My Return To The Hospital

Since leaving the OBL in September 2021, I’ve been working locums primarily in a hospital setting, many miles from my home.  I still cover an OBL site for vacation weeks and help consult on PAE cases which is a nice way to keep active in that space, but I now derive the majority of my income from a hospital-based assignment. As I look back on 2021 and my journey to this point, I thought I’d take a moment to reflect back and share some thoughts.

My current position is unique in that it is 100% IR. It’s in a large community hospital which is a referral center for the area. The closest academic medical center is over 2.5 hours away. It’s a level 1 trauma center, but isn’t all too busy with craziness. I work with two wonderful full-time IRs who have 20+ years of experience, but are progressive when it comes to using new toys and learning new tricks. The work here is mostly bread and butter: biopsies, biopsies, more biopsies and chest ports after the biopsy results come back. There of course are our share of “bigger” cases including oncology work like Y-90, vertebral augmentation in addition to a fair number of after-hours emergencies like bleeds. The group works in a vein clinic in the hospital outpatient center. Given the patient demographics in this area, fibroid embolization isn’t very common, but the section has started taking on prostate embolization and I’ve been happy to help the group build this up and teach the team what I know.

Returning to the hospital after spending almost a year and a half in the outpatient setting has been a huge kick in the rear. I take the majority of call since I am here strictly for work. While most nights are quiet, there have been some disaster nights as well. I think of the one night where I had to do an emergent BRTO followed by two arterial embolizations. COVID has not spared this area either, which means there has been plenty of clot to extract from leg veins and pulmonary arteries. 

My return to hospital IR has also been quite humbling.  Now granted, while things have been largely uneventful, hospital work reminds me of the overall lack of control we have in this setting. IR is often the last-line for many patients and we get put in very undesirable positions trying to prolong life for patients who are dying. And while the vast majority of the time procedures go well, they sometimes don’t. I was reminded of this recently when I had a bad complication which largely came down to being asked to do something risky in a patient who was actively dying, but the family wanted to press on. The procedure was medically necessary and I made the decision to try. I unfortunately had a complication which led to a code on the table, subsequent ROSC and later transition to comfort care. While I did call the patient’s family for consent prior to the procedure, it is tough breaking bad news to people you don’t have a great rapport with. It’s brutal, frustrating, sad, makes you question your worth and can’t help but make you feel uncertain about your existence as a medical professional.

Despite the inevitable tough outcomes, there have been plenty of wins and I’m glad to have the opportunity to do what I can to help patients. I think it’s important we keep reminding ourselves of this.

While I’m lucky to be in a position where I can continue to hone my skills, do so on a schedule that I get to decide and get paid well for it, there are things that I don’t like about this job and it all comes down to being in a hospital. I don’t like that IR is still viewed by many in the hospital as an order-based service. Yes, this is a 100% position with no diagnostic responsibilities. There are two APPs who are great. We are theoretically “referral-based,” but the “you pick-em and we stick-em” mentality still exists. And it has to simply to get through the volume of procedures every day which is largely aimed at patient throughput. 

There is a clinic, but it’s hard to have a full day in the clinic when procedures need to be performed and the needs of the hospital need to be met. So what happens is the APP essentially staffs the clinic with the physician available for critical decision making as needed. 

Again, this all comes down to money. In this case, physicians here are hospital employed and lumped under the division of radiology. IR like in many hospitals is a cost center subsidized by diagnostic radiology. The hospital pays their IRs quite well. So by all measures this is a “good job.” The two full-time IRs are very skilled and experienced, allowing a young IR like myself to receive mentorship, do good work including advanced cases, have a clinic with APPs and at the same time make a lot of money. I think this is what many IR grads look for. Jobs like this do exist, though they tend to be rare. The ones in major metropolitan areas tend to get snagged by those with “pedigree” and ones like this in the middle of nowhere have a tough time getting candidates creating opportunities for vagabond monkeys like me to fill in gaps. 

At the end of the day, whether you’re working for a radiology group, private equity, or a healthcare system, IR largely exists to serve the needs of the hospital. We are asked to do many simple and some not-so simple procedures in sick patients. Our benefit to patients is great, but the indirect financial benefits through reduced length of stay while substantial is difficult to quantify and it’s hard to develop the financial leverage necessary to fight for things like substantial protected clinic time. In order to evolve to a true clinical-based service in the context of hospital reimbursement and financial control not in the hands of the physicians performing the service is a daunting task that likely won’t be possible unless 1.) IRs accepted less remuneration for their services or 2.)were provided the freedom to seek revenue from outside of the hospital to subsidize their hospital services in order to maintain current income levels. The latter also requires an entrepreneurial mindset that frankly the majority of physicians lack and is becoming increasingly difficult given structural considerations like healthcare consolidation and the presence of radiology groups and their pseudoexclusive contracts.

I have now had the unique experience of working in a physician-run hospital based private practice radiology group, doing locums in a different hospital based private practice radiology group, being a minority owner in my own OBL practice, working locums in a corporate owned OBL, working locums in a long standing physician owned OBL and working locums in a hospital where radiologists are hospital employees. I’ve also had the experience of doing diagnostic radiology for the government.  I’m only 3.5 years out of fellowship, but I think I’ve seen more settings than most IRs see in their entire careers. I’m not claiming to have more knowledge than others. I’m still learning everyday and I’m nowhere near my peak excellence as an IR, but I’ve learned certain things that I think others can benefit from.

As I look to the new year, I’m going to keep sharing what I’ve learned. For me, the one thing that I learned is at the core, I enjoy being a physician, but I like to have control over my environment and I don’t like people telling me how to practice medicine. I like to have the time to get to know patients and families. I don’t want to feel like I’m in a pressure cooker environment. I don’t want to make a million dollars a year doing a million procedures in record time. I like to teach and mentor. I like to read.  I like to share my wins and losses. I like to sleep at night. I want to workout every day. I want to cook. I want to travel at least twice a year to cool places. I miss playing golf when the weather is nice. Sure would be nice to see my family more often…

It would be great if I could make IR my hobby and not a job that I need to pay my bills and fund my retirement. When you slow down and are able to take good care of patients, that’s when good things happen. I’ve come to the realization that perhaps my entrepreneurial spirit should be directed towards other endeavors outside of medicine and I should use just enough energy to carve out the practice I want without becoming a slave to it. I’m going to be spending my 2022 making my dreams come true. I hope you will do the same.

Wishing you health and wellness for the new year and beyond.