William Nghiem, MD, is an interventional radiologist employed by Horizon Vascular Specialists in Maryland—a vascular surgery group in which Dr. Nghiem is the only IR. It’s an unusual collaboration, but one that offers its own unique opportunities. IR Quarterly spoke with Dr. Nghiem about his practice, his colleagues and the tools necessary for collaboration.
IRQ: How did you join your current practice?
William Nghiem, MD: I finished my IR fellowship in 2014 and joined a community-based radiology practice, and it was not what I was expecting. An interesting thing about IR training is that many of the things you do in your fellowship are very different from the realities of actual private practice, where many of us end up. You often don’t have a clinic, you don’t have midlevel support and you’re not doing many high-level procedures. Shortly after joining my radiology group, I realized their business model was far more based on DR work. I wanted to do cancer programs and offer specific IR therapies, and while my group was vocally supportive, there was a strong push for me to do diagnostic radiology. As a result, I wasn’t very satisfied with the situation.
During this time, however, I met some of the vascular surgeons who shared the catheter lab at the hospital. One of them was very progressive and aware that certain aspects of his vascular practice may take a hit in the future, so he was looking to expand his services. As we got to know each other better, he began to understand more about what IR is and what can be brought out of the hospital into a different setting. The vascular surgeons were aware that my group didn’t afford the IR-focused work I’d anticipated, and so the vascular practice offered me those opportunities. Since they are a surgical practice, they already had the offices, staff and midlevel providers. I joined them 6 years ago, and I am now able to practice 100% clinical IR.
IRQ: Did you receive support in your decision to move to a vascular practice?
WN: To tell you the truth, some of my vascular colleagues were hesitant at first because it was an unknown model. We all agreed that it was a trial, and they knew it was a huge risk for me—I could have stayed at my DR practice for guaranteed salary and service. Even my mentors were divided on whether it was a good idea and said they wouldn’t have done it, especially not a year out of fellowship. But I viewed it as an opportunity because I wasn’t set in my practice type. I had the ability to take a risk but still move on if it didn’t work out. Someone who is more established in their practice may be unwilling to take that kind of risk.
IRQ: What services do you offer?
WN: Starting out, I brought everything I could from the hospital to the outpatient setting. We have an office-based laboratory, so I was doing biopsies, women’s health, pelvic congestion, etc., just trying to figure out what would work. Over the years I’ve whittled it down to what we do best. I don’t do biopsies anymore, for example, because oncologists use the staff at their own hospital, so it didn’t make sense for the patient.
IRQ: How do you find patients?
WN: At first, I did a lot of marketing. To promote uterine artery embolization, I used to have lunches with every obstetric group in two counties to build relationships. In addition, although I was only at the hospital for a year, I did have relationships with some oncologists that I was able to leverage by showing them how I could provide better service for their patients in an outpatient setting. Now I’ve been in the area long enough to have a reputation and gain patients via word of mouth and referrals from previous patients.
IRQ: Do you practice entirely in an outpatient setting, or do you have hospital admitting privileges? Do you have difficulties with exclusivity clauses?
WN: Exclusivity clauses were a big issue for me early on, and they’re a huge issue across the country. If you can’t get hospital privileges, you can’t work in private practice, really. When I left my radiology group, I lost my hospital credentials, and two of the other hospitals in the area wouldn’t credential me because of exclusivity contracts. It was difficult to make the hospitals understand that my goal wasn’t to steal services from the radiology group, but I was still seen as a threat. Eventually, another hospital in my area granted me credentials because I provide services that the other groups don’t. It was a relief because I needed those privileges in case someone in my vascular group needs me to fill in. Luckily, though, 90–95% of my practice is in the outpatient setting.
IRQ: How often do you collaborate with your vascular surgeon colleagues? Do they ever send you patients?
WN: They do. When it comes to pelvic congestion, up to 50% of patients get lower extremity and venous disease, and our practice sees a lot of lower extremity disease. My group does our own ultrasounds so if a partner sees a patient who has valve failure in the pelvic tributaries, they may refer the patient to me for evaluation. I also offer headache treatments and the medical assistants will screen patients for me. If a patient has neuralgia and still have headaches despite medication, they’ll be referred to me. There’s a lot of collaboration in that aspect. And when I began practicing, I was nervous about not having another IR for backup, but my partners were very reassuring. They pointed out that when an IR needs to call someone for help, they call a surgeon, and I’m surrounded by surgeons who have my back.
IRQ: Are you an independent entity within the vascular practice?
WN: Yes. The vascular practice is its own entity, and my practice is a piece of that. My partners are pretty hands off.. I have everything I need within reason, like a budget for marketing. Because my partners don’t know IR, they’re very open to any ideas I have to grow the practice from a marketing standpoint or procedures I’d like to add. And because they’re established, they have the flexibility and leeway to help me grow my practice.
IRQ: It sounds like you’ve received the support from the vascular surgeons that you hoped to receive in your previous practice.
WN: I really have. I know it may be controversial, because my practice model takes a totally different mindset. But each practice is different, and I see larger practices that have a lot of services and support for IR. I know that there are a wide variety of practice situations out there, and my earlier experience isn’t universal.
IRQ: Historically, there have been turf wars between vascular surgeons and IRs, for a range of reasons. Do you experience that at all?
WN: At the end of the day if you can throw out egos, the best practices should have IRs, cardiologists and vascular surgeons working together. My partners know their skills and mine. If they need help they’ll ask and I’ll come, and vice versa. There’s no territorial aspect to it. It’s very collegial.
Too often, we try to make people our enemies. We’re here to run a business but operating from a turf war perspective will only build animosity. It’s hard to overcome barriers, but eventually that animosity will cause issues with patient care. Yes, IR and vascular surgery exist in some of the same treatment areas, but the techniques are different and there are things we can learn from each other.
IRQ: What advice would you give to other IRs who would like to set up a model like this?
WN: If they work with other specialties at the hospital, it’s always worth exploring if there are collaboration opportunities. I’ve seen other IRs who partner with urologists, for example. It just comes down to thinking outside of the box and being willing to venture beyond your radiology group. Take a risk and get creative. When I talk about my practice model, people think it’s interesting and wish they had this opportunity.
Establishing a practice is an uphill battle to be sure, but it’s worth it if you’re determined to carve a path where you can practice the way you love. And if you have a bit of luck.
