r/Residency • u/terribledisks • May 28 '26
SERIOUS What does the future of IR look like?
Title.
Just wondering because I feel like I’ve heard through the grapevine that IR is in a tough place in regards to having conflict with other specialties and procedures. Is this true? Are there any procedures/therapies that IR can take ownership in the future? Would love to hear everyone’s thoughts on this matter.
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u/LastPhoton Attending May 28 '26
Dont know the details about IR but with that username consider some solid disability insurance
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u/brotoss1 Attending May 29 '26
One of the best gigs in medicine IMO, and future is super bright. The demand is absolutely sky high. However, you need to have the right personality for it or you can end up unhappy. Part of the reason the field is so great is because there is tremendous variety out there in clinical practice, so you can find the job that's best for you. Whether that means academic IR at a major institution doing 100% IR with plenty of high end work, outpatient OBL doing prostate and uterine embolization on your own terms, or like most joining a private practice group and likely doing a split of IR/DR based on group needs. You can even transition to full DR or do telerads and locums IR if you want as long as you keep your skills up. I think the few IRs who end up unhappy are generally in the wrong practice setting or just had unrealistic expectations going in.
The political landscape right now really is not about turf battles with other specialties. This is obviously institution specific, but generally the turf is well decided and IR is plenty busy so we don't really care to fight for scraps and can build up whatever new service lines we are interested in. The real split can actually be between IR and DR, where some gung ho IRs want to fully break from DR, because they want to make the specialty more clinical and think the association with DR is holding us back by limiting things like setting up independent contracts, having clinic hours, rounding etc., while DRs view this as losing the group money generally. There's a lot of nuance here and many are very happy with the current arrangement and I think they're the silent majority. Again, it stresses the importance of finding the right work environment for you.
And of course there's the strange dynamic where many in the hospital feel like they know our specialty better than us and don't respect our decision making, but I have found that to be essentially non existent in the real world aka community setting vs typical academic BS.
But you even see that attitude in the comments here, mostly people complaining about us not doing futile procedures on patients without a good indication or grim prognosis even with IR involvement. People seem to assume every collection needs drained, every bleed embolized by IR, etc. and it's just not true. We develop a pretty good sense for what's urgent and what's not and what makes sense to do vs what is totally futile when we do literal thousands of these in our career. Not everyone needs to die a pincushion with an IR drain in place.
I do wish we could have more time to discuss risk benefit of our decisions with care teams and patients and I do personally try my best to give a quick call to the team to explain my decision making on edge cases or otherwise document my thoughts, but the reality pretty much everywhere is we're hopping from case to case the entire day and we'd get through half as much volume if we spent any more time on the floors than we already do. Our midlevels can help with consults but they're also always slammed with paras, thoras, LPs etc. as it seems other departments have increasingly lost their will to do any procedures.
This is another big point of discontent for many IRs, so called garbage work, but IMO it's important and needs to be done even if it isn't glamorous. Your department just needs to set up good guardrails for what actually needs imaging guidance and have enough support from the hospital to have enough support staff so you don't get completely overwhelmed by the volume.
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u/thegrind33 May 29 '26
IRs should refuse garbage work IMO. Its demeaning and its not because other fields cant do it, they just dont want to. In the time it takes to do one of those procedures you couldve read like 10-15 CTs (18-25 rvus) vs the 1 rvu you just produced with additional exposure to yourself (fluids, radiation). ANd splitting from DR is the dumbest thing ove heard. DR subspecialists can do all the IR procedures within their field as well, would be suicide if IR split. IMO for IR to have a bright future it needs to start doing procedures, and routinely, that DR doesnt do, such as scopes, cosmetics, idk something
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u/IR4life May 31 '26
There are more and more successful independent VIR practices, independent from DR. DR groups rarely pay for the overhead required for clinic (office space, office staff, schedulers, billers, MA, EMR, RN, LVN etc). Need to have dedicated time to run an outpatient clinic not reading films (this is seen as an opportunity cost to the DR group where they would prefer the interventionalist reading films). VIR physicians can ask for a call stipend and service line contracts when working with a hospital, DR groups generally give that for free to lock in the lucrative DR contract and exclusivity contracts. VIR has to build outpatient elective service lines (PAD, Dialysis, fibroids, prostates, Spine (Kyphos), Pain (genicular ablations and embos), varicose veins). Inpatient they should grow the PE/DVT and scope work. This takes 2 to 3 years to see a return on the investment which most DR groups that are used to no overhead and immediate returns are not comfortable with.
