Ir/vs

[youngdoc8205]

Advertisement - Members don't see this ad

not to start a digital turf war, but I wanted to get the perspective of surgeons, especially any attendings here. I'm hoping to do IR with a very clinical slant (i.e. admitting, clinic, outpatient/inpatient consults) for arterial/venous and oncologic procedures, which is the new paradigm shift in IR anyway, with longer fellowships, etc. . But I wanted to know how do the VS surgeons or surgeons feel about sharing the turf with IR if they take their clinical duties seriously. Especially in private practice.

Thanks

Again not trying to start anything. 🙂

 

[SLUser11]

not to start a digital turf war, but I wanted to get the perspective of surgeons, especially any attendings here. I'm hoping to do IR with a very clinical slant (i.e. admitting, clinic, outpatient/inpatient consults) for arterial/venous and oncologic procedures, which is the new paradigm shift in IR anyway, with longer fellowships, etc. . But I wanted to know how do the VS surgeons or surgeons feel about sharing the turf with IR if they take their clinical duties seriously. Especially in private practice.

Thanks

Again not trying to start anything. 🙂

I'd be interested to see this "clinical slant" with admitting, patient management, etc....I've never experienced that....usually when outpatient radiology procedures go bad, I'm the one bringing the patient in....

Still, to answer your question, where I work there is a general feeling of mutual respect between the really good Vasc radiology guys and the vascular surgeons. I think when EVAR was newer, they were sort of learning together, and they've been symbiotic since then, now several years later.

Honestly, until the training changes so you guys have experience with patient care and operative management of complications, you will always be met with some animosity from the surgery folks.....but this "turf war" is probably more pronounced in the academic setting.

I personally really like the radiologists here....but these are the types that don't mind coiling spleens at 3am.....

 

[SocialistMD]

I'm hoping to do IR with a very clinical slant (i.e. admitting, clinic, outpatient/inpatient consults) for arterial/venous and oncologic procedures, which is the new paradigm shift in IR anyway, with longer fellowships, etc. . But I wanted to know how do the VS surgeons or surgeons feel about sharing the turf with IR if they take their clinical duties seriously. Especially in private practice.

The only beef that surgery really has with IR is from the resident perspective; attendings don't mind the extra patient or two on their service, as they will interact with them minimally (if at all) in most cases. I don't think your increased floor presence will change the culture that already exists in your hospital regarding the patient referrals, so I think you will be met with open arms from the surgeon, as you aren't really going to change anything except lessen the workload of the surgical resident.

 

[maxheadroom]

The only beef that surgery really has with IR is from the resident perspective; attendings don't mind the extra patient or two on their service, as they will interact with them minimally (if at all) in most cases. I don't think your increased floor presence will change the culture that already exists in your hospital regarding the patient referrals, so I think you will be met with open arms from the surgeon, as you aren't really going to change anything except lessen the workload of the surgical resident.

It's been a while since I've been directly involved with these issues, but there was a major turf war between VS and IR when I was a junior resident. There were several IR complications that had to be admitted to the VS service. The Vascular attendings were getting more and more upset by what they saw as dumps of complicated patients.

Eventually, the Vascular attendings went to the hospital administration and flatly said that they would not back up the IR docs when they did procedures X, Y, and Z. They had data showing the IR docs had higher complication rates with those procedures. The IR docs responded that they were qualified to do procedures X, Y, and Z and that they would continue to provide those services.

A couple of months later, one of the IR guys got into trouble on an EVAR. He called Vascular -- they said, "No." Eventually, one of the CT guys who did a fair amount of Peripheral Vascular came and bailed them out. Fortunately, the patient did OK. The hospital administration eventually worked out an accommodation between the two groups. Part of it was contingent on the IR docs admitting and managing their patients.

 

[Celiac Plexus]

It's been a while since I've been directly involved with these issues, but there was a major turf war between VS and IR when I was a junior resident. There were several IR complications that had to be admitted to the VS service. The Vascular attendings were getting more and more upset by what they saw as dumps of complicated patients.

Eventually, the Vascular attendings went to the hospital administration and flatly said that they would not back up the IR docs when they did procedures X, Y, and Z. They had data showing the IR docs had higher complication rates with those procedures. The IR docs responded that they were qualified to do procedures X, Y, and Z and that they would continue to provide those services.

A couple of months later, one of the IR guys got into trouble on an EVAR. He called Vascular -- they said, "No." Eventually, one of the CT guys who did a fair amount of Peripheral Vascular came and bailed them out. Fortunately, the patient did OK. The hospital administration eventually worked out an accommodation between the two groups. Part of it was contingent on the IR docs admitting and managing their patients.

My experience in general surgery residency was similar to this. Though the IR guys were not doing EVARs. I can't imagine how a patient would wind up undergoing an EVAR by an IR person. There is a significant amount of work-up, and clinic time that goes in to getting these patients ready for repair. Maybe the patient was referred by a medicine doctor?

I can remember a few times I saw cold extremities in the ED that needed thrombolysis. When I tried to get IR to come in and place a TPA catheter, they sometimes refused and told me to call vascular. Then when I got vascular on board, the IR guys wouldn't let them use their IR suite and we'd have to ask the cardiologists to let us use their suite.

I can also remember a lot of bail-out calls for catheter misadventures. Once we took over, we'd never hear/see from the IR guy again. And then there were the multiple referrals from IR for "post-procedure management" of things like, oh... patient with claudication whom had been stented up.

I guess IR types may do things differently at other institutions, but I cannot imagine an IR person running a clinic, and having an inpatient service. I just don't see it. It would probably be a good thing for them though. Taking care of your complications tends to be a useful learning tool.

 

[maxheadroom]

Taking care of your complications tends to be a useful learning tool.

Agreed

 

[youngdoc8205]

when I'm talking about the clinical component of IR, I mean things like: a consult service for RFA, cryos etc, if we do any procedure we follow for duration until window for complications is closed. we have our own admitting or at least recovery unit, and to deal with our own complications (most intra-vascular complications can be treated intra-vascularly). To be quite honest, I'm not sure where this attitude of not following pt's or dumping complications comes from, it's the reason IR lost cards and not doing much arterial work these days, at least in academics, I do think they've learned their lesson with oncology and are actually doing all the things I mentioned above. I'm just trying to see how other fields view IR, b/c I think it could be a very useful field, particularly with innovation, if people just changed their attitude. Thanks for the feedback

 

[SocialistMD]

Perhaps it is just my institution then, but the only time we really see IR patients is when they have done RFA on liver tumors that are subsequently admitted to one of our surgical services (because IR doesn't have an admitting service). While it is fine 95% of the time, as the IR guys still see the patients (as "consults") while in the hospital, it is still a pain for the surgical intern who has to field the overnight calls, and if the patient needs a longer hospital stay, it is the surgical intern who is left dictating the discharge summary. Our IR guys don't do much endoluminal work that would require admission (they do some outpatient stuff, and if they do inpatient work, they must admit to medicine, as we never see them), which is probably why I have such a positive opinion of them. That, and they never refuse to come in for a procedure in which they are needed. We also have our own "surgical IR suites," so there is no turf war there, either.

Regarding the management of complications, I think it is a slippery slope to get upset about managing the complications of an IR procedure but not a pericentesis/thoracentesis or central line placement gone wrong on the medical service. I understand the difference in taking procedures that we want (IR-type vascular work) versus those we don't (aforementioned medical service complications), but in the end, we as surgeons manage complications of procedures done.

Again, my perspective is likely due to the relative infrequency of overlap in procedures at my institution, but I do live in an environment where all services that like wires and catheters play well in the sandbox.