Anyone feel like ESIR has made their radiology class feel gunnery?

[GoPelicans]

Wondering if anyone else is getting this vibe.

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[Norick13]

Yep, and IR/DR residents think they’re better than the “regular” DR residents. At least at my, and other programs in a major east coast city.

We also have 2 program directors jockeying for control of the first 3-years of residency.

I get having a few integrated residencies like how CV/thoracic/plastics etc... have done for a few specific applicants, but completely doing away with a fellowship was such a dumb initiative.

Especially with non-ESIR residents basically being 2nd class applicants.

 

[NDcienporciento100]

I strongly disagree! The evolution of IR to its own specialty/residency was necessary do to the progression of the field, IR has migrated so far from DR as a clinical specialty that the standard 1 year fellowship was not sufficient. I don’t see ESIR as second rate applicants at all, it’s just another pathway into IR with more programs transitioning to the 5 year direct path I agree it will be more difficult for ESIRs to get that final year of training because of dwindling spots. Look, the direct pathway has made IR Main stream and has increased awareness to the specialty and more people are coming to understand what an IR is early on all of which is a good thing. Coming from a place of someone who just did all my interviews there are many 4th and 5th year DR residents that don’t even understand what IR is about. Overall the IR/DR residency is a good thing!

 

[126230]

What DR residents don't know what IR is about? They all do IR rotations.

 

[NDcienporciento100]

What DR residents don't know what IR is about? They all do IR rotations.

The answer to your question is actually quite complex but I will answer the best I can. Most traditional radiology residents never have done an IR rotation as a medical student, I did 5 IR rotation at 5 different institutions. The types of procedures you do in IR various greatly by institution (unlike other specialty’s), some programs do lots of PAD (ex:Rush) some do none, some programs do lots of stroke (ex:Brown) some do none, some programs may never see a TIPS procedure and some programs you will see one every day (ex: Cleveland Clinic) some programs all you see are the things that only IR can only do aka TIPS, Y90, ablations, and lots of PICC lines, some programs have no pediatric exposer. What I can tell you is no and I mean no program has everything that is one thing I’m sure of. I went on lots of interviews and it shocked me how some residents going into IR where obvious to the scope of IR, I went to one program the resident going into IR told everyone interviewing there “we do everything here, there is not an area of IR we don’t cover” it turned out they did zero PAD, aorta, neuro IR, peds, and they are a very weak program. Haveing done rotations as a medical student I have seen many IR programs and have been exposed to the variety of IR that most DR residents can’t match. I went to one highly respected institution where the resident said that virtually no IR’s do PAD anymore (such an ignorant statement) the reality is that in private practice IR’s do PAD all the time, and I have many more examples. Final point most DR residents are not in on the complex procedures if at all, The last away rotation I did was at an institution that does very complex angio procedures and the DR resident never stepped in the room, the resident did a few CT guided biopsy’s went with the PA to do some US guided procedures but he never stepped foot in Angio.

 

[GoPelicans]

Sir this is a Wendys

 

[SeisK]

Case in point...

 

[NDcienporciento100]

Sir this is a Wendys

I’m more of a Chick Fillet kinda person.

 

[YoungDoc25]

I’m more of a Chick Fillet kinda person.

 

[irwarrior]

Agree there are so many challenges with the whole process. The ESIR program does not get scrutinized by the ACGME in the same way that the integrated IR residency or even the independent IR residency do. So, what type of clinical and technical experience can vary greatly with the ESIR graduate. The other challenge is that ESIR occurs (ie PGY5) after the application/match for the independent residency. Often the "ESIR" applicant will have only done 2 to 3 months of IR prior to the interview process.

So , how does an applicant for independent residency differentiate themselves from the rest of the "pack". I believe it would require some of the things you did in medical school.

1) In service exams scores (doesn't hurt your cv if you do really well on them)
2) Good letters from IR and DR
3) Research in IR presented at national meetings
4) Long term interest in IR (ie starting as early as medical school) showcases commitment.
5) A full case log with many primary operator cases and scope of complex cases
6) Involvement in clinical rotations early (ICU/vascular surgery) etc
7) Involvement in national committees such as SIR RFS
8) Networking and presenting at the local angio clubs/national IR conferences
9) phone calls on your behalf from an IR who is known at the national level
10) busy surgical internship with some degree of autonomy
11) Workig
As more and more residents who have done a great deal of clinical rotations and VIR rotations in the finally year (PGY5), the VIR faculty may have less patience with training trainees in fundamentals of clinical medicine or technical components of VIR. It is akin to an attending surgical oncologist working with a surgical intern vs working with a surgical chief resident.

Great deal of growing pains, but it should start to level out as we get a more uniform curriculum and expectations of case logs.

