Interventional Radiology v. Vascular Surgery

[Ischemia1032]

Hi! So I am a pre-med who is greatly considering the former specialty after a lot of research and shadowing. Of course I still have a lot of time to decide. I have heard IR(but not Neuro IR which I am also very interested in) may be overtaken eventually between cardio and vascular surgery. What are your opinions. I love scans a lot, but I also want to see patients, and I think IR is the best way for me to achieve this. In future years, based on articles I have read by the ABR, they plan to make interventional radiology a bit more patient oriented by having the IRs meet with their patients before hand compared to the current max efficiency model I have heard of by basically having patients come to the IR and they start the procedure. Either way, I wanted to get some opinions on the differences and why IR may not last. I would think given radiology's tech advantage over other specialties in that radiology has the most potential in tech, I cannot see it really disappearing any time soon.

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[Psai]

Ir doesnt own patients so you have little power when it comes to turf wars. Cardiologists are venturing out of the heart because we are finding out that stents are good for decreasing symptoms but arent useful for prolonging life. Vascular surgery is a great field and has a bright future imo but they work long hours with a very sick patient population. If you like chronic uncontrolled diabetes with diabetic feet, smokers who wont quit and fat people, vascular is for you. Ir is a more technical field and they are very innovative

 

[Ischemia1032]

Thanks! I think IR is more my thing. Although as I said I am pre-med, so I do not have the exposure of a medical student yet, I am more into the tech and innovation side. I like new toys to play with if you get my thing. Also, being IR, you also have to be certified in DR, and honestly I could see myself when I am 60-65 getting tired of being on my feet all day, and maybe at least switching to half IR half DR. Yes I plan to work well beyond 60, I am not the type to sit at home and nothing. I am more excited then anything to see how IR develops, given it's technological potential. I do wish they got more patient interaction. So I guess it is back to go do some chem work lol.

 

[Gadofosveset]

It's generally good to think ahead, but you probably don't look too closely into this yet. The turfs will change by the time you're applying for residency and the IR/DR residency will have some kind of a track record.

The bigger question you might want to ask yourself right now is if you want to take on med school debt to be in the interventional suite with its rewards and headaches, or if you want to design equipment for a device manufacturer. The patient populations in vascular surgery and vascular IR can be a challenge.

 

[Ischemia1032]

Good point. I just know my passion is in medicine. I mean, I am not super interested in creating equipment, but I am very interested in using it to help me help my patients. As I am sure most MD candidates find, medicine is my calling per say, and I really cannot imagine any other profession whether I be in IR or not in the future. I do agree with you now that I think about, the field can change, how difficult it is to be accepted. To my knowledge, radiology is on the harder side to get accepted to and is not an easy specialty by any means in daily practice despite the stigma of sitting on your butt all day. I am ready to take on the debt, I am more nervous about getting into med school, just a bit nervous for pre-med, starting this year.

 

[cbrons]

just focus on being a freshman in college and typical 18 year old things.

 

[avgn]

I am more nervous about getting into med school, just a bit nervous for pre-med, starting this year.

Yeah so maybe it's a good idea to stop posting threads to ask people what the future of a field is going to be in 8-10 years? I am not sure how many people need to speak with you before you stop spamming the forum with this type of question.

 

[md-2020]

I am ready to take on the debt, I am more nervous about getting into med school, just a bit nervous for pre-med, starting this year.

Yeah good luck getting a decent GPA at that ungodly grade deflated institution.

 

[Dr. Stalker]

@mimelim can we get a vascular surg consult on this post plz?

 

[avgn]

@mimelim can we get a vascular surg consult on this post plz?

Um, no? He has more important things to do? Don't abuse the bat signal, please. Don't become the boy who cried cry wolf

 

[Goro]

Get into med school first, before thinking about a specialty.

