The IR Startup

If you’ve made it to this point in the blog, you’ve now heard about all the problems facing interventional radiologists. To your pleasure, or chagrin, I have gone out of my way to eloquently (or not so eloquently) highlight significant shortcomings with our field in an effort to stimulate discussion and identify exactly what needs to be fixed. No, the “roof isn’t burning” and no, I’m not trying to incite a riot. I just want readers to realize what the current situation is like through the lens of someone who is living it. I’m not the only one by the way. There are many others who talk to me privately who would rather not have their names out there for fear of all sorts of repercussions. I am in a unique position, by hard work and choice, where I do not fear any such repercussions.  I will speak the truth, in a respectful fashion, always. Whether or not it resonates with you is your problem, not mine. 

Some of my recent posts have been met with a lot of praise. I’ve heard very kind words from attending physicians young and old in addition to trainees. In fact, some academics liked what I had to say. Some even said that my post should be “required reading for everyone in training.” One of the private practice members in the SIR even suggested that this article be printed in IR Quarterly. I have yet to hear back from the SIR. I can’t say I’m necessarily shocked, though I would be glad to work with the SIR on this. 

I’ve also had several people who really did not like what I had to say. One particular academic luminary thinks I’m being too negative and that I should spend more time promoting positive messages. This individual thinks my problems are not unique or really noteworthy, brushing off my writings as jaded and trite “early career problems.”  Program directors and IR education advocates think I am literally scaring off potential strong recruits to our field. Personally, I think the truth scares them. 

I would like to kindly remind everyone out there, both supporters and people who would rather have me silenced, a brief history lesson with respect to both me and this blog. 

I never wanted to be a radiologist. My story began as a medical student interested in psychiatry. I had very strong mentorship throughout medical school and was very academically productive. It wasn’t until my psychiatry rotation which I saved for the last rotation of medical school when I realized that what I enjoyed from the research side did not necessarily translate to the clinical practice of psychiatry. I was at a total loss. It wasn’t until I did a radiology rotation in September of my fourth year where I met the most badass interventional neuroradiologist who was so personable, engaging, humble and brilliant. Seeing him coil aneurysms, treat strokes, see patients on the floor, longitudinally in clinic and read imaging like a boss was one of the most inspiring things I have ever witnessed. I knew from that moment that in some form or fashion, image-guided procedural medicine is where I needed to be. This was and to this day remains the future. 

I chose radiology because I saw this as a path to where I wanted to be in terms of becoming an interventiontionalist. I wanted to combine clinical medicine with image-guided procedures to provide truly state-of-the-art comprehensive care much like the physician I worked with as a student.  In residency I decided to pursue IR because to me it seemed more practical in terms of career opportunities than NIR, and I loved the variety it offered. The IRs at the county hospital where I rotated played a huge role in molding me. My overall training experience was far from perfect but was overall very positive as I solidified some of the great theoretical IR knowledge and overall amazing DR experience I received from some big names in residency with practical hands-on work from some terrific fellowship faculty. 

During my time as a trainee, I learned that while I enjoy doing research, my heart is set on direct patient care. I knew that my clinical training overall was lacking, but do not conflate this for a condemnation of my training or those who worked hard to train me. It was simply a reflection of the time where the IR residency was just beginning and programs had not fully adapted to this new paradigm. I chose private practice because I knew I wanted to build something for myself and others. I really became disenchanted with the politics of academics despite my love for teaching and research. 

You see, no one ever told me about the critical roadblocks which make clinical practice development a significant challenge in many traditional practices. I simply thought I could show up and through hard, honest work achieve my dream of developing a true clinical practice.  No one ever taught me financial drivers of a radiology practice. No one ever taught me how to really build a practice. No one taught me about the infrastructure required for a clinic.  I had no clue what a “good group” should look like. I had no clue what an OBL was. I certainly had no idea what pseudoexclusive contracts were. I think I was like most young graduates: pretty naive and following the crowd in terms of trying to find a good job where I could do “big cases,” make some money, and enjoy some time off. I thought that my skills and drive to do good work would make my colleagues happy because I would be filling a need they currently weren’t filling. 

