May 18, 2009

Radiology Today Interview With Brian F. Stainken, MD — IR’s Place in Radiology’s Future
Radiology Today
Vol. 10 No. 10 P. 24

Brian F. Stainken, MD, FSIR, is president of the Society of Interventional Radiology (SIR), as well as a professor and the chairman of the diagnostic imaging department at Roger Williams Medical Center in Providence, R.I. Radiology Today editor Jim Knaub had the opportunity to interview Stainken at SIR’s recent annual meeting.

Radiology Today (RT): Establishing IR’s role in a successful radiology group can be a real challenge. Some groups work it out, and others never do. There doesn’t seem to be any template for how it is done. Why is that?
Brian F. Stainken, MD, FSIR: It’s probably the nature of people. IR never fit easily in the diagnostic practice model. Over the past decade, as others recognized the validity of our solutions and began to copy them, we had to adjust. IR has experienced a very fundamental culture shift, with a refocusing of priorities and reassessment of exactly what we are and how we relate to patients. As our shape changed, the issues with the diagnostic “fit” have become more acute and challenging. We relate in a different way to our patients, our colleagues, and hospitals. We are hands-on clinicians and expert, board-certified radiologists. It's a unique breed that others desperately want to emulate.

That we are clinicians is not news. We always have been. In many hospitals, the medical staff regard the interventional radiologist as one of the best clinicians in terms of being an innovative problem solver, a trusted ally, and a critical resource in a tough situation.
What has changed is that we are formalizing our clinical role with offices, rounding, and formalized consultation. We are refining what we do so that we can compete, deliver better care, and take credit for what we've been doing all along.

It's the nature of any organization to resist change. Those groups that “work it out” do so because they have the ability to realize the opportunity.

RT: What do you tell your radiology colleagues?
Stainken: Within the context of a radiology group, the message we need to deliver is twofold: First, we can compete and succeed as interventional radiologists, but we must be supported. We must have the time and the clinical infrastructure. Second, take a second and think. IR is critically important to us—it's everything that we're about—but it's also a good business. Professional groups should look anew at the margin that IR generates back to its group and to the hospital.

RT: Would you elaborate on that?
Stainken: We all tend to be a bit myopic when we look at numbers. I submit that too few organizations look at their interventional radiologists in the same manner as other (less valuable) services. When interventional radiologists refer imaging examinations, we tend to refer them back to our affiliated group or institution. When we admit, it's usually to the hospital with which our group enjoys a fairly unique contractual affiliation. That's unique. It's not something that many diagnostic groups capitalize on, or come to grips with, in their planning. IR can become a top referrer, either directly because of our patients or via consultant referrals. If the doctor referring all that work was not a radiologist, he or she would be among the most appreciated physicians by the group or hospital. But there's a tendency when it's in the family, so to speak, for people to not recognize their own.

RT: How do you change that?
Stainken: Look, we all want to take good care of patients. We all want to do the best job we can. To continue to do that in IR, it is required that we change and formalize our clinical practices. The ACR endorsed our shifting paradigm way back in 2001, recognizing that we are clinical physicians who need an office presence, time allocated to see patients, time to consult with referring physicians, and time to see patients on the ward. We need diagnostic groups to understand why we've changed and support our clinical practices.

We want to be held accountable. The IR practice should grow as the group and partner hospitals invest.

The resistance to change is understandable. We don't fit the standard radiology operating/work day model. On the surface, one could argue that E/M [evaluation and management] codes don't reimburse as well as advanced imaging and that office overhead is high. But these are shallow perspectives. Groups need to look at the big picture, the downstream referrals, the indirect gains, and the relationships.

RT: You see IR practices set up different ways. Sometimes, it’s part of the diagnostic group; sometimes, it’s set off in its own practice; and sometimes, it’s with other specialties, such as vascular groups. Does that get in the way? In some camps, that could be seen as sleeping with the enemy.
Stainken: It’s no different than what you see in other medical specialties. Some diagnostic radiologists are part of multispecialty groups. Some are hospital employees. Some are members of private practices. Some are in university faculty practices. Similarly, interventional radiologists work in a variety of practice settings. Some work in freestanding practice environments. Some are hospital employees. Some are in radiology groups, and some are in multispecialty groups. Some radiology and IR groups have taken it in the other direction and brought other specialties, such as vascular surgeons, into their group.

