What is the future of IR?

[aslkfdj]

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Where are things heading work, innovation, and compensation/reimbursement-wise? What are the chances that IRs will finally start opening their own clinics to solve the patient referral problem?

 

[SeisK]

A few new procedures slowly starting to gain traction: PAE, GAE, and others that are a little older are also gaining altitude, again slowly.

Reimbursements precipitously decreasing, like everywhere else.

Solving the referral pattern is a tough cookie as the in place institutions (radiology practices) don’t like forking over time for IRs to practice build without them taking a paycut for their decreased productivity in image reading. If you want to build practice you can, but it will entirely depend on how much time, blood, sweat, tears, and your own money you want to sacrifice. Unsurprisingly, few IRs want to do that when they have the DR cash cow they can easily hitch to.

 

[Tiger100]

Compensation-wise:
If IR stays under the umbrella of DR, it will do well.

If IR separates itself from DR, it will become similar to generally surgery. Low average salaries, but a small percentage of them especially in rural areas or in certain practice settings make good salaries.

 

[irwarrior]

VIR with DR will be a struggle to build high end practices will be relegated to hospital work biopsies, drains, fluid management . Endovascular work takes a lot of clinical acumen and work. Time that is an opportunity cost in DR groups where IR will be asked to read the list.

 

[NDcienporciento100]

There are groups that have stuck together and made good models for continuing forward. Nicholas Petruzzi opened and obl with his DR group and now IR makes more the DR for that group on average. There are other examples.

Pediatric radiology makes less than breast radiology for example. So what are you going to do? Are you going to kick all the pediatric radiologist out? of course not that’s why you’re in a group you realize that certain specialties make more than others and that’s just part of the contract. Frankly, the average radiologist could not do what I do just like I can’t do what they do at the level they do it. Diagnostic radiologist need us! Period. The problem is some IRs allow themselves to be bullied by DR. **** that! Without us the hospital would cancel their contract before business days, end! Fact.

 

[irwarrior]

VIR only thrives with clinic. No other subspecialty needs clinic in rads. VIR would do better joining surgery or IC or a multi specialty physician group. Clinic is costly lots of overhead and the downstream benefits takes at least 3 to 5 years to see the return on investment.

 

[Tiger100]

There are groups that have stuck together and made good models for continuing forward. Nicholas Petruzzi opened and obl with his DR group and now IR makes more the DR for that group on average. There are other examples.

Pediatric radiology makes less than breast radiology for example. So what are you going to do? Are you going to kick all the pediatric radiologist out? of course not that’s why you’re in a group you realize that certain specialties make more than others and that’s just part of the contract. Frankly, the average radiologist could not do what I do just like I can’t do what they do at the level they do it. Diagnostic radiologist need us! Period. The problem is some IRs allow themselves to be bullied by DR. **** that! Without us the hospital would cancel their contract before business days, end! Fact.

If the group has an exclusive hospital contract, then IR helps DR to have a little more stability but it is not like that they will lose contract over night.
Otherwise, if it is a big healthcare system like Kaiser or if the group is hospital employee, DR does not need IR.

On the other hand, IR can not support its salary in most markets and needs to be subsidized either by DR or by hospital OR it should get used to lower salaries like general surgery.

Before jumping in and saying that without IR, DR group losing its contract and everything will be shifted to telerad, I am going to reply to the hype.
I have not seen any hospital to have a reasonable DR service if it is completely covered by telerad. Even the hospitals that have IR on site and do most of their DR by telerad, have a crappy DR service and eventually try to find a DR group to staff them.

Also telerad is not composed of aliens. There are many DRs who work for telerad and make salaries that are more than most IRs.

My 2 cents.

 

[Tiger100]

VIR only thrives with clinic. No other subspecialty needs clinic in rads. VIR would do better joining surgery or IC or a multi specialty physician group. Clinic is costly lots of overhead and the downstream benefits takes at least 3 to 5 years to see the return on investment.

A mutli-specialty group or any partnership is two sided.

You like to join VS or IC but they don't want to. There are few exceptions esp in rural areas that there is shortage of physicians but in most places, IC and VS don't see any point in partnership with IR.
If you doubt it, Just take a look at all vascular centers and see how they are staffed.

The problem that I have with your arguments is the fact that you always talk about exceptions and not market norms. OBL can be successful but may be 10% of IR are running an OBL at most. Clinic is great, but at most 10% of IRs are running a thriving clinic. These are the facts.

I am saying this for medical students because they deserve to know the realities:
A typical IR job is very diverse, rewarding and pays very well. It is a great field to go into.
A typical IR job is 20 % high end IR, 40% basic procedures and 30% DR. IMO, it is a great mix and if you like it definitely go for it.

But what some people talk about here are IR in big cancer centers, IR in academics or exceptions in the community and not the practice norm in community.

My brother is an IC. I also know a handful of ICs. Most of them agree that running your own clinic or your own outpatient cath lab is extremely difficult in this market. Even one of them who had his own clinic, closed it and became employee of the hospital.

Telling medical students and residents to go into a field but completely ignore 90% of the jobs in that field and instead trying to open your own clinic and OBL which needs a lot of experience and a lot of business skills is not fair.

Good Luck.

 

[NDcienporciento100]

I’m going to give a reality check! Most radiologist in private practice don’t like what they do. Why? Because the volumes of what they are required to read are too high. You can tell the difference between an academic read vs PP read. I seen transfer patients outside reads all the time . Garbage reads. Calling things that should not be called and could have been sorted out by simply looking at a prior but most don’t care or don’t have the time. Tons of missed reads. There is my reality check. There happiness shows in their quality of work.

 

[Tiger100]

Most DRs are happy in private practice. I know at least 40 other DRs and most of them are satisfied with what they do.

Most radiology reports in the community are high quality and essential to patient care . Most physicians heavily rely on radiology reports. For example, oncologists follow radiology reports almost word for word. If the radiology reports were garbage, most patients with cancer would be mismanaged in the community. The same for ER. Saying that all reports are garbage is like saying that the entire ERs in the US or the entire cancer treatment is US are garbage and they mismanage the patients.

If someone thinks that all people around them are losers, he maybe the main loser himself.

 

[irwarrior]

If you join most DR groups as an IR you will be delegated to abscess drains, central lines, g tubes, paracentesis , thoracentesis and biopsies. If you want to do a lot of endovascular procedures/embolizations etc you will need an outpatient clinic. Most IR are still traditionally trained and haven't acquired adequate clinical skills to support a robust practice. The current job market is run by DR and private equity (radpartners/envision etc) and they do not gain any benefit from IR running clinics. If medical students want to join these type of practices why put yourself through IR training , just do DR and perhaps supplement with ESIR type rotations or do MSK IR or mammo and procedures etc.

