While medical systems everywhere are facing workforce shortages, there is more interest in IR as a specialty than ever; the desire for IR training outmatches residency slots and job openings. However, as trained radiologists, minimally invasive specialists and all-around longitudinal physicians, IRs have an opportunity to fill an as-yet unmet need: providing care to rural, small and medically underserved areas. By utilizing new practice paradigms and technologies, IRs may be able to bring life-saving care to whole new populations.
IR deserts
In the United States, many communities live in a healthcare desert, unable to access specialized care without substantial travel requirements. This includes IR services. According to a review of SIR membership data, only 15% of U.S. counties have at least one practicing IR. Looking at overall population distribution, that means approximately 30% of the U.S. population does not have access to an IR. Of the 487 counties with an IR presence, 141 of them only had one practicing IR. The same review found that most of the IR population is centered around large cities and counties with higher incomes and education levels.1
According to Elizabeth A. Ignacio, MD, FSIR, chair of the Small and Rural Practices Committee and president of the Hawaii Medical Association, this means that almost a third of the nation does not have easy access to minimally invasive IR therapies such as biopsies, drainages, vascular care, oncology and pain management.
In rural areas, this gap is even wider. About 82% of counties classified as rural are also considered “medically underserved.”2
“While there is a paucity of all medical specialists, IR physicians are often one of the first specialties to leave or the last to enter,” wrote Laura Findeiss, MD, FSIR, in her account of working in a rural IR desert in West Virginia.
According to Drs. Findeiss and Ignacio, there are multiple factors causing the workforce shortage in these areas: debt and training costs for IRs are high, and pay in these rural and small areas is low.3 Smaller hospitals have fewer beds, meaning they have less funding to invest in subspecialty care.
There is also an awareness factor, according to Dr. Findeiss.
“It is not emphasized enough to trainees why they would want to consider practice in smaller communities, many of which offer a high quality of life,” she said.
The benefits of a smaller community
Ava Star, MD, knew she did not want to pursue an academic research role, and instead wanted a hands-on, clinical position. She found an opening at a small practice in Olympia, Washington, which is close to Seattle, but situated in a small community. One of the hospitals her group covered had up to 400 beds, while another in the community was so tiny it only had 10 ICU beds.
“I really enjoyed rotating the smaller hospital,” Dr. Star said. “It was such a different atmosphere. At the larger hospital, administration wasn’t always as supportive of staff, so there was constant turn over.”
Alternatively, at the smaller hospital, Dr. Star met staff who had been in their roles for years.
“The pace was slower, and everyone was so much more collegial,” she said. “It was such a great feeling, and everyone was so kind and appreciative, especially the patients and referring physicians.”
To Dr. Star, that feeling embodied the joy of working in a small community.
“The patients are able to receive a service they may otherwise have had to travel hours to receive—or not receive at all, because their income level doesn’t allow them to drive to a big city, get a hotel and have a family member come with them to help with aftercare and transportation,” she said.
The sense of community is something that Thomas Tullius Jr, MD, appreciates most about small practice. Dr. Tullius initially chose to practice in rural New Mexico to be closer to family and developed strong ties with his patients and colleagues.
“It’s nice to have a relationship with the patient that you may not have in a big hospital system,” he said. “And also, because it was a small hospital, I knew most of the other providers. We were a team—there was no competition.”
Part of the challenge in enticing IRs to rural practices is the fact that, due to limited providers, IRs in these communities will likely be required to offer diagnostic radiology services, as well as more basic procedures.
According to a survey conducted by the American College of Radiology on IR services in small and rural communities, 48.8% of IR respondents said they did not want to practice in a small or rural setting, while 67.5% reported that these practices were associated with a perceived inadequate “complexity of case mix.”4
Dr. Ignacio says there can be immense satisfaction found in the “bread and butter” cases of IR, however.
“I really enjoy treating oncology patients and chronic disease patients,” she said. “They’re already going through a war, and in Hawaii especially they have to travel so far even for something small like maintenance on a catheter.” While it may be “kindergarten IR” to some, Dr. Ignacio said she appreciates being able to provide any kind of service that will ease her patients’ worries and stress.
“Patient interaction and clinical decision making are the most gratifying part of my job,” Dr. Star said. She enjoys being part of the patient’s clinical care team and helping to guide their treatment plan—especially when able to provide additional therapy options.
“Even if the tumor board at a tiny hospital is just four people, it’s still great to have a seat at the table,” she said. “And you’d be doing your patients a disservice if you’re not there, because you may not be advocating for a procedure that could ameliorate a condition that the referring provider may not even know there’s an IR treatment for, or a therapy that could be a stepping stone toward more chemotherapy or pain relief.”
An IR presence in a community hospital can also open doors for other specialties to enter, said Dr. Ignacio.
“Something I didn’t realize is that a lot of small hospitals are unable to recruit certain service lines at all because they don’t have an IR,” she said. “An IR entering a community health service can have a huge impact. It can enable a trauma surgeon to be recruited, or a gastroenterologist or a nephrologist. And having a baseline of specialists is necessary to provide good, standard care.”
