Recently my posts have been indirectly alluded to in SIR Connect Forums and misbranded as career unhappiness and “vitriol.” I find it sad to be associated with such feelings because the point of my blog is to educate others who find themselves in my shoes so that they can be empowered with the necessary knowledge to better their own careers. I firmly believe that we as physicians have a choice when it comes to how we structure our lives and practices. Too many of us live in fear. The funny thing is once you start taking your own path and realize that everything you need to be successful is sitting right between your two ears, things appear much clearer and fear quickly subsides. The independent physician mind is not a force to be reckoned with. I hope everyone reading this feels that at some point because this mindset is truly life changing.
One of the interesting comments that came up on the SIR Connect Forums was the observation that our training paradigm has come a long way in a short period of time, but unfortunately the job market has not caught up. The conversation quickly led to the familiar theme of academic versus private practice. The infamous pseudo-exclusive contract reared its ugly head again. Some of the comments were clearly political with overt virtue signaling. Frankly, one post was simply contradictory to what the same individual posted as a comment on this blog. I’ll let the astute reader do some investigative work between cases to figure out the details.
Needless to say, I have a history of being critical in my assessment of academic IR. I believe most programs have not fully adopted a clinical model, and I am not afraid to call them out on it. For crying out loud, we have some programs more concerned about their paracentesis workflow than developing dedicated IR clinics for the longitudinal management of disease states, or the less refined term, “service lines.” What I haven’t done is take the time to praise the several programs out there who have carved out a true clinical presence in their local healthcare ecosystems, particularly with respect to vascular disease. These programs are modeling the behavior necessary to groom the next generation of IR practice builders who will improve health in the communities that need it the most. Thank you to those of you who work so hard to train the next generation of IRs.
Great private practice groups and academic IR divisions are often celebrated by leaders in the Society of Interventional Radiology for “breaking the mold,” and “demonstrating the value of IR.” In many ways they should be celebrated. In these divisions, there were usually one or two visionary IRs who worked very hard over many years to develop a clinically oriented practice which resulted in a division practicing IR in a way many of us wish to. Oftentimes, these practices still exist in the confines of a radiology division, which to me is like enduring a bad marriage just for the kids. Think about the hurdles that these academic luminaries and clinically oriented hospital-based private practice IRs had to jump through:
1. Create a clinically oriented culture which de-emphasizes RVU productivity.
2. Establish buy-in from diagnostic radiology colleagues and hospital administrators.
3. Be clinically and technically excellent resulting in great patient outcomes.
4. Leverage great outcomes to grow referral base through education and outreach.
5. Prove their financial worth through appropriate coding and billing, much of which was uncharted for novel IR therapies.
6. Go through multiple iterations of quality improvement to fine tune operations.
7. Attract top level talent to help grow the division, offer around the clock service, and ease the diagnostic call burden.
In many ways, the mentality required for the creation of a clinically oriented practice is not too different in the OBL world. Here are those hurdles:
1. Establish procedural and clinical excellence.
2. Obtain hospital privileges independent of a DR group which may similarly require some degree of buy-in from diagnostic colleagues, threatening letters from lawyers, or a lawsuit.
3. Fund your new facility and not be swayed by the opportunity cost of the radiology cocoon with its partnership track and double-digit weeks of annual vacation.
4. Hire a team and promote a positive workplace culture to attract and retain great employees (the retention part tends to be challenging for some Napoleonic types).
5. Continually market one’s practice and cultivate relationships to endure a very competitive healthcare landscape which is rapidly changing with acceleration of healthcare consolidation.
6. Go through multiple iterations of quality improvement to fine tune operations.
7. Attract the magical unicorn of an individual as a successor who shares your vision, commitment, and skills who won’t do it on their own despite being as motivated, stubborn, and confident as you.
When future or existing interventional radiologists look for new jobs in academic medical centers or in “good groups,” they are often joining in at step number 7. The hard work pertaining to infrastructure has already been mostly completed for them. What they are not necessarily participating in are steps 1-5, which can take years if not decades to accomplish, if these entrepreneurial IRs are lucky to be in settings where true change is even possible. These entrepreneurial IRs had a vision, and they connected the requisite dots to get to their final destination of a clinically oriented hospital division or office interventional suite practicing at a very high level. I’m talking about a practice that takes care of patients longitudinally with cases generated through clinical consultation, not simply order based processes which is the norm for any radiology department.
