How to find your interventional radiology independence through an OBL (office-based lab)

Episode Transcript

Recorded live from the Cook booth at SIR and featuring leading experts in the field of interventional radiology discussing a wide range of IR-related topics. This is The Cook@ SIR podcast series.

This is Shamit Desai coming to you live from Salt Lake City in the Cook podcast booth, this beautiful glass enclosure that we’re in with Dr. Kavi Devulapalli. Very fortunate to have the sponsorship and help of Cook to get educational and important content out there as they have been doing for many years, since the time of Charles Dotter. We have a very interesting 45-minute podcast today with an expert in the field who has a bit of a following. Dr. Kavi Devulapalli is with us. I am here as the host. My name is Shamit Desai. I’m a Chicago-based interventional radiologist who also does a bit of locums independent contracting work. I have my sense of independence in IR, but also in a full-time private practice, and I’m just happy to welcome my friend, and in many ways mentor, Dr. Devulapalli. I’d like him to just make a quick introduction.

Thanks so much, Shamit. That’s very kind of you to say. Very much friends. We’ve known each other for over five years now. Pleasure being here today live in the Cook booth. A little bit about myself, I’m a practicing interventional radiologist. I’ve been out of training since 2018. Trained at UCSF out on the West Coast and then moved to UNC Chapel Hill where I did my IR fellowship. I stayed in North Carolina for several years and really that’s where I became introduced to the OBL space that we’re going to talk about today. But I was in practice in a traditional DR-IR group, a group of approximately 20 radiologists and three IRs. I was practicing in that setting for a little under two years, and then right at the height of the pandemic, I left that setting to start an OBL with an interventional cardiologist.

I was in that setting for a little under a year and a half, and then due to some circumstances related to my family and my wife, who is also a physician, and us having to leave market, made the decision to sell my stake and share in OBL and moved off and actually been very involved in independent contracting since, and I found myself now living in Columbia, Missouri, which is my new home where I am focused on creating my own practice.

Thanks, Kavi. Such an interesting story for early career. I think a lot of people are interested in this space, independence and what it means to you. We’ll get into this as the podcast evolves here at the Cook booth. We’ll really talk about the OBL space as a focus of this podcast, which may eventually be a series, but we really want to also focus on what independence means. Is it just the OBL or are there other options out there for independence in the world of interventional radiology? The landscape’s obviously changing. People are feeling market pressures from all over the place. Even as early careers, we feel it, and we want to give trainees and early careers options to practice interventional radiology the way that they want to.

I’m just going to dig right in. We talk every day, so we might have to break it down a little bit for some people, but let’s get into it. Why did you move into the independent space, OBL, direct contracting? What’s been your experience and what were your motivations?

Sure. My story really began in the hospital, like most of us. Coming out of training, super passionate about IR, very clinically minded, I knew I wanted to build a practice, so I picked the setting where I needed to live, which was locally in Durham, North Carolina. And I found a practice that actually didn’t have a whole lot going on in terms of IR other than usual bread and butter cases, but I knew there was a potential in this setting. It was a pretty busy community hospital. It was actually a county hospital, about 400 beds, so some pretty interesting pathology, but I knew there was potential there and there was a patient base there that I can build service lines that I wanted to. In the hospital, I had a good experience, pretty much cutting my teeth early, getting a lot of the basic skills that we need to get early in our career, supportive partners from that setting.

But where I didn’t have support was building a clinic, and I think very much I came to this realization that there’s some dark secrets in the world of interventional radiology, especially when it comes to how we structure our practices. It just so happened that I learned the hard way where I became pretty much accustomed and really educated on what was a diagnostic radiology financial model, which is the predominant model for most, not all, but most hospital-based interventional radiologists, and I didn’t have that support for the clinic that I needed to really build what I wanted to do. I was doing all sorts of things like prostate embos and critical limb ischemia with pedal access. I was doing some IO, a lot of venous disease, but I was doing it on my own as an army of one. Building up those referrals when you have diagnostic responsibilities and trying to build your clinic when you don’t have the infrastructure support was super challenging.

How many RVUs were you reaching per day in that model?

Great question. Not enough. Not enough.

It’s never enough, is it?

