What is the future of IR?

[SeisK]

Jack of all trades, master of none.

Then what about UFE?
You have to buy donuts for PCP and tell them to send you patients with abnormal vaginal bleeding. Then you can put in an effort to pick up a damn uptodate article and learn how to manage vaginal bleeding. Also you can watch some youtube videos to watch how to do endometrial biopsy

Next you can do the same for Prostate artery embolization.

Then in order to grow your business in TACE you can learn how to manage HCCs and tell PCPs to send patients with cirrhosis to you. Then you can pick up a damn UpToDate article to learn how to manage Cirrhosis and how to manage HCC. You can even learn systemic chemotherapy by reading some articles.

Cardiology does renal denervation mostly on their own patients. They don't need nephrology for that. Most cardiologists manage hypertension at least 5-10 times a day.

The more I read your post, the more I come to conclusion that IR lives in its own dream land and does not have a good understanding of how referral patterns work.

Yeah, more or less, actually. This process can take 3-5 years for surgical subspecialists before they’re satisfied enough with their referral pattern that they can pull off on it. For any IRs out there that want the high-end pattern, you should be picking up the UpToDate article before every high end procedure you do in residency/fellowship, so that you know the medical management of this stuff in advance. There are practices that have a successful track record of doing exactly what you’re suggesting. That’s the point lol, they actually never stop.

When you meet guys who establish high end referrals you find it’s really not that difficult to do. If an IR did what you’re suggesting for every procedure they were capable of performing they would be completely inundated and would have waitlists months long. You pick a handful of what you want to do / be known for, and you stick with that, and still you might have waitlists months long. I trust the guys who actually did establish high end referrals more than I trust some rando with what I assume is a subconscious axe to grind. I know their names, I’ve talked to them. These people don’t exist in a fantasy land. You’re running contrary to what is empirically proven success, and therefore prevailing sentiment among IR circles. The reason IR doesn’t get these procedures isn’t because of failure of trying, it’s lack of trying (historically, usually) or simply being stonewalled by their practices.

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[irwarrior]

It seems you are just a fellow and do not have a good understanding of the business side of medicine.
I am trying to help you.

For some reason?

Outside academic centers, all the IR procedures is easily dwarfed by PAD work. That's the main reason the conversation goes back to PAD. For every Uterine artery embolization, there are 10 PADs out there.

Yes. You raise some good points. The focus at academic centers on interventional oncology and TIPS and not enough PAD training, makes it harder for the graduates to build a practice as most of the IO and even TIPS referrals go to the transplant centers. There just is not enough liver cancer to go around to have the community interventionists also performing these. PAD is much more common disease in the aging population and perhaps the average Interventional graduate maybe lacking the clinical and technical training to compete with many of the other specialties in the pad space. More and more programs are recognizing this and educating the trainees in this process as seen by the numbers NDcienporciento100 has already achieved.

There is a decent volume of symptomatic fibroids that can be managed with UAE, but the patients first line of treatment is usually OCP,mirena IUD (if. not much cavitary distortion), medroxyprogesterone and perhaps leupron. Many IR just learn the technical component and imaging of fibroids, but may not feel as comfortable prescribing meds and counseling patients. Also, the recurrence rate of UAE is around 30 pct at 3 to 10 years and the interventionists may only do a short term follow up, not the 5 to 10 years that may be required to capture the redo UAE. These patients may go to myomectomy or hysterectomy and the patient and gynecologist will lose faith in the procedure. Sometimes you can align yourself with an FP who manages their AUB patients.

 

[irwarrior]

Yeah, more or less, actually. This process can take 3-5 years for surgical subspecialists before they’re satisfied enough with their referral pattern that they can pull off on it. For any IRs out there that want the high-end pattern, you should be picking up the UpToDate article before every high end procedure you do in residency/fellowship, so that you know the medical management of this stuff in advance. There are practices that have a successful track record of doing exactly what you’re suggesting. That’s the point lol, they actually never stop.

When you meet guys who establish high end referrals you find it’s really not that difficult to do. If an IR did what you’re suggesting for every procedure they were capable of performing they would be completely inundated and would have waitlists months long. You pick a handful of what you want to do / be known for, and you stick with that, and still you might have waitlists months long. I trust the guys who actually did establish high end referrals more than I trust some rando with what I assume is a subconscious axe to grind. I know their names, I’ve talked to them. These people don’t exist in a fantasy land. You’re running contrary to what is empirically proven success, and therefore prevailing sentiment among IR circles. The reason IR doesn’t get these procedures isn’t because of failure of trying, it’s lack of trying (historically, usually) or simply being stonewalled by their practices.

