Office-based labs

Episode Transcript

Hello everybody. I’m Dr. Mary Costantino. I’m an interventional radiologist at Advanced Vascular Centers in Portland, Oregon. And I’m here with the great Dr. John Lipman. We’re here live at an SIR event in a soundproof booth at the Cook’s booth in the exhibit hall for my first live podcast. It’s a little intimidating because you can’t bleep out all the “ums.” We wanna share with you our journey in the OBL practice and give our future predictions. This is Cook’s 60th anniversary, so they decided to throw this special event, and I know for sure I’m honored to be included. Dr. Lipman, can you tell the audience about you and what inspired you to start your OBL?

Well, thanks. Yeah, it’s great seeing you. This is so much fun. I I really appreciate Cook having us talk couple of old friends sitting around having some cocktails and talking about OBLs. I started— I left my practice, this was many years ago. I’ve been an independent IR for 20 years now. But that was after being in a traditional practice. And what led me to leave my practice and is still a situation today, is I wanted to take care of patients. I wanted the longitudinal care of patients, and that led me to becoming a first a solo interventional radiologist, and then ultimately to the office-based lab that I’ve been thrilled to have for the past eight years now. But I’ve been independent for 20, and we are at the Atlanta Fibroid Center for those that don’t, don’t know what we do. It’s a completely independent, physician-owned medical practice that does primarily UFE, and I have had the privilege to care for patients suffering with fibroids and adenomyosis. And that’s my OBL.

I’m just laughing because you talk about our cocktails, and mine looks like a bottle of water, but you’re wearing a master’s Augusta pin and I’m thinking you have a little G and T in yours or something. I don’t know why.

I didn’t have the pimento sandwich, but I felt that I had to get sufficiently up for this.

Well, you know, you had a little time between your hospital job and your OBL, which actually could be more pertinent now because, you know, I’m running this—well, not anymore as of this week, I’m not running the private practice section anymore—but just this morning we had our meeting and you were going around the room and everybody’s talking about their practice models. And one thing that’s more clear now than ever before is all the various practice models. So—

That’s really true.

Can you talk about post-hospital, pre-OBL?

Yeah. And I thought that I had practiced in every single possible combination of IR practice that was out there only to learn that a good friend of mine, Kavi Devulapall, he’s a locums IR. I’d never even heard of that. So that’s one that I have not done. But when I left the traditional practice—well, I originally was very briefly in academic, so I had a little academic exposure—and then I went to a traditional radiology practice. And then when I left my group— And the reason I left the group was say a common thing. They just didn’t recognize the value that IR brings. They didn’t want me to have a clinic, and that was an absolute, I had to have a clinic. And then when they finally agreed to let me have a clinic, they left me with a nice stack of films and other work to do when I had finished clinic.

And eventually I said, “I’ve just gotta go off on my own.” And I did. And originally it was just to provide IR services at a hospital that didn’t have IR. And it was a professional fee. And that was fine for the time, but eventually the professional reimbursement wasn’t— it got pretty whacked. And it was clear that you really need to have access to the technical component to really make a go of it. And so I was actually in a joint venture with a hospital that didn’t have interventional radiology. And that was a great arrangement. We had a joint venture between myself and the hospital, which itself was a joint venture, and they paid me a fair market value for the IR services that I provided. so I didn’t have to bill or collect. And it was a very nice arrangement. And it was, well for quite a number of years until the hospital—the two partners, the two hospital partners eventually parted ways—and the hospital clothes. So that really kind of forced our hand, if you will. We always talked about having an OBL, but that really was the impetus to get into an OBL.

Yeah. I mean, half of these things, at least from my experience, is the same thing. It’s fear, it’s change that has to happen—not fear. Change has to happen for some reason. And you’re like, “Well, there’s no other way to do this.” I was in the same boat. I was in a practice, a regular private practice, and I just was determined to do fibroid embolization. And I was going to rent a room in like a gynecologist office. I didn’t know what I was gonna do. I was just gonna figure it out. And it’s like when you are called to do this stuff, you’re like, “All right, well I’ll take that loan and build it.” Because it’s like you have to do it right. But I tell people now, and I’m curious about your opinion on this. You know, all these people want to go into OBLs, and I’m kind of, start with, try to find the reasons not to do it. Because there’s a lot of practices, which may be great, just not your experience or my experience. Because it’s not easy work. So what is your thought on all these people now who wanna go into OBLs?