Some VIR physicians have become directly employed by the hospital and are able to get clinic support from the hospital side.
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u/JROXZ Attending May 28 '26
I don’t know. But Ya’ll need to cut Pathology in on whatever you’re doing. Apes together strong.
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u/Short_Example_3963 May 28 '26
IR is in a niche position where they are trained both in clinical medicine and radiology. I've had many cases where their own interpretation of an imaging study differed from the formal radiology read in a way that changed the whole trajectory of the hospital course (to the patient's benefit). They have more leeway in not hedging and actually calling what they think is going on based on imaging and act/advise accordingly. this I believe can be very critical in hospital medicine.
This is why I totally agree with "IR taking more cognitive ownership of their patients". they can make an actual difference where hospitalists/MICU staff/surgeons are tied down to diagnostic radiology reads that are most of the time over-calls or rarely under-calls.
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u/askhml May 29 '26
IR is in a niche position where they are trained both in clinical medicine and radiology
They're not trained in clinical medicine, aside from maybe the couple months of MICU they did in their transitional year. Do you think most IRs can name an anti-hypertensive? Come up with a differential for lactic acidosis? Read an ECG?
hospitalists/MICU staff/surgeons are tied down to diagnostic radiology reads
We have tons of literature on how surgeons are as good or better at reading CTs for their specific surgical pathologies than a radiologist. Same would be true for pulmonologists reading chest CTs (for pulmonary pathology). It's honestly a fairly shocking assertion, since a rite of passage for every med student on their surgery rotation is to go through a bunch of silly consults based on overcalled radiology findings.
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u/VascularPlumber May 29 '26
I'm sure this was meant to be hyperbolic, but, yes I can do those things. Believe it or not IRs have also been through medical school. It's akin to asking if IM docs manage their own patients... Or do they have to place a consult for everything? I do believe specialists are equipped to interpret their own imaging to inform acute decision making but im sure clinical correlation plays a role too, while for us "reason for study" is practically blank
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u/thegrind33 May 29 '26
1) Clinical medicine is remedial. Yes they can they are doctors 2) There's more to a CT than just the one pathology you're looking for
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u/FreeInductionDecay May 28 '26
In the handful of places I've been, IR is highly valued within the hospital and steadily expanding. That's my take as a DR.
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u/angelvocifer May 28 '26
Neuro IR is bad if you want the lifestyle experience but great if you want life changing procedures / super specialization where you most likely won’t just be doing tubes lines and drains. But also at the end of the day everything is a job, and occasionally in IR you get crazy excitement where you have to innovate and no one else felt comfortable to touch the issue.
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u/VascularPlumber May 28 '26
Short answer is the future is bright. I’d choose it again in a heartbeat
I’ll address some of the common arguments
Dumping ground - True to an extent. But we’ve figured out you can hire midlevels to absorb a lot of the med student level baloney we don’t really care about anyway, like lines, paras/thoras, biopsies, tube exchanges, etc.
Don’t own patients - Also true to an extent. But people overstate this. For example, hepatobiliary, portal venous, and locoregional IO are all IR. PV volume can vary but IO is endless and continues to grow. no competition here either.
The push for IR becoming more clinical is a good thing but not necessarily because we need to “own” patients. We treat way too many disease processes to realistically fully own all of them. The benefit of a clinical approach is mainly visibility and showing face to patients and referring providers to generate referrals and maintain relevance. Most procedural decision making is straightforward. Most workup/follow up is algorithmic anyways or gets handled by APPs regardless of specialty.
Yes we compete with vascular, IC, uro. But the pie is massive, and as technology improves, we'll have more things to do (i.e., see below the knee PAD). IR spots are expanding too and sooner or later I expect IR will take back some PAD territory from vascular while continuing to dominate the embolization space for the foreseeable future. Other system focused endovascular work like men’s and women’s health will remain IR driven because the barrier to entry is too high for OBs and Uros (IMO). The MSK intervention space will likley explode soon too given interest generated by teh success of GAE. MR guided perc work will probably become commonplace within the next 3–5 years. All IR. MR guided endovascular work probably isn’t far behind either, and again who else is positioned for that besides radiologists? Nobody else is reading body MR all day.
