I am a 3rd yr. student thinking about applying to rads specifically to do IR this year. I have been really fascinated by all of the procedures and the idea that IR is essentially minimally invasive surgery where instead of having to suture someone up you just put a bandage over the entry site. It seems like IR invents new procedures that are quickly integrated in other fields (interventional cardiology or vascular surgery). I think that I would love IR but am concerned about the turf wars with other specialty. For example, at my school a surgeon lecturing to our class said that the vascular surgeons refused to handle complications from the IR physicians in our community and therefore the IR guys could only do biopsies, abscesses, vascular access, etc. Is there any truth to that in the real world? What kind of procedures can you do in private practice or are the "high level" procedures limited to academic institutions? I think I would really like to do IR but I am having second thoughts if 100% of your job is basic procedures.
Considering IR, is this true?
- Thread starter Doctor D
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I agree with OfficeDepot's statement that there is turf everywhere, we are just more sensitive to it being interested in IR. That being said, nobody can dictate to you how you will practice - that is up to you.
Young, aggressive IRs are out there seeing patients first, seeing them in clinic and on the floors, and treating them if needed - whether with minimally-invasive techniques or medical management. There is a strong paradigm shift in IR towards this purely clinical model where we are equally as important and knowledgeable for a variety of diseases - we should and need to be disease experts.
In private practice, you can and should be doing "high end" procedures including things like TIPS, interventional oncology, PAD, and neurointerventions (stroke treatments, etc.). Again, it's about how you want to work and how hard you get your name and reputation out there as a disease expert. Once you have established your reputation, both in knowledge, skill, and patient care, other clinicians (including surgeons) will send you referrals. At the same time, you can help to educate clinicians such as primary care docs and ER docs on conditions that you are an expert in (by CME talks, grand rounds, etc.) and they will look to you when they get patients with these problems.
Your professional destiny is in your hands. I strongly encourage you to shadow a clinical IR (you can find a local mentor - http://directory.sirweb.org/mentors/) and see what their practice is like. Best wishes.
Young, aggressive IRs are out there seeing patients first, seeing them in clinic and on the floors, and treating them if needed - whether with minimally-invasive techniques or medical management. There is a strong paradigm shift in IR towards this purely clinical model where we are equally as important and knowledgeable for a variety of diseases - we should and need to be disease experts.
In private practice, you can and should be doing "high end" procedures including things like TIPS, interventional oncology, PAD, and neurointerventions (stroke treatments, etc.). Again, it's about how you want to work and how hard you get your name and reputation out there as a disease expert. Once you have established your reputation, both in knowledge, skill, and patient care, other clinicians (including surgeons) will send you referrals. At the same time, you can help to educate clinicians such as primary care docs and ER docs on conditions that you are an expert in (by CME talks, grand rounds, etc.) and they will look to you when they get patients with these problems.
Your professional destiny is in your hands. I strongly encourage you to shadow a clinical IR (you can find a local mentor - http://directory.sirweb.org/mentors/) and see what their practice is like. Best wishes.
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To OP:
I applied to radiology specifically to do IR, though there were a lot of things I liked about DR, like peds and non-invasive vascular imaging, and even liked nucs; but couldn't then, and can't now imagine doing anything more than 25% IR (which sounds like a lot, but if you really think about it, it's about 1/5 or 6 days per week that you will have to DR, and if you read my other posts, if you're doing IR the other days, it definitelly feels like day off, or at the very least a welcome change of pace).
The vascular surgeon who came and talked is probably a dbag or completely ignorant, or both or has had some really crappy IRs working with him who wouldn't come in for emergencies or wouldn't do cases when he asked or indeed had an unacceptably high complication rate.
It always makes me chuckle when a surgeon comes around saying they want to do IR procedures because IR doesn't handle their own complications, when pretty much the majority of CT and US guided procedures (with exception of biopsies) is dealing with their complications; We have a huge transplant center (hepatic and renal and pancreatic) and we have at least 1-2 endovascular cases a week if not more dealing with "their complications" like coiling pseudoaneurysms/bleeds, stenting stenotic hepatic and renal transplant arteries; not to mention the innumerable post-op abscesses we have to deal with. I have seen exactly 2 cases in which a surgeon has had to get involved with one of our cases, that's 2 of ours, for dozens upon dozens of their's.
