I want to spend the next two blog posts discussing a topic that I think some of you would like to hear more about and that’s being an early career IR in the OBL setting. I’m going to spend some time discussing my experience and then will transition into a second post about finding the right OBL opportunity for you.
I entered the OBL after nearly two years in a traditional hospital based IR/DR role with a small sized private practice group. I’ve written extensively about my experience in that group, my quick distaste for practicing in a hospital with diagnostic responsibilities, my revelation that the financial model in which I was practicing was not conducive to taking care of patients the way I would like and for making the amount of money I felt should be earning given the work I was doing.
For me, the move to the OBL was almost mandatory. The reasons are three-fold:
- Practice Clinical IR doing high-end interventions.
- Generate significant revenue doing procedures and not diagnostics.
- Fuel my entrepreneurial passion (which unfortunately took me 32 years to recognize).
In the hospital, I was tired of doing bread and butter procedures as quickly as possible so I could “read the list” which was the real revenue generating activity for the group. This made it impossible to have a meaningful clinic, grow a meaningful IR program and do the higher level work I craved including peripheral arterial disease work and embolizations.
In the hospital, diagnostic work subsidized my IR passion. I had little to no leverage for creating the systems I needed to practice in a truly clinical fashion. Furthermore, it was very difficult/impossible to convince senior IR partners to change the way they’ve been practicing for decades.
By moving to the OBL, I was able to get exactly what I wanted which was the ability to do high-end elective cases, be financially incentivized to take good care of patients and continue to drive revenue to the center and build a business from scratch without any corporate or “big-brother” like interests such as large private equity groups, healthcare systems or diagnostic radiology groups.
All in all, my experience being full-time in an OBL was largely great. I enjoyed the work I was doing. It was very meaningful. I spent more time in the clinic than I did doing procedures which is the way we all should be practicing. Finally, I finally felt that I was making the money I should have been making all along given my passion, commitment to excellent patient care and ability to grow service lines.
With all this being said, there are so many challenges to entering the OBL as an early career IR and in many ways I was very lucky to get the exposure that I did. Here were my challenges:
- Being Clinically and Technically Inexperienced.
You have to be brutally honest with yourself and know your strengths and weaknesses. I have always been a 300% effort and 50th percentile ability kind of guy. I’m not the smartest person in the room, but I will excel due to pure stubbornness and brute force. In fellowship, I was not the most technically gifted in my class. In residency, I was not the person getting all the answers correct in hotseat conferences. I have failed, faltered, stumbled, embarrassed myself so much and have second guessed my ability for decades. Nevertheless, I have always found a way to succeed because I’ve leveraged my inherent strengths and cultivated a strong positive mindset.
For me, those two years in a hospital doing emergent cases and having senior partners, who I respect despite our philosophical differences, was vitally important to getting to a level of baseline competence and more importantly, for establishing a healthy level of confidence to move on to pure independent practice where I knew that I could have good outcomes, practice somewhat efficiently and leverage those necessary ingredients to build a viable business.
Despite having some experience prior to moving to the OBL, I knew that there were significant gaps in my knowledge. I mitigated risk by joining a very experienced interventional cardiologist who, despite our differences and fundamental disagreements leading to our split, played a very important role mentoring me in a disease state I had very little experience with: critical limb ischemia. Scrubbing in with him, working with him in the clinic, and just immersing myself in this service line was in itself a near fellowship like experience.
Even in areas where I did have experience, such as uterine fibroid embolization, prostate artery embolization and treatment of venous disease, working by yourself on an island is hard. I don’t care where you trained. No degree of training will make up for time and reps. When the old dinosaurs say the hardest part of being in a technical field isn’t performing the actual procedure, but rather the cognitive processes involved before and after the procedure, they are so right. Knowing when to do something, when not to do something, planning a case, deciding on clinical management and communicating all of the above to patients and referring physicians is just as much an art as it is science. No amount of [insert big name institution] training will make you a wizard on day 1 of attending-hood. You get there through experience. Experience includes making some really dumb mistakes, but using those mistakes as opportunities to do better the next time, and the time thereafter.