 

[SeisK]

If you join most DR groups as an IR you will be delegated to abscess drains, central lines, g tubes, paracentesis , thoracentesis and biopsies. If you want to do a lot of endovascular procedures/embolizations etc you will need an outpatient clinic. Most IR are still traditionally trained and haven't acquired adequate clinical skills to support a robust practice. The current job market is run by DR and private equity (radpartners/envision etc) and they do not gain any benefit from IR running clinics. If medical students want to join these type of practices why put yourself through IR training , just do DR and perhaps supplement with ESIR type rotations or do MSK IR or mammo and procedures etc.

The funny thing is they do gain benefit. I know people who work in private DR groups that actually established a clinical service line to maintain PAD/endovascular referrals. These guys who have high endovascular volume and get through the procedures quick cover their own salary, and it stops being a loss-leader. The problem is it requires startup investment on part of the group. My experience is if it isn’t of immediate financial benefit, radiologists aren’t interested. It’s why they can’t even hold onto some of their own imaging studies. Much more difficult for cardiology to learn nuclear imaging than it was for radiologists to learn how to administer stress agents, yet somehow the cardiologists put in the legwork and radiologists didn’t. A bit frustrating to marry yourself to such a lazy field sometimes.

 

[SeisK]

Most DRs are happy in private practice. I know at least 40 other DRs and most of them are satisfied with what they do.

Most radiology reports in the community are high quality and essential to patient care . Most physicians heavily rely on radiology reports. For example, oncologists follow radiology reports almost word for word. If the radiology reports were garbage, most patients with cancer would be mismanaged in the community. The same for ER. Saying that all reports are garbage is like saying that the entire ERs in the US or the entire cancer treatment is US are garbage and they mismanage the patients.

If someone thinks that all people around them are losers, he maybe the main loser himself.

Most private radiologists are never given a reality check. Having seen both (and drawn from a diverse sample of private groups), academics is considerably higher quality. I’ve seen missed acute/disaster cases that I don’t think the radiologist that misread ever got word of, because it’s easier to just deal with ****ty reads than to go through the hassle of threatening to / actually breaking contract, if medical/surgical docs even decide to complain, which they often don’t.

Private rads probably just aren’t ever told of their awful misreads. A few I saw in residency: an adnexal cystic mass misidentified as a bladder, an MR enterography diagnosing terminal ileitis that was actually appendicitis, a very obvious, large volume GI Bleed on a tagged RBC study that was called normal (I don’t think the rad even looked at the image, or if they did, they had no idea what they were looking at). Postradiation change of an irradiated lung mass that was called tumor progression. Tubular nodules (impacted airway secretions) that were “concerning for malignancy.” The reads can be… awful. I’ve never seen quality so shoddy from an academic subspecialist.

 

[irwarrior]

The funny thing is they do gain benefit. I know people who work in private DR groups that actually established a clinical service line to maintain PAD/endovascular referrals. These guys who have high endovascular volume and get through the procedures quick cover their own salary, and it stops being a loss-leader. The problem is it requires startup investment on part of the group. My experience is if it isn’t of immediate financial benefit, radiologists aren’t interested. It’s why they can’t even hold onto some of their own imaging studies. Much more difficult for cardiology to learn nuclear imaging than it was for radiologists to learn how to administer stress agents, yet somehow the cardiologists put in the legwork and radiologists didn’t. A bit frustrating to marry yourself to such a lazy field sometimes.

True. They can reap benefit but it takes several years for the clinic to take off and have a profit return. In fact a busy clinical IR can refer a considerable amount of advanced imaging to the DR group. But ,most DR groups and physicians want low overhead and immediate return on investment. They are willing to give up certain things to maintain contracts and also to have less hassle. IR clinic is a lot of hassle for a company that has historically not had to deal with such.

 

[NDcienporciento100]

There are IRs out there that actually like to read DR. I personally don’t believe you can do both at a high level. The future will be many of these procedures being done away from the hospital setting. That trend is growing and will only continue to grow. Certain procedures, will not be able to be billed extra for being done in the hospital in future in my opinion. A UFE could probably be done for a fraction of what it costs in a hospital With no change in how the procedure is performed (granted there are some jerks in OBLs trying to do it without a micro-catheter but those are rare). I think this is an area that is evolving. If you get an sfa stent in the hospital most likely it wil be a drug coated stent or supera. You get an SFA stent in the OBL you will get some piece of crap bare metal none drug coated stent. That’s wrong and the people doing it in OBls no it’s wrong. Billing needs to change so the system still saves money but you can still use equipment with good data behind it. Some big radiology groups have seen the light and are investing in OBLs most have not. Envision and Radpartners are horrible companies. There sole goal is pay you as little as possible and themselves as much as possible. That’s what they won’t tell you at the steak recruitment dinners. Hope I never have to be associated with those people.

 

[irwarrior]

There are IRs out there that actually like to read DR. I personally don’t believe you can do both at a high level. The future will be many of these procedures being done away from the hospital setting. That trend is growing and will only continue to grow. Certain procedures, will not be able to be billed extra for being done in the hospital in future in my opinion. A UFE could probably be done for a fraction of what it costs in a hospital With no change in how the procedure is performed (granted there are some jerks in OBLs trying to do it without a micro-catheter but those are rare). I think this is an area that is evolving. If you get an sfa stent in the hospital most likely it wil be a drug coated stent or supera. You get an SFA stent in the OBL you will get some piece of crap bare metal none drug coated stent. That’s wrong and the people doing it in OBls no it’s wrong. Billing needs to change so the system still saves money but you can still use equipment with good data behind it. Some big radiology groups have seen the light and are investing in OBLs most have not. Envision and Radpartners are horrible companies. There sole goal is pay you as little as possible and themselves as much as possible. That’s what they won’t tell you at the steak recruitment dinners. Hope I never have to be associated with those people.

Hospital lobbies are extremely powerful and are trying to limit the growth of OBL/ASC. Most surgeons do several days of clinic a week and operate the remainder as it takes seeing many patients to get to that and grow a sustainable model. IR trainees are not historically accustomed to that and so when they go out they often struggle more to establish practices when compared to other endovascular specialists. I do agree that many IR procedures would be better served being done in the outpatient arena.

