Prostate artery embolization

[Gvataken]

http://kstp.com/article/stories/s2612757.shtml

There was a great discussion about prostatic artery embolization for BPH at this year's IR annual meeting and initial results from Portugal and Brazil were presented. Certainly is interesting. Will need further data before we know what role it plays.

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[shark2000]

Like the rest of IR, if it replaces TURP or most of TURPs, then will be taken over by urologists.

 

[shark2000]

Agree. You mentioned that your IR service admits their own patients etc. -- do you think that clinical model protects against this at all...or just kind of a pathetic survival mechanism for IR?

Nop. It may help a little bit, but not in a large scale.
The IR has its own huge Achille's Heels that make it very amenable to turf loss:

1- It is broadly dependent on referral from one or a few services, most of them surgery. You do not work up the patient from scratch yourself. For example this prostate embo, will only dependent on Urology referral. Very few if any family doctors will tell the patient: "OK, Mr smith, I think you have a BPH. now go to this IR person for prostate embo". Most will refer the patient with urinary obstruction symptoms to urologist.

2- It is not a true clinical service. We admit our patients, but it is usually mostly post-procedure. It does not help. For example we do tons of Chemo-embos and Y 90s. Nobody call us from ED or IM service that the patient has a liver mass or hepatic metastasis of tumor, please work up for chemo-embo. Patient with liver mass will be referred to an oncologist. Then it will go through a lot of referrals including liver surgeons before being referred to us. Now if any of these services want to do Chemo-embo themselves, they will take it over completely.

3- It is completely different from DR. At least half of our diagnostic studies come directly from IM, ED, or other services. For example I was in chest room today reading mostly chest CTs. About 80% of my chest CTs come from non-pulmonologists. At least half come from ED, IM, Hospitalist. Many come from oncology. A lot come from surgeons and orthopods to rule out PE. This make it less amenable to turf loss, unless all of these services start reading their own chest CTs (ortho guys reading chest CT ???).

4- Despite what medical students may think, IR procedures are easy to learn. It is not the case in DR. DR is much more complicated to learn. For sure nothing is magic in medicine and everybody can learn everything. As I mentioned before you can teach a technician to do most IR procedures. MR techs who have done it for 20 years, still can not read even the easiest cases. On the other hand, our IR technologists easily can deploy an IVC filter. The same for me. I can do many IR procedures comfortably as a senior resident, however still do not feel comfortable with many DR studies.

I may be biased or wrong, but to me doing radiology just for IR is stupid. On the other hand, if you don't mind and see light IR work as a diversity to your DR work it is great. For example doing biopsies, lines, drains, ... in between your DR work as a fun.

On the other hand, if you exclusively want to do IR, don't do it.You will have hard time doing high end cases. Even if most of a certain high end procedure is done by IRs, at your place it may not be the case and may be done by vascular surgeons or .... You will end up with many after hour and complicated cases. It is very notorious that vascular cases go to vascular surgery during the day and the night ones will split between IR, cards and surgeons.

 

[shark2000]

Excellent post, particularly points 3 and 4. Point 3 is especially important since most med students have a weak understanding of the business fundamentals of specialties.

Based on my understanding, IR will eventually become a trash dump of a sub-specialty. I won't start rads for another year, but because of this realization in the last 6 months, I've gone from wanting to do 50/50 to more like 75-90% DR. On the one hand, being "the end of the line" in terms of sub-specialty care is great. But in the case of IR, what's more likely is they will get the cases that no one else wants to handle that pay a pittance.

1- Light IR is still busy and will be viable for the foreseeable future. This include body biopsies for which you need to make a good rapport with an oncologist and surgeons do not have edge over you. In fact you can get it before them. As a body imager you are the first one who find the new lesion on the CT. You can call your oncologist and discuss the ddx for it and ask for CT guided biopsy. In fact you are better than surgeons as they can not give ddx as good as you. Also Central catheters and IVC filters from oncology service. You can also do spine injections and joint injections as many orthopods and neurosurgeons are not willing to do it. The same for bone biopsies. Though allof them can be done by neurosurgeons or orthopods, they prefer to spend time in OR rather than working with flouro.

