It has been an interesting few days since I published my last post. I wasn’t expecting it to gain as much traction as it did. Frankly, I think I have much better articles which have gone largely unnoticed, but nevertheless I’m glad I have somebody’s attention and we are talking about the important issues that are facing our field. For those more curious about who I am and what my life looks like please check out the About section and my Locums Life posts. One of these days I’ll write more about how I got to where I am.
I think social media in particular has changed things and has allowed blogs like this to spread messages faster than they have in the past, but the truth of the matter is the message I am spreading is not new. Perhaps it is packaged differently than it has in the past, but the theme of my blog has been a rallying cry for a small minority of interventional radiologists for decades. My goal is to guide my generation of IRs to take control of their professional and personal lives through entrepreneurship or at the very least an entrepreneurial mindset. In short, I want outpatient practices to be a viable career option for all interventional radiologists. They currently are not.
But instead of going down a rabbit hole about outpatient practices, the fact of the matter is for 95% of you reading this right now that is not really relevant or of interest. My blog readership is typically students, residents and young attendings who have an entire career ahead of them. I’m at a unique point in the history of this 3 year old blog, and it may be fleeting, where I have a broad IR audience.
Being an IR hospitalist 2-3 weeks a month and being on the road a lot, I find myself with downtime between moments of chaos to reflect on things. I’ve started to write a lot more because it helps me clear my mind and allows me to focus. In turn, I’m able to add some value to others in this world, particularly those in interventional radiology because I really do love IR. I’ve always loved teaching and mentoring, but I always hated the politics of academic departments. This blog is my way of paying it forward and really is a tremendous source of personal satisfaction.
I’m not sure what it was, but I just had a bad work week last week. Nothing terrible happened, but it was the perfect storm of sideways flying sewage without an umbrella for cover. When I have bad days or moments at work, it’s not hard for me to think about everything that is wrong with our field. I just think back to all the unpleasant moments I’ve had and what brought me to this point in time. I promise you the drama is all in my head and I am not a total weirdo.
The next thing you know is we end up with blog posts like my last one. Honestly, I was shocked it got the response like it did. Seeing the comments on the blog, Twitter, LinkedIn, Facebook and on SIR Connect were really fascinating and enlightening for me. This isn’t my first rodeo using strong language and riling people up, and it probably won’t be my last. Just have to wait for some more bad weeks, I suppose.
What I learned the last few days is there is a lot of unhappiness in interventional radiology. And look, there is unhappiness everywhere, but having lived both the OBL and hospital IR life, I get where people are coming from. I’ve experienced inpatient settings, outpatient settings, corporate settings, and physician owned settings. I’ve seen more types of practices in a short period of time than many IRs will see in their entire career. I’ve been praised by academic leaders and I’ve also been ignored and many times felt misunderstood by them. I don’t have all the answers, but believe me when I say that I honestly get where most people are coming from.
From reading all the comments, some general themes emerged. The overarching theme is that many IRs feel that their work is not valued. I think my blog definitely resonated with people who feel like they are dumped on. It is clear that professional remuneration for the “bread and butter” (at best) or “trash” (at worst) procedures is not where it needs to be. We feel that many don’t understand our worth, particularly hospital administrators and our fellow diagnostic radiology colleagues. Some of us feel kind of stuck and don’t believe we have a real handle on our current professional situation. Change seems almost impossible.
But really what I noticed is that there is a clear split between those who are interested and believe in hospital IR and those like me who frankly don’t care for it and know there is an option better suited for our interests and talents in the outpatient arena.
My initial intention with this post was to convince you to care about outpatient IR practices, but what I have learned is that I’m not going to convince most practicing IRs to make significant changes in their career trajectory based on what they heard from some kid on the internet who has only been in the game for several years. This is particularly true when I think about some of the failures of even some of my mentors who have come before me yelling from the top of the mountain about how we need to leave the hospital to achieve our true potential. These cries have been going on for decades, yet here we are with a predominantly hospitalist IR existence mostly tethered to radiology groups. I still think those IRs before me are right, but their cries sadly haven’t really gotten us anywhere other than to inspire a few other individuals like myself. Many in the hospital setting don’t care for or understand the outpatient IR existence. Along the same lines, yelling about an outpatient existence seems to not do a whole lot but upset the majority of our field which works in the hospital dealing with hospital things, no matter how unpleasant or wonderful you may think that is.
