Imagine a landscape where you can use your talents to create your own practice. This is what I dream of when I think about the future of IR. Why can’t I join forces with several of my closest IR colleagues in my market to create this sweet practice? My dreams are really not all that crazy seeing as many other physicians in different specialties have built practices that we can model after.
If you think of other procedural medical subspecialists or surgical subspecialists, many practice in both the hospital and outpatient setting. They often exist with other like-minded partners who support each other as they care for patients. Economically speaking, they often use their office to drive revenue and they maintain hospital privileges to offer comprehensive services for patients, support their local community and of course more practically to maintain their ability to have an office.
What should the ideal practice look like? Everyone will have their own opinions regarding this, but having experienced a variety of practice types in a short period of time, I have a good sense of where our field should be headed to best use our skills to do the greatest good for patients and to of course to keep our daily professional existence intellectually satisfying. Here are several key elements I think the ideal IR practice should have:
1. An outpatient setting for clinics and procedures.
Simply put, the OBL is essential to have a robust IR practice. The majority of procedures in IR can be performed safely on an outpatient basis. Reimbursement for procedures in the outpatient setting are favorable and allow the physician to control finances unlike the hospital where overall reimbursements and costs are higher and a smaller proportion is paid to the physician. By being able to take charge of our economic destiny in the office, we can have robust clinics where we are seeing patients and providing comprehensive longitudinal care without having to justify our existence to stakeholders who don’t understand the type of medicine we as interventional radiologists are capable of practicing. The outpatient setting is more convenient for patients and most patients preferred to be treated in the OBL compared to a hospital where timely care is simply not possible due to the unpredictability of inpatient services and the emergency department.
2. A hospital service.
As much as I am an advocate of the OBL and as strongly as I feel that it should be the anchor for any strong IR practice, it would be incredibly short-sighted to ignore the important role that IRs play in hospital settings. There are certain service lines that cannot be supported without a hospital presence. Gastroenterologists rely on us for treatment of both arterial and portal hypertensive hemorrhage. Hospitalists rely on us for forms of central venous access, fluid drainage, kyphoplasty and more. The emergency department and ICU need us for a lot of different things. More than just supporting the hospital community, we as IRs need the hospital to care for patients who are simply too sick to be treated in the OBL setting. We need to be involved in the care of patients who we have treated in the outpatient setting at some point who end up hospitalized, regardless of the reason. It’s what any other physician would do, so why should it be different for us?Practically speaking, hospital privileges are essential in many states to have the ability to even treat patients in the OBL.
3. Physician Ownership
No one understands the complexities of our profession better than us interventional radiologists. So why in the world should our future be driven by the whims of non-physician administrators, diagnostic radiologists or physicians in other specialties? When we call our own shots, we have the greatest potential to provide the best services possible for patients. Furthermore, through practice ownership we have the ability to groom the next generation of private practice IRs which allows our field to continue to thrive and innovate. And of course, when we own our own practices, we have the greatest potential to financially benefit. With all the work involved in creating a robust IR practice, we need to be able to reap the potential rewards.
What are the barriers which prevent this future from becoming a reality? Well, I should preface this by saying that there are interventional radiologists who have created independent IR group practices with both outpatient and inpatient services. They are few and far between, but they do exist. But there are clearly reasons which prevent this from happening at scale
1. Non-clinical mindset.
Anyone who has created an independent IR practice free of outside financial interests has leveraged their ability to take care of patients both procedurally and non-procedurally to build a robust patient panel. This is what I call, “clinical IR.” And as much as we talk about “clinical IR,” the truth of the matter is very few people practice in this manner. There are several structural considerations which prevent the widespread adoption of clinical IR services. Most notably, I think it’s a generational identity issue regarding who we are as IRs. It takes time for a culture to change, and that culture is rapidly changing with the new generation of IRs coming out of training. With continued education and selecting future IRs from a pool of students interested primarily in taking care of patients with diagnostic imaging as a tool to accomplish this goal, the culture will continue to change. In the interim, there will be growing pains as it’s almost impossible to teach some old dogs new tricks, or in this case the adoption of a new mindset. Unfortunately, this old dog mentality exists even in my generation of IRs (0-10 years out of training). Hearing about the types of jobs new grads are taking, I don’t think things are really changing much despite all the talk out there. I predict the tail end of my career will look very different than it does now.
