In a bit of a departure from the usual long-format post on this blog, I want to highlight an article from my good friend and mentor, Dr. William Julien. For those who don’t know Bill, he’s a pioneer in the independent IR movement. Bill was the first person to contact me to offer support after I posted about my struggles in a radiology group on SIR Connect. He called me a couple of hours after I posted and flew me down to South Florida the following week to introduce me to the concept of the office interventional suite. That initial phone conversation and subsequent in-person visit saved my career. I’d also like to publicly thank and express appreciation to Mary Costantino for encouraging me to make that post public (it was initially an email addressed to her while she was on the private practice committee for the SIR), Aneesa Majid and Sonali Mehandru for reaching out back then and providing support along this very scenic journey now in its sixth year. We are lucky in IR to have some amazing colleagues willing to lend a hand.
For those younger IRs who may not know the history of the outpatient space, Bill Julien and Jerry Niedzwiecki were among the first IRs in this country to create office interventional suites. I have since gotten to know both and learned much from their combined forty years of experience in this space. They are both founders and past presidents of the Outpatient Endovascular and Interventional Society.
Recently, Bill and I were both invited to speak at the Southeastern Angiographic Society annual meeting. Big thanks to Dan Siragusa, Joanna Kee-Sampson, and Peter Bream for their hard work putting together that meeting. It was a great time, and I will dedicate a separate post to speak about my experience there, but before doing so, I want to highlight some of the work Bill presented.
At that conference, he talked passionately about steps the Society of Interventional Radiology can take to support independent interventional radiologists in obtaining hospital privileges. I have recorded the talk (albeit somewhat poorly, but I think it is good enough…I hope). Bill took the time to put together a nice article posted here for your edutainment. Please see my commentary to follow:
Steps the SIR Can Take to Improve the Ability for Independent Interventional Radiologists to Obtain Hospital Privileges.
Note that this is being posted simultaneously on SIRConnect https://connect.sirweb.org/ OEISConnect https://connect.oeisociety.com, LineMonkeyMD.com https://linemonkeymd.com/, and BackTable Podcast “How to get independent IR hospital privileges” https://www.backtable.com/ and various other social media platforms.
Attachments include the SIR position paper, ACR position paper, SIR 2018-22 strategic plan.
Problem: For decades, the SIR has encouraged IRs to have a clinical practice. Although some IR/DR groups have embraced this idea with robust clinics and inpatient rounding services, many IRs are either not interested in or not allowed to have a clinic. Instead, they spend significant time reading imaging studies and performing commoditized and mundane image-guided procedures. With the rise of private equity-run groups, demands to increase productivity have resulted in IRs interpreting even more imaging studies for the sake of RVU production. Folks who choose that model should be free to, but others may want to practice independently from a radiology group to build a longitudinal clinical practice and improve access to critical interventional radiology services. Because most radiology groups are contracted with the hospital for radiology services, they commonly have an exclusive contract to provide imaging services. “Interventional Radiology” is typically included in that contract. However, over the past several decades, most high RVU minimally invasive image-guided procedures have been performed by other specialists despite this contract being in place. In most hospitals, non-radiology specialists can perform any interventional procedure they want. So, in reality, these IR/DR groups have an exclusive DR and nonexclusive IR contract, hence the term “pseudo- exclusive.” The problem arises when an IR, not an IR/DR group member, applies for hospital privileges, and the group invokes its exclusive contract to block the IR. An independent IR is commonly blocked at all hospitals in an entire city because of this, while other specialists are free to perform interventional procedures wherever they want. Some may say, “Why don’t you just work in an OBL or an ASC and stay away from the hospital?” Although some states allow this, many require hospital privileges to open an OBL. Furthermore, insurance companies often require hospital privileges to become contracted.