It’s never enough. But nonetheless, you do your best and I think at that point I was getting pretty burned out. I mean, when you’re an army of one anywhere, it’s hard, and I think what happens to a lot of folks is they either just acquiesce to the status quo and inertia takes over and it is what it is, and you just do what you can, and some people go a little ballistic, and I probably went the latter. I started a blog, Line Monkey MD for those who want to check it out, and I posted on the SIR Connect forums. I posted about my experience and Mary Costantino encouraged me to actually make public my experience. She was on the private practice committee at that time, and I posted my story on there and literally within two days I received a few direct messages, one of whom was my mentor, Bill Julien, who reached out to me and said, “You need to come down to Florida and check out this thing that I’ve been doing for 20 years. It’s called an OBL. Come check it out.”

So he flew me down and I checked it out and I didn’t look back. The OBL was a mechanism for me to practice the way I wanted to practice, building up longitudinal care, taking care of patients, doing elective cases, not having to worry about that diagnostic responsibility, and that’s pretty much what led me into it.

That is a great answer. If you’re someone who doesn’t have a way with words like Line Monkey MD, Dr. Devulapalli, and in your early career, you’re still a trainee, if you’re someone in that space who’s thinking they want to do what they’re being trained to do and they don’t meet a Bill Julien, for example, how do they go about and navigate this evolving landscape? It seems like everyone’s pulling at IR from different ways. How do you navigate the world these days? Truly, it’s our career.

It’s hard. It’s so hard, and I think that’s probably one of the biggest issues that we face as a field. I think it’s hard to get meaningful mentorship. I think there’s a lot of people out there who are really well-intentioned, but it’s hard to find that one right person. I think for me, some of it was a little bit of dumb luck, but I think I increased my luck surface area by putting my story out there. And I think the best thing that people could do is share their experience with others. For me, that was being on a forum. I hope people listen to this podcast and reach out to either you or I, share their stories and their struggles. Because it’s a pretty small world in IR, and I think once we get to know each other, you’ll realize that there’s plenty of opportunities out there.

I think one of the biggest things to have in mind is kind of an idea of what you want your life to look like. In about five years when you’re done with training, what do you want that life to look like? I think if you can answer that with honesty, then you can just connect the dots and do what’s necessary to get to that point. Easier said than done.

How similar is your life and the way that you’ve structured it to your training programs, which were at UCSF and UNC for fellowship?

Very different and I don’t mean that as a knock. I think when you and I were training, it was still actually a different time, right? IR was actually a fellowship of DR. We didn’t have an integrated training pathway. You had excellent training at Northwestern, I believe I had excellent training as well, and we’re very competent in everything that we do, but there was a little bit change in mindset that’s been going on these last few years. I think folks like Bill, who I referenced earlier, were probably a couple decades ahead of their time. I think for me, I realized maybe kind of in a backwards fashion, that you have to be clinically focused in order to build a longitudinal care program. It took me a little while to get to that conclusion.

I was always under the mindset of “You know what, I’m just going to market my services and do cool cases,” but you have to learn how to get those referrals and you can’t get those referrals unless you take care of patients. That’s, I think, probably where my practice now maybe differs from what my training programs did back in the day, though I’m sure they’re different now because everything’s changing.

I mean, it’s crucial. I mean, it’s crucial, man. As IR professionals, we are clinicians first, and we are proceduralists second, and that shift is definitely palpable in our community. I have a residency program, it’s a privademics type situation where we train four per year, and it’s very palpable. Even the diagnostic radiology residents know that the ESIR spot is going to have a clinical focus to it. So it’s out there because it has its own training program now. A big question that I want to ask you is how does independence demonstrate the value of IR when some in more traditional settings might say that you’re something like a bit of an outlier, or if you’re doing it through a non-traditional means like independent contracting with a hospital, you’re more of a hired gun for the hospital because you’re not in a group.

That’s a great question, Shamit. I think a couple things. I think first it’s good to maybe take a step back and just make sure we’re clear on what independence means. I think there’s a lot of terms that get conflated and confused. We talk about academics, we talk about private practice, we talk about OBL, we talk about hospital-based private practice. We talk about privademics, but I think the concept of independence really is greater than any of these one terms or their definitions. Independence in my mind refers to practicing vascular and interventional radiology outside of a diagnostic radiology context. It means not only being culturally but also financially independent of diagnostic radiology. I think that’s really the biggest thing, and I think it’s important that people realize that there’s perhaps more than one way to do this. I think the OBL offers a great mechanism to do that, but it’s not the only one.