Ie how many TACE/Y90s , peripheral leg cases, IVC filter removals, TIPS, BRTO, GI bleeds, prostate embolizations, UFE, Vertebroplasty, vein ablations, IVC recanalization, carotid stents, stroke revascularizations, biopsies (throughout body), ablations (lung, liver, kidney, bone), nonvascular interventions (abscess drains, nephrostomy drains, biliary drains and stents). Though there is not a great deal of difference in diagnostic training, I agree that there is tremendous variability in VIR training both in the clinical and technical aspects. I hope to see that improve with time.

With time it is likely that most VIR physicians will go through the integrated training pathway and there will likely be less independent spots available. But, no one can say for sure.

 

[Norick13]

I strongly disagree! The evolution of IR to its own specialty/residency was necessary do to the progression of the field, IR has migrated so far from DR as a clinical specialty that the standard 1 year fellowship was not sufficient. I don’t see ESIR as second rate applicants at all, it’s just another pathway into IR with more programs transitioning to the 5 year direct path I agree it will be more difficult for ESIRs to get that final year of training because of dwindling spots. Look, the direct pathway has made IR Main stream and has increased awareness to the specialty and more people are coming to understand what an IR is early on all of which is a good thing. Coming from a place of someone who just did all my interviews there are many 4th and 5th year DR residents that don’t even understand what IR is about. Overall the IR/DR residency is a good thing!

Case in point - didn’t even really read my post before responding.

IR in every day practice vs IR at academic centers is going to catch a lot of the direct pathway applicants off guard when they go out into the wild.

It’ll be interesting to see if the SIR marketing team can keep the gunners from med school interested as the DR job market continues to open up. I already know 2 people who want to switch into DR only.

 

[Tiger100]

Since the moderator closed the thread, I also delete my post. If the moderator doesn't want the discussion to continue, I respect his/her opinion and won't contribute to the discussion.

Good luck.

 

[126230]

I went on lots of interviews and it shocked me how some residents going into IR where obvious to the scope of IR, I went to one program the resident going into IR told everyone interviewing there “we do everything here, there is not an area of IR we don’t cover” it turned out they did zero PAD, aorta, neuro IR, peds, and they are a very weak program.

I doubt those residents were oblivious.

They were trying to sell you the program.

 

[NDcienporciento100]

This is a very shortsighted and terrible statement. In fact, it means that you are in big trouble.

If a 4th or 5th year old DR doesn't understand what IR is about, how do you expect the clinicians understand IR? What is really IR that only its own people understand it?

If a highly educated physician (i.e DR) with 4-5 months of rotation in IR doesn't understand what IR is about, how can other physicians without any IR experience or general public understand IR with a few talks and bulletins?

You angry? Lol! I said some, and the statement is not wrong. And yes many Doctors do not understand what IR is about. I heard a famous IR say in a lecture that his own mother does not know what he does for a living. I have seen IRs give lectures to people at their institution on aspects of IR and those docs get tons of referrals that way, the IM doc referring does not no anything about IR many times but he knows enough to send the pt to the right person.

 

[NDcienporciento100]

I doubt those residents were oblivious.

They were trying to sell you the program.

Then they did a bad job. Lol

 

[NDcienporciento100]

I1- R in academic centers is way way different than IR in community setting.

2- I know some IR fellows from top institutions who get surprised when you tell them that in average community program, most people don't do Y-90 and very few TACEs are done every months. They don't understand that a lot of high end IR procedures are done in transplant centers and big cancer centers.

3- Regarding PAD. I agree that IR does some PAD in the community unlike most academic centers.

4- For the foreseeable future, the typical IR job outside academics will be 10-20% high end procedures, 40% bread and butter procedures like biopsies, drains and lines and then 40% DR. Let's be realistic. The volume of DR and bread and butter procedures are going up and up unlike the volume of high end procedures.

5- If an IR applicant has a negative view of DR or can not tolerate DR, then they will have a hard time finding a job in private practice.
Despite all the advertisement by SIR, there is not enough IR work out there for all IRs to do 100% IR. There is about 40-50% IR work for every IR graduate out there and the rest should filled with either DR work or doing some "basic non-IR procedures" like FNAs, LPs and any needle work.

6- Unfortunately I have seen more negative view towards DR by IRs recently. There is a wrong misconception among some groups IRs that DR is the reason that they can not do high end procedures left and right.


About me: I have been in PP for a long time. Have done vascular work (not any more), Light IR, lines, drains and all aspects of DR and have been in different practice settings including being the chief of radiology at one community practice with 25 radiologists.

Regarding number 6, the complaint I have heard from IRs in DR private practice is that IRs in there groups often do less RVUs then there DR counterparts and take heat for it, when IRs are often working far more hours dealing with complications and dealing with lots of issues that take a lot of time but do not necessarily generate RVUs. Also I have heard that DRs push back on giving IRs resources to open an IR clinic if they become more busy.

 

[NDcienporciento100]

Your comment is wrong at many levels.

I have been in different practice settings. In all practice settings, IR makes less RVU than DR, however at the end of the day both had similar pay. However, I’ve never seen any complaints from DR people about the IR pay. In fact most DR people are totally fine with the current pay model.

