What procedures can radiologists do?

[IJL]

I've worked at a few different hospitals and it seems like there is no general consensus as to what exactly falls in the radiologists' turf as far as procedures go.

Biopsies? Drains? Lines? Are any of these solely left to an interventional radiologist? What can a DR do?

If I want to learn and do a lot of procedures during DR residency, would I be able to? (I'm sure it's somewhat institution dependant).

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[shark2000]

I've worked at a few different hospitals and it seems like there is no general consensus as to what exactly falls in the radiologists' turf as far as procedures go.

Biopsies? Drains? Lines? Are any of these solely left to an interventional radiologist? What can a DR do?

If I want to learn and do a lot of procedures during DR residency, would I be able to? (I'm sure it's somewhat institution dependant).

Biopsies, drains, chest tubes, Lines, percutaneous nephrostomy, percut cholecystostomy, arthrograms, joint injection/aspiration and Myelogram are considered general radiology skill sets. If you go to a fine residency program you should be able to do them by the end of your residency.

Since a lot of vascular work is takes away from IR, these procedures are done by IR. Also a lot of radiologists prefer to not do these procedures and leave it to IR.

There are many groups that expect you to know how to do these procedures. It is obvious that even if you are IR trained, you get better and esp faster as you go through your practice. However, you are expected to know. Similar to MSK MRI, Brain MRI, Body MRI, OB US, CT temporal bone, .... Groups expect you to be able to handle them well.

 

[IJL]

Biopsies, drains, chest tubes, Lines, percutaneous nephrostomy, percut cholecystostomy, arthrograms, joint injection/aspiration and Myelogram are considered general radiology skill sets. If you go to a fine residency program you should be able to do them by the end of your residency.

Since a lot of vascular work is takes away from IR, these procedures are done by IR. Also a lot of radiologists prefer to not do these procedures and leave it to IR.

There are many groups that expect you to know how to do these procedures. It is obvious that even if you are IR trained, you get better and esp faster as you go through your practice. However, you are expected to know. Similar to MSK MRI, Brain MRI, Body MRI, OB US, CT temporal bone, .... Groups expect you to be able to handle them well.

Thanks for your informative response, and that's awesome to hear (MS4 pretty pumped about rads 😎)

Do you have any specific examples of radiologists that that do a lot of procedures (non- IR) ? These may be ridiculous questions but unfortunately I got very little exposure to radiology during 3rd year

 

[chronicidal]

thanks for your informative response, and that's awesome to hear (4th year pretty pumped about rads 😎)

do you have any specific examples of radiologists that that do a lot of procedures (non- ir) ? These may be ridiculous questions but unfortunately i got very little exposure to radiology during 3rd year

MSK (vertebroplasty, kyphoplasty, radiofrequency treatment of bone metastases, cementoplasty, osteoid osteoma treatment, nerve root blocks)


neuro-IR (aka ESNR [endovascular surgical neuroradiology] or INR [interventional neuroradiology])

 

[PJB1018]

How much hand skills are involved with these procedures? For example, do you have to have really good hands to do IR procedures like in Plastics? Or is it more like Ortho, where you can get away with having average hand skills?

 

[shark2000]

How much hand skills are involved with these procedures? For example, do you have to have really good hands to do IR procedures like in Plastics? Or is it more like Ortho, where you can get away with having average hand skills?

Average skill is good enough.

It is not the skill of the operator. It is the technology and the experience of the operator. That is why everybody and their mother is doing endovascular work.

 

[Silent Cool]

I've worked at a few different hospitals and it seems like there is no general consensus as to what exactly falls in the radiologists' turf as far as procedures go.

Biopsies? Drains? Lines? Are any of these solely left to an interventional radiologist? What can a DR do?

If I want to learn and do a lot of procedures during DR residency, would I be able to? (I'm sure it's somewhat institution dependant).

Cash checks
Write checks

What kinds of procedures do you enjoy?
I'm cute, huh?

 

[tco]

Biopsies, drains, chest tubes, Lines, percutaneous nephrostomy, percut cholecystostomy, arthrograms, joint injection/aspiration and Myelogram are considered general radiology skill sets. If you go to a fine residency program you should be able to do them by the end of your residency.

Since a lot of vascular work is takes away from IR, these procedures are done by IR. Also a lot of radiologists prefer to not do these procedures and leave it to IR.

