BackTable Vascular & Interventional

In this episode, host Dr. Aaron Fritts interviews Dr. Jim Melton and Amanda Stanley about intravascular lithotripsy in the ASC, including reimbursement trends, patient selection and the future of the device. --- CHECK OUT OUR SPONSOR Shockwave Medical https://shockwavemedical.com/?utm_source=Backtable-Podcast&utm_campaign=Backtable-Podcast --- SHOW NOTES We begin by discussing Amanda’s role in the practice. She is an ex OR nurse and has been clinical director for their original hybrid ASC/OBL in Oklahoma City for 8 years. She has taken on many roles over the years, the most recent being COO. Some of her functions under this title include clinical revenue cycle management (RCM), payer negotiation, credentialing and accreditation. Since partnering with a private equity firm, she has also been collaborating with others in ASCs they have acquired around the country. Dr. Melton states that intravascular lithotripsy (IVL) reimburses very well in the outpatient space, but that this is only true in the ambulatory surgery center (ASC) and does not translate to outpatient based labs (OBLs). Medicare pays for all associated Shockwave intravascular lithotripsy CPT codes, commercial insurance does not. They found in their practice that by using the Medicare fee schedule, they could prove to their local commercial insurance providers that it was worth paying for, and they are now getting it approved via both parties. Specifically, C9765, which is for IVL, percutaneous transluminal angioplasty (PTA) and stenting, pays $5000 more than the code that is just for PTA and stenting. Lastly, we go over sizing and patient selection. In the ASC, he most commonly uses the 5.5, 6 and 7, which all go through a 5-6 Fr slender sheath in the foot. If you use an 8 then you’ll need a 7 Fr sheath, and if you use a size 9, 10, or 12, you’ll need an 8 Fr sheath. Dr. Melton emphasizes the importance of selecting the right patients for the ASC and hospital. In those with significant comorbidities or a femoral artery that will need a size 9, 10 or 12 balloon, he tends to do these in the hospital. He finds that he places a stent more often than not after IVL and PTA because of what he sees using intravascular ultrasound (IVUS). He shares a tip for using the current IVL balloon. Because it emits the strongest sonic pressure impulse at the center of the balloon, he uses IVUS to mark the most calcified segment, then targets this area with the center of the balloon. He remarks that the newer version, coming out soon, has a shorter balloon and emits the same strength across its entire length, allowing you to skip this step. --- RESOURCES Ep. 287 OBL/ASC Reimbursement Update January 2023 https://www.backtable.com/shows/vi/podcasts/287/obl-asc-reimbursement-update-jan-2023

10 Apr 202324min

In this episode, host Dr. Aparna Baheti interviews Dr. Tarang Patel, diagnostic radiologist and creator of the Doctor Money Matters Podcast, about private equity in radiology, from why to get in to how to get out. --- CHECK OUT OUR SPONSOR RADPAD® Radiation Protection https://www.radpad.com/ --- SHOW NOTES After getting out of the air force, Dr. Patel didn’t know what to do with the significant salary increase he was given. He had a lot of questions and wanted to learn how to manage his finances as a physician. In 2015, he created a website, which soon developed into a podcast. In doing this, his goal was to speak with guests who were experts in aspects of physician finance so that he could learn. He was also interested in disseminating the information with others, because he knew many physicians had similar questions about finance. Next, we discuss the private equity (PE) landscape, specifically in Phoenix, where Dr. Patel practices. He is a hospital employee and has never been part of a PE owned practice, but knows many in Phoenix who went through the Rad Partners buyout there. He explains the evolution of the Rad Partners deal. There were three dominant radiology groups that employed over 100 radiologists. They were approached by Rad Partners and decided to sell and become one large group. This resulted in one dominant radiology group in all of Phoenix. These physicians were all locked into a 5 year contract, which ended in late 2022. At this time, there was a mass exodus of radiologists from this group due to their dissatisfaction with the way the practice was run or how their contracts ended up playing out. Dr. Patel explains how they were able to attract so many people by incentivizing the deal with a heavy cash to share ratio. This gave providers a sense of a guarantee, which a higher share buyout would not have provided. This is because the PE company ascribes value to the shares, and it is unknown at onset whether they will financially profit in the long run. Dr. Patel further explains that joining a PE owned practice is generally a bad deal for young radiologists, because they are offered lower salaries and don’t get any buyout. This has resulted in PE companies failing to hire young doctors. Additionally, many older doctors near retirement use a PE deal as a way to get a large cash payout, work for a few more years, and retire. Dr. Patel believes that due to hiring difficulties and the high debt burden of many PE companies, they will start to close practices, which will open up the market for new practice models. He believes the radiology landscape will be vastly different in 5 years than it is now. Dr. Patel ends by saying you should never trust an offer that advertises low risk and high return. Additionally, for young radiologists looking for jobs out of training, he urges you not to follow the highest offer, but rather find the practice you enjoy going to work at everyday, even if the pay is lower. In the end, you will make the money, and it is worth enjoying your job and your colleagues. --- RESOURCES Ep. 287 OBL/ASC Reimbursement Update January 2023 https://www.backtable.com/shows/vi/podcasts/287/obl-asc-reimbursement-update-jan-2023

