Med student interested in IR and concerned about "turf wars"

[Seaweed_Man]

Hello all,

I'm a medical student interested in/exploring IR. I have a few questions that I'm hoping some of the seasoned IR docs/residents on SDN might be able to answer re: the future of IR and "turf wars."

I originally came to med school interested in heme/oncology, but quickly realized I enjoyed working with my hands. The natural tendency would be top opt for some sort of surg onc ( via ENT, NSGY, gen surg, urology, etc), which I did. However, it seems like apart from a few types of cancers, the role of surgery will slowly diminish in oncology, in favor of chemo/immuno therapy, and minimally invasive procedures (such as interventional onc, interventional GI, etc) when intervention is deemed necessary (only makes sense given cost effectiveness and improvement of these techniques). It is this realization, combined with the new advent of the IR integrated residency, that got me interested in IR. I also love the idea of being able to do work all throughout the body. I truly believe that IR will drastically change our idea of "surgery" in the next century.

I see myself as an interventional oncologist, but I had the following questions about its present day practice:

1. To what extent has the practice of IR physicians improved in taking care of patients pre-procedurally and post-procedurally (i.e., are IR docs following up with patients in clinic to the same extent as, say, a urologic oncologist would for surveillance, etc)? Are these practices becoming ingrained structurally in the healthcare system?
2. Is interventional oncology at risk of being "poached" by heme onc/rad onc/surg onc the same way previous innovations by IR have? This worries me because unfortunately many physicians I've worked with on rotations don't see IR as partner doctors who are capable of practicing a focused area of clinical medicine (similar to surgeons) but rather as a techs (ironic given IR requires insanely high Step scores/strong clinical grades, as I'm painfully realizing hehe). It worries me because this is a perception problem by referring providers rather than a knowledge base problem on the part of IR docs, and doctors often have rigid views about other specialties. Is my experience a biased one/is the perception of IR changing?

Thanks and hoping for some answers!

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[throwaway123342]

1. Very little for the most part. People who go into IR do so specifically because they do not have to follow up with people. One of the best perks of radiology if not talking to patients. If this is something you want then perhaps radiology isnt the field for you.

2. IR is becoming more used, not less. More doctors are willing to just call IR rather than manage problems themselves and take on the liability. There is zero threat to IR nationally. At my institution IR runs the thoras paras, angio suite, stroke intervention, etc.

 

[Yhwach]

To answer #2:
If you go to SIR meetings you'll see the general trend is to "own the patient" or to at least try to. IRs are holding clinics and some people like Dr. V at Kaiser Permanente want to really own the whole patient. I'm sure it you have an OBL that's even more the case.

 

[DOVinciRobot]

IR is a great field, but not sure what gives you the impression that surgical management for cancer is going to diminish or go anywhere anytime soon.

 

[Wordead]

Also even if interventions go less invasive why would it go to IR? Like if theres a magical treatment for cancer that requires minimally invasive placement, the urologist/ENT or whatever is going to do it.

I think it's great if IR is taking more ownership because thats a 180 from what Ive seen - usually IR never follows up on squat. Wont even take out their drains half the time.

 

[throwaway123342]

if theres a magical treatment for cancer that requires minimally invasive placement, the urologist/ENT or whatever is going to do it.

Not really. At academic centers they will punt all that to IR. Training for IR is only getting better, meanwhile salaried surgeons are staying lazy.

 

[Wisco99]

Perhaps things will change but you can really tell that IRs are radiologists and not surgeons in the way they think about their post-ops. They don't take ownership of their patients, at least in my institution. Very difficult to get them to do or answer anything as soon as the patient has left the IR suite.

 

[Seaweed_Man]

Not really. At academic centers they will punt all that to IR. Training for IR is only getting better, meanwhile salaried surgeons are staying lazy.

I guess this is part of the question-its been hard to understand whether the culture of medicine will be to punt to IR (which is great for IR provided they take ownership of patients) or whether surgical specialties will eventually just learn to do things themselves (ex. interventional neurology learning from interventional neuro-radiology). I think if the latter happens, I'd be scared to go into IR because a doc would just do the procedure themselves (or refer to someone in the same dept)--for ex. brain aneurysm coiling going to an endovascular nsgy or interventional neurologist versus the IR person. Not sure how this would look with interventional oncology. I see myself wanting to take ownership of post-procedure management....but don't see the same level of procedural innovation (when it comes to cancer surgery) anywhere except IR right now (for ex., seeing a bunch of ENT surgery and talking to the ENT docs, it seems like head and neck cancer surgery is more or less staying the same and has been so for a while). Any insight on this? Or anyone know of any other "surg onc" fields where there is a lot of cool innovation being done?