There are many groups that expect you to know how to do these procedures. It is obvious that even if you are IR trained, you get better and esp faster as you go through your practice. However, you are expected to know. Similar to MSK MRI, Brain MRI, Body MRI, OB US, CT temporal bone, .... Groups expect you to be able to handle them well.

Give me a break. I don't know one general radiologist that does PCNs or percutaneous cholecystostomies...let's not even get into general rads doing vascular work... That's just laughable. I know you don't have any respect whatsoever for IR, but let's not make up lies... Someone might actually believe you.

 

[shark2000]

Give me a break. I don't know one general radiologist that does PCNs or percutaneous cholecystostomies...let's not even get into general rads doing vascular work... That's just laughable. I know you don't have any respect whatsoever for IR, but let's not make up lies... Someone might actually believe you.

Typical for a medical student or a junior resident. You are right because the only radiologists you have seen are the ones in your subspecialized medical center. You are right. Your chest attending can not put in a PCN. But he also can not read an abdominal CT, since he has not read anything but chest in the last 20 years.

You are wrong at many levels. If you think putting a Port is a vascular work, you are way behind the game dude. Our PA is also doing them.

I don't know your level of training, but these are done by general rads in many places. I am not IR trained but I do PCNs, percut Chole and Ports.

FYI, in many academic places body imagers are doing abscess drain, biopsies and PCNs.

Once, our group president told me that there is shortage of jobs, but there is a greater shortage of well trained candidates. After interviewing with some neuroradiology candidates last year, I came to the same conclusion. Don't get surprised if the new group expect you to do a lot of things that you think is not in the realm of general radiology. Also don't get surprised if nobody cares about you knowing all zebras and weird entities.

 

[tco]

Typical for a medical student or a junior resident. You are right because the only radiologists you have seen are the ones in your subspecialized medical center. You are right. Your chest attending can not put in a PCN. But he also can not read an abdominal CT, since he has not read anything but chest in the last 20 years.

You are wrong at many levels. If you think putting a Port is a vascular work, you are way behind the game dude. Our PA is also doing them.

I don't know your level of training, but these are done by general rads in many places. I am not IR trained but I do PCNs, percut Chole and Ports.

FYI, in many academic places body imagers are doing abscess drain, biopsies and PCNs.

Once, our group president told me that there is shortage of jobs, but there is a greater shortage of well trained candidates. After interviewing with some neuroradiology candidates last year, I came to the same conclusion. Don't get surprised if the new group expect you to do a lot of things that you think is not in the realm of general radiology. Also don't get surprised if nobody cares about you knowing all zebras and weird entities.

I made up a huge post on my phone and my browser crashed.

In short, who said anywhere that ports are vascular work? Jesus, I put in I ports last month as a medical student, and I wasn't under the delusion that I was doing vascular work. You're making all kinds of assumptions... You normally make great posts, then when someone mentions IR, you freak out. Who hurt you, shark?

The reimbursement for you doing a PCN is stupidly low, I'm sure. At least compared to you reading a knee MRI or doing a joint injection, where you could do a few of these in the same amount of time. I'm not sure of the reason to have you do those procedures other than your group must not have a dedicated IR guy... Then again, I'm just a ***** medical student, right? Probably wrong about that, too.

 

[shark2000]

I made up a huge post on my phone and my browser crashed.

In short, who said anywhere that ports are vascular work? Jesus, I put in I ports last month as a medical student, and I wasn't under the delusion that I was doing vascular work. You're making all kinds of assumptions... You normally make great posts, then when someone mentions IR, you freak out. Who hurt you, shark?

The reimbursement for you doing a PCN is stupidly low, I'm sure. At least compared to you reading a knee MRI or doing a joint injection, where you could do a few of these in the same amount of time. I'm not sure of the reason to have you do those procedures other than your group must not have a dedicated IR guy... Then again, I'm just a ***** medical student, right? Probably wrong about that, too.

We have 5 dedicated IR people. But once you join a pp group you will figure out that pp is not as specialized as you think. In our group I also read brain MRs, while we have neuroradiologists. Also I some non mammo trained people read mammo, while we have more than enough mammo people.
Still the majority of PCNs in my group is done by IR, but there are days that the IR guy is reading MSK Xrays and I do biopsies, abscess drains and PCNs. It may seem weird to you, but this is how pp works.

