Interventional radiology

[JKP]

Just hoping to start a discussion on interventional radiology for more info. What is it, how do you get into it and how difficult is it? I'm also interested in general surgery, ent, ortho... any thoughts out there on how these fields might intersect with interventional radiology?

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[Docxter]

Check out this website for answers to your questions:

www.sirweb.org

 

[MD3s]

interventional radiology is usually a 1 year fellowship and sometimes 2 year fellowship after finishing diagnostic radiology residency. IVR track diagnostic radiology to this date gear you towards fellowship but do not make you eligible for IVR boards after completion.. you still have to complete an IVR fellowship.

it's relatively competitive but reachable since most grads of rads residency are going into private practice.

the major competitor for IVR prodedures are the vascular surgeons, followed by urologists, neurosurg, nephrologists, gen surg, ob/gyn (in no specific order)

exciting field, surgeon lifestyle, and continuing turf battle.

 

[Docxter]

interventional radiology is usually a 1 year fellowship and

it's relatively competitive but reachable since most grads of rads residency are going into private practice.

Two mistakes in your response:

1. Interventional radiology is not competitive AT ALL. About two-thirds of all interventional radiology fellowship positions went unfilled last year. It is one of the least competitive subspecialties now, in part due to a (true or false) perception of uncertain future of the field.

2. More than 70% of radiology residents still do a fellowship.

 

[Hudson]

Regarding IR lifestyle: From what I can gather there seems to be a wide range lifestyle among IR docs. Some work a lifestyle closer to that of a DR and some closer to that of a surgeon. Why the variablity? It also seems that if IR docs get pushed out of vascular work and into more chemoablative/non-emergent procedures that lifestyle, particularly while on call, would improve. Do these guys work themselves like gen surgeons, or does the specialty require it? What are the procedures/ emergencies that make IR such a more demanding lifestyle than DR? I understand how Neuro Int is a surgery lifestyle, but it seems that IR should fall into place along ENT/ Urology not gen surg. Any thoughts?

 

[Whisker Barrel Cortex]

Regarding IR lifestyle: From what I can gather there seems to be a wide range lifestyle among IR docs. Some work a lifestyle closer to that of a DR and some closer to that of a surgeon. Why the variablity? It also seems that if IR docs get pushed out of vascular work and into more chemoablative/non-emergent procedures that lifestyle, particularly while on call, would improve. Do these guys work themselves like gen surgeons, or does the specialty require it? What are the procedures/ emergencies that make IR such a more demanding lifestyle than DR? I understand how Neuro Int is a surgery lifestyle, but it seems that IR should fall into place along ENT/ Urology not gen surg. Any thoughts?

The volume of requested procedures in IR continues to go up and often times you must stay late to finish the workload, usually not as late as general surgery, but still adds to hours. As for call, although vascular surgeons do much of the angio at many academic centers, the majority of private hospitals have a IR doing angiography. I am sure this will change. Other call procedures include an obstructed, infected kidney or biliary tract in a very sick patient. With the relative lack of floor work, I would agree that the lifestyle is more similar to surgical subspecialties such as ENT or urology than general surgery.

 

[Santiago]

Two mistakes in your response:

1. Interventional radiology is not competitive AT ALL. About two-thirds of all interventional radiology fellowship positions went unfilled last year. It is one of the least competitive subspecialties now, in part due to a (true or false) perception of uncertain future of the field.

2. More than 70% of radiology residents still do a fellowship.

Dear Docxter,

Are you sure 70% of Rad residents do a fellowship?I find the figure a bit on the higher side.
Also I beleive that Interventional Rads is gonna get competetive atleast till the outsourcing bug is there coz its still not replaceable by teleradiology.

 

[Sean2tall]

Dear Docxter,

Are you sure 70% of Rad residents do a fellowship?I find the figure a bit on the higher side.
Also I beleive that Interventional Rads is gonna get competetive atleast till the outsourcing bug is there coz its still not replaceable by teleradiology.

