Interventional Radiology and Ortho

Discussion in 'General Residency Issues' started by vm26, Nov 28, 2002.

  1. vm26

    vm26 Member

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    does anyone know if there's a residency that combines radiology with ortho surgury? I was thinking about a scenario where a Doc will confirm a diagnosis such as an ACL tear or meniscal tear and then surgically correct for it themselves. Thanks.
     
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  3. blackcat

    blackcat Senior Member

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    that is what good orthopedic surgeons do.
    many orthopedic surgeons believe that they can read films better than radiologists. many neuro and general surgeons believe the same. in any specialty you will learn to interpret the films that are used most often as well as the radiologist, better even, given that you know the whole history and have the physical exam.
     
  4. ljube_02

    ljube_02 Senior Member

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    can the ortho surgeons get paid for reading their own films?

    also i asked this before and was told that most ortho surgeons work crazy hours until they're 50+ yo. but can a newbie join a practice and just take a 10wk vacation, or the other surgeons will be mad at him?
     
  5. embolicintent

    embolicintent Junior Member

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    As far as orthopods and surgeons reading their own films, some have tried. Problem is that while say most orthos can look at a plain film and almost never miss a fracture, it is not unusual for them to miss the very subtle chondrosarcoma that is on the corner of the film or the lung tumor that happened to be caught on the shoulder film. Most pods know that they do not have the time nor training to interpret MR as well as radiologists. Of course some have tried and after one or two multi-million dollar law suits decided that it was not prudent.

    The really good orthos that I know work closely with MSK radiologists. They know that it is the radiologists job to look at the whole study and should something be missed the radiologist shoulders the blame and lawsuit while the ortho simply washes their hands of the deal. Likewise, I have met many neurosurgeons who were excellent at reading brain/spine MR but again they do not have the time to properly dedicate themselves to reading these studies which is very tedious and time consuming. Instead, they look at exactly the area of the study that they are interested in and ignore the rest. It is the neuroradiologists job to look at the whole study. I will not comment on neurologists.

    As for general surgery most of these guys are quick to wait on the rads interpretation and then retrospectively point out the pathology to their team. It is a whole lot harder when you do not have people pointing everything out.

    I do not know of any programs that combine ortho and rads. I do know many who were orthopods before they went back to do rads and one who was a 2nd year rads resident who switched to ortho. If you are want to be involved with treatment then ortho would be the path to take. Their are some interventional ortho procedures such as vertebroplasty and bone tumor cryoablations which IR is pioneering, but ortho will and should eventually take over most of these procedures.

    Anyhow thats just my opinion.
     
  6. droliver

    Moderator Emeritus

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    I would disagree slightly...... at least in the 6-7 different hospitals I've worked in (in multiple settings) I frequently see orthopedists interpreting their own plain films & often extremity CT/MR studies without radiology input. Neurosurgeons and the Ortho-Spine surgeons here as well seem to do this with head/c-spine CT, cspine plain films, lumbar-thoracic spine films, and myelograms regularly. There is also the world's largest hand practice here (Kleinert,Kutz,& Assoc......the hand transplant guys) whom I dare say would never need any help interpreting their studies. I think myself as a general surgeon probably interacts the most with my colleagues in radiology for the nuances of abdominal CT's and some of the trauma films (although @ this point I pick up most everything by myself of signifigance on CT)
     
  7. embolicintent

    embolicintent Junior Member

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    I certainly have limited experience in the prviate wolrd, but in the four hospitals that I have worked at this has not been the case. While it is true that all of these services look at their own studies, in my experience they do not officially interpret them. Of course in the real world they may; I don't know. Reading bone CT is not difficult. Reading MR on the other hand is a whole different game. You cannot interpret or even properly protocol an MR study if you do not have an intricate working knowledge of MR physics. You have to know what sequences you need T1,T2, proton density, gradient recalled echo, fluid attenuation inversion recovery sequences, and so on , what coils to use, do you need to fat suppress the study, do you need gad etc... One can basically make any tissue or fluid look any way they want just with changing these factors. You must know what type of pathology you are looking for and modify the study to find it. It goes a little farther than CT with or without contrast.

    In the last six months a few of the things that I can recall seeing that were missed initially include:
    Several pneumothoraces including one tension/fractures including C-Spine, hip and pelvis (one hip that was cleared by ortho and the woman collapsed in the hospital parking lot from her subcapital fracture/a few tumors including bone, lung, and an atrial myxoma/ at least two cases of multiple pulmonary emboli detected incidentally on Chest CT done for other reasons/two cases of necrotizing fasciitis one involving the mediastinum/ and one case of a misplaced central line that was put into the subclavian artery in a relatively healthy young woman who died when the line was removed. The radiologist interpreted that film for the plaintiffs.

    As you say, I doubt that those guys in Louisville need Rads help very often, but I would also bet that being the excellent clinicians that they are, they likely have most if not all of their studies read by Rads because that is what we are for.

