Can you actually be satisfied by doing 50% DR and 50% IR?

[Stoop Kid]

Current R2, been really enjoying my DR residency so far. My favorite rotation was IR, mainly due to the ability to use skills that I learned from a surgical intern year and my radiology years. Moreover, what entices me is that IR can allow me to practice a heavily procedure based specialty using catheters and work as a diagnostician.

I am nearly set on swallowing the IR pill, but some IR attendings at my institution gave me pause about a month ago. They said that while traditionally, there have been many jobs with a mix of IR and DR in PP, many IR attendings doing this are mostly unhappy and usually beg to have a 100% IR job.

Been trying to reach out to IR docs outside the academic setting, but in the meantime would like to hear people's thoughts about the statement above.

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[SeisK]

Yes. Lots of IR docs like diagnostic imaging. The median IR doc does 50/50.

Keep in mind the faculty you encounter at academic institutions took a pay cut for 100% procedure volume, and are a sample biased minority.

 

[irwarrior]

The problem is in a part time 50/50 practice you will not get clinic time. It is hard to build a high end practice without clinic in the non academic environment. You often have to do the lines, biopsy, drains for the group and now with DR doing more remote work, the IR is asked to do anything with a needle (lp, pyelogram, arthrograms etc).

To do the high end interventions (PAD,dialysis, Pain, oncology, fibroids, BPH) a clinic is becoming more and more a requirement.

 

[guytakingboards]

Current R2, been really enjoying my DR residency so far. My favorite rotation was IR, mainly due to the ability to use skills that I learned from a surgical intern year and my radiology years. Moreover, what entices me is that IR can allow me to practice a heavily procedure based specialty using catheters and work as a diagnostician.

I am nearly set on swallowing the IR pill, but some IR attendings at my institution gave me pause about a month ago. They said that while traditionally, there have been many jobs with a mix of IR and DR in PP, many IR attendings doing this are mostly unhappy and usually beg to have a 100% IR job.

Been trying to reach out to IR docs outside the academic setting, but in the meantime would like to hear people's thoughts about the statement above.

That latter bolded sentiment is weird. It's somewhat got to be understood what you/anyone is getting themselves into when picking a job. If you want a 100% IR job, a community practice job where you typically won't get to practice 100% IR is the wrong job.

I've worked in two different big PP groups. The first one was big enough to be running its own clinic and OBL. Even in that group, IR's had to cover a few DR day and call shifts. I think most of them would have preferred more IR time, but saying that doing whatever percentage of DR made them unhappy is a stretch. It's just part of doing business.

Flip side I have a friend who left academic IR to join a community practice and has been extremely unhappy with the amount of low-end procedures and DR they have to do. In that case, they should have stayed in academics.

Personally, I'm a neuro DR person and the group I'm in now I read a lot of general. Would I prefer more neuro? Sure. Is that a bigger deal than all the other benefits of my group/job? No.

Just got to have some perspective of what matters.

 

[irwarrior]

More and more are shifting to the OBL. It is hard to run that fresh out of training as you may not be able to bail yourself out of complications and be comfortable doing PAD CLI interventions if you did not get that during training.

But check out oeisweb.com. This gives you some insight into how to go bout establishing this.

Some are specialized such as for PAE for BPH, geniculars for knee pain, UAE for fibroids and others are more broad. If interested would check out the local OBL/ASC VIR physician that is there. The benefits are you get to run the ship but you have to go out and seek referrals and be comfortable clinically . If you run it on your own , have to be comfortable with leasing office space, hiring and firing office staff, preauthorization and navigating insurance companies, managing your own inventory, buying your own Fluor units, EMR , billers, schedulers, x ray techs, MA, sedation nurses etc. Finally you need to have good marketers and navigate the competition.

Some also joint the multi specialty groups (GI for hemorrhoid embo, PAE with urology, Knee GAE with ortho/msk clinics etc)

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as an example.
Lots and lots fo opportunities. The biggest challenge may be the "pseudoexclusive contracts"

Backtable.com has some great podcasts on these options of OBL , multi specialty VIR groups etc.
linemonkeymd.com has some interesting blog material talking about the challenges of establishing the VIR clinic in the real world.

