The IR Apologist: Examining Our Relationship with Diagnostic Radiology

Who are we as interventional radiologists? I can’t help but think of this hilarious meme that has been circulating around the internet when I ask myself this question:

One of the frustrating parts of being an IR is not having a clear identity. Ask 5 different IRs and you will get 5 different answers about what it is that we do for a living.

Historically, we are a field born from diagnostic radiology. Even as little as five years ago when I was entering my IR fellowship, IR was really just that-a subspecialty of diagnostic radiology. It was a field that was equivalent to other diagnostic radiology fellowships. The old way of doing this included spending a year as an intern, four years as a diagnostic radiology resident followed by a year dedicated to IR. My fellowship year was the second to last year of this paradigm with the new way of doing things being a confusing and somewhat convoluted way of reaching a primary “IR/DR” certificate. Diagnostic time in 2 out of the three pathways has been reduced to 36 months while time on IR or non-diagnostic radiology IR related disciplines has been introduced. These programs exist in an effort to make IR more clinical.

What has not changed is how IR is practiced post-training. The majority of trainees end up in positions centered within radiology departments and suffer from an identity crisis of sorts. Most are not afforded the opportunity to build true clinical practices and many may not actually want to do so as the opportunity cost can be substantial. We have a situation where there is a clear mismatch between the expectations of trainees and the reality of the cruel world that needs us but doesn’t yet know how to accommodate our unique potential.  

When you talk with academic leaders about this problem, you can’t help but notice some sense of shame or regret in their voices. Many knew this would be happening, but they don’t really have practical or immediate solutions. Some are convinced that if enough trainees demand clinically oriented IR jobs, the nature of jobs will change over time as more exhibiting the “founder mentality” make their ways into existing practices and begin to change things. Others just act like there is nothing wrong and proceed with business as usual. After all, there are some “good jobs” out there where their trainees are doing “good work.”

As IR evolves, we need to question its relationship with other fields, and I think that starts with diagnostic radiology.

What do we get out of our relationship with DR?

Yes, diagnostic radiology provides the requisite imaging expertise and competitive advantage for IRs to outperform every other specialty in image-guided procedures. But outside of a training paradigm, the IR/DR marriage is toxic and overdue for divorce. At first, some tried gaslighting me into believing that I just had a bad go of things the first time around in a radiology group, but having now worked for two radiology groups, helped create an OBL with a non-IR, contracted with multiple OBLs and directly with a large healthcare system for locums, and connected with over 100 IRs in the last six months (some of whom are senior and well-known in the academic or organized radiology spheres, but would probably not want it disclosed publicly that they have been talking with the lowly “Line Monkey”),  it has become abundantly clear to me that our business relationship with diagnostic radiology is more harmful than helpful.

Many leaders in academic interventional radiology are proud card-carrying members of the American College of Radiology. They argue that “there is strength in numbers” and that being “within the house of radiology” improves our chances of positively advocating for our profession and preventing further reimbursement cuts. I personally don’t buy this argument, as it is possible to politically organize with diagnostic radiologists on common issues but still practice in an independent fashion in the clinical marketplace. See radiation oncology as a prime example of this thought in action.

Before you call for my removal from the SIR (I should probably renew my membership…oops), I want to make one thing abundantly clear: our business relationship with diagnostic radiologists needs to be divorced from our educational up-bringing. What do I mean by that? In a nutshell, radiology is an important tool for us to perform our minimally invasive procedures, but in the marketplace our financial goals and objectives are simply not aligned with those of diagnostic radiologists. Let’s break it down further for clarification:

What gives us a leg up over our endovascular competition is our foundation in diagnostic radiology. The training we receive in imaging anatomy is an essential component of who we are and is a true value-add for patients. If anything, I think the pendulum has probably swung a bit too far away from diagnostic radiology training because it really is important. I love that I have the imaging knowledge that I do and I can use it every day to make a difference in the lives of people. With that being said, this knowledge is one of several key tools we have, and while we should all be proud of it, we should not hang our hat on this as being the most important. More on this later.

What is our business relationship with diagnostic radiology?

The business model of diagnostic radiology, much like its practice in real life, can be a snooze-fest. It’s very simple in concept and is more or less the same regardless of one’s practice setting: inpatient, outpatient, academic, private etc. The entire premise is obtaining a contract with a healthcare system then servicing the imaging needs of that client. Read, report, repeat, and raise hell when reimbursement is cut.

How interventional radiology plays a role is by serving as an anchor for this contract. By offering “interventional services,” a group is committing significant resources to their client and more or less proving their worth and preventing some teleradiology service from stealing their lucrative imaging contract.  Generally, this involves providing this valuable on-site service at low to no-cost. And since these services we provide, the wonderful “bread and butter” IR Hospitalist level work of which 90% of which is true trash collection in most community and academic settings, is reimbursed quite poorly as if it were akin to diagnostic imaging “procedures” most interventional radiologists are at a competitive disadvantage to their diagnostic radiology colleagues when practicing together. Interventional radiologists are largely subsidized by the professional revenue generated by their diagnostic imaging colleagues to make the salaries you see and hear about. Our ability to do procedures no one else wants to do and of course the unique life-saving services we offer are dangled like a carrot to the C-suite of large healthcare systems so radiology groups can exist.

