Peripheral Arterial Disease and The Culture of IR Training: The Academic Fallacy

If you haven’t already guessed it, I’m a huge nerd. I’d like to consider myself a scientific dude that tries really hard to practice evidence based medicine when possible. While this is probably easier to do in cardiology where large randomized trials with cute names exist for the handful of conditions they treat, it is harder in a field like interventional radiology where data for the incredible breadth of our procedures is relatively lacking. Nonetheless, we try our best and stay true to what we know and take calculated risks to help our patients based on the experiences of others and using our intuition.

One of the things that actually attracted me to interventional radiology, asides from the cool toys and evolving technology which we use to do awesome procedures is the fact that this is a nascent field with respect to outcomes research. This was an area I studied as an undergraduate and medical student. I carried on with research well into residency. The potential of interventional radiology from a research perspective, outside of the growing context of new medical devices and emerging therapies, but from an outcomes standpoint including the need for cost-effectiveness data is exciting. This is the work that we as a field need to do to prove our value. We all know we are valuable, but it’s never real unless it’s published.

With that being said, everyone I knew thought I was destined for academic greatness. With multiple first author publications, podium presentations, a real passion for hearing the sound of my own voice, academics seemed like a good fit for me. Well, it seemed great until IR mini-fellowship in residency and subsequent IR fellowship made me think twice about this career path. 

First, I fell in love with clinical IR. Actually translating science into practice is fun. Discussing procedures with patients and their families, explaining the evidence behind what we do and confidently reassuring them that we are there to help made me excited. I actually liked IR clinic. Then, crushing the procedure, which is like a high stakes video game, and spiking the football when you have a good outcome…it’s one of the best feelings. It was probably after the first uterine artery embolization I did and the subsequent clinical follow-up where I realized that my real passion is actually taking care of patients. Sure would be cool to combine the clinical passion with an academic interest, right? So why not academics?

I learned in residency and then in fellowship that the IR who does UFE, doesn’t do prostates. The prostate person doesn’t do oncology even though they want to because it will piss off the oncology guy. The onc dude doesn’t do kypho because it isn’t interesting. The kypho person doesn’t do venous malformations because there’s already a person for that. Subspecializtion in most centers is kind of out of control. 

Despite hyper-subspecialization, one thing academic attendings had in common: lack of a true clinical mindset. They were not aggressive in growing their practice because it was largely pre-built and they were not interested in crossing lines which may result in political conflict. Things are the way that they are and that’s the way it’s going to be. These academic practices, while doing great cases, still largely did commoditized procedures. Lines, tubes drains etc compromised the far majority of their practices. I did 400 central venous catheter insertions as a fellow! 

I think what frustrates me more than anything was the lack of real clinical training I had in IR. Both my residency and fellowship were on an “order-based” system. Largely a “you pick em we stick em” sort of deal where technologists ran our board and real consultations didn’t happen. In fact, E&M billing was in its infancy in my fellowship. In residency, I was the first trainee to ever go to clinic because I simply asked for it. You want to give up a procedure day for clinic? Suit yourself… My fellowship was thankfully more advanced in that respect as we did have a robust outpatient clinic, but I had to push really hard to go more than twice a month. The way I saw it was I needed to go to the clinic so I could evaluate patients, develop good habits and really get in on these high end cases. I can’t say all other trainees felt the same way. There was very much a mentality of “oh I’d rather just do these cases that fall in my lap then I’ll go home.” Sounds like some old school stuff, right? Unfortunately this was in the years 2016-2018. 

And honestly, I can’t blame some of my friends who adopted a passive mentality, because this is the prevailing mindset of the majority of interventional radiologists. At the end of the day we are still radiologists and this is how we train. We are ordered to do things. We bitch and moan about what we do, but we are more or less commoditized. 

So here I was in August 2017. A motivated IR fellow with an aggressive mindset looking to grow a practice. I was fortunate to be offered two contract offers: one from my local private practice and one from my fellowship institution. With little hesitation, I took the private practice offer (even though the money difference, believe it or not, was not significant), because I saw an opportunity to build a practice and evolve as an IR.