What I have learned though is we all have a lot more in common than we think. We are dedicated physicians with a very unique skillset doing our best to serve our communities the best way we know how. For the majority of you that’s doing a mix of IR and DR in the hospital. For a small minority it’s a harmonious relationship in a diversified radiology group where you practice close to 100% IR with robust inpatient and outpatient services. For a growing proportion of our field, our future will involve developing comprehensive clinical practices in an outpatient setting because this is where medicine as a whole is heading. And perhaps some of you are in weird transitional phases in your career like I am and are finding creative ways to make your own living utilizing all your skills.
The beauty of IR is we have so many choices for how we would like to practice because the depth and breadth of our specialty is truly quite remarkable. But is this really true? Many of us feel like we don’t have much of a choice even though we theoretically should. There’s this huge disconnect between what our field looks like on paper and what it is in reality. Why is that?
We give up control when we align ourselves with groups who do not share our interests. Pretty broad statement which is rather meaningless without context, I know, but for the purposes of this discussion I am talking about practical matters. For better or worse, what matters in American healthcare is money. And the root of our problems, for the vast majority of us, is our business relationship with diagnostic radiology. Please note that I said business relationship and I said vast majority. I am not talking about the importance of diagnostic radiology skills which is the foundation of our training or the minority who have a wonderful IR existence within a radiology setting.
I’ve written about our relationship with diagnostic radiology before, but I’ll provide my quick take on it here again. In theory, interventional radiologists serve as an important anchor for an often very lucrative radiology contract with large healthcare systems. Our ability to take call and provide image-guided interventions is quite valuable for the hospital and adds value to what can be, though really shouldn’t be if done correctly, a commoditized service in imaging interpretation. For purely arbitrary reasons many of the interventions interventional radiologists perform in the hospital have low wRVU designations so it is very difficult for interventional radiologists to keep up with their diagnostic radiology counterparts. As such, we are often viewed as “less productive,” when in reality we perform a critical function. This can result in a lot of tension as I and many others have experienced. Even more though, this game where we are only focused on wRVUs results in an existence in many private practices where a radiology group will not want to invest in the clinical infrastructure and associated resources necessary to allow their IRs to develop true clinical practices with multiple service lines. If you look at data, you’ll realize that the vast majority of IRs spend less than 90% of their professional time practicing IR, which suggests that the economics of mixed IR/DR which I describe is alive and well. Some of this is cultural or just practical but the fundamental reason is financial. There are some groups where IRs practice close to 100% in their subspecialty. Perhaps in these settings this is justified by downstream imaging revenue generation from clinics, appropriate E&M coding, investment in an outpatient facility for IRs to take their cases, being in a a large group which can absorb the impact of IRs being “away from the list,” or just maybe because the diagnostic partners are reasonable human beings and realize this hospital game is completely rigged. How many of these practices exist? They’re out there, but not nearly as many as there should be. As such, many IRs will be tasked with creating these practices. I tried, and actually created a small practice for myself in the hospital doing PAE, CLI, UFE with an MRI holding bay as my clinic space. I was my own MA and RN. I used to show up early to clean the list so I can have time between my thyroid biopsies and declots to go market my practice, by myself. I learned how to code E&M and had to teach my billers. I soon learned that it was a waste of time trying to do this in a setting that doesn’t care for my skills or talents. If I can build my own patient panel, I should have an OBL where I’m actually rewarded for this work and not told to just shut up and hit the list like a good boy on a partnership track.
Perhaps I was just in the wrong place at the wrong time with perhaps the wrong attitude. Some would say “I just wasn’t a good fit,” but what is clear is that regardless of your feelings about who we are as interventional radiologists, many of us have an incredibly unhealthy relationship with diagnostic radiologists. We can argue our value to diagnostic radiologists until the cows come home, but I’m not convinced this is sustainable or worthwhile for most. This is my personal opinion. Many of you will disagree with this and that’s fine, but let’s say you’re one of the non-trivial number of new graduates with a unique skillset and ability to build a patient panel much like a cardiologist or surgeon can. You decide to not partake in the hospital-based IR/DR model and you want to practice independently. Well, you will be looking to take your patients to an outpatient-based lab because your mental health, financial well being and ability to control the patient experience are all aligned in this model. You’ll have so much energy ready to take on the world only to quickly learn about a ridiculous roadblock that our fellow radiologists impose upon us.
The biggest problem right now is many IRs don’t really have a choice in how they would like to practice and I am absolutely convinced that unless we solve this issue, our field will never reach its full potential. The issue of pseduoexclusive contracts is one which I have beaten to death on prior posts, and has been thoroughly addressed by many IRs senior to me. In fact, there have been published papers on this topic which I encourage you to read. Every IR, regardless of one’s philosophical belief regarding their role in the healthcare ecosystem, needs to become educated on this topic.
