Happy Medical New Year

I want to wish everyone reading this a happy “Medical New Year.” This time of the year is always both bittersweet and somewhat exciting, particularly for those of you leaving training and entering practice.  We say goodbye to old friends and hello to new colleagues as we transition into new roles. What they don’t tell you in training is becoming an attending is just the beginning of a new adventure full of challenges. Once you leave the academic cocoon you quickly realize how cruel this world really can be. No one will care more about you and your career development than you. There is no curriculum and where you decide to take your career is truly your call. It’s simultaneously exhilarating and terrifying. As I enter my “PGY-11” year I still feel this way.

With that being said, the further I get from training the easier I realize it is to lose sight of the hard work it takes to become an attending interventional radiologist. I was reminded of that last month at the OEIS conference where I was invited to give a talk in the resident and fellow section. The title of my talk was “Doing Your Homework: What You Should Know Before Working in an OBL.” Before and after the talk I had the opportunity to meet with some of the students and residents and it became apparent to me that some of the material at this business heavy conference may have been over their heads. It certainly isn’t because they are not capable of comprehending a lot of the discussions at the conference, but simply because they haven’t been exposed to the world of office interventional suites let alone the world of business development.  Even beyond that, many trainees are simply in survival mode. Many of my discussions centered on advice pertaining to getting into residency or finding good opportunities after training.

The idea of being in survival mode was made especially apparent to me this past week when I connected with a couple residents over the phone. One in particular seemed kind of listless. He was just checked out and not sure really how to move forward beyond training. I couldn’t help but think of my own experience as a senior trainee feeling the same way: tired of feeling like a cog in a wheel, unsure about where I stand with respect to my ability to take care of patients and perform cases, uncertain about my future in an ill-defined field and trying to figure out how all of these concerns impact my life outside of medicine.

The beautiful thing about the “New Year” is it’s a chance for new beginnings. As much as I encourage everyone to have a vision as I have in my last post, it would be disingenuous of me to not admit that it is hard to have a vision when you haven’t experienced a little life as an attending. Perhaps some of us have pivotal moments earlier on in training or before which define us, but a lot of us truly don’t begin to figure things out until we get out there and start working.

For me, I didn’t have my “aha moment” until my first job out of training. I encourage every reader to go back and look at the first several posts of this blog to see what was going through my head at that time. I hated that job with a passion. It was through that experience I quickly learned what drove me. That job taught me a lot of truths about our field. During my subsequent OBL endeavor I learned even more truths. Many of these truths are uncomfortable ones as they tend to shed negative light on a status quo which many powerful people in our field depend on for their livelihood.

I want to share some of these uncomfortable truths with you because doing so will provide a much needed framework for trainees and early career interventional radiologists as they decide how they want to shape their own careers

1. Your Training Is Far from Perfect

Interventional Radiology training has gone through significant changes over the last several years, on paper. And while I wish I could legitimately say that there have been real changes, the truth of the matter is these changes are actually much easier to show on an ACGME document or talk about at a medical student symposium than they are to demonstrate through tangible outcomes. What do I mean by that? Well, the fact of the matter is the majority of trainees have now reduced time on diagnostic radiology and are being farmed out to off service rotations in an effort to become “more clinical.”  I don’t know about you, but I find it really hard to believe that we can simply flip a switch and make programs more clinical. Kind of hard to do when the personnel in charge of these programs are fundamentally practicing the same way they have been for decades. Furthermore, this pervasive mentality that interventional radiology is a subspecialty of diagnostic radiology, akin to pediatric radiology, musculoskeletal radiology, neuroradiology etc. does nothing but continue to attract individuals to this field who are completely fine with doing diagnostic radiology when we should be attracting students who are more interested in something surgical. It is the non-radiologists at heart which are necessary to move the needle in our inevitable direction away from an existence centered with a radiology ecosystem. We are simply attracting the wrong people to our field, even with the new training paradigm. Proper recruitment is one of many necessary steps in our evolution. I’m frankly tired expending energy interacting with people who would be content with doing diagnostic radiology for a living but are still contemplating IR. The “IR lites” would be better served practicing a subspecialty of diagnostic radiology that affords some “needle-time” and not waste their time doing what will undoubtedly become a field distinct from diagnostic radiology. I’ll save the my rant for another post.  

