Anyone feel like ESIR has made their radiology class feel gunnery?

[Gurby]

All your hospital admin need to replace your group (assuming you are a typical group with nighthawk tele in place already), is to add day service.

Ignorant med student here with a question:
If it's this simple, why isn't everyone doing it?
Doesn't the in-house radiology group usually over-read the nighthawks and field questions from clinicians?

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[Tiger100]

Do you know how much radiation you would get by doing declots all day long? It’s one of the most radiating procedures in all of medicine to the person doing the procedure. And they would be doing them all day long. Knock yourself out!

I was not talking about radiation. If they start to do it, it will be near impossible to compete with them, irrelevant of the amount of radiation.

 

[Tiger100]

Ignorant med student here with a question:
If it's this simple, why isn't everyone doing it?
Doesn't the in-house radiology group usually over-read the nighthawks and field questions from clinicians?

Good question and simple answer:

Especially in mid and long run, radiologists do a lot more than just reading images. Most hospitals that gave their service to telerad completely, tried to bring "on-site radiologists" after 1-2 years.

 

[NDcienporciento100]

1- So you don't have any reference. Giving the fact that 90% of IR programs even don't train their fellows to do PAD, your numbers are probably not correct. The one who is talking *** is probably you.

According to this article, the breakdown of PAD work between 2006 and 2011 was as below:

Cardiology 39.4 %
Vascular surgery 38.5%
Radiology 15.8 %
Other 6.2%

Unfortunately, The marketshare of radiology was dropping between 2006 and 2011 and was 12.9% in 2011. The new numbers may be slightly higher but probably not that much.

View attachment 271117

http://www.onlinejacc.org/content/accj/65/9/920.full.pdf

 

[NDcienporciento100]

I’m not post a article from a cards journal the reference in the picture is straight from the source. Read his article and states that only at a 5% of Medicare. This article takes into the whole picture.

 

[NDcienporciento100]

I’m not post a article from a cards journal the reference in the picture is straight from the source. Read his article and states that only at a 5% of Medicare. This article takes into the whole picture.

 

[NDcienporciento100]

Go minute 13:30 in this lecture. Once again proofing tiger does not know what he’s talking about!

 

[deleted950463]

You are repeating my own posts to me. Please read them first before making any comment.

I said a doctor who lives in rural areas is NOT A COMMODITY. You can check my previous post. Now you tell me that someone in Nebraska is not a commodity which is what exactly I said.

Also you mentioned ED that is a commodity. You example was not a good one.


Also trauma surgeon in Nebraska is not a good example since there is not a whole lot of trauma happening there and a lot of times it is managed by general surgeons.



As I mentioned except for clinicians that deal with chronic diseases in rural areas and except for very famous ones, most other physicians are commodities.

You are ignoring the difference between the degree of mobility for radiology reads vs other clinicians, either out of ignorance or malice.

So let me rephrase it, again. To fire a surgeon and find another you, you need to interview for one and credential for one.

Most private radiology group and community hospitals use some sort of telerad already, who are already credentialed. All you need to do to ramp up production is to convince the telerads to do more shifts.

Difference number 2: to recruit a doc onsite in a pinch you need to pay big time, while radiologists who read remotely take a PAYCUT for location. It can be cheaper for the hospital to replace rads with tele.

For the med student, right now that’s not happening as much because the DR job market is good so not many people do telerad. But the scenario I’ve stated did happen, not well though. Google Wayne state.

I agree with what tiger100 said about radiologists are more than those who read imaging. However, reading imaging is the only major revenue generator.

Like he said, an onsite rad is needed there to manage the tech and participate in hospital committees. Here’s the catch though. IR too can do this (we are fully diagnostically trained).

It’s hypocritical to demand your IR colleagues to take a pay cut for having a clinic because it doesnt generate as much revenue (debatable as each IR consult generate a lot of advanced imaging down the line), yet states that DR’s value to hospitals lies on the non-revenue generating aspect of their woek.

 

[irwarrior]

ESRD and dialysis work is a cornerstone in many successful VIR practices. When done right, It should not entail much in the sense of radiation. A well formulated program should have strong surveillance and coordination with the dialysis nurses so catching these before they thrombus. Since dialysis can currently only be provided by nephrologists, they certainly have the upper hand. In order to garner a role in this disease process, it is critical that the VIR physician follows these patients in the office longitudinally ie every 3 to 6 months and establish a long term relationship with the patient. Follow their flow rates, ktV, recirculation etc and duplex their shunts in the office. These patients will often have concomitant PAD and that should also be evaluated during the office visit. You can truly benefit this patient population. Many physicians (cardiology, nephrology, vascular surgery, VIR physicians) can offer these interventional services and would be more than happy to take on this patient population. I certainly enjoy my dialysis patients and they are extremely grateful when you educate them about their fistulas and show that you care about them as a person not just as a hemodialysis intervention.