2- It makes IR people angry, but IR has already become the trash dump of the hospital. Most after hour procedures go to IR. Abscess drainage in regular hours are done by surgery and then after pm goes to IR. Pulmonologists do Thoras left and right and then dump the Friday evening ones on IR. Vascular surgeons do elective cases during the day and dump the splenic aneurysm rupture on saturday 11 pm on IR. Neurologists ask IR to do LP on patients on coumadin.
You can not blame anybody. The exact opposite happens in our mammo and body service. Our body section do most of biopsies including lung biopsies and then complicated ones are turfed to surgeons or IR. We have a busy Mammo section. One of our attendings do a lot of biopsies and whenever she comes to a complicated case or a difficult patient, she sends the patient to a breast surgeon for 2nd opinion.

And just one point. Many light procedures known to medical students as IR ones, are in fact general radiology skills that you will obtain in most programs during your residency. In pp everybody does it, but in big groups and university setting is done by IR. You have to be able to do the procedures I mentioned above without IR fellowship. No brainer.

 

[kubIR]

From my user name, I am obviously an IR guy. What Shark saysdoesn't upset me, but rather makes me feel bad for residents trained underthose circumstances.

Where I am IR is baller. We are not the trash-dump of thehospital. Of course we get our Friday 5pm PCN's, 2 am pelvic trauma's orweekend abscess, but that is part of the job of being an on-call physician. Ouropinions about patient care and imaging are valued and sought after by surgeons,medicine and specialists in between. We are staples in tumor board and makemulti-disciplinary decisions with Onc and Surg Onc. The only setting I can imagine in which IR is atrash dump is is if the staff have become complacent - not taken care ofpatients they treat and have not become experts in the pathology of what wetreat. This is not to say that our IR staff are oncologists – they wouldn'thave the slightest idea how to treat leukemia or what chemo stage 3b melanomapatient should be on. But when it comes to HCC, they know just as much as theOncologists and have the advantage of being experts in imaging. We know thedata, the medical treatments, the surgical treatments and where IR fits in. Whenit comes to metastatic CRC, we know the data. Etc. etc. If you don't know thedisease you can't be on the level, and you will become a trash-dump. I am sorryif this was your experience Shark.

 

[shark2000]

From my user name, I am obviously an IR guy. What Shark saysdoesn't upset me, but rather makes me feel bad for residents trained underthose circumstances.

Where I am IR is baller. We are not the trash-dump of thehospital. Of course we get our Friday 5pm PCN's, 2 am pelvic trauma's orweekend abscess, but that is part of the job of being an on-call physician. Ouropinions about patient care and imaging are valued and sought after by surgeons,medicine and specialists in between. We are staples in tumor board and makemulti-disciplinary decisions with Onc and Surg Onc. The only setting I can imagine in which IR is atrash dump is is if the staff have become complacent - not taken care ofpatients they treat and have not become experts in the pathology of what wetreat. This is not to say that our IR staff are oncologists – they wouldn'thave the slightest idea how to treat leukemia or what chemo stage 3b melanomapatient should be on. But when it comes to HCC, they know just as much as theOncologists and have the advantage of being experts in imaging. We know thedata, the medical treatments, the surgical treatments and where IR fits in. Whenit comes to metastatic CRC, we know the data. Etc. etc. If you don't know thedisease you can't be on the level, and you will become a trash-dump. I am sorryif this was your experience Shark.

1- Tumor, tumor, tumor. This is the rationalization that most IR passionate people say. I am pretty sure its turf will be maintained for now. Why? It is not the bread and butter practice of community. It is the same as cardiac MR for cardiologists or liver transplant fellowship for surgeons. You go and do a year of this high end IR fellowship. Now please show me a job in pp when you can do tons of liver chemo-embo or Y 90s. Please let me know how many community hospitals which are 90% of practice of medicine have a radiotracer called Y 90.
This is the effort of IR to show it is still high end. One of my GI friends told me nobody does Endo-US fellowship these days because in the community it is done once in a while and he is right. Cardiologists beg for a cardiac imaging fellow as there is practically no job for them out there. Now at our medical center there is huge number of all these junk including Endo-US, TACE, Y 90.
You may start to argue with me. But if really IR was a viable practice it could save its turf in PVD. For every TACE there are at least 20 PVDs out there. They do it in the boonies.
Tumor board exist only in your fellowship. Once you done, you will not see it is the practice.