2. You Are A Highly Trained Wage Worker

In the US, we practice within a very dirty healthcare system. While I hope we all enter the medical profession because we truly believe in the mission of improving the health of our society, the fact of the matter is our healthcare system is incentivized to promote sick care. It has been absolutely gutted and rigged in such a way that it is quite obvious to most that the ultimate motives here are profit, like any other industry. The main difference is it is not a free-market and the financially astute and morally intact physician cannot help but feel very dirty knowing that there are individuals and organizations making millions off of some of the most marginalized individuals in our society. Many of these individuals enjoying these profits aren’t even physicians but they’ll act like they’re smarter than you. The truth is they aren’t. You just haven’t been sufficiently educated and empowered to call them out on their crap.  What makes matters even more frustrating that there is very little any single individual physician can do to improve the situation because the system is designed to treat us like commodities.  

The way to combat this is to break free from the cycle of healthcare system employment and practice independently. Even then, when you’re in a field such as ours which has very high overhead costs, it is hard to not accept insurance for reimbursement. The moment one accepts insurance products is the moment one subjects themselves to the terrible games that plague our healthcare system. Very few students and residents know about this sad truth because we are largely shielded from it. We are conditioned to accept that we will simply press on and do our best as individuals more or less oblivious to the system we choose to work in. Even worse, once in practice many of us are actively discouraged from being involved in financial matters being told by our supposed mentors who have sold out our future to the likes of large healthcare systems or private equity firms that these matters “are best left to the C-suite.” Don’t get played. Keep asking hard questions as stupid as they may seem because this is how you get to the truth.

3. Modern Practice Building is Not Benign

A common theme for early-career folks as they leave the training nest is this concept of “practice building.” It used to be that one needed to practice the “three As” of availability, affability and ability in order to build a practice. When most faculty or private practice IRs give these types of talks, and believe me I know well because I’ve given residents these types of talks before, they mean well and they are absolutely correct. Every hardworking IR physician, be it in academics, hospital-based private practice, multispecialty group practice or OBL/ASC has had to work very hard to build some type of clinical practice. There are some tremendous resources out there to guide readers in the right direction. I’d encourage every reader to check out the Founder Mentality post.

What isn’t being told is the sad truth when it comes to practice building. The game is actively being ruined by those that introduce clear financial relationships in an effort to build referral streams. The three As have morphed into the three As and a P, with the P standing for profitability. Some would even argue that the “ability” part has been largely replaced by profitability. Financial relationships are common throughout medicine and they are only becoming more common as our healthcare system continues to consolidate, Whether it is an academic physician building a practice through multidisciplinary collaboration (read shared financial incentives in the same healthcare system), or an OBL owner/operator bringing on investors in an OBL/ASC or perhaps creatively arranging multidisciplinary group practices to work-around AKS Safe Harbor rules, every year more and more people are playing the same game. It’s a game where financial incentives drive patient care. And while some claim that patient care is enhanced with consolidation, and in a select few settings that may be the case though I would contend that has more to do with the physicians working in these systems and not necessarily the financial structure, the fact of the matter is the continued consolidation of healthcare does nothing but reduce competition which in turns drastically increases the cost of care for patients. Furthermore, it limits the potential for the next generation of physician to have ownership stakes, which contrary to popular belief isn’t to fatten our pockets, but rather to place us at the decision-making table where we are best positioned to change our healthcare system for the better. Take all these talks about “multidisciplinary care” and “value-based care” with a huge grain of salt, because what they really mean is sharing a pot of money and not necessarily improving outcomes for patients. Again, not true of all endeavors with these buzzwords, but the general theme applies. Once you learn the learn the requisite language to perhaps sound nice during an interview or conference and appease slick business folk you learn to read between the lines.

4. Passion Trumps Profits

What does passion have to do with IR? Well, it has everything to do with it. When you love what you do and are passionate about it that you wake up every day to do your best for patients despite all the crap around you, that is what truly keeps you going. More than money, vacation time, or whatever incentives you may have. If you don’t love taking care of patients, this will end up being a truly miserable existence for you.

For those of you entering our field as new attendings, I welcome you with open arms. Whether or not you agree with me what makes our field great is that we have wonderful people in it who largely share a passion for taking the best care of patients possible.

For me, even with all the negative experiences I’ve had and all the challenges, setbacks and difficulties with being an independent physician, practicing medicine is fun. If this isn’t fun for you right now then you need to make some changes to make it fun. For those of you who are ok with the typical hospital-based existence, your road will be a little easier. I don’t necessarily think this road is our future, but I’m not going to judge your decisions. For those like me who want to see a future of true financial independence from the diagnostic radiology ecosystem, I think the best way to make work fun is to do the following:

1. Find several pathologies you like to treat and become an expert in them.
2. Treat your diagnostic radiology skill as a true asset to generate revenue to fuel your IR business.
3. Quickly funnel as much money as possible into income generating assets outside of medicine to financially free yourself from this dirty system. Review this post for a brief overview.

