Where are things heading work, innovation, and compensation/reimbursement-wise? What are the chances that IRs will finally start opening their own clinics to solve the patient referral problem?
There are groups that have stuck together and made good models for continuing forward. Nicholas Petruzzi opened and obl with his DR group and now IR makes more the DR for that group on average. There are other examples.
Pediatric radiology makes less than breast radiology for example. So what are you going to do? Are you going to kick all the pediatric radiologist out? of course not that’s why you’re in a group you realize that certain specialties make more than others and that’s just part of the contract. Frankly, the average radiologist could not do what I do just like I can’t do what they do at the level they do it. Diagnostic radiologist need us! Period. The problem is some IRs allow themselves to be bullied by DR. **** that! Without us the hospital would cancel their contract before business days, end! Fact.
VIR only thrives with clinic. No other subspecialty needs clinic in rads. VIR would do better joining surgery or IC or a multi specialty physician group. Clinic is costly lots of overhead and the downstream benefits takes at least 3 to 5 years to see the return on investment.
If you join most DR groups as an IR you will be delegated to abscess drains, central lines, g tubes, paracentesis , thoracentesis and biopsies. If you want to do a lot of endovascular procedures/embolizations etc you will need an outpatient clinic. Most IR are still traditionally trained and haven't acquired adequate clinical skills to support a robust practice. The current job market is run by DR and private equity (radpartners/envision etc) and they do not gain any benefit from IR running clinics. If medical students want to join these type of practices why put yourself through IR training , just do DR and perhaps supplement with ESIR type rotations or do MSK IR or mammo and procedures etc.
Most DRs are happy in private practice. I know at least 40 other DRs and most of them are satisfied with what they do.
Most radiology reports in the community are high quality and essential to patient care . Most physicians heavily rely on radiology reports. For example, oncologists follow radiology reports almost word for word. If the radiology reports were garbage, most patients with cancer would be mismanaged in the community. The same for ER. Saying that all reports are garbage is like saying that the entire ERs in the US or the entire cancer treatment is US are garbage and they mismanage the patients.
If someone thinks that all people around them are losers, he maybe the main loser himself.
True. They can reap benefit but it takes several years for the clinic to take off and have a profit return. In fact a busy clinical IR can refer a considerable amount of advanced imaging to the DR group. But ,most DR groups and physicians want low overhead and immediate return on investment. They are willing to give up certain things to maintain contracts and also to have less hassle. IR clinic is a lot of hassle for a company that has historically not had to deal with such.The funny thing is they do gain benefit. I know people who work in private DR groups that actually established a clinical service line to maintain PAD/endovascular referrals. These guys who have high endovascular volume and get through the procedures quick cover their own salary, and it stops being a loss-leader. The problem is it requires startup investment on part of the group. My experience is if it isn’t of immediate financial benefit, radiologists aren’t interested. It’s why they can’t even hold onto some of their own imaging studies. Much more difficult for cardiology to learn nuclear imaging than it was for radiologists to learn how to administer stress agents, yet somehow the cardiologists put in the legwork and radiologists didn’t. A bit frustrating to marry yourself to such a lazy field sometimes.
Hospital lobbies are extremely powerful and are trying to limit the growth of OBL/ASC. Most surgeons do several days of clinic a week and operate the remainder as it takes seeing many patients to get to that and grow a sustainable model. IR trainees are not historically accustomed to that and so when they go out they often struggle more to establish practices when compared to other endovascular specialists. I do agree that many IR procedures would be better served being done in the outpatient arena.There are IRs out there that actually like to read DR. I personally don’t believe you can do both at a high level. The future will be many of these procedures being done away from the hospital setting. That trend is growing and will only continue to grow. Certain procedures, will not be able to be billed extra for being done in the hospital in future in my opinion. A UFE could probably be done for a fraction of what it costs in a hospital With no change in how the procedure is performed (granted there are some jerks in OBLs trying to do it without a micro-catheter but those are rare). I think this is an area that is evolving. If you get an sfa stent in the hospital most likely it wil be a drug coated stent or supera. You get an SFA stent in the OBL you will get some piece of crap bare metal none drug coated stent. That’s wrong and the people doing it in OBls no it’s wrong. Billing needs to change so the system still saves money but you can still use equipment with good data behind it. Some big radiology groups have seen the light and are investing in OBLs most have not. Envision and Radpartners are horrible companies. There sole goal is pay you as little as possible and themselves as much as possible. That’s what they won’t tell you at the steak recruitment dinners. Hope I never have to be associated with those people.
