All IR is Local

S. Mehandru, M.D. FSIR

I’ve been reading the articles in this series (responses to Dr. Daniel Poulsen’s original article, There’s Not a Shortage of Interventional Radiologists) with great interest and fascination. Mostly because the experts that have so far weighed in on this important discussion about Interventional Radiology are esteemed and experienced interventional radiologists who clearly care deeply about this topic as reflected in their very thoughtful, insightful, and heartfelt essays. But also because I can honestly say that for the last 13 years, there have been few other topics that have occupied my mind more than this.

For those that know me well, to say that I care about Interventional Radiology is probably an understatement. Ever since my radiology residency when I encountered this fascinating specialty with its dizzying combination of clinical patient care, minimally-invasive technical skill and precision, and in-depth imaging expertise, I was immediately hooked for life. Words like “innovation,” “cutting-edge,” “life-saving,” “life-improving,” and “impactful” are often used to describe what we do, and I agree with all of those and so much more. Those of us who are interventional radiologists who are reading this immediately and viscerally know what I am talking about. Our’s is a very special specialty.

And yet – as many of us also know -- the “real world” of IR practice has often been anything but supportive of our special, innovative, and extraordinarily impactful specialty. In fact, it seems that most non-IRs hardly even know what interventional radiology is. Rather than uplifting and upholding the practice of IR to the level it deserves, the “real world” often greatly diminishes IR’s role and impact, relegating it to the back reading room where it hides behind endless diagnostic worklists and disjointed discussions of RVU’s. There it flounders and, in some places, dies altogether. Much to the detriment of the patients in that practice who could have greatly benefitted from IR in their lives – and who now either must be transferred somewhere else where they can get this care – or simply have to go without it. Many of us reading this article know what challenges I am talking about, and these have been outlined and discussed numerous times for many years in the IR community in this blog and elsewhere. For a long time, I honestly thought it was just me and my own bad luck to get stuck in IR practices that were sub-par, and to a certain extent that may have been true. I used to think that most of the other groups out there had much more robust and fulfilling IR practices. But as I moved on in my career, I found the same pattern recurring almost everywhere I went. In fact in most practices I have worked in in my career – I have noticed that IR has been practiced at just a small fraction of what it is capable of. And in many hospitals in the United States, IR doesn’t even exist whatsoever. As I became more involved in IR leadership roles, and in national IR societies, I started meeting other IRs from diverse practices around the country. I quickly realized that this pattern was indeed more widespread than I first thought.

Recently I was asked to provide a list of all hospital affiliations I have ever had for the purposes of credentialing at a new facility. After some thought, I came up with a list composed of around 25 hospitals. I was dismayed at first (I don’t think I look or feel that old!) but then I realized that this is simply the product of working in 2 private practice IR jobs where in each group I covered 5-6 hospitals for IR call, as well as about 3 years of locums work (where I worked at a wide variety of academic tertiary hospitals as well as community hospitals across 6 different states). Then throw into that mix a stint at an OBL and about 6 years at a VA hospital, and you quickly end up with a very long hospital list! As I’ve traveled on this vast and very diverse IR journey I have seen first-hand the challenges of how to have a satisfying & well-supported IR practice. But what has perhaps fascinated me the most is that these challenges happen pretty consistently across a variety of practice settings, locations, and group structures. Recounting the similarities and differences between these experiences has been an eye-opening and interesting mental exercise – and one that sheds light on some generalizable issues within our specialty as well as perhaps some possible solutions.

We typically think that academic, tertiary-level hospitals have well-supported and highly functioning IR sections, and that smaller community hospitals that are staffed by IR/DR groups tend to have less developed and supported IR sections. This is often true – but not always. I have worked in a couple of high-level academic hospitals in large metropolitan cities where IR is unsupported, lacking morale, lacking a complex/interesting case mix, and remains an afterthought in a predominantly diagnostic radiology environment. These are academic centers where there are high-level specialty services in the hospital (e.g. transplant services) and yet somehow the IR section mysteriously does very little transplant IR. The IRs were not happy there. Meanwhile, I have worked in a community hospital in a small rural town that lacks a transplant service – and yet the IR section is a fully-functioning impact-making machine with a varied complexity case mix, state-of-the-art equipment, and a team of IR mid-levels that help provide a truly clinical service (e.g. inpatient rounding, office visits, follow-ups etc.) and support for simpler procedures. At this smaller community hospital there are fewer advanced medical services available than in the academic hospital, however the IR experience feels richer, more complex, and much more satisfying. The IRs were happy there.