Also,there is a growing role of VIR in placing PD catheters and there is a national push to increasing PD utilization. Finally, with a couple of companies now involved in endovascular fistula creation, VIR trainees should definitely get trained in this arena.

In a smaller community hospital, it is critical to establish these various service lines and you have to go out and compete for these referrals and develop loyalty not only with referring physicians but more importantly with the patients. The VIR clinic should be the cornerstone of your practice to establish these relationships with patients and their families. If as a VIR trainee, it is so important that you go to an established clinic. This has been a classic weakness of VIR training and if your faculty are not equipped with a robust clinic or clinical skills , the trainee should go to a clinic that is well established run by vascular surgery or interventional cardiology etc.

There is a great deal of PAD being done in the community by nonacademic VIR physicians. The academic VIR physicians often time are not trained to compete for referrals as they are used to being handed cases by transplant and trauma services and specialists. Or they chase academic niche interests that they can do research on. (bariatric embolization, geniculate embolization etc). The innovation is important to expand the field, but it should not come at the expense of not maintaining or growing pre-existing service lines.

In the community you have to compete against other well trained vascular specialists (cardiology/ vascular surgery). To level the playing field you must come out trained not only in the procedural aspects, but more importantly the medical aspects of these conditions. ie putting them on statins , ace I , antiplatelets. Managing their wounds . Keeping their HBA1c <7 and making sure BP is adequately controlled (AHA guidelines) . Working closely with podiatry to prevent amputation is vital. Unfortunately only a handful of academic centers are providing this degree of clinical education and practice development, though the tide has slowly been changing.

 

[NDcienporciento100]

ESRD and dialysis work is a cornerstone in many successful VIR practices. When done right, It should not entail much in the sense of radiation. A well formulated program should have strong surveillance and coordination with the dialysis nurses so catching these before they thrombus. Since dialysis can currently only be provided by nephrologists, they certainly have the upper hand. In order to garner a role in this disease process, it is critical that the VIR physician follows these patients in the office longitudinally ie every 3 to 6 months and establish a long term relationship with the patient. Follow their flow rates, ktV, recirculation etc and duplex their shunts in the office. These patients will often have concomitant PAD and that should also be evaluated during the office visit. You can truly benefit this patient population. Many physicians (cardiology, nephrology, vascular surgery, VIR physicians) can offer these interventional services and would be more than happy to take on this patient population. I certainly enjoy my dialysis patients and they are extremely grateful when you educate them about their fistulas and show that you care about them as a person not just as a hemodialysis intervention.

Also,there is a growing role of VIR in placing PD catheters and there is a national push to increasing PD utilization. Finally, with a couple of companies now involved in endovascular fistula creation, VIR trainees should definitely get trained in this arena.

In a smaller community hospital, it is critical to establish these various service lines and you have to go out and compete for these referrals and develop loyalty not only with referring physicians but more importantly with the patients. The VIR clinic should be the cornerstone of your practice to establish these relationships with patients and their families. If as a VIR trainee, it is so important that you go to an established clinic. This has been a classic weakness of VIR training and if your faculty are not equipped with a robust clinic or clinical skills , the trainee should go to a clinic that is well established run by vascular surgery or interventional cardiology etc.

There is a great deal of PAD being done in the community by nonacademic VIR physicians. The academic VIR physicians often time are not trained to compete for referrals as they are used to being handed cases by transplant and trauma services and specialists. Or they chase academic niche interests that they can do research on. (bariatric embolization, geniculate embolization etc). The innovation is important to expand the field, but it should not come at the expense of not maintaining or growing pre-existing service lines.

In the community you have to compete against other well trained vascular specialists (cardiology/ vascular surgery). To level the playing field you must come out trained not only in the procedural aspects, but more importantly the medical aspects of these conditions. ie putting them on statins , ace I , antiplatelets. Managing their wounds . Keeping their HBA1c <7 and making sure BP is adequately controlled (AHA guidelines) . Working closely with podiatry to prevent amputation is vital. Unfortunately only a handful of academic centers are providing this degree of clinical education and practice development, though the tide has slowly been changing.