More than two years later, even though I hated the structure in which I practiced, I do not regret the decision. I think I could have been smarter about certain things including contract negotiation and exploring other avenues of practice such as non-radiology based practices and office-based suites, but on the whole with the information given to me at the time, that was absolutely the right decision. Despite all the crap I dealt with including Q3 call and an endless line of dialysis patients requiring declots, I grew a small, but robust practice in 18 months on the job and have developed skills that I did not have as a fellow.

I’ll tell you what though, as I look back I am more pissed than ever. I am annoyed by the lack of career guidance, clinical instruction and modeling of practice building behavior. But the biggest lie I’ve ever been told, just infuriates me to no end: peripheral arterial disease is gone. 

In residency, this is what they told me: We don’t do any peripheral arterial disease treatments in IR. Our surgeons and cardiologists do those. We have plenty of other great things to do like interventional oncology and portal hypertension interventions. Those skills readily translate to PAD work.

In fellowship, this is what they told me: We trained our vascular surgeons to do endovascular work about 15 years ago and since they control the patients, they do the procedures now. We focus our efforts on other things. Don’t worry, you’ll spend time with them and obtain important skills. Most IRs don’t do this line of work anymore. Interventional oncology has really grown and will be IRs focus moving forward.

Here’s what they both told me: We have a TERRIFIC relationship with our vascular surgeons. We have a joint conference every week. 

Let’s lay down some facts:

• According to the CDC 8,500,000 Americans have peripheral arterial disease. Many feel this is a gross underestimation with some placing 20% of the population with peripheral arterial disease. 
• The prevalence of critical limb ischemia is approximately 2 million and will likely continue to climb with the increasing age of our population and associated risk factors. Also, likely an underestimation.
• According to the American Cancer Society, there will be 42,810 new cases of Hepatocellular Carcinoma diagnosed in 2020. HCC incidence has tripled since 1980 and is expected to increase until 2030. 

Here are some “facts” from my IR fellowship case log at a top academic institution:

• 19 lower extremity arteriograms and interventions performed with vascular surgeons. No atherectomy. No pedal access.
• 56 interventional oncology interventions including 30 chemoembolizations, 11 radioembolizations and 15 thermal ablations.

Now, let’s lay down some observations:

• Unless you live in a city with a strong private practice oncology presence or your practice services a prison facility, interventional oncology work is largely tumor board driven and will be controlled by academic medical centers.
• Peripheral arterial disease work, while commonly performed by cardiologists and vascular surgeons, is a much larger pie with many patients going untreated or undertreated each year.
• Many operators lack the technical skills required for below the knee revascularization to prevent amputations in patients with critical limb ischemia. 
• While PAD can be technically challenging, the clinical management of patients, including the decision making with respect to performing or not performing a procedure is often the most difficult part of taking care of these patients. 
• Interventional radiology trainees are conditioned to believe that PAD work is either not exciting and/or not possible due to market trends. 
• These wonderful joint vascular surgery and IR academic conferences are rarely if ever attended by IR faculty.

Ok, now I’m going to take the gloves off and explain things the way I see it:

• Interventional oncology has exploded in academic departments because patient selection and “clinical management” is largely algorithmic and spearheaded by medical oncologists. This lends itself to high paying order based interventions like transarterial embolizations or thermal ablation. Are the labs appropriate? Do the lesions fit imaging criteria? Great, let’s get them on the schedule…
• Academic interventional radiologists do not have the bandwidth (or clinical knowledge) to take on complex and sick peripheral arterial disease patients without sacrificing other potentially high paying procedural work with less political implications. PAD work, especially CLI, is often a thankless job requiring significant clinical work and multidisciplinary coordination without a formal academic tumor board like setting.
• Academic interventional radiology division chiefs are afraid to hire ambitious interventional radiologists to grow PAD either in conjunction with other vascular specialists or independently because of arbitrary political divisions (i.e. playing nice in the sandbox). 
• IR and vascular surgery relationship in the academic setting is largely bullshit and does nothing to strengthen the training of either vascular surgeons or IRs. Vascular surgeons in academic centers on the whole lack the catheter skills necessary for high end below the knee CLI work (there are some excellent endo VS operators out there! They’re in the minority still). IRs lack the balls to grab the bull by the horns and actually take care of patients. Both could benefit from each other, but politics and money tends to get in the way because why would a vascular surgeon want to concede high paying endovascular work to a clinically weak IR? IRs can bitch about training vascular surgeons, but that’s the fault of dinosaur IRs who didn’t have the insight to think about what would happen if they didn’t actually take care of their own patients. 
• PAD work, especially in office based suites, pays incredibly well and is almost mandatory for an IR office to thrive. Unless you want to turn into a dialysis access center, PAD is important to make the numbers work. Office based work on the whole is critical for IR to thrive as a clinical specialty independent of diagnostic radiology, given current reimbursements. 
• The only way to succeed in PAD work as an IR immediately out of fellowship is either go to one of the 5 IR fellowship programs that actually does this work, or learn on your own from growing your own practice and seeking mentorship from outside of academics. And of course, why would you do this unless you were incentivized to do so, or are like me and are on some crusade?

