IR/DR, IR split

[nikmad]

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I am curious to how the residency spots(numbers) are going to be affected when this comes into effect. Also what do you think on how this will affect the competitiveness of both .

 

[Doctor D]

I don't believe that a separation between IR and DR will be happening anytime soon.

 

[cowme]

FAIRFAX, Va., Sept. 12, 2012 /PRNewswire-USNewswire/ -- The Society of Interventional Radiology hailed the September 11 decision by the American Board of Medical Specialties—the organization that has oversight of the 24 recognized medical specialty boards—to approve the American Board of Radiology's application for a new Dual Primary Certificate in Interventional Radiology and Diagnostic Radiology. With this approval, ABMS and its member boards confirmed the benefit to patients of the unique interventional radiology skill set comprised of competency in diagnostic imaging, image-guided procedures and periprocedural patient care.

"The interventional radiology and diagnostic radiology certificate will help ensure that all patients in the country continue to receive high-quality, consistent, diagnostic, procedural and clinical interventional care," said Jeanne M. LaBerge, M.D., FSIR, an ABR trustee and interventional radiologist at the University of California, San Francisco. "The recent approval of the interventional radiology and diagnostic radiology certificate formalizes this belief and gives 'specialty' status to the field of interventional radiology while maintaining its intimate and necessary relation to diagnostic radiology," said Matthew A. Mauro, M.D., FSIR, an SIR past president and ABR trustee. "The elevation of interventional radiology to a 'specialty' level with its own distinct residency program places interventional radiology/diagnostic radiology on the same level as surgery, pediatrics and internal medicine in the ABMS hierarchy. This ABMS vote is much more than a superficial clerical action—it is one that initiates a formalized enhanced training program that will benefit patients across the country and serve as a model throughout the world," added Mauro, professor and chair, department of radiology, University of North Carolina, Chapel Hill.


Read more here: http://www.heraldonline.com/2012/09...f-interventional-radiology.html#storylink=cpy

 

[shark2000]

That is a really great idea.DR people will do 70% of what IR is doing right now. Body people will do biopsies, drains, percut nephrostomies, biopsies,...
MSK people will do bone biopsies, joint injections, nerve block and probably kypho, vertebroplasties.
Vascular surgeries will continue their PVD and may start doing embo/chemoembos.
The best part is that we DR people will get rid of these arrogant, constant complainer IRs.


Good Luck.

 

[badasshairday]

That is a really great idea.DR people will do 70% of what IR is doing right now. Body people will do biopsies, drains, percut nephrostomies, biopsies,...
MSK people will do bone biopsies, joint injections, nerve block and probably kypho, vertebroplasties.
Vascular surgeries will continue their PVD and may start doing embo/chemoembos.
The best part is that we DR people will get rid of these arrogant, constant complainer IRs.


Good Luck.

As much as I love VIR, shark has a point. In theory splitting IR sounds great in advancing the specialty, but realistically the above could/would happen.

The thing that I have noticed, some Vasc surgery departments have really crowded into IR turf. Even places that have/had strong IR departments have had this happen. I know of a strong IR program (they do it all including PVD/Onc/billiary/etc) that has the Vsurg fellows actually do 4 months of pure IR during there fellowship in which they work with the IR attendings on everything. This includes embolizing GI bleeders while on call. During the day they focus on PVD type stuff, but on call anything goes.

Sure they don't touch MSK interventions and body drains/perc nephs/biopsies etc, but again as indicated above, this can be done by other radiology sections. The only thing IR will have purely for itself will be transvenous liver biopsies, TIPS, chemo/radio embos.

 

[drizzt3117]

That is a really great idea.DR people will do 70% of what IR is doing right now. Body people will do biopsies, drains, percut nephrostomies, biopsies,...
MSK people will do bone biopsies, joint injections, nerve block and probably kypho, vertebroplasties.
Vascular surgeries will continue their PVD and may start doing embo/chemoembos.
The best part is that we DR people will get rid of these arrogant, constant complainer IRs.


