By: Jared Cline, MS3, Keck School of Medicine of USC
As a third year medical student interested in IR, I’ve had the privilege of being at an academic institution with an integrated residency program and a faculty heavily involved in the leadership of SIR who have access to a variety of resources to get all of my questions answered. After talking to some of my colleagues not already interested in the specialty and those at other schools, however, it seems that there are still many unanswered questions regarding the specifics of the practice of IR. Below are questions that were sent to Interventional Radiologists from two institutions over email and answered over the phone. Though they represent a small sample size, the responses may provide some insight into the field of IR that some students have not had access to before.
Dr. Geogy Vatakencherry, Kaiser Permanente Medical Group Los Angeles
Is IR one monolithic specialty? If not, how does it vary based on practice location/model? Can you specialize within interventional radiology?
There is tremendous variability in practice patterns for Vascular and Interventional Radiology (VIR) physicians.
There is the academic model, which has primarily focused on transplant and trauma. If an institution houses a liver transplant surgery department, the VIR physicians are often busy performing hepatobiliary interventions including TACE and Y90 for liver cancer, management of portal hypertension with TIPS and BRTO, and biliary drainage procedures. Outside of academic centers with liver transplant or cancer centers, there is rarely enough interventional oncology cases in the community to sustain a 100 percent vascular and interventional radiology practice.
Some academic departments have fully transitioned to a more surgical model by seeing formal consults on every patient, rounding on inpatients, admitting to their own service, and coordinating a busy outpatient clinic booked with initial consults and follow-up patients in a longitudinal fashion. Unfortunately, this is not universal. Some centers still do not have outpatient clinics, do not do formal inpatient consultations on patients, and, thus, act more like a technician.
There are three types of outpatient VIR private practice models:
1. VIR physicians do somewhere around 50 percent interventions and 50 percent diagnostics with minimal clinical work. In these instances, they are often performing some of the more basic interventional procedures including biopsies, drains, gastrostomy tubes, and fluid drainages (paracentesis/thoracentesis/abscess drains).
2. Others have a 100 percent interventional role in the hospital setting with formal inpatient consults and outpatient longitudinal clinics, where they are in charge of clinical decision making and provide comprehensive longitudinal clinical care.
3. Finally, a growing number of interventional radiologists practice as independent practitioners in an outpatient clinic and do their procedures as an outpatient in an ambulatory surgery center/outpatient lab. The office-based lab VIR physicians are primarily doing peripheral arterial disease, dialysis interventions, fibroid treatments, varicose veins, and pain procedures. This is one of the fastest growing sectors of VIR practice, but unfortunately very few students and residents have exposure to this model and many training programs do not prepare their trainees adequately to succeed in this environment.
The latter two models of private practice enable the IR physician to take a more active role in the care of the patients and requires dedicated clinic time.
The majority of interventionalists are trained to provide vascular access, image-guided biopsies, abscess drainages, and emergent embolization procedures for bleeding.
There is a growing need for IR in emergency situations such as in the setting of trauma, acute limb ischemia, Pulmonary embolus thrombectomy/thrombolysis, management of gastrointestinal bleeding, massive hemoptysis, post-partum hemorrhage, and post procedural /post-surgical bleeding. This often requires 24/7 coverage of VIR in the hospital setting.
In general, there is a tremendous scope and breadth of pathologic conditions that are currently managed by vascular and interventional radiology. The concept of the service lines was developed years ago by the Society of Interventional Radiology. The various service lines include Vascular disease which is focused on peripheral arterial disease, aortic disease, DVT, Pulmonary embolus ,varicose veins, IVC filters, and dialysis interventions. The GI/GU/Reproductive service line focuses on the treatment of fibroids with uterine artery embolization, BPH with prostate artery embolization, male infertility with varicocele embolization, and female infertility with fallopian tube recanalization. The pain division is also a great area of growth and includes vertebral body augmentation with vertebroplasty, kyphoplasty, nerve blocks , rhizotomy, spinal cord stimulators and pain pumps.