Turns out that I had plenty of time off, got to do some “big cases” and made decent money. But I was still not happy. The reason being is I did not have the freedom to build my practice as I wished. Namely, I could not get the support of my group to build a real clinic, including the senior IR partner in my group who simply did not believe in this model. And in retrospect, the rad group was not to blame because they are simply running a business and given the size of the group this would come at the cost of me not generating significant revenue for the practice in the short to intermediate term since it takes time and money to build a truly robust practice. Nevertheless, I was furious. I was so upset when my senior partner told me to justify a clinic through demonstrating the volume of “big cases” it could generate, which I did when I started doing those cases regularly, but my hopes for a clinic still did not come to fruition. I was stuck seeing patients in an MRI holding bay for eternity, all at my own personal time and expense. I was chastised for spending more time doing a fair number of complex PAE and CLI cases when I should have apparently been tending to the list and taking care of the never ending stream of paracentesis patients.  I just saw no future for myself in this setting where I was working long hours to prove my existence in a setting which didn’t care for it. There was no amount of money that would make this arrangement remotely acceptable to me.  In 2019 I was so miserable that I went on to the SIR Connect forum and I wrote this tome in response to a post asking what the private practice committee can do to support IRs:

After I made this post, two people reached out to me. I am so thankful to both of them to this day for guiding me in the right direction. One person in particular has made all the difference for me in terms of my overall career trajectory by introducing me to the OBL concept and truly advocating for me as I march along this scenic road of independent practice. 

I started writing to clear my head. I needed a healthy way to channel my frustration into something productive. It became my mission to make sure every IR graduate and future trainee starts their journey with their eyes wide open. I decided to chronicle my entry into independent IR practice because believe it or not these are relatively uncharted waters for a large proportion of our field, especially someone in their early career. I feel a sense of purpose guiding others so they can do better and pass on their knowledge to the ones coming up behind them. This is how we improve and grow as a field. I do this publicly on my independent platform because I want this knowledge to not only be readily accessible, but I want it to be on my terms with my unique voice. I don’t want to be beholden to any political organization.  If you don’t like what I have to say then that’s fine. We can talk about it respectfully and likely come to some degree of mutual understanding. A lot of us want the same thing, but maybe have different approaches for achieving it. 

Over the last couple years I have left a radiology group, helped build an OBL from the ground-up, left the OBL after a failed partnership and started locums work as a bridge while my spouse finishes fellowship training. In the process I became intimately familiar with practice building, hospital contracts, business ownership, human resources, revenue cycle management, managerial services organizations, private equity, business partnerships, leadership skills, multidisciplinary collaboration, personal finance, real estate investing and more. I am not an expert in any of the above, but I truly believe I have learned more from making bold choices than most physicians of my vintage. I have crafted an existence to practice IR and DR on my own terms and when the time is right, I will finally work on developing the long term clinical practice I crave with the goal of creating meaningful opportunities for future IRs. 

What hasn’t changed one bit is my passion and love for interventional radiology. The reason I write what I write is because my goal is to create a real-time roadmap for IRs to develop their own clinical practices. I want to see our field prosper because this is the best field in medicine. I don’t want it to be a secret. I want it to thrive. If I didn’t care, I wouldn’t go out of my way to write these posts, pay money out of my pocket to host a website and spend significant time engaging with so many people on a daily basis. My writing is leading to the development of a community of like-minded individuals.  In many ways, this may be what I was meant to build all along. 

Why should you develop a clinical practice? First, if you are a practicing IR already, I am likely not going to change your mind. If you enjoy traditional IR/DR private practice, I truly am happy for you and I wish you well on that path, even to that senior partner who upset me so much and brought out the worst in me. I just don’t think this model is our future.

I would like to show you an excerpt from a blog post I wrote over a year ago. To me, this is why clinical practices matter:

When approached the right way, interventional radiology has the potential to be a very fulfilling field. It blends medicine, procedures, and imaging. We have the potential to build long lasting relationships with both our patients and our referring physician colleagues. The other day I received a call from one of my chronic DVT patients on whom I performed an iliac vein recanalization a year ago. He called to follow-up on his ultrasound scheduling and to check in as I had instructed him to do. Hearing about his progress and how his life has improved reminded me of why I sacrificed so much to become a physician. These small reminders are what keep you going despite all the noise and obstacles we as physicians have to overcome. If I didn’t do a formal consultation, formal rounds and clinic visits with this patient, what value am I adding beyond someone who simply does what they are told (which was a request for an IVC filter)? I now have a patient who trusts me as an expert in venous thromboembolism and a referring physician who knows that I care about what I do and will send me patients down the road. 