However, some IRs (usually a minority) want to have their own clinic but they’re not willing to give up some of their salary for that. That's the root of the problem.

And one more point:
Once people start their own family and/or are in practice 5-10 years, they really don’t care about what kind of cases they do or most people don’t care about the clinic. They're totally fine with being part of a DR group and do a mixture of DR and bread and buttet IR. What you’re talking about and all the hype about IR clinic is usually some excitement at the level of medical students, residents and fellows (and some academic IRs).

In fact, Most IRs in their mid carrier (40s) prefer to do a good amount of DR and not having clinic or being on call all the time.

Think about what this person just did! He tells me my statement is wrong and then goes on to agree with almost everything I just stated. He agrees that DR makes more RVUs then IR, he agrees that some IRS want there own clinic! The only thing he disagrees with is that he states that no DRs ever get upset with IRs for making less RVUs then DR, which I can tell you I’m not wrong, go to SIR forum and you will see multiple posts less then a month old with multiple IR’s in practice with DRs who are giving them crap about making less RVUs. Oh and then he goes on a rant And basically says once you have been in practice a few years you won’t care what you do, I’m sure it’s true for some but not me. I’m still trying to figure out what this person is doing on this thread.. it’s not passion for rads or IR. Advice, go get some green tea and read a few CXRs and woosahhhh!!!

 

[NDcienporciento100]

Nobody is angry. So let's not make personal attacks if you want to have a reasonable discussion.

I know a good number of IRs with healthy practice. Nevertheless, the "myth" that you give lectures and all of a sudden get "tons of referrals" is a big time exaggeration. It is mostly driven by academics who have easy referral from transplant service and are blind to real world. I have seen fellows talk about it a lot.
I am not saying you can not build an IR practice. But it is a lot of work. It is not just some lectures. It takes 5-6 years of work. You may have to give up high salary for a few years and/or move to a location that is not desirable to you. On the other hand you will see your colleagues will join DR groups doing half IR half DR with better salary and better lifestyle but your practice may or may not thrive. If it thrives, it will be great but don't think you will make 3 times more than them or will have a better lifestyle.

Life is all about choices and you may be totally fine or enjoy practice-building. But it is not for everyone and also people should know about lufe realities. IMO, academics is advertising in a way that people think they will finish IR fellowship, will go to a community practice, will give 4-5 lectures and all of a sudden all high end cases will come their way (You also mentioned something similar) which is far far from reality especially if you are in a big or mid-size city.

Good Luck.

You just told me my statement is “terrible” and then he complains that I am making personal attacks!! Short memory, Lol! Now to punch holes in only “transplant centers” drive up high end procedure referrals ridicules statement! Transplant centers increase your TIPS, BRTO volume and Y90, TACE volume and a few other thing that are much less common. They do nothing for referrals for UFE, PAE PE lysis, splenic embos, GI bleeds, fistula declots, PAD, stroke thromblysis, ct guided procedures pain management procedures and I could keep going. Yes obviously it takes time build a successful practice which I have never said it didn’t. Lol

 

[NDcienporciento100]

I1- R in academic centers is way way different than IR in community setting.

2- I know some IR fellows from top institutions who get surprised when you tell them that in average community program, most people don't do Y-90 and very few TACEs are done every months. They don't understand that a lot of high end IR procedures are done in transplant centers and big cancer centers.

3- Regarding PAD. I agree that IR does some PAD in the community unlike most academic centers.

4- For the foreseeable future, the typical IR job outside academics will be 10-20% high end procedures, 40% bread and butter procedures like biopsies, drains and lines and then 40% DR. Let's be realistic. The volume of DR and bread and butter procedures are going up and up unlike the volume of high end procedures.

5- If an IR applicant has a negative view of DR or can not tolerate DR, then they will have a hard time finding a job in private practice.
Despite all the advertisement by SIR, there is not enough IR work out there for all IRs to do 100% IR. There is about 40-50% IR work for every IR graduate out there and the rest should filled with either DR work or doing some "basic non-IR procedures" like FNAs, LPs and any needle work.

6- Unfortunately I have seen more negative view towards DR by IRs recently. There is a wrong misconception among some groups IRs that DR is the reason that they can not do high end procedures left and right.


About me: I have been in PP for a long time. Have done vascular work (not any more), Light IR, lines, drains and all aspects of DR and have been in different practice settings including being the chief of radiology at one community practice with 25 radiologists.

Lastly, your not and IR so stop talking on this forum as if you are, mentioning the few procedures you do and such lol! Your a DR that’s pissed that IR has this new found hype. Your statement that high end procedures are being reduced is laughable!!!!! When you where training (I’m guessing in the 80s but I’ll be generous and say 90s) they did not do UFEs, PAEs, the tools for PAD where not there, y90 did not exists, splenic embos, stroke thrombectomies where a pipe dream, and list could go much further lol the many procedures IRs need to know continues to rise (hence why the changes in training structure). You work in a DR private practice job and know nothing about how IR is today which is why you are seeing more and more IRs try to work independent from them. What you need to do is stop hating, get up in the morning put your boxers on go to your computer and start reading films and stop talking like your an IR.