Complications are a well described, known, and expected entity in medicine and keeping score of who is bailing out whom is not the best way to practice; look at the best multi-disciplinary centers like Mayo, Toronto, most tumor boards most VA hospitals (where everyone is salaried and no RVUs come into play) where surgeons, IRs, med docs, rad oncs etc do what they do best and the patient wins, in general revenue is a little down but everyone is happier and there are no turf issues.
As far as various turf battles: I have heard of vascular surgeons doing chemoembo, when I try to follow-up, either asking a device rep who works at the hospital where it's supposedly going on, or a resident or other doc, it turns out to be false. I can't imagine any VS out there who would have the hubris to do chemoembo or y90, because it's more than just twiddling a wire into the hepatic artery.
I've also heard of cards doing portal venous stuff, which was so outlandish (that means there is a cardiologist sticking a needle into the liver all willy-nilly without any sort of training) I thought no way someone can make that up, turns out it was made up.
It's extremely unlikely surg onc will start doing endovascular oncology (they lack the catheter skills, and no one will teach them), they already do and have done in the past ablations surgically, we technically "stole" that from them.
Rad onc is extremely unlikely to start doing IR, because they are just not that procedural, in fact, while extremely smart, I find it hard to define what they actually physically "do"; though I do agree IR/rad onc dual training would be good, though that sort of training would take around 8 years, and in the end you'd still do one or the other because of different skill sets; those 2 specialties should work much more closely together then they currently are though.
Like above people have said you will always turf battles, but if you want to do IR, admit patients do consults, and not be relegated to drains and access there are many practice settings where you can do that.
We get to rotate through the VA here (large academic med center in mid-size midwest metro area) and they have 2 vascular surgeons and 1 IR who do all EVARs together, cardiac gets involved for TEVARs, IR does the vast majority of endovascular lower and upper extremity PVD; the same IR goes to tumor board and has a healthy onc practice, and they have a DR who does CT and US guided interventions; everyone is super happy and super busy. That sort of model will always be in place at the VA.
At Mayo clinic (jacksonville for sure, rochester ?, and don't know about scottsdale) there heart and vascular center is run by IR/VS/Cards; they alternate call/consult pagers q1 week, and IR does their own thing with CT/US/oncology/hepatobiliary/portal vein stuff; cards does heart and VS does open stuff; again very busy and very happy
PP: to do any significant IR you have to go to a large practice, though not necessarily a large city: check out Riverside Radiology Assoc in Columbus OH; Inland Imaging in Spokane WA and Maine Medical Center in Portland, I could list more but don't have time.
Academics: pretty much anywhere with a healthy hospital system; though more politics dependent.
Bottom line is you have to do what you love, there are tons of good IR jobs out there but you have to be more than a procedure monkey, and there certainly aren't jobs where you can just sit around and wait for someone to order a procedure, be prepared to work surgeon like hours.
I applied to radiology specifically to do IR, though there were a lot of things I liked about DR, like peds and non-invasive vascular imaging, and even liked nucs; but couldn't then, and can't now imagine doing anything more than 25% IR (which sounds like a lot, but if you really think about it, it's about 1/5 or 6 days per week that you will have to DR, and if you read my other posts, if you're doing IR the other days, it definitelly feels like day off, or at the very least a welcome change of pace).
The vascular surgeon who came and talked is probably a dbag or completely ignorant, or both or has had some really crappy IRs working with him who wouldn't come in for emergencies or wouldn't do cases when he asked or indeed had an unacceptably high complication rate.
It always makes me chuckle when a surgeon comes around saying they want to do IR procedures because IR doesn't handle their own complications, when pretty much the majority of CT and US guided procedures (with exception of biopsies) is dealing with their complications; We have a huge transplant center (hepatic and renal and pancreatic) and we have at least 1-2 endovascular cases a week if not more dealing with "their complications" like coiling pseudoaneurysms/bleeds, stenting stenotic hepatic and renal transplant arteries; not to mention the innumerable post-op abscesses we have to deal with. I have seen exactly 2 cases in which a surgeon has had to get involved with one of our cases, that's 2 of ours, for dozens upon dozens of their's.
Complications are a well described, known, and expected entity in medicine and keeping score of who is bailing out whom is not the best way to practice; look at the best multi-disciplinary centers like Mayo, Toronto, most tumor boards most VA hospitals (where everyone is salaried and no RVUs come into play) where surgeons, IRs, med docs, rad oncs etc do what they do best and the patient wins, in general revenue is a little down but everyone is happier and there are no turf issues.
