It’s probably time for an update on my OBL practice (www.igsmissouri.com). We are coming up on two years now, which is somewhat hard for me to believe. When I started, there were plenty of doubters. Some were subtle about it and others were pretty direct. I heard all the reasons independent outpatient IR in Columbia, MO wouldn’t work. The procedures wouldn’t be enough, referrals wouldn’t come, patients wouldn’t find us, hospitals controlled the patients, and you couldn’t build a real clinical IR practice outside of the traditional system. I was taking too much risk and leaving too much money on the table. Why not just take a nice employed job and stop trying to make everything so difficult? I took receipts. They’re laminated.

Two years later, here we are. We remain open four days a week, treating comprehensive venous disease, vertebral augmentation and ablation, embolotherapy, and now starting to build out CLI work. I generally see 30–40 patients in clinic every week and operate two half days. The practice continues to grow and financially it has exceeded anything I imagined when I started. My locums days no longer seem financially attractive. More importantly, we built the kind of clinical practice I wanted to build. For those who told me it wouldn’t work, I don’t really have much to say. The results speak for themselves.

The point isn’t that I am some business genius because I most certainly am not. The point is that physicians, and IRs in particular, dramatically underestimate what is possible when you stop waiting for somebody else to build your practice for you. I didn’t need a hospital to somehow discover a secret population of patients and hand them to me. We made ourselves available, built clinical programs, treated patients well, followed them, developed relationships and solved problems. We continued to remove barriers between the patient and us and, amazingly enough, patients came.

None of this has changed my opinion about employment. I thought employment was a terrible bargain before I opened the practice and I still think it is a terrible bargain today. And those who know me realize I’m sugar coating how I really feel because my true feelings would get me cancelled. Anyone who has followed this blog knows that I have been encouraging entrepreneurship and ownership in IR for years, so please don’t interpret this post as some newfound epiphany after two years of practice ownership. If anything, what I now have is a real-life experiment showing me what happens when I take the same effort I would have put into somebody else’s organization and put it into something I own. That has made it much harder for me to look at hospital work the same way. Furthermore, it’s not my first rodeo. I built up a very successful practice in an even more saturated and consolidated market two years out of training. Clearly, this is something that is very much possible despite the challenges.

Lately I have been thinking about hospitals quite a bit. On the surface they act like terrorist organizations. I remain very active with SIR, so here comes the obligatory disclaimer that these are my opinions alone and do not represent the Society. I am but one voice, and I remain a strong advocate for independent outpatient IR. There has been a tremendous amount of work within SIR and elsewhere demonstrating the value IR brings to hospitals and healthcare systems. We shorten length of stay, provide minimally invasive alternatives to surgery, support almost every other service line in the hospital, prevent transfers, treat emergencies and generate substantial procedural and downstream revenue. I support the work being done to quantify all of this, but I am increasingly questioning why we spend so much energy trying to convince hospitals of our value in the first place.

Recently, I have been talking with a local hospital about providing IR services one day a week. It is roughly a 200-bed hospital, part of a larger regional system that has not had a good history retaining IRs, and currently has part-time IR coverage. It seemed like something that should be pretty easy to figure out. They need IR, I am thirty minutes away, and I can provide services that are not consistently available there today. We talked, negotiated and ultimately could not agree on compensation that made sense to me.

Normally I would just chalk this up to a hospital being cheap and move on with my life. The problem is that I have now seen essentially the same thing repeatedly. I have seen it negotiating locums contracts for PSS, negotiating hospital contracts for Travelier, and now personally. At some point you stop looking at these as isolated negotiations and start wondering whether there is something more fundamental going on. There seems to be a remarkably consistent ceiling to what hospitals are willing to pay physicians, and that ceiling often has surprisingly little to do with the actual economic value being created.

Before getting into why I think that is, we need to talk about what clinical IR actually means because I think this is where a lot of the discussion about our “value” gets confused.

CLINICAL IR IN THE REAL WORLD

When we talk about demonstrating our value to hospitals, we tend to look at IR through the lens of the large tertiary hospital. In that environment, the value of traditional IR is pretty obvious. A large hospital with trauma, transplant, oncology, hepatobiliary surgery, vascular surgery, complex cardiology and every other imaginable subspecialty needs interventional radiology. Somebody has to embolize the bleed at two in the morning, drain the abscess, place the nephrostomy, manage complicated vascular access, perform the TIPS and support all of the other highly specialized services that make a tertiary hospital a tertiary hospital. I am not minimizing this work in any way. It is important work, some IRs absolutely love doing it, and large tertiary hospitals should have excellent IR departments because frankly a lot of what those institutions do would fall apart without us.