The culture of lost peripheral arterial disease work has now become so ingrained in the fabric of academic interventional radiology divisions that young IRs don’t even think about PAD. Let me tell you a brief story. As a confession, this Line Monkey is still a member of the Radiological Society of North America. Not too long ago, I self identified as a radiologist. I have since lost that identity as I found my true calling in life during fellowship and the first few months of attending hood. Nonetheless at the recent annual meeting, I went to my residency’s happy hour in a fancy Chicago hotel, fitting for faculty of a residency program that is self perceived as the best. I had an opportunity to catch up with one of the junior attendings from residency who helped train me. He’s a nice guy, but he’s kind of full of himself. He probably thinks the same of me. I told him about my job and some of my gripes with my own training. His response: “I’m sorry you feel that way. Our graduates have gone on to create successful peripheral arterial practices. I don’t do PAD, because I’m not interested in it. I have better things to do with my time.” Well, dude, I’m not interested in doing gastrostomy tubes, but I still need to learn how to do them! When I pointed out to him that the majority of his recent grads (my friends!) practice less than 50% IR in community hospital based private practices with very little to no PAD, I challenged him by asking: do you know what it’s like to be in private practice? “Umm, I guess not…good catching up, I need to go chat with the abdominal guys over there about this project we’re working on…”  

In many ways, most IR graduates are doomed for failure as an independent clinical practitioner. We are lacking the clinical skills and knowledge needed to compete with our cardiology and vascular surgery colleagues. To me, the academic IR community as a whole is to blame for not having a clear vision for their trainees when they go out into the real world and are faced with the reality that the peripheral arterial disease pie is simply larger than the oncology pie and is critical in order to get paid so we can grow practices independent of diagnostic radiology. I don’t say this to discredit oncology whatsoever. That work is important and is difficult in its own right! I did some oncology interventions in my hospital based private practice job and it was challenging. I bring this to light simply to say that we are doing our trainees a huge disservice by not practicing peripheral arterial disease as interventional radiologists in academic settings where the goal should be to model the behavior necessary to groom the next generation of clinical interventional radiologists. So yes, let’s get super excited about our new independent specialty and promote a clinically oriented training paradigm then do absolutely NOTHING to really train our students in a way that will actually be beneficial to them when they are charged with the daunting task of getting it on their own. 

And therein lies the academic fallacy. 

Peripheral arterial disease training, or the lack thereof, is really a symptom of a greater problem which isn’t necessarily unique to just academic IR practices.  And that problem is radiology. Most IR divisions are part of a larger radiology department often with diagnostic radiology leadership. Radiology departments make a living forging strong alliances with other clinical specialties because they simply cannot exist unless other physicians order studies! This is also how most academic and private interventional radiology departments still function. The majority of work being done in these divisions are still “orders” that are coming from other services. Oncology interventions masquerade as clinically driven work, but they are basically glorified orders from medical oncologists based on tumor board recommendations. Lower extremity angiograms were once upon a time order based interventions. Now those who control the patient flow (cardiologists and vascular surgeons) know how to do these procedures, so why would they ship them out? So let’s get this straight. As a radiology department you specialize in customer service. One of your customers doesn’t need you anymore. I guess you just go and get new customers, right?

