Neurointerventional training

[radiology_hopeful]

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Hey all,

I'm hypothetically/maybe/possibly/who-really-knows interested in neurointerventional work, but I think I need some clarification regarding the training pathway. My generic understanding is that it requires a year of diagnostic neuro, followed by dedicated NIR. That being said, what is the typical NIR fellowship length? Is it at all comparable to diagnostic neuro in that there are both one- and two-year programs, depending on your goals? Also, do most people do the diagnostic component at the same institution as the NIR training? One of my major reservations about the field is simply time commitment (worst-case scenario, 2 years diagnostic neuro + 2 years NIR = PGY9!).

Any insights are much appreciated!

 

[shark2000]

3 years of combined diagnostic+NeuroIR.

 

[radiology_hopeful]

Do NIR folks tend to be full-time proceduralists, or is there room for a practice model incorporating diagnostic work, as well? I don't think I would want to do it full time.

 

[shark2000]

Most of their time is spent doing general radiology and diagnostic neuroradiology, unless you are in a big referral center.
The job that you find is not usually what you want to do. So don't get surprised if a group hires you to do 60% general radiology, 30% neuro and 10% cerebral angiograms.

 

[TUGM]

according to ACGME, for radiologists it's 1 year diagnostic neuro + 2 years IR (1 year of which is dedicated to clinical neurology, neurosurgery, and neurocritical care).

practice models seem to vary. i know at my institution, which has a busy NIR practice, the radiology-trained NIRs still do both diagnostic and interventional, usually 50-50. the neurology-trained IR does 100% interventional (but has a counterpart diagnostic neuroradiologist who doesn't do IR at all).

 

[radiology_hopeful]

Which institutions are known for having strong NIR divisions?

 

[TUGM]

The usual culprits... Columbia, MGH, UPMC, TJU (they do more aneurysms than anyone else from what I hear), UCSF (Higashida is a beast, and pretty much only trains radiologists under him), UCLA (Duckwiler and gang invented the Merci retriever), UMiami, Barrow, Cincinnati, MCW (but is run completely by extremely talented neurologists who are dual trained in critical care - they do >1100 cases a year).

There are many more institutions with NIR divisions, but the ones that have the most volume (usually LARGE academic centers) usually have the strongest divisions. I know for a fact, though, that there are some extremely strong private practice set ups with large volume and amazing interventionalists.

 

[radiology_hopeful]

Is UWashington any good?

 

[TUGM]

Haven't heard much about UWashington's NIR. I know there are two NIRs (may be neurosurgery-trained) working at Harborview, but not sure as to the strength of the department. I'm sure they get volume due to referrals from all over the northwest, including Alaska. Haven't seen much as far as research from over there though.

I know their VIR department is very strong though.

 

[cowme]

Why not just go into neurology?

3 years Neuro + 1 year fellowship. Radiologists don't really have much turf left in this field, save for a handful of academic centers.

 

[radiology_hopeful]

Is it mostly neurology dominated at this point?

 

[cowme]

Mostly neurosurgery actually.

But neuro definitely has more of a footprint than radiologists in the community setting

 

[radiology_hopeful]

I realize you alluded to this previously, but is the same true in academics? Will radiology-based NIR ever go away?

 

[badasshairday]

But neuro definitely has more of a footprint than radiologists in the community setting

Not saying your wrong, but as far as I know this is not true. If you have some sources let me know. Neurointerventional as far as I know is still mostly surgeons and radiologists.

Also for neurology to do the NIR route they do neurology residency that is 4 years, followed by 2-3 years of vascular neuro or neuro critical care, then another two years of NIR. So it too is a LONG route just like other fields.

 

[TUGM]

A few things -

1. ESN/NIR is headed towards domination by neurosurgeons. Radiologists pioneered and developed the technique and technology, (although the first cerebral angiogram was performed by Egas Moniz, a Portuguese neurologist, in the 1920s), but have had trouble holding on to the field. It is important to note, however, that most departments are still run under radiology and probably an equal number being run by neurosurgery. Though neurologists have taken strides in contributing to research and development of the field, they are still relatively small in number and there aren't too many departments that are run by neurology. This may change in the future, but it seems that neurosurgeons are holding on as tightly as possible, and have considerable power given all the $$$$ they bring in for a hospital.

2. Radiology-based ESN/NIR will continue to exist as long as radiologists take an interest in the field. Most of the lost turf in ESN/NIR has been due to radiologists distaste for the strenuous increase in work hours without a significant pay increase. Though things are much more hectic in diagnostic radiology these days, IR and ESN/NIR lifestyles are more comparable to surgery hours - NIR/ESN (stroke call) is especially tiresome.

