Future Prospects of Interventional Pulmonology

[surfking123]

Hi,

I am currently a resident who is very interested in IP. Lung cancer and transplant were my original interests before discovering this field which complements my strong interests in procedures as well. I know prior threads on this topic have been here but its been been several years and the field has advanced so wanted to ask a few questions.

1. What is the job market like for IP? Is it still mainly just in academic centers with limited jobs available?
2. Is it possible to work mainly IP (clinic + procedures) with limited ICU time?
3. Is the reimbursements for IP procedures still low? Any chance this will change for the better?
4. How will impending ACGME accreditation change the field and training overall? Will this overall be a positive development?

I seem to enjoy the field but given my limited knowledge of the market and limited experience working in IP, I wanted to hear other's thoughts especially since it is an additional year of training and if you have limited job opportunities, lower pay, and worse hours would not be worth it to me. Thank you all for the help in advance!

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[NewYorkDoctors]

hello there. I am a community pulmonologist so I do not have the final say on these matters. But from talking to my IP colleagues, it seems IP remains an academic job.
Tracheobronchomalacia, robotic bronchoscopy for small lung nodules that thoracic and IR cannot touch, airway tumors for stents and debulking, endobronchial lung volume reduction etc... still remain fairly uncommon things and need to be connected to a tertiary center.

My hospital colleagues inform me that IP alone does not quite bring in enough revenue by itself but they supplement it to "keep the cancer patients in house for their chemo and surgeries." This is institutional specific.

I hope others can comment further for you on the other details.

Bottom line is you will not be seeing an Interventional Pulm who does a mix of general pulm and interventional the same way an interventional cards does that. there is no STEMI equivalent for IP.

Still if you like it go for it. You'll always be in demand. ICU coverage depends on institution I suppose

 

[surfking123]

hello there. I am a community pulmonologist so I do not have the final say on these matters. But from talking to my IP colleagues, it seems IP remains an academic job.
Tracheobronchomalacia, robotic bronchoscopy for small lung nodules that thoracic and IR cannot touch, airway tumors for stents and debulking, endobronchial lung volume reduction etc... still remain fairly uncommon things and need to be connected to a tertiary center.

My hospital colleagues inform me that IP alone does not quite bring in enough revenue by itself but they supplement it to "keep the cancer patients in house for their chemo and surgeries." This is institutional specific.

I hope others can comment further for you on the other details.

Bottom line is you will not be seeing an Interventional Pulm who does a mix of general pulm and interventional the same way an interventional cards does that. there is no STEMI equivalent for IP.

Still if you like it go for it. You'll always be in demand. ICU coverage depends on institution I suppose

Very insightful response I appreciate your help! My biggest concerns would've been the job market/hireability and work/life balance. Would enjoy working in academics but wanted to be able to have the option to opt out I become location locked in the future. From your response, it seems like the job is still in-demand which is nice to hear

 

[NewYorkDoctors]

Very insightful response I appreciate your help! My biggest concerns would've been the job market/hireability and work/life balance. Would enjoy working in academics but wanted to be able to have the option to opt out I become location locked in the future. From your response, it seems like the job is still in-demand which is nice to heari

the pure IP doctors I see who ONLY do IP and no MICU or general pulm business (doing a EBUS TBNA for staging or diagnosis is not really an IP procedure. IP can do it to help out general pulms who are not trained in it but EBUS TBNA is not really an IP only procedure) are usually at the largest tertiary care centers that have a lot of cancer in house.

I have also seen IP doctors are smaller tertiary care centers who do not have a large cancer program who ends up helping the other general pulms do the more basic bronch procedures. that's not really worth ones time as an IP

In the community general pulms who are not certified for EBUS TBNA send to thoracic surgery to do it. Thoracic in the community happillydoes it.

 

[gutonc]

I'm not a pulmonologist, but I know a bunch of them. The busiest IP docs I know (and there are 3 of them in my medium sized city) work in community-based academ-ish settings and 2/3 of them are pretty much just doing advanced procedures with little or no gen pulm or ICU. One of them is the director of critical care at a Level 1 hospital so does a fair amount of ICU, but that's a choice.

Bottom line, you can find a job that works for you if you're flexible in location and/or practice setting.

 

[surfking123]

I'm not a pulmonologist, but I know a bunch of them. The busiest IP docs I know (and there are 3 of them in my medium sized city) work in community-based academ-ish settings and 2/3 of them are pretty much just doing advanced procedures with little or no gen pulm or ICU. One of them is the director of critical care at a Level 1 hospital so does a fair amount of ICU, but that's a choice.