 

[Tiger100]

If you join most DR groups as an IR you will be delegated to abscess drains, central lines, g tubes, paracentesis , thoracentesis and biopsies. If you want to do a lot of endovascular procedures/embolizations etc you will need an outpatient clinic. Most IR are still traditionally trained and haven't acquired adequate clinical skills to support a robust practice. The current job market is run by DR and private equity (radpartners/envision etc) and they do not gain any benefit from IR running clinics. If medical students want to join these type of practices why put yourself through IR training , just do DR and perhaps supplement with ESIR type rotations or do MSK IR or mammo and procedures etc.

I did a reality check and I saw you have been posting about IR clinic and etc over and over again in the last 10-15 years.

Except for anecdotes, can you tell me how things have changed in the last 20 years for IR?

IR pathway training has been changed 3 times in the last 20 years? What has been changed really for the practice of IR?

 

[irwarrior]

I did a reality check and I saw you have been posting about IR clinic and etc over and over again in the last 10-15 years.

Except for anecdotes, can you tell me how things have changed in the last 20 years for IR?

IR pathway training has been changed 3 times in the last 20 years? What has been changed really for the practice of IR?

More and more graduates have incorporated clinic. 15 years ago it was very small number, now it is a growing minority. Still struggling with IR vs DR which is now coming to a forefront in discussion at SIR. More and more such as linemonkeymd.com have brought up the issues. OEIS society has challenged exclusive rights. SIR position statement stronger against exclusive rights. December 6th SIR/ACR having joint discussion should IR and DR continue together? Training of IR residents and DR residents continues to diverge.

 

[irwarrior]

Steps the SIR Can Take to Improve the Ability for Independent Interventional Radiologists to Obtain Hospital Privileges.

Note that this is being posted simultaneously on SIRConnect Home - SIR Connect OEISConnect Home - Outpatient Endovascular and Interventional Society, LineMonkeyMD.com Line Monkey MD – Independent IR Lives Here, and BackTable Podcast “How to get independent IR hospital privileges” https://www.backtable.com/ and various other social media platforms.

Attachments include the SIR position paper, ACR position paper, SIR 2018-22 strategic plan.

Problem: For decades, the SIR has encouraged IRs to have a clinical practice. Although some IR/DR groups have embraced this idea with robust clinics and inpatient rounding services, many IRs are either not interested in or not allowed to have a clinic. Instead, they spend significant time reading imaging studies and performing commoditized and mundane image-guided procedures. With the rise of private equity-run groups, demands to increase productivity have resulted in IRs interpreting even more imaging studies for the sake of RVU production. Folks who choose that model should be free to, but others may want to practice independently from a radiology group to build a longitudinal clinical practice and improve access to critical interventional radiology services. Because most radiology groups are contracted with the hospital for radiology services, they commonly have an exclusive contract to provide imaging services. “Interventional Radiology” is typically included in that contract. However, over the past several decades, most high RVU minimally invasive image-guided procedures have been performed by other specialists despite this contract being in place. In most hospitals, non-radiology specialists can perform any interventional procedure they want. So, in reality, these IR/DR groups have an exclusive DR and nonexclusive IR contract, hence the term “pseudo- exclusive.” The problem arises when an IR, not an IR/DR group member, applies for hospital privileges, and the group invokes its exclusive contract to block the IR. An independent IR is commonly blocked at all hospitals in an entire city because of this, while other specialists are free to perform interventional procedures wherever they want. Some may say, “Why don’t you just work in an OBL or an ASC and stay away from the hospital?” Although some states allow this, many require hospital privileges to open an OBL. Furthermore, insurance companies often require hospital privileges to become contracted.

The above environment, in large part, blocks clinical IRs from thriving in the United States. The SIR has identified this and recently released the third version of a position paper on exclusive contracting. This states that if non-IRs perform interventional procedures in a particular hospital, independent IRs should be allowed to perform these procedures. Even the ACR recently released a position statement that says the same thing. The SIR’s 2018-22 Strategic Plan’s #1 goal was “IR Physicians will thrive in their chosen practice model leading to high-quality patient care,” came and went with little change. What change did occur was by hard-fought battles by individuals on a local level. The SIR has adopted a laissez-faire approach. That is probably because the largest due-paying constituency to the SIR is hospital-based IRs in an IR/DR group.

People have asked, “What can the SIR do?” and this is the primary reason I am writing this. If they had done more, I would not still discuss this after a 31-year career. This is what I think the SIR can do to improve independent IRs’ ability to get on staff at hospitals:

1. Use their bully pulpit at every opportunity to promote a clinical practice with longitudinal care, especially those independent practices that are pure clinical ones. Part of thatbully pulpit is to be intolerant of the ubiquitous practice of radiology groups blocking independent IRs from getting hospital privileges at facilities that otherwise have an open staff policy for interventional procedures (essentially all private hospitals in the USA). They should also use the bully pulpit to criticize the IR groups without a clinical practice.

2. Identify the states where an OBL can be opened without hospital privileges so IRs can move there.

3. OBL sessions at the SIR annual meeting (currently in process).

4. Encourage IR residents to spend time in OBLs for clinical training and learn procedures they may not be exposed to, such as PAD and SVI.

5. Help develop staffing and financial models to staff IR coverage for hospitals. Currently, IR co-coverage is just a freebie thrown as part of an IR/DR contract, which is incredibly devaluing to IR. Whether part of an IR/DR group or independent, IR services should be able to negotiate a professional service agreement.

6. Develop a “How to get on staff” lecture at SIR annual meeting, which I gave in 2018

7. Be honest with med students: “There are very few jobs where you can practice full-time clinical IR. And if you want to develop your own practice, you will most likely be blocked from getting on hospital staff by the radiology group. Other specialties get on staff without a problem and do whatever procedures they want.”

8. There needs to be a change in IR leadership makeup. Currently, there is no independent IR on the Executive Committee.

9. Showcase clinical success, including OBL/independent IR at the annual meeting and “The Wire.”

10. Pay for an Amicus brief on the legality of the so-called “Exclusive” contract that allows everyone except independent IRs to get on staff at hospitals.

11. Showcase legal successes (and their lawyers) of independent IRs obtaining hospital privileges when opposed by radiology groups or the hospital.

12. Terminate SIR membership for those IRs who do not have a clinical practice or who block independent IRs from getting on staff at their hospital in direct violation of the SIR’s recommendations.

