In the 50 years since Dr. Charles Dotter’s ingenious decision to progressively dilate a tight, focal arterial stenosis in lieu of open surgery, interventional radiology has showcased its unique triad of imaging expertise, procedural acumen and clinical patient-based care. Although those first two tenets have been a mainstay of IR since its beginning, clinical patient care has begun to surface for most SIR members relatively recently. Today, the importance of clinical patient-based care has become so recognized and embraced that it has changed the IR training paradigm and, for many IRs, their entire practice.
Obstacles to evolution
Interventional radiology seems to be entering its adolescence as it tries to strengthen that identity. Over the past few decades, interventional radiologists in academic centers have changed to a more clinical model and are now largely independent of their diagnostic colleagues in almost every way.
Private practice IRs, however, have evolved much more slowly, largely because of restrictions placed on them by their partners and facilities. Those practicing in a more traditional private setting with diagnostic radiology partners face several issues. While many IRs also want to perform some diagnostic imaging, the question frequently is how much the radiology group wants or requires. Spending a large amount of time doing diagnostic work or interposing diagnostic reads with one’s IR procedures may not lend itself to establishing a high-end clinical practice.
Another challenge is whether the diagnostic radiology partners value and are willing to support IR becoming a clinical service. The transition necessitates the creation of an outpatient IR clinic with staff so that one can accept referrals for treatment, establishing an inpatient consult service so that inpatient procedures are requested rather than being ordered by other services, and following patients longitudinally.
Supporting those needs also likely means renting or building office space, hiring additional staff, spending more time doing things not readily converted to a wRVU chart, seeing follow-ups on the floor and in the clinic (sometimes for minimal reimbursement), and spending a long time and having conversations with patients telling them when a procedure is not indicated (and thereby turning down an income opportunity because doing so is better for patient care).
Not many radiology groups would willingly invest time and capital to build such a robust clinical IR service, particularly when it means that some of their interventional partners will be reading fewer imaging studies, with the implication that the diagnostic partners will then be doing more work.
Yet another challenge arises from the inherent conflicts of interest within a group. A particular contract or referral stream for imaging might be compromised if the IR aspect of a practice too vigorously pursues an area of clinical practice. For example, a general radiology group might perceive that its access to vascular imaging studies will be reduced if it supported an IR partner who was trying to compete with vascular surgeons for peripheral vascular interventions or that a large-volume referrer for women’s imaging might turn elsewhere if the IR service were too aggressive in pursuing UFE as an alternative to that provider’s hysterectomy practice.
Different faces of IR
Potential challenges aside, some IRs simply do not wish to pursue a clinical practice in the first place. Most IRs appear to fall into one of two categories: 1) radiologists who are adept at minimally invasive procedures and 2) clinical physicians who treat their patients’ diseases with minimally invasive procedures.
IRs in the first category are generally happy in a traditional radiology group, doing IR a few days a week or intermixed with diagnostic work and performing technically challenging procedures as ordered, and are generally content with not being involved in the aftercare and follow-up of the patients they have treated. They are not interested in admitting patients, getting calls for postprocedural nausea or pain, dealing with labs or talking with patients about the futility of a cancer treatment.
Those in the second category are prepared to answer endless questions from anxious patients, admit them as necessary to the IR service, and deal with their labs and medications and, in return, experience the satisfaction of seeing them improve—or, if the treatment is ultimately unsuccessful, still feel the satisfaction of knowing that these patients see them as “their” doctor who did absolutely everything he or she could for them.
This second type of IR likely has struggled—or will—with his or her group to build a clinic and explain why they should be able to spend time there instead of reading films, talk to referrers to build their referral base and elective outpatient procedures, and even spend time fighting with the EMR powers-that-be and medical informatics groups to change “IR orders” to “IR consults.”
Taking those calls in the middle of the night, giving out personal cell phone numbers to referrers and answering patient-related emails even while on vacation may not be for everyone, but they are the price of being a clinical interventional radiologist.
The divide between these two approaches to IR in private practice has resulted in a true divergence in practice models. Over the past 15 years, many IRs have split off from their radiology groups out of frustration, joined forces with other specialties, or found other innovative ways to follow their true passion. This trend has been compounded over the recent years by vascular surgery reinventing itself as an endovascular field and interventional cardiology expanding beyond the scope of the heart. Many IRs have won turf battles, many have lost, and others found different and new ways to reinvent themselves.
Addressing the need
In 2016, to help define and address these challenges, the SIR Executive Council formed the Private Practice Task Force. The group was charged with defining “private practice” and assessing the need for dedicated private practice representation at the Executive Council. The task force came together for multiple impassioned conference calls regarding 1) the difficulty in defining private practice, 2) the unique needs of those members, and 3) how SIR might help meet those needs. To help assess the private practice needs of the IR community, the task force conducted a survey later that year.
The group quickly realized that accurately defining "private practice IR" is made difficult by the incredible variety in practice types, a view confirmed by the myriad survey responses received. While respondents confirmed that most private practice IRs indeed work with diagnostic radiologist colleagues at a community hospital and contract with a hospital, an eye-opening one-third of respondents reported that they were not part of a group with a hospital contract for IR and imaging.