If you join most DR groups as an IR you will be delegated to abscess drains, central lines, g tubes, paracentesis , thoracentesis and biopsies. If you want to do a lot of endovascular procedures/embolizations etc you will need an outpatient clinic. Most IR are still traditionally trained and haven't acquired adequate clinical skills to support a robust practice. The current job market is run by DR and private equity (radpartners/envision etc) and they do not gain any benefit from IR running clinics. If medical students want to join these type of practices why put yourself through IR training , just do DR and perhaps supplement with ESIR type rotations or do MSK IR or mammo and procedures etc.
More and more graduates have incorporated clinic. 15 years ago it was very small number, now it is a growing minority. Still struggling with IR vs DR which is now coming to a forefront in discussion at SIR. More and more such as linemonkeymd.com have brought up the issues. OEIS society has challenged exclusive rights. SIR position statement stronger against exclusive rights. December 6th SIR/ACR having joint discussion should IR and DR continue together? Training of IR residents and DR residents continues to diverge.I did a reality check and I saw you have been posting about IR clinic and etc over and over again in the last 10-15 years.
Except for anecdotes, can you tell me how things have changed in the last 20 years for IR?
IR pathway training has been changed 3 times in the last 20 years? What has been changed really for the practice of IR?
The funny thing is they do gain benefit. I know people who work in private DR groups that actually established a clinical service line to maintain PAD/endovascular referrals. These guys who have high endovascular volume and get through the procedures quick cover their own salary, and it stops being a loss-leader. The problem is it requires startup investment on part of the group. My experience is if it isn’t of immediate financial benefit, radiologists aren’t interested. It’s why they can’t even hold onto some of their own imaging studies. Much more difficult for cardiology to learn nuclear imaging than it was for radiologists to learn how to administer stress agents, yet somehow the cardiologists put in the legwork and radiologists didn’t. A bit frustrating to marry yourself to such a lazy field sometimes.
Most private radiologists are never given a reality check. Having seen both (and drawn from a diverse sample of private groups), academics is considerably higher quality. I’ve seen missed acute/disaster cases that I don’t think the radiologist that misread ever got word of, because it’s easier to just deal with ****ty reads than to go through the hassle of threatening to / actually breaking contract, if medical/surgical docs even decide to complain, which they often don’t.
Private rads probably just aren’t ever told of their awful misreads. A few I saw in residency: an adnexal cystic mass misidentified as a bladder, an MR enterography diagnosing terminal ileitis that was actually appendicitis, a very obvious, large volume GI Bleed on a tagged RBC study that was called normal (I don’t think the rad even looked at the image, or if they did, they had no idea what they were looking at). Postradiation change of an irradiated lung mass that was called tumor progression. Tubular nodules (impacted airway secretions) that were “concerning for malignancy.” The reads can be… awful. I’ve never seen quality so shoddy from an academic subspecialist.
I think it is time for DR to separate itself from IR and vice versa.More and more graduates have incorporated clinic. 15 years ago it was very small number, now it is a growing minority. Still struggling with IR vs DR which is now coming to a forefront in discussion at SIR. More and more such as linemonkeymd.com have brought up the issues. OEIS society has challenged exclusive rights. SIR position statement stronger against exclusive rights. December 6th SIR/ACR having joint discussion should IR and DR continue together? Training of IR residents and DR residents continues to diverge.
