IR vs Ortho vs Oto

[johnson87]

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[officedepot]

my take:

IR - adding from what you said; I think the future isn't as bleak as people want to make you think. Some docs think rads is taking over the field while others not so much. There's only so much a cardiologist can do for example. With IR be ready to really not have control over a patient's care. You need to decide if that bothers you or not - all your work is essentially referrals unless you work in a special group or something. Lots of the procedures you do will be minimal ones at that (vasc access, nephr tubes, etc) - though occasionally you get a cool one. Lifestyle wise it honestly isn't easy from what I have heard. Lots of call with long regular days (that's why so many in rads still don't want to go into it making it a field not too difficult to get a fellowship in). Also you have to go through 4 years of learning dx rads and reading films and that turns lots of people off.

Personally I think it's a great field despite what some consider to be negatives I mentioned. The procedures are cool, don't take too long, minimally invasive, etc. You can do stuff no other doc can (or PA or NP...). Also I personally like reading films and having a very vast knowledge base and rads can fullfill that for sure. You can still get really good pt contact in rads with IR and if you get trained can moonlight at community ED, volunteer, etc.

Ortho - I find the people to be all like frat boys. They don't like the medicine aspect of taking care of patients and really just want to do their operation and be done. Having the physical strength helps but isn't the necessarily required. Lifestyle wise it is tough during residency but after that it shouldn't be if you don't do trauma stuff. furthermore you would have to be comfortable with a knowledge base that is fairly specific which some people like. Overall I think the field is pretty dang cool but just can't stand the people I'd have to work with (rads people are so much better imo).

ENT - I don't have a lot of experience here but from what I can tell residency isn't as bad hour wise as the other surgical fields. Procedures are detailed and you sometimes get to do super cool facial operations. Again the knowledge base is pretty specific. Hours after residency should be great.




I think you should also consider something like ophtho. Hours are really really good (3-4 clinic days and 1 OR day a week). Operations are very delicate like ENT but I think they are quicker from what I can tell. Also everyone loves Ophtho because literally no one knows anything about the eye and when something goes wrong they come screaming. I seriously considered this field for a while but found the clinic to not be to my liking. In private practice most of your work is clinic stuff. However the clinic work is still pretty cool (just the different ways to look in the eye is interesting).


edit: obviously I have a positive bias for IR and ophtho so try to get that positive view of ortho from someone else lol

 

[johnson87]

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[Evergrey]

Oto - once again, nice but really long and sensitive surgeries. Cool and complicated anatomy. Variety of different procedures. Very nice people. Difficult residency. Unlike what most say, not much if a lifestyle specialty...there are a fair amount of trauma cases and they work pretty darn hard! Lifestyle specialty but compensation is significantly lower than the other 2! Surprisingly so, imo.

Please help! 🙂

I don't know too much about ENT (probably less than you do), but my understanding is that ENT at an academic medical center is quite different from community practice, i.e. there is a lot more trauma and H&N cancer in the academic setting and thus they tend to work longer and more erratic days. In the community setting, it's possible to only do 1 or maybe 2 days of surgery per week (and a lot of ENTs move away from surgery as they get older and stick to outpatient procedures and medical management), so there's a lot of flexibility in how much and how hard you want to work.

 

[Zuerst]

Ortho is a changing field. The boys club/frat boy stereo-type may apply 5 - 10 years ago, but it is simply not the case in a lot of programs today. A good number of program I have experience with have around 20-30% female residents and most of them are rather petite in size. Hell, some of the attending and some male resident are not huge physical specimens. Take a look at a program's resident population, talk to people with actual experiences, you just might find some programs that could be a good fit.

It is a more demanding field for sure, but a good amount of ortho residents also have their own family, kids...etc. It is doable, but of course harder to balance than other less time demanding fields.

Having old ortho stereotypes perpetuated on these forums is just entertaining sometimes. If you're not a hammer wielding meathead who doesn't know jack about diabeetus you need not apply.

 

[ZagDoc]

ENT - I don't have a lot of experience here but from what I can tell residency isn't as bad hour wise as the other surgical fields. Procedures are detailed and you sometimes get to do super cool facial operations. Again the knowledge base is pretty specific. Hours after residency should be great.

