Pros/Cons of different IR practice models

[IRmonkey]

I would be interested to hear peoples thoughts on the Pros/Cons of the different types of IR practice models in private practice:

• Hospital employee
• IR mixed with diagnostic radiology group practice
  • Doing part time IR with some diagnostic radiology or
  • ~100% IR in a group with diagnostic radiologists
• Pure IR group
• IR/vascular surgery groups

Academic IR can also be included in this discussion.

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[IRmonkey]

My uderstanding is that most private practice IR jobs are as part of a "radiology group" that includes both diagnostic radiologists and interventionalists. This generally seems to work well with the diagnostic group refering patients for procedures who then get their follow-up imaging form their diagnostic colleagues. There are a few caveats to this model however that have generated some discussion in the IR communinty.

• With IR becoming more of a clinical subspecialty, some diagnostic radiologists have had diffilculty understanding why interventionalists need clinic facilities and time to see patients (when they may otherwise be generating RVUs). I have spoken to practices where this has been a sore spot and others where it has been a non-issue.
  • An aggressive interventionalist that markets his services to local physicians/patients could potentially bring in additional RVUs to the practice however by seeing patients in clinic and following them longitudinally. Some have argued that for this reason interventionalists should recieve a pay differential when part of a "radiology group" -they bring in new patients that will require procedures and pre-/post- imaging.
• Radiology groups are increasingly seeing interventionalists as critical to thei long-term viability in the age of PACS. Aggressive outside radiology groups can now scoop hospital contracts from local groups and provide subspecialty reads, overnight coverage, etc in addition to daytime coverage. Having "boots on the ground" makes this much less likely to happen. IR is something that cannot be provided remotely and is therefore very desirable for radiology groups to have.
• Mixded groups may also have call inequalities that are a potential source of contention. i.e. interventionalists may have increased call due to a smaller interventionalist pool to cover call and/or need to help cover diagnostic all as well.

There are of course more Pros/Cons/issue to be discussed, but I thought I'd bring up a few points for discussion.

 

[badasshairday]

bump.

 

[shark2000]

- Many groups in big cities are becoming hospital employees. So option number one is not a real separate one.

- Pure IR groups are not common. There are very few of them.

- Outside academic centers and big groups, 100% IR job is very very difficult to come by. There are very few practices, but overall the typical practice is DR mixed with IR.

Pros and Cons of each:
- When you are a part of DR group, there is mutual benefit. For DR it provides stability of the practice. Even the DR groups that are not doing IR, try to seek stability by doing procedures from feeding tubes to biopsies and drains. On the other hand, if you are IR it is generally easier to find cases if you have strong DR department. For example, finding spine procedures without having tons of spine MRs to read is very difficult. By doing DR, you can find cases. This is one of the reasons vascular surgeons try to read all vascular US in any hospital. US for AAA coming from family physician ---> find AAA --> EVAR.

- The flip side is lack of appreciation of what you do to establish a practice when you are a part of DR group. I myself do procedures including a lot of pain procedures. I have to spend time with patients to follow them and give them post op instructions/pain management. In order to fit this into my schedule, I have to work longer hours. The same happens for other procedures. The major emphasize in pp is on productivity and a lot of things you do for procedures do not generate RVU per se. Bottom line: be ready to spend more hours than your DR colleagues with similar pay check.

- Mixed DR and IR in some practices is schedules very bad. They expect you to read DR between your IR cases in the same day. This does not make sense to me. You can not take care of post procedure patients well. Also you can not do a consult in a cemprehensive way. The best practice setup I have seen is to have an IR week and then DR week. This helps to run a clinical IR department, since you can easily admit patients or do consults. Also having dedicated IR and dedicated DR days is the best next model.

- Right or wrong, a lot of IR jobs don't give you enough time and opportunity to establish a practice. They just want to join the group and do light procedures to help seniors not move from their chair. On the other hand, there are a lot of places where you can establish a practice and grow it. This is also a two sided problem. Unfortunately, because of the market, at least some people do IR just to get a job without any incentive to grow a practice. Having colleagues with such mentality can kill your practice.

In my experience, if you put time and energy you can establish a good practice even in a competitive market. Everybody in this forum knows that I am not a great fan of IR. However, if you like it, go for it. I personally am not IR trained (I did a procedure heavy MSK fellowship and a body mini fellowship). However we started a spine/pain management service with one of my colleagues not a long time ago and right now our schedule is booked for the next two months. Also our biopsy numbers have increased dramatically since oncologists now prefer us to do them. And all of this happened in a short time in a super competitive market where pain was controlled by anesthesiologists (and somehow PM&R) and where a lot of IR groups were and are complaining of not having enough business.
Bottom line: If you do it right, there are tons of opportunities, both in DR and IR.

 

[irwarrior]

shark2000 has the right attitude. You have to work to be a successful IR and you can succeed in a competitive environment. It will not be handed to you on a silver platter. Though there are few 100 percent IR jobs, these seem to be growing in number over the past several years. More and more IR are becoming hospital employees, working in an outpatient vascular center, having separate IR groups, joining a surgery group or even cardiology group.

I agree that mixing DR and IR during a workday is impractical if you offer comprehensive care, admit your patients, round on them, discharge them etc. Many DR practices don't comprehend IR much less clinical IR. Though there is no great RVU for office based practice, rounding etc, these tasks are critical to good patient care and vital to doing the higher end IR procedures such as AAA, interventional oncology, pain interventions etc.

 

[SIRStudents]

There will be a webinar hosted by the Medical Student Council of SIR on December 12th at 9pm EST on the various IR practice models as well as IR job outlooks. I encourage you to attend this for more information and perspectives from various IR attendings across the country. Join the RFS mailing list serve for the official invitation.