Time is going by way too fast. I blink, and the next thing you know, we’re two months removed from SIR, and I am scrambling to prepare for OEIS 2023 this week in Orlando, FL. Life has been extremely busy with no shortage of work and other professional activities, which have kept me on airplanes, deprived me of sleep, and gotten in the way of writing on this blog. I have several longer articles planned for the blog, but instead of chipping away at those and dumping massive posts at once, I decided to do something different this time and get some thoughts on paper.
It has been a year since I wrote about the IR Hospitalist—the wonderful dual identity rockstar: simultaneous hospital MVP and glorified trash collector. I’ve said trash collector so much that it has seemed to have caught on. What I love about the concept of a trash collector is it makes certain people upset. And I love it when people get upset for a really stupid reason.
Recently, I was tagged in a Twitter post with the #trashcollection that stirred up some interesting commentary and usual virtue-signaling. I’ll post the image here for you:
I love this exchange. To me, this is vintage #trashcollection. It’s just way too good. It’s so good that I commented that it needs to be a classic case on an IR Oral Boards exam. Anyone who has worked in a community IR setting is quite familiar with the classic nurse page to IR attending about a pending consult for a patient. I don’t know what’s trashier than a hospitalist having their nurse page the IR attending about a consult for a patient. Well, there were the half dozen times in Minnesota where the HUC paged me. And please, before you cancel me, this isn’t disparaging other healthcare professionals. What makes this a prime example of trash collection is that the hospitalist doesn’t feel it is essential to have a physician-to-physician discussion with the interventional radiologist regarding this particular patient. It’s almost akin to having the nurse call down to figure out the timing of the CT or MRI for this patient. And if you think about it, it all makes sense because of “radiology.” In this text exchange, there may have been some element of “shooting the messenger,” but you know what? I get where this IR is coming from because I’ve been there before, and it’s insulting to be treated like dirt.
Trash Collection is not a derogatory descriptor. It is not being negative about a profession we love. It is how I view what has become the total commoditization of our field, much like the field of diagnostic radiology. The only way to save interventional radiology is to say no to this commoditization and redirect our energy towards advancing as a field. This involves 1.) rebranding, 2.) recruiting the right people, and 3.) improving our skills as clinical specialists.
More on that action plan for another day. I was again reminded of the future of our field when a 5-year-old discussion regarding pseudo-exclusive contracts (PECs) resurfaced on the SIR Connect forums (Elephant in the Room post for the 60% of you IRs who are dues-paying SIR members) with the results of a recently published survey. Here is the abstract:
Here are the highlights:
First and foremost, thanks to the authors for executing this project and publishing on this important topic near and dear to my heart. Long-time readers of this blog know that I’ve written about how I’ve applied for hospital privileges and have been rejected based on these PECs. The research shows that radiology practice leaders are clearly worried about the impact on their bottom line with independent IRs coming into the hospital. However, little do they know the most significant competitors for independent IRs are medical and surgical subspecialists. There are very few (if any) of us independent IR with office interventional suites who care to partake in diagnostic reads, the primary source of revenue for any radiology group, which often dangles the interventional radiology services for hospital administrators to maintain the contract.
However, the research clarifies that those hospital-based interventional radiologists value sharing hospital IR duties with outsiders. That is a fair point, provided the interventional radiologist seeking privileges intends to use hospital interventional radiology resources. If the goal of the independent IR is to have admitting privileges so they can operate within an OBL, then one’s participation in hospital IR services is probably less relevant.
The truth is the discussion regarding PECs has more or less been “ear-muffed” by most IRs because they aren’t affected by these issues, which are almost professional life-or-death matters to people like myself or people who I view as mentors who dealt with this over twenty years ago. I’m unsure what’s more telling than this research endeavor’s 11% response rate. Furthermore, those who are adamant about the removal of PECs tend to be loud and proud (for good reasons, I believe), and it has likely been offputting for most of the field who work in hospital settings and don’t share these same concerns.
The SIR conveniently posted an updated position statement about PECs which you can read here. While I think it’s excellent that the SIR has taken a strong stance on this, I find it troublesome that it has taken over 15 years for this to happen, seeing that the original luke-warm statement was produced in 2007. Opinions regarding independent IR practice evolve as diagnostic and interventional radiology fields diverge. I firmly believe that even if PECs were somehow eliminated, it wouldn’t solve our primary problem about culture and identity. See my action plan above for the actual fix. I’ll be doing a deep dive on this soon.
I am ending this post by addressing a recent question in an article I posted in December about finding the right job out of training.
First, thanks to RP for the compliment and for posting this question. My answer brings us back to the concept of Trash Collection. Trash has nothing to do with being pessimistic about the IR skillset. Contrary to popular belief, it also has nothing to do with how “big” or “complex” the type of IR work being performed is. It has everything to do with commoditization and, in many ways, clinical autonomy. What RP is describing here is a high-end trash collection. The telling sentence is, “Pts followed up by IRs in the recovery area without a dedicated clinic.” This is an example of a common hospital-based IR practice that engages in a “you pick em’ we stick em’” practice pattern with no clinic and likely a rudimentary or absent inpatient consultative service. The fact that the practice worries about losing referrals has nothing to do with the relatively inefficient professional fees collected by these hospital IR cases. It has everything to do with pissing off the referring medical and surgical subspecialists and making hospital administrators mad, which may jeopardize one’s commoditized imaging contract. The most important metric for evaluating any future job opportunity should not be the types of cases or the percent IR being performed; it should be the presence of a meaningful IR clinic. The problem is, when one doesn’t have a great alternative in their market, what should you do?
That’s the tricky question, RP and I don’t have a great answer other than leave that market and find a better job in a different market. Suppose you have to stay in this particular market and don’t have a decent academic or OBL/ASC option available. In that case, you may need to take this job and try to build some small clinical presence, fully knowing that the sustainability of this practice in a culture that doesn’t value this type of service will be slim. How do I know that will be the case? See the image below.
Once upon a time, I tried changing a culture that didn’t want to be changed. I’d say about a 10 on the X-axis and a corresponding 10 on the Y-axis. That’s when I started writing this blog.
The good news is that we all need to start somewhere, and our first job will unlikely be our last. Any experience can be leveraged into something better. Those serious about endovascular and interventional surgery (not interventional radiology) can likely steer you in the right direction. So to RP, please reach out, and let’s chat privately to see if we can get you set in the right direction.
Thanks to everyone for checking out this shorter-than-average post. Looking forward to writing more soon. For those of you going to OEIS in Orlando later this week, looking forward to catching up with you there.