2- I am doing residency in one of the most reputable IR places. We in fact do some PVD. I see how our fellows spend most of their time here at tumor board, TACE, RFA, ... Now from all of our fellows except for one who is going to a university, other tell me that their new job is very good, but they will not do cancer work. Also they will not do RFAs. PVD is done by vascular surgeons in their new hospital. Now what kind of procedures are they doing? Isn't it more than Some BS procedures?

3- Everybody is talking about clinical IR. And they go and read two pages of some cirrhosis classification or HCC classification and they put it in their note. Now they think they are clinicians. It is exactly equal to what clinician do with imaging. They look at some head CTs and think they are radiologists.

4- You didn't get my point. The matter is not post-procedure management. They point is who is getting the patient first. It is not about whether a breast surgeon can do a biopsy better than me (and for sure he can). The truth is that I get the patient first, so that is the reason that most of breast biopsies are done by mamo people.

5- Like it or not, IR lost almost all it had because it barely gets the patient from primary services. In US health system, more than 50% of health care providers are primary care ones and they become more and more as PAs and NPs are getting more and more independent.
I read tons of studies a day coming from these groups. In fact most hospitalists and primary care doctors first order some Diagnostic test before doing a consult. For example headache, they order MR or CT, then they do consult. Now show me a hospitalist who referes a patient to you to do Y 90 on or stent a carotid. For example they put the order: consult IR to do TACE.

The ABC of a specialist business: If there is a procedure which takes over a lot of a specialist business, they will fight it as hard as they can, whether it is vascular surgery or it is an orthopod. But if it is just 5% of their business, they will let it go and you may have some protected turf. That is the fact. Now if TACE becomes a routine of liver tumor management and replaces surgery, then it will be taken over by surgeons. But currently many do not give a $hit about it as it is nothing business-wise.

Let's be honest. Many IR people do it because they hate general radiology. Probably only recently some do it to take a job and as soon as they can, they get out of it. My famous statement: Doing radiology only for IR is stupid. If you like procedures, suck it up and become a surgeon.

Diagnostic radiology is the Gist of medicine.

 

[Dandon]

Dear shark2000,

First of all, this thread started with a scientific post about a great procedure which may change the future management of one of the most prevalent diseases in the world. There is nothing about IR being good or bad. You could have started your own thread talking about IR business. In my opinion you either wanted to do IR at some point and did not match or applying for IR next year and trying to decrease the competition with posting completely irrelevant comments in a scientific thread. I love the fact that your sidekick is also helping you with this attempt.

Now, let's talk about your false, misleading and sometimes insulting comments. There are some great points in your comments as well, which are being addressed at the SIR level as we talk.

1- "100% referral": DR is a 100% referral as well. You mentioned a few specialties refer to IR. This is false! There is no section in the hospital that you can see a GI, an Onc Surgeon and a Urologist at the same time in the same room but IR.

2- "It is not a true clinical service": False. I am sorry, maybe your program is like that. Recently I was visiting a friend in his IR clinic, and in half a day, we saw a full range of patients from PAD, aortic dissection, HCC, RCC and ..., some of which pre-op and some post-op. You can definitely expand your clinic and take care of your patients. And please don't tell m that your friend's clinic is the only one. There are many examples like that.

3- "It is completely different from DR": Very true but in a different way than what you described. Have you heard of radbay.com? If not, please take a look. That is the difference between IR and DR. Recently multiple hospitals got rid of their radiology groups and do you know who they kept? Only IRs. DR is a great field but it is becoming a commodity. With the new changes in healthcare, DR is not going to be a moneymaker any longer, hospitals are actually going to loose money for having DRs and that in addition to an exponential increase in the number of ordered studies, will make it easier to the get the cheapest guy available out there. I hope that never happens because I love DR but it is a good possibility.

4- "IR procedures are easy to learn": Who writes a comment like that? Which procedures? At what level? It is easy for who? IR is such a huge field that many older IRs have not performed some interventions well into their career. So, happy that you can do procedures by yourself, that is great! Would you please let us know what kind of procedures you do? I am a senior resident as well and for the last 3 years I have been to many conferences and meetings. I have seen many famous IRs talk about their new experiences and difficulties. The minute you start thinking that you are great in doing something, especially at the resident level, you are in deep trouble!!! I have never seen a world class IR saying IR procedures are easy! Yes, you can get good at some of them if you do them often enough but easy? Even a PICC placement can go drastically wrong. By the way, sorry for your MR techs but our techs always call us with emergent findings and they are really good at those.