 

[Wordead]

Not really. At academic centers they will punt all that to IR. Training for IR is only getting better, meanwhile salaried surgeons are staying lazy.

Yeah man academic surgeons dont have RVU goals at all or anything. The surgical oncologists are just going to fade away into the ether and retire instead of learning to do an easy procedure

 

[throwaway123342]

Yeah man academic surgeons dont have RVU goals at all or anything. The surgical oncologists are just going to fade away into the ether and retire instead of learning to do an easy procedure

Most surgeons have a minimum RVU they have to hit. But at the end of the day they will do the absolute minimum possible to punt to Medicine or IR. Meanwhile IR is booked full everyday no matter what.

Its clear as day that many things that were going to surgery 30 years ago are now being sent to IR. That gap will only continue to grow.

And yes, absolutely. Old Surg oncs are 100% willing to fade away and retire with 500k/yr salaries rather than displace radiology. We already are seeing that at any academic institution in the country. More and more is being punted to IR. Its not as if surgery is aggressively pursuing cases, quite the opposite.

 

[throwaway123342]

I guess this is part of the question-its been hard to understand whether the culture of medicine will be to punt to IR (which is great for IR provided they take ownership of patients) or whether surgical specialties will eventually just learn to do things themselves (ex. interventional neurology learning from interventional neuro-radiology). I think if the latter happens, I'd be scared to go into IR because a doc would just do the procedure themselves (or refer to someone in the same dept)--for ex. brain aneurysm coiling going to an endovascular nsgy or interventional neurologist versus the IR person. Not sure how this would look with interventional oncology. I see myself wanting to take ownership of post-procedure management....but don't see the same level of procedural innovation (when it comes to cancer surgery) anywhere except IR right now (for ex., seeing a bunch of ENT surgery and talking to the ENT docs, it seems like head and neck cancer surgery is more or less staying the same and has been so for a while). Any insight on this? Or anyone know of any other "surg onc" fields where there is a lot of cool innovation being done?

....yeah go look up how many thrombectomies are being done by interventional neurology. Neurosurgery is different because nsg and radiology were there together from day 1. Oncologists do not have will to add fluoroscopy and interventional procedures to their toolbox. They will not be displacing IR doctors from doing lung bx or interventional Onc.

 

[aldol16]

Turf wars exist everywhere. Just look at vascular interventions and how IR, vascular surgery, CT surgery, interventional cardiology have all gotten their hands into the same pie. Ortho and neurosurgery do the same thing for the spine. IR and neurosurgery for some endovascular interventions in neurosurgery.

 

[Dr G Oogle]

IR will be fine but it is a quarternary referral specialty, meaning that most patients are going to come to IR from another specialty which attenuates the number of patients you’ll see for high yield procedures. This means that you might end up at an institution where IR is basically a line and drain service or you could be somewhere where IR is doing AAA. Interventional oncology right now is mostly for salvage or to downstage liver cancer, it may be primary for RCC but usually at discretion of the urologic oncologist who like to operate, some institutions, the urologist might come down to “hit the button” and bill for the cryo or RFA, or at least part of it. UFE is another good example, obgyn never going to start doing these, but many of them will not refer and recommend myomectomy or hysterectomy first unless the patient requests a consultation. PCN is the same, there are now endourology fellowships teaching urologists how to do PCN, who in turn teach residents, once you hit a critical mass, daytime PCN might go away in some places and only weekend and overnight or otherwise inconvenient PCN will be available to IR. The thing with IR is that no matter how technically good you are, you will never be as good at managing the actual illness/condition as the referring service and will not typically the first consult by a patient, so while “owning the patient” is great and all, it’s not going to guarantee that you’ll only be doing high end cases. At my institution, I was in some leadership thing with an IR, and he was complaining that even though they can do things like mediports, ablations and vascular stuff quicker and cheaper they still don’t see a lot of referrals for these things, and this is at a place where everyone knows IR and they have clinics and admit their own patients. As long as your ok not being the first stop and not basking in the glory (which let’s be honest is a big part of being a surgeon/interventionalist) than IR is a great gig with a very big salary (usually much more than a surgeon)

 

[guytakingboards]

Is interventional oncology at risk of being "poached" by heme onc/rad onc/surg onc the same way previous innovations by IR have? This worries me because unfortunately many physicians I've worked with on rotations don't see IR as partner doctors who are capable of practicing a focused area of clinical medicine (similar to surgeons) but rather as a techs (ironic given IR requires insanely high Step scores/strong clinical grades, as I'm painfully realizing hehe). It worries me because this is a perception problem by referring providers rather than a knowledge base problem on the part of IR docs, and doctors often have rigid views about other specialties. Is my experience a biased one/is the perception of IR changing?