Hi! So I am a pre-med who is greatly considering the former specialty after a lot of research and shadowing. Of course I still have a lot of time to decide. I have heard IR(but not Neuro IR which I am also very interested in) may be overtaken eventually between cardio and vascular surgery. What are your opinions. I love scans a lot, but I also want to see patients, and I think IR is the best way for me to achieve this. In future years, based on articles I have read by the ABR, they plan to make interventional radiology a bit more patient oriented by having the IRs meet with their patients before hand compared to the current max efficiency model I have heard of by basically having patients come to the IR and they start the procedure. Either way, I wanted to get some opinions on the differences and why IR may not last. I would think given radiology's tech advantage over other specialties in that radiology has the most potential in tech, I cannot see it really disappearing any time soon.

 

[Cyberdyne 101]

@Dr. Stalker, here's a mimelim post about VS.

Lifestyle in Vascular surgery has a big range like most specialties. It is not unheard of for a full time surgeon working 45-50 hours a week. Most of the private practice guys can get down to that level if, #1 its what they want, #2 they are in a large group, #3 they are established (5+ years into practice). For various reasons they tend not to. (no judgement, just my observation). The biggest reason is obviously money. The more active you are, the more you get compensated. The second big reason though is simply the nature of the pathology. We don't really 'cure' many people. There is a reason I can be away for 3 months at another hospital and come back and know 2/3rds of the patients on the list. Your access patients and your limb salvage patients are going to keep coming back over and over. There is a lot of business to go around if you stay in one place to get established.

Yes, the field has changed in the last 10 years dramatically and it is still rapidly evolving. And yes, our interventions are tending toward the less invasive and shorter in terms of average procedure length. But, overall, endovascular procedures are LESS durable than their open counterparts. Which means patients return sooner. At the same time, our medicine colleagues are keeping the vasculopaths alive longer and longer and so we are operating on older and older and sicker and sicker patients.

None of our surgeons at the main hospital (6) work less than 60 hours a week. At least one works 80-100. He also does ~20-25 access cases plus an additional 6-10 other cases per week and has correspondingly large clinics. Not everyone is as operatively busy, but between research, administrative, educational and clinical duties, they all work pretty damn hard. Our outlying hospitals that have 1 or 2 vascular surgeons are much more 'community' based and are less busy. I don't really have a great feel for how much they work. The biggest problem with the endovascular revolution is that a lot of different people are getting in on the action because reimbursement is good. (or better than non-procedural stuff at least). Interventional radiology, interventional cardiology, interventional nephrology etc. They also (IC and IN) control the referral networks, so you have to play really nice most of the time. But, for the most part, none of them work weekends or take care of their own complications. The reimbursement for managing those complications is usually lower than what they got paid for the index operation (given the amount of work that is required to deal with it).

It is next to impossible to be a "solo practitioner". I don't think its even possible these days. There aren't THAT many emergencies, even at a quaternary referral center like we are. But, when they hit, they hit. Everyone gets ruptured AAA and cold legs. But, we also get the large DVT/PE for catheter directed thrombolysis and aortic dissections that will go at night, no matter when they show up. A given week of night call for me would be 1 night off, 3 completely quiet nights, 2 nights with a single case or a complex management and then 1 night of pedal to the metal, gogogogogogo all night long. Mine last week was 4 aortic dissections, 2 PEs and a cold leg. Between those 7, we went to the OR with 3 patients and at one point were running 2 rooms between the attending, fellow and myself. Not everyone gets that (or would ever want that), but somebody has to do it.

Bunch of quick thoughts, just sorta rambled .

 

[mimelim]

Hi! So I am a pre-med who is greatly considering the former specialty after a lot of research and shadowing. Of course I still have a lot of time to decide. I have heard IR(but not Neuro IR which I am also very interested in) may be overtaken eventually between cardio and vascular surgery. What are your opinions. I love scans a lot, but I also want to see patients, and I think IR is the best way for me to achieve this. In future years, based on articles I have read by the ABR, they plan to make interventional radiology a bit more patient oriented by having the IRs meet with their patients before hand compared to the current max efficiency model I have heard of by basically having patients come to the IR and they start the procedure. Either way, I wanted to get some opinions on the differences and why IR may not last. I would think given radiology's tech advantage over other specialties in that radiology has the most potential in tech, I cannot see it really disappearing any time soon.