 

[Tiger100]

You just told me my statement is “terrible” and then he complains that I am making personal attacks!! Short memory, Lol! Now to punch holes in only “transplant centers” drive up high end procedure referrals ridicules statement! Transplant centers increase your TIPS, BRTO volume and Y90, TACE volume and a few other thing that are much less common. They do nothing for referrals for UFE, PAE PE lysis, splenic embos, GI bleeds, fistula declots, PAD, stroke thromblysis, ct guided procedures pain management procedures and I could keep going. Yes obviously it takes time build a successful practice which I have never said it didn’t. Lol

Keep using "lol" in your posts 100 more times.

It seems I am talking with a second grade kid.

 

[Tiger100]

The typical scenario of talking with "some" current IR fellows:
Nobody knows what is IR about.
Radiologists currently in practice "should not" give any comment about IR.


Stupidity doesn't have any limits.

 

[NDcienporciento100]

The typical scenario of talking with "some" current IR fellows:
Nobody knows what is IR about.
Radiologists currently in practice "should not" give any comment about IR.


Stupidity doesn't have any limits.

I love DR, get the facts straight, in order to be good at IR you have to be good at DR. The statement had nothing to do with your age, and had everything to do with your bogus statement on how IR procedures are going down, my comment was only to exemplify how far IR has come sense you trained as counteracting your crazy statement. And you know that! Which is why you did not defend the position.

 

[NDcienporciento100]

The typical scenario of talking with "some" current IR fellows:
Nobody knows what is IR about.
Radiologists currently in practice "should not" give any comment about IR.


Stupidity doesn't have any limits.

You brought this on yourself! Good night and good luck!

 

[thatsrad]

The reality is at least half of DR residents who were “100%” set on IR coming in, changed their mind after a month or two of IR rotations. You think this might be a good reason to trap them in as naive med students and make it difficult to switch out to DR?

The ones who didn’t change their minds about IR fellowship, from some IR attendings as I’ve heard them say “didn’t want to have to crank through DR work lists day after day” (in other words, not fast readers).

 

[Norick13]

I love DR, get the facts straight, in order to be good at IR you have to be good at DR. The statement had nothing to do with your age, and had everything to do with your bogus statement on how IR procedures are going down, my comment was only to exemplify how far IR has come sense you trained as counteracting your crazy statement. And you know that! Which is why you did not defend the position.

The Koolaide pitcher is empty after this guy huh?

The reality is that most of the ‘high-end’ procedures that apparently necessitates IR being an independent residency just aren’t there for most practitioners outside of academics. Just like with most surgical sub-specialties. Wanna be a pediatric oculoplastics surgeon? Cool you’ll be at one of a handful of pediatric hospitals.

Bread and butter IR has come a long way, and rightfully so, but more or less every procedure boils down to a few steps - just like every procedural specialty. Bread and butter IR just doesn’t require more than a year of training. Heck, most DR fellowship trained young attgs I work with tell me that they’re able to do most procedures in PP just off of doing a IR-heavy 4th year along with their normal rotations.

The difference is that other surgical specialties are losing numbers, and will want to start to take on new procedures, which IR is lousy with currently. When was the last time anyone saw an acute chole actually removed? We always get consulted to put a tube in.

The muckity mucks at SIR are making IR its own residency in order to control the flow of referrals. They want clinics to recruit patients. They don’t want a cash cow like interventional cards to slip away again.

That’s it.

You can try to make it more complicated than that, but it isn’t.

But thank you, you’ve entirely supported the original question of this thread.

 

[irwarrior]

The rapid expansile growth of VIR into aspects of more common disease is what enables the OBL to currently flourish. There has been a huge expansion in PAD with VIR now able to do pedal access, SAFARI, TAMI, etc. Many are adopting an endovascular approach first. Of note, there are many involved in the PAD space including VIR, IC, and VS. I agree that IO and even complex hepatobiliary (TIPS/BRTO) is a niche process primarily limited to liver transplant centers and there are around 20,000 Hcc cases and these are thus primarily done in large cities with academic centers. The challenge is that most VIR graduates get a year of technical skills primarily focused on Y90 and IO and hepatobiliary and this will be a detriment to building a practice in most non academic / non transplant centers. Unfortunately very few training programs focus on PAD, venous interventions (varicose veins etc), spine interventions which is truly what can be built in the community hospital. Also, as those areas are lucrative one will face more competition and many VIR are not used to competing for referrals as in academics they tend to still easily get referrals from specialists (surgical oncology/transplant surgery/hepatology/medical oncology). If you want to grow your practice in the community setting your focus should be on primary care, urgent care , ER etc. This takes 3 to 5 years to build. The new VIR training pathways are emphasizing more clinic time and consults, but unfortunately many are still technically based with their VIR residents doing inadequate clinic, minimal hospital admissions and inconsistent inpatient consultations. Also, the gap years of PGY2 through 4 with only 3 months of IR puts the VIR trainee at a clinical disadvantage to their clinical counterparts.