Pseudoexclusive contracts have prevented some of our brightest stars from opening independent IR practices both in the hospital and outside of it. Why? Because inability to achieve hospital privileges or obtain transfer agreements can prevent important things like insurance credentialing and the simple ability to do procedures in an office setting due to state laws. Pseudoexclusive contracts results in a skewed distribution of the IR workforce towards the hospital setting when the truth is that outpatient care is our future due to the minimally invasive nature of our field with new therapies that can impact millions of patients in a site of service which helps keep our healthcare expenses in check.
Free IRs to practice how they wish and watch wonderful things happen across many different communities in our country. Imagine the best and brightest banding together to create comprehensive and sustainable practices that truly utilize our entire skillset. My generation is poised to do this as we are living a nightmare with corporate entities, private equity, healthcare systems and even our senior physician colleagues gutting our financial upside, limiting our autonomy and pushing us into a meager existence. We are hungry to build and provide meaningful equity-ownership pathways for future IRs because many of us have been affected by greed and understand that this is not the path forward. We are academic minded and love to teach. Think about the amazing partnerships we can have with training programs to bridge the community and academic divide? Why is this not happening already?
Are we afraid that if radiology groups more or less let other IRs come on staff that they will steal their typical IR work? Last time I checked, IR work wasn’t even valued in most diagnostic settings. Do you really think an independent IR really wants to do your LPs and drains? Why would radiology groups worry about independent IRs taking the CLI patients away from cardiologists who already took over this service line in the hospital and who happen to also conveniently use the hospital IR suite on a near daily basis for their cases?
Are diagnostic radiology groups afraid of their IRs leaving for greener pastures? Well last time I checked many in our field actually enjoy being IR hospitalists and probably more so they sure enjoy their generous salaries and relative stability that comes in a diversified radiology group setting which has its ducks in a row.
Are radiology group leaders afraid of losing their hospital contracts? This may be a legitimate concern, but as long as they have a few IRs who can provide services and they do their jobs as DRs they’ll be fine. For the foreseeable future you can always find a hospitalist IR because it’s the safest financial path available and a necessary role in many communities. This model isn’t going anywhere anytime soon. I bet you even those young entrepreneurial IRs across the street in their new OBL would love to do teleradiology for these groups in the evenings or take hospital call or both. In fact, I still do diagnostic radiology on my own time. It has expedited my path to financial independence and is one of the reasons I never worry about having an IR job. The only difference is I don’t do it as an IR tethered to a hospital-based group limiting my ability to practice IR as I wish and giving me grief for producing below average wRVUs because I’m too busy in the clinic proving our value to the world one patient at a time.
The SIR needs to be far more proactive in promoting the power of choice. There are dozens of IRs out there silently fighting hard to open independent practices and are supported more by cardiologists and vascular surgeons than their own professional society. Historically the thinking has been for the SIR to stay out of this “because it needs to support all of its members,” but that’s only reasonable if the playing field is level. Right now, it is far from level. Just let us IRs be free to choose for ourselves no matter how stupid or misguided some you think this is. If we fail, that’s on us.
Contrary to popular belief among hospital-based IRs, independent IRs like me want to be able to come into the hospital to take care of our complications, admit our own patients and do the right thing. Why should I need to join a cardiologist or vascular surgeon to backdoor my patients into the hospital? Do we really hate each other so much that we’d rather join our “competition” because that is the only way we can get access to a hospital setting for our patients? I’ve lived this nightmare personally where I felt more aligned with an interventional cardiologist than I did my fellow IRs. I once had a CLI patient who was way too sick for the OBL. I had to have my cardiology partner admit the patient and have him do the procedure so I can do the right thing for the patient and have some semblance of control over the situation as to not dump the patient on the hospital-based vascular surgeon who performs cases in the IR suite.
I see all those comments on SIR Connect insinuating that IRs in OBLs don’t “care about the hospital.” Are these IRs even given the chance to be a part of the hospital community? When you experience something like I have, it’s hard not to become jaded, cynical and frankly just pissed off. I’m only in my fourth year doing this and I’m already contemplating an early retirement, channeling my passion for entrepreneurship towards other endeavors and just being a good spouse to my talented wife who frankly practices more interventional radiology as a vascular surgeon than most of you reading this. This may not be surprising considering that she is being trained by vascular surgeons who have learned from some SIR gold medal recipients.