Bottom line, you can find a job that works for you if you're flexible in location and/or practice setting.

Hey, that's helpful appreciate it! Any idea what their work life balance is typically? Are they on call a lot, burnt-out etc?

 

[chessknt]

Flex bronch interventions continue to bill poorly and will never be a good source of revenue unless you can either churn cases quickly (ie 20-30 mins a bronch) or own the facility, largely because many of these individuals are on public insurance. The tie in of other specialists (EM, anesthesia, ccm, gen surg, ent, CT surg) performing bronchs will keep these procedures low forever, unlike left heart Caths or colonoscopies. If you can get VATS trained and do thoracic surgery then you'll be cooking with gas but obviously that can ignite a turf war and is rare to see because CT surgeons dint like to give up any of their fat cash cows that make them the most special people in the hospital.

You'll definitely have a specialized skill set that will be in demand and uncommon but you aren't going to be compensated to match that value the same way surgeons are. You will probably make more straight ccm or straight PP pulm (with facility ownership) but the satisfaction won't be quite the same as a cog in the wheel.

 

[NewYorkDoctors]

whenever I do a flex bronch myself (uncommon as I seldom have a need to do them for most cases I see outpatient. most infectious conditions can be diagnosed with good sputum induction with chest physiotherapy with a vest and 7% saline. Mycobacteria is better obtained through sputum rather than BAL for a few reasons. the reproducibility of multiple sputums and the fact that lidocaine is bacteriostatic and may reduce AFB culture yield are some considerations. most cases of malignancy or concerning nodules I just give to thoracic, IR, or IP and they do a much better job than I ever could do... plus it might save the patient from going to two procedures), I often do not get paid much for it at all and it take sme out of the office where I can run PFTs and other procedures like clockwork

anyway recent cases were patients with nonresolving pneumonia despite sputum culture demonstrate susceptible Klebsiella organisms treated with appropriate antibiotics . no endobronchial mass appreciated on the CT scan just non resolving pneumonia . in these cases, it would NOT be appropriate for me to ask thoracic surgery or IP to "take a look for a mucus plug."

I go in there and clear up a mucus plug in a patient and get some micro on BAL. yay

I go into the next patient and find a right lower lobe endobronchial mass. I get some brushings and forceps biopsies - benign tissue.
refer to IP to debulking + stent. IP goes in and tries to take it down but finds it is not a tumor but some thick scar tissue. planned for superior segment right lower lobe lobectomy by thoracic now.
that's three procedures for the patient. yay.


for each of those patients I need to take out a full half day from my office to go to the hospital yes I have to do it i'm not ocmplaining it smy job.
but im just saying I got paid $250 or so for each of those bronchs

I would make $250 for one office patient doing a PFT + broncho ($150) + FENO ($30) + 6MWT ($30) + lung U/S ($40).
that's not even counting the office visit 99202-5.

anyway not everything is money. but bronchs just are not a money maker unless one IP has many general pulm feeding patients. but even then I cannot see IP becoming a community based specialty like interventional cardiology can be.

the IP procedures are just not for "common" things.

 

[surfking123]

Got it makes sense. So the IP skillset is useful for certain cases but simply doesn't generate much revenue. Will that at all change since ACGME accreditation for IP is here and it's more mainstream now? Ony reason I ask is concern for job security down the road. If I'm not generating enough revenue as a proceduralist in IP, I'm assuming my desirability for the job would be lower from the hospitals perspective

 

[chessknt]

Got it makes sense. So the IP skillset is useful for certain cases but simply doesn't generate much revenue. Will that at all change since ACGME accreditation for IP is here and it's more mainstream now? Ony reason I ask is concern for job security down the road. If I'm not generating enough revenue as a proceduralist in IP, I'm assuming my desirability for the job would be lower from the hospitals perspective

Revenue generation is related to WRVU which is largely determined by the RUC at the AMA which is controlled by surgeons. Nav bronch has been around for almost 10 years now and still reimburses less 1/2 than a lap appy despite taking 2-3x longer. Reimburses about 1/20th of a total knee for reference. It will never get better.

 

[TexasMed22]

Revenue generation is related to WRVU which is largely determined by the RUC at the AMA which is controlled by surgeons. Nav bronch has been around for almost 10 years now and still reimburses less 1/2 than a lap appy despite taking 2-3x longer. Reimburses about 1/20th of a total knee for reference. It will never get better.

Do you have a source that the RUC is controlled by surgeons? I know surgeries get reimbursed very well in our healthcare system, but my understanding was that each specialty gets a seat at the RUC table.