Much of this sub-specialization is learned by attending various meetings and attending dedicated courses on these topics and shadowing practices that are on the forefront of these interventions. Often a proctor can aid you as you start to develop technical competency in a specific procedure and clinical acumen for specific disease processes.
I personally have had a particular interest in vascular disease and, in particular, the evaluation and management of aortic aneurysms and dissections. I also have an interest in peripheral vascular disease and the management of critical limb ischemia and diabetic foots wounds with the ultimate goal of preventing major limb amputation. With the increase in obesity, diabetes, and overall aging population, there is a great need for VIR practitioners who can manage this spectrum of disease.
How has clinic made its way into your practice on a daily/weekly basis? What is the ratio of clinic to OR time?
Monday morning: Outpatient Clinic
Monday Afternoon: Operating
Tuesday and Wednesday all day: Operating
Thursday: Inpatient Consults
Friday: Outpatient Clinic
So I do about 1 to 1.5 days of clinic and half a day of inpatient consults.
I operate 2 to 2.5 days a week. So about 40 percent of my work is non-procedural clinical activities and 60% is procedural in nature. About 80% of my clinic is composed of follow-ups and 20 % new consults. “A marker of a robust clinic is that not all consults lead to procedures and that you have more follow-ups than new consults.” My clinic has a very broad array of pathologic conditions, but consists primarily of patients with vascular conditions and neoplastic pathologies. Patients with claudication, critical limb ischemia and diabetic foot wounds, visceral aneurysms, abdominal aortic aneurysms, fibroids, hepatocellular cancer, neuroendocrine tumors, Pulmonary artery vascular malformations, and DVT patients take up the bulk of my practice.
I will follow many patients for the life of the patient. Any patient who I have put a stent in for peripheral vascular disease or aortic disease will get lifelong follow up and I often order sequential imaging including ultrasounds, CT scans, and MRIs. Many of my cancer patients I also follow for life and order repeat imaging and labs. In my peripheral vascular disease and aortic aneurysm patients, I also make sure that they are on a smoking cessation program, on high intensity statin therapy, and that their HBA1c is under control during their clinic visits. If it is a critical limb ischemia patient with a wound, I follow them very closely every few weeks until they have healed the wound; then I lengthen the interval of follow up to every 6 months after it has completely healed to prevent wound recurrence. You learn a tremendous amount from clinic and your follow ups. You not only learn what you do well, but more importantly you learn what you did not do as well and how to improve your practice for the benefit of future patients. Clinic follow up is critical to optimize your patient’s outcomes.
How do you see IR changing in the way that most affects how you practice?
I think that the VIR of the future will have far more longitudinal clinic and will likely be doing a 100 percent of their trade. We will have less itinerant interventional radiologists. I think that the current VIR training has inadequate amount of clinical rotations and VIR rotations during the first 3 years. In fact, the clinical training pathway that UVA adopted years ago was probably the ideal program. Having a 3- or 4-year gap with only 3 months of VIR is just simply inadequate clinical training to become a full- fledged competent clinical interventionalist.
I have restructured my VIR integrated residency as well as ESIR programs to reflect this. The integrated Kaiser VIR residents will do their first year in general surgery which includes a month of vascular surgery and a month of VIR with our group. The PGY2 year, the integrated residents do monthly weekend VIR call, 80 hours of Medical Intensive Care training and 2 months of VIR. The PGY 3 and 4 year they end up doing an additional 4 months of VIR, 1 month of neuro interventional and 1 month of CCU. During the PGY5/6 year they are doing additional CCU, ICU, Vascular surgery, and 3 to 6 months of Neuro-interventional training. Finally, it is imperative that the VIR trainee have adequate outpatient clinic exposure. Our Kaiser integrated residents will do a half day of clinic every week of their residency from PGY2 through 6 years no matter what rotation they are on.
