The internet has been ablaze over the last few weeks and months with IRs and DRs bragging, criticizing, and pontificating. Salaries continue to explode…well, not salaries, really, but earnings. Seven-figure discussions have become the center of these conversations.

The most recent Facebook thread started with an anonymous DR poster bragging that he or she earned well over seven figures...in just six months.

The responses ran the spectrum: disbelief, disdain, shock, awe; you name it. It became a pile-on.

The thread is still hot and, at last count, had more than 196 comments, which, by subspecialty physician Facebook group standards, is “viral.”

Simultaneously, super-secret WhatsApp discussions among independent IRs have been focused on a parallel conversation: the explosion of PSA opportunities and other independent contracts. While an IR could never simply click his or her way to the multi-million-dollar contracts that DRs are taking advantage of, the per-day and call rates are astronomical; even compared to just two years ago.

With the same number of DRs and IRs being newly minted and the talent pool remaining relatively stable, what’s going to be the end game? How long will this last and what will ultimately slow down or reverse the current opportunity explosion in IR and DR?

Will continued Medicare cuts to DR wRVUs undermine this bonanza?

Will AI open the door to larger pools of physicians (cardiologists, vascular surgeons, orthopedic surgeons, hepatologists) interpreting their own imaging and expanding the available physician workforce in radiology?

Will hospitals eventually realize that much of inpatient hospital IR consists of paracenteses, thoracenteses, and biopsies, and that the majority of those cases could be performed by one or two supervised APPs?

The most important question, though, is this:

How should the average IR respond to this unique moment?

I met an IR a few weeks ago who went independent immediately out of fellowship, performing hospital PSAs as a solo practitioner.

His reasoning was simple: he saw no reason to accept a two- or three-year pay cut just to earn the privilege of becoming a partner when he could immediately earn at or above the 90th percentile.

Granted, he came from a family of entrepreneurs and business owners. Contracts didn’t intimidate him. He understood finance, taxes, and business operations.

More importantly, and ubiquitously, most IRs coming out of fellowship understand IR better than many of the groups they’re joining.

I can use myself as an example.

When I joined my group, I found myself mentoring senior partners who had been out of fellowship for years on how to perform procedures. Whether because of disinterest, lack of exposure, financial incentives, or simply group culture, many newly minted IRs will find themselves in exactly the same position essentially mentoring or leading groups of fellow IR partners who either let their skills atrophy, or didn’t stay abreast of new advancements. Many people recommend a fellow join a group for the guidance and mentorship from senior partners. But with this reality of a super hot market, why would they join such a group? For sign on bonuses? Health insurance? A steady paycheck? Equity ownership in a rapidly evolving business space with outdated business structure?

Unless an IR joins one of the relatively rare advanced IR practices in a major metro area—or remains in academics—there’s a good chance the new fellow will actually be a more technically skilled and clinically knowledgeable physician compared to the IR’s docs they’re joining in many of the mixed IR/DR groups whose practices revolve around paracenteses, thoracenteses, the occasional renal ablation and GI bleed.

I speak with IR fellows and residents preparing to graduate over the next two years on a regular basis.

Most are seeking advice about contract negotiations, starting salaries, group culture, and career decisions. Many already view private practice or academics as little more than a pit stop on the way to independent practice.

I wrote about one such conversation here:

I also speak even more frequently with practicing IRs around the country.

The conversations sound remarkably similar.

They’re dissatisfied with the model they chose.

The same complaints come up over and over again: partners who don’t share the same vision, hospital administrators whose priorities diverge from building a robust IR program, resistance to developing OBLs or parallel practices because they’re viewed as competition to the hospital.

For me, the answer became obvious.

Strike while the iron is hot.

Capitalize on both bonanzas.

Remain independent in IR and take advantage of the surreal rates hospitals, OBLs, and ASCs are willing to pay simply to remain operational.

At the same time, continue working in DR, from the comfort of your own home, sharing in the extraordinary earnings so many radiologists are currently bragging about on Facebook.

Cole water to the face: I’m betting that these bonanzas last about three years.

Five, if I’m being generous.

The truth is, nobody really knows. This could be the new normal.

But there are a few things I do know.

You won’t earn this much as a hospital employee.

And the moment you stop making financial sense, they’ll cut your salary—or let you go.

Your “partners” will still be texting you on Sunday, asking if you’ll perform that esophagram when you’re not even on call.

So why not take a remote contract with a DR group whose vision actually aligns with yours? (Honest pay for honest work.)

Why not approach that hospital 20 minutes away and ask whether they’d be interested in a PSA?

Why not explore opening that OBL or ASC with the guy across town you respect and align well with?

Because one thing seems increasingly clear.

There won’t be another opportunity quite like this one.

Subscribe now

Share

Share

One year after leaving the University of Chicago, I found myself having a conversation with my father that I don’t think I will ever forget. My father is not someone who often talks about himself. Like many immigrant fathers, he is stoic, practical, and measured with his words. He worked hard, provided for his family, and rarely made his own sacrifices the center of conversation. But on this particular day, as we spoke about the first year of Joint and Vascular Institute, he told me something I had not fully appreciated at the time I left my academic position.

He told me he had been very worried about me.

From the outside, I understood why. I had a stable job at a world-class academic institution. I had recently been promoted to Professor of Radiology at the age of 41. I had built a clinical and academic niche in musculoskeletal embolization. I had published more than 150 peer-reviewed manuscripts. I was invited to national and international meetings. I had an NIH-funded trial preparing to begin. I had helped build a pulmonary embolism medical device startup. By most conventional measures, I was exactly where an academic interventional radiologist would hope to be.

But my father’s worry came from a deeper place.

He began telling me about his own life. After immigrating from India and holding a master’s degree in chemistry from University of Georgia, he took a better-paying job at Cook County Hospital in Chicago to support our family and his family back home in India. It was a job that, at least on paper, required only a high school diploma to start. He didn’t tell this story with bitterness. He told it simply, as fact. He had done what he needed to do. And then he told me something that stayed with me: he had not always been able to take the risks he wanted to take.

That conversation reframed everything for me.

Subscribe now

Leaving the University of Chicago was not an impulsive decision. It was not because I lacked appreciation for academic medicine. In many ways, academic medicine had given me my professional identity. It trained me, challenged me, and gave me a platform. It allowed me to develop as a researcher, educator, clinician, and mentor. I had tremendous colleagues and extraordinary patients. I was proud of what I had built there.

But something inside me did not feel right.

It was not burnout in the traditional sense. I was not tired of medicine. I was not tired of interventional radiology. I was not tired of building. In fact, it was the opposite. I was afraid of slowing down.

I had reached a point in my career where, despite outward success, I feared plateauing. I felt constrained by the pace of large institutional life. Every new idea required layers of discussion, approval, committee review, administrative alignment, and institutional bandwidth. Even small changes could become slow and complicated. I do not say this to criticize universities; large systems are built that way for a reason. But for someone who wanted to move quickly, build directly, and create something different, it began to feel limiting.

The commute didn’t help. Driving nearly an hour and a half each way into the city became a daily reminder that my time, energy, and focus were being spent in ways that did not align with where I wanted the next phase of my career to go.

I still had too much I wanted to do.

I began thinking about whether there was a way to build an interventional radiology practice that combined the best of academic medicine with the best of old-fashioned patient care. I wanted to create something that felt academically serious but personally accessible. A practice that could participate in clinical trials, publish, teach, host trainees, collaborate with industry, and attend national and international meetings --- but also feel like going to your doctor when you were growing up.

That became the philosophy.

An academic-oriented outpatient practice with a personal, concierge feel.

I wanted to build a place for patients who did not want to go to a hospital for an elective procedure and deal with the same frustrations I had watched patients experience for years: long drives, long waits, inefficient systems, confusing bureaucracy, and the gradual erosion of the doctor-patient relationship. I wanted a practice where patients could be seen quickly, treated thoughtfully, and followed closely. I wanted the physician to remain central to the experience.

Initially, I proposed a version of this model within the university. But it became clear quickly that even if the idea was sound, the timeline would not work for me. The more I worked through the proposal, the more I realized something important: my partner, Dr. Mikin Patel, and I had the skill set to do this ourselves.

Mikin brought a level of financial discipline, operational thinking, and business judgment that was essential. I brought experience building clinical programs, developing referral networks, creating academic momentum, and telling the story of new procedures in a way that patients and physicians could understand. Together, we began to believe we could do this.

We spoke to mentors. One of the most important was Dr. Jafar Golzarian at Northstar in Minnesota, who had already shown that an independent IR practice could maintain clinical excellence, academic credibility, and entrepreneurial independence. Those conversations helped us see that there was a path, even if it was not the conventional one.... Eventually, we decided to take the plunge.

We opened Joint and Vascular Institute.

The beginning was not glamorous.

In fact, it was humbling.

We started very lean. At first, it was just Mikin and I. We rented some small office space from a GI practice. We answered the phones ourselves. We checked in patients. We placed orders. We followed up on labs. We called patients back. We dealt with scheduling, insurance, supplies, forms, vendors, and every small operational issue that comes with starting something from nothing.

There were moments when it was a significant hit to the ego. I had just left a major academic institution as a newly promoted professor. Now I was sitting in a small rented office space, answering phones and figuring out workflows that had previously been handled by layers of staff.

There were also moments of fear.

I wondered if I had made a mistake. I wondered whether patients would come once the university was no longer attached to my name. I wondered whether referring physicians would trust a new independent practice. I wondered whether leaving the security of a major university had been reckless.

But slowly, something began to happen.

Patients came. Referring physicians called. Procedures were scheduled. Follow-up visits turned into success stories. The practice began to take shape.

More importantly, we began to feel the power of independence.

If something needed to change, we changed it. If a workflow was inefficient, we fixed it. If we wanted to launch a new service line, we built the pathway. If patients needed to be seen quickly, we made room. If a referring doctor had an idea, we could meet, decide, and execute.

We could move at the pace we wanted to move.

That was the most liberating part.

Independent practice does not mean easy practice. In many ways, it is harder. There is no large institution behind you absorbing every problem. Every decision matters. Every hire matters. Every expense matters. Every patient experience matters. But there is a clarity that comes with that responsibility. The work you put in has a direct relationship to what you build.

One year later, Joint and Vascular Institute looks very different than it did at the beginning.

We now have two sites, with a third site coming soon. We have fourteen employees, including two nurse practitioners, a research fellow, a research coordinator, medical assistants, an X-ray technologist, a manager, revenue cycle support, marketing support, and in-house counsel. We have medical students and residents who still come spend time with us. We have built clinical programs in musculoskeletal embolization, hemorrhoid artery embolization, prostate artery embolization, fibroid embolization, thyroid embolization, venous disease, and other outpatient interventional therapies.

Just as importantly, we have maintained our academic identity.

We are participating in multiple clinical trials and registries. We are continuing to work with industry. We recently hosted a genicular artery embolization workshop through GEST. We remain involved in national and international meetings. We continue to teach, publish, collect outcomes, and contribute to the broader development of the field.

That was always the goal.

I did not leave academics to stop being academic. I left to build a different academic model.

I did not leave academics to stop being academic. I left to build a different academic model.

I believe independent interventional radiology practices can occupy a unique space in medicine. They can be nimble without being superficial. They can be patient centered without being small in ambition. They can be entrepreneurial while still being evidence-based. They can create new clinical pathways faster than large systems, while still holding themselves to high academic standards.

For interventional radiology specifically, I think this matters.

Our specialty has always been built by people willing to create new paths. We have repeatedly taken procedures that did not exist, built the evidence, educated referring physicians, trained the next generation, and convinced patients that there was another way. In that sense, independent IR practice is not a departure from the spirit of the field. It is very much aligned with it.

But it requires a different mindset.

You have to be willing to do things that feel beneath your title. You have to be willing to build before anyone believes in what you are building. You have to tolerate uncertainty. You have to accept that there will be days when the prestige of your old position feels very far away. You have to be comfortable with the fact that no one is coming to save you.

At the same time, you get something rare in return.

You get alignment.... You get to decide what kind of practice you want to build. You get to decide how patients are treated. You get to decide what procedures matter. You get to decide how fast to move. You get to decide whether research remains part of the mission. You get to decide whether education is built into the model. You get to create the culture rather than inherit it.

That is not a small thing.

When I think back to the conversation with my father, I realize now that taking risks is itself a luxury.

My father did not have that luxury. He had responsibilities that came first. He had a family to support here and a family to support back home. He made choices that gave me the ability to make different choices. His sacrifice created my optionality.

That is not lost on me.

When he tells me now that he is proud of what we have built, it means something different than a professional compliment. It connects his journey to mine. It reminds me that independence is not just about autonomy or entrepreneurship. It is also about honoring the opportunities that other people sacrificed for you to have.

Forging your own path is risky. It is scary. It is time intensive. It can be lonely. It will challenge your identity, your confidence, your finances, your relationships, and your assumptions about what success is supposed to look like.

But it can also be deeply rewarding.

Because when you build something yourself, there is a direct return on what you put in. The extra call to a patient, the late-night planning session, the difficult hire, the new clinical protocol, the research registry, the community lecture, the referral relationship, the follow-up visit. All of it matters. All of it becomes part of the structure.

One year in, I know we are still early.

There is much more to build.

But for the first time in a long time, I feel that the pace of my career matches the pace of my ambition. I feel that the practice reflects the kind of medicine I want to deliver. I feel that we are creating something that is both personal and academically meaningful.

And most importantly, I feel like I am not slowing down.

I am just getting started.

Subscribe now

Subscribe now

Happy INDEPENDENCE Day!

America is 250!

Born on the shoulders of men and women who risked it all for us to enjoy the freedoms we do today. Among those freedoms are Life, Liberty, and the pursuit of happiness.

Today, I want to honor the trailblazers and road makers of INDEPENDENT IR and share my list of those who, over recent years, have risked much, shared much, and done the work to make the practice of IR unsubsidized and INDEPENDENT.

Whether you agree or disagree with their business models, none can be denied as amazing doctors and innovative leaders in the effort to make IR a viable INDEPENDENT specialty.

Thank you to each and every one of you for taking the risks, doing the hidden work, and showing every IR that it’s possible to deliver the magic and value of IR through independent practice.

In the spirit of the original 13 colonies, these are MY list, along with many others I polled, of those leading the way for the rest of us to follow in INDEPENDENT Interventional Radiology practice. I gave them each an original colony to make it fun!

Some are GIANTS. Others are simply showing every day, through the hard work of building practices, that there are solutions and options for INDEPENDENT IR practice.

Obviously, there are many more who could be added to this list. But this is mine, and many of my close IR friends’ list, of those around the country making a difference and sacrificing to blaze a trail.

Please share comments below on how any of these people have influenced you, helped you, inspired you, and who else you think could make this list, because I know I’ve definitely missed some who are contributing greatly to INDEPENDENT IR.

The Original 13 of Independent IR

(in random order)

• Geogy Vatakencherry, MD, FSIR
  (Virginia)
  The “Mother of Presidents,” representing wisdom, statesmanship, and foundational leadership that has shaped generations of IR physicians.

• Francis (Frank) R. Facchini, MD, FSIR

  (New Jersey)
  The crossroads colony, connecting commerce and ideas, much like building practical pathways for independent IR and showing others what is possible.

• Fred Johnson, MD
  (Georgia)
  The youngest colony, built on expansion and new frontiers, fitting for someone helping expand the boundaries and possibilities of modern IR practice.

• Mary Costantino, MD
  (Massachusetts)
  The birthplace of revolutionary ideas and intellectual leadership, reflecting her role in advocacy, education, and advancing the specialty through vision and thought leadership.

• Kavi Devulapalli, MD, MPH
  (North Carolina)
  Known for the Mecklenburg Resolves, an early declaration of self-determination, fitting for someone calling others and demonstrating that IR can build and sustain itself independently.

