Building a Clinical Practice

Having been entrenched in the world of private practice interventional radiology, I have gotten the opportunity to meet many different interventional radiologists. Some have been successful transitioning to outpatient practices while others have struggled somewhat. One consistent feature I’ve seen in those who have succeed is the fact that many have built clinical practices before opening their outpatient centers.

The funny thing about all of this is when you talk with non-IR docs, this is a no-brainer. Why wouldn’t you establish your reputation in a given market before taking the risk of healthcare business development? For many cardiologists and vascular surgeons, it is very common for them to basically take their existing patient panel and transition it from a big-box healthcare system to their own outpatient facility. In interventional radiology, we sadly don’t have that same luxury in many settings mostly due to pseudoexclusive contracts.

Despite the political issues which I have discussed before, the key thing most interventional radiologists don’t seem to realize is that the most important predictor of success in building an independent outpatient IR practice is their ability to build a local clinical practice first. While the pseudoexclusive contract issue and associated politics can be a major hinderance, I still get the sense most interventionalists, both seasoned and early career, overlook the importance of building a patient panel.

It is very difficult to just show up in any given market, open an OBL, and expect some Field of Dreams situation where patients will be lining up outside your door. If anything, going to a random market with no reputation is a recipe for disaster, or at best, a very long path to profitability unless you take some legally and somewhat morally questionable shortcuts including some I’ve taken a close look at in prior posts. Look, most of us have significant difficulty explaining to our own family what it is we do 50-60 hours each week. You think patients are going to just google “interventional radiology” and seek you out? Maybe a handful, but most of them won’t and many won’t care. They just want their problem addressed. Do you think potential referring physicians are just going to start sending you patients? They have no idea who you are or what you can do. You’ll be more likely to be asked to biopsy lung nodule or drain some ascites than you would to see a patient for a foot ulcer because sadly that is their association with our specialty. Believe me, I’ve been there.

Sure, you can go to the internet and bombard your market with direct-to-consumer advertising and that certainly can help, but you still need to work incredibly hard to build your reputation for people to trust you. The fact of the matter is you need to establish yourself and create your presence in a given market. Every interventional radiologist should have an elevator pitch of sorts, where in 30 seconds or less you can clearly explain what it is you do and why it matters. And the one thing that most successful IRs in OBL settings do to distinguish themselves, is they do not label themselves as “interventional radiologists.”

So how can we go about building our clinical practices when in many settings we are prevented from even practicing independently? The short answer is by jumping through an insane number of hoops. But before you go hoop jumping, you need to build a positive regional reputation. Building a positive regional reputation involves consistent demonstration of excellence over a significant period of time. It isn’t about crossing some crazy CTO, or being able to catheterize a type 1 origin in 5 minutes or less or showing off your slick skills on Twitter. It’s about building a positive reputation among the local medical community and your target patient demographic who want their problems addressed and don’t really care about how you do things technically speaking. I think a cardiology colleague told it to me best when he said that regional reputation often trumps national reputation when it comes to building a medical practice. Who you know and how you are perceived among the local medical community goes a long way towards building a sustainable business. A national reputation will get you paid by medical device companies (whether or not you’re actually an expert on said subject matter which is an interesting observation I’ve made as I’ve gotten to know this incredibly small world) and make you look good on social media. While those are great, they don’t pay the bills really. On a daily basis, building your reputation in the community comes down to the simple things which can make a world of difference:

-having a clear goal and being able to communicate the need that you meet in a given market.

-consistent communication with referring physicians via text, email or phone.

