Teaching PAs procedures... a penny-wise, pound-foolish strategy?

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RadsFTW123

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I am seeing more and more PAs/NPs in IR. I'm also hearing more stories of PAs leaving radiology groups after getting trained and going to work for the local referring MDs and doing the work they previously did for IRs (I.e. Doing the lines and ports in the oncologists office that used to be sent to IR that were done by that PA in IR).

Do IRs not see the huge long term risks in training others to do our jobs? Let's be honest, a lot of IR, especially in the community, is "bread and butter" cases that people are teaching their PAs to do. In the short run, this is a great idea. However as the examples above show, this could really hurt IR in the long run. I can't think of another specialty that is using PAs in an almost replacement function like IR does (oh wait, CRNAs, that hasn't caused any problems for anesthesia...)

I really think we should have PAs act as assistants that augment us (help with notes, assist with cases, etc) like neurosurgeons, cards, ortho, etc does. We do not own most of our patients, and once referrers realize they are sending us cases to be done by a PA they will smartly hire that person away from us and take those cases. I also think it cheapens our training to teach someone how to do a case a few times while saying our extensive training is why we should get the cases...

Interested to hear people's thoughts!

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I am seeing more and more PAs/NPs in IR. I'm also hearing more stories of PAs leaving radiology groups after getting trained and going to work for the local referring MDs and doing the work they previously did for IRs (I.e. Doing the lines and ports in the oncologists office that used to be sent to IR that were done by that PA in IR).

Do IRs not see the huge long term risks in training others to do our jobs? Let's be honest, a lot of IR, especially in the community, is "bread and butter" cases that people are teaching their PAs to do. In the short run, this is a great idea. However as the examples above show, this could really hurt IR in the long run. I can't think of another specialty that is using PAs in an almost replacement function like IR does (oh wait, CRNAs, that hasn't caused any problems for anesthesia...)

I really think we should have PAs act as assistants that augment us (help with notes, assist with cases, etc) like neurosurgeons, cards, ortho, etc does. We do not own most of our patients, and once referrers realize they are sending us cases to be done by a PA they will smartly hire that person away from us and take those cases. I also think it cheapens our training to teach someone how to do a case a few times while saying our extensive training is why we should get the cases...

Interested to hear people's thoughts!

My thoughts on these matters are often at odds with the majority opinion on SDN, but I think physician training is too long and many physicians place themselves on a pedestal as a result of having undergone grueling training. The reality is, if outcomes are the same with a PA performing a procedure as a physician performing that procedure...then yes hospitals will tend to hire the lower-cost alternative. There are many studies showing that CRNAs + one overseeing anesthesiologist is equivalent to an anesthesiologist in every room.
 
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At my home institution, we have a team of PICC nurses that place all the PICC lines. The NP/PAs on IR (some even on DR) were performing the tasks that the attending did not want to be doing (taking a history, writing notes, performing fluoroscopy). They rarely assist in cases and they never perform their own procedures (other than the super-specialized PICC nurses mentioned above).

Unlike anesthesiology, the biggest threat to IR is not from nurses, but from other physician specialties (vascular surgery, interventional cardiology, endovascular neurosurgery, interventional neurology, interventional nephrology, etc.).
 
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Your attendings are smart to employ mid levels in that way (more ancillary). I totally agree that's a smart practice.
 
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My thoughts on these matters are often at odds with the majority opinion on SDN, but I think physician training is too long and many physicians place themselves on a pedestal as a result of having undergone grueling training. The reality is, if outcomes are the same with a PA performing a procedure as a physician performing that procedure...then yes hospitals will tend to hire the lower-cost alternative. There are many studies showing that CRNAs + one overseeing anesthesiologist is equivalent to an anesthesiologist in every room.

I have never been fond of telling people that they are going to feel differently when they have actually been through the thing they are talking about. But in your case, it is so likely true that I can make an exception.
 
i'd rather have a PA do all the ports and spend my time doing complex interventions. i'm not spending 6 years post grad training to do low tier cases
 
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You've got it medgator. Most people don't understand that there is a small proportion of truly high end cases. The vast majority of people that go into IR will not do exclusively high end cases (that's like saying all Surg oncs do all whipples all day, they don't, many do things like melanoma excisions etc because that's what pays the bills). IR is foolish to do anything that could endanger these procedures that pay the bills for most people in private practice. People going into IR now seem to think they're too good for everything except the most complex arterial cases and don't seem to understand that there aren't jobs for 200 people per year to do y90 all day.
 
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You've got it medgator. Most people don't understand that there is a small proportion of truly high end cases. The vast majority of people that go into IR will not do exclusively high end cases (that's like saying all Surg oncs do all whipples all day, they don't, many do things like melanoma excisions etc because that's what pays the bills). IR is foolish to do anything that could endanger these procedures that pay the bills for most people in private practice. People going into IR now seem to think they're too good for everything except the most complex arterial cases and don't seem to understand that there aren't jobs for 200 people per year to do y90 all day.
What percentage of graduating IRs would you guess end up practicing high-end vs. bread&butter IR?
 
