DIRECT PATHWAY programs

[irwarrior]

Very few body imagers do ablations. The only places where the body imagers do ablations is in academics and this is not even the norm. MGH, Brown (Dupuy), UCLA. However, the bulk of ablations are done by IR throughout the country in private practice.

Most Diagnostic radiologists are afraid to do biopsies and their yield is often poor so IR is often asked to do these as well.

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[irwarrior]

I feel that when a general radiologist reads a vascular study or vascular ultrasound they interpret it incorrectly not infrequently and the vascular surgeon can often do a better job.

As far as reading post TACE/ablation cases part of it is laziness at not reviewing what has been done on the patient from lipiodol based TACE, to the various ablative approaches, to Y90 to drug eluting beads and the IR who has treated the patient will have a better understanding of the natural history of the cancer as well as what treatments they actually performed and will be able to better assess tumor burden based on RECIST or EASL etc and generate a valuable report based on tumor type etc.


Now a subspecialist may be different ie a vascular radiologist or an abdominal imaging specialist. But, even they are so focused on cranking through the list that sometimes they don't pay due dilligence to the study and look up all the priors or review the oncologic treatment history etc.

 

[irwarrior]

The field of PAD has really open up to aggressive clinical interventionalists. This is probably due to the aggressive treatments by peripheral interventionalists in the fields of vascular surgery and cardiology, but this has opened our toolbox in IR to do more and more treatments. PAD is very common and if you look at studies such as PARTNER you can tell how common and underdiagnosed and treated it is. With modern day tools and techniques we can offer so much more and there is really enough work for all.

But, as an IR you must have clinic and both the clinical and technical expertise to do these cases which often involve tibial interventions and pedal access.

 

[shark2000]

Very few MSK people do pain. The bulk of MSK fellowships don't train in pain and most diagnostic radiologists (in general) do not like to do procedures and dump even the minor procedures on IR. We would love for them to do some of the minor procedures, as we are quite busy with more complex treatments at our group and we have discussed with our hospital administrators.

Hospital administration is very supportive of us as we actually bring in patients to the hospital and generate millions of dollars of revenue for them. The hospital is aware that we can take many of our patients to nearby hospitals where we also have procedural and admitting privileges.

The radiology group does not actually bring in patients, so the hospital sees them as potentially expendable and replaceable.

The moment you become the hospital employee, as the future is going in this way, all your calculations will be incorrect. You can not take a patient to the nearby hospital if you are the employee of one hospital.

 

[shark2000]

Very few body imagers do ablations. The only places where the body imagers do ablations is in academics and this is not even the norm. MGH, Brown (Dupuy), UCLA. However, the bulk of ablations are done by IR throughout the country in private practice.

Most Diagnostic radiologists are afraid to do biopsies and their yield is often poor so IR is often asked to do these as well.

They are not afraid to do biopsies. They give it to IR because eventually the RVU will stay in radiology department. If IR separates itself from DR, IR will loose many of the biopsies it is doing now.

Your argument about lower skill of DR people is incorrect. First doing CT and US guided biopsies is not rocket science. Second, It is not about who is more qualified. You are making the same mistakes over and over again. You may be more qualified than the cardiologist, but he is the one who does PVD and not you.

 

[shark2000]

I feel that when a general radiologist reads a vascular study or vascular ultrasound they interpret it incorrectly not infrequently and the vascular surgeon can often do a better job.

As far as reading post TACE/ablation cases part of it is laziness at not reviewing what has been done on the patient from lipiodol based TACE, to the various ablative approaches, to Y90 to drug eluting beads and the IR who has treated the patient will have a better understanding of the natural history of the cancer as well as what treatments they actually performed and will be able to better assess tumor burden based on RECIST or EASL etc and generate a valuable report based on tumor type etc.


Now a subspecialist may be different ie a vascular radiologist or an abdominal imaging specialist. But, even they are so focused on cranking through the list that sometimes they don't pay due dilligence to the study and look up all the priors or review the oncologic treatment history etc.

If the do it right they can give much higher quality reads than you.

You problem is, you think you are the only person who is doing the right thing, and the rest of radiology are losers.

Vascular US is done by vascular surgeons in many departments. From your point of view, learning to read vascular US is rocket science, but you can easily learn to manage hepatic encephalopathy. This is the high Ego in IR people, who has, is and will result in more and more turf loss.