Ir doesnt own patients so you have little power when it comes to turf wars. Cardiologists are venturing out of the heart because we are finding out that stents are good for decreasing symptoms but arent useful for prolonging life. Vascular surgery is a great field and has a bright future imo but they work long hours with a very sick patient population. If you like chronic uncontrolled diabetes with diabetic feet, smokers who wont quit and fat people, vascular is for you. Ir is a more technical field and they are very innovative

@mimelim can we get a vascular surg consult on this post plz?

IR and Vascular Surgery are completely and totally different specialties. They overlap in some procedures that they do, but in almost every other regard, they are completely different.

IR is not patient centric in any way shape or form. It is procedure centric. If the patient isn't perfectly setup by other physicians/services, IR will not touch them. IR will perform their procedure (usually extremely well), drop the patient off back in their room/bed and walk away, never to see them again (even if something goes wrong). The people that go into it are generally those that want that. They don't want to see patients. They want to perform procedures and be paid well to do it. Yes, they are trying to start up integrated IR residencies where residents will learn to actually take care of patients, not just how to read films and then how to do procedures. The reality is that this will not likely work. First, the people who go into IR don't want it, they lose their lifestyle. In general the medical students that pick radiology are the ones that didn't want to really see patients in the first place.

This is in contrast to Vascular Surgery which is very patient centric. You have to practice vascular medicine. A lot of initial management of venous, arterial and aneurysmal disease is medical, not endo or surgical. We do not do as good a job as a dedicated Vascular medicine IM doc, but it is a part of our daily practice in clinic and on the wards. Every day interns/second years are asked, "Why didn't you start this person on a statin/ASA?" with the understanding that yes, not everyone should be on them, but the question should always be asked. Then there are the less invasive approaches via endo and the maximally invasive approaches in the surgical realm. Does everyone in practice cover all of these? No. But, if nobody from that team is watching out for them, your outcomes are not going to be nearly as good. Vascular lifestyle is terrible: http://archinte.jamanetwork.com/article.aspx?articleid=1105820 Like anything, there is a lot of practice variation, but on average? Lots of very sick people that globally aren't going to do well. Lots of emergencies. I was on call this weekend, Saturday/Sunday we did 6 cases. The cases that we don't want to do or don't have time to do, we send to IR. Of course, only between 8am-4pm M-F.

To be honest, you should not be deciding between IR and Vascular because they are on opposite ends of the spectrum in terms of specialties. You should figure out whether or not medical school is right for you first, then work on getting in, then figuring out a specialty. Jumping the gun can be harmful.

 

[Dr. Stalker]

Um, no? He has more important things to do? Don't abuse the bat signal, please. Don't become the boy who cried cry wolf

\

I think mimelim can handle deciding whether he wants to respond to a post or not. Since he is an active member on SDN, I was merely tagging him to see if he'd be interested in answering a student's question about his particular specialty. Mimelim can decide whether he feels like answering this question or not after being tagged. I figured by tagging him he'd be able to see the question more quickly to help out OP. No need to get so defensive.

 

[tortelliniboy]

Dude while it's great you have a specialty you're interested in you need to relax and have fun and focus on your tasks at hand such as classes, ecs, hobbies. Take some time to chill and have fun whether that be in the form of watching anime while sporting a fedora or getting krunk and womanizing. If you're already this neurotic as a new high school grad, people are going to find you nigh insufferable by the time application/interviews roll around

 

[avgn]

getting krunk and womanizing

The only things OP wants to womanize are adcoms and big-time PDs

 

[sovereign0]

Outside of having some exceptional experiences, I really doubt that a pre-med yet to start college has any idea what specialty they want to get into. I was there once, idealizing specialties and pretending to understand what their profession might be like. Then I woke up.