7 Apr 202345min

In this episode of BackTable, Dr. Bagrodia interviews Dr. William Flanary, a physician-comedian popularly known as Dr. Glaucomflecken, about lessons he has learned as a two-time testicular cancer survivor and the importance of humor in medicine. --- 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 free AMA PRA Category 1 CMEs: https://earnc.me/VJvXZx --- SHOW NOTES First, Dr. Glaucomflecken shares about his first diagnosis of testicular cancer. During his third year of medical school he felt a lump in his testicle, which led to a quick workup, diagnosis, and a full orchiectomy. The diagnosis was emotionally difficult, as he was in his mid-twenties and healthy. He returned to comedy, a skill he had developed in high school and college, to cope with his diagnosis. This time, however, he started to practice medical-based comedy with his new experiences as a medical student. He recounts other discussions he had about his cancer, such as fertility, the possibility of chemotherapy, and active surveillance. Four years after his first orchiectomy, he received his second diagnosis of testicular cancer during his last year of residency. He recounts feeling distraught and overwhelmed, as questions about fertility, hormone replacement, medical expenses, and postponing residency became more serious. He decided to have a full orchiectomy and testosterone replacement therapy, which solved his issues with fatigue and irritability. Additionally, his wife got him involved in testicular cancer support groups and foundations, including one called First Descents, an organization that encourages young adults with cancer to explore the outdoors. He notes that young patients are often overlooked in cancer support groups and encourages cancer patients to find their support networks outside of friends and family as well. Then, Dr. Flanary discusses his experience with suffering from cardiac arrest in 2020, which led to his wife doing ten minutes of chest compressions to keep him alive. He reflects on this event and concludes that it taught him how to be a better physician to his patients by making sure he involves patients’ families and encouraging him to address medical insurance issues directly. Finally, Dr. Flanary discusses how he uses humor to advocate and educate patients on social media. He notes that comedy can stimulate conversation and debate and encourages physicians to have social media presence. --- RESOURCES Knock Knock Hi Podcast https://podcasts.apple.com/us/podcast/knock-knock-hi-with-the-glaucomfleckens/id1659572053 First Descents https://firstdescents.org/