13. Promote separation of IR from DR much like radiation oncology has split from radiology. I have written about this before and encourage interested readers to check out a recent AJR article on this topic. https://www.ajronline.org/doi/10.2214/AJR.23.29815

Additional thoughts: Other societies would have never let this fester so long. If their people were blocked, they would have taken to the airwaves, called stakeholders, filed lawsuits, etc. What has the SIR done? Approve a position paper and otherwise sit idly by while a group, largely without longitudinal clinics or rounding services that mostly read films and perform low-level procedures, block purely clinical independent IRs. Why does the SIR not support the ones who want to practice IR like the society recommends we practice? Which group will make the SIR proud and help create IR leaders in our communities? There will be some who will say, “Let’s study this” (some more). To that, I would say this is a decade-old problem that has not changed much since Jerry Niedzwiecki and I brought it up at the 2004 Phoenix SIR Annual Meetin Business Session. At that time, a significant number in the audience of thousands booed us. An entire generation of IRs have been affected by this problem and have had their options limited. Most of the SIR membership has either blocked the independent IRs, were complacent, or, in some cases (academics mostly), were unaware or did not care.



These actionable suggestions should serve as a roadmap for the leaders in IR to correct course. However, If the consensus is to talk about it some more or do nothing, medical students who want to pursue clinical IR should consider applying to other specialties without the current barriers to a clinically oriented independent interventional radiology practice.

William H. Julien, MD DFOEIS

https://www.sirweb.org/globalassets...clusive-contracting-policy-statement-2023.pdf

https://www.acr.org/-/media/ACR/Files/Governance/Digest-of-Council-Actions.pdf

https://www.sirweb.org/globalassets...ernance/2018-2022-strategic-plan_approved.pdf

 

[Tiger100]

The funny thing is they do gain benefit. I know people who work in private DR groups that actually established a clinical service line to maintain PAD/endovascular referrals. These guys who have high endovascular volume and get through the procedures quick cover their own salary, and it stops being a loss-leader. The problem is it requires startup investment on part of the group. My experience is if it isn’t of immediate financial benefit, radiologists aren’t interested. It’s why they can’t even hold onto some of their own imaging studies. Much more difficult for cardiology to learn nuclear imaging than it was for radiologists to learn how to administer stress agents, yet somehow the cardiologists put in the legwork and radiologists didn’t. A bit frustrating to marry yourself to such a lazy field sometimes.

Lol. Who lost the biggest turf? IR or DR? What do you smoke?

So you are saying that if DR loses 5 % of its turf ( Nucs cards is about 5 % of imaging and is still done 20-30% by radiologists), it is because they are lazy. But if IR loses 90% of its turf (PAD), the blame is one DR? hah.

Nucs cardiology is one of the easiest studies to read. The reason that caridologist got into the game is the same reason that they took away PAD from IR. They control referrals.

Most radiologists that I know of, invest in real estate and stocks. They don't look for immediate financial benefit but for a lot of them investing in OBL does not make sense financially. Most DRs (and IRs) can comfortably reach financial independence in their 50s.

Practically, you are saying that DR is obligated to help IR. Otherwise, they are shortsighted.

I think it is a lot better for IR to seperate from DR. But then don't expect DR to help you establish clinic. Go your own way.

 

[irwarrior]

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[irwarrior]

Line Monkey MD Commentary:
As someone who has lived the struggles of being an independent IR, having been denied privileges at over six hospitals to date due to pseudo-exclusive radiology group contracts (PECs) and gaslit into believing that all of this is somehow my fault for not establishing good working relationships with local hospital-based radiology group employed interventional radiologists, Bill’s post rings true. It is downright embarrassing for us as a field that the issue of pseudo-exclusivity has been going on for decades. Like everything in life, politics are involved and the devil is in the details. I have learned these lessons the hard way.
When many academic leaders in the SIR and ACR hear the names Bill Julien or Jerry Niedzwiecki, they roll their eyes and react negatively. A mid-career IR friend even used the term “ear-muff” when describing the typical academic IR reaction to the issue of PECs. I have been encouraged not to associate myself with Bill or Jerry because they have reportedly “burned many bridges” and have been described as “like a bull in a china shop.” I’m not exactly sure what happened at these professional meetings in the late 1990s or early 2000s, nor do I care. At that time, I was more worried about my parents getting on the phone and interrupting my Naspter music downloads on my blazing-fast 36.6 dial-up internet than I was about interventional radiology. Many readers of this blog were probably in diapers. Fast forward 20+ years later, having a few initials after my name and a greater appreciation for the politics of our profession, I, too, am pretty upset given the fact that my professional livelihood is threatened by a group of radiologists more concerned with protecting the status quo than with improving our ability to impact change at scale.
Although there are significant negative undertones as a result of the challenges presented by the reality of independent IR, particularly within the context of a healthcare landscape where the concept of private practice is dwindling, there is hope to be gleaned thanks to the hard work of independent IRs who have come before me, including Bill and Jerry. I want to highlight the positive trends I’ve noticed:

1. Trainees and young IRs are interested in providing longitudinal care.

While this may not be true for every trainee, more trainees now than ever are interested in providing comprehensive IR services, including clinic and rounding services. This has been reflected in the changing training paradigm brought about by the IR/DR residency. While the new training is far from ideal, it was a critical step in altering the direction of interventional radiology.

1. IRs Seek New Opportunities

When I wrote the “IR Hospitalist: Hospital MVP or Glorified Trash Collector,” it got such a popular response not just because of my language but because the hospital Trash Collector resonates with many interventional radiologists. The practice pattern comes from commoditizing image-guided procedures lumped under a “radiology services” contract. Trash collection is supported and encouraged by a radiology business model, which often dangles image-guided procedures as a free carrot to a healthcare system in exchange for the opportunity to interpret their diagnostic imaging. Continued decreases in reimbursement which have accelerated private equity buy-outs and rapid commoditization of our profession all within the context of a global pandemic, have created a general sense of angst and frustration among many. IRs want change, and many realize that most radiology groups do not provide the avenue for the autonomy, purpose, and mastery that they desire.

