BackTable Vascular & Interventional

In this episode, guest host Dr. Venu Vadlamudi interviews Dr. Martin Radvany about where neurointerventional training stands in 2022, including stroke training for residents, barriers that IRs face in finding training after residency, and future directions of stroke care.

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RapidAI

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SHOW NOTES

We begin by discussing stroke training in neurointerventional radiology. The Society of Interventional Radiology (SIR) has been prioritizing stroke training for IRs for years, with their former Clots Course and current Stroke Course, with Dr. Vadlamudi and Dr. Radvany as the directors of the course. This course occurs at the annual SIR meetings. Courses such as these are necessary because many residents aren’t trained in neurointervention but when they get out in the community the need is there and their employers often expect them to be able to provide stroke care. Dr. Vadlamudi hopes to grow the stroke course and eventually break away from the annual SIR meeting into it’s own free-standing course, such as has been done with the Y90 course.

Next, we cover some of the barriers to IRs getting involved in stroke care. Often, practitioners with years of experience want or need to start performing neuroendovascular interventions but didn’t get a lot of experience in their training. Industry support is an important area that requires some growth to be able to support this pathway for IRs already in practice. Simulators are also a key aspect in training, and we discuss the possibilities of leveraging this for stroke training. By bringing patient specific anatomy into the simulator, anyone could use this to train in stroke thrombectomy and be able to practice with a patient's unique anatomy before performing the actual case.

Finally, we discuss what trainees should expect going forward in IR residency and neuro fellowship. Interventional radiology is becoming very clinical, and it is important for trainees to focus on this. Spend the time in the ICU and on the floor. Knowing how to take care of your patients is essential in IR; we need to do more than just master the procedures. There are many ways to get training in stroke intervention. Mentorship at all levels is important and encouraged to push the field forward.

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RESOURCES

Outcomes of Stroke Thrombectomy Performed by Interventional Radiologists versus Neurointerventional Physicians:

https://pubmed.ncbi.nlm.nih.gov/35150837/

In this episode, host Dr. Aaron Fritts interviews Drs. Chad Laurich and Neal Khurana about how they looked past traditional competition between IR and vascular surgery to build a multidisciplinary practice to meet market need and provide comprehensive patient care for an underserved community in South Dakota.

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Viz.ai

https://www.viz.ai/

Boston Scientific Nextlab

https://www.bostonscientific.com/en-US/nextlab.html?utm_source=oth_site&utm_medium=native&utm_campaign=pi-at-us-nextlab-hci&utm_content=n-backtable-n-backtable_site_nextlab_1&cid=n10008040

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SHOW NOTES

We begin by discussing how Dr. Khurana joined Dr. Laurich at his practice in South Dakota. When Dr. Laurich opened his solo practice, he realized there was a lack of medical care in the community and he knew he would not be able to meet the demand on his own. He decided he wanted to bring an IR to his group due to his respect for IR and the breadth of procedural and clinical knowledge they would bring. He knew that their combined skills would provide better patient care than hiring another vascular surgeon.

Next, we discuss the concept of collaboration over competition in vascular surgery and interventional radiology. Dr. Khurana advises that in order to enter into a partnership such as this, you have to understand that you are not the only one able to do endovascular work, that there are vascular surgery and interventional cardiology colleagues who are extremely talented in vascular intervention. All egos must be put aside, and you must never forget that the goal is to help the patient. Dr. Khurana joined Dr. Laurich with this mindset and an eagerness to learn as much as he could to benefit their community.

Dr. Laurich and Dr. Khurana hope this collaborative model grows in popularity among all endovascular specialists. The OBL model affords physician autonomy, excellence in patient care, and provides an out from the burnout caused by the hospital grind. What ends up happening at a well designed and operated OBL is that everyone wins: physicians, patients and staff. This VS-IR powerhouse hopes to provide master courses in the future for physicians to learn how to master certain diseases or procedures that they need to run a successful multidisciplinary endovascular OBL.

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RESOURCES

Ep. 129: OBL/ASC Business Pearls:

https://www.backtable.com/shows/vi/podcasts/129/obl-asc-business-pearls

Ep. 205: Update on Reimbursement Cuts for the OBL/ASC:

https://www.backtable.com/shows/vi/podcasts/205/update-on-reimbursement-cuts-for-the-obl-asc

In this episode, our host Dr. Aaron Fritts interviews physician-entrepreneur couple Drs. Kasie and Rockford Adkins about the path to starting their healthcare recruiting platform, STAT Careers.

