A lot has transpired since my last post. I have some interesting professional developments in the works, but before I get into that let’s revisit some old news…
I began writing this post several months after starting my job, but haven’t had time to finish this piece till now. Too busy doing paras and banging my head against a wall, I suppose. 10 months later I realized nothing has really changed. While many of the themes that I’m about to discuss I have previously touched upon, I think this post strikes a tone that I hope you’ll appreciate. Ultimately, I hope that this piece will set the stage for a series of informative articles that I will publish over the next few months…
Medical imaging is amazing. What we are able to diagnose non-invasively has changed the way medicine is practiced. It’s quite apparent when you look at younger physicians and compare their physical examination skills to their seasoned colleagues. Percussion, anyone?
Now days if you think something is going wrong with your patient, just throw them into the answer machine (i.e. the CT scanner). For certain other suspected abnormalities, one might just throw them in the MR scanner. Certainly, plain films (x-rays) are here to stay since they are so easy to acquire. Of course lets not forget ultrasound and nuclear medicine which both play their role as well.
The older radiologists I work with recall the days where image acquisition was a cumbersome process. Naturally, this meant less work. Plenty of time to get coffee, chat with clinical colleagues etc. Radiology truly seemed like a “lifestyle” specialty.
Those days are over. With new technology and ways to store and transfer information, what used to take days or hours now takes less than a minute. The number of imaging studies being ordered has increased significantly and will only continue to grow in the future. You would think radiologists would benefit from this and they have to a certain extent, but the returns are diminishing. And it’s not like payers haven’t caught on. Reimbursements for imaging exams have decreased over time. So radiologists are doing more work for less pay. Salaries, like most in medicine, have remained flat or have decreased over time. The work hours keep growing.
As a field born out of diagnostic radiology, interventional radiologists in many settings feel the brunt of “the list,” the seemingly never ending queue of imaging studies needing to be read. In my particular practice where I function in the typical IR/DR role, I am asked to help out reading studies when possible. Often times, this means me begrudgingly reading cross sectional images either in the morning before starting cases, or at the end of the day. If there are gaps between cases, then it is expected that I pick up the mic and dictate. About 8-12 days a year I function as a dedicated diagnostic radiologist. On weekend call, I read all urgent inpatient MRIs (usually 20 or so each weekend call). All in all, 30% of my time at work is spent doing diagnostic radiology. For many diagnostic radiology based practices, this is pretty good as many who are trained in IR spend less than 50% of their time doing procedures.
I hate the list with a passion. I hate it not because I dislike diagnostic radiology (I think it’s very fascinating and important. Definitely a post for another time). I hate it because it makes me feel like a commodity and less like a real doctor. I hate it because it takes me away from doing the things that I love doing which include growing my practice and doing a higher volume of complex cases. The list is a total ball and chain.
Like most issues in life, the problem comes down to time and money. Radiologists make more money when they read more studies. They can only read studies if they have demand for those studies (i.e. contracts). If they don’t read studies in a timely and accurate fashion, they could lose their contracts. Diagnostic work is becoming very commoditized especially with teleradiology being a large presence in many healthcare landscapes. Furthermore, machine learning is real and there is a likelihood that at some point in the near future machines will play a larger role in the interpretation of imaging studies. Regardless, private practices currently need all hands on deck to meet the demand, maintain their salaries without having to hire more staff and to keep their customers happy so their work doesn’t get shipped off to the next person willing to do the job for cheaper.
Building a practice in interventional radiology in many ways is like building any other business. There are significant start up costs involved. The biggest one is time. It takes time to see patients on the floor. It takes time to give talks to other doctors and let them know you what you can do to help their patients. It takes time to staff a clinic. The costs are further magnified by the additional resources needed to help aid in the process including advanced practice providers like NPs and PAs, marketing staff or the physical infrastructure needed to partake in such endeavors. Of course having the infrastructure needed to grow a practice also requires money. It’s not just about having the money to pay for staff and space, but in the context of a radiology practice it’s the opportunity cost involved having your interventional radiologists not tackling the list. Let’s not kid ourselves. As Americans become older, imaging volumes will continue to remain high, if not grow. Of course, slack in imaging interpretation could in theory be picked up by diagnostic radiologists working even harder, but you really think that’s going to fly? It’s easy for diagnostic radiologists to feel resentment towards their interventional colleagues since DRs spend all day trying to keep their head above water reading studies while IRs are presumably having fun doing procedures.