1. A Greater Interconnectedness Among IRs

Despite its annoyances and problems, social media has resulted in a more interconnected community of IRs who seek to advance their craft and elevate their colleagues. I have seen this in my own life. Our ability to leverage technology to build a community of like-minded individuals passionate about IR encourages me. With improved avenues to connect and communicate, our community will only become more enhanced in due time.
The common thread that binds us all interested in a new path of clinically oriented interventional radiology services is the concept of longitudinal clinical care. A robust practice must be centered around evaluation and management services, which drive procedures. Whether this is in a hospital, an outpatient interventional suite, or an ambulatory surgical center is not necessarily as important as identifying the common culture and motivation that should unite us all.
As long as interventional radiology is lumped under “Radiology Services,” the issue of pseudo-exclusive contracts will continue to hinder many well-intentioned and passionate IRs interested in expanding or creating interventional radiology services in their respective communities. Some of our academic leaders understand this, but too many play a political game that precludes them from acting on this issue. I can kick and scream as loud as I want, perhaps louder than Bill has for the last couple of decades, but the choice is theirs to decide if they want to lay the groundwork for a better future. Suppose they choose to continue with the status quo. In that case, they are well aware of the consequences of that decision, which will largely be motivated by self-preservation, fame, and economic gain rather than advancing our field to new heights.
Promoting the mission of independent IR also depends on you, the reader. Being vocal about how you want to see the field advance, including participation in societies like SIR and OEIS, is critical. While politics are inevitable, change never happens unless a critical mass of people want to see that change.
Regardless of what happens regarding independent IR on a larger scale, this blog will support those looking to create their own independent path. We must stick together and support one another. It is easy to be negative and use the challenges people like Bill and I have identified as an excuse in our professional lives. To medical students and trainees, you need to understand the reality of interventional radiology and be ready to adapt to the ever-changing nature of this field. There are far more well-defined and clinically oriented fields of medicine where you can plug and play into a job that will be satisfying, but consider these challenges outlined here as the cost to play in the magical sandbox that is IR. Things may look different in the future, but crystal balls tend to be cloudy, and no one knows how this will play out. There will always be challenges and headwinds, but we will never achieve anything great without focusing on what we can control. Bill taught me that lesson and exemplifies what is possible in IR. I hope our community embraces the message of longitudinal clinical care and takes the requisite political steps to support those who choose to follow in Bill’s footsteps.

 

[Tiger100]

Most private radiologists are never given a reality check. Having seen both (and drawn from a diverse sample of private groups), academics is considerably higher quality. I’ve seen missed acute/disaster cases that I don’t think the radiologist that misread ever got word of, because it’s easier to just deal with ****ty reads than to go through the hassle of threatening to / actually breaking contract, if medical/surgical docs even decide to complain, which they often don’t.

Private rads probably just aren’t ever told of their awful misreads. A few I saw in residency: an adnexal cystic mass misidentified as a bladder, an MR enterography diagnosing terminal ileitis that was actually appendicitis, a very obvious, large volume GI Bleed on a tagged RBC study that was called normal (I don’t think the rad even looked at the image, or if they did, they had no idea what they were looking at). Postradiation change of an irradiated lung mass that was called tumor progression. Tubular nodules (impacted airway secretions) that were “concerning for malignancy.” The reads can be… awful. I’ve never seen quality so shoddy from an academic subspecialist.

I agree that most private practice radiologists including IRs are not give reality check.

I have personally seen IRs doing a worse or a lot worse job treating PAD compared to VS and IC. There are publications that show IR has higher complication rate. But these IRs mostly look for their financial gain and they don't care about patients.

These are reality checks:
Most IR residencies and fellowships don't train their IR to do PAD well.
Most IR residencies and fellowships don't train their IRs to have clinic.

So it is a huge disservice to the patient to do things that are above your level of training. On the other hand most VS and ICs are very well trained to do PAD both from medical management stand point and procedure wise.
A lot of ICs do about 300-500 PAD cases during their fellowship. Most IRs do less than 50. And medically off course they are better trained.

 

[irwarrior]

I don't know too many IC fellows doing 300 to 500 PAD cases during training. Which ones? Agree IR trainees need to expand their exposure to clinics and to PAD training. Medical students should ask about this when interviewing to see how much exposure they will get to PAD and to clinic in general.

 

[Tiger100]

More and more graduates have incorporated clinic. 15 years ago it was very small number, now it is a growing minority. Still struggling with IR vs DR which is now coming to a forefront in discussion at SIR. More and more such as linemonkeymd.com have brought up the issues. OEIS society has challenged exclusive rights. SIR position statement stronger against exclusive rights. December 6th SIR/ACR having joint discussion should IR and DR continue together? Training of IR residents and DR residents continues to diverge.

I think it is time for DR to separate itself from IR and vice versa.

As you mentioned above, DR will do some bread and butter procedures like biopsies, drains, Thoras, FNAs and etc in order to comply with hospital contract requirements. they may even hire an IR to do these procedures for them.

And IR can continue to create its own specialty.

But it is now fair to expect DR to support you. DR is already heavily subsidizes IR. In our group, IRs generate about 60% of their income. We are fine with the setup and the IRs are also satisfied with that. But if an IR expects more or they are not satisfied, they can go their own way.

Eventually, by separating itself IR probably needs to be subsidized by the hospital.

I know some IRs who make a lot of money, probably 50% more than an average DR. But these people are mostly in rural areas and they get to that point after 5-10 years of practice building. And even if that case, if a DR work similar number of hours they can make similar salaries.
However, in big and midsize cities, IRs who have OBLs don't make significantly more than busy DR groups in the area.

People are free to choose what they want. But our responsibility is to inform them with accurate information. The rest is up to them.

 

[Tiger100]

I don't know too many IC fellows doing 300 to 500 PAD cases during training. Which ones? Agree IR trainees need to expand their exposure to clinics and to PAD training. Medical students should ask about this when interviewing to see how much exposure they will get to PAD and to clinic in general.

My numbers were from one of the busy west coast teaching hospitals from what I heard from my brother. He may include all the second and third hand assistance cases as the number of cases or he may include all the cases during 3 years of residency plus fellowship.
I also said IRs do less than 50. But realistically in most IR fellowships, they do less than 10 or sometimes close to zero.

 

[Clean7795]

Don't waste too much energy arguing guys.

IR will not separate from DR in the near future because it is not financially feasible on a large scale, nor is there an established training pathway that doesn't include a ton of DR rotations.
DR will still prefer to have a few IRs since there is a significant clinical need for "lite-IR" (biopsies, lines) that cannot be offloaded.

So the near-intermediate future will still be majority DR/IR practices. I believe as radiology labor becomes increasingly stretched thin, more groups will negotiate for IR subsidization.

 

[irwarrior]

Don't waste too much energy arguing guys.

IR will not separate from DR in the near future because it is not financially feasible on a large scale, nor is there an established training pathway that doesn't include a ton of DR rotations.
DR will still prefer to have a few IRs since there is a significant clinical need for "lite-IR" (biopsies, lines) that cannot be offloaded.

So the near-intermediate future will still be majority DR/IR practices. I believe as radiology labor becomes increasingly stretched thin, more groups will negotiate for IR subsidization

I do think the training continues to diverge as the IR residents do less and less DR and will not be taking the DR orals . The DR residents are not doing as many procedures as to compared to prior to the institution of the integrated IR resident. Independent IR would have a very hard time competing with a mixed practice of IR light and reading when it comes to time off and financial compensation.