At last you wrote: "I may be biased or wrong, but to me doing radiology just for IR is stupid." Why are you insulting people if they do something that you don't want to do or "you don't want them to do"? There are many talented medical students who are planning to do DR to get to IR. That could be predicted from a record breaking number of med students at the SIR annual meeting. There are many great IRs who did that as well. This also can be easily understood with the number of empty DR seats this year and competitiveness of IR match last which led to 20 or so unmatched residents.

And for Dumb, if you are in medicine to think about fundamentals of business, you got it wrong! You would have been much better in the Wall Street. My friend is already a millionaire and drives a Lamborghini and I still have to finish my residency and go for my fellowship. You have not even started radiology, your idea of DR and IR is probably based on your electives in you med school unless you have a family member who is IR or DR. At this point of your career, you need to think about how you can get the best education to become the best in your future profession. You should not think about the business part of it, you need to see what satisfies you and man, if it is just business part of it, my suggestion is leave it all together and start a business soon. You'll see many of these ups and downs during you professional life, one day hospitalists are going to make more than DRs (which they are already doing at some places), one day oncologists may get more patients than IRs. But believe me if you like what you are doing and you train well at it, you'll be a respected member of the healthcare team and community. Regarding referrals from primary docs, SIR members are working hard to get the word out there and talk about what we have to offer to the patients. IR is a vibrant field, if a procedure goes away, we get a new one and guess what? We are trying to collaborate with others to get the old procedures back too. Just think about new hypertension and BPH interventions in the past 12 months for a clear example. We need more aggressive IRs who are going to go out there and see their patients, talk to their primaries and follow them longitudinally.

Cheers,

 

[shark2000]

Dear Dandon:

1- I do residency at a very reputable IR program. Once our PD say they had trouble filling their sluts with highly qualified applicants 8 years ago, but this year they got some crazy number. I can not believe resident's interests change so fast in less than a decade. If IR is popular and it is, it is because of job market and not true interest.

2-"true clinical service". Could you please tell me how many times in an average hospital (an do not just say it happens in Miami Vascular), somebody put IR consult and for what?

3- This point that hospitals are losing money on DR is BS. Still imaging is the biggest money maker of the hospital directly and indirectly. It may not be the case in the future. I don't argue. Also firing radiology groups in over-emphasized. I can bet comparable number happens to other groups.

4- When I talked about IR procedures are easy I mean it. Do not talk about some esoteric case you saw in an SIR meeting. Talk about bread and butter of IR.

Now please answer my questions:
1- How many typical community hospitals are doing Chemo-embo or Y 90 that you guys are constantly talk about tumor board and cancer?

2- For every PVD, how many TIPS are out there?

3- If you do not do cancer work and PVD, that most IRs are not doing, could you please tell me what high end procedures are done by an IR doctor?

4- If IR is a clinical service, how did you learn all these clinics? Doing DR residency? Also you didn't get my point.

5- Whatever you say may be true, but history does not support that. And the future will not be any different. Do not talk about one or a few exceptions.

6- Please name 10 programs out of all IR fellowships in which you can learn PVD work in large scale? MGH? Hopkins? Or Upenn?

7- IR has even turf war with DR people. Take a look at MGH and UCLA body fellowships. They do most of the biopsies, drains and US guided procedures.

8- Like it or not, most IR procedures are easy to learn and that is the reason it is turfed out easily. How long does it take to teach a technician to put a drain in a fluid cavity in the abdomen. I do not know why should you do medical school for that.

Also I was never interested in IR and never applied. I could easily stay at my program which is a great one.
If I wanted to do surgery and be a clinician, I would have chosen an organized and more respectable surgical field with better hours, more intellectual and more protected turf.

At the end I appreciate your seemingly true interest in IR. Good Luck!

 

[cowme]

Dear Dandon:

1- I do residency at a very reputable IR program. Once our PD say they had trouble filling their sluts with highly qualified applicants 8 years ago, but this year they got some crazy number. I can not believe resident's interests change so fast in less than a decade. If IR is popular and it is, it is because of job market and not true interest.

Maybe that's cuz you got hotter sluts since then

 

[shark2000]

Maybe that's cuz you got hotter sluts since then

Exactly.

