We are already married,” says Neil J. Halin, DO, chief of section for cardiovascular and interventional radiology at Tufts New England Medical Center in Boston. “I’m afraid what we may be looking at is more like a divorce.” Halin is talking about the alliance between diagnostic radiology and interventional radiology, and like most interventional radiologists, he is concerned about the future of his subspecialty. He is concerned that diagnosticians do not grasp the much different practice demands faced by their interventional colleagues.
Ted Chambers, MD, a professionally active interventional radiologist at Fairfax Hospital in Fairfax, VA, puts it bluntly: “If interventional radiology becomes extinct in another 10 or 15 years, a large part of the blame will rest on the shoulders of general radiologists and the American College of Radiology (ACR) for not recognizing that interventional radiology must get clinically involved with its patients.”
Chambers’ words are strong, but no stronger than are those of many IR doctors who believe they are fighting a battle on two fronts to survive. On the one hand, they see themselves fighting competition from cardiologists, vascular surgeons, and other non-radiology-trained specialists, who in recent years have developed image-guided, noninvasive treatments of their own and who are aggressively marketing these competing treatments to IR’s historic pool of patients.
But competition from outside is not the only battle IR doctors believe they have to fight. The second battle is an in-house one. What makes the situation worse than just outside competition, say the IR doctors interviewed for this story, is that within radiology itself there is a lack of understanding about the pressure on IR physicians to build patient-based practices. Many IR doctors feel they need to join traditional radiology groups to function professionally, but when they do join, they find little compatibility in the marriage. They may be asked to read film instead of holding IR clinics, for example. But if they do not run the clinics, which admittedly do not pay well, then they lose out to competitors on the highly profitable IR surgical cases. The surgical patients flow from the clinics. Another sore point with interventionists is that diagnostic radiologists do not understand how much time the IR specialists have to spend just farming their skills to primary care physicians (PCPs) to get referrals.
Chambers, who practices at Fairfax Hospital but who is one of five interventionists in a 50-member radiology group that covers two hospitals, says, “The diagnostic imaging people tend not to be aware of the needs of IR. They do not see how meeting the needs of IR can strengthen the whole practice. We are subjected to such intense scrutiny by general radiology. It requires tremendous time and work just to hire another guy or to put a lab together.”
Curtis W. Bakal, MD, MPH, calls the IR alliance with general radiology “a good marriage.” But he qualifies that heavily-very heavily. “IR consists in equal parts of imaging and clinical experience,” he says. “From the imaging standpoint, it’s an excellent match. From the clinical experience and practice point of view, it’s a terrible match.”
Bakal is division director for vascular and interventional radiology at Beth Israel Medical Center and St Luke’s Hospital in New York City. He is a professor of radiology at the Albert Einstein College of Medicine. He is also immediate past president of the Society of Interventional Radiology (SIR).
Bakal says the dichotomy between IR and DR starts in medical school, where radiology students are taught to decipher images, but not to treat patients. “Interventional radiology is a hard sell to people doing diagnostic imaging, because they’ve already been preselected out of it during their training. They don’t know how to take care of patients, there is no culture in radiology of having the skills to take care of patients. Even if they choose IR, they come into it without learning these skills, which is something we need to do.”
And unless radiology curriculums are adjusted to the needs of IR doctors, the problem will only grow, Bakal says. “If we think about the groundbreaking fields ahead of us, where we can lend a lot of value, such as in oncologic therapy, it’s not going to be imaging alone. You need to have a good knowledge of the clinical diseases you are dealing with. In vascular medicine we have a good idea at the macro level of what the diseases look like. But more and more of the treatments that we can be a part of are going to be cellular and molecular in nature. Many of the oncologic diseases that we can be in the forefront of have a molecular basis or a medicinal basis in the agents that we administer. We’re not really versed in those clinical vocabularies. We’re not really versed in enough clinical vocabularies. We need people who have clinical experience and who have a clinical bent.”
Bakal adds, “Often the hospitals don’t understand and the diagnostic radiology groups are shorthanded or shortsighted. So, instead of going on practice-building missions and spending time on the floors seeing patients, the interventional radiologists are stuck with stacks of film to read-and that’s no way to build a practice. It’s now reached a crisis point, where if we don’t change the culture in radiology, many of these procedures will not be done by interventional radiologists. They will be done by somebody else.”