Another often overlooked component of IR is the involvement of educating our clinical colleagues and the general population at large. This means giving grand rounds to the various departments. It is important for patients and physicians to know that there are such minimally invasive options available to them.
Why did you choose IR or why should someone choose IR? What are reasons not to choose it?
The minimally invasive nature, component of rapid recovery, and tremendous variety of pathology each week make this field my passion. My favorite part of IR is the scope and breadth of clinical conditions and procedures that I can perform; and it’s increasing each year. I never thought that I would be treating benign prostatic hyperplasia, removing permanent IVC filters, reconstructing the abdominal aorta with fenestrated endografts, repairing life threatening aortic dissections, and stopping active bleeding.
I love the fact that I still am able to guide and counsel patients on dietary modifications, exercise regimens, smoking cessation, and diabetic management. There is always some new device that comes out or a new stent that increases the scope and breadth of patients that I can treat. For me IR provides a true opportunity for a life-long learning process.
I would not choose VIR if you think it is a lighter form of surgery or do not have the stamina to handle the hours. Our days start earlier to round on inpatients and end later as we often have late add-ons and emergency consults. We have an expanding role in medicine and there are a growing number of VIR emergencies often requiring timely middle-of-the-night intervention. Our day-to-day existence reflects surgery.
How does innovating new procedures work in IR?
Well, it’s not completely uncharted territory when you develop a new procedure or attempt to fix a problem in a way no one has before. You have three things to rely on.
1. From your radiology background, you get a great foundation in anatomy and pathology.
2. You also will be confident in your catheter and procedural skills which translates to any part of the body from head to toe, regardless of the novelty of the procedure.
3. You have to do your research before you go in. You have to have a firm understanding of all aspects of the disease process you are innovating in. You need to talk to the VIR doctors involved in these new innovative procedures for perspective and have a plan that minimizes risk and gives you the best chance of procedural and clinical success. It’s just like innovating in any surgical field, the difference is we just don’t focus on a single organ system and we use image-guided techniques. So, often we see something used in another body part by another specialty and implement that in a whole different area of the body.
What are the threats to the practice of IR (both internal and external)? What is one fear you have about the future of IR and the job market?
If you practice in an old-fashioned model without a clinic and no longitudinal follow up, the VIR practice will likely not be sustainable. It will only be sustainable with a clinic where the VIR physician provides comprehensive and longitudinal care. Lack of clinical acumen causes danger both to the specialty and more importantly danger to the patient. In the past, clinical skills have been the most inherent weakness in the specialty.
Now, VIR is full of expanding complex interventions, but now we are also increasing our involvement in seeing patients in our own clinics, admitting patients to our own service, performing formal inpatient consults and innovating new procedures and treatments using the catheter skills we already have to solve problems that we may not have a treatment for currently.
We see patients from initial consult in the outpatient clinic and follow them in our clinic. For example, a patient might come to our clinic with a non-healing wound of their foot. In these instances, we make sure that the wound is adequately debrided, home health is arranged, and the patient’s family is educated on wound care. We try to improve diabetic control. We also confirm that they are on high-intensity statin therapy, anti- platelet therapy, and ace-inhibitors. We also optimize their nutrition, and make sure the wound is off loaded. We may need to further re-vascularize the patient and maintain further patency of the vessel. Finally, we educate the patient on how to prevent wound recurrence. This all requires a passion to eradicate disease and a true comprehensive knowledge of the disease process and appropriate medical management.
Anonymous Physician, Private Practice Radiology Group, Kaiser, Academic backgrounds
Can you specialize within interventional radiology?
While there are no official sub-specializations, we are all a product our environment and our preferences. Depending on the center you trained at, you may come to a group with a skill set that is stronger in certain procedures or subset of procedures. Once in a practice, you may find that there is a local need for a certain procedure or there may be a procedure that you particularly enjoy and thus increase your expertise in that procedure so as to become the local expert and the person to whom your colleagues come to for advice or case referral. This may be particularly true in large academic practices. So in general, yes most end up having cases that they “specialize” in. However, in an ideal practice environment, all of the IRs on a team should be more or less interchangeable, so call coverage is homogeneous.
