IR and DR: The Dirty Truth

On 12/6/2023, the American College of Radiology and the Society of Interventional Radiology will hold a joint town hall webinar about the relationship between diagnostic and interventional radiology. There has been enough “vitriol” and tension to spark this much-needed discussion. Maybe it was the creation of a dual IR/DR residency certificate, the integrated IR residency, or some colorful blog posts and podcasts from a few community IRs? I’m unsure, but something tells me all these factors are probably related.

All professional societies are political organizations. The ACR comprises over 40,000 members, and the SIR is around 8,000. Society leaders don’t sign up for uncompensated homework unless there is some political angle or indirect financial reward for these extra-curricular reasons. Why would these societies want to address this somewhat taboo topic head-on? The answer depends on who you ask, and the devil is always in the details.

Before I give you my take, I want to address the topic of IR working with DR in a comprehensive manner. Readers of this blog should know where I stand. Over the last several years, I have thoroughly and hopefully entertainingly addressed various topics ranging from the business relationship with diagnostic radiologists and interventional radiologists to perceptions of professional identity, and, most recently, cultural differences.

The truth is that any reasonable people or groups can work together as long as there is mutual understanding and a joint mission. So, IR and DR can work together, but only if there is a clear distinction in professional roles and responsibilities. Namely, a separate board certification for interventional radiologists, distinct from diagnostic radiology, will be necessary for any meaningful advancement on this issue. Here are the significant matters summarized for your information:

Professional and Cultural Identity

Diagnostic radiologists are master consultants primarily focused on being a doctor’s doctor. Their role is mainly non-patient facing, with apologies to certain specialists like breast and pediatric radiologists. They are an essential piece of the healthcare puzzle. Without a well-functioning radiology department, a hospital will likely fail.

Interventional radiologists have emerged from diagnostic radiology once as procedural wizards and have slowly morphed into this hybrid existence where they are not only procedural experts but are adopting a more longitudinal care model. I contend that they aren’t moving to longitudinal patient care fast enough. Nevertheless, the movement towards longitudinal care is the trend. Many young interventional radiologists believe in the importance of the clinic and being a patient’s doctor over being just a doctor’s doctor. There is more interest in focusing on IR-specific work and less on diagnostic radiology than at any other point in the history of the specialty.

Business Model

Diagnostic radiologists are one of the few specialists remaining who can survive on professional fees only. The efficiency of diagnostic radiology is unparalleled from a pure revenue-generating standpoint. Rapid technological advancements have allowed diagnostic radiologists to read faster than ever before. Most diagnostic radiologists are excited by AI because it will enable them to read significantly quicker and generate even more revenue. They are correct to a certain point. That point will be when CMS reduces payment for radiology yet again. I personally know of diagnostic radiologists who do over 20,000 wRVU a year without AI. Whether or not you view that as dangerous or impressive, I’ll leave it to you to decide.

The ability to collect professional fees only in a pretty epic fashion can be a positive when it comes to making money and protecting the integrity of a private practice. The less reliance a group has on hospital technical dollars to generate revenue, the more likely it is to remain independent and buck the trend of hospital employment. From an academic standpoint, pure professional revenue generation provides leverage when it comes to supporting department initiatives. Indeed, many academic IR divisions have benefited from the professional revenues of diagnostic radiologists (or rather, their army of trainees doing most of the work).

Interventional radiology, at one point in time, used to be compensated very well from a professional fee standpoint. That has changed, and we have reached a point where the critical work we do, even with mundane cases like biopsies, is valued so little relative to the work it takes to care for any of these patients appropriately. The alternative of providing diagnostic interpretations is far more lucrative per unit of time. Any work not spent in the chair interpreting studies will likely lose a radiology practice significant money. I have documented in extensive detail on this blog how my previous efforts to establish a clinic in a traditional radiology group fell flat. I even demonstrated how my efforts to talk about the truth, like how the sky is blue, have been met with resistance and less-than-flattering responses from fellow IRs (is that you, Frank?), including supposed leaders in our society (I will never forget).

Interventional radiologists predominantly work within radiology groups within a professional fee-only business model. Radiology groups dangle interventional radiology services like a carrot to the healthcare system administrators to maintain a lucrative imaging contract. Clinics are often not encouraged, and interesting IR work may or may not happen depending on the size of the hospital and the presence of subspecialty services.

