WCVIS Recap and More

Thanks to those who tuned into the WCVIS Private Practice and OBL panel. Special thanks to the students and residents who worked hard to create a great event. Also, special thanks to the modern-day Dotter/IR Evangelist, Dr. Vatakencherry, who has worked tirelessly to promote a future rooted in sustainable and ethical practice patterns. 

I sincerely appreciate the chance to participate and was excited to have the opportunity to interview some incredible panelists in private practice. This was not your typical symposium panel where we wax poetic about our lives and artificially hype how amazing our field is. Our field is amazing, and our lives are very enriching, but we humans live in a world of imperfection, and it’s fair to say that all of the panelists have faced real challenges in a young medical specialty that is trying to define itself.  I want to recap the session briefly and add my own thoughts to the mix, given the time constraints for the panel discussion. 

The panel consisted of mini Q&As with four private practice IRs, including Dr. Torre Andrews (hospital-based IR/DR radiology private practice group), Dr. Brooke Spencer (Hospital and OBL practice focused on the complex venous disease), Dr. Neal Khurana (Hospital and OBL practice focused on the full gamut of IR including PAD/CLI), and Dr. Ian Wilson (Hospital-based radiology group and OBL independent contractor). 

This was a very unique panel, perhaps as unique as they get when it comes to “IR Private Practice Panels.” During the session, we discussed some tough topics and kept things about as real as possible. Some may have watched a session at this and thought it was perhaps too complex or intimidating, but I’m coming to learn that the average medical student reader of this blog actually has tremendous insight and knows the right questions to ask. My perspective has always been that students need the truth, followed by appropriate guidance. I firmly believe that the average academic interventional radiology environment does not offer them that perspective, largely to no fault of the faculty. It is simply a product of exposure. One only knows what they know and what they have been exposed to. 

80% of our practice is in the “real world.” It’s a world that can be cold and uncaring at times. It’s also a world of limitless potential. I write on this blog and participate in webinars like this because we have so much potential to create meaningful lives for ourselves and improve the health of millions of patients. I want us to tap into that potential and do awesome things. This will not happen unless more people like myself model that change and take tangible action to support the next generation of colleagues who will one day work alongside us in private practice. I’m so thankful to be part of sessions like this, where I can channel that insane fire inside of me and use it to play a small role in creating a better future. 

We started the session with Dr. Torre Andrews, who gave his perspective on the reality of the job market in the most traditional practice pattern: hospital-based IR/DR private practice. The vast majority of physicians in our space practice in this setting. In fact, yours truly spent two years toiling away in this setting. Here are some posts you can refer to to get a sense of how I truly feel regarding this type of practice:

1. A brief overview of the IR job landscape in 2019. I don’t think a ton has changed. 
2. My struggles trying to establish a clinic my first IR/DR group. It didn’t work out. 
3. Me being really pissed off about my group. In this post, I wrote that I’m ambitious, I’m really loud, and I’m going to get shit done. This is prime Line Monkey material.
4. I finally quit that job. Here’s why. 
5. The truth about radiology and its business model. Newsflash: it is in direct conflict with a future of longitudinal clinical care. 
6. The cold truth about hospital-based IR. This was the article that went “IR-viral” and caused my wife to force me to turn off my phone for 48 hours after this post. 
7. I even created The Apologist character to better frame our identity crisis and how it pertains to common practice patterns. 

Dr. Andrews relayed his rich experience working in an IR/DR setting. He laid out the cold hard truth that most hospital-based IR/DR jobs expect a chunk of one’s time to be devoted to diagnostic radiology. We even discussed why, getting somewhat into the weeds of financial drivers of practice, including RVUs. If I had to put our entire mini Q&A into a brief summary, it would be the following:

Typical IR/DR practice in most settings does not allow for a practice pattern defined by longitudinal care and clinical consultation, including robust E&M services and associated rounding. People are out there who actively fight me on this “rhetoric,” but even those of you know practicing in radiology groups doing a high level of clinical work know exactly what I’m talking about. Many of you sacrifice significant time after hours to do the work you otherwise would be doing during the day to meet RVU productivity expectations. The majority of you have your own problems with diagnostic radiologists. Some groups out there permit a true 100% VIR practice pattern with clinics and rounding (because the term 100% VIR without clinic is basically a trash-collector role), but these are far the exception and not the rule. Yet, these radiology group opportunities are the vast majority of jobs available for new graduates. 