The problem is that most interventional radiologists do not work in giant tertiary referral hospitals surrounded by every imaginable subspecialty. I have written about this repeatedly over the years. Academic IRs represent a minority of our practitioners, yet the academic environment has historically had an outsized influence on how our specialty defines itself and how we train the next generation. This was part of what I was getting at in Clinical IR: An Identity Crisis Rooted in the Concept of “Ownership” (https://linemonkeymd.com/clinical-ir-an-identity-crisis-rooted-in-the-concept-of-ownership/) and later in IR and DR: The Dirty Truth (https://linemonkeymd.com/ir-and-dr-the-dirty-truth/). Most IRs are going to spend their careers in the community, often at a 200-bed hospital or some smaller regional health system, and trying to replicate the practice of a 1,000-bed academic hospital in that environment makes very little sense.

This is where I think we continue to miss perhaps the largest opportunity in our specialty. There are tens of millions of patients walking around this country with diseases we can treat. Peripheral arterial disease, chronic venous disease, uterine fibroids and benign prostatic hyperplasia alone represent well over 50 million potential patients, before we even start talking about compression fractures, osteoarthritis, venous thromboembolic disease and the growing list of outpatient conditions where image-guided therapy has a role. I made this argument years ago in IR and DR: The Dirty Truth and also in Building a Clinical Practice (https://linemonkeymd.com/building-a-clinical-practice/). Nothing I have seen since writing those posts has changed my mind. If anything, actually opening a practice has made me realize that the missed opportunity is probably even bigger than I thought.

These patients are not lying in an ICU waiting for another physician to place an order for IR. They are at home. They are going to work with legs that hurt every time they walk. They are bleeding every month from fibroids. They are waking up repeatedly at night to urinate. They have wounds that won’t heal, compression fractures that have wrecked their quality of life, or venous disease that they have slowly accepted as something they just need to live with. Many will eventually interact with the healthcare system, but there is absolutely no reason to believe they will ever make their way to an interventional radiologist.

This is what I mean when I talk about clinical IR. Traditional IR generally starts with a procedure. Somebody else identifies the problem, somebody else decides an intervention may be needed, and eventually somebody sends the patient to us. Clinical IR starts with a patient who has a disease. We evaluate that person, establish or confirm the diagnosis, understand the alternatives, determine whether an intervention is appropriate, treat them when necessary and continue to care for them afterward. I wrote about this idea of ownership years ago in Clinical IR, and the distinction remains important. If we want to be a clinical specialty, we need to own the patient relationship and not simply the procedure.

This matters even more in smaller community settings. A 200-bed hospital may never have a liver transplant program. It probably doesn’t need somebody doing complex portal venous reconstruction every Wednesday. There may not be enough major trauma to support a massive trauma embolization practice or enough surgical oncology to recreate the interventional oncology program at some huge academic referral center. What that hospital absolutely does have is a surrounding community filled with patients who have vascular disease, venous disease, fibroids, prostate disease, compression fractures and all sorts of other common problems that we know how to treat.

This is how you build value in the community. You don’t sit around the hospital waiting for enough interesting procedures to magically materialize. You build a clinical practice around diseases that are actually prevalent in the local population. You create access, see patients, develop disease-state expertise, educate patients and referring physicians, and create a pathway from diagnosis through treatment and follow-up. Instead of defining the relevance of IR by how many other hospital service lines need us, perhaps we should define it by how many people in the surrounding community we are actually capable of helping.

This is also why I have been so critical over the years of what I called the IR Hospitalist in The IR Hospitalist: Hospital MVP or Glorified Trash Collector? (https://linemonkeymd.com/the-ir-hospitalist-hospital-mvp-or-glorified-trash-collector/) and The IR Hospitalist Revisited (https://linemonkeymd.com/the-ir-hospitalist-revisited-a-closer-look-at-our-identity/). It is incredibly easy for a community IR to be busy. In fact, hospitals are quite good at keeping us busy. There are always lines, drains, biopsies, paracenteses, inpatient add-ons and whatever other thing nobody else feels like doing that day. You can spend your entire career running from room to room taking care of everybody else’s patients and convince yourself that because you are exhausted you must have built a successful clinical practice. Those are not the same thing.

