Turf

[youngdoc8205]

Hi Guys,
]
Quick qualifying statement before my question/statement:

I think this thread is a great idea, unfortunately I switched out of radiology into GS, and will probably do a breast onc fellowship, I switched for mostly personal reasons

I think a frank discussion about issues facing IR should be addressed here, and probably better here then anywhere else b/c of all of the attendings and fellows, and to a lesser extent residents with significant IR experience

the main issues I'm talking about are

1)Turf Battles: mainly with PVD between cards and vascular surgery, unfortunately IR seems to have lost that battle on the surface, but where I did a year of my rads residency there was quite a healthy arterial practice, and there are IR only practices who do arterial work

Venous is still done primarly by IR I feel, but VS seems to be encroaching

so what are the opinions of attendings/fellows on turf? particularly with the new oncologic stuff, what's to stop surgical oncologists from doing these, currently they are more for salvage, but if you put them head to head (which no one has done as surgery is the standard of care, and to do that you would have withhold standard of care from the experimental group) and with improvements they may very well become first line therapy

those procedures are great though I've seen people with inoperable HCC get TACE and revert to candidates for transplant, more importantly they are re-imbursed very highly (the main reason for turf battles)

I even heard of a case series out of ??florida?? where an IR did cryo or RFA of a breast CA pre-surgically and got clean margins, so who will be doing those in the future surgery or radiology?

which brings up the next issue

2) IR is on a precipice right now moving to a clinical specialty (which is what Dotter recommended, and predicted the encroachment of other specialties if radiologist didn't start taking care of their patients)
who should take care of IR patients? IR or the specialty that takes care of the particular organ/system treated by IR? ex: s/p TACE of HCC does the pt go to IR service or to hepatobiliary surgery/GI

in my opinion it should be IR: you do a procedure, you should know the history, pre/post-op care, and associated issues, thus basic inpatient mgmt skills i.e. DM and HTN should be taught, which I feel is not plausible given the current training model of a 1 year fellowship

so I always thought that IR should really break from DR much like radonc did 20+ years ago

thought?

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[Gvataken]

I agree with you. The way that IR is changing is into service lines.

I do primarily oncology and vascular.

So, when we get a consult on hepatoma. We see the patient in the office. Then, based on imaging, hepatitis serologies, AFP etc we decide what to do.

AASLD (american association study of liver disease) has great guidelines

THen the breakdown is

1. Trasplant criteria (Milan 1<5 or3 <3cm)
2. Resection (no evidence of portal hypertension/reasonable liver synthetic function.
3. Ablation (</=3 cm) oligomets
4. TACE/DEB/ (multifocal disease)
5 nexavar (sorafenib, tk inhibitor)

Resection and ablation have been compared head to head with equivalent 4 yr diesease free and overall survival.

So, at that point we follow the patients.

If we tace or ablate we follow them with imaging and labs every 1-3 months for life. We admit them to our IR service overnight. The patients follow up with us for life. Some of these patients I have followed for 5 years. I then may refer for resection, transplant, nexavar and then continue to follow them.

So, this is the model that is now emulated with other branches of IR.

veins
fibroids
vascuar/pad
pain
etc

If you don't do it this way then it won't be sustainable long term. Gone are the days of waiting for someone to send you "good stuff". If you wait for things to trickle down, you will end up getting the piccs, paracentesis, thoracenesis or the things that no one wants to do.

 

[werewethere]

Hi Guys,
]
Quick qualifying statement before my question/statement:

I think this thread is a great idea, unfortunately I switched out of radiology into GS, and will probably do a breast onc fellowship, I switched for mostly personal reasons

I think a frank discussion about issues facing IR should be addressed here, and probably better here then anywhere else b/c of all of the attendings and fellows, and to a lesser extent residents with significant IR experience

the main issues I'm talking about are

1)Turf Battles: mainly with PVD between cards and vascular surgery, unfortunately IR seems to have lost that battle on the surface, but where I did a year of my rads residency there was quite a healthy arterial practice, and there are IR only practices who do arterial work

Venous is still done primarly by IR I feel, but VS seems to be encroaching

so what are the opinions of attendings/fellows on turf? particularly with the new oncologic stuff, what's to stop surgical oncologists from doing these, currently they are more for salvage, but if you put them head to head (which no one has done as surgery is the standard of care, and to do that you would have withhold standard of care from the experimental group) and with improvements they may very well become first line therapy

those procedures are great though I've seen people with inoperable HCC get TACE and revert to candidates for transplant, more importantly they are re-imbursed very highly (the main reason for turf battles)

I even heard of a case series out of ??florida?? where an IR did cryo or RFA of a breast CA pre-surgically and got clean margins, so who will be doing those in the future surgery or radiology?

which brings up the next issue

2) IR is on a precipice right now moving to a clinical specialty (which is what Dotter recommended, and predicted the encroachment of other specialties if radiologist didn't start taking care of their patients)
who should take care of IR patients? IR or the specialty that takes care of the particular organ/system treated by IR? ex: s/p TACE of HCC does the pt go to IR service or to hepatobiliary surgery/GI

in my opinion it should be IR: you do a procedure, you should know the history, pre/post-op care, and associated issues, thus basic inpatient mgmt skills i.e. DM and HTN should be taught, which I feel is not plausible given the current training model of a 1 year fellowship

so I always thought that IR should really break from DR much like radonc did 20+ years ago

thought?

"Turf" remains important, but it is not be the only model to consider when discussing IR and medicine in general.

The fact is that medicine is moving toward an outcomes driven model via CQI and various governmental (i.e. AHRQ) and non-governmental agencies (i.e. IOM), and that does not mean that one group does everything, but that those who do it best get to keep doing it. If they, the government/insurance/patients, are going to pay for it, you have to prove that you are the guy who should do it. For instance, some of the most successful practices have interdisciplinary groups where IR, cards, and VS may all be present. Why? Because you want to be able to get the best results to attract patients, and no one field has all the answers. This applies to hospitals as well. Which hospital is going to thrive, the one with the one surg onc guy, or the one with the "caring, interdisciplinary team" that has all the latest techniques and people who know how to do them?

This has been an ongoing process for decades now. It use to be, for instance, that surgeons were considered "operating internists," able to do the preoperative care, management of chronic health issues and critical care, anesthesia, and operate all simultaneously. Now you have medicine consults for cardiac clearance, co-admission of patient with the hospitalist, specialized anesthesia, intensivists for the post op critical care, etc, etc. If one tried to do it all yourself today, you'd probably get sued out of medicine. Consider, even if you become a specialized surgeon such as NSGY or ortho, you're probably going to work on a small subset of the people in your field (i.e. tumor, trauma, vascular, pediatric, etc). The same applies to IR, as the specific problems related to a disease process become more complex and have actual solutions, you need to have someone who doesn't just know something can be done, you need someone who knows why, when, and how it should be done. It's not just pop a stent in there and be done.

Of course, this argument favors specialization, not the existence of IR.

So, why not have one group take over all of vascular and cardiac work?

Because outcomes require experience and there is only so much time in the day. The surgeons know it. How many studies have indicated outcomes related to the number of times you do a given procedure in a given period of time? If you're doing cardiac caths all day, or fem-pop bypasses, where do you have the time to keep up the skills for your EVAR?

Even in your field, a breast surgeon is better off doing breast surgeries than biopsies. You can even read your own mammograms, until you miss one and find yourself in court saying that your training is equal to a subspecialty trained mammographer who reads as many studies in a day you read in a year. Sure you can do biopsies, and you might if your volume of surgeries is low, but is it the best use of your time and the best outcome for your patient. Could you be practicing new interventional approaches. Certainly, but will you be able to keep up both surgical and interventional skill sets up, or are your outcomes going to suffer?

You're right about IR challenges that have not been successfully addressed in the past, but there is definitely an ongoing change within the field and its reflected in a growing demand for IR fellowships. Many new IRs come out with an understanding of longitudinal care and management of disease process, not just procedures. Of course some don't, and just want to be proceduralists doing mostly lines and taps. But that's true in other fields too, not all cardiologists want to stent, not all vascular surgeons want to do EVAR.

Frankly, it's not just IR, but other specialists out there as well. Sure people compete and there are places where one specialty dominates the others, but ability to collaborate across fields is not just something IR does, its something other specialists do. If you come in well trained, willing to handle a patient's disease process, willing to collaborate with other like-minded specialists and keep up your clinical, radiologic, and interventional skills, your outcomes will eventually lead to success. Although interdisciplinary and outcomes may not be the dominant factor in all settings and turf battles will probably continue to exist in essentially all fields, outcomes are going to loom larger and larger as time goes on. It is an exciting and uncertain time, but the need for IR remains and grows.