This relationship is incredibly toxic as it devalues IR services and does nothing to improve our chances at evolving into a true clinical specialty. Most interventional radiologists who practice in a way such that their outpatient/elective practice drives their revenue generation do so through years of “relationship building” with their diagnostic radiology colleagues who frankly do not share their same interests at heart. This often results in the formation of a few “good groups” where graduates from the better programs in IR tend to flock to. Others are tasked with trying to change cultures which often don’t want to be changed and create systems in places where there is little to no buy-in for the level of service that one wishes to render. Of course, all this “rocking of the boat” comes at the threat of potentially putting that coveted partnership track position at jeopardy. Seeing as most physicians lack the risk-tolerance to be unique, most just put-up and shut-up, eventually getting with the program or perhaps even being part of the problem. Many of these types end up connecting with me, but most don’t make moves. Too risky they say.  The ones who’d rather leave medicine altogether than work in such a ridiculous set-up eventually rip the cord and either create OBLs, join other specialists, or do locums. Some may even write a blog.

Introducing the IR Apologist: A Threat to The Future of Image-Guided Surgery

In order to create a solution to this problem, one has to be cognizant of the devil among us. And that devil is the IR Apologist. There are hundreds of them out there. In fact, I would argue that the majority of SIR constituents, including many but not all in leadership, are IR Apologists.

You see, the IR Apologist is one who benefits disproportionately from their relationship with diagnostic radiology. These are often mid to late career partners in radiology groups who are collecting generous paychecks for largely diagnostic radiology professional fee interpretation with occasional “needle-time.” Some may claim they do great IR work and have real clinics, and I’m sure some do, but they’re still providing their services for peanuts as their diagnostic colleagues totally use them to their advantage.

The IR Apologist also takes the form of the early career IR who enjoys having a mixed practice of DR and IR within the same group. They love being able to hang-up the lead every now and then. This individual often fails to realize that it is difficult if not impossible to “have it all” in the form of being able to practice part-time “high-end” IR and part-time DR with their IR work being nothing more than a majority hospital trash-collection service. Running a clinical practice is a full-time business. Anyone who tells you otherwise isn’t running a real clinical practice.

The most dangerous form of the IR Apologist are the high-powered IR division chiefs and chairs of academic radiology departments. These are individuals, some of whom are well-meaning and talented, who exist within the radiology ecosystem and need to play nice to climb the promotional ladder, even at the minor expense of selling out their fellow and future IR colleagues. You will never see them engaging with this blog, because doing so would be career suicide.

In many ways, I feel sorry for the IR Apologist. While sometimes it’s hard for me to tell if they enjoy burying their head in the sand or if they truly believe that there is nothing wrong with the current state of affairs, I’d like to believe a select few truly understand the issues I raise and realize that they may not directly be part of the ultimate solution, but their trainees will. Contrary to what some may believe, I’m not here to ruin anyone’s promotion. Anonymous Twitter accounts (but are they really anonymous, Derek?) exist for that purpose.

A Reason for Cautious Optimism

In order to move towards a future of image-guided surgery, a primary specialty distinct from diagnostic radiology, it begins with our vision which needs to be implemented with definitive action and supported by the market in which we practice.

So why am I cautiously optimistic?

1. We have made some improvements in recruiting, though we still have work to do

If the vision is to have a clinical practice distinct from diagnostic radiology where we can serve as a primary referral source for our fellow physicians across a variety of specialties and service patients directly via marketing endeavors, we need to get clinical. We are nowhere close to being clinical.

Having a clinical service is taxing. It is hard. It is messy. E&M revenue generation can be sizable, but it is significantly harder to generate than it is to rip off a bunch of non-contrast head CTs from “the list.” In order to live this life, you have to truly believe in it and want it.

The type of person to do this is not someone who would otherwise want to be a diagnostic radiologist. Radiologists enjoy working less, not more, and smarter, not harder. Running a clinical service is the opposite of this life.

Part of my optimism for our future rests in the fact that every year there are a few more people entering our field who would have otherwise done something surgical in nature. While some would like to believe that there are many of these people entering our field, I don’t think that’s actually the case as most still drawn to IR would be content doing diagnostic radiology. And while there are some within this cohort who can (and historically have) created fantastic clinical practices, the likelihood of finding someone interested in that life from this group is much smaller than it is from one who may otherwise be interested in a surgical existence. I believe if we rebranded ourselves distinct from radiology we could be more successful attracting the right people to our field.

2.  The market is changing as we speak

The late-career IR Apologist has had no qualms with selling out their practice to a private equity buyer so they can enjoy their millions in buy-out money and a five-year path to retirement where they will have even more opportunity to work on that short-game than their current 16 weeks of vacation currently affords them.  

The beauty of private equity acquisitions of radiology practices is it has destroyed radiology groups in many settings. With partners no longer being emotionally invested in the success of their business, salaries being gutted to promote profit generation for the big-box firms, and the subsequent extreme difficulty in hiring quality radiologists without frankly catfishing them in the recruitment process, these groups are experiencing some negative feedback from their hospital-system clients with some even splitting their DR and IR service contracts. This in turn is opening up more opportunities for the enterprising IR interested in a full-fledged clinical practice to fulfill a market need.

3. The internet

The internet and social media have made our world more interconnected than it ever has been.  While this can result in some truly vitriolic exchanges and make me reach for Zofran when I look at certain attention-seeking “TwittIR” cases, it has also resulted in like-minded people reaching out to one another for support and to develop meaningful connections. There is a sizable group of IRs out there who are interested in being more clinical and practicing independently. I’m convinced this group will continue to grow in number over the course of the next five to ten years. As this group grows, we have to support each other because this is the only way we can create a better tomorrow.

Conclusion

It is incredibly frustrating to realize that many of our fellow IRs may not share our vision for clinical excellence. As biting as this commentary may have been, I feel it is important because everyone should realize the difficult environment in which we exist. Yes, the IR Apologist is real, but do not let this creature stop you from achieving your dream, because at the end of the day, our biggest enemy is not other specialists, it is our fellow radiologists. I encourage everyone interested in a brighter tomorrow to rip that cord and create your own existence. There’s a great chance you will be forever happier for doing so.