great deal of time at MGH and within the Harvard PartnersCare umbrella, I am surprised the IR guys were not coerced to help the vascular team by the admin in the name of patient advocacy/safety.


    That is certainly true, but in my limited experience, I have not seen as intense a turf war in any of those fields in that it is not a daily or even weekly issue. I am sure this varies a great deal between institutions, though.
  13. VIRads

    VIRads

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    qft definitely.

    It really just depends. Personally, if you are affable, available, and able, turf will not be an issue.

    Honestly, turf wars are blown up. They do surely exist. But guess what, a lot of what people are talking about that is being "taken away from IR" is stuff that IR took away from other specialties. Radiology in general has been a specialty that took a lot of turn from other specialist, and now other specialist are trying to reclaim a lot of there lost ground. For instance, there wouldn't much left of vascular surgery if they did not enter the endovascular realm.
  14. VIRads

    VIRads

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    Do you have any links for these? Thanks.
  15. Dumb

    Dumb USMLE Tutor - PM me for info

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    This actually makes matters worse, though. That vascular or cardio or whoever is justified in stealing marketshare only makes it more likely they will follow through with a vengeance. It also means that administrators will view them as "freedom fighters" rather than "terrorists."

    Also important is the distinction between innovation and imitation. Yes, the innovative IR techniques were disruptive to other fields, as all true innovations are. There is a difference between disruptive innovation and simple imitation, though. IR may have taken business from vascular through innovation, but did not simply copy the same old technique. The vascular guys are posers :p
  16. davidjones

    davidjones

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    First to address Dumb's questions: cardiologists and vascular surgeons are neither terrorists nor freedom fighters but just people out to make a living. Just like IR. the reason the are viewed favorably is that they bring in patients I.e revenue. The practices with IRs that are heavy on patients are treated quite well especially if you offer novel stuff like oncology and fibroids that results in admissions.

    I just don't see them getting into the oncology, transplant or other stuff we do with exception of dialysis and venous stuff of which there is tons. For better or for worse IR has had to focus on that stuff due to loss of PAD turf and cards and vascular already know vascular but not the other stuff. To do onc you have to go to tumor board etc. and frankly I don't think there is an interventional guy who would sell out enough to teach those guys. I'm sure there are people like that but I doubt it would be as wide spread as the PAD stuff. IR has a lot more bargaining power.


    Shark, I'm in the Midwest, not sure why I had so many ophtho issues but thought it was serendipitous. I agree that DR is a great field. I disagree that if you're procedural you shouldn't go into IR especially if you're interested in breadth of disease exposure.

    While the majority of Private Practive jobs require you to do diagnostic as well, many such jobs are going to be replaced by 100% IR jobs either by smaller practices being eaten up by large ones or hospitals. Also all academic jobs are pretty much 100% IR. the change will happen over 10 to 20 years as people like the ones on this forum enter the field.

    I also disagree that DRs should be doing invasive things other than things like injections . Even biopsies can be dangerous and comLications usually require IR to help. At my institution the DRs that do biopsies and drains do them every single day and that's the majority of what they do. I've seen DRs who do these infrequently particularly in PP, and it's frankly terrifying.

    Here are some private practices for IR

    Riverside in Columbus
    Inland Imaging in Seattle
    CIRA in Peoria
    Carle in champagne
    Kaiser LA
    Just off the top of my head
  17. Dusn