It’s very well possible that you could have a direct contract with the hospital and technically be an independent radiologist who has a group of IRs and you guys contract with the hospital. You may or may not have an office, interventional suite, but you’re technically practicing independent of diagnostic radiology. I think the model is powerful because I think what this allows us to do is this allows us to focus our value centered on longitudinal clinical care. This isn’t a knock against traditional diagnostic radiology practices. Obviously there’s a variety of them, there’s a heterogeneity of them, but the business model is such that most of them make their revenue based on diagnostic imaging.

It’s not that there aren’t well-intentioned folks in those groups who want to be doing longitudinal clinical care. In fact, there’s some large groups that are pretty diversified that you can have these longitudinal care pathways in a hospital and they exist, but it’s harder to do. I think as such, what ends up happening is a hospital becomes more or less accustomed to that contract, and that contract is basically one in which interventional radiology services are offered for free. There are exceptions, but that is the norm. When that’s the case, it’s a little bit challenging to prove your “value” in that context, but by being independent, you have to prove your value.

What is the future with IR-DR contracts in the moving landscape where IRs want to practice clinical IR? What is the worth value proposition that you are offering to IR-DR groups?

Yes. I think for IR-DR groups, I think it’s important to recognize what they have in IRs. An IR is not just an anchor for a contract. You need to have interventional radiology services to maintain a radiology contract because unfortunately, radiology has become so commoditized. It’s pretty easy to just hire teleradiology, export that work, but IR allows that contract to be maintained. But I think it needs to go a step further. I think IR allows for very crucial pathways within a hospital. I think it supports very important services, services like VTE, services like trauma, potentially stroke, depending on your setting, and those are just really services that are centered on episodic care. We’re not even scratching the service about longitudinal care, like things that we can be doing with men’s health, women’s health, arterial disease, venous disease on an outpatient basis. You can certainly have those programs, but I think if any IR-DR group, I would implore them to consider that value proposition for that IR, the value that they bring and I think that value has to be demonstrated to the hospital and it can’t just be offered for free.

But Kavi, you could be reading two CTs and doing a PICC in the same amount of space that you could be doing a kyphoplasty or a PE thrombectomy. Why should young IRs and independent IRs in the hospital based—we’ll get into OBLs for the remainder of the talk—why should they demonstrate that value and how does that work out financially for the hospital and for the group and/or individual physicians?

Yes. A couple answers to that really good question. The first answer is because it’s the right thing to do for the patient. There are patients in need. When we talk about these common conditions that I mentioned, I mean they affect over 50 million patients. We got to do the right thing and in many settings, there may not be a capable physician of doing that or offering that service. I think A, it’s just the ethical thing to do is to take good longitudinal care of patients. That’s the first answer. From the financial aspect, there’s a clear discrepancy between what those procedures make on a professional fee basis only for a group versus what they make for a hospital. Sadly, that discrepancy has only been growing by the year. In fact, professional fees, when indexed to inflation or compared to inflation, have actually decreased by 20% in the last decade plus, whereas technical fees are continuing to rise.

When you or I do that kyphoplasty or we do that embolization, it is making the hospital plenty of money, well out of proportion to what it’s making our group, which is why maybe somebody like you or I in that setting may be asked to read those two CTs and maybe with AI it’s 10 CTs. But I think once that economic reality is set, it is then incumbent on those physicians in that group to realize that and to potentially leverage that. So that value is there. That value could be achieved because that is aligned with good patient care.

Interesting. The other aspect that will come down in the hospital setting, I’m sorry we’re focusing so much on hospitals, we will get to the OBL, I promise the audience, is how does this work—and we’ll transition from here to the OBL—how does this work with other specialties? Because turf has become a popular trend over the last 20 years. It wasn’t as much prior to that. Turf and finances coexist. How do you add a value proposition to other specialties and how do you make interventional services its own value-based model within a hospital while other services are interested in your space?