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RapidAI

http://rapidai.com/?utm_campaign=Evergreen&utm_source=Online&utm_medium=podcast&utm_term=Backtable&utm_content=Sponsor

Athletic Greens

https://www.athleticgreens.com/backtablevi

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SHOW NOTES

Our guests describe their firsthand experiences with job searching in IR and Mohs surgery. Completing fellowship programs at different times and moving to different cities made it difficult to negotiate hiring contracts. Dr. Kasie Adkins recounts her frustration with the high cost of third party recruiters and a lack of transparency about pay and job structure during the application process. She also highlights the need to level the playing field for skilled physicians who are underrepresented in certain specialties.

To learn more about pain points in hiring and retention of healthcare professionals, the doctors reached out to their hospital administrators and colleagues. They compiled this market research into an online web application that matches candidates to positions. STAT Careers allows candidates to filter positions based on factors such as skill set, call schedule, and location, free of charge. Each employer can build a custom template for each position that lists specific characteristics and responsibilities.

The founders outline their growth trajectory, from building their initial algorithm, to hiring full time employees, to seeking international opportunities. Currently, they are developing ways to better match applicants to positions based on culture fit. We close the episode by discussing the importance of learning from retention rates and remaining transparent to optimize team function.

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RESOURCES

STAT Careers:

https://statcareers.com/?utm_source=Backtable&utm_medium=Podcast&utm_campaign=A+better+job+for+you

The Staggering Costs of Physician Turnover:

https://www.todayshospitalist.com/staggering-costs-physician-turnover/

Physician Turnover: A Costly Problem:

https://go.gale.com/ps/i.do?p=AONE&u=googlescholar&id=GALE%7CA414692555&v=2.1&it=r&sid=AONE&asid=53fcd53a

The Cost of Nurse Turnover:

https://www.beckershospitalreview.com/finance/the-cost-of-nurse-turnover-by-the-numbers.html

Beyond perception: the role of gender across marketing scholars’ careers, in reply to Galak and Kahn (2021):

https://link.springer.com/article/10.1007/s11002-021-09585-5

VA National Teleradiology Program:

Email [email protected]

Episode 110- When That First Physician Job Isn’t a Good Fit:

https://www.backtable.com/shows/vi/podcasts/110/when-that-first-physician-job-isnt-a-good-fit

Episode 201- Jobs: The Good, The Bad, and The Snugly:

https://www.backtable.com/shows/vi/podcasts/201/jobs-the-good-the-bad-the-snugly

Episode 202- Staffing the OBL:

https://www.backtable.com/shows/vi/podcasts/202/staffing-the-obl

In this episode, cohosts Dr. Michael Barraza and Dr. Aaron Fritts interview Dr. Chris Thomson, veterinary surgeon and interventional radiologist about how he learned veterinary IR, his area of focus in interventional oncology, and the future of the specialty.

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Athletic Greens

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SHOW NOTES

Dr. Thomson begins by taking us through his training. During his residency at the University of Minnesota, Shamar Young taught him embolizations and interventional oncology at the medical school and the veterinary school there. He then adapted it to dogs. He then did a surgical oncology fellowship at Colorado State which grew his passion for practicing interventional oncology. There is no training specifically for IR; you train in your specialty of cardiology or oncology, then go on to learn IR skills later in practice.

In the interventional oncology world, Dr. Thomson does prostate artery embolizations for prostate tumors, chemoembolizations, and caval and urethral stents for malignant obstructions. He primarily treats cats and dogs, but occasionally he will help out with an intervention for an animal at the San Diego Zoo. He recently helped do renal sclerotherapy for a dik-dik to treat idiopathic renal hematuria. Dr. Thomson discusses some of the challenges he faces with the different sizes of animals he treats. The size of the animal and the size of the equipment often don’t match up well which poses many technical difficulties for the operator.

We end by discussing the future of veterinary IR. In the cardiovascular IR world, veterinary specialists are beginning to do endovascular valve replacements. In the interventional oncology world, radiofrequency ablation and cementoplasty for appendicular bone tumors is the next big procedure that will impact many patients. Dr. Thomson is excited about being able to provide this minimally invasive treatment for his cat and dog patients as it will prevent many amputations and allow his patients to receive chemotherapy while retaining the highest quality of life possible.

In this episode, host Dr. Jacob Fleming interviews Dr. Jack Jennings about cryoablation, multidisciplinary care, and practice building for the treatment of desmoid tumors.