What is unique about practicing IR at an academic setting vs private practice?
Private practice contracts and environments can vary widely. Most IR private practices are part of a Diagnostic Radiology group, many of which will ask that the IR physicians cover some diagnostic responsibilities, often reading vascular-related studies as well as some general radiology. The percentages of IR practiced will vary. Compensation in private groups generally is going to be stronger than most academic settings. The general trend seems to be that academic centers are going to be a higher percentage of IR and that the academic case load would be more complex. This, however, is not always true, and I have numerous colleagues that are doing very high level IR in private settings, eclipsing their academic training settings. All residents will experience the academic training and setting, so each individual can decide if that environment is somewhere they’d like to practice. As for private practice, I’d recommend rotating through one or finding a mentor in that setting to better understand the differences. Additionally, those relationships often turn into jobs or job leads.
Which procedures make up the majority of your practice? How long are these typically?
In our group, we perform the whole array of IR including Venous access, Venous interventions, TIPS, TACE, urologic, biliary, urgent vascular cases such as trauma and GI bleed, as well as standard image-guided biopsies and drains. Although I trained at a center that did EVAR/TVAR and PAD work, I leave that mostly to the vascular surgeons, occasionally they’ll ask me to scrub in and lend a hand on those cases. Our relationship with the Vascular Surgeons is amicable.
What is the lifestyle like? Hour/call flexibility and time for family?
This will depend on how busy your practice is, and specifically if you cover trauma call, as well as the number of IRs you are splitting call with, obviously.
How much time do you dedicate to work each week?
I typically dedicate at least 40 hours per week, but the amount of work time depends heavily on the number and types of cases, call schedules, emergencies, etc.
And is that because you choose to or is it difficult to do less in IR?
This will depend widely on the type of group you practice with.
What about vacation time?
Can vary widely, but most people I know get 8-12 weeks of vacation by various production incentivized mechanisms.
Why did you choose IR or why should someone choose IR? What are reasons not to choose it?
IR is a challenging field. The breadth of cases that we are responsible for makes mastering all of them worthy of an intense effort. The IR years of your training should and will be time consuming and transforming. Once mastered, the breath of cases makes for a varied schedule and the combined skill set attained will make you a unique physician that hospitals depend on to provide that high level problem solving perspective to local patient care. If you are looking for more cookie cutter cases, choose another interventional specialty.
What are some suggestions you have regarding how medicine could expand the public awareness and student interest in IR?
I think it will take self-promotion from inside of IR to make the public aware of what can be offered. Websites such as the Interventional Initiative are a good start, but more work needs to be done to directly lobby Congress, as the delineation of Medicaid payment will, for better or worse, dictate future funding for our interventional procedures and ultimately impact the health of the field.
An Undergraduate Perspective:
As an undergraduate interested in medicine, how aware are you of interventional radiology as a medical field? Furthermore, how aware are your peers of the specialty?
No one in my pre-med track seems to be aware of the field of IR, and only a few have an understanding of radiology in general. Because my father’s practicing IR, I am very much aware of it and learn a great deal about not only his specialty but also the field of medicine, which gives me many different career paths in medicine to take. Most aren’t so lucky and likely won’t find out until they get to medical school.
Is research in IR accessible to students at the undergraduate level?
Most of the research that my pre-med colleagues are involved in is either bench level basic science research or research in one of the mainstream medical specialties. IR- specific research seems pretty scarce, as it’s not as well-known or popular amongst undergraduate students. It would be beneficial to both undergraduate students and IRs across the country to have someone from the field speak to us more about the field. This would not only open up conversations about the field but also spark interest in students to start the journey on a career in IR.