IMO, I don't think you can know what specialty you want to go into until you've spent a day behind the scalpel as a med student during clerkships and rotations. Even shadowing as a pre-med offers you an outsider's limited view of the specialty.

There's nothing bad about having specialties that you're interested in, but don't be naive. Get some clinical experience and shadowing, then get into med school.

 

[lilmiffy]

Yeah so maybe it's a good idea to stop posting threads to ask people what the future of a field is going to be in 8-10 years? I am not sure how many people need to speak with you before you stop spamming the forum with this type of question.

Um, no? He has more important things to do? Don't abuse the bat signal, please. Don't become the boy who cried cry wolf

The only things OP wants to womanize are adcoms and big-time PDs

You really don't have anything nice to say do you? OP's just asking a question. You could just be polite and tell him that its kind of early to start thinking about specialties... Plus, these are people on the internet you have never met before. Try not to make judgements about others so readily.

 

[supremus]

Let the boy discover his path. If you have valuable information for him, share it. If you don't have valuable information, then there is really no need to see the countless replies telling the OP he should not consider x specialty before going to med school.

This sub-forum is becoming a really toxic environment, mods need to do some cleaning.


To the OP: Some helpful threads
Vascular & Interventional Radiology
Vascular Surgery v/s Interventional Radiology
Cardiac Procedures by Interventional Radiologists

 

[Gadofosveset]

IR is not patient centric in any way shape or form. It is procedure centric. If the patient isn't perfectly setup by other physicians/services, IR will not touch them. IR will perform their procedure (usually extremely well), drop the patient off back in their room/bed and walk away, never to see them again (even if something goes wrong). The people that go into it are generally those that want that. They don't want to see patients. They want to perform procedures and be paid well to do it. Yes, they are trying to start up integrated IR residencies where residents will learn to actually take care of patients, not just how to read films and then how to do procedures. The reality is that this will not likely work. First, the people who go into IR don't want it, they lose their lifestyle. In general the medical students that pick radiology are the ones that didn't want to really see patients in the first place.

IRs as interventional oncologists are active players in multidisciplinary conferences. At the institution I work at, the surgical oncologists, transplant surgeons, and the interventional oncologists work together closely with surprisingly little need for ego. Each know their role in management and discuss their patients, transitioning their care back and forth at multiD clinics as needed. IR has a clinic. IR manages their complications unless the complications necessitates surgical intervention, and there's nothing wrong with that. If a GI endoscopist perfs a colon, he doesn't fix it himself, nor is it necessary to be able to do so in order to be an endoscopist.

This is where IR is going and this is what the IR/DR residency will deliver. I have no doubt it will work since those going into IR aren't any more patient averse than an endoscopist or an interventional cardiologist.

SIR (the society of interventional radiology) is steering away from vascular stenosis work and aneurysm repair, although there are still quite a few members who are into it. The future will probably be vascular surgeons and interventional cardiologists fighting it out for the right to stent.

 

[Ischemia1032]

Lol totally missed the point. Get through college first, bro

IRs as interventional oncologists are active players in multidisciplinary conferences. At the institution I work at, the surgical oncologists, transplant surgeons, and the interventional oncologists work together closely with surprisingly little need for ego. Each know their role in management and discuss their patients, transitioning their care back and forth at multiD clinics as needed. IR has a clinic. IR manages their complications unless the complications necessitates surgical intervention, and there's nothing wrong with that. If a GI endoscopist perfs a colon, he doesn't fix it himself, nor is it necessary to be able to do so in order to be an endoscopist.

This is where IR is going and this is what the IR/DR residency will deliver. I have no doubt it will work since those going into IR aren't any more patient averse than an endoscopist or an interventional cardiologist.

