Turf wars

[MikeTheGipper]

I've heard in a few different places that their are turf wars between interventional radiologists and interventional cardiologists because they do some of the same procedures. I'm wondering why it is that these turf wars occur? How would a given patient end up with an interventional radiologist doing a specific procedure as opposed to an interventional cardiologist doing the procedure? Does some of it or all of depend on which specialist the primary care physician refers the patient to? Just curious.

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[elwademd]

I've heard in a few different places that their are turf wars between interventional radiologists and interventional cardiologists because they do some of the same procedures. I'm wondering why it is that these turf wars occur? How would a given patient end up with an interventional radiologist doing a specific procedure as opposed to an interventional cardiologist doing the procedure? Does some of it or all of depend on which specialist the primary care physician refers the patient to? Just curious.

it depends on the ed... it depends on the primary... it depends on the politics of the place... it depends on availability... it depends on the capability of the operator... and in some cases can depend on the hospital privileges of the operator as well.


patient comes in with a stemi... ends up going to the cath lab with an interventional cardiologist... and the i.c decides to go to the level of the renals (i've seen this happen), and its noted that the renal artery is quite stenosed, what's the next step?

should the cardiologist go ahead and stent it?
did he/she explain this before the procedure?
does he/she have the technical knowledge to do it?
does he/she have the privileges to do it?



someone comes to the ed with shortness of breath... ends up being found to have a pericardial effusion... should cards get a crack at it... should radiology... should a ct surgeon?


so, all i can say is that yes, there can be "turf" wars. the questions i posed above i think can help to lead you as to why some of these things happen.

personally, as a hospitalist, i don't necessarily care who does the procedure, as long as it will benefit my patient, and the procedure can be done in a timely and safe manner.

 

[MikeTheGipper]

Thanks for the reply. I definitely have a better understanding about how and when this sort of thing can occur. I definitely agree with your last statement, too.

 

[elwademd]

Thanks for the reply. I definitely have a better understanding about how and when this sort of thing can occur. I definitely agree with your last statement, too.

wait until you get into the hospital. you'll see that sometimes specialists don't seem to agree with that because they may have a slanted view.

these sorts of issues are important, and it'd be great if specialists from both sides would chime in. but alas, i don't hold out hope for that.

 

[hans19]

i

patient comes in with a stemi... ends up going to the cath lab with an interventional cardiologist... and the i.c decides to go to the level of the renals (i've seen this happen), and its noted that the renal artery is quite stenosed, what's the next step?

That is utter BS. As in IR fellow we do mesenteric angiography ALL the time. Unless you actually select (seek and catheterize) the renal arteries, you CAN'T actually tell whether or not there is stenosis in a renal artery. We do Aortic angiography when we absolutely cant find the orifice of a mesenteric vessel (the renals are in the same neighborhood) and even then you dont get a true sense of whether or not stenosis of the renal artery.

A cardiologist who is trying to catheterize the coronaries "due north" of the renals, would have even less of a chance of seeing the renals well enough to make a call of stenosis.

The other thing is you use the minimal amount of contrast to get the job done... Contrast can be nephrotoxic. The additionally, there is a risk of dissecting a vessel when you catheterize it. You don't select vessels just for the hell of it unless there is an indication to do so.


The IC decides to go to the renal vessels? Based on what indication? As an IR I work right next to the renals all the time, I could easily do a renal angiogram, but I don't... Why? Because there is no indication to do so. Its not the right thing to do.

If you look at the reimbursement for procedures, coronaries are 800-1000 bucks. Renal angioplasty and stenting, because its new, is close to 6000 bucks. Does something smell fishy to you?

 

[radslooking]

That is utter BS. As in IR fellow we do mesenteric angiography ALL the time. Unless you actually select (seek and catheterize) the renal arteries, you CAN'T actually tell whether or not there is stenosis in a renal artery. We do Aortic angiography when we absolutely cant find the orifice of a mesenteric vessel (the renals are in the same neighborhood) and even then you dont get a true sense of whether or not stenosis of the renal artery.

A cardiologist who is trying to catheterize the coronaries "due north" of the renals, would have even less of a chance of seeing the renals well enough to make a call of stenosis.

The other thing is you use the minimal amount of contrast to get the job done... Contrast can be nephrotoxic. The additionally, there is a risk of dissecting a vessel when you catheterize it. You don't select vessels just for the hell of it unless there is an indication to do so.


The IC decides to go to the renal vessels? Based on what indication? As an IR I work right next to the renals all the time, I could easily do a renal angiogram, but I don't... Why? Because there is no indication to do so. Its not the right thing to do.

If you look at the reimbursement for procedures, coronaries are 800-1000 bucks. Renal angioplasty and stenting, because its new, is close to 6000 bucks. Does something smell fishy to you?

thanks hans. that's informative.

 

[elwademd]

That is utter BS. As in IR fellow we do mesenteric angiography ALL the time. Unless you actually select (seek and catheterize) the renal arteries, you CAN'T actually tell whether or not there is stenosis in a renal artery. We do Aortic angiography when we absolutely cant find the orifice of a mesenteric vessel (the renals are in the same neighborhood) and even then you dont get a true sense of whether or not stenosis of the renal artery.

