The IR Hospitalist Revisited: A Closer Look at Our Identity

I think like most of us who are Society of Interventional Radiology dues paying members, we are greeted each morning by email alerts showing us recent activity in the SIR Connect forums. I couldn’t help but notice an announcement for an ACIR (Association of IR Chiefs for those not in the know) webinar titled IR Hospitalist and Weekend IR: Controversy or Future Subspecialization.

I didn’t make much of it at that time, but my phone started to blow up with some text messages. Dude they’re appropriating your blog post! Not to name any names, but it’s not the first time the society has taken something en vogue at the time and have used it for their own programming. Needless to say, I truly wasn’t aware of the term “IR Hospitalist” before my blog post. In fact, this term in my life came up when I was lamenting about our existence with one of my senior colleagues. Specifically, we were talking about how miserable one of the internal medicine hospitalists makes us feel when she calls us routinely at 8 PM on a Friday for a paracentesis.

Well it turns out that I am not the first person to use the term IR Hospitalist. In fact, I have been told by one of my mentors that the term originates from a talk given by Dr. Muneeb Ahmed of Beth Israel Deaconess Medical Center several years ago.  So, credit to Dr. Ahmed for first using this term, perhaps in a somewhat different fashion than I did for my blog post. The IR Hospitalist is a position that some divisions have created, or are creating, in an effort to deal with the staffing challenges of a busy hospital service. The upcoming ACIR webinar is meant to discuss this role in the context of hospitals facing staffing challenges. Of course, the timing of the discussion and the title with the use of the word “controversy” is still somewhat suspect in my mind, but I’ll let that go for now.

I’m pretty sure that every IR who works in a hospital setting knows that servicing the needs of the hospital can be downright exhausting. It can feel like a total slap in the face to spend your day treating scheduled outpatients only to contend with eight “IR-lite” add-on cases leaving you and your team with a very late night, of course not mentioning the traumas, pulmonary emboli or GI bleed consults which can fall on your lap at any time. As I tell all trainees and students, IR is not a lifestyle specialty. It is not, never has, and never will be meant to be, “like surgery but with a better lifestyle.”

The concept of the IR Hospitalist is a shift-based position which exists for the sole purpose of dealing with the needs of the busy hospital setting. Imagine if you had a dedicated IR to deal with all the add-ons. All the great things that perhaps you would not want to deal with after a long day doing outpatient clinic driven work: drainage procedures, venous access, acute hemorrhage, venous thromboembolism and more. The IR Hospitalist in essence is a 1.0 FTE simultaneous trash collector and hospital MVP.

Imagine a position like this, maybe it involves a week on with 24/7 call coverage, perhaps at multiple hospitals simultaneously, followed by a week off. When you think about it, it’s not actually that unique seeing as many of us practicing in the community setting work on a rotating call schedule doing what would be expected of the IR hospitalist. In fact, I’d contend that the majority of interventional radiologists are in fact IR Hospitalists as they lack robust outpatient clinics. Of course, this type of position strikes close to home for me as a 100% IR locums physician. As I’m writing this I’m currently coming off of 14 days of consecutive hospital call. I’ve done some very interesting and challenging cases during this stretch including multiple embolizations, venous thromboembolism cases and vertebral augmentations in addition to four to five times as many bread and butter type cases.

Who in the world would want a job like this? Well, everybody has their price and there is something to be said for being a busy hospital monkey. I think doing a high volume of work can be very beneficial, such as for physicians like myself who are early in their career. The ability to do a high volume of work, some of which is complex, helps develop procedural skills and efficiency. Some of the most interesting and challenging cases occur in the hospital setting and can literally come out of nowhere. Nothing teaches you better than experience and there is no better learning than just getting your hands dirty. The ability to work like an emergency medicine physician, hospitalist, or anesthesiologist with shift work can potentially help one achieve a better work-life balance. Clearly the ability to take care of patients in a timely fashion helps the hospital with reduced length of stays and most certainly is better for patients. This work makes any hospital IR division look like responsive, responsible physicians who care about patients and may help the other IR physicians build the overall practice.

Fundamentally, I think it’s important to step back and ask why we are here even talking about the IR Hospitalist. Personally, I think we as IRs have been pigeonholed into doing a variety of procedures that we should not even be wasting our time with. Sorry, but I didn’t spend 6 years of post-graduate training to stick a tube down a patient’s nose or put a needle in a sea of fluid particularly when these can be done by other physicians, or even non-physicians for that matter.  I sure didn’t plan on being a Line Monkey placing non-tunneled central venous catheters for ICU patients who could have these procedures done at the bedside by the intensivist. Of course, doing all this to then be told by some diagnostic radiologist that “this is the life you signed up for, just accept it, oh and by the way can you also read these studies on the list?” The disconnect here is that there are some departments who do not engage in this type of work or necessarily have this degree of negative energy with their diagnostic colleagues, or are even under the financial structure of radiology, but they are the minority and tend to be the ones talking about this new paradigm of IR Hospitalist work. While likely not intentional, it does reek of some level of elitism and more broadly speaking a false sense of reality for the vast majority artificially stuck in IR 1.0. 

Let’s think broadly for a second.  Who are we as interventional radiologists? Are we radiologists who happen to do procedures? Or are we a different beast all-together? These are great questions. Dr. Eric Keller, a Stanford IR resident, has explored this topic in key research papers, as a medical student. Please read his original work from 2017 and the subsequent commentary in 2018.  Talk about a great synergy between a bright and motivated medical student with terrific forward-thinking mentorship in Dr. Vogelzang at Northwestern. I think some in our community tend to discount the importance of qualitative research, which is a shame because we cannot chart our course unless we have a clear understanding of who we are collectively speaking.