 

[NDcienporciento100]

I agree that most private practice radiologists including IRs are not give reality check.

I have personally seen IRs doing a worse or a lot worse job treating PAD compared to VS and IC. There are publications that show IR has higher complication rate. But these IRs mostly look for their financial gain and they don't care about patients.

These are reality checks:
Most IR residencies and fellowships don't train their IR to do PAD well.
Most IR residencies and fellowships don't train their IRs to have clinic.

So it is a huge disservice to the patient to do things that are above your level of training. On the other hand most VS and ICs are very well trained to do PAD both from medical management stand point and procedure wise.
A lot of ICs do about 300-500 PAD cases during their fellowship. Most IRs do less than 50. And medically off course they are better trained.

Most ICs do know where near this number in there 1-2 years of procedure training in fact some do none.

 

[NDcienporciento100]

I think it is time for DR to separate itself from IR and vice versa.

As you mentioned above, DR will do some bread and butter procedures like biopsies, drains, Thoras, FNAs and etc in order to comply with hospital contract requirements. they may even hire an IR to do these procedures for them.

And IR can continue to create its own specialty.

But it is now fair to expect DR to support you. DR is already heavily subsidizes IR. In our group, IRs generate about 60% of their income. We are fine with the setup and the IRs are also satisfied with that. But if an IR expects more or they are not satisfied, they can go their own way.

Eventually, by separating itself IR probably needs to be subsidized by the hospital.

I know some IRs who make a lot of money, probably 50% more than an average DR. But these people are mostly in rural areas and they get to that point after 5-10 years of practice building. And even if that case, if a DR work similar number of hours they can make similar salaries.
However, in big and midsize cities, IRs who have OBLs don't make significantly more than busy DR groups in the area.

People are free to choose what they want. But our responsibility is to inform them with accurate information. The rest is up to them.

You can get away with this in the middle of know where but know where of size.

Hospital administrator: what do you mean no one is available to do a PTC?
Diagnostic Radiologist: yeah we just let them go. They’re not as profitable as negative head CT’s from the ER.
Hospital administrator: we have a busy hepatobiliary service and unfortunately that is a requirement your contract states you need to fulfill we’re looking for somebody to fill the contract as yours will terminated shortly.

 

[NDcienporciento100]

My numbers were from one of the busy west coast teaching hospitals from what I heard from my brother. He may include all the second and third hand assistance cases as the number of cases or he may include all the cases during 3 years of residency plus fellowship.
I also said IRs do less than 50. But realistically in most IR fellowships, they do less than 10 or sometimes close to zero.

I have already done over 100.

 

[irwarrior]

I have already done over 100.

That is a solid number of leg revascularizations

 

[NDcienporciento100]

For some reason the conversation always unjustly comes back to PAD. It’s not really fair. PAD is a fraction of what we can and do do. I happen to love it. Many of my co residents don’t like it.

SFA/Iliac Disease: short segments anyone can do. SFA long segment occlusions can be difficult, but a couple reentry cases with outback and even those are not too bad.

Tibial disease/pedal disease: I argue that there is only a couple hundred operators in the us doing this at a high level regardless of specialty, antegrade/retrograde access, CART/Reverse Cart, EVUS, atherectomy, shockwave, accessing occluded vessels, DVAs. Very few operators do all these things well. In fact most regardless of speciality do not. CLI Fighters organization has large proportion of them. But let me be clear not ever vascular surgeon resident, cardiologist, or IR is getting tranined to do the above at a high level. The vast majority are not. There is a small number of physicians doing it.

 

[NDcienporciento100]

There is much more we do other than PAD. Superficial Venous disease as just one example is multiple times more common than arterial disease. Requires clinical and longitudinal follow-up.
More important Hospitals need us! Any radiology group that is letting the one eyed fangless Tigers of the world make you think you your not meeting your worth needs to put your foot down and say **** that I’m gone if you want to lower my salary you will see how quickly they change there mind.

 

[irwarrior]

The challenge is in the hospital the needs for IR are different ie paracentesis, thoracentesis, chest tubes, g tubes, biopsies, central lines, abscess drains, nephrostomy tubes , lp, myelograms, arthrograms etc. Hospital will also occasionally have the bleeder that may require IR skillset.

Veins and pain are much more prevalent and can definitely be built in the OBL, but PAD and atherectomy codes and balloon codes and stent codes are often needed to stay viable. Embolization codes also work to a lesser degree and you can grow GAE, PAE, UAE, PCS etc as well . These will take a bit more effort to expand with marketing and changing referral patterns and pre-authorization codes etc. The hospital work does not generate much in the way of RVU and so often requires subsidy from DR groups or the hospital itself. Historically the hospital has not been required to subsidize this but if they want "IR" services and DR does not have IR the hospital administration will either have to subsidize it or transfer patients out.

 

[NDcienporciento100]

As far as separating from DR. That is a tough one for me. It really is my secret weapon. I get a consult asking me to do something because the read says this. I look at it myself and can very confidently agree or disagree for many disease pathologies from head to toe. It is a huge separation/advantage. I think the heavy imaging skill set is necessary for the wide variety of diseases we treat.

 

[irwarrior]

As far as separating from DR. That is a tough one for me. It really is my secret weapon. I get a consult asking me to do something because the read says this. I look at it myself and can very confidently agree or disagree for many disease pathologies from head to toe. It is a huge separation/advantage. I think the heavy imaging skill set is necessary for the wide variety of diseases we treat.

Every skill set matters. Our vascular surgeons are quite good at CTA and vascular us and look at it differently from the average radiologist. ie when looking at pad, they look at soft/hard plaque/occlusive lengths/ iliac/ sfa/tibials/pedal circulation. The average radiology graduate may not know the foot vascular anatomy like a CLI interventionist does (arterial/venous). Vascular surgeons are well versed in vascular us (tcpo2/toe pressures/ non invasives/PVR/segmental limb pressures) while most DR residents don't learn this. Echo and ICE is becoming more and more important for IR who are in the PE space and that is not being taught to most radiologists while cardiologists are learning this during their fellowship years. Radiology used to do a good job in teaching angiographic anatomy but that is not as common now a day and with the new DR orals it will not have IR as a section so they will have even less of a need to learn angiographic anatomy.