Well said, thank you for the post!

 

[badasshairday]

Cards took a lot of PAD and even venous work in some location due to having the referral base for it. I think it’s ultimately very, very difficult for IR to compete against cards in the PAD space because they can comprehensively manage the whole physiology from statins to coronary stenting. Cards have muscled out vascular surgery in a lot of places for PAD.

On the front of dialysis intervention, a lot of nephrologist started doing it because ultimately most fistula work isn’t very punishing even if complications occur. The most catastrophic scenario I can think of, if you aren’t messing around in the arterial side, are central venous rupture or retained balloon fragments, both are exceedingly rare and have good bailout options available. Again nephrologist have proximity to their own dialysis patients. There are staff IR attendings graduated from certain very well known programs who have essentially no experience with fistula work.

Lots of misunderstandings in this thread. I will address a few as a private practice VIR in a traditional IR/DR practice.

1. Cardio does PaD cases on their patients who more often then not are there patients because of pre existing heart conditions. Not because of "comprehensively manage the whole physiology from statins to coronary stenting". I manage PAd physiology. It is not rocket science. And the only comprehensive ones are vascular surgeons.

2. "Cards have muscled out vascular surgery in a lot of places for PAD." No see above. Way too many cardiologists trashing feet having no clue what they are doing. And they piss off surgeons when they dump complications on them.

3. I have grown my PAD practice by doing it better and faster and providing comprehensive care in hospitalization setting.

4. Most nephrologists are not into procedures. Also the ones that are not as good as IR. I know because I take care of a lot of there patients.

 

[badasshairday]

Btw declots are not super radiating.

Most of my declots are between 3 and 8 minutes fluoro time.

 

[deleted950463]

Lots of misunderstandings in this thread. I will address a few as a private practice VIR in a traditional IR/DR practice.

1. Cardio does PaD cases on their patients who more often then not are there patients because of pre existing heart conditions. Not because of "comprehensively manage the whole physiology from statins to coronary stenting". I manage PAd physiology. It is not rocket science. And the only comprehensive ones are vascular surgeons.

2. "Cards have muscled out vascular surgery in a lot of places for PAD." No see above. Way too many cardiologists trashing feet having no clue what they are doing. And they piss off surgeons when they dump complications on them.

3. I have grown my PAD practice by doing it better and faster and providing comprehensive care in hospitalization setting.

4. Most nephrologists are not into procedures. Also the ones that are not as good as IR. I know because I take care of a lot of there patients.

Again, this is heavily regional/practice dependent. There are big centers where cards took away all the PAD for VS. I am not saying PAD physiology is difficult or PAD skills are difficult to acquire (particularly above the knee), but there are a lot of chefs in the kitchen for PAD and cards can be a one stop shop for heart issues as well as PAD issues, two pathologies that go hand in hand.

I am not saying to not try to develop PAD. There is a lot of headway in reclaiming PAD by working with podiatrists and also in the varicose vein population because you are by definition evaluating their legs.

Agreed that declot should not take a lot of radiation, but then again depends on the population you may not always be decloting grafts. If you try for a couple minutes then give up obviously fluro time will be low. If you are doing total venous reconstruction, including sharp recans in thrombosed fistula then fluro time can get up there.

 

[badasshairday]

My declot success is high. If you need to spend inordinate amount of time declotting there is either of these problems: 1. Your technique is subpar. 2. It wasn't meant to be.

Regarding PAD I do mostly infrainguinal work and below knee work. I get referrals from internists and nephrologists and surgeons. I have on fact taken patients from cardio. And the 1 stop shop isn't a good shop if they are stenting everything under the sun and do not understand that unlike the coronaries you shouldn't stent everything and there is a role for surgery.

 

[deleted950463]

My declot success is high. If you need to spend inordinate amount of time declotting there is either of these problems: 1. Your technique is subpar. 2. It wasn't meant to be.

Regarding PAD I do mostly infrainguinal work and below knee work. I get referrals from internists and nephrologists and surgeons. I have on fact taken patients from cardio. And the 1 stop shop isn't a good shop if they are stenting everything under the sun and do not understand that unlike the coronaries you shouldn't stent everything and there is a role for surgery.

Just saying, between “it wasn’t meant to be” and an hour of fluro time there are patients that you can potentially help. And as you know, access is one of those thing that’s like sand in a sand glass each time they lose it....