The study identified three distinct interventional radiology “developmental pathways” among trainees they interviewed:

Radiologic Surgeon

Surgical Radiologist

Clinical Proceduralist

	Radiologic Surgeons	Surgical Radiologists	Clinical Proceduralists
Early interests	Surgical field, e.g., “I always thought I was going to be an … surgeon….”	Computer science, engineering, diagnostic radiology	Many different fields, clinical medicine, e.g., “I liked everything but tended to like medicine a bit more than surgery….”
Core values	Fixing problems, working with hands	Technology, knowing something about everything	Connecting with people, improving patients’ lives
Driving force towards IR	Avoidance of surgical lifestyle or personalities	Patient interactions, getting to “do” things and work with my hands	Being able to intervene procedurally as well as clinically
View of DR	A tool or means to an ends	A key part of my professional identity and what I want to do	A tool or means to an ends
Description of patient interactions	“Interesting cases,” focusing on procedural innovation and technique	“Interesting cases,” focusing on pathology, imaging, and technology	“Interesting patients,” focusing on symptom resolution and effect on patient’s life
View of future of IR	Need to be separate from DR and be more clinical like a surgeon	Need to remain closely tied to DR, strong DR training is imperative to be a good IR	Need to be more clinical, round on patients, see them in clinic, and take full responsibility for our patients

The radiologic surgeon is someone who is surgically minded who uses imaging as a tool to care for patients.

The surgical radiologist is basically a radiologist who likes doing procedures. This probably encompasses most current practicing interventional radiologists as these were individuals who chose interventional radiology as a fellowship after diagnostic radiology residency.

The clinical proceduralist is someone who thinks broadly and deeply about patients, much like an internist, and happens to do procedures to treat patients.

I’d contend that the challenge for many young interventional radiologists early in their career is practicing in a field which lacks a distinct identity and has a complicated relationship with its parent specialty while being trained in a somewhat immature paradigm which does not quite reflect the reality of most current practice settings. Even among trainees and young attendings, our perception of who we are varies quite widely. I would contend that many who disagree with my overall perception of hospital IR is because they simply have a different perception of their professional identity than I do. Particularly, these individuals may happen to identify as surgical radiologists.  

I can’t speak for older radiologists or perhaps a fair number even in my generation, but I would contend that a sizeable proportion of younger IRs, particularly those in training with the new IR/DR residency paradigm, most likely view themselves less like radiologists and more like surgeons. In Eric’s work, of 28 fellows who participated, 19 identified radiologic surgeons, 6 as surgical radiologists, and 3 as clinical proceduralists. Of course, this is a relatively small sample size, but I think there is something to be said for a trend towards more surgical-type thinking in IR. I would think things have certainly changed even more so towards the surgical direction in the last 5 years since this work was published. It would be interesting to repeat this analysis today.

Personally speaking, imaging is simply a tool that I use to do my job which is taking care of patients. I spend my time more focused on learning about and treating disease states. Diagnostic imaging is a tool for me to take care of my patients and a way for me to create financial freedom so I can focus on my entrepreneurial passions. I’m fundamentally a clinical proceduralist who is transitioning into a radiologic surgeon as this mentality is essential for my chosen path of independent IR practice. When somebody asks me what I do for a living, this is what I tell them:

I am an image-guided surgeon working through tiny pinholes in the skin. I take care of patients with blocked arteries in the legs, men who have trouble urinating, women who have heavy or painful periods, and patients with vein problems.  

That’s my elevator pitch and those are my chosen niches. When I tell my patients that I’m a “surgeon” most know I work in a clinic-based fashion with longitudinal follow-up.  I do not go down some rabbit-hole about “radiology” or “interventional.” Nobody knows what that is, nor do they care. You tell someone you’re a radiologist and they’re likely to tell you about their cousin who enrolled part-time in some radiologic technologist classes at the local community college. Or they may confuse it for radiation cancer treatment. I’ve had many such conversations while getting a haircut.  

I strongly believe that our field should involve clinical service lines focused on the longitudinal care of patients. Whether or not you do this as a surgical radiologist, radiologic surgeon, or clinical proceduralist is up to you, but I think this goal is essential for our evolution as a field. I’m talking about a future where we are recognized as a field distinct from radiology. While I believe that the surgical mentality is important as we collectively build clinical practices, I think there is room for each of these “phenotypes.”  A lot of what we do in interventional radiology can be done safely and cost efficiently in the outpatient setting and this is the direction I strongly believe we need to collectively head as it is conducive for the development of clinical practices where we can carve out a clear identity. With that being said, there is also beauty and truth in the concept of the IR being “expert generalists” in the hospital setting as I think many of us live that in our professional lives. In many ways, these two ideas of our future shouldn’t be mutually exclusive. 

So, what’s the problem with the IR Hospitalist? This is a position which does not entail the true development of a clinical practice. It’s like an acute care surgeon who deals with the needs of the hospital which are unpredictable, except without a clinic. I think being a good citizen in one’s local medical environment and doing your best to take care of hospital patients is essential, but the only reason people want this position to exist is because they want to ease the call burden and focus on developing their clinical practice which largely involves the treatment of outpatients within the hospital setting. In many ways, the IR Hospitalist in these settings is a true second-class citizen. How can you build a clinic when you’re too busy saving lives and taking out the trash (or putting out fires, or doing “bread and butter” cases, or however it is you perceive this work)? Is that what we want for the future of our wonderful field? I certainly don’t, but maybe you think differently.

Maybe my perception is all wrong and of course every local environment has different needs. Regardless, I look forward to tuning into this webinar, and I encourage you to, as well. Keep the discussion of professional identity in mind, because I think it can go a long way in framing how we discuss these topics with one other.