 

[NDcienporciento100]

Every skill set matters. Our vascular surgeons are quite good at CTA and vascular us and look at it differently from the average radiologist. ie when looking at pad, they look at soft/hard plaque/occlusive lengths/ iliac/ sfa/tibials/pedal circulation. The average radiology graduate may not know the foot vascular anatomy like a CLI interventionist does (arterial/venous). Vascular surgeons are well versed in vascular us (tcpo2/toe pressures/ non invasives/PVR/segmental limb pressures) while most DR residents don't learn this. Echo and ICE is becoming more and more important for IR who are in the PE space and that is not being taught to most radiologists while cardiologists are learning this during their fellowship years. Radiology used to do a good job in teaching angiographic anatomy but that is not as common now a day and with the new DR orals it will not have IR as a section so they will have even less of a need to learn angiographic anatomy.

I understand. But we treat head to toe. Most vascular surgeons knowledge of cerebral anatomy stops above the carotid bifurcation.

My patient is complaining of back pain I look to see if there is an acute compression fracture so I can do vertebral augmentation on them. IC and VS don’t do that. Our skill set allows us to treat a wide variety of diseases other than vascular disease. The best way to diagnose those diseases is with imaging, planning your procedure involves dissecting the imaging, I can do this easily because I have read thousands of cross sectional studies, US, XR etc. I just don’t know how we do away with all of it.

 

[SeisK]

Lol. Who lost the biggest turf? IR or DR? What do you smoke?

So you are saying that if DR loses 5 % of its turf ( Nucs cards is about 5 % of imaging and is still done 20-30% by radiologists), it is because they are lazy. But if IR loses 90% of its turf (PAD), the blame is one DR? hah.

Nucs cardiology is one of the easiest studies to read. The reason that caridologist got into the game is the same reason that they took away PAD from IR. They control referrals.

Most radiologists that I know of, invest in real estate and stocks. They don't look for immediate financial benefit but for a lot of them investing in OBL does not make sense financially. Most DRs (and IRs) can comfortably reach financial independence in their 50s.

Practically, you are saying that DR is obligated to help IR. Otherwise, they are shortsighted.

I think it is a lot better for IR to seperate from DR. But then don't expect DR to help you establish clinic. Go your own way.

You are taking this way too personally. When I say “marry myself” I mean me, personally marrying to radiology as a whole. Not IR to DR. I’m not exclusively IR, and I very much enjoy DR. You must really not like the IRs in your group lol.

The blame is on laziness. I know plenty of lazy IRs and DRs. I’m not saying anyone is obligated to help anyone, I’m saying you get what you pay for. If you sit on a couch and eat potato chips, you’re not gonna reap the benefit of having a professional soccer player’s physique. The DR groups that built up a clinical service line for their IRs (not many, but a few) resulted in IR being less of a loss leader, or not at all. It didn’t even necessarily require infrastructure investment, just time and meticulous forethought and planning. Those groups that didn’t are incessantly PO’d at having to subsidize their IRs, a trap they built for themselves. I don’t particularly care what one group or another does, there’s plenty of endovascular jobs in the country to go around. But if IR being a loss leader ticks your group off, your group probably created the circumstance for itself long ago. Just like the fat couch potato. There are ways to make it not a loss leader, which requires personal sacrifice. If you don’t want to run, don’t. But don’t act like it’s anyone’s fault but your own (lazy IRs and DRs both. The number of lazy IRs I see whining about lost endovascular stuff is hilariously mind-numbing. They pride themselves as “image-guided surgeons” but try to dump, divert, and refuse to think about any consult thrown at them… “let primary worry about that question” ). My philosophy’s simply “Put in the effort to tighten ship, or stop whining.“ If you treat any subdivision like crap, don’t be surprised if the CIRCUMSTANCES you crafted for that subdivision start treating YOU like crap.

 

[Tiger100]

Most ICs do know where near this number in there 1-2 years of procedure training in fact some do none.

Most ICs do a lot more PAD cases compared to IR. And obviously they have better clinical training to deal with it.

But I know that you are an exception.

 

[Tiger100]

I have already done over 100.

This is an exception and not the rule.

Go back to my post from last week. The problem with IR on forums is that people keep talking about outliers and not typical IR practice.

Most IR training programs do not get even close to that number.

 

[Tiger100]

For some reason the conversation always unjustly comes back to PAD. It’s not really fair. PAD is a fraction of what we can and do do. I happen to love it. Many of my co residents don’t like it.

SFA/Iliac Disease: short segments anyone can do. SFA long segment occlusions can be difficult, but a couple reentry cases with outback and even those are not too bad.

Tibial disease/pedal disease: I argue that there is only a couple hundred operators in the us doing this at a high level regardless of specialty, antegrade/retrograde access, CART/Reverse Cart, EVUS, atherectomy, shockwave, accessing occluded vessels, DVAs. Very few operators do all these things well. In fact most regardless of speciality do not. CLI Fighters organization has large proportion of them. But let me be clear not ever vascular surgeon resident, cardiologist, or IR is getting tranined to do the above at a high level. The vast majority are not. There is a small number of physicians doing it.

It seems you are just a fellow and do not have a good understanding of the business side of medicine.
I am trying to help you.

For some reason?

Outside academic centers, all the IR procedures is easily dwarfed by PAD work. That's the main reason the conversation goes back to PAD. For every Uterine artery embolization, there are 10 PADs out there.

 

[Tiger100]

The challenge is in the hospital the needs for IR are different ie paracentesis, thoracentesis, chest tubes, g tubes, biopsies, central lines, abscess drains, nephrostomy tubes , lp, myelograms, arthrograms etc. Hospital will also occasionally have the bleeder that may require IR skillset.

That is correct.

 

[Tiger100]

I understand. But we treat head to toe. Most vascular surgeons knowledge of cerebral anatomy stops above the carotid bifurcation.

My patient is complaining of back pain I look to see if there is an acute compression fracture so I can do vertebral augmentation on them. IC and VS don’t do that. Our skill set allows us to treat a wide variety of diseases other than vascular disease. The best way to diagnose those diseases is with imaging, planning your procedure involves dissecting the imaging, I can do this easily because I have read thousands of cross sectional studies, US, XR etc. I just don’t know how we do away with all of it.

IR is not the person who manages patients with back pain. A patient with back pain normally goes to their primary care doctor. The PCP order back Xray or CT or MRI. The MRI shows compression fracture. Then the PCP usually sends the patient to a doctor who usually takes care of back pain issues esp if the patient has lower extremity numbness or etc or may send the patient to a pain management doctor.

It is extremely uncommon for PCPs to send the patient with compression fracture to IR. And to be honest, it is not the right thing to do.