In many ways, the IRs who helped create these practices are who I consider to be “founders.” They are functionally no different from founders of any other successful company which began life as a small start-up. These individuals had a vision and turned it into reality through decades of hard work and perseverance. To do this, you must really love what you do and be so steadfast in your determination that you are committed to overcoming all obstacles. You never take no for an answer. When founders identify a problem, they work relentlessly to find a solution.
What makes IR really unique compared to other clinically focused medical or surgical subspecialties is the things that other fields often take for granted simply don’t exist in most IR practice settings. I’m thinking about a clinical mindset and basic infrastructure such as physical clinic space, medical assistants, nurse navigators, revenue cycle management systems attune to evaluation and management and advanced procedural codes, an answering service for patients, mid level providers, etc. Much like start-up founders, these entrepreneurial IRs who have built great practice environments started from dusty, garage-like basements which house most IR divisions. Do you think a gastroenterologist, cardiologist, or vascular surgeon goes to work having to create a clinic space and infrastructure for themselves? Generally speaking, the answer is no. I’m sure there are many issues in their work flow which have to be tweaked, but seeing as clinics drive their revenue, the aforementioned essential resources are taken for granted. Remember, evaluation and management codes alone account for a third of their revenue. When I explain to my cardiology and vascular surgery friends what needs to be done to create an IR clinic, they look at me bewildered.
The IR founder doesn’t flinch when faced with obstacles. For he or she is not a Line Monkey. Nay, they are a Line Gorilla. He or she is so steadfast in their determination to build a clinical service, they play ball with their diagnostic radiology colleagues if hospital based and find a way to carve out their mere right to have a clinical infrastructure. A few of them split from their diagnostic colleagues and secure their own hospital contracts. The OBL Line Gorillas are true rogue warriors who leave the hospital to hang their own shingles and reinvent their new existence from scratch.
Once these founders lay the groundwork for their clinical existence, they then get to the hard part of “practice-building”: establishing referrals, protocols, and systems to grow. These Gorillas, whether hospital or outpatient based, then hire junior gorillas, or perhaps monkeys depending on the state of the labor market, to create an army of excellence. They reach the top of the mountain and beat their chests. They have made it. Generally at this point they will get on social media and big-dog the Line Monkeys out there who correctly point to the challenges and inequities in our field which prevent us from cultivating the positive environment necessary to help encourage more future trainees to become founders. More on this truly toxic culture in another post.
I think most IRs fail to realize what is actually necessary to build a clinical practice. I certainly did. How stupid was I? I literally thought I could show up to a hospital that was large enough, with good pathology and surgical subspecialties, and find a way to carve out a true clinical existence through honest hard work and brute force. After all, this is what I was taught in training. Unfortunately, I think this short-sighted advice is still all too common even among the most brilliant and dedicated of academic mentors. What I failed to realize is success, which in this context should be defined as building a clinical practice from scratch as an image-guided surgeon (IGS), requires five key elements
1. Vision
2. Patience
3. Resources
4. Skill
5. Luck
Vision
Vision is the end game, the grand idea that the founder is striving to achieve. Vision is about the future. You must know what it is you’re trying to accomplish and you have to internalize it. We all need a vision.
Founders of IR practices share the vision of wanting to improve the health of their communities by sharing the best kept secret in medicine and simultaneously deriving tremendous professional satisfaction. They internalized this vision and made it their number one objective. If you don’t have a “why” for what it is that you’re trying to accomplish, you have already failed.
Patience
When it comes to building a clinical service starting from dusty radiology department ground zero, you have a long way to go in order to make it to a floor with windows or the beautiful corner office setting. Patience is truly a virtue. I don’t think this really became apparent to me until I got to the OBL and realized that something truly remarkable is never built overnight. I had to contend with the challenges of building a practice while also building my own skills as a physician and leader only two years into my career. I would say for most of us in IR, it takes at least 5 years to reach some level of procedural comfort. Another challenge for many of us in practice is not only becoming technically excellent, but clinically excellent, which involves a level of commitment that goes above and beyond what many expect of an IR because these skills were not a core part of training in the 1-4-1 fellowship paradigm. Non-procedural clinical decision making is an iterative process which requires significant repetition to fine-tune. Personally, I have learned to embrace this process and take joy in the many baby steps necessary to achieve success.