3. As has been discussed before, here are the ACGME recommendations for ESN/NIR training for various pathways:

Radiology: 1 year prelim + 4 years radiology + 1 year diagnostic neuroradiology + 2 years ESN/NIR (there will be training in vascular neurology, neurocritical care, and neurosurgery with a focus on re-acquiring clinical skills during the first year of ESN/NIR training).

Neurosurgery: 7 years neurosurgery + 1-2 year ESN/NIR (there has to be preparatory angiography and radiological training, but this can be done during residency, itself.)

Neurology: 1 year prelim + 3 years neurology + 1 year vascular neurology OR 1-2 years neurocritical care + 2 years ESN (the first year is spent obtaining radiological skills + diagnostic angiogram skills; the second year is focused therapeutic intervention).

NOTE: Regardless of route, the training for ESN/NIR is EXTENSIVE - it will take 7-9 years regardless of pathway.

Hope this helps. I am also a ESN/NIR hopeful 🙂 - will be attempting the neurology ---> stroke + CC ---> ESN/NIR pathway. It's a long road ahead, but for those of us who are passionate about driving this exciting field forward, it's well worth it.

 

[TUGM]

Also, if you would like to peruse the ACGME guidelines:

http://www.acgme.org/acgmeweb/Porta...endovascular_neuroradiology_07012013_1-YR.pdf

 

[radiology_hopeful]

Recognizing of course that no one can know for certain what will happen in the future, what do you all predict will be the direction of a NIR/ESN? Is it going to be primarily a NS subspecialty in the future?

 

[cowme]

You can look on aubtminnie and search the forums.

It's not only over saturated like other fields in radiology, but you're competing with the referring physicians themselves for the work.

Just my honest opinion, but I don't see how radiology has any turf left in NIR come next generation. Once the referring docs show interest in an ir procedure, its all over. See vascular surgery or interventional cardiology

 

[shark2000]

You can look on aubtminnie and search the forums.

It's not only over saturated like other fields in radiology, but you're competing with the referring physicians themselves for the work.

Just my honest opinion, but I don't see how radiology has any turf left in NIR come next generation. Once the referring docs show interest in an ir procedure, its all over. See vascular surgery or interventional cardiology

I thought the turf is already lost.

 

[TUGM]

I think less and less radiologists will choose to pursue the field... but there are still a significant amount of them already practicing at this time. Shark, maybe you're right about the next generation.

It'll be a toss up between neurologists and neurosurgeons in the future, with the neurosurgeons taking over most departments.

It's kind of sad that there were no initial regulations on training... in just 8-10 years, the field has gone from a huge shortage of physicians to being over-saturated. The field really needs to become wholly ACGME accredited and the number of fellowship spots drastically reduced and contained to big-volume centers - there are WAAAAYYY too many small programs with "NIR" fellowships.

I find it hard to believe that all these places can provide the volume it requires to become technically proficient at performing these delicate procedures.

 

[TUGM]

If you're really dead-set on doing NIR with no other interests, I'd highly recommend doing neurosurgery and completing a combined cerebrovascular/endovascular fellowship. You can clip and coil to your heart's content, and do some general neurosurgery if there aren't enough aneurysms to go around...

 

[shark2000]

Outside large referral centers, there is not enough endovascular business even for busy neurosurgeons. Endovascular work doesn't pay as good as spine procedures or other NS procedure. However these days endovascular procedures to NS is like Nuclear medicine to Radiology. They may not be genuinely interested in endovascular work and it may not be a big money maker for them, but most of them see it as ANOTHER PROCEDURE to learn on top of many other things. More and more NS residencies are incorporating endovascular training into their schedule. This is exactly similar to how we look into Nuclear medicine; another modality that we do on top of other things. We are not very interested in it and it does not make a huge revenue, but we do it just because it passes through our department.

Since it is not as well paid as other parts of NS, in remote areas where there is shortage of neurosurgeons, radiologists may still do it in the future. But outside remote areas and esp in the coasts, the lion share of it will be done by NS in the (near) future.

 

[je355804]

Is there a list somewhere of all the NIR fellowships? On FRIEDA I am only able to find a list of Endovascular neurorads - which lists a total of 3 programs.

For that matter, is there a list somewhere which details all of the fellowship possibilities after a DR residency?

 

[DoctwoB]

Agree with what some have said above. NIR is a new field, and as such started off with a big shortage, followed by a rapid increase in supply, and is now saturated or approaching saturation with far too many grads being churned out. The data for interventional work for stroke tx is severely lacking, leaving aneurysm and cerebral angio as the fields bread and butter, and soon there will be more then enough endovascularly trained neurosurgeons to handle that work.

