Line Monkey MD
@linemonkeymd
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Image-Guided Surgery blog for the new generation brought to you by Kavi Devulapalli, MD. MPH. #IGSurg (formerly #irad ).
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Just learned that my former interventional cardiology partner is offering GAE. No, I did not teach him. And yes, there are many like him offering embo. If this doesn’t bother you then you are part of the problem.
@SIRspecialists
, more independent IRs need a seat at the table.
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7 years of hard work. It takes dedication to build a robust longitudinal clinic. The strength of an IR practice is reflected in how robust the outpatient clinic is. The number one factor imo when it comes to determining jobs and training programs. Well done.
In 2023 a dedicated IR clinic should really be the Rule not the Exception for any clinical
#IRad
practice.
Started with 2 patients in my first clinic in 2016 and see where we are now 📈
#ClinicalIR
@SLU_VIR
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@TherealDoctorJ
Thanks for taking the time to write this out. I suspect it will resonate with most docs. The sooner we collectively take control of our own lives, starting with the ability to say “no,” the better we will be. I’m so sorry for your loss.
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IR can thrive without DR, but in order to do so it has to function like a surgical service.
You know you've made it as a CLINICAL Interventional Radiologist (
#VIrad
) when clinical encounters,not procedures top your wRVU CPT heat map.
Embo's, Revasc, Thromb'mies n more: is
#IRad
THE more diverse specialty in modern day medicine?
@SIRspecialists
@VISLAMDSCAIP
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IR must become a standalone specialty. This is not about site of service. It’s about culture and identity. Check out the
@AJR_Radiology
commentary and these blog posts if you haven’t already:
@SIRspecialists
New
@AJR_Radiology
Accepted Manuscripts:
"The Future of Interventional Radiology"
🟡Point—Standalone Specialty, By Drs
@linemonkeymd
& Julien
🟡Counterpoint—IR & DR Better Together, By Drs
@AdamTalenfeld
& Min
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Agreed. PE in healthcare is largely a mechanism for capital in order to generate scale and to create leverage in a dying fee for service environment. While the goals may seem admirable on the surface, it comes at a significant cost. For every physician retirement PE funds, it
@B_Madden4
@mcuban
@costplusdrugs
PE is an evil scourge on America. In healthcare they have driven up costs, reduced quality and disenfranchised physicians. There isn’t a single example of PE improving the value equation. The industry preys on physicians that can’t see beyond the empty promises.
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Being able to do DR well and efficiently could give you the **money** to build a 100% IR independent outpatient practice. Either capital for investment into the appropriate resources or money to float you while you build your clinical presence or both. I’ve learned the hard way
@rkryu
Being able to do DR well and efficiently could give you the flexibility to build a 100% IR independent outpatient practice. Ask me how I know…
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4 years ago Bill Julien saved my medical career by introducing me to the idea of independent IR. I was ready to quit medicine. Everyone should listen to this episode. And
@bahetimd
, let’s not confuse controversy with denial. Too many IR Apologists are in denial.
This week on BackTable: Dr. Bill Julien shares the evolution of the outpatient based lab, from early days to present day challenges
#medEd
@bahetimd
@SFVascular
@drcostantino1
@DonGarbettMD
@linemonkeymd
@OEISociety
@bretwiechmann
@Watts_IR
@JimGMelton
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There are many challenges in healthcare and IR, but I am still bullish about OBLs and their positive impact on patients and IR physicians. Thank you to
@bretwiechmann
for the opportunity to contribute to this
#TVIR
issue. There are some outstanding contributions in this edition
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IR is quite the startup. Working our way from a dusty garage (basement) to a floor with actual windows... The challenges are many, but it's worth it to me. I hope it is to you too.
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Busy week at
#SIR23PHX
. I realized I don’t have any great pictures, but I thank
@alialikhanimd
for this one which perfectly captures the week. Great catching up with old friends and making new ones.
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Nice poster
@nathansimk
@EmoryIRad
It’s good to see that most
#irad
are treating
#UFE
as an outpatient procedure. No reason for admission. Some people like their nerve blocks. I’m a fan of IA lido and keeping things simple.
#SIRSLC2024
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It’s Rank List time. Here’s an unconventional perspective. Best of luck to those looking to match into “IR.”