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RADPAD® Radiation Protection

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SHOW NOTES

First, Dr. Jennings describes the typical presentation of desmoid tumors, also known as “aggressive fibromatosis.” These are neoplasms of fibrous connective tissue, but unlike sarcomas, they do not metastasize to other parts of the body. We quickly review characteristic imaging findings such as hypointense T1 and T2 signals. In the last decade, sorafenib (tyrosine kinase inhibitor) was established as a therapy for desmoid tumors. However, since sorafenib has failed to show significant efficacy, there has been exploration into other treatments such as surgical resection and cryoablation.

Dr. Jennings encourages IRs to attend sarcoma tumor boards to learn about desmoid cases and opportunities to perform cryoablations when desmoids cannot be surgically resected. In extra-abdominal desmoids, cryoablation is ideal, since the interventionist can see the low attenuation ice ball forming and sculpt ablation zones to match irregular desmoid shapes. Dr. Jennings recommends forming a 10mm ablation margin around the tumor. Additionally, he discusses both active and passive thermal protection techniques for surrounding tissues. He utilizes carbon dioxide, hydropneumodissection, and motor/somatosensory evoked potentials to keep non-target tissues out of the ablation zone. The bowel and nerves (especially in the extremities) are critically important to avoid.

For post-procedural care, Dr. Jennings emphasizes that pain is very common, due to large inflammatory responses. He usually admits patients overnight to monitor pain levels and give IV Decadron. Patients are then sent home with Medrol Dosepak. We also talk about the importance of informed consent about pain and potential nerve injuries.

Finally, we discuss how IRs can be advocates for patients with desmoids. Dr. Jennings believes that preemptive measures can go a long way when talking to third party payers. He will usually include current National Comprehensive Cancer Network (NCCN) guidelines and current cryoablation papers in his clinic notes to support his recommendations. He also encourages IRs to collaborate with oncologists, surgeons, and radiation oncologists to craft the best treatment plan for their patients.

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RESOURCES

Washington University MSK Interventions:

https://www.mir.wustl.edu/education/subspecialty-programs/musculoskeletal-imaging-and-interventions/

Neuroanatomic Considerations in Percutaneous Tumor Ablation:

https://pubs.rsna.org/doi/10.1148/rg.334125141

Anatomically Based Guidelines for Core Needle Biopsy of Bone Tumors: Implications for Limb-sparing Surgery:

https://pubs.rsna.org/doi/10.1148/rg.271065092

National Comprehensive Cancer Network (NCCN) Guidelines for Soft Tissue Sarcomas (including Desmoid Tumors):

https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1464

Society for Interventional Oncology (SIO):

http://www.sio-central.org/

Cryoablation for Palliation of Painful Bone Metastases: The MOTION Multicenter Study:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8011449/

In this episode, host Dr. Eric Keller interviews Dr. Sean Tutton about palliative care as an interventionalist, how he became interested in palliative care, and why he believes it is a crucial aspect of patient care in interventional radiology.

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RADPAD® Radiation Protection

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SHOW NOTES

The role of palliative care is to talk with patients about their goals, make them comfortable, optimize medical management, help patients understand their diagnosis, and coordinate care. Though palliative care involvement does not mean a patient is close to death, many palliative care patients will enroll in hospice at some point. Once in hospice, life-prolonging therapies are no longer pursued. Hospice care is a benefit of Medicare. It has support such as home care, and it can be expensive but is covered by the government. Due to this, there are guidelines that need to be adhered to. Frequently, palliative interventional pain procedures such as a celiac plexus block or neurolysis may not be covered so patients may have to come off hospice to get the procedure, then go back on.

Next, we talk about how an IR can start to incorporate these ideals and practices into their daily work. Dr. Tutton emphasizes that you don’t need to do the fellowship. You can start rounding with palliative care, go to their conferences, and establish relationships. Having residents and fellows rotate with palliative care is a great way for future IRs to learn how to practice with a palliative care mindset, and also to educate palliative care on the minimally invasive options that IR can offer to patients such as nerve blocks and ablations. By adopting palliative care ideals as an interventionalist, you can help your patients achieve better pain control, improve their cognition and reduce narcotics use.