Some heavy questions. I like it. A couple of things. I think the most important thing above and beyond anything else is we have to be doctors. We have to take good clinical care of patients, and I think the reason we get into turf battles historically is because I don’t think as a field we’ve kept our clinical skills up at the same level that these other fields have. Certainly there’s financial incentives. Obviously. I mean, if you do a multilevel CTO, you do tons of those, you can imagine there’s other vascular specialists who are wanting to do that, but it’s kind of low-hanging fruit for other specialists to pick up work if you’re not the ones actually taking care of the patient and providing that longitudinal piece.

I think that’s the most important thing. I think when you take good care of patients, you’re a clinical expert first and an imaging and technical expert second. That allows you to maintain that “turf,” and I think it goes beyond that. I think it changes the culture of your program and allows you to actually collaborate appropriately with other vascular specialists or other specialists, whatever service line that’s in question that may be in competition. I think that’s the most important thing. The finances follow after that. I mean, if you’re providing good care and you’re competing or appropriately collaborating, the money will follow.

I just think that your head is screwed on straight and you understand the marketplace, and at the end of the day, facts speak. There are models out there. I’m in a private practice. I work with diagnostics every day. I have a phenomenal group, phenomenal. They are all world-class physicians, including my diagnostic counterparts. In my group, they value what IR does. We are given autonomy and independence. We are clinically focused, and we have a clinic at both of our hospitals. I fear I am what some of the younger career people who have talked to me, what they call a unicorn group, where the value prop that you were talking about of IR is the face and high-end procedures being developed in the clinic. I wonder where that goes, and I wonder if that’s sort of the trend that’s leading some people to outpatient-based medicine. What is the value prop of outpatient-based medicine? What is the value prop of an OBL or ASC? And get into the difference a little bit about those two words, those two acronyms.

Sure. That’s a great question. I think we are really underestimating, as a field, we are underestimating the power of ambulatory care in general. There are so many patients who can and need to be treated and we can have such a tremendous public health impact, but we’re really focused on the hospital. Your group, good group, that’s what I call them, I call them “good groups,” that’s a one out of 10 proposition. For every group like yours, there’s going to be nine that don’t operate in that context, which is why we sense so much angst and frustration among our colleagues, especially early-career folks and folks coming up the ranks. They’re looking for a different model. When you think about that public health impact, you think about that arterial disease, venous disease, men’s health, women’s health, chronic pain, 50 million patients—mentioned that before, I’ll keep mentioning it—that has to be kept in focus because that is our potential.

You have to ask yourself, why do we concern ourselves solely with doing episodic hospital care at the detriment of not taking care of those patients? I’m not saying that they’re mutually exclusive things, but we as a field have typically ignored that aspect of it, and folks like myself or those who’ve come before me are then viewed as outliers. But that paradigm is changing, and I think the office interventional suite, OBL, those are synonymous terms, it’s simply defined as a site of service, and that just comes from the government. The ASC, that’s a site of service, but the OBL offers a mechanism to actually have independence to take care of those patients and do the right thing.

The ASC is just another site of service. It’s different from an OBL and that there’s more regulations involved. It’s more tightly regulated in general. It’s a lot more expensive to start up, and in certain states it’s a little bit more onerous because there’s something called a certificate of need. I encourage listeners to look that up. We can do an entire 45-minute podcast on that term alone, but it becomes pretty tough. But the office is simply that, it’s a physician office. You or I could open it, we can treat patients and we can get to work doing the great things that we do. Definitely easier said than done. There’s barriers in certain states. Again, we can go down a rabbit hole about that, but it’s the most accessible way for an IR to do this.

Really interesting. The other side of all of this is the patient, the most important side. I think as physicians, when we get deep into some of these conversations, and although it’s always in the top of our mind, whether you’re doing a paracentesis or you’re doing an iliocaval reconstruction, of course it’s always about the patient. Anything else is just virtue signaling, and we fully understand that. There is no argument to state that we don’t care about patients. We all do. We’re physicians. Let’s leave that aside. We are not hospital administrators who have their own budgetary and other concerns on their mind and have serious pressures on their end, because you have to prove value to them. There’s nothing wrong with doing a paracentesis because we all care about patients, but tell me why the outpatient space makes sense for patients. OBL/ASC, why does that make sense for patients?