 

[Clean7795]

Current R2, been really enjoying my DR residency so far. My favorite rotation was IR, mainly due to the ability to use skills that I learned from a surgical intern year and my radiology years. Moreover, what entices me is that IR can allow me to practice a heavily procedure based specialty using catheters and work as a diagnostician.

I am nearly set on swallowing the IR pill, but some IR attendings at my institution gave me pause about a month ago. They said that while traditionally, there have been many jobs with a mix of IR and DR in PP, many IR attendings doing this are mostly unhappy and usually beg to have a 100% IR job.

Been trying to reach out to IR docs outside the academic setting, but in the meantime would like to hear people's thoughts about the statement above.

Most community practices are split IR/DR and the IR procedures are usually basic "low-end" type cases with the occasional bleeder/cirrhotic. If you like DR and you're fine doing a lot of biopsies, lines, tubes, drains for IR, then that will work well for you.

If you want to do more advanced/complex cases then you're going to have to work in either academics or a large community practice that can support that (mostly this will be in academics). There are some outpatient labs that do vascular procedures but you probably aren't going to be comfortable doing that as your first job, as you will still be building your skills.

That latter bolded sentiment is weird. It's somewhat got to be understood what you/anyone is getting themselves into when picking a job. If you want a 100% IR job, a community practice job where you typically won't get to practice 100% IR is the wrong job. ...

Personally, I'm a neuro DR person and the group I'm in now I read a lot of general. Would I prefer more neuro? Sure. Is that a bigger deal than all the other benefits of my group/job? No.

Just got to have some perspective of what matters.

Agreed.

 

[vm26]

Current R2, been really enjoying my DR residency so far. My favorite rotation was IR, mainly due to the ability to use skills that I learned from a surgical intern year and my radiology years. Moreover, what entices me is that IR can allow me to practice a heavily procedure based specialty using catheters and work as a diagnostician.

I am nearly set on swallowing the IR pill, but some IR attendings at my institution gave me pause about a month ago. They said that while traditionally, there have been many jobs with a mix of IR and DR in PP, many IR attendings doing this are mostly unhappy and usually beg to have a 100% IR job.

Been trying to reach out to IR docs outside the academic setting, but in the meantime would like to hear people's thoughts about the statement above.

If you really enjoy using surgical skills why not consider surgery/surgical subspecialty? DR (especially DR overnight call) is a different beast. IR attendings in PP are there for the money. Each PP group works differently but I would guesstimate IR partners make at least 20% more than pure DR primarily due to overnight call coverage. This can potentially change (eg. after the appropriate legislation has been passed, hire mid-levels to take overnight call)....Regardless whether in academics or PP, IR will get dumped on with lower reimbursement procedures performed during off-hours. Anything lucrative (particularly elective/out-pt) is likely to eventually get snatched away by specialists since they control the patients.

 

[SeisK]

Anything lucrative (particularly elective/out-pt) is likely to eventually get snatched away by specialists since they control the patients.

That’s not how this works really.

 

[irwarrior]

That’s not how this works really.

It is hard to build or sustain high end service lines of VIR , if you don't have clinic and if you are unable or unwilling to provide comprehensive clinical care.

If offering PAE, have to see a patient with LUTS check PSA, uroflow and IPSS, SHIM, IEFF , UA , prostate US etc. You have to be comfortable prescribing tamsulosin, finasteride ,tadalis, mirabegron , etc. Also, you have to counsel on alternative MIST options beyond turp including urolift, holes, rhezum, aquablation etc. Finally you have to target referrals from patients and primary care.

If offering PAD/CLI . You have to again have a clinic to see and follow patients. Feel comfortable with prescribing high intensity statins, anti HTN, anti-platelets, low dose rivaroxaban etc. You also have to feel comfortable with the clinical trials (CAPRIE, HOPE, COMPASS, VOYAGER, BASIL1 AND 2, BEST CLI). You have to be comfortable with diabetic foot ulcer management and noninvasive lab evaluation (Skin perfusion, Toe pressures, TcPo2), prescribing antibiotics, basic wound care and revascularization strategies (antegrade access, retrograde pedal access, safari, cart, reverse cart, DCB, DES, orbital atherectomy, laser etc).