    Dusn

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    The stereotype of "easy work and high pay" is as inaccurate about ophthalmology, and I'm sure about many of the other specialties you mentioned, as it is about radiology and there were plenty of ophthalmologists who were working on Christmas. I'm an ophthalmology resident and I can promise you, it is not easy. I saw 26 patients on-call yesterday, on New Years Eve, a few of them being true emergencies that needed to go to the OR with the attending on-call coming in. Granted, this is at a tertiary care hospital but my uncle, who's an ophtho attending in private practice was also called in to see his private patient on Christmas -- and in a large family of doctors, was the only one who wasn't there for Christmas dinner. In addition, the salary of most starting ophthalmologists right now on the east or west coast, near a city, is about 100K in an extremely saturated market, which is far less than that of a starting radiologist.
    I think ophtho is a very interesting field but so is IR. My brother, who is in IR, makes a salary that dwarfs the salaries of most ophthalmologists and his lifestyle is not any worse. Granted, everything I'm saying is based on anecdotal personal family experiences but don't think that other people have it easier or better based on uninformed stereotypes and then put down your own field based on that.
    My advice to medstudents interested in any of the ROAD specialties is to find out what those fields are actually like by talking to multiple people who are actually in them. Don't listen to stereotypes and don't listen to people from other fields. Your internal medicine preceptor can't identify the parts of the eye, or a complex imaging study, let along give you advice about what it's like to be in these fields.
  18. davidjones

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    excellent advice Dusn; I strongly advocate picking what you love and not listening to what people in other specialties say, because all they see is how they interact with the specialty which is really the tip of the iceberg.
  19. Dumb

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    Yes, but what about the stereotype of "easier work and higher pay" than non-ROAD specialties?
  20. shark2000

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    Private practice is a completely different world. Most outpatient clinics close during the holidays and their patients shift to the academic centers. As a result, the ENT resident may need to see 40 patients on the Christmas Eve, because most of the pp ENT doctors are not working. One or two experiences can not be generalized. It is obvious that the odds of getting called at 1 am is much less for an ophthalmologist attending compared to an interventional radiologist.
  21. blackadder

    blackadder my old office view

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    Steering this back to the original question, what are the chances that robotic systems (similar to da Vinci) or MRI-guided procedural imaging will emerge in the next 10 years--and thus greatly reduce radiation exposure to the physician performing the procedure?

    I know there are ways to augment protection in addition to the vest/skirt/glasses combo by using leaded gloves/hats/face shields and I've heard of a screen system being developed for the physician to work behind--anybody have experience with any of these things?

    Honestly, the current data (though still relatively sparse) on the cancer incidence of IR docs DOES concern me--I've pub-meded the crap out of this subject and along the way I ran into this consensus paper published in Radiology in 2009:
    http://www.ncbi.nlm.nih.gov/pubmed/19188321
    Of note, they cite studies (though admittedly underpowered) that found odds ratios of 3.5 and 6 of interventional docs developing brain malignancies.

    I'm an MSIII and am trying to figure out what I want to do with my life and I'm fascinated by IR (specifically interventional oncology). While I realize there are different types of risk in every field of medicine, the increased possibility of developing cancer is dissuading me from pursuing IR. Are any attendings/fellows/residents who grapple(d) with this issue and are willing to comment on how they've addressed their concerns or the outlook on the future of radiation exposure in the IR suite?

    Thanks in advance.
  22. shark2000

    shark2000

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    MRI-guided procedures are done on Breast. The only indication is when you can not find a lesion on mamo or US and can see it only on MR.
    Despite some movements, MR guided procedures have not been successful at all for many reasons. The spatial resolution of MRI is one of the least in medical imaging. Also Its temporal resolution is very low. You have to use a lot of very specific non-magnetic devices.
    In summary, it will not play a major role in IR in the foreseeable future.
    If you do not feel comfortable working with ionizing radiation, do something else. Do DR or a completely different specialty. It does not mean it is hazardous. The only fact is, in the volume that we are using it these days, nobody has conducted a randomized controlled trial. Also are understanding of cancer itself is very limited.

    The vest, shield, ... has been there for a while. many use it. First they are not 100% protective, but help you decrease the dose significantly. They are really a pain in the neck. The gloves decrease your skills and are not commonly used.
    These were my arguments here. Doing a procedure at 3 a.m. on an unstable GI bleeder. you have to also put on a 5 lb lead, wear glasses, watch the fluoro time and ... . All of these are doable if you are passionate enough. If you are choosing it for wrong reasons, you will be miserable more than once a day.
    Still I don't know how does a medical student know he/she is interested in IR.

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