@WCVISociety
@OEISociety
@SIRspecialists
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This is a huge issue which honestly informs a lot of what we see in modern healthcare: loss of autonomy, moral injury, turf battles, consolidation, private equity and generalized angst/unhappiness. As much as I want to be positive when talking to future physicians it wouldn’t be
Medicare physician payment has dropped 30% over the last quarter century when indexed to inflation, yet patients’ demand for care has never been higher. Physician practices and their patients are dying while industry profiteers enjoy record windfalls. We are in crisis.
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This was a very powerful episode and a much needed one. Thank you
@TherealDoctorJ
and
@SDhandMD
for an excellent episode.
There is a lot of unhappiness in medicine and it is true that there are many factors outside of our immediate control that not only lead to moral injury,
Today on BackTable: It's Mental Health Awareness month
@TherealDoctorJ
and
@SDhandMD
discuss the importance of open conversations about mental health struggles in care providers
#medEd
#VI450
@stuschroff
@rkryu
@MountSinaiIR
@MinaMakaryMD
@SIRRFS
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When we choose how we want to practice, good things will happen. But is that even possible?
#irad
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Why are people "stealing" our procedures? No procedure is truly sacred.
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Appreciate the opportunity!
Starting day 2 with
@linemonkeymd
talking about the viability of
#Locums
work in IR and DR setting
@futureradres
@SIRRFS
@PennRadiology
#HTBAR2023
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Very astute observation. When urologists find out they can bill for the procedure by hiring their own IR they all of a sudden become very interested. It coincidentally is the highest paying procedure in an office setting for BPH and happens to be the one procedure urologists do
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I encourage every trainee and young IR to learn about private equity. Read about it, ask questions and draw your own conclusions. You need to know about money. I have my personal opinions and you may not agree, but do your due diligence.
@SandeepBaglaMD
@Watts_IR
@AgnesSolberg
@eliebalesh
@LessneVIR
As physicians, our altruism is an easy target for those to capitalize on. While it’s admirable to offload the financial aspect and focus on the patients, it soon becomes a problem of control. That unfortunately translates to subpar patient care dictated from the bean counters.
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While I disagree with this report, this thread is clear. Many of our surgical colleagues don’t expect us to be “clinical.” They question our competence outside of procedures. What are we doing as a field to prove them wrong? Our training and focus must shift.
@VISLAMDSCAIP
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I’ve been approached several times in the last few months. My answer is always the same. I do not support ICs performing PAE. We have many opportunities to collaborate, but this isn’t one.
Been asked 3x in one week by 3 different cardiologists to teach them
#PAE
🤦🏽♂️
@SIRspecialists
@SIRRFS
.
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I will be moderating the private practice panel. This is a great venue to learn more about our specialty and how amazing it is when practiced the right way. We encourage any interested medical student to tune in.
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Sometimes I feel like people who read my posts don't actually take the time to read every word. The goal of the blog isn't to complain that we don't do "idolized sexy things 100% of the time." The goal is to push for a better future for our specialty.
#irad
@SIRspecialists
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We must focus our collective efforts on fostering the development of a standalone specialty that supports future endovascular and interventional surgeons. That begins with defining a surgical practice pattern and culture.
The governance issues we face for
#irad
in ANZ are universal. But it is clear the worldwide IRs are united in the NEED for changes. Let's hope they are imminent
@RANZCRcollege
@IRSA_IRs
#CIRSE2023
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Have to focus on specific disease states and build practices around those conditions, or the past will repeat itself. This has to be done by folks who have a surgical mindset so it is important to attract the right people to the field which we are missing the mark on, and we need
One of the main problems the specialty of Interventional Radiology faces is that it’s a subspecialty characterized by the tools (tech and devices) it uses rather than an organ system or a small cohort of disease processes. This is fundamentally different than any other specialty.
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I’m tired of people with vested interests who are threatened by my posts suddenly relaying personal advice and looking out for my professional and personal well-being. I will not live in fear and neither should anyone reading this. More content coming soon.
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Tomorrow at 8:30 AM. 229AB. Excellent talks in the private practice and outpatient IR session. I will be sharing my story pertaining to challenges and triumphs on the road to independent practice.
#SIRPHX23
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Was a pleasure doing this with
@vdkadakia
who is a locums legend and
@shamitsdesai
who is the best podcast host ever. Appreciate the opportunity
@AaronFrittsMD
and hope others find it helpful.