 

[werewethere]

Hi Guys,
]
Quick qualifying statement before my question/statement:

I think this thread is a great idea, unfortunately I switched out of radiology into GS, and will probably do a breast onc fellowship, I switched for mostly personal reasons

I think a frank discussion about issues facing IR should be addressed here, and probably better here then anywhere else b/c of all of the attendings and fellows, and to a lesser extent residents with significant IR experience

the main issues I'm talking about are

1)Turf Battles: mainly with PVD between cards and vascular surgery, unfortunately IR seems to have lost that battle on the surface, but where I did a year of my rads residency there was quite a healthy arterial practice, and there are IR only practices who do arterial work

Venous is still done primarly by IR I feel, but VS seems to be encroaching

so what are the opinions of attendings/fellows on turf? particularly with the new oncologic stuff, what's to stop surgical oncologists from doing these, currently they are more for salvage, but if you put them head to head (which no one has done as surgery is the standard of care, and to do that you would have withhold standard of care from the experimental group) and with improvements they may very well become first line therapy

those procedures are great though I've seen people with inoperable HCC get TACE and revert to candidates for transplant, more importantly they are re-imbursed very highly (the main reason for turf battles)

I even heard of a case series out of ??florida?? where an IR did cryo or RFA of a breast CA pre-surgically and got clean margins, so who will be doing those in the future surgery or radiology?

which brings up the next issue

2) IR is on a precipice right now moving to a clinical specialty (which is what Dotter recommended, and predicted the encroachment of other specialties if radiologist didn't start taking care of their patients)
who should take care of IR patients? IR or the specialty that takes care of the particular organ/system treated by IR? ex: s/p TACE of HCC does the pt go to IR service or to hepatobiliary surgery/GI

in my opinion it should be IR: you do a procedure, you should know the history, pre/post-op care, and associated issues, thus basic inpatient mgmt skills i.e. DM and HTN should be taught, which I feel is not plausible given the current training model of a 1 year fellowship

so I always thought that IR should really break from DR much like radonc did 20+ years ago

thought?

"Turf" may not be the only model to consider, since it assumes a given training rather than practitioner is the best answer for the patient.

The fact is that medicine is moving toward an outcomes driven model via CQI and various governmental (i.e. AHRQ) and non-governmental agencies (i.e. IOM), and that does not mean that one group does everything, but that those who do it best get to keep doing it. If they, the government/insurance/patients, are going to pay for it, you have to prove that you are the guy who should do it. For instance, some of the most successful practices have interdisciplinary groups where IR, cards, and VS may all be present. Why? Because you want to be able to get the best results, and no one field has all the answers. And this has been an ongoing process for decades now. It use to be, for instance, that surgeons were considered "operating internists," able to do the preoperative care, management of chronic health issues and critical care, anesthesia, and operate all simultaneously. Now you have hospitalists, specialized anesthesia, intensivists, etc, etc. If one tried to do it all yourself today, you'd probably get sued out of medicine. Consider, even if you become a specialized surgeon such as NSGY or ortho, you're probably going to work on a small subset of the people in your field (i.e. tumor, trauma, vascular, pediatric, etc). The same applies to IR, as the specific problems related to a disease process become more complex and have actual solutions, you need to have someone who doesn't just know something can be done, you need someone who knows why, when, and how it should be done. It's not just pop a stent in there and be done.

Of course, this argument favors specialization, not the existence of IR.

So, why not have one group take over all of vascular and cardiac work?

Because outcomes require experience and there is only so much time in the day. The surgeons know it. How many studies have indicated outcomes related to the number of times you do a given procedure in a given period of time? If you're doing cardiac caths all day, or fem-pop bypasses, where do you have the time to keep up the skills for your EVAR?
Even in your field, a breast surgeon is better off doing breast surgeries than biopsies. Sure you can do biopsies, and you might if your volume is low, but is it the best use of your time and the best outcome for your patient. Could you be practicing these interventional approaches. Certainly, but will you be able to keep up both surgical and interventional skill sets up, or are your outcomes going to suffer?

You're right about IR challenges that have not been successfully addressed in the past, but there is definitely an ongoing change within the field and its reflected in a growing demand for IR fellowships. Many new IRs come out with an understanding of longitudinal care and management of disease process, not just procedures. Of course some don't, and just want to be proceduralists doing mostly lines and taps. But that's true in other fields too, not all cardiologists want to stent, not all vascular surgeons want to do EVAR.

Frankly, it's not just IR, but other specialists out there as well. Sure people compete and there are places where one specialty dominates the others, but ability to collaborate across fields is not just something IR does, its something other specialists do. If you come in well trained, willing to handle a patient's disease process, willing to collaborate with other, like minded specialists and keep up your clinical, radiologic, and interventional skills, your outcomes will eventually lead to success. It is an exciting and uncertain time, but the need for IR remains and grows.

 

[youngdoc8205]

I agree with everything werewethere said: i.e. the more you do something the better you are at it, but my point is turf battles are not rooted in that, rather they are rooted in money and referrals, else cardiologists (in my opinion the worst offenders of anyone) wouldn't be trying to read perfusion scans or cardiac MRI, when I was in rads, i would see so many mistakes by cards it would be laughable if it wasn't so dangerous, but that's besides the point.

the main reason I posted was to try to get a discussion on how IR training paradigms are changing to make sure that the right people are doing the right procedures

while it's true a surgeon would be best be doing surgeries rather then interventions, what happens when intervtions become the standard of care as EVAR already has, while it is important to know how do to an open AAA repair, that is not the first line modality for the vast majority of patients, so if a surgeon doens't know how to do the intervention he/she will be SOL, and why would they or PCP refer to IR if IR (as they have in the past) excels at only doing the procedure and not pre/post care

Additionally I got the feeling as a rads resident, that in private rads practices, IR is like the red headed step child, you cant generate as many RVUs doing a TACE seein the patient pre and post-op and following them in clinic, then if you spent that whole time reading MRIs or CTs thus IR suffers from external (other specialties) and internal (DR colleagues)
any thoughts from PP IR attendings would be most insightful.

Any SIR people know anything new about an IR residency?

Like I said IR is a fantastic specialty, it is in the cusp of something great if it can get through the hurdles, and I always was interested in this topic, just ironically never got to investigate it until I became a surgeon

 

[Gvataken]

Great questions:

Yes, there are some hurdles to be overcome.

There are many types of IR practice.
-academics
-diagnostic group/private practice
-independent ir group
-solo ir practitioner
-hospital employee

Many of my friends have faced the same struggles in conventional diagnostic groups and were not given clinic time and were asked to do imaging in between cases. They could not grow their practice by spending time in the office or on the floor etc. So, many of them left to start their own IR group, work as a hospital employee, or go to another radiology practice.

I think that the diagnostic group just wants IR to maintain the hospital contract and cover call. Doing anything with a needle including lp, para, thoras etc. So, this is felt to be not as exciting for recent graduate fellowship trained IR.

The more recent IR (less than 5 years out) are the ones most interested in true clinical care of patients and understand the importance of longitudinal care.

The key issues are changing the culture of whatever practice and hospital you go to. The 2 challenges that I faced were really the diagnostic colleagues, but even my more senior IR were not comfortable with the whole clinical model. But, slowly and surely we are changing every procedure to a consultation first.

I decided that regardless of what my colleagues did, I was going to admit my own patients and take call for thos admissions. Discharge them etc and later set them up for follow up. As my practice grew, the other IR's slowly started to jump on board and now we all see patients in the office.

This has proven very fruitful and I see more and more of my friends in private practice doing this, getting direct referrals be it from primary care or podiatry etc and doing formal consultations.

As far as the primary certificate, Dr. Kaufman is working hard to get it through ABMS. But, what I have instituted at our program and I hope more radiology programs do this is generating a IR pathway of sorts. The key is that the ACGME allows up to 16 months of one radiology subspecialty during training.

So, a motivated resident could do 2 months for the first 3 years and then 10 months their senior year and then go to an IR fellowship. This gives them 1 year of clinical medicine or surgery (12 months). Then during the subsequent 4 years of diagnostic training they do 6 months of IR their first 3 years and 30 months of diagnostics . After that they take their CORE exam in diagnostic radiology. Their final year PGY 5 they can take up to 10 moths of IR (mixed in with clinical rotations and INR) and do 2 months of diagnostic rotations. So in 6 years they would have 28 months of IR, 32 months of diagnostics and at least 12 months of non procedural clnical activity (internship). this somewhat resembles the certificate, but with this pathway any program can start instituting it for current PGY2 trainees.

 

[fiatlux]

If you want solid facts to support gvataken and what others are saying about longitudinal care of patients... see this article just published in JACR. A great start but more work still needs to be done to create the mindset that IR is a "consult" specialty and not a "procedure only" specialty.

Clinical Services by Interventional Radiologists: Perspectives From Medicare Claims Over 15 years. Duszak et al.
http://www.jacr.org/article/S1546-1440(10)00285-1/abstract

By this I meant that we need to work on having referring allow us to decide the procedures that are most beneficial for our patients. The entire concept of a referring placing an 'order' mentality needs to be addressed. But while we see changes in the clinical mindset we are continuing to lose procedures that were previously in our purvue. Now, it appears that nephrologists have solidly asserted themselves as interventionalists with the rise of interventional nephrology. Here is the link for the article...

Evolving Roles of Radiologists, Nephrologists, and Surgeons in Endovascular Hemodialysis Access Maintenance Procedures. Duszak et. al.
http://www.radiologysource.org/periodicals/jacr/article/S1546-1440(10)00167-5/abstract

How do we address this further erosion and encroachment? Is this study indicative of what others are seeing at their respective hospital and offices.

 

[badasshairday]

If you want solid facts to support gvataken and what others are saying about longitudinal care of patients... see this article just published in JACR. A great start but more work still needs to be done to create the mindset that IR is a "consult" specialty and not a "procedure only" specialty.

Clinical Services by Interventional Radiologists: Perspectives From Medicare Claims Over 15 years. Duszak et al.
http://www.jacr.org/article/S1546-1440(10)00285-1/abstract

By this I meant that we need to work on having referring allow us to decide the procedures that are most beneficial for our patients. The entire concept of a referring placing an 'order' mentality needs to be addressed. But while we see changes in the clinical mindset we are continuing to lose procedures that were previously in our purvue. Now, it appears that nephrologists have solidly asserted themselves as interventionalists with the rise of interventional nephrology. Here is the link for the article...