IO isn't at any risk of being poached IMHO. While the theoretical risk is there, it doesn't make a lot of sense when you break down the risk/benefit for each clinical specialty.

Rad onc: this wouldn't be poaching, this would be obviating the need for IO.
Heme/onc: for a non-procedural specialty, there would be a huge bar to learning the skill level required to do IO. this is to the point where it would prevent practicing other parts of heme/onc.... not worth it.
Surg Onc: IO is a relatively complex/high level case. Most surg onc's I'm familiar with are either weak/not interested in endovascular work. If they're gonna book a complex case, they may as well do a big open case.

 

[throwaway123342]

IR will be fine but it is a quarternary referral specialty, meaning that most patients are going to come to IR from another specialty which attenuates the number of patients you’ll see for high yield procedures.

Most IR patients are coming from Internal Medicine. Its not as if Internal medicine is asking surgery's opinion before calling IR for tissue.

 

[Dr G Oogle]

Most IR patients are coming from Internal Medicine. Its not as if Internal medicine is asking surgery's opinion before calling IR for tissue.

I don’t know the breakdown of referrals. If you’re talking about paras and thoras and most likely biopsies then yes, most likely it’s an IM referral. But if you’re talking about high end stuff like embo, PAD, IO, most likely surgery has at least evaluated the patient, with possible exception of a GI bleed, but another procedural specialty (GI( is still involved. I bet there are IR departments where they are more involved, a few years back I know that Mayo in Jacksonville IR, cards and vascular all shared cold leg call and all three had a very collegial and collaborative existence, not sure if that’s still the case, but for now they are an exception not the rule, though in an ideal world this is how it would/should work.

 

[throwaway123342]

I don’t know the breakdown of referrals. If you’re talking about paras and thoras and most likely biopsies then yes, most likely it’s an IM referral. But if you’re talking about high end stuff like embo, PAD, IO, most likely surgery has at least evaluated the patient, with possible exception of a GI bleed, but another procedural specialty (GI( is still involved. I bet there are IR departments where they are more involved, a few years back I know that Mayo in Jacksonville IR, cards and vascular all shared cold leg call and all three had a very collegial and collaborative existence, not sure if that’s still the case, but for now they are an exception not the rule, though in an ideal world this is how it would/should work.

At my institution IR is the first call for everything that is intervenable. GI Bleeds. Embolizations. thrombectomies. biopsies. complex paras. IO. etc. Booked full every day, etc. Furthermore, we have a procedure team of NPs/PAs that cover most of the "low level" large volume paras, LPs.

 

[Dr G Oogle]

At my institution IR is the first call for everything that is intervenable. GI Bleeds. Embolizations. thrombectomies. biopsies. complex paras. IO. etc. Booked full every day, etc. Furthermore, we have a procedure team of NPs/PAs that cover most of the "low level" large volume paras, LPs.

That’s awesome! I don’t think that’s the case everywhere, at my institution (quaternary hospital system with 2.5 million lives) IR is also very busy (too busy, wait times are 3 days) but do mostly pcn, lines, drains and biopsies, IO maybe 1-3 procedures per week, UFE a handful a month, and a smattering of other embolization type stuff, no vascular at all, and vascular surgery has even taken pelvic congestion syndrome and other venous stuff in the pelvis and virtually every IVC filter except for the emergency ones

 

[Cognovi]

IR tumor ablations are not going to be poached by surgery, but it is an uphill climb to demonstrate why an ablation would be beneficial compared to a more radical surgery or to medical or radiation therapy. Those clinicians control the referrals until the IR field can demonstrate with level 1 evidence the superiority of an IR approach for a specific disease. Obgyns rather refer fibroids to hysterectomy, for instance.

The exception is neurosurgery, who will try to poach anything. SRS from rad onc, HIFU from radiology, angio from radiology.

 

[mistafab]

I'd say the biggest think with IR right now is if you talk with IR folks -> majority of jobs are not 100% IR. Most are 50/50 at best (IR/DR), though since IR is so new this may change in the future.

