I have spent most of my career in academic IR practices. Aside from the satisfaction that came with training the next generation of IR docs, the biggest advantage of academic practice for me was the focus on IR. Everyone I worked with every day was full-time IR—lived and breathed it throughout the work day and beyond—and was not expected to do otherwise. There were no distractions, and my partners and I shared our vision of what we wanted to accomplish.
People often talk about the “publish or perish” paradigm of academic medicine as if it’s a bad thing, but I found it to be a constant source of excitement. It’s really only in an academic setting that you have the freedom to chase down whatever aspect of IR happens to catch your interest. You find yourself with a question about something you’ve seen and, rather than cast it aside for someone else, you can focus on it, study it, answer it and then tell people about it. That’s not a punishment—it’s a joy.
It’s really only in an academic setting that you have the freedom to chase down whatever aspect of IR happens to catch your interest.
In more recent years, I’ve been in private practice. Unlike an academic setting, which is clearly divided into large, monolithic departments in which the chair has an enormous amount of power, private hospitals tend to be more loosely organized. Though this may change with time, physician groups in private practice are generally smaller and less unified, and the chair position is almost a formality. These factors reduce the ability of any one group to dominate another.
For example: in an academic setting, a chair of surgery might pressure his or her surgical oncologists to direct port placements, gastrostomies and even (perhaps) catheter-directed oncologic treatments to other surgeons rather than IRs. In a private practice, such pressure is far less likely to be effective. Also, the opportunity for IR to compete with other physicians is greater when their finances are separate: the dean of a medical school would have no reason to fund competing vascular labs in surgery and radiology, but a private radiology group that wants to increase its vascular diagnostic and interventional work could certainly choose to invest in its own vascular lab.
Even in a fairly large private practice, there is usually an expectation that all members of the group will contribute to the general imaging work. Full-time, exclusively IR jobs are the exception rather than the rule. This makes it very difficult to have the kind of focus on IR that one sees in academics; i.e., members of the IR group might alternate between IR and imaging work over the course of the day and might be completely out of the IR suites for days at a time, which disrupts continuity. I have found it much harder in private practice to organize a daily review of cases, a monthly M&M, a journal club, and other peer review or educational activities that are integral to the academic world.
One fear that I had in leaving an academic practice was that I would no longer be doing interesting cases. I had always enjoyed being at the end of the referral chain, getting the cases that others had found to be too difficult. I do think that is a real risk for many who make the transition.
However, I was fortunate enough to land at a private facility with a liver transplant program and a very active oncology service. I find that I am doing a similar volume of TIPS, yttrium, ablation and similar cases, but I no longer have to let “the fun part” be done by someone else as I supervise. Cases move through the angio lab much more quickly than when a trainee is involved.
The trade-off is that I now have to do all of the paperwork as well, such as H&Ps, consents, pre- and post-op orders, the procedure note and the dictation. So while I am able to do my cases more quickly, I’m actually spending a larger percentage of my time on paperwork than in the academic setting.
The financial considerations of a move to private practice are much less compelling now than in the past. For years, I watched my fellows take jobs that paid more than mine but, as I moved into administrative positions and the economy changed, that gap shrank. By the time I moved out of academics, the relative balance had actually shifted and my salary went down. I also find that, as a partner in a private practice group, the issues of reimbursement, contracts, equipment costs, etc—which I had rarely if ever thought of in the past—are now unavoidable.
For me, the greatest single difference in private practice is a marked increase in free time. Since I no longer have either research or administrative responsibilities, I can leave my work behind me at the end of the day. In fact, I no longer have an office at the hospital because, when I am not working in the angio lab, I am not working at all. On the other hand, in many practices, the IR docs are expected to share in general call responsibilities while also having either separate IR or IR backup call. Many of us who move from academic to private practice find that call frequency actually increases.
All things being equal, I preferred the focused and insular academic environment over the increased freedom of private practice. If I had the flexibility to relocate, I would pursue another academic job. Since that’s not the case, I’ll instead use my extra free time to play with my kids. Not a bad trade at all.