Look, IR has a lot of problems. How we are valued in the inpatient setting is a big one. The devaluation of our services is fundamentally rooted in our historical laziness at building clinical service lines. This of course is directly related to our identity historically as imagers first which of course has something to do with both our training in addition to the financial arrangements in which the majority of us practice. Proving our value can be difficult, but would be made easier if clinically motivated IRs had the leverage to readily leave restrictive situations like many hospital based radiology groups.
And contrary to popular belief, it’s not just about practicing in the magical OBL which has its own set of headaches as some of you have astutely pointed out and as I know from first hand experience. Choosing how we want to practice has implications for how we are valued in the hospital. The ability to choose how we practice should mean that we have the power to negotiate directly with hospital systems to achieve fair agreements. When we are part of diagnostic groups, poking the proverbial hospital bear is very difficult for fear of jeopardizing the hospital contract. Perhaps some groups can accommodate their IRs appropriately, but most cannot and will not go to bat for their colleagues. What should be a harmonious relationship is often eroded by egos, finances and just overall lack of alignment. An all too common theme in modern medicine.
The final thing I’m going to leave you all with is mindset. This isn’t specific to interventional radiologists, but physicians as a whole. We are way too risk averse and have incredibly stifling limiting beliefs. Oh you’ll never get referrals in my market. Have you heard of the internet and the power of white glove service? I give my cell phone number out to every clinic patient. It’s extreme, but it works. Independent IR practice is too risky. Is it more risky than destroying career longevity by burning out in the hospital dealing with trash (or treasure) at random hours of the night? Why can’t you just accept that this is a job and all jobs will have things about it that suck? Because maybe we are passionate about what we do and want to do it at the highest level possible? We don’t know how to really take care of patients. Maybe we can learn, just like we learned to read imaging? You’ll get back and neck issues from wearing lead which is why you need diagnostic radiology to fall back on. Have you heard of clinic? Pretty sure scatter radiation is pretty low there. Additionally, one can always practice DR on their own time without being stuck in a radiology group.
I’ll tell you what, I haven’t had a guaranteed salary in over 2 years. People look at me like I’m insane. Ever since I left my safe IR/DR existence at the start of COVID, I created a practice, exited a practice, did locums and have significantly increased my financial net-worth, professional network and my overall happiness during this time. Is it everything I want and more? No, I’m clearly transitioning into a new phase of my career which will take patience, but what I did do for myself is take charge of my own destiny and that to me is wonderful. My professional path isn’t for everyone, but we need more IRs to build clinical practices and that begins with having choices. This is how we advance as a field. We need to collectively do a better job supporting each other, kindly educating each other and ensuring that future generations of physicians have the opportunities to build meaningful practices as they wish. We all need to think abundantly. There is no one-size fits all solution for everyone. My trash may be your treasure. There is room for all of us to be successful and happy in our own way, but the game has to be fair for all players.
Bold change requires bold leadership, which we lack. The sad fact of the matter is the average private practice IR such as myself does not have the political connections or frankly the interest to play the SIR game of committee promotion and mutual back-scratching which I personally think exists as a mechanism for academic promotion at the unfortunate exclusion of the majority of our field which is out here doing great things for patients day in and day out. This phenomenon of course is not unique to the SIR. This is the game in pretty much any professional society or organization.
Change however can happen if there is collective discussion which yields collective action. I got a lot of you talking, which is great. What gets me more excited though is I know there is an entire new generation of IRs looking to have the freedom to make their own career choices. These are some extremely talented individuals asking questions about building clinical practices and figuring out the best way to do that. I spend on average 5 hours a week talking with residents and medical students, providing mentorship and just doing what I can to guide our future IRs to new heights the best way I know how, which is sharing my failures. And trust me, with massive action comes failure, so there will be more to come which I will gladly share. Nonetheless, it’s up to the new generation of IRs to push for change. I am only one voice viewing the IR world through my unique lens. I’m not here to start a riot, but it’s probably time we blow something up because the status quo isn’t working.
What can SIR really do? Contracts between private parties at a local level right? If all hospitals were a public resource then I suppose it would be a different fight. Are doctors, in general, entitled to be considered to be granted privileges wherever they apply to be on a medical staff?
they could at least take a strong public stance?
I think so. They can support IRs who want togo independent like OEIS does already. They could help support any IR who sues a hospital for privileges. They just need to be more vocal. More than anything, I think they need to have a better vision for our field because as I see it right now that vision is lacking. I think another great step would be to have more truly independent IRs be part of leadership. I said this before, but right now for me it feels like taxation without representation.