Residency for otolaryngology is still very much a surgical residency. All the junior residents above 70 hours most weeks, with the occasional week up into the 90s or even 100s on busy services/busy trauma weeks. Don't say that to dissuade you, just to let you know... its a surgical residency. It isn't derm.

Now yes, once you're out in practice you do have a great deal of flexibility. The field is very nice in that regard. But this is also down the road... as the junior member of the practice (either in academia or in PP) you'll still be working quite hard to earn your spot. Just-out-of-residency contracts for surgeons are often incentivized with RVU targets to become full partner in a practice.

 

[45408]

I like both clinic and OR.

IR isn't going to fulfill your clinic need...

IR- seems super interesting as minimally invasive surgery and a bunch of procedures. Broad field with exposure to a bit of everything. Good hours. Great compensation. But with the healthcare reform, I doubt that will last. A lot of turf wars with cardio and vsurg. If the job is the same in 10 years at is is now, I would be very interested. But the future of IR is sketchy 🙁

Our IR docs don't have great hours, nor do the other ones I've worked with. If someone is bleeding from <insert difficult to access location> and needs it embolized now, you're coming in now.

Oto - once again, nice but really long and sensitive surgeries. Cool and complicated anatomy. Variety of different procedures. Very nice people. Difficult residency. Unlike what most say, not much if a lifestyle specialty...there are a fair amount of trauma cases and they work pretty darn hard! Lifestyle specialty but compensation is significantly lower than the other 2! Surprisingly so, imo.

Most of the ENT cases outside of a large academic center are not long and sensitive. You can tailor your practice quite a bit. One of my relatives is an ENT and happens to think her lifestyle is great.

And if $$$ isn't as good for you as $$$$, then I guess ENT makes a lot less, but they still make a lot of dough.

 

[lildave2586]

Residency for otolaryngology is still very much a surgical residency. All the junior residents above 70 hours most weeks, with the occasional week up into the 90s or even 100s on busy services/busy trauma weeks. Don't say that to dissuade you, just to let you know... its a surgical residency. It isn't derm.

I think this is very program dependent. I know that the ENT residents at my place aren't putting in anywhere near 100 hours even on a busy week. My guess is they average 60-70.

 

[officedepot]

I like both clinic and OR.

oh I neglected to see this. Yeah so IR probably won't give you a ton of satisfaction if you like clinic stuff as there is very little of it (though there is some depending on where you go). Also remember you have to do a diag rads residency first. And yeah hours are tough pretty much all the time unfortunately (but I don't think they are as bad as gen surg). Though if you go and work for an outpt practice group they should be much better.

Anyway yeah look into ophtho. Have lots of clinic but still get some OR time. Hours not too bad either during residnecy (from what I have seen) and esp in the real world. Plus if you do retina surg you could make bank. serious bank. It's an early match too so you'd have to decide sooner rather than later to probably get an elective in and do whatever you need to (any research if time, LOR, etc).

 

[Radonkulous]

Check out this IR practice in the bay and tell me there isn't any clinic: http://www.endovascularsurgery.com/

The old way of IR is out. They are shifting to a clinical model, especially in the last 5 years with all these crazy turf wars going on. BCVI, Brown, UVA, MCW, UI-Peoria, etc. are great examples of programs churning out clinically competent IR docs. Plus, you get to be on the cutting edge of medicine. There aren't too many other fields in medicine that can say that.

ENT and ophtho might be up your alley as well. Personally, I still think the ortho stereotype holds true to some extent (maybe not as much as before but still true).

 

[Instatewaiter]

my take:

Personally I think it's a great field despite what some consider to be negatives I mentioned. The procedures are cool, don't take too long, minimally invasive, etc. You can do stuff no other doc can (or PA or NP...). Also I personally like reading films and having a very vast knowledge base and rads can fullfill that for sure. You can still get really good pt contact in rads with IR and if you get trained can moonlight at community ED, volunteer, etc.

The old way of IR is out. They are shifting to a clinical model, especially in the last 5 years with all these crazy turf wars going on. BCVI, Brown, UVA, MCW, UI-Peoria, etc. are great examples of programs churning out clinically competent IR docs. Plus, you get to be on the cutting edge of medicine. There aren't too many other fields in medicine that can say that.