FREIDA Graduation Plans Statistics for DR

I am pretty interested in IR also, but hey I am just starting medical school, so who knows, right? Anyway, MeaCulpa, it seems like the general consensus from reading boards and talking to people is that the future of IR will certainly entail losing some procedures to vascular surgery, cardiology, etc., but that the field will pioneer new techniques, some of which are becoming hot already (like the various cancer techniques etc.).

 

[Docxter]

Dear Docxter,

Are you sure 70% of Rad residents do a fellowship?I find the figure a bit on the higher side.
Also I beleive that Interventional Rads is gonna get competetive atleast till the outsourcing bug is there coz its still not replaceable by teleradiology.

1. The 70% was a very conservative estimate. I actually believe it's more. There were 468 active applicants (not counting those who withdrew or didn't submit a list) out of a class of just under 900, or approximately 52%. This figure does not include those who stayed at their own institution for fellowship and the fellowships that did not go through the match. I would say that these people constitute AT LEAST another 20-25%, if not more. For example, the majority of the residents at my program or many other larger programs, stay on in their own institution for fellowship. These are larger programs that contribute more percentage points to the statistics. Also, many programs did not participate in the match and we have to add those to the numbers as well.

Even in 2002, where the job market was better than now and people were "flocking off" to big paying private practice jobs, about 75% did fellowships (http://www.ama-assn.org/vapp/freida/career/0,1238,420,00.html). Now that the job market has slowed down a little, I would expect that even more people are doing fellowships.

So, the 70% estimate is quite conservative, and I wouldn't be that surprised that the real percentage is above 80%.

2. You are assuming that the popularity of IR will increase since outsourcing will drive diagnostic radiology jobs away. Well, it hasn't materialized yet and this remains to be seen. For now, it's just speculation. The fact of the matter is that currently, the popularity of IR is at an all-time low. IR fellowships can't get their positions filled and hence some are training nonradiologists to be able to perform their workload and these new nonradiologist trainees will make it worse for the future of IR.

 

[Santiago]

Thanks Docxter,I didn't take into account the guys who stayed at their own place for fellowship. .You are right on.
Regards

 

[JKP]

IR seems to be a VERY cool field! I did look at the SIR website and they had a list of all procedures that IRads do. Do practicing IRads further specialize to do only certain types of procedures, eg. gyn, neuro, cardio, or do they do all types. Seems like IR is a very interdisciplinary field but at the same time can be fragmented in the future such that non-IRads will do procedures in their respective fields. Is this likely to happen?

 

[Resident Alien]

Is already happening. Most of the cool stuff (hence $$) are taken by the vascular surgeons.

The only procedures i see VIRs here do are:
-PICC lines (vast majority)
-Perc. nephrostomy
-Perm cath
-Tunnel cath
- biliary studies
-occasional arterial/venous runoffs
-evaluating AV fistulas
-rest rare or i havent seen them in 6 months.

 

[Docxter]

Is already happening. Most of the cool stuff (hence $$) are taken by the vascular surgeons.

The only procedures i see VIRs here do are:
-PICC lines (vast majority)
-Perc. nephrostomy
-Perm cath
-Tunnel cath
- biliary studies
-occasional arterial/venous runoffs
-evaluating AV fistulas
-rest rare or i havent seen them in 6 months.

So your IR department doesn't do any chemoembolization for hepatic or other tumors? No RFA for cancer? No uterine fibroid or varicocele embolization? No trauma work? No GI bleeds? No endovenous laser? No J-tubes? No FB removals? No TIPS? No transjugular liver/kidney biopsies? Wow, that is a real shi**y IR service. I knew many IR departments were having probelms, but the situation you describe is the worst I've heard. Lesson for all: Don't do a fellowship there.

 

[Resident Alien]

It is entirely possible they also do what you describe. I wasnt there 24/7 so some of these procedures you mention may not have been AS bread and butter as PICC lines which definitely is done more.

Again please dont judge it from my experience, as a second yr student, i spent 6 hours a week for some 5 or so months, so please put that into perspective.

