ACR meets SIR townhall discussion on IR and DR relations

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irwarrior said:

IR and DR: The Dirty Truth – Line Monkey MD

linemonkeymd.com linemonkeymd.com

Interesting townhall/ discussion on the future of IR and DR and whether IR will go the way of radiation oncology.
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I like this blog, but seems a little tone-deaf regarding diagnostic radiologists. I would not make the comparison IR are eagles and DR are chickens. I’d stop trying to pressure DR groups into doing what the handful of IRs want just because. Both groups needs to understand what the other group wants.

DRs goal is maximizing revenue, IRs goal is to maximize revenue while also doing what they consider fulfilling work. DRs may consider an MRI of the abdomen with contrast more fulfilling than a plain film of the chest, but at the end of the day if their takehome pay is the same, they don’t really care.

IR can convince DR to invest what they’re interested in if they demonstrate the profit of “more fulfilling, high-end work despite the clinic.” There are example cases where IR service lines in DR private practices established clinical lines of service and became “green / less red” These examples need to be demonstrated through breakdown and analysis, especially in cases where they didn’t involve investment in infrastructure (OBL/ASC) which a risk-averse DR group may not buy into given the relatively small cost of IR, and therefore the small benefit of running less red with an OBL in face of the very substantive risk of the large infrastructural investment. If you can demonstrate that you can make everyone in the group more money while also doing what you love, and that it’ll cost little in terms of resource or risk investment to engage in this, there is no reason not to (except maybe spite at this point).

Alternatively, DR groups would likely be fine with IRs investing the time to practice build with the contract-hospital’s clinical / procedural infrastructure, but the IR then has to accept the pay decrease that accompanies this when DR groups understandably don’t want to subsidize what they view as the IR’s hobby-shop.

tldr: prove that high-end clinical IR, without infrastructure investment, makes the practice ”less red.” Failing that, accept that DRs will not want to subsidize you building your passion project. It is THEIR WORK which heretofore has afforded the IRs very nice pay, not the IR’s. You can’t take on more work you enjoy that comes at the expense of the group/expect the group to keep paying out handsomely. You can still build your practice you want, but it’ll have to come at your expense (time, money, etc).
 
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SeisK said:
I like this blog, but seems a little tone-deaf regarding diagnostic radiologists. I would not make the comparison IR are eagles and DR are chickens. I’d stop trying to pressure DR groups into doing what the handful of IRs want just because. Both groups needs to understand what the other group wants.

DRs goal is maximizing revenue, IRs goal is to maximize revenue while also doing what they consider fulfilling work. DRs may consider an MRI of the abdomen with contrast more fulfilling than a plain film of the chest, but at the end of the day if their takehome pay is the same, they don’t really care.

IR can convince DR to invest what they’re interested in if they demonstrate the profit of “more fulfilling, high-end work despite the clinic.” There are example cases where IR service lines in DR private practices established clinical lines of service and became “green / less red” These examples need to be demonstrated through breakdown and analysis, especially in cases where they didn’t involve investment in infrastructure (OBL/ASC) which a risk-averse DR group may not buy into given the relatively small cost of IR, and therefore the small benefit of running less red with an OBL in face of the very substantive risk of the large infrastructural investment. If you can demonstrate that you can make everyone in the group more money while also doing what you love, and that it’ll cost little in terms of resource or risk investment to engage in this, there is no reason not to (except maybe spite at this point).

Alternatively, DR groups would likely be fine with IRs investing the time to practice build with the contract-hospital’s clinical / procedural infrastructure, but the IR then has to accept the pay decrease that accompanies this when DR groups understandably don’t want to subsidize what they view as the IR’s hobby-shop.

tldr: prove that high-end clinical IR, without infrastructure investment, makes the practice ”less red.” Failing that, accept that DRs will not want to subsidize you building your passion project. It is THEIR WORK which heretofore has afforded the IRs very nice pay, not the IR’s. You can’t take on more work you enjoy that comes at the expense of the group/expect the group to keep paying out handsomely. You can still build your practice you want, but it’ll have to come at your expense (time, money, etc).
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Well said.
 
