Interventional Pulmonologist

[Torsades42]

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Does any one have more back ground information in this specific field? I've searched relentlessly and all I'm able to gather is a list of procedures that that do. I can't seemed to find details about lifestyle or the training required (IM -> interventional pulm. fellow or IM -->CCM/Pulm fellow --> interventional). Thanks in advance!

 

[Hernandez]

http://www.aabronchology.org/

Start at that link. It's not a ABMS recognized specialty yet (at least last time I checked) but it is IM->pulm-cc OR pulm -> interventional bronch. So minimum of 6 years but more than likely 7 years total

 

[Rikab]

Interventional Bronch is no doubt a fascinating field.But I have seen them relegated to academic centers.The few people I have met have not sounded enthusiastic.Should we have a discussion on this topic.? Thanks for any comments.

 

[jdh71]

Well. Part of the problem here is that you can't currently bill more for a procedure where you bx, brush, BAL, stent, and laser than a lookie-lou bronch. As such there's not much incentive for many centers to get set up with this kind of thing because there's no real way to pay for the equipment at current procedure reimbursement. If we can find a way to bill for TIME doing the procedures we might be getting somewhere.

 

[Chakrabs]

The hell? Interventional pulmonology is a thing now? Everyone wants to be a surgeon, but doesnt want put in the work needed to do it.

 

[jdh71]

The hell? Interventional pulmonology is a thing now? Everyone wants to be a surgeon, but doesnt want put in the work needed to do it.

lolwut

nothing "surgical" about interventional pulmonary

are you high?

 

[Torsades42]

Any idea if one can go EM --> CCM/Pulm and then interventional pulm.? I'm just not sure of the outlook of that track since it is relatively new.

 

[Hernandez]

The hell? Interventional pulmonology is a thing now? Everyone wants to be a surgeon, but doesnt want put in the work needed to do it.

pulm-cc isn't work? I also don't know any surgeons doing comparable procedure (other than biopsys, which i as a lowly pulmonologist do without fancy interventional training) to what interventional pulm does.

 

[jdh71]

Any idea if one can go EM --> CCM/Pulm and then interventional pulm.?

No. You can't do any pulmonary out of EM. Most CC fellowships will give you enough training in bronchs to lavage, maybe even do perc-trachs, but not anything interventional.

 

[jdh71]

pulm-cc isn't work?

Exactly. I'm regularly paging the surgical residents to give them the pulmonary rec's on their pateints, because, you know, they don't think so good (they also tend to think EVERYONE needs a bronch), and I find them OUT of the hospital. I'm still there. Hmm?

Working.

Ha.

 

[Hernandez]

No. You can't do any pulmonary out of EM. Most CC fellowships will give you enough training in bronchs to lavage, maybe even do perc-trachs, but not anything interventional.

He could do im-em then pulm-cc then interventional. I do know one crazy kid doing 2/3 of this route.

 

[jdh71]

He could do im-em then pulm-cc then interventional. I do know one crazy kid doing 2/3 of this route.

Yeah there is that.

5 + 3 + 1

Ugh.

I'm out 4 years, about to start 5 years post-grad and I'm DONE homie. I know, you know that feel.

Honestly, there isn't anything about interventional pulm that really excites me personally, and I'm glad because an extra year . . . I can't do it. There've been a few docs I've been working with (not at the University) who keep telling me the sleep fellowship will be worth it . . . but I just don't think I can do it.

 

[proman]

I think the field is very promising. As the number of lung transplants goes up the need for IP will increase greatly. That and the advancements in tracheal reconstruction will also lead to more opportunities. Of course, this is a very academic subspeciality. So what if you can't currently bill for everything, billing frequently lags medical advancements. I've worked with several different guys and they've all been very nice and smart.

 

[jdh71]

I think the field is very promising. As the number of lung transplants goes up the need for IP will increase greatly. That and the advancements in tracheal reconstruction will also lead to more opportunities. Of course, this is a very academic subspeciality. So what if you can't currently bill for everything, billing frequently lags medical advancements. I've worked with several different guys and they've all been very nice and smart.

You don't need any interventional bronch abilities for lung tx patients, unless you're lumping transbronchial bx into "interventional" bronchoscopy.