At the end of the day, one has to ask themselves if it makes sense to “partner” with diagnostic radiologists. Like any partnership, your mileage will vary depending on the values of each individual partner/group. While some find radiologists who support their vision for longitudinal clinical care, most will not. I personally believe trying to change their minds is an exercise in futility rooted in third-grade math. Buyer beware. 

We started this session by highlighting a huge problem. It’s a problem most IR leaders don’t have a great solution for. It’s a problem rooted in culture (radiology first), training (lack of clinical training), and business (hospital-based RVU production versus time and labor-intensive clinical practice development in both hospital and outpatient settings). How do you fix this problem? You must create a new culture, train people the right way, and concurrently create meaningful opportunities for the next generation. That’s part of the goal with the WCVIS, and I’m actively playing a role in it via this blog and other endeavors. 

We then transitioned to a mini Q&A with Dr. Brooke Spencer. For those who don’t know Dr. Spencer, she’s a big deal in the vein world. You can find more information about her practice here. She has created a practice focused on complex venous disease patients. Our conversation today hopefully made it clear to students that she worked hard to become an expert at a particular disease state. She took that passion and worked over many years to carve out her ideal practice. It takes a particular mindset to do what she has done. She shared some tips for success, including focusing on clinical training and following your passion. Regarding mindset, she recommends the book You Are a Badass by Jen Sincero. I endorse the recommendation.

Having spent significant time around other successful IRs in the private world who have carved out their own outpatient practices, it has become abundantly clear to me disease state expertise and development of patient panels are the most important leverage one can have when it comes to avoiding a future of hospital-based IR within a radiology context. I encourage every reader to read this post about why clinical practice development is so important to our future as a specialty. 

Dr. Spencer also relayed that most people, not just physicians, don’t want to be entrepreneurs. She correctly points out that there are employment opportunities for IRs interested in OBL practices. She is absolutely right; however, I caution readers that many out there are not practicing in this space in a manner that is consistent with the ideals of an ethical practice rooted in legal referral patterns and meaningful longitudinal care.  Please take some time to understand the “Stark Law” and my overview of OBL jobs, having actively looked for these at one point. For the medical student, these posts are probably 400-level content reads, but you’re more than capable of understanding them. Feel free to post questions or contact me if you need more information/clarification. For those who choose to go down the path of OBL employment, I encourage working with other physicians who own and operate their practices. In this article, you can read my take on coming up with a financial plan for this scenario. 

We then transitioned to Dr. Neal Khurana, an early career IR partner in a multidisciplinary OBL and hospital-based private practice with a vascular surgeon. You can read more about their practice here.  Dr. Khurana has had an interesting path in that he has spent his entire career thus far working within vascular-heavy 100% VIR practices with longitudinal clinics. We discussed the importance of seeking the right training with a clinic-first mentality. Like Dr. Spencer, Dr. Khurana has a robust outpatient clinic which is the economic engine for his dynamic practice. 

Dr. Khurana has made the leap into practice ownership and carved out a tremendous presence relatively quickly. Having had the chance to get to know him and his vascular surgery partner, Dr. Laurich, I know these guys are modeling what multi-disciplinary vascular practices should look like. Please check out this BackTable podcast episode for more details about their practice. 

As someone who once created a multi-disciplinary OBL practice with a cardiologist, which was far from ideal, I have unfortunately been privy to the ugly realities of faulty partnerships. Dr. Khurana is absolutely correct when he stated on the webinar today that for these partnerships to thrive, egos must be left at the door. We discussed challenges, including differences in training backgrounds and cross-coverage issues. 