Well, I, I think it’s good because I think OBLs is where we get medicine back. You can have work in the hospital and that’s fine. But for me, the hospital was just a frustrating, inefficient place that really didn’t value what we did. And when you build your own center, it’s your mission. It’s your baby, and you really take ownership, and you can really serve patients the best way possible. You can care for them. People love coming to our OBL. And I’m able to control the process. In the hospital, you can’t control anything. It’s very inefficient. The people that work there are a reflection of you, even though they’re not your employees. So I think if you can do an OBL, it’s phenomenal. It’s very rewarding on a personal level. And it’s also financially sound. But I think you’ve gotta understand what you love to do. Because there’s so much physician burnout now, and particularly in the IRs. I talk to IRs in my community, at Angio Club, and a lot of them are really frustrated, working in the hospitals. They’re burned out. They feel like their issues are not being addressed. And they look at me, and I’m like, happy as a clam.

You’re aging backwards.

Yeah, I love going to work every day. I truly do. People like look at me like I’m crazy. I love going to work. I love going to my center. It’s because I’ve created something that works for me. And I think that’s what the key is for IRs: to figure out what you love to do. And I, I use this term, I stole it from the Japanese, it’s called “ikigai” and you can look it up. It’s a Japanese term for “what’s your reason for being?” And so it’s this Venn diagram, and it’s four circles. And the first circle is what you love to do. The second circle is what you’re good at. The third circle is what the world needs. And the fourth circle is what you can get paid for. And ikigai is the center of those four circles. And if you can get there, then that’s where I’m at.

You are loving life because when you’re happy doing what you love to do, it shows. And patients pick up on it. And conversely, the same thing’s true when I hear guys say, “Ah, I hate dialysis work,” or “I hate G tubes,” or “I hate whatever.” Most communication is non-verbal, and that comes across to patients. So if you don’t like it, and I’ve seen references to trash collection and some of these other terms for the, not very fun parts of IR. Well, no one says you have to do that. If you’re not passionate about gastrostomy tubes, why not carve a practice that you don’t have to do that? I really only do fibroid work. There are other people that only do PAD or only do veins. Find what you love to do. So, it takes a little self-awareness, but look at your situation and figure out what you love to do and what will work. And who better to bank on but yourself?

Yeah. And you know, when I did—I started my practice with fibroids too, as you know, and then went into PAD work—and one of the best things about our lives is that I still do a lot of fibroids and I do the PAD stuff, and now I’m contemplating PAE. Do you do PAE? Why don’t you do PAE?

Because we serve women.

It’s like right up your alley.

We serve women.

You’ve got a prostate.

We’re a women’s practice. Now we’re probably gonna do orthopedic.

Wait, really? Why can’t you— you have a beautiful building with a nice lobby.

Thank you, thank you very much.

Why don’t you get the other half and make like man cave. And have urinals. And do prostate.

Right. Yeah. I just didn’t want to mix the guys with Foleys with— I mean, one of the things, when we built our center, we asked—we had a number of focus groups of women, because that’s who we serve—what’s important to you in healthcare? And one of the top things, you know, besides quality, was privacy. Women valued privacy. And I just can’t see mixing the prostate men with our patients. That just, it doesn’t mix.

We have that too. I mean, we have, we have our gangrene patients mixed with our cosmetics. But I don’t know how we get away with it. We have what we call YUFE Thursdays, my all-time favorite day. So we have our schedule. We have our critical limb day, which is Wednesday, which is when I have Jill Sommerset. So we have our schedule really sorted out. And I love that because Monday’s clinic day when my staff tries to torture me a little bit, they put in clinic in between the patients. I’m like, Monday’s the only day I’m supposed to be clinic because my non-clinic brain is on—my operative brain is on. But, you know we have sort of like a different patient population almost every day, which I really like.

Yeah, and that’s the thing. It’s deciding what you are passionate about and what you’re good at and what you like to do. For me, I just want to focus right here, but as I say, you like to do and are good at multiple things, and that’s great.

I also love GJ tubes. I love those. I wish I could do more of those. I loved getting it. I loved making a G into a GJ. It’s so fun. You like get to turn things and turn corners.

I hope you use the Cook set.

Always, of course. I didn’t know there was another one. Actually, I don’t. Do you use a lot of Cook product?

Fair. I mean the micros sticks are Cook’s, I use them. Excellent.

Yeah. So, okay, OBL business world.

Yeah. That’s a big topic. You know, we’ll get asked all the time here at the meeting, like, “How did you get started?”

I wanna know how you’re gonna expand.

That’s another tough thing.

That’s a harder topic.