As far as various turf battles: I have heard of vascular surgeons doing chemoembo, when I try to follow-up, either asking a device rep who works at the hospital where it's supposedly going on, or a resident or other doc, it turns out to be false. I can't imagine any VS out there who would have the hubris to do chemoembo or y90, because it's more than just twiddling a wire into the hepatic artery.
I've also heard of cards doing portal venous stuff, which was so outlandish (that means there is a cardiologist sticking a needle into the liver all willy-nilly without any sort of training) I thought no way someone can make that up, turns out it was made up.
It's extremely unlikely surg onc will start doing endovascular oncology (they lack the catheter skills, and no one will teach them), they already do and have done in the past ablations surgically, we technically "stole" that from them.
Rad onc is extremely unlikely to start doing IR, because they are just not that procedural, in fact, while extremely smart, I find it hard to define what they actually physically "do"; though I do agree IR/rad onc dual training would be good, though that sort of training would take around 8 years, and in the end you'd still do one or the other because of different skill sets; those 2 specialties should work much more closely together then they currently are though.
Like above people have said you will always turf battles, but if you want to do IR, admit patients do consults, and not be relegated to drains and access there are many practice settings where you can do that.
We get to rotate through the VA here (large academic med center in mid-size midwest metro area) and they have 2 vascular surgeons and 1 IR who do all EVARs together, cardiac gets involved for TEVARs, IR does the vast majority of endovascular lower and upper extremity PVD; the same IR goes to tumor board and has a healthy onc practice, and they have a DR who does CT and US guided interventions; everyone is super happy and super busy. That sort of model will always be in place at the VA.
At Mayo clinic (jacksonville for sure, rochester ?, and don't know about scottsdale) there heart and vascular center is run by IR/VS/Cards; they alternate call/consult pagers q1 week, and IR does their own thing with CT/US/oncology/hepatobiliary/portal vein stuff; cards does heart and VS does open stuff; again very busy and very happy
PP: to do any significant IR you have to go to a large practice, though not necessarily a large city: check out Riverside Radiology Assoc in Columbus OH; Inland Imaging in Spokane WA and Maine Medical Center in Portland, I could list more but don't have time.
Academics: pretty much anywhere with a healthy hospital system; though more politics dependent.
Bottom line is you have to do what you love, there are tons of good IR jobs out there but you have to be more than a procedure monkey, and there certainly aren't jobs where you can just sit around and wait for someone to order a procedure, be prepared to work surgeon like hours.
IR is becoming necessary for any decent sized hospital. I recently visited a friend of mine who is in a 100 bed hospital and he has only been there for a year. But, in that time he has developed a pretty solid IR practice and is quite busy. He is doing everything from TIPS to arterial thrombolysis and recanalizations to embolizations. He practices like a surgeon with full consultative practice and call coverage. In a short amount of time he has established a good referral pattern and he also has been referring a fair number of patients to other consultants. He admits and follows his own patients. He is an independent contractor and that allows him the flexibility to practice build.
There are many hospitals who are looking for clinically sound and technically aggressive interventional radiologists.
The radiology groups are trying to recruit IRs to staff the call coverage (as this is critical to get many hospital contracts), but at the same time do not want to fund the expensive overhead (office staff, schedulers, physician extenders, electronic medical records, office space etc). Also, a lot of what we do rounding, office based consultations, admitting patients etc do not generate that much in terms of revenue for the radiology practice. However, the hospital reaps a substantial benefit from the technical fees. So, the radiology groups often want the IR to read imaging (generating RVUs) rather than seeing patients (poor RVU generator).
Many of the modern day IR, want to see patients and feel this is critical for a rewarding and fulfilling practice. This has resulted in more and more IR setting up independent IR practices or contracting with the hospital. Then the hospital will often help subsidize some of the overhead for the IR physicians.
There is plenty of work to be had. The inpatient side of things can keep you busy with inpatient biopsies, dialysis work and abscess drainages . However, there is a fair amount of elective work that you can be proactive about developing that is fairly common. To generate these referrals, you have to be an expert on all aspects of the disease you are treating including the medical management.
1. Pain interventions (ESI, facet blocks, vertebroplasty, kyphoplasty, celiac blocks etc)
2. Peripheral arterial interventions (wound care and leg revascularization as well as the management of claudicants (often medical treatments and exercise regimens)
3. Venous disease (varicose veins, dvt lysis, PE treatments, IVC filters)
4. Neurointerventional (Stroke therapy and carotid stenting)
5. Women's therapy (fibroid embolization, tubal recanalization, pelvic congestion syndrome)
6. Oncology (ablative therapy; transarterial therapy (TACE/Y90), ports.
There are many hospitals who are looking for clinically sound and technically aggressive interventional radiologists.
