Clinical IR: An Identity Crisis Rooted In The Concept of “Ownership”

I want to start this new post off by addressing some comments from my treatise on academic radiology and peripheral arterial disease published in May 2020. Most of the responses were on my Twitter page (https://twitter.com/linemonkeymd). What I love about Twitter is engaging other interventional radiologists in an informal fashion. It’s a great platform to post cases, ask questions and learn from some really talented physicians. For bloggers like me, it’s also a great platform to reach an audience.

Based on the comments I received, I get the sense that the point of my last post was not clear. Perhaps it was the fact that my post was really freaking long, or my passion and subsequent tone distracted from the underlying substance. I tried addressing some of these comments on the Twitter page, but there is only so much one can say in 140 characters. It also doesn’t help that people need to “play it safe” and not really speak their minds on the professional Twitter space. Needless, to say, there are two themes which emerged from the comments:

1. Line Monkey MD is being unnecessarily harsh in his treatment of academic interventional radiologists. 
2. Line Monkey MD complaining about lack of peripheral arterial disease training is not helpful because interventional radiologists have created peripheral arterial disease practices on their own despite shortcomings in formal training. 

Perhaps I was being too hard on academic interventional radiologists. It is true that the majority who choose academics do so for benevolent reasons. They are taking less pay with less vacation time to devote their talents to training physicians and advancing science. The academic mission is a noble one. Without academic radiology, I would not be where I am today. I am incredibly grateful to my mentors.

However, despite their importance, they do not get a pass when discussing the shortcomings of our field. While they account for less than 20% of our practitioners, they dominate leadership positions within the Society of Interventional Radiology. The collective voice of the academic establishment carries significant weight. If they are going to lead, they need to lead by example. While I applaud those in academics who are responsible for the culture change we are trying to undergo in IR, we all know there are plenty in academics who are not actively engaged in this change. Furthermore, many of these physicians have never spent a day in private practice where the majority of graduates end up. If we are going to change our field, we all must change, especially those in leadership roles. Unless they actually walk the walk, how can anyone take them seriously?

Several have correctly pointed out to me that there are some institutions which have been doing great things with respect to peripheral arterial disease training. Again, I applaud those institutions. I still bet you that for every one example of a progressive academic practice, I’ll find you nine that are not. 

On to point two. Yes, I complain a lot, but I do so because I seek to address issues we know are true but people are afraid to talk about publically. Doing so will naturally make people feel uncomfortable and could potentially compromise their role in an institution or practice, but unless we address our challenges how do we advance? That is the point of this blog. I’m not here to tell you that I or you can never be what we want to be because of a faulty system or certain opportunities not being afforded to me. If you have what it takes to become an interventional radiologist, you have all the tools to be successful, and that includes building a PAD practice. In fact, I have built a PAD practice and am building an even better one right now despite people telling me that it can’t be done or that it shouldn’t be done. I am here to show you that it can be done. But if I’m not being honest about challenges we as a field face, I feel I am not doing my part to help advance this field from a philosophical standpoint. 

The biggest challenge facing interventional radiology is our identity. Who are we? What is our mission? How do we accomplish that mission? These are really heavy questions. The answers to these questions will vary significantly depending on who you ask. For other procedural fields the answers are a bit more clear as most other specialties are organ system based: cardiology, gastroenterology, urology etc. For interventional radiology, it’s not clear at all. 

One thing we know is that as a field we are committing to a future of clinically oriented care: patient first, image/technical stuff second. This has ultimately become to be known as “Clinical IR.” For our colleagues in procedural frields, this has been their mantra from day one. Because of our unique history as imagers first, interventional radiology has unfortunately been late to this revelation that it is important to take care of patients first. 

What do I mean by taking care of patients? Many would contend that pre-procedural consent, successful execution of the procedure and immediate post-procedural care would constitute excellent patient care. In fact, I remember my old boss in private practice telling me that formal consultative services were redundant because agreeing to do a procedure and executing on it consists of everything one would do in a formal consultation. It just isn’t fully documented. After all, you are still looking through the chart, noting allergies, medication lists, doing a pertinent physical exam and then performing the procedure. And while he is right to some extent, I believe the lack of formal consultation simply devalues our profession and misses a key opportunity to demonstrate to others that interventional radiology can play on a the same field as other specialties. 

Clinical IR frankly involves consistent behavior that reflects your role as a physician who can add value to the care patients. And by value, value beyond the successful execution of a procedure that you are trained to do. This should entail consults, not orders. It should entail clinic visits where patients can turn to you as an expert in that disease process. 

Perhaps then for many inpatient procedures it is impractical to do a formal consultation. After all, this service is poorly reimbursing when your time as a radiologist is economically speaking quite valuable. Unfortunately, many radiology practices have evolved to value money over real patient care. A culture cannot change unless we take the time to do what it is right for patient care.