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irwarrior said:

IR and DR: The Dirty Truth – Line Monkey MD

linemonkeymd.com linemonkeymd.com

Interesting townhall/ discussion on the future of IR and DR and whether IR will go the way of radiation oncology.
Click to expand...

The discussion is a self-serving discussion that tries to push the interests of certain IRs in academics.

I can not explain it better than SeisK.

The only thing I can say is that the IR argument is very childish. Practically IR community acts like an entitled 20 year-old spoiled child that expects his father to buy a Lamborghini because he likes it.

The DR does not really benefit from IR doing high end procedure. So why do you expect DR to invest in your personal interest?

Most DRs only want IR service in order to fulfill the hospital contract requirements. Within some limitations the less IR does, the better for DR.

Now if IR wants to go and open its own shop, great for them. Do it on your own. Do what makes you happy.

Rad onc is a totally different story (At least oncologists do not try to steal procedures from them). Anyway, if you think they have gone the right pathway, you can ask any current rad onc resident about their job prospects.
 
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Here is another interesting blog about the challenges of exclusive contracts.
 
Agree that IR can not expect to have their cake and eat it too. Clinic does not generate anywhere near the revenue that DR can produce and a clinical IR division physician can not afford to take 8 to 16 weeks of vacation time. They need to be readily available to their consultants and their patients. Trainees going into IR do not understand how hard the call can be and how busy IR is becoming. This has led to considerable attrition. During the hot job market in DR, IR always has a hard time filling their "fellowship/independent" spots and this is currently the case with IR (1 with ESIR or 2 year after DR training) fellowships.
 
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irwarrior said:
Agree that IR can not expect to have their cake and eat it too. Clinic does not generate anywhere near the revenue that DR can produce and a clinical IR division physician can not afford to take 8 to 16 weeks of vacation time. They need to be readily available to their consultants and their patients. Trainees going into IR do not understand how hard the call can be and how busy IR is becoming. This has led to considerable attrition. During the hot job market in DR, IR always has a hard time filling their "fellowship/independent" spots and this is currently the case with IR (1 with ESIR or 2 year after DR training) fellowships.
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So what is your solution for current IRs?
 
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Anyone know where a recording of this could be found?
 
The best way DR can support IR is by letting IR be free. Stop restricting our ability to practice to the fullest extent possible by holding us hostage to a culture and business model not conducive to the quest for “autonomy, purpose, and mastery” we seek. This includes understanding that interventional radiologists are like eagles among a pen full of diagnostic radiology chickens. Let the eagles free and stop trying to tell them they are chickens like the rest.

-----------------------------------------

The above lines are from the article.

One of the most stupid paragraphs that someone can say. I am not sure what he was smoking.
 
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sloh said:
Eagles without wings lmao
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Yeah I’m not a big fan of that analogy. Everyone in healthcare is a chicken, let’s be real.
 
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Tiger100 said:
The best way DR can support IR is by letting IR be free. Stop restricting our ability to practice to the fullest extent possible by holding us hostage to a culture and business model not conducive to the quest for “autonomy, purpose, and mastery” we seek. This includes understanding that interventional radiologists are like eagles among a pen full of diagnostic radiology chickens. Let the eagles free and stop trying to tell them they are chickens like the rest.

-----------------------------------------

The above lines are from the article.

One of the most stupid paragraphs that someone can say. I am not sure what he was smoking.
Click to expand...
Sounds like a happy diagnostic radiologist there…..
 
SeisK said:
Yeah I’m not a big fan of that analogy. Everyone in healthcare is a chicken, let’s be real.
Click to expand...

His statement is the reflection of the mindset of IRs. They have an extremely inflated sense of self worth. It seems doing thoras, paras, PICC lines and nephrostomy tubes or some angios in the middle of the night (because Vascular and cards don't want to do them) do that to people.
 
NDcienporciento100 said:
Sounds like a happy diagnostic radiologist there…..
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Yep. A lot happy with my career choice. To be honest with you at this point in my life, if I didn't like DR, I would quit tomorrow. I don't need the money at all. I make more from passive income than from private practice Radiology.

I am changing jobs in a few months. Going from pp to a VA that has residents and fellows. It will be a cush job.