 

[shark2000]

The field of PAD has really open up to aggressive clinical interventionalists. This is probably due to the aggressive treatments by peripheral interventionalists in the fields of vascular surgery and cardiology, but this has opened our toolbox in IR to do more and more treatments. PAD is very common and if you look at studies such as PARTNER you can tell how common and underdiagnosed and treated it is. With modern day tools and techniques we can offer so much more and there is really enough work for all.

But, as an IR you must have clinic and both the clinical and technical expertise to do these cases which often involve tibial interventions and pedal access.

The share of IR for doing PAD is going down and down. You may take a few. But you are in a state of ignorance about turf loss. You have to accept the fact that it is the most common high end procedure in minimally invasive endovascular treatment and is lost to cards and vascular surgeons. The reason you are doing thoras and paras and biopsies is because you have lost most of your truf in vascular disease.

 

[shark2000]

Sooner or later you will become the hospital employee and you are doomed to do whatever the hospital wants you to do.
The hospital has enough vascular surgeons to do PAD and they have enough other groups to do your job. They will refuse to give you clinic or even admission privileges. Eventually you will end up doing thoras and paras all day.

You are very positive about future, without looking at what happened in the past. In late 90s all IR people were bragging about taking over vascular surgery and none of them could see the truth. Now the same here. You are not seeing the true nature of the story.

In modern medicine, you can not be the guy who does stroke work up, then jump to TACE, then work up a perimenopausal bleeding, then run a pain clinic, ....
As I said before, IR people are the generalist of low end procedures. It will continue to become worse and worse as we see new generation of Vascular srugeons with more and more catheter skill. In the last decade it was not you who became PAD specialist, it was vascular surgeon who became interventional specialist.

Medial students: Don't listen to what SIR says. Go to the nearby community hospital or ask radiology groups about true nature of what IR does in pp. Then choose your field.

 

[cbtk18]

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[shark2000]

Does anyone get the feeling that shark doesn't have a high opinion of IR?

It is not my opinion. It is the bitter truth. I have seen it both in academics and in pp. I have worked with some of the top names in IR during my residency. My institution is and was always considered one of the top IR programs.

I have seen the so called clinical IR. I have taken lots of IR called.
I have seen how the IR department becomes busy after 8 pm and during weekends. I have seen in front of my eye, how vascular surgeons took over at least a great share of many procedures. When I started residency, dialysis intervention was done exclusively by IR. By the end of my residency vascular surgeons start doing it more and more. And the truth is, they are the ones who put the AV fistula.

In my pp, which is in one big metropolitan coastal cities, even a new cardiologist or a new vascular surgeon has a very very hard time start a PAD or even coronary intervention program. For an IR, it is next to impossible. Cancer work is almost exclusively controlled by 2 big hospitals and oncologists send the patients there. The new IR people end up doing BS. Still IR job market is good, because senior partners even do not want to do a thora and with the new generation of PAs, NPs and Hospitalists there is a need for someone to do these low pay low end procedures.

Anyway, good luck.

 

[irwarrior]

Look no egos here and I appreciate the benefits of a solid imager as much as the next guy. I see that any specialty can do anything. I think that radiologists tend to think that imaging is in their purview only. There is a ton to learn from all specialists who can do advanced imaging, be it orthopods, cardiologists or surgeons.

I personally like my radiology colleagues and get along quite well with them. They call me about imaging findings and send me "referrals". Having said that , in general they don't understand the concept of clinic and patient care. I am more in tune with my colleagues in cardiology, vascular surgery and general surgery as we face similar issues in our day to day practice.

I am quite happy with my practice and my clinic and procedures are booked at least 2 months in advance. Our IR practice continues to be the major area of growth in the department and we have expanded with several physican extenders as well as IR attendings.

Look, I would hope that my imaging colleagues keep up to date and go to the most recent annual meetings in the various speciaties but unfortunately they don't all do this and I often try to overcome this by educating them on what we as IR do and give them lectures on advanced abdominal imaging and oncologic imaging as it pertains to what IR can and does do. I also give lectures to radiology on vascular imaging including ultrasound, CTA, MRA and post interventional look outs. I don't expect the average radiologist to know much of this, as I did not know much of this until I started treating patients and intervening and following my patients closely. I feel my radiology colleagues appreciate it and I get more referrals from them and questions about some of the more complex imaging cases pertaining to what I do. Being a solid imager is critical to being a great interventionalist. But, a strong IR needs to have solid clinical, technical as well as imaging skills.