I should add that this same patient still keeps in touch with me today. In fact, every patient I have ever seen in the clinic has my personal cell phone number. I get many notices about birthdays, special occasions and in some cases sadly, even funeral arrangements. They check in on me and miss “their doctor.” Having built a respectable clinical presence in one market only to leave was truly a gut-wrenching experience because when you develop these bonds with people, it’s not easy leaving. Simply put, more than slick technical feats of excellence, money or whatever notoriety I may have developed from furiously typing away on this laptop, being clinically focused and providing longitudinal care has brought the most meaning to my professional life. Some of these encounters in the clinic are just so special that in those moments you simply forget about all the crap on the outside and just take pride in what we can do for our fellow humans on a daily basis. 

I want to show future interventional radiologists how to build clinical practices which can be sustainable and truly advance our field forward. There are some tremendous IRs out there who have done this in their respective practices and they should be applauded and highlighted as models of success. Yes, there are key structural problems in our field which make this very difficult from happening in every location and in every practice setting. These structural inequities get me so fired up because I experienced them first hand. I would be totally lying to you if I didn’t tell you that the job market has not caught up to the new training paradigm and likely won’t for a while. I bring up these challenges to raise awareness and promote fruitful discussion. I do not want trainees to be deceived much like I felt like I was deceived and gaslit which continues to this day. The deception is not purely the fault of academics, because they exist in their own bubble, and to many of them private practice is simply about “making money.” Newsflash: it isn’t. Private practice is an avenue to practice medicine on your own terms. 

What many do not seem to understand is that for over 50 years into its existence, IR continues to operate like a startup company. The end product currently being produced is the new IR residency graduate trained to manage multiple disease states using a unique combination of clinical medicine, imaging interpretation, and image-guided procedures. Central to the success of this model is the ability to longitudinally bridge inpatient and outpatient care via IR clinic. 

In the early to mid 2000s, a few academic radiology training programs established prototype IR residencies, then known as the Clinical and DIRECT pathways, which went largely unsubscribed and failed to gain widespread adoption. Later, an IR only primary residency was proposed but rejected by the ABMS, with the subsequent redesigned IR/DR certificate gaining ABMS approval with the blessings of the ABR and other stakeholder professional societies. This pathway is now the standard for IR training, with the sunset of the traditional fellowship in June 2020. 

Before the IR Residency model can be successful at scale, it needs significant investment to avoid succumbing to the “valley of death,” which refers to a prolonged period of financial loss as the business develops. In the start-up world, investment is usually in the form of money from venture capitalists or institutions. In the IR world, this investment has to be in the form of time capital from both academic and private practice IR visionaries, support from relevant professional societies, and personal investment by IR trainees who need to have a personal vision and purpose for clinically oriented IR. 

In this analogy, while not perfect, the profit/loss on the Y axis can be considered the number of interventional radiologists practicing in a truly clinical fashion. We are currently in early product launch and are entering the valley of death. What is happening is young graduates and trainees are out here realizing the truth about the job market and understand that their training may not translate to a clinically meaningful practice in many settings. In Silicon Valley parlance there is no product-market fit. We are at a critical juncture in our IR start-up. Will there be the investment necessary to bridge us to a sustainable growth phase? Or will we have to keep pivoting to remain viable?

This analogy also applies on the individual IR level. To be successful at practicing in a clinical fashion, you have to either join an existing practice which functions in this model, or you have to build this for yourself. Since there are way too few of these practices out there to meet the future demand of new interventional radiologists, these practices need to be built. Your research and development will consist of things like understanding politics and power dynamics in any given setting. Figuring out HR and staffing concerns. Knowing the economic model in which you practice and whether or not clinical work will be incentivized. If not, how can you develop a business plan to show profitability? This all is part of the homework. Developing the clinic is the product launch. Will you and your practice partners invest in the development of this clinical practice to get to a point of sustainable growth?