The problem with the reimbursements is that you can't get a hospital or group to invest in the equipment if there is not going to be an increase in money flow coming in. Factor in that, and that really relatively few bronchial interventions are needed or called for, outside of EBUS which is becoming SOC in lung CA staging, the only people who are really going to be doing this stuff are people at "centers of excellence" and there won't be enough cases for more than one or two guys.

So honestly, I don't know what the future of it all is. Most of what can be done from inside the lung with the scope, from an interventional perspective, just doesn't seem to make a difference in patient outcomes when they look at these things "scientifically".

 

[proman]

I was referring more to stenting anastamotic strictures which is not regular pulmonary. I've worked with thoracic surgeons and IP who both do EBUS, so I'm not sure how exclusive that will be for IP.

 

[Hernandez]

I was referring more to stenting anastamotic strictures which is not regular pulmonary. I've worked with thoracic surgeons and IP who both do EBUS, so I'm not sure how exclusive that will be for IP.

EBUS won't be exclusive at to IP, I'll be doing them. I may even do some super-d navigational work. I can even do basic fiduciary, and brachytherapy catheter placement. Things I kinda consider IP are stents (or thoracic), yag laser, non-invasive lung volume reduction (glue and one way valves), thermoplastic, etc. younger trained docs will be doing more and more of this. But the list I posted are things even I'm a busy plm practise you won't see too much of. And IMHO, you do have to do more than 1 a year to provide a good service for those.

 

[jdh71]

EBUS won't be exclusive at to IP, I'll be doing them.

Ugh.

You can have them.

 

[jdh71]

I was referring more to stenting anastamotic strictures which is not regular pulmonary. I've worked with thoracic surgeons and IP who both do EBUS, so I'm not sure how exclusive that will be for IP.

Ah. I have yet to see an anastomatic stricture that anyone thought actually needed a stent, but we don't do as many tx's as a Duke, CCF, or Pitt, and probably run middle of the road. You must see more of this at your shop.

 

[Hernandez]

Ugh.

You can have them.

I'll take them. They're much easier with anesthesia helping sedation, but under CS is doable. I saved a guy a full thoracotomy by not only getting the answer but also getting enough staging info for him as well yesterday. Ebus makes needle aspirations easy, I would not have gone after what I did given its proximity to very large vessels blindly with a wang. Honestly, about the only thing I'm comfortable using a wang needle on is a level 7 node

 

[jdh71]

I'll take them. They're much easier with anesthesia helping sedation, but under CS is doable. I saved a guy a full thoracotomy by not only getting the answer but also getting enough staging info for him as well yesterday. Ebus makes needle aspirations easy, I would not have gone after what I did given its proximity to very large vessels blindly with a wang. Honestly, about the only thing I'm comfortable using a wang needle on is a level 7 node

Oh, I've done them. And I get how they are helpful clinically, I just don't want them. They take to long, even with experienced operators, and I don't enjoy doing them. Might be ok if that the ONLY thing you were doing. But if you've got clinic patients to see, consults to do, or ICU admits, forget it. Kill me now.

 

[Hernandez]

Oh, I've done them. And I get how they are helpful clinically, I just don't want them. They take to long, even with experienced operators, and I don't enjoy doing them. Might be ok if that the ONLY thing you were doing. But if you've got clinic patients to see, consults to do, or ICU admits, forget it. Kill me now.

Wait till you see navigationa then if you haven't yet. Those are painful

 

[jdh71]

Wait till you see navigationa then if you haven't yet. Those are painful

I've not done one yet, but I've seen a couple. I'll pass on that too

 

[Torsades42]

Since you two seem well versed on the topic (which I'm overtly grateful for), what is your opinion on the compensation? Do you feel the extra year of training in such a specific field is worth it?

 

[Hernandez]

Since you two seem well versed on the topic (which I'm overtly grateful for), what is your opinion on the compensation? Do you feel the extra year of training in such a specific field is worth it?

I frankly don't think there is that much difference in compensation. But it all depends on how many procedures you do and how your contract or insurences pay or these procedures

 

[jdh71]

Since you two seem well versed on the topic (which I'm overtly grateful for), what is your opinion on the compensation? Do you feel the extra year of training in such a specific field is worth it?

It's worth it if you like doing it. You'll be in demand and always busy.

