15: Interventional Radiology: A Community Doc Shares His Story

Session 15

This week, I speak with Dr. Fayyaz Barodawala, a community-based Interventional Radiologist from Atlanta, Georgia, about his career decisions, what an IR physician does on a daily basis, the struggles and triumphs that come along with his practice and specialties opportunities outside IR and other interesting topics like exclusive hospital contracts and artificial intelligence replacing diagnostics.

[01:15] Choosing Interventional Radiology

Practicing medicine since 2005, Fayyaz knew he wanted to be an Interventional Radiologist on one particular day during his third day of medical school. He initially found interest in plastic surgery, vascular surgery, and orthopedics.

He had exposure to medicine growing up with his parents both physicians but it was on his third year, surgical rotation that he remembered being chewed out after having observed a surgical procedure passively for so long. During that same day, he went to see a family friend how happened to be called in for a pulmonary arteriogram and surprised at how quick the procedure was. At that point, he was considering orthopedics or radiology with the full intention of going into interventional, if he did the latter. What he likes about the field is the fact that you get to do different and relatively short procedures that make a difference and people happy.

[04:10] Traits of a Great Interventional Radiologist

Fayyaz says the things that make great interventional radiologists are knowledge of imaging and problem-solving. A lot of what he has to do is a lot of problem-solving. There may be defined pathways to do certain things but If they don't go as planned, then you have to improvise a lot. You have to be able to figure out how to accomplish your goal using the tools you have.

A running joke during his fellowship was that IR was the last name on the chart so when everybody thinks a procedure is too high-risk for them, they'd call IRs to take care of it. IRs do so much work like put filters in, arterial work, oncologic work, spine work, etc. So they have their hands on a whole bunch of different places but problem-solving and thinking outside the box are good traits to have for Radiology. And of course, you need to know your Anatomy.

[06:22] Types of Patients

Interventional radiologists treat younger, healthier patients that they might see for as simple as venous access like a PICC or younger women who have heavy menstrual bleeding due to fibroids. They do uterine artery embolization. They treat veins for cosmetic and medical reasons like a vein ablation and sclerotherapy.

They also treat older patients with spinal fractures for vertebroplasty or kyphoplasty. They treat a lot of oncologic patients which branches off into its whole own sub or super-specialty, even treating hepatic tumors such radio embolization, chemo embolization, or radiofrequency or microwave ablation or cryoablation.

Hence, the see a full spectrum of patients who are younger and healthier to older and very, very sick.

[07:32] A Typical Day for an Interventional Radiologist

His current practice is less hard core and interventional than he would have liked. Bread and butter for them would be paracentesis, thoracentesis, chest port placement for chemo, various biopsies, vertebral kyphoplasty for spinal fractures. In his latest practice, he had gotten into a lot of pain management procedures such as epidural steroid injections, lumbar puncture, and myelogram. In between, he reads diagnostic imaging.

Interventional radiologists do a wide variety of cases. Today, Fayyaz did paracentesis, thoracentesis, fluoroscopy, breast biopsies, and red PET scans. Other days, he could be doing a lot more like nephrostomies, biliary drainage, kyphoplasties. They're also currently ramping up their oncologic work at the new group he's in, doing ablations and radio embolizations that are...

Session 15

This week, I speak with Dr. Fayyaz Barodawala, a community-based Interventional Radiologist from Atlanta, Georgia, about his career decisions, what an IR physician does on a daily basis, the struggles and triumphs that come along with his practice and specialties opportunities outside IR and other interesting topics like exclusive hospital contracts and artificial intelligence replacing diagnostics.

[01:15] Choosing Interventional Radiology

Practicing medicine since 2005, Fayyaz knew he wanted to be an Interventional Radiologist on one particular day during his third day of medical school. He initially found interest in plastic surgery, vascular surgery, and orthopedics.

He had exposure to medicine growing up with his parents both physicians but it was on his third year, surgical rotation that he remembered being chewed out after having observed a surgical procedure passively for so long. During that same day, he went to see a family friend how happened to be called in for a pulmonary arteriogram and surprised at how quick the procedure was. At that point, he was considering orthopedics or radiology with the full intention of going into interventional, if he did the latter. What he likes about the field is the fact that you get to do different and relatively short procedures that make a difference and people happy.