Obviously I don’t know you at all, but when an IR says his/her declots are mostly between 3-8 mins of flurotime it seems like you are calling it if 3-8 mins of fluro can’t get you across.

My big pet peeve is IRs who can’t be bothered to try to salvage difficult fistula/grafts. Obviously it’s one of those things that’s very subjective, but if you haven’t done much sharp recan in clotted fistulas there are probably a few that could have their venous outflow reconstructed.

 

[NDcienporciento100]

Agreed that declots are low on radiation if proper technique is used. But they are one of the easiest to get you the operator caught in the beam especially in a tough case. That’s all I’m saying and it has nothing to do with flouro time, and I have seen it first hand.
Really like what all the IRs that have weighed in on this thread have contributed.

 

[badasshairday]

Just saying, between “it wasn’t meant to be” and an hour of fluro time there are patients that you can potentially help. And as you know, access is one of those thing that’s like sand in a sand glass each time they lose it....

Obviously I don’t know you at all, but when an IR says his/her declots are mostly between 3-8 mins of flurotime it seems like you are calling it if 3-8 mins of fluro can’t get you across.

My big pet peeve is IRs who can’t be bothered to try to salvage difficult fistula/grafts. Obviously it’s one of those things that’s very subjective, but if you haven’t done much sharp recan in clotted fistulas there are probably a few that could have their venous outflow reconstructed.

No dude. I do 1 - 3 declots a week. Im an experienced operator. I rarely fail. Surgeons and nephrologists ask me to try again if another interventionalist has tried and failed. Dialysis access is my bread and butter and it is the life for a patient and my job. I take good care of them. I have spent even on rare occasion 90-120 minutes to salvage thigh graft with success on young patient. But even then my fluoro time is not more than 20. That is rare. Pulse fluoro. Use it sparingly. Dont have a lead foot. Shoot to get declots done in 45 minutes with 5 minutes of fluoro time. I lace with tpa , use lots of heparin and use thrombectomy device if needed. HeRo graft declots can be done in 25 minutes from puncture to purse string sutures.

If I take 2 hours on every declot there would be sooo many patients that would not get procedures done they need or the que to get procedures done would go up too high which would be unacceptable to other patients and referring. In a busy hospital based practice you have to be efficient. I do between 10 and 20 procedures a day.

 

[badasshairday]

Just saying, between “it wasn’t meant to be” and an hour of fluro time there are patients that you can potentially help. And as you know, access is one of those thing that’s like sand in a sand glass each time they lose it....

By not "meant to be" i mean it. You haven't seen some of the Frankenstein non standard grafts i have seen created that dont even male sense. Clot before ever used and im asked to declot. That is what i mean. Or those ones that I declot every 1 to 2 weeks for 2 months before surgeon wants to call it. That is what I mean.

 

[deleted950463]

By not "meant to be" i mean it. You haven't seen some of the Frankenstein non standard grafts i have seen created that dont even male sense. Clot before ever used and im asked to declot. That is what i mean. Or those ones that I declot every 1 to 2 weeks for 2 months before surgeon wants to call it. That is what I mean.

Sorry you have to deal with stupid grafts. You can’t fix poor surgical techniques.

 

[Tiger100]

You are ignoring the difference between the degree of mobility for radiology reads vs other clinicians, either out of ignorance or malice.

So let me rephrase it, again. To fire a surgeon and find another you, you need to interview for one and credential for one.

Most private radiology group and community hospitals use some sort of telerad already, who are already credentialed. All you need to do to ramp up production is to convince the telerads to do more shifts.

Difference number 2: to recruit a doc onsite in a pinch you need to pay big time, while radiologists who read remotely take a PAYCUT for location. It can be cheaper for the hospital to replace rads with tele.

For the med student, right now that’s not happening as much because the DR job market is good so not many people do telerad. But the scenario I’ve stated did happen, not well though. Google Wayne state.

I agree with what tiger100 said about radiologists are more than those who read imaging. However, reading imaging is the only major revenue generator.

Like he said, an onsite rad is needed there to manage the tech and participate in hospital committees. Here’s the catch though. IR too can do this (we are fully diagnostically trained).

It’s hypocritical to demand your IR colleagues to take a pay cut for having a clinic because it doesnt generate as much revenue (debatable as each IR consult generate a lot of advanced imaging down the line), yet states that DR’s value to hospitals lies on the non-revenue generating aspect of their woek.