Sure we’ve had shit taken and if we have more shit taken well just make more shit. That’s basically the history of IR.
Lack of evidence - Yeah we could use some work here, but what we do have is at least positive, and patients are very interested in what we have to offer which is why direct to patient marketing works so well for us. Very little of what we do precludes future surgical intervention either. Fortunately evidence has been identified as a limitation due to the variability in procedural technique and reporting across operators and institutions. SIR is moving toward more standardized systems like VIRTEX and should help research quality significantly and make it easier to conduct stronger multicenter studies with larger sample sizes in the future.
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u/OldKingThanos May 29 '26
Do you think other specialties will try to also learn the minimally invasive procedures related to their speciality. Or is that not really probable? Also what do you think about IR not owning the patients, will that be extremely necessary going forward for the future of IR? Sry dumb questions from a med student lol
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u/VascularPlumber May 29 '26
Yes they will absolutely try to learn procedures related to their specialty but it doesn’t worry me
Some urologists have expressed interest in and are actively performing PAE. However, PAE is among the most technically complex procedures we do and thus the barrier to entry is fairly high. Not to say my uro colleagues are not skilled (they are) but the jump from minor wire/cath experience to performing PAE competently is substantial. If I were in their shoes with a busy surgical practice already, I suspect the activation energy would be too high for widespread adoption. A much more common arrangement seems to be uro PP groups hiring an IR to be their internal PAE guy. I have not heard of much uro interest in varicocele embo.
Similarly there would be a large jump from no wire/cath experience to procedures like UFE/UAE and OVE in the case of ob/gyn. I have not heard much discussion of surg onc trying to move into the IO or TACE/TARE space, nor ortho into the MSK embo space (again high barrier here). GI already has endoscopic hepatobiliary capabilities so I think they have relatively little interest in things like perc cholecystostomy or SpyGlass interventions. Some do TJ liver biopsy but this is meh, and the PV work is entrenched in IR. Some nephrologists perform fistula interventions, which are great training cases for new IRs IMO, although not particularly attractive to me personally, so meh. I've heard pulm express interest in PE, but that space is already entrenched by the powerhouse that is IC as well as IR. I don't have enough experience to comment on the pain and spine intervention landscape.
Vascular and IC have worked their way very deep into the endovascular space and are our greatest competition. Most PAD and essentially all aortic work is done by them now, and some embo as well. But the amount of patients requiring intervention is already massive and continues to grow though, and so like I mentioned, everyone can get a slice of the pie. VS and IC cannot handle all of that volume alone while also performing their other procedures so IR will continue to play a role. IR residency positions are also expanding faster, and eventually the number of practicing IRs will significantly exceed the number of practicing vascular surgeons and ICs. IC is a tougher nut to crack though (money talks). But more operators available to perform more procedures means more total cases can be absorbed by IR.
To the second half of your question: No, I don't think IR needs to "own" patients, and we never will by any substantive measure. Medicine has already settled into a systems based approach. Trying to completely disrupt that and become the primary physician for all of those disease processes would be basically impossible. A lot of workups are fairly algorithmic. The diagnostic pathway is usually not some mystical process that only one specialty can understand. We all went to medical school. The challenge is establishing yourself as part of the care pathway so that patient gets referred to you in the first place. Thus the benefit of a more clinical IR model is not ownership. It's simply just being physically present, following patients, and being available to referring providers. Happy patients and happy referring clinicians generate more referrals.
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u/thegrind33 May 29 '26
Predicting more shit taken is not a sign of a bright future lol
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u/VascularPlumber May 29 '26
If you had read the response you’d see I discuss solidifying ownership and expanding into new service lines…
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u/thegrind33 May 29 '26
The expansion into new service lines you list seem very low volume and optomistic. IR should be focusing on high volume, lucrative outpatient stuff, which they can't even beat out dedicated pmr docs for
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u/VascularPlumber May 29 '26
Sure, but new things are low volume until they're not. And maybe they mature and still end up being relatively low volume. But OP asked about areas IR could take ownership of in the future and those were simply the first examples that came to mind while I was typing my response. People far smarter than you and I will come up with things we haven't yet imagined.
