Interventional Radiology and Diagnostic Radiology: Know The Rules

I recently had a great conversation catching up with a friend who is a diagnostic radiologist in private practice. My friend wanted to get my perspective regarding unhappiness in his hospital based radiology practice. In particular, it seemed as if there were some pretty stark disagreements between diagnostic and interventional radiologists relating to the value of interventional work. I actually found it incredibly refreshing to hear his take on the issue. While for confidentiality matters I won’t rehash specifics, I do have to say that the conversation led me to re-examine the relationship of interventional radiology with diagnostic radiology and what our future may entail. 

On the whole, it is no secret that I am not a fan of traditional hospital-based practices largely due to the financial structure in which interventional radiologists are forced to practice in. Please see this post for more details.

I am going to rehash my argument and suggest a possible path forward, but prior to doing so I want to make it crystal clear that my stance has nothing to do with the intrinsic value that diagnostic radiologists offer society, nor does it have anything to do with the value diagnostic radiologists provide for us interventional radiologists as we train. Some of my best friends are diagnostic radiologists and I am forever grateful for my diagnostic background. I really did learn from some of the best. Please do not confuse the arguments for independent interventional radiology services with an outright indictment of radiology groups or the value of interventional radiologists who chose to practice in those groups. I know that there are many wonderful interventional radiologists working in these settings. 

What I Believe:

Interventional Radiologists should be able to choose how they would like to practice. 

My Beef:

Our formal relationship with diagnostic radiology prevents interventional radiology from reaching its potential as a clinical-based specialty which is consistent with the goals and aspirations of an increasing proportion of our current practitioners and trainees. 

With that being said, while it is unpopular to be publicly stated, there are still plenty of IR trainees and early career IRs out there who do not want to practice 100% IR and who actually enjoy the traditional hospital-based existence. The real truth is, the far majority of our trainees end up in this type of practice whether they like it or not because that is how we are generally structured to practice. To deviate from this path involves significant luck, tremendous connections, above-average geographic flexibility or a very high risk tolerance. 

There are a handful of hospital based radiology group practices which practice advanced interventional radiology. I have friends in groups like this and for the large part, many are happy. They feel that their work is valued and they are professionally fulfilled. Often these are very large groups with stable contracts and significant subspecialization. 

Despite the ones who end up in “good groups” the fundamental premise of hospital-based radiology is wRVUs are king. And the truth of the matter is it is incredibly challenging for an interventional radiologist to pull their relative weight because the hospital game is simply rigged. Direct patient care is economically inefficient compared to diagnostic work. For this reason alone, many interventionalists in hospital based practices have to devote a relatively large proportion of their practice to diagnostic radiology. Even for those in “good groups” who don’t have to spend more than 10% of their time doing diagnostic radiology, it is very clear that their pay is largely subsidized by the wRVU production of diagnostic radiology colleagues. Look, there are some exceptions to this rule, but on the whole this is the truth and is even supported by data seeing as the majority of interventional radiologists practice less than 90% IR in their current practice and for the mere fact that direct patient care in the hospital with our current mix of CPT codes is not favorable relative to the revenue that can be achieved with diagnostic imaging interpretation. I’m not saying that you can’t produce lots of wRVUs practicing clinical IR. You most certainly can, but it involves the creation of the proper infrastructure to do so. 

Ultimately at the end of the day most interventionalists are put into situations where they are significantly handicapped. As such, they have to go through significant hoops such as the following to “create a clinical practice”:

1. Explaining to radiology group leadership the importance of evaluation and management codes.
2. Creating a business model to justify clinic time.
3. Actually implementing said codes into daily practice.
4. Getting referrals within a system that has well defined referral patterns or spending the requisite effort to go outside of the hospital system to achieve new referrals.
5. Later creating business plans to justify the hiring of advanced practice providers which are in many settings vital for the smooth running of a clinical interventional radiology service (a post for another day).
6. Expending a lot of energy to exhibit the degree of emotional intelligence to maintain a harmonious working relationship with diagnostic colleagues who feel they are doing you a service.

