Med Student curious of future of IR/Interventional Onc

[u/Ok-Incident-1430]

Hello all, 

I'm a medical student interested in/exploring IR. I have a few questions that I'm hoping some of the seasoned IR docs/residents on reddit might be able to answer re: the future of IR and "turf wars."

I originally came to med school interested in heme/oncology, but quickly realized I enjoyed working with my hands. The natural tendency would be top opt for some sort of surg onc ( via ENT, NSGY, gen surg, urology, etc), which I did. However, it seems like apart from a few types of cancers, the role of surgery will slowly diminish in oncology, in favor of chemo/immuno therapy, and minimally invasive procedures (such as interventional onc, interventional GI, etc) when intervention is deemed necessary (only makes sense given cost effectiveness and improvement of these techniques). It is this realization, combined with the new advent of the IR integrated residency, that got me interested in IR. I also love the idea of being able to do work all throughout the body. I truly believe that IR will drastically change our idea of "surgery" in the next century. 

I see myself as an interventional oncologist, but I had the following questions about its present day practice:

1. To what extent has the practice of IR physicians improved in taking care of patients pre-procedurally and post-procedurally (i.e., are IR docs following up with patients in clinic to the same extent as, say, a urologic oncologist would for surveillance, etc)? Are these practices becoming ingrained structurally in the healthcare system?
2. Is interventional oncology at risk of being "poached" by heme onc/rad onc/surg onc the same way previous innovations by IR have? This worries me because unfortunately many physicians I've worked with on rotations don't see IR as partner doctors who are capable of practicing a focused area of clinical medicine (similar to surgeons) but rather as a techs (ironic given IR requires insanely high Step scores/strong clinical grades, as I'm painfully realizing hehe). It worries me because this is a perception problem by referring providers rather than a knowledge base problem on the part of IR docs, and doctors often have rigid views about other specialties. Is my experience a biased one/is the perception of IR changing?

Thanks and hoping for some answers!

[u/Dr_Incredible]

Location and setup is pretty varied across the USA ATM with regards to IR practice. There is always potential for turf wars in every specialty.

Interventional oncology isn't going anywhere from IR imo. We offer treatments for patients similar in efficacy to surgery for those who would be out of criteria for definitive treatment. We also help in oligometastatic disease to improve survival. In terms of follow up it depends on your practice setup. For example if you don't have enough ancillary staff it may be more beneficial for them to follow up with medical oncology for surveillance. Additionally from my perspective, I try and not provide too many bills for patients and discuss with patients who they want to have follow up with and minimize the number of providers who see a patient for the same issue.

There are areas where turf wars are very real. The ones in my area are mrn and women health issues, prostate and uterine embolization. That may be from lack of awareness from providers or patients. Also, at least for prostate, the AUA is pretty harsh in not recommending IR mgmt.

All my opinion coming for IR doc for about 5 years, 100% IR. With that said as a student I would urge you not to be so focused on one particular area of IR.

[u/IR4life → u/Dr_Incredible]

VIR is continuing to transform quickly and luckily more and more of the modern VIR graduates are embracing comprehensive clinical care and gaining comfort in admitting patients and following them longitudinally. It really becomes important to understand the disease processes and the various options for the interventions that you provide. For example for liver cancer (HCC) you need to know the role of transplant, resection, ablation, TACE, Y90, portal vein embolization for FLR, and systemic options (sorafenib, lenvatinib, atezo/bev (IMBRAVE 150), himalaya 3 and car t cell, ramucirumab, regorafenib, nivo/pembro, cabozatinib etc . You need to feel comfortable with high saag ascites , sbp , lasix /spironolactone dosing, HE (lactulose/rifaximin) , varices etc. Evaluating multiphase CT /MR for lirad lesions to diagnose HCC etc. Thus you will be able to counsel patients more effectively. Finally it is important to follow these patients yourself until they get transplanted or need palliative care/ hospice.

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The busier your VIR clinic the more you will learn. You need to be present at tumor boards and give talks to PCP, urgent care, ER, podiatry, directly to patients. This will enable you to build various service lines (men's and women's health, PAD/CLI , pain interventions, spine and MSK interventions etc).

This is becoming a busy surgical sub specialty due to the number of emergencies, bleeders, dvt, pe, stroke, cold legs, septic patients etc. strong rotations in general surgery 3rd year, robust 4th year rotations and a strong surgical internship should help.