A few key reasons. One, it’s more accessible. Think about maybe going to your dentist in your community. You just pull up your car, you park, you walk right in. Could you imagine doing that for your critical limb ischemia patient or your fibroid patient? It’s so much easier than having to go to a hospital, park your car, pay for parking, walk multiple floors, check into the desk, go to another lobby, et cetera. It’s far more accessible, number one. I think number two, in addition to accessibility, it allows for personal care. The entire model, both culturally and financially within an office interventional suite or an OBL, is focused on longitudinal care. You are not going to be showing up to that office, nor should you show up to that office, unless you’ve been seen by your doctor and you’ve had an appropriate consult and visit.

Not to say that that doesn’t happen in the hospital, but there’s more pressures in a hospital. There’s time pressures. You got sick inpatients to deal with. You got emergencies that get added on. You have other responsibilities. It’s hard. It’s hard practicing ambulatory care in most community settings. Now, certainly there’s plenty of tertiary care centers or larger centers where you can spread out the load and you can devote yourself to that. I’m not saying that it can’t happen there, but I think it’s easier to do in the office where that is how you make a living. You have to provide that good care in order to keep the lights on.

I think for those two reasons, it’s much better. I think a third reason might be a financial reason, and it might be—not true in every setting—but certain patients may elect to pay cash, and generally speaking, you can get more favorable cash-only prices with an independent physician practice than you could with a large healthcare system who will tend to charge significantly more as they tend to get paid a lot more based on their commercial contracts. Cash pay tends to be a lot cheaper in this setting. I think those are the three big reasons.

A lot of our audience, a lot of your followship, I mean obviously there are mid-career and late-career followers of your blog, of your presence, but most of what I get approached with is early career and trainees predominantly: medical students, residents, fellows—I guess we’re calling them all residents now, past our time.

Showing our age.

Yes. What do you need to know before you consider office-based medicine or independent practice of medicine? What are the hurdles and what should you know and what should you be equipped with?

Great question. These are all amazing questions. I wish we had more time, but I’ll try to make it brief to hit the highlights. I think the biggest thing about independent practice, just 30,000-foot view, is you’re not dependent on diagnostic radiology to make a living, which is challenging when you’ve spent three years of your life learning how to do diagnostic radiology. That’s not to say you don’t use those skills. I use those skills every day. I’m always looking at imaging. I may not be interpreting it in the OBL other than my ultrasounds, but I use those skills, but I don’t bill for that all the time. If you get a CT or MRI on a patient for a procedure, potentially, you’re not the one billing for that generally speaking, so you’re not dependent on that model, which means you have to be clinical. It’s everything.

Independent IR equals exceptional clinical care. There’s no question about it. If you don’t know how to primarily manage disease states, it is very, very challenging to make a living in this space. It is a lot easier to just go down the traditional radiology path. I think that is the biggest barrier. There are folks who get caught up on the financials and I’ll talk about it, that’s important, but I think culturally and knowledge base, you got to know about that. So it’s a clinical care. I think you got to be an expert at that. The second thing you have to realize is it takes time. It’s not as simple as leaving training and starting something. I know the trainees coming out now are far better than I was. I mean, they kind of embarrass me. I’m here at SIR and these guys are geniuses, so that’s great.

But even with the exceptional training that folks are getting these days, I don’t think it’s necessarily the wisest move. I know people have differing opinions, but I don’t think it’s the wisest move to just go out into the OBL. I think it takes time to develop not only clinical, but then technical and imaging expertise to be good. So that’s an issue. Now you’re getting into more of the meat and potatoes about—

But are you saying that you learn stuff after you leave fellowship? Is that what you’re implying here?

Surprisingly, yes. What a concept, right?

I learned more in the first three years out of fellowship armed with an extremely high skillset from Northwestern, from a clinical and patient management and liability perspective, than I was able to as a trainee. It’s not that they didn’t want me to learn that. It’s that I was now fully responsible. If I take this extra risk, it’s on me, and I don’t have someone backing me up in private practice.