I would say your biggest thing with considering IR and wanting to do mostly procedures is... are you okay with doing straight rads for half your job/ half your training? If the answer is no, then look elsewhere as many specialties can do procedures. IM->specialty->procedure means you are spending tons of training doing straight IM until you become a proceduralist. Same with Neuro->neurointerventional means a lot of neuro. Gotta pick your poison if you're not going surgical route.

 

[Wordead]

At my institution IR is the first call for everything that is intervenable. GI Bleeds. Embolizations. thrombectomies. biopsies. complex paras. IO. etc. Booked full every day, etc. Furthermore, we have a procedure team of NPs/PAs that cover most of the "low level" large volume paras, LPs.

Do you honestly think that this is true at 99% of other hospitals?

 

[throwaway123342]

Do you honestly think that this is true at 99% of other hospitals?

Mid tier academic center. Nothing else particularly notable. Our IR isn't considered "top tier" or anything either.

 

[TelemarketingEnigma]

To what extent has the practice of IR physicians improved in taking care of patients pre-procedurally and post-procedurally (i.e., are IR docs following up with patients in clinic to the same extent as, say, a urologic oncologist would for surveillance, etc)? Are these practices becoming ingrained structurally in the healthcare system?

From the perspective of a non radiologist who is happy to send ALL the IR referrals: what exactly is the follow up care you want to be involved in? All the IR folks Im familiar with are super happy to punt the post procedure care off on someone else. Taking on more responsibility for non procedural care for inpatients might mean working more weekends (gasp) which IR simply does not do where I am except for specific emergencies. For outpatients, if you’re hoping to do primary medical management/screening, I’m not sure radiology training would give you the experience you need to take full ownership of that (happy to hear if that’s wrong, but I’d feel real uncomfy if a patient of mine had cancer being exclusively managed by IR)

 

[Cognovi]

It sounds like some IRs just want the field to become like her older sister of the same mother, radiation oncology, formerly known as therapeutic radiology. That is, they hope IRs can be someone people think of as a type of oncologist rather than a type of radiologist, who can do a physical exam, see consults in clinic, manage a steroid taper, and bloviate about molecular pathways in oncogenesis, beyond just zapping the tumor in question.

 

[LucidSplash]

My experience at both big academic centers with IR training programs as well as smaller hospitals without training programs is that, at least in my sample, while there is an on-paper "push" at the larger places with big training programs for more involvement in the ongoing patient care, that has yet to trickle down to the everyday IR practice, and I'm not sure that it will. Even the folks I keep in touch with that trained under a place with more of a push for ongoing patient involvement, but who then went out to work at smaller level II trauma or community places, revert quickly to the role of excellent proceduralists who are happy to otherwise punt care. I have seen a couple of IRs who joined vascular practices who have clinic and such. But they tend to be doing mostly PAD work and not much of anything else. And agree that most of the smaller places don't have IR exclusive practices, the hospitals can't support that, they need them to cover DR as well.

You may do well to pose your question in a direct message to some of the more high-profile IR folks on Twitter and gather their thoughts. I suspect there will be a range of responses and opinions.

 

[NecrotizingFasciitis]

1) IR practice varies widely across the country. Where I train (and where I did 3 different sub-I's in 4th year), the PAs will round on patients for a day or 2 after procedures & see consults on the floor, but we do not ever take primary. We have clinic, but there is no continuity. I freakin' love it. I don't want to deal with any of that post-procedure stuff & I absolutely hate rounding. As mentioned above, some institutions take more ownership. Honestly IR is too busy of a service to deal with all that nonsense.

2) Absolutely not; not even close. And as mentioned above, it is extremely dependent on where you practice/train what procedures are done & by whom. Some places (like mine) IR does 100% of everything (except PAD... we let vascular do that).

Also as a side note: whether or not IR is integrated shouldn't impact your decision in slightest; like not even a little bit. I would argue ESIR is the better pathway (as someone in an integrated program.)

ESIR is the same number of training years (6) & you reap the benefit of having a couple years to experience IR as a resident (to ensure you actually want to do it) before applying for a fellowship. As icing on the cake, you'll be able to see how two different institutions do procedures through the ESIR pathway if you do fellowship elsewhere.

 

[ACSurgeon]

Hello all,

I'm a medical student interested in/exploring IR. I have a few questions that I'm hoping some of the seasoned IR docs/residents on SDN might be able to answer re: the future of IR and "turf wars."

