FRA - Subspecialties
GI/GU radiology has become Body Imaging for the most part. We do not do nearly as many UGI, BE or IVP exams as 10-15 years ago, but we are responsible for them. At LBJ the number of those traditional fluoroscopic studies is still significant; but at Hermann the number of studies using barium is quite small. We do a large number of studies tailored for a specific question such as "is there a fistula?" or "where is the obstruction?", but we use water soluble agents such as Omnipague or Hypaque. IVP's have virtually been replaced by CT urograms. We also read nearly all of the plain films of the abdomen and pelvis. We cover 2 outpatient clinics in which we may do everything except neuroradiology and pediatric radiology.
As body imagers we read CT, US and MRI of the abdomen and pelvis. Most of us have had a fellowship for one year in body imaging with some fellowships limited to MRI only. We typically read out with residents at Hermann and LBJ, but may be on our own in the OP clinics. The OP clinics are much like private practice tending to be very busy and less popular.
The good fellowships are generally at the same places that have good residencies. Fellowships are not part of a match, and they can be offered at any time during the interview year. We currently have 2 fellows who are limiting their year to MRI only.
- Dr. Redwine
IR is a subspecialty of radiology which provides interventions while using radiographic guidance. It can be roughly divided into two categories-vascular and nonvascular.
Vascular cases vary in complexity but usually begin with establishing vascular access. The first step to establish access is to stick a needle into the (usually) right internal jugular vein under US guidance. Then a guidewire is placed through the needle and the track is dilated. Then a catheter is placed over the guidewire and fed to the region of interest with fluoroscopic guidance. If you are placing a central line the last step is to suture the catheter in place. (Central line)
Placing an IVC filter is a common procedure. After achieving access a wire basket is placed in the inferior vena cava to prevent deep venous thrombosis from the legs from embolizing to the lungs.
Although angiography is less common nowadays, there are still indications. After achieving vascular access the catheter is fed through the vascular tree to the region of interest. Then a radioopaque dye is injected and the vascular tree is visualized. This can give a variety of data including demonstration of vascular malformations, loss of blood vessel fidelity or blocked vessels (ie during a cardiac cath).
Non-vascular cases range in complexity as well. Simple cases that you can perform as a medical student include thoracentesis or paracentesis where the radiologist drains fluid from the patient’s chest or abdominal cavity respectively. This procedure is normally performed with ultrasound guidance to assist in avoiding vital structures. Another common procedure (especially at Anderson) is biopsy. If a mass is found in any organ a biopsy is normally indicated. Common sites are lung masses or abdominal lymphadenopathy, although bone, kidney and liver biopsies are not infrequent. Biopsies are performed with long needles (~14cm) which are placed under CT guidance, most commonly, or US guidance. MRI guidance is used at Anderson as an experimental method.
Another very common procedure is placement of a drain. If a patient has an abscess the radiologist uses CT guidance (although US can be used as well) to place a large tube from the patients skin into the abscess to allow for drainage.
Post-renal failure can be treated by placing a nephrostomy tube to alleviate the obstruction. This is performed by first placing a needle into the renal pelvis and then placing a tube over a guidewire to drain to the exterior and/or to the bladder via a ureter stent. A similar method can be employed to treat biliary obstruction.
Two treatment modalities for cancer are chemoembolization and radiofrequency ablation. With chemoemolization vascular access is achieved and then the catheter is fed to the tumor site. Once the radiologist is assured that the catheter is in a vessel that feeds the tumor, he injects embolic particles into the vessel to occlude the lumen. This dramatically decreases blood flow to the tumor causing it to shrink (but will not normally kill the tumor). This is particularly useful procedure before surgery. With radiofrequency ablation probes are placed into the tumor and the tumor is destroyed by heat.
A rare procedure is vertebroplasty, where the interventionalist injects synthetic material percutaneously into a collapsed vertebrae to repair it.
For more information you can visit: http://www.sirweb.org/fellows-residents-students/ or can contact Dr. Steve McRae, who coordinates the MS-4 IR rotations at MD Anderson. (firstname.lastname@example.org).
I am a 63 year old radiologist now in my 29th year of solo practice in Bay City, Texas. I graduated medical school in l972 from UTMB and completed a rotating internship and diagnostic radiology residency at Brooke Army Medical Center in San Antonio.
Following three years active duty as a diagnostic radiologist at Darnall Army Hospital (Fort Hood, Texas). I left the U.S. Army and reported for civilian duty at Matagorda General Hospital in Bay City.