P.S. from your list i recall the TIPS and transjugular liver biopsy. Lesson: Dont judge your potential fellowship experience from mine and Doxter's dialogue

 

[RADRULES]

VS and Cardiology has taken most of the vascular stuff at my place. Of course, by vascular stuff I mean angiograms and vascular stents. Almost all stent grafts are done with a VS and IR team in the OR.

Frankly, I doubt it will be much longer before agriograms are replaced by CT and MR angiography. So, then the loss will really only be stenting.

While everyone has been crying about losing "vascular" stuff.... IR has expanded to many new and exciting areas.... vertebroplasty, interventional oncology, embolization therapy, etc.

I, for one, am not worried AT ALL about IR... it has a very bright and exciting future. New stuff keeps popping up which replaces stuff that is being lost.... and I do not think losing peripheral stenting is going to matter much.

Going into IR right now is like buying low in the stock market... expect IR to explode over the next 5 years. Right now most fellowships are wide open.

I decided a different direction for my career mainly because of lifestyle issues. But, to be honest, IR is the cutting edge of radiology and sometimes I really have second thoughts about my decisions.

Plus, most radiologists are clinicians b*tches and they know it.... IR guys are worshiped because they are badass and bail out stupid clinicians all the time. I suppose that doesn't matter to everyone, but being a b*tch to surgeons all day can get old.

 

[Hudson]

Radrules, You said you chose against IR because of lifestyle issues. Would you mind giving some more specifics. Is it that the DR lifestlye is so good or that the IR lifestyle is so bad. I brought this question up earlier, and another poster said they thought the lifestyle was equivalent to that of a surgical subspecialist, ENT/URO. Would you agree? It may just be me, but there does not seem to be a clear consensus on this issue. I'm curious to hear the pro's and con's from someone who has gone through the decision making process of DR vs. IR. I am a MSIII about to be MSIV and like both IR and DR (from my limited exposure), and I'm tring to figure out what makes the IR lifestyle so unattractive. It seems to me that the lifestyle is comparable if not better than other procedurally oriented/surgical fields, i.e. cards/GI/URO/ENT. Any thoughts? Also you refer to being a treated like a surgeon's B***ch. Do you think that this type of interaction with surgeon's/ER doc's etc. is specific to residency, or does this persist into the PP/attending world. I have personally never witnessed residents or attendings being treated poorly by fellow physicians. Once again, maybe I just have limited exposure.

 

[RADRULES]

Well, I do think the poor treatment of DRs by other physicians is a residency thing.... as well I think it is very institutionally dependent, especially in the academic world. During my moonlighting experience out in the "real world" away from the Ivory tower I noticed that it is much different. Radiologists were respected much more by surgeons and other referring docs. They often would come seek out my opinion on cases and I (even though I was not board certified at the time) would have good interactions with them. There is a general respect out in the real world that you do not find in the academic world because most business is referral based. As a DR out in the real world, you understand that your 500k a year is based on providing good service to physicians whom you develop relationships with over many years. They trust your reads and act on them and you go out of your way to help them out, making the extra phone call, fitting in a late CT or biopsy, etc. Of course, there are malignant personalities in the private world as well (ie. neurosurgeons), but for some reason my experiences have been that is it far worse in academic environments. I can't say why exactly.

As for the IR lifestyle... once again it depends on where you practice. I can say that at my residency institution it was a busy service, but not really comparable to surgical services. Our call was about once every 3-4 weekend and one week per month. When you are on call it is busy and you have to work those weekends pretty much. Again, out in the real world it is a totally different animal.... as a private practice IR guy you work very hard, probably about like a surgeon, because your business is referral based. That perm-cath can't "wait until the morning" because there is someone who will put it in if you are unwilling to come in. So, when you are on-call you work and are at the beck and call of your referring physicians. Of course, you also make mad back and get 10 wks off a year.

Like eveything in life, it is a trade-off. I, for one, can't stand the ivory tower attitude of academia and how radiologists are often treated. Even though I like to teach and like residents, I am bolting for the private world where we are treated like collegues. Later.