Good Luck.

My home institution has probably the strongest AI department in the country and even there there's no way they'd do PCN and hepatobilliary stuff. They're busy enough doing CSIR stuff like microwave and cryo ablutions and biopsies. They also don't want the call that additional non-scheduled procedures would require.

As far as vascular surgery goes, certainly they may turf things like ivcf, fistulograms, etc, as well as renal artery stents, but I don't think interventional oncology is a field they're really interested in entering. Some heme/onc and hepatobilliary GS people are getting involved there but those are both long training pathways as it is.

 

[badasshairday]

My home institution has probably the strongest AI department in the country and even there there's no way they'd do PCN and hepatobilliary stuff. They're busy enough doing CSIR stuff like microwave and cryo ablutions and biopsies. They also don't want the call that additional non-scheduled procedures would require.

Sorry what is AI?

Also, agreed, hepatobilliary procedures are definitely solidly in the realm of IR as well.

 

[drizzt3117]

Sorry what is AI?

Also, agreed, hepatobilliary procedures are definitely solidly in the realm of IR as well.

Abdominal imaging.

 

[shark2000]

My home institution has probably the strongest AI department in the country and even there there's no way they'd do PCN and hepatobilliary stuff. They're busy enough doing CSIR stuff like microwave and cryo ablutions and biopsies. They also don't want the call that additional non-scheduled procedures would require.

As far as vascular surgery goes, certainly they may turf things like ivcf, fistulograms, etc, as well as renal artery stents, but I don't think interventional oncology is a field they're really interested in entering. Some heme/onc and hepatobilliary GS people are getting involved there but those are both long training pathways as it is.

1- Take a look at body fellowship at UCLA, MGH and BWH and many other programs. In all of these, I know personally that body people are doing almost all the non-vascular interventions including hepatobiliary work, perc nephrostomy, biopsies and ...

2- You are right. In many places it is not done by Body people, and done by IR. It will be the case as long as the money stays in radiology department. The moment IR split itself, it bet it will be lost to body people. I am not body or IR fellowship trained, but was trained in a well organized program and I do perc nephrostomies once in a while. Most general radiologists can do it.

3- The reason it is done by IR, is that senior partners or even your radiology department prefer to hire an IR person to do it rather than body person as long as the money stays in the radiology department. But as soon as the money goes to IR as a split department, they will hire a body person and start to compete. Then IR will enter a new turf war, probably one of the most serious ones.

4- Your statement about chemoembo may or may not be true. It is not still a big money maker in pp. If an IR only wants to do chemo-embos he will not probably find a job.

 

[drizzt3117]

1- Take a look at body fellowship at UCLA, MGH and BWH and many other programs. In all of these, I know personally that body people are doing almost all the non-vascular interventions including hepatobiliary work, perc nephrostomy, biopsies and ...

I rotated at bwh last year, all the hepatobilliary stuff and pcn stuff was done by IR. I'll let you know about UCLA next year.

2- You are right. In many places it is not done by Body people, and done by IR. It will be the case as long as the money stays in radiology department. The moment IR split itself, it bet it will be lost to body people. I am not body or IR fellowship trained, but was trained in a well organized program and I do perc nephrostomies once in a while. Most general radiologists can do it. [/img]

It's not a question of being able to do them or not. I spent 6 weeks on urology and 10 weeks on IR in med school and 4 weeks on it in residency. I can easily do a PCN w/o supervision. The question is whether I want to take time away from reading CTs to spend an hour doing so (for less money)


3- The reason it is done by IR, is that senior partners or even your radiology department prefer to hire an IR person to do it rather than body person as long as the money stays in the radiology department. But as soon as the money goes to IR as a split department, they will hire a body person and start to compete. Then IR will enter a new turf war, probably one of the most serious ones.

4- Your statement about chemoembo may or may not be true. It is not still a big money maker in pp. If an IR only wants to do chemo-embos he will not probably find a job.[/QUOTE]

Why don't you ask geschwind about that?