I don't know too many IC fellows doing 300 to 500 PAD cases during training. Which ones? Agree IR trainees need to expand their exposure to clinics and to PAD training. Medical students should ask about this when interviewing to see how much exposure they will get to PAD and to clinic in general.
I do think the training continues to diverge as the IR residents do less and less DR and will not be taking the DR orals . The DR residents are not doing as many procedures as to compared to prior to the institution of the integrated IR resident. Independent IR would have a very hard time competing with a mixed practice of IR light and reading when it comes to time off and financial compensation.Don't waste too much energy arguing guys.
IR will not separate from DR in the near future because it is not financially feasible on a large scale, nor is there an established training pathway that doesn't include a ton of DR rotations.
DR will still prefer to have a few IRs since there is a significant clinical need for "lite-IR" (biopsies, lines) that cannot be offloaded.
So the near-intermediate future will still be majority DR/IR practices. I believe as radiology labor becomes increasingly stretched thin, more groups will negotiate for IR subsidization
Most ICs do know where near this number in there 1-2 years of procedure training in fact some do none.I agree that most private practice radiologists including IRs are not give reality check.
I have personally seen IRs doing a worse or a lot worse job treating PAD compared to VS and IC. There are publications that show IR has higher complication rate. But these IRs mostly look for their financial gain and they don't care about patients.
These are reality checks:
Most IR residencies and fellowships don't train their IR to do PAD well.
Most IR residencies and fellowships don't train their IRs to have clinic.
So it is a huge disservice to the patient to do things that are above your level of training. On the other hand most VS and ICs are very well trained to do PAD both from medical management stand point and procedure wise.
A lot of ICs do about 300-500 PAD cases during their fellowship. Most IRs do less than 50. And medically off course they are better trained.
You can get away with this in the middle of know where but know where of size.I think it is time for DR to separate itself from IR and vice versa.
As you mentioned above, DR will do some bread and butter procedures like biopsies, drains, Thoras, FNAs and etc in order to comply with hospital contract requirements. they may even hire an IR to do these procedures for them.
And IR can continue to create its own specialty.
But it is now fair to expect DR to support you. DR is already heavily subsidizes IR. In our group, IRs generate about 60% of their income. We are fine with the setup and the IRs are also satisfied with that. But if an IR expects more or they are not satisfied, they can go their own way.
Eventually, by separating itself IR probably needs to be subsidized by the hospital.
I know some IRs who make a lot of money, probably 50% more than an average DR. But these people are mostly in rural areas and they get to that point after 5-10 years of practice building. And even if that case, if a DR work similar number of hours they can make similar salaries.
However, in big and midsize cities, IRs who have OBLs don't make significantly more than busy DR groups in the area.
People are free to choose what they want. But our responsibility is to inform them with accurate information. The rest is up to them.
I have already done over 100.My numbers were from one of the busy west coast teaching hospitals from what I heard from my brother. He may include all the second and third hand assistance cases as the number of cases or he may include all the cases during 3 years of residency plus fellowship.
I also said IRs do less than 50. But realistically in most IR fellowships, they do less than 10 or sometimes close to zero.
That is a solid number of leg revascularizationsI have already done over 100.
Every skill set matters. Our vascular surgeons are quite good at CTA and vascular us and look at it differently from the average radiologist. ie when looking at pad, they look at soft/hard plaque/occlusive lengths/ iliac/ sfa/tibials/pedal circulation. The average radiology graduate may not know the foot vascular anatomy like a CLI interventionist does (arterial/venous). Vascular surgeons are well versed in vascular us (tcpo2/toe pressures/ non invasives/PVR/segmental limb pressures) while most DR residents don't learn this. Echo and ICE is becoming more and more important for IR who are in the PE space and that is not being taught to most radiologists while cardiologists are learning this during their fellowship years. Radiology used to do a good job in teaching angiographic anatomy but that is not as common now a day and with the new DR orals it will not have IR as a section so they will have even less of a need to learn angiographic anatomy.As far as separating from DR. That is a tough one for me. It really is my secret weapon. I get a consult asking me to do something because the read says this. I look at it myself and can very confidently agree or disagree for many disease pathologies from head to toe. It is a huge separation/advantage. I think the heavy imaging skill set is necessary for the wide variety of diseases we treat.