Where VIR are flourishing are in pain interventions (spine procedures/esi/facets/rhizotomy/vertebroplasty/kyphoplasty/spine jack). They are having a growing role in fibroid therapy and slowly expanding prostate therapy (BPH is very common in older males). Also they have a foothold in varicose veins which again is extremely prevalent. On top of the emergency cases such as acute DVT and PE, GI bleeds, trauma, epistaxis, hemoptysis etc. There is a growing role of VIR in medicine. This is where they can thrive, but the lifestyle in the hospital setting is very busy. Also, the imaging division generates so much revenue from ability to read so fast and such high volumes that very few VIR physicians can compete with that. The E and M coding though critical to a vibrant VIR practice does not generate enough revenue and is an opportunity cost for a radiology group (ie cost of leasing office space, Medical assistants, nurses, schedulers, EMR, extenders). Most DR groups would prefer the VIR tor read imaging and complete the lists.

Too most but not all radiology groups, they have VIR coverage simply to keep the other docs and administration happy (ie biopsies, drains, gastrostomy tube, bleeders, piccs, vascular access, occasional nephrostomy etc). If the VIR group covers stroke , that is a huge boon for a comprehensive stroke center or thrombectomy center. The problem that many new VIR graduates face is that the DR group currently has exclusive rights to radiology including VIR and so it is hard for someone to get privileges in the hospital in this setting. The VIR lifestyle is far more rigorous than the DR lifestyle as the call frequency is higher and the number of emergent add ons is high and direct patient care is always less efficient and unpredictable compared to true shift work. This can be frustrating to the VIR who truly does not embrace clinical medicine . If you are uncertain about VIR , I would recommend you pursue DR and a procedural subspecialty . I truly enjoy VIR for its scope and breadth and direct patient impact and longitudinal clinical follow up, but have accepted a surgical lifestyle and realize that my DR counterparts have better lifestyles and in general make more money per hour worked.

 

[irwarrior]

Competition even in training period is not necessarily a bad thing and perhaps the ESIR will make the integrated VIR residents less complacent. I do think that there will be a certain element of drop out from VIR integrated residency as residents will have buyers remorse when they see the DR co residents coming in later and going home at 5 pm, when the VIR trainee gets in sometimes before 6 am and stays very late and comes in not infrequently and handles lots of pages even when at home. Just like most surgical specialties (urology/ortho/ENT etc) it is important for the student interested in VIR to do multiple busy external rotations, where the hours and days are long to see if they still truly enjoy it even when tired.

 

[NDcienporciento100]

Good post by irwarrior.

If someone wants to do IR in its current model meaning doing 40% DR, 40% Bread and butter procedures and 10-20% high end procedures that happen to come through the department, I don't see any problem with that. Similarly, if someone wants to have IR clinic and practice new IR model, then great for them.

My problem is when some fellows think that the former group of traditional IRs or DRs are bunch of jerks or a$$hole and sometimes call them "greedy", sometimes call them "money hungry" and sometimes call them losers or look down at them. You could see some of it in the above posts. Comments like "wake up in the morning and go read your boring xrays in your dark cave" or "you guys hate me because I do a GI bleeder case at 2am" are childish at best and show some level of Hatred and disrespect towards current practicing Radiologists.

Good Luck.

I made no such negative comments about DRs not just on this forum but ever! My rude comments where directed to you alone, because you came on here and tried to very rudely say everything I said was wrong and terrible and discredit everything I said again in a very rude way. And I don’t know if you noticed but IRWorrier did not disagree with my points. Next time come in more reasonable and you will get a reasonable response!

 

[deleted950463]

Good post by irwarrior.

If someone wants to do IR in its current model meaning doing 40% DR, 40% Bread and butter procedures and 10-20% high end procedures that happen to come through the department, I don't see any problem with that. Similarly, if someone wants to have IR clinic and practice new IR model, then great for them.

My problem is when some fellows think that the former group of traditional IRs or DRs are bunch of jerks or a$$hole and sometimes call them "greedy", sometimes call them "money hungry" and sometimes call them losers or look down at them. You could see some of it in the above posts. Comments like "wake up in the morning and go read your boring xrays in your dark cave" or "you guys hate me because I do a GI bleeder case at 2am" are childish at best and show some level of Hatred and disrespect towards current practicing Radiologists.

Good Luck.

Tiger100 is known to be very condescending toward trainees and IRs. Best ignore that and focus on what’s useful.

He is correct that despite IR anchor DR groups to the hospital, direct patient care does not generate enough revenue.