Many great comments but I disagree with the Bill Julien originated term “pseudo exclusive contracts”. My first radiology practice was an ‘open staff’ hospital in Dallas. We had 5 radiology groups and doctors simply had to specify in their orders who they wanted to read the imaging. There was no exclusivity in any specialty. It worked fine. Since then almost all hospitals have transitioned to true exclusive contracts in radiology. I was caught in one in 1996 when I was forced to leave my practice in Phoenix because we broke from my radiology group and formed a group with the vascular surgeons and cardiologists. Since that time, hospitals developed exclusive contracts with pathology, ER, anesthesia. Now, all of my current hospitals also have exclusive contracts with cardiology and Cardiothoracic surgery. One of my good friends was a cardiac surgeon who was actually already on staff but then had to leave when a new group got the contract and wouldn’t hire him. The next step was exclusive employed contracts which now exist in 4 of my hospitals. The vascular surgeons and cardiologist are employed by the hospital system and have exclusive contracts. I think wasting time whining about pseudo exclusivity is barking up the wrong tree. If anything, these contracts will become more common rather than less. Current talks are underway with urology groups, orthopedic surgeons etc. I think outpatient practice is great and I do both…..but we need a better pathway then pretending to mock radiology contracts. I have a lot more to say about the rest of your posts but I am not a prolific writer and I’ll stop with my current points. Thanks for continuing the discussion and being a passionate IR.
Luke – great points, and I completely agree with you on this. Yelling about PEC’s hasn’t worked. There are those of us who have supportive combined “Diversified” radiology groups, and I’m in one of them. Nothing is ever perfect, and everything always needs some work.
There’s something to be said for “breaking some eggs” and “blowing it up”, but I also believe in the slow burn – the building up of change through intentional relationships with real people and hard work that I’ve seen benefit my practice immensely. And, there’s something to be proud of in that as well.
Peder, thanks for taking the time to visit my humble blog. Love your content and presence on Twitter. Please, take this with the utmost respect, but I’m going to push back: Have you ever applied for hospital privileges and been denied, Peder? Have you ever had a super sick CLI patient ask why their doctor (me) can’t treat them in the hospital, but instead they need to see someone else? Did you ever have to explain to your referring colleague (which is a relationship established with a real person through hard work) why it is you can’t treat the patient? This is why I am “yelling” about PECs. I’ve lived this nightmare. There is no question that intentional relationships with real people and hard work are essential elements, but I don’t think the question here is about causing some revolution. The real issue at stake is how can we free interventional radiologists to do the greatest good for our society. Some of our patients with the greatest needs live in places where groups like Diversified Radiology of Colorado don’t exist and people like me are boxed out from providing services others can’t/don’t just because I’m a “radiologist.’ Do you see where I’m personally coming from? I don’t think there is any slow burning our way out of this issue, but if you think I’m wrong then give me some suggestions.
Luke there are true exclusive contracts and then pseudo exclusive contracts. I am not sure you understand the difference.
martin luther : catholic church :: linemonkeymd : SIR
This is hilarious. I’m just saying what is on a lot of people’s minds but they’re too afraid to say it. I have nothing to lose, but everything to gain. The SIR will continue to get their $950 from me annually in addition to my very generous monthly SIRPAC donations. I have no doubt there are good individuals in SIR doing good work, but for me this feels like taxation without representation. The problem is people who share my struggles maybe reflect less than 10% of society membership. People are too afraid to leave their radiology bubbles.
First of all, I am so flattered that Luke Sewall spelled my name correctly!
May I kindly suggest Luke is missing the point? There is nothing wrong with exclusive contracts and I am fine with them. I am not fine with someone calling it an exclusive contract and letting everyone do those procedures except one group which they exclude. Take your friend, the cardiac surgeon who lost his privileges when the other group got the contract (and didn’t invite him to join). Ok. Too bad but he goes and works elsewhere. However, what if the hospital let a bunch of other groups stay on staff and did not remove them? That wouldn’t be right if only he was asked/forced to leave.
In the case of IR, pretty much any other specialty group who wants to perform Endovascular procedures in most U.S. hospitals is allowed to, the most prominent example being IC/VS performing PAD but also NS/Neuro with stroke, urology with nephrostomy tubes, VS with AAA/trauma Embo and pulmonary thrombectomy, etc. In those hospitals where pretty much any specialist is allowed to perform the Endovascular procedures they want, is that a legitimate “exclusive radiology contract”? Of course not, and yet that is the most common situation in United States hospitals. And in those hospitals independent IR’s cannot get privileges because the radiology group says they have an exclusive contract. Is that right?