I understand. But we treat head to toe. Most vascular surgeons knowledge of cerebral anatomy stops above the carotid bifurcation.Every skill set matters. Our vascular surgeons are quite good at CTA and vascular us and look at it differently from the average radiologist. ie when looking at pad, they look at soft/hard plaque/occlusive lengths/ iliac/ sfa/tibials/pedal circulation. The average radiology graduate may not know the foot vascular anatomy like a CLI interventionist does (arterial/venous). Vascular surgeons are well versed in vascular us (tcpo2/toe pressures/ non invasives/PVR/segmental limb pressures) while most DR residents don't learn this. Echo and ICE is becoming more and more important for IR who are in the PE space and that is not being taught to most radiologists while cardiologists are learning this during their fellowship years. Radiology used to do a good job in teaching angiographic anatomy but that is not as common now a day and with the new DR orals it will not have IR as a section so they will have even less of a need to learn angiographic anatomy.
You are taking this way too personally. When I say “marry myself” I mean me, personally marrying to radiology as a whole. Not IR to DR. I’m not exclusively IR, and I very much enjoy DR. You must really not like the IRs in your group lol.Lol. Who lost the biggest turf? IR or DR? What do you smoke?
So you are saying that if DR loses 5 % of its turf ( Nucs cards is about 5 % of imaging and is still done 20-30% by radiologists), it is because they are lazy. But if IR loses 90% of its turf (PAD), the blame is one DR? hah.
Nucs cardiology is one of the easiest studies to read. The reason that caridologist got into the game is the same reason that they took away PAD from IR. They control referrals.
Most radiologists that I know of, invest in real estate and stocks. They don't look for immediate financial benefit but for a lot of them investing in OBL does not make sense financially. Most DRs (and IRs) can comfortably reach financial independence in their 50s.
Practically, you are saying that DR is obligated to help IR. Otherwise, they are shortsighted.
I think it is a lot better for IR to seperate from DR. But then don't expect DR to help you establish clinic. Go your own way.
Most ICs do know where near this number in there 1-2 years of procedure training in fact some do none.
I have already done over 100.
For some reason the conversation always unjustly comes back to PAD. It’s not really fair. PAD is a fraction of what we can and do do. I happen to love it. Many of my co residents don’t like it.
SFA/Iliac Disease: short segments anyone can do. SFA long segment occlusions can be difficult, but a couple reentry cases with outback and even those are not too bad.
Tibial disease/pedal disease: I argue that there is only a couple hundred operators in the us doing this at a high level regardless of specialty, antegrade/retrograde access, CART/Reverse Cart, EVUS, atherectomy, shockwave, accessing occluded vessels, DVAs. Very few operators do all these things well. In fact most regardless of speciality do not. CLI Fighters organization has large proportion of them. But let me be clear not ever vascular surgeon resident, cardiologist, or IR is getting tranined to do the above at a high level. The vast majority are not. There is a small number of physicians doing it.
The challenge is in the hospital the needs for IR are different ie paracentesis, thoracentesis, chest tubes, g tubes, biopsies, central lines, abscess drains, nephrostomy tubes , lp, myelograms, arthrograms etc. Hospital will also occasionally have the bleeder that may require IR skillset.
I understand. But we treat head to toe. Most vascular surgeons knowledge of cerebral anatomy stops above the carotid bifurcation.