Evolving Roles of Radiologists, Nephrologists, and Surgeons in Endovascular Hemodialysis Access Maintenance Procedures. Duszak et. al.
http://www.radiologysource.org/periodicals/jacr/article/S1546-1440(10)00167-5/abstract

How do we address this further erosion and encroachment? Is this study indicative of what others are seeing at their respective hospital and offices.

Where are these other specialties getting interventional training? Are Neph guys doing IR fellowships? Or are they learning these procedures in Neph fellowship?

Kind of crazy stuff. IR is totally a specialty trying to define itself, but pieces are being torn off from it due to other specialties. As the future of medicine trends toward minimally invasive procedures, is IR going to be the general surgery of the future? Ie. the most coveted procedures poached by specialists of a particular organ system?

Or perhaps we will see IR become its own residency, distinct from DR. Then following IR residency, fellowships would be available in Interventional Neph, Interventional Onc, Interventional (insert organ/specialty)

 

[nick_carraway]

Now, it appears that nephrologists have solidly asserted themselves as interventionalists with the rise of interventional nephrology.

Makes sense. I'm creating a database of fistulograms at my hospital and I was wondering why nephrology was sending away maintenance of vascular access to IR. Seems like a very easy, lucrative addition to their scope of practice. It seemed like a matter of time before they went the route of every other specialty and started doing it themselves.

Where are these other specialties getting interventional training? Are Neph guys doing IR fellowships? Or are they learning these procedures in Neph fellowship?

The more I think about IR and the great things it has going for it, the negatives seem formidable. While IR creates awesome procedures, the barrier to learning them is low. Improvements in imaging and technology will continue to lower the learning curve and make it harder for IR to keep their own patients.

Interesting that you brought up that IR could be generalists of the future. I never thought about it, but it seems to be the way things are headed if the situation doesn't improve.

I like IR and have spent a considerable amount of time so far heading that direction for residency, but I'm starting to think it's not on the ascension.

 

[NappingGuppy]

Where are these other specialties getting interventional training? Are Neph guys doing IR fellowships? Or are they learning these procedures in Neph fellowship?

Kind of crazy stuff. IR is totally a specialty trying to define itself, but pieces are being torn off from it due to other specialties. As the future of medicine trends toward minimally invasive procedures, is IR going to be the general surgery of the future? Ie. the most coveted procedures poached by specialists of a particular organ system?

Or perhaps we will see IR become its own residency, distinct from DR. Then following IR residency, fellowships would be available in Interventional Neph, Interventional Onc, Interventional (insert organ/specialty)

I'd second your thoughts. As another medical student who is trying to weigh future options, IR is some really fantastic tech and people in it, but the feeling that we're going losing turf right and left is pretty pervasive and something I don't think a lot of people in IR have a good solution to right now.

I'd love to see IR as its own primary residency (somewhat similar to G Surg), with fellowships in sub-specialties to make us "masters" of a particular organ system and help us network with the referrers in that field. That being said, this will probably be a long way off if at all, and be a pretty politically charged process.

 

[badasshairday]

I'm at a community hospital this month for general surgery, and the gen surgeons do it all (vascular, breast, thyroids, colorectal, appys, gall bladders).

They also do the exposures for IR procedures.

I was able to see an aortic stent graft today. And honestly, I think it takes a great amout of skill, plus reading the flouro isn't always very easy. It can get tricky. Anways, it was an amazing procedure. Is IR all over aortic stent grafts? Or is this a point of contention with vascular surgeons?

 

[fiatlux]

There is quite a bit of overlap regarding procedures that VS, gen surg, and IR do on a daily basis. However, the importance lies in the local marketplace of the physician pool and this drives control. Take for example vascular procedures done at 2 hospitals. Hospital A has recently hired newly trained endovascular VS and with an older trained IR physician group. The 'established' vascular IR practice will slowly start losing cases to the younger VS given that the VS has the benefit of adding periprocedural care (ie see patients in his clinic). Now hospital B has the opposite scenario, young IR doc with older general surgeon/VS; the procedures that were done by the VS/GS will still remain with them, the IR doc will only attract newer patients, but he will primarily focus on areas that are currently not dominated by already established VS/GS physicians (areas of IR growth... UFE/UAE, msk interventions, IO, etc). While there is overlap, the breadth of procedures is expansive enough that from a business standpoint, the IR department is positioned at the center of at least 60-70% of all elective (UFEs, TACE, RFA, stents, embos) and ancillary patient care interactions (PICC, ports, drains) in a hospital. More than plenty of work, just not enough next-gen IR docs.


Also the problem lies not in competing with VS, GS or the other surgical specialities because this is something I think we are on the road to handling. The issue is when the referring clinicians start doing the procedures themselves (akin to cards doing stents, nephrologists doing dialysis interventions). When the organ system specialists create an "interventionalist" suddenly the work that was previously referred from 3 medicine-ologists is no longer part of the pie. This inherent "patient control" is what dominates turf issues besides the increased profit margins of arterial procedures that many specialties vie for.

 

[badasshairday]

This one is interesting, gives the viewpoint of Vascular Surgery/Interventional Rads/Interventional Cards over the turf issue:
http://www.cxvascular.com/vn-archiv...tion-2/whose-turf-is-it-anyway?highlight=turf

Table at the bottom how the endovascular pie changed up until 2005:
http://www.cxvascular.com/vn-archiv...fy-over-endovascular-training1?highlight=turf

 

[fibonacci011]

Hi Guys,
]
Quick qualifying statement before my question/statement:

I think this thread is a great idea, unfortunately I switched out of radiology into GS, and will probably do a breast onc fellowship, I switched for mostly personal reasons

I think a frank discussion about issues facing IR should be addressed here, and probably better here then anywhere else b/c of all of the attendings and fellows, and to a lesser extent residents with significant IR experience

the main issues I'm talking about are

1)Turf Battles: mainly with PVD between cards and vascular surgery, unfortunately IR seems to have lost that battle on the surface, but where I did a year of my rads residency there was quite a healthy arterial practice, and there are IR only practices who do arterial work

Venous is still done primarly by IR I feel, but VS seems to be encroaching

so what are the opinions of attendings/fellows on turf? particularly with the new oncologic stuff, what's to stop surgical oncologists from doing these, currently they are more for salvage, but if you put them head to head (which no one has done as surgery is the standard of care, and to do that you would have withhold standard of care from the experimental group) and with improvements they may very well become first line therapy

those procedures are great though I've seen people with inoperable HCC get TACE and revert to candidates for transplant, more importantly they are re-imbursed very highly (the main reason for turf battles)

I even heard of a case series out of ??florida?? where an IR did cryo or RFA of a breast CA pre-surgically and got clean margins, so who will be doing those in the future surgery or radiology?

which brings up the next issue

2) IR is on a precipice right now moving to a clinical specialty (which is what Dotter recommended, and predicted the encroachment of other specialties if radiologist didn't start taking care of their patients)
who should take care of IR patients? IR or the specialty that takes care of the particular organ/system treated by IR? ex: s/p TACE of HCC does the pt go to IR service or to hepatobiliary surgery/GI

in my opinion it should be IR: you do a procedure, you should know the history, pre/post-op care, and associated issues, thus basic inpatient mgmt skills i.e. DM and HTN should be taught, which I feel is not plausible given the current training model of a 1 year fellowship

so I always thought that IR should really break from DR much like radonc did 20+ years ago

thought?

How many IR doctors are there? I thought fellowships in IR are pretty easy to get. SDN if full of students going into diagnostic radiology. Now im sure a handful miss clinical medicine after a few years and go into IR but are there really that many?

I think the medicine doctors should continue to manage their patients and that is how it will be most likely. Why would the hospital want to change that? Why not get the specialist to do the interventional procedure. I understand most radiologist have a higher step 1 score than medicine doctors, but there no way in hell someone with CHF should see an interventional radiologist for their management. I'll take a cardiologist with 1 year of IR training as opposed to a radiologist with 1 year of IR training. I heard they're a few interventional nephrology programs starting too? Just makes more sense. Why try to turn IR doctors into medicine doctors when you already have medicine doctors that are training with more interventional procedures.

 

[fibonacci011]

I'd second your thoughts. As another medical student who is trying to weigh future options, IR is some really fantastic tech and people in it, but the feeling that we're going losing turf right and left is pretty pervasive and something I don't think a lot of people in IR have a good solution to right now.

I'd love to see IR as its own primary residency (somewhat similar to G Surg), with fellowships in sub-specialties to make us "masters" of a particular organ system and help us network with the referrers in that field. That being said, this will probably be a long way off if at all, and be a pretty politically charged process.

You should go into internal medicine and do a fellowship in interventional cardiology. That will allow you to be a specialist in a particularly organ system that lets you perform procedures as well.

 

[fibonacci011]

I agree with you. The way that IR is changing is into service lines.

I do primarily oncology and vascular.

So, when we get a consult on hepatoma. We see the patient in the office. Then, based on imaging, hepatitis serologies, AFP etc we decide what to do.

AASLD (american association study of liver disease) has great guidelines

THen the breakdown is

1. Trasplant criteria (Milan 1<5 or3 <3cm)
2. Resection (no evidence of portal hypertension/reasonable liver synthetic function.
3. Ablation (</=3 cm) oligomets
4. TACE/DEB/ (multifocal disease)
5 nexavar (sorafenib, tk inhibitor)

Resection and ablation have been compared head to head with equivalent 4 yr diesease free and overall survival.