Exactly. That’s it. I mean, you’re on your own. Everything starts and stops with you. I think having a couple of years of experience under your belt at minimum is good to get in this space. Then you’re talking about some of the issues with actually doing it. A couple of different pathways to get into the OBL space. If we’re talking about the entrepreneurial pathway of creating your own, then that becomes very challenging because you are dealing with a very high financial startup cost. I mean, we are talking high six figures, if not seven figures. I think if you would’ve talked to me three, four years ago, maybe listened to a couple of our BackTable podcasts, I would’ve said 300,000, 400,000, but things have changed. Inflation has changed, it’s gone up. Supply chain issues. Everything costs more. It costs more to hire people. Everyone’s paying more for staff, which means you have to pay more for staff, and reimbursement’s going down.

So the pressures are real. What’s not told in this entire story too is your insurance contracts, especially if you’re an IR, you’re generally going to be accepting insurance payments for the work you do. It’s hard to be credentialed and payer contracted and be paid fair rates. Many of my friends are getting below Medicare rates doing it as an independent. You have to be cognizant of that, means you have to have volume, and how do you get those patients? You need a reputation. That takes time. It takes time to build capital. It takes time to develop a reputation. That’s really hard. Then finally, we get into the concept of pseudo-exclusive contracts, and we’ve done BackTables on it. There’s papers on it, plenty of programming on it, but long story short—

SIR launched a memorandum on it very recently.

They did. I think their third edition or something like that. But the general idea is that in certain states, many states, you need hospital privileges in order to start an OBL practice. That’s hard because many radiology groups have “exclusive” contracts, that’s why we call them pseudo-exclusive. So that’s a problem. There’s a lot of politics to getting hospital privileges, and it’s definitely beyond the scope of this podcast, but those reasons make it challenging when you go down the entrepreneurial route.

Is it as simple as just not calling yourself a radiologist or is it tied to your board certification? Say you called yourself an imaging specialist or a procedural image-based specialist. Would you be able to override those pseudo-exclusive contracts, or is it tied to the fact that you’re certified by the ABR?

Unfortunately, it’s tied to the certification. On my Twitter, I put endovascular and image-guided surgeon. I have friends who say vascular and interventional specialist. I mean, you can call yourself whatever, but as long as your board certification reads diagnostic and interventional radiology, you’re technically still a radiologist. That’s the issue.

What questions do you get asked from trainees that you want to address here that we have not addressed about either independent contracting or the outpatient space?

I think a few things. I think one question that trainees often ask me is, “Well, I’m worried about the types of patients I’m going to see in training, and the program that I match to doesn’t do X, Y, or Z type of procedure or see X, Y, or Z type of patient. Am I going to be hosed trying to be an independent IR in the future?” I think you’re a living example of the answer is no. I think you do have to put yourself out there, and I think something that you’ve done that’s inspirational is you’ve actually put yourself in a position where you force yourself to learn certain skills—clinical and technical—that you didn’t have training in. I think that’s easier said than done. I think the BackTable you did on it was beautiful and folks should definitely listen to that, but you have to put yourself in the right position, and doing it as an independent IR is hard. I think you can do it, but it takes time. It takes time to see patients.

Are there any resources that can help in that kind of space, like if you’re trying to learn something outside of what you learned in training? We’re all good with a needle, a wire, and a catheter. We can place a sheath. Where do you go for those kinds of resources?

I think there’s plenty of resources. Since we’re live at SIR in the Cook Medical booth, you have to put a plug in for Cook Medical, there’s some great programs, educational programs here. People should definitely check that out. Plug for Aaron and BackTable, plenty of great content there. Then there’s all sorts of us just out there doing it. I think anybody who sends me a Twitter DM or you a Twitter DM or shoots you a text, I mean the beauty of IR is we’re all pretty friendly and we support each other. I think people are always receptive to having people come spend a day or two with them, check out your practice, learn.

I think the biggest thing is once you get these resources and you engage with these resources, then the onus is on you to actually pull that trigger and build that practice. There’s going to be a level of discomfort there where you’ve never done X, Y, or Z case on X, Y, or Z patient, but you have to start by knowing the disease and seeing many of those patients. The more you see, the more you learn and the better you get.

Talk to me about two things in the OBL and outpatient space: briefly on marketing and creating partnerships, both within medicine and outside of medicine.