Even when one has developed the refined skills, focused mindset, and healthy habits of a true image-guided surgeon, the practice, which is larger than any individual physician within it, has yet to achieve the “flywheel” effect. Self-sustaining growth does not happen overnight, and if it does, it is probably because you have cheated to get there—such as paying for referrals in either a barely legal or outright illegal manner. Many OBL business models rely heavily upon meticulously crafted legal arrangements with other specialists as partial owners in accordance with Safe Harbor, Stark, and Anti-Kickback laws, which may fall like a House of Cards at the stroke of a legislative pen. Organic growth, however, comes down to the founder reaping what he or she sows in terms of market research, outreach and education, and performing reliably excellent technical work buttressed by equally excellent end-to-end clinical care. Good outcomes beget more referrals which provide more opportunities for more good outcomes at progressively leaner costs: the flywheel effect at play in IR.
Even when you do establish the practice of your dreams, you still need to be patient, because you will need to learn how to be an effective mentor to the next generation of IRs to follow in your footsteps. I believe true mentorship, without any bells or whistles, is an essential part of our healthcare lifecycle which is sorely lacking in the field of image-guided surgery and in the broader landscape of medicine, as well. IR mentors of today should pass the baton instead of selling it to the highest corporate bidder.
Resources
In order to build a successful practice, you need resources. Time is certainly a resource. Money is also an important resource. The hospital-based founder will need to make a business case for their motivations. They will have to contend with their practice leaders and the nebulous C-suite which strategically exists to keep you in your place as a busy wage worker. The OBL founder will of course need to bring significant capital to the table to invest in their future success.
Our relationships with other people are also an important resource. No healthcare leader has created something without engaging and leaning on other individuals. Relationships are all about acknowledging value and making sacrifices.
The hospital-based founder will more likely than not need to engage with their diagnostic radiology colleagues in a meaningful fashion to see their vision become a reality. For those who choose to play in the radiology arena, one will need to understand the pain-points for their DR colleagues and work strategically to cultivate a good working relationship. This involves a level of sacrifice, likely in the form of accepting some degree of diagnostic responsibilities or call, in order to get what the founder wants.
Even though I personally feel the relationship with diagnostic radiologists is inherently one that is not healthy for most image-guided surgeons, what I have not told you about are the hardships that the independent physician in the hospital setting has to engage in. This enterprising individual will need to establish open lines of communication with hospital administration to understand their needs and create a professional services or employment agreement which is justifiable and mutually beneficial. Dealing directly with the hospital isn’t without its own set of headaches, however, as this more likely than not involves dealing with non-physicians who simply think and play in a different arena than you do. Even the hospital-based founder within a radiology group will likely have to interface with the hospital in conjunction with their DR colleagues when it comes to certain asks.
The OBL founder will have their own unique set of relationship building challenges. He or she will need to create meaningful relationships with their employees and strategic partners including consultants or managerial service organizations.
Finally, every physician leader will need to work on cultivating meaningful relationships with their referring physicians. Like everything else, this is an iterative process which requires significant time and commitment.
Skill
One needs to be a skilled physician and leader to bring a certain vision to reality. While many of us have procedural skills, a lot of us, whether we care to admit it or not, are lacking the clinical skills to longitudinally manage patients. This is largely a reflection of our antiquated training focused on imaging and wire/catheter techniques. Our ability to manage disease states over time, from diagnosis to prognosis, is what will dictate our long-term survival as a specialty. I think our new training paradigm is a huge step forward in teaching the future image-guided surgeon the entire set of skills needed to survive and thrive in clinical practice, but this is only a part of the process. What our training paradigm lacks are critical lessons in leadership, healthcare economics, and pay-it-forward mentorship which are essential for the aspiring founder. The truth is in order to “make it” as a founder today, one must overcome more hurdles than our predecessors did during the “Golden Age” of radiology, or than our contemporary counterparts in competing fields like vascular surgery and interventional cardiology. In many ways, IGS practice development skills will require a high degree of self-motivation and will not be something that can be readily taught in many existing academic practices. I think those of us who have created practices have a moral responsibility to pass this knowledge on to the next generation of image-guided surgeons to secure the future of our specialty.
Luck
There is no question that succeeding in the development of a clinical practice in one’s chosen environment involves some degree of luck. After all, it is always better to be lucky than good. But what is not being told is what goes into luck. Fortune favors the prepared. In other words, one can position themself to get lucky. This involves surrounding yourself with people who share your goals, learning from others who are at a point that you aspire to reach, and removing negative energy that is not conducive to your professional goals.
At the end of the day, in order for our field to advance, we need more colleagues with the founder mentality. We need individuals who are on a mission to achieve the vision of building clinical practices. To me, this is how we must innovate. The future of image-guided surgery must involve more gorillas and fewer monkeys.
Lots of good points here. I am a first year attending and I’m seeing a lot of what your mentioning.