SIR (the society of interventional radiology) is steering away from vascular stenosis work and aneurysm repair, although there are still quite a few members who are into it. The future will probably be vascular surgeons and interventional cardiologists fighting it out for the right to stent.

Hi! Thank you for some actual information Dr. Gadofosveset. Would you mind if I PMed you, I had a few questions and I would love to ask them, I would be much obliged.

 

[Gadofosveset]

Sure

 

[mimelim]

IRs as interventional oncologists are active players in multidisciplinary conferences. At the institution I work at, the surgical oncologists, transplant surgeons, and the interventional oncologists work together closely with surprisingly little need for ego. Each know their role in management and discuss their patients, transitioning their care back and forth at multiD clinics as needed. IR has a clinic. IR manages their complications unless the complications necessitates surgical intervention, and there's nothing wrong with that. If a GI endoscopist perfs a colon, he doesn't fix it himself, nor is it necessary to be able to do so in order to be an endoscopist.

This is where IR is going and this is what the IR/DR residency will deliver. I have no doubt it will work since those going into IR aren't any more patient averse than an endoscopist or an interventional cardiologist.

SIR (the society of interventional radiology) is steering away from vascular stenosis work and aneurysm repair, although there are still quite a few members who are into it. The future will probably be vascular surgeons and interventional cardiologists fighting it out for the right to stent.

Hi! Thank you for some actual information Dr. Gadofosveset. Would you mind if I PMed you, I had a few questions and I would love to ask them, I would be much obliged.

This may work for some niche jobs or in large academic centers for specific patient populations, ie transplant or oncology. The vast majority of IR docs don't ascribe to this model and the people going into it aren't looking for it. Secondly, who is going to train these IR docs to take care of patients? They actually were trying to setup this up at our hospital and the radiologists were basically going hat in hand to the IC/vascular guys begging to have their residents live on our services for several months. Same thing happened at our neighboring hospital, and at another the state over from us. We actually had a discussion about this at a regional conference last week. GI and IC have 3-6 years of IM training for managing patients.

Nobody is against a radiology integrated residency. I just can't think of a single person that would have gone that way (currently in radiology) if they had to take care of patients outside of films/procedure. The majority said during MS3, "wow, I hate clinical medicine, what is available to me where I don't have to see people in clinic or on wards." Granted my n=10ish.

 

[Gadofosveset]

The IR/DR residents will learn to take care of patients the same way everyone else does: floor months, clinic, consult months and MICU/SICU rotations. The details of how much of each is still being worked out. There's more information here: http://www.sirweb.org/fellows-residents-students/

The instance of going "hat in hand" to learn from another service seems like a fair trade, since at a large center as recently as eight years ago, I saw vascular residents spending extended amounts of time learning endovascular techniques from IR docs.

IO is already a dominant component of most IRs work, along with venous and portal venous work and GU procedures... at least at the six centers I have experience with. Nationwide, vascular arterial work as an IR is becoming the niche.

In my experience incoming trainees who are IR-minded do not have any special aversion to clinical rotations, so I would argue that your MS3 sample is not representative of future IRs.

 

[badasshairday]

This may work for some niche jobs or in large academic centers for specific patient populations, ie transplant or oncology. The vast majority of IR docs don't ascribe to this model and the people going into it aren't looking for it. Secondly, who is going to train these IR docs to take care of patients? They actually were trying to setup this up at our hospital and the radiologists were basically going hat in hand to the IC/vascular guys begging to have their residents live on our services for several months. Same thing happened at our neighboring hospital, and at another the state over from us. We actually had a discussion about this at a regional conference last week. GI and IC have 3-6 years of IM training for managing patients.

Nobody is against a radiology integrated residency. I just can't think of a single person that would have gone that way (currently in radiology) if they had to take care of patients outside of films/procedure. The majority said during MS3, "wow, I hate clinical medicine, what is available to me where I don't have to see people in clinic or on wards." Granted my n=10ish.