Yes. Marketing, for me, I am a little old school when it comes to this. There’s all sorts of great technologies these days. People are focusing on SEO, they’re doing all sorts of direct-to-patient marketing, which I think is excellent.

SEO being?

Search engine optimization. People pay people a lot smarter than me to optimize their websites, and that’s important, I think you have to do that. But for me, nothing beats just direct communication with other referring physicians. I’m a fan of doing things like lunch and learns, getting out in the community, meeting your fellow physicians, letting them know what you can do, how you can help their patients who maybe they don’t have great options for. I think that’s how you build collaborative lines. Some of the best things I’ve ever done was, for instance, I’m passionate about prostate artery embolization and BPH. I’ve done talks at country clubs. That’s been super receptive. I even had a patient once who was a Walmart greeter. Literally handed him 500 of my brochures, he just went out there and started passing them out to men at work and that was great.

I think just old school, getting out there, getting the word out, that’s super important. That takes time, that takes effort. That comes at an opportunity cost where you could be reading studies and doing radiology and making plenty of money. You have to really love this in order to want to do it. With respect to partnerships, I’m speaking as somebody who actually entered into the OBL space as a partner with the cardiologist, and my entry into the space, which I think would be interesting for listeners to note, is I was pretty early on a couple of years out of training actually just a little less, and I didn’t have that million dollars. I had money, but not a million dollars money, but I joined in on a minority basis with a experienced cardiologist who fronted most of the money and took up the risk, and I came in at a minority percentage with ownership stake and build it that way.

I think you can create those equity partnerships to enter into the space, but you have to make sure you have a meaningful path for growth. So that’s very important. I think there are other partnerships that can be had with non-physicians. I would just be very wary of those. Just do your due diligence. Overall, I think there’s a few ways to go about doing it, but you have to really think about where you see yourself in five years and how you want that life to look like.

That’s a great answer. We’re going to do a little bit of a summary here before we get into our final thoughts. I want to basically try to summarize some of the things you were talking about. It seems like you have a very entrepreneurial mindset. Independence is king to you and you’re trying to combine that with a platform that is all clinically based. That seems to be the key that you think will lead to sustainability for independence, both in hospital contracting and out of hospital contracting in the OBL and ASC space. It’s more about independence as a physician for autonomy—and true patient care—than it is about being in a box. The other thing I want to talk about is that the overall purpose of the OBL may not just be financial. In fact, it seems from what you’re saying that it’s less financial and more about physician and patient autonomy and choice. In five years, what do you envision the OBL to be—the OBL and ASC to be—and what clinical information or other nonclinical information do you want listeners to get from this podcast?

A few things. One, there are going to be more people entering the ambulatory space, I’ll call it that, ambulatory. I think right now the OBL space faces challenges. I think as an IR, one of the great things that we can do is we can diversify. We have a lot of different offerings, a lot of different disease states that we’re masters in. We can weather storms that maybe other specialties can’t, so that provides us more longevity in this site of service. However, as we live in a healthcare environment that is rapidly consolidating with forces like vertical and horizontal integration, it’s harder to be independent, but you can make it happen. There has been a purposeful shift of reimbursement to the ASC space, and that’s very important to keep in mind, especially for service lines like critical limb ischemia. Because those folks getting started now may potentially find themselves in a position where it may be challenging to keep their businesses afloat with just an office.

Now, I don’t think that’s going to be entirely true for everything we can do in IR. I think it’s possible, but I think diversification is important from that standpoint. I think in five years we’re going to see more folks like you and I who are going to be working primarily in this space. I think there are going to be more entrepreneurs, but I don’t think it’s going to be as many as we think. I think it’s going to be the ones maybe as crazy as me, but there may not be enough of those, and that’s not a bad thing. There’s many ways to find happiness. So I think that’s going to be important, but I think the OBL is just one part of it. I do think that when it comes to independence, there are going to be more people directly contracting with hospitals as well.

Interesting. What sort of flexibility does this kind of work give clinicians? A huge part of our workforce that’s underrepresented is women in interventional radiology. My sister is actually an interventional radiologist. She has left the IR workforce to be a diagnostic radiologist, full-time to—admirably so—help raise the children and have the career flexibility that their family needed. What sort of options are there, not just for women, but for people who have life circumstances that require flexibility?