If you go on Twitter, everyone wants to show their wins. Look at this cool clot I sucked out! Check out this prostate I embolized in 27 seconds and 25 mGy. Look at this uterus I saved from the evil gyno! Hey, I can’t hate because I’ve done that as well. But you know what no one talks about? This:
- I just cannot get into this bile duct. Senior partner bailed me out. I suck.
- Argh, why won’t this wire pass this huge staghorn calculus? Senior partner bailed me out again. I just can’t do this.
- For the life of me I cannot biopsy this 10 mm nodule sitting behind a rib. I had to put a chest tube in after creating a huge pneumothorax. Senior partner bailed me out on the follow-up. Fail.
- Crap, I was only able to embolize one side of this 400 gm prostate and it took me 5 Gy and 5 hours. Techs hate working with me. Patient upset it took forever and only half done. I’m not sure I’m meant to do this.
- My day today sucked. My patient died on the table. Am I going to get sued?
Those are all real scenarios from my professional life. People fail, people make mistakes. We all need help whether we think we do or not.
Now when you get to the OBL, not only do you need to be competent, you really need to be excellent. Patients will review you. You need to be better than your competitors. You need to be faster than your competitors. And you need to do all of this fully committed to your patient at all times with a huge smile on your face. No retreating to the reading room post procedure to never see this patient again.
Anyone who thinks they have the skills and more importantly the mental fortitude to practice on their own with no support on day 1 post training is likely very delusional or is telling you a lie because they trained in a machismo culture with very insecure mentors who engender a frankly dangerous culture and sadly have no idea how the real world works (more on that in another post). The ones who do go out and practice solo for sure grow-up very quickly, but oftentimes have significant support from senior partners who they can lean on for help.
- Professional Isolation
Let’s face it, if you’re reading this blog, chances are you are somewhat drawn to it because you may not necessarily be feeling the status quo when it comes to IR. That status quo consists of hospital based practice within a diagnostic radiology setting. It also involves professional society politics and leadership driven by academica, which is more or less synonymous with a large hospital based radiology presence.
Having been privileged enough to train at some great places, including an “elite” diagnostic radiology residency, when I made the decision to enter private practice instead of taking the academic position graciously offered to me at my fellowship institution, I was told that “I was making a big mistake.” “Oh looks like you just care about money and not using your talents to advance our field.”
Ever since that pivotal moment, each subsequent year in practice has resulted in further alienation from the academic power structure which controls our field. Now curiously enough, when I became very vocal about Clinical IR and criticized the current structure, it actually resulted in some attraction from local academics in my market. I was invited to give some talks to both my home program and the competing program nearby about “how to practice build.” Then, when word got out that I was leaving my private practice position to help open a new OBL, then I had at least one academic PD ask if I’d be interested in training future fellows. While that was intriguing, the truth of the matter is when you’re trying to manage your office, build your referral line and be better than anyone else technically in your competitive market just to survive, things turn from friendly to cold very quickly.
Here’s a story, one of my former attendings at the same institution interested in forging a clinical alliance called me 3 months into my stint at the new OBL telling me to “back off” when he found out that some of the techs in the department have decided to do PRN work for our lab and I had asked one of the current nurses there to see if they’d be interested in joining our lab full time. I love this dude who shall not be named, but that was an eye opening experience. I’m just trying to survive and this guy is trying to protect his turf.
Or, when a very famous radiology chairman in my area told me at a regional conference where I gave a very passionate talk that OBL endeavors in general are futile and we are destined for failure, yet the same attending has no experience whatsoever outside of the safety net of a very large and financially successful healthcare system in a semi-rural area. You have no idea how badly I wanted to tell this person to go to hell at that moment, but just couldn’t because they kind of pioneered our field and may or may not be responsible for a famous peripheral arterial disease procedure whose acronym is an activity enjoyed among people traveling to Sub-Saharan Africa.