So, at that point we follow the patients.

If we tace or ablate we follow them with imaging and labs every 1-3 months for life. We admit them to our IR service overnight. The patients follow up with us for life. Some of these patients I have followed for 5 years. I then may refer for resection, transplant, nexavar and then continue to follow them.

So, this is the model that is now emulated with other branches of IR.

veins
fibroids
vascuar/pad
pain
etc

If you don't do it this way then it won't be sustainable long term. Gone are the days of waiting for someone to send you "good stuff". If you wait for things to trickle down, you will end up getting the piccs, paracentesis, thoracenesis or the things that no one wants to do.

you're having patients with liver disease follow up with you? not a gastroenterologist? or more specifically a hepatologist? wouldn't it just make more sense for the guy who's expertise is in that area to see someone with liver disease? i wonder if GI doctors can also start an interventional fellowships. Seems like a very sensible thing to do.

 

[IRGuru]

You should go into internal medicine and do a fellowship in interventional cardiology. That will allow you to be a specialist in a particularly organ system that lets you perform procedures as well.

I had a pretty long response to your string of statements but decided that, and I don't mean this to be glib or combative, you don't sound especially aware of what's happening in interventional radiololgy...e.g. your statement on CHF...under what circumstances has anyone even spoken about going to an IR for CHF management? and form a patient perspective, I'd want anyone treating my hepatoma to know about the underlying cirrhosis, ascites etc. which is why IRs are learning it (yes, we have REALLY high board scores so we are in fact able to open books and learn things). It's just good patient care. I'd also want that person to be an expert in the procedure technically, not some GI who got "credentialed" to treat HCC after 2-3 chemoembos (that's why I go to a GI to get a scope instead of a family med doc who does them in their office)...this brings to light the fact that the most other specialties involved in turf wars with us do so because of financial incentive, not improved patient care. That's why VAs for instance, are places where IRs easily retain a significant portion of the vascular work. Anyways, enough of that because its a fruitless argument over the internet... At the end of the day, the fact is that the IRs that act as clinicians have no problems building a practice. It's happening all across the country and all you had to do was go to SIR or talk to a clinician IR to realize that...

As for me, my options came down to IR and cards. The reason I chose IR over cards...suffice it to say that one of the most exciting part of interventional radiology is that we are the most prolific innovators in medicine. Period. Keep in mind that interventional cardiology literally exists because of interventional radiology. Without IR's, we'd still be hacking of limbs instead of treating the way we do currently. No medicine person would be putting in central lines had a radiologist not invented the technique. Watch what happens to fibroid therapy as we bypass gynecologists, get better at marketing, and more women hear about UAE vs. hysterectomy. Along similar lines, I view IR not through the spectrum of radiology, but rather minimally-invasive medicine (in my mind, clinician IRs are not of the same planet as diagnostic radiologists). If you want to be an expert on the heart, go into cardiology, but if you want to be an expert in minimally-invasive medicine ranging from vascular disease to strokes to cancer, and whatever treatment you yourself can conceive and invent in the future, go into interventional radiology.

 

[fibonacci011]

People love to take as much as they can away from Internal Medicine and try to belittle it as much as possible. You hear remarks about managing fluids and hypertension all day and endless rounding. Fine. There's no glory to it. But now its become personal because the rules are changing that if you can't manage your patients, you can't do the procedures. I'm sorry but Internal Medicine doctors are far superior to medically managing their patients and have far superior clinical skills then radiologists.

 

[fibonacci011]

I had a pretty long response to your string of statements but decided that, and I don't mean this to be glib or combative, you don't sound especially aware of what's happening in interventional radiololgy...e.g. your statement on CHF...under what circumstances has anyone even spoken about going to an IR for CHF management? and form a patient perspective, I'd want anyone treating my hepatoma to know about the underlying cirrhosis, ascites etc. which is why IRs are learning it (yes, we have REALLY high board scores so we are in fact able to open books and learn things). It's just good patient care. I'd also want that person to be an expert in the procedure technically, not some GI who got "credentialed" to treat HCC after 2-3 chemoembos (that's why I go to a GI to get a scope instead of a family med doc who does them in their office)...this brings to light the fact that the most other specialties involved in turf wars with us do so because of financial incentive, not improved patient care. That's why VAs for instance, are places where IRs easily retain a significant portion of the vascular work. Anyways, enough of that because its a fruitless argument over the internet... At the end of the day, the fact is that the IRs that act as clinicians have no problems building a practice. It's happening all across the country and all you had to do was go to SIR or talk to a clinician IR to realize that...

As for me, my options came down to IR and cards. The reason I chose IR over cards...suffice it to say that one of the most exciting part of interventional radiology is that we are the most prolific innovators in medicine. Period. Keep in mind that interventional cardiology literally exists because of interventional radiology. Without IR’s, we’d still be hacking of limbs instead of treating the way we do currently. No medicine person would be putting in central lines had a radiologist not invented the technique. Watch what happens to fibroid therapy as we bypass gynecologists, get better at marketing, and more women hear about UAE vs. hysterectomy. Along similar lines, I view IR not through the spectrum of radiology, but rather minimally-invasive medicine (in my mind, clinician IRs are not of the same planet as diagnostic radiologists). If you want to be an expert on the heart, go into cardiology, but if you want to be an expert in minimally-invasive medicine ranging from vascular disease to strokes to cancer, and whatever treatment you yourself can conceive and invent in the future, go into interventional radiology.

Clinician IRs?? All this from 1-year fellowship? Technical wizards and masters of clinical medicine?? You don't see that as a bit absurd? I understand your need for it but come on you want people to put an IR clinical/medical knowledge on par with an internal medicine doctors???

 

[IRGuru]

People love to take as much as they can away from Internal Medicine and try to belittle it as much as possible. You hear remarks about managing fluids and hypertension all day and endless rounding. Fine. There's no glory to it. But now its become personal because the rules are changing that if you can't manage your patients, you can't do the procedures. I'm sorry but Internal Medicine doctors are far superior to medically managing their patients and have far superior clinical skills then radiologists.

Clinician IRs?? All this from 1-year fellowship? Technical wizards and masters of clinical medicine?? You don't see that as a bit absurd? I understand your need for it but come on you want people to put an IR clinical/medical knowledge on par with an internal medicine doctors???

Not once in the IR forum has anyone belittled medicine and I respect medicine docs. What is absurd is your last post and that it demonstrates how little you really know about how an IR gets trained. I don't blame you since it's hard to get an appreciation for a clinician IR if one doesn't exist at your institution. That will surely change as younger IRs replace older ones. But just do some research, or at least a google search before you start getting all high and mighty on an anonymous internet forum.

I'll drop some knowledge for your benefit and then we'll have to agree to disagree. In my case by the end of my training, I will have completed a true medicine internship in one of the best medicine programs in the country (by choice, I feel that those who know that want to do IR should only do prelim med or surg, not TY). Yes, my board scores were that high that a strong medicine program thought lil' old me, an aspiring IR, would be able to learn how to diagnose abdominal pain/SOB and the like. After my medicine year, I'll complete one year-16 months of IR in residency. So that's 2-2.5 years so far of actually managing patients. Then, on top of that, I'll complete a clinical IR fellowship (BCVI, UVA, Brown, MCW etc.). And personally, since I want to do vascular work, I'll do a fellowship in vascular medicine after that. Thats FOUR to four and a half YEARS of clinical care I'll have in managing patients that are within the purview of IR. That's in addition to three years of dedicated imaging which no medicine doc gets. Make no mistake that imaging is tough...that's why rads is a 5 year residency while medicine is only a 3 year residency. And at the end of the day, while a medicine doc may be better than me at managing COPD or whatever, not a chance he can sincerely say he's better at managing diabetes/HTN, especially after all the train I will have received. And if I have a patient with COPD or some other mysterious disease I've never heard of, I'll consult medicine just like any other service whether its psych or surg. And besides, most people that go into IR are exceptionally smart. Most come from top-half if not top-25% of our respective classes..there's a reason our board scores and third year grades are so strong...we can no doubt learn anything anyone else can and if you or cards or whoever thinks they can learn to image as well than a radiologist, you better believe I can learn how to manage DM/HTN/vascular disease as well if not better than any medicine doc etc.

 

[fibonacci011]

Not once in the IR forum has anyone belittled medicine and I respect medicine docs. What is absurd is your last post and that it demonstrates how little you really know about how an IR gets trained. I don't blame you since it's hard to get an appreciation for a clinician IR if one doesn't exist at your institution. That will surely change as younger IRs replace older ones. But just do some research, or at least a google search before you start getting all high and mighty on an anonymous internet forum.