The above environment, in large part, blocks clinical IRs from thriving in the United States. The SIR has identified this and recently released the third version of a position paper on exclusive contracting. This states that if non-IRs perform interventional procedures in a particular hospital, independent IRs should be allowed to perform these procedures. Even the ACR recently released a position statement that says the same thing. The SIR’s 2018-22 Strategic Plan’s #1 goal was “IR Physicians will thrive in their chosen practice model leading to high-quality patient care,” came and went with little change. What change did occur was by hard-fought battles by individuals on a local level. The SIR has adopted a laissez-faire approach. That is probably because the largest due-paying constituency to the SIR is hospital-based IRs in an IR/DR group.
People have asked, “What can the SIR do?” and this is the primary reason I am writing this. If they had done more, I would not still discuss this after a 31-year career. This is what I think the SIR can do to improve independent IRs’ ability to get on staff at hospitals:
1. Use their bully pulpit at every opportunity to promote a clinical practice with longitudinal care, especially those independent practices that are pure clinical ones. Part of thatbully pulpit is to be intolerant of the ubiquitous practice of radiology groups blocking independent IRs from getting hospital privileges at facilities that otherwise have an open staff policy for interventional procedures (essentially all private hospitals in the USA). They should also use the bully pulpit to criticize the IR groups without a clinical practice.
2. Identify the states where an OBL can be opened without hospital privileges so IRs can move there.
3. OBL sessions at the SIR annual meeting (currently in process).
4. Encourage IR residents to spend time in OBLs for clinical training and learn procedures they may not be exposed to, such as PAD and SVI.
5. Help develop staffing and financial models to staff IR coverage for hospitals. Currently, IR co-coverage is just a freebie thrown as part of an IR/DR contract, which is incredibly devaluing to IR. Whether part of an IR/DR group or independent, IR services should be able to negotiate a professional service agreement.
6. Develop a “How to get on staff” lecture at SIR annual meeting, which I gave in 2018
7. Be honest with med students: “There are very few jobs where you can practice full-time clinical IR. And if you want to develop your own practice, you will most likely be blocked from getting on hospital staff by the radiology group. Other specialties get on staff without a problem and do whatever procedures they want.”
8. There needs to be a change in IR leadership makeup. Currently, there is no independent IR on the Executive Committee.
9. Showcase clinical success, including OBL/independent IR at the annual meeting and “The Wire.”
10. Pay for an Amicus brief on the legality of the so-called “Exclusive” contract that allows everyone except independent IRs to get on staff at hospitals.
11. Showcase legal successes (and their lawyers) of independent IRs obtaining hospital privileges when opposed by radiology groups or the hospital.
12. Terminate SIR membership for those IRs who do not have a clinical practice or who block independent IRs from getting on staff at their hospital in direct violation of the SIR’s recommendations.
13. Promote separation of IR from DR much like radiation oncology has split from radiology. I have written about this before and encourage interested readers to check out a recent AJR article on this topic. https://www.ajronline.org/doi/10.2214/AJR.23.29815
Additional thoughts: Other societies would have never let this fester so long. If their people were blocked, they would have taken to the airwaves, called stakeholders, filed lawsuits, etc. What has the SIR done? Approve a position paper and otherwise sit idly by while a group, largely without longitudinal clinics or rounding services that mostly read films and perform low-level procedures, block purely clinical independent IRs. Why does the SIR not support the ones who want to practice IR like the society recommends we practice? Which group will make the SIR proud and help create IR leaders in our communities? There will be some who will say, “Let’s study this” (some more). To that, I would say this is a decade-old problem that has not changed much since Jerry Niedzwiecki and I brought it up at the 2004 Phoenix SIR Annual Meetin Business Session. At that time, a significant number in the audience of thousands booed us. An entire generation of IRs have been affected by this problem and have had their options limited. Most of the SIR membership has either blocked the independent IRs, were complacent, or, in some cases (academics mostly), were unaware or did not care.