 

[samsoccer7]

How can a private practice IR guy get 10 weeks off per year? And do you know any neuroIR guys that get anywhere near that? I suppose if you're in a group of 3 or 4 you might be able to, but I still can't seem to figure out the logistics.

 

[Santiago]

How different is Neuro IR from VIR?
What about the scope of Neuro IR?

 

[Goober]

How can a private practice IR guy get 10 weeks off per year? And do you know any neuroIR guys that get anywhere near that? I suppose if you're in a group of 3 or 4 you might be able to, but I still can't seem to figure out the logistics.

Hmm what so hard to understand? If you have 2 guys that do IR, take call a week at a time. When one guy is gone the other can't be on vacation. Usually even if there are 2 main IR guys there maybe one or more guys extra that are in the call pool such as Neuro IR or even some general rads. If you are at a 200-300 bed community hospital the call is generally not that bad (0-2 times coming into hospital after hours avg and 3-4 times for a busy night)

In California I heard of a sitaution of 4-5 rads groups putting all the IR guys in one big call pool that covers all the hospitals so they are only on call like 1/8 weeks. They probably had some type of backup plan if 2 emergencies came up at once, but I really didn't look into it since I don't do IR.

 

[Docxter]

Call in NeuroIR is very frequent since you are probably going to be either the only NeuroIR or one of two in the larger groups. So you're either on call all the time or every other week. In most groups, the non-interventional neuroradiologists or body IR guys have to chip in for some call and less complicated things like IA thrombolysis.

 

[Santiago]

Thanks Docxter.
One more query please.
How much of an overlap is there between the three ...that is Neuro IR,VIR and IR.Are there three diffrent fellowships?Also how much Intervention is there is plain Neuroradiology fellowship?

 

[Docxter]

Thanks Docxter.
One more query please.
How much of an overlap is there between the three ...that is Neuro IR,VIR and IR.Are there three diffrent fellowships?Also how much Intervention is there is plain Neuroradiology fellowship?

Well, in most places you have to have done some neuro in order to do a NeuroIR fellowship. The amount of NeuroIR in neuro fellowships varies by institution. Most of the neuroIR faculties in the country have only done a neuro fellowship but since in the older days, there was a large angiography component to neuroradiology, they became very facile with neuroIR as well. Today, however, with addvances in CTA, MRA and TCD, the amount of neuroangio work is less, but if the institution doesn't have separate neuroIR fellows, the neuroradiology fellows will be assisting the attending for cases.

 

[hans19]

I would have posted this at Auntminnie.com, but all the residents are appropriately defecating bricks post-oral boards or preoccupied with a micturating contest over politics.

Some casual observations from a PGY-1 doing a rotation in PP radiology:

1) IR is alive and kicking:
IR guys in PP in this city in the SE do 50% procedures and 50% reading films.
Of the procedures they still are getting a lot of referrals from vascular surgeons to do angiography and peripheral interventions.
2 of the IR guys were NIR trained.

Side note: It has been said that chemoembolizations are the future of IR.
However, I have not seen any oncologists ask for this. A cursory pubmed search yielded basically nothing. I don't think chemoembo has shown any mortality advantage in unresectably primary liver CA or solitary liver mets, SO FAR. So exactly how relavent/practical will chemoembo training be in IR fellowship. Is it a dead end?

2) NIR interventions such as GDC, embolizations, thrombolysis, aren't really done in PP in this town. There are a good number of vertebroplasties being performed, and they are starting to do kyphoplasties as well. However, if you want training in these, in the future you will likely have to do an MSK fellowship.

Bottom line: (Samsoccer7 are you listening?) NIR interventions are few and far between outside of academia, unless you have the population base to support it. NIR training seems versatile though. If you can get a microcatheter into tiny cerebral vessels, in theory angio in the rest of the body should be cake. However the 2 years it takes you to get NIR trained (1 neurorads then 1 year of NIR) will mean that you will forget a lot of non- Neuro stuff. I think its safe to say that FEW IR guys will do 100% IR in private practice.