[04:10] Traits of a Great Interventional Radiologist

Fayyaz says the things that make great interventional radiologists are knowledge of imaging and problem-solving. A lot of what he has to do is a lot of problem-solving. There may be defined pathways to do certain things but If they don't go as planned, then you have to improvise a lot. You have to be able to figure out how to accomplish your goal using the tools you have.

A running joke during his fellowship was that IR was the last name on the chart so when everybody thinks a procedure is too high-risk for them, they'd call IRs to take care of it. IRs do so much work like put filters in, arterial work, oncologic work, spine work, etc. So they have their hands on a whole bunch of different places but problem-solving and thinking outside the box are good traits to have for Radiology. And of course, you need to know your Anatomy.

[06:22] Types of Patients

Interventional radiologists treat younger, healthier patients that they might see for as simple as venous access like a PICC or younger women who have heavy menstrual bleeding due to fibroids. They do uterine artery embolization. They treat veins for cosmetic and medical reasons like a vein ablation and sclerotherapy.

They also treat older patients with spinal fractures for vertebroplasty or kyphoplasty. They treat a lot of oncologic patients which branches off into its whole own sub or super-specialty, even treating hepatic tumors such radio embolization, chemo embolization, or radiofrequency or microwave ablation or cryoablation.

Hence, the see a full spectrum of patients who are younger and healthier to older and very, very sick.

[07:32] A Typical Day for an Interventional Radiologist

His current practice is less hard core and interventional than he would have liked. Bread and butter for them would be paracentesis, thoracentesis, chest port placement for chemo, various biopsies, vertebral kyphoplasty for spinal fractures. In his latest practice, he had gotten into a lot of pain management procedures such as epidural steroid injections, lumbar puncture, and myelogram. In between, he reads diagnostic imaging.

Interventional radiologists do a wide variety of cases. Today, Fayyaz did paracentesis, thoracentesis, fluoroscopy, breast biopsies, and red PET scans. Other days, he could be doing a lot more like nephrostomies, biliary drainage, kyphoplasties. They're also currently ramping up their oncologic work at the new group he's in, doing ablations and radio embolizations that are starting to pick up now.

Even if you're a little ADD, you can find stuff that's good because it's not monotonous. On the flip side, they do very heavy-duty cases like TIPS which do not occur as often but these cases could be longer.

In their group of 4 IR doctors, they're on call every fourth so once per quarter for a weekend and random days here and there depending on the hospital setup. Fayyaz further says that if there's enough for two or three people to do full time interventional, the more interventional you want to do, the more call you have to take because in their practice, it's not full-time interventional all the time.

[12:21] Work-Life Balance and Managing Expectations

As reimbursements have fallen, IR does not generate as much income for the practice. Fayyaz thinks it's about managing expectations. You're better being a diagnostic radiologist if you simply want to go in there, punch a clock, and get out. There are also non-traditional options like the outpatient vascular access centers where they do dialysis interventions which are pretty regular hours. Then your work-life balance can be great.

Fayyaz would describe his work-life balance as pretty good, starting work at 8 am and usually done by 4:30-4:45 pm. Diagnostic calls can be brutal but interventional calls are not as bad. Again, it's about managing expectations.

If you prefer cool cases, then you might get called in the middle of the night for a G.I. bleed for instance. But if you're doing bread and butter cases, work-life balance is fine.

[14:25] The Residency Path

Back in the mid-90's, there was a time when internship was not required so you go right into Radiology. That changed in around 1995 when they've changed the mandate.

The traditional pathway is a year of internship (surgery. medicine, pathology, transitional, pediatrics) then you do four years of Diagnostic Radiology and then one year Interventional Fellowship  It's a six-year thing.

The direct pathway is for the Diagnostic and Interventional Radiology-enhanced clinical track. However, this is going away in favor of a pure IR residency right now as they shift into a new paradigm that's evolving more quickly. As more and more programs go towards that, you will match into Interventional Radiology directly from medical school, which includes more clinical time, cut down the diagnostic time a bit and increase the interventional time. (The first set of programs was just approved last year. so they're just starting.) This is great if you want to do something interventional but Fayyaz is not sure how this is going to work for the private practices so he has some reservations.