However, the issue is that the most profitable activity of DRs, that of reading imaging, can be outsourced entirely. DR is becoming a commodity, and as long as there are people willing to read at less than medicare pro fee rate so they can read imaging from Kansas in their Manhattan apartments, DR groups face competition in that space. What’s stopping hospitals from replacing your private practice group with a much smaller group that is mostly IRs with the bulk of imaging handled by remote readers, especially if your location is not popular?

100% or near 100% IR jobs definitely exist. Academic IR is an obvious choice. Hospital employed situation can commonly be very IR heavy. I urge trainees who are interested in mostly IR to look into those two above.

 

[NDcienporciento100]

Tiger100 is known to be very condescending toward trainees and IRs. Best ignore that and focus on what’s useful.

He is correct that despite IR anchor DR groups to the hospital, direct patient care does not generate enough revenue.

However, the issue is that the most profitable activity of DRs, that of reading imaging, can be outsourced entirely. DR is becoming a commodity, and as long as there are people willing to read at less than medicare pro fee rate so they can read imaging from Kansas in their Manhattan apartments, DR groups face competition in that space. What’s stopping hospitals from replacing your private practice group with a much smaller group that is mostly IRs with the bulk of imaging handled by remote readers, especially if your location is not popular?

100% or near 100% IR jobs definitely exist. Academic IR is an obvious choice. Hospital employed situation can commonly be very IR heavy. I urge trainees who are interested in mostly IR to look into those two above.

Well said! And I feel pretty good about exposing his ignorance.

 

[NDcienporciento100]

Well said! And I feel pretty good about exposing his ignorance.

I could have responded to the ignorance or Noric talking about how IR gave up Cards, when IR never had Interventional Cards ever! first balloon angioplasty in the coronary was done by cards and they have owned the space ever sense and I could keep going on other things he said but there is only so much time in the day.

 

[deleted950463]

I could have responded to the ignorance or Noric talking about how IR gave up Cards, when IR never had Interventional Cards ever! first balloon angioplasty in the coronary was done by cards and they have owned the space ever sense and I could keep going on other things he said but there is only so much time in the day.

Cards took a lot of PAD and even venous work in some location due to having the referral base for it. I think it’s ultimately very, very difficult for IR to compete against cards in the PAD space because they can comprehensively manage the whole physiology from statins to coronary stenting. Cards have muscled out vascular surgery in a lot of places for PAD.

On the front of dialysis intervention, a lot of nephrologist started doing it because ultimately most fistula work isn’t very punishing even if complications occur. The most catastrophic scenario I can think of, if you aren’t messing around in the arterial side, are central venous rupture or retained balloon fragments, both are exceedingly rare and have good bailout options available. Again nephrologist have proximity to their own dialysis patients. There are staff IR attendings graduated from certain very well known programs who have essentially no experience with fistula work.

At the end of the day, the field of IR is so broad, nearly no training program will get you completely comfortable with everything. What does training serve, is to give you the clinical and procedural skillset and framework to make your niche as needed.

Ultimately, for clinical minded IRs, I simply don’t think private practice groups are first choice after training. The first year out in a surgical practice for a minimally invasive surgeon/IR is incredibly important from a skills development prospective. You want to have the high end cases and senior partners to be around to help if needed.

There are also hybrid groups out there combining both IR and VS and those IRs are heavily involved in PAD and aortic work. This is made possible in a multispecialty group practice setting.

 

[NDcienporciento100]

Cards took a lot of PAD and even venous work in some location due to having the referral base for it. I think it’s ultimately very, very difficult for IR to compete against cards in the PAD space because they can comprehensively manage the whole physiology from statins to coronary stenting. Cards have muscled out vascular surgery in a lot of places for PAD.

On the front of dialysis intervention, a lot of nephrologist started doing it because ultimately most fistula work isn’t very punishing even if complications occur. The most catastrophic scenario I can think of are central venous rupture or retained balloon fragments, both are exceedingly rare and have good bailout options available. Again nephrologist have proximity to their own dialysis patients. There are staff IR attendings graduated from certain very well known programs who have essentially no experience with fistula work.

I was starting to like you! Lol jk, but seriously the biggest steel on pad is vascular, and will continue to be because there the ones doing bypasses etc, and interventional cards is incredibly busy doing heart stuff, honest any of the 3 pathways could find there way into pad if you really pursue it. If nephrology want to get the **** radiated out of them all day by doing declots all day by all means come on in! Let’s compete!

 

[Tiger100]

I don't think PAD turf is completely lost but it has been cherrypicked big time especially by cardiologists. If their cardiac patient has an easy to fix PAD, they fix it. Otherwise they leave it to vascular surgery and probably IR is smaller areas.

 

[Tiger100]

The older vascular surgeons didn't have catheter skill and used to work with IR and make hybrid groups. I'm not sure what will happen with the new generation of VS

 

[NDcienporciento100]

1- You don't have any proof of your first paragraph. The problem is if someone gives a realistic comment, a lot of peopke will fingld it condescending. Useful things are realistic ones and not imaginary ones.