The alternative has basically been the recurring theme of this blog for years. In Building a Clinical Practice, I argued that developing a real patient panel is the prerequisite for meaningful outpatient independence. In Clinical IR, I argued that clinical practice requires longitudinal responsibility for patients instead of simply doing whatever procedure somebody ordered. In IR and DR: The Dirty Truth, I argued that IRs are fully capable of generating enough work to sustain themselves when they focus on common diseases and actually have the infrastructure and freedom to develop those practices. These have never really been separate arguments. I have essentially been saying the same thing for years in slightly different ways: stop defining our specialty primarily by what other physicians ask us to do and start defining it by the patients we can help.

The last two years have allowed me to test that instead of just talking about it on the internet. Thirty to forty clinic patients every week did not magically appear because a hospital administrator decided I deserved more volume. They came because we built a practice around diseases people actually have. We made ourselves available, developed relationships, treated people well and continued to remove barriers between patients and us. What I had previously argued about clinical IR in theory is now basically my normal workweek.

Importantly, this model also tells us how IR can create tremendous value in smaller community hospitals. If you are running a 200-bed hospital and want IR to be something more than tubes, drains and intermittent emergency coverage, the opportunity is sitting outside the hospital walls. A community IR can build vascular, embolization, venous, spine and other clinical programs that bring new patients into the healthcare system rather than simply servicing the patients who happen to already be there. Those programs can retain patients locally, generate clinic visits, imaging, procedures and downstream care, and turn IR into something much more important than a hospital support service.

Here is where I now have a problem with the whole arrangement. If the interventional radiologist is the one identifying the opportunity, learning the disease, building the clinic, educating the community, establishing referral relationships, creating the patient-access infrastructure, developing the service lines and ultimately generating the patients necessary to make IR valuable in that smaller community setting, what exactly is that physician doing? He isn’t merely “providing IR coverage.” For all intents and purposes, he is building a business inside the hospital.

Hospitals certainly bring something to the table. They have capital, rooms, equipment, nurses, technologists, payer contracts and institutional resources, and obviously all of those things matter. I am not trying to pretend an angio suite and support staff somehow fall out of the sky. But in this model the scarce ingredient is not the angio suite. There are angio suites all over America sitting underutilized. The scarce ingredient is the physician with the clinical ability, motivation and entrepreneurial energy to build an actual patient-facing practice around one.

Once that physician succeeds, the economics start becoming apparent. He creates the clinic, develops the referral relationships, generates the patients and builds the service line. Those patients generate professional services, facility revenue, imaging and downstream care. The hospital now owns a clinical enterprise that really did not exist before that physician arrived, while the physician remains an employee whose compensation ultimately has to be justified as payment for physician services.

THE GAME IS RIGGED

This is where I finally started to understand why hospital compensation negotiations often feel so disconnected from the value being created. For a long time I assumed hospitals were simply being cheap. That is certainly part of it, because nobody voluntarily pays more than they have to, but there is something much bigger underneath all of this that I don’t think most physicians understand. I certainly didn’t when I came out of training. You can probably practice medicine for twenty or thirty years, make a lot of money, generate vastly more money for the healthcare system around you, and never really understand how the dollars flow.

We spend a decade learning medicine and almost no time learning the economics of the industry in which we practice. Maybe this is intentional or maybe nobody involved in our training knows either. My mentors were generally academic physicians who taught, researched and took care of patients while somebody else worried about the money, which is pretty typical. Regardless, once you start understanding the mechanics, physician employment starts to look a little different.

At the most basic level, CMS separates the economics associated with the physician from the economics associated with the facility. The exact terminology and payment mechanism vary depending on the service and site of care, but the distinction is fundamental. There is a professional side associated with the physician’s work and a technical or facility side associated with providing that care. In the hospital outpatient environment, the hospital generally gets paid under OPPS while the physician is paid under the Physician Fee Schedule. People who know far more about coding than I do can argue over APCs, technical components and the proper terminology, but for purposes of this discussion the economic point is straightforward: the physician and the facility live in different payment buckets.