I'll drop some knowledge for your benefit and then we'll have to agree to disagree. In my case by the end of my training, I will have completed a true medicine internship in one of the best medicine programs in the country (by choice, I feel that those who know that want to do IR should only do prelim med or surg, not TY). Yes, my board scores were that high that a strong medicine program thought lil' old me, an aspiring IR, would be able to learn how to diagnose abdominal pain/SOB and the like. After my medicine year, I'll complete one year-16 months of IR in residency. So that's 2-2.5 years so far of actually managing patients. Then, on top of that, I'll complete a clinical IR fellowship (BCVI, UVA, Brown, MCW etc.). And personally, since I want to do vascular work, I'll do a fellowship in vascular medicine after that. Thats FOUR to four and a half YEARS of clinical care I'll have in managing patients that are within the purview of IR. That's in addition to three years of dedicated imaging which no medicine doc gets. Make no mistake that imaging is tough...that's why rads is a 5 year residency while medicine is only a 3 year residency. And at the end of the day, while a medicine doc may be better than me at managing COPD or whatever, not a chance he can sincerely say he's better at managing diabetes/HTN, especially after all the train I will have received. And if I have a patient with COPD or some other mysterious disease I've never heard of, I'll consult medicine just like any other service whether its psych or surg. And besides, most people that go into IR are exceptionally smart. Most come from top-half if not top-25% of our respective classes..there's a reason our board scores and third year grades are so strong...we can no doubt learn anything anyone else can and if you or cards or whoever thinks they can learn to image as well than a radiologist, you better believe I can learn how to manage DM/HTN/vascular disease as well if not better than any medicine doc etc.

lol so you again choose to take the approach that YOU are capable of learning anything and everything, but the stupid little medicine doctor can't learn interventional procedures because its something that comes only witing a 240 on USMLE Step 1. I also like how you call radiology a 5 year program in reading images but then right before that mention your 1 year of internship. So really it's 4 years right? Yes a medicine doctor can manage diabetes/HTN better than you. It's his/her job to know everything about it when they spend 8 hours rounding and recalling the latest trials, literature pertaining to it.

Maybe what should happen is a 3 year fellowship in Interventional Medicine that comes after an Internal Medicine residency. That would be very sensible. I mean considering this hybrid thing you're putting together with all this training you're doing, hell just do 3 years of IM and do 3 years of IR fellowship. I really think that does sound great.

I'm sure you don't need to be able to read all the modalities diagnostic rads guys can to do some of the IR procedures, hence the reason vacular and int cardio guys do it as well.

 

[IRGuru]

lol so you again choose to take the approach that YOU are capable of learning anything and everything, but the stupid little medicine doctor can't learn interventional procedures because its something that comes only witing a 240 on USMLE Step 1. I also like how you call radiology a 5 year program in reading images but then right before that mention your 1 year of internship. So really it's 4 years right? Yes a medicine doctor can manage diabetes/HTN better than you. It's his/her job to know everything about it when they spend 8 hours rounding and recalling the latest trials, literature pertaining to it.

Maybe what should happen is a 3 year fellowship in Interventional Medicine that comes after an Internal Medicine residency. That would be very sensible. I mean considering this hybrid thing you're putting together with all this training you're doing, hell just do 3 years of IM and do 3 years of IR fellowship. I really think that does sound great.

I'm sure you don't need to be able to read all the modalities diagnostic rads guys can to do some of the IR procedures, hence the reason vacular and int cardio guys do it as well.

First bold phrase- Takes a clinical year to be a good radiologist so I do count it...if you don't that's fine, it's still a four year residency which is longer than any medicine residency

Second bold phrase- agree to disagree

Third bold phrase- you're essentially describing the IR primary certificate except its not sequential but rather, integrated...it's already in the pipeline- stay tuned. And yes, you'll have to have high board scores to do it...why? because it's cool and popular fields required you to be excellent throughout your medical career (e.g. derm/plastics).

Last paragraph- it doesn't take an entire internal medicine residency to learn how to manage several specific conditions just like it doesn't take learning all of imaging to image the heart...that's why IR guys can do it as well. And as we invent more procedures for more conditions, we'll learn to manage those conditions as well. That, by the way, is another point of differentiation. IRs lead image guide therapy because we invent techniques that are paradigm-shifting and don't go around stealing procedures to make an extra buck which is what you're advocating. If you want to be an expert in minimally invasive medicine, do better in medical school and then go into IR.

 

[davidjones]

sigh...you are obviously a troll, but for the sake of the younger generation of people interested in IR I will step in and say some stuff in addition to IRGuru.

1)3 years of IM and 3 years of IR, there is actually something like that in the works...right now there is a DIRECT pathway where you do 2 years of clinical medicine 2-3 years of imaging and 2 years of IR, however the training is still in radiology no through medicine. SIR is working on a primary certificate for IR, so that there is an IR residency, will probably happen in 5-10 years...anyone intimately related to this please chime in as I only know what I read on SIRweb

2)you do not need to know how to manage diabetes/htn/copd etc as an IR...I don't see any surgeons doing that, however as an IR you do have to learn all aspects of the diseases you are treating...UFE, liver CA and liver mets, bone mets etc. An IR is not going to work-up dysfunctional uterine bleeding, but he/she will work-up any patient who comes in for fibroids to see if it is the appropriate treatment, like wise for any cancer patient. Thus the IR will see the patient before and after the treatment, and in case of cancer often for the duration of the rest of their life. In addition the people will also be followed by whatever physician referred them. In the case of fibroids, the IR may be the only person following the woman, as there is no reason for ob/gyn to be involved.

In the case of liver cancer, there is a thing called a tumor board (sarcasm); if TACE or Y90 are determined to be the best therapy for the patient, he will be followed by IR for the treatment which is often multi-staged; by some GI oncologist, (not a gastroenterologist) and occasionally by surgical oncology (if the goal is to downstage the person)

In this very specific case of Y90, IRs are the only ones legally allowed to procure and use it; in other cases you are creditialed by the hospital to do certain things, and in this era of consumer medicine, no knowledgeable patient will go to an IM guy specialist or not who took a weekend class and have thier GDA embolized. Like IRGuru said, why go see someone who's done 10 procedures when you can go see someone who has done 1000. In addition, they have to get this training somewhere, the only place to get it is from an IR, and if you find an IR willing to train someone outside of the field, I will give $1000.

Also, most IRs bring a ton of business to the hospital, especially people with clinics and people who run vein centers, so good luck getting time in the IR suite if you are not an IR,

3)Other specialties doing IR procedures, like nephrology, they have approximately 6 months of training and only do stuff with fistulas, I have seen them practice and it is downright scary, sort of like an OB doing breast surgery. It is not as easy as it looks. Also I cannot tell you how many times we have had to go fish out wires dropped into veins by the critical care ATTENDINGS who allegedly are better at lines than us.

4) 1 year fellowship: not enough to learn clinical aspect and the huge amount of procedures; hence the IR primary certificate, new generation of IRs doing 2 or even 3 year fellowships, and rearranging of the DR residency so that the 5th year is actually a mini-fellowship, not to mention the 6-8 months of IR you get as a resident, compared to exactly 0 days of exposure to catheter and needle and image guidance in IM. Not to mention the fact, that there is no longer a requirement by the ABIM that residents need to be able to do paras and thoras, (seriously, check it out).

Now you can say even a 2 year fellowship is not enough, but cards does exactly 1 year of intervention and goes on to do EVARs, when most don't even get that as part of their training, so a 1 year IR fellowship is certainly enough to get started in practice, but like in all fields of medicine, you keep learning.

None of this is to rag on IM, I think they are perfectly competent and it is a great specialty and any are welcome to switch to radiology and do IR , but you can't honestly expect to come on here, make troll like comments and expect people to agree with you. Go on to the general surgery forum and suggest that all colonoscopies should be done by GI (which most are anyway) and you'll get more slapped around than you did here.

 

[davidjones]

re: badasshairday about the number of procedures done

don't look so much at the percentages but at the actual number, since 1996, the number of PAD cases has almost tripled, and while the % of cases done by rads dropped by 50%, the actual number of cases has stayed more or less the same, that may be more of a reflection of the number of IRs willing to take the time to do PAD clinically rather than wait from referals from cards and VS. So if you're willing to do the work, i.e. clinical workup, long term management, and market yourself AND have a group of DRs who understand you have to do this and not sit and read scans all day, than you could have more PAD than you know what to do this. Personally I prerfer the onc stuff, but you gotta know it all

 

[Radonkulous]

...

 

[fibonacci011]

interventional cardiologist are darn good at what they do and are well known for that. ptca, stenting.. they do what they do and are well-trained at it. you all get 1-year fellowship training in a broad array of procedures. they spend there 1-year just focus on coronary/cardiac intervention and they spent the 3 before that studying cardiovascular medicine. you can keep trying to ignore that high level of training but the fact is Inteventional Cardiology exists and the rest of you all just want in. it gets old hearing tales from your IR guys about how they're not as good or as well trained when you all do the same dam 1 year training.

this is more of an ego thing and you can tell because you all LOVE grouping yourselves into a family with the vascular surgery guys. your logic is that they're surgeons with the manual skills to do this kind of stuff. okay, so where do you all get your skills from 4 years doing diagnostic radiology? this is a simple mindset of yours that surg specialist = radiology > medicine.

You aren't anything like a vascular surgeon.. at all. your training was NOTHING like theres. please believe that. if anything you'd be closer to medicine in that you actually need to understand the diseae process behind what you're looking at so please get off your high horse

im done responding to your nonsense. in the end radiology itself is a crucial part of medicine and interventional radiology is kind of badass but your suggestion that its a skill only diagnostic radiologist are able to acquire is absurd

 

[fibonacci011]

sigh...you are obviously a troll, but for the sake of the younger generation of people interested in IR I will step in and say some stuff in addition to IRGuru.