Let’s not also forget about that time where the academic program across the street from my former IR/DR private practice tried stealing my UFE patient after I sent her to the university hospital for an MRI of the pelvis. While this honestly was likely a systems issue (order for MRI pelvis with history of fibroids triggering an IR alert in their EMR), someone somewhere was instructed at some point to get that patient into their clinic when this happens. This resulted in an interesting phone call with the IR division chief.
It’s not just academics that will make you feel isolated. Private practice IRs in hospital settings will also make you feel like someone who has taken a plunge into the deep-end. First, they’ll deny your request for hospital privileges. The main group in town “competing” with me for IR business would always have one of their IRs text me cryptic messages. They once called my office to leave me a threatening message after they found out I had referred a patient to the hospital where they provide IR/DR services to undergo a CTA when the competing outpatient center I usually referred to denied our imaging request because of a contrast allergy.
Needless to say, if you go the privately owned OBL route, you are inherently in the anti-hospital/large healthcare-system-controlled cohort which makes you more or less a renegade IR in people’s eyes. Those “friendly” relationships with other IRs become real very quickly. Your only friends may be random people like me online, or other OBL types who realistically may be more interested in exploiting you for cheap labor for their own entrepreneurial endeavors than they are in fostering your career growth.
- Financial Pressures: Freedom Isn’t Free
If you choose to be independent of non-physician investors and corporate interests, your freedom will come at a cost. When you enter the OBL world, it is really no different from entering a hospital setting in that you exist primarily to make money for your institution. In the hospital, you will have no control over your financial destiny. You will do what you’re told and that is normalized. In the OBL, if you choose to be truly independent, you have really bought yourself 3 full-time jobs: physician, marketer and manager.
I will discuss this more in the upcoming post about how to find the right OBL opportunity, but to go out and do this on your own is difficult. When you’ve spent your entire life learning how to be a doctor, it’s hard enough to focus on that alone. Then you throw on the other responsibilities and you can see how challenging and stressful this can be.
For me, I of course spent my efforts on being the best OBL physician I could be. I spent an equal amount of time marketing my practice because if I’m not seeing patients in the clinic and getting patients on the table for procedures, I’m not making any money. That so-called easy 8-5 outpatient life is not as easy as it seems when you spend the hours of 5-8 creating your ability to generate revenue from 8-5.
Then there’s management. You can hire an office manager and have an MSO help out with HR, but at the end of the day you will still need to create the systems which work for you. This involves a healthy degree of managing the managers until a certain level of homeostasis is achieved. Not an easy feat.
- Questionable Safety-Net With Early Differentiation
The moment you commit yourself to the OBL, you’ve essentially committed yourself to becoming an expert at only a handful of procedures and disease states which you will then treat in high volume. You will in short order learn to do these faster and more efficiently than anyone practicing primarily in a hospital setting. The problem? Let’s say things don’t work out for whatever reason and you need to go back to the hospital. When was the last time you’ve done a GI bleed? How about biopsies and drains? Do you remember how to do a TIPS or BRTO? How about PE or DVT thrombectomies? Or biliary drains? Or nephrostomy tubes? Or even diagnostics?
What makes hospital IR work interesting to IRs traditionally is the breadth of the work involved spanning a variety of organ system and pathologies. Of course, none of this work will come at very high frequency because unless you are in a small group servicing a very large hospital with a large catchment area, you will spend the vast majority of your time doing bread and butter procedures then you’ll find yourself in random moments of hell at 3 AM remembering how to do a BRTO. Can you imagine that same moment from hell, only this time you’ve never had the experience of actually doing one on your own?
Conclusion
Early career OBL life is hard. For those fresh out of training, I don’t recommend it unless you can work with a senior partner who has a vested interest in mentoring you and you have a mechanism for being incentivized to grow with them. Even better if you get OBL experience in addition to hospital experience. There is a lot to be said for spending some time in a hospital and learning how to function independently and to get some of those traditional big cases under your belt. Ironing out some kinks and establishing a level of procedural consistency and confidence as an IR is key.
With that being said, there are some who go straight from training to the OBL setting. I just question those who claim they are doing so with little to no support. I don’t buy it. Anyone that good right out of training is more dangerous than they think.