House of Radiology
Despite the stressful forces working on IR from within and without, the IR doctors themselves seem to feel most comfortable remaining in the “House of Radiology,” as many of them term it. Some IR doctors are defecting to vascular surgery and cardiology practices, but there are many advantages to staying in the imaging community despite its less than happy fit for clinical practice. Says J. Kevin McGraw, MD, co-director of IR at Riverside Methodist Hospital, a 900-bed, tertiary care facility in Columbus, Ohio, “Radiology controls the imaging, so it’s beneficial for us to remain. Also, the diagnostician can help IR in that any time an abnormality is noted-for instance, a narrowed kidney artery-my diagnostician will call me, and I will call the referring physician or the PCP and try to set that patient up for renal angioplasty.”
Other IR specialists, however, say they seldom if ever get referrals from the diagnostic side. But they agree that sharing modalities and expertise in imaging with diagnosticians is a big advantage. In fact, none of the interventionists interviewed regret their background in radiology, and most see it as a significant plus. “If you have good skills in diagnostic radiology, you do a better job in interventional radiology,” says Arl Van Moore, Jr, MD, practice president at Charlotte Radiology in Charlotte, NC. “You understand the imaging aspects much better than individuals who are just hands-oriented. It’s very important when you are evaluating patients with imaging techniques and not using direct vision.”
Chambers agrees. “My radiology training made me a better interventionist,” he says. “I became very proficient at evaluating CT scans and ultrasound cross-sectional imaging, studies that really helped me as an interventionist.”
Another reason for interventionists to remain in the house of radiology is that if they join surgical practices, they risk becoming second-level practitioners doing the simpler procedures, while the surgeons skim the more profitable cases for themselves. Says Halin, “I personally feel that interventionists who leave radiology and go to surgery will become second-class citizens. An interventionist can’t call himself a surgeon unless he’s done a surgical residency, but there’s an easy route for surgeons to come to interventional radiology, because their boards will certify them to do these procedures.”
There are lots of horror stories, of course, about surgeons who have taken weekend courses in certain IR procedures who then bring patients to grief because they really do not know what they are doing. But the doctors consulted for this story admit that many cardiologists and vascular surgeons have become very skilled at interventional procedures. The competition is real in terms of skill also.
Other motives for IR to remain wedded to radiology include the clout of the radiology community, and just plain shared experiences and brotherhood. “It is very important that IR stays in the house of radiology,” says Michael Pentecost, MD, a professor at Georgetown University Medical School and an interventional radiologist at Georgetown University Hospital in the nation’s capital. “I think it’s good for interventional radiologists even though they may have serious issues with their diagnostic colleagues. It is still their home, and they are still among kindred spirits. I don’t think there is any other discipline that would hold them as close as the radiology community does.”
Diverse Practice Patterns
Another factor that may or may not bind IR to DR but one that certainly impacts the way IR operates within radiology is the need of IR to be hospital oriented by virtue of its surgical nature. This does not mean that IR outpatient clinics are not springing up. But these clinics tend to be for imaging and examining purposes rather than places to conduct treatments. “Some basic interventions like dialysis are quite reasonably done in an outpatient setting,” Pentecost says. “A lot of the procedures can be done outpatient-but many of them can slip into inpatient in a hurry. If you are not in a hospital setting and the ER and OR are not a couple of floors away, it’s just not as comfortable practicing. Why wouldn’t you want to practice in an environment where you can do everything comfortably, versus one where 80% to 90% of what you do, you do slightly uncomfortably?”
Diagnosticians do recognize that there are advantages to having an IR component in their groups. Noninvasive techniques are in demand, and it behooves diagnostic practices to include an IR component. Still, setting up outpatient clinics for IR is a tough sell for interventionists when dealing with diagnostic colleagues, IR doctors say, because the clinics take a while to become profitable. IR doctors admit they can probably bring more income into a practice by reading film than by seeing patients in a clinic, but they need the clinics to generate patients. Eventually, the clinics do move into the black.
Marcia Flaherty is CIO for Riverside Radiology Associates, the group to which McGraw belongs, and which essentially serves Riverside Methodist Hospital in Columbus. Flaherty says the group opened its IR outpatient clinic in 1998 but that it took 18 to 24 months to become profitable. She estimates that opening the clinic with nurses, support staff, and examination rooms cost about $200,000. “We are still kind of a work in progress,” Flaherty says. “We are in the process of developing a stroke program at the hospital.”
But Flaherty says that having the clinic has strengthened the entire practice, including DR. “Staying in radiology pays off business-wise for IR,” she says, “because one of our body imagists will spot something and take that to IR. It’s a very important and compatible relationship. The availability of IR seems critical to the growth of this practice.”