1)3 years of IM and 3 years of IR, there is actually something like that in the works...right now there is a DIRECT pathway where you do 2 years of clinical medicine 2-3 years of imaging and 2 years of IR, however the training is still in radiology no through medicine. SIR is working on a primary certificate for IR, so that there is an IR residency, will probably happen in 5-10 years...anyone intimately related to this please chime in as I only know what I read on SIRweb

2)you do not need to know how to manage diabetes/htn/copd etc as an IR...I don't see any surgeons doing that, however as an IR you do have to learn all aspects of the diseases you are treating...UFE, liver CA and liver mets, bone mets etc. An IR is not going to work-up dysfunctional uterine bleeding, but he/she will work-up any patient who comes in for fibroids to see if it is the appropriate treatment, like wise for any cancer patient. Thus the IR will see the patient before and after the treatment, and in case of cancer often for the duration of the rest of their life. In addition the people will also be followed by whatever physician referred them. In the case of fibroids, the IR may be the only person following the woman, as there is no reason for ob/gyn to be involved.

In the case of liver cancer, there is a thing called a tumor board (sarcasm); if TACE or Y90 are determined to be the best therapy for the patient, he will be followed by IR for the treatment which is often multi-staged; by some GI oncologist, (not a gastroenterologist) and occasionally by surgical oncology (if the goal is to downstage the person)

In this very specific case of Y90, IRs are the only ones legally allowed to procure and use it; in other cases you are creditialed by the hospital to do certain things, and in this era of consumer medicine, no knowledgeable patient will go to an IM guy specialist or not who took a weekend class and have thier GDA embolized. Like IRGuru said, why go see someone who's done 10 procedures when you can go see someone who has done 1000. In addition, they have to get this training somewhere, the only place to get it is from an IR, and if you find an IR willing to train someone outside of the field, I will give $1000.

Also, most IRs bring a ton of business to the hospital, especially people with clinics and people who run vein centers, so good luck getting time in the IR suite if you are not an IR,

3)Other specialties doing IR procedures, like nephrology, they have approximately 6 months of training and only do stuff with fistulas, I have seen them practice and it is downright scary, sort of like an OB doing breast surgery. It is not as easy as it looks. Also I cannot tell you how many times we have had to go fish out wires dropped into veins by the critical care ATTENDINGS who allegedly are better at lines than us.

4) 1 year fellowship: not enough to learn clinical aspect and the huge amount of procedures; hence the IR primary certificate, new generation of IRs doing 2 or even 3 year fellowships, and rearranging of the DR residency so that the 5th year is actually a mini-fellowship, not to mention the 6-8 months of IR you get as a resident, compared to exactly 0 days of exposure to catheter and needle and image guidance in IM. Not to mention the fact, that there is no longer a requirement by the ABIM that residents need to be able to do paras and thoras, (seriously, check it out).

Now you can say even a 2 year fellowship is not enough, but cards does exactly 1 year of intervention and goes on to do EVARs, when most don't even get that as part of their training, so a 1 year IR fellowship is certainly enough to get started in practice, but like in all fields of medicine, you keep learning.

None of this is to rag on IM, I think they are perfectly competent and it is a great specialty and any are welcome to switch to radiology and do IR , but you can't honestly expect to come on here, make troll like comments and expect people to agree with you. Go on to the general surgery forum and suggest that all colonoscopies should be done by GI (which most are anyway) and you'll get more slapped around than you did here.

again, stop spitting stats about future fellowship requirements. as of now its a 1- year fellowship that is broad-based IR. Interventional cardiology is a 1-year fellowship JUST IN CARDIAC PROCEDURES!

It's a simple fact that they're focusing on one thing. So like you said, why not see the guy doing 1000 rather than 100. You know I'm right and that's why the field exists and is doing great. They're a well-respect division within most hospitals and that's not changing. Your' 1 year of IR fellowship has x% on cardiac interventions. There percentage of training in cardiac issues that 1 year far surpasses yours. So why should someone see you instead?

 

[IRGuru]

interventional cardiologist are darn good at what they do and are well known for that. ptca, stenting.. they do what they do and are well-trained at it. you all get 1-year fellowship training in a broad array of procedures. they spend there 1-year just focus on coronary/cardiac intervention and they spent the 3 before that studying cardiovascular medicine. you can keep trying to ignore that high level of training but the fact is Inteventional Cardiology exists and the rest of you all just want in. it gets old hearing tales from your IR guys about how they're not as good or as well trained when you all do the same dam 1 year training.

this is more of an ego thing and you can tell because you all LOVE grouping yourselves into a family with the vascular surgery guys. your logic is that they're surgeons with the manual skills to do this kind of stuff. okay, so where do you all get your skills from 4 years doing diagnostic radiology? this is a simple mindset of yours that surg specialist = radiology > medicine.

You aren't anything like a vascular surgeon.. at all. your training was NOTHING like theres. please believe that. if anything you'd be closer to medicine in that you actually need to understand the diseae process behind what you're looking at so please get off your high horse

im done responding to your nonsense. in the end radiology itself is a crucial part of medicine and interventional radiology is kind of badass but your suggestion that its a skill only diagnostic radiologist are able to acquire is absurd

Apparently, you don't have access to google and you've had a little trouble reading the previous million posts on how IR pioneered endovascular medicine e.g. we were there first so it's not really a matter of us wanting to get in as much as it is a matter of cards wanting to get in...oh and I don't remember anyone mentioning anything about coronary interventions, just peripheral ones

I guess you're right dude, it's your world and we're just living in it

 

[badasshairday]

interventional cardiologist are darn good at what they do and are well known for that. ptca, stenting.. they do what they do and are well-trained at it. you all get 1-year fellowship training in a broad array of procedures. they spend there 1-year just focus on coronary/cardiac intervention and they spent the 3 before that studying cardiovascular medicine. you can keep trying to ignore that high level of training but the fact is Inteventional Cardiology exists and the rest of you all just want in. it gets old hearing tales from your IR guys about how they're not as good or as well trained when you all do the same dam 1 year training.

this is more of an ego thing and you can tell because you all LOVE grouping yourselves into a family with the vascular surgery guys. your logic is that they're surgeons with the manual skills to do this kind of stuff. okay, so where do you all get your skills from 4 years doing diagnostic radiology? this is a simple mindset of yours that surg specialist = radiology > medicine.

You aren't anything like a vascular surgeon.. at all. your training was NOTHING like theres. please believe that. if anything you'd be closer to medicine in that you actually need to understand the diseae process behind what you're looking at so please get off your high horse

im done responding to your nonsense. in the end radiology itself is a crucial part of medicine and interventional radiology is kind of badass but your suggestion that its a skill only diagnostic radiologist are able to acquire is absurd

Hey man, Interventional Cards is badass. Nobody is said otherwise. They take care of super sick people and have incredible catheter skills. Cards is unstoppable and making huge gains since they have the patient flow. Just discussing IR's role in the disease process. Actually I appreciate that you are contributing to the discussion as this forum is usually pretty quiet. But I think you are overreacting a bit.

 

[davidjones]

dude calm down...known is attacking cardiology or medicine for that matter, in fact, it seems as if you came here to attack IR, for what reason I'm not sure. Did an IR maybe run over your puppy when you were younger?

I agree that cards focuses on 1 year of doing coronary intervention...my point is after one year they are delving into carotid artery stenting, EVARs (w.o vascular surgery supports) and intra-cranial stuff (which doesn't have anything to do with the heart) without really getting exposed to it in fellowship...so if cardiology wants to learn how to do a major aortic procedure without any prior training and than credential themselves after doing a total of 5...why is it so hard to fathom that an IR who does all of those procedures, is expert and the pathophysiology and imaging of vascular disease,wants to perform the medical/non-invasive component of PAD and other illnesses we treat invasively, if anything our motivation is more altruistic as it doesn't gain us more money, whereas cardiologists motivation is somewhat suspect; for the record most interventional cards I know who do 100% intervention rarely do any more than pre and post-procedure stuff, sending the patients to their non-invasive cards colleagues.

also the 3 year cards fellowship is really 2 years plus 1 year of research...and again DR residents get at least 8 months of interventional, more if it's split it up into vascular and non-vascular interventional radiology, and many do 2 years of fellowship and thus have as much training in their various diseases as cards...this is particularly true for oncologic stuff...there are dedicated interventional oncology fellowships. and I am part of the new training model in DR, which means I take my boards at then end of my PGY4 year and have all PGY5 to do IR rotations, vascular medicine, surgical and medical oncology etc. so I and any of my colleagues who want to practice clinic IR will in fact have 32 months of IR including the clinical stuff (that's 8 months in PGY2-4, 12 months in PGY5, and 12 months in fellowship, and again many will likely go on to do additional fellowships in vascular medicine and oncology)

i gotta tell you, you are getting super defensive, almost as if you have some inferiority complex; what exactly was the purpose of you coming here other than to rile people up...which in case you haven't noticed...you really havent...so what's your deal? honestly, just want to know, 'cause your behavior sort of borders on the manic side

 

[ENTswitch]

Not once in the IR forum has anyone belittled medicine and I respect medicine docs. What is absurd is your last post and that it demonstrates how little you really know about how an IR gets trained. I don't blame you since it's hard to get an appreciation for a clinician IR if one doesn't exist at your institution. That will surely change as younger IRs replace older ones. But just do some research, or at least a google search before you start getting all high and mighty on an anonymous internet forum.