This week on The Podcast:
@shamitsdesai
talks with
@DevulapalliKavi
and
@vdkadakia
about locums opportunities in IR
#medEd
@linemonkeymd
@JacobFlemingMD
@SaudSAhmedMD
@omarsaleh66
@MaryamBoumezrag
@nlradIR
@VenuVadlamudiMD
@SIR_ECS
@LocumTenens_com
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The Founder Mentality. Do you have what it takes to be successful?
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@SDhandMD
giving an excellent talk on DVA in
#CLI
at
#WINGS24
. Great breakdown of data and technique.
@FadiSaab17
@_backtable
@keithppereira
@VISLAMDSCAIP
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This is one of the greatest threats to the future of IR and it’s sadly happening at scale. Sustainable practice models don’t happen overnight. True collaborative care requires IRs to make educational and infrastructural investments in a clinical care model consistent with IR
@drmcumming
@MishaGinsburg
@SandeepBaglaMD
@AriIsaacsonMD
@IR_Doctor
@IR_Nutt
@SIRspecialists
@uroegg
@Kbaum_Uro
@SBHATIAMD
@AmerUrological
Urologists are smarter than that - they can hire IRs to do the work and then take most of the profits 🥶
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Working with
@DrRAO_MD
and
@AlexDabrowiecki
to create the best trainee and early career meeting content
@OEISociety
. Stay tuned. Students/trainees: free to join OEIS!
@FadiSaab17
@drmcumming
@BobTahara
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Great case! Glad you were there to help out. Access to IR services is a public health issue. We are trying to address that problem with Travelier ().
@ImagingDoctor
Covered a smaller hospital the other day that doesn’t normally have IR/angio services. Able to embolize post partum hemorrhage and prevent a hysterectomy for a young patient. Makes you wonder about access to care/IR services across the country.
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We must rebrand. We are not a subspecialty of DR. Must become a distinct ABMS recognized field independent of DR and rooted in longitudinal clinic. Begins with training and getting the right people to do this. Current academics need to wise up.
#IGSurg
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In general, if someone promises you a low 7 figure pay day, and opens up clinics in new markets with 0 pre-existing ties, you need to be suspicious. Follow the money.
Modern Vascular appears to have shuttered clinics after an investigation by
@azcentral
, a complaint from the DOJ that quoted the story, and Medicare suspending payments.
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If you are an IR in training and are not interested in growing a longitudinal practice, do us all a huge favor and LEAVE IR 👻. By continuing the cycle of IR linked to DR finances we limit our potential public health impact including the treatment of vascular disease.
If you are an IR, or IR in training, NEVER lose your diagnostic skills. Read diagnostic studies as part of your practice or pick up a side DR gig.
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@QNguyenMD
@SIR_ECS
@radtrivedi
Femoral. Been burned enough by old dudes with type 3 arches and athero for one lifetime. Radial largely driven by industry or those paid by industry. Good solution for some patients, but it isn’t some magical fix.
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People point to procedural innovation in IR as being exciting, but this is the unspoken innovation right here. Such a complex yet timely topic largely related to professional culture and identity. Look out for a blog post soon.
@_backtable
@drmoneymatters
@bahetimd
@JMichaelBarraza
@DHidlayVIR
@JimGMelton
@drcostantino1
@DonGarbettMD
@SDhandMD
@OEISociety
@SandeepBaglaMD
@benwhitemd
@DaveJohnsonMD
Beyond
@drmoneymatters
insight on the rapidly changing healthcare landscape was the prediction on the widening DR - IR split, with increased opportunities for IR in multispecialty OBL/ASC groups, Hospital employment, or coverage of underserved hospitals
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Innovation and surgical practice patterns are not mutually exclusive. The need to innovate to remain relevant is a problem. There is data that shows the vast majority of “IRs” don’t actually practice “IR.” The perceived safety net of diagnostics is just that-perception and not
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Attention
@SIRRFS
and med students interested in learning more about outpatient practices. Deadline for scholarships to
@OEISociety
annual meeting (5/18-20 in Orlando) has been pushed back to 4/1. This will be an excellent meeting. Come join us.
Great opportunity with generous scholarship opportunity - limited spots available!
