I’ve spent significant time crafting posts over the last several years documenting my personal career struggles. Readers of this blog have had the unique perspective of tracking my trajectory from a standard IR/DR group as an ambitious graduate to a newly minted OBL entrepreneur, followed by a messy business divorce and eventual transition to a full-time locums physician with multiple hospital systems and OBL contracts. I’m approaching five years of incredible highs and lows, but one thing I have been consistent with has been my utmost conviction that we have a significant branding and recruiting problem when it comes to interventional radiology. I feel like the struggles I have experienced, and many before me, are truly reflective of an identity crisis rooted in our formal professional upbringing and labeling.
I want every reader to take a few minutes and watch this video. Before I write more, Sarel is actually a friend of mine, and I enjoy watching his takes. Even though I don’t agree with many of them, much like he may not agree necessarily with what I have to say on this blog, it is possible to respect one’s game and be friendly. I always admire people who aren’t afraid to say what they want to say publicly and put time into content creation. Some readers don’t necessarily feel the same, as I’ve received interesting criticism over the years. Be it a division chief of a renowned department slanderously critiquing me on the SIR Connect forum or some anonymous IR in Northern New Jersey insinuating I’m a typical millennial and that they are praying for me. The truth is that if you aren’t making elitists upset, you aren’t moving any needles. And these elitists can apologize to me whenever they’d like to because they are out of line. I’ll be at the SIR Annual Meeting, ready to collect, but only after my podium talks. Not bad for a “hired gun.”
So hats off to you, Sarel, because you got this monkey up at midnight before a long clinic day fired up about your video. What’s interesting about this video is Sarel’s perception that IR is merely a subspecialty of radiology. It is how IR is being sold, even though it has been repackaged into an integrated residency which is functionally the same cultural upbringing as it has been in the past with perhaps less time on DR and more time on IR. We are still growing up in a radiology context with formal board certification in diagnostic radiology. He is right in that we are signing on a dotted line acknowledging that we are still radiologists at a hospital system and payer credentialing level based on our formal board certification label.
All this talk about IR training is very timely because this weekend is the West Coast Vascular and Interventional Symposium. I’ve been very critical of medical student symposiums over the years because there has been too much false advertising regarding the daily reality of interventional radiology. Very esoteric and exotic procedures tend to be glorified, and students rarely leave these sessions with a true understanding of what it is like to be a practicing interventional radiologist. The exposure to this wonderful field is already so poor at baseline; glorification of what we do without the honest truth regarding our challenges can mislead even the brightest and most well-intentioned student down a dark tumultuous path which may not necessarily lead to the best outcomes for either that student or the future of our field.
What I like about the WCVIS is it is rooted in the mantra that longitudinal clinical care is our guiding light toward a bright future. Everything “negative” I have said about interventional radiology is related to our identity crisis as an immature field that has failed to live up to the standard of longitudinal clinical care, which our peer competitors in surgical and procedural medical subspecialties take for granted. My most widely read article is simply a reflection of the most common practice pattern for interventional radiologists. Other widely read articles are about structural inequities concerning our ability to function outside of a radiology context, including pseudo-exclusive contracts and our overall lack of clinical training despite recent changes with the new integrated residency pathway. I even wrote a scathing editorial about how our relationship with radiology is abusive.
Why do I spend so much time fired up about interventional radiology, hosting my own domain, which is a money loser? Because that is how much I care about this specialty. People can throw all the shade they want, but I’m sticking to my vision, and I will keep shooting shots and being that annoying voice until there is lasting change.
So if you’re a medical student possibly interested in interventional radiology, there is a decent chance that you have read some of this content, and I have scared you off. I’m actually really proud of that if that’s the case. Please, do something else. When the 2023 match results are released, we will see the true results of the “Line Monkey Effect.” Because if you are scared about what I have to say, wait until you get out of training. You are not meant for this IR life.
For those who aren’t afraid, I want to remind you why interventional radiology is an amazing specialty. If you ask many program directors or thought leaders in academia, you’ll be given some standard line about how we are “innovative,” “minimally invasive,” or “cutting-edge.” And while all those answers are factual and seemingly attractive, they get old and trite after some time. I remember seeing some SIR promotional material with some younger luminaries discussing similar things back in 2010.