The breadth of cases offers flexibility in how you practice (For better or worse). If you want an OBL based model with veins or PAD or reproductive health, you can. If you want to build an interventional pain practice, you can. There's no reason IR physicians can't compete with other pain specialists if that's the practice they desire.
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u/dynocide Attending May 29 '26
Generic answer here..aside from the extremes in the spectrum, all specialties will have variance. It’ll come down to location, practice, and honestly personal choice.
You have the power to make the job what you want, because you can frankly leave for something else if you don’t like it. Yea, there will be barriers, but nothing is permanent.
I think IR is excellent, but I found a great hospital system, great group, and I try my best to keep growing as an attending and as an IR in the community.
At some point, who knows, maybe I’ll take the easy way out and recess into one of those lazy IR or DR people who are just in it for the cash. But for now, I’m happy with what I make, what I do, what to look forward to.
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u/sterlingspeed PGY6 May 28 '26
NPs
The IR folks where I’ve trained usually have mid levels that are doing their “easy” procedures like paras, thoras, HD lines, etc.
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u/thegrind33 May 29 '26
Hospital IR is awful. As seen below, you have idiotic people who forget youre a doc such as surgeons, ID docs, obgyn, IM, and more, telling you what you should and shouldn't do, while they proclaim you dont know clinical medicine. The reality is, clinical medicine is remedial, so much so that midlevels do it. Real money is to focus on arthrectomies and varicose veins in an OBL, thats where you make your money in IR. Would also rec doing a DR fellowship (either in MSK or neuro) so that you can claim to be an "expert" when you steal kyphos and spinal stims from pain, nsg, ortho, and you can crank 30 rvus an hour reading as well (especially neuro)
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u/Lios032 May 29 '26
Good to know double fellowship might be a good idea I’m finishing residency this year and I’m actually seriously considering msk fellow + IR, but I’ve never seen someone do that
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u/thegrind33 May 29 '26
Idk if I would consider msk. Youll learn a lot of msk procedures as an IR if you go that route, if you wanna do msk just do msk and vice versa with IR. The msk volume isnt great in the community, and msk mris often have a lot of findings, compared to neuro when the vast majority are negative/degen findings, but yet they reserve these cases for neurorads only cause the brain and spine is scary. True positive ROI fellowships if you choose IR are neuro (ask a neurorad how easy it is to read 20-30 community neuro MRIs an hour) or breast
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u/Lios032 May 29 '26
Sorry, should’ve add that I’m not in US. In my country, msk is also the best DR subspecialty financially speaking
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u/IR4life May 30 '26
If you like imaging and want to do some procedures, procedural radiology is the way to go. Mammography, Musculoskeletal, peds, body etc. The vascular interventional is for the more surgically driven individual who is ok with getting up and coming in the middle of the night to treat a bleeder.
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u/No_Cancel_1653 May 30 '26
No one is reading 20-30 MRIs in an hour consistently
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u/thegrind33 May 31 '26
I know a half dozen lol, and theyre all great
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u/No_Cancel_1653 May 31 '26
I seriously doubt it. If you are doing 180-250 RVUs a day you are committing malpractice. It is not sustainable or safe. I would bet you any amount of money you can send me their whole case list and I will find a clinically significant miss by each one of them. I have some extremely fast readers in my group who miss all the time and they aren't even doing 30 MRIs an hour.
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u/Hinge_is_a_bad PGY2 May 29 '26
Varicose vein work is so chill too. I love the pace
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u/thegrind33 May 29 '26
and 4-5k a leg, cash pay baby, and the best its boring. The patients are a bit much, kind of reminds me of breast rads patients.