He further explained that a lot of these plans are placed by academics which is a really different setup than private practice. It's tough for a private practice doctor that doesn't have a ton of interventional because they're not going to be as versatile. Hence, in huge practice, it's great but in a not-huge practice, that remains to be seen.

The new model is to set up your own practice just as a surgeon or cardiologist would, see patients clinically and then bring them to a hospital. But that's probably they're going to end up. In order to compete, you can't have the old model just sitting there waiting for procedures to come to you. You have to market, you have to evaluate patients and do consults which not some of the older guys are used to.

[18:14] Matching for Interventional Radiology

Competition for interventional radiology goes in phases. As a job, the competition has tightened as more interest is starting to happen in interventional due to the difficulty of outsourcing it. People also enjoy doing procedures so it has been incredibly competitive in the last couple of years, to the point that people are not matching for Interventional Fellowships.

To be competitive for matching, you have to be a hard worker and have a mentality of saying yes almost all the time. And if you say yes all the time and then you say no, then people respect your opinion. Be willing to get your butt kicked for a while so you will be ready to handle everything that comes at you.

Other things that can make you competitive are being innovative, being able to do problem-solving, knowing the imaging, being clinical, willing to constantly learn new things, and understanding that there are things you don't know so just be able to take in what you can and learn as you go afterwards.

Fayyaz doesn't necessarily believe that scores tell everything. It's one tool for weeding but it shouldn't be the only tool.

Fayyaz went to a program where research was not a priority but if you're looking at research-heavy programs, it depends on what your goal is. If your goal is academic research and publish, then look for a program that can cultivate and nurture that. If you want to be a work horse, then you want something that gives you more clinical training. During his residency, there were very few Fellows so they had to do a ton as a resident.

It's nice to have a highly resident-centric program when you're a resident and a very fellow-heavy program when you're a fellow. Nevertheless, research is important in helping the interventionalist. A lot of procedures are pioneered by radiologists but as they get more commonplace and more routinely and more lucrative, other specialties start snipping away at it so you're going to be experiencing turf battles. For instance, a lot of people might be fighting for a cerebral angiogram which can be done by interventional radiologist or a vascular surgeon, a neurologist, and neurosurgeons.

[24:47] Bias Against DOs

Fayyaz worked in New York hospital that had a deep Radiology residency DO program and would be joking to them about how MDs couldn't go into the DO programs and DOs could go into the MD program. On a serious note, he doesn't really see any distinct bias but it's there for some other people.

[26:50] Special Opportunities for Sub-Specialties

Some interventionalists would like to do peripheral arterial but that’s contentious because different specialties have gotten involved and everybody wants to do it thinking it's cool and reimbursements can be very high. Some people work with vascular surgeons and even joined vascular practices.

But the big thing right now is Interventional Oncology and that's where everybody wants to get into. It involves stuff like radio embolization, chemotherapies, and various regimens. Other people do Neuro Interventional which typically requires a Neuro Radiology Fellowship and then Neuro IR Some also get involved in Stroke Intervention. There is some overlap between Neuro Intervention and IR next. You can also do Pediatric Interventional Fellowship.

[28:48] Working with Primary Care and Other Specialties

Speaking of clinical IR and not waiting for people to refer to you, Fayyaz meant not waiting for  a vascular surgeon or cardiologist or somebody else to refer to you. Peripheral vascular disease, for example, are marketed successfully by primary care physicians to family practice, internal medicine, pediatrists. He's not sure if they really understand exactly what  IRs do which has been a problem for them because they're not aware of the services they offer.  IRs hundreds of chest ports and they could probably do even better than surgeons sometimes as backed by evidence. They could do it faster and cheaper. So  IRs do more than just that, they do biopsies, spine interventions, peripheral arterial, biliary stuff and those people thought as surgical procedures. They also do fibroid embolization, venous disease, and gastrostomy in so all these things can be done. What feels frustrating is they sometimes feel just as a back up and they're only sought for because no one else is available to do it. It would be nice to have a great relationship between the primary physician and the IR. Check what  IRs are doing because you might be surprised what the interventionalist can do for you.