These actionable suggestions should serve as a roadmap for the leaders in IR to correct course. However, If the consensus is to talk about it some more or do nothing, medical students who want to pursue clinical IR should consider applying to other specialties without the current barriers to a clinically oriented independent interventional radiology practice.
William H. Julien, MD DFOEIS
https://www.acr.org/-/media/ACR/Files/Governance/Digest-of-Council-Actions.pdf
Line Monkey MD Commentary:
As someone who has lived the struggles of being an independent IR, having been denied privileges at over six hospitals to date due to pseudo-exclusive radiology group contracts (PECs) and gaslit into believing that all of this is somehow my fault for not establishing good working relationships with local hospital-based radiology group employed interventional radiologists, Bill’s post rings true. It is downright embarrassing for us as a field that the issue of pseudo-exclusivity has been going on for decades. Like everything in life, politics are involved and the devil is in the details. I have learned these lessons the hard way.
When many academic leaders in the SIR and ACR hear the names Bill Julien or Jerry Niedzwiecki, they roll their eyes and react negatively. A mid-career IR friend even used the term “ear-muff” when describing the typical academic IR reaction to the issue of PECs. I have been encouraged not to associate myself with Bill or Jerry because they have reportedly “burned many bridges” and have been described as “like a bull in a china shop.” I’m not exactly sure what happened at these professional meetings in the late 1990s or early 2000s, nor do I care. At that time, I was more worried about my parents getting on the phone and interrupting my Naspter music downloads on my blazing-fast 36.6 dial-up internet than I was about interventional radiology. Many readers of this blog were probably in diapers. Fast forward 20+ years later, having a few initials after my name and a greater appreciation for the politics of our profession, I, too, am pretty upset given the fact that my professional livelihood is threatened by a group of radiologists more concerned with protecting the status quo than with improving our ability to impact change at scale.
Although there are significant negative undertones as a result of the challenges presented by the reality of independent IR, particularly within the context of a healthcare landscape where the concept of private practice is dwindling, there is hope to be gleaned thanks to the hard work of independent IRs who have come before me, including Bill and Jerry. I want to highlight the positive trends I’ve noticed:
- Trainees and young IRs are interested in providing longitudinal care.
While this may not be true for every trainee, more trainees now than ever are interested in providing comprehensive IR services, including clinic and rounding services. This has been reflected in the changing training paradigm brought about by the IR/DR residency. While the new training is far from ideal, it was a critical step in altering the direction of interventional radiology.
- IRs Seek New Opportunities
When I wrote the “IR Hospitalist: Hospital MVP or Glorified Trash Collector,” it got such a popular response not just because of my language but because the hospital Trash Collector resonates with many interventional radiologists. The practice pattern comes from commoditizing image-guided procedures lumped under a “radiology services” contract. Trash collection is supported and encouraged by a radiology business model, which often dangles image-guided procedures as a free carrot to a healthcare system in exchange for the opportunity to interpret their diagnostic imaging. Continued decreases in reimbursement which have accelerated private equity buy-outs and rapid commoditization of our profession all within the context of a global pandemic, have created a general sense of angst and frustration among many. IRs want change, and many realize that most radiology groups do not provide the avenue for the autonomy, purpose, and mastery that they desire.
- A Greater Interconnectedness Among IRs
Despite its annoyances and problems, social media has resulted in a more interconnected community of IRs who seek to advance their craft and elevate their colleagues. I have seen this in my own life. Our ability to leverage technology to build a community of like-minded individuals passionate about IR encourages me. With improved avenues to connect and communicate, our community will only become more enhanced in due time.
The common thread that binds us all interested in a new path of clinically oriented interventional radiology services is the concept of longitudinal clinical care. A robust practice must be centered around evaluation and management services, which drive procedures. Whether this is in a hospital, an outpatient interventional suite, or an ambulatory surgical center is not necessarily as important as identifying the common culture and motivation that should unite us all.