My career has had lots of ups and a few downs but overall a rewarding career. The major drawback (and one I should have anticipated before accepting the position) was the lack of easily available vacation and call coverage. Due to the internet, call coverage is not a problem except for the expense - $50.00 for a preliminary read of a CT-scan and $25.00 for a plain film. Medicare pays about $37.00 for a CT scan and around $5.00 for a plain film. My night call (12 midnight to 7:00am) averages about 1-2 cases. I do initial read on almost all of these at home on my PC then review and dictate the final report in the office the next morning.
The major problem is vacation time off. The current rates for locum tenum coverage are $2000-$2400 per 8 hour shift or $10,000 to $12000 per 5 day week not including $25 to $50 per pop for each after hours plain film or CT read. This can run as much as $2000-$400/day.
Because of the heavy cost I tend to take as much vacation as possible on long weekends. I also intercept most of the call cases on these weekends by use of a wonderful portable PC with an internet card. I carry the portable everywhere on trips – even reading 3 CT studies while on a boat in the middle of Lake Tahoe. These exams take only a few minutes to read if the signal is good and are easily managed because my load is only about 4-5 CT’s per day on weekends.
When I began practice in l979 we did not have CT scan or MRI and only nuclear medicine as a portable service. I introduced ultrasound to Bay City in l979. Most of my work was reading plain films and a significant amount of fluoroscopy, intravenous pyelograms, ultrasounds and mammograms. My current load at Matagorda General Hospital is about 2200 procedures per month – including:
|Fluoroscopy - mostly esophograms||25|
The most procedures for one day during my recent practice were 135. The load keeps me busy but I still have time to read ultrasound screenings from outside the hospital and spend 2 partial days a week in Houston reading MRI’s and plain films – about 120 MRI’s and 70 plain films per month.
I will plainly admit that my lack of time off would be considered unacceptable by most radiologists, I know of two group practices in Texas offering 21-23 weeks off per year with malpractice coverage, moving expenses and one year to partnership and ample retirement plan.
At age 63 I am too set in my ways and too close to retirement to consider a move. My age would also be a drawback to a group seeking a long-term commitment. Due to the miracle of the internet and the ease of PAC’s I have so arranged my schedule that I do have plenty of time off and am able to accomplish all that I desire so long as I have my portable computer.
The financial side of radiology just as in the rest of medicine shows some troubling trends. First of all, the Medicare boondoggle shows clear signs of deep trouble. The unfounded liability is in the trillions of dollars. In 1979 when I began civilian practice Medicare reimbursed about 65% of bill-out – now the reimbursement is about 35%. My best income year was 2005 and despite increasing caseload my income is down about 20%. Most of the other insurance companies are reimbursing at or minimally below Medicare rates. For a CT scan of the brain I charge $100 and Medicare pays about $37.
As everyone knows the ER has become the big “free” outpatient clinic for the uninsured. My ER load has increased from about 50 procedures per weekend 8 years ago to 100 procedures at present. Many of these procedures are unnecessary and reflect a troubling “cover your butt” approach at the expense of proper evaluation of the patient. The physical exam has become something of a lost art. Multiple CT scans on each trauma patient have become much more common with a very high negative rate. Last year about 100 million CT scans were performed in the United States and the numbers continue to grow. The party is nearing an unhappy finale.
An unfortunate experience of a relative of mine in a large hospital ER is an example of the lunacy much too prevalent in modern medicine. The relative, just married and one week into her honeymoon reported to the ER with flank pain, fever, and burning on urination. She had no history of kidney problems or other health issues. To make a long story short, a case of straightforward “honeymoon cystitis” turns into an $8500 workup – including a multi-slice CT scan of abdomen and pelvis for stone protocol. $8500 is a lot of workup for a patient who miraculously recovered on antibiotics in less than 24 hrs. It seems that common sense has been replaced by “cookbook medicine’. Unfortunately these horror stories are all too common and their numbers are increasing.
In my long career I have seen a number of changes in the practice of radiology. Over the years more and more specialties have discovered imaging and the turf battles are constant. Of course, fluoroscopy has been severely blunted by endoscopy but of the other imaging modalities ultrasound has been most readily adapted by other specialist. – OB/GYN, urology, cardiology, etc. Cardiology has appropriated a great percentage of cardiac nuclear medicine and vascular radiology. Neurologists and neurosurgeons have also taken a sizable number of MRI and CT scan interpretations. The only cure is for the radiologist to continue to offer a better interpretive product.
I hope this treatise gives you some idea of the strength and weaknesses in the solo practice of radiology. I have enjoyed the career and hope to continue for a number of years yet. Radiology, especially in the group format, still offers a regarding career. Subspecialties such as interventional radiology allow the aggressive young radiologist to get very hands-on but there is still a place for the diagnostic radiologist.
Good luck in your careers.
Bob R. Maxcey M.D.
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