A cardiologist who is trying to catheterize the coronaries "due north" of the renals, would have even less of a chance of seeing the renals well enough to make a call of stenosis.

The other thing is you use the minimal amount of contrast to get the job done... Contrast can be nephrotoxic. The additionally, there is a risk of dissecting a vessel when you catheterize it. You don't select vessels just for the hell of it unless there is an indication to do so.


The IC decides to go to the renal vessels? Based on what indication? As an IR I work right next to the renals all the time, I could easily do a renal angiogram, but I don't... Why? Because there is no indication to do so. Its not the right thing to do.

If you look at the reimbursement for procedures, coronaries are 800-1000 bucks. Renal angioplasty and stenting, because its new, is close to 6000 bucks. Does something smell fishy to you?

i'm not an interventional cardiologist, and have no stake (personally or professionally). but when i get a patient after heart cath who's received a stent to the circumflex, and another in a renal artery... clearly the cardiologist decided to make his way to the level.

and that was my point.

there are physicians out there who will do the right things for the right indications.
there are physicians out there who will do the wrong things for the right indiciations.
there are physicians out there who will do the wrong things for the wrong indications.
and there are physicians out there who will do the right things for the wrong indications.

in my opinion, a cardiologist looking at the renal artery on a stemi patient is doing the wrong thing.

but you might be surprised what you see if you ventured over to a cardiac cath. as i have seen more than one cardiologist (in separate groups), go ahead and shoot the renal arteries.

i'm not saying its right or wrong (i happen to think its wrong fyi), but it does indeed happen.

so, if an ir guy/gal knows this is going on in his/her hospital... i would think that it could contribute to a turf war, as it would affect the politics in the hospital... not to mention, people checking up on privileges, equipment, etc. ... a slippery slope indeed.

 

[radslooking]

Actually, I don't think you should shoot the kidneys. but if it pays 6000, then I probably would.

 

[ESU_MD]

in my experience-
in the typical IC group- theres always a guy or two who like to do unindicated procedures, or "push the limits"

the vast number of IC guys I know are happy enough doing coronaries and have no interest in pushing the envelope, probably because they dont want to deal with the complications.

i dont think theres as much drive-by angio going on as one would like to think.

 

[windowwasher]

Actually, I don't think you should shoot the kidneys. but if it pays 6000, then I probably would.

I hope you're kidding. If not, you might be better utilized as a lawyer.

 

[radslooking]

I hope you're kidding. If not, you might be better utilized as a lawyer.

I was employing some sarcasm to illustrate a point.

 

[Myostatin]

Active areas of turf war between cardiology and radiology are:

1) Peripheral Vascular Disease (vascular surgery is in on this one as well)
2) Cardiac MR, CT, and in some cases nuclear.

IR docs don't go near the heart.

It really doesn't matter who's doing the procedure / imaging interpretation as long as they're qualified, but bottom line is that cardiologists actually see patients = referral base.

Also, at least at my institution, IR is unwilling to deal with anything pre or post-prcocedurally. Why would I refer to a physician who does not have admitting priviliges, and who dumps the pre and post op care on others, if other equally qualified people are actually willing to do the work. Not to mention that where I train the internal medicine intern must babysit patients during anything other than a PICC line because the radiology attendings/fellows are not required to be ACLS certified. How you can have priviliges to perform angiograms/TIPS/etc and not be required to be up to date on ACLS is beyond me. If IR wants to make money doing the procedures, great, but there needs to be a willingness to actually manage the patient peri-operatively as well.

On the other side, cardiology may very well lose the battle re CT and MRI, given that we're not trained in reading the non-cardiac portions of films -> the idea of discarding all non-cardiac information on such scans is ludicrous. A hybrid approach where cardiologists read the cardiac portions of a scan and radiologists read the non-cardiac portions is a possibility, but why would radiology let this happen when they can easily get training in the cardiac aspects of ct/mr.

 

[Myostatin]

Active areas of turf war between cardiology and radiology are:

1) Peripheral Vascular Disease (vascular surgery is in on this one as well)
2) Cardiac MR, CT, and in some cases nuclear.

IR docs don't go near the heart.

It really doesn't matter who's doing the procedure / imaging interpretation as long as they're qualified, but bottom line is that cardiologists actually see patients = referral base.

Also, at least at my institution, IR is unwilling to deal with anything pre or post-prcocedurally. Why would I refer to a physician who does not have admitting priviliges, and who dumps the pre and post op care on "the PMD", if other equally qualified people are actually willing to do the work. Not to mention that where I train the internal medicine intern must babysit patients during anything other than a PICC line because the radiology attendings/fellows are not required to be ACLS certified. How you can have priviliges to perform angiograms/TIPS/etc and not be required to be up to date on ACLS is beyond me. If IR wants to make money doing the procedures, great, but there needs to be a willingness to actually manage the patient peri-operatively as well.

On the other side, cardiology may very well lose the battle re CT and MRI, given that we're not trained in reading the non-cardiac portions of films -> the idea of discarding all non-cardiac information on such scans is ludicrous. A hybrid approach where cardiologists read the cardiac portions of a scan and radiologists read the non-cardiac portions is a possibility, but why would radiology let this happen when they can easily get training in the cardiac aspects of ct/mr.