The only thing I could see changing the equation is if new data/treatments come out for interventional stroke therapy, which could increase NIR volume.

 

[TUGM]

Agree with what some have said above. NIR is a new field, and as such started off with a big shortage, followed by a rapid increase in supply, and is now saturated or approaching saturation with far too many grads being churned out. The data for interventional work for stroke tx is severely lacking, leaving aneurysm and cerebral angio as the fields bread and butter, and soon there will be more then enough endovascularly trained neurosurgeons to handle that work.

The only thing I could see changing the equation is if new data/treatments come out for interventional stroke therapy, which could increase NIR volume.

The biggest component of ESN research now is proving better outcomes in stroke. If that can be accomplished, then there is hope.

 

[Gunny]

Where are the best places to train in NIR at the moment? Anyone any ideas? Presumably some are more NS dominated than others, and should be avoided for places where a more collaborative model works...

 

[TUGM]

Places with the really big names from all 3 specialties in no particular order:

Columbia (Meyers and Lavine)
UCSF (Higashida et al)
UCLA (Duckwiler et al.)
MGH (Yoo)
BNI (Albuquerque and McDougall),
UPMC (Jovin, Weschler)
UMiami (Yavagal et al.)
MCW (Zaidat et al.)
Hopkins (Gailloud et al.).
Rutgers/UMDNJ (Gandhi)

Other places I've heard have good training: MUSC, UT-Houston, UAB, SUNY Buffalo, Stanford, UIowa, Mayo, UMN... I'm sure I left out a few, I'll add them if I think of them.

 

[shark2000]

Where are the best places to train in NIR at the moment? Anyone any ideas? Presumably some are more NS dominated than others, and should be avoided for places where a more collaborative model works...

Training is not important. You may get a good training from NS. The important thing is to find a job after. You may be the best NIR trained radiologist. But if nobody refers to you, you can not find a job.

 

[TUGM]

Training will take up most of a decade... Hopefully in that time, there will be some changes in the job market. Who knows? Some of these guys have been around for a while... maybe they'll be retiring lol...

But in all seriousness, the job market is very tight. As I've said before, the field needs to instill ACGME accreditation as a requirement, and needs to limit the number of trainees significantly... and prove that IA stroke therapy actually works.

 

[shark2000]

Training will take up most of a decade... Hopefully in that time, there will be some changes in the job market. Who knows? Some of these guys have been around for a while... maybe they'll be retiring lol...

But in all seriousness, the job market is very tight. As I've said before, the field needs to instill ACGME accreditation as a requirement, and needs to limit the number of trainees significantly... and prove that IA stroke therapy actually works.

Too many assumptions in your post.

Who knows? We may all be dead in a decade.

 

[TUGM]

Luckily I'll have neuro-critical care/vascular neurology to fall back on if IR doesn't pan out - the job market for these fields are still pretty good. I think the important thing to take away is that, whilst it's perfectly fine to pursue NIR, you need to make damn sure you're okay with practicing your base field - neurology, radiology, or neurosurgery.

Too many assumptions in your post.

Who knows? We may all be dead in a decade.

And seriously, that would totally suck... I just got out of medical school.

 

[Gunny]

What about any of the Canadian programs - anyone know anything about Toronto?

 

[radiology_hopeful]

Does everything that has been emphasized in this thread thus far apply to academics and PP equally? This is of course purely anecdotal, but the NIR departments/faculty/programs I know of at a few big-time research hospitals seem to be doing well, but maybe that's wrong/naive/etc.

 

[TUGM]

It's true that the big-time research hospitals (i.e. places like MGH, Columbia, UMiami, etc) do well because they get referrals from all surrounding areas. They also have a lot of money to begin with, in terms of research, and have faculty recruited and dedicated to conducting research and clinical trials. This all goes towards contributing to their well-being.

Private practice scenarios vary drastically. As shark has mentioned before, there are very few 100% NIR practices. Most practices will require you to devote a significant portion of your time to diagnostic radiology, neuroradiology, general neurosurgery, stroke, or neurocritical care depending on your environment. The few PPs I know of that are 100% NIR are currently doing extremely well - but it's for the same reasons as before - they get all the referrals in a metro/surrouding area of 250+ mile radius.

Another issue that arises with the not-as-large private practice that hire an NIR who only devotes, say 10-20% of time and really only performs cerebral angiograms, is the issue of retaining technical skill. I believe that IR procedures and NIR procedures are very delicate, and it would be impossible to keep up your technical skill without volume.

 

[tco]

Too many assumptions in your post.

Who knows? We may all be dead in a decade.

Stop engraining my biggest secret fear.

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