Do you want to know why IR is great? Here are rough epidemiological stats (likely conservative) regarding the common conditions we can treat:
Peripheral Vascular Disease: 8.5 Million
Chronic Venous Insufficiency: 25 Million
Uterine Fibroids: 25 million
BPH: 40 million
Interventional radiologists can potentially have a greater population health impact than any other medical specialty outside primary care and psychiatry. When you couple the significant impact we can have on a population level with the ability to foster meaningful long-term relationships with patients and the ability to do ninja-like minimally invasive procedures akin to playing high-stakes videogames for a living, I think it’s pretty easy to see why this is the best field in medicine. As you do more cases, the adrenaline rush tends to wear off, and those relationships with patients truly fuel your fire. Take this from someone with over 500 patient contacts on their cellphone. That is what keeps you going. This field is not about doing sick cases. It’s truly about taking care of patients.
Do you know what the problem is, though? Your average interventional radiologist is not treating peripheral vascular disease, chronic venous insufficiency, uterine fibroids or BPH. And if they are, these patients are a small subset of their overall practice largely rooted in hospital-based “sick care,” which is necessary for the hospital wheels to keep turning…round and round and round again. How many actually have clinics? A pathetic minority.
So while some out there will disagree with me and tell me that I am doing a great disservice to this profession, I am really doing everyone out there a huge favor by demonstrating straight facts you cannot refute. Our field is one of tremendous potential, which is largely untapped.
The type of person ready to take on this challenge of tapping into seemingly unlimited potential is not the type who is otherwise attracted to diagnostic radiology. This is not the first time I’ve made this claim, and it sure won’t be the last. Some of you are reading this and probably fuming because you’re thinking to yourself: This arrogant prick. I do really good IR and DR in my practice. Who is he to tell me that we can’t be good at both?
Yes, I know the criticism and I sense the microaggressions through various podcasts and SIR Connect posts, but the problem is when we are structurally linked to diagnostic radiology, that means we are married to their business model. So while great IRs out there practice in a traditional capacity and still have more progressive parts of their practice, like longitudinal clinics and rounding services, these are far more the exception than the rule. I have discussed ad nauseam on this blog and other venues why this is not a winning strategy to mainstream longitudinal care for our specialty. And I am not the first. There have been others before me who have been more vocal 20 years before I became an attending.
The discussion about our future has to change from “the kids just want to do cool cases and not read films” to “the kids want to take care of patients and use radiology skills as one of several tools to do so.”
Real symposia will engage community practitioners and have a meaningful dialogue to demonstrate what is possible in creating longitudinal clinical practices, so students of the right mindset can be appropriately mentored and be put in a position to succeed. The right student is interested in a surgical path. This type of student has to understand that their ability to perform these cool procedures is a true treat. One that will not be deserved unless they can demonstrate that they can appropriately care for the patient and successfully compete for referrals. The right student will realize that we are in the early innings of this IR ballgame, and the tail end of their careers will look nothing like what it may look like when they begin this path a few years from now. The only thing certain is uncertainty. But in that will be growth and a very low likelihood of stagnation. I’d rather have 50 graduating trainees a year excited to do this the right way than 300 lacking a unified vision for their professional existence. We are recruiting future vascular and interventional specialists focusing on the blood vessel as their organ system of expertise. That’s the party line, and I’m with it.
This Sunday, 2/12 at 10:00 AM PST, I will be hosting a panel of private practice IRs for the WCVIS. If you’re a student interested in learning more about this great specialty, this will likely be the most effective 30 minutes of your professional life. We have an incredible line-up of hospital-based, OBL, and locums IRs ready to tell you the truth about the real world and give you strategies to succeed. Tune in and ask hard questions.
God bless Charles Dotter, IR Jesus. He was literally a prophet. Indeed. Why are we still struggling with his prophecy from the 1960s?
God bless Dotter, indeed. A wise man once told me that we are wasting our time branding ourselves by modality and not by organ system. That man has gone on to model the behavior necessary for the future generation of clinical IRs to succeed independent of diagnostic radiology.