 

[shark2000]

Light IR is needed in all hospitals and can be done by a general radiologist or other radiology sub-specialists as they are doing more and more. I am talking about many light procedures including biopsies, drains, fouro procedures, injections, pain management, ... These will remain in the realm of general radiology as they are simple procedures, fast, do not need referral from a subspecialized service and are very high in number. For example biopsy, which barely needs surgery consult and can be referred directly from Internist or oncologist. And there are tons out there that will be done by many different services.
High End IR does not have a clear future and IMO is doomed to fail because of its innate multiple defects that make it un-sustainable in the long run.

 

[Dandon]

1- I clearly understand the impact of market on IR popularity, however, this has nothing to do with our discussion.

2- Many times! There are more and more programs who run on a consult based module. I say this because I just finished interviewing.

3- What brings money to the hospital is the number of admitted patients and procedures. Radiology does none of that except for IR.

4- If you think these procedures are easy, you should have done IR, such a waste of talent!

Answers:

1- I know many hospitals doing Chembos including community hospitals. You may be right with Y90 due to required guidelines, hospitals may have hard time providing it. That is not all of IR though. Thoracic interventions, biliary interventions, PAD and so many more are there to expand. You are probably in a big academic program from what I can tell, there are many active IR based PAD practices in the community, believe me.

2- Not that many, that is why IR is focusing on getting back PVD practice and collaborating with vascular surgeons. As soon as new guidelines for management come out, there is more and more role for endovascular approach and increasing role for IR.

3- Many IRs do cancer and PVD work. You need to stop this high end nonsense, who reads the ICU chest films everyday? Probably the same radiologist reading cardiac MRs. That is part of the job, unless you are so bright that you are just going to read cardiac MR studies for all your career. Who reads the useless low back pain lumbar films? The same person reading post op MRIs. I don't understand your problem with low end cases, that is part of IR. Yes, nobody wants to do PICCs all day long, but when PICC team has trouble putting it in, you need to do it and probably you are the only one who can do it!

4- Why do you think learning clinical medicine is harder than your easy IR procedures. Yes, I agree there is a problem with DR residency having no clinical training as it is being addressed with DIRECT, clinical and dual pathways, but believe me there is a large group of DR residents out there trying to stay close to clinic as much as they can. They have monthly clinical lectures given by other specialties and etc. Don't worry about it, I went through medical school and a rigorous internship as well.

5- There is no question in this line, it is all your funny conclusion. So if history does not support something, there is no way that thing can happen, ha? Great discussion! So many things happened for the first time with no indication in the history, cardiologists took cardiac cath, vascular surgeons took PAD and clearly we can took some of it back. I am not aware of any time in the history of IR that people were aware of importance of patient focused longitudinal clinical care. This may help!

6- Miami vascular, MCW, Mount Sinai, Georgetown, UCSD, UCLA, UVA, Brown, Upenn, Yale, Peoria, George Washington, UTSA. Need more? Do your research and get back to me.

7- So what? Turf wars are mainly local in the hospitals. If you don't like to work at UCLA and MGH, go somewhere else with no turf war. BTW, there is no turf war in UCLA, they collaborate there and both sides are extremely happy about it. Why do you think we need to do it alone.

8- Believe me, you can teach a technician to read radiographs as well, that is not the discussion here. You can teach people to do surgeries as well. Why do you think DR is much more superior to anything else? And I think, deep inside you may not believe it, maybe that is why you spend so much time on this unrelated forum!!! Again I very much enjoy DR, I would love reading CTAs and MRAs. My discussion has nothing against DR, but I don't take destroying IR for making DR look better. You need to change your attitude and come up with better answers. DR is going down, as long as you guys don't take control over your job. This situation is not sustainable, as doctors, you need to have a decision making role in what you do on a daily base. The way DR has become these days, is like a surgeon who operates without knowing if the operation is needed or not and can't even say no I don't do this surgery. It is crazy, right? That is how DR is nowadays. You can't even stop ER from possibly harming patients with getting panscans based on some BS research done in 80s, showing you may diagnose 2%???? more injuries if you panscan people after trauma. They screen people after trauma based on things that no one can tell, i.e.:
1- How fast you were driving when you had the accident? funny!!! Yes, I am always checking my speed especially before accidents!!!
2- Did you lose consciousness? Everybody would say something like: "I was so confused that I can't even remember." and panscan comes after that!!!!