So therein lies the natural conflict between diagnostic and interventional radiology. It’s a conflict that is making me resent my job only 15 months after starting it. Some would call it “burnout,” but I really hate that word. I’m really growing to dislike my job, for reasons that have nothing to do with patient care or my actual love for doing image guided procedures requiring the skills and expertise I have trained hard to acquire. Here are a few reasons why I really hate my job:
1. I do a lot of garbage cases
I don’t mean garbage, as in my patients are garbage. I love my patients. However, half of my cases do not require 6 years or post-graduate training to perform. I spend 25% of my professional existence performing a procedure any well trained medical student should be able to perform: the life-saving paracentesis. 15% of my cases are thoras, which is maybe a step up in complexity from the paracentesis, but still a very basic procedure. 10% of my cases are thyroid biopsies, 99% of which are an exercise in futility.
The majority of my other cases may require a higher level of technical expertise, but are essentially commodities in the landscape of procedural medicine: abscess drains, abdominal and lung biopsies, bone marrow biopsies and a smattering of epidural steroid injections.
We have a large dialysis population in our practice, so plenty of dialysis access maintenance/salvage which undoubtedly is a step up in expertise/skill required for successful completion, though is still very commoditized. About once or twice every month I’ll do an elective embolization: generally a uterine artery or prostate artery embolization. These are the cases which really get me excited about my job since it requires a high level of technical and clinical expertise to not only perform the procedure, but to successfully manage the patient both before and after the procedure.
2. I am “ordered” to do procedures as opposed to being “consulted” for a problem
If you have a patient with appendicitis, you don’t order a surgeon to do an appendectomy. You consult them for their professional opinion/management. If you have a postoperative abscess, however, it is apparently totally acceptable to place an “order” in the electronic medical record for an IR drainage procedure. The procedure will magically be completed and you will never hear from the IR again. The classic example of “you pick em’ and we stick em’.
3. I have no clinic.
My clinic is non-existent. I have to either beg for space in the pre-operative clinic, or use an old closet to see patients for consultation. My technologists book my patients and procedures, but I am responsible for bringing patients from the waiting room to the physical “clinic.” I am responsible for doing their intake, vitals, assessment (obviously), but also their pre-authorization and any subsequent follow-up. I have no one to help me with any of this. Oh and when I’m done with my assessment, I have to fax my consult note to my coders who are largely clueless about evaluation and management billing. I am the only radiologist in my practice who bills for E&M.
4. No one really cares if my professional potential is being met.
My diagnostic radiology colleagues view interventional radiology as the “Face of The Practice.” We interface with clinicians and get things done. People like us because we will bend over backwards to make things happen. A paracentesis prior to discharge at 4pm on a Sunday afternoon? No problem! An angiogram at 3 AM for a GI bleed in a patient who is on anticoagulation who is otherwise hemodynamically stable but has had a drop in hemoglobin without real resuscitation? Yes, sir. We’re on top of it. You see, this is customer service at its finest. This customer service is fine if it helps build a practice, but in this case it does nothing but meet the demands of our group’s radiology contract. And my fellow IR colleagues? They don’t care either. They’re fine with their existence as long as they continue to make their salaries, and have double digit weeks off each year. This after all is part of the job. Buyer beware.
So yes, I’m here to tell you that hospital based IR in a diagnostic group is hideously frustrating. I’m in my early 30s and I am having an early mid-life crisis. Really, this is an existential crisis.
Who am I? What am I put on earth to do?