A couple of different options that I can think of. One thing is it’s possible to enter into some OBL agreement where you are working part-time. That’s definitely possible. I think there’s opportunity for collaboration with other specialties who may be suffering from a lack of reimbursement with services like critical limb ischemia, PAD. Maybe they want to diversify and they need an IR to do that. It’s challenging when you join another specialist because the expectation is that you have to bring in your own book of business. No one’s going to just do that for you, and if they say they’re going to do that for you, I’d really take that with a grain of salt. You as a physician should be the one who’s really in charge of that. But I think there’s opportunities to do that on a part-time basis or with some semblance of flexibility.

That’s something I’ve noticed in my own life as I do independent contracting. Even just as little as a couple of days a month for another OBL out of state where I’ll provide longitudinal care and follow up with those patients, but it’s just on that day or two. I think that could be extrapolated on a larger scale. I think for folks looking for flexibility, there’s always independent contracting with hospitals and other practices. I think that’s not going anywhere. In fact, if anything that’s going to increase. For listeners who may be interested in entering this space, please feel free to reach out to myself or Shamit. We have exciting news about a company that is really focused on helping our colleagues in this space, Physician Staffing Solutions, and I encourage you to reach out if you’re interested. We have all sorts of great educational content about that on the blog, on BackTable, on Twitter, so one way or another that information’s out there and we’re happy to help anyone.

No, I mean, Kavi, thank you so much for navigating the space for certain people that have all these questions pent-up and don’t know who to ask. Certainly I’m always a resource, as I do maintain a full-time job and I do some independent work on the side. You’ve really elucidated me on a lot of these things over the years that we’ve known each other. You’ve done a service to the community at large by transparently talking through your story sometimes longer than I’m able to read with more words than I can pronounce or have a tolerance for it because I fall asleep at some points. But the posts are vital to the community. It’s looking into the future because you’re experiencing what so many other interventional radiologists feel in this country. I think it’s a great time to tell people what they should do if they want to achieve independence and is that through an OBL or what is the mechanism to achieve independence? I think we’re going to close on your comments here.

Perfect. I think the first thing to do is to cut that cord. Just cut it. If you are unhappy with what you’re doing, just don’t do it anymore. I think there are so many opportunities out there to independently contract that you can make a great living. I mean, I probably made the best living I ever could have imagined doing this, and happy in multiple senses, not just financially, but spiritually, patient-care wise. Just do it. I think that’s the most important thing. I think in medicine, we’re very risk averse. I think we want to take a prescribed path. I think there’s a lot of stigma about doing things differently, about not being in the same group for 30 years. Those days are gone. It’s a new era.

I think it’s important to explore possibilities. There’s plenty of folks like you and I doing that, and I think just do something different. That’s the biggest thing. Connect with other people on that path. Try to find somebody a couple years ahead of you and engage with them. Get their story share thoughts. Network. SIR is a great place to do that. Plug for OEIS for those who really want good outpatient content. There’s many, many opportunities to engage with folks who could really help you out. I definitely did that. I did it out of frustration and thankfully people came to my rescue and I’d be happy to do that for anyone.

Thank you. Thank you for putting yourself out there. I mean, you make the plug for cutting the cord. Full disclosure, I am not cutting the cord with my practice. I am very happy with what I do. I’m very happy for the level of service that we provide. From my take on it, you’re not saying “Everybody quit your job tomorrow.” You’re saying “If you have professional dissatisfaction, find people who can get you the right advice to get you in a position that works for you, and there’s lots of flexibility out there.” Is that right?

That’s it. If you’re unhappy, then cut the cord.

We are really, really honored to be here in this beautiful Cook booth, live in Salt Lake City at SIR, our premier Interventional Radiology Society meeting. We want to thank everyone at Cook for letting us use this booth and this space, and we encourage everybody to come by, check it out, and see what new stuff’s out there. If anyone wants to follow us, my Twitter is @shamitsdesai, Kavi’s is—

@linemonkeymd.

We’re proud to be launching physicianstaffingsolutions.com as of Wednesday, in two days. Thanks a lot.

Thank you.