IR ?'s

[citarita]

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Hi. I am interested in IR, and I had a few ?'s I was hoping someone could answer. There is something called the "direct program" that I have been interested in for awhile where you basically match into a 6 year IR/Diagnostic program from medical school. I was wondering if there was anyone out there with info on: how "competetive" these programs are in general, which schools have the best ones (I'm looking in Chicago, Michigan, Cali, and Wis), and whether or not once you're done and actually done several years in IR, you can go straight into diagnostics if you get burned out. Thanks--citarita

 

[f_w]

> how "competetive" these programs are in general,

Difficult to tell. They are a fairly new animal, time will tell how competitive they are. From the people involved in setting this up, I was given the impression that they are looking for people whose competitiveness could get them into either general surgery or radiology. They are very conscious of the fact that given the competitiveness of either specialty, some people might see it as a 'back door' who would otherwise not make the cut.

> and whether or not once you're done and actually done several
> years in IR, you can go straight into diagnostics if you get burned out.

You will have the formal qualification (BC) to do diagnostic radiology. But like everything else, DR is a skill maintained by actually doing it. So someone coming out of a combined program who doesn't do any DR for a while might find it hard (and incur a significant liability) to get back into DR. However, most community IRs practice a mixture of DR and IR and don't have much of a problem to get back into full time DR once the frustrations of IR get to them.

 

[MD Dreams]

> once the frustrations of IR get to them.

Could you please comment on what some of the frustrations of IR are. Thanks.

 

[f_w]

Could you please comment on what some of the frustrations of IR are.

You
- work physically a lot harder than your partners
- you expose your health to considerable doses of ionizing radiation and potentially lethal infectious agents (hep-c, hiv)
- have more frequent call (and different from your partners you are not peacefully at home troubleshooting studies that the night-hawk company couldn't read, but rather you stand in the angio-suite at 2 in the morning trying to keep someone from bleeding out)
- everyone wants a piece of your practice even if they are only half as good at your job.
- are forced to do lots of mindnumbing simple stuff to pay the bills and fill the time between the interesting cases.

Still:
- you get the same partnership salary as your partners
- have to listen to their whining how your service is a loss-leader and causing lots of overhead (contrary to public opinion, IR as a whole is not highly lucrative on the side of pro-fees, at least compared with modalities like MRI and CT)

On the other hand:
- you can actually physically help patients. With some of them you will develop an actual doctor-patient relationship.
- if you are good, you have the respect of your clinical colleagues (something not every DR gets)
(I wouldn't want to miss it)

 

[Molly Maquire]

"...have to listen to their whining how your service is a loss-leader and causing lots of overhead (contrary to public opinion, IR as a whole is not highly lucrative on the side of pro-fees, at least compared with modalities like MRI and CT)."


HI,

Can you elaborate on this? I thought IR had the highest reimbursments.

 

[f_w]

In the time it takes you to:
- pre-op a patient
- do the case
- follow-up
a case which might net you a couple $100 in pro-fees, you could be plowing through a stack of CTs and MRIs making considerably more (and if you own the imaging center also participate in the technical component). It still beats working at the 7eleven, but within the specialty of radiology is is not a high-revenue field.

(The starting salaries offered for IRs might be the same or often higher than for DR jobs, but that is just a result of the shortage of IRs at this time. This is not what I am talking about, I am talking about the revenue end from the radiology groups perspective)

 

[illiniryan]

F_W

As a third year considering IR, I have a couple questions as it seems you have some insider's view of the field.

1. Do you think IR has a good future, or will the field get fragmented by interventional cards and others?

2. Do most IR's seem to like their job?

3. Could you ballpark how much the average IR works per week, if they do strictly IR? Is it 5 days a week in the angio suite, or are there a couple days of clinic mixed in there?

Thanks for any input you can provide.

 

[f_w]

> 1. Do you think IR has a good future, or will the field get
> fragmented by interventional cards and others?

I think it has a bright future. It just won't look anything like it does today. Today, most IRs practice as part of radiology groups holding exclusive contracts for a hospital. In the future, IRs will practice in small specialized clinical practices similar to surgical specialists or they will be part of surgical groups. There are already a number of practices working under this system, and by all I can tell they are very successful and financially attractive.

Also, the scope of practice will be shifted away from arterial vascular intervention. Most people will offer a whole smorgasbord of arterial, venous, body, GU and neuro (pain) procedures. With the broadened referral base, issues like turf competitions with vascular surgery and cards will represent less of a threat.

> 2. Do most IR's seem to like their job?

Yes.

At this time, most IRs have the option to walk away from it and to do DR only, but they don't.

> 3. Could you ballpark how much the average IR works per week,

There might be an average, but it is meaningless without knowing the distribution. Most IRs I know of work 5 days per week, 7-5, not unlike the 'average' diagnostic radiologist. The difference is in the call which tends to be far more often. In a 10 person radiology group, usually you will have 3-4 people sharing IR call. And how busy your call is depends on the size of the hospital, the scope of procedures you offer on call and the average IQ of your referring surgical colleagues.