5 Apr 202357min

In the second part of our IR Locums series, guest host Dr. Shamit Desai interviews Drs. Kavi Devulapalli and Vishal Kadakia, reuniting at SIR 2023, to discuss the process of finding and negotiating locum tenens opportunities. They each provide an update on their clinical practice and perspectives about the job market in the last year. --- CHECK OUT OUR SPONSORS Medtronic HawkOne Directional Atherectomy System https://www.medtronic.com/hawkone Reflow Medical https://www.reflowmedical.com/ --- SHOW NOTES Dr. Devalupalli begins by describing the choices that IRs can make about networking, whether they prefer to personally search for locums opportunities, or whether they work with a staffing agency. Through conversations with people in the staffing industry, he has learned that their margins are around 30-40% of an IR’s daily rate. Deciding whether or not to use a staffing agency is up to the physician and their networking needs, but there are an abundance of direct ways to connect with jobs through online communities, conferences, and device representatives. Having more personal contact with employers and practice owners can also provide more information about each site’s work environment, case load, case variety, and expectations. Dr. Kadakia notes that some clients have signed exclusive locums contracts, so they are prohibited from working with physicians that do not go through the staffing agency. He also talks about national groups establishing locums departments to staff different branches in need of extra help, and how this could be an alternative to staffing agencies. Dr. Devalupalli mainly works with physician-owned practices and he emphasizes the value of speaking directly to practice owners. This is a good way to build trust and reduce bureaucratic inefficiencies. Dr. Kadakia shares a personal marketing tip: He creates a one-page introduction to his skills and reviews, which succinctly lets clients know what he can offer. Next, we discuss the changing job market as demand for IRs is increasing and trainee interest in locums is growing. IR training primarily occurs within a hospital-based setting, so it would be an easier transition for early career IRs to do inpatient locums, as opposed to starting in an OBL setting. Overtime, as one proves their skills, confidence, and efficiency, it will become easier to find outpatient opportunities. Finally, the doctors discuss the importance of transparency around contracts and fees. They give concrete examples of price floors and necessary terms to define in locums contracts. Both doctors also speak about being open to variability in rates based on the need for travel, case and payer mix, and call schedule. --- RESOURCES Ep. 225- Approaches to IR Locums: https://www.backtable.com/shows/vi/podcasts/225/approaches-to-ir-locums Ep. 218- Building a Skillset Outside of Training: https://www.backtable.com/shows/vi/podcasts/218/building-a-skillset-outside-of-training Line Monkey MD Blog: https://linemonkeymd.com/ Outpatient Endovascular and Interventional Society (OEIS): https://oeisweb.com/

3 Apr 20231h 3min

In this episode, Dr. Aaron Fritts interviews Dr. Nisha Mehta, a radiologist and founder of the Physician Side Gigs online community. --- CHECK OUT OUR SPONSORS Medtronic AV DCB https://www.medtronic.com/avdata Reflow Medical https://www.reflowmedical.com/ --- SHOW NOTES Dr. Mehta traces her journey from being a radiologist between jobs to managing and advocating for one of the largest grassroots physician communities, with more than 162,000 online members. She started Physician Side Gigs as a private Facebook group with a few doctors to get advice on managing finances for her paid writing and speaking engagements. Overtime, the size and scope of the group grew so much that there was a branch point where a separate group, Physician Community, formed. Both groups remain active today– while Physician Side Gig still centers around business and personal finance education, Physician Community is more free flowing and fosters a variety of conversations about the healthcare environment, clinical practice, and physician advocacy. This advocacy really came into the spotlight during the peak of COVID-19, when members of the online community collaborated to create a list of physician demands for the federal government and were successful in securing $70 billion for physicians in a stimulus package. Dr. Mehta cites the lack of bureaucracy in the group as factors that helped contribute to this outcome. The groups’ goals are to provide members with peer support and bridge them to opportunities to pursue other interests and revenue streams. We also discuss Dr. Mehta’s personal career trajectory and how her priorities shifted throughout the years. In the beginning stages of Physician Side Gigs, she was able to balance a full time clinical practice and manage the online group in her free time. However, as the group grew in audience and partnerships, she re-evaluated her priorities and saw that fostering the community gave her more energy and allowed her to make more impact than her clinical practice did. She now practices radiology on a per diem basis and devotes most of her time to Physician Side Gigs and physician advocacy. She has also hired staff members to help moderate the group and ensure that it remains a safe and supportive environment. Finally, Dr. Mehta speaks about physician autonomy. The decision to pursue a side gig is not always based on revenue maximization. Instead, side gigs can be a way for physicians to dedicate time to pursuing their non-clinical interests and prevent burnout. Her biggest advice for doctors is to be intentional about what they want their lives to look like, and to not get caught up in others’ expectations for them. In the long run, having career autonomy can extend career longevity and allow physicians to navigate their lives on their own terms. --- RESOURCES Physician Side Gigs Website: https://www.physiciansidegigs.com/ Ep. 194 (VI)- Financial Basics with the White Coat Investor: https://www.backtable.com/shows/vi/podcasts/194/financial-basics-from-the-white-coat-investor Ep. 277 (VI)- Private Equity and the Radiology Job Environment with Ben White: https://www.backtable.com/shows/vi/podcasts/277/private-equity-the-radiology-job-environment Ep. 27 (INN)- Physician Underdog with LOUD Capital Founder Navin Goyal: https://www.backtable.com/shows/innovation/podcasts/27/physician-underdog