It also didn't happen when the radiology job market was tight. So there is more to it than just demand-supply.

An onsite radiology group composed of different skillsets is needed if you need quality work. If you don't need quality work, then a lot of hospitals can survive even without most surgical subspecialties. I know hospitals which do not have vascular surgeons, neurosurgeons or some other subspecialists in practice (there is just a name on their board).

An IR is trained to do DR but is not well trained to do all aspects of imaging and aslo if you want to run a clinical IR service, won't have the time to be available to provide the service.

Example: The hospital hires a new gyn-onc surgeon who asks the radiology to start pelvis MRI. How many IRs out there have such experience?
Or the hospital wants to buy a new PET scanner and someone has to supervise the techs.

In addition to that, who is going to run the mammo service?

So while an IR is DR trained, he is not FULLY Trained. Let me correct you.

 

[Tiger100]

Agreed that declots are low on radiation if proper technique is used. But they are one of the easiest to get you the operator caught in the beam especially in a tough case. That’s all I’m saying and it has nothing to do with flouro time, and I have seen it first hand.
Really like what all the IRs that have weighed in on this thread have contributed.

I thought you said previously that it was high radiation. Probably you have to improve your knowledge.

 

[Tiger100]

Lots of misunderstandings in this thread. I will address a few as a private practice VIR in a traditional IR/DR practice.

1. Cardio does PaD cases on their patients who more often then not are there patients because of pre existing heart conditions. Not because of "comprehensively manage the whole physiology from statins to coronary stenting". I manage PAd physiology. It is not rocket science. And the only comprehensive ones are vascular surgeons.

2. "Cards have muscled out vascular surgery in a lot of places for PAD." No see above. Way too many cardiologists trashing feet having no clue what they are doing. And they piss off surgeons when they dump complications on them.

3. I have grown my PAD practice by doing it better and faster and providing comprehensive care in hospitalization setting.

4. Most nephrologists are not into procedures. Also the ones that are not as good as IR. I know because I take care of a lot of there patients.

Let's be honest about number 4. None of us were born with a special skillset.

Nephrologists may not be into procedures and you are right. BUT IF in a specific geographic area, a few nephrologists want to do dialysis work, it will be almost impossible to compete with them. In my area, 3 nephrologists do them all the time and pretty much they have taken over 80-90% of the outpatient market. If the patient (usually uninsured) ends up in hospital, then that's a different story.


As I mentioned before, Cards haven't taken over the PAD. But they have cherrypicked it. If it is easy, they do it. I have seen in several several times. They do easy cases and dump hard cases on vascular surgery or probably IR.

 

[NDcienporciento100]

Tiger I thought you where “done” lol what are you still doing here?

 

[Jamiu22]

Tiger I thought you where “done” lol what are you still doing here?

Bruh! just stop it already, the bickering is getting old - we are all colleagues, so let's respect one another (doesn't matter who started it).

Tiger has a lot of experience I actually like his perspective from a DR. Of course the perspectives of IRWarrior and Badasshairday are always golden, I've followed their advises for years and they've both inspired me with their love for the field, tenacity and aggressiveness. The perspective of these 3 experienced providers are often divergent, but mostly valid - just from a different vantage point.

However, like many in my program who started out as IR (after completing 8 IR rotations during residency - busy tier 1 program where you see and do almost everything - except aortic intervention), I switched to Neuroradiology for personal reasons.

On a side note, I enjoy your enthusiasm for the field, it will serve you well as you progress in the field.

 

[NDcienporciento100]

Bruh! just stop it already, the bickering is getting old - we are all colleagues, so let's respect one another (doesn't matter who started it).

Tiger has a lot of experience I actually like his perspective from a DR. Of course the perspectives of IRWarrior and Badasshairday are always golden, I've followed their advises for years and they've both inspired me with their love for the field, tenacity and aggressiveness. The perspective of these 3 experienced providers are often divergent, but mostly valid - just from a different vantage point.

However, like many in my program who started out as IR (after completing 8 IR rotations during residency - busy tier 1 program where you see and do almost everything - except aortic intervention), I switched to Neuroradiology for personal reasons.

On a side note, I enjoy your enthusiasm for the field, it will serve you well as you progress in the field.

Point taken I won’t respond to him anymore.

 

[deleted950463]

It also didn't happen when the radiology job market was tight. So there is more to it than just demand-supply.