What we try to do is we only have one angio suite. Now, it’s not a C-arm. I have a full angio suite, which we made that decision early on that we wanted to have that. But, whatever, we have one lab if you will. And so we were trying to optimize. Because right now, the lab really runs from 7:30 in the morning to like 1:30 in the afternoon, five days a week. And as we’re getting busier now, we’re trying to start extending. So we’re gonna have to hire a second set of nurses, because our first nurse comes in at 6:00 am. So you know, that’s fine. Because that’s the biggest expense, is your equipment. And so we’re going to first expand and extend into the day, so that we’re done before— so it doesn’t get too late in the evening. We don’t want to send anybody home, you know, after say 6:30 or 7 o’clock at the latest. So we’re gonna optimize that time, and if we get to a place where it’s really pushing up against that, then we’ll have to start a discussion about getting a second room or even a second location.

What about Saturdays and Sundays?

We thought about Saturdays and opening Saturdays, but I’ll tell you. We have all holidays off, all weekends off. Once you have that in the system, if you will, because we don’t work weekends or holidays, getting the staff to do that is difficult. Now ,December is the busiest month of the year because everybody’s met their deductible. And December’s always crazy busy. So the staff will let me have them come on, and we pay them time and a half to come in a couple of Saturdays during December. But as a full-time thing, that would be a tough sell for me, for our group.

Yeah, yeah, my staff all works four days a week, and I would have to hire more staff to get them to do. They’re in a very sweet spot. But, you know, they’re happy, I’m happy. I’m not driven necessarily solely by money, but that is the stuff you consider, I mean, staff is one of the big expenses.

It is, and getting more difficult because we saw recently that it was very difficult to hire more nurses. Fortunately we have a good group of nurses now, but as we were talking about getting another shift, it became difficult and we found that some travel nurses make $90, $100 an hour. And that’s just something that I can’t do. So I think the market is gonna shift back a little bit. I don’t think it can be sustained at that level.

Well, and the hospitals have lost a gajillion dollars doing that. And so I feel it’s shifting back. But we lost a nurse—a travel nurse—which I mean, why not? She was single, had no animals, no kids, no husband. And she was like, “Well, why would I work here when I could go make–” she was making like $7,000 or $8,000 a week or something. So one area of practice difference that you and I have is—you know, where it’s coming. I love the radial!

And people come up to me all the time. I mean, because they know I’m a femoral guy, and radial is fine. It really is. If I did other interventions, if I did renal intervention or GI intervention or other types of cardiac intervention, whatever, like if I did upper abdominal stuff, particularly renals, when you have the way it’s oriented, the renal arteries, radial makes a lot of sense. And so I would do radial, but for UFE, I’m here to tell you my bias is it has absolutely no place in doing fibroid embolization. The reason why I’m so adamant about it is I know that there’s strokes out there and these women are young, otherwise healthy. I know of two strokes in the Atlanta area. Neither one is our center. I’m a femoral-only person, and my colleague will do radial, but neither one of these was his case either. And, to me that’s too high.

Well you say there’s no place, but there’s a place in Portland, Oregon, that will do your radial UFE. But John, I will not do tibial UFE just because I respect you so much.

Well I appreciate that. That was all tongue in cheek.

I know, I know. There was a paper published on tibial, and of course, you know, I get a little ahead of myself. I always love this sort of, “Oh wait, you can do that? How cool, I wanna do that.” And it was. Well, I thought the person who did this study was great. I mean, for me, it helps me when other people— I cannot be inventive. I am on my own in an OBL, there’s a community standard of care, God forbid. I did not do radial for a very long time because of stroke. I watched the cardiologist do radial. And I went to two courses. I was not afraid of hitting a radial artery. I don’t think that’s hard for any interventional radiologist. But I had the same feeling of like, okay, these are young, healthy— these are not the cardiology population.

And so I waited a really long time. It was maybe 2009. And I remember going into the cath lab and watching these guys do it, and I was really, really wanting to try it. And it wasn’t until the Canadian, Darren Klass, and Aaron over at Mount Sinai, they had published all this data. And I agree with you. I think these are the kinds of things that you do until you have a stroke and then you’re like, oh. And same with same with hypogastric nerve block. I did those, and then I had friends who had patients go into like complete seizures and septic shock. And you know, going through the bowel and having put enough needles through those. Do you do hypogastric nerve blocks?