• Jerry Niedzwiecki, MD
  (New Hampshire)
  The first colony to declare independence, representing the willingness to go first, take risks, and prove that a new path can work.

• Osman Ahmed, MD, FSIR, FCIRSE
  (Rhode Island)
  Founded on principles of independence and freedom of thought, mirroring innovation, entrepreneurial spirit, and the courage to challenge conventional practice models.

• Aneesa S. Majid, MD, MBA, FSIR
  (Delaware)
  The First State, symbolizing pioneering leadership and an entrepreneurial spirit that helped demonstrate that independent IR could be built successfully and at scale.

• Bill Julien, MD
  (South Carolina)
  The first colony to vote for secession, embodying boldness and the willingness to break from established models to pursue a different vision for practice.

• Shamit Desai, MD

  (Pennsylvania)
  Home of Philadelphia and the Constitutional Convention, symbolizing institution-building and creating frameworks that others can follow or join in independent practice.

• Jafar Golzarian, MD, FSIR

  (Connecticut)
  A colony known for self-governance and strong institutions, reflecting leadership, organization, and the ability to build systems that endure.

• Ahmed A. Farag, MD
  (Maryland)
  A colony that served as a bridge between North and South, reflecting versatility, and the ability to integrate different aspects of IR practice into a cohesive whole while working feverishly to ensure quality and consistency in every aspect.

• Sandeep Bagla, MD
  (New York)
  The economic and commercial engine of the colonies, representing innovation, global influence, and the ability to think outside the box and create economic power.

  Share

Also, pro tip: If you’re looking to become an independent IR, try to connect with these folks or at least learn as much as you can about the details of how they’ve built what they have and the details that have made them successful.

I consider them a living set of textbooks and how-to guides. One of them even has a few years of weekly blog posts on the topic. They are a wealth of information and experience.

Happy Independence Day, everyone.

The future of Independent IR will not be built by one person or one model. It will be built by people willing to share, teach, and blaze trails for those who follow.

There is a concept in Shinto called musubi — the generative, binding force that arises when things are allowed to connect and grow as they naturally should. It is not about force or conquest. It is about alignment. About finding the current that already exists and having the courage to step into it.

I thought about musubi a great deal while I was in Japan recently. I walked through shrine gates — torii — that mark the passage from the ordinary world into something more expansive. What struck me was not their grandeur but their simplicity. They do not block the path. They frame it. They say: here, something different is possible. You are allowed to enter.

I came home thinking about how many of my colleagues in interventional radiology have never been shown that gate. Have never been told that a different path exists, one that leads toward ownership, autonomy, income diversification, and a practice life that is genuinely theirs. Not because they lack ambition or skill. But because no one ever held up the frame and said: you are allowed to walk through.

This piece is that frame.

Share

Know a friend interested in learning more about independent IR practice? Please share.

The Information Gap — and Where It Comes From

Interventional radiology is one of the most technically demanding specialties in medicine. The skillset is rare. The demand is real and growing. And yet a striking number of IRs operate with an almost entirely incomplete map of their professional options. They know their clinical options. They do not know their professional ones.

The source of that gap is specific and worth naming directly. The physicians training the next generation of IR — program directors, fellowship faculty, academic division chiefs — are, with rare exception, products of quaternary academic environments. They are extraordinary clinical educators. They have also spent their careers in fully staffed departments with institutional infrastructure, subspecialty support, and a referral base that arrives by virtue of the institution’s reputation. They know that world in exhaustive detail, and they are overwhelmingly employed physicians, few if any of whom have run an IR business. Just as I’ve never won “abstract of the year at SIR,” those molding the minds of our specialty’s current trainees are not well versed in the essential business of delivering care at the community level — an estimated 80 to 90 percent of hospital admissions in the US.

They do not know how IR is delivered at a community hospital in a mid-sized market with two IRs, a strained relationship with hospital administration, and a referring base that needs educating. They do not know what it takes to negotiate a hospital service agreement, build a call structure from scratch, or manage the business of an independent practice where there is no billing department down the hall and no department chair to escalate a problem to. Their understanding of community IR delivery is, at best, anecdotal. That absence is being passed forward to every fellow who trains under them.

The natural instinct is to look to the specialty society to fill this gap. The SIR has shown more openness in recent years to practice management and non-academic IR realities, and that is welcome. But it should not become the funnel through which this conversation flows. When I developed an independent IR locums forum within the SIR, it was given nominal acknowledgment and allowed to atrophy. Not because the idea lacked merit, but because the institutional appetite for taking community IR delivery seriously as a strategic priority simply was not there. That experience was instructive. It was also the clearest signal that this work had to happen outside those walls.

Being a section chief is often the closest an institutionally employed IR gets to anything resembling business leadership, and it illustrates exactly how large the gap is. Managing schedules and navigating departmental politics inside a system that absorbs all business risk is not the same as running a practice. The “spoke and hub” model of delivery does not make the quaternary hub an expert in delivering care; it is a band-aid solution in many instances, and this can be subtle and site specific. Running an independent IR group means understanding which contract clauses expose you, pricing your services to account for malpractice and true overhead, building relationships with hospital CFOs, and knowing when to walk away. It means operating as a business owner, not a highly compensated employee. Very few IR physicians have been taught any of this. The ones who have built independent practices figured it out through trial, error, and hands-on exposure to decisions that no fellowship curriculum has ever systematically addressed.

What IR Lost at the Community Level — and What It Can Reclaim

There is a second dimension to this problem. Private equity consolidation and vertical integration across radiology have quietly changed what IR feels like — and what it means to the patients and hospitals that depend on it — in non-quaternary care settings across the country. IR is increasingly delivered through large national groups operating on volume-driven contracts, with rotating physicians who have no continuity with the facility, no relationship with referring clinicians, and no investment in the long-term procedural capabilities of the institution. The contracts are focused on diagnostic radiology revenue mechanisms, increasingly reliant on hospital stipends and demanding remote work only. The wRVU model still favors mammography and neuroradiology, which are assigned the highest RVU professional fee per time in our global specialty, somewhat arbitrarily. IR, however, remains the contract anchor for all of these groups, and trainees are forced to play a kind of lottery when entering DR/IR groups: how valued their services actually are depends almost entirely on group and hospital culture and politics. The result is an IR service that often functions transactionally — procedurally competent, but institutionally absent.

When IR is packaged as a commodity and sold at scale, the relational architecture that makes it genuinely valuable at the community level erodes. Referring physicians stop thinking of IR as a consultative partner and start treating it as a referral destination. Hospital administrators lose the ability to build IR strategy with a physician who is invested in the outcome. Patients in community settings, without access to quaternary care, receive procedures without the longitudinal clinical engagement that could meaningfully change their care trajectory.

IR was not built to be diagnostic radiology with a catheter. It was built on the premise that a proceduralist who not only thinks like, but is, a clinician — who knows the patient and the team and takes ownership of outcomes — produces categorically different results. That premise remains true. The systems now delivering IR in many community environments have made it structurally difficult to act on.

The community hospital deserves better, and independent IR is how it gets it.

The independent IR group and the serious contract IR practitioner are, in this context, not just professional alternatives. They are corrective forces. A physician-owned group embedded in a community hospital has every incentive to build relationships, expand service lines, and invest in institutional IR capabilities that a rotating national group simply does not. This is the larger opportunity — not just financial or professional, but clinical and ethical. IR has a chance to re-engage with community-level care on terms the consolidated model cannot offer.

Physician Staffing Solutions: Infrastructure for Independent IR

Physician Staffing Solutions (PSS) was built specifically for this space — a boutique independent contracting firm with a single niche: interventional radiology. My co-founders and I built this company in direct response to the SIR independent contractor forum experience, after aligning on a need to create a market alternative to traditional employment and big box companies. We wanted to do our small part in shaping the conversation about the future of IR. Helping our colleagues demonstrate and define their value has been a genuine privilege, one we take seriously as practicing IR docs ourselves. Most locums firms treat IR as one line item among dozens of specialties, producing placement without context and relationships built on volume rather than fit. PSS operates differently. Because the focus is exclusively on IR, the understanding of what a hospital actually needs from a contract IR — and what an IR physician should expect in return — runs substantively deeper.

On the hospital side, PSS builds partnerships with facilities that have genuine, ongoing IR needs the consolidated model has failed to meet: community hospitals managing growth, systems navigating coverage gaps, outpatient centers expanding procedural capability. The goal is not to fill a shift. It is to place the right IR with the right facility in a way that builds something durable — a clinical relationship that improves care over time, expands what the hospital can offer its community, and gives referring physicians and administrators a real IR partner rather than a rotating stranger.

On the physician side, PSS serves two groups. The first is the IR with capacity looking to expand their professional footprint and capture income on their own terms, controlling their schedule and selecting their markets. The second is the IR at a transition point: leaving a position, finishing training, or deliberately building a non-traditional career through independent contracting. What PSS provides in both cases is the infrastructure — credentialing support, contract negotiation, malpractice coverage coordination, and market intelligence. The physician brings the skills. PSS handles the architecture around them.

Contract IR work is not a fallback. For a growing number of physicians, it is the deliberate architecture of a professional life built on their own terms.

Gotham Medical: What the Independent Group Model Actually Looks Like

If PSS represents the contracting and staffing side of this equation, Gotham Medical LLC is the proof of concept for what the independent IR group model becomes when built with intention and held to that standard over time.

Gotham Medical is a physician-owned independent IR group built on the premise that a small, agile practice can deliver something the large consolidated groups structurally cannot: genuine institutional partnership, clinical continuity, and the kind of responsive, accountable IR service that community hospitals need but rarely receive. It is not a national platform with rotating coverage. It is an independent IR practice with direct relationships to the hospitals and health systems it serves, and physician-owners with `a personal stake in the quality and longevity of those relationships.

In practice, Gotham Medical engages with hospital partners as a clinical enterprise rather than a vendor. It expands service lines where clinical need and volume justify it, maintains presence at the department, administrative, and bedside level in ways a rotating group cannot replicate, and brings fellowship-trained IR capability to environments where patients have historically had to travel to quaternary centers to access that level of care.

PSS and Gotham Medical are complementary by design. PSS is the entry point, placing IRs in hospitals that need coverage and continuity. Gotham Medical is the destination, demonstrating what that continuity looks like when it matures into a full institutional partnership. Together they represent both ends of the independent IR spectrum, and a coherent argument that the independent model is not a workaround but a genuine advancement in how IR can be practiced and delivered at the community level.

A Seat at the Table We Built

Let me be clear about what this is and what it is not. This is not a course, a coaching program, or a consulting pitch. The IR physician reading this does not need another person monetizing their professional anxiety. What they need — what this specialty needs — is an honest account of what is possible, from people who have actually built it.

Interventional radiology is the greatest field in modern medicine. IR invented techniques that entire surgical subspecialties now depend on. It created access, ablated tumors, restored flow, stopped bleeding, and extended lives in ways that would have been unthinkable a generation earlier. Since Charles Dotter first threaded a catheter through a stenosed artery in 1964, this specialty has done nothing but innovate.

And for decades, IR has cooked gourmet meals for others to get fat off of.

The procedures have been absorbed into surgical practices and hospital service lines. Reimbursement has been restructured to favor institutions over the physicians operating the equipment. The clinical relationships IR built — with oncology, vascular surgery, hepatology — have been quietly converted into referral pipelines that now route around IR entirely. The specialty that invented the toolkit has too often been left holding the bill while others captured the value.

This happened because IR has historically been better at clinical innovation than at business self-determination. We are better at inventing complex new therapies — think about the dawn of MSK embolization — while sometimes falling short on the fundamentals of clinical care as the center of our work. Consider how few community IR practices offer meaningful E&M engagement on the patients they treat. We trend toward solving the next technical problem rather than protecting the value of the last one. We gave opportunities to those who said they would advocate for us. Across twenty years of consolidation, that advocacy has not been enough.

Since 1964, IR has been the most adaptable specialty in medicine. It is time to bring that same relentless innovation into the business of how we practice.

The adaptability that has defined IR from the beginning — the willingness to iterate, to move faster than the institution, to find the solution no one else was looking for — is precisely what independent practice demands. And precisely what the consolidated, volume-driven model extinguishes.

The independent IR group. The serious contract practice. The boutique staffing firm built from inside the specialty by someone who has done the work. These are not peripheral options for a niche cohort of outliers. They are the architecture of a specialty that decides, finally and deliberately, to take its seat at the table. Not to wait for an invitation. Not to petition a society for a working group. But to build the table itself, with the same precision and resourcefulness IR has always brought to the clinical problem in front of it.

That is what PSS and Gotham Medical were built to do. That is what this platform exists to advance.

The gate is there. We built it. It is time to walk through it.

If you’re early or mid-career and want more control over how you practice — whether that’s earning income while pursuing other interests, controlling your schedule, or testing a different model — let’s talk. Independent contractor work with a company founded and operated solely by interventional radiologists . admin@physicianstaffingsolutions.com

If you want full-time clinical IR work but prefer independent ownership structures or want to avoid the standard hospital politics and pressure — we have options that operate differently. shamit@gotham-medical.com

by Joe Pazona, MD

Dan published a piece a few weeks back that I haven’t been able to stop thinking about.

Not because it was about IR. I’m a urologist. I don’t have a horse in the IR race.

I haven’t been able to stop thinking about it because every paragraph could have been written about me. Swap “IR” for “urology” and you’d have my career. The trained-for-something-that-doesn’t-exist part. The bullshit-cases-and-being-taken-for-granted part. The walking-away-from-the-thing-you-actually-loved part.

I lived all of it.

So if you’ll bear with a fellow physician from a different specialty for the next 1,700 words, I want to tell you what I did about it. Because I think Dan is right. The problem is not a shortage of doctors. The problem is a shortage of opportunities worth staying for. And nobody is going to build those opportunities for you.

I’m going to take you through three things.

One. My own version of Dan’s story. Two acts. Both painful. Probably familiar.

Two. What I had to let go of before I could see a way out. (This is the part I think IR needs to hear most.)

Three. What I built once I did. Spoiler — it’s not a manifesto. It’s a working model. Patients are alive today because of it.

Thanks for reading Built in IR! This post is public so feel free to share it.

Share

Act 1: Rural Washington

My first attending job out of training. On paper, perfect. Beautiful community. Great people. Solid paycheck. I was finally a real doctor and not a resident eating free sandwiches from drug reps.

But something was wrong.

I kept seeing patients getting hurt. Not from anyone being negligent. From being unable to access the right care in time. The one that broke me was a woman in her sixties. Nine months of antibiotics for what everyone called “recurrent UTIs.” None of her cultures ever grew bacteria. Nobody questioned it. She lived 90 miles from the nearest urologist.

She finally got referred to me. I did a cystoscopy in the office. Within an hour I had her diagnosis. Muscle invasive bladder cancer.

She died a year later.

I started pushing for things. Robotic surgery for better outcomes. Scribes to give physicians their evenings back. APPs to extend our reach to patients who couldn’t drive 90 miles.

The answer was always the same.

“That’s not how we do things around here.”

I heard it so many times I started wondering if it was in the employee handbook.

(I want to be careful here. The people in that organization were not bad people. They were good people inside a calcified system. But good intentions inside a broken model still produce broken outcomes. And in medicine we have a word for what happens when blood stops moving. Stasis. It kills you.)

Act 2: Alabama

I wasn’t miserable in Washington. I was just quietly aware that this wasn’t where my story ended. So one day I opened my laptop, not really expecting much. And there it was.

A job posting that started with this line:

“Are you feeling underappreciated? Come build the practice of your dreams.”

In retrospect, that is one of the funniest sentences I have ever encountered. They might as well have written, “Dear Dr. Pazona, we heard you specifically.”

Chief of Urology. Director of Robotic Surgery. We packed up. We moved.

It was a nightmare from week one.

The locum who’d been covering before us had been operating solo, 24/7, for two years with no oversight. Healthy 27-year-olds were ending up in the ICU after routine kidney stone surgery. He had to go. Which meant I was now on call ten days a month at a Level 1 trauma center. (Not in the job posting.)

