NIR

[ashar008]

What is the outlook like recently for diagnostic radiology prospects applying for NIR training after neuro radiology fellowship. Is there a demand for NIR trained specialists still or is the market oversaturated? Any current or graduated NIR members can give insight or advice and someone looking into it as a career goal. I don't mind the amount of time or training it takes. I like how super specialized and unique it is. I am just wondering what the general outlook for this specialty is. Thank you.

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[NDcienporciento100]

What is the outlook like recently for diagnostic radiology prospects applying for NIR training after neuro radiology fellowship. Is there a demand for NIR trained specialists still or is the market oversaturated? Any current or graduated NIR members can give insight or advice and someone looking into it as a career goal. I don't mind the amount of time or training it takes. I like how super specialized and unique it is. I am just wondering what the general outlook for this specialty is. Thank you.

The demand is very high at the moment. Mr Clean trial came in 2015 which proved stroke Thrombectomy was extremely affective in large vessel occlusion stoke and since the demand has skyrocketed.

 

[Cognovi]

The demand is very high at the moment. Mr Clean trial came in 2015 which proved stroke Thrombectomy was extremely affective in large vessel occlusion stoke and since the demand has skyrocketed.

Let's not exaggerate. LVO thrombectomy is a minority of the work of a NIR, even if it rationalizes why they're always on call. The annual incidence of thrombectomy-eligible large vessel occlusion is 3 procedures per 100,000 population. That's 150 procedures a year in a metro region the size of Boston, which has at least 10 neurointerventionalists. That's only an average 15 stroke thrombectomies per NIR per year. A population-based incidence of acute large vessel occlusions and thrombectomy eligible patients indicates significant potential for growth of endovascular stroke therapy in the USA | Journal of NeuroInterventional Surgery

The demand comes from people not wanting to be on call q2 days or q3 days. So you expand your group, but you don't have enough procedures to justify it. Most of the day is filled with diagnostic angiograms to follow up aneurysms you treated or may treat in the future. The better CTA and MRA get, the less justifiable invasive cerebral angiograms will become. So people find side gigs. The radiology-trained NIR does body IR stuff or reads DR. The neurosurgery-trained INR does open cerebrovascular surgeries and trauma. The neurology-trained NIR attends on the neurology inpatient stroke service or the ICU.

Being superspecialized is tough, because you're always in demand but only a few people are needed.

 

[2brads]

Being superspecialized is tough, because you're always in demand but only a few people are needed.

This. The market is small and the pool of docs is small, kind of like how radonc used to be before they screwed up their supply of docs. Most NIR have awful call schedules. But then again, they make close to 7 figures, so maybe not having a life is worth it.

 

[irwarrior]

That number seems low. Many sites are doing well over a 100 thrombectomies a year. There are not a lot of intracranial aneurysms or AVMs . But there is. considerable amount of strokes. There are many peripheral interventionalists who are doing stroke mainly to distribute the call. The Dawn and Defuse III (which extended the time window) on top of the 5 RCT (within 6 hrs) including MR CLEAN etc that came in 2015 changed the landscape of stroke interventions.

 

[NDcienporciento100]

Number is definitely low, where I train does almost 150 stroke a year. Your telling me MGH, Brigham, Beth Israel and Tufts only do 150 strokes a year? They probably do 3-4 times that.

 

[NDcienporciento100]

The call is brutal and most people don’t do just neuro that is correct.

 

[cybermed2424]

Can anyone in the field comment on the procedures one might commonly do in NIR? Is 90% of the day usually diagnostic angios or is there normally a good mix? Thanks all.

 

[Cognovi]

Can anyone in the field comment on the procedures one might commonly do in NIR? Is 90% of the day usually diagnostic angios or is there normally a good mix? Thanks all.

2/3 diagnostic, 1/3 embolization and stenting

Even if your center is doing 150 stroke thrombectomies a year, one every 2.5 days, elective procedures remain the primary source of work and revenue for the INR program. Don't forget clinic, too.

 

[cybermed2424]

2/3 diagnostic, 1/3 embolization and stenting

Even if your center is doing 150 stroke thrombectomies a year, one every 2.5 days, elective procedures remain the primary source of work and revenue for the INR program. Don't forget clinic, too.

Do radiology trained neurointerventionalists have clinic responsibilities? Apologies for my ignorance on the field.

 

[Cognovi]

Do radiology trained neurointerventionalists have clinic responsibilities? Apologies for my ignorance on the field.

You have to have clinic to tell patients how you're going to treat their aneurysm or AVM. You can't just meet them in pre-op the day of their procedure.

 

[irwarrior]

You also have to follow your patients' intracranial aneurysms (treated or untreated), follow up on carotid stents and intracranial stents etc. There are also new consultations where you are not intervening but medically managing.

 

[clonoGnic]

You also have to follow your patients' intracranial aneurysms (treated or untreated), follow up on carotid stents and intracranial stents etc. There are also new consultations where you are not intervening but medically managing.