-going the extra mile to make sure patients and their families are happy with your service

-asking patients for testimonials and leveraging those testimonials to generate new referrals

-treating your employees and partners with respect and developing a reputation as a fair and loyal co-worker

-being receptive to criticism and always looking for ways to improve

-educating referring physicians and office staff with good/honest intentions

The second thing you need to do to build a clinical practice is to focus on spending more time in clinic than in the angio-suite. My former cardiology partner had a mentor he looks up to who practices in a very large, competitive city. This guy apparently created this very robust PAD practice and has been insanely successful. He says that on average it takes 4 new referrals to generate a PAD or vein case. Particularly for vascular disease, I have actually found this to be somewhat true. Basically, if your clinics aren’t packed with patients, then you’re not generating enough referrals or you may be inappropriately selecting patients for cases, or both. From a financial standpoint, evaluation and management accounts for up to a third of total practice revenue for most vascular surgeons and cardiologists. Let that sit in your head for a minute. Clearly as IRs we are not spending enough time in clinic. My friends in “good groups” and in academic practices get about a half to one full day of protected clinic time each week. In my humble opinion, that is insufficient. And those are in progressive radiology group settings. Can you imagine life for the majority of IRs who sit in a dark room most of the time? And on the flip side, can you imagine life even for those IRs who are already in ASCs/OBLs who are spending the majority of their time crushing commoditized cases that don’t require robust clinic consultations like dialysis work? No matter how you slice it, we are selling ourselves short by not devoting a significant time in the clinic to shift the collective narrative away from our label as technicians to our desired perception as clinicians.

I’m going to double down on clinic for a minute. Yes, we need to have clinic to appropriately take care of patients and to generate cases for our labs and meaningful revenue for our practice despite the fake news about clinic being a money loser, but why else do we need to have clinic? To simply become better doctors. The fact of the matter is our exposure to clinic as interventional radiologists, even with the new training paradigm, has gone from non-existent to perhaps barely acceptable in the most progressive settings. Why is this? Because we are too diversified as a field. We are literally all over the place: young, old, liver, GI, GU, vascular etc. As cool and exciting as it may seem to aspiring IRs, young trainees or early career IRs, it’s frankly a hinderance when it comes to developing true expertise in a given disease state. In order to generate referrals and establish your presence in a given market, you need to be an absolute expert in everything about that particular pathology you are treating. And while there are some who revel in the fact that they think they can be experts in everything, the truth of the matter is that while they may be technical masters they are far from subject matter experts. The most successful IRs in the OBL world are those who have niched down to one, or perhaps two disease states and simply own that space. By doing so you do the necessary work to go from mere technician who is at the mercy of market forces and attitudes among referring offices to a highly sought-after expert with a clear focus and mission. A focused clinic allows you as a physician to hone your skills and to make the changes over time to better select patients for procedures and perhaps more importantly, to work on your non-procedural management skills which in turn give patients and their referring physicians the confidence that you know your stuff and are committed to longitudinal care. I know I’m probably going to get some heat for this because I have some friends and colleagues who are very good at a variety of things, but the fact of the matter is it is more than just being good. You have to be the best. And you don’t become the best at one thing in a short period of time by diluting your time with a variety of other things. Maybe you can claim you’re an expert at all those things after 20 years or so. While you’re spending that time getting great at everything, I’d contend one could spend a focused 3-5 years and become great at one or two things and be well positioned to have some degree of leverage in determining how they would like to practice.

The other reason building a clinical practice matters is it is how we gain back control over our professional lives. When you are in a hospital, without a high-volume focus, you are simply subject to the needs of the hospital and associated community of physicians which is frankly incredibly unpredictable. You never know when that bleeder will pop up, or that submassive PE will show up in the ED. While this environment is ideal for some, and particularly for those of us just starting out IR journey as we can keep all our skills somewhat sharp and practice with the safety net of having colleagues and other support staff available, the uncertainty and lack of control in this environment in conjunction with the messed up financial incentives in most settings is a recipe for burnout among a good proportion of us, particularly those of us who are entrepreneurial minded and seek to shape our work lives. The way you Marie Kondo this situation is to focus on what you love doing and to do it in very high volume while simply minimizing/limiting the work that you are not passionate about. Maybe for you your passion is portal hypertension or trauma work. To that, I say more power to you. I think for many of us, that frankly isn’t the case. There are many service lines we can build and focus on as IRs that don’t involve acute in-hospital care:

• Vascular disease.
• Men’s health
• Women’s health
• Interventional Oncology
• Pain management

In fact, when you look at that list you realize that there are literally hundreds of millions of potential patients for us in America, and billions worldwide. We are frankly doing a piss poor job as a field at improving the health of many who should be benefiting from our services right now. I’m so tired of interventional radiology being the “best kept secret in medicine.” It’s only a secret because 1.) we are collectively subpar at being real doctors and 2.) we are handicapped by the structure that many of us are pushed to practice in. When we focus on building a clinical practice above and beyond anything else we do, that is how we can change our field for the better.