The practice manager didn’t really manage. The full-time RN was being asked to run the office in her spare time. Patients weren’t getting their calls returned. Every problem I raised got handled the same way. Warm smile. Reassuring nod. Zero action.

Behind closed doors I was being a “difficult employee.”

So we called a meeting with the chairman and the executives. We laid the whole thing out. The patient experience. The burnout. The Level 1 trauma call. Their response was beautiful.

“Joe, we’re going to fix this.”

And they did.

Four months later. When they fired me.

“Joe, you’re a great urologist. But you just don’t fit in here. Six-month termination without cause.”

I called my future wife. Three words.

“I was fired.”

The Halloween Floor

Here is the part I want you to sit with for a second. Because I think this is where IR is right now.

I went home and I lay on the kitchen floor. It was around Halloween. I couldn’t move. Thirteen years of training. Two cross-country moves. A wife and a baby on the way. And it ends with me on the floor.

My future wife came over, looked at me, and did the only reasonable thing you do when an Italian man is falling apart.

She fed me.

(I don’t know what was in that pasta but it changed my life.)

Somewhere between the food and what came after, I stopped the pity party. And I started asking a question I haven’t stopped asking since.

Why do we make it so hard for doctors to take care of patients?

What I Had to Let Go Of

Here are the four things I had to release before I could see clearly. I think IR is sitting on top of all four right now.

One. “Maybe I’m the problem.”

This is the trap I lived in for months after I got fired. Maybe I’m too difficult. Too idealistic. Too impatient.

I have since talked to hundreds of physicians who told themselves the exact same story.

The problem was not the doctors. The problem was the model we kept asking ourselves to fit into.

If you are a strong IR and you are unhappy, the most likely explanation is not that you’re the problem. The most likely explanation is that the model around you was not built for the work you were trained to do.

Two. “Someone will fix this if I just explain it loud enough.”

I tried this in Washington. I tried it harder in Alabama. The result was the same in both places. Warm smile. Reassuring nod. Six-month termination notice.

Dan’s IR colleague at the interview said the same thing in different words. “Maybe someday if the system starts valuing IR, I’ll come back.”

The system is not going to start valuing IR on its own. Hospitals will not wake up tomorrow morning and finally understand contribution margin and downstream revenue. Your DR partners will not suddenly champion your clinic time and procedural growth.

You have to stop waiting for permission to build the practice you trained for.

Three. “That’s not how we do things around here.”

This isn’t a sentence. It’s a wall. And it’s the wall I hit every time I tried to innovate inside someone else’s broken model.

If you keep hearing it, the answer is not to keep arguing. The answer is to stop trying to renovate the building and start drawing blueprints for a new one.

(I’m aware that sounds easier than it is. I’m not telling you to quit on Monday. I’m telling you to stop pretending the existing structure is going to flex around you. It won’t. Mine didn’t.)

We tend to overestimate the risk of taking action. We dramatically underestimate the risk of sitting idle.

Four. “I have to do this alone.”

This is the lone wolf myth. And it might be the most expensive one. The idea that the only way to deliver high-quality specialty care is for one heroically trained physician to do every part of the work themselves.

You can’t play football with only a quarterback. You can’t run a service line with only a physician.

A modern IR practice — the real one your training prepared you to deliver — needs a team. APPs trained to handle routine work. Care coordinators who actually own the patient experience. Technology that gets administrative friction out of your way. Maybe a partner physician. Maybe two.

The minute you accept you don’t have to do it alone, the math changes.

What I Built

Once I let go of those four things, the path forward got embarrassingly clear.

I started a company called https://myvirtucare.com/providers/dr-joseph-pazona/. We partner with hospitals that lack consistent specialty service lines and we deliver hybrid, team-based care. Part-time and remote physicians working alongside well-trained APPs. Continuity of care. Top-of-license practice. None of the locums chaos.

Here is one example.

A 25-bed critical access hospital in rural Illinois. Patients waiting months for urology. Driving across state lines for routine specialty care. We brought in a hybrid team. One of our patients had an elevated PSA. He got biopsied. He had a potentially life-threatening prostate cancer. Got connected fast to the right specialist. Treated. Disease-free today.

Here is what he told us afterward.

“There was no way I was driving an hour and a half to see that other doctor. I would have rather died.”

That is not hyperbole. That is the daily reality of access in this country. And it is the reason I am not interested in “someday” anymore.

Now. I’m a urologist, not an IR. The clinical model is not transferable plug-and-play. But the principles are. A team-based model with real leverage. Physicians practicing top of license, every day. Hybrid coverage that doesn’t require one specialist to be everything to everyone. A structure that protects the patient-physician relationship. And a willingness to stop asking whether the existing system will let you build it.

A Direct Invitation

Here is what I want every IR who has read this far to hear.

You are one of the most procedurally elite specialties in medicine. You can shrink a 300 g prostate without a foley catheter. You can cure a patient’s variceal bleeding while a surgeon is still scrubbing.

You do not need a wizard. You do not need a hospital administrator to suddenly “get it.” You do not need permission from your DR partners to build the practice you trained for.

The power was in the ruby slippers the whole time. You just have to click them.

If any of this lands — if you’re an IR carrying around that quiet “maybe someday” feeling, or a hospital leader who knows your IR program is fragile and you’re tired of pretending — I would genuinely love to talk. You can reach me at [VirtuCare contact / booking link TBD]. Or come find Dan. He knows where to send you.

I am not selling anything in this article. I am inviting you to stop waiting.

Two roads.

Your call.

Enjoyed this article?
Built In IR explores how physicians are designing, building, and leading clinically driven interventional radiology practices and service lines across the country.
Subscribe to receive future essays in the new Solutions series and connect with physicians who are building the future instead of waiting for it.

Subscribe now

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

Subscribe now

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

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

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

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

Why is this?

It is worth spending time to ponder this question.

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

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

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

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

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

My point is, All IR is fundamentally local.

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

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

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

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

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

These practices:

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

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

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

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

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

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

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

Subscribe now

Surprisingly, med school held some of the best years for our family. We had very little, but because we were extremely frugal, had a modest mortgage, my PT license from undergrad, our nest egg (that we cracked and poached), and President Obama’s medicaid expansion, we made it through those 4 years relatively unscathed. Additionally, Upstate NY has a lot to offer a young family of 5. Between the YMCA and other great New York programs like the Syracuse children’s theater and ISKI NY our kids had a lot of great opportunities, like learning how to ski on ski-swap equipment each winter at a mountain just minutes from our house for pennies on the dollar. The med school schedule was also surprisingly conducive to being the kind of dad I didn’t have myself, with a little bit of adjusting. Yes, most nights after we put the kids to bed I stayed up ‘til 1am studying. But overall we made it work.

For residency I decided on something conducive to being a father and husband. Ortho, I assessed, would be too much time away from my family. I discovered radiology. A challenging and noble profession focused on deep knowledge of anatomy translated to diagnosis. Radiology quickly led serendipitously to a Vascular Interventional Radiology rotation my second month in residency. To me, IR was a little understood, but soon-to-be revealed, powerful and bewitching specialty with cutting edge treatments and cures for diseases like osteoarthritis, cirrhosis and uterine fibroids containing dramatic effects.

My passion for interventional radiology was immediate once being exposed to it. And by sheer luck, I was chosen to join the integrated program despite the other 4 extremely qualified and motivated candidates. Thank God. I originally wanted nothing to do with IR, due to my suspicion that it would pull me away from my family. But that familiar surgical bug got me quickly. During that first rotation as a very green resident, despite my original lack of interest, I was pretty quickly finding myself reviewing the steps before every procedure I was allowed to participate in with the tech outside the room (thanks Blaine and Steve). The faculty who granted me the opportunity for this training knew better than I did what I was built for.

I finish VIR residency. I’m in my 40’s. I trained in Virginia and we wanted to stay in the US South Atlantic because that’s the region my wife and I love. We also wanted to stay in Richmond for ourselves and for the kids. Sunshine and continuity are important to us. But, nothing was available. With a specialty as small as IR, timing is everything. But, we still had a few great options and chose an extremely friendly and intelligent group of men and women outside Charlotte. Their tenured IR’s were welcoming and supportive people. However, they’ve largely been doing drains, once-in-a-great-while GI bleeds and an occasional elective renal tumor ablation for the last 30 years, which they and the hospital they served were content with. I discuss this practice in my post “You’re first job is your second residency”.

Another young and newly trained vascular interventional radiologist joins the group at the same time as I do. It was slow at first, but with dedication and a lot of hard work, we had significant success. I focused on building the women’s health service line while my partner started a PAE program from the ground up. By the time we were 13 months in, I was doing multiple elective embolizations a day, we set up a new PERT team with Interventional Cardiology, I had completed 5 TIPS within the two months ending my first year at the practice, and boot strapped togetehr an ad hoc clinic service to facilitate longitudinal care of our patients as well as daily rounding with functional E/M. We turned a 95%/5% VIR/DR program into a flipped scenario of nearly 100% VIR except for DR call. I was Available, Affable and Able. My partner was smarter. He was leaving at 5pm. He was available, but not at the cost of his family.

Here is where I get very real. I did all this working 60-70 hours per week. But, the hours weren’t the real problem. Even when I wasn’t rounding, scrubbed in, reading DR, or seeing patients in clinic, I was never truly “off”. Yes, I was home, but my wife would say “You’re thinking about work, aren’t you?” And I was…ev-er-y time. Because here’s what you’re not told when you’re going to build and modernize an IR program centered on real clinical care in a traditional mixed IR/DR group structure that had never previously needed to support that kind of practice: no one really knows what’s necessary to build it and no one has the same immense desire that you do for it to succeed.

That’s not any individual’s fault; it’s just the way Interventional Radiology developed out of, and has now outpaced, most of the traditional real-world radiology groups we’re joining after residency and fellowship. And for a guy who grew up with nothing because men either leave or abdicate their responsibilities, I had an unreasonable, primal and visceral fear of failure. There are beliefs baked in you when you grow up like I did. Being hungry the last few days of the month because there’s nothing left in the cupboard and the checks don’t drop ‘til the 1st of the month; it does something to your ability to assess risk appropriately. Life becomes an all or nothing proposition. Great skills and motivation for a perfectionist on a wrestling team, football field or in medical school. As an adult navigating the real world, this takes the form of an illogical fear, success is all on you, and failure is not an option.

So what did that look like? Lot’s and lots of work outside of clinical care, procedures and diagnostic radiology duties. Some examples include:

Writing protocols and manuals for technologists how to set up the room and prep the equipment. And then staying late at work to review and make sure they’re ready to go the next day. And then coming in early the next day to ensure the equipment instructions you gave them are being followed.

Creating and delivering education sessions for the nursing staff to know how to monitor the patient’s pre-/post- and intraprocedure.

Meeting with the supervisors, mid-level admins, and hospital executives to ensure they understand the program and its financial impact so they understand that it’s economically advantageous to purchase the equipment, hire the staff, give the space, and motivate IT to create the order set and billing codes in Epic.

Monitoring and ensuring catheters, wires and sheaths were available.

Calling the ICU at night to make sure that the heparin drip was actually started.

To be honest, even with all the above. I was grateful for the opportunity and I would’ve kept going. I ignored my better judgment and did the work to facilitate program expansion and service lines that really required a staff of 3-5 people and another 2-3 years to build at a reasonable pace.

But instead, I let my family pay the price. Present at home physically, but still at work mentally. As I described above, I was consumed. My intentions were well placed, but my decision to do it on my own, right now and in an environment not yet built to handle it resulted in me choosing to neglect my family.

Last September was a wake up call. I met several respected leaders at the Strategic Radiology fall summit. They opened my eyes up to a lot. First, they told me what it looks like to grow an IR program within an environment that was grown over time by many physicians aligned in the effort, preserving balance. They were leaders within groups creating and growing interventional radiology service lines in a culture shared with the entire group.

The group I had joined were excellent clinicians. But they were of a different mindset, culture, expectations and goals. Rather than see or understand that, as I should have, I decided to just do the work myself. I gave all the time, effort, energy and attention necessary to make it successful. But who paid? My family. I was losing them and I was ignoring them while they were begging me to stop. Something had to change. It was either the practice or my family, the ones who always supported me. Last summer and fall were when I slowly decided something had to be sacrificed. And it wasn’t going to be my family anymore.

So, the partners in my small mixed radiology group were gracious. They were supportive in facilitating the winding down of my practice in a way that preserved patient care.

In the months since the late fall of 2025, I’ve had dozens of hours back with my family. I’ve spent more time listening and being present than I had since my oldest was 10 years of age (by this time he was 20). This past January I was in the living room with my youngest daughter, Clara. She looked over at me after we finished reading the Hobbit together for the second time and said “Dad, it’s nice having you back.” That was the most bitter sweet moment of my entire life to this point. The little girl who’s hand I could once easily hold in the crease of my palm. One of the three smartest and beautiful women in the world, who I adored, told me in one phrase how I had been gone…for over a year. I still have a hard time writing and thinking about this as I sit here typing.

So, Who is Dan Poulsen?

A kid who learned early he had to do it all on his own because no one was coming.

A guy who didn’t unlearn that lesson despite the men who contributed to his life along the way.

A nearly failed father and husband, but for the grace God, his wife and children…and a few caring mentors.

A guy who loves interventional radiology and the transformation it brings to the lives of patients.

A guy who knows how to build programs quickly and successfully. But has learned that quickly is much much much less important than doing it in the right place and time and in the right environment.

So that’s what brought me to February of 2026 and starting a new chapter.

I initially started Built In IR as a catharsis and homing beacon asking:

“Who out there feels like me?” Mismatched with the real world, trained for a setting that doesn’t seem to exist. It turned out, there were quite a few of us.

My search for others, and finding them, quickly developed into asking:

“Who’s building excellent life-changing vascular interventional radiology programs?” Because I’ve learned, I can’t do it alone, none of us can.

Built In IR is about doing those two things. Bringing dedicated clinicians together who are experiencing the same thing, a mismatch in the health care system and then connecting them with others who are sharing their insight on how they’re navigating it.

For the foreseeable future I’m asking respected IR’s from around the country to come and be seen and to share their knowledge and wisdom; so that other like minded and passionate IR’s who are also interested in learning from them can.

Because the truth is, somebody is coming, you just have to look in the right direction and ask the right questions to find them…sometimes you’ll find they were standing there the whole time.

Subscribe now

I’m a terrible student in high school but I’m a good enough athlete to get into college as a football player and wrestler. I’m known more for being the accomplished jock and notorious thrower-of-beer-parties which drew literally 100’s of kids from across Erie and Niagara county high schools. Parties routinely broken up by cops and featuring unplanned MMA style fights between wrestlers from rival high schools. Wrestlers are bizarrely capable and intelligent folks. But being the connector party guy has its upsides…like being voted senior class president. An honor roll girl scoffed and said a dumb jock could never get elected when I jokingly said I’d be running against her. My response? I threw a huge kegger the weekend before voting. Everyone who promised to vote for me got bottomless beer for $5. I still made like $100 after expenses. (Early echoes of unofficial IR bourbon nights?)

OK, so I make it through high school and go to college.

Fast-forward, I’m a senior in college. Some great people show me how to be a student and I’m now the first division 1 NCAA academic all-American at my school, ever. The president of the university is my pal and I get into medical school; he makes a special point to be at my honors convocation just so he can personally hand me my diploma and high five me. A photo op and proof of his success in building a division 1 football program with academic integrity. It’s 2000 and the world is my oyster.

I deferred med school for a year while doing orthopedic and osteoarthritis research in the lab at the university connected with the department of physiology and biophysics. My goal was to be an orthopedic surgeon and a guy a few years ahead of me from my high school football team, who matched surgery, recommends that I figure out how to do some quality research to solidify my chances of matching into ortho. So, I follow his advice and enroll in a Master’s program with the goal of getting some orthopedic relevant research and a publication or two.