Take a look at body imaging fellowship at MGH, BWH, Univ of Wisconsin, UCLA and a few others. PCN is done by body section. Do you think they don't have dedicated IR radiologists? You stated that you don't know of any non-IR radiologist who is doing PCNs. You can find enough of them on the website of the mentioned programs.

 

[Bradstein]

Give me a break. I don't know one general radiologist that does PCNs or percutaneous cholecystostomies...let's not even get into general rads doing vascular work

At my institution I just did some peripheral vascular intervention with one of the neuroradiologists. When I asked him how he got comfortable doing PVD work without any "interventional" fellowship he said you get plenty in residency.

 

[tco]

We have 5 dedicated IR people. But once you join a pp group you will figure out that pp is not as specialized as you think. In our group I also read brain MRs, while we have neuroradiologists. Also I some non mammo trained people read mammo, while we have more than enough mammo people.
Still the majority of PCNs in my group is done by IR, but there are days that the IR guy is reading MSK Xrays and I do biopsies, abscess drains and PCNs. It may seem weird to you, but this is how pp works.

Take a look at body imaging fellowship at MGH, BWH, Univ of Wisconsin, UCLA and a few others. PCN is done by body section. Do you think they don't have dedicated IR radiologists? You stated that you don't know of any non-IR radiologist who is doing PCNs. You can find enough of them on the website of the mentioned programs.

I looked at a few of those sites. It seems as if most of the procedures they claim to do are CT guided - ablutions, biopsies, etc. Not fluoro guided PCN or PCNL placement. I'll give it to you that you're probably right in that some general rads do PCN placements. However, I've always felt that you need to be able to fix your own mistakes if you screw something up, so I don't feel that you should be doing them... Bleeding is a potential complication if you poke too central. Who fixes that?

 

[shark2000]

I looked at a few of those sites. It seems as if most of the procedures they claim to do are CT guided - ablutions, biopsies, etc. Not fluoro guided PCN or PCNL placement. I'll give it to you that you're probably right in that some general rads do PCN placements. However, I've always felt that you need to be able to fix your own mistakes if you screw something up, so I don't feel that you should be doing them... Bleeding is a potential complication if you poke too central. Who fixes that?

You are right. If I were the only radiologist in the middle of nowhere, I would not even do liver biopsies. But I have IR back up. I have surgery back up and ...

Fixing your own mistakes is a logic that surgeons use to steal our turf. With the same logic, no GI doctor should do colonoscopies because they can not fix a colon perforation (happens in 1/1000). With the same logic no IR or cardiologist should do PVD and it should only go to vasc surgeon. With the same logic, no OB should do hysterectomy because they may hit the bowel or ureter and they cannot fix it.

I highly encourage radiologists to be pro-active regarding doing procedures. I agree with you. You should HAVE A SOLUTION to the complications. It should either be yourself or an IR or surgery backup. Do you know how many times surgery asks IR to fix their complications? The best example is transplant surgeons asking IR to stent the stenosis of hepatic artery. No transplant surgeon that I know of can stent it himself. They always send it to IR. And many IR people use transplant surgeon as a back up for complications that need surgery.

I also agree with you that many general radiologists don't do PCNs. But on the other hand, as a field we have to well train our general people to do as much procedures as they can. Otherwise, someone else will take it. The best examples are Ob US, Echo and most NeuroIR procedures. There is much more to turf loss, but one side of it is not having enough radiologists to do it. Why? because in 80s and 90s general radiologists refused to read OB US, Echo or do cerebral angiograms. Many felt it is in the realm of subspecialist. And you know what happened.

If you make it more difficult for general rads to read brain MRI or to do biopsies, then an internist with a weekend course will start to do it. In my neighborhood, a family doctor is doing thyroid US and US guided thyroid biopsies. He even tried to do US guided breast biopsies. If he can do it, I doubt a general radiologist with 5 years of training can not do liver biopsy or PCNs.

We as a community, should encourage our colleagues either IR or Chest radiologist to do more and more.

Good Luck.

 

[tco]

You are right. If I were the only radiologist in the middle of nowhere, I would not even do liver biopsies. But I have IR back up. I have surgery back up and ...