ENT and ophtho might be up your alley as well. Personally, I still think the ortho stereotype holds true to some extent (maybe not as much as before but still true).

The problem is that IR has to get referrals to do procedures while cardiology/vascular surg have their own patients who are at risk for PAD. As Cards starts to do more peripheral stuff, they will start to take over peripheral interventions. Of course IR has tons of stuff they do beyond peripheral vascular disease, but with regard to peripheral stenting, the well will probably dry up in the next 2 decades. It's not like they will be hurting for business though.

 

[Radonkulous]

The problem is that IR has to get referrals to do procedures while cardiology/vascular surg have their own patients who are at risk for PAD. As Cards starts to do more peripheral stuff, they will start to take over peripheral interventions. Of course IR has tons of stuff they do beyond peripheral vascular disease, but with regard to peripheral stenting, the well will probably dry up in the next 2 decades. It's not like they will be hurting for business though.

I would respectfully disagree. I understand you are at Hopkins and the PAD involvement by IR over there isn't that great but these things vary from institution to institution. I agree Cards and VS have made significant inroads into PAD, but IR has far from lost it. Just take a look at the programs I mentioned. It's all about developing a strong relationship with PCPs.

 

[45408]

I would respectfully disagree. I understand you are at Hopkins and the PAD involvement by IR over there isn't that great but these things vary from institution to institution. I agree Cards and VS have made significant inroads into PAD, but IR has far from lost it. Just take a look at the programs I mentioned. It's all about developing a strong relationship with PCPs.

I really don't see how referral patterns should be shifting from vascular surgery toward IR for vascular disease. A vascular surgeon who can do endovascular work is the ideal person to manage patients with vascular disease. There's no reason that they can't collaborate (our IR group does thrombolysis for vascular patients), but I don't think it's appropriate for a patient with vascular disease to be followed only by an IR who then hands off the patient to a vascular surgeon only after all the endovascular options have been exhausted (potentially burning bridges in the process).

Overall, I think the role for IR is expanding, not shrinking, but I think that some turf wars should cede the ground when something is best for the patient. I also don't see why a cardiologist would be putting in iliac stents, but they're doing that too.

 

[DocEspana]

Ortho is a changing field. The boys club/frat boy stereo-type may apply 5 - 10 years ago, but it is simply not the case in a lot of programs today. A good number of program I have experience with have around 20-30% female residents and most of them are rather petite in size. Hell, some of the attending and some male resident are not huge physical specimens. Take a look at a program's resident population, talk to people with actual experiences, you just might find some programs that could be a good fit.

It is a more demanding field for sure, but a good amount of ortho residents also have their own family, kids...etc. It is doable, but of course harder to balance than other less time demanding fields.

Having old ortho stereotypes perpetuated on these forums is just entertaining sometimes. If you're not a hammer wielding meathead who doesn't know jack about diabeetus you need not apply.

forget about ortho being a boys club. You want a boys club? Go uro. 95% male physicians, last time I checked.

 

[Radonkulous]

I really don't see how referral patterns should be shifting from vascular surgery toward IR for vascular disease. A vascular surgeon who can do endovascular work is the ideal person to manage patients with vascular disease. There's no reason that they can't collaborate (our IR group does thrombolysis for vascular patients), but I don't think it's appropriate for a patient with vascular disease to be followed only by an IR who then hands off the patient to a vascular surgeon only after all the endovascular options have been exhausted (potentially burning bridges in the process).

Overall, I think the role for IR is expanding, not shrinking, but I think that some turf wars should cede the ground when something is best for the patient. I also don't see why a cardiologist would be putting in iliac stents, but they're doing that too.

By that logic, we shouldn't be ok with cards doing stents. That should be the role of CT surgeons.

 

[Instatewaiter]

I would respectfully disagree. I understand you are at Hopkins and the PAD involvement by IR over there isn't that great but these things vary from institution to institution. I agree Cards and VS have made significant inroads into PAD, but IR has far from lost it. Just take a look at the programs I mentioned. It's all about developing a strong relationship with PCPs.