The scope and breadth of modern day clinical VIR has expanded and the specialty is becoming more and more complex with requirements of increased clinical acumen as compared to 5 to 10 years ago. I

 

[Stoop Kid]

Thanks for the replies all.

I should clarify a few things. I am aware that in order to do the high end IR procedures, I would need to either do academic or 100% IR PP. That job does not interest me as of right now. I am, however, interested, in providing DR and IR coverage for basic bread and butter procedures and emergent procedures (GI bleed embolization, trauma embolization etc).

My point was that I had that vision in mind when I just finished up my rotation on IR. When I explained that to some of the IR people on staff, they suggested that the IR docs who are in private practice doing this were often not happy and were begging for a 100% IR job in academics (even if they originally thought they wanted a PP like practice). They told me nowadays, IR is best practiced as irwarrior described, and if I were steadfast in including diagnostics as part of my practice, it is best if I choose a diagnostic specialty that also does some procedures.

I was trying to find out if there were IR guys on here that do a mix of diagnostics or if anybody knew IR guys who practice like this and what their response would be to this sentiment.

If you really enjoy using surgical skills why not consider surgery/surgical subspecialty?

No, I am a diagnostic resident who enjoys diagnostics and IR catheter based procedures.

 

[guytakingboards]

providing DR and IR coverage for basic bread and butter procedures and emergent procedures (GI bleed embolization, trauma embolization etc).

This is the majority of community IR coverage.

 

[SeisK]

This is the majority of community IR coverage.

Truly.

I’ll reiterate what I said before, the majority of IRs do DR as well, as private practice radiologists compose the majority of radiologists in the US (something like 70% if I remember the figure correctly), and most IRs in PP do some DR. There was a figure floating around some time ago that the median IR doc does 50/50 IR/DR.

The academic guys telling OP this about “IR docs aren’t happy doing DR” are those that chose to take a paycut so they could do more procedures in academics (it pays less than PP, for both DR and IR), so you are getting a narrative from IRs that is sample-biased against DR.

The number of IR docs doing ZERO IR is roughly equal to the number doing 100% IR. A lot of IR docs love procedures, others figure out they really don’t love it at all and just want to do pure imaging instead. Most however want to do some, and also some DR, even if it means not doing as much high end stuff during normal business hours.

 

[sloh]

others figure out they really don’t love it at all.

What do you see are the usual reasons for this?

 

[SeisK]

What do you see are the usual reasons for this?

Burnout with call.

 

[Stoop Kid]

I’ll reiterate what I said before, the majority of IRs do DR as well, as private practice radiologists compose the majority of radiologists in the US (something like 70% if I remember the figure correctly), and most IRs in PP do some DR. There was a figure floating around some time ago that the median IR doc does 50/50 IR/DR.

I understand this, it still does not answer their satisfaction status. If you told me that the IR guys you have talked to at your practice enjoy this mix for x,y reasons, I think that would be a valuable perspective.

so you are getting a narrative from IRs that is sample-biased against DR.

I am also aware of this, that's why I asked the question here and have been contacting IR doctors out in the community.

 

[guytakingboards]

I understand this, it still does not answer their satisfaction status. If you told me that the IR guys you have talked to at your practice enjoy this mix for x,y reasons, I think that would be a valuable perspective.

The answer to this question of satisfaction varies widely.

There are plenty of community IR's who would prefer to never dictate a study but do so because there's not enough procedures and/or they need to make up their RVU's with diagnostic.

There are plenty of other community IR's who like procedures but also enjoy having moments of relative calm just doing some DR, either in between cases or on designated shifts.

Some people prefer a full schedule of drains and biopsies, some would rather do DR than the 8th biopsy/drain of the day.

 

[qxrt]

I do around 50/50 IR/DR.

Both in my prior and my current practice, I read general radiology (I can read almost all XR/US/CT exams as well as quite a bit of MR), and I also practice high-end IR (I've done TACE/TIPS/BRTO/etc, most recently did a prostate artery embo yesterday, have a right heart thrombectomy case on the schedule tomorrow as well as a bunch of other smaller IR cases).

