Defining Our Culture

I was recently invited to write an editorial for the American Journal of Radiology about why IR needs to split from DR. I was a bit shocked that someone from the editorial board reached out to me and even more amused that they contacted me via my blog account (linemonkeymd@gmail.com). Long-time readers of the blog and even people who know me from before the blog days know that I’m a pretty passionate individual, and I’ve for a long time believed IR should be separate from DR. This blog post from last year best conveys my feelings regarding this subject. 

The hard part of me writing an editorial is the 1,000-word limit. Anything short of 5,000 words on my part is a true accomplishment. Also, about the topic of IR separating from DR, I will be debating Dr. Alan Matsumoto regarding this subject at the upcoming Southeastern Angiographic Society (SEAS) meeting in Amelia Island, FL in October. For those who haven’t attended a SEAS meeting, it’s a great laid-back meeting with a mix of IRs, both in private practice and academics. I highly encourage you to check it out. I look forward to golfing with the luminaries and taking their money.

Ironically, the further I’m removed from training, the more academic exercises I seem to become invited to partake in: writing, speaking, mentoring, and participating in research and various society committees. I state this not to brag because very few truly envy the uncompensated homework I seem to create for myself as I make the transition from assistant to associate professor of self-employment, but to demonstrate to others that speaking your mind is so important if you wish to see a change in your profession. Despite seemingly condescending criticism from one individual, many people seem to think my mission has “legs and ears.” 

As I go about crafting this opinion piece for AJR, I couldn’t help but address what I think is the root of our identity issue in IR. No, it’s not pseudo-exclusive contracts or site-of-service, despite my advocacy for outpatient IR and my strong agreement with vocal individuals discussing these problems for decades. The most crucial factor is relatively mundane yet vital. It is embarrassing that it took me close to five years of my career to realize that this factor matters more than anything else. That thing is culture. 

I often find myself at odds with interventional radiologists who work for radiology groups. I worry you are using your megaphone to spread the wrong message. This one reader engaged me in a very entertaining and thought-provoking conversation that got me thinking. This person is a leader in a large subspecialized radiology group with what they would perceive as a “clinical interventional radiology” service. And by all accounts, it sounds like they have a nice practice, so I would firmly categorize their group as the less than 10% of radiology groups that are “good groups.” This person feels practicing higher-end IR in a diagnostic setting is possible. I often argue with people about this point, not to prove that they lie to themselves about their existence, but to point out the absurdity of what they had to accomplish to fit what was once a square peg (maybe) into a round hole. They don’t hear the 9/10 people who may grow frustrated and disenchanted trying to change a culture that doesn’t want to be changed. While the Founder Mentality is vital to creating a new practice, being stubborn will not always work.  In IR, we do a poor job of supporting embattled IRs by blaming them for being unable to accomplish the seemingly impossible in environments not conducive to their vision. Perhaps a little less flexing and more listening would go a long way. 

Culture matters. You may hear about this in CEO groups or YouTube clips from business leaders. As I have gone down the road of independent IR, I’ve been exposed to business ownership and the requisite lessons of leadership that emerge from such endeavors at a relatively early stage in my career. Having gone through a job with a DR group, creating an OBL with a cardiologist where I learned some tough lessons about leadership, then transitioning to full-time locums with exposure to some incredibly well-run practices in both hospitals and OBLs and now preparing to make another transition this fall as I enter a phase of establishing roots in a new community, I’ve concluded, not all that different from what you hear famous business executives and luminaries state: leadership influences culture and culture matters. 

What is the culture of radiology?

Radiology focuses on being a doctor’s doctor and not necessarily a patient’s doctor. The emphasis has always been placed on imaging orders and excellent reporting with a draw towards technology and innovation. Those interested in procedurally applying these skills gravitated to interventional radiology. The concept of longitudinal clinics and rounding services were relatively uncommon. Why would one be interested in that? After all, we are radiologists, right?

The culture of radiology has many practical advantages. Radiology culture values working efficiently. The culture is one of working smarter, not harder. Radiology culture focuses on servicing an imaging contract through timely reads and appropriate staffing to accomplish that goal. Radiologists, in general, tend to value their time off. As a field, radiologists have some of the best vacation time compared to most in medicine. Much of this is rooted in the fact that the radiology business model is derived from a culture that values efficiency. Radiology leaders perceive interventional services within a radiology culture as a relatively inefficient value-add proposition to help make what has been made an increasingly commoditized product in imaging services more sticky. 

What is the culture of interventional radiology?