My patient is complaining of back pain I look to see if there is an acute compression fracture so I can do vertebral augmentation on them. IC and VS don’t do that. Our skill set allows us to treat a wide variety of diseases other than vascular disease. The best way to diagnose those diseases is with imaging, planning your procedure involves dissecting the imaging, I can do this easily because I have read thousands of cross sectional studies, US, XR etc. I just don’t know how we do away with all of it.
You can get away with this in the middle of know where but know where of size.
Hospital administrator: what do you mean no one is available to do a PTC?
Diagnostic Radiologist: yeah we just let them go. They’re not as profitable as negative head CT’s from the ER.
Hospital administrator: we have a busy hepatobiliary service and unfortunately that is a requirement your contract states you need to fulfill we’re looking for somebody to fill the contract as yours will terminated shortly.
As far as separating from DR. That is a tough one for me. It really is my secret weapon. I get a consult asking me to do something because the read says this. I look at it myself and can very confidently agree or disagree for many disease pathologies from head to toe. It is a huge separation/advantage. I think the heavy imaging skill set is necessary for the wide variety of diseases we treat.
You are taking this way too personally. When I say “marry myself” I mean me, personally marrying to radiology as a whole. Not IR to DR. I’m not exclusively IR, and I very much enjoy DR. You must really not like the IRs in your group lol.
The blame is on laziness. I know plenty of lazy IRs and DRs. I’m not saying anyone is obligated to help anyone, I’m saying you get what you pay for. If you sit on a couch and eat potato chips, you’re not gonna reap the benefit of having a professional soccer player’s physique. The DR groups that built up a clinical service line for their IRs (not many, but a few) resulted in IR being less of a loss leader, or not at all. It didn’t even necessarily require infrastructure investment, just time and meticulous forethought and planning. Those groups that didn’t are incessantly PO’d at having to subsidize their IRs, a trap they built for themselves. I don’t particularly care what one group or another does, there’s plenty of endovascular jobs in the country to go around. But if IR being a loss leader ticks your group off, your group probably created the circumstance for itself long ago. Just like the fat couch potato. There are ways to make it not a loss leader, which requires personal sacrifice. If you don’t want to run, don’t. But don’t act like it’s anyone’s fault but your own (lazy IRs and DRs both. The number of lazy IRs I see whining about lost endovascular stuff is hilariously mind-numbing. They pride themselves as “image-guided surgeons” but try to dump, divert, and refuse to think about any consult thrown at them… “let primary worry about that question” ). My philosophy’s simply “Put in the effort to tighten ship, or stop whining.“ If you treat any subdivision like crap, don’t be surprised if the CIRCUMSTANCES you crafted for that subdivision start treating YOU like crap.
IR is not the person who manages patients with back pain. A patient with back pain normally goes to their primary care doctor.
Jack of all trades, master of none.I think this may be the part that’s not computing. The person who manages back pain is the person who manages back pain, which actually can be IR if they want to be. You seem to have this illusory concept that there’s this magical period of training during residency and fellowship, outside of which no one can develop a skillset to do anything. You can, if you want to. Just like a new grad surgeon trying to establish practice, you have to put in good work to develop a referral pattern. This is why some groups held onto PAD and some didn’t. It’s because they put in the effort to pick up a damn UpToDate article and learned when to angioplasty/stent and when not to, and what to do when they didn’t. Learning the ins and outs, thoroughly, on one particular disease doesn’t take that much effort. But it takes effort, and there’s reasonable risk it won’t be rewarded. But if you don’t make effort, it definitely won’t be rewarded.
Another shocker, there are pain management fellowships that take IR lol. Give a few grand rounds to the PCPs, buy them some donuts, be available when they have questions, be nice, smile, never say no, make their life easier so that the back pain patients don’t come back to them, forward clinic note AND call after every procedure on their patients, and you can be the (uncomplicated) back pain guy, without the fellowship, if you want to.
… How is it you think referral patterns are established? How is it you think cardiology started picking up renal denervation consults from nephrologists? It’s not a self-evidently cardiology consult. They ran for it, and because of that, they deserve it.