I tried it just because I wanted to see like if it really would make a difference in my practice. What it did was, it works, but it just added more time. And so for me, I just abandoned that. Our pain protocol works really well. I don’t get many calls, you know, like we used to. It was more frequent, you know, four or five years ago. Still then, not a lot, but more frequent then than now. And we kind of keep tweaking our pain protocol such that the number of calls is really low. And occasionally somebody has a rough first night. They’ll just come back to the center the following morning, we’ll, plug them in for IV pain relief and fluids. And they’ll be in the center a couple hours and then that’ll be it. And they’ll go and they won’t bounce back.

That’s how it is at ours. And I’m always amazed they come. I mean, this happens probably under five times a year. I have the same experience. And yeah, some of them have a rough first night, but a lot of them don’t. And what’s amazing is the ones that do come back in the morning, you give them like half of a milligram of Dilaudid and they’re fine. Like there’s about— I feel like the stress and anxiety of pain can be really tough on people or something because we’re not actually doing a whole lot for them, but maybe some TLC when they come back. That’s the other thing is that people don’t realize that what do you do if you— we’ve come back in the middle of the night to put a Foley catheter in. Somebody had urinary retention and I called up my nurse and I said, “Come back in here.” We’ve had maybe two or three people who really couldn’t pee. One came back like the next day. And then of course your mind says, “Did I have some non-target embolization of the bladder?” I mean I think there’s like some— I always wonder about bladder ischemia, you know, like if we really had a camera in there, would more people have some bladder issues? I don’t put Foley catheters in anymore. I used to do that.

Oh no, never. Because I had one— I’ve had one myself, and I’ve never put a Foley in any patient. And I always, you know, bristled at— we never used antibiotics as a routine. Now there are patients we’ll give antibiotics to, but we don’t use routine antibiotics ever. And we don’t put Foleys in anybody. And we’ll have an occasional, rare, patient that will have some issues peeing. They’ve gotta pee so they can leave the center. That’s our low bar. Their vitals are are fine. You know, simple stuff. And they’ve had to pee. Yeah. And if that’s the case, then they leave. And occasionally they’ll hang around a little longer, whether it’s they’re dry, so we give ’em more fluids, or we try to play that chutes and ladders game where we have to straight cath them because they’re so uncomfortable and then we have to reload them again till they can pee themselves. Or we’ll sometimes give them stuff to try to help them, relax and so they can pee, turn the faucets on.

It’s amazing how few people can pee on a bed. We should do at next SIR instead of the sound booth. Let’s have a “everybody try to pee on a bed” booth. It can be private. You can have your privacy curtains that you guys like. You could have private privacy booths, and everybody can try this because nobody can pee. Nobody can pee on the bed. Even like our PAD patients. And like the peeing thing is a legit— we see it because we’re there. These patients aren’t in some recovery bay like three floors away, like in the hospital. That’s the thing, in the hospital, they all go to recovery and none of this is your problem. Except for, in my center, I’m literally like 20 feet from all of this happening.

Yeah, me too.

Yeah. So, you really get to know everybody’s ins and outs. When I was pregnant, the two things I was most scared of was not actually delivering this big boy, it was— I was worried about the IV. I did not want an IV. And I was worried that somebody was gonna come and try to come out with one of those Foley catheters. And I was like petrified of all of it. And the IV. So even the IV stinks, but, you know, those are the things you can make so nice in an OBL. We use EMLA, and I’m always like, look, don’t stress. If you’re a tough stick, we’ll put it in. I mean, you do this too, right? And there’s no stress around any of it.

Yeah. Right. And it’s like you have the control of everything in the operation and you take pride in that. And when everybody signs up to your mission, it really works. And so that’s why I say our staff loves working there as well as I do. And you know, we also do things be outside of the practice, which is fun. Occasionally we would go out like with the hospital people when I was in the hospital. But you know, when you’re in the OBL setting, it’s really a team and it’s really your family. And it’s a lot of fun. I mean we went to Top Golf. We went roller skating. We went bowling.

Roller skating? I hope you didn’t roller skate.

Oh yeah. I’m an old hockey guy.

If you break your wrist, you’re hosed. Do you have big man insurance?

Not yet, but somebody did mention that I should. If you get hit by a bus, what happens?

I mean roller skating’s a high-risk activity. I slowed down snowboarding because I was like, I am not gonna fall now that I have this thing.

Yeah, I guess. I mean we did an escape room. We did an escape.

Yeah. That’s why not doing one, because my team will figure out how dumb I am. We try to do team activity stuff and I’m like, they’re gonna look at me and say, “Don’t you know what this is?” I’m like, no, I’m not. I push catheters.