The radiology groups are trying to recruit IRs to staff the call coverage (as this is critical to get many hospital contracts), but at the same time do not want to fund the expensive overhead (office staff, schedulers, physician extenders, electronic medical records, office space etc). Also, a lot of what we do rounding, office based consultations, admitting patients etc do not generate that much in terms of revenue for the radiology practice. However, the hospital reaps a substantial benefit from the technical fees. So, the radiology groups often want the IR to read imaging (generating RVUs) rather than seeing patients (poor RVU generator).
Many of the modern day IR, want to see patients and feel this is critical for a rewarding and fulfilling practice. This has resulted in more and more IR setting up independent IR practices or contracting with the hospital. Then the hospital will often help subsidize some of the overhead for the IR physicians.
There is plenty of work to be had. The inpatient side of things can keep you busy with inpatient biopsies, dialysis work and abscess drainages . However, there is a fair amount of elective work that you can be proactive about developing that is fairly common. To generate these referrals, you have to be an expert on all aspects of the disease you are treating including the medical management.
1. Pain interventions (ESI, facet blocks, vertebroplasty, kyphoplasty, celiac blocks etc)
2. Peripheral arterial interventions (wound care and leg revascularization as well as the management of claudicants (often medical treatments and exercise regimens)
3. Venous disease (varicose veins, dvt lysis, PE treatments, IVC filters)
4. Neurointerventional (Stroke therapy and carotid stenting)
5. Women's therapy (fibroid embolization, tubal recanalization, pelvic congestion syndrome)
6. Oncology (ablative therapy; transarterial therapy (TACE/Y90), ports.
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There's a bright future for IR as it encompasses so many different potential modalities, and the skill set they acquire is flexible enough to do many (most) procedures.
I believe it's wishful thinking however to think that IR is going to be a major player in arterial disease in many settings down the road. They're just not positioned to ever dominate this, and their ability to do this is in part dependent upon the willingness of vascular surgeons to be their backup. People who dismiss this scenario (of urgent surgery being required for adventures from passing stents/wires) being required just haven't been around long enough as it's not that uncommon and can be real scary. As the newer generations of vascular trained surgeons are doing increasingly large % of their practices in endo suites, referrals will dwindle for elective PAD procedures to IR's except in institutions with some unique or legacy situations. I've already seen this neutering of vascular referrals to IR play out in about 6-8 hospitals where I've trained or practiced.
I believe it's wishful thinking however to think that IR is going to be a major player in arterial disease in many settings down the road. They're just not positioned to ever dominate this, and their ability to do this is in part dependent upon the willingness of vascular surgeons to be their backup. People who dismiss this scenario (of urgent surgery being required for adventures from passing stents/wires) being required just haven't been around long enough as it's not that uncommon and can be real scary. As the newer generations of vascular trained surgeons are doing increasingly large % of their practices in endo suites, referrals will dwindle for elective PAD procedures to IR's except in institutions with some unique or legacy situations. I've already seen this neutering of vascular referrals to IR play out in about 6-8 hospitals where I've trained or practiced.
I do think that there is always that potential for a complication that may need surgical backup. However, these issues are becoming less and less of an issue. There are certain cases that will require a bail out such as an acute limb ischemic patient that may need 4 compartment fasciotomy as you reperfuse the limb.
But, if you look at cardiac cath and its evolution. Cardiology is able to handle the bulk of their complications with the advent and progression of devices. The jostent has allowed for ruptures to be managed endovascularly. The various thrombectomy and aspiration catheter and devices also have allowed for an endovascular first approach to dealing with distal embolus or acute thrombosis (be it angiojet, pronto,export catheters etc).
In the peripheral vasculature this is also becoming the same. There are numerous interventional cardiologists and vascular interventional radiologists who are performing peripheral vascular endovascular interventions whether it be recanalizing the entire SFA or tibial vasculature or even pedal vessels. They are able to manage many of the complications (thrombosis,embolization, rupture,dissection) with various adjuncts. Again the pronto, export, angiojet, trellis device, covered stents , embolization coils, thrombolytics, IIbIIIa receptor inhibitors, embolic protection devices all either reduce or are amazing bail outs for endovascular operators. In fact there are many interventionalists who are doing peripheral arterial disease interventions routinely in the outpatient centers. It is imperative that if you are going to do this, that you have a decent operator experience and are well versed in all the bail out techniques and pick your patients wisely and have the bail out tools at your fingertips.