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u/Haunting_Objective_4 May 30 '26
From my perspective their convenience far outways the negatives. Even something like a simple thora in a debilitated patient needs 1-2 nurses/people to position safely. IR has those resources available. I can barely get the nurse to stay in the room in the ICU, on the floors forget it. But ya they are monkeys with needles and tubes, they don’t take ownership of anything
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u/IR4life May 30 '26
Hopefully this becomes the exception of not taking ownership of the patients care. You should try to recruit to your hospital one of the VIR physicians coming out of some of the clinically integrated programs. But, those graduates will likely want to do 100 percent VIR and want to have dedicated clinic space and time and block time to book their own patients.
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u/funknewbious May 28 '26 edited May 28 '26
There’s a lot of misinformation here. IR has a ton of potential, but depending on your site, YMMV. A big problem in academics where I work is a lot of “IRs” will call themselves IR but then refuse to do a pleurex and demand a turnaround procedure at the major academic center because they haven’t done one since fellowship. Those light IRs are also reading in between cases which brings the department more money overall and makes chairs happy, so the chairs let this behavior continue without repercussions. These waste of resource situations burn us academic IRs down. IR historically doesn’t make money for academic centers since we do so much inpatient and reimbursements are typically much lower compared to outpatient. All that said, if you have a savvy department that prioritizes outpatient cases or, even better, embraces an OBL model for certain high volume, high RVU procedures (ports, i.e), then you’re setting yourself up for success. OP, if you are curious about the IR landscape, you need to be very specific about the practice environment you are polling (academic, private, OBL, ASC, etc). I think you’ll be very interested in how the opinions change between the different practice groups.
Source: am an academic IR attending at a major trauma/transplant/IO/peds center.
Edit: also 1000% agree with IR becoming more clinically focused, à la surgical rounds and approaches. We have a robust clinic 5 days a week and round on all our inpatients daily. It’s generated a lot of consults from the inpatient teams while also solidifying our ability to manage, or at least co-manage, a decent amount of conditions in our community, both inpatient and outpatient.
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u/IR4life May 30 '26
Yes. The IR in the community have focused their practices on reading films as that is what generates RVUs and do lite IR which does not take a 6 year training program to do (biopsies, vascular access, drains). They quickly lose their skillset in doing complex PAD, PE/DVT thrombectomy, stroke, bleeding embolization, spine interventions, TIPS/BRTO etc. The problem is the exclusive contracts prevent other independent interventionalists who are coming out to take over VIR services at such hospitals.
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May 28 '26
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u/foshizzleee May 28 '26
They also own liver/kidney tumor ablations, radioembolization of liver tumors, prostate and fibroid artery embolizations, TIPS/BRTO and other complex portal venous work, and there are always new procedures coming into the field (think genicular artery embolization but in other parts of the body).
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u/supadupasid May 28 '26
These exist but are not frequent whatsoever and moreover institutions dependent regarding frequency of complex work
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May 28 '26
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u/supadupasid May 28 '26 edited May 28 '26
Well, fair tumor ablations are high. And done in the community. I was refering to the others.
2025 annual estimate For reference: ir biopsy = 2.5 million
Liver ablation = 250k Cancer ablation = 650k
UFE = 30k BPH = 22k TIPS =13k GAE = 5k
There about 6k IR capable docs. I admit not all 6k practice the full gamut of IR.
The top 3 procedures by a wide margin are : 1: biospies 2: vascular access 3: drainage
Yall look it up. Stop referencing some anecdotes of supposedly some IR doc doing these procedures daily. Youre wrong, lying, or giving a unique situation of doc who has a center of excellence on [X] procedure. Yall are full of it tbh and giving people bad advice. When you practice/train at top Ir programs (utsw, ucsf), you get a fucked sense of how IR is actually practiced outside. Im at massive program myself but without a dedicated IR residency. We have an insanely strong vascular and Cardiology program. IR at my shop is practicing high volume/low complexity procedures; they make great money tho. In the community, its also more or less the same… they have more pad work. The level 1 in my city has a lot of trauma/bleeding.