Wish your IR job goes well. IR is exhausting in private practice. Many of my mid career IR colleagues are burnt out and look for ways to exit. Most of them have developed chronic back issues. Also radiation risk is something that is not well understood. It is not like that people get cancer from radiation left and right but in this day and age that life expectancy is going to be 85-90, I hope adverse effects from radiation don't effect people during older ages.
 
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Tiger100 said:
His statement is the reflection of the mindset of IRs. They have an extremely inflated sense of self worth. It seems doing thoras, paras, PICC lines and nephrostomy tubes or some angios in the middle of the night (because Vascular and cards don't want to do them) do that to people.
Click to expand...
Not all IRs. Some of us like doing both.

VS and Cards already have their hands full with other BS in the middle of the night. IR call still better than theirs most of the time I think.
 
SeisK said:
Not all IRs. Some of us like doing both.

VS and Cards already have their hands full with other BS in the middle of the night. IR call still better than theirs most of the time I think.
Click to expand...
I disagree. Cards get called for an mi or maybe PE . And that is pretty much all they’re coming in for. IR gets called for bleeds everywhere, PEs, septic drain placement, stroke if they cover. Not to mention all the bs phone calls that won’t even go. VS is highly dependent on where they practice. Average run of the mill level 3 center, they almost never come in. Big referral center is different. It’s probably a wash.
 
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IR call is getting busier and busier . There are so many patients with GI bleeds, hemoptysis, trauma bleeds, post op bleeds, post op abscess, cholecystitis (non surgical), failed ERCP with cholangitis, diverticular and appendices abscess, Suprapubic tubes, thoracentesis, paracentesis, LP , joint aspiration for septic joint, NG tubes when floor can not place them, empyema drains, DVT/ PET/ mesenteric vein thrombosis/ Acute limb ischemia/ Ivc thrombosis/ extremity clot/ stroke etc. The growing list can be daunting and has made IR more and more challenging when on call.
 
More and more jobs are becoming 100% IR. It used to be the only way to do 100% IR was to go to an academic center. That’s not the case anymore. Lots of people coming out of training want to practice how they trained “clinical IR”. Private practice jobs are adapting with more offering higher percentage IR.
 
SeisK said:
Not all IRs. Some of us like doing both.

VS and Cards already have their hands full with other BS in the middle of the night. IR call still better than theirs most of the time I think.
Click to expand...


Agree with you. But IR leadership is pushing for something totally different. It seems Academic IR and IR leadership are detached from realities of community practice.
 
irwarrior said:
IR call is getting busier and busier . There are so many patients with GI bleeds, hemoptysis, trauma bleeds, post op bleeds, post op abscess, cholecystitis (non surgical), failed ERCP with cholangitis, diverticular and appendices abscess, Suprapubic tubes, thoracentesis, paracentesis, LP , joint aspiration for septic joint, NG tubes when floor can not place them, empyema drains, DVT/ PET/ mesenteric vein thrombosis/ Acute limb ischemia/ Ivc thrombosis/ extremity clot/ stroke etc. The growing list can be daunting and has made IR more and more challenging when on call.
Click to expand...


In the last 10 years you keep saying that. This may be the case for you yourself as an exception. But if you look at the national numbers, IR is not getting that much busier productivity wise. I don't see a huge jump in IR RVUs. The workload of high end procedures has not significantly changed.

Stroke is done mostly by NeuroIR and not body IR. While some body IRs dabble in stroke, for every IRs who are doing them there are 2-3 neurologists who are getting trained to do them (look at the national number of stroke fellow that are from Neurology versus radiology).

Similarly PAD was never completely taken away from IR but was cherrypicked. IR might be busier on Saturday night at 11 pm but not on Tuesday at 11 am doing PADs.
 
NDcienporciento100 said:
More and more jobs are becoming 100% IR. It used to be the only way to do 100% IR was to go to an academic center. That’s not the case anymore. Lots of people coming out of training want to practice how they trained “clinical IR”. Private practice jobs are adapting with more offering higher percentage IR.
Click to expand...

You are mixing two different concepts. 100% private practice jobs are more common but not clinic. Most private groups won't give IR clinic time since it is a money loser for them. And FYI, in most practices right now all the Fluoro is done by IRs e.g upper GIs, BEs, swallow studies, etc.

