To many in the hospital, but outside of the angiography suites, interventional radiology seems like a great gig. As IR physicians, we get to do cool procedures without a lot of the “scut,” associated with surgical fields and other procedural oriented endeavors like interventional cardiology and gastroenterology. Some of that perceived scut includes rounding and dealing with long clinic visits. After IRs do a procedure, they either discharge the patient, or in the case of hospital based practices, are able to send the patient back to the floor or unit to be dealt with by their primary team. In the eyes of many, we get to leave by around 5 pm and collect a fat paycheck. After all, we are still radiologists.
I hope that many of you reading this will see significant flaws and fallacies with what I just wrote. There are plenty of IRs out there who are currently working like clinical physicians and less like mere proceduralists. Gone are the days of being told to do something. No more “ordering” of lines and tubes and stuff like that. The new IR embraces consults and outpatient clinic. In many this is a more sustainable model that strives to generate business organically rather than simply be at the mercy of which way the winds are blowing in any given healthcare landscape. The new IR doesn’t need someone to send them a case. They are being sent patients and are being valued for their clinical opinion.
This is not a novel concept. This is what the rest of medicine has been doing forever. The Society of Interventional Radiology has been embracing the clinical IR concept. Interventional Radiology is now its own specialty. Fellowships in IR now a thing of the past. On the surface this is a great thing, but many young IRs like myself are learning that this is not how reality works.
The next generation of IRs coming up in this new training paradigm will be in for a true culture shock when it comes time to working in the real world. Before I go into more detail, let me do a quick break down of the most common job options available for new interventional radiologists. There will of course be some novel set ups out there including outpatient based labs, IRs employed directly by hospitals or those working for surgeons/multidisciplinary clinics, but here are the two most common options:
Option 1: Hospital Based IR Working For a Radiology Private Practice
This is by far the most common option out there with the majority of IRs in this setting. These jobs invariably will include a mix of interventional radiology and diagnostic radiology. Most common splits are 50-80% IR with the balance being DR. Some groups will make you read everything. Others are larger and may limit your diagnostic responsibilities including diagnostic call. These groups often hire for partnership track positions which can be lucrative depending on the set-up. In general, these groups tend to be the “safest” option in terms of high pay and work-life balance. Starting salaries will be lower (generally around 300k) with partnership salaries of 500k+ after 2-3 years. Of course these numbers will have to be adjusted depending on geography and the structure of the group. Those groups that tend to own their own equipment and real estate may have a higher “buy-in” for partnership, but a potential for higher salaries during partnership. Overall though, these jobs are the most common jobs out there for IRs.
The problem with these groups is that they are diagnostic radiology run with IRs being an overall small fraction of the group. These groups are primarily focused on diagnostic imaging and protecting their contracts. RVUs get counted and productivity is key. These groups tend to do whatever is necessary to maintain high partner salaries.
Most IRs are hospital based because that’s where the DR business is. Daily work is service oriented and low-reimbursing. Think lines, tubes, paracentesis, thoracentesis, maybe the occasional embolization. These groups generally don’t have real clinics. IR merely exists as an anchor to keep other clinicians happy and therefore maintain that all important radiology contract. Some groups will of course be more modernized than others with respect to clinical IR.
Option 2: Academic IR
Most of you will be familiar with the academic set up. The IR division is a branch of the department of radiology generally staffed by X number of IRs who exclusively do procedures and maybe read vascular cross sectional images. These IRs work in tertiary care centers and do mostly interventional oncology work though they still do a lot of the same BS stuff done out in the real world like lines and tubes etc. IRs in this setting usually start at 200-300k and will be lucky to sniff salaries of over 400k 12+ years later after making professor. They generally get 4-6 weeks off, and variable academic time. Many IRs in this setting will be required to do significant teaching and be expected to academically productive. Of course, in many large centers this is not necessarily the case as there is a new breed of “clinical track” academic IRs who are not expected to bust out research, but to be clinical work horses. Generally these positions will start at salaries which may be equal or higher than private practice.
The benefits of working in an academic center should be obvious to most who train here. Academic centers tend to get the coolest complex cases. Many get to bounce ideas off their colleagues and trainees. These groups tend to function in a clinically oriented manner. Newly minted attendings do not need to necessarily grow a practice. There is a lot of intellectual stimulation and it provides a great opportunity to become “famous.” By that, think professional development with respect to fancy academic titles and appointments on national committees. Many leaders in the Society of Interventional Radiology are academic physicians. This phenomenon of course is not unique to IR.
Now that I gave you that quick breakdown, you can probably see what the problem will be going forward. In theory, the majority of new interventional radiologists training in the new training paradigm of clinical IR will be very disappointed professionally. They will have spent the last 6 years doing the minimum amount of diagnostic radiology to be competent (36 months) with the balance in interventional radiology and related clinical disciplines only to get out into the real world and asked to stare at mammograms, plain films or CT/MRI up to half the time. They will likely have no clinic. They certainly won’t have the coolest toys and gadgets to do the crazy awesome cases they were trained to do. They will be practicing with older IRs who are looking to protect their 10+ weeks of vacation and 500k+ salaries. These are guys who maybe once were ambitious about clinical IR but have grown used to their lifestyles. These ambitious graduates will try to change the culture or advance clinical IR but will face significant headwinds. A few may succeed, but many will either grow disenchanted as they’re actively discouraged from doing so and will go with the flow. I suspect many IRs in private practice are in the latter camp.
How do we change this? I think change starts within. As someone who took Option 1, I did so knowing that this is how life is going to be. So maybe the joke is on me, but I do believe there are things we can do as IRs to change the culture. It is my hope that LineMonkeyMD can foster a community of like-minded young IRs and future IRs to be that change. I’ll be tackling more of these issues as the blog evolves. Stay tuned for more content.
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