Our IR practice has become large enough that we can subspecialize. We have one who does women's health therapy (interface with gynecology), another who does Pain intervenitons (practice buiilds on that side of things), a few who do oncology and even that is broken down into renal ablative therapy and various types of liver treatments, we have another few IR who primarily do venous interventions including varicose veins, dvt work etc.

Now, when it comes to call cases/inpatient cases we all can cross cover that component as well as call cases..

Again, I do applaud the fact that you are proactive and seek out cases and practice build on your own dime and time. This is something I had to do myself to practice build, spend many hours and weekends to build a practice. But, looking back there is no doubt it was well worth it.

 

[badasshairday]

Our IR practice has become large enough that we can subspecialize. We have one who does women's health therapy (interface with gynecology), another who does Pain intervenitons (practice buiilds on that side of things), a few who do oncology and even that is broken down into renal ablative therapy and various types of liver treatments, we have another few IR who primarily do venous interventions including varicose veins, dvt work etc.

Now, when it comes to call cases/inpatient cases we all can cross cover that component as well as call cases..

irwarrior, thanks for sharing your views. What part of the country are you located? Is your group an IR group or are you part of a larger radiology group that involves both IR / DR? What is your schedule like? How often do you have clinic? Who rounds on inpatients and does discharge work for you, do you have midlevels? Do you have competition from surgeons and cardiologists for PAD? Thanks.

 

[shark2000]

irwarrior, thanks for sharing your views. What part of the country are you located? Is your group an IR group or are you part of a larger radiology group that involves both IR / DR? What is your schedule like? How often do you have clinic? Who rounds on inpatients and does discharge work for you, do you have midlevels? Do you have competition from surgeons and cardiologists for PAD? Thanks.

Naive question. The correct one is: How could he break into a market already controlled by vascular surgeons and card?

IMO, this guy is doing a great job if this is the truth about his practice. Honestly, I don't know about any IR group in my area which is a large coastal city, which has been so successful.

Anyway, despite my general opinion about IR and a lot of disagreements, I highly respect this guy for what he does.

 

[irwarrior]

Clinic 1 to 1 and 1/2 days a week.

We model ourselves similar to Baptist. ie we have a larger radiology group that we are part of, but we function independently and are seen by the hospital administrators as an independent entity. The hospital spends a lot of resources on us, simply because of what we bring in.

We do have midlevels that help with some of the floor work and inpatient follow ups and discharges. But, we make certain that all of the IR are seen on the floor and have one IR physician per week who is in charge of all consults and works with the midlevels to get the floor work (consults, follow ups, discharges etc) done.

Competition for endovascular cases is fierce and my colleagues (vascular surgery and cardiology) are very good at what they do both clinically and technically. We all have different referral patterns and the key is to maintain good relationships and provide good service with your current referral docs and find any new doctors who are coming into the region and the more outreach to them you have the faster you can grow it.

Some of the key areas of practice development for PAD are the vascular lab, CTA, MRA etc. The legs for life campaign is of medium yield. But, you need to be patient to grow your patient referral base.

As you are developing your PAD practice it is critical to develop all other aspects of your practice (fibroids, veins, dvt work (lysis, filters), oncology, pain interventions (esi, facets, vertebro, kypho).

Follow all of your patients as much as feasible and bring them back to your office. This will generate a long time network of patients for you. Theses patients often need multiple repeat interventions (from veins, pain , pad and even fibroids). This is something that most IR do a poor job with.

Give lots and lots of talks (grand rounds,morning reports, tumor boards). Give talks to the local press and any community talks (women's groups etc). Marketing is key and advertising is important. Also company reps will provide dinners as you market to local hospitalists, podiatrists, FP, IM, PA/NPs etc.

 

[badasshairday]

Clinic 1 to 1 and 1/2 days a week.

We model ourselves similar to Baptist. ie we have a larger radiology group that we are part of, but we function independently and are seen by the hospital administrators as an independent entity. The hospital spends a lot of resources on us, simply because of what we bring in.

We do have midlevels that help with some of the floor work and inpatient follow ups and discharges. But, we make certain that all of the IR are seen on the floor and have one IR physician per week who is in charge of all consults and works with the midlevels to get the floor work (consults, follow ups, discharges etc) done.

Competition for endovascular cases is fierce and my colleagues (vascular surgery and cardiology) are very good at what they do both clinically and technically. We all have different referral patterns and the key is to maintain good relationships and provide good service with your current referral docs and find any new doctors who are coming into the region and the more outreach to them you have the faster you can grow it.