My PI was an orthopedic surgeon and researcher who was the first person to teach me how to really write. I also got to spend dozens of hours dissecting apart knees, hips and pelvic bones for anatomic based research focused on better understanding the etiology and pathophysiology of osteoarthritis. I spent hours becoming excellent at the technical skills necessary to preserve and dissect out the structures of interest in human cadavers. I also had a field day performing all my own cartilage transplant procedures on our research subjects: sheep. I fell in love with all of it. I originally was going to medical school to be an orthopedic surgeon, I was the football player, academic all-American who knew all the ortho’s by first name. I was the heir apparent. But that year gave me the idea that I could do something more. I figured why spend 10 years doing med school and residency in orthopedic surgery when I can cure osteoarthritis and you don’t even need surgery? I know, I know, nothing like hubris combined with inexperience. But I promise you, my heart was in the right place, despite my stupidity.

My undergrad degree was in Physical Therapy and the best pathway for me to continue in this effort was combining this background with my experience in surgical and bench research. So, I took an opportunity and went to a university with a group of folks starting a PhD program in Rehabilitation Science. I was going to leverage my experiences and develop a non-invasive pathway for the treatment of OA. Honestly, I didn’t know what that was going to end up being. But I loved understanding cartilage, osteoarthritis, and research and this plan combined all of it.

Fast-forward and I finish the PhD, published in clinical assessment of OA and I’m on a path to be a professor while continuing my research.

At this point I’m married, have 3 kids and eventually take a tenure track professorship in Syracuse at Upstate Medical University….and not too long after, bored as hell. Meetings, lectures…teaching uninspired students topics like orthopedic physical exam, musculoskeletal physiology, while doing just enough research and administrative work to hopefully convince T&P committees to rubber stamp my promotion. What’s worse is that I’m becoming hip to the real game. Faculty and department meetings regularly focused on topics like “How do we expand the program numbers?” or “What summer classes should we add?” The overt reasoning was to make students “better prepared”. But how does adding another 4-credit hour summer class on “social determinants of health” really help a student in physical therapy become better at helping patients recover from a torn ACL? I was in a structure focused on expanding itself at the financial and time cost to students. The goal that started me on this path and remained my deep desire was to directly improve patient’s lives, and I felt a million miles from doing just that.

I remember the day vividly; I was in my early 30’s and looked up an orthopedic knee replacement surgery on youtube. I was like, “man, I screwed up”. I thought I was gonna cure osteoarthritis. Instead, I got swallowed up. Academic research and teaching was once for me, like it is for many other folks, an exciting proposition, but instead it became an exercise in reaching the next rung without actually ever making a demonstrable difference in forwarding the field. For some, getting up each day to teach the next generation while arguing verb-tense in a research question does it. And thank God for them. But I just ain’t built that way. I took a 9-year detour to realize that I am truly attracted to and inspired by working directly with patients and doing what makes them better directly and immediately. The last time I was happy, truly happy, with my day to day was doing cartilage transplant surgeries on my sheep to see what changes could benefit their human counterparts three floors up in the operating room.

I did some math on an excel sheet and told my wife I wanted to “go back” to plan A…medical school. Except now I wanted to do it with a mortgage, in my 30’s with 3 kids under the age of 10. Damn. Still can’t believe it. But my wife said “yes”. So, I planned to apply to the very medical school I was teaching at. It was precarious. Had to hide it from everyone. Teaching in the AM, finishing my biochemistry classes in the afternoon, because in the interim, US allopathic schools started requiring it (which I actually think was a very good addition). Even had to retake the MCAT, ugh. But I made a deal with myself, I wouldn’t move my family and I’d only apply to one school. If I didn’t get in, I didn’t get in. I wasn’t going to sacrifice my family for a pipe dream. A year later I was accepted.

My wife said “yes”, again. She saw more in me, and wanted more for me, than I wanted for myself…even at the price she knew she’d have to pay over the next 8 to 10 years.

Medical school round two wasn’t just about changing careers. It was about finally aligning my work with what I found out I was built for, the long way around, and doing it with the people I loved.

Subscribe to receive notification of the final installment later this week

Part 3 of 3: Coming Home

Subscribe now

I was born in a small upstate NY town outside of Buffalo. By the time I was 5 years old my parents had managed to ascend to a government housing project apartment. I vividly remember sitting on the steel and concrete porch watching for my dad’s headlights. You can’t tell what kind of car is coming at night by looking at its headlights. You’re blinded until the final moment it passes by you and is illuminated. None of the cars ever belonged to my dad. I stopped waiting when it was his day. The cherry on the Sunday was a day my brothers and I now jokingly reminisce about. Mom woke us up one Saturday and said “Get up and pack! Your dad is comin’ to get us ‘n move in with him.” We got up excitedly and packed our things into our garbage bags. Sat out in front of the apartment in the cool morning grass until it gave way to the hot afternoon sun. Guess what, we didn’t move out of that project apartment for another 6 years…No one is coming.

Subscribe now

Because of this, I tried to follow through on my dad’s prior parting mandate. On his way out the back door he lifted me up into the utility room sink. Now eye to eye he said: “Danny, you’re the man ‘o the house now. Take care of your Mom and brothers.” Never have 4 syllables reverberated so thoroughly. Man-uh-tha-house. The phrase to my 5-year-old self was completely unfamiliar yet the meaning clear; stamped on my heart to this day. There’s something unusually comical yet, now as a father myself, simultaneously horrific about this scene. The words: man, house, care. Strung together in a directive to a kid capable of physically and psychologically absorbing them but without the intellectual, experiential or emotional connective tissue to do anything but collapse and misshape under their effects like a sandcastle encountering the rising tide.

The fact is, Mom was the only one capable of caring for anyone. She was my first model of a healer. If healthcare is a hierarchy, she never left the bottom rung. But, if defined as service and love, I’ve never met her equal. Sons are tempted to exaggerate their mother’s saintliness. But I have dozens of first-person experiences observing her at work with patients and, as a result, could only risk understating it. A nurse’s aide trained at the local community hospital; she kept the lights on caring for the elderly and disabled. She invented homecare before it had a name. Thankless, messy work, but always with a warm smile. 30-year-olds in diapers who suffered anoxic brain injury during childbirth, elderly grandmothers who long forgot their own names…she treated each as her own. It wasn’t just cleaning feces, wiping faces and sponge baths, but long conversations, singing old hymns and personalized renditions of “Jonah rode a boat ashore” as one of those special 30-something’s pounded away shirtless on his parents’ old stand up piano singing unintelligibly with glee. Mom did the thankless hidden things. But also saw the soul of each person, rehumanizing them in a way others couldn’t.

My first example of medicine was our pediatrician, Dr. Dahl. He was still making house calls into the 1980’s long before “Direct Primary Care” and “Concierge Medicine” became en vogue. An anachronism who had much in common with country doctors paid in kind from a time gone by. His office, located on the first floor of his home, was run by his wife. I now realize looking back through my adult experience, he must’ve been well into his 70’s. But Dr. Dahl was still carrying his black bag to visit left-behind kids in a rundown government housing complex, for mothers who didn’t have the means to make it to his office one town over. Once, after seeing my brothers and me for whatever was ailing us, he dozed off; right there on our frayed holey orange living room couch while sitting upright. Mom, upon walking back in with the tea glass of water she promised him, reverently whispered “shhhh, Dr. Dahl is tired. Let him sleep.” One saint, looking after another, recognizing the fatigue that comes after draining yourself for others.

Fast forward, now and I’m 14 years old. My mom managed to pull us up out of the projects with a little help. She married my stepfather who was a “rich” swing shift worker at the local power plant. We moved to that adjacent town where Dr. Dahl’s office was and lived in the first place that we owned outright. At this point I was a terrible student but a promising athlete. I started playing football and later joined the wrestling team in high school. I was a bit of a home-town hero. Really, just a big fish in a little pond. But good enough to make the local papers. I was even featured once as the athlete of the week on WKBW news channel 4 after I did some amazing feats as a wrestler.

Who made this possible? A coach named Dan Fire and his brother Dave. These guys were unique and a little bit crazy, but in a good way. I tried to quit wrestling halfway through my junior year of high school because I wanted to get a job and buy a crappy car. Dan Fire called my house every night. “You have the rest of your life for a shitty job, you only have NOW to be a wrestler.” He did this until I relented and finally agreed to come back to the team. Another Saturday I overslepped on a tournament day. Panicked, I looked at the black digital clock with red numbers next to my bed and realized it was too late to make the bus…next thing I hear…the bus horn blowing in front of my house. Peering through the frosty window I see coach Dan hanging out the bus window waving his arm while yelling “Poulsen, get your a8$ out here!” I waited out front for my dad to pick me up and these guys were chasing ME.

These men gave up every afternoon after their regular jobs (Dan a postal worker and Dave a high school maintenance man) to teach a bunch of nobody kids in a nobody town how to wrestle. Of those kids they taught, one went from being convicted in a courtroom of grand theft to being a prominently known lawyer, another became a hospital system CEO known for turning around institutions from deep in the red to the black, another was a kid who moved to Philadelphia to teach kids in the hardest schools in the country that they could learn with a little inspiration, they just had to do the hard work and have somebody show them the way; that was until he overdosed visiting his friends back in my hometown that he used to get high with. And that illustrates the duality of where I came from. We all grew up in a nowhere town in the midst of the opiate epidemic. These men, the Fire brothers, for basically no money and no glory for themselves, donated 1,000’s of hours to kids that nobody else believed in to teach them that somebody cared about them and hard work pays off…like really hard work. Wrestling is a beast. If you wrestled in high school or college, you’re a hardworking mother…but you only made it because you had coaches who cared more about you than you cared about yourself.

All that grit and guidance carried me into college, but it didn’t make me a good student. At least not at first.

Part 2: Becoming Dr. Poulsen (the long way around)

This will be a 3-part series published entirely this week.

Next installment Tuesday May 12, 2026

Subscribe below so you don’t miss it

Subscribe now

Dr. Ashu Rao and Dr. Kavi Devulapalli offered two very different but equally fascinating perspectives on why Interventional Radiologists (IRs) are unhappy. If you haven’t already read their take, it is highly recommended. I am going to take a less psychological and structural view, but instead opt for a more practical, “ole country doctor” approach to this important topic.

The Pattern: Unhappy IRs Everywhere

Just like Dr. Poulsen as mentioned in the original substack article, There’s Not a Shortage of Interventional Radiologists, I’ve had the opportunity to interview several IRs in my former practice, Vascular and Interventional of Thomasville Associates (VITA). At VITA, we began recruiting 2 years after I moved to a town of 20,000 people, Thomasville, GA. There was such a diversity of applicants that came to rural south GA to learn about and decide if there was a future for them in such a small community. Applicants came from Denver, CO, St. Petersburg, FL, New York City, NY, Fayetteville, NC, Augusta, GA, Salt Lake City, UT, as well as many other cities larger than Thomasville, GA.

After numerous delicious, yet time and financially taxing, dinners with candidates, I noticed a common theme.

All decided to come to visit this small town not because it was a desirable place to be, but because they were simply unhappy in their current professional position.

I realize one may say that’s not breaking news for someone to come and interview because they are unhappy. Before leaving my practice with Jackson Radiology Associates JRA in Jackson, TN, I did not make the decision to leave based on being unhappy per se. I was a “young” dad who abruptly had to figure out how to function as a single dad to two daughters. JRA was a great job in that we did lots of high-end IR ranging from EVAR, peripheral angiograms with intervention, carotid stenting, kidney and liver ablations, PE and DVT thrombectomy, dialysis access procedures and all sorts of bread and butter IR. In addition to the breadth, the volume was high, on the order of 25-35 cases per day.

So, I did not leave because I was unhappy. I left because I needed to be a decent single parent to two daughters for which the high volume IR environment I was in coupled with the extremely high volume diagnostic radiology did not accommodate.

My point is simple: people leave jobs for more reasons than being unhappy.

Fear Is the Real Barrier

However, each time I interviewed an IR for the Thomasville gig, it struck me that all were unhappy professionally. Having only been in two practices, both of which provided for high end Interventional Radiology that kept me engaged and yearning to a better IR, I couldn’t understand just how an IR could be unhappy doing one of the most stimulating jobs in the world IMO. After greater than 10 interviews, we finally cajoled one curious soul to take the leap and come to Thomasville. There was only one problem- they stayed just three months before returning to familiar territory.

I’ve had the opportunity to speak with a number of those IRs after they came to Thomasville to interview. To my knowledge, all remain in the same position they were in when they interviewed with VITA.

This tells me one thing- one of the greatest challenges for unhappy IRs is FEAR. Specifically, the fear of change.

Some of the most talented and smartest individuals I’ve met are IRs. These are individuals who readily welcome challenges. IRs stay ready to snake their way into someone’s brain and remove a clot, impose their presence into a patient’s abdomen to stop a life threatening bleed, and so many more heroic measures that require bravery and confidence.

However, the area I’ve seen IRs cave most is when it comes to making a decision for themselves, especially decisions that deal with their own happiness.

The Paralysis of High Performers

This week, a dear friend of mine sent me a text. It read, “I’m thinking about changing my situation again. I’m not sure I’m justified in making a change.” All too often I’ve seen this fear of change inflict unnecessary distress on such high performing, exceedingly capable individuals (i.e. IRs).

These extraordinary individuals move from the IR suite, making swift, tough decisions to bring someone from the brink of death to being crippled by a decision that determines their (and often their family’s) happiness.

Many IRs have come to accept it as status quo to not be happy professionally.

One of the biggest misconceptions in Interventional Radiology is that we, as IRs, do not have the ability to take control of our professional lives and improve it. Yet, the only recourse that we feel we have is to lower our expectations, depend on someone else (e.g. “leadership”, administration, investor group) to make the changes we desire or gaslight ourselves into thinking we are the real problem.

The Structural Reality

I agree with Kavi in that a significant reason for the unhappy IR is due to structural issues. IRs as well as other physicians have been conditioned to believe that we are not capable of sustaining ourselves and being self-sufficient.

This is the result of a well-orchestrated, systematic brainwashing of some of the most talented people in this country, which is evidenced by the large transition of physicians from independent private practices to now being employed. One may say that I am ignorant of the realities of healthcare economics. To that I say, I am knowledgeable of the drivers healthcare economics.

IRs and other physicians dedicate sometimes more than half of their lives to education and training to take care of the physical and mental health needs of people. It’s heartbreaking to see their professional life ultimately dictated by someone who does not have the ability, credentials or certifications to do work that produces an RVU or worthy of a CPT code, the engine that drives healthcare economics.

The unhappy IR stems, in large part, from the fear of changing an undesirable situation they have been conditioned to believe they cannot change.

Stated another way, many have come to accept being unhappy.

Purpose Drives Satisfaction

I really appreciate the intricacies and differences that we all share. I enjoy learning the true and genuine make up of people. Those differences include things that interest us, things that make us anxious (e.g. change), our backgrounds, different languages we may speak, hobbies we take up, etc. What also makes us different are our priorities. Our priorities are what drive us and our decision making.

Interviewing IRs over the years has given me the opportunity to examine where the priorities of people lie. I’ll again reference my situation before moving to Thomasville. As mentioned above, I was a part of a high volume, high-end IR practice before moving to South GA. That first job was a critical time in my professional life in that it molded me as an IR and it showed me what I value most professionally.

Without a doubt, I learned that having a sense of purpose in what I do every day is what provides me with the most professional satisfaction.

My appeal to rural IR stems from being able to impact the lives of so many in our small community. It’s the impact one feels when two female patients show up in your clinic on the same day because they heard that you offer a treatment for their heavy bleeding that their friend who lives in Atlanta had but they don’t want to travel 4 hours away. It’s the impact one feels when the legally blind patient hugs you tight because she didn’t have to pay someone to give her a ride to Jacksonville, FL for her kidney ablation.

