IR 1.0

I was recently having a conversation with another IR who works for a group a few hours from where I currently practice. He made a remark that stuck with me: It looks like your group is stuck in IR Version 1.0. I’d say in my practice we’re at 2.0 trying to get to 2.5. It takes years to get out of 1.0

Having been in my job for a little over a year, I realized he’s right. I’m trying to get to the next level, but I feel like I’m stuck in the mud. 

My current job was taken mostly out of convenience. It’s in a desirable market where my spouse moved to for her job over 6 years ago. After spending many years apart we finally live together in a great location. We both have jobs. I’d say when you take a step back, things are going well.

My job is in a small private practice of about 20 radiologists. We work mostly in a community hospital of 300 or so beds that is affiliated with an academic medical center that is several miles down the road. It’s a strange set-up because our group maintains its independence yet works in a larger health care system that has its own group of docs. Hospital employment is the norm in our system. 

Somehow, our group has managed to hold on to this contract for decades. As a radiology group we provide good service: timely reads that satisfy the needs of our referring physicians. We are not particularly specialized. Our IR service is oriented towards service. We gladly do paras, thoras, abscess drains, thyroid biopsies. All the things that are considered “low-level,” we do, with a smile on our faces. We get the occasional kyphoplasty or GI bleed, and the exceptionally rare TIPS. We do a several outpatient uterine artery embolizations each month. I started a prostate embolization service that is slowly ramping up. We have a busy university employed vascular surgeon in our hospital who focuses on dialysis access. 50% of our practice is focused on hemodialysis access maintenance and salvage. I probably did more fistula and graft declots my first month than I did throughout training!

I’d say physicians in our hospital are happy with our IR division. My senior colleague has been practicing IR longer than I have been alive. He has done a good job growing relationships with different referrers over time. People seem to trust and respect him. He takes pride in his work and clearly doesn’t mind the nature of the work he has built for our group. 

When I first took this job, I saw an opportunity for growth unlike any other that I’ve seen in our market. Our hospital has some tremendous pathology and a patient population that is very sick and underserved. A lot of urgent higher level cases end up getting sent to the main academic medical center. Some never make it since the main hospital is often on divert. Many potential elective cases end up going untreated. 

After a couple months into my job, I went out on the floors and met the various physicians in the hospital to let them know that I can offer services for their inpatients that have never been offered before in this hospital including DVT/PE lysis, BRTO, Transesophageal Gastrostomy, Celiac Plexus blocks etc. After a short while, I was starting to get some great inpatient referrals, but I realized doing the work that I preach including formal consultations, rounding and outpatient follow-up is not sustainable as an army of 1. Hey guys, want to join me in creating an inpatient rounding list? Not only is it good patient care, but we can capture evaluation and management charges we have been letting go. Crickets. Apparently reading studies in between cases instead of striving to provide high quality care is the norm in private practice.

And about outpatient follow-up and new outpatient consults. That has turned out to be a huge struggle.

Oh don’t worry, there is a clinic where you can see patients. That’s what they told me when I interviewed for this job. What they didn’t tell me is there is no receptionist, intake nurse or anyone to manage my schedule. They also didn’t tell me I’d have to beg for space to see a patient in the clinic since that belongs to the hospital. I also didn’t know that when there isn’t clinic space available, I can do my consultation in the IR manager’s office with the wonderful photos of her happy family and half eaten lunch on the desk. 

You see, this is IR 1.0. A world where “clinic” is merely time away from generating high-yield revenue. A world where you pick em, we stick em, then you can deal with the consequences. It’s a world where everything any other doctor would take for granted isn’t afforded to you because your existence as a physician who evaluates real patients and not just images isn’t even acknowledged. 

Oh my gosh, I was so surprised to see you rounding on my GI bleed patient after you stopped his bleed. You also left a really nice note in the chart. I didn’t realize IR does that! That is the acknowledgement of a happy referring hospitalist who is used to IR 1.0. I was convinced when I started that I am the upgrade this section finally needed.

There is one problem. The upgrade is here, but it’s useless when no one on your team cares for it.