This recipe is actually quite simple and it works because others before me have done it and I am actively doing it myself. These days I am not so concerned with point 2 or even point 3 and am more focused on creating a sustainable clinical business with the right partners. The concept of financial independence as it relates to the independent interventional radiologist deserves a post of its own, but the entire premise here is to create a life that you want to live.

For me, I want to build a clinical practice. I don’t want others to tell me what to do or how to do it. I’m not kissing any rings or playing any games. How many do that for a lifetime just baffles me.  Medicine in the United States is best practiced as a hobby, not as a necessary perpetual exchange of time for money which is being used to create generational wealth for those who are savvy and play cute financial games. I don’t want to worry about making millions of dollars and expecting some ungodly exit at the end. Why is it not possible for all of us to 1.) do what we love, 2.) continue to impact patients in a positive way because it is this passion which fuels our lives and 3.) meaningfully mentor a few individuals to follow suit? If you don’t have this passion and work hard early on to free yourself from the golden handcuffs that is medicine, then you need a job working for someone else with ample vacation time so you can fuel other passions outside of medicine and continue to make a steady paycheck. This is how most physicians practice. Some of them have the inherent passion for medicine that I describe, but don’t want to “take a risk.” I’d contend that not taking a risk in our changing healthcare landscape is in many ways riskier than going down the road that I’m describing. Furthermore, we need more people creating legitimate opportunities for future generations of image-guided surgeons. If it isn’t fueled by passion for patient care and a true love for your craft and the betterment of your fellow physician colleagues, it will crash and burn. Unfortunately, I feel we are currently witnessing a lot of crashing and burning.

5. True Mentorship is Tough to Find

Mentorship in interventional radiology is lacking, particularly for those spiritually invested in a future of clinical practices outside of the hospital setting. We are being taught largely by academic physicians who are employed within big-box healthcare systems practicing within a radiology ecosystem. And while a select few are extremely talented and do a great job teaching, the moment you decide not to play in this arena is the moment you realize that you need to find mentorship elsewhere. Many of these folks falsely measure their success as educators by your ability to obtain a “prestigious” academic job. They lump all of “private practice” into a separate category solely focused on profit generation. They collectively admit the job market has not caught up to the demand of trainees, but at the same time believe that trainee demand alone will fundamentally change the nature of interventional radiology jobs. I find this somewhat delusional as would anyone who has basic financial knowledge.

What will really change the game for us as image-guided surgeons (not interventional radiologists) is proving our financial value to those who truly run healthcare. The two most important players here are the government and insurance companies. In our field, we have not collectively unlocked our greatest potential to exhibit our inherent value. We are too fragmented, too divisive, and lack a true identity. We spend too much embracing heterogeneity and use “local and regional practice patterns” as a lazy excuse to not organize and create a true vision.  Despite what I believe to be true though will undoubtedly be mischaracterized by some as a “negative-take,” here is what I do know:

1. Patients demand minimally-invasive image guided therapies.
2. What we do is cost-effective compared to the surgical alternatives

How we are not a dominant force in the healthcare landscape is a wonderful case-study in organizational mismanagement, poor marketing, insufficient clinical and scientific research, poor political strategy and comfort in the golden-handcuffs of diagnostic radiology subsidization which prevent us from ushering in an era of true clinical dominance.

There are about 20 people in our field who have figured out how to practice in a way which I believe is consistent with the direction in which we should be heading. I have met most of these people by this point, and no I will not mention their names.

With this being said, finding the people who are doing good things is not hard. Ask around and you’ll find out very quickly who is “on the cutting edge,” philosophically speaking, and who isn’t. And they aren’t necessarily the biggest names out there. Try to find someone practicing in a way you want to practice. Reach out, pick their brain, but in turn offer to be of assistance to them because simply leeching off people is not how you make meaningful relationships in this world.

Conclusion

Welcome to another year. I hope this year is a great one for you. If it isn’t, ask yourself what you can do to make it better. If there is something I can do to help you, please reach out. If I don’t know the answer or feel I am not best suited to help you, I probably know someone who can help you and am not afraid to make an introduction. I’m working to create that community that I promised in my last post. I hope you’ll be a part of it.