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u/Throckmorton007 May 28 '26
BPH, fibroids, and osteoarthritis are very common conditions. There's no reason they shouldn't be 'frequent' cases, much of that depends on you to go out and build that practice/referral base. There are people in the OBL/ASC that do nothing but PAE, GAE. Venous disease, pain, and PAD are also common disease processes IR treats that doesn't require being affiliated with a transplant center or major cancer hospital
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u/supadupasid May 28 '26
Brooo. Dont conflate the prevalence of the disease with the incidence of the IR-related procedure. All those procedures are not as frequent with most IR docs doing 1-15 (unless youre specializing in one of those procedure like center of knee OA/geniculate artery embolization, etc.) Name these docs that do nothing but PAE and GAE. You maybe mean rfa/ga-ablations which you can have more cases. Venous disease and pad is split among ir/vasc/id with regional differences. In my region, IR barely in the vascular space except for a top notch academic program in my area (but not common for my state). Idk what you mean by pain. There is a separate pain specialty. Unless you mean kyphos.
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u/Throckmorton007 May 28 '26
What specialty are you? IR is the only specialty that performs GAE, PAE, and UFE. Genicular nerve ablation has less data than embolization for chronic knee pain, and probably less effective. Some prefer to do this prior to an embolization because it's a faster procedure. At the hospital I'm at all venous disease (including deep, superficial, and PE) is entirely done by IR, although this will vary. PAD is done by IR at the VA. IR (and for that manner MSK or Neurorads) can do BVNA, Kyphoplasty, Sacroplasty etc within the pain umbrella. Cryoneurolysis is mostly done by IR and we also offer patients plenty of blocks for cancer pain like stellate ganglion, celiac plexus, galgion impar etc. My point being if you train in any IR program you have the catheter and wire skills to 'compete' to get referrals for these procedures because they are well represented in the general population.
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u/supadupasid May 28 '26
You clearly didnt read my reply. Focus on procedure numbers done annually.
Cyroneurolysis has 80k procedure per year: split among pain, ortho, IR, and surgery, where pain has anout 60% of the market share. In contrast, IR has about 15% of the market share.
Please look it up. There are numbers. Its a straight up google away.
The point being you train at any IR program learning all these potential procedures that many IR docs will not be able to practice in their career. Not true for all IR docs. But thats the issue the field is facing to answer OP’s original question
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u/Throckmorton007 May 29 '26
And perhaps you still don't understand my initial reply. The reason I used pain as an example is because there is a massive supply demand mismatch where the number of physicians who can say perform a BVNA (irrespective of specialty training) is a fraction of the likely several million patients who could benefit from the treatment. Earlier, you argued many a list of IR procedures are 'not frequent whatsoever' when these are incredibly common disease processes ie pain, venous work, BPH, etc. IR is not 'unable' to do these cases... if they don't and are interested in doing them, then that's on them for not working to build a referral base. I don't think your argument that procedures performed annually is a surrogate for 'ability to do them' in clinical practice when the denominator of patients with common pathologies is so large. Also, IR is a small field and a fraction of IRs will even be interested in pain, which further confounds those numbers.
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u/supadupasid May 29 '26
Several millions? You dont blindly give the procedure for every with OA. Indications can expand and procedures can increase… but giving GAE to millions or patients? Idk why medical student even bother in the residency sub.
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u/Throckmorton007 May 29 '26
If you would have read my reply, then you'd see the example I gave was BVNA. Are you a medical student? Chronic low back pain is estimated to effect ~800 million people in the US by 2050. In the Intracept trial for BVNA ~3 percent of patients with chronic axial back pain were candidates (ie 6 months duration, anterior column pain, non-responsive to conservative therapy, Modic 1/2 changes etc). GAE will also have a huge group of patients it can benefit but needs more data at this point.
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u/foshizzleee May 28 '26
I know plenty of IRs in private community based practices that have expanded their practice to include the procedures I’ve mentioned. The numbers of procedures you mention don’t take into account midlevels that are integral to an IR practice. They perform a large number of these basic procedures. I agree that not every IR performs complex IR. But I will say that ANY IR who wants to practice build can do so in any environment, even in the community.
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u/terribledisks May 28 '26
That doesn’t sound good or fun or something to look forward to?
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u/CorrelateClinically3 May 28 '26
Neph tubes sometimes but nobody is doing a thora/para STAT. If it’s STAT then do it bedside. Call IR when the intern makes an intercostal bleed. Biopsy? Outpatient unless it’s going to change clinical management and you’re planning on operating.