> if they
> do strictly IR? Is it 5 days a week in the angio suite, or are there a
> couple days of clinic mixed in there?

80% of IRs at this time work part-time IR and part-time DR. Only a minority practice 100% IR 5-6 days/week. Nowadays, most will see patients in one way or another. Some have a dedicated clinic day, others just see patients between cases.

 

[KB_Xiii]

3 questions:

1. I am much better in medicine rather than surgery, I dislike the pre/post op evaluations, and everytime I attend ORs I get hypoglycemic attacks from all the blood shed. Now IR is minimally invasive, and I certainly love the "on the table" results acheived, I just want to know is it too much surgery? as in I might as well be doing a surgical subspeciality?

2. Can an IR work independently in a clinic? Like urologists or ENTs?

3. How is Interventional Neuroradiology different from IR when it comes to lifestyle and salaries?

 

[f_w]

> 1. I dislike the pre/post op evaluations,

Seing patients pre- and post procedure is a key component of a clinical practice, won't get around that.

> and everytime I attend ORs I get hypoglycemic attacks from all the
> blood shed.

We try not to shed too much blood, but at times you will get your gloves or the drape messed up. Not a good place for someone with a problem dealing with blood.

> I just want to know is it too much surgery? as in I might as well be
> doing a surgical subspeciality?

Looking at the future of IR, it will be more of a surgical specialty than a radiology lifestyle.

> 2. Can an IR work independently in a clinic? Like urologists or ENTs?

If you mean a freestanding office to see patients pre and post procedure yes. But most of procedural IR work is performed in a hospital (some simple procedures can be performed in a imaging center or ASC).
At this time, most hospitals contract with a radiology group in the form of an 'exclusive contract' giving the group discretion on who has access to imaging equipment. In this setting, it can be difficult to get access to the necessary angio suite.

> How is Interventional Neuroradiology different from IR when it comes
> to lifestyle and salaries?

In most hospitals, you will have only one or two neuro IRs. So if you are lucky, you have 1:2 call, but 24/7/365 is more typical. However, there are few NIR emergencies. Most aneurysms can wait until the morning and at this time, only a small minority of strokes are eligible for interventional therapy.

Many NIRs have the expectation to make more than other rads in the group to be sorely disappointed when that isn't the case. Rads groups tend to value income parity. They might have a bonus for production, but just because you did 2 more years of fellowship, typically groups won't give you a special deal.

 

[KB_Xiii]

Very informative FW.

Are IRs eligible to carry out Neuro procedures? and vice versa?
I mean a neuroradiologist should be able to carry out other interventions since he's been through the same IR foundation..

You've been very helpful, thanks 🙂

 

[f_w]

> Are IRs eligible to carry out Neuro procedures? and vice versa?

If you can convince your hospitals credentialing committee that you can safely perform neuroangiography, there is no law preventing you from doing so. In order to do core NIR procedures such as aneurysm coiling or AVM treatment, a NIR fellowship is inevitable.

> I mean a neuroradiologist should be able to carry out other interventions
> since he's been through the same IR foundation.

In the 'old days' (until 10 years ago), that was correct. A neuro fellowship involved 100eds of angiographies. A neuroradiologist was certainly qualified to work in other territories. Now that diagnostic neuroangio is DEAD, few neuro fellows get the case volumes to be even confident to do basic diagnostic work. (during residency I worked with neuroradiologists who did general IR so I was undecided for the longest time. only after interviewing for both fellowships, I realized that a neuro fellowship doesn't give the angio skillset these days and decided to go with straight IR).

 

[zzz1]

You
- work physically a lot harder than your partners
- you expose your health to considerable doses of ionizing radiation and potentially lethal infectious agents (hep-c, hiv)
- have more frequent call (and different from your partners you are not peacefully at home troubleshooting studies that the night-hawk company couldn't read, but rather you stand in the angio-suite at 2 in the morning trying to keep someone from bleeding out)
- everyone wants a piece of your practice even if they are only half as good at your job.
- are forced to do lots of mindnumbing simple stuff to pay the bills and fill the time between the interesting cases.

Still:
- you get the same partnership salary as your partners
- have to listen to their whining how your service is a loss-leader and causing lots of overhead (contrary to public opinion, IR as a whole is not highly lucrative on the side of pro-fees, at least compared with modalities like MRI and CT)

On the other hand:
- you can actually physically help patients. With some of them you will develop an actual doctor-patient relationship.
- if you are good, you have the respect of your clinical colleagues (something not every DR gets)
(I wouldn't want to miss it)

How much harmful radiation does IR get? Is this something to worry about long term? Cancer possible?

 

[f_w]

How much harmful radiation does IR get?