The problem is that IR is dependent on referrals to get business for stents. This cohort of patients have either a cardiologist or vascular surgeon already. So, as cardiologists and vascular surgeons start doing more percutaneous peripheral vascular procedures, there will be fewer referrals. It's not like IR is seeing these patients for other issues like the cardiologists or vasc surgeons. So, when turf wars occur, it is often that the IR docs "lose." Again though, they have a host of other procedures they do

 

[officedepot]

so OP as you can see IR has "turf war" issues. Personally I think a lot of it is overblown. You'd have to talk to IR docs and get their take as they'd be the best ones. Lots of specialists depend on referrels and to be a specialist in endovascular procedures takes away from what else that person can do. It would be tough for a vasc surgeon to be completely competent at both endo and open procedures in my opinion. The issue is that they can just refer to other vasc surgeons or cards or whatever... Everyone wants a piece of the pie. Rads just has to take a stand against training these sorts of people and be more active (e.g. doing a f/u on a in patient if it can be justified - maybe insurance/medicare/medicaid doesn't pay for this??) imo.

IR's main issue is that lots of other docs don't like how they don't follow patients long term. They don't, generally, admit patients and be the primary team. It seems this is changing based on posts here and IR docs attempting to make it more well known what they do so hopefully the new batches of IR docs reverse this trend.


good thing about the other fields you, OP, listed (and ophtho) is that there aren't these turf wars for the most part.

 

[Law2Doc]

...I agree Cards and VS have made significant inroads into PAD, but IR has far from lost it. Just take a look at the programs I mentioned. It's all about developing a strong relationship with PCPs.

I think things are a bit backwards here. It's not vascular surgery making inroads into IR work, it's vascular surgery working hard to take back some areas that IR grabbed from them a few years back, because they lost sight of where the cash cows live. IR is the new kid on the block, not the other way round. At some facilities IR does a lot of tasks nobody else wants, like impossible to place PICC lines, PEG tubes GI dont want to deal with, nephro tubes uro doesn't want to deal with. Transjugular liver biopsies. as well as embolization work. A hot area for them tends to be chemo embo work, fibroid embolization, etc. Basically a grab bag. Interventional cardiology is taking big hits from studies that are showing that stenting may not provide as much value as jumping straight to bypass, so they are scrambling for new opportunities. I don't think any of these fields are dying, but I think interventional cardiology is perhaps struggling hardest to keep their plates full.
I don't think IR or ortho are really lifestyle fields.

 

[Radonkulous]

I think things are a bit backwards here. It's not vascular surgery making inroads into IR work, it's vascular surgery working hard to take back some areas that IR grabbed from them a few years back, because they lost sight of where the cash cows live. IR is the new kid on the block, not the other way round. At some facilities IR does a lot of tasks nobody else wants, like impossible to place PICC lines, PEG tubes GI dont want to deal with, nephro tubes uro doesn't want to deal with. Transjugular liver biopsies. as well as embolization work. A hot area for them tends to be chemo embo work, fibroid embolization, etc. Basically a grab bag. Interventional cardiology is taking big hits from studies that are showing that stenting may not provide as much value as jumping straight to bypass, so they are scrambling for new opportunities. I don't think any of these fields are dying, but I think interventional cardiology is perhaps struggling hardest to keep their plates full.
I don't think IR or ortho are really lifestyle fields.

Do you have any idea what are you talking about? You clearly don't know the facts so stop spreading misinformation. They came up with these techniques, including coronary stenting (think Charles Dotter). IRs used to dominate the PAD field up until ~10 years ago, which they started to lose to cards and vs. The reason being they didn't follow a clinical model (i.e. admitting and f/u). The few that did survived, which include BCVI, UVA, MCW, Yale, Brown, etc.

 

[officedepot]

Do you have any idea what are you talking about? You clearly don't know the facts so stop spreading misinformation. They came up with these techniques, including coronary stenting (think Charles Dotter). IRs used to dominate the PAD field up until ~10 years ago, which they started to lose to cards and vs. The reason being they didn't follow a clinical model (i.e. admitting and f/u). The few that did survived, which include BCVI, UVA, MCW, Yale, Brown, etc.

I think his point is that, yes, IR developed these techniques but those then took patients and procedures away from vs and cards which they originally had (which I think is true). However now vs and cards are trying to get some of that back by basically doing what IR does... I think he is right about int cards though and they may be in some trouble but they will still have the cath lab for acute MI. IR has to do a better job of keeping PAD and that's where their role in the hospital with following pts and the community with any necessary f/u come into play.