Deadline April 1st
Learn why many interventionalists have an
#OBL
and why it should be on your radar when done training
@linemonkeymd
@DrRAO_MD
@OEISociety
@_backtable
@SCAI
@VascularSVS
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@DoctorCliffyy
@dr_cellini
@SIRRFS
The truth is this is actually an excellent poll. One thing I realized is it’s not worth convincing radiologists to be something they aren’t. Most of the 25% (which I’m a part of) would have been better off in a surgical discipline most likely, but their views are valid and they
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Fantastic teaching point. Also relevant for prostate artery embolization.
@danielveyg
@tymattinson
Be wary of superficial -deep external pudendal collateral loop when embolizing anterior pelvic bleed! ( I had to look it up 🤪)
Here is a good example-> found back 🚪 & voila!
#irad
@SIRspecialists
@SIRRFS
#MedTwitter
@ElmasriFakhir
@laronecampbell
@keithppereira
@kmadass
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Very fascinating excerpt. Key lessons:
1. Medical Tribalism is real
2. In IR we have to adapt. That means focus on longitudinal clinical care and leaving the diagnostic radiology umbrella.
3. We didn’t really learn any lessons. Why?
So what lessons, if any, did we in IR learn in the last 25 years?
@linemonkeymd
@SIRspecialists
@SIRRFS
@SIR_ECS
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Wishing all my US-based friends a happy Independence Day. New blog post is up.
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As “radiologists” we have an uphill climb in any patient care endeavor. Similar example for those independent IRs seeking hospital privileges. I too am tired of being labeled as “vitriolic.” Lots of uncomfortable truths here.
Personal, real world example of how motivated & qualified radiologists become excluded from multidisciplinary cardiovascular patient care. The gatekeeper “National Board of Echocardiography” refused to even grant me the opportunity to write them a check & crush their “board exam”
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IR Hospitalists you say? I googled it and all I saw was a blog post 🤔
@MaureenKohi
@robsheridanavir
@angiowoman
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We must ditch radiology. No offense to my DR friends, but it’s time for us to move on. The future is not hospital based practice. The outpatient setting must be the economic engine to power our existence. Time to go the way of rad onc. Long overdue.
@eliebalesh
Couldn't agree more! We are still in the early stages of our specialty, perfect time to rebrand. Having 'Radiology' in the name is mis-leading and confusing to both patients and even primary care.
Image guided surgery
Interventional surgery
Interventional medicine
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Great recording this with
@RezaRajebi
and
@AaronFrittsMD
!
This week on The Podcast: In Ep 201
@RezaRajebi
and
@DevulapalliKavi
discuss the red and green flags to look out for when choosing a new job
#MedEd
@MaryamBoumezrag
@shamitsdesai
@SaudSAhmedMD
@SIR_ECS
@SIRRFS
@JacobFlemingMD
@IR_Ethics
@bahetimd
@iRadRock
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Enjoyed hanging out with this crew today. Serious conversations. Serious faces. Appreciate the invite!
@Team_RISQCS
@IR_Ethics
@Fritz_Angle
@VISLAMDSCAIP
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The future of IR is not about just doing cool procedures. No, it has to be about developing meaningful longitudinal clinical practices. Innovation is great, but we cannot keep surviving on innovation alone.
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@alexalevey
I think we would be better off creating our own distinct culture and society. There are so many great IRs who care who just want to do the right thing. Time to organize.
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This was a terrible town hall. I’m so disappointed in what was said and the representation of the panel which is not reflective of the next gen IR trying our hardest to do honest work and take the best care of patients possible. Lack of IR services is a public health issue. And
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YES. Though sadly 90+% of
#SIRPHX23
programming is not based on true clinical care. Where are the workshops on non clinical management?? Let’s build patient panels and act like surgeons. That’s how we get out of the gutter.
I’ll start. Clinic is a must. Being a technician is not sustainable. If you don’t make time for clinic, pretty soon those cases you want to do will end up going someplace else. It is not enough to be good at doing the case. We need to be able to manage diseases.
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I think every young
#irad
and trainee needs to print this out and refer to it daily.
After every
@SIRspecialists
meeting, I come to the same conclusion: excellence is 90% mindset, 10% skillset. There’s so much work left to do.
