Interventional Neuro

[sonicator]

Hello all. This is my first post in this forum. I'm just wondering about this small sub-specialty because there doesn't seem to be many resources on the internet about it or a lot of talk in this forum. I have a few questions (mostly related):

With the shortage of Neurosurgeons in most parts of the country, do you think this will be a growth area in the next 10 years?

Do you think it will expand to medium-sized community hospitals at some point (not small-town hospitals, but regional centers -- like Lankanau, Lehigh Valley, Reading, etc...) or will it always be the domain of major academic centers?

Do you think the current model of a multi-subspecialty radiology practice will last or do you see single-subspecialty practices gaining popularity (I.E. - all diag. or all IR)?

I hope these questions haven't been asked too regularly, but I'm having trouble finding answers.

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[Carb Addict]

Hello all. This is my first post in this forum. I'm just wondering about this small sub-specialty because there doesn't seem to be many resources on the internet about it or a lot of talk in this forum. I have a few questions (mostly related):

With the shortage of Neurosurgeons in most parts of the country, do you think this will be a growth area in the next 10 years?

Do you think it will expand to medium-sized community hospitals at some point (not small-town hospitals, but regional centers -- like Lankanau, Lehigh Valley, Reading, etc...) or will it always be the domain of major academic centers?

Do you think the current model of a multi-subspecialty radiology practice will last or do you see single-subspecialty practices gaining popularity (I.E. - all diag. or all IR)?

I hope these questions haven't been asked too regularly, but I'm having trouble finding answers.

That's quite a heavy dose of questions! I'll offer my humble opinions, which basically rely on hearsay. First of all, predicting what will happen in the medical market is notoriously difficult, whether it be the future need for neurosurgeons or type of radiology practice. Some in the radiology community are skeptical that interventional neuroradiology (this area has lots of different names) will remain filled with previously trained radiologists. It will probably draw mainly from neurologists and neurosurgeons. That's just something time will tell.

Secondly, it's doubtful it will make many inroads to medium-sized hospitals. The indications for INR stroke thrombolysis are in a small, if not very small subset of stroke patients. This practically necessitates tertiary care, which is not often present at medium-sized hospitals. If such a hospital were in an area underserved or far away from another larger tertiary care center, an INR practice may be successful. Other INR procedures either absolutely require a tertiary center for adequate patient numbers (tumor embolization, AVF/AVM's, aneurysm coiling, intracranial stenting) or can be performed by general IR's or other subspecialized radiologists (carotid stenting, pain procedures, diagnostic angios, vertebroplasty, etc).

Finally, multi-subspecialty radiology practices will continue for the forseeable future. This may change if the structure of IR training programs happens to change (i.e., separate residency altogether) such that IR's can practice more independently. There are already opportunities to join IR-only groups (correct me if I'm wrong on this one), collaborations with vascular surgery, or even become an employee of a cardiology group (*shudder*). These are definitely not the norm, though. Most IR's practice within a radiology group. So, once again, time will tell and it's hard to predict the future of medicine.

 

[f_w]

With the shortage of Neurosurgeons in most parts of the country, do you think this will be a growth area in the next 10 years?

#1 An INR doesn't supplant a neurosurgeon.
#2 There is no shortage of neurosurgeons in the US (just like there is no physician shortage). There is a maldistribution with neurosurgeons clustering in interesting urban and suburban markets where the well insured or workmans-comp C-spine fusion for 45k is still a reality. There is a shortage of neurosurgeons to do the craniotomy on the uninsured GS victim in a high litigation state or the emergent repair of a MMC in a geographically isolated market.
#3 I see two influences the availability of neurosurgeons can have on the INR 'labor market':
A. If you don't have a sizeable neurosurgery group at your hospital, you won't get enough referrals for an INR practice.
B. If all the neurosurgeons are busy doing neurosurgery, they have less incentive to venture into a foreign field like neuroradiology (just like cardiologists who are busy fixing hearts have little interest di#*ing around in peoples tibial vessels).

Do you think it will expand to medium-sized community hospitals at some point (not small-town hospitals, but regional centers -- like Lankanau, Lehigh Valley, Reading, etc...) or will it always be the domain of major academic centers?

I think it will remain the domain of tertiary care level facilities. You need a critical mass of neurosurgeons and neurologists to support a viable INR practice.
Unless a 'killer application' (no pun intended) comes around, I don't see the INR market expand enough to support INRs in smaller practice settings. At this point, I don't consider interventional stroke therapy a killer-app. It kills allright but the fraction of patients who can potentially benefit from it is low. There is some potential for primary or secondary stroke prevention, but that is typically a elective procedure that should be performed at a referral center (anytime someone prefaces their talk with 'Every year over 700 thousand people in the US suffer a stroke', the likelihood is high that he wants you to buy carotid stents) .

Do you think the current model of a multi-subspecialty radiology practice will last or do you see single-subspecialty practices gaining popularity (I.E. - all diag. or all IR)?

I believe that the future will see more single specialty IR practices. There are a number of reasons for this:
- the concept of the exclusive radiology contract is on the way out. With nonradiologic specialties grabbing more and more areas of rads, an exclusive contract is getting less and less meaningful
- combined diagnostic and interventional groups have inherent conflicts of interest. And as in the fight of ##s and $$s the diagnostic side usually wins, there is little to be gained for IR by being part of a combined group.
- there are ways to run a single specialty IR practice with less overhead and in a much more flexible manner than a combined enterprise. Again, this works to make a single specialty IR practice more appealing.

 

[sonicator]

Thanks for both of your comments. I really appreciate the thoughtful and thorough answers.

 

[Carb Addict]

I believe that the future will see more single specialty IR practices. There are a number of reasons for this:
- the concept of the exclusive radiology contract is on the way out. With nonradiologic specialties grabbing more and more areas of rads, an exclusive contract is getting less and less meaningful
- combined diagnostic and interventional groups have inherent conflicts of interest. And as in the fight of ##s and $$s the diagnostic side usually wins, there is little to be gained for IR by being part of a combined group.
- there are ways to run a single specialty IR practice with less overhead and in a much more flexible manner than a combined enterprise. Again, this works to make a single specialty IR practice more appealing.

I'm curious, f_w, do you think this change to single specialty IR practices can occur in the current state of affairs, or will a new model of IR training be a requisite to real and lasting change? Perhaps it will simply be an economic necessity, but I wonder if a new training paradigm would be influential in such practice changes.

 

[f_w]

I'm curious, f_w, do you think this change to single specialty IR practices can occur in the current state of affairs, or will a new model of IR training be a requisite to real and lasting change? Perhaps it will simply be an economic necessity, but I wonder if a new training paradigm would be influential in such practice changes.

The new model of IR practice will take hold, I don't think that this necessitates a new model of training. I do think that the DIRECT pathway is a good idea, but I don't see the classic 1+4+1 model go away quite yet. Just like a urologist won't manage his patients in the ICU or manage their hypertension, a clinically oriented IR needs a focussed set of clincal skills but doesn't have to be the doctor for every ailment the patient experiences. I think a good internship is key, and some continuing clincal practice througout rads residency would be desireable, but again, I don't think that DIRECT or an entirely separate IR residency is the only way to go.