IR’s should be allowed to practice in whatever manner they wish including a hospital based radiology group, independent IR groups whether in hospital or outpatient, or multidisciplinary groups. But in most cities IR’s have one option, join a radiology group (who, at least in South Florida are allergic to an office and clinical work).
You may say “just open an Office Interventional Suite and stay clear of the hospital” but in Florida and other states you MUST have hospital privileges OR a transfer agreement (can’t get!) to open an OIS.
So while I am wining (Brunello Di Montalcino 2015; I would be happy to share a glass with you, Luke) about this issue I would summarize to say that IR’s should:
-be able to get hospital privileges just like ANY other specialist. If there is an “exclusive” no problem. But giving every other specialist endo privileges except independent IR’s is not an exclusive contract. It is an “pseudo-exclusive” contract and wildly inappropriate to block independent IR’s.
-For new IR’s. if you want to be in a radiology group with a salary support and ability to read imaging, then great; there are many options. But if you want a robust clinical practice focused on the outpatient setting and an office Interventional Suite you have a an uphill challenge. You will have trouble getting off the starting gate. While VS/IC do whatever they want (including getting on staff and getting privileges wherever they want) you wont be able to even get privileges!!
-IR’s need help. Start by putting pressure on the SIR (otherwise known as the Society of Interventional Radiology in hospital based radiology groups). Say “I want to be afforded the same opportunities as other specialists” .“Otherwise, why did I go into IR? I should have been a VS.””Why did you advertise and sell us on this great clinical Endovascular program when there is nowhere for us to go?’ “Why do you have a new IR residency when we can’t even get hospital privileges?”
-become a member of the multidisciplinary OEIS where all specialist are welcome. And not surprisingly our VS/IC colleagues can’t even comprehend the issue of IR’s not getting hospitals privileges; because we are the ONLY procedural speciality plaqued by this issue
Right on point Bill
Haha. Since my name has been misspelled for years I also appreciate the returned favor. I would love go ‘wining’ with you over some Brunello. I completely agree with your assessment of radiology groups and the need for clinically oriented IR and I have tirelessly worked to change that in my area. I guess the discussion lies in the fact that contracts are exclusive to specialty groups and not to ‘procedures’. Radiology was an outlier is this because of the imaging exclusivity, but even this is changing with cardiologists now reading their CTA’s, nuclear medicines studies etc. Vascular surgeons reading vascular lab. Neurologists reading some CT and MRI, Ob/Gyn reading OB ultrasounds. Yes, the vascular surgeon can do Endovascular work if he is part of his group’s exclusive contract. Yet some other vascular surgeon with a better skillset can not just come into the hospital if it has a contract with one vascular surgical group. The same applies to cardiology, CT surgery, anesthesia. etc. Anesthesia pain doctors might say that they don’t want to put people to sleep, they simply want to do vertebral augmentation, epidural pain injections etc……Yet if they are not part of the anesthesia group’s ‘exclusive contract’ they are not allowed on staff. I can site multiple other examples that are exactly the same as your critique. Pick your specialty that does any crossover procedures. The point is that exclusivity does not revolve around a procedure, it revolves around a group. As you correctly point out, procedures are becoming more blended every day. Ob/Gyns doing UFE and PCS, trauma surgeons doing embolizations, nephrologists creating AV fistulas. Charles Dotter saw this coming 60 years ago. While not all hospitals are expanding exclusive contracting across multiple specialties, most that I work at are doing so. I predict the near future will see more exclusive contracts and less exclusive procedures. So, while I agree with your plight, I do not believe the solution is to propogate terminology that will not help create a solution and may even create discord among the young residents and fellows coming out of training who may be tainted by the misconception that radiology is being unfairly targeted by these contracts.
Luke, I appreciate your comments and spending time on this blog. You’ve offered some interesting observations which I can summarize as you viewing these contracts as exclusive with groups and not related to procedures. But what you haven’t done is offered any potential solutions for those of us who are trying to obtain hospital privileges. From my experience of applying for hospital privileges and being denied in the state of NC, I whole heartedly agree with Bill Julien. Give us some ideas for how the growing number of young IR physicians who think and act like me can make strides in their careers. I’m talking about the minority subset who want to be independent and follow in your and Bill’s footsteps and not join someone as an employee. So far the answer I see is, “tough world kid, just figure it out.” And if that’s the case, then I’ll go “whine” about something else and use your words as fuel to accomplish my goals.