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@drmoneymatters
Transitioned to locums. Negotiated significant increase in pay. Work more than before. Multiple contracts=multiple income streams. Putting post tax dollars in cash flowing RE. Turned primary home into STR and have nearly eliminated living expenses.
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Thanks
@_backtable
!
Happening now in a secret corridor
#SIR23PHX
@shamitsdesai
@linemonkeymd
and
@vdkadakia
discuss the current locums market in 2023, coming soon!
#meded
@SIR_ECS
@SIRRFS
@MaryamBoumezrag
@JacobFlemingMD
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Looks like I’ve made it to Hawaii 🏝
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I wish I had this opportunity when I was in training. Our future is in the outpatient setting. I encourage any interested trainee to attend. The connections you make here can be life changing.
@SIRRFS
@VascularSVS
@SCAI
@BobTahara
@FadiSaab17
@bretwiechmann
@CLI_Global
Come join the exclusive Resident-Fellow Symposium during the OEIS 2023 annual meeting (May 18-20) and learn everything you need to know about the “real world” you don’t learn during training!
#businessofmedicine
#vascular
#irad
#cardiology
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@TheRealDoctorOs
@drmcumming
@MishaGinsburg
@SandeepBaglaMD
@AriIsaacsonMD
@IR_Doctor
@IR_Nutt
@SIRspecialists
@uroegg
@Kbaum_Uro
@SBHATIAMD
@AmerUrological
What’s worse is the biggest offenders facilitating this model are fellow IRs. Take 20% off the top then take advantage of the in-office ancillary services exception of Stark as the foundation for a very “creative” arrangement. Label it as an altruistic arrangement rooted in
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What does Evangelism have to do with IR? Everything. What to look for in a training program and more.
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Want to know what a typical IR job looks like? Celebrated by the folks at
@RadiologyACR
. Tolerated by leaders of
@SIRspecialists
. This is what “strength in numbers” looks like.
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This is excellent.
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Nice post! That’s the retropubic branch of the obturator. Can have gland supply in large glands and atherosclerotic disease.
PAE anatomy tip: when I started out, always saw this branch off obturator which faked me out as prostate artery and I burned time selecting this. For true type 3 origins, should see a first lateral then medial course of PA and more proximal origin (Crossing obturator sign).
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#irad
, the hospital MVP. Nicely done.
Massive left gastric artery bleed!🩸
#irad
#GITwitter
#MedTwitter
@muddasir_ayazMD
@SIRRFS
@SIR_ECS
@SIRspecialists
@VIRDelaware
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“LIVE” from
#SIRSLC2024
, a discussion regarding independent IR and OBL practice with
@shamitsdesai
@CookMedical
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If I hear another independent OBL owner/operator use vague AKS/Stark rules to limit physician compensation to less than 10% facility revenue I will go mad. The game is simply rigged. The only way to win is to control the asset.
Meanwhile employed physicians must be paid according to opaque and vague fair market value pricing. 🤔🤦🏽♂️
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Looking forward to this meeting!
Making a case for non-hospital
#healthcare
delivery.
@OEISociety
annual meeting.
#VEGAS
@SIRspecialists
@ISETNews
@VIVAPhysicians
@krosenfieldMD
@JRUNMD
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IR Apologists are back it. The TLDR of this article: shut up and “work together.” What do you think?
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If you are looking for an outpatient job, key questions to ask:
1. How are referrals being generated?
2. Are there investors?
3. Is there an actual clinic where you the physician sees patients (not just NP/PA)?
4. What’s the exit plan for the practice owner(s)?
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Private practice in
#irad
can vary significantly. Contrary to noise perpetuated in academia, we aren’t here just to make money and do boring work. Small world. Make connections and decide for yourself.
@SIR_ECS
@SIRRFS
Friendly and unsolicited advice to residents: if you are considering private practice, please talk to some docs who actually work in private practice. There is really a lot of misinformation out there.
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A real problem. Access to IR care is a huge issue. There’s even a paper courtesy of
@TheRealDoctorOs
et al. to show it’s a problem! Pretty wild stats.
We’re trying to address some of these issues with
@ImagingDoctor
#RuralIR
. Rural ND patient (pop 750), hepatic abscess. Traveled 330 miles for drain placement. 2 weeks later drain occluded and patient septic. Traveled 175 miles to a different hospital for exchange. Will travel 95 miles to a third hospital for drain removal.