Interventional radiologists in many settings have done well operating independently of diagnostic radiologists. Within a hospital context, this typically involves creating a professional services agreement with the hospital or accepting direct hospital employment. In either model, the interventional radiologist relies on a component of technical reimbursement to maintain their salary relative to the market average in a given region. Depending on one’s ability to convince a hospital that their services deserve stand-alone treatment with a clinical model no different from a surgeon or medical subspecialist, it is possible to have a significant practice within this context.

Alternatively, or additionally, many IRs have gravitated towards physician-owned office-based labs (OBLs) or ambulatory surgical centers (ASCs) to support an IR-only practice economically. In the OBL, there is a global payment for services rendered, whereas an ASC functions similarly to a hospital regarding professional and technical reimbursement categorization; however, unlike a hospital, ownership can capture a component of technical fees. These models support the presence of a clinic and appropriate infrastructure to drive OR revenue.

The OBL/ASC model has become so popular that many radiology groups are now looking at this to achieve further revenue and attract IRs to their groups. It’s a rather exciting yet puzzling trend, as physician-owned offices in IR are over 25 years old. It’s kind of like discovering the internet several decades after the fact.

How Can IRs and DRs Work Together?

As mentioned earlier, any group of reasonable individuals who share a joint mission can find ways to work together harmoniously. Partnerships can break down for various reasons, but in the case of IR and DR it comes down to each party’s relative value to the other.  

For DR, the value of IR is clear. Radiology has become such a commoditized service. With a massive shortage of radiologists and the surge in imaging examinations over the last decade, groups are pressured to find novel staffing solutions to maintain their contracts. The COVID-19 pandemic created a new standard that is remote coverage for diagnostic services. IR physicians find themselves in a position where they are on-site to help deal with all the crap that diagnostic folks no longer deal with, further detracting from their already limited ability to build longitudinal clinical programs in hospital settings. The presence of an IR physician is crucial for a diagnostic group. Without that on-site presence, who is the “face” of the group, it is relatively easy to lose an imaging contract to another party. When one’s business model depends entirely on a contract with one large healthcare system client, one will do anything humanly possible to protect that relationship. Be it an “exclusive” contract for radiology services or pushing their IRs to deal with things they never wanted to deal with, like arthrograms, paracentesis, thoracentesis, LPs, and slinging barium, among other daily trash collection endeavors, all the while hanging their relative wRVU inefficiency over their heads.

Nobody wants to go through 14 years of training after high school to be told that their profession is not profitable, and they should be thankful they have the resources and leverage of a large radiology group to support their salary and generous allotment of vacation time. Furthermore, they don’t want to struggle to convince their group that they need basic infrastructure like an appropriately staffed clinic and the ability to bill evaluation and management charges to reach their potential. It’s like convincing someone you need gas to run your internal combustion engine. It’s so infuriating it may even drive one to quit a group, start a blog, and join a cardiologist.

The best way DR can support IR is by letting IR be free. Stop restricting our ability to practice to the fullest extent possible by holding us hostage to a culture and business model not conducive to the quest for “autonomy, purpose, and mastery” we seek. This includes understanding that interventional radiologists are like eagles among a pen full of diagnostic radiology chickens. Let the eagles free and stop trying to tell them they are chickens like the rest.

From a cultural standpoint, this means interventional radiologists must function like surgeons. They have to have clinics to fuel their ORs. They must market their services not only to other physicians but also directly to patients. They must become masters in disease states and not avoid undifferentiated patient care. Evaluation and management coding must become a significant part of their revenue.

From a business standpoint, in a hospital setting, interventional radiologists generally have to establish professional service agreements with hospitals or find suitable employment arrangements to ensure they achieve their value. Being subject to a professional fee-only model can only work when an alternative site of service can fuel revenue doing IR work, such as an OBL or ASC. The model of being a loss leader for diagnostic radiology groups should not be the market standard. This means that a diagnostic radiology group includes IRs should seek stipends from healthcare systems for providing interventional radiology services.

IR can currently support DR by choosing to partake in diagnostic services as it wishes. Many independent IRs, including myself, still participate in teleradiology. We tend to do so as a means to support our IR-only practice, though it would not be necessary if we had more opportunities to practice IR the way we would like to without jumping through the unnecessary hoops to navigate political nightmares like radiology pseudoexclusive contracts.