Keep in mind, these are the observations of a PGY-1 during a 1 month private practice radiology rotation in a city in the Southeast. I have no idea how things are for IR in the rest of the country.

If any veterans out there (RadRules!) wish to comment or clarify things, please feel free.

Hans.

 

[doepug]

Side note: It has been said that chemoembolizations are the future of IR.
However, I have not seen any oncologists ask for this. A cursory pubmed search yielded basically nothing. I don't think chemoembo has shown any mortality advantage in unresectably primary liver CA or solitary liver mets, SO FAR. So exactly how relavent/practical will chemoembo training be in IR fellowship. Is it a dead end?

Survival advantages for chemoembolization of HCC have been demonstrated by two good randomized trials (Llovet et al., Lancet 359:1734; Lo et al., Hepatology 35:1164). There are several dozen less rigorous studies that make the same assertion as these papers. As long as there's a shortage of livers for transplantation, chemoembolization will keep many patients alive long enough to have surgery. That being said, TACE makes up a small fraction of what IRs do. In that sense, it's misleading to call TACE "the future" of IR practice. It's not a dead end, but it won't be the crux of IR.

 

[samsoccer7]

hans19: I actually spent 3 days during my spring break shadowing a Private Practice NeuroIR guy. He did a decent amount of angio, but that was usually to set up his procedures. He would of course do angio before every "procedure" like coiling, angioplasty, stenting, etc. He's really the only guy on the west side of the state, and he was literally getting busier every day I was there. It was sick how many referrals he would get. He also spent time in between procedures reading neuro films and consulting with docs. The setup was awesome. If he had 1 or 2 partners (they're looking right now I believe) they would split call, but it would be pretty quiet except for aneurysm/SAH or stroke. He says he wishes he went to a bigger center, but that's only because he has TOO MUCH work to do, not that he's bored or losing money. I agree this situation is rare, but it obviously can be done, and with the trend toward less invasive procedures (a successfully coiled aneurysm goes home the next day!!!), I think these procedures will become more mainstream, and people will be demanding this rather than drilling into their head.

 

[hans19]

Doepug: I stand corrected. Thanks for bringing those articles to my attention-- I'll check them out.

Sam:

hans19: I actually spent 3 days during my spring break
shadowing a Private Practice NeuroIR guy.

I like your style man. I skipped lectures 2nd year and spent 3 days of my 3rd year spring break to hang out with the IR staff at my institution.
IR is what drew me to radiology. But, I'm finding out the rest of radiology is equally fascinating.

-Hans

 

[samsoccer7]

The more I learn about radiology, the subtle findings, the relationship of the anatomy, everything, it becomes more and more interesting to me. The diversity is awesome, and even though I still think I'll want to do IR, the 4 yrs of training will by NO means just be "something I need to get through."

 

[badasshairday]

VS and Cardiology has taken most of the vascular stuff at my place. Of course, by vascular stuff I mean angiograms and vascular stents. Almost all stent grafts are done with a VS and IR team in the OR.

Frankly, I doubt it will be much longer before agriograms are replaced by CT and MR angiography. So, then the loss will really only be stenting.

While everyone has been crying about losing "vascular" stuff.... IR has expanded to many new and exciting areas.... vertebroplasty, interventional oncology, embolization therapy, etc.

I, for one, am not worried AT ALL about IR... it has a very bright and exciting future. New stuff keeps popping up which replaces stuff that is being lost.... and I do not think losing peripheral stenting is going to matter much.

Going into IR right now is like buying low in the stock market... expect IR to explode over the next 5 years. Right now most fellowships are wide open.

I decided a different direction for my career mainly because of lifestyle issues. But, to be honest, IR is the cutting edge of radiology and sometimes I really have second thoughts about my decisions.

Plus, most radiologists are clinicians b*tches and they know it.... IR guys are worshiped because they are badass and bail out stupid clinicians all the time. I suppose that doesn't matter to everyone, but being a b*tch to surgeons all day can get old.

How true is this now in 2010? A positive spin on IR's future.