I like being able to read and do nearly everything in radiology. I don't like being super subspecialized and unable to read or do basic radiology exams. I enjoy the big IR cases, but I wouldn't like doing them constantly - the DR days are comparatively relaxing. I do not want to become a 100% IR who can't read general radiology to save his life, nor do I want to be an IR-lite who only does drains and biopsies.

I can do all the big IR cases the 100% academic IR at the big tertiary care hospital can do, and I can also read and do everything at the high volume and efficiency that a general radiologist at a small community hospital can do (and I actually split my time between both settings, so I speak from first-hand experience).

I think I am currently in a very good position for what I wanted out of my job.

The colleagues I've admired the most are the ones who can read and do nearly everything - and if there's something they haven't tried before, they're willing to give it a try, instead of saying "I don't do that." I want to be like them.

 

[Stoop Kid]

I do around 50/50 IR/DR.

Both in my prior and my current practice, I read general radiology (I can read almost all XR/US/CT exams as well as quite a bit of MR), and I also practice high-end IR (I've done TACE/TIPS/BRTO/etc, most recently did a prostate artery embo yesterday, have a right heart thrombectomy case on the schedule tomorrow as well as a bunch of other smaller IR cases).

I like being able to read and do nearly everything in radiology. I don't like being super subspecialized and unable to read or do basic radiology exams. I enjoy the big IR cases, but I wouldn't like doing them constantly - the DR days are comparatively relaxing. I do not want to become a 100% IR who can't read general radiology to save his life, nor do I want to be an IR-lite who only does drains and biopsies.

I can do all the big IR cases the 100% academic IR at the big tertiary care hospital can do, and I can also read and do everything at the high volume and efficiency that a general radiologist at a small community hospital can do (and I actually split my time between both settings, so I speak from first-hand experience).

I think I am currently in a very good position for what I wanted out of my job.

The colleagues I've admired the most are the ones who can read and do nearly everything - and if there's something they haven't tried before, they're willing to give it a try, instead of saying "I don't do that." I want to be like them.

This is really awesome, thank you so much for this write up, I feel like this is exactly the job I want to shape out for myself. I have a couple of questions:

1. Are these type of jobs more common out in rural areas? I plan on living in a suburban area and was curious if geography matters.

2. I also admire people who can read almost anything and do almost anything, I want to practice in a setting similar to your practice. However, are there certain subspecialty studies that you draw the line (MRI skull bases, MR cardiac, diagnostic mammo etc.)

3. Do you think that some of the frustration that my attendings talked about (also frustration expressed by attendings on SIR) are due to something inherit in doing IR/DR or is it more based on expectations and private practice group they choose?

 

[vm26]

This is really awesome, thank you so much for this write up, I feel like this is exactly the job I want to shape out for myself. I have a couple of questions:

1. Are these type of jobs more common out in rural areas? I plan on living in a suburban area and was curious if geography matters.

2. I also admire people who can read almost anything and do almost anything, I want to practice in a setting similar to your practice. However, are there certain subspecialty studies that you draw the line (MRI skull bases, MR cardiac, diagnostic mammo etc.)

3. Do you think that some of the frustration that my attendings talked about (also frustration expressed by attendings on SIR) are due to something inherit in doing IR/DR or is it more based on expectations and private practice group they choose?

When I lived 60 miles away fro Sac, our group did most bread and butter light IR and all breast. Even though we had IR guys that once did vascular work, these cases were either done by vascular surgery or pts were shipped to out to different hospital in the same system.

Who reads what and who does X procedure is very dependent upon the practice and location. I'm currently in the mid-west, and who can read what and do X procedure is very scrutinized (I'm guessing largely due to competition from major academic centers in the area). I was in the NYC metro area before and this was much more relaxed and left to the group to decide. So it really varies.

Good thread on AM about IR call comp. In general an IR in PP (even one that reads dx in-between cases) will not produce wRVUs equal to that of a Dx rad and maybe about 35% less than a pure breast imager. Once a partner in PP all rads in general get the same cut but these days it seems like subspecialties are trying to justify why they deserve a larger cut.

 

[Tiger100]

If you don't want to do DR, IMO don't do IR. Choose a surgical subspecialty or GI or cards.