Taking the time to document your findings and communicating to the referring physician via  formal consultation sets a standard for excellence. For simple procedures like paracentesis of central venous catheter insertions, perhaps there is little immediate value to add through formal consultative services on the surface. And while my old boss may have a point, I look at the bigger picture and that is showing the healthcare system as a whole that interventional radiology values patient care. Our mere presence in the chart and on the floors shows our referring physicians and patients we are serious about our work. We will always find ways to add values may it be as simple as paracentesis post procedural management or as complex as discussing alternative treatment strategies to the treatment of lower urinary tract symptoms. 

Once our fellow physicians and our patients view us as clinical physicians, the sky is the limit for our field regardless of our local environment. I applaud the IRs who have taken the time in their respective practices to lead by example and develop a clinical mindset. 

Going down this road of clinical IR is not easy. To any IR trainee or early career graduate reading this, I contend that you will be pressured to not provide this level of service. In private practice, you will have significant time constraints. You will have to take time out of your daily procedural and imaging responsibilities to provide this service.You will have to contend with your fellow IRs who don’t believe in this or share the mentality you do. You will also have to contend with referring physicians who are totally oblivious to this concept of clinical IR. Finally, you will have to accept the reality that practicing in this fashion will hurt your bottom line financially speaking as you build your practice. 

More importantly, how far do we take clinical IR and where do we draw the line, if so at all? Should we be managing hypertension and hyperlipidemia in our PAD clinics? Should we be doing our own wound care? Should we be managing diurses in our cirrhotic patients? Should we be initiating our own trial of voids and BPH medication management in our LUTS patients? 

Even if you decide to take on all of this work, are you really trained to do this? One of my biggest challenges in doing clinical IR is contending with my own shortcomings in training including being significantly removed from daily medicine and surgical work as an intern. I have had to spend significant time learning about not only imaging and procedures, but pathophysiology and medication management. Since we are not organ based this becomes even harder as a “generalist” interventional radiologist who in a diversified inpatient and outpatient practice can in theory deal with many different pathologies. 

So ultimately it is hard to practice Clinical IR. It incurs a high opportunity cost as a radiologist, involves significant professional rebranding and requires learning/relearning a lot of medical material. Why would anyone in their right mind want to do this?

Well as inconvenient as it may sound and as little as most radiology practices private and academic are currently set up to facilitate this kind of work, you do it because it is the right thing to do. It is right for your patients. It is right for your referring physicians. Would you want a surgeon operating on you if they were not a true expert in your disease state? Certainly not. Why should IR be held to a different standard? 

When approached the right way, interventional radiology has the potential to be a very fulfilling field. It blends medicine, procedures and imaging. We have the potential to build long lasting relationships with both our patients and our referring physician colleagues. The other day I received a call from one of my chronic DVT patients who I performed an iliac vein recanalization a year ago. He called to follow-up on his ultrasound scheduling and to check in as I had instructed him to do. Hearing about his progress and how his life has improved reminded of me of why I sacrificed so much to become a physician. These small reminders are what keep you going despite all the noise and obstacles we as physicians have to overcome. If I didn’t do a formal consultation, formal rounds and clinic visits with this patient, what value am I adding beyond someone who simply does what they are told (which was a request for an IVC filter)? I now have a patient who trusts me and a referring physician who knows that I care about what I do and will send me patients down the road. 

It all comes down to ownership. And I know there are some out there that hate this word. No one should “own” a patient in that sense. What I mean is we need to have pride in taking care of patients to the fullest extent possible. Interventional Radiology should primarily be a clinical discipline, not merely a technical one. If you don’t want to practice this way, just don’t do it. Maybe you need help with medication management. Maybe you need to learn wound care. Maybe you need to collaborate with another specialist. That’s ok. But you need to be a champion for your patient and strive to be an expert in any given disease state you are treating. This is how you add value and ultimately build trust among patients and other physicians. This is how you organically build a practice. 

Ownership also means structuring your practice to reflect your ideals. If you don’t have a clinic, then how can you actually take care of patients longitudinally? Unfortunately, most interventional radiologists still don’t have clinics. If you don’t round, are you really demonstrating commitment to your patients? Most interventional radiologists still don’t round. Even if you do split off from a radiology group and decide to start your own outpatient practice, how can an interventional radiologist readily obtain hospital privileges to treat inpatients when radiology groups actively block them from doing so? This last question really hits close to home for me. More on that in a later post.

I’m excited about the future of IR because we are in the process of training an army of intelligent individuals who I hope will possess this ownership mentality. They should be motivated for the right reasons. Unfortunately motivation alone will not lead them to fulfilling careers as clinical interventional radiologists. We will need policy change to supplement changes in training to create the ideal environments for the interventional radiologists of the future. When you take a step back and look at the big picture, it’s clear that we should be doing much better. 

What is your idea of clinical IR? Are you in the ideal environment to practice this way? Comment below.