 

[shark2000]

I rotated at bwh last year, all the hepatobilliary stuff and pcn stuff was done by IR. I'll let you know about UCLA next year.



Why don't you ask geschwind about that?

If your only way to protect your turf is that other services do not have time to do it or naming a person who may or may not be in practice in a few years, good luck with your career as IR.

The more I talk with IR people, either the 60 year old Guru or 25 year old new generation resident who claims a clinical model of IR, the more I come to the conclusion that this is not vascular surgery or cardiology who took it form them, it is IR itself who gave its turf to others. The model of IR that you guys are dream of, is neither practical nor sustainable with this mindset that you have. It is not your DR colleagues or your clinical training that hurts you, it is your mindset that hurts you.

 

[Dr. USMLE]

If your only way to protect your turf is that other services do not have time to do it or naming a person who may or may not be in practice in a few years, good luck with your career as IR.

The more I talk with IR people, either the 60 year old Guru or 25 year old new generation resident who claims a clinical model of IR, the more I come to the conclusion that this is not vascular surgery or cardiology who took it form them, it is IR itself who gave its turf to others. The model of IR that you guys are dream of, is neither practical nor sustainable with this mindset that you have. It is not your DR colleagues or your clinical training that hurts you, it is your mindset that hurts you.

Agree. IR is a truly fascinating field, arguably the most innovative in all of medicine and has the potential to disrupt every surgical field with enough advancement. But people in IR seem to get blindsided by that and miss the bigger picture. The reality is that IR's pie will always be shrinking and the only way to make it bigger is to innovate. When a disruptive innovation does occur, the affected surgical field will clamor to overtake the breakthrough and will always win due to the very nature of the business model. A clinical practice model does not protect against this because medicine is conservative - the referral will almost always go to the appropriate regional specialist first. Unless there is a breakthrough innovation in the business model itself, there is no way to break that first referral pattern. In other words, the cards are stacked against IR before the game even starts and the house always win. The only relevant counterargument is what IR did to CT surgery, but even in that case you have interventional cards who stepped in and took it all back anyway.

 

[duckie99]

Agree. IR is a truly fascinating field, arguably the most innovative in all of medicine and has the potential to disrupt every surgical field with enough advancement. But people in IR seem to get blindsided by that and miss the bigger picture. The reality is that IR's pie will always be shrinking and the only way to make it bigger is to innovate. When a disruptive innovation does occur, the affected surgical field will clamor to overtake the breakthrough and will always win due to the very nature of the business model. A clinical practice model does not protect against this because medicine is conservative - the referral will almost always go to the appropriate regional specialist first. Unless there is a breakthrough innovation in the business model itself, there is no way to break that first referral pattern. In other words, the cards are stacked against IR before the game even starts and the house always win. The only relevant counterargument is what IR did to CT surgery, but even in that case you have interventional cards who stepped in and took it all back anyway.

you make it sound like there were IR docs doing all the heart interventions and then all of the sudden cards came and took it... cardiologists were involved with the beginnings of this stuff. A radiologist originally developed it but a cardiologist (Gruentzig) trained in it as well. So at the very beginning there was already a split happening, if one ever even occurred in the first place.

However, what you say about the practice models of medicine and surgery are true in my opinion. Medicine will likely at the least most always consult surgery first before seeing if there is an IR procedure for some issue since right now surgery is the gold standard for most of the conditions it can treat. Therefore IR will continue to lose turf they have gained from surgery if what was gained significantly decreases surgery's turf. Surgery will just train in that stuff and get the turf back. That is not to say there won't be work for IR, but high end cases will be few and far between outside academic institutions, and even there they will decrease as surgeons start doing it. The clinical model just seems really late to the game imo.