Interventional radiology emerged from the field of diagnostic radiology. As little as five years ago, when I was finishing my training, IR was still a fellowship of diagnostic radiology. While it is now a primary specialty, it is functionally still treated like a fellowship. Most practitioners of interventional radiology grew up in a diagnostic radiology department. As such, to this day, the culture of interventional radiology, even in the most progressive departments and practices, is rooted within a radiology context. Most interventional radiologists work within radiology divisions and are perceived by other specialists, hospital administrators, and payers as radiologists. Furthermore, all trainees now undergo a training pathway that still affords them board certification in both interventional and diagnostic radiology, which will likely tether them to some radiology infrastructure as attending physicians.

Two cultures are present in what we know as interventional radiology: the procedural radiologist and the endovascular and interventional surgeon. Shamit Desai, a “privademic” interventional radiologist in Chicago gave a wonderful talk to a large group of medical students discussing some essential truths about our field at the recent SIR 2023 Annual Meeting in Phoenix. I’d like to share one of his slides which is spot on:

Interventional radiology, in the most commonly practiced pattern, is procedural radiology and deserves to be labeled as such. It has been dressed up in lovely ways, such as consults within the EMR or the addition of half-day clinics every week, which are mostly glorified pre-op clinics, in even the most perceived progressive hospital-based practices. Still, as long as the business model of departments is rooted within a radiology context, the culture of a department likely hasn’t changed, and most early career IRs, particularly within private practice, come to the same harsh reality that I came to over four years ago when one realizes that many of us end up in a culture that doesn’t support how we’d like to practice. The concept of the IR Startup has been explored on this blog before, and the notion of a product-market mismatch needs to be taken seriously by those responsible for training the next generation of interventional radiologists and those with the political power necessary to push for change. 

To evolve as a specialty and realize our greatest societal impact, we must focus our collective efforts on fostering the development of a standalone specialty that supports the future endovascular and interventional surgeons. That begins with defining a surgical practice pattern and culture. What does a surgical practice pattern mean for the endovascular and interventional surgeon? In practice, it means focusing on the longitudinal management of disease states where clinics fuel our operating rooms. Any episodic care is rooted in true clinical consultations and follow-up in the hospital setting, even for seemingly mundane things I proudly label as trash. Practitioners in this culture value developing meaningful connections with their patients. Disease state expertise and the non-procedural management of patients are equally as important as the innovative, minimally invasive image-guided procedures we can perform. From a business standpoint, this model is not novel and is achieved through hard work, which radiologists describe as relatively inefficient. In some instances, surgical practice patterns may have 30-40% of their revenue, or more, be driven by evaluation and management coding. The nature of direct patient care is unpredictable, and there are undoubtedly easier ways to make money, but we do it because this is what drives us. While we love doing great cases, these potential technical feats of excellence are merely the rewards of caring for patients and being their doctor. Direct non-procedural care always comes first, which is the point of adopting a surgical mindset. 

Is a surgical practice pattern not possible in a radiology group? There are certainly “good groups” out there who have figured this out. Still, it seems that all of these groups have an inherent tension between diagnostic radiologists and endovascular and interventional surgeons when one digs deep and asks hard questions. Here are common sources of tension for these groups regardless of how high functioning or seemingly harmonious they may seem:

• IR services are relatively devalued in a professional fee-only business model.
• IR services are offered to a hospital at little to often zero added cost to the hospital.
• IR service line growth is intentionally limited for fear of upsetting other surgical or medical subspecialists with competing procedural offerings.
• Generational differences in perception of radiology or surgical practice patterns among IR partners may create internal friction and ultimately weaken a group.

There is nothing inherently wrong with the culture of radiology when it comes to providing diagnostic services. We need quality radiologists in all communities, though these days, they are more likely to work from home than in an actual healthcare facility. Diagnostic radiology can be an exceptionally satisfying career for the right individual. It is likely a fantastic career choice for the majority of current IR practitioners who were trained in a radiology culture, spend a significant proportion of their time performing diagnostic interpretations, and do not want to sacrifice their current income or lifestyles to focus on the work necessary to build a surgical service. For many of us who are endovascular and interventional surgeons, we may enjoy learning about diagnostic radiology or appreciating the parts of diagnostic radiology which are relevant to our clinical practice. We may even tolerate it as we partake in diagnostic radiology to fund our standalone IR endeavors. The problem is that introducing a primary certificate that openly acknowledges the value of a surgical practice pattern creates a new culture that is forced to operate in a larger radiology culture with which its at odds.