Obviously you don't really need f/u for things like picc lines but I'm sure there are procedures they do which warrent f/u in clinic or inhouse.

I mean how long can it take to see a pt you put a renal artery stent in as f/u the next day to just check in, write a super brief note, and make your presence known to the patient and primary team... I know they'd appreciate the time and the little things like that make a difference for the field as a whole. Certain procedures could warrant a clinic visit months later I am sure as well.

 

[Law2Doc]

...
I mean how long can it take to see a pt you put a renal artery stent in as f/u the next day to just check in, write a super brief note, and make your presence known to the patient and primary team... I know they'd appreciate the time and the little things like that make a difference for the field as a whole...

I think most in house IR programs do a next day follow up, at a minimum to check for hematoma at the access site. The complaint arises mostly in cases where a patient has intervention but is someone who is a "rock" and stays on the wards for months, and IR probably never goes to see them again after that single next day visit, unless called for another consult. You get more longitudinal followup from consults like cards, ortho, surgery who may keep a patient on their "list" until they leave the hospital (one way or another).

 

[45408]

By that logic, we shouldn't be ok with cards doing stents. That should be the role of CT surgeons.

....except that CT surgeons aren't trained to do cardiac stenting, but newly-trained vascular surgeons are trained to do peripheral endovascular work.

so OP as you can see IR has "turf war" issues. Personally I think a lot of it is overblown. You'd have to talk to IR docs and get their take as they'd be the best ones. Lots of specialists depend on referrels and to be a specialist in endovascular procedures takes away from what else that person can do. It would be tough for a vasc surgeon to be completely competent at both endo and open procedures in my opinion. The issue is that they can just refer to other vasc surgeons or cards or whatever... Everyone wants a piece of the pie. Rads just has to take a stand against training these sorts of people and be more active (e.g. doing a f/u on a in patient if it can be justified - maybe insurance/medicare/medicaid doesn't pay for this??) imo.

I don't think it's overblown, but I don't think it's something to worry a whole lot about. As imaging gets better, there's an increasing role for IR procedures. IR isn't going anywhere (nor do I want it to), but their range of practice is shifting and will continue to do so.

Do you have any idea what are you talking about? You clearly don't know the facts so stop spreading misinformation. They came up with these techniques, including coronary stenting (think Charles Dotter). IRs used to dominate the PAD field up until ~10 years ago, which they started to lose to cards and vs. The reason being they didn't follow a clinical model (i.e. admitting and f/u). The few that did survived, which include BCVI, UVA, MCW, Yale, Brown, etc.

So are you upset that IR isn't doing cardiac stents either?

I think that a specialty should not do anything in a given field if they cannot manage their own complications, and there is another specialty that can do the initial procedure and manage the complications. If you go to a vascular surgeon and get an iliac stent, and it then occludes, they can do a mechanical thrombectomy, anatomic or extra-anatomic bypass, or even an amputation. Or we could let IR snatch the low-hanging fruit and then dump the vascular nightmares on the surgeons. Not cool.

 

[MossPoh]

IR is moving towards clinic and medical management in their training. If you want to do the fun and complicated stuff in IR then your practice is going to be organized more like a surgical subspecialty most likely. The days of sending the patient, sticking a needle in them and turfing them are starting to fade. The best IR fellowships tend to have some sort of clinic component. (There are ones that don't, but it wouldn't surprise me to see that shift in a couple of years)

 

[2012mdc]

I think most in house IR programs do a next day follow up, at a minimum to check for hematoma at the access site. The complaint arises mostly in cases where a patient has intervention but is someone who is a "rock" and stays on the wards for months, and IR probably never goes to see them again after that single next day visit, unless called for another consult. You get more longitudinal followup from consults like cards, ortho, surgery who may keep a patient on their "list" until they leave the hospital (one way or another).

Where I'm doing my IR rotation currently a fellow and/or NP rounds on patients until d/c (or until the problem that IR was consulted for completely resolved).

Only have experience at 2 different hospitals (both academic) for IR but both of them practiced the "new" more clinical way of IR and there was a lot of cooperation with other specialties.

Obviously private practice is a whole different thing