Independent IR: Illusion or Reality?

Greetings from SIR 2026 in Toronto. The meeting is off to a great start. It has been an action-packed day 1, catching up with old friends and hearing about our stories within our specialty. I had the pleasure of participating in the Early Career Section programming today to discuss my career and what led me to the OBL space. I’ve been getting more involved in society leadership and looking forward to beginning a term as the Practice Management Division Vice Counselor. How did I get to this point? I have no real clue, but it might have been related to this blog.

It’s good to see more “private practice” representation in SIR leadership, and I encourage my friends and colleagues reading this to consider volunteering their time to help the society. We are moving in a direction I believe is advantageous for independent IR, and I encourage all who engage with this blog and are passionate about our specialty to volunteer. If our voices are not heard, we will struggle to make progress.

As we enter another SIR Annual Meeting, I have been struggling with a question. I need you to think really hard about this one and be honest with yourself regarding the answer.

Can Interventional Radiology actually stand on its own as a specialty?

Not in the way we talk about it at meetings or present it to trainees, but in the real world, where patients have to find you, and where revenue from your IR work actually supports your practice, and where no one is obligated to send you anything.

My career has been a pursuit of independence. Financial independence from hospitals and other specialties, autonomy over my clinical practice, and the ability to define what it is that I do in a system that increasingly prefers to define that for you. That’s what led me to build Image Guided Solutions of Missouri. It is working, and I believe in what we’re doing, but it is also a grind in a way that I don’t think is fully appreciated unless you’ve actually tried to do it yourself, because most people never actually have to.

What makes that harder to ignore is how many easier paths exist right now, and how rational those paths look when you step back and think about them. You can read from home, you can do locums, or maybe a combination of the two. You can work in a multitude of settings, distilled to the point of being able to step into a system where someone else has already built everything, and you just function within it. In many cases, those paths pay more, they’re more predictable, and they don’t require you to build anything from the ground up. That’s the reality we’re operating in, and if that’s the reality, then we should at least be honest about what we are incentivizing as a field.

We say we are a clinical specialty. We talk about independence. We talk about growth and innovation, but when you look at how careers are actually being built, they often move in the opposite direction. We still recruit students with some version of “you get to do procedures without the surgical lifestyle,” and that message lands exactly as you would expect. “Surgery lite” becomes the identity, whether we intend it or not, and people build careers that reflect exactly that, with limited clinic, limited responsibility outside the procedure, and efficient procedural work inside systems that already exist. That’s exactly what we told them this field was.

At the same time, the structure around us is shifting in ways that should probably make us more uncomfortable than they do. The transition from IR-DR private practice models supported by diagnostic revenue to employment models and hospital-controlled systems is well underway and mirrors what is happening across healthcare. In the outpatient space, independent practices are disappearing while corporate entities and specialty-owned groups continue to expand, and IR increasingly appears as an add-on to those systems rather than as a defining force. We are also watching procedures we developed and refined move into other specialties that already control the patient relationship, and none of this should surprise anyone once you consider how medicine actually works.

Disease state expertise and management are mandatory.

Trying to build IGS forced me into that realization in the most real way possible. Working in a rural setting, you don’t have the luxury of a steady stream of fully worked-up consults. Patients show up with problems, not diagnoses, and those problems don’t always map cleanly to what you were trained to do. Back pain, leg pain, pelvic symptoms, things that don’t line up neatly with a procedure, and you either figure it out or you don’t have a practice.

That means the clinic becomes central whether you like it or not, and it means spending time on patients who may never become procedural candidates, and it means managing things that fall outside what most of us were formally trained to handle. You start to realize pretty quickly that the gap isn’t because we’re incapable, it’s because we’ve built a system where we haven’t had to develop those skills consistently.

The referral piece becomes very real once you try to step outside of it. Anyone who has tried to build a UFE or PAE practice without shared incentives understands how fragile those pathways can be. Even when referrals exist, they are rarely enough on their own to build something sustainable, which forces you into a different way of thinking about how patients find you and why they would come to you in the first place, and that’s where most of the real work actually is.