This matters enormously in IR because the facility economics associated with what we do can be substantial. I can see the patient, diagnose the disease, recommend the treatment, perform the procedure, assume the professional liability and follow the patient afterward. In clinical IR I may have also spent several years developing the referral relationships and building the program that caused that patient to arrive in the first place. The hospital obviously provides meaningful resources through the facility, equipment, nurses, technologists, supplies, anesthesia when needed and everything else required to safely provide care. Again, I am not saying all the money should go to the physician. The important point is that the economics have already been separated before the physician and hospital ever sit down to discuss how much that physician should be paid.

This is all happening in a healthcare system where physicians consume a surprisingly small part of the overall healthcare dollar. I discussed this in Money and IR (https://linemonkeymd.com/money-and-ir/), and I think it is something every physician should understand. We tend to think of healthcare as being centered around doctors because we are the ones making the clinical decisions, but financially that is simply not the case. The vast majority of healthcare spending is going somewhere other than physician compensation. At the same time, physician reimbursement has faced relentless downward pressure, with the Medicare Physician Fee Schedule failing to keep pace with inflation and the cost of actually running a practice.

Almost everything involved in delivering healthcare becomes more expensive over time. Employees cost more, nurses cost more, health insurance costs more, rent costs more, devices cost more, drugs cost more, software definitely costs more and hospital care costs more. Somehow the physician is repeatedly expected to become more efficient, see more patients, document more, comply with more regulation and accept less real reimbursement for doing it. For those who want a much deeper dive into this, go back and read Money and IR, because once you understand the different buckets of money in American healthcare, a lot of otherwise confusing behavior suddenly makes sense.

Now put the employed physician into this structure. The physician has already been separated from much of the facility economics by the payment system and then becomes an employee of the institution receiving those economics. An entrepreneurial IR can build a clinical program that brings entirely new patients into the system, creates clinic visits, imaging, procedures and downstream care, and keeps patients from leaving the market. In many community settings, that IR may have had to build most of the clinical machinery himself just to create enough appropriate procedural volume to satisfy whatever productivity expectations were in his employment contract.

Let’s say the program eventually creates several million dollars of annual economic value for the hospital. Everybody can see it. The CEO understands it, the CFO understands it, and the IR certainly understands it. In almost any normal business environment you would expect a fairly straightforward conversation about how the person creating that incremental value participates in it. Unfortunately, healthcare isn’t a normal business environment.

This is where Stark and the Anti-Kickback Statute come into the picture. The relationship between physician compensation and business generated for a hospital is highly regulated, which makes it very difficult to simply look at the economic value created by an entrepreneurial physician and compensate that physician proportionally. Instead, the conversation gets pushed back toward fair market value, commercial reasonableness, compensation for actual physician services, outside benchmarks and whether some valuation firm is willing to support the arrangement.

Think about how bizarre this can become for a clinical IR. I can build a program that did not exist before I got there, develop the referral relationships, create the clinic, generate the patients, perform the procedures and produce millions of dollars of new facility economics. The hospital can measure that value, present it to a board, use it to justify investment and congratulate itself on the growth of the service line. When it comes time to figure out what I should be paid, however, we are suddenly talking about how many wRVUs I produced, what fair market value is for call coverage, how many hours I spent doing administrative work, what other employed IRs make and what percentile my compensation falls into.

This is why I increasingly describe the game as rigged. I don’t mean there is some guy at CMS sitting around trying to figure out how to personally ruin my life. What I mean is that once you understand how the pieces fit together, the result becomes pretty obvious. CMS separates the physician economics from the facility economics. The hospital owns the facility and employs the physician. The physician can then create tremendous additional enterprise value for the hospital, while Stark and AKS make it difficult to simply reconnect physician compensation to the downstream economics that physician helped create. Compensation gets pushed back toward the defensible value of physician labor, which is then informed in part by surveys of what other physicians operating inside the same system are being paid. If that doesn’t strike you as at least somewhat circular, I don’t know what to tell you.

Clinical IR makes this comparison even more ridiculous. One IR can walk into a mature service where the patients, referral relationships, staff and infrastructure already exist and produce 10,000 wRVUs. Another can walk into a place with essentially no clinical IR infrastructure, spend several years building clinics and referral relationships, develop entirely new service lines, generate the patients and eventually also produce 10,000 wRVUs. Those two people did not perform the same job. Yet from a productivity and compensation standpoint they can eventually end up sitting next to each other in the same spreadsheet because they happen to share a specialty and a wRVU number.

