Any interventional radiologist knows our field’s immense value to patients, other physicians and the healthcare system. It is an unfortunate truth that most patients, non-IR physicians and administrators are unaware of the breadth of our clinical and procedural expertise. This is especially true in smaller and rural communities that have not had exposure to modern-day IR. Fortunately, this fact becomes an opportunity for an IR to start a practice.
Given the breadth of diverse practice models available to IRs—from hospital-employed, private practice, IR within a DR group and outpatient-based labs—there are a few tenets to keep in mind when developing a new practice. Even though each community will have unique politics, referral patterns and prior history with IR, there are several universal principles that, when applied, will result in the high-quality patient care that we are ultimately striving to provide.
Know and educate referring providers
The crucial process of learning referral patterns and educating referring providers requires consistent effort. In my opinion, it takes at least 3 years to mature a new practice. During that time, you will get to know who is familiar with IR and who is not, and who is willing or unwilling to refer to you. Educating other doctors can be met with resistance due to longstanding referral patterns or even met with insult.
For example, an established oncologist may have a surgeon place ports for their patients. If offering your service to place ports is met with resistance, it may not be worth trying to change their mind at first. A better approach would be to find out what is not being done for their patients, e.g., thermal ablation, intra-arterial therapies and palliative procedures. With good patient care and follow-up communication, the rest of your services—like ports—will follow.
Beware of going directly to the patient and behind the provider’s back, as it is a sure way to lose the trust of that colleague. Keep a lookout for new and younger physicians who are more likely aware of the benefits of IR and make sure to engage them as they start their practice. Contact referring physicians often to discuss cases before and after. Remind referring physicians that you will see their patients in the clinic before more complex procedures and follow up afterward. This is especially important when primary care refers to you, so they understand you are a clinician, not just a proceduralist. Offer to provide “lunch and learn” sessions to other practices to educate them and their staff on what service you can provide. Attend tumor board and other multidisciplinary conferences. Seize the opportunity to be a part of committees, grand rounds or M&M conferences. Become involved with medical education by providing noon lectures to local residency and nursing programs. Acquainting yourself with ER and hospitalist providers is a sure way to build your reputation as they hold the key to inpatient referrals.
Lastly, multidisciplinary care is powerful when establishing your practice. Offering to work with vascular surgery or cardiology (e.g., in a pulmonary embolism response team or abdominal aortic aneurysm program), will go further than the turf wars that tarnish the healthcare system.
Clinical care in and out of the hospital
The concept of clinical IR is not new. However, the concept of IR rounding, writing progress notes and seeing patients in the clinic can be new for a local healthcare system. Discussion of the financial feasibility of a clinical IR program is beyond the scope of this editorial. However, there is no doubting the immense value this brings to patients and the future viability of IR. For inpatients, other providers will recognize you as a clinical entity. They will also soon understand they cannot just “order” a procedure but need to put in a consult and hopefully discuss the patient with you.
You may need to work with your hospital IT department to develop an IR consult order in the EMR. Coding and billing may be new to you as you start a practice. It is essential to familiarize yourself so that you are properly reimbursed for your consults, progress notes and clinic patients. There are ample resources within SIR to educate yourself.
Having an outpatient clinic is essential if you are to be providing care beyond basic IR procedures. Discussing risks and benefits with patients and developing a relationship for longitudinal care will be key to your success. For example, if you are to perform a TIPS, setting the patient’s expectations and managing their clinical follow-up is compulsory. The opposite (the patient calling their gastroenterologist or primary care during follow-up) will result in poor patient care and loss of respect.
Contracts with the community hospital
This topic is fraught with complexity and will be unique to each locale. Hospital systems cannot calculate the true value of interventional radiology. Beyond relative value units, there is real dollar value in shortened length of stay, fewer complications and less cost. In addition, there is usually more IR-related longitudinal outpatient imaging which the hospital benefits from. Painting a picture of this value can be challenging if the hospital administrators have not worked closely with IR. Arming yourself with data (e.g., Medical Group Management Association revenue benchmarks) and explaining clinical scenarios to showcase IR value to a healthcare system may seem like a sales pitch and awkward to do.
However, most administrators have very tight budgets, and they need to explain to corporate-level executives why they are investing in IR. Other factors to discuss in a negotiation would be a call stipend, a trauma call stipend (IR is required for Level I and II trauma), professional fee collections, expected annual growth, financial support for an advanced practice provider versus a hospital-provided advanced practice provider, clinic space within the hospital, and marketing by the hospital. It is possible to have a mutually beneficial relationship with a hospital system, but you must be compensated for the value you bring.
Overall, building a successful IR practice takes time, effort and persistence. By focusing on education, relationships and clinical care, you can provide the best possible care to your patients and help others understand the value of our field.