The survey also shined a light on how unique IR practices can be and how they vary in ways that may seem counterintuitive. For example, some IRs who staff university hospitals with a full complement of trainees consider themselves to be in private practice because they are not employed by the hospitals and instead operate through professional service agreements (PSAs) made between these hospitals and their independently owned partnerships.
Many other IRs are solo practitioners or work in IR-only practices that contract independently with one or more hospitals or even with corporate entities.
Still others have joined with vascular surgeons, cardiologists and other specialists with whom they relate more closely than with diagnostic radiologists, and formed partnerships that do not include diagnostic imaging.
Some private practice IRs are directly employed by hospitals or multidisciplinary practices, while others own such practices and employ nonradiologist physicians. In short, the reality seems to be that while a traditional academic practice can generally (but not always) be clearly defined, private practice IR cannot.
In addition, the survey showed that although private practice IRs have varied practice models, they do share common concerns and issues. The most significant factors for choosing private practice include salary, location and having the autonomy to build a clinical practice. The principal concern, not surprisingly, was needing help in providing more clinical services.
Perhaps the most striking finding from the survey was that the challenges presented to respondents by conflicts with their own diagnostic colleagues were nearly equal in importance to them as were turf battles with other specialties like vascular surgery and interventional cardiology.
Entry point
IR fellowships have historically done a commendable job training fellows to succeed in the academic setting, in which divisions between IR and DR responsibilities are clear, resources are available to help with clinical and longitudinal follow-up, and the role of an outpatient clinic has had years to evolve.
However, after fellowship, most graduates will find themselves working in an entirely different environment, which can be a rude awakening.
According to survey results, private practice IRs will likely find that DR responsibilities conflict with their clinical responsibilities, clinical resources are not readily available (if at all), referrals have more to do with politics than medical need, and objective financial measures are given more weight than are subjective measures of patient care.
Newly graduated IR physicians may also be expected to do procedure that, in training, were done by a different subspecialty of radiology or another specialty altogether, and with which he or she has had no prior experience (joint aspirations, CT-guided biopsies, pain control, kyphoplasties, etc.).
Those who wish to do IR full-time may have to choose between joining a radiology group, being employed by a hospital or private company, joining with a vascular surgery/multispecialty group, creating a separate professional service agreements, or becoming completely independent. However, those who try to work independently from a DR group may find themselves restricted by noncompete agreements or exclusive DR contracts that prevent independent IRs from maintaining hospital privileges, but which paradoxically do not apply to other specialties that perform exactly the same procedures.
Plan of action
Raj Pyne, MD, describes SIR's efforts to address the needs of IRs in private practice.
Based largely on the survey results and task force discussions, the group recommended the creation of a dedicated private practice position on the Executive Council, which was recently approved. The SIR Executive Council has appointed Gerald A. Niedzwiecki, MD, FSIR, as private practice councilor (ex officio), for a 1-year term. It is anticipated that, following a bylaws change at the 2018 SIR annual meeting, this will convert to a voting position with a three-year term.
Having established formal representation for IR private practice on the Executive Council, task force members are now working with SIR leadership to determine whether private practice would be better served within the society as a division or section (the differences between which are beyond the scope of this article). Subcommittees representing the major types of private practice, described above, will be needed as well.
Furthermore, beyond the creation of a formal SIR division or section, some of the more specific goals and objectives for the task force in coming years include the following:
- Creating a private practice resource center with a file of useful documents and a list of opportunities for networking with other IRs in comparable practice and business models who have navigated through common obstacles
- Creating a template of mechanisms by which private practice IRs can lobby their own groups and hospital administrations on the importance of a true clinical IR practice, including sample pro formas and a list of benefits that many may not perceive, so that clinical IR and private practice IR become the norm, not the exception
- Designing a private practice educational track at the SIR annual meeting
- Building a formal exchange opportunity whereby SIR members can spend time at each other’s practices to learn new techniques and procedures
- Developing a formal mentorship program and network for the various private practice subtypes
- Putting out a more robust and detailed survey to better understand all SIR members’ practice environments
- Creating web-based virtual IR “Grand Rounds” to showcase interesting cases, complications, and/or tips and tricks
While some of these goals may seem monumental in scope, we feel that they are necessities—not luxuries—for the future of private practice IR, and will allow it to thrive rather than just survive. It is exciting to be at the crossroads of past and future, with private practice IR being pushed toward further evolution in the coming years.
Ideally, we will be able to answer the core dilemma for the future of private practice IR: will splitting away from diagnostic radiology and into IR-only or multispecialty groups be the best (or only) pathway for those clinically oriented nonacademic IRs? Or can private practice IR evolve in the next decade into the clinical practice it needs to be, augmented synergistically by our diagnostic radiology partners?
For more information about SIR’s Private Practice Task Force, or if you want to get involved with projects and subcommittees, please email ccouture@sirweb.org or raj.pyne@rochesterregional.org for more information. Watch for more articles about practice models in upcoming issues of IRQ.