Meanwhile, the hospital owns what the second physician built. It owns the clinic infrastructure, employs the staff, owns the facility, controls the payer contracts, collects the facility revenue and benefits from the imaging and downstream care. If the physician leaves, the hospital will presumably attempt to hire another IR to step into a clinical program that physician may have spent years creating. The original physician might have been paid extremely well, but at the end of the day he was still being compensated for labor while the resulting enterprise remained with the hospital.

Extend this over an entire career and I think the distinction becomes even clearer. A physician can spend twenty years developing a hospital service line, building referral relationships, recruiting other physicians, establishing new programs, creating patient demand and generating tens or even hundreds of millions of dollars of healthcare activity. He may earn a very good living during those twenty years. Then he retires. There is no equity account representing the service line he built, no ownership interest in the referral network he developed and no payment for whatever goodwill he created. He got paid along the way for his labor and the enterprise belongs to somebody else.

MAYBE HOSPITALS DON’T CARE AS MUCH AS WE THINK

This has always been one of my problems with employment. What I don’t think I fully appreciated until more recently was just how deeply our payment and regulatory system reinforces this arrangement. I also think I previously overestimated how badly hospitals actually want to solve the IR problem.

We in IR spend a tremendous amount of time demonstrating why hospitals need us. We produce studies about downstream revenue, reduced length of stay, avoided surgery, emergency coverage and keeping patients inside a health system. There seems to be this assumption that if administrators could just understand how valuable IR is, they would naturally invest in building comprehensive services. I am increasingly skeptical that the issue is a lack of understanding.

Hospital consolidation makes this pretty easy to see. A small independent hospital without IR historically had a problem because patients left the hospital. Transfers meant lost admissions, lost procedures and lost downstream care. If that hospital wanted to retain those patients, eventually it had to develop enough specialty capability to take care of them. A 200-bed hospital that is now one piece of a much larger regional system has another option. It can transfer the patient to the mothership. The local hospital may have lost the patient, but the healthcare system did not necessarily lose anything.

That changes the incentive to invest locally. Why spend heavily recruiting an interventional radiologist, staffing comprehensive IR coverage and developing programs at every smaller hospital when the same corporate system owns a tertiary center forty-five minutes away? What an IR sees as a major deficiency in care might look to a health system like a relatively straightforward transportation issue. I don’t necessarily like that answer, particularly for patients who now need to be shipped elsewhere for care that could have been provided locally, but I increasingly think it is the reality.

I suspect more small hospitals are going to settle for limited IR rather than comprehensive IR. That limited IR will largely be performed by advanced practice providers. These hospitals will maintain enough capability to deal with basic procedures and transfer whatever they cannot handle. Health systems will centralize more complicated services and probably call it regionalization, optimization or some similarly impressive healthcare administration term. Maybe that makes financial sense for them. What it certainly does not do is make me particularly excited about spending my time convincing them to build a service they may have already decided they do not actually need.

This is what my recent hospital negotiation clarified for me. I initially approached it as a question of what they would have to pay me to give up a day of my practice. As the conversations continued, I found myself asking a more fundamental question: why am I working this hard to figure out how to make the arrangement work? Every day I spend at that hospital is a day I am not spending on my own practice. That opportunity cost is no longer theoretical to me. I know what happens when I spend my time developing new clinical programs, improving access, building referral relationships and making the practice better, because I have now spent almost two years doing exactly that.

OWNERSHIP

I have always encouraged entrepreneurship and ownership in IR, so again, none of this represents some sudden conversion. What has become much clearer is the distinction between getting paid more for labor and actually owning the value created by your work. I spend plenty of time in my practice doing things that generate zero wRVUs. I work on patient intake, staffing, referral relationships, marketing, new service lines and operational issues. If something I fix today makes the practice better for the next five years, I participate in that benefit. If we develop a new program, it becomes part of the practice. If the business eventually develops value beyond my personal ability to perform procedures, I own an interest in that value.

An employed physician can obviously make an extraordinary income. He can produce more wRVUs, negotiate a better conversion factor, receive compensation for call, medical directorships and administrative work, and move higher and higher in whatever compensation survey is popular that year. That can make you rich by almost any reasonable definition, but you are still fundamentally selling labor. Ownership creates another economic category because the entrepreneurial work can create infrastructure, systems, goodwill, recurring revenue and equity that continue to exist beyond the individual procedure you did this morning.