I know it was to get off the track. But the thing about the escape room, for those who haven’t done this, you don’t know really where you are. Like with a computer, when somebody’s loading a program on the computer, it tells you kind of how long, like where you are on the trail and you’re almost completely loaded. But with an escape room, we’re 10 of us and there’s five on each side of the wall. And we figured out how to get the wall to go away. And then the 10 of us are all high fiving like, we’re gonna escape. That was such a little part of it. But we thought we were like all the way through. So you have no idea where you are on that continuum. And of course we failed, and we sank the sub. We drowned.

Now that I know that if I ever take them to the escape room, I’m just gonna stay in the first room with my cocktail and let them go try to sort it out. So what’s your favorite— They, one time my staff wanted snacks, and I looked him in the eye and said, “I never want to hear about snacks ever. I have far too much stuff to do.” I said, “Here’s my credit card, I need you to go around to everybody, ask them what they want and get it ordered.” And so I liberalized— I was liberalized of the snack order and that was the staff particularly loved that. And like Costco delivery trucks started showing up. And you know, in the end, it wasn’t so bad. I just did my year-end financials and I was like, all right. That was easy enough.

Yeah. It’s, it’s money well spent. When your staff is happy and you just kind of— it’s fun. It’s a fun environment. I say people, I work in paradise. I mean, I really do. So you can do that. I think that’s— one of the nice thing is when I came out of training, I’m not doing any of the stuff that I did when I was in training. And so that’s one of the great things about IR is that we adapt and we’re innovators. And we just kind of look at things and kind of figure it out. And that’s a great trait to have and that’s part of our DNA that we just kind of figure it out and adapt and evolve. And so that’s why it’s really important for people to figure out—

They don’t have to accept the traditional paths. That’s really important. Like when I came out, it was like academic or private practice. That was it. And you don’t have to do that. As I say, there are so many different paths, as you mentioned. And there’s even some that I wasn’t even aware of until I came here. And so that’s a really cool thing because the more it shifts into the outpatient world, the more people start doing OBLs and opening up OBLs, we’re going to take healthcare back because that’s patients love coming into the OBL l setting. They get better care. It’s less expensive. Anything in the hospital is two and a half, three times or more expensive than what you do in the office or any outpatient setting.

So it’s less expensive. It’s better quality. I mean, the value of that is just immeasurable. So everyone’s happy in that scenario. So the more people that get into the OBL space, I encourage them to do so. Don’t worry. I think the biggest worries, the two biggest worries that I hear about are: I don’t know if I can do this, there’s risk. Well, yeah, there is. Financial risk, you have to understand your financial situation, and everybody has different amounts of financial debt or burden. And you’re actually betting on yourself, as we mentioned. I think who better to bet on. If you’ve gotten really good training and you’re really set in your skills. I wouldn’t come right out of your training and go into an OBL. I would— hopefully you’d get the best training that you’ve got in your residency and your fellowship. And once you’re really well trained, get a little seasoning and then consider transitioning to an OBL, once you get a few gray hairs maybe.

And you can go to the SIR business institute to learn everything you need to know to not make big mistakes.

Yeah. You don’t have to make the mistakes of other people. And that’s why things like this are helpful, I think, to learn from people that did it before. I mean, when I did it, there was no safety net. I had to just take a leap of faith. My partners in my traditional radiology practice, when I told them I was leaving, they thought I was insane. They were like, “Well, where are you going?” I’m like, “I’m not going anywhere. I’m staying in Atlanta. I’m going to do my own thing.” And they looked at me like I had three heads, and there was no safety net. There was no nothing. Now there’s more places that are actually out there doing OBLs. There are choices for people to join an established OBL. You can do that, you don’t have to do this from scratch. yourself. You could do it, but you could consider joining an established— go to Portland. Come to Atlanta, come,

Come do my job so I can take a little vacay. Be great!

Right.

So you are overall a very positive person apparently, because it’s all good, positive happiness.

Yes.

So, you know, I’m kind of more— I’m happy but I’m kind of negatively—like trust-no-one type—wired. I’ve been burnt a lot, John. I’ve been burnt a lot. Okay. So what would you say if I forced you to say what the top two hardest parts of starting the OBL were and the top three hardest components of owning and operating. And then I also want to know, I think you went to a management group recently.

Well we did for a brief period of time. We wanted to try to kick the tires on that. We still have a relationship with them, but I run the practice.

Oh, okay. Wait, talk about that first and then the other ones.