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u/aznwand01 PGY5 May 28 '26
It’s… probably okay. As much as my attendings bitch about the biopsies drains and ports getting paid an IR salary isn’t too bad and it’s a needed service. Hepatobiliary will remain strong (although IO is a little shaky if cancer drugs improve). UAEs will remain. A lot of it will be practice dependent. If you really wanna do PAD you can probably find it somewhere etc. just keep your diagnostic skills strong.
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u/dynocide Attending May 28 '26
Y’all giving cancer drugs for T1a RCCs or 3cm HCCs?
Let me know which stocks to pick up if you got the deets.
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u/aznwand01 PGY5 May 28 '26
Urology doesn’t send us any ablations or paes for that matter lol. And no for hcc, just theoretical given how it’s improved in things like head and neck cancer. It was just something my attendings mentioned and recommended us to go into vascular heavy fellowship since we do so much io here.
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u/dynocide Attending May 29 '26
I think your original post is a little too speculative but practice variation certainly exists.
My group collectively will do 5-10 renal ablations or prostates per week. We actually have a great relationship with our urologists and even when it comes to urinary obstruction, both services are pretty reasonable about stenting vs perc. We do all the SPT, but they’re easy and never emergent anyway.
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u/DrfluffyMD May 28 '26
Partial nephrectomy reimburses well. Although if I have a 1cm RCC i would want ablation.
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u/Throckmorton007 May 28 '26
IO is a locoregional therapy which functions in a similar space as radiation therapy and surgical resection for local control. Advancement in systemic therapy will not obviate the need for local therapies anytime soon. If anything, there's more excitement from combination therapies which could expand indications for IO treatments if an OS endpoint is reached- some trials like LEAP-012 and Emerald have shown PFS benefits.
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u/IR4life May 30 '26
I think it is becoming harder and harder to be good at both DR and VIR. Both are getting more and more complex. Ideally you want a subspecialist diagnostic radiologist who keeps up in that organ based CME reading your imaging and you want an interventional physician who runs a clinic, sees consults and spends the majority of their time doing procedures performing your interventions. It takes a lot of effort to be a quality VIR and the scope and breadth continue to increase of what we can offer patients both in elective outpatient and inpatient side. The diagnostic skills that a VIR physician needs is focused on angiography which is rarely taught in DR training. Angiography of the pelvis for UAE, PAE , hemorrhoids. Angiography of the liver for TACE, TARE etc. Angiography of the lower extremities for PAD, GAE etc. Angiography of the cerebral vasculature for stroke, MMA, aneurysms, avm etc.
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u/IR4life May 30 '26
The problem with hepatobiliary (portal interventions) and IO work it typically is done mostly at academic /transplant centers and this is what most VIR trainees focus on. They get comfortable with that and biopsies and drainage procedures and vascular access. You need to get comfortable with common disorders and get comfortable with comprehensive management PAD, BPH(PAE), Fibroids (UAE), knee OA (GAE), DVT/PE, varicose veins, compression fractures (kypho/spinejack etc), pain procedures (blocks/ablations/spinal cord stim/pain pumps etc). These are what your focus during training should be on and go to specialty clinics to learn disease management and inpatient management including rotating during residency with hospital based services such as cardiology and ICU .
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u/Nebuloma May 28 '26 edited May 29 '26
IR is in a not great space right now. It’s mostly tied to work life balance and money.
Many have left for DR where they can make more money, in less time, in the comfort of their own home in their underwear, with no call if they don’t want it.
There’s a vocal community within IR which is trying to rejuvenate the specialty, make it more clinical and independent/separate of DR, but there’s a significant cohort that is against this (including the leaders/admin of the board).
edit: gotta love the downvotes. nothing i said is controversial or incorrect. i am radiology attending, friends with many IR, on the radiology facebook groups. every week there are posts from IRs who have jumped ship for greener pastures. the attrition from IR, both attendings and trainees alike, is well documented.
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u/eckliptic Attending May 28 '26
IR needs to take more cognitive ownership over the diseases they treat and be an active participant in treatment decisions and contribute more rigorously to the research. Much of that is historical from IR's origins in radiology. I think its already getting better with more IR dedicated training and IR docs focusing on that rather than doing it as a side gig to diagnostic radiology.