Dr. Tutton recommends all IRs understand the medical management of post-op pain for any procedure they perform. He provides a standard medication regimen for a patient having an ablation. He uses Tylenol 1g pre-op and gabapentin 300-600mg 48-72hrs before the procedure and intraoperative steroids and NSAIDs such as Decadron 8-10mg and Toradol 10-30mg. All of these have level 1 data, help reduce narcotic requirements, and help with post-op nausea and pain. He discharges patients on a Medrol dose pack, ibuprofen, Tylenol, and gabapentin for a couple of days. Doing a nerve block can help as well, he frequently does ankle, digital, intercostal, and hypogastric blocks for his MSK and palliative interventions.

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RESOURCES

Ep.199: Advanced Minimally Invasive Pain Interventions with Dr. Prologo

https://www.backtable.com/shows/vi/podcasts/199/advanced-minimally-invasive-pain-interventions

Ep. 68: RF Ablation for Bone Metastases with Dr. Levy and Dr. Bagla

https://www.backtable.com/shows/vi/podcasts/68/rf-ablation-therapy-for-bone-metastases

In this episode, host Dr. Aaron Fritts interviews Dr. Rachael Forsythe and Dr. Konstantinos Stravapoulas about their Research Collaborative for Peripheral Arterial Disease (RCPAD) survey on bullying in the European vascular workplace, and overall trends in reported bullying incidents.

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Medtronic Abre Venous Stent

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SHOW NOTES

We start the episode by learning about the RCPAD goals to enhance research collaboration between European vascular departments. The workplace bullying online survey is one of the RCPAD’s current projects. This survey was disseminated via social media and society mailing lists, and it received a total of 586 medical practitioners in vascular specialties.

Next, we review major findings from the survey. Workplace harassment was experienced at all levels, starting from trainees and continuing in consultants/attendings. 43% of respondents had experienced bullying, harassment, undermining behaviors within the last 12 months, and 75% had witnessed colleagues experiencing these. Many respondents wrote about specific themes of harassment, including gender, pregnancy status, ethnicity, sexuality, and religion.

Dr. Forsythe references annual data collected by the trainee-centered Rouleaux Club, which shows an upward trend in reported bullying towards trainees. Dr. Stravapoulas highlights the importance of providing good role models who display ethical behaviors in the OR, since the training period is such a malleable time. We end the episode with a discussion about how increasing diversity in vascular departments can help expose colleagues to people of different backgrounds and hopefully decrease fear and judgment of the unknown.

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RESOURCES

Research Collaborative on Peripheral Arterial Disease (RCPAD):

https://www.rcpad.org/

Vascupedia:

https://vascupedia.com/

Rouleaux Club:

http://rouleauxclub.com/

ACC Health Policy Statement Outlines Strategies to Address Bias, Discrimination, Bullying and Harassment in the Workplace:

https://www.acc.org/latest-in-cardiology/articles/2022/03/17/16/16/acc-hps-outlines-strategies-to-address-bias-discrimination-bullying-harassment

Workplace Bullying Among Surgeons—the Perfect Crime:

https://journals.lww.com/annalsofsurgery/FullText/2019/01000/Workplace_Bullying_Among_Surgeons_the_Perfect.11.aspx

BackTable Urology Ep. 24: Operate with Zen with Dr. Phil Pierorazio:

https://www.backtable.com/shows/urology/podcasts/24/operate-with-zen

Audible Bleeding Podcast:

https://www.audiblebleeding.com/

In this episode, host Dr. Aaron Fritts interviews Dr. Aneesa Majid and Dr. Roger Tomihama about how an MBA can benefit physicians and their career goals, and how they both went about getting their MBAs as mid career interventional radiologists.

The CME experience for this Podcast is powered by CMEfy - click here to reflect and unlock credits & more: https://earnc.me/OrwQwd

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Athletic Greens

https://www.athleticgreens.com/backtablevi

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SHOW NOTES

We begin by discussing the paths these physicians took to get their MBAs, and what their individual goals were for this extra degree. Dr. Aneesa Majid works at VIR Chicago and is the CEO of Zipdata, a biotech company working to get rid of fax machines in health care. She completed her MBA at Kellogg before her move into the biotech industry. Dr. Roger Tomihama is an associate professor of interventional radiology at Loma Linda, a former navy doctor, and is just starting his MBA program at Wharton.

They discuss the different types of MBAs, including the traditional MBA path and the healthcare specific MBA. They both recommend IRs do the traditional track because it opens up many more networks outside of the physician community, and allows you to develop a business mindset, which may be more limited in a group of physicians only. Dr. Tomihama recommends talking with both physicians and non physicians who have done MBAs to better understand the culture and the expectations before signing up. It is important to do your research about which institution is best for your goals, as well as looking at specific program criteria. For example, some institutions don’t require physicians to take the GMAT before applying.