One of the problems with multi-disciplinary practice models with IRs and other vascular specialists is often unequal weighting concerning the ability to drive revenue. Vascular surgeons and cardiologists have very large patient panels. IRs joining these physicians are potentially second-class citizens and may rely on non-IR partners to send referrals. Again, the way to avoid this is to do what Dr. Khurana has done and create a robust patient panel so you can be on an equal footing with your non-IR partner, who ideally should share your values and treat you like a human being. This is how you create meaningful collaboration with other specialists such that the whole truly is greater than the sum of the individual parts. 

We finished our session by picking the brain of Dr. Ian Wilson. Dr. Wilson has had a unique path, having spent many years in academics, transitioning to primary OBL ownership, and then pivoting to life as an IR working in hospital-based and OBL practices. We discussed the challenges of OBL practice. Dr. Wilson was graciously willing to talk about his experience opening an OBL and the factors which resulted in him having to close the doors to a practice he has poured countless hours into. I really appreciated his honesty. As someone who seemingly glorifies OBL practices on this blog, it is important for students to realize that these practices are hard to establish. Being a talented physician does not always translate into business success. Take it from me that it can absolutely be soul-crushing to pour your life into an endeavor and then have to pivot away from it. 

With that being said, what I love about what Dr. Wilson had to say is how he took what seemed like a negative at the time into a huge positive. He restructured his professional life such that he could practice IR on his terms: a practice rooted in a longitudinal clinical presence working in multiple settings. We discussed the potential for meaningful IR work within a locums capacity. This is possible as I actively live this life 48 weeks of the year. You can learn more about my experience doing locums through this post, followed by this post and also this BackTable podcast with my friends Dr. Shamit Desai and Dr. Vishal Kadakia. 

Every panelist on this forum today has failed at some point. Every future IR who tries to break the mold of the typical hospital-based practice pattern will encounter challenges. Our success will not be defined by what our peers think of us but rather by what we do to combat our challenges and how we care for patients. I encourage every student to adopt the right mindset to face adversity, and I thank Dr. Wilson for bringing his great perspective into this discussion. You can read my take on the mentality needed to succeed in our evolving specialty right here. 

In less than one hour, we covered a ton of material. It’s so much material that even my head is spinning as I write this recap. I want to end by distilling all these posts into a nice 30,000-foot overview for potential future vascular and interventional radiologists. 

Our field is like a startup. The analogy may seem funny at first, but it really is true. We are one of the youngest medical specialties. We are going through significant growing pains right now. One thing that has not changed is the fundamentals of our field. We have the potential to help over a hundred million unique patients in the US alone and likely over a billion worldwide. Our potential is largely untapped. What we can do is not only exciting, but it is so meaningful on multiple levels. The ideal student will see the challenges and find solutions to create a one-of-a-kind existence in an evolving healthcare system. That necessary change to create a better future for our specialty and our potential patients starts with embracing longitudinal clinical care. As someone who did not have this type of philosophy beat into my core, I have had to work hard as an attending to learn what I wish I would have learned as a trainee. 

As of now, our path forward will have to be within a radiology-centric training environment. The future IR will learn all sorts of minutiae about various imaging-related topics. One might wonder why I should go through that to become a clinically focused vascular and interventional specialist. I don’t have a good answer for you other than that is our current process, and until that changes, that is what we will have to do. A follow-up question may be, what do I do with all that DR training I acquire? A student may be afraid of losing that information. To that, I respond that I use my DR training daily to interpret images for my patients and understand anatomy. For those who are really inclined, it is possible to do diagnostic radiology on one’s own time away from their IR practice. As DR becomes more commoditized, it becomes easier to do this than ever. For entrepreneurial-minded IRs such as myself, the ability to do teleradiology is a boon, but it is by no means mandatory, as our ultimate goal must be developing a meaningful longitudinal practice to avoid commoditization. 

Thanks again to those students who logged in today. I hope the session was of value and some of you will decide to pursue this truly amazing field. If we scared you a way, I’m sorry, but you can thank us down the road. If you’re really excited about what we have to say, please let us know how we can help you on your path.  Those of us out here building longitudinal clinical practices truly love it and are excited to share the potential of this field with you.