If one adheres to basic principles of radiation protection, it is difficult to exceed the legal limits. You have to carry a monitoring badge which gets read out monthly to identify people who need improvement in their radiation protection habits (and to catch the very rare problem of equipment radiation leaks).

Is this something to worry about long term?

Yes.
It is a job associated risk. A risk however which can be managed.

Cancer possible?

Cancer is allways a concern. In modern times (50s and later), radiologists have not been shown to have abnormally elevated cancer rates. There are only occasional case reports and 'cluster' ore case-control type studies. A small cross-sectional study found posterior subcapsular cataracts of the left eye in a population of very active IRs, but to my knowledge there is no systematic study when it comes to cancer.

 

[Apollyon]

The hand surgery guys talk about manual malignancies being documented and published due to so much time under fluoro, but I don't have access to that data at this time.

 

[f_w]

The hand surgery guys and some of our ortho colleagues are also not known to embrace radiation protection to the degree most radiologists do. While it is in rare cases unavoidable to get your fingers in the beam, it should be exactly that, a rare occasion.

 

[Leukocyte]

Who is more competetive for an IR fellowship position:

-An avarage Radiology resident? OR
-An avarage General Surgery resident?

I heard that PDs tend to favour GS residents, is this true?

Thank You.

 

[hans19]

Who is more competetive for an IR fellowship position:

-An avarage Radiology resident? OR
-An avarage General Surgery resident?

I heard that PDs tend to favour GS residents, is this true?

Thank You.

Not really. The ideal candidate would be a radiology resident who has done a surgical internship, as IR becoming more and more clinical.

Have some IR fellowships taken people who have only a GS background? Perhaps a few, but likely because they are so short staffed that they need warm bodies to get the work done. But similarly GS will take anybody to fill intern spots.

If you have not completed a full radiology residency you will not be eligible for the VIR CAQ exam and your lack of imaging skills will be a detriment. No radiology group will hire you. As most hospitals have contracts with radiology groups to do interventions, you will not be able to find a job at a hospital as an interventionalist.

There are a few IRs that have joined vascular groups and perform very little imaging but nowadays, few IR fellowships will give you the case load of pure arterial interventions to make you attractive to a vascular surgery group.

Some may argue that vascular surgeons do not have a radiology background, but perform arterial interventions. But if you want to do arterial work, why not just finish GS and do a vascular surgery fellowship or residency?

-Hans

 

[f_w]

Here and there you will find a GS resident doing an IR fellowship. The only time that happens is if an IR fellowship was unable to fill. (VS fellows get some endovascular training these days)

It looks like applicant numbers are up again. Confounding this picture are a number of larger fellowships that haven't filled in years so if you look at the overall numbers you thing 'ghosh, only 40% filled, it is easy to walk into a slot'. In the meantime, the more interesting IR fellowships seem to fill again.

 

[KB_Xiii]

If you had the choice, which path would you follow? And why?

1. Neurology - Interventional fellowship

2. Dx. rads - IR - INR

Do they actually end up doing the same procedures?

 

[f_w]

2. (and maybe do a year of neuro residency in between internship and rads residency to hone your neuro exam and stroke assessment skills)

 

[adeelmd]

2) . Dx. rads - IR - INR

My thinking was that you can't do inr after doing interventional... The pathway is doing a year of neuroradiology, then inr.... correct me if i'm wrong?

 

[hans19]

My thinking was that you can't do inr after doing interventional... The pathway is doing a year of neuroradiology, then inr.... correct me if i'm wrong?

Correct. The pathway for Endovascular Surgical Neuroradiology (INR) is 1 year of diagnostic neuro (or neurosurgery residency) followed by 2 years of neurointerventional.

 

[f_w]

My thinking was that you can't do inr after doing interventional... The pathway is doing a year of neuroradiology, then inr.... correct me if i'm wrong?

Well, the official pathway (in the ACGME document) says that you have to do 12 months of neurorad. This is a holdover from the times when neurorad was actually doing meaningful numbers of neuro-angios. If you do regular IR and apply to INR fellowships, I would be suprised if they wouldn't cheerfully take you.
Lets see, angio experience for the various pathways into INR:
- neurologist with stroke fellowship: 0 (ok, stood behind the neurointerventionalist during a couple of stroke cases)
- neurosurgeon: 0
- radiologist with 1 year neurorads: maybe 50 general from residency + 50 from fellowship (if very lucky)
- interventional radiologist: 50 from residency and 200+ from fellowship

Also, the 12 month diagnostic NR thing is often interpreted to include NR time during residency. If you come out of an IR fellowship, an INR program would probably set you up with the 3-4 months you are missing.

 

[Napoleon1801]

A little off topic, but which schools are the most IR focused in the country?

 

[citarita]

A little off topic, but which schools are the most IR focused in the country?

Couls someone coment on this if possible?

 

[citarita]

Couls someone cooment on this?