Furthermore, trying to function in this new culture within a greater healthcare landscape that still expects interventional radiologists to be radiologists creates tremendous frustration for the early career endovascular and interventional surgeon. And of course, it is easy to get angry about this because there is no ready solution for the problem other than the expectation that trainees themselves will change the field for the better. While I agree that training is the most important way to change our culture over a generation, most trainees are coming out of residency with multiple six figures in educational debt and are fearful of rocking any boats which may put their livelihood in jeopardy. While we need true IR warriors, we also need political action and support from key stakeholders in our field to match the energy and enthusiasm of the new generation who are working hard to create a culture that will support the existence of a new standalone specialty. Meaningful change can only happen with other leaders in our profession advocating for this change and creating structural changes married with sound business principles, which will readily allow for a better product-market fit. This begins with our leadership understanding that our field will forever have a division unless we have a common culture that binds us. 

Right now, that common culture does not exist. As trendy and well-intentioned “inclusion” is in our professional society, I would argue that we have been far too inclusive regarding the culture of our profession. Before you cancel me by confusing my words for discussion about DEI, what I mean is our professional society has intentionally chosen to be a home for “all IRs.” In doing so, it has, deliberately or not, supported the status quo of the IR functioning within a radiology culture. Unless we formally define the culture of the endovascular and interventional surgeon and make this the cultural expectation for practitioners in this unique field which deserves its own specialty recognition, we will continue to have the following problems:

• Loss of market share in both “red-ocean” services like peripheral vascular disease care and venous thromboembolism in addition to seemingly safe “blue-ocean” services like embolotherapy.
• Pseudo-exclusive contracts that restrict true endovascular and interventional surgeons who choose to practice independently of radiologists. 
• Difficulty competing with surgical disciplines in recruiting talented medical students most apt to succeed as an endovascular and interventional surgeon 
• Frustration among the growing number of younger well-intentioned academic leaders who feel limited by functioning within a radiology context and providing novel training pathways for residents.
• Perpetually trying to prove the value of interventional services to payers and hospital administrators who view us as radiologists.
• More interventional radiologists functioning within an IR Hospitalist practice pattern. 
• Moral injury among a growing number of young endovascular and interventional surgeons who will lack support for the fuel that will light their fire: a real clinic. 

Even among endovascular and interventional surgeons, there tend to be many arbitrary divisions: academics versus private practice, hospital versus outpatient, radiology group versus independent…and more. While it is easy to get distracted by all these divisions, we don’t evolve as a field unless we focus on the one thing that all modern endovascular and interventional surgeons have in common: our belief that practicing with a surgical mindset is our guiding light. We have a tremendous opportunity to redefine our field by focusing on the common thread that binds all passionate about our specialty. 

How and why should a professional society partake in the development of what should ideally be a standalone specialty? Without the backing of a professional society, the push for standalone endovascular and interventional services will never gain widescale legitimacy with healthcare systems, payers, and the public other than what some can accomplish on a local level or what “creative” individuals accomplish through shady financial arrangements. We do not grow this unique field and have the positive public health impact that we could unless we organize and rally around a culture that is truly distinct from procedural radiology.

Endovascular and interventional surgeons need a society that has their back and is just as fearless as they are when doing the right thing for patients. It would behoove the Society of Interventional Radiology to understand this unique and growing culture within interventional radiology and to understand that this path is the future of our field. Leaders in our society have spent too many years not taking a firm stand on the future direction of our field by taking the easy political play in favoring the status quo of radiology over the growing dynamic culture of endovascular and interventional surgery, which will propel our specialty to new heights. While the society has done some excellent things like producing more business-related content and doing a wonderful job with political and payer advocacy, it conveniently dodges the difficult issues I raise on this blog. Until it does that, all things IR will remain local, and we will never have widespread success as a specialty.

It would also behoove those like me who are just as frustrated, if not more, as I sense from many offline discussions with many of you, to participate in the society and make your voice heard. I criticize the society all the time, but I still donate to SIRPAC, participate in the mentorship match, and create content for the annual meeting in addition to the Early Career Section. I have absolutely zero career incentive to do any of this but do so because I feel it is the right thing to do to bring about the change I’d like to see. 

I understand that some out there believe what I am pushing for is a lost cause and that they are tired of any noise I and others like me generate regarding this topic. Often this manifests in comments and critiques about me as an IR, questioning what I’ve accomplished and what I’m doing in my current IR practice. Some think it would be better to transition my content to daily affirmations and focus on building my desired OBL practice. Some don’t care if our specialty continues to erode as long as they get to do what satisfies them, particularly from a financial standpoint.  Many of these individuals fail to realize that I am on my own unique path as an endovascular and interventional surgeon with goals that transcend being successful in my own practice. Anyone who knows me well knows exactly what I’m up to and accomplishing. I’ve been documenting it on this blog and am proud to know that I’ve positively impacted numerous IRs at various stages of their career over the last several years. I’ve done so out of an abundance mindset with zero financial incentive. If we can uplift each other and I can play a role in that process, then I absolutely will. I want to see this field move in a positive direction but with some sense of urgency. I appreciate you making it this far. Please comment below.