Surgery then an interventional fellowship--possible?

[Guest Kirsteen]

Hi there,

 

I was having a blab with a vascular surgeon yesterday and we were chatting about the future of vascular surgery. One of my questions broached the issue of the encroachment of the vascular surgery realm by the interventional radiologists. The surgeon mentioned that it's not unusual for vascular surgeons and vascular interventional radiologists to spend a common year together in fellowship training, i.e., learning the same techniques. How common is this? Although vascular surgeons currently use transluminal techniques, e.g., deploying carotid or thoracic aortic stents, it would be fun to expand the milieu in which transluminal procedures may take place. Thus, recently, I've been thinking that it might be interesting and fun to complete a surgical residency and then tack on some sort of fellowship in interventional radiology. Are any programs offering this sort of opportunity of which anyone is aware? Or, is it the case that two complete residencies would have to be done, i.e., one in surgery then in radiology, or vice versa? :rolleyes

 

Cheers,

Kirsteen

[Guest Ian Wong]

In Canada, I think that IR still does the majority of the peripheral vascular interventions. In the US, this is starting to become the minority, as cardiologists and vascular surgeons have gotten increasingly aggressive with their endovascular management of PVD patients. This is a real example of a full-out turf war. There's a definite sentiment in many parts of the US IR community that IR will continue to lose angio turf (if it hasn't done so already), because of the fundamental factor that IR doesn't see patients in clinic, and therefore has no control over the referral process.

 

If you are in a big cardiology or vascular group, and you have a member who is willing and credentialled to perform endovascular techniques, all of your referrals will be directed to that individual, which "keeps the money within the group", and very little, if anything, will be sent to IR unless it is too difficult or scheduled at an inconvenient hour. Seeing patients in clinic allows you to cherry-pick the easier cases, and send the bad stuff elsewhere.

 

The flip side to this is that the local IR practice finds it harder and harder to remain competitive (less money, busier nights when on call, etc), and it becomes harder and harder to recruit new partners to that location. Once the referral pattern sets in, and the endovascular group from cards or vasc surgery gets more widely known, then all the internists and family medicine/primary care folks also start directing their referrals that way.

 

This is why IR has completely dropped off the radar as a competitive specialty in radiology. 10-15 years ago, when IR was new and hot, it was an extremely competitive specialty to match into. Now, the number of radiology graduates applying to IR is a miniscule proportion of the number of available fellowship spots, and even many of the top programs often don't completely fill.

 

Unfortunately, as the total volume of patients increases, there's still too much arterial workload for the IR departments to survive without fellows, and they end up having to take vascular surgery fellows on in order to get the work done. No IR department really wants to do that; why would you ever commit your own resources to training vascular surgeons who will eventually put you out of business?

 

What IR is trying to do at this point, is concede that the arterial battle with cards and vasc. surg has been lost unless the IR guys become more clinical, and start marketing heavily to internists, family doc's, and other PCP's before those individuals have done the complete referral to a cardiologist or vascular surgeon. What this means is that in the US, IR guys are starting to see patients in clinic, admit patients directly to the hospital and consult as needed, round on their patients, etc. They are looking into trying to be the one-stop shop for your 70 year diabetic with limb claudication, the same way the vascular surgeons are. PCP's love that kind of thing because you the IR guy can theoretically handle the whole problem instead of just stenting the guy and then dumping him back on the PCP for post-procedure management (which is what used to happen in IR, and probably one of the reasons why practicing IR in that "old-school" fashion was so sweet.)

 

Now, what IR wants to is something like: "We'll read the lower limb arterial doppler. If it's positive, we can then read the CT angio or perform the LE angio for your patient, and then stent them and see them in followup, and re-image them as needed in the following years to make sure things stay patent."

 

The other thing that IR is doing is heavily diversifying out into other non-arterial/PVD procedures, and I think this, and not the clinical gig, is really what is going to keep IR going. There's no doubt that the future of medicine is in imaging and minimally-invasive techniques. Well, actually, it'll hopefully be in preventative medicine, but I've seen no evidence that we are accomplishing that. Anything we can to do prevent large and lengthy hospital stays, and decrease operating room time is something that is going to be heavily endorsed by administrators and bean-counters everywhere.

 

IR has always dipped its hand into the endovascular angioplasty and stenting stuff, and the skills learned in arterial work is going to be a huge part of interventional oncology. There's lots of stuff going on with percutaneous treatments of all sorts of solid organ tumours with chemo-embolization/radio-frequency ablation/cryotherapy. IR guys are embolizing fibroids to minimize the possibility of TAH for people with bad symptoms. There's still all sorts of venous work out there, although this generally tends to be tedious. IR will do things like TIPS procedures or IVC filter placements. I'm sure that in the next 10-20 years, there will be a whole new generation of procedures out there that we haven't even envisioned yet, that will all be in demand due to their minimally-invasive nature.

 

In that sense, IR hopefully will have managed to diversify enough outside of the arterial vascular business (which is being taken over by cards and vasc. surgery), that it survives as a distinct entity, and doesn't get absorbed into a larger body (which is what has slowly happened to Nuclear Medicine getting sucked into Radiology in the US). Maybe the lifestyle will even improve.

 

Anyway, back to the original question. You'd need to be going into vascular surgery to get IR training. Even then, I think the training you'd get would be heavily based in vascular interventions, and the abdominal/GU/oncology stuff would probably not be something you'd see as much. In other words, the training you get through vascular surgery isn't going to be the same skill-set you emerge with from a dedicated IR fellowship.

 

The other thing is that at least from the radiology perspective, so much of what makes IR possible is the imaging skills you have learned during the diagnostic radiology portion of your training.

 

Many radiologists would argue that until you've gotten the skills to interpret imaging safely, you have no business going after lesions.

 

I'm sure the converse arguement from the clinicians is that until you've gotten good at patient care and managing the disease (and post-op complications) safely, you have no business going after lesions either.

 

I guess the last point to make is that the endovascular stuff is an incredibly dynamic field and is therefore very volatile. This is a subspecialty area that didn't exist a few decades ago until technology made it possible, and in that intervening time, has become so prolific that it managed to single-handedly derail what was once an incredibly coveted specialty (that being cardiac surgery). With the onslaught of diabetes and obesity, there is going to be an unbelievable amount of atherosclerotic disease to go around.

 

Ian

[Guest Kirsteen]

Hi there,

 

Thanks for those insights, Ian. I had no idea that IR was losing in its turf war with the vascular and cardiology folks. It's a shame that, given the number of patients with atherosclerotic vessels, that the work can't be shared equitably and within a more cooperative, learning environment encouraged among the IRs and vascular surgeons or cardiologists.

 

I agree re: the plight of cardiac surgery and the skyrocketing prevalence of endoluminal procedures. In the vascular realm, at least, one of the classic operations, and former gold standard approach to carotid occlusion--carotid endarterectomy--is quickly being usurped by protected carotid angioplasty and stenting. I think the rate of PCAS employment is limited solely by the number of qualified practitioners able to perform the procedure. Given the ease of PCAS employment relative to CEA, I wonder how many vascular folks are now opting for the endoluminal training? I'd imagine that is quite the competitive fellowship at the moment.

 

Which makes me think of another issue, but I'll save that for another post. Thanks again.

 

Cheers,

Kirsteen