Why IRs Are Unhappy: It’s More Than Psychological

I was recently invited to contribute to a series of blog posts regarding the perceived “IR Shortage” by my friend Dr. Dan Poulsen who is a practicing interventional radiologist in North Carolina. Dan has been on a tear recently, connecting with a variety of IRs coast to coast after coming to the realization that many of us more progressive-minded IRs come to in a traditional IR-DR practice setting. I’m honored to be able to contribute to this series and excited for the conversations that Dan is sparking among our community. If you haven’t already, check out his blog on Substack. Please see the first post from Dr. Ashu Rao prior to reading mine.

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I recently read Ashu Rao’s post on why interventional radiologists are unhappy.

It’s a thoughtful piece, and to his credit, he moves beyond surface-level explanations. He argues that IR unhappiness stems from the gap between expectations and reality, as seen in how we experience procedures, using thoracentesis and pulmonary thrombectomy as a very fascinating example. In my experience, I am more likely to be consulted for a thoracentesis in a patient with an effusion that is over 5 years old with an O2 saturation of 99%, but maybe things are different in magical Atlanta, GA. Who knows.

I believe the root cause of IR unhappiness is deeper and more structural.

At first glance, that explanation makes sense. Many IRs have preferences, and we tend to gravitate toward higher-complexity cases and away from procedures that, fairly or not, seem doable by non-physicians. After speaking with over a thousand interventional radiologists in various practice settings, career stages, and geographies over the past eight years, it is clear this is not really about the procedures themselves.

A pulmonary thrombectomy and a thoracentesis both help patients and can be appropriate, valued by the referring team. Yet they feel completely different, not because of the procedure itself, but because of factors like how the case arrives, timing, context, disruption, and your level of control.

I have written about this before in the idea of the IR as both the hospital MVP and the glorified trash collector.

That post resonated more than I expected—not because it was novel, but because many IRs recognize the dynamic. Most in the field have experienced it.

I certainly have. In my own practice, day-to-day work at times felt less like what I trained for and more like a stream of low-complexity tasks done mainly to support a diagnostic imaging contract. It was not one specific procedure; it was the sum of the work, lack of control, and the feeling that I was not using my full training. This disconnect eventually led me to question whether to stay in IR or even in medicine.

This led me to realize that my dissatisfaction was rooted not in workload or call demands, but in a misalignment between the practice environment of current IR and the field I envisioned—highlighting a structural, not personal, disconnect.

I have written about this before in The IR Startup, but I keep coming back to the same idea. Most of us went into IR because we were drawn to the combination of clinical medicine and image-guided procedures. There is something compelling about diagnosing and treating patients with minimally invasive image-guided techniques and following them longitudinally, through the good and the bad, which is inherently very satisfying. While the longitudinal component wasn’t something I was truly exposed to in IR training, as I am today in my solo practice, that is the type of practice I wanted, and these days, many coming out of training are better exposed to a more clinically oriented pathway.

However, there are still a few roles where you can practice IR fully, build a longitudinal practice, and have your work valued within the system. Many end up in hybrid IR/DR roles from an earlier era, where IR operates as a loss-leader procedural service tied to diagnostic radiology.

That model works incredibly well financially, but that often involves trade-offs. You try to build something longitudinal in a transactional system, seek a clinical identity in a procedural environment, and operate with limited control over workflow, patient selection, and direction. I’ve met so many IR/DRs who make insane salaries, yet are very unfulfilled.

Ultimately, this is not simply an expectations-versus-reality mismatch. There is a structural gap between the field’s aspirations and the actual opportunities available to practice IR as intended.

And the interesting part is that the market seems to be adjusting, whether we explicitly acknowledge it or not.

We often talk about an IR shortage, and there is truth to that. It is not easy to hire. Coverage is a challenge. Many groups are relying on locums just to keep basic operations going. But that framing is incomplete, because at the same time, there is a noticeable shift in how IRs are choosing to practice.

I see this directly through Physician Staffing Solutions, which I run with my cofounders, Dr. Shamit Desai and Dr. Aneesa Majid. Over the past several years, we have had conversations with a large number of interventional radiologists, enough to start seeing patterns that are difficult to ignore. The pattern that keeps emerging is not just one of shortage, but one of movement.

Interventional radiologists are not simply unavailable. They are making deliberate decisions about where and how they want to practice.

I have spoken with partners in traditional IR and DR groups, people who have been in practice for more than 20 years, who are worth tens of millions of dollars, and who are now stepping away from those roles to pursue independent contracting. Others are moving toward direct employment models with health systems. Some are shifting into locum work, not just as a temporary bridge, but as a long-term strategy to gain more control over their time and workflow. And then there are those who are stepping away from IR entirely and pursuing teleradiology, as this option offers a very lucrative payday without the hassles of dealing with a field that has failed to define itself in our current healthcare landscape.

Interest in outpatient and office-based models is rising. Economics and autonomy play a role, but mainly it’s about building a practice that matches IR’s clinical potential, not a structure designed for something else.

Viewed together, this is less about individual career choices and more a broader market signal. The system isn’t static, and IRs are responding rationally to their options.

When asking why IRs are unhappy, we should focus on the underlying structures shaping the field rather than on internal mindsets or values alone. This shift better explains the persistent dissatisfaction IRs describe.

Based on personal and professional experience, dissatisfaction among IRs is rarely a straightforward mismatch between expectations and reality. More often, it emerges gradually: something about daily work feels disconnected from the field that initially attracted them. Over time, the feeling becomes hard to ignore, and soon you may end up cleaning a fish at work like Peter from Office Space. I myself have had that Office Space moment and hope no one feels like that, but sadly, I have spoken with dozens over the years in our specialty who have had that exact same moment.

What we are seeing now feels less like a psychological phenomenon and more like a response to that structure. The underlying issue is that there aren’t enough practice environments that meet the demands of what many interventional radiologists actually seek. The field has evolved in its aspirations, particularly around clinical care and longitudinal patient relationships, but the available jobs have not kept pace with that evolution. There is a draw to contract-based work because it rewards the interventionalist for practicing interventional radiology and not using diagnostic radiology as the economic engine to provide episodic interventional care as a mere afterthought.

This growing gap between IR’s potential and current practice environments is structural and will persist without intentional change.

If anything, it suggests that part of the responsibility falls on us to build those opportunities rather than wait for them to appear. This is the reason I started my own OBL practice, Image Guided Solutions of Missouri. Building new practices means we need to place greater emphasis on entrepreneurship within the field, whether through outpatient practices, new care delivery models like what I am accomplishing with my co-founders, Dana Dunleavy and Ian Wilson, at Travelier, or more intentional efforts to create IR-focused clinical services. It also means thinking more carefully about how we train and mentor the next generation, not just in technical skills but also in longitudinal non-operative clinical care, business development, and in how to navigate and shape the environments in which they will practice.

If these changes take hold, today’s dissatisfaction may be seen differently. Not because the work changed, but because practice conditions would align with why many chose IR. We must work hard to support our colleagues and build the IR practices of the future. If we don’t address this problem now, IR will cease to exist.