I went back and read your previous blog after reading this one and was surprised how rational and professional it was. After my first 14 years of experiencing the same thing my post would have consisted of 5 pages of obscenities and a paragraph of incoherent rage. You have given a lot of thought putting these frustrations into organized and useful sentences with a common theme all IRs understand. My salvation was finding full time work in the OBL 8 years ago. I worked for an IC for 3 years and learned about OBL operation and regulations. After a brief stint starting an OBL with a DR group I partnered with a very smart businessman and now serve as medical director in my own OBL with part ownership. It’s not easy, but I don’t go to bed hating myself every night and very rarely rant anymore (spoiler alert: I don’t miss it). The bottom line is that outpatient IR or hospitalist IR, you must either have a clinical practice or enjoy life as a bottom feeder.
Shawn, thank you for the kind words and for taking the time to read the last couple blog posts. If you take a look at some of my early posts from 3 years ago or so, you can see how angry I was. I figured out pretty early that this hospital-based existence (for me) is not satisfying. I also figured out pretty early from being a minority owner in an OBL that there are lots of pitfalls. I agree with you that establishing a clinical practice is the most important consideration to avoid being a monkey. Let me know if you’ll be at OEIS this year. Would love to meet you.
Will do
Thanks again for such an insightful entry. It’s encouraging to see and hear from faces I’ve seen in the Twitterverse here on this blog page. People are losing attention, and that’s the first step toward effecting change in the specialty. You are certainly getting this early-in-training IR thinking a lot more deeply about the OBL space than I ever would have been able to do on my own. The variety of opinions help guide the discussion. Keep up the genuinely fabulous writing, and I look forward to more entries in the future.
Thanks so much Sam! More to come soon.
PAYING* attention!! Haha literally the worst place for a autocorrect typo 😂 this is why I leave the writing to you.
Haha it’s all good. Tons of typos in my stuff too. People text me all the time! Thanks again for taking the time to read the posts.
Luke,
I’d like to point out some errors in your posts.
First (and least important), Pseud -exclusive was a term I first used at the SIR annual meeting after Bill and I were talking about exclusive contracts and the fact that the contracts aren’t truly exclusive 🙂 I coined the phrase and feel it is a useful term in the lexicon because nothing about IR contracts are exclusive.
Second: Respectfully, your statement that exclusive contracts are based on specialty not procedures is inaccurate at best.
The most ubiquitous exclusive contract is the Diagnostic Radiology exclusive, that I’m sure you would agree attempts to prevent ALL specialties from interpreting imaging studies (this is a billable CPT code analogous to procedures) and therefore is procedure based NOT specialty based. It is true that now hospital are bastardizing the term “exclusive contract” to try to make it mean “we will bar anyone else in this specialty from staff”, but that is more the exception than the rule.
I think though what is being lost in the discussion is why exclusive contracts have been upheld by the courts in the past and how things have changed, as well as are there better alternatives.
Historically, courts have given wide discretion to hospitals to employ exclusive contracts to improve operational efficiencies, improve quality of care, improve utilization of hospital resources and deliver optimal healthcare to the community it serves. This argument worked best when procedures were performed along strict specialty lines. However, as turf lines have been blurred and when multiple specialties perform the same services (as is the case almost everywhere) all the arguments to support exclusive contracting fall apart and cannot be justified.
So why do hospitals pursue exclusive contracting? The simple answer is control and money. By exclusive contracting, the hospital offers something that a group perceives has value but costs the hospital NOTHING. The hospital then is able to dictate to the holder of the contract what the hospital wants in order for the contract to remain in place.
The hospital says jump and the contract holder says how high.
Additionally, the hospital recognizes that there are procedures and patients that no physicians care to do or take care of, because of low or no reimbursement. This is why there is mandatory ER call when obtaining staff privileges at a hospital, to ease the burden and ensure these patients are cared for. But sometimes this breaks down and there is a need that is not being met, so the hospital has to satisfy this need. This is why exclusive contracts are offered. To get someone to willingly accept the responsibility of providing this care because the contract holder believes the income received from the “exclusive” business will offset these losses. This costs the hospital NOTHING and now the hospital has a defacto employee that does their bidding without having to pay them directly.
I would suggest a better solution is not accepting exclusive contracts but rather entering into professional services agreements where the hospital PAYS physicians for the services and coverage they need. Let all qualified physicians on staff. There are rules of governance for physicians on staff (the bylaws) and the defined needed services are provided for via the professional services agreement.
Exclusive contracts pit physician against physician and lead to centralization of services thereby removing the autonomy of physicians. This is dangerous and not good for physicians and medicine in general.