I promise you won't starve 😀

 

[Torsades42]

It's worth it if you like doing it. You'll be in demand and always busy.

I promise you won't starve 😀

Good to know ;-). Anyone care to put a number on it? I've heard that Pulm/CCM max out in the low 300K range. What do you guys think the interventional part would add? Frankly I'm surprised more people don't discuss this specific field, it is quite interesting to say the least.

 

[Hernandez]

Good to know ;-). Anyone care to put a number on it? I've heard that Pulm/CCM max out in the low 300K range. What do you guys think the interventional part would add?

Ha, there is realistically no max in any field. I won't give detailed numbers but your max is my 1st year out guaranteed base. But I will also be doing pulm and critical care. Right now CC is making really good money.

I personally think it would take the right hospital system for interventional to add any take home money value.

 

[Veritas86]

Even as a nontrad, I'm totally interested in this. If my interests stay the same (I'm keeping my options open), planning on doing EM/IM, interventional pulm. If I'm doing my math right, I'd be 43 out of fellowship.

Options to work ICU, ED, or hospital/primary care sounds excellent to me.

 

[Hernandez]

Even as a nontrad, I'm totally interested in this. If my interests stay the same (I'm keeping my options open), planning on doing EM/IM, interventional pulm. If I'm doing my math right, I'd be 43 out of fellowship.

Options to work ICU, ED, or hospital/primary care sounds excellent to me.

13 years including medical school? Insane........

Unless your IQ is in the 180 or higher range, I can't imagine one would be able to continuously do all those things well.....

If I'm out of the ICU for more than 2 weeks I feel rusty and it takes a day or 2 to get back into my groove.

 

[Veritas86]

It's mostly taking my age into consideration. ED and ICU are where I'm leaning right now, but being able to settle into a hospitalist position later on as I age sounds decent.

But who knows. May just settle on categorical EM or IM. Crossing that bridge when I get there.

 

[Hernandez]

It's mostly taking my age into consideration. ED and ICU are where I'm leaning right now, but being able to settle into a hospitalist position later on as I age sounds decent.

But who knows. May just settle on categorical EM or IM. Crossing that bridge when I get there.

Then IM plus CC. 5 years after med school and you a) make great money in CC and will have the skills to do hospitalist work of you burn out. Pulm isn't all asthma and copd and cancer, And an extra year for interventional or sleep are only worth it if you really really like those fields. Interventional bronch is a skill that you would consistently need to use to stay proficient. And to get those cases youd need a busy out-pt practice or have an unspoken agreement with either a busy oncology practice of a thoracic surgery practice

 

[Veritas86]

Awesome 🙂

Good advice. Still exploring my options at this stage, but definitely considering pulm/crit.

Thoughts on EM/crit though?

 

[jdh71]

Good to know ;-). Anyone care to put a number on it? I've heard that Pulm/CCM max out in the low 300K range. What do you guys think the interventional part would add? Frankly I'm surprised more people don't discuss this specific field, it is quite interesting to say the least.

Max low 300s??

That's probably where you start with almost any PP gig.

You realistically can max around 500-600k, but I bet you WORK for every thin dime of that.

Bronchs may add some to what you can bring in, but you probably won't get paid more because you can bill for each bronch, but rather for the service you'll bring to a group. If being able to do these procedures means you, your group, and your hospital can offer this service without having to refer the patient 2 or 3 hours away to "big name university" then you carry some additional value.

 

[AquaFortis]

Hernandez, I'd be interested in hearing more about the schedule of that PP job you were talking about. How will you be splitting your time with pulm and CC?

 

[Hernandez]

Hernandez, I'd be interested in hearing more about the schedule of that PP job you were talking about. How will you be splitting your time with pulm and CC?

Completely depends on the place. Many places I've talked to are a pure consult service. Some cc consults some pulm consults then head to office every day.

The places I'm talking to with more interest are 1 week cc then 2-3 weeks of in-pt pulm consults and office. then back to CC

 

[jdh71]

The places I'm talking to with more interest are 1 week cc then 2-3 weeks of in-pt pulm consults and office. then back to CC

This seems the most sane.

 

[AquaFortis]

Thanks Hernandez. So, no CCM during your pulm weeks, but on your ICU week, you're on 24/7? If that's true, seems like you would have more of a life, at least during your 3 weeks of pulm.