Finally, we discuss how physicians can grow their business knowledge without getting an MBA. Many IRs need a better understanding of business especially if they are interested in starting an OBL. Dr. Majid and Dr. Tomihama recommend educational material provided on Coursera or AAPL as ways to gain important information without the huge time and monetary investment of an MBA, which is not feasible for all physicians, especially those who want to maintain their clinical IR practice.

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RESOURCES

Coursera:

https://www.coursera.org

American Association of Physician Leadership:

https://www.physicianleaders.org

In this episode, guest host and vascular technologist Jill Sommerset interviews interventional radiologist Dr. Mary Costantino about the use of advanced arterial ultrasound in the setting of chronic limb-threatening ischemia (CLTI), especially in pre-procedural mapping.

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Boston Scientific Eluvia Drug-Eluting Stent

https://www.bostonscientific.com/en-US/medical-specialties/vascular-surgery/drug-eluting-therapies/eluvia/eluvia-clinical-trials.html?utm_source=oth_site&utm_medium=native&utm_campaign=pi-at-us-de_portfolio-hci&utm_content=n-backtable-n-backtable_site_eluvia_1&cid=n10008043

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SHOW NOTES

Jill and Dr. Costantino describe the workflow at their practice and discuss how ultrasound findings can be translated to drawings that help with interventional planning. Dr. Costantino says that ultrasound is traditionally seen as a mundane part of radiology training, but it can be extremely useful if it is operated and interpreted by a skilled technologist. In fact, Dr. Costantino often relies solely on ultrasound to map CLTI patients, instead of diagnostic angiograms. She believes that ultrasound can provide more information about blood flow characteristics and cap morphology. Dr. Costantino also favors ultrasound over TBI and ABI measurements, since the latter values are usually inaccurate in diabetic patients.

We look at examples of successful cases where ultrasound results affected access points, how the cath lab setup, and the overall efficiency of the procedures.

Jill highlights the use of ultrasound in the immediate post-procedural period. This often shows immediate improvement in pedal acceleration time (PAT). Patients are also followed up after two weeks to ensure that the PAT is sustainable.

To end the episode, Jill discusses the current state of complex arterial duplex education. She recognizes the need for more technologists to be trained in this modality. Additionally, Jill describes how ultrasound findings can be used in the context of multidisciplinary limb salvage meetings in which interventional radiologists, interventional cardiologists, vascular surgeons, and podiatrists engage in cases together. Jill believes that the first step to integrating advanced ultrasound is to invest in training for vascular technologists.

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RESOURCES

Advanced Vascular Centers:

https://advancedvascularcenters.com/

Society for Vascular Ultrasound (SVU):

https://www.svu.org/

HENDOLAT:

https://www.hendolat.com/

In this episode, host Dr. Michael Barraza interviews Dr. Kyle Cooper, interventional radiologist and Dr. Tahmeed Contractor, electrophysiologist about how IR and EP work together at their institution, including how they perform complex pacer lead removals, and how the have embraced collaboration over competition.

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Inari Medical

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SHOW NOTES

The doctors begin by discussing how they began working together. It was somewhat by chance that they started to work so closely, because the EP and the IR labs are directly across from each other at Loma Linda, where they work. They both began finding patients that had overlapping problems requiring intervention by both specialties, such as someone who needed a pacer lead out who also had an occluded AV fistula on the same side.

Their relationship developed further due to the nature of the complexity of some of the EP cases. They often have to remove multiple pacer leads that were placed in the patient over 30 years ago. When these devices were created, they were not designed to be removed, so it is often quite difficult to do. Furthermore, because they are mostly plastic, not metal, they often break during removal. When this happens, it is not uncommon to have to call IR to help retrieve the piece. Though a cardiothoracic surgeon is usually always scrubbed into EP cases, open heart surgery is only done if all else fails.

The two discuss how this collaboration has allowed them both to learn new skills. Dr. Contractor now does many lead extractions and will only call Dr. Cooper if there is a complication. Similarly, Dr. Cooper says he has learned many techniques from Dr. Contractor such as how to use intracardiac echo (ICE), or more commonly called intravascular ultrasound (IVUS) in IR for many more procedures than he was previously able to. Some of the challenges they have encountered is reimbursement and scheduling. With EP, CT surgery and IR are all in the room and helping, it complicates who gets paid. In general, IR bills for any venoplasty done during the procedure, and EP and CT surgery bill for the rest.