Why is this?

It is worth spending time to ponder this question.

One observation I have made in my experience is: the more autonomous an IR section/group/department is, (usually) the better they end up doing.

This conclusion is very aligned with what Dr. Devalupalli eloquently describes in his article, Why Are IRs Unhappy: It’s More Than Psychological. There is no doubt that the structural systems in which IRs practice have a direct and significant impact on “how the case arrives, timing, context, disruption, and your level of control.” I agree that this is the root cause of much IR unhappiness, and why many IRs are now seeking alternative or novel practice settings where they have this level of autonomy. It is simply undeniable that if you are starting with a structure that is not aligned in favor of IR, you will not be able to practice satisfying and well-supported IR. So you really do have to start there.

But it is equally important to address another related fact: IR practices can only be built to the extent of the unique needs, strengths, and idiosyncrasies of the local environments in which they exist.

IR is not practiced in a vacuum – it depends on referrals from appropriate specialists who are aware that we exist and understand what we do. If you don’t work in a hospital that has a busy oncology service, you likely won’t be doing much Y-90 or tumor ablations or port placements in your IR practice regardless of how supportive your DR group is, or how many mid-levels you hire, or how many bells and whistles your new angiography unit has, or how many clinic days you schedule. If your hospital does not have a liver transplant service, it will be very difficult to build a hepatobiliary IR service. If your hospital does not see/treat many patients with cirrhosis it will be very hard to consistently do many TIPSS cases or even enough to feel continuously competent in them. If you don’t have a strong critical care unit, you likely won’t have a PERT team or be doing many PE thrombectomies. If your OBL is in a town where interventional cardiology and vascular surgery already have a large footprint with established referral patterns, you will have an uphill battle in starting PAD work (not impossible, but it will take a lot of time and it will be very difficult for a while). It is not that these procedures absolutely cannot exist outside these frameworks, but it will be extremely challenging to build them.

All of this high-level IR care (e.g. interventional oncology, hepatobiliary, venous thrombectomy, PAD, etc.) is very vital to modern healthcare, arguably all patients everywhere should have access to them, and arguably most IRs would like to perform these types of procedures in their practice. But realistically how many IRs are actually doing them on a daily or weekly or monthly basis in the United States? The fact remains that apart from the inherent group/hospital structural dynamics that can limit an IR practice, one’s IR practice is also affected by very strong local factors. And it is often not immediately obvious to an interventional radiologist how they can impact those local factors or strategically develop them in their favor.

My point is, All IR is fundamentally local.

And without the knowledge, time, tools, support, and structure to know how to masterfully maximize these local factors to benefit IR in their local environment, this causes significant moral injury, angst, frustration, and defeatism amongst many interventional radiologists.

Having said that, we also must understand the idea that Dr. Ashu Rao emphasized in his very thoughtful piece, Why Are IRs Unhappy?, in which he explains that happiness is in part related to the interplay of expectations vs. reality. For example, as he discusses, if we approach a thoracentesis as a procedure “dumped” on us instead of viewing it as the clinically impactful procedure that it is -- we are likely to feel unsatisfied with it. This dissatisfaction will permeate the daily work of an interventional radiologist because the fact remains that most hospital-based IR still consists of mostly low-RVU procedures that are not as technically interesting but are still commonly done, necessary, and very important for patient care in hospitals across the United States. Although they generate great clinical value and impact, procedures like a thoracentesis do not have significant financial/RVU return. This disconnect between a procedure’s clinical value and its financial “worth” is a core issue for our specialty. It will need to be addressed, because most of us work in American healthcare and fundamentally American healthcare is a for-profit system. Regardless of how we address this issue (e.g. hiring mid-levels to perform these procedures, subsidizing low-RVU procedures through hospital contracts, etc.) we should accept that at the end of the day we do what we do because we care about patients, and the fact is that many patients – especially in the hospital setting -- will need lower-RVU procedures done to save or improve their lives. (Side Note: I have seen practices where thoracenteses and paracenteses have been relegated back from IR to other services -- and the pro’s and con’s of that approach is too complicated of a debate to have here, however my point simply is: before dismissing certain types of procedures based solely on RVUs we must think strategically and carefully about doing anything that could diminish our role in a healthcare system that already often either doesn’t care or doesn’t know that we exist.)