But, if you look at cardiac cath and its evolution. Cardiology is able to handle the bulk of their complications with the advent and progression of devices. The jostent has allowed for ruptures to be managed endovascularly. The various thrombectomy and aspiration catheter and devices also have allowed for an endovascular first approach to dealing with distal embolus or acute thrombosis (be it angiojet, pronto,export catheters etc).
In the peripheral vasculature this is also becoming the same. There are numerous interventional cardiologists and vascular interventional radiologists who are performing peripheral vascular endovascular interventions whether it be recanalizing the entire SFA or tibial vasculature or even pedal vessels. They are able to manage many of the complications (thrombosis,embolization, rupture,dissection) with various adjuncts. Again the pronto, export, angiojet, trellis device, covered stents , embolization coils, thrombolytics, IIbIIIa receptor inhibitors, embolic protection devices all either reduce or are amazing bail outs for endovascular operators. In fact there are many interventionalists who are doing peripheral arterial disease interventions routinely in the outpatient centers. It is imperative that if you are going to do this, that you have a decent operator experience and are well versed in all the bail out techniques and pick your patients wisely and have the bail out tools at your fingertips.
There is risk of colonic rupture with colonoscopy esp when you do polipectomy, as a result GI docs should not do colonoscopy.
There is risk of ureter injury during C/S, so OB-Gyn should not do it unless they are trained in Uro-Gync which less than 1% of them are.
There is risk of Pneumothorax when doing bronchoscopy so pulm people shouldn't do it.
There is a risk of Acute renal failure with most medications, so nobody should prescribe any medication other than nephrologist.
When it comes to money, people's arguments are ridiculous.
And I don't know why these complications can only happen when there is money involved.
Don't forget that in most VA systems vascular surgeons do not have any problem backing up IRs doing vascular work.
There is risk of ureter injury during C/S, so OB-Gyn should not do it unless they are trained in Uro-Gync which less than 1% of them are.
There is risk of Pneumothorax when doing bronchoscopy so pulm people shouldn't do it.
There is a risk of Acute renal failure with most medications, so nobody should prescribe any medication other than nephrologist.
When it comes to money, people's arguments are ridiculous.
And I don't know why these complications can only happen when there is money involved.
Don't forget that in most VA systems vascular surgeons do not have any problem backing up IRs doing vascular work.
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Your analogies are overlooking the elephant in the room.
Cardiologists and Gastroenterologists are the gatekeepers for referrals for CV surgeons and general surgeons. THAT'S why they back them up for complications (and consequently why cardiologists with CTVS backup are better positioned then IR for vascular cases) for those procedures. IR is not a gate keeper, but rather a competitor of sorts to vascular surgery and cardiololgy. Completely different relationship and why IR is always going to lose that battle when there's other players .
Cardiologists are competitors for CT surgeons since they stent almost everything and leave the CT surgeon with no landing room when the patient really needs CABG. This is well known and is reflected by the declining numbers of CABG being performed. Also, with covered stents, the Cardiologist does not need CT surgery backup if/when they rupture a coronary vessel.
In a similar way, ERCP, EUS, and other tools/techniques used by GI competes with general surgery and the ones that go to surgery are often the train-wreck cases with diverticulitis, Crohn's, etc. And even with these cases, I am referring more cases to general surgery than GI does since there is such an abundant use of CT to diagnose these diseases. And when there are complicated cases with abscesses, I can work with general surgery if the patient is a candidate for abscess drainage vs open surgery -- this is something they greatly appreciate.
In our practice, GI is a great referral source and we have an excellent relationship with them. TIPS is certainly something that only a skilled IR can perform and helps the GI/hepatology service, especially in bridging the patient.
Sometimes we are even consulted before GI. The other day, we were consulted to perform a PTC with biliary stenting for a patient with ascending cholangitits and I told the general surgery service we'd be happy to do so, but that they should consult GI to perform/attempt ERCP with stenting first since this would be better for the patient. GI was not able to perform the stenting and the patient was sent to us where we were successful. Our IR service has a great reputation for not only being able to help/bail out others, but that we do what's right for the patient (even if that means that someone else should be doing a procedure/surgery).