Well, that’s interesting because I say I looked at trying to see about having someone help manage and grow our practice, and it’s difficult because I wasn’t aware of what I wanted was someone to help me manage my practice, having the experience of managing other practices. And what really kind of came down the pike was I can get you that service, whatever that service is. And I kind of wanted someone to manage the practice and so not to go find it. I can go find it. I’m wanted to pick you to manage it. And so that’s where the—

I get that it’s so hard with staff versus consultants versus— when you start, everybody comes at you— how they’re gonna help you in ways that you don’t know that you need help.

Right, right.

And then you realize, “Oh wait a minute.” Here’s the thing about interventional radiologists. We’re all smart enough to do any part of it.

Right.

It’s not like we can’t understand coding, billing. You just have to sit down and learn it. I don’t think there’s any part of operating these things that we can’t understand, and we haven’t learned operating agreements. And you know the right people, you start to get your right network in place and it’s not hard. It’s not hard to do some of— most of this stuff. The hard part is when you don’t know. I mean when people tell you. Well, I mean I could see if you’re coming out, there are a lot of mistakes you can make that are very expensive, certainly where I think we are and you are. I mean, you’ve been doing this a lot longer than I have now. I look at it and I’m like, “Oh, it kind of seems easy enough,” you know? But then how are people helping you or are they—

Well, I think, you know, what you touched on is like having a team of people. Like when I came out, I was really confident in my angio skills. I wasn’t that confident in my business skills. I didn’t have any formal business training. I didn’t have any business courses. I knew how to balance a checkbook. That’s about it. So my business stuff I was not very confident in. So I think constructing, getting a team of people to help you is really important. Getting a trustworthy banker is important. And talking about your financial situation and what kind of debt you can accept. Having a business-savvy person. Fortunately a good friend of mine was in the hotel and hospitality industry and owned hotels and managed hotels. And when you think about it, a lot of the stuff that we do is hospitality and customer service.

And so one of the things I loved is this. I read this book about this very successful restaurateur in New York City, Danny Meyer. And he, whenever he opens a restaurant, it’s gold mine. And there is such competition for new restaurants in New York City. It’s unbelievable pressure. And he hits it every time. So “I’m like, this is cool. I want to learn about what’s your secret sauce?” Because I’m in the hospitality business too. Really. I mean, so his key is, boiling it down, is he hires people based on their hospitality quotient. It’s the measure of someone’s ability to derive pleasure in pleasing other people. And I thought, “Wow, this is really cool. I’m gonna, I try that.” So I had to hire an angiotech and I worked with these people at the hospital and two women applied that were the final two candidates.

One was the boss, the senior person. She’d been an angiotech for years and years. And the other one was a new, newly trained angiotech. And I hired the newly trained one. And so when she came to work at the Atlanta Fibroid Center, she sat down, and I could tell something was on her mind. So I was like, “What’s up? You have that funny look.” She’s like, “Why did you hire me?” And I was like, “Well, you know, I really like the way you interview, I like the way you work. But when I looked at the references that you provided me. Everyone, to a person, said you were the most pleasant person they had ever met.” And so her hospitality quotient was off the chain. And I hired her and sure enough, the patients loved her. She loved the job. And that’s what you hire for. You hire for HQ. I can teach, as you can, you can teach an MA or an RT, whatever, particularly in our stuff because we’re so nichey, I can teach them what I need them to know. But what I can’t teach them is what’s in their heart. And so that’s been a really good thing in hiring people because that’s an important part of this too.

Well, the other thing is by the time people get to you, they’re happy, not unhappy. So, you have the whole park at the hospital, go in, oh, you’re the wrong wing. And then you gotta check in administration and then you gotta walk up to the fourth floor and then you gotta go down a hallway and then you gotta turn right. Oh no, it’s left. Oh, it’s not the hub. You gotta go to the pub and then you’re like back down the hallway by the time they get to you, and it’s five in the morning, because everybody arrives at the same time. And it’s just not how it is at the OBL. People arrive and they’re happy, and you’re hungry. We get you something to eat. And so people— I feel like I’m kind of irrelevant. People are like, “You know, you’re great but guy, your staff!” And they talk and talk and talk about the staff. So, okay, let’s go back to some really good nitty gritty stuff. Expansion.

We would love to expand. It would be great. It’s just, you gotta do it, I think, kind of thoughtfully. I don’t want to just— some people go out there and really scale it, and good for them. But I move slower. You have to understand yourself. And so I really want to optimize where I am. I do have an office share in Macon an hour away. Because we do see a number of people from throughout the state of Georgia and other states that would rather, even though we have a tele option, they wanna see who’s operating on them, if you will. And so Macon is convenient for them rather than coming up to the big city.