2- You are right about your second paragraph to some extent. There is always a limit. DR does a lot more than just film reading IN THE LONG RUN. Someone has to supervise techs, bring in new modalities, do mammo, do Flouro and go to hospital committees. But anyway, if the hospital decides to do it remotely they definitely can. But you know what will happen to the IR. They have to do the above-mentioned tasks on top of being on call every other night (the call frequency goes up if you go from 50% IR to 100% IR) and still making less than the traditional model. If that what makes them happy, that's great. But probably most don't like it.

3- Your last paragraph is incorrent. Outside academics, most IR jobs are a combination of IR and DR. And for unknown reasons, this makes people pissed off and they get offended if I say 100% IR jobs are difficult to find.

One last point to medical students. You keep hearing that DR is commodity. Some people including the above poster keep tepeating it without understanding what it means. Except for the doctors who live in very rural areas and except for some very famous doctors, pretty much everybody else is a commodity. I have seen that several times in my career.

Statement 3 is not incorrect, he says 100% IR jobs definitely exist and they do! He did not say there all or even most 100% IR, maybe you should trying reading a little slower before responding.

 

[deleted950463]

1- You don't have any proof of your first paragraph. The problem is if someone gives a realistic comment, a lot of peopke will fingld it condescending. Useful things are realistic ones and not imaginary ones.

2- You are right about your second paragraph to some extent. There is always a limit. DR does a lot more than just film reading IN THE LONG RUN. Someone has to supervise techs, bring in new modalities, do mammo, do Flouro and go to hospital committees. But anyway, if the hospital decides to do it remotely they definitely can. But you know what will happen to the IR. They have to do the above-mentioned tasks on top of being on call every other night (the call frequency goes up if you go from 50% IR to 100% IR) and still making less than the traditional model. If that what makes them happy, that's great. But probably most don't like it.

3- Your last paragraph is incorrent. Outside academics, most IR jobs are a combination of IR and DR. And for unknown reasons, this makes people pissed off and they get offended if I say 100% IR jobs are difficult to find.

One last point to medical students. You keep hearing that DR is commodity. Some people including the above poster keep tepeating it without understanding what it means. Except for the doctors who live in very rural areas and except for some very famous doctors, pretty much everybody else is a commodity. I have seen that several times in my career.

Tiger100, the point is that what keeps reading contracts secured are things that many DRs don’t like to do because they don’t generate RVUs. Guess what, those are the same thing that are commodizied.

Also, it seems like it is you who don’t understand exactly how much more of a commodity DR is. you can say that “everything is a commodity”. But to recruit a boot on the ground doc like FM or ED, you need to recruit them, post ads, etc, fly them out, wine and dine them (and their spouses) and get your groups together to interview, then negotiate contract, then credential them, etc. Meanwhile, to get more reading power for a remote hospital, all the admin need to do is to ask the existing telerad provider for additional service. It’s not even comparable how much more of a commodity a DR is compared to everyone else. The only thing that make a DR valuable is willingness to do procedures, which many newer DRs are not willing.

On the topic of hospital employed or IR only groups, tiger100 I urge you to do your own research (and everyone else). Many hospital employed situations are IR only.

 

[deleted950463]

The older vascular surgeons didn't have catheter skill and used to work with IR and make hybrid groups. I'm not sure what will happen with the new generation of VS

The specific group I know has a new VS grad who works with IR. It turns out when a VS and IR work on an EVAR together you can bill more.

 

[NDcienporciento100]

I don't think PAD turf is completely lost but it has been cherrypicked big time especially by cardiologists. If their cardiac patient has an easy to fix PAD, they fix it. Otherwise they leave it to vascular surgery and probably IR is smaller areas.

Stop trying to piggy back on other people’s comments. Fact: VS does the most by far PAD work!!! Between the cold legs, bypass grafts, and endovascular work it’s not even close!!!! Just stop! You don’t know what your talking about.

 

[Tiger100]

The specific group I know has a new VS grad who works with IR. It turns out when a VS and IR work on an EVAR together you can bill more.

That's not probably the typical setup. There are always some outliers but in most places vascular surgery works independently and is not willing to work with IR.

 

[Tiger100]

Stop trying to piggy back on other people’s comments. Fact: VS does the most by far PAD work!!! Between the cold legs, bypass grafts, and endovascular work it’s not even close!!!! Just stop! You don’t know what your talking about.

I said they cherrypick it and it is a true statement in most markets. I didn't say they do most of it. Improve your reading skills.

About 40% of PAD is done by cards, 40-50% by VS (there are less VS than cards so they do more cases per physician) and about 10% done by IR.

 

[NDcienporciento100]

I said they cherrypick it and it is a true statement in most markets. I didn't say they do most of it. Improve your reading skills.

About 40% of PAD is done by cards, 40-50% by VS (there are less VS than cards so they do more cases per physician) and about 10% done by IR.

