A recent article on MedPage Today opened my eyes to a new and apparently growing subspecialty—interventional nephrology.
In case you haven’t heard, nephrologists are apparently dissatisfied with the service they are receiving from surgeons and interventional radiologists, who are supposedly not sensitive to the needs of patients requiring renal biopsies and dialysis access.
Interventional nephrologists are performing procedures such as ultrasound-guided biopsies, insertion of peritoneal dialysis catheters, placement of stents, declotting arteriovenous fistulas, and even creating AV fistulas for dialysis.
Unbeknownst to me, interventional nephrology has been around since at least the year 2000 but is not yet a recognized subspecialty of internal medicine.
Twenty centers in the US are offering training in some or all of these for varying periods of time. The Accreditation Council for Graduate Medical Education has not accredited any of them, but a few are recognized by the American Society of Diagnostic and Interventional Nephrology.
Although the stated reason for the development of interventional nephrology as a subspecialty is for better continuity of patient care, it is also possible that nephrologists simply want to get in on the procedural side of medicine, which pays much better than the so-called cognitive side.
A natural extension of this phenomenon would be for infectious disease specialists, who are notoriously underpaid and procedure-less, to start draining skin abscesses. Why stop there? They might as well do ultrasound-guided pelvic abscess drainages, laparotomies for perforated diverticulitis, and craniotomies for brain abscesses.
What about pediatrics—another low-pay, no-knife specialty? They are already up most of the night answering phone calls from parents whose children have “fevers” of 99.8 degrees anyway. There is no reason that a pediatrician couldn’t learn how to do a laparoscopic appendectomy on a child. After all, pediatricians are certainly more sensitive to the needs of children and parents than mean old surgeons.
Then there’s pathology, a specialty on the ropes. At a time when thousands of med school graduates can’t find jobs, fewer than half of the 597 available positions in pathology were filled by US grads in this year’s match and 51 (8.5%) positions went begging.
Why should pathologists have to wait until someone brings them a specimen? A surgeon is not necessary. Pathologists are already familiar with anatomy so why couldn’t they remove colons and stomachs?
Pathologists should also easily be able to biopsy things such as kidneys, thereby encroaching on the turf of the interventional nephrologists, who will be forced to counter by setting up their own labs and learning to read their own histology slides.
An interventional pathology fellowship would have to include a module on talking to patients, a skill not in the armamentarium of the average pathologist.
Meanwhile maybe surgeons, with the possible exception of orthopedists, should think about becoming more “cognitive” to stay ahead of the curve if and when the big upheaval in the way doctors are compensated occurs.
We will have to brush up subjects like the “10-point Review of Systems” to maximize our coding and billing. Here’s a link to an 89-page CMS manual on the subject of evaluation and management services.
And don’t get me started on the interventional preventive medicine guys.
Skeptical Scalpel is a retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and critical care and has re-certified in both several times. He blogs at SkepticalScalpel.blogspot.com and tweets as @SkepticScalpel. His blog averages over 1400 page views per day, and he has over 9400 followers on Twitter.