And so many more examples. You can't even make clinicians to give you pertinent clinical findings. How many CTs have you read lately saying "Rule out stroke"? DRs don't even have guts to go out there and say you can't write "rule out" on the reason section. If you can't control your job environment, you become like a lab technician who does CBCs on every single request they get and finally you'll get paid like one too.

I am ready to answer any other question.

Cheers,

 

[Dandon]

Dear Dumb,

1- Good luck with this attitude. Yes, everybody out there who dedicated their life to one branch of science without considering business aspect of it, is stupid and you are the brightest in the world. I am sorry, you might end up being a billionaire but I will never work for you or with you. I am seeing more and more this type of people who say "my way or no way". Dude all I am saying is the amount of money in pure clinical medicine does not even worth trying. The highest paid clinical practitioner may make $500,000 and the lowest paid $200,000 a year. That money does not worth planning and trying. You go to medicine for something else. Become a great doctor and you may get financial satisfaction by investing in something else.

2- There is no doom discussion here, there are many ups and downs in medicine financially. Go ask your attendings how was radiology in early 90s. That is all I have for you.

3- That is insufficient for you and learn how to talk to other people. That is the first step to become a good doctor and human being. You and I live in two different worlds in terms of practicing medicine, why do you think I can't get it? You are not the first person who came up with this discussion in my world, I have seen many people like you, who just think about business in medicine. I get it but I think it is the wrong way of doing it.

4- There are many practices out there in the community that never lost those procedures except for cardiac cath. If IR continues seeing patients in the office and follows them longitudinally, no one else can do the procedures better than IR, given their understanding the imaging part of it. Remember, these are image guided procedures and we are radiologists. You are trying to infuse the same passive attitude of DR into IR and I am sorry most IRs out there are different type.

Again, ready for any other questions or comments.

Cheers,

 

[shark2000]

1- Case scenario:
Patient comes to the ED with flank pain. A CT KUB shows left obstructive ureteric stone. The ED doctor starts pain management and fluids.
Now what is the next step:
a- Call IR for consult.
b- Call Urology for consult.

I bet it is the second choice everywhere other than your program that is a "clinical one". Now if the urologist learn to do pecut nephrostomy (which is the hardest procedure in the world in your opinion, but you learned in probably 1-2 months during your fellowship), your business is gone.
The same is for biliary work. Patient with biliary obstruction goes to GI first 100% of the time. Then they decide what to do. Now if they want to do percut biliary drain they will do it.

I understand that you can say the same for DR, but my point is for DR it does not come from one service all the time.

2- The last time I checked none of the vascular surgeons or cardiologists believe in collaborating with IR and sharing the procedures. They may say it sometime just for political reasons, but they do not believe it. It is always IR who talks about collaborating with other groups. Good luck taking back coroany angio.

3- Turf is not local to the hospital. The number of PVD in IR is decreasing day by day and is flat or mildly increasing in other services.

4- I don't say learning medicine is easier or more difficult. BUT you need to spend time to learn it. You need to run clinics, you need to admit patients and you need to take ICU calls. It does not happen in radiology residency except for you program.

5- You can teach anybody to do anything, but it is about the time and energy required to do it.

6- You clearly destroyed DR in both of your posts as a loser specialty and non-sustainable, then you recommended that there is no point in destroying one another.

7- This is the same attitude of all IR departments. Clearly they think they do a much greater job than DR. Statements like DR is not making money for the hospital, DR does not have patients, hospitals can discontinue DR contract if there is not a strong IR department , .... and most want to separate from DR. It may or may not happen in the future. I don't know would it better or worse for any of them.

8- In order to do IR procedures you do not need DR residency. This is the justification of IR people that they did not "waste" their time doing DR residency. You do not need to know the differential diagnosis and imaging feature of all liver lesions on US, CT and MRI to biopsy it.