The Tradeoffs Are Real

My priorities are where my personal sense of purpose is. That has been living in places where there is a true need, rural communities. There is clearly a need for UFE and renal ablations in Miami, Chicago, San Antonio and other large cities. However, there is a relatively abundant supply of IRs in these larger cities as compared to smaller communities like Moultrie, GA and Cape Girardeau, MO.

What’s been my experience is that most IRs do not prioritize where the demand for their skillset truly is, such as rural communities. As a result, many have settled for jobs where the IR work is mundane, scarce and/or the diagnostic radiology responsibilities are plenty.

We’ve all seen it on IR forums and talked to way too many IRs who are unhappy due to prioritizing other aspects of their lives (location, money, entertainment opportunities, spouse). Let me be clear. I am not judging or criticizing the choices anyone makes. Some of these are worthy considerations for priorities. My point is we all must live with the consequences of our decisions, myself included.

Redefining Wealth

Is my job “golden” as I heard an IR this week describe an opportunity? No, it’s not perfect. I’m pretty sure I’m not in that group Kavi described as making “insane money.”

For me, wealth isn’t solely measured in dollars and cents.

I feel wealthy in that I have autonomy and there is no one sending me an e-mail to generate more RVUs, especially someone who does not have the ability, credentials or certifications to generate their own RVU. I am wealthy in that I don’t have to convince anyone of the value of the Minimally Invasive and Vascular Solutions MIVS clinic.

Does it irritate me that I had to wait 3 weeks to get a plumber to come to my house last month to fix my hot water? Yes! It’s not fun having a scarcity of certain resources as compared to living in Atlanta. But these undesirables are balanced by being able to go to a practice that I own, make the decisions for and was in the black after the first 30 days of opening the doors.

Independent should not be misconstrued as a failure to recognize the value of collaboration with other providers, practices or healthcare entities. I’ve learned that when true collaboration occurs and all parties recognize the value that each other brings, everyone involved wins, especially the patient. Have I been bitten by attempts at collaborating? Yes, but I still believe in the power of genuine collaboration.

The Two Drivers of Happiness

Practicing in a rural community can certainly require a mind shift and for many is a total paradigm shift. For me, this work in rural communities has proven to be deeply purposeful and fulfilling.

So, what has led to at least this one IR being happy is 1) getting rid of the fear of change and 2) prioritizing a sense of purpose over all other things, even if it takes you into the most rural parts of America.

Happiness truly is a choice.

Ashu Rao opened this series by reframing IR dissatisfaction as the gap between expectations and reality. It was a sharp lens—and one that resonated.

This next piece is part of a collaborative, cross-published effort with Kavi Devulapalli, whose work on Line Monkey MD, MPH has become a defining voice in how many of us think about IR practice today.

In Part 2, he takes the argument further—making the case that IR unhappiness isn’t just psychological, but structural, rooted in the mismatch between what the field has become and the environments we’re actually given to practice it in.

Subscribe now

I recently read Ashu Rao’s post on why interventional radiologists are unhappy.

It’s a thoughtful piece, and to his credit, he moves beyond surface-level explanations. He argues that IR unhappiness stems from the gap between expectations and reality, as seen in how we experience procedures, using thoracentesis and pulmonary thrombectomy as a very fascinating example. In my experience, I am more likely to be consulted for a thoracentesis in a patient with an effusion that is over 5 years old with an O2 saturation of 99%, but maybe things are different in magical Atlanta, GA. Who knows.

I believe the root cause of IR unhappiness is deeper and more structural.

At first glance, that explanation makes sense. Many IRs have preferences, and we tend to gravitate toward higher-complexity cases and away from procedures that, fairly or not, seem doable by non-physicians. After speaking with over a thousand interventional radiologists in various practice settings, career stages, and geographies over the past eight years, it is clear this is not really about the procedures themselves.

A pulmonary thrombectomy and a thoracentesis both help patients and can be appropriate, valued by the referring team. Yet they feel completely different, not because of the procedure itself, but because of factors like how the case arrives, timing, context, disruption, and your level of control.

I have written about this before in the idea of the IR as both the hospital MVP and the glorified trash collector.

That post resonated more than I expected—not because it was novel, but because many IRs recognize the dynamic. Most in the field have experienced it.

I certainly have. In my own practice, day-to-day work at times felt less like what I trained for and more like a stream of low-complexity tasks done mainly to support a diagnostic imaging contract. It was not one specific procedure; it was the sum of the work, lack of control, and the feeling that I was not using my full training. This disconnect eventually led me to question whether to stay in IR or even in medicine.

This led me to realize that my dissatisfaction stemmed not from workload or call demands, but from a misalignment between the current IR practice environment and the field I envisioned, highlighting a structural, not personal disconnect.

I have written about this before in The IR Startup, but I keep coming back to the same idea. Most of us went into IR because we were drawn to the combination of clinical medicine and image-guided procedures. There is something compelling about diagnosing and treating patients with minimally invasive image-guided techniques and following them longitudinally, through the good and the bad, which is inherently very satisfying. While the longitudinal component wasn’t something I was truly exposed to in IR training, as I am today in my solo practice, that is the type of practice I wanted, and these days, many coming out of training are better exposed to a more clinically oriented pathway.

However, there are still a few roles where you can practice IR fully, build a longitudinal practice, and have your work valued within the system. Many end up in hybrid IR/DR roles from an earlier era, where IR operates as a loss-leader procedural service tied to diagnostic radiology.

That model works incredibly well financially, but that often involves trade-offs. You try to build something longitudinal in a transactional system, seek a clinical identity in a procedural environment, and operate with limited control over workflow, patient selection, and direction. I’ve met so many IR/DRs who make insane salaries, yet are very unfulfilled.

Ultimately, this is not simply an expectations-versus-reality mismatch. There is a structural gap between the field’s aspirations and the actual opportunities available to practice IR as intended.

And the interesting part is that the market seems to be adjusting, whether we explicitly acknowledge it or not.

We often talk about an IR shortage, and there is truth to that. It is not easy to hire. Coverage is a challenge. Many groups are relying on locums just to keep basic operations going. But that framing is incomplete, because at the same time, there is a noticeable shift in how IRs are choosing to practice.

I see this directly through Physician Staffing Solutions, which I run with my IR cofounders, Dr. Shamit Desai and Dr. Aneesa Majid. Over the past several years, we have had conversations with a large number of interventional radiologists, enough to start seeing patterns that are difficult to ignore. The pattern that keeps emerging is not just one of shortage, but one of movement.

Interventional radiologists are not simply unavailable. They are making deliberate decisions about where and how they want to practice.

I have spoken with partners in traditional IR and DR groups, people who have been in practice for more than 20 years, who are worth tens of millions of dollars, and who are now stepping away from those roles to pursue independent contracting. Others are moving toward direct employment models with health systems. Some are shifting into locum work, not just as a temporary bridge, but as a long-term strategy to gain more control over their time and workflow. And then there are those who are stepping away from IR entirely and pursuing teleradiology, as this option offers a very lucrative payday without the hassles of dealing with a field that has failed to define itself in our current healthcare landscape.

Interest in outpatient and office-based models is rising. Economics and autonomy play a role, but mainly it’s about building a practice that matches IR’s clinical potential, not a structure designed for something else.

Viewed together, this is less about individual career choices and more a broader market signal. The system isn’t static, and IRs are responding rationally to their options.

When asking why IRs are unhappy, we should focus on the underlying structures shaping the field rather than on internal mindsets or values alone. This shift better explains the persistent dissatisfaction IRs describe.

Based on personal and professional experience, dissatisfaction among IRs is rarely a straightforward mismatch between expectations and reality. More often, it emerges gradually: something about daily work feels disconnected from the field that initially attracted them. Over time, the feeling becomes hard to ignore, and soon you may end up cleaning a fish at work like Peter from Office Space. I myself have had that Office Space moment and hope no one feels like that, but sadly, I have spoken with dozens over the years in our specialty who have had that exact same moment.

What we are seeing now feels less like a psychological phenomenon and more like a response to that structure. The underlying issue is that there aren’t enough practice environments that meet the demands of what many interventional radiologists actually seek. The field has evolved in its aspirations, particularly around clinical care and longitudinal patient relationships, but the available jobs have not kept pace with that evolution. There is a draw to contract-based work because it rewards the interventionalist for practicing interventional radiology and not using diagnostic radiology as the economic engine to provide episodic interventional care as a mere afterthought.

This growing gap between IR’s potential and current practice environments is structural and will persist without intentional change.

If anything, it suggests that part of the responsibility falls on us to build those opportunities rather than wait for them to appear. This is the reason I started my own OBL practice, Image Guided Solutions of Missouri. Building new practices means we need to place greater emphasis on entrepreneurship within the field, whether through outpatient practices, new care delivery models like what I am accomplishing with my co-founders, Dana Dunleavy and Ian Wilson, at Travelier, or more intentional efforts to create IR-focused clinical services. It also means thinking more carefully about how we train and mentor the next generation, not just in technical skills but also in longitudinal non-operative clinical care, business development, and in how to navigate and shape the environments in which they will practice.

If these changes take hold, today’s dissatisfaction may be seen differently. Not because the work changed, but because practice conditions would align with why many chose IR. We must work hard to support our colleagues and build the IR practices of the future. If we don’t address this problem now, IR will cease to exist.

Last week at the Society of Interventional Radiology Annual Conference in Toronto, I spent part of one evening in a basement bar cleverly named “1Below” at the Fairmont Royal York Hotel. Embarrassingly and despite it’s well chosen name, I had to ask the concierge how to find it as I didn’t have my wife with me to ensure I got to the right place at the right time…it was one floor below the main level. Anyhow, this was an industry event held by Boston Scientific, the type that I love not just for the free drinks but because it’s an example of the side gatherings where the real conversations happen. It was the same kind of setting that gave rise to things like an unofficial SIR bourbon night, less structure and more signal, where people tend to speak more honestly about what they are actually seeing in practice. That is where I met him, an R6 about to graduate, fresh-faced but not naive, thoughtful in a way that stood out. He listened closely, asked deliberate questions, and carried himself with a kind of perspective that you do not always expect from someone at that stage..an old soul.

He asked about trajectory, about how I got started, what worked and what did not, and where I thought the field was actually going, not the version we present in formal settings but the version that plays out in day to day practice. When I turned the conversation back on him and asked about his plans, his answer came quickly and without hesitation. He was going into an academic practice for a couple of years, and then hoping to pivot to private practice. I have heard this same answer from a growing number of high-caliber trainees and genuinely support it as the uncomfortable reality is that the logic holds.

We continue to talk about a shortage of interventional radiologists, but that statement doesn’t apply in every context. There are certain environments where there are more IR applicants than available positions. At the same time, there are far more practices, including many private groups, mixed IR and DR models, and even many OBL and ASC settings, that cannot recruit an interventional radiologist at all. The market is not uniformly tight or loose. It is bifurcated. The dividing line is not simply compensation or geography. It is whether the job actually allows a physician to practice interventional radiology in a way that resembles their training. New graduates are not asking which jobs have the best pay, benefits, time to partner…they are asking which opportunities will allow them to become what they spent a decade preparing to be.

This is where the idea that your first job is your second residency becomes less of a metaphor and more of a description. The majority of early career interventional radiologists are stepping into roles where the majority of their time is still spent in diagnostic radiology, where the procedural mix is heavily weighted toward maintenance work such as drains, thoracenteses, and paracenteses, and where any effort to build a program is either unsupported or quietly resisted. The implicit contract is that you will prove your value first, integrate into the system, and then, at some undefined point in the future, you may be given space to expand into more complex or programmatic work. The problem with that framework is that it ignores the fact that these individuals have already spent ten years proving their value in a highly selective and demanding training pathway.

The resident I spoke with understood something that many current practice environments have not fully internalized, which is that academia, for all of its imperfections, often represents the highest probability path to preserving the skillset developed during training. It offers procedural volume that is aligned with what was learned, access to complex cases, and a clinical identity that is anchored in being an interventionalist rather than a hybrid generalist. In contrast, many private practice roles expect a new graduate to simultaneously build a program, navigate resistance from diagnostic partners, convince hospital administrators of the value of interventional radiology, and maintain a substantial diagnostic workload to justify compensation. That combination effectively turns the early career period into an unfunded startup phase, but without the structural support or ownership that typically accompanies that level of effort in other domains.

My own experience was shaped by a degree of luck that I recognize more clearly in retrospect. I joined a group where timing and personality created an opening, and alongside a colleague with a complementary background, we were able to generate momentum and begin building a program (I wrote about that experience here: https://open.substack.com/pub/drpoulsen/p/your-first-attending-job-isnt-a-job?r=7gya7o&utm_campaign=post&utm_medium=web). Even in that setting, however, the underlying structure remained unchanged. Diagnostic priorities continued to dominate decision making, administrative friction was a constant, and the broader system was not designed with the expectation that interventional radiology would lead as a clinical service line. Over time, those structural realities outweighed the opportunity.

What is emerging now is a quiet standoff. Early career interventional radiologists are increasingly choosing to remain in academic settings, if they can, preserving their skills and waiting for a more aligned opportunity. At the same time, many private practices report difficulty recruiting, and hospital systems continue to employ locums and most commonly underappreciate the full clinical and economic value of a well-developed IR program. The result is a growing cohort of highly trained physicians who are either underutilized, partially redirected into diagnostic roles for financial stability, or holding in place within academic environments while waiting for the practice landscape to evolve.

The central question that remains largely unanswered is:

Which groups are actually offering a pathway where a new or early career interventional radiologist can function as a true interventionalist, participate in building and growing a program, integrate clinically, and contribute in a way that is both meaningful and sustainable?

Not in theory or in recruitment language, but in the actual day to day structure of the job. In the relatively rare instances where that environment does exist, the issue is not a lack of available candidates. It is a lack of visibility. The individuals who are looking for those roles often do not know where to find them.

For those practices that have successfully aligned their structure around an interventional radiology forward model, the implication is that recruitment challenges are less about supply and more about communication. There are trainees and early career physicians actively searching for environments where they can fully apply their training. They are simply not seeing enough clear examples of those environments in the current landscape.

So the mandate and solution to your IR shortage in some instances becomes straightforward. If you are part of a group that has built something that works, where interventional radiology is practiced at a high level and supported as a clinical service line, it is worth making that visible. If recruitment has been a challenge, it is worth examining whether the issue lies not in the availability of candidates but in the alignment between what is being offered and what those candidates are seeking. And for the resident I met in that basement in Toronto, and others like him, the decision to wait is not a lack of ambition. It is a rational response to a market that has not yet fully caught up to the capabilities of the people entering it.

Built in IR is about closing that gap between what we train for and what we are actually allowed to practice.

This essay is the first in a four‑part series responding to my recent post (There’s Not a Shortage of Interventional Radiologists) arguing that we don’t have a true IR shortage so much as a shortage of fulfilling opportunities for IRs to practice the way they were trained.

To open the series, Ashu Rao, MD, an IR, senior partner and practice leader at Quantum Radiology, offers his perspective on why so many IRs feel unhappy in today’s practice environments, and what that reveals about our expectations, obstacles, and potential solutions.

There is a significant shortage of Interventional Radiologists (IR’s) in the U.S. Many facilities are forced to hire locum tenens IR just to cover their IR needs day to day. Adding to the IR shortage are the reports of IR’s leaving the practice of IR because they are unhappy.

We may not be able to quickly train more IR’s to fill the IR shortage, but we can focus on how to keep unhappy IR’s from leaving or curtailing their IR practice.

But first, as physicians, we must arrive at the diagnosis before offering a prescription. Dx comes before Rx.

Here is the fundamental question we seek to answer: Why do unhappy IR’s suffer?

Let us not get lost in the sui generis Anna Kerenina principle, where “Each unhappy IR is unhappy in their own way”. We must dive deep to find the core of the issue which we can more generally apply to all unhappy IR’s. What is this core issue?