Do NIRs have support from radiology departments and hospitals for this type of model? Any issues with RVUs, disincentivization to have clinical model? Do NIRs use APPs to round on post-op pts (healthy/outpt)? For sick pts, will NIR directly manage in NSICU or do most of them admit to neurology? Besides stroke, does NIR get a lot of stat inpatient consults? Or is the work flow mostly scheduled outpatient cases + stroke? Is there a lot of butting heads with neurology/nsx/vascular surgery/internal medicine/etc.?

 

[NDcienporciento100]

There are several issues from my standpoint with the current state of radiologist pursuing NIR. The first being that diagnostic neuroradiologist don’t get trained in cerebral angiography anymore. You may find one or two examples but for the vast majority of Dx Neuroradiology fellows In today’s era Won’t know what a “Water’s View” Even means. And the cerebral angiography requirement was recently removed for Dx neuroradiology fellows. There are some body Interventional fellows out there that have expressed a great deal of interest in this field. And I think you could argue that from a skill set point of view none of the other specialty’s can match body IR in term of catheter and wire skills acquired during there training. If one wishes to pursue neuro IR they should pursue a significant amount time doing electives in neurology and neurosurgery that is undeniable. The issue becomes that a Dx neuroradiology fellowship is still required for cast certification. So that means that for a body IR that just finishes body IR fellowship and has that awesome acquired skill set some of whom will already be certified by SIR to perform stroke interventions will have to take a year off the Angio game to just read images allowing there body IR skill set to get rusty. This to me is not a good approach. I’m not saying that Dx neuroradiology is not important it is I’m saying the 5-6 months we get in training should be adequate. Let’s not forget there is none fellowship trained radiologist out there that read neuro all the time. So SIR needs to work on a solution with both CAST and ACGME to get this requirement removed. Otherwise it’s going on weaken radiologist stance in the field. And radiologist are important! Let not forget the majority of the physicians in the Mr Clean Trial were body Interventional radiologist not even trained in NIR.

 

[Cognovi]

Do NIRs have support from radiology departments and hospitals for this type of model? Any issues with RVUs, disincentivization to have clinical model? Do NIRs use APPs to round on post-op pts (healthy/outpt)? For sick pts, will NIR directly manage in NSICU or do most of them admit to neurology? Besides stroke, does NIR get a lot of stat inpatient consults? Or is the work flow mostly scheduled outpatient cases + stroke?

If the radiology department doesn't support it, it'll just go to neurosurgery.

Stat consults other than LVO include 1) carotid blow-out in head and neck cancer patients, 2) unsecured aneurysmal subarachnoid hemorrhage, but that can usually wait until morning.

 

[clonoGnic]

If the radiology department doesn't support it, it'll just go to neurosurgery.

Stat consults other than LVO include 1) carotid blow-out in head and neck cancer patients, 2) unsecured aneurysmal subarachnoid hemorrhage, but that can usually wait until morning.

Sorry for so many questions. For usual neurorad fellowship the requirement is 50 angios per RRC/ACGME vs CAST requiring 200 prior to 2 years of NIR? Means that it is easiest to apply to "combined" neurorad + NIR 3-yr fellowship out of residency in which the neurorad year has altered schedule so you have 6 mos of clinical exposure (per CAST) and more time on angio service to get the 200 #? Otherwise if you just apply to neuro first and you're not on track to hit 200 angios, will you be ineligible to apply for an CAST approved NIR fellowship afterwards? Also if 6 mos of clinical time required, will the diagnostic experience be enough for NIR to confidently read high level neuro in between cases, equivalent to neuro dx rads?

 

[Cognovi]

Sorry for so many questions. For usual neurorad fellowship the requirement is 50 angios per RRC/ACGME vs CAST requiring 200 prior to 2 years of NIR? Means that it is easiest to apply to "combined" neurorad + NIR 3-yr fellowship out of residency in which the neurorad year has altered schedule so you have 6 mos of clinical exposure (per CAST) and more time on angio service to get the 200 #? Otherwise if you just apply to neuro first and you're not on track to hit 200 angios, will you be ineligible to apply for an CAST approved NIR fellowship afterwards? Also if 6 mos of clinical time required, will the diagnostic experience be enough for NIR to confidently read high level neuro in between cases, equivalent to neuro dx rads?

The CAST requirement is for 1 year of NIR. Most fellowships are 2 years, in which the first year is unaccredited and lets you get the prerequisite requirements (200 angios, 6 months clinical).

NIR training is at least 8 years after medical school regardless of which training path you take.

 

[NDcienporciento100]

Sorry for so many questions. For usual neurorad fellowship the requirement is 50 angios per RRC/ACGME vs CAST requiring 200 prior to 2 years of NIR? Means that it is easiest to apply to "combined" neurorad + NIR 3-yr fellowship out of residency in which the neurorad year has altered schedule so you have 6 mos of clinical exposure (per CAST) and more time on angio service to get the 200 #? Otherwise if you just apply to neuro first and you're not on track to hit 200 angios, will you be ineligible to apply for an CAST approved NIR fellowship afterwards? Also if 6 mos of clinical time required, will the diagnostic experience be enough for NIR to confidently read high level neuro in between cases, equivalent to neuro dx rads?

The 50 cerebral Angio is being removed. Vast majority of fellows were not actually doing them anyway and have not for >15 years. It was a rubber stamp if you will.