But however we approach the question of how to build a satisfying and well-supported IR practice, we have to start with the local factors that mold and shape this practice.

In my experience traveling and working around this country, I noticed that the IR practices that succeeded were the ones that strategically built upon their unique local strengths (i.e. their OBL location, the available referring specialties and what services can help them, disease prevalence and treatment needs of the local patient population, strategically aligning hospital C-suite visions and goals, etc.). These IR practices began with the autonomy to make their own decisions, and then they approached those decisions through the lens of what will strengthen (not diminish) interventional radiology. This takes a lot of work and thought and effort. You cannot sit in a reading room reading CT’s and expect this to happen by itself. You have to fight, fight, fight for IR --- constantly, diligently, and strategically -- and you have to keep doing it until people listen. And if you aren’t in a place to have the autonomy to take on this fight in the first place: then try to change that or leave. As Dr. Frederick Johnson beautifully captures in his essay, Happiness in IR is a Choice: “the unhappy IR stems, in large part, from the fear of changing an undesirable situation they have been conditioned to believe they cannot change.” (Side Note: as much as I agree with this, in reality this is easier said than done. I experienced significant life upheaval twice after leaving two different private practice IR/DR groups because they did not support IR to the extent that I wanted. Each time I was thrust into total career/life uncertainty for years. The psychological impact of this level of existential uncertainty is profound and can be very damaging.)

In my travels and experience, I’ve also learned that just about all IR practice types – if built well -- CAN be sustainable and work to their maximum capacity in their own unique ways. Given the dramatic variability in how IR is practiced geographically, regional case mix, and differences in practice types, there is no one-size-fits-all solution. This is likely the reason why national groups such as the Society of Interventional Radiology have had little ability to impact the day-to-day practice challenges for most interventional radiologists in any meaningful capacity. Yet whatever is the local IR practice type, based on my experience I believe there are some general factors that I have noticed the most successful IR practices have followed.

These practices:

• Maximize the autonomy of IRs to function at their full capacity (this includes financial considerations).

• Maximize IR efficacy: the ability of IRs to use and apply their special technical skills to perform a wide array of procedures that vary in complexity and pathology. Arguably, most IRs want to do at least some meaningful percentage of “high-end” procedures that are rewarding, impactful, and allow use of skills that have been carefully developed and honed in their training and experience. This of course varies from IR to IR.

• Educate and widely disseminate the value of IR to hospital administrators, referring providers, and patients themselves. It never ceases to amaze me that in the 21st century, a hospital cannot function at optimal economics and efficiency without IR services, and yet most hospital administrators, referring providers, and patients have no clue what IR is or does. Why is this? As a specialty we urgently need to change this.

• Maximize patient impact (by providing a comprehensive IR service that is as broad as possible for that specific patient population). Having all your eggs in one or two baskets may work financially but it ignores the hugely varied impact that IR has across a variety of pathophysiology in both inpatient and outpatient settings.

Groups that hit the mark on several or all of these factors tend to have the happiest interventional radiologists. Groups that hit none or few tend to have the most unhappy interventional radiologists.

So these observations may start to provide us with a general roadmap for building possible solutions to this very deep-rooted and complex issue of how to build a satisfying, robust, and well-supported IR practice. Although the roadmap is general, execution will have to be local and that is where the difficulty lies. After all, dealing with these factors on a local level will vary greatly from practice to practice and place to place and IRs around the country need support in figuring out how to do this effectively. Furthermore, IR residents will need to become well-versed with these challenges in their IR training. I believe a good start is by discussing and teaching trainees about IR Practice Development: something that has been significantly lacking in IR education for decades.

As a specialty we need to start systematically and thoughtfully thinking about how to assess and strategically develop a robust IR practice based on local factors. Most interventional radiologists, let alone trainees, are currently not equipped to think about let alone know how to deal with these factors. And I believe this has contributed greatly to the declining number of practicing interventional radiologists, and the corresponding decline of IR care in the United States. I think it is a travesty that in the year 2026, most patients in the United States still do not have access to an interventional radiologist and the innovative, life-changing, life-saving care that IR can provide. We as a specialty must change this: our future depends on it.