And that’s exactly what IR departments have done nationwide and largely to great success. There is so much that can be done in IR from high end portal venous interventions, interventional oncology, fibroid embolizations, prostate embolizations, vascular malformations, fancy and not so fancy enteric access and central venous access procedures etc. Who cares if PAD is so lost? IR is so well diversified in a theoretical sense, and it keeps inventing new procedures. 

The problem though isn’t about procedures. It’s about patients. When IR lost PAD, they never really lost anything, because it wasn’t theirs to begin with. The same goes with just about every line of work that IR specializes in. Patients primarily don’t belong to IR or any field really. IR is a technical based specialty that is trying so hard to become clinically based but suffers from a fatal flaw: no true clinical identity. I guess you can say the one unifying thing about IR is that all IRs agree that not having a defined clinical identity is in itself an identity. 

Radiology is a technical field. Radiology is what makes IR unique, yet it is the same thing that keeps it from advancing as an independent field. It’s a complicated relationship that drives me crazy. I love being a radiologist because I have trained hard to learn so much cool stuff from head to toe.  At the same time, I hate it because it keeps me from becoming the kind of doctor I’d like to be. I would venture to say that IRs my age want to function like surgeons! 

Despite our unique and complicated background, IRs can and have succeeded as independent practitioners. Often this is outside of academic settings where red tape is less burdensome and IRs may be able to take their shot. This involves thinking and acting like a surgeon. It involves being clinically minded and taking charge of patients’ care. It requires going from an order-based mentality to a consult-based mentality. This is where we are going as a field. In most settings, this will likely involve divorcing from a radiology group all together because the missions of clinically driven IR and diagnostic radiologists seldom align. 

Yet how is any of this possible with our current training paradigm? We are conditioned from a young age to think like radiologists, because that’s who we are at our core. We as a field are promoting a future of clinically driven interventional radiology, yet we spend little if any time during training in IR clinics that actually work-up patients. Instead, trainees are being farmed out to surgeons and medical specialists for their “clinical training.” How can we promote a future of clinical practice if our academic “thought-leaders” aren’t even practicing in this fashion?  Can you look at this monkey in the eyes and tell him that academic IR programs are setting up our field for a future of success? Maybe there are a few programs out there that do (arguably the ones that still do PAD work), but I’d contend the far majority do nothing more than teach our trainees how to be good citizens capable of doing largely commoditized procedures without any real clinical backbone. Is this what we really want for the future of IR?

And here we are in 2020. Interventional radiology is the most competitive specialty in all of medicine. Every region has fancy medical student symposia where faculty IRs give talks about their practice. There are so many trainees working incredibly hard to match into these IR residencies. They are banking on a future of endless opportunities. 

I think this is fantastic for the future of interventional radiology. We all obviously want the best and brightest students in our field. But the real truth of the matter is we not only want them, we damn well need them. We need these brilliant individuals to survive. We need them to keep inventing new procedures so we can stay relevant. I wonder how many academic leaders are willing to admit that to their students. 

I personally think we need the best students in the IR to not only innovate, but to advance our field from a philosophical standpoint. We need a future of clinically aggressive, technically competent, business-minded physicians to change the way we practice. They need to be willing to go against the grain and forge a new path free of diagnostic radiology. This will undoubtedly involve more work and professional uncertainty than any other field a brilliant student could match into. If this were common knowledge, why would IR be the most competitive specialty? 

Most academic IRs sell Kool-Aid that is tasty, but really should not be consumed for those looking to practice IR the right way. Many of my friends are academic IRs and I do respect them. Unfortunately, their system promotes false advertisement that would make used car salesmen blush. We can and should do much better.

So to anyone in academic IR reading this, thank you for teaching this Line Monkey valuable skills. Apologies to the few in academics who go against the grain to practice IR in a progressive fashion. To the majority who don’t due to lack of interest, skill, desire or concerns for their own professional well-being given their local political environment, please think long and hard about what I’m posting here. Our future as a field is dependent on your actions.

And to the students and residents reading this blog, I don’t mean to scare you away from IR. It really is the best field in medicine, but only if you work hard to make it that way. This means demanding excellent clinical training from your academic faculty and seeking mentorship beyond traditional academic centers. It’s time to change the game, and only you can do that. It won’t happen on its own.