Giving Thanks

If you’re looking for my next dissertation, I’m sorry to say that this current post will not meet your expectations. I’ve gotten into this pattern of bottling all these thoughts in my head then going on epic writing sessions which have resulted in some interesting blog posts over the last few years. A friend recently gave me some feedback and said, “hey I’d like to know what’s going on in your head more often.” 

Perhaps that may be unwelcome by some, but I want to break the pattern of extremely long posts to take a moment and do something we are all hopefully doing this week which is giving thanks. Expressing gratitude can seem kind of corny, but there is some research to suggest that giving thanks can make you happier. For those who know me, I’ve become a huge proponent of working on mindset and I think part of that involves learning how to be happy. It seems kind of strange, or at least it did to me at first, but expressing thanks is a way of taking stock of what you have and being happy for that. In our medical journeys, it’s so easy to get caught up in making it “to the next step.” I’m convinced that the sooner we pause and learn to genuinely enjoy the process, as painful as that can seem at times, we can be more fulfilled.

A book that was recommended to me recently is “The Gap and The Gain” by Dan Sullivan and Benjamin Hardy. I’m not a huge self-help or motivational book kind of guy, but I found the message in this book rather simple, yet very effective. The authors advise living in “the gain” which refers to taking stock of how far you’ve come and not stressing about “the gap” which is worrying about how much work remains. Part of living in “the gain” is being thankful. 

Some people express gratitude verbally, some pray, some meditate and others like me write. Thank you to my family, friends, colleagues and even people who I disagree with for helping to get me to this point in my life. My road has been somewhat scenic, but it has been so entertaining and enlightening. Through various professional experiences and by taking the leap of expressing my thoughts through this blog I have been able to meet some incredible people who have helped me grow. Several years ago I was not very happy with the way my career was shaping out. I hated my job and felt like I was being completely underpaid for my work. I took to the SIR forums and wrote this lengthy post. I’ll put it here for reference:

As a relatively new grad, I’m still trying to figure out my way in this world, but I thought I would add my voice to this forum. I currently practice in a traditional radiology private practice like most new grads do. I apologize up front for this incredibly long post. 

The traditional model for practicing IR in private practice is alive and well. That tradition of course is being a radiologist who does procedures. At their core that individual is still a radiologist. This often means no real clinic, a “you pick em we stick em” mentality and a job working with colleagues focused on maintaining hospital contracts and turning around reports as efficiently as possible in an effort to maintain salaries

Had I really known the truth about life in a private radiology group as a medical student, I would have given strong consideration to pursuing a different career path. It pains me to say that since I love IR when practiced the right way. Some radiology groups are better than others at supporting IR, but at the end of the day anyone who works for a hospital based radiology group that doesn’t capture some part of the technical fee involved in procedures will realize that IR is economically inefficient. As such, they will be subject to the golden handcuffs of diagnostic radiology to “subsidize” their IR endeavors.

Furthermore, as young IRs finish training and jump into the real world, it becomes hard to make the bold choices required to really practice IR the right way. The comfort provided by collecting a steady paycheck sets in. Non-competes and exclusive contracts result in inertia.  Many in IR succumb to this reality which is likely why the majority in our field spend less than 50% of their time doing interventions. I can see how it could be very easy to become stuck. I worry about that all the time.  

Then there are those who have made bold choices such as leaving radiology groups to form their own IR groups or start their own outpatient practices. Now that we are attracting students to IR who would have never done radiology in the first place, this is the direction IR is heading. You have to realize that even among early career IRs, there are still significant differences in training and philosophy. Remember, the concept of clinic and rounding is still very new to many academic practices. To me, and I’d imagine all current trainees, establishing a clinic is non-negotiable. To many other IRs who still may be early in their careers, but who didn’t train in the new clinical model, being able to do procedures and retreat to the reading room is fine and may be what attracted them to radiology in the first place.