What this wise man has done is not something that has made its way to the academic power structures which are responsible for training future IR physicians. It just so turns out that this wise man also told me that no assessment of a situation is truly complete without understanding the politics. So why are we still struggling? My thought is the following: it simply isn’t politically tenable to practice like Dotter when we are beholden to the culture and business model of diagnostic radiology. We have to move beyond this relationship to truly advance. The eagles among the chickens will soar. The chickens will remain in the pen and the dogs sitting on their rusty nails won’t budge one bit.
That wise man of course is you and this monkey is appreciative of all the great lessons you have taught me.
Hello! I am a 4th year medical student and I would love to attend this panel, but am looking to obtain a link?
To register for day 1:
https://arizona.zoom.us/webinar/register/WN_OlYkzZojTkKs6sag8caTuw?_x_zm_rtaid=Jn-iy8JNTq2oB_6BGpZSKg.1676083388800.16587ae7fd0fadd0ebbd55b8563eb68b&_x_zm_rhtaid=108
For day 2:
https://arizona.zoom.us/webinar/register/WN_gdZmrvc_TYivv57w7_5IGA?_x_zm_rtaid=Jn-iy8JNTq2oB_6BGpZSKg.1676083388800.16587ae7fd0fadd0ebbd55b8563eb68b&_x_zm_rhtaid=108
For info on WCVIS
http://wcvis.squarespace.com/
When I matched into the IR/DR residency, I thought “One step closer to doing 100% IR in an OBL!”
Now, as I study for an annoyingly detailed CORE exam which I am required to pass and has little IR on it, and after taking weeks of grueling independent DR call in the middle of the night, but developing a certain mastery in DR nonetheless, I ask myself “Do I really want to lose this skill I’ve worked hard to master throughout residency?”
Wouldn’t be an existential problem if I just had to learn the basics of DR, not take DR call or take CORE.
Great comment and questions.
Does it bother you that you don’t remember all the minutae you expertly crammed for Step 1? How about all those years in undergrad studying whatever your major was? I was once chemistry major and let me tell you, other than the scar on my wrist from the drop of 18M hydrochloric acid I spilled on myself as a freshman, I don’t remember a whole lot.
Studying for the CORE is nothing like practicing as a board certified diagnostic radiologist. It’s a stupid test you have to take like all the other stupid hoops we jump through to get to a point. Now, I understand potentially “losing” a skillset, but ultimately this comes down to what drives you. If you love imaging, then just be a radiologist. If learning DR was kind of painful and you’d rather be patient focused, then do that instead. Simple as that.
Is it an existential issue? Yes, it most certainly is. We have an identity crisis. My entire professional life is one big identity crisis. Because we end up training in a structure which actually has relatively little in common with our daily practice. Training has to evolve and I think we are headed in that direction, albeit slowly.
Maybe the ideal change in training should be this:
1. People who want to do IR from medical school match into IR residency which is: One year of surgery, one year of DR, 3 years of IR doing the full gamut of procedures (understanding that this type of training is likely not available at most academic hospitals). These people will be setup to do high end IR and OBL work. Additionally, academic centers and large hospital systems will be incentivised to hire these IRs and let them have a clinic similar to urology and ENT, because the cases they will be doing will be higher RVU work, which makes up for not reading DR.
2. Medical students/residents who are unsure/want to do DR too: One year preliminary year in whatever, preferably surgery. 3-3.5 years DR. 1-1.5 years IR. These people will be setup to be hospital based IRs–doing lower RVU cases, which are still vital to the hospital and patient care. But they will also have to make it up by reading DR in between cases or during dedicated days, similar to how most PP radiology groups currently function.
Thanks so much for taking the time to write out this comment.
I think you are on to something. In essence, we have two different types of IR practitioners. We have those focused on longitudinal patient care, and the latter focused on radiology. Right now the majority of people in our field fall in the radiology camp. That was certainly how I was trained. It takes a lot of courage and conviction to not practice in the second model you describe.
Ultimately our future is path 1, which I’m convinced isn’t even “radiology.” In order for this to work, practically with respect to hospital and payer credentialing, it has to be a distinct field from diagnostic radiology. I’m not sure how to make that happen, but it starts with creating a culture around path 1 and working hard to support more people along this journey.