Some of the key areas of practice development for PAD are the vascular lab, CTA, MRA etc. The legs for life campaign is of medium yield. But, you need to be patient to grow your patient referral base.

As you are developing your PAD practice it is critical to develop all other aspects of your practice (fibroids, veins, dvt work (lysis, filters), oncology, pain interventions (esi, facets, vertebro, kypho).

Follow all of your patients as much as feasible and bring them back to your office. This will generate a long time network of patients for you. Theses patients often need multiple repeat interventions (from veins, pain , pad and even fibroids). This is something that most IR do a poor job with.

Give lots and lots of talks (grand rounds,morning reports, tumor boards). Give talks to the local press and any community talks (women's groups etc). Marketing is key and advertising is important. Also company reps will provide dinners as you market to local hospitalists, podiatrists, FP, IM, PA/NPs etc.

Thanks. Given what you said, I'm going to assume you are in south Florida and you and your partners probably trained at Miami Vascular or somewhere similar like Peoria or MCW.

Good luck in the future. Your story is very inspiring.

 

[LaCasta]

I am an M3 interested in IR. I checked out the ABR website and it said it is possible to enter the DIRECT pathway straight from med school, but I wasn't able to find any more information on how that would work and what I would need to do.

Any response would be greatly appreciated.

 

[LaCasta]

I am an M3 interested in IR. I checked out the ABR website and it said it is possible to enter the DIRECT pathway straight from med school, but I wasn't able to find any more information on how that would work and what I would need to do.

Any response would be greatly appreciated.

Anyone?

 

[IRneuroIR]

See this link for more info on applying... http://theabr.org/ic-vir-direct

 

[DrMasochist]

See this link for more info on applying... http://theabr.org/ic-vir-direct

That link doesn't really have much info. I'm also interested to know if programs accept straight out of med school, but I think it may depend on the program. What I need to do (but haven't had time to do) is actually call each of those programs and talk to someone in this department. That's probably the best way to figure this out. It would be nice to hear from any SDNers who have actually applied to the DIRECT program this year or in the past.

 

[badasshairday]

That link doesn't really have much info. I'm also interested to know if programs accept straight out of med school, but I think it may depend on the program. What I need to do (but haven't had time to do) is actually call each of those programs and talk to someone in this department. That's probably the best way to figure this out. It would be nice to hear from any SDNers who have actually applied to the DIRECT program this year or in the past.

APply to programs that have a DIRECT program on ERAS, it is that simple. For example when you are selecting programs on ERAS they give drop down menu options for which program you want to apply to. So UVA will have the traditional radiology residency to choose to apply to... and they also have the DIRECT pathway to apply to. It is really simple.

 

[LaCasta]

APply to programs that have a DIRECT program on ERAS, it is that simple. For example when you are selecting programs on ERAS they give drop down menu options for which program you want to apply to. So UVA will have the traditional radiology residency to choose to apply to... and they also have the DIRECT pathway to apply to. It is really simple.

Ok, so even though you can't see these direct programs on FREIDA, you can see them and apply to them via ERAS?

 

[badasshairday]

Ok, so even though you can't see these direct programs on FREIDA, you can see them and apply to them via ERAS?

Yes. I specifically remember seeing UPENN and UVA having DIRECT pathway to apply to on ERAS.

 

[IR Residents]

I am an M3 interested in IR. I checked out the ABR website and it said it is possible to enter the DIRECT pathway straight from med school, but I wasn't able to find any more information on how that would work and what I would need to do.

Any response would be greatly appreciated.

Anyone?

The SIR-RFS is working on uploading an informative and detailed description of the various pathways into IR from medical school. Included in this is the DIRECT pathway, in addition to the traditional pathway and clinical pathway.

It's not uploaded yet, but if you are interested in some specific information, I have a contact that would be happy to email you directly some info.

If interested, PM me.

 

[IR resident]

Correction: Not currently accepting applications from medical students for 2013 start time.

Please contact Ms Roberta Wilcox at [email protected] or Dr Paul Rochon at [email protected] for questions regarding the Colorado DIRECT pathway

 

[wheewer]

Thanks for sharing such a wealth of information on this thread. I've given great thought to pursuing IR and I'm trying to get a sense of what kind of Step 1 score it takes to match at a place like Cornell or Penn for their direct IR programs. I understand that obviously "the higher the better" and "Step 1 is important but isn't everything" but I'd appreciate any numerical input you had beyond that - thanks!