Spencer Johnson M.D. presents this fundamental diagnosis of all unhappiness, suffering, and psychologic pain:

“Pain is simply the difference between what is, and what I want it to be.”

Aha! Genius. This insight will allow us to explore what is behind all unhappy IR’s. Let us pair this concept of unhappiness with one explaining happiness.

Tim Urban has an excellent framework for understanding happiness (well worth reading in its entirety) which we can apply to IR. His equation for (IR) happiness is as follows:

Combining these two concepts, therefore the source of all (IR) suffering is the difference between expectations and reality.

If everything (reality) was exactly the way we want it to be (expectations), how could anyone be unhappy? This truth seems obvious when expressed this way.

To balance this equation in favor of greater happiness, we must explore the expectations part of the equation (We will save the reality part of the equation for a future essay). But first a short digression is needed.

Trivia question: When was the last time that the Academy Award Oscar for Best Picture was also the highest box office grossing movie in the US?

Answer: Over 20 years ago, in 2004 when The Lord of the Rings: The Return of the King held both distinctions.

So there is a “disconnect” between objective, quantifiable success (box office receipts), and success as judged by the Academy. This effect is also seen in films rated on the popular media review website Rotten Tomatoes. Often films highly rated by critics (as measured by the Tomatometer) are poorly rated by moviegoers (as measured by the Popcornmeter), and vice versa. We can see a similar effect between critically acclaimed versus popular art, music, and modern architecture.

What is the nature of the disconnect between the Tomatormeter’s critical acclaim and the box office proven popularity? The answer is that the judgement differs based on the nature of the audience to which it is presented. And understanding our audience gets us closer to the nature of IR unhappiness.

Returning now to IR expectations, let us begin with a simple thought experiment illustrated by the following patient flow chart:

We will open up the box to collapse the wave function of Heisenber’s IR procedure to find one of two possible states.

1. Pulmonary thrombectomy. Result: IR is the hero who saved this patient’s life!

2. US guided thoracentesis. Result: IR is the sucker who was dumped on!

Either way, from the patient’s perspective the IR is a hero. From the patient’s family’s perspective, the IR is a hero. From the Hospitalist’s perspective, the IR served a very valuable service which helped care for a patient. But from the IR’s perspective, the outcomes are very different!

We can conduct the same thought experiment with countless other IR referrals. One quantum state leads to a happy IR, and the other quantum state leads to an unhappy IR, even when the patient and referring physician are equally happy with the outcome.

We can now see that IR procedure satisfaction is subjectively internal to the IR and not an objective reality to the patient or referring physician. This same IR subjectivity extends past the procedures themselves to the patient flow around the procedure. This includes who consults us and when they consult us, how they consult us, for what disease state we are consulted, etc etc etc. The entire experience of an IR practice is suffused with internal expectations of “good” and “bad” processes and procedures.

So what then are these IR expectations? Where do they come from? And what can we do about them?

These are fascinating questions about the human experience centering around the fundamental question “Why do we want what we want?” Obviously no IR was born with a preference for tumor ablation over tumor biopsy. These preferences were acquired later, from sources external to the IR.

Joseph Heinrich reveals that these expectations are culturally transmitted. We choose what is important to us by observing what is important to other people like us. Which are people in our IR tribe. This “copying” phenomena (procedural Schelling points if you will) means the IR tribe consensus may be that the pulmonary thrombectomy is “good” but a thoracentesis is “bad” as a purely subjective phenomenon. Our desires are mimetic. Alex Danco has a great introduction to these “Secrets about People” explaining Girardean mimetic theory.

Returning to our trivia question and the broken Tomatometer, normative judgements are tribal by definition. Directors wishing to make great films cater to other filmmakers. Architects’ sense of accomplishments is judged by the reaction of other architects. And IR practice expectations are formed by the “IR tribe”, which is simply other IR’s who are often in positions of higher status.

How does the IR tribe assign value to various procedures? There are many possible explanations. One method may be the challenge in the complexity of a procedure, with more complex procedures being more desirable. However, many complex IR procedures are not actively sought, and may even be avoided. Lymphatic embolizations and parathyroid vein sampling are examples.

Another explanation may be that higher reimbursing procedures not only generate more income, but they also generate higher IR status as judged by other IRs. This seems to be directionally true as embolization procedures of many types are considered good procedures and are highly reimbursed. But this explanation is also incomplete, as elective embolizations are prized much higher than inpatient emergent embolization.

Hopefully this exploration of IR expectations will lead to a more robust discussion of IR values as a community. For example, why is a CT guided abscess drainage which saves a 42 year old female from an open laparotomy considered a”dump”? Why do requests for procedures which we think are not indicated generate IR outrage, given the fact that referrals to subspecialty surgeons may only result in treatment in 10-40% of cases?

The unhappiness that IR’s feel from the gap between their expectations and reality stems from the fact that our expectations are our own internal judgements, not the judgement of patients and referring physicians whom we ostensibly serve.

“If you are pained by any external thing, it is not this thing that disturbs you, but your own judgment about it. And it is in your power to wipe out this judgment now.” - Marcus Aurelius, Meditations

We have the power to change our own expectations. Changing reality to rebalance the happiness equation to favor IR happiness can be the subject of future essays.

Rao reframes IR dissatisfaction as a gap between expectation and reality, shifting the conversation from external constraints to internal constructs. In Part 2 of 4, Kavi Devulapalli adds his perspective, continuing the exploration of what is driving IR practice dissatisfaction today. This series aims to broaden the conversation beyond “shortage” and toward a clearer understanding of modern IR practice.

Steel Belt vs. Ivory Tower

My residency was a true steel belt city program, an apprenticeship culture where catheter work was honed the way a welder learns to lay a flawless bead.

Y-90 tumor mapping meant identifying every feeder vessel with deliberate pre-procedure planning and disciplined post-procedure review.

An obsession with the technical minutiae that separates good from excellent.

One of our attendings, a Philadelphia native, never called it a department or program.
To him, the procedural suites, the faculty, the residents, it was “our shop.”

And in that shop, we built things well.

But like many traditional IR models of that era, the structure around the craft was different from what IR has become.

Most procedures were ordered by other clinicians.
We didn’t run daily clinics.

We rounded briefly.
We executed efficiently.

And then we handed off to hepatology, OB/GYN, primary care etc.

It was a respected model, technically rigorous, producing excellent operators.

But it was not yet a fully integrated clinical service line.

Subscribe now

Searching for the Right Fit

That gap wasn’t obvious to me at the time.

Six months before finishing a decade of medical training, I was searching the South Atlantic Coast for more than a job; I was looking for a partnership, and a future for my family.

I eventually joined a small group outside Charlotte.
They were advertising for an interventional radiologist to revive and revamp a program largely staffed by senior physicians who preferred diagnostic radiology and performed procedures more episodically.

The market was competitive.
The partnership track was short.
It looked attractive.

What I didn’t know was that they were simultaneously hiring another IR, also fresh out of training, someone with a background substantially different from mine.

My soon-to-be partner came from a prestigious “Ivory Tower” top ten program in California.

His training environment looked entirely different:

• Daily outpatient clinics

• Dedicated NPs and PAs

• Inpatient consult services

• Admitting privileges

• Administrative integration

He was technically excellent. And was trained to understand something I had not yet internalized:

Interventional radiology is not a procedure service. It is a clinical service line.

Fitting In vs. Building Forward

When I arrived at the practice, I did what most new attendings do.

I fit in.

I hit the diagnostic list hard. My RVUs climbed quickly. Senior partners praised me. Complex cases were handed to me. I learned their equipment. I took every kyphoplasty, bleed, and embolization that came my way.

I was welcomed warmly.

But in retrospect, I was being praised for fitting a pre-existing mold: an interventional radiologist who primarily functioned as a high-producing diagnostic radiologist with procedural capability layered on top.

My new partner was doing something different.

He was asking:

• What equipment do we need?

• What’s the state of the technologists?

• Why don’t we have clinic?

• How do we generate new referrals?

• Why are we waiting for cases instead of creating access?

Within weeks, we were in daily strategic conversation, on the phone to and from work, trading ideas, debating growth models, challenging each other.

He pushed me to think clinically. The group pushed him to contribute more to “the list”...and he did.

And we both learned how to build, modernize, and integrate an IR program from the ground up—balancing technical mastery with clinical excellence—within a systemically resistant hospital culture.

Building Before Permission

We didn’t ask for a fully built clinic.

We started one.

We scheduled patients ourselves. We used whatever room was available in the nursing unit. We created follow-up pathways. We began longitudinal care.

It was patchwork development.
It was messy.
It worked.

Clinicians began to notice. Patients began to ask for us directly. Hospital leadership began to pay attention.

And slowly, the tide shifted.

The Second Residency

That first year of partnership was formative in ways no residency could have been.

Every strength I brought from training—technical precision, evidence-based procedure selection—was amplified.
Every weakness was equally exposed: clinical integration, administrative navigation, service line strategy.

There are elements of interventional radiology that you cannot learn from a syllabus:

• Culture

• Character

• Political awareness

• Economic literacy

• How to build leverage without antagonism

• How to make yourself indispensable

No residency can give you the full spectrum.

But the right partner can.

Back-to-Back in the Foxhole

There’s something powerful about two newly trained physicians aligned in purpose.

We often joked that we were back-to-back in a foxhole.

That alignment mattered. Other interventional radiologists had joined that group before us and failed to make change. The gravitational pull toward “just read more CTs” is strong in mixed practices.

But two aligned physicians can change momentum.

Within a year:

• The women’s health embolization program expanded from single digits annually to multiple cases per week.

• A prostate artery embolization program was built from zero.

• A Y-90 service line was created from the ground up.

• We partnered with cardiology to expand PE thrombectomy and elevate DVT and the full spectrum of venous intervention programs.

• The hospital retained patients who previously would have out-migrated.

• The IR footprint became economically viable and clinically integrated.

The program shifted from drains and biopsies with the occasional ablation or GI bleed to a comprehensive embolization-driven service line.

Proof of concept became proof of value.

What I’d Tell Trainees Now

You cannot choose the perfect residency.
You cannot find a residency that fills every gap.

But you can choose your environment strategically.

If you trained in a technically dominant program, find colleagues from clinically integrated programs.
If you trained in a highly academic clinical model, spend time in a place that forces you to understand production, mixed practice economics, and group dynamics.

Seek difference.
Seek tension.
Seek complementary strengths.

The right professional partnership can alter the trajectory of your entire career.

Mine did.

And looking back, my first attending job wasn’t just a job.

It was my second residency.

Dr. Dan Poulsen
Founder, Poulsen Medical — focused on developing high-impact interventional radiology programs that drive clinical and economic value.
📩 dr@poulsenmedical.com

It happened again last fall.

We were interviewing another remote radiologist for an evening shift, the kind that’s always hard to cover. That day the candidate had flown in from out of state. Nice guy. Affable. Big smile. Easy to talk to.

Within a few minutes I could tell, you can just tell: he was an IR.

And now he was doing full-time diagnostic radiology from home.

We got to talking, joking, swapping stories about cases, about how cool IR can be when it’s working the way it’s supposed to. The conversation was easy and familiar. But eventually it took the turn it always does.

“So why are you doing DR from home?” I asked him.

I mean, I get it. Home is comfortable. The lifestyle is easier. But this guy was clearly excited about IR. His eyes lit up when we talked about cases.

When my partners were nearby, the answer was the usual one:

“Those midnight calls get old.”

Fair enough. Everyone says that.

But then my partner stepped away for a moment, and the conversation got real. It was like the warden had been distracted by a fight in another part of the yard.

He glanced back and forth, leaned in and whispered that familiar sentiment:

“I got sick of doing bullshit cases and being taken for granted.”

For about ninety seconds we had the same conversation that early-career IRs have with mid-career IRs all the time.

The quiet, honest conversation.

Tired of fighting my own partners just to have a clinic. Tired of dealing with hospital administrators who ask for “longer runways” or say “we can’t make that compliant.” Tired of seeing patients who desperately need help — real help — from a physician uniquely trained to provide it.

A patient with severe anemia who could be cured without major surgery. A patient just two tiny incisions away from permanent control of variceal bleeding. A patient with chronic pelvic pain who finally has someone willing to explain what’s actually happening.

And then being scolded because explaining it took too long. Because in the same amount of time, you could have read 4 CT scans and generated twice the wRVUs.

We shook hands. Exchanged numbers.

“Maybe someday,” he said.

“Maybe someday if the system starts valuing IR, I’ll come back.”

The Myth of the IR Shortage

So I’ll tell you something.

There is not a shortage of interventional radiologists.

What we have is a shortage of the opportunities IR training prepares us to fulfill.

Residency and fellowship prepare physicians for something very specific — a robust practice that combines:

• Emergent inpatient interventions

• Complex elective procedures

• Longitudinal patient care

• Outpatient clinical practice

That’s the promise.

But in many places, that promise never materializes. Instead, talented physicians drift away from the field they trained years to practice. Not because they can’t do the work. Because the system and players make it difficult to want to keep doing it.

So What’s Actually Causing the Problem?

The answer is complicated. It’s multifactorial.

But someone once gave me a piece of advice that changed how I look at problems — and it’s kind of counterintuitive:

“Don’t focus on YOUR solution. Focus on THE problem.”

The point is, if you don’t understand where the difficulties and obstacles lie, you’ll hold on to your favorite solution even at the expense of really solving the problem. If you think an OBL is the only solution to fulfilling your desire for practicing the full spectrum of IR, you’ll never do a PE case, BRTO, or TIPS again. And you might be fine with that — but a majority of the IRs I speak to didn’t choose IR because they wanted to do 5 UFEs a day for the next 20 years.

So let’s talk honestly about the problems.

Problem #1: IRs Don’t “Own” Their Patients

Interventional radiology historically evolved inside diagnostic radiology departments. That structure worked when IR was primarily procedural support. But modern IR is different. It requires clinic, referral relationships, follow-up care, and community visibility.

That takes time.

And most IR physicians simply don’t have that time.

To build a referral base you need to be present:

• Community education events

• Physician outreach

• Clinic development

• Collaboration with referring specialties

You need to be visible.

But many IRs are already covering call, reading studies, and performing procedures. Being everywhere at once is not sustainable. Trust me. I’ve tried. It works — for a while — but often at the cost of balance, family, and connection.

If only there was a way that we could reach patients without expensive or time-intensive ad campaigns and marketing…

Problem #2: Hospitals Don’t Understand the Economics of IR

A friend of mine once told me something that stuck.

“You have to learn to speak Excel.”

Hospital administrators think in spreadsheets. Contribution margin. Service line growth. Downstream revenue.

Interventional radiology creates enormous economic value for hospitals:

• Admissions

• Imaging

• ICU stays

• Oncology collaboration

• Surgical referrals

• Long-term patient retention

But most IR physicians were never trained to articulate that value. You didn’t learn Excel in fellowship. You learned how to pull clot from the right lower lobe and right middle lobe pulmonary artery with precision — with no hemoptysis or cardiac injury — sparing a 45-year-old father from severe cardiac stress and a lifetime of pulmonary hypertension.

Those skills are extraordinary.

But they don’t automatically translate into a business case. And until someone translates them, hospitals struggle to see the full value of the service line.

Problem #3: The Structural Tension of IR/DR Groups

Many IR physicians are recruited into combined IR/DR practices where cultural alignment is fragile at best. Sometimes there is tolerance. Many times, quiet resentment.

That dynamic makes it very difficult to build the kind of program a highly technical surgical specialty requires.

Think about it this way: how many vascular surgeons spend their careers fighting to justify their existence to their own partners? Not many.

But in many radiology groups, IR physicians must constantly justify:

• Clinic time

• Program investment

• Marketing efforts

• Longer procedures

• Lower immediate wRVU production

That tension slowly erodes enthusiasm. Trust me, I know — it’s exhausting.

And enthusiasm is the fuel that keeps IR programs growing.

