Ep. 546 IR Practice Development: Residency to Real-World with Dr. Quinn Meisinger

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. --- CHECK OUT OUR SPONSOR Athletic Greens https://www.athleticgreens.com/backtablevi --- EARN CME Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/7O0Ic5 --- 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.

15 Aug 202242min

In this episode, host Dr. Jacob Fleming interviews Dr. Jack Jennings about cryoablation, multidisciplinary care, and practice building for the treatment of desmoid tumors. --- CHECK OUT OUR SPONSOR RADPAD® Radiation Protection https://www.radpad.com/ --- EARN CME Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/aNJOCP --- 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. --- 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/

12 Aug 20221h 6min

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. --- CHECK OUT OUR SPONSOR RADPAD® Radiation Protection https://www.radpad.com/ --- EARN CME Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/OYDxfn --- 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. --- 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

8 Aug 202250min

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. --- CHECK OUT OUR SPONSOR Medtronic Abre Venous Stent https://www.medtronic.com/abrevenous --- 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. --- 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/

5 Aug 202229min

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 --- CHECK OUT OUR SPONSOR Athletic Greens https://www.athleticgreens.com/backtablevi --- 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. --- RESOURCES Coursera: https://www.coursera.org American Association of Physician Leadership: https://www.physicianleaders.org

1 Aug 20221h 11min

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. --- CHECK OUT OUR SPONSOR 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 --- 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. --- RESOURCES Advanced Vascular Centers: https://advancedvascularcenters.com/ Society for Vascular Ultrasound (SVU): https://www.svu.org/ HENDOLAT: https://www.hendolat.com/

29 Jul 202237min

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. --- CHECK OUT OUR SPONSOR Inari Medical https://www.inarimedical.com/ --- 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.

25 Jul 202250min

Host Aparna Baheti interviews Barbara Hamilton and Aarti Luhar about navigating training and early career during a pregnancy. They discuss factors to consider such as scheduling, parental leave policies, radiation exposure risks, and childcare. --- CHECK OUT OUR SPONSORS Athletic Greens https://www.athleticgreens.com/backtablevi Medtronic Abre Venous Stent https://www.medtronic.com/abrevenous --- SHOW NOTES Our guests start by sharing their paths to motherhood. Dr. Luhar was pregnant as a diagnostic radiology trainee, while Dr. Hamilton was pregnant as an attending. We talk about the benefits of being part of a large department or group during maternity leave, due to more flexibility of scheduling changes and availability of coverage. Both of our guests recommend that IRs reach out to their HR departments as soon as they feel comfortable sharing their pregnancy news. Establishing contact with the department is a helpful way to clarify parental leave policies, specifically if one qualifies for parental leave and how long the leave can be. Additionally, Dr. Luhar encourages listeners to reach out to colleagues who have been pregnant before, since they can be a valuable resource for insights on the granular details of practicing IR while pregnant. In terms of radiation as an occupational exposure, Dr. Hamilton did not change her caseload during pregnancy. She shares her preference to wear extra radiation protection around her waist. Dr. Luhar reached out to her hospital’s radiation physicist for guidance. She received the advice to use standard radiation protection and follow the principle of ALARA (as low as reasonably achievable). Additionally, we discuss the risks of pathogen exposure and needle sticks. Both doctors agree that having supportive staff and colleagues can make the pregnancy process more manageable. Additionally, we discuss unexpected challenges during pregnancy. Dr. Hamilton describes her experience with the risk of premature labor and bedrest. Dr. Luhar recounts the struggle of scheduling prenatal appointments and dealing with pregnancy complications while working a full caseload. We close the episode by giving advice for evaluating the culture of your work environment, relying on support systems that are in place, and not being afraid to ask important questions. --- RESOURCES Dr. Barbara Hamilton Twitter: @TSuperheroine Dr. Barbara Hamilton Instagram: @TiredSuperheroine SIR Pregnancy Toolkit: https://www.sirweb.org/practice-resources/toolkits/pregnancy-toolkit/

22 Jul 202257min