Finally, I’d like to end this post with a quick word about advanced practice providers. First, no one should call them “mid-levels.” I learned from an APP in training (thank you Alicia) that this term is offensive. I’ve seen a lot of different settings and it’s no secret that APPs are proliferating in interventional radiology. I’ve been lucky to work with some very excellent ones who have made my life a lot easier, particularly in the hospital setting where they can offload some of the less intellectually intense tasks and soul sucking documentation which exists for the mere purpose of compliance and billing. Honestly, if I never do a thyroid biopsy or paracentesis again, I’d be ok with that. Unfortunately, I have also seen some settings where “clinic” means having the APP see all patients and tee patients up for procedures. This of course leaves the physician free to focus on just cases. There are clear economic advantages to this model, but personally I don’t think that’s how we should be practicing medicine. We need to be in clinic seeing patients and more importantly, working to develop that reputation we need to establish true independence. We don’t develop that expertise and reputation being a procedural monkey. Also, I find it very troubling that we are more or less letting individuals with a mere fraction of our training decide who should be teed up for a procedure and who shouldn’t, particularly when the decision to practice in this model is made by non-physician owners and executives who only look at finances. Now of course, an APP will only be as good as how you train them and I know senior IRs who have moved to a model where they do procedures only, but only after many years of establishing non-procedural excellence and developing systems to appropriately train APPs. The problem is I’d contend that most of us coming out of training still don’t have a good sense of non-procedural management of patients. We need to be in clinic going through the motions and developing that expertise for ourselves. While it anecdotally takes 5 years on average to develop procedural expertise in a given area, I believe it takes even longer to develop non-procedural expertise. There is no better teacher than experience.

At the end of the day, the way we should be practicing isn’t how many of us are practicing and it’s unfortunate. There are several key barriers which prevent the development of focused clinical practices:

1. Our training which is incredibly broad-based with primary focus on imaging and not direct patient care.
2. Our training again which excludes key service lines in many academic settings. The biggest one being peripheral arterial disease, sadly for political reasons and lack of gonads among academic section chiefs.
3. Our hospital-based contracts which are often rooted in radiology settings where production is driven by wRVUs.
4. Our hospital-based contracts again which are pseudoexclusive and prevent those who choose to break off from doing so in most markets.
5. Our opportunity cost which is a comfortable existence as part of the radiology umbrella.

Despite changes in the IR training paradigm, I’d contend that most future IRs will not want to exert the energy necessary to achieve independent IR practice with a high-volume outpatient focus. I’d also contend that the existing academic power structure that controls leadership roles in the Society of Interventional Radiology and has close ties with both the American Board of Radiology and American College of Radiology also does not want to see this future as hospital-based radiology groups need us to remain the proverbial anchors for their lucrative imaging contracts. If these groups really did care, real changes would be happening and some guy with a blog wouldn’t be talking about it. And since the primary issue isn’t really a philosophical one, but rather a legal one, the only change I see that will matter is literally divorcing IR board certification from DR so hospital credentialing committees don’t lump IR services under “radiology services.”  

With that being said, this future of independent IR practice which I’m describing is one where I’m convinced we need to head as a field to do the greatest good for the greatest volume of patients. I wish there were some clear road-map to get more people down this road, but unfortunately that map does not exist. The best you got right now are my blog posts and other voices in this growing community of “rogue” IRs. But what I do know is you want something bad enough you will find a way to make it happen. IRs before me have figured it out and I’m convinced that many of you reading this will figure it out too. The first step to going down this path though is developing a true clinical practice, a task which takes patience, time and a significant degree of self-motivation given our current educational paradigm and practice limitations.

As always, please leave your thoughts below or share your comments with me via Twitter, LinkedIn or via email at linemonkeymd@gmail.com