You see, I sacrificed my 20s to get to where I am. While my friends were building their careers and enjoying their lives, I took out a $200,000 mortgage at 6.8% interest to fund a medical education. I found an innovative field of medicine which is in line with the future of healthcare. A field that seeks to provide minimally invasive treatments for a variety of conditions. A field that continues to evolve and remains in high demand. A field of almost endless opportunities. It’s a field that is now the most competitive field in all of medicine. You work hard, and you can make great things happen. That’s all I’ve been told during training.
I finally made it. Yet here I am, questioning my professional existence. Every morning, it takes significant will-power to get out of my car, change into my scrubs and get to work. I constantly listen to financial independence podcasts because I am looking for a way out. I am disgusted when I see my vascular surgeon waltz into our IR suite and start doing cases while I am relegated to the reading room to read CTs and MRIs. I am even further disgusted when my IR colleagues tell me to relax and just go with the flow because “this is just the way it is.” It pissess me off when my group leadership judges future IR candidates by their willingness to read diagnostic imaging and their ties to the area instead of their interest and aptitude in practice-building and interventional procedures. I am annoyed by my hospital’s insistence that we hire technologists based on the number of cases we do and not by the complexity or billing of each case. We do paracentesis in our fluoroscopy rooms because it makes “the numbers look good.” I hate taking Q3 call and not being paid to do so. I’m paid at the 25th percentile even though I know I am worth so much more, all because I had a genius academic neuroradiologist who I consider as my mentor once tell me that I shouldn’t negotiate my salary because I might lose my job offer.
You see, I am pissed. For a variety of reasons. It’s clearly unhealthy. I feel like I’ve been mislead and sold a bag of crap. Total crap. What’s worse? I really have no one else to blame except for myself.
I got myself into this mess because I blindly trusted people who I thought had my best intentions at heart. And it is now my mission in life to make sure no young IR ever gets into the same mess. I am literally making this my career mission. You see, I’m at the point where I really have absolutely nothing to lose other than a job I really don’t like. Thanks to diligent savings, moonlighting and living like a resident as an attending, I am now out of debt. I’m ambitious, I’m really loud and I’m going to get shit done. But are you?
That’s a hard question to answer. It’s so easy to be suckered into a road of mediocrity because the headwinds for our specialty, which are largely self induced, are so great. You really have no idea until you get out here and realize how ridiculous things are for a private practice IR who wants to actually be a doctor and not just a radiologist who does procedures.
What good is a high salary and loads of vacation time, if you have are not professionally satisfied? If you’re doing IR because you think it’s a good gig that’s conducive to a nice life with some of the highs of surgery without any of the inconveniences, GTFO right now. I don’t want to talk to you. I work harder than some of the surgeons in my hospital. IR is not a lifestyle field. I repeat, IR is not a lifestyle field.
Do IR because it’s innovative, impactful and extraordinary. Do it because it’s the best kept secret in medicine. Do it because you want to change this field and take it to the next level. Most importantly, do it for your patients who need your help.
Finally, if you are not doing 100% IR. You’re not practicing real IR. End of story. With that being said, 95% of all jobs out there are pure garbage. Some groups will have you doing higher end procedures. Some groups will have clinic. But all groups with diagnostic radiologists are more or less the same. Don’t be fooled.
Is the ACR going to fix this for you? Is the SIR going to fix this for you? No and no. The only person who is going to fix this for you is YOU.
This is literally a revolution. It’s only going to happen if you have the guts to get up and do something about it. I’m doing it. Are you going to join me?
Over the course of the next few months, I will unravel the pieces to this puzzle. We will explore the politics and money behind the private practice IR/DR existence and better understand why things are the way they are. We will explore the fallacy of academics and how our “thought-leaders” while well intentioned, are clearly failing us. I admit, while my private practice is at an extreme of the spectrum, the fundamental problems I face still exist for any IR practicing within a radiology group. I think the sooner we redefine ourselves as IRs and act like a specialty independent of diagnostic radiology, the better off we will be as a field. I will show you why. Let’s make interventional radiology the best field in medicine like it deserves to be.
Dear Dr Monkey,
Your passion is refreshing and invigorating, and your anger justified. You were told lies about the field you were entering, mostly by folks who don’t know any better because so very few IRs actually practice clinical IR. They are either in ivory towers and are clueless about the real world or are IRs in the radiology groups who read boatloads of films and do many med student procedures and an occasional interesting one; all while never doing a consult. Is that even ethical?