An onsite radiology group composed of different skillsets is needed if you need quality work. If you don't need quality work, then a lot of hospitals can survive even without most surgical subspecialties. I know hospitals which do not have vascular surgeons, neurosurgeons or some other subspecialists in practice (there is just a name on their board).

An IR is trained to do DR but is not well trained to do all aspects of imaging and aslo if you want to run a clinical IR service, won't have the time to be available to provide the service.

Example: The hospital hires a new gyn-onc surgeon who asks the radiology to start pelvis MRI. How many IRs out there have such experience?
Or the hospital wants to buy a new PET scanner and someone has to supervise the techs.

In addition to that, who is going to run the mammo service?

So while an IR is DR trained, he is not FULLY Trained. Let me correct you.

Pelvic MRI is not a good example. Some IRs interpret pelvic MRI as a part of UAE work up by providing final read and all IRs do UAEs look at their own pelvic MRs.

PET interpretation belongs to the skill set of a general rad.

In both example you are citing areas of expertise that a general DR, for which Many IRs received the same training as you, should be able to develop.

It’s disingenuous to suggest that IRs aren’t fully trained in pelvic MR or PET/CT unless you believe a pelvic MR should only be read by a fellowship trained body imager or PET should only be read by a NUCS trained person.

 

[Tiger100]

Pelvic MRI is not a good example. Some IRs interpret pelvic MRI as a part of UAE work up by providing final read and all IRs do UAEs look at their own pelvic MRs.

PET interpretation belongs to the skill set of a general rad.

In both example you are citing areas of expertise that a general DR, for which Many IRs received the same training as you, should be able to develop.

It’s disingenuous to suggest that IRs aren’t fully trained in pelvic MR or PET/CT unless you believe a pelvic MR should only be read by a fellowship trained body imager or PET should only be read by a NUCS trained person.

Disagree with you.

1- IRs look at pelvis MRI only to see how much the fibroid enhances and probably the blood vessels. But they don't read compkex ovarian masses, cervical cancer staging, endometrial cancer staging and etc. Also generally speaking they don't protocol studies. Pelvis MRI was oneexample. There are tons of other specialty imaging.

2- 3 years of IR won't train Someone as good as a DR with one fellowship. But let's say it prepares equally. I don't know your stage of training, but most radiologists and most other physicians learn most of their skills AFTER they are done with fellowship IN THE FIRST FEW YEARS of practice. If you do 100% IR for 5 years, you will lose a lot of your DR skillset even if you were fully prepared to do it during residency.

3- I have hire several DRs in the past and I can tell you that there is a HUGE difference between someone with 4-5 years of experience and someone right after training.

4- About PET-CT: A general radiologist can easily interpret them IF he supervises the techs on a constant basis (probably a 100% IR person doesn't have the time) , communicate with oncologists, GOES to TUMOR BOARDS, and closely works with the person who does the biopsies (IR in many places but also a lot of general rads do them).

5- So yes. In theory some random person in Manhattan can read PET-CTs remotely but the report will be like this: " Technically limited study. Area of increased metabolic activity which can be artifact or bowel activity but mets can not be excluded. Correlate Clinically"

Anyway, most US hospitals are located innig or midsize cities and hiring a DR group is not hard. Not every hospital is in remote areas.

IR can add a lot of value to every practice and has a lot of skillsets but let's not exaggerate it's capabilities. While there are very few hospitals in US that have onsite IR and the rest of the Radiology is done remotely, the quality of the work is usually terrible. And in a big or midsize city (The majority of US hoapitals) where you can easily hire a DR there is no need to do such an unusual thing.

Having said that I don't deny that a DR group is easier to replace than an IR group but it is not like that Radiologists across US are losing their sleep over it. I have seen a few times that a bigger entity has taken over the contract of a smaller hospital and in most cases they tried to keep the radiologists in place. Whether they accepted the new offer or not is a different story (In the case og Wayne state the all decided to leave because they could easily find a better paying job somewhere in Michigan )

 

[CherryRedDracul]

Yes, but not in the sense that they were sabotaging one another, but they were working hard to be eligible for a spot.

 

[irwarrior]

Nephrologists do control hemodialysis and so if the group wants to keep it internal it would be challenging to compete with them. One would need to establish a longitudinal continuity practice for HD patients. There is definitely a role for IR in this arena, particularly in the outpatient office based lab as IR can do such breadth of procedures. UAE, vertebroplasty, peripheral arterial disease, varicose veins, fistula interventions, oncology etc.