Great points. The motivated interventional graduate has the opportunity to learn the disease and build a service line (BPH/PAE; fibroids/UAE; pain/msk/spine (kyphoplasty/spinal cord stim/cementoplasty/rhizotomy/GAE /GNB etc). PAD,DVT/PE/varicose veins etc. This is based on the motivation and drive of the graduate and the willingness of the rads group. It does take 3 to 5 years of really working hard to build such a practice. It is key to try to achieve as much clinical and technical training during your integrated interventional training to set yourself up for success and recognize it will be an up hill battle in most non academic private practice groups.

 

[irwarrior]

If IR separates itself form DR, then PTC will become the responsibility of the separate IR group and not DR group. The hospital admins will change the contract terms over night.

It is not easy to replace a DR group. In this market, it is almost impossible.

The DR market is insanely hot. It is much easier for us to hire an IR than a DR in the current market.

 

[NDcienporciento100]

Yes. You raise some good points. The focus at academic centers on interventional oncology and TIPS and not enough PAD training, makes it harder for the graduates to build a practice as most of the IO and even TIPS referrals go to the transplant centers. There just is not enough liver cancer to go around to have the community interventionists also performing these. PAD is much more common disease in the aging population and perhaps the average Interventional graduate maybe lacking the clinical and technical training to compete with many of the other specialties in the pad space. More and more programs are recognizing this and educating the trainees in this process as seen by the numbers NDcienporciento100 has already achieved.

There is a decent volume of symptomatic fibroids that can be managed with UAE, but the patients first line of treatment is usually OCP,mirena IUD (if. not much cavitary distortion), medroxyprogesterone and perhaps leupron. Many IR just learn the technical component and imaging of fibroids, but may not feel as comfortable prescribing meds and counseling patients. Also, the recurrence rate of UAE is around 30 pct at 3 to 10 years and the interventionists may only do a short term follow up, not the 5 to 10 years that may be required to capture the redo UAE. These patients may go to myomectomy or hysterectomy and the patient and gynecologist will lose faith in the procedure. Sometimes you can align yourself with an FP who manages their AUB patients.

I’m going to disagree.
Look at pain management. IRs are leaders in high end pain intervention. You can literally make a very busy just pain management alone practice. If you don’t believe me look at the exciting things Dr Doug Beall is doing, vertebral augmentation, basovertebral nerve ablation, SI joint fusion, percutaneous spacers for spinal stenosis, injections, etc. Venous disease is on the order of multiple times more common than pad. There are vein centers that just do veins that are very profitable. Dialysis work, super common tons of patients from routine fistulagram for surveillance, outflow stenosis balloon angioplasty, Declots, percutaneous fistula creation etc.,THDC placement etc. you supplement any of this with UFE, PAE, plus all the routine/emergent IR cases drains, biopsy’s, bleeds etc you are going to be busy.

 

[NDcienporciento100]

The DR market is insanely hot. It is much easier for us to hire an IR than a DR in the current market.

The IR market is insane as well. I know because I’m looking at it.

 

[irwarrior]

I’m going to disagree.
Look at pain management. IRs are leaders in high end pain intervention. You can literally make a very busy just pain management alone practice. If you don’t believe me look at the exciting things Dr Doug Beall is doing, vertebral augmentation, basovertebral nerve ablation, SI joint fusion, percutaneous spacers for spinal stenosis, injections, etc. Venous disease is on the order of multiple times more common than pad. There are vein centers that just do veins that are very profitable. Dialysis work, super common tons of patients from routine fistulagram for surveillance, outflow stenosis balloon angioplasty, Declots, percutaneous fistula creation etc.,THDC placement etc. you supplement any of this with UFE, PAE, plus all the routine/emergent IR cases drains, biopsy’s, bleeds etc you are going to be busy.

True it is feasible. But, look at the majority of OBL/ASC work and the ones that are profitable whether it be IC, VS and IR most are doing some degree of PAD and includes hemodialysis interventions (fistula/graft maintenance). There are few people doing what Doug Beall is doing in the IR community and he does in a hospital that I believe he owns. Vein centers can be lucrative but there is so much penetration by VS, IR, IC and countless others including dermatology, cardiac surgery, gynecology as well as FP physicians. The work from IR centers is typically done in collaboration with urology, GI, ortho and is essential a subsidiary of that practice.

 

[irwarrior]

The IR market is insane as well. I know because I’m looking at it.

Not denying the fact that it is difficult to hire doctors including IR in the Current market. But, it is really hard to hire psychiatrists, anesthesiologists and DR .

 

[Tiger100]

Yes. You raise some good points. The focus at academic centers on interventional oncology and TIPS and not enough PAD training, makes it harder for the graduates to build a practice as most of the IO and even TIPS referrals go to the transplant centers. There just is not enough liver cancer to go around to have the community interventionists also performing these. PAD is much more common disease in the aging population and perhaps the average Interventional graduate maybe lacking the clinical and technical training to compete with many of the other specialties in the pad space. More and more programs are recognizing this and educating the trainees in this process as seen by the numbers NDcienporciento100 has already achieved.