31 Mars 202351min

In this episode, host Dr. Sabeen Dhand interviews Dr. Jihad Mustapha, interventional cardiologist, about new technology for treating CLI, including CTOP classification, CTO crossing techniques, and reentry devices. --- CHECK OUT OUR SPONSOR Reflow Medical https://www.reflowmedical.com/ --- SHOW NOTES Dr. Jihad Mustapha is an interventional cardiologist who practices at Advanced Cardiovascular in Grand Rapids, MI. He used to perform the entire scope of interventional cardiology, until finding his passion in critical limb ischemia and dedicating his career to treating this complex disease. Advanced Cardiovascular has grown, and now includes a dedicated interventional cardiology department and a PAD/CLI specific department. The basic principle for treating chronic total occlusions is to approach them from the best direction. This generally starts with an up and over technique to do the initial planning angiography. Dr. Mustapha then uses the wire and catheter technique, but limits his efforts to 5 minutes. If he can’t cross, he tries a new method. If he can cross but can’t reenter distally, then there are multiple methods to turn to, including reentry devices like the Outback and Pioneer. He emphasizes that when using reentry devices, you must measure the CTO and enter just after it ends, allowing no more than 1-2 mm of space between the cap and your reentry point. If it is impossible to reenter at that level, you should not use a reentry device and should turn to another method. The Chronic Total Occlusion crossing approach based on Plaque cap morphology (CTOP) classification is helpful when deciding how to safely approach a CTO or which technique to turn to, and Dr. Mustapha uses it in all his cases. Next, we discuss pedal access. Dr. Mustapha acknowledges he hasn’t used reentry devices for years now, due to the fact that pedal access is so much quicker and works just as well. If a CTO has a complex CTOP classification, he doesn’t even try anterograde first, he just goes directly to pedal access and crosses retrograde. When he uses the retrograde approach to cross the CTO cap, he often finds the occlusion is not as long as he expects it to be, and also that he is intraluminal much more often than he initially anticipates. For long chronic total occlusions (CTOs), he starts with pedal access, crosses the CTO plaque cap, and continues through the occlusion, stopping just before the reentry point. If it pops through the cap, he then uses the tibiopedal artery minimally invasive retrograde revascularization (TAMI) technique, but if it does not, he comes anterograde and uses the flossing technique. Finally, we discuss how to use the Wingman device, as well as tips for using the Jenali and modified Schmidt techniques. Finally, we discuss new devices coming soon in the CLI arena. Dr. Mustapha is excited about companies that are creating a 2-in-1 device that allows you to cross the CTO and then use it as a reentry device. Dr. Mustapha parts by telling listeners that CTOs are never friendly, whether long, short, calcified, or non-calcified, but as long as you anticipate this and go into a case expecting surprises, you’ll do well. --- RESOURCES Ep. 60: Building a Limb Salvage Program https://www.backtable.com/shows/vi/podcasts/60/building-a-limb-salvage-program CTOP Paper: https://capbuster.com/wp-content/uploads/2021/03/Chronic-Total-Occlusion-Crossing-Approach-Based-on-Plaque-Cap-Morphology-The-CTOP-Classification.pdf Tibial Pedal Access Paper: https://www.openaccessjournals.com/articles/tibialpedal-arterial-access--retrograde-interventions-for-advanced-peripheral-arterial-disease--critical-limb-ischemia.html Jenali Scoring System: https://evtoday.com/pdfs/et0910_Feature_mustapha.pdf Find this episode on backtable.com to view the full list of resources mentioned in this episode.