Neil Messinger, MD, FACR, is a diagnostic radiologist and chairman of the Department of Radiology at Baptist Health Systems in Miami. Messinger says his group of about 38 diagnosticians and 12 IR specialists-organized as the Miami Vascular Institute-has been split into two sections, an IR section and a DR section, although the whole group acts as one economically. The division, he says, has allowed each IR practitioner “to go out there and be a clinician, admitting patients and taking care of patients.” Messinger says the IR doctors “have become recognized as one of the top clinical services in the hospital.” The IR specialists only read vascular film and they do not handle night rotations as part of the overall radiology effort. “I think this has been tremendously beneficial,” Messinger says. “The group has gained tremendous stature by doing this. We have an office component to see patients. We bring the patients in and work them up. We call a doctor and tell him that ?this patient needs a cardiac workup’ before we do a procedure.” Messinger says splitting IR and DR has allowed the group “to have the best of all possible worlds.” Only one thing is missing-IR clinic profitability. Messinger acknowledges that the IR clinic is running slightly in the red, but he calls that “an anomaly” based on Florida’s reimbursement rates for office visits. When it comes to profits generated by IR surgical cases, Messinger says those are sizable. “I’m sure the hospital is making lots of money on it.”
Some radiology groups want an IR presence in order to offer patients the total range of radiology services. Rick Granaghan, MD, is practice president for Radiology Associates of Tarrant County in Fort Worth, Tex. The group is made up of about 52 radiologists of whom a half dozen are interventionists. Granaghan himself is a diagnostician, but he says the interventionists are a key component of the 65-year-old practice. “I think we all realize we’re a lot stronger as a group if we can provide the whole gamut of services. Offering that quality of care is the number-one incentive.” One point that Granaghan makes is that it is not a professional sin for interventionists to contribute by reading film. “Only one or two of our IR people flat out don’t do anything but run catheters in people. The others will read when they can. We’ve never had an us-vs-them mentality. Why, I don’t know. I think we are just fortunate that we’ve never really had that problem.”
At the Society of Interventional Radiology, executive director Paul Pomerantz points out that IR doctors reading film is nothing unusual. As many as two thirds of the society’s 4,000 members may read some film, Pomerantz says. And he, like Granaghan, sees nothing out of the ordinary with image-based interventional techniques being taken up by nonradiology specialists. “Technology migrates throughout medicine. The boundaries of technology are very permeable. We can wish we didn’t have to compete, but it is a situation that we have to accept,” says Pomerantz.
What IR Wants
To help IR compete, the Society has launched an awareness campaign to brand into the public consciousness what an IR doctor does and how IR physicians can help patients. “We are providing our members with a lot of tools,” says Pomerantz. “We are repositioning the specialty as a clinically based specialty. A lot of IR is still heavily, heavily involved with vascular care, but many are looking at new areas. We don’t want other specialties who are not appropriately trained to do interventional procedures, but more and more are getting trained. You can’t stop competition.”
Many of the IR doctors interviewed for this story complain that radiology curriculums did not prepare them to deal with patients, and that they wasted valuable time learning, for instance, mammography and musculoskeletal imaging, which they seldom, if ever, use in their practices. The American College of Radiology has acknowledged this and has come out in favor of a separate training track for interventionists.
Pentecost not only practices and teaches at Georgetown, he also sits on the ACR board of chancellors. The ACR-favored training track would let IR students in radiology pursue electives in vascular surgery or intensive care or other patient-based courses so they would emerge prepared to handle patients. “These would be wonderful skills, and they should be permitted to take electives like that when they are in their radiology training,” Pentecost says. “Interventional radiologists have to provide ongoing care for patients. That involves having clinical space, admitting privileges at a hospital, access to the vascular laboratory, time to make rounds on patients. These are not optional things, these are not luxurious things-these are core, fundamental resources needed by any physician who provides clinical care, regardless of the specialty.”
Pentecost says that minimally invasive procedures are “the future of surgery.” Because of that, the techniques will attract surgeons as well as those trained in radiology. “I do think the pie will be split up more and in different ways,” he says. “Some of the surgeries themselves will be split up in different ways. In my hospital, I use the example of back surgery. Both orthopedists and neurosurgeons do back surgery. One of them doesn’t have a rule that the other one can’t do it. They compete for patients, and whoever does it best gets the patients. I think that’s the way a lot of peripheral vascular practice will be. That’s part of the bare-fisted practice of medicine. I don’t lament it. We will lose some turf battles, but we will win a lot more than we will lose.”
What IR doctors want is the cooperation from their diagnostic colleagues to help them stand as they must stand-with one foot in imaging and one foot in patient care. They want understanding from their colleagues, too, that they will need to market their skills.
“We can no longer sit and wait for cases,” says Ted Chambers. “In the past all the cases rained down to us because no one else had the skills. That is not the case any more. We have to go out and get cases.”
George Wiley is a contributing writer for Decisions in Imaging economics.