Yes. We have an office.

So we have an office share.

That’s so smart. Do you– I think that everybody should know about what’s been going on in Rhode Island. I think there’s a lot of things about being in an OBL. We have a lot of similarities to our hospital colleagues. And one of them is an interest in IR and SIRPAC and making sure we still have reimbursement and jobs and IRs included in things. So we are truly all in this together. And I know part of the private practice thing is— I think there was a little bit of disgruntlement in the beginning of, “Oh, this was an OBL. Oh you OBL people.” And you’re like, well, you know, at the end of the day, we all do the same procedures.

Absolutely.

And so we need to make sure that we stick together 1000% when it comes to SIRPAC, our society, and the work that needs to be done. And I think that this–

Oh yeah, big supporter of SIRPAC, I think it’s great. I think we don’t contribute enough. Other specialties contribute more to their PACs. And I think we really gotta do that. You gotta get in there, and you gotta play the game. You gotta be a part of it. And I do think that there is some rationale for breaking off from our diagnostic colleagues. I mean, that’s the big elephant in the room. I mean, I know there’s been a lot of talk about that. But I do think it’s time. I mean it’s the reason I left, and I think it’s the reason for a lot of frustration to this day. There shouldn’t be any reason that anyone is doing IR that’s not doing it in a clinical setting. You gotta have a clinic, you gotta have an office. You don’t have to be in an OBL, but you gotta have a clinical practice so that you can be the patient’s doctor, do the longitudinal care that’s necessary. It’s 2023, there’s no excuse for not doing clinical work. So if your DRs are preventing you from doing that, you’ve gotta break free of that. And I think as a society, we’re an independent specialty now, I think it’s time. Just like the radiation oncologist, I do think that we need to separate from the diagnostic group completely.

Okay. But don’t you think there are some people out there who have some really happy with their–

And that’s fine. If they’re happy, if they’re truly happy, that’s fine. I’m not going to say that there aren’t such situations, but I think in general, I think we do need to make the split.

What do you do about the people who actually like doing some diagnostic? And I’m on your side. I mean, I did not have a good DIIR. I had exactly what you’re saying, for sure. When I started building this fibroid things, I did it on my quote “free time” (because I was working all the time) on the weekend. So I am just being devil’s advocate, because that’s my job, isn it? As the hard ass of the group. Oh, can I say that on live TV? Sorry. Or live whatever we’re on. So, I mean, there are IRs who like to do the diagnostic. I mean, there’s a role for that, right?

Rhere is. But I think, as I say, what’s not negotiable to me is the clinical part.

Right. Right.

If they’re not on board with that, and they’re not supporting you on that, you must leave.

Right. So you’re fine with any variation as long as the people who are practicing are. You know, what’s amazing to me is that we even are still saying that.

Right?

Im ean how long has this been going on? 20 years.

Forever. That’s why I think it’s time to really, seriously look at the separation of the societies such that we’re not joined at the hip. My former colleague said “All business isn’t good business.” And I think the argument is, “Well we’re, we’re, we’re stronger together.” No, I think you’re weighing us down and you’re not helping us.

Are you talking about the acr?

Yeah.

Yeah, I get the sense that it seems like SIR leadership is taking some stronger—I mean, now I’m gonna get in trouble in some way.

Yeah. I know. You’re on the inside.

I know that was supposed to be politically correct, and “Oh my god, dude.” I c the sense that the stand up for yourself and stuff is happening and from the top. Because with a different residency and fellowship and the young ones coming out, man, they all just seem like a completely clinically oriented crowd.

Which is great. I’m really excited about that. And talking to a number of people that are in their training now or just finishing their training, they are better trained, which is great. Much more clinical focused.

Because they’re doing that long pathway where they’re spending all this stuff.

That’s great.

We only have five minutes. So I want to make sure everybody knows, because this is where we’re going with this, what the work that you’ve done on SIRPAC with this really critical thing that was happening in Rhode Island, which Rhode Island and Oregon are the two places. They’re the gateway drug to the country. If you want to have some toxic substance be legal in your state, get a law passed in Oregon, and if you wanna get some healthcare thing passed, get it passed in Rhode Island. So tell everybody what you did.