When you look at productivity, since 10 years ago the DR productivity has gone up about 30% but IR has stayed steady. I am talking about national average and typical scenarios But I also know you are doing all high end procedures including spine surgeries as IR.
 
NDcienporciento100 said:
I disagree. Cards get called for an mi or maybe PE . And that is pretty much all they’re coming in for. IR gets called for bleeds everywhere, PEs, septic drain placement, stroke if they cover. Not to mention all the bs phone calls that won’t even go. VS is highly dependent on where they practice. Average run of the mill level 3 center, they almost never come in. Big referral center is different. It’s probably a wash.
Click to expand...

Agree. Cards get called for MIs and PEs. A lot of them do a high number of PADs cases but they cherry-pick them and refuse to cover after-hour cases.

VS is on call for PAD in most hospitals and may or may not get called for it. Some VSs send after-hour PAD cases to IR.

IR gets called for several things including Paras, thoras, chest tubes, lines, drains, abscesses, GI Bleeds, PEs, nephrostomy tube (esp if urologists are busy), cholecystostomy tubes, dislodged G-tubes etc. In some places IR may cover stroke but I don't know what happens to the service with large number of neurology graduates
 
The number of jobs that are 100% IR is increasing. The number of jobs in PP with clinic is also increasing. 20 years ago it was almost unheard of. As the new generation of IRs desire/demand high percentage IR I think that number will increase.

Word on DR. Burn out rate for DR is extremely high and is one of the highest among all specialty’s. Look it up. DR losses territory whenever another specialty wants it. Cards comes in and says I want all the cardiac MR and coronary CTs as just one example they get it. But there are “exclusive contracts” how can that happen? Because they’re pseudoexclusive. These hospitals break their contracts all the time for things like this. Groups can’t do anything about it. Vascular ultrasound often gone to vascular services usually people that have an RPVI status (get your RPVI IRs out there), OB Ultrasound gone.
IRs doing Fluoro, not that common in situations where you see a 100% IR job. Not surprisingly when you see a 100% IR job the IRs have time to build a practice and steady stream of high end cases. You know what I see a lot of? IRs getting stuck with biopsies and drains in hospitals where that should fall on DR in which DR says they’re not comfortable doing the procedure.

I think Tiger probably has mostly worked in low level hospitals/centers in which there is low level Stuff all around not just IR.
I have never seen an IR come into a hospital at 1:00am to do a para or Thora as Tiger suggested. That falls on the ER attending/PA. Lines? Maybe in a very low level hospital. The type of place that makes you think oh god don’t let me get in a car accident on the road in front of this hospital out of fear that they might actually take me to that hospital. Gi bleed, PEs absolutely you’re getting called in for that. Call me anytime for a bleed or PE so I can come in and save someone’s life which is exactly the opposite of what the radiologist coming in at 7am to clean up a bunch of ICU plain films is doing. Nephrostomy tubes, choly tube sure you will get called in for that but it’s rare can usually wait tell the morning. still life saving maneuver and makes me feel good to do it. Dislodged g or j tube. I have never seen an IR come in the middle of the night for this. It can always wait tell the next morning. Neurology graduates covering stroke. Being a neurology graduate does not make you qualified to cover stroke. You have to do a stroke fellowship followed by a 2 year Neuroendovascular fellowship. I will concede the number of neurologist doing stroke is increasing.
“Being on call for pad” statement does not make any sense. No one comes in to treat CLTI at 1 am or even on the weekend for that matter those get treating during the week. acute limb ischemia is mostly covered by surgery because these are often surgical cases, cutdowns with fogarty Thrombectomy in some cases bypass, faciotomy, IR or cardiology can help in cases that are early enough to attempt an endovascular approach. The new pounce Thrombectomy device works great for this, penumbras suction thrombectomy device also works well for this, lytic therapy especially if a stent or bypass has gone down is great. But acute limb should only be done with surgery backup. His statements clearly shows a lack of basic IR call knowledge.
 
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NDcienporciento100 said:
The number of jobs that are 100% IR is increasing. The number of jobs in PP with clinic is also increasing. 20 years ago it was almost unheard of. As the new generation of IRs desire/demand high percentage IR I think that number will increase.

