You are a special case, my friend. You are a hammerhead.
Most medical doctors are the opposite. They like to have their futures well-planned out for them, without any real struggle of uncertainty. Even the hard-core neurosurgeons, who work endless hours, know that they will have work at the end.
I don't doubt that IR has a billion things to offer patients, and that in many ways it is poised to become the future high-standard of invasive interventions. It's just that it won't become that way until it is generally accepted by the status quo. Your case, as I said above, is a special one because of your spirit.
His case is very rare.
The problem in IR is the referral pattern of IR. It is not the education or the pathway or even post procedure management.
For example this intern interested in IR asking about post procedure management. Though it is important, it does not protect your turf.
The IR docs should understand that turf loss is not about quality, it is about the referral pattern.
As long as nobody considers you as "clinical specialist" you are at the mercy of the original clinical service.
Some examples from his sample procedures:
even thoracentesis and paracentesis may need a consult as we are starting to offer other things for these patients. For example for malignant pleural effusions we may consider pleurx catheters or chest tube wiht pleurodesis. And for malignant ascites, we may consider pleurx drains as well. For ascites due to portal hypertension we may consider TIPS and on occasion we may consider Denver shunts (IR guided). These interventions have truly improved the quality of life of many of these patients as they can now manage their fluid status on their own at home before they get shortness of breath or symptomatic abdominal distension, This is a great palliative service that we are able to provide our oncology patients as well as our end stage liver disease patients.
You are right. But every cirrhosis patient has a GI doctor, unless you live in boonies. You are not the one who decide what should be done for the patient. For malignant pleural catheter, you are at the mercy of oncologist. Now if the cardiothoracic surgeon in your hospital decides to send his lung cancer patients to the oncologist for chemo and gets all the malignant pleural effusion referrals from him in return, he can easily bypass you and you lose your control. Many cardiothoracic surgeons start to put pleural catheters. You have to compete with them.
But, there is a growing amount of outpatient clinics being done by IR and it is a gamut of patients being seen. Venous disease (varicose veins, dvt, PTS, venous insufficiency, venous malformations),
Everybody and their mother is doing varicose veins these days. Family doctors, vascular surgeons, dermatologists, cards, OB, surgeons, CTS, .... You may find some success in this field as it does not need referral.
claudicants, wound management (arterial, venous, neuropathic, mixed),
PAD is lost to vasc surgeon and cardiologists man. You may kill yourself and find a few cases. Most of these patients have already a cardiologist.
Also more than 90% of family doctors and ER doctors know vascular surgery and cardiology as VASCULAR specialist. You never see them put IR consult for mesenteric ischemia. If they do it, it is a disservice to the patient. IR does not have the clinical experience for mesenteric ischemia.
You are at the mercy of OB-GYN. It means that an OB-GYN should kiss his income for doing hysterectomy goodbye and refer the patient to you. If a family doctor refers his Vaginal bleeding patient to you for w/u it is a disservice to the patient. IR does not have the expertise. The patient should be referred to OB-GYN for work up of vaginal bleeding. Also most women have an Gyn, unless they live in boonies. Even if the patient knows about Fibroids, a Gyn can easily badmouth it. The truth is, there is not a huge difference between embolization and hysterectomy/myomectomy. They can easily say if we do hysterectomy, you wont get endometrial cancer, Do you know how many people die of endometrial cacner each year?
oncology (renal mass, lung primary or mets, bone mets, adrenal, liver primary and mets);
You are at the mercy of specialist. You want to ignore it, but oncology work for IR is limited to big academic or cancer centers. The only benefit has been proven for HCC. Renal mass is referred to Urologist and not to IR. The urologist will do partial nephrectomy and not refer for RFA. If some time in the future, they prove RFA is better than open surgery, I guarantee you 100% that urologists will learn how to do it. In any case, it is not the money maker in pp.
pain is a growing area of practice (esi, rhizotomy, celiac blocks, hypogastric blocks, vertebro, kypho etc);
As an MSK radiologist, I do pain mamagement from injections to Kypho-vertebro. I have a light clinic where I give patients medication. It is not as rosy as you say. You are at the mercy of orthopods. In most markets it is controlled by anesthesiologists. In radiology, neurorads do more of them that IR or anybody else. The only reason we still do it, is the large number of cases.
complex abscess drains for diverticulitis, perforated appendicitis, post op infections etc. Not to mention biliary and GU interventions.
This is done by Body people in many practices. There is not need to be trained in IR. This is a general radiology skill.
A lot of interesting things coming down the pipeline (renal artery denervation for treatment of hypertension, prostate artery embolization for BPH, additional treatments for male infertility).
Good luck. The patient has refractory HTN. I assume the family doctor will send the patient to cardiologist and not IR for further medical management. The cardiologist works on 7 different drugs and then decides it need intervention. And then, he refers it to you. Good dreams. This pattern of referral sounds very familiar to me.
The reason for my long post, is to make something clear: It is not about quality, it is not about understanding the procedure. It is about, who is KNOWN as a specialist in field to be referred to. The level of knowledge of PAs, NPs, And family doctors about who does what is low. They don't care, they just want someone to take care of patient's higher level of need. Chest pain is referred to cardiologist. Fracture is referred to orthopod, now if you invent an IR procedure to fix hip fractures, it does not help. The patient still goes to orthopod. Vaginal bleeding is referred to OB-Gyn and not IR.
You can not win the game unless you change the pattern of referral. It means you have to convince almost all family doctors and ER doctor in US which are about half of milion people to refer vaginal bleeding to you and not to OB-Gyn. Good luck.
Thanks
). I have no problem working my tail off. I just worry about all the competition, as you said.