From a training standpoint, IR can support DR by continuing cross-pollination during training. There is no question that diagnostic radiology is important to help understand the imaging anatomy we use daily in interventional radiology. We probably don’t need to do specific rotations and undergo a ridiculous board examination process that does nothing to advance our IR practices. Imaging rotations relevant to the organ systems we treat are of tremendous value. Likewise, those diagnostic radiologists who understand interventional radiology have the potential to offer improved interpretations that are not all that different from what they would provide by understanding the wants and needs of their other referring physicians.

From a political and organizational standpoint, leveraging the larger community of radiologists in the ACR provides a practical advantage in advocating for the protection of our reimbursement. Of course, it is possible to support each other jointly without being subject to the same business model and culture. Radiation oncology is an example of this. And yes, IR differs from radiation oncology in the scope of practice and the heterogeneity of services offered. While those differences are real, they are irrelevant to the idea that one can have a separate identity from a historic parent specialty yet join forces for battles against familiar foes. 

What About Patients?

Patients don’t care about our professional politics. They just want their problems solved. Despite this harsh truth, our decision to maintain formal ties to diagnostic radiology on a practice level has largely limited our ability to impact patients positively. The general lack of longitudinal care and dependence on innovation to stay relevant in the marketplace for minimally invasive procedures has kept us largely relegated to hospital-based settings and dependent on the goodwill of other medical and surgical subspecialists to keep us busy. Common conditions such as peripheral arterial disease, venous disease, uterine fibroids, and benign prostatic hyperplasia, which affect more than 50 million patients combined in the United States, are essentially not treated by most interventional radiologists with their focus directed to episodic hospital care and other niche applications like oncology. That is not to say that disease states such as HCC are not necessary, nor do those patients not deserve our dedication and expertise; instead, we are missing the mark of the global impact we can have by choosing a practice pattern that is largely dependent on other subspecialists. It’s not what we can do in a 1,000-bed hospital that matters. It’s what we can do in a 200-bed hospital or, better yet, an OBL or ASC that will move the needle for our specialty.

One of the biggest tragedies we suffer in IR is our inability to expand our services to communities that need the magic only we can perform. Almost a third Americans do not have ready access to interventional radiology services. The current status quo of hospital-based radiology practices has failed to meet the needs of rural communities. Even in more populated communities, the gutting of practices with private equity buy-outs and even more added pressure for IRs to generate RVUs has resulted in geograhies where certain groups have suffered a mass exodus of physicians after a five-year vesting period. If you want more details, talk to Radiology Partners.

There is a significant opportunity for interventional radiologists to meet the service demand by contracting directly with healthcare facilities or creating their standalone outpatient practices. Radiology pseudo-exclusive contracts essentially prevent this and are the most significant barrier to improving population health metrics such as amputation rates, post-partum mortality rates, trauma outcomes, stroke outcomes, mortality rates from venous thromboembolic events, mortality rates downstream of compression fractures, quality of life in the setting of chronic venous insufficiency, uterine fibroids, benign prostatic hyperplasia and more. I’d be livid if I were a patient or family member affected by any of the conditions listed and knew about this issue.

Challenges Interventional Radiologists Face: Separating Fact from Fiction

While I love my IR colleagues, most do not choose to vote with their feet and leave radiology group settings, which just upsets me to no end. Some wonderful, well-intentioned IRs in radiology groups feel somewhat shackled and privately lament their professional existence yet put up with it. Why? Radiology group settings provide stability and income potential in the most risk-free way possible. Simply put, there are very few, if any, market alternatives for employment as a board-certified diagnostic and interventional radiologist. The last time I checked, the median income for a radiologist is $550,000 with an average of 12 weeks off of vacation time. Unfortunately, the work we discuss that supports this salary and lifestyle is primarily diagnostic radiology-related work. Anyone who runs a clinical service, whether inpatient or outpatient-focused, understands that practicing in such a fashion is far from a lifestyle play. Despite how well-intentioned any given IR is, most succumb to this reality and reach some level of homeostasis with a fair amount of heterogeneity in the scope of practice and “percent IR” practiced in any given radiology setting.

Many diagnostic radiologists and interventional radiologists genuinely don’t believe they can generate enough IR work to sustain them without some source of diagnostic radiology revenue. I’d say that’s primarily not true as long as one is focused on common conditions and can 1.) have the appropriate clinical infrastructure to care for patients, 2.) can market their services freely, and 3.) have the clinical and technical skills to achieve above average outcomes. If anything, I think most IRs are risk-averse individuals afraid of staking their future on a model of care that is not common in their field.