Word on DR. Burn out rate for DR is extremely high and is one of the highest among all specialty’s. Look it up. DR losses territory whenever another specialty wants it. Cards comes in and says I want all the cardiac MR and coronary CTs as just one example they get it. But there are “exclusive contracts” how can that happen? Because they’re pseudoexclusive. These hospitals break their contracts all the time for things like this. Groups can’t do anything about it. Vascular ultrasound often gone to vascular services usually people that have an RPVI status (get your RPVI IRs out there), OB Ultrasound gone.
IRs doing Fluoro, not that common in situations where you see a 100% IR job. Not surprisingly when you see a 100% IR job the IRs have time to build a practice and steady stream of high end cases. You know what I see a lot of? IRs getting stuck with biopsies and drains in hospitals where that should fall on DR in which DR says they’re not comfortable doing the procedure.

I think Tiger probably has mostly worked in low level hospitals/centers in which there is low level Stuff all around not just IR.
I have never seen an IR come into a hospital at 1:00am to do a para or Thora as Tiger suggested. That falls on the ER attending/PA. Lines? Maybe in a very low level hospital. The type of place that makes you think oh god don’t let me get in a car accident on the road in front of this hospital out of fear that they might actually take me to that hospital. Gi bleed, PEs absolutely you’re getting called in for that. Call me anytime for a bleed or PE so I can come in and save someone’s life which is exactly the opposite of what the radiologist coming in at 7am to clean up a bunch of ICU plain films is doing. Nephrostomy tubes, choly tube sure you will get called in for that but it’s rare can usually wait tell the morning. still life saving maneuver and makes me feel good to do it. Dislodged g or j tube. I have never seen an IR come in the middle of the night for this. It can always wait tell the next morning. Neurology graduates covering stroke. Being a neurology graduate does not make you qualified to cover stroke. You have to do a stroke fellowship followed by a 2 year Neuroendovascular fellowship. I will concede the number of neurologist doing stroke is increasing.
“Being on call for pad” statement does not make any sense. No one comes in to treat CLTI at 1 am or even on the weekend for that matter those get treating during the week. acute limb ischemia is mostly covered by surgery because these are often surgical cases, cutdowns with fogarty Thrombectomy in some cases bypass, faciotomy, IR or cardiology can help in cases that are early enough to attempt an endovascular approach. The new pounce Thrombectomy device works great for this, penumbras suction thrombectomy device also works well for this, lytic therapy especially if a stent or bypass has gone down is great. But acute limb should only be done with surgery backup. His statements clearly shows a lack of basic IR call knowledge.
Click to expand...

You lose all your credibility by saying that "DR has one of the highest burn out rates among all specialties".

Don't listen to what this guy says. He lives in a different world that is detached from realities.

I am telling to medical students that this is not true at all. Many DRs work up to their 70s and 80s and while it is not a piece of cake, DR is better than most medical specialties. Also don't forget that it is DR that is subsidizing IR's salary (Look at above post that IR leaders are begging DR for more support). So in real life, this guy does not dare to say half of these things.


Look at some realities:
There are 200 radiology training programs. Look at following facts:
Most of them don't train their IRs to do stroke work.
Most of them don't train their IRs to do PAD work because they don't have enough cases.
Vascular ultrasound is interpreted by the department that does PAD. Since IR lost most of its PAD work, they also interpret vascular ultrasound. Otherwise, IR should read them.
But
Most of them train their residents to read cardiac CTs, MRs, Nucs, OB ultrasound since radiologists still do a good number of these cases.


I am saying for the last time. PAD was not completely taken away. It was cherrypicked. Vs and Cards choose bread and butter cases, patients with good insurance and regular hour works and leave the rest for IR. IR does about 20% of PAD work but mostly on people with HMOs, complex ones and difficult patients.
 
NDcienporciento100 said:
IRs doing Fluoro, not that common in situations where you see a 100% IR job. Not surprisingly when you see a 100% IR job the IRs have time to build a practice and steady stream of high end cases. You know what I see a lot of? IRs getting stuck with biopsies and drains in hospitals where that should fall on DR in which DR says they’re not comfortable doing the procedure.
Click to expand...

It is hard to keep IR busy and it was the case in the last decade.
In the past, thoras, paras, FNAs, line end etc became part of IR.
Not it if Fluoro time like BE and VCUGs.