The traditional argument for employment is that you give up some of that upside in exchange for security. The hospital supplies the capital, employees, equipment, contracts and infrastructure and takes the business risk, while you show up and practice medicine. I have no problem with that trade if that is actually the trade being offered. If somebody hands me a mature clinical service with a functioning clinic, established referral relationships, good staff, a full schedule and minimal administrative nonsense, then sure, there is some number at which selling my labor makes perfect sense.

That is not how many community clinical IR jobs work. The hospital may provide the physical infrastructure, but the IR is still expected to convince the hospital this modern IR existence is worthwhile, develop the referrals, create the clinical programs, educate the market and solve a surprising amount of the operational mess required to build the service. If it doesn’t work, everybody wants to know why the IR isn’t productive. If it does work, the hospital owns the resulting program and the physician goes back to negotiating the value of his labor. I already knew employment was generally a bad bargain for somebody with my personality. What I am increasingly coming to terms with is that spending entrepreneurial energy building somebody else’s enterprise is an even worse bargain.

MAYBE WE ARE ASKING THE WRONG PEOPLE

This brings me back to something I think our specialty needs to confront. We spend an extraordinary amount of time trying to convince everybody other than patients that we are valuable. We convince hospital administrators that IR makes money. We convince surgeons and other specialists that we can take care of their patients. We convince health systems that they should invest in us. We convince administrators that we need clinics, marketing, staff and appropriate compensation. Our professional societies generate data demonstrating our value to healthcare systems, after which we take the data back to those healthcare systems and ask them to please appreciate us. Maybe we need to ask ourselves why.

Historically, I understand exactly how we got here. IR grew up inside radiology departments. Somebody else owned the patient relationship, somebody else made the diagnosis, and somebody else decided when the patient should come see us. For much of our history, success depended on convincing another physician that we deserved to participate in the patient’s care. Unfortunately, I think a lot of that mentality remains deeply embedded in the specialty even as we continue to talk about becoming “clinical.”

If we actually believe all the stuff we say about clinical IR, perhaps the person we should spend more time convincing is the patient. I don’t need a hospital CEO to understand the value of uterine fibroid embolization nearly as much as I need a woman with symptomatic fibroids to know there is an alternative to hysterectomy. I don’t need another hospital committee to appreciate vertebral augmentation nearly as much as I need a patient sitting at home with a painful compression fracture to know that treatment exists. The same applies to venous disease, prostate embolization, peripheral arterial disease and the rest of the common diseases we have spent years saying we want to own.

This has probably been one of the most liberating parts of independent practice. Instead of spending my time convincing an institution to create the infrastructure that might eventually allow patients to reach me, I can spend that same time figuring out how to remove the barriers between me and those patients. If people understand what we do, can find us, can get an appointment and ultimately receive good care, you can build a clinical practice. The tens of millions of patients I have been writing about for years do not need another PowerPoint presentation explaining IR’s downstream value to a hospital. Most of them simply need to know that we exist and that we may be able to help them.

I have always believed the path forward for IR involves clinical excellence, entrepreneurship and ownership. Learn diseases rather than collecting procedures. Become technically excellent, but understand that crossing some ridiculous CTO does not by itself build a medical practice. See patients before procedures including non-operative care, and follow them after any procedures over the course of their lives. Understand your outcomes. Make yourself accessible. Build a positive reputation in your local community. Educate patients and referring physicians honestly. Remove barriers between yourself and the people who need your care, and own as much of what you build as reasonably possible.

What has changed for me is not the underlying philosophy. It is how willing I am to spend finite time trying to convince hospitals to participate in that vision. Hospitals will act in their own interests and health systems will act in their own interests. If transferring a patient makes more sense to them than investing in local IR, they are probably going to transfer the patient. If the amount required to obtain excellent IR coverage does not fit inside their compensation structure, they are not going to pay it. If a physician spends five years building a valuable clinical program inside their institution, the hospital will own the resulting enterprise. None of this should be particularly surprising once you understand the incentives.

Interventional radiologists should probably become equally comfortable acting in their own interests. We have spent decades convincing hospitals, administrators and other physicians of our worth, perhaps because for most of the history of IR those people controlled our access to patients. I am increasingly convinced that the more important work is removing those layers between us and the people we can actually help. There are tens of millions of those people in the community. I would rather spend my time figuring out how to reach them than convincing another hospital committee that an interventional radiologist is valuable.