There is a decent volume of symptomatic fibroids that can be managed with UAE, but the patients first line of treatment is usually OCP,mirena IUD (if. not much cavitary distortion), medroxyprogesterone and perhaps leupron. Many IR just learn the technical component and imaging of fibroids, but may not feel as comfortable prescribing meds and counseling patients. Also, the recurrence rate of UAE is around 30 pct at 3 to 10 years and the interventionists may only do a short term follow up, not the 5 to 10 years that may be required to capture the redo UAE. These patients may go to myomectomy or hysterectomy and the patient and gynecologist will lose faith in the procedure. Sometimes you can align yourself with an FP who manages their AUB patients.

This is the part that we have a huge disagreement over.

A patient with fibroid has vaginal bleeding. I honestly believe that it is outside the scope of an IR or even family doctor to manage a patient with Abnormal uterine bleeding.

Now if it is a remote area and there are not enough OB-GYNs around, I can understand that an IR or family doctor step in. But here in California in my neck of woods, if you just randonly through a stone, it will hit an OB-GYN who is tired of OB and wants to do exclusively GYN i.e abnormal uterine bleeding. To be fair, they are a lot better at managing AUB.

So a lot of it depends on the location. As I mentioned before, I see IR similar to general surgery. In big cities, general surgeons don't do that much. They don't do chest, colorectal, biliary, liver, pancreas or even breast surgeries and even if they do, they are under a lot of pressure from hospitals, other surgeons and lawyers and eventually a lot of them end up dropping it. Only a handful of them can success in doing a variety of procedures. But in rural areas they are the king and they do everything (Even some of them do hysterectomies).

 

[Tiger100]

Not denying the fact that it is difficult to hire doctors including IR in the Current market. But, it is really hard to hire psychiatrists, anesthesiologists and DR .

A lot of groups are negotiating better terms with the hospital.

7 years ago the hospitals abused a lot of groups. Now it seems the pendulum is swinging the other way.

I have heard some radiology groups asking crazy incentives from hospital systems. Esp the groups that were under huge pressure form hospitals in the past.

Good Times.

IF you are a fellow right now, don't sell yourself short.

 

[NDcienporciento100]

A lot of groups are negotiating better terms with the hospital.

7 years ago the hospitals abused a lot of groups. Now it seems the pendulum is swinging the other way.

I have heard some radiology groups asking crazy incentives from hospital systems. Esp the groups that were under huge pressure form hospitals in the past.

Good Times.

IF you are a fellow right now, don't sell yourself short.

Right now as you have said previously people like Radpartners are paying radiologists a lot of money. It’s still not what you can make in PP in a radiologist owned group but it’s a lot of money. When this market turns and eventually it will they will slash there radiologist salary with a smile on their face while they do it.

 

[OnlyScans420]

Right now as you have said previously people like Radpartners are paying radiologists a lot of money. It’s still not what you can make in PP in a radiologist owned group but it’s a lot of money. When this market turns and eventually it will they will slash there radiologist salary with a smile on their face while they do it.

What would stop DRs from just leaving and getting a job elsewhere if that happens? With the volumes as they are now, I'm not sure if even radpartners could risk their DRs quitting. Plenty of PEs end up folding after they're DRs leave and they can no longer keep up with their contracts. As long as the volumes remain high I don't foresee salaries getting slashed astronomically. Volume has put us in a position similar to the surgical subs, where demand far out paces supply and that means subsidies as well as bargaining power, especially for more patient facing DRs like mammos. At worst it means more of us will be hospital employed, which is bad, but it is the general trend across all of medicine

 

[NDcienporciento100]

What would stop DRs from just leaving and getting a job elsewhere if that happens? With the volumes as they are now, I'm not sure if even radpartners could risk their DRs quitting. Plenty of PEs end up folding after they're DRs leave and they can no longer keep up with their contracts. As long as the volumes remain high I don't foresee salaries getting slashed astronomically. Volume has put us in a position similar to the surgical subs, where demand far out paces supply and that means subsidies as well as bargaining power, especially for more patient facing DRs like mammos. At worst it means more of us will be hospital employed, which is bad, but it is the general trend across all of medicine

The market changes. Right now the power is in the radiologist hands. That will change! It always does. And when it does, they will reduce their salaries because the market will allow them to. Because they will have more control. Right now they can’t because the market is so strong. Look at envision. They practically own the Radiologist market in Florida! If 90% of the jobs are from one employer and the market starts to go south for the radiologist the employer will have the power and rest assured, they will reduce there salaries because these PE firms only care, about one thing and that’s money.