The Convenient Excuse: “Other Specialties Won’t Refer”

It’s an easy narrative.

OB/GYNs just want to do hysterectomies. Urologists just want to do TURPs.

Sometimes that’s true. But most of the time, that’s not actually the problem.

In my experience, when patient care comes first and collaboration is genuine, referring physicians are very open to working together.

Blaming other specialties reminds me of high school wrestling. There was a guy named Tim Fike. Biggest, toughest guy in the school. He handed me my ass regularly. I remember telling my coach:

“Coach, he’s just too big. I don’t even have a chance.”

And my coach responded with the line every coach eventually uses:

“Poulsen… excuses are like—”

You know how the rest of that sentence goes.

Blaming other physicians is usually just that — an excuse. They’re doing what they believe is best for their patients. Just like we are.

So What Are We Going to Do About It?

If we accept that the problem isn’t a lack of trained interventional radiologists, then the real question becomes this:

How do we create environments where talented IR physicians want to continue to give their time and talent doing what they were trained to do — and frankly love to do?

How do we build programs where physicians can practice the full scope of what they trained to do?

How do patients in regional communities gain access to highly skilled IR physicians without needing to be flown to distant tertiary centers?

How do we build systems where interventional radiology becomes not just available — but indispensable?

Because until we answer that question, the quiet migration will continue. Talented IR physicians will keep walking away from the field they trained for. Not because the work isn’t meaningful. But because the system around the work makes it harder and harder to do.

And that's a loss for everyone. Especially the patients. But you can't solve a problem you haven't honestly defined. Now that we have — I'm encouraged. The people I've been collaborating with give me real reason for optimism. I think we're closer to turning this around than we've been in a long time…

In the previous essays in this series, we discussed the foundations of building an interventional radiology program—the early stages when presence, trust, and operational ownership begin to transform a physician from procedural coverage into something durable and trusted.

But there is a truth that must be confronted early if a program is going to survive long enough to grow:

Your most important asset is not the cath lab. It is not the embolic. It is not the CT scanner. It is not the referral pipeline.

It is YOU, the interventional radiologist.

I. The Golden Goose: Protecting the Capital Asset

Every interventional radiologist represents an extraordinary investment of time and resources. Ten or more years of training. Hundreds of thousands of dollars in tuition. Often more than a million dollars in deferred income while learning to do this work safely and independently. Add to that thousands of supervised cases and the gradual accumulation of complication judgment, technical nuance, relationship capital, and clinical instinct that cannot be rushed.

You are, in every meaningful economic and operational sense, a capital-intensive asset.

And yet healthcare systems frequently reduce physicians to production metrics—cases, RVUs, throughput. When output becomes the only language spoken, it quietly pressures production beyond what the engine can sustainably deliver.

In his book The 7 Habits of Highly Effective People Stephen Covey described the tension between Production (P) and Production Capability (PC)—the output versus the capacity that makes output possible. In our field, production is procedural volume. Production capability is the combination of skill, stamina, judgment, relationships, and reputation that allows that volume to remain excellent.

When production consistently exceeds production capability, the decline is rarely dramatic at first. It begins subtly—with fatigue you rationalize, patience that shortens, reflection that decreases. Over time, that fatigue erodes performance and clarity. Outcomes soften. Tone changes. Relationships strain. Reputation quietly weakens.

And eventually, without anyone intending to, the system damages its most valuable asset.

In other words: you kill the goose that lays the golden eggs.

If you are building an IR program—or becoming indispensable within one—protecting the asset must become intentional. Not reactive. Not occasional. Built into how you operate.

II. Updating the Asset: Continuous Mindset Expansion

Protecting the engine is not only about preventing depletion. It is also about ensuring ongoing expansion. The physician who stops learning begins to contract.

And that learning must extend beyond specific interventional radiology techniques.

If you are building a women’s health practice—particularly embolization-based programs—one of the highest-value investments you can make is time with your obstetrics and gynecology colleagues, including urogynecology and gynecologic surgery partners. Attend their noon conferences. Sit quietly. Listen.

Not to present.
Not to persuade.
To understand.

Listen to how they evaluate fibroid disease. Listen to what leads them toward myomectomy versus hysterectomy. Observe how they determine surgical candidacy. Pay attention to how their intake is structured and what risk factors shape their recommendations.

These physicians—and their PA’s and NP’s—have often spent decades centering their professional identity around women’s health. If you are serious about building a durable women’s health IR program, learning their cognitive framework is not optional.

Adopt the posture of a pupil. Be humble.

Share your struggles in this space. Share your victories. Approach OB/GYN not as competitors, but as colleagues and friends working within the same ecosystem. The strongest programs are collaborative systems built on mutual respect.

Expanding the Rooms You Sit In

The Society of Interventional Radiology remains the central society supporting our profession. But it should not be the only room you occupy.

Many physicians in the outpatient women’s health space now attend the OEIS conference, which focuses on embolization programs in the outpatient environment. The SIR Business of IR meeting is another essential gathering. The recent meeting in Atlanta was exceptional—not because it taught procedural tricks, but because it addressed the structural forces shaping our field:

reimbursement compression,
healthcare politics,
insurance pre-authorization,
encroachment from other specialties,
Medicare and Medicaid policy shifts.

These forces ultimately determine what you can and cannot deliver to your patients. Understanding them is part of protecting your engine.

One presentation that stood out was Dr. Robert Lookstein’s discussion on ensuring hospital administration understands the economic viability of hospital-based IR in an era of margin compression. These conversations matter because they influence whether your system invests in you, protects your program, and retains the patients you aim to serve.

III. Learning Directly From Other Physicians

Conferences are valuable. But visiting other physicians is transformative.

A colleague recently said to me, “We don’t make widgets, we make friends.” That statement clarified something about my own approach. I do not network primarily for business. I network because I need the nourishment of being around physicians I respect—people who inspire me, challenge me, and remind me that this work can be both ambitious and deeply human.

Recently I traveled to visit colleagues (aka friends) in Atlanta who run a dynamic diagnostic and interventional radiology practice of more than one hundred physicians. What impressed me most was not the scale—it was the culture.

Diagnostic and interventional radiologists practicing optimally within their own lanes, while respecting one another’s work. Delivering excellent care to the hospital and community. Expanding the hospital’s footprint. Growing programs that generate margin while strengthening clinical quality.

I went to learn: their catheter preferences, their workflows, the niches they are developing, the strategic directions they are exploring.

But the most valuable part of the visit happened outside the suite—around a table, breaking bread, talking about families, vacations, children, and the integration of work and life. Those conversations nourish something that technique alone cannot.

To make that trip, I gave up two days of income. I covered my own travel and lodging. On paper, it looked costly. In reality, it was an extraordinary investment. The knowledge gained, the relationships strengthened, the perspective expanded—all of it compounds.

If you admire someone’s practice, buy the plane ticket. Make the drive. Ask to visit. Meet their technologists, APPs, front office staff, and administrators. Observe everything. Ask thoughtful questions. You will return sharper, more inspired, and more grounded.

IV. Learning Through Professional Communities

Growth also happens in the small, frequent exchanges between colleagues.

I routinely text other interventional radiologists: What catheter are you using for this anatomy? What access are you preferring? What embolic are you seeing good outcomes with? Who is partnering with academic institutions in an ASC model?

These conversations may seem minor, but over time they shape practice.

Informal communities amplify this. The Interventional Radiologists Only group on Facebook is one such forum. Within that closed environment, physicians are often candid and generous with insight. If you are unsure how to access it, email me at dr@poulsenmedical.com and I will connect you.

You will quickly discover who is collaborative and who is guarded. That clarity is helpful. I have encountered physicians who protect technique as if it were proprietary intellectual property. I approach medicine differently. The knowledge given to me was passed down by mentors; it was not meant to be hoarded.

Our ultimate aim is not personal leverage. It is better patient care. And open teaching accelerates that aim.

V. Physically Protecting the Engine

Interventional radiology is physically demanding. Long cases in lead. Prolonged standing. Subtle, repetitive strain.

Protecting your body is not self-indulgence. It is patient care.

An excellent discussion of this appears on the BackTable Podcast with Dr. Keith Horton, where he addresses ergonomics and the sustainability of IR practice. The message is straightforward: your procedure room should support neutral positioning.

Monitor height matters.
Ultrasound placement matters.
Foot pedal location matters.
Lead positioning matters.

If you must rotate your neck to see the ultrasound during vascular access, the room is poorly designed. Everything should be positioned so you can work comfortably and neutrally, even during prolonged cases.

Fatigue does not just make you uncomfortable. It narrows focus. It shortens patience. It increases error risk. It changes tone. Protecting your body protects your patient. It protects your technologists and nurses. It protects the emotional environment of the room.

One of my former professors, Dr. Brian Strife, emphasized this relentlessly: make sure everything is where you need it. When your setup is correct, your energy stays on the patient. It remains some of the best advice I received during training.

Closing Reminder

One of my former business partners, Dr. Tyler Callese, used to ask in the procedure suite:

“What’s the most expensive thing in this room?”

People would guess the imaging equipment. The staff. The hospital overhead.

He would always answer:

The physician.

Not from pride. From arithmetic.

More than ten years of training. Hundreds of thousands of dollars in tuition. Over a million dollars of deferred income. That investment makes the physician the most valuable asset in that room—and within the broader women’s health system you are trying to build.

If you fail to recognize what the most valuable asset is, you will fail to maintain it. You will neglect it. You will allow it to erode quietly.

Respect the engine.

Maintain it deliberately.

Because the golden goose must continue laying eggs.

And that golden goose—is you.

A note to my readers: I’m taking my own advice and will be back to continue the work with you all very soon!

Links:

OEIS Conference (Outpatient Endovascular and Interventional Society)

https://oeisweb.com/

SIR Business of IR (Society of Interventional Radiology)

https://www.sirweb.org/for-business/

Business of IR 2026 Virtual Course Page (SIR Education)

https://education.sirweb.org/content/business-ir-2026-virtual?_gl=1*5kxqko*_gcl_au*MjU2MjE3OTk2LjE3NzI2MzI2ODc.*_ga*NjI0NTEwODE2LjE3NzI2MzI2ODc.*_ga_N1J2ZP1LVP*czE3NzI2MzI2ODYkbzEkZzEkdDE3NzI2MzI4MDYkajIyJGwwJGgw*_ga_LBCB7ZXL0X*czE3NzI2MzI2ODckbzEkZzEkdDE3NzI2MzI4MDYkajIyJGwwJGgw#group-tabs-node-course-default4

BackTable VI Podcast – Dr. Keith Horton contributor page

https://www.backtable.com/shows/vi/contributors/dr-keith-horton

Dr. Brian Strife – Richmond Vascular Center

https://www.richmondvascularcenter.com/

Stephen R. Covey – The 7 Habits of Highly Effective People (Amazon)

https://www.amazon.com/Habits-Highly-Effective-People-Powerful/dp/0743269519

If you read nothing else in this series, read this. What follows is not a tactic, a marketing strategy, or a procedural roadmap. It is the foundation. The quiet center of building a women’s health interventional radiology program, and honestly, the foundation of any meaningful clinical practice. Before growth, before referrals, before metrics and recognition, there must be care, attention, and presence; presence for the patient in front of you and for every colleague carrying part of her story. This is the work beneath the work, and everything durable in medicine is built on it.

One of the most formative experiences I had in women’s health did not revolve around a procedure specific to women’s health per se. It involved a pregnant woman at advanced gestational age with diffuse lower extremity DVT. Severe swelling, pain, discoloration…venous congestion bordering on phlegmasia.

Her care required coordination across OB/Gyn, internal medicine, hematology, anesthesia, and our IR service. It demanded balancing maternal safety, fetal risk, anticoagulation strategy, and procedural considerations in real time. I rounded on her, sometimes twice daily. I re-reviewed current DVT standards. I communicated continuously with colleagues who were accustomed to transferring such patients to tertiary centers.

It was time-consuming. It was inefficient. It did not generate anywhere near the wRVU’s/hour of a 1st year radiology resident learning how to interpret chest x-ray’s.

But our guiding principle was simple: patient care first.

We managed her locally and safely. Well after my management of her DVT was over, I followed her to ensure appropriate follow up with OB/Gyn, hematology. Throughout the weeks after discharge I saw her in clinic. And after her delivery I saw her again to reassess for May-Thurner physiology once her uterus returned to post-parturition size several weeks after my interventions were completed.

That case did not produce an avalanche of referrals. It produced something more durable: trust.

Programs are not built through single dramatic events. They are built through steady, quiet demonstrations of reliability and service.

Before volume, referrals and growth comes presence, relationships and credibility.

Building a successful women’s health program in interventional radiology, moving from minimal annual procedures to thriving volume, requires prioritizing presence over promotion. Forgettable marketing tactics like free pens, lunch visits, and empty talk are inexpensive and ineffective. Genuine engagement is the essential starting point.

And being present does not mean being visible. It means being integrated; integrated from the hospital CEO down to the front desk greeter, and integrated into the ecosystem of women’s health as it actually exists in your hospital and community.

Women’s health is not a branding category. I’ve learned, it is a living network.

As it should be, that network is primarily carried by OB/Gyn physicians, nurse practitioners, physician assistants, nurse midwives, primary care physicians, maternal-fetal medicine specialists, labor and delivery nurses, and postpartum floor nurses. These are the people managing abnormal uterine bleeding in packed clinics, triaging pelvic pain at the end of long days, navigating postpartum complications at inconvenient hours, and absorbing the emotional weight of their patients’ lives.

If you are successful at building a women’s health IR program, you won’t just construct something parallel to that system, but interweaved within it.

That requires humility. It requires understanding their quality metrics, their staffing shortages, their medico-legal fears, their call burdens, and their financial realities. It requires knowing whether hysterectomy backlogs are months long, whether midwives are stretched thin, whether pelvic pain patients are circulating without answers.

You cannot become a benefit to that system, and the women it serves, until you understand it.

Presence, however, extends beyond hospital corridors.

What are you offering to the community you are planted in?

Are you showing up at the local YMCA; not only as a member, but as an educator? Is your entire team, from your front desk staff to your nurse practitioner, engaged in raising awareness about women’s health options? Are you attending church gatherings or community events not primarily to promote your program, but to listen?

Perhaps you give a brief 15-minute talk on fibroids or chronic pelvic pain. Then you remain for two hours and listen to women share their stories: a hysterectomy after a traumatic complication, years of unexplained pelvic pain, a quiet struggle with opioid dependence after being told repeatedly that nothing is wrong. You review a scan and say calmly, “This is real. It’s visible. And there may be something we can do.”

That is presence.

Integration happens vertically and horizontally. Leadership begins to see that you are steady. Nursing learns that you communicate clearly. Administrators recognize your reliability. OB/Gyn colleagues see that you collaborate rather than compete. Anesthesia trusts that you are prepared. Primary care physicians know that when they send a patient to you, you will carry the burden fully.

Pro-tip, make sure you have a system that not only supports patients but their overworked PCP or Ob/Gyn. They should all be able to refer a patient to you with a system that is intuitive, integrated and one step that reliably results in the patient being sent to you to handle EVERYTHING from imaging orders, to the procedure order, to preauthorization to post-procedure follow up and all that entails.

Over time, when your name comes up, the reflexive response becomes simple: thoughtful, dependable, takes care of the patient.

Volume comes later.

Indispensability does not come from marketing campaigns or procedure counts. It does not come from branding or quarterly growth. It comes from steady, disciplined, patient-centered service within the system you are planted in.

Recently, I heard a quote by Henry Miller that captured this beautifully:

“I have a theory that the moment one gives close attention to anything, even a blade of grass, it becomes a mysterious, awesome, indescribably magnificent world in itself. I have tried this experiment a thousand times and have never been disappointed.”