I have to disagree on one point. You wrote “I admit, while my private practice is at an extreme of the spectrum…”. Not true. Yours is a typical practice.
But here is the real issue: Who cares what the DR/IR groups do? If they are happy the way they practice then let them practice that way. The problem is that they will not let you on staff to independently practice as you see fit because of what they call an “exclusive” contract. It is a big lie. Most hospitals have numerous other specialists practicing endovascular and in the case of PAD most IRs are out of business. There is no reason you should not be able to get on staff and create a practice as you see fit like EVERY other specialty. All IRs should be able to CHOOSE whatever type of practice they want. In some cases they may make less money but that should be their choice.
Insurrection time?
Cheers, Lancelot
Dear Dr Monkey,
Your tone is appropriate and anger justified because you were sold a bill of goods about IR. You were told it was a great clinical specialty but in fact the only job available is a job in a DR group which largely relegates you to a technician performing procedures on patients you have never met and will never see again, and film reading (to boost your RVUs.). I would even go so far to say that most IRs practice unethical medicine in those type of ubiquitous nonclinical practices.
The key is to de-link IR from DR. That will eliminate the financial issues that drive many of the current DR/IR conflicts. It will also free up IR to pursue other financially viable practice models such as Office Interventional Suites which folks in DR groups frequently cannot do.
It is a waste of time and energy to try and “fix” a DR group. The key to success is being independent of DR and that means getting on staff at hospitals where IRs are blocked by the “pseudo-exclusive” contracts. Of course, every other specialty has no problem practicing endovascular at these facilities.
It is about CHOICE. An IR should be able to join a DR group or be independent. The SIR will not make that happen. You should join the OEIS (Outpatient Endovascular and interventional Society) which is the voice of Office Interventional Suites. They have a task force dealing with this issue; it is important to them because IRs cannot open OIS in most states without hospital privileges.
I disagree with only one of your points : “I admit, while my private practice is at an extreme of the spectrum…” I would say your is very typical
It is time for an insurrection! It is about CHOICE. You should be able to get independent IR privileges and create the IR practice of your dreams not what a bunch of DRs tell you you can do.
Cheers, Lancelot
Dr. Monkey,
As a PGY-2, soon to be 3, IR-DR Resident at a major west coast academic center – what you describe above is what I fear about my future. However, what inspires me is that the more I talk to trainees at my level, the more I realize that we all want the same thing. We want to be clinical IRs. We want to operate as a surgical sub-specialty, which we are. Everyone does procedures they don’t like – hopefully in the future, NPs and PAs can fill the void of paras, thoras, and simple lines like they do at some centers around the country – freeing us to do the things we want to do.
I’m inspired by the current wave of trainees, those that did not become IRs because they wanted to be DRs and then discovered they liked IR during residency, but those that chose IR during medical school when they could have chosen to pursue any field they wanted (Especially when you consider the caliber of the recent IR matches). They chose IR because they see and want all that you mention.
I think there is a growing groundswell of young talent that will push the field to the next level, not just at they large academic centers, but across all IR practices.
JuniorIRdoc,
I’m very excited about people like you entering the field. I just worry that the world today is not ready for your talents and motivations. It will be a long battle and changing the culture in many practices is not easy, as I’ve learned the hard way. I think it can be done and we need people like you to help make this change. It won’t happen overnight, but likely over a generation. You will not be financially motivated to make this change in many settings. Your older colleagues will look at you funny. It’s a very complicated issue and is not as easy as it may seem. I just want trainees to hear another perspective which I believe is more in line with the experience of many IRs, both private and academic. It will take special talent to work collectively to demand change.
I think the best we can do is stick together and help each other out. I’m rooting for you all and am going to do my tiny part to show what’s possible in our field beyond an academic setting. I love the enthusiasm among the new generation. It certainly drives me to speak out and improve my own practice. At the end of the day, IR is amazing when practiced the way you describe.
Thanks for the comment!