Building an IR practice by walking the halls

March 06, 2020
By Dr. Ankit H. Shah

A few months ago, I was walking down the hall of the county hospital ICU where I practice when I was confronted with what I thought was a most unusual question from the hospitalist on call:

“Are you lost?”

Puzzled, I let her know that I was actually checking in on a patient that I had done an embolization on yesterday. I was still new to the hospital and to my role of section chief of interventional radiology, yet I assured her that I was quite confident that I knew the way to the patient’s room. But her concern wasn’t with my ability to navigate the hospital, as she later explained to me. She said she had not seen an interventional radiologist outside of the angiography suite in some time and she wondered what I was doing in her territory.

Her simple question crystalized what would become my greatest challenge in building up the IR practice: challenging the status quo to build a culture of collaboration, trust, and support that would make us all more effective and would bolster the status of the IR practice.

As one of the newest medical specialties, interventional radiology is still expanding its boundaries and clearly identifying what it has to offer to patients and to the rest of the clinical team. We do not have our own identifiable organ system, something that would put us on the anatomical map like other specialties and would give our patients and colleagues an easier frame of reference for thinking about IR. Our image-guided, minimally-invasive techniques inspire creativity for approaching some of medicine’s most difficult cases, but the specialized nature of our practice also creates a layer of mystique that can be difficult to overcome for building a strong and diverse IR clinical practice.

I faced this challenge head on as I started last year. While 90% of my clinical work happens in the angiography suite, I came to strongly believe that IRs need to spend time walking the halls of the hospital. I see it as a means to develop important relationships, to gain a true understanding of the value we bring to the hospital ecosystem, and to remind our colleagues and hospital administrators of the value we add to the enterprise.

With this in mind, there are five key themes that are critical for building a strong IR practice and working well with other specialists.

1. Get a grasp on the resources available at your hospital or health system
With any new role, one key element is understanding the resources of your institution. For new practice areas, you’re usually provided few resources. This can be intimidating and requires patience to realize that you will need time to build up the infrastructure, including clinic staff, patient referrals, and technology, rather than being able to establish the practice you envision on Day One. To do so, you need to understand what already exists to effectively use the tools at your disposal. What are the strong practice areas? Who are the leaders? What technology is available?

IRs must go beyond their comfort zone to meet colleagues from other specialties. Learn more about their challenges, but also what they see as the strengths and potential of the hospital.

By walking the hospital floors, IRs can look to develop important relationships with other clinicians, as well as carve out time for patient consults to get a pulse on the needs of the hospital. These interactions can demonstrate how IRs can adapt their diverse skillset to fill the greatest need, and can also build trust between providers.

2. Understand the patient population (to see where you can add value)
The needs of our colleagues can also be identified through the patients we treat. What are the common conditions they are presenting with? How are our colleagues addressing their conditions? Is there an unmet need?

Conversations with my colleagues showed a lack of bandwidth that was leaving quite a few patients with venous disease either untreated or receiving only medical management for their symptoms. Vascular surgery had helped a great number of patients, but there were a handful that were not benefiting from the standard treatment protocol.

For example, a problem with a patient’s IVC filter had caused phlegmasia. The team had exhausted the treatment options and were planning a transfer to another hospital to address the pain caused by the filter. Because I got to know the vascular surgery team when walking the halls, the team was open to collaborating with IR and learning more about innovative treatments IR offers to help patients with IVC filters. Through a series of venoplasties, together we were able to get the vein open and prevent post-thrombotic syndrome. Then, we removed the filter and eliminated the patient’s pain and swelling.

In this case in particular, it isn’t always about offering the flashiest, newest treatments to our patients. It’s about understanding what our colleagues and patients need and working together to build a better outcome for all.

3. Lead with data and evidence
Because there is a lack of awareness and understanding of clinical IR, having good data and outcomes on hand is a more effective introduction than any clinical anecdote I could offer. There may be a general understanding that IR treatments can be safer for patients, make patients more comfortable, and can be completed without anesthesia. But what our colleagues might not know is what IRs can do to specifically help them and their patients.

I make it a point to present literature to show the benefit of various IR interventions in areas specific to their practice, as well as take the time to learn from others. These conversations help strengthen our knowledge as clinicians, while recognizing ways that we can advance and improve the care we offer to our patients.

For example, I often share the results of the ATTRACT trial. The study (known as Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis) compared two treatment strategies for various forms of DVT in a randomized, multicenter trial. The study found that patients with DVT should continue to be treated with drugs alone, without necessarily undergoing any procedure-based intervention. However, the study also showed that a minimally-invasive catheter-directed therapy can provide greater relief of initial leg pain and swelling and is likely to prevent disability in certain DVT patients.

Administrators also need to see outcomes data on our work to demonstrate the value IR is providing to the hospital and its patients. Properly contextualized outcomes and cost data help create useful metrics to make the business and clinical case for IR.

I’ve found that these conversations most often come together informally, creating a need to constantly be at the ready to share information, whether it’s in an elevator or at the lunch counter.

4. Create a team-based culture
The evolving skillset of IRs can present a challenge to our colleagues and patients in understanding how and when to tap into IR to improve care. This creates a need for constant education and relationship building to demonstrate the power of the specialty. The best way to create this model of collaboration is by creating a culture of support and teamwork that starts with the IR team.

This type of collegiality is critical at a time where clinician burnout is rampant across every generation and specialty. We must all put ego aside to consider the challenges we each face and how we can work together for the benefit of our patients. Furthermore, we must take the time to train and educate medical residents and create a positive work environment.

While the tone and intention behind creating a supportive work culture are paramount, I’ve also found that it doesn’t hurt to throw in donuts or pick up dinner occasionally to bring everyone together and help break out of the hospital food desert.

5. Show up, be present and follow through
Accessibility of IR is key for building an environment of trust and accountability. Answer the phone when a colleague calls. Carve out time for patient consults. Volunteer services to help on all different types of cases. Bring patients into clinic to continue to follow their progress. These are the things that differentiate IR from proceduralists. We are partners in clinical care, not technicians, and we must nurture these relationships.

Dr. Ankit H. Shah
As a specialty, we have so much to offer our colleagues and patients to improve care for all, but we won’t find success without building strong cross-disciplinary partnerships with our colleagues.

About the author: Dr. Ankit H. Shah is section chief of interventional radiology at Valleywise Health Medical Center in Phoenix, Arizona. The views expressed in this article are the author’s own and do not necessarily reflect the views of the author's employer or organization.