I'll drop some knowledge for your benefit and then we'll have to agree to disagree. In my case by the end of my training, I will have completed a true medicine internship in one of the best medicine programs in the country (by choice, I feel that those who know that want to do IR should only do prelim med or surg, not TY). Yes, my board scores were that high that a strong medicine program thought lil' old me, an aspiring IR, would be able to learn how to diagnose abdominal pain/SOB and the like. After my medicine year, I'll complete one year-16 months of IR in residency. So that's 2-2.5 years so far of actually managing patients. Then, on top of that, I'll complete a clinical IR fellowship (BCVI, UVA, Brown, MCW etc.). And personally, since I want to do vascular work, I'll do a fellowship in vascular medicine after that. Thats FOUR to four and a half YEARS of clinical care I'll have in managing patients that are within the purview of IR. That's in addition to three years of dedicated imaging which no medicine doc gets. Make no mistake that imaging is tough...that's why rads is a 5 year residency while medicine is only a 3 year residency. And at the end of the day, while a medicine doc may be better than me at managing COPD or whatever, not a chance he can sincerely say he's better at managing diabetes/HTN, especially after all the train I will have received. And if I have a patient with COPD or some other mysterious disease I've never heard of, I'll consult medicine just like any other service whether its psych or surg. And besides, most people that go into IR are exceptionally smart. Most come from top-half if not top-25% of our respective classes..there's a reason our board scores and third year grades are so strong...we can no doubt learn anything anyone else can and if you or cards or whoever thinks they can learn to image as well than a radiologist, you better believe I can learn how to manage DM/HTN/vascular disease as well if not better than any medicine doc etc.

I think you are understating the clinical training of interventional cardiologists who also do peripheral (which is now an additional year of training beyond interventional cardiology)

3 years internal medicine
3-4 years cardiology (including 6 months of cath, 2 months of EP). 4 year program would generally include a year of research, but we still do clinic during this time.
1 year interventional
1 year peripheral

So that is 8 years of clinical medicine, 5 of which are dedicated to cardiovascular disease ONLY. 2 years, 8 months of catheter skills focusing on vascular disease ONLY.

I fully respect the training of IR. But to say that you can manage diabetes/HTN better than an IM doc (which includes cardiologists) because you learned it from other IRs during IR rotations when you don't see patients who come to your clinic solely for these problems is probably a bit of an overstatement.

Also, keep in mind that while radiology grades/board scores are better than those for IM, cardiology is a very competitive subspecialty that attracts the best of IM. Most of us have similar board scores and could have matched in radiology had we chosen to.

To end, I completely respect everything that IR does. One of my greatest mentors is an IR. However, I believe that respect goes both ways.

 

[davidjones]

ENTswitch,
again nobody on here is ragging on cardiologists, but there are many who do things they shouldn't be doing, such as EVARs without surgical support and intra-cranial work, as well as IVC filters etc, which is really not at all related to the heart, and the typical stereotype of a cardiologist is what has been said above, however untrue it is for most of them,

Likewise, nobody on here is claiming to be more adept at managing chronic conditions better than an IM, however, if a patient comes in for PAD referral, than it would be poor medical care for the IR not to review the cholesterol, and diabetes HTN history and meds and control of these issues in an effort to prevent any invasive therapy, to be perfectly honest it is not as easy as it sounds, but neither is it hard, and if cards thinks they should stent things in the brain, than IR is certainly well within their realm to manage these issues. Is a cardiolgist as adapt at managing diabetes as a PCP or endocrinologist, unlikely, and most don't bother, but some do. Also we don't learn from IRs on IR rotations, I personally learned it in my intern year, and practice primary care in a free clinic, and many IR fellowships have non-IR rotations such as vascular, etc. to gain more exposure in this. Also many younger residents and fellows are doing or will do fellowships in vascular medicine. Even still, no IR is going to take over management of these diseases or claim they are better at it than a medicine doc, no specialist would. Even stroke docs, who deal directly with the complications of DM, HLD and HTN don't really manage these conditions in an outpatient setting.

Also for things like cancer, especially for the invasive therapies, the IR had better understand all components of the therapies, prognosis etc, because the patient will ask those questions, and "please call your oncologist" is not an acceptable answer. Or doing UFEs and not being able to manage the patients various complications, questions about fertility, and so on.

IR is a clinical specialty and only now for some reason people are starting to wake up to that fact. Which means IR is going to become even more clinical, and there is resistance to that from both DR (less RVUs when you're seeing patients) and other endovascular specialties (more competition).

Nobody on here from the IR side is saying anything inflammatory, however, the fibonacci guy did come on here, with what appears to be a goal of inciting some sort of flame war.

I have nothing but respect for most cardiologists, but there are many who go into a hospital and start saying only I should get to do the intravascular stuff, cardiac imaging, carotid stenting, perfusion scans etc or I won't send you patients, not exactly the kind of person you'd like to deal with is it? Similarly what if an IR came to hospital and said nobody gets any y90 or TACE unless I also get to do all the PAD stuff, doesn't make for a very pleasant work environment.

Respect does go both ways, but many cardiologists don't really show it towards radiology, and often feel that that is ok.

Also, when I said the 3 year cards program includes a year of research, I was talking about the program at my hospital, I'm sure it varies from place to place.

 

[magic_drm]

Can someone said some more light on the primary IR certificate down the road? Will it be possible to train through the primary IR certificate starting in 2014-2015?

there is a vote this coming november. if passed, IRs will get both radiology and IR credentials. with this new credentialing ir's will have greater ability to admit patients.

 

[ENTswitch]

ENTswitch,
again nobody on here is ragging on cardiologists, but there are many who do things they shouldn't be doing, such as EVARs without surgical support and intra-cranial work, as well as IVC filters etc, which is really not at all related to the heart, and the typical stereotype of a cardiologist is what has been said above, however untrue it is for most of them,

Likewise, nobody on here is claiming to be more adept at managing chronic conditions better than an IM, however, if a patient comes in for PAD referral, than it would be poor medical care for the IR not to review the cholesterol, and diabetes HTN history and meds and control of these issues in an effort to prevent any invasive therapy, to be perfectly honest it is not as easy as it sounds, but neither is it hard, and if cards thinks they should stent things in the brain, than IR is certainly well within their realm to manage these issues. Is a cardiolgist as adapt at managing diabetes as a PCP or endocrinologist, unlikely, and most don't bother, but some do. Also we don't learn from IRs on IR rotations, I personally learned it in my intern year, and practice primary care in a free clinic, and many IR fellowships have non-IR rotations such as vascular, etc. to gain more exposure in this. Also many younger residents and fellows are doing or will do fellowships in vascular medicine. Even still, no IR is going to take over management of these diseases or claim they are better at it than a medicine doc, no specialist would. Even stroke docs, who deal directly with the complications of DM, HLD and HTN don't really manage these conditions in an outpatient setting.

Also for things like cancer, especially for the invasive therapies, the IR had better understand all components of the therapies, prognosis etc, because the patient will ask those questions, and "please call your oncologist" is not an acceptable answer. Or doing UFEs and not being able to manage the patients various complications, questions about fertility, and so on.

IR is a clinical specialty and only now for some reason people are starting to wake up to that fact. Which means IR is going to become even more clinical, and there is resistance to that from both DR (less RVUs when you're seeing patients) and other endovascular specialties (more competition).

Nobody on here from the IR side is saying anything inflammatory, however, the fibonacci guy did come on here, with what appears to be a goal of inciting some sort of flame war.

I have nothing but respect for most cardiologists, but there are many who go into a hospital and start saying only I should get to do the intravascular stuff, cardiac imaging, carotid stenting, perfusion scans etc or I won't send you patients, not exactly the kind of person you'd like to deal with is it? Similarly what if an IR came to hospital and said nobody gets any y90 or TACE unless I also get to do all the PAD stuff, doesn't make for a very pleasant work environment.

Respect does go both ways, but many cardiologists don't really show it towards radiology, and often feel that that is ok.

Also, when I said the 3 year cards program includes a year of research, I was talking about the program at my hospital, I'm sure it varies from place to place.

I agree with you, and you make very rational statements. There are some cardiologists who think that it is okay to take a weekend class and then do intracranial work. There are also many IR who did not learn chemoembo in their training and do the same sort of thing.

The new generation of fully-trained cardiologists who do peripheral training will be fully adept at PAD, carotids, and IVC filter. If you think about it, they will do as many of these procedures in their training as you did in yours, and will likely do many more endovascular cases as a whole since the volume for coronary angiography is much higher than volume in the rest of the body. EVAR is probably out of the question, since no one will be getting the numbers they need since vascular surgery has started doing most of these. I think a few of the older cardiologists give us all a bad name trying to do some of these procedures without full fellowship training. However, if you take a cardiology fellow who has had 6 years studying internal medicine then cardiovascular medicine (which includes the heart, arteries, and veins), give them a high level of training in endovascular intervention, it is hard to believe that patients will not get great care. I also think that they could get this great care from IR who take additional clinical training focused on vascular medicine. Both are highly trained.

Any good medicine subspecialist is an internist as well, and should feel comfortable managing the comorbidities unless they are significantly complex. Perhaps the reason that stroke docs do not feel comfortable managing these conditions is because their true internal medicine training is limited to an internship year. We do three years doing just that before we move on to subspecialty.