Though it would be feasible for an IR group to manage a DR group and has happened in smaller markets. If you have a true clinical practice, you will have admissions, rounding responsibilities , clinic, consults and growing patient base. This will make it harder and harder to perform high volume , high quality imaging interpretations. Though you can finish PGy4 with a fairly solid foundation in imaging, you will become farther and farther removed from diagnostics as your last 2 years are clinical and procedural based. This will make you a better global physician, but will be challenging to be as strong a comprehensive diagnostician (neurorads, peds, MSK, Head and Neck, Nucs, mammography, US, fluoroscopy, cardiac, Thoracic etc). It is feasible that you can be decent at vascular imaging and body imaging but again with clinical responsibilities your time to spend on formal imaging will be less.

There will certainly be challenges in the upcoming years as IR training continues to transition and as the younger guard starts to demand clinical non procedural time to provide quality care to their patient base.

 

[NDcienporciento100]

Nephrologists do control hemodialysis and so if the group wants to keep it internal it would be challenging to compete with them. One would need to establish a longitudinal continuity practice for HD patients. There is definitely a role for IR in this arena, particularly in the outpatient office based lab as IR can do such breadth of procedures. UAE, vertebroplasty, peripheral arterial disease, varicose veins, fistula interventions, oncology etc.

Though it would be feasible for an IR group to manage a DR group and has happened in smaller markets. If you have a true clinical practice, you will have admissions, rounding responsibilities , clinic, consults and growing patient base. This will make it harder and harder to perform high volume , high quality imaging interpretations. Though you can finish PGy4 with a fairly solid foundation in imaging, you will become farther and farther removed from diagnostics as your last 2 years are clinical and procedural based. This will make you a better global physician, but will be challenging to be as strong a comprehensive diagnostician (neurorads, peds, MSK, Head and Neck, Nucs, mammography, US, fluoroscopy, cardiac, Thoracic etc). It is feasible that you can be decent at vascular imaging and body imaging but again with clinical responsibilities your time to spend on formal imaging will be less.

There will certainly be challenges in the upcoming years as IR training continues to transition and as the younger guard starts to demand clinical non procedural time to provide quality care to their patient base.

Good point! Which is why when I am done I plan on practiceing 100% IR, even if I have to live in a less desirable area for a while.

 

[recycledpaper]

Lol at this thread.

 

[UChicagoIR]

Interventional nephrology was brought up at our institution but never took hold. The reasons:

1) The care we provided for the nephrologists and their patients was second to none.
- We were doing complex fistula/graft work including very difficult recans. An interventional nephrologist simply does not have the skill set. As IRs we not only manage fistulas but we do very complicated endovascular work elsewhere in the body and this experience makes our fistula/graft skill set exponentially better.
- We also ran multidisciplinary conferences and helped manage patients in our clinic.
- I think from nephrology's perspective the potential increase in revenue wasn't worth the risks involved (losing IR support, having poor patient outcomes - eg, failed fistula/graft converted to central line, etc).

2) Most nephrology groups don't have the volume or resources for a full time interventionalist or a group of multiple interventionalists.
- There are times when an urgent declot or central venous access needs to be performed and an interventional nephrologist would have to turn to IR because we are staffing an angio suite full time and have the capacity to add on a case. One of the biggest advantages we have as IRs is that our turn-around time is outstanding. It's the same reason we get all the port placements and G-tubes from our oncologists. We can do them within 24 hours of a request.

3) I think there is truth to point #4 from earlier in this thread. There is a personality difference in various specialties. Most nephrology fellows are not procedurally inclined, just like most diagnostic radiology residents. They are a different personality from cardiology fellows or vascular surgery residents/fellows. On a tangent, this also is one reason IR had to separate from DR to recruit more procedurally-inclined/surgeon-mentality residents.

Let's be honest about number 4. None of us were born with a special skillset.

Nephrologists may not be into procedures and you are right. BUT IF in a specific geographic area, a few nephrologists want to do dialysis work, it will be almost impossible to compete with them. In my area, 3 nephrologists do them all the time and pretty much they have taken over 80-90% of the outpatient market. If the patient (usually uninsured) ends up in hospital, then that's a different story.

As I mentioned before, Cards haven't taken over the PAD. But they have cherrypicked it. If it is easy, they do it. I have seen in several several times. They do easy cases and dump hard cases on vascular surgery or probably IR.