    As a radiologist, I like most others, get a little irritated when my work is not appreciated. A good radiologist is worth their weight in gold to clinicians and a bad one is essentially useless. I take a lot of pride in what I do and my absolute favorite part of the job is when I add something to the clinical picture. None the less, we are the Rodney Dangerfields of medicine; we don't get no respect.

    I am sure that you do pick up most things, but as a wise clinician which I think that you are from reading your posts in the past, I am sure that you realize that a good radiologist is an expert at what he/she does. We look at studies all day every day and we see things and know to look for things that non-radiologists generally do not. We are a valuable part of a team and unfortunately all too often in medicine clinicians forget that we are all on the same team. I often find myself just as guilty as others in making [email protected] comments about some other specialty when they do something stupid; particularly on call. I am desparately trying to quit doing that. Anyhow, I guess we can agree to disagree on this point. Cheers!
     
  8. vm26

    vm26 Member

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    embolicintent
    as a radiologist do you basically work a 9-5 schedule? Can you supplement your income by working extra hours? Is it possible to specialize in musculoskeletal radiology without dealing with worker's comp/no fault cases? Thanks
     
  9. embolicintent

    embolicintent Junior Member

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    First off Bone Cutter, I wasn't intending to insult ortho or any other specialty, we all are defensive of our professions. Many of my good friends are pods and if I had done anything else in medicine it would likely have been ortho so don't get your proverbial panties in a wad.

    As for saying that MR physics is not that difficult, only someone with no working knowledge of this would make that statement. Go over to your scanner and do a study without any help what so ever from the MR tech. Then tell me how easy it was.

    I never said that only radiologists have the ability and motivation to learn this. It has been my experience that the motivation part is mostly the case, but of course any intelligent human being can take the time to learn MR physics. The only specialties outside of radiology that I have personally seen take the time to understand MR is neurosurg to some degree and as of late cardiology. I wish more physicians would take the time to understand at least the basics because about 20% of the people that order MR studies do not even understand the capabilities of what it can and cannot do.

    As for the blame/lawyer subject, we obviously have seen this from different viewpoints. All of those cannot excludes and too small to characterize statements etc... were created because of lawyers. Radiology is one of the most commonly sued professions because anytime anything goes awry, any radiologist whose name is on that patients chart gets named in the suit. Most cases that I have heard of against a radiologist involved a clinician saying "The radiologist didn't tell me about that finding".

    As for the radiologist testifying, you can be sure that if you interpret your own films and get sued for missing something then a radiologist will eviscerate you on the stand. Although part of me feels that this is justified, my morals would not allow me to do it. I have never and will never testify against a physician of any sort unless of course there was malicious intent. However, there are many that are experts at doing just that. As to that particular case, I was asked to look at the film by a colleague that did testify without knowing the circumstances or history whatsoever and my statement to him within 5 seconds of seeing the film was "That line is in an unusual location". It was clear and it was missed because of a physician's negligence.

    VM26, radilogy as a resident is usually in the area of 7:30-8 to 5 when not on call. As a private practice radiologist though it is usually more on the lines of 6:30-7 until the work is done which is in the 5-6 range usually. This of course is when you are not on call. It also excludes Interventionalists who work much longer hours. As for income I am sure you could supplement if desired. However, I do not know why you would need to at the current time when most Rads are pulling in the 400-800k range. Residents commonly moonlight for 2000-2500 a day. In radiology you read the films and rarely even know the clinical history other than a brief statement about the medical necessity of the study. So you rarely would know if you are reading a workmans comp case or just another low back pain study.
     
  10. droliver

    Moderator Emeritus

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    embolicintent,

    I truly value my interaction with my radiology colleagues, its added a lot to my education. A talented interventional radiologist is essential for percutaneous drainage of intraabdominal collections that you get a lot with complex general surgery and oncology patients. We do get a little irritated with some of the reads that are clearly liability driven & sometimes little asides @ the end of the dictation ("recommend that.....") have been the basis of spurious lawsuits. I would never submit that I personally will approach the skill & throughness that a radiologist has with imaging studies, but I can & do routinely read many of my films and do some clinical intervention before they even get around to seeing the xrays. For more subtle findings & studies I know I don't interpret well (mediastinal CT's, MRI, some ultrasounds), I'm the first in line for assistance.

    With my last post I mean to point out that there are really a lot of studies done that do not get interpreted by radiologist & there are a lot of inhospital studies that will get read by radiologist (as you point out) but these will be self-interpreted by some of the specialists who will never read a radiologists input (especially bony studies & arteriograms) because they are at least as good as radiologists in interpreting certain films. Even with MR studies, I know orthopedists who become fluent in them, especially of the ones they see repetatively (knees/shoulders/ankles) that they do not need to really understand the physics to properly interpret them & plan their tx.
     
  11. womansurg

    womansurg it's a hard life...

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    No doubt.