What happened in Rhode Island is I got heads up that Rhode Island was going to pass legislation such that any of the following treatment options for fibroids would have to be covered by insurance. And it sounded like a really good thing, because the way they were pitching it was “Here we’re helping predominantly African American women, people that might not have access to care. They might not have the most access to care. They may not even have insurance, but if they did have insurance, the following options would be treated for fibroids.” And it sounded like, well this is good for people because it provides more coverage for things. But it didn’t include UFE, which was really shocking to say the least.

Because it’s only 25 years old.

Right? So we had a meeting with the representative, and she was fine. She really didn’t understand. She was getting fed by gynecology community on here are the options that need to be treated. And they just forgot about UFE. And once we met with her and talked to her about it and explained and provided her information, she changed the legislation to include UFE. Because if that would’ve passed, it could have been the blueprint for a lot of other states and it would’ve been a really big mess for IRs that were doing UFE.

Established a precedent, right? That establish a precedent of what you legally need to cover. It was so critical that you were there and I think Teresa was there and SIRPAC was there. And this is why it’s so critical that we are all on the same team. Because if Lipman and his OBL, l mean he obviously has a strong interest in fibroids and is gonna be a strong advocate for uterine fibroid embolization. And if anybody else in the country wants to do it, we need the John Lipmans of the world going and making sure these laws don’t pass that exclude these things from insurance coverage. Which blows our mind that this is can be 25 years in the making and still happen.

I know. And you know, I’m just one person. And so when I saw that this legislation was heading for passage I reached out to the SIR, and I know people in leadership at SIR. And that’s why it’s really important for IRs to be members of SIR. Iknow that there’s a lot of grumbling, people maybe unhappy about this or that, but you’ve got to have— we’ve got to be in SIR to at least then have them help us. Because as one person, you can’t get anything done.

Yeah. I mean I know the membership, I mean believe me, I looked at how much I pay in membership costs last year and this comes outof my own pocket as you know, every expense in my professional life comes out of my own money. Nobody’s given me anything to do any of it. But I mean I think it’s like, kind of worst case scenario is you’re literally taking it out of the mouths of your babes to give to whomever. But you have to keep doing it because we have to have members. Without membership, we have no say right about anything. And so, yes, okay, so it’s a thousand dollars and believe me, we’re trying to make that less. I mean, it may keep you mad, but we’re trying. We’re trying to say, look, this can’t be an endless increase forever and ever, but we have to have members in order to have strength to make these decisions. So when you look at sort of what the hit is, if you’re not a member, it’s almost like—even if you think the society does nothing for you, which I can guarantee you is not true, it’s just you don’t know what it does for you—then it’s still worth writing the check because at the end of the day, it’s what’s going to pay you.

Yeah. You gotta be—

No matter what situation you’re in.

And even one person, as I say like this can make a difference. I mean, so—

You’d think this was a commercial for SIRPAC or something.

Well hopefully people will join SIR and contribute to SIRPAC because SIRPAC really needs our help because it’s the only way we can make sure that— You gotta vote and you gotta have influence in legislation that is right for us. And, and that’s the only way to do it.

Yeah, I totally agree. Well, on that note, that’s it. See I feel like that’s a positive note.

Yeah, no.

You turned me around, Lipman. you turned me around. I was trying to go for the, the bad, the ugly. But you stuck with the positive. Stay positive.

Stay positive. All right. Positive energy. It it carries, I mean,

Yeah. Yeah. Well it’s always a pleasure to see you. I only get to see you once every couple years, at these meetings. All of the friends are all back together and it’s so fun. I always have to get like mentally prepared for this week forever because— I can’t help myself though. Every, it’s so great to see everybody and to have the conversations. I’m so glad we’re back in person. I never wanna go back to Zoom ever again. And just to be able to have direct conversations and get to know, We’re such a rare breed, so it’s great to see you.,

And thanks to Cook for doing this. I hope there was enough pearls in there, aand people who are listening to this, by all means if they want to reach, I’m easy to find, as Mary’s easy to find.

Actually I think last time I tagged you on Twitter, you’re like “Excuse me, is this, do you really think this is me?” Do you remember that? It’s like if you could do John Lipman. What is it, like an actor, but I mean the picture is this big, I couldn’t tell right. What’s your Twitter? What’s your Twitter handle?

@DrLipman1.

One. It was the one.

I don’t use Twitter very often, occasionally, but the easiest way to reach me is either my email john@atlii.com because our website is atlii.com or Instagram dr_lipman.

Perfect. Well, I’ll make sure not to tag the wrong Dr. Lipman anymore or talk anything about tibial access or radial, but I’m still gonna do it.

As you should.

Thank you so much and thanks to Cook.

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