Other specialties Interventional Radiologists work the closest with include Oncology, Orthopedics, Hospital/Critical Care. Fayyaz says the best way would be an alliance between vascular surgery and radiology and interventional competing against cardiology.

[33:05] Diagnostic Radiologists Replaced with A.I.

Interestingly, Fayyaz mentioned that there have been thoughts of merging Diagnostic Radiology and Pathology into one specialty. The argument is that given it's a lot of pattern recognition on the diagnostic side, those should be handled by computers and the physician would be instead be involved in the management.

I personally believe that within 20 years, radiologists are going to be replaced with AI for diagnostic purposes. Fayyaz agrees it may come and could be scary. But there is a lot of grey zone for now. If computers could just highlight findings of questionable significance and let somebody go through it then that would be helpful in making their job faster and better.

[37:00] Other Special Opportunities Outside of IR

Radiologists have a lot of unique opportunities since they interact with a lot of specialties.  They can be very strong in administration. Fayyaz adds that  IRs are somewhat anchors for the group in the hospital because they're providing a lot of coverage that can't be easily outsourced. Again, it's important to not wait for things to come to you but to be out there somewhat marketing yourself, being available, getting your face shown so people know who you are and getting up there. If you're in the academics, you can get into the consulting industry.

[39:37] Exclusive Hospital Contracts & Diagnostic versus Interventional Radiology

What he wished he knew before going into Interventional Radiology is that you're being behold into a hospital for contract. One of the difficult things is that as people break off and form their own interventional practices, the model for Radiology is typically within exclusive contract so the group may have an exclusive contract in the hospital. So even if the IR guy is new to the city, you might be able to find a place to do your procedures since the radiology group in the hospital may block you from getting any privileges there. If you want to bring a peripheral arterial case into the hospital for instance, they'll block you from doing it because they would say they have an exclusive contract yet the cardiologist or the vascular surgeon who does the same thing and wants to get into the hospital can come in.

Second, Fayyaz recognizes the difficulties in interaction between the diagnostic and interventional physicians because they have to realize that in order to build a good clinical practice, you do need some clinical time. But it can be very hard for the diagnostic people to see that and find that time but they have to realize that builds their credibility.

Third, there are options to do some of the interventional stuff not through Interventional Radiology residency or fellowship but other fields can chomp at your toes but that keeps you fresh and innovative.

[42:33] The Best  and the Worse Things About an IR

Fayyaz loves helping people through their tough times and being there to help them and see them get better. He likes that he can calm somebody down and loves how quick the procedures can be and people get to see the results fast. He would love to expand his practice and get into the cosmetic side of IR or expand in Oncology. overall, seeing his patients get better is the most gratifying.

The least thing he likes about being an IR is getting dumped on with cases other specialties are not willing to do. As frustrating as it seems, you can't let it get to you. In general, radiologists are happy and they do what they do. They can always find a niche depending on what you really want to do.

If he were to choose another specialty again, Fayyaz doesn't actually know considering his interest in plastic surgery. Although Interventional Radiology could still be on top of his list, he could not deny the difficulties and risks related to doing private practice although that could depend on your geographic location. Overall, he likes what he does but some parts can be very frustrating specifically, the exclusive contracts and being behold into a hospital. However, Fayyaz sees that over the next ten years, more and more exclusive contracts will fall and you will get that new model where two or three interventionalists get together to bring cases in and not have a group that blocks you from being in a hospital.

[49:25] Last Words from Fayyaz

Do what you like and don't try to chase it because you think there will be a job afterwards. If you don't like it, don't do it. Second, try to spend time with somebody in that field or at least talk to them to see what their life is really like. Third, see what life is like after and see if this is something you can really do. Realize that a lot of practices may not be all high-powered cases all the time. Tap into resources to learn more about the kind of procedures we do. You're going to have to weigh money, time off, location, case mix, and with all those together, you would have to find the best mix and adjust the dials to where you can live with something and say this is good. There is no perfect job ever. You don't let people tell you no. If they say no then find a way to do it and give it a shot.

Links:

MedEd Media Network