    In my program, the expectation is that the surgeon personally looks at every film, preferably with the radiologist (exceptions being routine pre-op CXR, etc.) It's very helpful for the rads to have real time interaction about the patient's clinical background ("our anastamosis was right in this area....and the bowel looked thickened throughout...")

    Most of our radiologists consistently seek feedback on the accuracy of their calls ("did you find dead bowel on that guy?") and even come down the operating room to peek over our shoulders and see if they were on track in their readings (way!). They welcome information about missed diagnoses without getting defensive or feeling threatened, but rather look at it as the natural learning curve as one accumulates experience.

    In my opinion, we have a fantastic working relationship. Frequently the radiologist picks up on findings which we overlook (which is what we expect), but there are certainly many occasions where we find something which they have missed. They also rely heavily on each other's expertise. A difficult film might have six different docs peering at it, offering the benefit of their years of experience. Sometimes we disagree with the official interpretation, in which case we always act on our own (surgeon's) interpretation. I don't think this is typical in most institutions, but our good working relationship with the rads, and our own personal strong experience in film interpretation probably lets us be more confident.

    Personal experience in film interpretation is very important for non-rads: sometime, somewhere, you are going to have to make clinical decisions in the middle of the night on a patient, either without the input of a radiologist, or with input from a radiologist whom you don't feel you can rely on.

    cheers!
     
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  12. embolicintent

    embolicintent Junior Member

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    Dr. Oliver I think that we are mostly in agreement. I do hope that interventionalists do a little more than drain puss pockets :)

    As for those ambiguous statemtents on dictations, we hate having to say them as much as you hate having to read them, but unfortunately that is where the system has taken us. I would love to be able to tell you exactly what I think on every study, but I would be wrong on occasions because I would not have seen the patient and would not know the entire history. It is an unfortunate failure of the system particularly for the patients.

    I would agree 100% that you should not wait on a radiologist to interpret a study that you are comfortable with particularly in acute situations. That would be foolish. However, it is also foolish not to read the dictations on studies later when you have time. If I see significant findings I always call the clinician immediately often telling them something that they already know. However, several times a week I also tell them about significant findings that they did not know about.

    As far as needing to understand MR physics in order to properly interpret the images, we simply disagree on that point and that is OK. I can easily remove an appendix but does that mean that I should. Ive done it before and I know the anatomy as well as any surgeon. In fact I could remove a gallbladder without much difficulty as well. Ive done several Nissen's. Simple fact is that I could not do it as well as you can because you have done it hundreds/thousands of times.

    Womansurg it sounds like you guys have a program where things function as they should which is in the best interest of the patient. I am one of those types that seeks as much feedback as I can get though I do not get to the OR that often except for AAA stents and such. Maybe I will try to do that if the opportunity presents itself. I do not get defensive with others when I miss something (which happens far more than it should), but I can promise you I get pissed off with myself as it is unacceptable to me. Sounds like you have a great program and I cannot find fault with anything that you said.

    Yam seng to both of you guys!
     
  13. blackcat

    blackcat Senior Member

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    i feel a little responsible for a lot of this thread since my original comment set off the comments.

    i think radiologists are indispensable to the medical field. i think that radiologists should interpret all formal studies that are performed. that is what they are there for. they have the training and the patience for looking at the whole picture.

    however, many physicians (especially the very specialized surgical subspecialist) can interpret their films as well (even without knowing how the equipment works) as the radiologist. they will miss the surrounding information since they are tunneled visioned to their area of interest. neurosurgeons can look at spine mri and head mri but will miss all the soft tissue stuff surrounding. these subspecialist should only want to read their own studies if they are willing to shoulder the responsibility for the whole film - not likely and that is the role of the radiologist.

    i think radiologists get a lot of respect. they are the physician's consultant. they mostly interact with educated people all day long (the solely diagnostic ones that is). we all need a radiologist.

    to to comment about specialist missing simple things like pneumothoraces - i've seen a lot of radiologist miss similarly simple things. mostly fractures but also aortic dissections despite being directly questioned about it...my patient.

    i respect radiologists because i used to be a radiology resident, now working in emergency medicine.

    to answer the original question of the post - i don't think there are any positions to combine interventional radiology and ortho.

    blackcat!
     
  14. Tenesma

    Tenesma Senior Member

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    this must be another thread about who is better....

    it is obvious that almost every specialty has some overlap on another specialty... Those doing interventional procedures (surgeons) would be crazy not to read their films first - and i would argue that because of their intimate 3-dimensional feel for the structures often have a better gut feeling about the films pertaining to their field... However, in this day of litigious medicine it would be reckless not to have all films be read by rads...

    the dangerous moment is when somebody thinks they are too comfortable and doesn't heed somebody elses input... I read every x-ray i order - and whenever i have the slightest doubt I will always find rads (of course, sometimes it is irritating to have a spanking new PGY2 rads resident be the only person i can find :)...
     

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