I think you example of patient adverse students refers to diagnostic radiology. There are plenty of people picking radiology residency purely for IR these days and ascribe to a patient centered model. The most high profiled IR programs in the country are run like a surgical subspecialty in which every patient prior to procedure is seen as a consult.

 

[meddude5510]

^eh I wouldn't go that far either. There are plenty of people picking DR simply because they love radiology. It is a really interesting specialty. Most of the IR guys I have met loved DR, they just wished to expand their horizons and become more procedurally oriented. With IR residencies and the phasing out of fellowship this will slowly change I think.

Although yes, many IR programs are working in a consultation fashion nowadays, particularly in academic centers with well developed departments.

 

[badasshairday]

^eh I wouldn't go that far either. There are plenty of people picking DR simply because they love radiology. It is a really interesting specialty. Most of the IR guys I have met loved DR, they just wished to expand their horizons and become more procedurally ...

.

I didn't mean to insinuate that most people are going into radiology for IR. I simply meant to say that many people are liking IR in med school and choosing radiology purely because of IR. More pick radiology foe diagnostics I agree. diagnostic imaging is awesome and a lot of people initially saying they want IR switch to staying purely diagnosticd. I enjoy it too. But I also like direct patient care as well despite the lifestyle drawback. Radiology is the best field in medicine.

 

[mimelim]

I think you example of patient adverse students refers to diagnostic radiology. There are plenty of people picking radiology residency purely for IR these days and ascribe to a patient centered model. The most high profiled IR programs in the country are run like a surgical subspecialty in which every patient prior to procedure is seen as a consult.

^eh I wouldn't go that far either. There are plenty of people picking DR simply because they love radiology. It is a really interesting specialty. Most of the IR guys I have met loved DR, they just wished to expand their horizons and become more procedurally oriented. With IR residencies and the phasing out of fellowship this will slowly change I think.

Although yes, many IR programs are working in a consultation fashion nowadays, particularly in academic centers with well developed departments.

I didn't mean to insinuate that most people are going into radiology for IR. I simply meant to say that many people are liking IR in med school and choosing radiology purely because of IR. More pick radiology foe diagnostics I agree. diagnostic imaging is awesome and a lot of people initially saying they want IR switch to staying purely diagnosticd. I enjoy it too. But I also like direct patient care as well despite the lifestyle drawback. Radiology is the best field in medicine.

This disappears rapidly when you leave academics. Good for "high profile IR programs". But, that does not represent what the vast majority do. So, for 90%+ of hospitals, IR simply functions as technicians, which they seem very happy with.

 

[badasshairday]

This disappears rapidly when you leave academics. Good for "high profile IR programs". But, that does not represent what the vast majority do. So, for 90%+ of hospitals, IR simply functions as technicians, which they seem very happy with.

Depends on the place. I don't disagree with you that a many locations, IR acts as a "hired gun" for procedures for many different specialists doing things like g-tubes(gi), chest tubes(pulm/thoracic surg), perc neph (urology), complex PAD (vascular surg) etc. But there are community places as well that continue to provide high end procedures, which tend not to be oncologic procedures like TACE and y90, but rather PAD. Obviously that is a turf war with cardio and vascular surgery but there are places where IR takes primary patient care role to keep a competitive edge.

-Miami cardiac and vascular
-Endovascularsurgery.com
-Kaiser Los Angeles
'Tampa USF (private practice loosely associated with USF and competes and collaborates with surgery/cards).
-Local hospital in my area doing PAD after a clinical minded IR decided to take an aggressive patient center approach grew his arterial practice from nothing to doing carotid stents and evar/tevar.
-st. Jo in orange County ca.

These are a community practices that come to mind rapidly that are at big hospitals with big vascular surgery and cardiology presence. Future of high end IR is very patient centered.