We had a clinic off site many years ago, but we hemorrhaged money. We tried getting the hospital to get us a clinic space, but they won’t because they’d rather those patients go to the university employed IRs at the main academic center. Be grateful for what you have. Clinic is overrated and doesn’t pay the bills.

That’s what my boss told me when I asked him about clinic. 

To do this job you have to be fine with being the guy behind the scenes. I’m okay with reading diagnostic imaging and getting to do cool procedures every now and then. I don’t need to be the point person. This is why we did radiology.

That was what my partner 5 years out of training told me when I asked him about clinic.

Clinical IR sounds great, and we want you to be able to take good care of patients, but right now I don’t see how we can accommodate that when our diagnostic volumes are through the roof. When will you even have time to see patients?

That’s what my group president, a diagnostic radiologist told me when I asked him about starting a clinic.  Little does he know that I round on my patients daily, after my work for the group is done and I average about 3 new outpatient consults a week.

You see, a clinic is essential to practicing good interventional radiology. What do I mean by good IR? I mean not doing cases that any well trained medical student should be able to do.  It means being asked for your clinical opinion and rendering an assessment. Consult, not order. 

The problem is, when you work in a hospital where your group has no ownership stake in any of the equipment, the economics do not lend themselves to practicing high quality IR without someone or some entity taking a financial hit. I’m about to mention some numbers. They are not exact, but it shouldn’t take away from the point.  Imagine a hospital based private practice doing lots of embolizations. Let’s say each one averages about 2 hours, including room turnover time (wishful thinking, I know). Lab is open from 8-6. That’s 5 embolizations a day. Let’s assume each embolization pays a technical fee of $10,000 and a professional fee of $500. Your group doesn’t own any equipment and only collects the professional fee. This is becoming more prevalent as groups are selling out to large healthcare systems.. That means your hard day of work nets your group $2500. Now imagine that instead of doing embolizations you read brain MRIs during those hours, averaging 4 an hour. That’s 40 brain MRIs at $300 a pop, equaling $12,000. Why would you ever want your interventional radiologist doing procedures?

Well, at the end of the day, someone has to do procedures. And while it is unlikely that any community hospital will support a volume of 5 embolizations in a day, there will be plenty of paras, thoras, PICCS, dialysis catheters and abscess drains that will need to be done which pay far less. Referring physicians love it when they can simply click a button on the EMR and magically their requested procedure is handled. What’s more, they love it when they can page their friendly IR on a Saturday afternoon to do that paracentesis. While they are at it, they’ll ask for their opinion about some imaging study that was also ordered on that same patient, because after all, they have a radiologist on the phone. IR is not only a true line monkey, but they are a monkey with a pretty face that becomes the customer service representative for the group. I don’t say this to minimize the role of a consultant radiologist. It is crucial, which is why diagnostic radiologists need IR to maintain their contract. The DR’s time is way too valuable to waste spending hours interfacing with clinicians. Imaging volume continues to go up with our aging population. Reimbursements per study continues to go down and the pressure to turn around accurate reports is of utmost importance.  Maintain that contract at all costs. That’s the motto. Especially when we live in a world where diagnostics is becoming commoditized and the only thing that keeps our imaging from being outsourced to Bangalore are arbitrary laws protecting home turf.

Ultimately IR 1.0 is not what the new generation of IRs are training hard to do. Unfortunately, this is what many of them will see when they get out there, including yours truly.  It’s a problem that is also quite prevalent in academic IR. While many academic practices have moved on from 1.0 to perhaps 1.5 or 2.0, think about all the progress that still needs to be made. For example, consider the following: How many places have a real clinic beyond tumor board referrals for locoregional treatment? How many places actually treat peripheral arterial disease? How many places have daily rounding services? How many places admit patients? How many places get referrals directly from primary care? Hell, how many actually have split off from diagnostic radiology completely? I’ll save that last question, which is admittedly quite loaded, for another day.

Solving this problem for the new generation of IRs will require making bold choices and going against the grain. It’s something I’m trying to figure out for myself. Have you figured it out? Drop a comment below. More to come soon.