Many academic leaders believe that macro healthcare trends like consolidation and vertical integration lend themselves to the need to have strength in numbers not just on a political advocacy level but on a practice and operational level. They believe that the only way to survive is to be consolidated within a radiology department and to find ways to work together.

While negative macro trends are undoubtedly real, whenever considering someone’s viewpoint, it is essential to understand their relevant conflicts of interest. Those same luminary physicians promoting “strength in numbers” are the same physicians who have for decades drawn millions of dollars in salary from radiology departments structured within large institutions, some of which are funded by taxpayer money. Their entire career trajectory has been fueled by requisite games of promotions, thinking and learning about issues with committees, subcommittees, podium talks funded by industry masquerading as education, and more to perpetuate the status quo. Whether or not that is their intention is less relevant than the functional outcome. 

Let’s consider even the worst-case scenario, one which I don’t believe will happen, where private practice ceases to exist, and every physician becomes employed by some extensive healthcare system. Even in this case, why would you not want interventional radiology to be able to expand its reach and promote career longevity among its practitioners who are passionate about the field? Self-limiting beliefs about our ability to generate revenue, fill care voids, and function as an autonomous entity will persist unless leaders in professional society truly believe that independence is possible. Choosing to be tied to the hip of diagnostic radiology is admitting to the world that one does not think IR independence is possible. It is choosing a future of self-limiting beliefs to protect the mighty’s self-interests at the expense of the many who can positively change a population’s health. What a shame.

Moving Forward

The dirty truth is that diagnostic radiologists need interventional radiologists far more than interventional radiologists need diagnostic radiologists. Interventional radiologists can achieve significant value by appealing to healthcare systems and patients independent of diagnostic radiology. The problem is most interventional radiologists are raised to be diagnostic radiology chickens, and only the true eagles among the bunch are disgruntled enough to raise a stink about it.

The world will be a better place if eagles are set free. The interventional radiologists committed to a future of longitudinal care and surgical practice patterns must be able to structure practices and recruit the right people to join them. Doing so will improve both access to care and quality in many environments.

Many current interventional radiologists are “interventional” in name only and basically function as procedural radiologists. They are content with their existence of primarily reading diagnostic imaging and spending time away from the workstation expertly guiding needles into random places to get necessary procedures done to primarily improve hospital throughput. There is absolutely a role for procedural radiology in modern healthcare, but it needs to be defined as such and cannot be conflated for the interventional specialist, who is an image-guided surgeon functionally no different than other surgical subspecialists in terms of practice pattern, values, and supporting economic practice models.

Ultimately, a distinction in specialties must be made at the American Board of Medical Specialties level to have any practical significance in the marketplace. Currently, there are over 300 diagnostic and interventional radiology graduates a year. I’d say anecdotally that less than 50 of those graduates spend more than 90% of their time practicing interventional radiology, with the vast majority falling into radiology practice patterns. It just so happens that the 50 or so who are serious about independent IR practice are the ones with the focus and dedication to create opportunities for the next generation, but sadly, they are unable to readily do so due to structural issues, which I have highlighted.

To free the small subset of graduates who are serious about image-guided surgery, they will require a board certification that is recognized by healthcare systems, state medical boards, CMS, private insurance companies, and patients as distinct from diagnostic radiology. For that to happen, several things must also occur:

1. Leaders in the SIR must acknowledge a growing appetite for change. Change would be facilitated by having more non-academic voices involved in leadership. 

2. Training must be revamped again to provide an appropriate pathway to ensure graduates are capable of proper longitudinal care of patients.

3. Current and future interventional radiologists interested in a future practice pattern distinct from diagnostic radiology must speak up and make their voices heard.

Ultimately, IR independence is not solely in the hands of the ACR or SIR. Webinars like the one Wednesday primarily exist to keep dissenting voices in check. The academic luminaries and so-called anointed practice leaders may adjust their Zoom settings and use a stern voice to make sure the kids behave, and law and order is restored in their house. It functionally does not matter what they say because, knowing their conflicts of interest, they will never act in a fashion consistent with a future of IR independence. You, the reader, have significant unrealized power. Make your voices heard, and let’s work together to create a collective voice that cannot be ignored.

If you are an IR or IR trainee that:

1. Is interested in a future of longitudinal care.

2. Seeks a practice pattern independent of diagnostic radiology

Please comment below or send me an email at linemonkeymd@gmail.com. I want to hear from you. By organizing together, we can serve as a collective voice to advocate for the profession we love and steer this ship in a new direction. The quest for independence will not stop. We are on a mission.