The IR Exodus

It has been 4 months since I opened my practice, Image Guided Solutions of Missouri. Our practice is growing nicely, but it has not been easy. Getting a new medical practice off the ground in a new community where people don’t know you or what you’re capable of is quite challenging. Thankfully, in the last several months, we have proven to patients and physicians in our area that we can offer services that are not readily offered in hospital settings, and we can do so efficiently, safely, and with favorable outcomes. We have been primarily focusing on vein and kyphoplasty cases while waiting for a new C-arm with a vascular package to be installed. We will introduce embolizations in March and hopefully grow from there to offer services for CLI patients. While the cases are fun, I spend about 75% of my time in the clinic. My clinic visits are long and detailed. We spend time getting to know patients and ensuring our name gets out in the community via word-of-mouth. This is a small place, and everyone knows everyone.

I have not made a dime from my practice yet. While I wait for January collections to be tallied, I anticipate that we will be close to breaking even. It usually takes most medical practices close to a year to reach that point, so I say we are doing ok; it is always very unsettling when money leaves your account faster than it comes in. It is also alarming when you realize that equipment, supplies, and labor are up to 30% more expensive than the last time I was in the outpatient setting in 2021. The final kick to the gonads is that everything I am doing now pays at least 15% less than it did several years ago. 

Keeping expenses low has been critical because the prevailing “wisdom” in the outpatient community has been leveraging things like marketing and technology to increase referrals. While exercises to increase volume may look very attractive from an Excel spreadsheet, I am learning that it is very easy to find yourself spending a lot only to have to work a lot to support that level of spend. The hamster wheel spins faster and faster, and before you know it, you’re finding yourself in a position where work is no longer enjoyable. Ultimately, that’s a position that I want to avoid.

Most OBLs cost over 1M to start up. So far, I’ve spent $80,000. Most practices require large loans. I’ve self-funded my business and intend to keep it that way. While I have saved up money from over three years of very productive locums IR work, in the absence of the ability to readily take call in my local community hospital (pseudo-exclusive contracts), I have had to resort to teleradiology to bootstrap my efforts; thus far without having to tap into my savings. These days, I do at least ten hours of teleradiology an average week and at least one marathon weekend of 30 hours a month to cover my business and personal expenses and continue meeting my savings goals. I also take call at the local academic center one Friday and the adjacent weekend each month (a “locums” arrangement), which helps. Between building the practice, seeing patients, and working after hours to support my 8-5 endeavors, I have pretty much no time and often find myself pretty depleted. It turns out that working 8-5 in what I love to do is what energizes me to get me through the relative drudgery of after-hours teleradiology work or a challenging weekend of hospital call to support that existence in the start-up phase. 

This has made me think hard about our field and our future. Being involved in both short and long-term staffing with Physician Staffing Solutions and Travelier has kept my finger on the pulse of IR nationally and seeing where peoples’ heads are. Every week, I encounter at least one new IR choosing to leave traditional employment to enter the world of independent IR. The combination of locums IR plus teleradiology has become quite hot, and having been involved in both worlds, I can see why. Traveling for work is challenging, and while I could do so pretty intensely for three years, I also found myself at a unique point in my life where I could do that. Heavy-duty travel is possible for folks earlier in their career or later. However, doing so with any semblance of a home life with responsibilities for human or animal beings is quite tricky. For that reason, I am noticing that the most sustainable arrangements tend to be folks willing to travel 1-2 weeks a month who then choose to spend 1-2 weeks either doing work locally or doing teleradiology should there not be a suitable IR position in their local community. This combination can be very lucrative, generally on the order of $60,000-$100,000 monthly, with minimal expenses. The likelihood of replicating that level of financial success in an independent OBL practice is very slim, no matter what you may hear out there. That is probably a level of financial success I would achieve at peak efficiency within the next 3 years, provided reimbursements don’t nosedive by that point. 

Unfortunately, for every person moving from a traditional academic or private practice position to a life of independent contracting, there seem to be two IRs who leave interventional radiology for teleradiology. We are facing a crisis in our specialty. The IR mass exodus is here, and we only have ourselves to blame. Having the option to leave IR to do teleradiology is another example of how DR optionality hurts the future of clinical IR practice. 

Some people may look at my experience and wonder, isn’t it great that I can do teleradiology to support my IR practice? In many ways, the answer is certainly yes, but unfortunately, as long as that option is there, the majority of people will choose this path for their primary source of income because the one that I am taking is insanely challenging. Unless there’s nothing else you’d rather be doing in life, using that income to fund an IR business isn’t realistic for most. 

Ultimately, my teleradiology days will come to a close when the income I derive from my practice meets or exceeds what I could generate from doing teleradiology, which generally varies between $400-$600/hour, depending on the time of day. Even then, I would be choosing to leave an opportunity with defined rates per unit production to focus on a line of work where payments are never guaranteed, and there is constant non-clinical work required to merely have the opportunity to generate income that will likely continue to diminish each year. All of this in an environment requiring significant overhead in terms of labor, capital equipment, and disposable supplies, with all of these factors getting more expensive over time. 

So why even do IR anymore? I chose to do it because I do enjoy it. I love outpatient IR and what we can do for patients. What we do is truly magical; I’m reminded of that daily. Given time constraints and the many layers of bureaucracy in large healthcare systems, I think most patients don’t have positive interactions with the medical system. An outpatient IR practice can eliminate those bureaucratic layers and improve communication and treatment adherence, ultimately leading to more successful outcomes. What we can offer is underappreciated and underrecognized. While the economics may be challenging now, the ones who genuinely enjoy this work will only tend to be fulfilled by doing this work. And if you’re going to do it, you need to be the best at it because, in the future, superior outcomes at a relatively lower price point will win. As painful as it is to say goodbye to a potential seven-figure guarantee, I know over the next 10-20 years, the current play will be more satisfying for me. I fear that there aren’t enough in our community who feel the same way. The only way to change that is through recruitment and education.

Ultimately, all roads lead to the elephant in the room: our diagnostic radiology board certification. The sooner we can all let this go, the sooner we can unlock what should be a bright future for IR. Meanwhile, the IR exodus will continue.