2. Employee mindset and coming to terms with opportunity costs.
Whether or not you do it for yourself, a diagnostic group, a random cardiologist OBL owner or some corporate entity, you need an entrepreneurial “go-getter” mentality to build your practice. It involves significant marketing and communication which honestly is not taught in training. Many IRs are motivated to do this because they don’t want to feel stuck doing “bread and butter” procedures. The real thing though, is it’s not just about doing procedures. It’s about building patient panels by treating disease states. When we adopt this mindset, I feel it becomes easier to fill your clinic which really should be 20-30 deep on a given day. The problem is that by focusing on E&M services primarily to drive your procedural volume comes at a significant opportunity cost. When you can make a healthy six-figure salary doing hospital-based IR with some diagnostic responsibilities many aren’t willing to take the plunge to practice true clinical IR because it will likely involve either ruffling significant feathers in one’s existing practice environment or will involve the financial risk of separating and not having that guaranteed financial safety-net that diagnostic radiology can provide.
3. Psedoexclusive Contracts.
This might be the biggest barrier which prevents us from reaching our potential in private practice. There has been significant discussion regarding this both on this blog, the SIR forums and other venues. I’ve been spending some more time thinking about this issue and as easy as it is to be angry at the SIR, and believe me-I’ve been angry at the society for a minute, we need to ask ourselves what needs to really happen to fix this problem? There honesty is only so much the SIR can do. They have a statement issued which clearly discusses the issue and acknowledges that these contracts are harmful to independent IR practice, but the main issue here is a legal one. Most pseudoexclusive contracts prevent other radiologists (typically definied by board certification by the American Board of Radiology) from obtaining hospital privileges. So the ways to get around these are to 1.) negotiate with the radiology group holding the contract, 2.) to lawyer-up and fight them claiming that you aren’t providing “radiology services,” 3.) partner with other high-powered physicians who can advocate on your behalf (often at a financial cost), or 4.) just forget the hospital and provide only outpatient services in a state which does not require privileges.
I think in order to really move the needle on this issue, we need to do something radical. We need to break off from diagnostic radiology completely and have our own board certification process independent of the American Board of Radiology. If we want to be treated differently from diagnostic radiologists and not be held to the provisions of these pseudoexclusive contracts we need to truly be different on paper. I think this will happen at some point. I’m just not confident it will happen anytime soon. Change is slow and the existing power structure (academic radiology and private practice hospital based radiology services) benefit from the current model.
Addressing the inevitable concerns:
But Line Monkey, diagnostic radiology is an important part of who we are!
No doubt. You are correct, but it comes at a huge cost and that’s our future to practice independently and provide the greatest good for society. Yes, some places provide tremendous clinical IR services in the context of radiology groups, but these groups are few and far between. Furthermore, these groups have their own issues with their diagnostic radiology partners which may not be openly stated despite all the flatteries on social media.
Yes, you are correct diagnostic radiology education is essential to be a good IR. I rely on my wonderful diagnostic training every day. We can embrace the importance of DR education and also embrace the fact that the economic model for DR is not right for a clinical IR practice. This should not be offensive to diagnostic radiology. Some of my best friends and mentors are diagnostic radiologists. I enjoy practicing teleradiology on my own time to supplement my income and utilize skills I worked hard to obtain, but I don’t like mixing it with my IR work. We can still enjoy both apples and oranges.
But Line Monkey, we need diagnostic radiology because there isn’t enough work out there for everyone to practice 100% IR!
There are enough BPH and fibroid patients out there alone to support 100% IR practices for every IR right now doing solely PAE and UFE. Then you consider PAD, venous disease, portal hypertension, interventional oncology and you quickly realize that there are a ton of patients out there not making their way to us. Often because they don’t know who we are and what we can do! It’s a marketing problem which is rooted in our culture and more deploy rooted in the economic models in which most of us practice. Combine our diversified service lines with the potential for even more (MSK emebolization anyone?) and you quickly realize that there are plenty of patients to go around. Patients need us and we are collectively shooting ourselves in the foot through our limiting beliefs, cultural mentality, antiquated training paradigms and association with diagnostic radiology and subsequent pseudoexclusive contracts. We can fix this if we really wanted to. But do we, really?
If you really want it, you’ll find a way to make it happen.
Yes, there are headwinds. There are some clear issues out there which prevent a true 100% IR practice in many markets, but I’m firmly of the belief that if you want it, you’ll make it happen. That’s what I’m doing. It’s what others before me have done and I’m confident that those coming up will want this professional existence as well. There isn’t a clear roadmap because things will look different depending on your market and circumstances. My goal is to bring these issues to light, educate others on the issues pertinent to the creation of independent IR practice and to connect with and coach those who may be interested.
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