Building practice does not happen when IR joins a DR group( you can see the above talk from IR leaders). If you want to build practice, go solo and do it. But as long as you join a DR group ($$$), you are stuck with lines, tubes, drains, thoras, paras and now Fluoro. This is what most IRs say. irwarrior has mentioned several times in his posts.
 
NDcienporciento100 said:
www.beckershospitalreview.com

29 physician specialties ranked by 2022 burnout rates

Last year, 53 percent of physicians reported burnout. Among them, emergency medicine specialists had the highest rate at 65 percent, according to Medscape's latest report on physician burnout and depression.
www.beckershospitalreview.com www.beckershospitalreview.com
Click to expand...

This is the list. Could you please explain to me how you came to the conclusion that "Burn out rate for DR is extremely high and is one of the highest among all specialty’s"?


Also FYI, in that list it does not seperate DR from IR. I best manyof those burnt out "radiologists" are IR.




1. Emergency medicine — 65 percent of physicians reported burnout
2. Internal medicine — 60 percent
3. Pediatrics — 59 percent
4. Obstetrics and gynecology — 58 percent
5- Infectious diseases — 58 percent
6. Family medicine — 57 percent
7. Neurology — 55 percent
8- Critical care — 55 percent
9- Anesthesiology — 55 percent
10. Pulmonary medicine — 54 percent
11. Radiology — 54 percent
12. Oncology — 52 percent
13. Gastroenterology — 52 percent
14. General surgery — 51 percent
15. Diabetes and endocrinology — 51 percent
16. Rheumatology — 50 percent
17. Otolaryngology — 49 percent
18. Allergy and immunology — 49 percent
19. Dermatology — 49 percent
20. Ophthalmology — 48 percent
21. Physical medicine and rehabilitation — 47 percent
22. Psychiatry — 47 percent
23. Urology — 47 percent
24. Plastic surgery — 46 percent
25. Orthopedics — 45 percent
26. Nephrology — 44 percent
27. Cardiology — 43 percent
28. Pathology — 39 percent
29. Public health and preventive medicine — 37 percent
 
NDcienporciento100 said:
54% of radiologists are burnt lol
Click to expand...

Also:

49% of Dermatologists are also burnt out according to the same list.
46% of Plastic surgeons
59% of Pediatricians


You see.
This is the best of your logic. You use similar way of reasoning when it comes to discussing IR issues.

Honestly, I feel I wasted my time talking to you.
 
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Tiger100 said:
This is the list. Could you please explain to me how you came to the conclusion that "Burn out rate for DR is extremely high and is one of the highest among all specialty’s"?


Also FYI, in that list it does not seperate DR from IR. I best manyof those burnt out "radiologists" are IR.




1. Emergency medicine — 65 percent of physicians reported burnout
2. Internal medicine — 60 percent
3. Pediatrics — 59 percent
4. Obstetrics and gynecology — 58 percent
5- Infectious diseases — 58 percent
6. Family medicine — 57 percent
7. Neurology — 55 percent
8- Critical care — 55 percent
9- Anesthesiology — 55 percent
10. Pulmonary medicine — 54 percent
11. Radiology — 54 percent
12. Oncology — 52 percent
13. Gastroenterology — 52 percent
14. General surgery — 51 percent
15. Diabetes and endocrinology — 51 percent
16. Rheumatology — 50 percent
17. Otolaryngology — 49 percent
18. Allergy and immunology — 49 percent
19. Dermatology — 49 percent
20. Ophthalmology — 48 percent
21. Physical medicine and rehabilitation — 47 percent
22. Psychiatry — 47 percent
23. Urology — 47 percent
24. Plastic surgery — 46 percent
25. Orthopedics — 45 percent
26. Nephrology — 44 percent
27. Cardiology — 43 percent
28. Pathology — 39 percent
29. Public health and preventive medicine — 37 percent
Click to expand...
29 specialties and radiology is the seventh highest for burnout. Yes, tied with others. Orthopedic Surgeons are less “burnt out” than radiologists. If IR was on this list by itself, it would have a lower burn out rate then radiology definitely lower for those that are doing 100% IR. Just my opinion.
 
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