 

[chessknt]

Do you have a source that the RUC is controlled by surgeons? I know surgeries get reimbursed very well in our healthcare system, but my understanding was that each specialty gets a seat at the RUC table.

What Every Physician Should Know About the RUC

A small group of physicians has a big say in what you get paid.

www.aafp.org

Everything in this article is still mostly true. Equal representation is stupid--it would be like if Wyoming and New York got the same number of votes.

 

[The kitchen sink]

whenever I do a flex bronch myself (uncommon as I seldom have a need to do them for most cases I see outpatient. most infectious conditions can be diagnosed with good sputum induction with chest physiotherapy with a vest and 7% saline. Mycobacteria is better obtained through sputum rather than BAL for a few reasons. the reproducibility of multiple sputums and the fact that lidocaine is bacteriostatic and may reduce AFB culture yield are some considerations. most cases of malignancy or concerning nodules I just give to thoracic, IR, or IP and they do a much better job than I ever could do... plus it might save the patient from going to two procedures), I often do not get paid much for it at all and it take sme out of the office where I can run PFTs and other procedures like clockwork

anyway recent cases were patients with nonresolving pneumonia despite sputum culture demonstrate susceptible Klebsiella organisms treated with appropriate antibiotics . no endobronchial mass appreciated on the CT scan just non resolving pneumonia . in these cases, it would NOT be appropriate for me to ask thoracic surgery or IP to "take a look for a mucus plug."

I go in there and clear up a mucus plug in a patient and get some micro on BAL. yay

I go into the next patient and find a right lower lobe endobronchial mass. I get some brushings and forceps biopsies - benign tissue.
refer to IP to debulking + stent. IP goes in and tries to take it down but finds it is not a tumor but some thick scar tissue. planned for superior segment right lower lobe lobectomy by thoracic now.
that's three procedures for the patient. yay.


for each of those patients I need to take out a full half day from my office to go to the hospital yes I have to do it i'm not ocmplaining it smy job.
but im just saying I got paid $250 or so for each of those bronchs

I would make $250 for one office patient doing a PFT + broncho ($150) + FENO ($30) + 6MWT ($30) + lung U/S ($40).
that's not even counting the office visit 99202-5.

anyway not everything is money. but bronchs just are not a money maker unless one IP has many general pulm feeding patients. but even then I cannot see IP becoming a community based specialty like interventional cardiology can be.

the IP procedures are just not for "common" things.

how is the set up at the hospital? Procedure suite under conscious? Or anesthesia?

Lung u/s reimburses? Under what cpt code? Does that require image uploading or a portable vscan image and documentation suffice?

 

[NewYorkDoctors]

how is the set up at the hospital? Procedure suite under conscious? Or anesthesia?

Lung u/s reimburses? Under what cpt code? Does that require image uploading or a portable vscan image and documentation suffice?

hospital im at all goes to the OR now under general anesthesia provided there is cardiac clearance in the right situation

even for something as easy as a bronch BAL. this buys more time for the fellows to do an airway exam of course.


76604 is US chest
my images are saved onto the butterfly IQ network cloud server
I have templated reports I write myself and save copies if anyone audits

the insurances just pay me as soon as I Put 76604 in through the clearinghouse

sometimes insurances check me and want records and notes. i have never submitted my actual images before. only my template reports and they A-OK it.

 

[NewYorkDoctors]

The images seem to be for liability potential lawsuit issues but what’s the ultimate fall back to a a lung sono ? Ct chest .

 

[chessknt]

The images seem to be for liability potential lawsuit issues but what’s the ultimate fall back to a a lung sono ? Ct chest .

Med--those are limited CPT codes. As long as you document exam was limited in scope and don't extrapolate beyond that in the report (eg dont say no evidence of lung cancer) youre fine.

 

[NewYorkDoctors]

Med--those are limited CPT codes. As long as you document exam was limited in scope and don't extrapolate beyond that in the report (eg dont say no evidence of lung cancer) youre fine.

Yep A lines B lines effusion lung sliding curtain sign and consolidation pattern . That’s all I ever write in the report itself

 

[surfking123]

Another question I had is how typical is it to use fluoro during diagnostic or therapeutic IP procedures? Had a back injury so wondering about how often I'll need to wear lead

 

[NewYorkDoctors]

unrelated but funny CT image - a ghost is inside the patient's mediastinum

 

[NewYorkDoctors]

I found a "rat" inside my patient's lungs.

 

[Ubba]

I found a "rat" inside my patient's lungs.

View attachment 385783

Subway pizza not doing it for them anymore?