Before going further, it’s worth being clear about what I mean by independence, because I’ve written about this before, and it keeps getting reduced to things that aren’t really the point. Independence is not just about being employed or not, although that does matter, and I do think private practice is necessary to support if we care about where this field is going. It’s also not just about owning an OBL or working for yourself. Those are just structures.

I’ve written about this before in IR and DR: The Dirty Truth, but the reality is that our relationship with diagnostic radiology has always been about more than just business structure. It’s culture, it’s identity, it’s how we see ourselves and how we’ve been trained to function within a larger system. And if we are serious about being a clinical specialty, it’s hard to argue that we can stay structurally and culturally tied to something else and fully define ourselves at the same time. At some point, that has to change if we’re serious about this.

Once you actually try to build something, you realize the question isn’t just whether we can separate from diagnostic radiology. It’s whether we can exist without being fed by anyone else. Whether we can attract patients, manage them, and build practices that don’t rely on someone else’s clinic to fill our schedule. That’s a very different standard.

I think we’ve convinced ourselves that some of these newer models (see below) solve that. Embedding into other specialties, aligning incentives, and building inside existing systems, we call that innovation. It works, it looks like growth, and it makes things easier.

But it doesn’t answer the question. If anything, it kicks the can down the road.

Here is what we need to ask ourselves:

• Are we capable of building financially viable practices without relying on other specialties?
• Can we actually take care of undifferentiated patients?
• Can we build pathways where patients come to us directly?
• Can we explain our value without leaning on cost savings or downstream revenue?
• Are we willing to take a harder path to build something that actually lasts?
• Are we going to make VASCULAR and interventional radiology great again?

Collaboration, Not Subordination

We have been giving away pieces of our field for decades. We call it collaboration, we call it improving access, and sometimes that’s true, but a lot of the time we are teaching other specialties how to do what we do, and accepting roles where we show up to do procedures and then leave, and over time that changes how IR is seen. We are not seen as a specialty that manages patients, but rather a set of procedures that can be performed anywhere. Once that starts happening, it erodes the specialty, whether we want to admit it or not.

The MSO-backed model is a major part of this, and we keep talking around it instead of just saying what it is. IR is being built into larger clinical platforms, tied to specialties that already control the patient care pathway, backed by capital, scaled quickly because the infrastructure is already in place, and, of course, it works because that’s exactly what it’s designed to do.

But it’s not independence, and I think we need to stop pretending that it is or that it somehow gets us there over time. When IR exists within someone else’s clinical and financial structure, where they control patient flow and the economics, we are not building something of our own. We are fitting into something that already exists, and over time, that matters more than I think we acknowledge. The more we embed ourselves into those systems, the less necessary we become as a standalone specialty. The procedures don’t have to leave their ecosystem. The patient never really leaves their care pathway, and what we do becomes easier to internalize and easier to absorb. This is not a hypothetical outcome. The commoditization of IR is happening and it should scare you. Our society needs to be proactive in protecting what we do, just as much as it needs to support innovation.

This is where the collaboration argument starts to fall apart. Collaborating with other specialists is important, but it must be done with mutual respect while preserving our value as independent practitioners.

Preserving our value and believing in the power of our specialty are not something we take seriously enough. Many times, I question whether my colleagues believe in our ability to be independent. We talk about IR as if it is already a fully formed clinical specialty, but when you look at how we train, how we practice, and how we structure our careers, there is a gap between what we say and what we are actually building.

I don’t think we take ourselves as seriously as we say we do, and if we did, independence wouldn’t feel optional; it would feel necessary.

So can IR stand alone?

It absolutely can, and it should. But it doesn’t happen by default. It requires making uncomfortable decisions and accepting short-term pain for something that is actually sustainable over time, and we, as a community, have not yet shown that we’re willing to do that.

I’m excited about the direction the society is heading, but we need to push harder, and that starts with IRs actually engaging with the society and being willing to define what independent IR looks like in their own communities. It involves making difficult decisions and re-evaluating how we care for patients and structure our practices.

As we head into SIR 2026, I’m less interested in what the next device can do and more interested in whether we are willing to take this question seriously in our actual practices.

The future of the specialty depends on you. How will you respond?