 

[Son of the sun]

I think what is continuously being missed here is the quality and understanding of an IR (and to a lesser extent a DR) in doing an endovascular or image guided procedure. At the end of the day not all the specialists who spend most of their time in direct pt care would know what all that distorted anatomy means in a post transplant pt. They may know the basics as you mentioned, but doing image guided treatments takes more sophisticated training than what you can get in most other residencies. This is being more and more appreciated by administration and decision makers in health care industry. What they do care, is not only money you make from doing a procedure, but also comparative success rate as well as complication rate. I have never seen a single surgeon claiming they are better at doing image guided procedures than an IR doc. For this very simple reason IR has been and will continue to be the front edge of minimally invasive procedures. What I really like about Dumb's example is using a very rapidly changing market as the example. Apple may have lost the battle on operative systems but have won the game in a bigger picture. By continuing to deliver high quality and "innovative" products now they are the most valuable company in the world. I am not saying that vascular surgeons or whoever else would be extincted from PAD market, but we will have our fair share if we keep doing what we are already doing. I totally think trying to bring IR outside the dark room and angio suite is going to be a game changer as it has already been in some practices. We are NOT trying to learn medicine MORE than a medicine doc or surgery more than a surgeon. This true about them as well, they CAN'T be more IR than us. What we are trying to do is to add value to pt care by knowing the context and educating other clinicians about what we can do and its role.

In terms of market shift I have seen much more of that shift in DR than IR (although it is essentially wrong to base what you want to do with your life on transient market changes). A very recent example is a friend who just graduated from a very big ivy league residency but could find a job in where I leave. Another friend who completed his IR fellowship in an above average training had 6 offers from the same city. I doubt hospitals are spending money to get such an expensive trash dump. This whole aspect of market and reimbursement is not important for me personally. I have already quit my previous ED staff position to do IR. I really like this job and have found it very challenging and rewarding. I had never seen it "the trash dump" in any hospital, after practicing in 5 different hospitals. And finally I feel much of this confident statements are coming from lack of experience in real world practice. I have always found a practice to be reflection of how each practitioner performs in what he does and interacts with colleagues and pts, If you want to develop an IR practice with emphasis on PAD, first you need to be the right person and then find the right environment.

 

[shark2000]

I think what is continuously being missed here is the quality and understanding of an IR (and to a lesser extent a DR) in doing an endovascular or image guided procedure. At the end of the day not all the specialists who spend most of their time in direct pt care would know what all that distorted anatomy means in a post transplant pt. They may know the basics as you mentioned, but doing image guided treatments takes more sophisticated training than what you can get in most other residencies. This is being more and more appreciated by administration and decision makers in health care industry. What they do care, is not only money you make from doing a procedure, but also comparative success rate as well as complication rate. I have never seen a single surgeon claiming they are better at doing image guided procedures than an IR doc. For this very simple reason IR has been and will continue to be the front edge of minimally invasive procedures. What I really like about Dumb's example is using a very rapidly changing market as the example. Apple may have lost the battle on operative systems but have won the game in a bigger picture. By continuing to deliver high quality and "innovative" products now they are the most valuable company in the world. I am not saying that vascular surgeons or whoever else would be extincted from PAD market, but we will have our fair share if we keep doing what we are already doing. I totally think trying to bring IR outside the dark room and angio suite is going to be a game changer as it has already been in some practices. We are NOT trying to learn medicine MORE than a medicine doc or surgery more than a surgeon. This true about them as well, they CAN'T be more IR than us. What we are trying to do is to add value to pt care by knowing the context and educating other clinicians about what we can do and its role.

In terms of market shift I have seen much more of that shift in DR than IR (although it is essentially wrong to base what you want to do with your life on transient market changes). A very recent example is a friend who just graduated from a very big ivy league residency but could find a job in where I leave. Another friend who completed his IR fellowship in an above average training had 6 offers from the same city. I doubt hospitals are spending money to get such an expensive trash dump. This whole aspect of market and reimbursement is not important for me personally. I have already quit my previous ED staff position to do IR. I really like this job and have found it very challenging and rewarding. I had never seen it "the trash dump" in any hospital, after practicing in 5 different hospitals. And finally I feel much of this confident statements are coming from lack of experience in real world practice. I have always found a practice to be reflection of how each practitioner performs in what he does and interacts with colleagues and pts, If you want to develop an IR practice with emphasis on PAD, first you need to be the right person and then find the right environment.

Overall, a fair post. Can not disagree, but some points are missing.
1- Talking about anatomy is not very relevant. For doing PAD or chemoembo of a liver mass, you really do not need to know a HUGE anatomy. Probably vascular anatomy is the most you need to know, for example replaced right hepatic artery or ... So you statement that IR provides the highest quality because they know imaging anatomy is not really relevant.