 

[Hernandez]

Thanks Hernandez. So, no CCM during your pulm weeks, but on your ICU week, you're on 24/7? If that's true, seems like you would have more of a life, at least during your 3 weeks of pulm.

Thats how it is at 2 places im interviewing. But at one place they have multiple ICU services and i still will get CCM consults when I'm not in the ICU. But I wouldnt be primary and fielding all the silly calls.

And few places have you on icu call 24/7 for a week straight.

 

[Torsades42]

How procedure intensive would you guys say Pulm/CCM is when compared to the other IM fellowships?

 

[Hernandez]

How procedure intensive would you guys say Pulm/CCM is when compared to the other IM fellowships?

In 21 months a fellows, I've logged 697 legitimate procedures, and I don't count lines I simply supervise. There is no other IM sub-specialty that does as many and as varied procedures that pulm-cc and cc do.

 

[Torsades42]

I'm assuming thoracoscopy/pleuroscopy are in the realm of CT surgeons? Or is there a turf war developing there as well?

 

[Hernandez]

I'm assuming thoracoscopy/pleuroscopy are in the realm of CT surgeons? Or is there a turf war developing there as well?

Yup. I only know of one pulm doc who was certified to do vats but the creditialling war that followed sides with the surgeon.

 

[jdh71]

I'm assuming thoracoscopy/pleuroscopy are in the realm of CT surgeons? Or is there a turf war developing there as well?

Depends.

None of the guys where I train do any of this, but there are places that are doing simple pleuroscopy as pulm/cc.

I don't know. I'm not convinced I would really want to mess with it myself. Though I could see a role for it that wouldn't necessarily require turf war with the surgeons.

 

[Poetic Silence]

That's a thing? With interventional cardiologists, interventional radiologists and vascular surgeons, isn't an interventional pulmonologist gonna eat up the need for cardiothoracic surgeons. I really wouldn't want to be them now.

 

[Hernandez]

That's a thing? With interventional cardiologists, interventional radiologists and vascular surgeons, isn't an interventional pulmonologist gonna eat up the need for cardiothoracic surgeons. I really wouldn't want to be them now.

This field is not threatening to replace a thoracic surgeons. There are simply too many things that only a surgeon can do at this point

 

[Poetic Silence]

It seems the job market for CT's is already at an all time low. It's intriguing because CT's used to be placed on the pedestal right next to neuro and orthosurgeons.

Amazing how things change with time.

The real question here, though, is this: what is an interventional pulmonologist doing that a dual board certified intensivist/pulmonologist isn't already doing?

 

[Hernandez]

EBUS won't be exclusive at to IP, I'll be doing them. I may even do some super-d navigational work. I can even do basic fiduciary, and brachytherapy catheter placement. Things I kinda consider IP are stents (or thoracic), yag laser, non-invasive lung volume reduction (glue and one way valves), thermoplastic, etc. younger trained docs will be doing more and more of this. But the list I posted are things even I'm a busy plm practise you won't see too much of. And IMHO, you do have to do more than 1 a year to provide a good service for those.

Already answered on page one

 

[ihearttriangles]

In 21 months a fellows, I've logged 697 legitimate procedures, and I don't count lines I simply supervise. There is no other IM sub-specialty that does as many and as varied procedures that pulm-cc and cc do.

Sorry for such a noob question but when you say you've done "697 legitimate procedures" what kind of procedures are you talking about? I assume the majority would be intubations and central/art lines but what other procedures do you guys do? Also, on average, how many intubations do you guys perform each week? Thanks.

 

[Hernandez]

Intubations are institution dependent. My main procedures of pigtail chest tubes/ thoracentesis, bronch, central lines, art lines, temp dialysis catheters, lumbar punctures, and entubations. But things I log that I don't count include nasogastric tubes, thoracentesis when I do pigtails, we have to log anyone we adjust mechanical vents, etc.

 

[ihearttriangles]

Cool. Thanks for the info. Not to push but do you think you could just elaborate a little on the question of intubations? Maybe throw out a range of average intubations from "intubation heavy" to "intubation light" intensivist jobs. Is the issue that some units have anesthesiologists perform all the intubations?