Let’s start with clinical IR. My program pushed it heavily when it came to the fellows, but I can count on one hand how many times I actually rounded on patients with an attending. From my experience clinical IR only applied to fellows and residents and was just a cool catch phrase for staff to throw around. It may not be this way everywhere, but seems like people are more concerned with promotions and using clinical Ir as a talking point rather than actually doing it.
As far as the job market not catching up, I am already seeing changes in my group. We have been unable to hire a new IR despite them trying before is started for 2 years. Most people we have talked to are wanting 80-90% or more IR just the same as me which I have the ability to do at the moment while understaffed. It has actually gotten to the point that we are discussing adding “daytime” outpatient IR in areas where it has not been provided in the past and we have diagnostic contracts already established. I fear this will be a slippery slope, but time will tell.
I hope an OBL/ASC is in our future. I’m trying to stay positive and hope the good will and support from our diagnostic colleagues holds up.
Agreed re: clinical IR false advertising. As a current IR resident I think that “clinical IR” usually equates to the resident writing consult or progress notes (often of no actual clinical value) for patients the attending never sees until they’re on the table. A lot of those notes won’t ever even get billed as a result. How can you expect attendings with no clinical acumen to pass on clinical acumen to residents? It’s the blind leading the blind. Most academic IR attendings are still DRs are heart because that’s how they trained. I know that’s an incendiary comment, but I bet many other residents will agree. We are starving for clinical training but we have to learn it on our own amidst a culture where it is very foreign. It’s like swimming upstream.
Obviously there are a number of exceptions, but overall the integrated IR residency in its current state is overhyped and falls well below what programs are advertising. It’s a very one-sided transaction where the academic med center gets WAY more than the resident.
The reality is that current IR residents have a LOT to learn outside of the mountains of responsibility and call in residency. Clinical knowledge, practice building, and all the aspects of leadership that Dr. Monkey talks about are all very necessary but extracurricular pursuits for modern IR residents. Luckily we can learn from experiences of Line Monkey and others on social media who have dealt with/are dealing with the real world.
As a former radiology executive, I am dismayed by how slowly radiology groups are awakening to the fact that they are creating a toxic career environment for enterprising IR docs. The administrator for a very large radiology group recently referred to one of his IR rads as “Mr. Too Big For His Britches” because the was pushing for the board to develop an ambulatory center for endovascular work. What?!!! I predict that group will have a serious problem in IR coverage within two years.
I hate to say it, but I believe the best way forward for IR may be to leave DR and partner with vascular surgery and IC. Functionally, IR has more in common with these interventionalists than the neuro rad reading MR all day.
the sir connect haters are basically like pat bev on espn yesterday throwing slander at cp3 all day despite bev being nearly universally disliked and having garbage stats compared to paul.
Pat bev treating his play-in win against the clips like he won the chip or something is actually the perfect metaphor
Great points! Building the clinical infrastructure takes a lot of time, effort and finances. Dedicated clinic space. Dedicated protected weekly clinic time not doing procedures or reading the list. Office staff (schedulers, MA,US technologists, extenders, billers, coders, marketing, office manager, HR etc). In the hospital setting this requires changing from an order entry to a consult only service again with dedicated time to see the consults and generate E and M codes.
We need to make sure that trainees acquire not only the clinical skills (dedicated outpatient clinic time seeing various disease states) , technical skills (broad array of disease states PAD/IO/ neuro/pain/ venous/ men’s and women’s health) but as important if not more importantly give them a foundation on how to set up an office and garner referrals to the clinic.
If I may, I’d like to add one more skill. People skills are woefully undervalued. We work in a service oriented field. We depend on customers, that being patients. Much as you and I have the choice to go to Best Buy or the Apple Store to purchase our iPhone, our customers/patients have the choice as to who performs their angiogram, place their port or performs their UFE. The informed patient will not simply accept who their PCP refers them to but will take the advice of those friends, family and co-workers who had a positive experience with Dr. X because he or she treated them with respect and dignity. I personally like to remind patients that they are empowered to make their own choices. Remember, people don’t care how much you know (or how procedurally skilled you are) until they know how much you care. Refine your “people skills.”
FDJ, you are spot on. This deserves an addendum to the original post. We need to treat patients like we treat our own family. Patients do indeed have choices and we should be honored that they choose us as their physician. I think the way we treat our patients should also extend to our relationships with fellow physicians, nurses, technologists, non-physician associates including advisors or managerial services organizations and other members of our team. There is something to be said for having emotional intelligence.