@SIRspecialists
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@SIRRFS
@arslanmd
@drcostantino1
for the official tag.
This will be fun and hopefully useful for those who want to learn more about independent IR, which is undoubtedly the future of our specialty.
Thank you for
@SIRspecialists
for giving us this opportunity. It’s a good step in the right
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Fail forward. I consider my failures as blessings.
@DocDifferently
If you're unwilling to fail you won't be successful. Ever hear that A students work for C students? Those who academically excel, like physicians, are taught never to make a mistake. If you're unwilling to make a mistake in business you will never get started -- and, you'll fail.
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Thanks so much. Appreciate the opportunity!
@OEISociety
Great student breakout at
#OEIS
regarding
#OBLs
! Thank you so much to Dr. Chris Kwolek,
@FadiSaab17
,
@StreamlineMD
CEO Harry Curley, Dr. Mike Cumming, and Dr. Kavi Devulapalli a.k.a
@linemonkeymd
for amazing educational presentations.
#OEIS2022
#IRad
@OEISociety
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@drcostantino1
@drmcumming
😆 maybe I need to publish this list! You know you’d be up there no doubt. Our colleagues need to know that independent practice is not trivial. The risk is definitely real. But the positive impact cannot be overstated 👍🏾 We need more
#irad
to follow in your footsteps!
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Practice owners who sell to PE are opportunists. I’m tired of these people BSing young doctors about PE. Stop it. The healthcare economic climate sucks and practice owners want to benefit. Just admit it and let’s call it what it is.
This is the selling point of private equity. We have the cash to grow your practice and give you more negotiating power with insurance companies, which is better for doctors and patients. Everybody wins, right?
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This is a great case. When you have bad disease/occlusion of the hypo look for collaterals via inferior epigastric and profunda. Plan your access accordingly!
#PAE
@SIR_ECS
Left internal iliac occlusion. Had to go the long way to get to the prostate via the deep femoral artery.
@SIR_ECS
@SIRRFS
@SandeepBaglaMD
@bonesz
@JeremyKimMD
@keithppereira
@JURI_Fr
@IR_juniors
@PairsWeb
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Thanks, Nathan! Big thanks to the residents and students who took the time to learn about a growing site of service. Let’s continue to grow the society and pave the way for the next gen.
@DrRAO_MD
@AlexDabrowiecki
@EddyArous
Lots of learning at OEIS the past few days! Special shout out to
@AlexDabrowiecki
@DonGarbettMD
@linemonkeymd
@EddyArous
for taking the time to speak with trainees and sharing their perspectives
#MedTwitter
#radiology
#IRad
#radres
#MedEd
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Spread the word! Residents, Fellows, and Students can register for the OEIS 11th Annual National Scientific Meeting for FREE!
If you or someone you know is a r/f/s looking to get ahead in the medical field and make more connections, click the link.
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Excellent example of deep pudendal supply in the setting of anterior division occlusion. Those blessed with doing these procedures in a PAD population will see this. Only the strong will survive.
Interesting PAE case: Anterior division occluded —> Had to go a long way around the world to get to the right PA
#irad
(no - wasn’t corona mortis!)
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Brilliant. Nicely done. 👍🏽
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Thinking about a future in the OBL? How will you get referrals? New post!
@SIR_ECS
@SIRRFS
@VISLAMDSCAIP
@Watts_IR
@SriniTummala
@drmcumming
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@ajgunnmd
@keithppereira
@uab_ir
@MountSinaiIR
@JBartRose
@JeremieLever
@DrReddy_HPB
@JMichaelBarraza
@mj_pucci
@SamGalgano
Nice drain placement. Something a well trained body radiologist should be able to do. What makes
#IRad
special is our clinical care. How are you clinically managing this pt? What’s your imaging (if any) and clinic followup?
@NoviRad_Inc
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The issue here really is our board certification process still being linked to diagnostic radiology. SIR can huff and puff all it wants, or not, but this won’t change unless we collectively reorganize.
From a former academic
#irad
,
Exclusive
#radiology
contracts prevent solo
#irad
from getting hosp privileges but VS/IC get them w/o issue.
Tell me
@SIRspecialists
how my dues are helping me. There are more pp than academic
#irad
in US & we need your help!
#SIR23PHX
@OEISociety
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