At the current stage of our existence, attrition is to be expected. The challenges are many, and the opportunity cost of a career in a competing organ-based specialty which functions more like a mature enterprise, or a tried and true model of stability in hospital based IR/DR are quite high, relatively speaking.  You can blame me all you want, but for me describing my thoughts about the most common IR practice pattern as the cause for trainee and early career attrition is ignorant of the global picture of structural inequities in IR practice, which suggests that there will be many future Line Monkeys much smarter than the original Line Monkey who will be quick to highlight the problems with our field. In fact, 25 years before me were a couple true Line Gorillas who felt so abandoned by their own professional society that they created their own. How are we going to let this story play out? Are we going to collectively support these individuals with a clinical passion or are we going to let them continue to figure it out on their own while we collectively bury our heads in the sand?

Our goal isn’t just to attract the best and the brightest, but it is to attract the students who want this existence so badly that they will develop the other necessary skills with respect to leadership and business development to help guide us to this future of IR practice which will be built to scale. 

So how do we build this future? The broad roadmap is as follows:

1. Recruitment
2. Clinical, Business, and Leadership Training
3. Infrastructure Development
4. Mentorship and Sponsorship

To this point we have done a tremendous job recruiting some really good applicants to interventional radiology. The medical student symposia are very well-structured and have created serious hype. I’ve seen some of these symposia and even I get super pumped about a future of clinically oriented interventional radiology. Interventional radiology is suddenly just as competitive as plastic surgery and dermatology. 10 years ago this field had to beg people to pick IR as a fellowship. It’s amazing how things have changed. Not fully aware of the existing challenges, students are buying overpriced stock in a hot tech startup that is lacking the fundamentals necessary for sustainable growth. The market is due for a correction.

What hasn’t changed is the reality of practice patterns in many settings which are fundamentally rooted in our diagnostic radiology centric business arrangements. What also hasn’t changed is our professional society which is slow to acknowledge the issues which are real. I believe myself and others have sounded the alarm, but change in any large bureaucratic organization is super slow. This is especially the case considering the vast majority of its constituents are fine with the traditional model of IR/DR practice. The senior academic IR who called me this past Wednesday encouraged me to be “evolutionary not revolutionary.” But these two concepts are not mutually exclusive. We need to be both revolutionary and evolutionary to right the ship and create durable change. Right now, we need to be revolutionary, much like transforming our training paradigm was revolutionary compared to the failed evolutionary efforts which preceded it. Bold change requires bold action. Without such, the startup will fail. This doesn’t mean we’re all going to be jobless. Rather, it means that the current status quo of IR/DR practice will persist, and many ambitious clinical IRs will feel very frustrated by the glass cage environment in which they are forced to practice. Some will break the mold, but not without receiving external criticism or even being ostracized for doing so. 

Regardless of the institutional concerns which are complex, nuanced and wrapped up in a miasma of shady political motivations, every market will always have inefficiencies. Part of my goal is to show trainees how to exploit these inefficiencies to create their clinical practice regardless of what our society is or isn’t doing to change things globally. It involves creative and unconventional methods utilizing all of their skills to their maximum potential. Until key structural considerations change in the IR world, which they likely won’t for a long time if ever, we will continue to jump through hoops to achieve this dream. I and others before me have jumped through those hoops. My next step on this blog is to show you how to do so. Yes, part of this means highlighting stories of success, but to be honest means sharing some failures, as well. I will not stop writing about or speaking about the challenges because to ignore this would be very disingenuous of me.

To the medical students, if the challenges I mention scare you and the established pathways of practicing a mix of IR and DR or pursuing an academic path does not excite you, then this may not be the right field for you. If you are excited about the possibility of shaping the course of an entire medical specialty, working with like-minded individuals to accomplish this goal, and developing a meaningful clinical practice which will keep you fulfilled for decades, then this field is indeed for you. In fact, it’s a unique opportunity to get in “on the ground floor” of a field which is working hard to transform from fledgling start-up to mature enterprise. We are still in the very early innings of this ballgame. I would apologize for my viral post, but I’m not sorry one bit. You need to do your due diligence and figure out for yourself if you want to make this investment. I’m convinced that the returns could be outsized, but it is not a passive investment and there certainly is no guarantee.  Please read all my posts and not just the one that went viral so you can understand exactly where I’m coming from. Talk with others and draw your own conclusion.

I’d like to thank the talented Elie Balesh, MD for helping me collect my thoughts so I can bring them to you in a more coherent fashion. One of the great things about IR is we have some truly awesome people willing to help you out when you need it.