In fact, these hoops have been so ingrained in the psyche of young interventional radiologists as they are common themes in “practice building” talks. I gave a talk to both local residency programs in my area in my first year of practice pertaining to “practice building.” Of course I went the extra step of saying how the game is rigged, which ended up in the creation of this Line Monkey MD blog and my subsequent pivot into independent private practice. 

Anyway, the point I’m trying to make here is that in hospital-based radiology groups the rules are clear. Production is king and it is generally difficult for an IR, relatively speaking, to keep up with the Joneses of radiology from an wRVU standpoint without practice building endeavors which often require a significant culture change. Even then, you are working incredibly hard to build a service line in a site of service which is inefficient and adds unnecessary societal costs when compared to the ASC or OBL.

Cultures can be changed but they require three key elements:

1. Persistence
2. Patience
3. Luck

You can be persistent. You can be patient. But you cannot control luck. Luck in this scenario is the willingness of your diagnostic partners to walk with you on this journey as you create a clinical IR presence. Luck is also your IR partners who have been thinking and acting a certain way for many years to adapt how they do their work. Not everyone wants what you want.

Every game has its set of rules. If you’re working for a hospital-based radiology group, whether hospital employed, private equity owned or in an independently run group, the rules are still largely the same. It’s easy to get frustrated at diagnostic radiologists, but this is the game you signed up for and unfortunately there are very few out there willing to tell you the truth. The sooner you understand those rules, the sooner you’ll maintain some semblance of mental health. 

Even if you’re in a “good group” that has a clinic, inpatient rounding service and affords you the opportunity to truly take care of patients using the training you worked so hard to acquire, I still believe that hospital based radiology group practices as currently structured are bad for the future of IR. Why? Accepting a position in a hospital based practice simply perpetuates the status quo of groups with pseudoexclusive contracts which prevent interventional radiologists from being independent. If we are not allowed to pursue independent practice which requires true clinical excellence for success, we will not move our field forward in a meaningful way. I’m not blaming anyone who works in a hospital (most interventional radiologists actually), but it’s clearly a systemic issue and there currently is no good solution. 

How do we move forward as a field?

First and foremost, my perception of interventional radiology’s future may not be your perception of the future. Like I said, there are plenty of young IRs out there who are fine with the status quo. Perhaps they don’t want to see patients in the clinic. Maybe they love doing diagnostic radiology. They enjoy the stability and clear path to partnership many groups provide with a median salary of 550k. It’s clearly the least risky route of practice seeing as it’s “tried and true” and happens to be the market standard for what we do. 

To this I say, that’s great! You need to do what’s right and what makes you happy. The fact of the matter is there will always be a role for physicians doing a mix of diagnostic and interventional radiology in a hospital setting. We need great physicians to service the basic needs of the hospital including fluid drainage, emergent embolizations, biopsies and central venous access. I also believe that we as IRs are excellent DRs due to the fact that we have a higher level understanding of clinical management compared to most of our diagnostic colleagues. Personally, I’d rather leave medicine than spend the rest of my life in the hospital, but that’s just me. The choice is for each interventionalist to make.

Currently hospital based practice is both the standard and expectation for IR practice. Any deviation from this makes you look like a total rogue. Or perhaps you may be considered “innovative,” or “entrepreneurial” at best. But the truth of the matter is people like me and those who have come before me are just trying to do what any other surgeon or medical subspecialist has been doing for decades. It’s really not that novel or interesting. It just so happens that the standard expectation for our practice comes with the significant baggage of pseudoexclusive contracts which makes independent practice extremely difficult, if not impossible in many markets. 

How do we move forward? There are a several ways to go about this:

1. Legal action
2. Encouraging the SIR to be more of a bully
3. Redefining our field

Legal action is what it is. All politics and lawsuits for that matter are generally local. Contractual disputes or any legal action usually comes with some contingencies such as non-disclosure which prevents a true precedent from being set which can be used to institute change on a global level. 