New IRs like myself need significant support as we head out into practice. It takes time to become skilled at interventional radiology and it is almost an impossible task to get out in the world and not only develop technical expertise, but try to build the clinical infrastructure needed to practice the way we were taught without appropriate mentorship and resources.  I am skeptical we will get the full support needed for clinical IR from hospital based radiology groups. Obviously there are some “good groups” out there and IRs ahead of their time who have built the needed infrastructure in certain environments, but I imagine that certain fundamental issues still exist. This has nothing to do with the diagnostic rad being out of touch or not sympathetic to our needs. It may seem that way, but like most things in life, it comes down to money. No number of ICU rotations or days spent in clinic during an IR/DR residency will fix this problem. Some may try to go out there and think they can fix it from within, but I’m learning the hard way that this is unlikely to happen. We will continue to produce a new breed of ambitious, clinically focused IRs who will be discontent with their professional existence. Furthermore, you’ll have DR groups looking to fill a need who will also be unhappy because their IR/DR grad will be weaker/not interested in diagnostic imaging compared to other radiology grads. DR is hard and 36 months may be fine for passing some test, but this new training paradigm is clearly not ideal for doing high volume- high end DR in the real world. That’s an issue for another day.

Fulfilling the needs of those wanting to practice clinical IR is difficult when the majority in our field hide behind their exclusive contracts or simply don’t wish to practice in this fashion. Many of these people are my friends and colleagues. While I firmly believe they will eventually be in the minority, this is still the reality for us in 2019. 

This post was from 8/28/2019. I remember that day vividly. I did 3 thyroid biopsies, 2 declots,  5 paracentesis, got into an argument with my senior partner over the use of ultrasound for nephrostomy guidance, subsequently learned that I was going from Q4 to Q3 call when one of the partners decided to leave to go do another fellowship and also learned that the partnership salary I was expecting at the end of the year was far less than what was told to me when I interviewed. I also received a less than flattering email from the lab manager about how my clinic visits in the MRI holding bay were disruptive to the IR workflow and how the technologists were getting upset. I remember going home, looking at all my diplomas which I hung up in my office, thinking about all the important events I missed over the last 10 years and wondering, what in the world am I doing with my life? I was so pissed. I got it together enough to write out something semi-coherent. 

The next day I received a call from someone who would later become my mentor and good friend. That phone call changed my life. 

Subsequently, I worked harder on this blog which has further expanded my network and allowed me to evolve in more ways than I ever imagined. Today my life looks completely different in the most positive way possible. 

It’s ok to be angry. This blog was born out of anger and to this day I remain incredibly angry wishing I knew what I know now over a decade ago. I’m angry at leaders in our field for not doing better or heeding the warnings of IR greats before them, the most notable of course being Dotter. I’m angry at the medical industrial complex, appointed physician “leaders” who fail to realize what’s at stake and those who choose short-term profit gains over the long-term health and well-being of both our patient population and the community of physicians and other healthcare workers who work so hard to take care of others. Commoditization of our profession is not the answer.

When you have strong opinions and you’re not afraid to share those opinions, you will receive some heat. I’ve evolved to learn that I can’t worry about what others think. I take a lot of shots on this blog yet I sleep like a baby at night because I mean what I say. A few may not take kindly to what I write, but I’m ok with that. What I can control is my thinking, my writing and what I do everyday to further my goal which is to promote a future of physician entrepreneurship in interventional radiology and beyond. There is no better way of doing that than documenting my steps as I march along this trail with the genuine intention of helping others because that is what led me into medicine in the first place. 

I am forever indebted to my friends and family for supporting me along the way. I am thankful for the dozens of students, residents and peer IRs who have contacted me for advice because I have learned just as much from you as you may have from me. Finally, I’m incredibly thankful for IR colleagues I have gotten to know over the last few years, some of whom I’ve established working relationships with in their practices. 

If anything, I encourage more of you out there to reach out to someone and share your story. Do not be afraid to be somewhat vulnerable. Chances are, you will soon soon find yourself in a better position.