I think that practices vary quite a bit and would not generalize things the way droliver did, but perhaps that more reflects his own practice. I agree with the sentiments of several others on this forum that IR is a specialty who's fate is in your hands. If you are aggressive, clinical, and affable, physicians will recognize your skills and knowledge and refer cases to you (and vice-versa). If you take a more "8-5" mindset and do not practice clinically (simply a technician), you will be sent the scraps and will more likely have a less satisfying career -- this was stated succinctly in 1968 by the father of IR, Charles Dotter:
"If my fellow angiographers prove unwilling or unable to accept or secure for their patients the clinical responsibilities attendant on transluminal angioplasty, they will become high-priced plumbers facing forfeiture of territorial rights based solely on imaging equipment others can obtain and skill still others can learn." - Charles Dotter, American College of Surgery meeting in 1968
In a similar way, ERCP, EUS, and other tools/techniques used by GI competes with general surgery and the ones that go to surgery are often the train-wreck cases with diverticulitis, Crohn's, etc. And even with these cases, I am referring more cases to general surgery than GI does since there is such an abundant use of CT to diagnose these diseases. And when there are complicated cases with abscesses, I can work with general surgery if the patient is a candidate for abscess drainage vs open surgery -- this is something they greatly appreciate.
In our practice, GI is a great referral source and we have an excellent relationship with them. TIPS is certainly something that only a skilled IR can perform and helps the GI/hepatology service, especially in bridging the patient.
Sometimes we are even consulted before GI. The other day, we were consulted to perform a PTC with biliary stenting for a patient with ascending cholangitits and I told the general surgery service we'd be happy to do so, but that they should consult GI to perform/attempt ERCP with stenting first since this would be better for the patient. GI was not able to perform the stenting and the patient was sent to us where we were successful. Our IR service has a great reputation for not only being able to help/bail out others, but that we do what's right for the patient (even if that means that someone else should be doing a procedure/surgery).
I think that practices vary quite a bit and would not generalize things the way droliver did, but perhaps that more reflects his own practice. I agree with the sentiments of several others on this forum that IR is a specialty who's fate is in your hands. If you are aggressive, clinical, and affable, physicians will recognize your skills and knowledge and refer cases to you (and vice-versa). If you take a more "8-5" mindset and do not practice clinically (simply a technician), you will be sent the scraps and will more likely have a less satisfying career -- this was stated succinctly in 1968 by the father of IR, Charles Dotter:
"If my fellow angiographers prove unwilling or unable to accept or secure for their patients the clinical responsibilities attendant on transluminal angioplasty, they will become high-priced plumbers facing forfeiture of territorial rights based solely on imaging equipment others can obtain and skill still others can learn." - Charles Dotter, American College of Surgery meeting in 1968
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I think a lot of specialists tend to focus on the "competitor" part, not just in IR/VS/Cards, but, neuro/ortho spine; ENT/OMFS/Plastics doing face stuff, Breast surgeons/plastics doing breast recons etc; and tend to overlook the very high value of having multiple related specialties practicing in a single practice.
Since this is an IR forum I will focus there
There are many groups where IRs/Vascular and even cardiologists work together and very synergestically, not only to the benefit of the patient, but to themselves; each specialty brings something to the table: IRs can do non-PAD stuff such as endovascular oncologic things, portal venous disease, UFEs, as well as read diagnostic imaging which is a huge revenue booster; vascular does open procedures, and Cards does the heart.
In a hypothetical practice with let's say 2 IRs, 2 vascular surgeons, one thoracic surgeon and 3 cardiologists (1 IC, 2 general): you could easily have overlap of PAD work with the vascular guys doign the AAA and TAA repairs as well as open cases, IR/IC/VS doing endovascular PAD and peripheral venous disease; all sharing vascular access/dialysis stuff, with call coverage split among each "interventional" person to cover cold legs, and separate IR/VS/Cards call for things related to those specialties like LGIB,TIPS, mesenteric disease, MI; the IR guys could rotate doing CTAs/MRAs as well as cardiac CTs/MRI; IR/cards/Vascular all staff the vascular lab; cards doing echo; all 3 staffing clinic or even bringing a vascular medicine doc on board to fill the procedure schedule.
Doing all that, and then calling themselves the "minimally Invasive Institute" or "center for endovascular care" or whatever and people come flocking.
These multi-discplinary teams are often overlooked, but they work really really well in oncology; and there are a lot of oncologic hospitals being built right now for that reason.
I think that's where the future lies, and if you look at the most successful practices in PP, you'll see that they follow the multi-disciplinary model.