Edit: IR does have one big advantage though, the cost it takes to get into the business. Radiology departments already have the equipment and the volume to support it. I find it would be difficult for a certain type of doctor (e.g. nephrology) to be able to afford buying in only to use the equipment for a few types of procedures and what would likely be very low volume. Thus I still only see interventional equipment and therefore procedures/operations being in the realm of radiology, cardiology, and surgery for a good while. Maybe GI can buy in and probably is at some places, but that's probably about it. And this goes further to shark's points about IR totally splitting and forming a separate department from radiology to be a bad idea. If money leaves the radiology department they will either higher a diagnostic radiologist who can do the procedures or get an IR guy who doesn't care about the clinical model.

 

[badasshairday]

you make it sound like there were IR docs doing all the heart interventions and then all of the sudden cards came and took it... cardiologists were involved with the beginnings of this stuff. A radiologist originally developed it but a cardiologist (Gruentzig) trained in it as well. So at the very beginning there was already a split happening, if one ever even occurred in the first place.

However, what you say about the practice models of medicine and surgery are true in my opinion. Medicine will likely at the least most always consult surgery first before seeing if there is an IR procedure for some issue since right now surgery is the gold standard for most of the conditions they treat. Therefore IR will continue to lose turf they have gained from surgery if what was gained significantly decreases surgery's turf. Surgery will just train in that stuff and get the turf back. That is not to say there won't be work for IR, but high end cases will be few and far between outside academic institutions, and even there they will decrease as surgeons start doing it. The clinical model just seems really late to the game as people in medicine specialties are beginning to be trained in some of these procedures as well (nephrology, heme/onc, etc).

So the question is will a medicine doc refer their newly diagnosed cancer patient to IR or their friend oncologist who can treat the patient both entirely medically and even interventionally if necessary or who can also decide if surgery is the best option and then consult surgery from there...

While some of what you say may be true, heme/onc is not exactly clamoring to do interventional procedures. Especially considering that it requires extensive imaging skills and microcatheter skills, something maybe a surgeon can pick up. That is like saying surg/onc can take over chemotherapy from heme/onc.

 

[duckie99]

While some of what you say may be true, heme/onc is not exactly clamoring to do interventional procedures. Especially considering that it requires extensive imaging skills and microcatheter skills, something maybe a surgeon can pick up. That is like saying surg/onc can take over chemotherapy from heme/onc.

Thanks. yeah I realized that after thinking a few minutes and fixed my original post. Should have said surg/onc instead.

Will reiterate that I think IR will always have more than enough work. Personally I'm not even sure if the volume is there for surg/onc to start buying into to chemo/embos at this time and I also don't know the full knowledge it takes to get good at this stuff. Also surg/onc is likely too busy as it stands now and may not have the time to train in these new procedures. A clinical model of IR could help solidify what exactly IR is best for and everyone will know, so in the end it will probably be OK. But I think there will be some hiccups along the way.

 

[shark2000]

While some of what you say may be true, heme/onc is not exactly clamoring to do interventional procedures. Especially considering that it requires extensive imaging skills and microcatheter skills, something maybe a surgeon can pick up. That is like saying surg/onc can take over chemotherapy from heme/onc.

If IR suppliment their work with onc that is great, but if they want to do only onc then they can not survive. Outside big centers, oncology is very rare to none.
In theory surgeons can take over interventional oncology. The problem is despite all the advertisements for clinical IR, even in those institutions, cancer is referred from oncology to surgery and if not operable, is referred to IR. More than half of chemo- embo cases come from surgery. IMO, the only reason it is not taken over by surgery is relatively low volume.
Doing IO does not need extensive imaging skill. Most of the IO people depend on interpretation of study by Body imagers. Also really you don't need to be a radiologist to do it. This is the justification of IR people to convince themselves why they are doing DR.
Regarding catheter skill, doing PVD needs much more catheter skill than TACE.
I think the only way for IO to remain in the realm of IR, is to break the chain of referral from oncology to surgery to IR. And that will not happen anytime soon. Unfortunately IR community did not jump into it fast enough and lost it.
Anyway, IO is not a big money maker and will stay in the turf of IR, IMO. Unless you want to work in a big academic center, don't be too excited about it.