The future of small and rural practice
Even if IRs are interested in pursuing practice in a small or rural area, the jobs may not necessarily be there—at least in the traditional sense. However, new and emerging practice models are paving the way for increased IR representation in underserved communities.
Locums
Locums tenens work—or short-term, “fill-in” work—is thriving in small communities where hospitals may not be able to afford a full-time position line, or need proof of its value to the community.
Sonali Mehandru, MD, FSIR, did locums work for 3 years, during which she was able to train and expand her IR toolkit, focus entirely on her patients and gain a deeper understanding of what she wanted from a practice.5
For those interested in working in a small or rural community, but do not want to immediately commit to a position, locums contracts offer an opportunity to “trial” the position before either searching out a full-time role or negotiating the short-term contract into a long-term one.
“Each locums position I worked could be viewed as an extended job interview,” said Dr. Mehandru. “And as an employee, you get the opportunity to try out a group before committing. The experience I had with each group helped me make an informed decision on what opportunity to pursue.”
House calls and outreach
In rural Indiana, IR Nazar Golewale, MD, partnered with a home-visit medical practice to provide ultrasound-guided needle biopsy, gastrostomy tube management, paracentesis and thoracentesis, ultrasound-guided joint injections for pain, wound care, drug infusions, and more.
By administering to elderly and chronically ill patients at their rural homes, Dr. Golewale and his partnering practice were able to treat more than 1,000 patients, reduce emergency department usage by 77% and reduce hospital readmissions by 50% over a 12-month period.6
“Our older, homebound patients have so few resources available for specialty care that they often delay seeking treatment until preventable issues become urgent and acute,” Dr. Golewale said.7 “They often were waiting months to see a specialist. By providing image-guided treatments in a patient’s home, we are improving access dramatically and avoiding countless hospitalizations.”
Telehealth
Since COVID-19 forced new practice models into reality, telehealth has increasingly taken off.
Telehealth has some downsides—in addition to licensing and state-specific telehealth laws, utilizing it requires access to internet and technology, and some patients may not feel comfortable sharing health details outside of a physician’s office.8 But telehealth can also allow physicians to see patients who otherwise would not be able to regularly travel to their practice.
According to Arun Jagannathan, MD, telehealth can minimize much of the administrative and pre-procedural labor that patients face. By doing initial consults, second opinions and follow-up visits virtually, it limits patients’ transportation time and negates the associated costs of that travel.9
It can also increase flexibility for small practices. “Many small or rural IR practices may have a limited number of physicians and minimal, if any, nurse practitioner or physician assistant support,” Dr. Jagannathan said. “Telehealth offers flexibility to these practices by providing a window of availability. This can allow for coordination of telehealth services without significant interruptions to the procedural workflow and also limits the amount of blocked time required to conduct an in-person clinic.”
Conclusion
As the workforce shortage grows, small and rural areas will increasingly be left behind. For IRs seeking patient-centered, longitudinal care-based practices, or who are open to pursuing nontraditional work models, these small communities may be a perfect fit. By pursuing jobs in underserved areas, IRs can find the flexibility to build their own careers while providing much-needed care to patients who will be truly grateful.
References
- Yusef A, et al. Geospatial and Socioeconomic Disparities in Access to IR Care in the United States. JVIR. 2023 Oct 28:S1051-0443(23)00789-3.
- National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Roundtable on the Promotion of Health Equity; Roundtable on Population Health Improvement. Achieving Rural Health Equity and Well-Being: Proceedings of a Workshop. National Academies Press; 2018
- Findeiss L. Crossing the IR desert; The need for IRs in rural communities. IR Quarterly. 2021. irq.sirweb.org/clinical-practice/crossing-the-ir-desert
- Friedberg EB et al. Access to Interventional Radiology Services in Small Hospitals and Rural Communities: An ACR Membership Intercommission Survey. J Am Coll Radiol. 2019 Feb;16(2):185-193. doi: 10.1016/j.jacr.2018.10.002. Epub 2018 Dec 11. PMID: 30545710.
- Mehandru S. Short term work, long term possibilities: The pros and cons of locum tenens work. IRQ. 2023.irq.sirweb.org/perspectives/short-term-work-long-term-possibilities
- Golewale, N. et al. A novel health care delivery model–house call docs. JVIR. 2020:31(3), S55.
- Perl P. Interventional radiology comes home: Adding IR to novel physician house call model yields remarkable results. IRQ. 2020. irq.sirweb.org/clinical-practice/interventional-radiology-comes-home
- Racine H. A workforce in crisis: How Hawaii’s physician shortage is deepening health disparities. IRQ. 2023. irq.sirweb.org/perspectives/a-workforce-in-crisis
- Jagannathan A. Dialing in; Utilizing telehealth to expand the reach of small and rural IR practices. IRQ 2023. irq.sirweb.org/clinical-practice/dialing-in