Indispensability grows from disciplined attention; not only to the patient’s clinical needs, but to the practical burdens carried by the referring providers who entrust them to you. When your systems reliably absorb the complexity of care — imaging, coordination, authorization, procedure, and follow-up — colleagues experience partnership rather than added work, and trust quietly accumulates across the ecosystem. Over time, this steady integration shapes your reputation as thoughtful, dependable, and fully accountable for the patient’s journey. Volume then emerges not as a target, but as a byproduct of presence, reliability, and service.

Yes, if you’re lucky, blessed, fortunate…whatever your preferred point of view on how good things come about…the referrals usually follow.

But by then, they are no longer the point.

You became part of something greater than yourself, a community of professionals united in service to the people entrusted to their care. You were granted the privilege of helping restore and protect the strength of the women in your community, their health, their dignity, and their resilience, while standing alongside colleagues who share the same quiet commitment to their well-being.

That is the real reward that will get you out of bed everyday looking forward to the satisfaction your soul is craving as a physician; as a person.

And that is more than a program.

This article is Part II of the From Zero to Indispensable series. If you missed Part I, you can read it here. Part III will explore the engine of women’s health programs.

Share

Part I — Study the Land Before You Build

I know it sounds like a strange place to start.

The first place you need to start — just like any business, any venture, any long-term plan — is with the environment you’re in.

I’ll be honest: I didn’t do this early in my career.

I dove in headfirst. I started talking about what I had to offer to internal medicine, OB/Gyn, emergency physicians, even the reception desk — anyone who would listen.

What saved me were my new IR partner and a few administrators who were far more patient and perceptive than I was. They quietly redirected me. They asked better questions than I was asking. They saw things I didn’t yet understand.

Thank God for serendipity.

Now, having learned through those ad hoc mentors, this is where I start every service line, every new role, every venture.

With the land.

If you don’t determine the environment first, you’re guessing.

And guessing is not a strategy.

Whether you’re:

• Outpatient OBL

• ASC-based

• Hospital-employed

• Private practice IR/DR

• Hybrid inpatient/outpatient
  

You must determine the population you are planted in.

Not theoretically.

Specifically.

1. Know the Population You Serve

Women’s health is not monolithic.

The implications of fibroid disease, adenomyosis, pelvic varices — they all vary depending on:

• Age distribution

• Ethnicity

• Economic strata

• Insurance mix

• Cultural background

• Access to primary care

• Access to OB/Gyn services
  

If you live in an area with a high proportion of African American women, the prevalence of symptomatic fibroid disease will be significantly higher than national averages.

If you are in a younger, higher-income suburban population, fertility preservation conversations may dominate.

If you are in a rural setting, delayed diagnosis and access barriers may be the central issue.

Educate yourself on national prevalence data for:

• Fibroid disease

• Adenomyosis

• Pelvic congestion syndrome

Then extrapolate it to your zip code.

If you don’t understand the demographic realities of your region, you will misalign your messaging, your clinic structure, and your partnerships.

All women will ask similar core questions.

But the context of those questions is shaped by lived experience.

And context determines trust.

2. Understand the Economics of Your System

After demographics comes economics.

If you are hospital-based, you need to understand:

• What is the hospital’s case mix index?

• Are you in a Level I trauma center?

• Is trauma, stroke, ICU, and high-acuity surgical throughput the institutional focus?

• Is women’s health elective volume strategically important — or peripheral?
  

A Level I trauma center prioritizing motor vehicle collisions and stroke care will view outpatient elective embolization differently than:

• A Level III trauma center

• A community hospital

• A hospital with an affiliated ASC

• A suburban system seeking margin stabilization

The approach must match the institutional priorities.

If women’s health is not currently a priority, you must frame it in a way that aligns with what is.

3. Know the Players — and the Territory

You also need to ask:

• Who’s providing surgical and non-surgical treatment of fibroid disease, May-Thurner, Pelvic congestion, Adenomyosis?

• What are they offering and how could what you’re offering be inadvertently perceived as a threat?

And perhaps more importantly:

Who are the core revenue drivers in your hospital?

Let’s speak plainly.

If you threaten to displace a high volume of hysterectomies without understanding the downstream revenue implications, you will be fighting an uphill battle.

No one will say this out loud in a conference room.

But financial incentives exist in every medical institution.

Your goal is not to destabilize.

Your goal is to create an intertwined tapestry — a healthy system where women have:

• Surgical options

• Medical options

• Minimally invasive options

• Shared decision-making

But that only works if you understand what you’re walking into.

Strategy without awareness of the players is naïve. Ask questions, talk less, listen more.

4. If You’re Outpatient — It’s Even More Critical

If you’re in an OBL or ASC model, the questions change.

Who are your competitors?

• Is there a PE-backed fibroid center in the nearest city?

• Is there a dominant OB group already aligned with a surgical center?

• Are patients already being siphoned out of your community?

If they are — what are they not doing?

Even if someone else has a well-established program, you must ask:

What can I offer that elevates care locally?

Holistic integration?
True collaboration with OB?
Hospital backup?
Longitudinal care?
Better pain protocols?
Better communication?

No environment is saturated beyond improvement.

I guarantee no one is delivering perfect care.

And I would welcome competition that elevates the standard.

If someone is providing high-quality care and raising awareness — that helps the entire ecosystem.

If they are siphoning patients while delivering poor-quality care — that’s a different conversation.

But either way:

You must know the terrain.

5. Strategy Is Environment-Specific

The same tactics do not work everywhere.

The approach in:

• A rural Southern community hospital
  is not the same as

• A Northeast academic Level I trauma center

And it is not the same as

• A private suburban ASC model

Your environment determines:

• Your messaging

• Your partnerships

• Your sequencing

• Your friction points

• Your leverage
  

Before you:

• Design a clinic

• Launch outreach

• Build ads

• Push volume

• Talk fertility data

• Approach administration

You must answer one question:

What land am I building on?

This is Part I of a 3-part series.

Next: Part II — Presence Before Volume

The Question That Wouldn’t Let Me Go

I recently listened to a conversation that gave words to a question I’ve been circling for years but didn’t know it. On the Healthcare Business Podcast out of the University of Texas, host Anne Dancarnuta spoke with Dr. Matt Brubaker, Chairman and CEO of the healthcare consulting firm FMG, about artificial intelligence, healthcare transformation, and the importance of keeping humans centered amid this rapid change.

One idea in particular stayed with me: the concept of the “last 5%.”

Across industries, AI is rapidly absorbing the first 95% of work. Pattern recognition. Data extraction. Drafting. Summarizing. Flagging abnormalities. In radiology, this is not hypothetical. We are watching it unfold in real time. The uncomfortable, but necessary, question that follows is simple:

If AI is closing the first 95%, what exactly am I doing with the last 5%, the part where my real value lives?

That question applies not only to radiology, but to every physician who intends to remain relevant, human, and indispensable over the coming decades.

Radiology as a Living Case Study

Radiology may be the clearest early case study for how AI will reshape medicine. Algorithms are already highly effective at detecting pulmonary nodules, identifying pneumothoraces on chest radiographs, flagging acute appendicitis, pulmonary emboli, intracranial hemorrhage, and more. The pace of improvement is accelerating.

What is worth remembering is this: the true value of a radiologist has never been limited to simply finding things.

Just as an internist does not personally analyze erythrocytes under a microscope, the radiologist of the future will not be defined by raw detection. The value lies in interpretation, prioritization, integration, and judgment. It lies in placing findings into clinical context, weighing significance, anticipating downstream implications, and communicating nuance clearly.

AI will increasingly deliver the findings. Physicians deliver meaning.

That meaning lives squarely in the last 5%.

What AI Has Actually Changed for Me

I am dual board certified in diagnostic and interventional radiology, and I already use AI daily. What has surprised me most is not just where the gains are, but where they are not.

Diagnostic Radiology: Efficiency With Less Cognitive Waste

In diagnostic radiology, the early gains are obvious. Improved efficiency. Reduced fatigue. Cleaner impressions generated from already identified findings. Fewer cognitive interruptions related to formatting, punctuation, and structure.

Large language models are exceptionally good at turning structured findings into concise, readable impressions. That does not eliminate physician responsibility. It concentrates it. I still live in that final review, that last 5%, ensuring accuracy, relevance, and clinical judgment. What has changed is that I am no longer burning cognitive energy on basic English or formatting tasks that I did not go to medical school to perform.

This is only the beginning of what AI will change on the diagnostic side.

Interventional Radiology: Less About Speed, More About Presence

Interventional radiology is different.

AI has not dramatically improved procedural efficiency inside the room, and that is expected. IR is inherently hands-on, patient-facing, and dependent on real-time decision making. Where AI has been transformative for me is in the quality of care and the quality of human connection.

I have experimented with several HIPAA-compliant AI medical scribes and ultimately settled on Commure Scribe (I receive no endorsement and am not in any way supported by or receive compensation from Commure Scribe or any of its affiliates). The reason was simple. It gave me the quality of time with my patients back to me.

Instead of typing, clicking, editing templates, and searching through notes, I can sit face to face with a patient, review imaging together, read body language, and listen fully. I am able to counsel them as a person rather than as a throughput problem.

Interestingly, the scribe often captures clinically relevant details I might miss while focused on imaging. Offhand comments, clarifications, or subtle cues that matter. The result is not just time saved, which is modest, perhaps five to ten percent, but a materially higher quality clinical encounter.

That is not efficiency. That is better medicine.

The Hidden Bottleneck in Interventional Radiology

There is another uncomfortable truth about efficiency in interventional radiology. As operators, we realistically control only five to ten percent of total procedural efficiency.

I can perform a uterine artery embolization in under an hour. That speed becomes irrelevant if room turnover is slow, supplies are missing, equipment has to be borrowed from another lab, or patient transport is delayed. These peri-procedural inefficiencies, staffing, supply chains, equipment tracking, and logistics, are where AI should ultimately have its greatest impact in IR.

Not by replacing physicians, but by smoothing the systems that surround us.

That is how access to care actually expands.

AI as a Force Multiplier for the Idea-Seeking Physician

For someone like me, an idea seeker and connector who thrives on mentorship, conferences, and synthesis, AI has quietly expanded my bandwidth.

I now routinely record conversations with colleagues (with their permission of course!!!), conference sessions, and planning discussions. Transcripts are generated immediately. Key ideas surface quickly. Concepts are integrated into protocols, procedure planning, and workflows while they are still fresh.

Instead of notes sitting untouched in a folder for months, ideas move rapidly from acquisition to synthesis to application. I still own the final judgment. I still live in the last 5%. AI simply accelerates everything upstream.

That is real leverage and the satisfaction of seeing these ideas more quickly and efficiently added to my practice is incredibly rewarding.

The Real Risk Is Not AI

My fear is not that AI will replace physicians.

My fear is that physicians who refuse to engage with AI will slowly make themselves obsolete.

Every knowledge profession eventually faces this moment. If we do not actively position ourselves at the leading edge of the first 95%, partnering with tools, shaping workflows, and redefining our role, the question eventually becomes why the role exists at all.

The answer must remain clear. Experience. Integration. Judgment. Human connection.

Those things cannot be automated. But they can be devalued if we pretend the world is not changing.

So What Are We Actually Doing

The question I ask myself, and the one I believe every physician should ask, is straightforward.

What am I doing today to protect, sharpen, and expand the last 5%?

That means letting AI handle what it does best. Refusing to spend physician time on clerical nonsense. Investing in tools that improve presence, not just speed. Doubling down on judgment, context, and human care.

Radiology just happens to be the early warning system.

The rest of medicine is not far behind.

Footnotes

1. Karnuta D, host. Centering Humans in Healthcare AI Implementation. The Business of Healthcare Podcast, Episode 129. University of Texas at Dallas; July 25, 2025. Guest: Matt Brubaker, MD.

Strategic Radiology is a national coalition of independently owned and operated radiology practices created to help physician groups navigate the growing complexity of modern radiology. It sits at the intersection of clinical excellence, operational reality, and the business pressures reshaping healthcare. I attended the Fall 2025 Strategic Radiology Conference as a newly minted partner in a private practice radiology group, eager and energized to take on the work of mining this collective expertise and translating it into something practical and durable for a small, independent interventional and diagnostic radiology practice. My goal was straightforward: to better understand how independent groups like ours could survive, adapt, and thrive amid consolidation, rising complexity, and shifting incentives.

What I did not anticipate was how deeply the experience would reshape my thinking.

At the conference, I was exposed to a wide cross section of radiology leaders. These were physicians who were not only excellent clinicians, but builders, strategists, and advocates. They spoke candidly about consolidation, misaligned incentives, access gaps, and the quiet erosion of physician agency. What resonated most was their willingness to acknowledge uncomfortable truths, including the intragroup dynamics between interventional and diagnostic radiology that too often undermine both.

Despite being closely aligned and mutually dependent, IR and DR can fall into patterns of internal competition. These tensions, shaped by historical structures and misunderstood value propositions, dilute the unique strengths that each brings to healthcare. In many ways, it reflects a recurring Cain and Abel type narrative, not born of malice, but of scarcity thinking. When these divisions persist, both disciplines suffer, and patients lose access to the full potential of a collaborative radiology profession.

Perhaps most unexpectedly, the conference opened the door to meaningful mentorship. In the months that followed, I connected with experienced clinical leaders across the Southeast, particularly throughout North Carolina, South Carolina, Virginia, and Georgia. Many serve as long-standing group presidents, service line leaders, and CMOs within the hospitals and health systems they support. They were generous with their time, eager to engage in thoughtful discussion, and willing to offer candid perspective shaped by decades of experience. Those conversations, often extending for hours and offered freely, helped sharpen both my thinking and my sense of responsibility as a physician leader in this region.

Through these discussions, I began to see interventional radiology not merely as a procedural specialty, but as a platform for leadership and system level change. The most effective leaders were not defined by titles, but by clarity of purpose and a willingness to challenge systems that no longer served patients or physicians well.

I also came to appreciate more deeply that meaningful progress in healthcare is not driven by physicians alone. Non physician leaders, administrators, and system builders play a critical role by aligning people, incentives, and operations. Their work often happens quietly, outside of procedure rooms and reading stations, yet their impact on access and patient experience is substantial.

Around this same time, I read Start With Why. The message resonated immediately, but its impact deepened as I reflected on my own career. Like many physicians, I had spent years focused on how to improve outcomes, how to grow programs, and how to increase efficiency. The book forced a more uncomfortable but clarifying question.

Why am I doing this at all.

For me, the answer crystallized with surprising clarity.

My professional why is rooted in providing care to patients where they are, in the best manner possible, regardless of ability to pay, insurance status, or walk of life. Interventional radiology has given me the privilege of entering peoples lives at moments of vulnerability. That privilege carries an obligation to ensure access, dignity, and excellence are not conditional.

This realization reignited a long standing passion for women’s health. Over the years, close friends have shared troubling stories. Hysterectomy presented as the only option. Pelvic pain dismissed as imaginary. Fear based counseling steering patients toward higher risk surgical options without meaningful discussion of less invasive alternatives. In many cases, these pathways were shaped not by malice, but by gaps in education and unrecognized financial incentives embedded within the system.

Too often, women’s conditions such as fibroids, pelvic pain, and postpartum complications are minimized or delayed. Interventional radiology offers minimally invasive, organ preserving options that can be transformative, yet access remains uneven and awareness incomplete.

What is new for me is the excitement around how to build this vision through an independent practitioner model. Independence is not about autonomy for its own sake. It is about alignment. It is about building a practice guided primarily by a core principle: women’s health and patient first care, regardless of external constraints.

Choosing this path feels less like stepping away from traditional medicine and more like returning to its essence. My investment in medicine and interventional radiology has always been about service. Exploring independence is simply an extension of that commitment.

The Strategic Radiology Conference, the mentorship that followed, and the reflection it prompted collectively pushed me toward this moment. I do not pretend to have all the answers. But I am clear on the question that will guide the next chapter of my career.

How can I best serve patients, especially women, where they are, in the way they deserve.

That is my why.