27 Mars 202345min

En este episodio de BackTable VI, Dr. Pilar Bayona Molano, Dr. Juan Ciampi, y Dr. Sara Lojo Lendoiro discuten el manejo de embolia pulmonar para pacientes con niveles de riesgos diferentes. --- EARN CME Reflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/CxjlQ7 --- SHOW NOTES Primero, Dr. Ciampi explica que un equipo multidisciplinario es más importante en el manejo del paciente con una embolia pulmonar. Si el paciente tiene un riesgo bajo o intermedio, el médico hará una primera valoración y puede darle la anticoagulación. Para pacientes con riesgo alto, el equipo necesita ser preparado para activar los códigos y empezar la intervención endovascular. Entonces, Dra. Lendoiro nota la importancia de evaluar los marcadores de laboratorio y considerar las comorbilidades y calidad de vida de cada paciente. Dr. Ciampi añade que hay un riesgo alto de desarrollar hipotensión. Por eso, el paciente podría necesitar vasopresores y también una ecografía para evaluar la función del ventrículo derecho. Entonces, los doctores discuten las técnicas de la trombectomía endovascular. Dr. Ciampi explica que usa la vía femoral ante todo, pero los radiólogos intervencionistas deben usar la técnica con que tenían la mayor experiencia. Enfatiza la importancia de remover la mayor cantidad de trombo posible. Adicionalmente, Dra. Lendoiro explica la necesidad del monitoreo continuo del paciente debido al hecho de que el estatus del paciente puede cambiar de momento a momento. Hay muchas complicaciones posibles durante el procedimiento, como la presencia de materia oclusiva y perforación vascular, que pueden tener consecuencias fatales. También discuten los materiales que usan durante las trombectomias, incluso el uso de la máquina de ultrasonido. Finalmente, los doctores discuten cómo pueden educar al público y a las especialidades médicas sobre las embolias pulmonares. Dr. Ciampi recomienda a los estudiantes interesados en esta condición leer las pautas médicas y observar intervencionistas. Dra. Lendoiro las anima desarrollar buenas relaciones con colegas de especialidades diferentes para practicar trabajar en un grupo multidisciplinario.

24 Mars 202333min

In this episode, host Dr. Aaron Fritts interviews Dr. Elsie Koh about physician coaching and leadership training, including the difference between mentorship and coaching, how to break through common barriers, and how to empower yourself to realize your potential. --- CHECK OUT OUR SPONSORS Medtronic AV DCB https://www.medtronic.com/avdata Reflow Medical https://www.reflowmedical.com/ --- SHOW NOTES Dr. Elsie Koh is an interventional radiologist and founder of Lead Physician, a physician specific coaching company. She trained in coaching at the Proctor Gallagher Institute (PGI), the International Coaching Federation (ICF), and received an Executive Master in Healthcare Leadership at Brown University. After working for only two years out of fellowship, she became the medical director of a surgery center. She had no experience in leadership, and due to her own insecurity and modeling after what she had seen in her medical training, she failed at this position. She was given feedback at a work event, which changed the trajectory of her career. After this occurred, she began reading self-help and personal development books. She sought out the PGI institute, and ended up training in their program to become a coach. Through this difficult experience, she realized other physicians could benefit from this type of guidance. Next, Dr. Koh explains the difference between mentorship and coaching. Mentorship is having someone tell you what to do, or modeling a behavior or career path that you want to emulate. Coaching allows a person to discover more of themselves, become aware of their blind spots, and learn what makes them unique. We discuss some of the most common barriers she sees among physicians that prevent them from seeking out coaching. She believes many hesitate because they don’t believe it will work for them. Many physicians simply don’t know what coaching involves and what their goals should be. Sometimes cost is prohibitive, mostly due to the fact that people are not used to investing in themselves in this way. Many physicians lack the confidence to admit they don’t know how to do something, such as start a company or be a successful leader. At Lead Physician, they have the advantage of only coaching physicians, which helps clients let their guard down, because they are around like-minded thinkers. Dr. Koh likes group coaching sessions because it allows people to build off each other's inspiration, and yields greater idea sharing than one-on-one sessions. --- RESOURCES Ep. 194: Financial Basics from the White Coat Investor https://www.backtable.com/shows/vi/podcasts/194/financial-basics-from-the-white-coat-investor BackTable Innovation Ep 27: Physician Underdog https://www.backtable.com/shows/innovation/podcasts/27/physician-underdog Contact Dr. Elsie Koh: info@drelsiekoh.com Lead Physician: https://www.leadphysician.org Elsie Koh TED Talk: https://www.youtube.com/watch?v=hX19-7VRRfI

20 Mars 202335min