This is very good for hospital administrators (no herding cats), who sleep easy at night and collect paychecks far bigger than any physicians around with the money they saved by offering an “exclusive” contract.
All this being said, as my very good friend Bill has pointed out Pseudo-exclusive contracts are an even more egregious restraint of trade that makes absolutely no sense. I will not rehash that argument. There is an article I wrote in Seminars in Interventional Radiology which goes into detail regarding the destructive nature of pseudo-exclusive contracts for the specialty of IR.
Excellent summary of how misguided the attempts at quelling this mentality were by prior posts. I’m sure our friends on the academic side are even more along the other lines and would love to see us battle amongst ourselves being handcuffed by PEC, as they actively teach vascular surgeons and cardiologists our tricks, tips, and techniques.
Cheers to them!
Jerry,
Great comments and great points. Sorry, I’m a little old and and my memory isn’t perfect; I remember hearing the term from Bill first. If you would like credit for coining it, I’m happy to change my comments. Let me start with reiterating the fact (which I’m sure you know already) that I am a rabid advocate for Interventional Radiology. I am also one who has suffered greatly from the contracts you so eloquently bash. I was banned from practice in an entire friggin city and forced to leave a state by my legal opposition to an exclusive contract.
I am not an academic but I read everything; including your seminars. You and I have presented in meetings together and you worked with Beth in the past from my office. I think we agree on much more than we disagree on. IF we are going to call ‘all’ current exclusive contracts pseudo exclusive, then I have no issue with the term. The cardiology group who has exclusivity does PVD, AAA, TAVR, vascular lab and cardiac Cath. The vascular surgery group who has an exclusive contract does AAA, PVD, vascular lab, carotid stents etc. The radiology group who has exclusive contract does imaging, PVD, vascular lab, carotid stents etc. All of their contracts are exclusive (or by your terminology pseudo exclusive).
My issue with the original post was the emphasis that we are being singled out as radiologists. If we try to win this battle by fighting both the hospitals desired system of exclusive contracts and the radiology groups desire to keep their exclusive contracts simply because we are singled out as radiologists, we will likely be fighting a losing battle.
I agree that contracting a service line though a PSA is a much more viable solution. I’m sure you know that I was one of the original proponents of this (which I did beginning in 2005 and have expanded it since then). I agree that some in academics set the specialty back by years for their personal and political gain by training other specialties to do what we do. In all of my current 10 hospitals the surgeons, cardiologists, CV surgeons, nephrologists and others do many of the things we do……yet if you watched them do it (and I have) you would cringe. I would fail a third year radiology resident for doing things they consider normal operating procedure. Being better at what we do doesn’t necessarily translate into being busier and getting referrals.
I also agree with your discussion about the hospitals motivation for implementing these contracts, yet I also have learned that hospital administrators are not always the best business people. All politics is local. In underserved areas, outpatient labs can be a financial boon. In oversaturated areas they can be a huge financial bust. In a perfect world, hospitals and doctors would joint venture on outpatient centers where both would benefit financially and patients would benefit medically.
I don’t have all the answers but I think the way I have carved it out has been a huge benefit to patients, the hospitals and the communities we serve. To the trainees and young people I would say that the world is not as grim as Kavi sometimes implies. It is clear that he had a bad experience in his first jobs. But I did not in any way imply “tough world kid, just figure it out”. What I might suggest is to interview and ask questions. Give a job you liked at first sight a chance. Work to make it better, but if you can’t, also, realize that most Interventional Radiologists (like other medical professionals) will have multiple different jobs in their first 10 years of practice.
Sorry for the somewhat random posting. If I learned anything in this process (my first ever posting on a blog), I learned that these discussions are much better in person or at a meeting.
I agree that it is much better to discuss this in person. If you’ll be at OEIS I would like to discuss this with you because you clearly have accomplished a lot and have much to offer.
We all know to ask questions about a job and I agree that due diligence is important. I’m not sure if you know my background, but I have now been employed and have created two jobs for myself. We need to create pathways for future IR physicians to be job creators, much like yourself. Making the leap from self-employed to business owner is difficult. It’s even more challenging when there are critical roadblocks like obtaining hospital privileges. I’d like to know how you did that, as would hundreds of young eyes looking at this right now.
You’re not the first person to suggest that I am being dark and grim in my assessment. I am simply being realistic about the issues in our field no one wants to talk about publicly. Trainees are not being educated on these subjects and to expect them to be a bunch of lemmings going down traditional employed pathways, be it hospital based or OBL, is a recipe for failure. In my humble opinion.