The best way to diagnose disease is not imaging. It is a combination of history, imaging, lab work etc. Similarly, the best way to treat disease is not catheters or image guided procedures. It is a combination of medical management, physical therapy(or other ancillary stuff) and if these do not work then image guided or open procedures.

 

[Tiger100]

You can get away with this in the middle of know where but know where of size.

Hospital administrator: what do you mean no one is available to do a PTC?
Diagnostic Radiologist: yeah we just let them go. They’re not as profitable as negative head CT’s from the ER.
Hospital administrator: we have a busy hepatobiliary service and unfortunately that is a requirement your contract states you need to fulfill we’re looking for somebody to fill the contract as yours will terminated shortly.

If IR separates itself form DR, then PTC will become the responsibility of the separate IR group and not DR group. The hospital admins will change the contract terms over night.

It is not easy to replace a DR group. In this market, it is almost impossible.

 

[Tiger100]

As far as separating from DR. That is a tough one for me. It really is my secret weapon. I get a consult asking me to do something because the read says this. I look at it myself and can very confidently agree or disagree for many disease pathologies from head to toe. It is a huge separation/advantage. I think the heavy imaging skill set is necessary for the wide variety of diseases we treat.

Let's be honest. Your imaging skills is better than ICs or VSs or many clinicians. But a DR with fellowship training reads imaging better than an IR.

Don't overestimate your skills and don't underestimate others.

 

[Tiger100]

You are taking this way too personally. When I say “marry myself” I mean me, personally marrying to radiology as a whole. Not IR to DR. I’m not exclusively IR, and I very much enjoy DR. You must really not like the IRs in your group lol.

The blame is on laziness. I know plenty of lazy IRs and DRs. I’m not saying anyone is obligated to help anyone, I’m saying you get what you pay for. If you sit on a couch and eat potato chips, you’re not gonna reap the benefit of having a professional soccer player’s physique. The DR groups that built up a clinical service line for their IRs (not many, but a few) resulted in IR being less of a loss leader, or not at all. It didn’t even necessarily require infrastructure investment, just time and meticulous forethought and planning. Those groups that didn’t are incessantly PO’d at having to subsidize their IRs, a trap they built for themselves. I don’t particularly care what one group or another does, there’s plenty of endovascular jobs in the country to go around. But if IR being a loss leader ticks your group off, your group probably created the circumstance for itself long ago. Just like the fat couch potato. There are ways to make it not a loss leader, which requires personal sacrifice. If you don’t want to run, don’t. But don’t act like it’s anyone’s fault but your own (lazy IRs and DRs both. The number of lazy IRs I see whining about lost endovascular stuff is hilariously mind-numbing. They pride themselves as “image-guided surgeons” but try to dump, divert, and refuse to think about any consult thrown at them… “let primary worry about that question” ). My philosophy’s simply “Put in the effort to tighten ship, or stop whining.“ If you treat any subdivision like crap, don’t be surprised if the CIRCUMSTANCES you crafted for that subdivision start treating YOU like crap.

It was IR who wanted to separate itself and not the opposite.

 

[NDcienporciento100]

🙄

 

[SeisK]

IR is not the person who manages patients with back pain. A patient with back pain normally goes to their primary care doctor.

I think this may be the part that’s not computing. The person who manages back pain is the person who manages back pain, which actually can be IR if they want to be. You seem to have this illusory concept that there’s this magical period of training during residency and fellowship, outside of which no one can develop a skillset to do anything. You can, if you want to. Just like a new grad surgeon trying to establish practice, you have to put in good work to develop a referral pattern. This is why some groups held onto PAD and some didn’t. It’s because they put in the effort to pick up a damn UpToDate article and learned when to angioplasty/stent and when not to, and what to do when they didn’t. Learning the ins and outs, thoroughly, on one particular disease doesn’t take that much effort. But it takes effort, and there’s reasonable risk it won’t be rewarded. But if you don’t make effort, it definitely won’t be rewarded.

Another shocker, there are pain management fellowships that take IR lol. Give a few grand rounds to the PCPs, buy them some donuts, be available when they have questions, be nice, smile, never say no, make their life easier so that the back pain patients don’t come back to them, forward clinic note AND call after every procedure on their patients, and you can be the (uncomplicated) back pain guy, without the fellowship, if you want to.

… How is it you think referral patterns are established? How is it you think cardiology started picking up renal denervation consults from nephrologists? It’s not a self-evidently cardiology consult. They ran for it, and because of that, they deserve it.

 

[Tiger100]

I think this may be the part that’s not computing. The person who manages back pain is the person who manages back pain, which actually can be IR if they want to be. You seem to have this illusory concept that there’s this magical period of training during residency and fellowship, outside of which no one can develop a skillset to do anything. You can, if you want to. Just like a new grad surgeon trying to establish practice, you have to put in good work to develop a referral pattern. This is why some groups held onto PAD and some didn’t. It’s because they put in the effort to pick up a damn UpToDate article and learned when to angioplasty/stent and when not to, and what to do when they didn’t. Learning the ins and outs, thoroughly, on one particular disease doesn’t take that much effort. But it takes effort, and there’s reasonable risk it won’t be rewarded. But if you don’t make effort, it definitely won’t be rewarded.

Another shocker, there are pain management fellowships that take IR lol. Give a few grand rounds to the PCPs, buy them some donuts, be available when they have questions, be nice, smile, never say no, make their life easier so that the back pain patients don’t come back to them, forward clinic note AND call after every procedure on their patients, and you can be the (uncomplicated) back pain guy, without the fellowship, if you want to.

… How is it you think referral patterns are established? How is it you think cardiology started picking up renal denervation consults from nephrologists? It’s not a self-evidently cardiology consult. They ran for it, and because of that, they deserve it.

Jack of all trades, master of none.

Then what about UFE?
You have to buy donuts for PCP and tell them to send you patients with abnormal vaginal bleeding. Then you can put in an effort to pick up a damn uptodate article and learn how to manage vaginal bleeding. Also you can watch some youtube videos to watch how to do endometrial biopsy

Next you can do the same for Prostate artery embolization.

Then in order to grow your business in TACE you can learn how to manage HCCs and tell PCPs to send patients with cirrhosis to you. Then you can pick up a damn UpToDate article to learn how to manage Cirrhosis and how to manage HCC. You can even learn systemic chemotherapy by reading some articles.

Cardiology does renal denervation mostly on their own patients. They don't need nephrology for that. Most cardiologists manage hypertension at least 5-10 times a day.

The more I read your post, the more I come to conclusion that IR lives in its own dream land and does not have a good understanding of how referral patterns work.