I originally came to med school interested in heme/oncology, but quickly realized I enjoyed working with my hands. The natural tendency would be top opt for some sort of surg onc ( via ENT, NSGY, gen surg, urology, etc), which I did. However, it seems like apart from a few types of cancers, the role of surgery will slowly diminish in oncology, in favor of chemo/immuno therapy, and minimally invasive procedures (such as interventional onc, interventional GI, etc) when intervention is deemed necessary (only makes sense given cost effectiveness and improvement of these techniques). It is this realization, combined with the new advent of the IR integrated residency, that got me interested in IR. I also love the idea of being able to do work all throughout the body. I truly believe that IR will drastically change our idea of "surgery" in the next century.

I see myself as an interventional oncologist, but I had the following questions about its present day practice:

1. To what extent has the practice of IR physicians improved in taking care of patients pre-procedurally and post-procedurally (i.e., are IR docs following up with patients in clinic to the same extent as, say, a urologic oncologist would for surveillance, etc)? Are these practices becoming ingrained structurally in the healthcare system?
2. Is interventional oncology at risk of being "poached" by heme onc/rad onc/surg onc the same way previous innovations by IR have? This worries me because unfortunately many physicians I've worked with on rotations don't see IR as partner doctors who are capable of practicing a focused area of clinical medicine (similar to surgeons) but rather as a techs (ironic given IR requires insanely high Step scores/strong clinical grades, as I'm painfully realizing hehe). It worries me because this is a perception problem by referring providers rather than a knowledge base problem on the part of IR docs, and doctors often have rigid views about other specialties. Is my experience a biased one/is the perception of IR changing?

Thanks and hoping for some answers!

Don’t over think it. In theory you can be the exception to any rule and you can find a job in whatever specialty to be tailored to what you want it to be. That said, you might have to give up some stuff to achieve that and you might not get everything you have in mind.

Instead I’d recommend you look at what a specialty does on average as a guide to what you can expect your job to look like.

IR mostly serves a procedural role. This includes deciding indications for a procedure, doing the procedure, and managing complications of the procedure. They’re mostly NOT cancer doctors. Sure they’ll do procedures to diagnose and treat cancer but that’s probably a small portion of what they do. They do a large variety of things. If your goal is to diagnose and treat cancer: do heme/Onc med/onc or Surg/onc. If your goal is be a pure technician: IR might be a good fit. If you want to do surgery, find a surgical specialty. If you want to do procedures, do a procedure based specialty (GI/cards).

 

[irwarrior]

VIR is becoming a busier field as it continues to expand its therapeutic options. Clinic and longitudinal follow up is becoming more and more important to provide quality outcomes to patients. When doing interventional oncology it is paramount to follow the patients imaging, labs and clinical condition and review with their patients the findings and next steps. Unlike surgery where when you resect a tumor you know your margins A0 etc, in VIR you rely on imaging and labs to determine if you need to do repeat treatments. Also, it is imperative that you follow patients with tumors such as HCC as new tumors frequently arise separate from the site of initial tumor. As an interventionalist/surgeon you can not rely solely on the imaging report but have to do your due diligence to review the imaging yourself. We see our tumor patients consistently every 1 to 6 months through out their cancer journey.

The VIR lifestyle has become busier and busier due to the emergency conditions. More and more acute bleeders (GI, epistaxis, trauma, iatrogenic(biopsy/surgery), hemoptysis etc). We are dealing with more clotting conditions including strokes, DVT/PE and acute limb ischemia. Also more and more ill patients that can not undergo surgery and need urgent IR drainage (infected renal collecting system/ nephrostomy, cholangitis, cholecystitis, post op abscess, empyemas, SBP, diverticular abscess etc). Those who go into VIR not recognizing the "surgical" nature of this field are often very unhappy when they realize how busy it can be even in mixed practices where you may be nickel and dimed into performing even minor procedures (LP, arthrograms, joint aspirations/injections, biopsies, lines etc).

The most exciting growth in VIR is the outpatient ambulatory setting which includes mostly elective cases such as spine interventions (kyphoplasty/vertebral augmentation), fibroid therapy, prostate therapy for BPH, GAE for knee osteoarthritis, Peripheral arterial disease interventions for CLI, hemodialysis interventions including Endovascular fistula formation, oncology treatments (Y90/ablations/ TACE) , venous diseases (Iliac venous disease etc). To build this side of the practice in a sustainable fashion requires longitudinal outpatient clinic and a deeper understanding of the disease and ability to guide and counsel patients on nonoperative management , interventional and surgical options.

The training is slowly changing to incorporate more comprehensive clinical management, outpatient clinics, admitting services, formal consultative practices and rounding.

See below for a commentary on current VIR and the evolution of the specialty.

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