 

[fibonacci011]

ENTswitch,
again nobody on here is ragging on cardiologists, but there are many who do things they shouldn't be doing, such as EVARs without surgical support and intra-cranial work, as well as IVC filters etc, which is really not at all related to the heart, and the typical stereotype of a cardiologist is what has been said above, however untrue it is for most of them,

Likewise, nobody on here is claiming to be more adept at managing chronic conditions better than an IM, however, if a patient comes in for PAD referral, than it would be poor medical care for the IR not to review the cholesterol, and diabetes HTN history and meds and control of these issues in an effort to prevent any invasive therapy, to be perfectly honest it is not as easy as it sounds, but neither is it hard, and if cards thinks they should stent things in the brain, than IR is certainly well within their realm to manage these issues. Is a cardiolgist as adapt at managing diabetes as a PCP or endocrinologist, unlikely, and most don't bother, but some do. Also we don't learn from IRs on IR rotations, I personally learned it in my intern year, and practice primary care in a free clinic, and many IR fellowships have non-IR rotations such as vascular, etc. to gain more exposure in this. Also many younger residents and fellows are doing or will do fellowships in vascular medicine. Even still, no IR is going to take over management of these diseases or claim they are better at it than a medicine doc, no specialist would. Even stroke docs, who deal directly with the complications of DM, HLD and HTN don't really manage these conditions in an outpatient setting.

Also for things like cancer, especially for the invasive therapies, the IR had better understand all components of the therapies, prognosis etc, because the patient will ask those questions, and "please call your oncologist" is not an acceptable answer. Or doing UFEs and not being able to manage the patients various complications, questions about fertility, and so on.

IR is a clinical specialty and only now for some reason people are starting to wake up to that fact. Which means IR is going to become even more clinical, and there is resistance to that from both DR (less RVUs when you're seeing patients) and other endovascular specialties (more competition).

Nobody on here from the IR side is saying anything inflammatory, however, the fibonacci guy did come on here, with what appears to be a goal of inciting some sort of flame war.

I have nothing but respect for most cardiologists, but there are many who go into a hospital and start saying only I should get to do the intravascular stuff, cardiac imaging, carotid stenting, perfusion scans etc or I won't send you patients, not exactly the kind of person you'd like to deal with is it? Similarly what if an IR came to hospital and said nobody gets any y90 or TACE unless I also get to do all the PAD stuff, doesn't make for a very pleasant work environment.

Respect does go both ways, but many cardiologists don't really show it towards radiology, and often feel that that is ok.

Also, when I said the 3 year cards program includes a year of research, I was talking about the program at my hospital, I'm sure it varies from place to place.

Why should a cardiologist give up their patient if they can perform the procedure? You call it altruism, this attempt of IRs to become more clinical when in reality it's a way to get control of the patient management so that the cardiologist and medicine doctors don't have primary access to them. Sorry for the inflammatory remarks before but this post is an actual post w/o any cruel intentions behind it.

This thread is called "Turf" and in the battle for it, IRs are trying to set up a clinical model so they don't lose ground to Vascular and Cardio which has been said all over this thread. That's not altruism, at least not any more than that cardio and vascular guys have

 

[badasshairday]

Cards took out CT surgery. Now the sights are on destroying Vascular Surgery and VIR.

 

[IRGuru]

...im done responding to your nonsense. in the end radiology itself is a crucial part of medicine and interventional radiology is kind of badass but your suggestion that its a skill only diagnostic radiologist are able to acquire is absurd

...and here you REALLY got my hopes up...shucks...

On a more productive note...badasshair day- a couple things:

Cards took out CT surgery. Now the sights are on destroying Vascular Surgery and VIR.

1. I love your enthusiasm since you obviously are going out of your way to learn about the field, strengths and weaknesses. I hope you pick IR over anesthesia since IR is that frickin' cool.

2. Beeeee caaalllmmmmmm...you're going to give yourself a stroke if you keep worrying as much as you do. CT was taken out because they refused to adapt to catheter techniques. Everyone knows that minimally invasive techniques are the future of medicine but they realized that too late. IR has not and will not make that mistake. We ARE minimally invasive medicine and clinician IRs will remain at the forefront of medicine.

3. Notice the years on that study- 2005 and prior- That's important for several reasons. Speak with any clinican IR attending (since you're at MCW, speak with Dr. Patel...guy trained at BCVI and is the epitome of a clinician IR...at BCVI, IR owns PAD and that's not changing any time soon) and he/she will tell you that truly clinician IRs are a relatively new entity (i.e. they are <5 years in practice) but where they exist, they do incredible PAD work. They're present at MCW, Brown, UVA, VCU, Kaiser LA, UIC-peoria, Maine Medical Center etc... Having been at SIR this past year and speaking with multiple vendors, they all said that IR has maintained just under 1/3rd of the market share in PAD (~30%). This is important because there're about 5,000 (at most) practicing IRs and about 21,000 practicing cardiologists and we've have held constant over the past five years despite that (actually, we dipped below 30% but there's been a noticeable resurgence in PAD as noted at SIR this year) so emerging clinician IRs are doing very well. Finally, as you notice, the "n=" shows a multiple fold increase in number of cases of PAD...It's natural for the specialty with the most number of folks to be doing the most number of procedures so I'm not surprised by it at all. My point for you and any other student considering IR is that if you can make yourself an EXPERT in a disease, you can easily practice it and you'll always be in demand. The beauty of IR is that you can become an expert in multiple entities like stroke care, PAD, cancer, pain, women's IR etc... And if worst comes to worst, you can simply innovate. This is what IR does!! For example, Dr. Ryu, the PD at Northwestern told a story and said a couple years ago, he was speaking with one of his residents about IR in general and they said "you know we need more blue ocean (aka new turf)". Across medicine, they looked for disease with high incidence that has had horrible outcomes despite the most aggressive treatment. They came up with pancreatic cancer and have worked to develop a completely novel technique called nanoembolization. In a few short years, this technique could provide a radical new approach towards treating pancreatic cancer...This is the beauty of IR and this is how IR changes medicine!...you literally just have to use your imagination.

http://www.modernmedicine.com/moder...noparti/ArticleNewsFeed/Article/detail/661587

 

[Radonkulous]

...

 

[magic_drm]

Will this be a straight 5-6 year residency where you get both certificates? Doesn't really sound any different than DIRECT.

To some extent not too different from Direct in that it will be 6 years and end up with credentials as both Diagnostic and IR but some key opportunities: Standardization of IR training across the board to be more clinical (not just the Direct pathways positions), this likely would be incorporated into 4th year residency at many programs. For example, our fellowship director mentioned the possibility of clinical rotations such as ICU (a lot of the onc patients are pretty sick and we should follow them after our procedures) and that he would be directly over the education of the 4th year IR residents as well as fellows. Also, by making IR a residency rather than a specialty, it is thought that there will be greater sway in admission privledges and ability to maintain and regain turf.

 

[Radonkulous]

...

 

[badasshairday]

3. Notice the years on that study- 2005 and prior- That's important for several reasons. Speak with any clinican IR attending (since you're at MCW, speak with Dr. Patel...guy trained at BCVI and is the epitome of a clinician IR...at BCVI, IR owns PAD and that's not changing any time soon) and he/she will tell you that truly clinician IRs are a relatively new entity (i.e. they are <5 years in practice) but where they exist, they do incredible PAD work. They're present at MCW, Brown, UVA, VCU, Kaiser LA, UIC-peoria, Maine Medical Center etc... Having been at SIR this past year and speaking with multiple vendors, they all said that IR has maintained just under 1/3rd of the market share in PAD (~30%). This is important because there're about 5,000 (at most) practicing IRs and about 21,000 practicing cardiologists and we've have held constant over the past five years despite that (actually, we dipped below 30% but there's been a noticeable resurgence in PAD as noted at SIR this year) so emerging clinician IRs are doing very well. Finally, as you notice, the "n=" shows a multiple fold increase in number of cases of PAD...It's natural for the specialty with the most number of folks to be doing the most number of procedures so I'm not surprised by it at all. My point for you and any other student considering IR is that if you can make yourself an EXPERT in a disease, you can easily practice it and you'll always be in demand. The beauty of IR is that you can become an expert in multiple entities like stroke care, PAD, cancer, pain, women's IR etc... And if worst comes to worst, you can simply innovate. This is what IR does!! For example, Dr. Ryu, the PD at Northwestern told a story and said a couple years ago, he was speaking with one of his residents about IR in general and they said "you know we need more blue ocean (aka new turf)". Across medicine, they looked for disease with high incidence that has had horrible outcomes despite the most aggressive treatment. They came up with pancreatic cancer and have worked to develop a completely novel technique called nanoembolization. In a few short years, this technique could provide a radical new approach towards treating pancreatic cancer...This is the beauty of IR and this is how IR changes medicine!...you literally just have to use your imagination.

http://www.modernmedicine.com/moder...noparti/ArticleNewsFeed/Article/detail/661587

True. A lot of the clinical IR's are the ones that finished training within the past 5 years. I'd like to see 2011 numbers for Peripheral Vascular Diesease. I'm definitely set on IR. IR is always pushing the envelope in medicine. It is always changing. A very exciting/interesting field.

 

[omarsaleh66]

Obviously Auntminnie is active in VIR discussions, but I would also join www.endovascular.org

This is a forum run by the BCVI guys and very prominent IR, vascular surgeons and cards share interesting cases and discussions.There are many great video clips as well of very complex cases that are great to learn as residents, med students and probably fellows

 

[The Dark Knight]

Cards took out CT surgery. Now the sights are on destroying Vascular Surgery and VIR.

Do you not perceive vascular surgery as a threat to your field then? Although you're right, it does appear the IC's are encroaching the most out of the two other fields.

I'm not sure how I feel about cards doing peripheral procedures. I'm really not sure why they're doing peripheral procedures - have they already cured all the heart disease on Earth and now need to move on to other things? I think coronary angio/cath belongs with cards. I think peripheral vascular IR makes sense being with the VIR and well call me crazy but maybe the vascular SURGEONS should do....surgery?