Fixing your own mistakes is a logic that surgeons use to steal our turf. With the same logic, no GI doctor should do colonoscopies because they can not fix a colon perforation (happens in 1/1000). With the same logic no IR or cardiologist should do PVD and it should only go to vasc surgeon. With the same logic, no OB should do hysterectomy because they may hit the bowel or ureter and they cannot fix it.

I highly encourage radiologists to be pro-active regarding doing procedures. I agree with you. You should HAVE A SOLUTION to the complications. It should either be yourself or an IR or surgery backup. Do you know how many times surgery asks IR to fix their complications? The best example is transplant surgeons asking IR to stent the stenosis of hepatic artery. No transplant surgeon that I know of can stent it himself. They always send it to IR. And many IR people use transplant surgeon as a back up for complications that need surgery.

I also agree with you that many general radiologists don't do PCNs. But on the other hand, as a field we have to well train our general people to do as much procedures as they can. Otherwise, someone else will take it. The best examples are Ob US, Echo and most NeuroIR procedures. There is much more to turf loss, but one side of it is not having enough radiologists to do it. Why? because in 80s and 90s general radiologists refused to read OB US, Echo or do cerebral angiograms. Many felt it is in the realm of subspecialist. And you know what happened.

If you make it more difficult for general rads to read brain MRI or to do biopsies, then an internist with a weekend course will start to do it. In my neighborhood, a family doctor is doing thyroid US and US guided thyroid biopsies. He even tried to do US guided breast biopsies. If he can do it, I doubt a general radiologist with 5 years of training can not do liver biopsy or PCNs.

We as a community, should encourage our colleagues either IR or Chest radiologist to do more and more.

Good Luck.

To be fair, most of your posts having to do with IR are negative. You have a negative opinion of the field, which is fine, everyone has their own opinion and it doesn't have to agree with mine. That's why I was calling you out earlier...I wanted proof. You just admitted that a generalist doing PCNs isn't the norm, so I'll take that. I'll also give in that some may do them. We've reached a common ground.

I'm not quite sure at what you're hinting about PVD work with IR's not being able to fix. I suppose you're implying dissection? Anyway, some of the other examples that you've provided are excellent examples of one field doing procedures that other fields can do. Surgeons can do colonoscopies, but don't because they aren't as efficient at them as GI. PCPs can do thyroid US guided biopsies after some training, but don't because they're not as comfortable and as efficient as rads or path. IR does PCN's and PCNL's on a daily basis...They can handle them in a much faster and safer way than any other service, including a well trained general radiologist (unless he has been doing them daily since residency as well!) There's no better teacher than experience... I also agree with you that all generalists should get as much procedure time as possible. It only makes them more marketable. However, unless the generalist does a lot of procedures, anything more complicated than a drain placement, thyroid FNA, or line placement should probably be left to IR.

As far as my mentality, yes...I've always had a surgeon's mentality. 😳

At my institution I just did some peripheral vascular intervention with one of the neuroradiologists. When I asked him how he got comfortable doing PVD work without any "interventional" fellowship he said you get plenty in residency.

What exactly was he doing?

 

[Bradstein]

What exactly was he doing?

PTA of the SFA

 

[irwarrior]

Shark2000 raises some very valid points. I think all radiologists should get more involved in patient care and perform procedures. With that they need to see the patient, counsel them on the procedure , admit them to their service (when needed) and follow them longitudinally and deal with any issues related to their procedure. If the patient is having pain, the radiologist should order the pain medications, if there is an issue with the tube the radiologist should figure it out and address it and PCN tubes need constant management and they should be automatically be scheduled for change every 3 months.

Shark2000 practices more like an IR then many fellowship trained "IR" out there and so we should encourage all radiologists to be more aggressive about taking care of our patients as a group.

I would encourage those going into radiology to not shy away from patient care or procedural aspects of radiology, otherwise you commoditize the specialty. Procedural aspect of radiology is critical to the field and is not the sole domain of IR.

It is important that you go to a training program that will allow you first operator experience and a breadth of basic procedures.

Now, I don't expect a general radiologist to do an aortic dissection repair or a pedal stick and tibial artery or SFA recanalization, but basic vascular access and nonvascular procedures should be within the scope of practice of a well trained general radiologist.