As long as interventional radiology is lumped under “Radiology Services,” the issue of pseudo-exclusive contracts will continue to hinder many well-intentioned and passionate IRs interested in expanding or creating interventional radiology services in their respective communities. Some of our academic leaders understand this, but too many play a political game that precludes them from acting on this issue. I can kick and scream as loud as I want, perhaps louder than Bill has for the last couple of decades, but the choice is theirs to decide if they want to lay the groundwork for a better future. Suppose they choose to continue with the status quo. In that case, they are well aware of the consequences of that decision, which will largely be motivated by self-preservation, fame, and economic gain rather than advancing our field to new heights.
Promoting the mission of independent IR also depends on you, the reader. Being vocal about how you want to see the field advance, including participation in societies like SIR and OEIS, is critical. While politics are inevitable, change never happens unless a critical mass of people want to see that change.
Regardless of what happens regarding independent IR on a larger scale, this blog will support those looking to create their own independent path. We must stick together and support one another. It is easy to be negative and use the challenges people like Bill and I have identified as an excuse in our professional lives. To medical students and trainees, you need to understand the reality of interventional radiology and be ready to adapt to the ever-changing nature of this field. There are far more well-defined and clinically oriented fields of medicine where you can plug and play into a job that will be satisfying, but consider these challenges outlined here as the cost to play in the magical sandbox that is IR. Things may look different in the future, but crystal balls tend to be cloudy, and no one knows how this will play out. There will always be challenges and headwinds, but we will never achieve anything great without focusing on what we can control. Bill taught me that lesson and exemplifies what is possible in IR. I hope our community embraces the message of longitudinal clinical care and takes the requisite political steps to support those who choose to follow in Bill’s footsteps.
Great points . The struggle is real. Key is to recruit trainees whose primary goal is to take care of their fellow humans. This entails mastery of history taking, physical exam skills, lab evaluation, understanding natural history of disease, prescribing medications, following patients longitudinally. Clinic is a must and can not be compromised. It is the unalienable right of physicians who want to perform invasive procedures and manage diseases.
This requires recruiting surgical types. Those who want to read films should apply to radiology not Interventional. This way they can do “ir lite” and read films and do remote reads. Those who go into interventional residency are delegated to taking call, doing emergency procedures on hemodynamically unstable patients that can occur at any time of the day or night. GI bleeders, septic patients, massive PE, strokes are growing in demand and we need those who are able to handle the lifestyle of this expanding field.
Training will have to change from its current construct as it has too little integrated training in the first 3 years after surgical internship and inadequate amount of clinic to really understand disease.
The two fields are unfortunately not aligned when it comes to the importance of direct patient care. The surgical fields and specialties are far more aligned than the imaging DR counterparts when it comes to what VIR neeeds to succeed.
Ultimately DR and IR will need to separate as they continue to diverge further and further away from one another similar to Radiation oncology and when it split from radiology
Great comments. Absolutely agree. We need to define this culture and that begins with training.
Thanks for sharing this amazing post! The SIR and individual interventional radiologists can contribute to a more favorable environment for obtaining hospital privileges, fostering collaboration between hospitals and the interventional radiology community.
Line Monkey MD raises important considerations regarding the challenges faced by independent interventional radiologists in obtaining hospital privileges. The insights shared underscore the need for collaborative efforts, and the suggested steps for improvement are valuable in addressing these issues. Kudos to Line Monkey MD for advocating for positive changes that can enhance the practice environment for interventional radiologists.
In a departure from the typical format of this blog, Dr. William Julien offers insights into steps the Society of Interventional Radiology (SIR) can take to enhance the ability of independent interventional radiologists to obtain hospital privileges. Dr. Julien, a pioneer in the independent IR movement, emphasizes the importance of collaboration between SIR and independent practitioners. He reflects on his own experience and advocates for a more supportive and inclusive approach within the IR community. This post sheds light on the challenges faced by independent IRs and proposes constructive measures for SIR to foster a more conducive environment.