I sure would like the SIR to be more of a bully. I know there are a couple people there working on this issue, though it seems very frustrating for people like me who are living this nightmare every day. It’s easy to be negative, but we also have to understand there is only so much a society can say or do. There are so many different stakeholders and change in large organizations is simply slow. The fact of the matter also remains that what we are asking for only benefits a small proportion of the current membership. Though I guarantee that proportion will be increasing as new trainees come out into the workforce feeling the same way I do. 

I think the way we really move forward is literally redefining our field. I want to frame this by more closely analyzing a personal rejection for my inquiry regarding obtaining hospital privileges at the facility literally across the street from the OBL where I was a partner. Certain names and titles omitted for legal purposes:

So before I’m even given an application to apply, I was rejected because I’m a radiologist. I suspect that this is the case in most hospitals with existing IR services. Sure, I could have proceeded through a couple different paths. I could have pushed my cardiology partner at the time to work some connections to get an application to only later get rejected. I could have called the president of the radiology group to discuss the situation and come to some compromise or he/she could have shut me down or made me take some poorly compensated call. I could have lawyered up and spent a lot of money to get privileges, or at the very least spent a lot of money trying.  At the end of the day, I didn’t need those privileges to practice in North Carolina so I didn’t push the matter.

But what if I didn’t have a cardiology partner to admit any patients I needed admitted or to do any procedures on patients who end up hospitalized? What if I didn’t live in a state which was lenient with respect to having privileges or transfer agreements? What if I were doing this on my own and I just wanted to be a good physician who has the ability to care for his patients in both inpatient and outpatient settings? One of the reasons I work so hard to become financially independent as fast as possible is because my future practicing in my own OBL in a future location TBD is most definitely not certain and it has nothing to do with my risk-tolerance, financial health, business knowledge, ability to generate referrals or skills as an interventional radiologist. It has everything to do with state laws, local radiology groups and hospital bylaws. 

In this case, I couldn’t even get in the door because on paper I’m a radiologist. And the only reason I wanted to get in the door is because I want to take care of my patients and not actually do “radiology” in the hospital. Believe me, I have no interest in taking over the local rad group’s stream of abscess drains, biopsies, gastrostomy tubes, or emergent embolizations. I of course want nothing to do with the interpretation of diagnostic imaging in the hospital. These radiology groups are going to deny independent interventional radiologists hospital privileges, but they let cardiologists and vascular surgeons use their labs to do image guided procedures. Give me one legitimate reason this is acceptable. I’ll be waiting right here.

At the end of the day, we are board certified Interventional and Diagnostic Radiologists. We can call ourselves what we want, but we are currently radiologists on paper. And that is perhaps our biggest obstacle of all. 

Do we need to redefine ourselves and will it matter? When we apply for privileges, should interventional radiology (or whatever we choose to call ourselves) be its own core specialty? Right now, even with the new training paradigm, it is not its own core specialty truly distinct from diagnostic radiology. It is labeled “Interventional Radiology and Diagnostic Radiology.”  Do we need to have our own specialty board distinct from the American Board of Radiology?

Look, I really don’t care what we call ourselves. We can be labeled medical plumbers for all I care. Patients don’t really care what we’re called either, but how we define ourselves can have significant implications when it comes to obtaining staff privileges.

What do we need to do collectively to make this pseudoexclusive thing disappear? This is literally the biggest challenge facing the future of interventional radiology. Until we handle this issue, I cannot in good conscience recommend interventional radiology as a viable career path for clinically oriented trainees without the caveat that moving forward with this line of training is a gamble and they have to be ok with the possibility of working in a traditional hospital academic or private practice based setting. You can potentially be fulfilled but it will involve some degree of luck, or many years of working hard to change a less than ideal culture which will likely make you feel undervalued and under-appreciated. Either that or you will need to go “rogue,” or again be “innovative” and “entrepreneurial” at best to have the same rights any cardiologist or vascular surgeon currently has. 

I know this comes across as negative, but the struggle is indeed real and it’s one you should recognize. If you are in a radiology group, I encourage you to assess your own group’s contract and see if it is “pseudoexclusive.” You never know when some independent IR will come knocking, and I promise you they aren’t there to take your cases, especially if your only site of service is the hospital.

Please comment below. Would love to hear your thoughts