The key is to look at the prevalence of the disease and then that will guide you to the likelihood of developing a busy high end practice.

So things that are prevalent include 900, 000 patients with DVT/PE and 60 to 100,000 deaths /year

1) DVT
2) PE

Thrombolysis/thrombectomy

Fibroids are very common: most common reason for hysterectomy in the US and UAE is a reasonable alternative with good evidence

PAD/CLI (1 to 2 million patients)
-endovascular revascularization

Strokes:
800,000 per year
Carotid stenting/stroke thrombectomy

Compression fractures (1.5 million patients)
-vertebroplasty/kyphoplasty

Varicose vein (20 million females, 10 million males)
-endovenous ablation

Primary liver cancer (29,000 patients/year)
-mostly transplant liver centers

The problem that I see is that the focus at most academic centers which are usually affiliated with transplant centers have focused on oncologic treatments and have not focused on building some of the other more prevalent clinical parts of the practice (Vascular, cerebrovascular, fibroids, back pain etc). The prevalence of these conditions is quite high and even the smaller hospitals have a significant amount of these conditions that a clinically well trained IR would be able to manage.

When looking for training, you should look and see if they are building all aspects of the IR practice vs focusing only on things such as transplant (HCC treatment, biliary, TIPS) and trauma related IR which is usually seen more at academic centers or tertiary hospitals.
 
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What percentage of graduating IRs would you guess end up practicing high-end vs. bread&butter IR?
I'd say maybe 10-15 percent do high end practices? I come from a fairly strong program and the majority grads this year took 25-50 percent IR jobs with pretty unexciting pay... there are way too many IR fellows IMO, i don't know of any other subspecialty that trains 8 people per year at a program... but that's radiology.
 
In VIR you have to be willing to do it all. Including the lowly paracentesis and thoracentesis ( I hate those, but they must be done). You have to do low end biopsies and drains. If you refuse those, good luck setting up a good referral base for PAD, veins, and onc. My dream practice is 100% outpatient VIR doing mostly peripheral arterial cases, UAE, and veins. But reality is that I will likely work in the hospital setting doing the gamut (including the garbage) and hopefully 1/3 of my practice is arterial disease since I enjoy treating peripheral arterial disease patients.
 
How does one compete with the newly trained vascular surgeons who can offer both endovascular and surgical management for PAD? Just try to take as much cold leg call from the ER as possible?
 
How does one compete with the newly trained vascular surgeons who can offer both endovascular and surgical management for PAD? Just try to take as much cold leg call from the ER as possible?

Forgive my ignorance, but how can you take "cold leg call" if you don't have access to open surgery? I mean I hate doing it, but sometimes you just have to cut down on vessels to get things open. Never mind the fasciotomies that invariably come with the cold legs. I can see an elective practice doing lower extremity work that passes on the patients that need endarterectomy or bypass to a surgeon, but emergent?
 
Forgive my ignorance, but how can you take "cold leg call" if you don't have access to open surgery? I mean I hate doing it, but sometimes you just have to cut down on vessels to get things open. Never mind the fasciotomies that invariably come with the cold legs. I can see an elective practice doing lower extremity work that passes on the patients that need endarterectomy or bypass to a surgeon, but emergent?

Presumably IR would do the initial diagnostic angio and go from there right? IR might also be able to get pedal / toe access for SAFARI/whatever. Atleast initially, emergent treatment might be catheter driven thrombolysis ---> open surgery if needed (at which point Vasc would need to get involved).
 
Forgive my ignorance, but how can you take "cold leg call" if you don't have access to open surgery? I mean I hate doing it, but sometimes you just have to cut down on vessels to get things open. Never mind the fasciotomies that invariably come with the cold legs. I can see an elective practice doing lower extremity work that passes on the patients that need endarterectomy or bypass to a surgeon, but emergent?
By offering angiograms and catheter directed thrombolysis? Call vascular if it doesn't work.
 
By offering angiograms and catheter directed thrombolysis? Call vascular if it doesn't work.

Doesn't that lead to a fair number of delays in definitive treatment? Obviously depends on availability of vascular surgery and the types of pathology that walk in your door. I'd have to run our numbers to see what our actual 'need for/utility of open intervention', but ballparking it, I'd say it has to be ~10% for real cold legs, excluding fasciotomies, which would bump that up significantly higher.

At our main (academic) hospital, in the middle of the night, it would probably take an hour or more to get a surgical team in from the time of call, which is acceptable (could be better) from the ER, but not really acceptable if the patient has already been in the hospital for 3 hours. At one of our community hospitals, it could easily be 2-3 hours.
 
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