Exact numbers! 46% vs, 29% IR 25% IC that’s PAD breakdown by Medicare! Once again you don’t know what you speak!!!

 

[Tiger100]

Reference??

 

[NDcienporciento100]

Reference??

James Bennanti MD Charles dotter lecture, you want the reference that bad go find it, before you talk **** he’s a top 5 name in IR, he’s private practice with VS, IC and IR as partners.

 

[Tiger100]

James Bennanti MD Charles dotter lecture, you want the reference that bad go find it, before you talk **** he’s a top 5 name in IR, he’s private practice with VS, IC and IR as partners.

1- So you don't have any reference. Giving the fact that 90% of IR programs even don't train their fellows to do PAD, your numbers are probably not correct. The one who is talking *** is probably you.

According to this article, the breakdown of PAD work between 2006 and 2011 was as below:

Cardiology 39.4 %
Vascular surgery 38.5%
Radiology 15.8 %
Other 6.2%

Unfortunately, The marketshare of radiology was dropping between 2006 and 2011 and was 12.9% in 2011. The new numbers may be slightly higher but probably not that much.

http://www.onlinejacc.org/content/accj/65/9/920.full.pdf

 

[deleted950463]

Rads also need credentialing.

You are wrong about ED.

In many places ED is covered by a company. The company brings ED doctors. A lot of them work per diem and don't go through the steps that you are talking about. The same for hospitalist service. They advertise the job and ding.

I'm not saying DR is not commodity but an interview and dinner with spouse doesn't give you job security. I have seen the hospital fired its orthopedic trauma surgeon over night and found a replacement in a week and gave them credentialing just in 10 days.

You can check what happened to a group of cardiologists/electrophysiologists in California recently. The hospital fired the overnight and brought a nee group in 2 weeks.

Wrong again. Perhaps ED is not the best example as they are also commodities. However, you are confused between recruiting people with a big premium in the setting of ortho trauma surgeon and granting them emergency privilege versus the ease of recruiting additional work load from a network of telerad who are ALREADY credentialed to read at your site. All your hospital admin need to replace your group (assuming you are a typical group with nighthawk tele in place already), is to add day service.

That is the fundamental difference between rads and ortho trauma. Your example cites California, an insanely popular location. Try Nebraska and see how quickly trauma docs can be replaced, while telerads won’t care where their study come from in their California beach house or Manhattan apartment.

It’s obvious that while you are familiar with some basic health care economics, you are only familiar with one particular practice setting, presumably that of a traditional diagnostic radiology private practice with light IR. I am very familiar with a variety of practice setting as I was involved in job search for IR very recently and may be more uptodate on how things are.

I can assure you, your type of practice arrangement is not a first choice for an outstanding, clinically oriented IR fellow, but then again, such a fellow would not be a good fit for your group.

 

[Tiger100]

I was starting to like you! Lol jk, but seriously the biggest steel on pad is vascular, and will continue to be because there the ones doing bypasses etc, and interventional cards is incredibly busy doing heart stuff, honest any of the 3 pathways could find there way into pad if you really pursue it. If nephrology want to get the **** radiated out of them all day by doing declots all day by all means come on in! Let’s compete!

If nephrologists start to do declots there is no way that IR can compete with them. Every ESRD patient has a nephrologist and is on dialysis and is supervised by his nephrologist 2-3 times a week at the Dialysis center. If they pick up the skill, the turf will be completely lost.

 

[NDcienporciento100]

1- So you don't have any reference. Giving the fact that 90% of IR programs even don't train their fellows to do PAD, your numbers are probably not correct. The one who is talking *** is probably you.

According to this article, the breakdown of PAD work between 2006 and 2011 was as below:

Cardiology 39.4 %
Vascular surgery 38.5%
Radiology 15.8 %
Other 6.2%

Unfortunately, The marketshare of radiology was dropping between 2006 and 2011 and was 12.9% in 2011. The new numbers may be slightly higher but probably not that much.

View attachment 271117

http://www.onlinejacc.org/content/accj/65/9/920.full.pdf

Hahah!! These numbers Include cardiac PCI of course cards has those numbers when you throw the PCIs in. Your are clueless and trying twist facts. I told you my reference!

 

[Tiger100]

Hahah!! These numbers Include cardiac PCI of course cards has those numbers when you throw the PCIs in. Your are clueless and trying twist facts. I told you my reference!

Read the article first. You are making a fool out of yourself by your comments. It is all PAD work.

The clueless one is you. You are not even capable of reading an article. This is the header of the table.

 

[NDcienporciento100]

If nephrologists start to do declots there is no way that IR can compete with them. Every ESRD patient has a nephrologist and is on dialysis and is supervised by his nephrologist 2-3 times a week at the Dialysis center. If they pick up the skill, the turf will be completely lost.

Do you know how much radiation you would get by doing declots all day long? It’s one of the most radiating procedures in all of medicine to the person doing the procedure. And they would be doing them all day long. Knock yourself out!