2- You can learn as much medicine required to run a healthy IR practice, no doubt. It is doable. You do not need to know all the staging process of lymphoma, to do a work up for PAD. I agree with this part. It is not rocket science. But the problem comes from referral model. For example abdominal aortic dissection goes to vascular surgery before you, as the ED doctor first call vascular surgery. The same statements are true for stroke, chest pain, dizziness, dialysis,...
For example doing AV fistula declot more likely will be done by a vascular surgeon, as they are the ones who put the fistula in the first place.

3-IR job market is very good now, one of the best in all medical specialties. It is great from my perspective as at the end of the day, it will help DR as well. But really it does not mean anything. Nowadays hospitals are hiring more and more hospitalists than cardiothoracic surgeons or neurosugeons. It does not mean anything.

4- Good Luck.

 

[fiatlux]

The funny thing about this post is where this "rant" is occurring. Nice job with the thread crapping there residents. Well done.

Also, if you actually talked to "GVataken" and see what goes on in the "real world" and not just thread crap his post, I am pretty sure you would sound a bit immature. We, junior residents will actually listen to you guys in a couple of years, until then, thanks for the opinions and good luck.

----

As for prostatic artery embo....I'd like to see a US paper in the upcoming year on it and see how it stacks up with TURP and oral meds. I agree, still is a bit too early to tell, though the stuff out of Portugal and the 1200 pts was short of amazing. Lets hope Golzarian or others do a a head to head RCT and hopefully we see some EMMY/REST type of paper.

Also, what do you think about the pancreatic islet cell transplantation in the May JVIR, now that is one interesting concept.

 

[shark2000]

Funny you should mention that...I've had a similar discussion with senior partners in a top IR pp who have been in this game for 20+ years and trained at ivies. They all agreed with my assessment and said that although the practice model is terrible, they have no interest in becoming clinicians, are all making >800k without a clinical model, and will exit IR before it bottoms out anyway. The silver lining is that even if you (incorrectly) pursued IR, you can always just fall back on DR.

If you hate DR and can not tolerate it, doing radiology only for IR is stupid. I have seen friends who entered radiology only for IR and now they are miserable. Although most can find a job in their desirable location, 100% IR jobs are very few. You have to be ready to do DR 100%.

Whenever I ask IR passionate people this question, I do not get any answer. If you really want to take care of patients, give 24 hour clinical coverage, become a clinician, run clinics, run inpatients, do consults, go to ER @ 2 am, do procedures, Why you do not do other fields? And how come many say they can only do IR and not any other field in medicine? Do not tell me you love clinical IR and at the same time you hate vascular surgery, cardiology, all surgical subspecialties, Urology, .... It is impossible to LOVE CLINICAL IR and hate vascular surgery or Urology.
If I wanted to do clinics, consults, and procedures, I would do something with better hours, better clinical education, less turf issues and "better defined" role in the hospital.

 

[MossPoh]

If you hate DR and can not tolerate it, doing radiology only for IR is stupid. I have seen friends who entered radiology only for IR and now they are miserable. Although most can find a job in their desirable location, 100% IR jobs are very few. You have to be ready to do DR 100%.

Whenever I ask IR passionate people this question, I do not get any answer. If you really want to take care of patients, give 24 hour clinical coverage, become a clinician, run clinics, run inpatients, do consults, go to ER @ 2 am, do procedures, Why you do not do other fields? And how come many say they can only do IR and not any other field in medicine? Do not tell me you love clinical IR and at the same time you hate vascular surgery, cardiology, all surgical subspecialties, Urology, .... It is impossible to LOVE CLINICAL IR and hate vascular surgery or Urology.
If I wanted to do clinics, consults, and procedures, I would do something with better hours, better clinical education, less turf issues and "better defined" role in the hospital.

I've gotten similar advice from a full time IR guy, gyn onc, vascular surgeon and urologist. The IR guy loves IR but his first love was radiology and then fell into IR. He told me that if I only wanted to go this path for IR, then I should just go into a surgical subspecialty because at least then, I'd have a much more definable skillset and wouldn't always be getting the patients that nobody else knew what to do with or didn't want to deal with.

It seems really difficult to market your skills in IR without including a DR component. I'm ok with that, but I rather have a split between the two and sacrifice the really complex stuff.