RT: Arrangements that work seem to focus on improving the continuity of care for the patient. If your organization can provide that continuum of care, it will benefit.
Stainken: Most people—in medicine and life—would agree that one-stop shopping is optimal. Patients expect that the doctor’s recommendation is made in the patient’s best interest. How much better is it if that solution can be easily accomplished at the same site?

RT: You said education is a key to making this happen. I’ve certainly heard the opinion among diagnostic radiologists that if an interventional radiologist is not in the procedure room, he should be parked in front of a monitor reading cases and making money for the group. They often don’t see that clinical time as generating good things for the group. Specifically, how do you go about making that point?
Stainken: We’re all busy, and busy people don’t necessarily take time to stop and reassess. In the context of the relationship between interventional and diagnostic radiology, it is time to stop, take a deep breath, and take a fresh look. Be willing to change. Part of making it work involves business planning. A good business venture requires some up-front investment. We believe we can demonstrate significant downstream revenue—both the direct revenue from clinical practice and revenue from imaging studies—will flow to the group and partner institutions. Strong IR can also enhance professional practices by helping retain a hospital contract or win them with new hospitals. Many interventional radiologists are among the top referrers of admissions to hospitals. Those are strong reasons why groups should stop, reassess, and decide that it’s time to follow their own college’s recommendation and provide the clinical time for interventional radiologists and also provide the clinical resources in terms of office space and office staff.

RT: In one session at this year’s SIR meeting, one of the panelists said something to the effect that radiology groups need to look at themselves as conglomerates instead of factories.
Stainken: I agree that there is strength in any organization that embraces diversity, and I think that is especially true for diagnostic radiology groups. But I think it is more difficult to manage a conglomerate than an assembly line.

RT: One lament you sometimes hear from radiologists is that they don’t control patients. IR can provide a tool to help.
Stainken: I fundamentally reject the notion of “patient control.” I think if patients ever heard that term thrown around with the candor that I see it used and blandly accepted in some specialties outside of my own, they would be shocked. We are obligated to offer patients our best service and expertise and always keep their best interests tantamount. We must restrict our practices to areas where we can claim legitimate expertise gained through formal training and competency. It’s time for our regulators to clamp down on incompetency. We need to recognize the effect that downward pressures on reimbursement and self-serving, industry-sponsored “sham education” have had on quality and professional referral patterns. Patient Control means not referring when you probably should and putting your priorities above those of your patient. Ultimately, patients pay the price. So, for as long as I can shout it, I will condemn any concept of patient control. We must do what is right by each individual and no less. Hopefully, most will understand and become loyal patients but never controlled ones.

RT: Also at the meeting, speakers referred to a statistic that 94% of people basically have no idea what interventional radiologists do. Is making the broader world aware of IR a fundamental challenge?
Stainken: We historically have been the doctors’ doctors, someone they turn to in difficult situations. Interventional radiologists solve most surgical complications. We’re also heavily involved with trauma and transplant care, working as a team with surgeons. Those physician relationships will remain in place, but we are ready to move into positions on the front line. We think that in many areas, we’re uniquely capable, experienced, skilled, and validated by board certification. It’s time for us to step up to the plate.

RT: How should IR go about that?
Stainken: There are several communities we need to speak to, starting with patients. We won’t achieve full name recognition in any short period of time, but patients are starting to seek us out. They are starting to understand who interventional radiologists are and what we do.

In the area of uterine fibroid ablation, our recognition is much greater. The benefits of the technique for sparing the uterus from unnecessary removal were widely circulated on the Internet. It was one of the first techniques to reach widespread dissemination that way. People found out about us through the Web.

RT: So that was a grassroots campaign?
Stainken: Yes, it was. And I think there are other areas where the same approach will work. As our profession evolves toward focused disease state domains, I think there will be opportunities for more patient advocacy. It’s already begun in interventional oncology. Patient advocacy is powerful. Many interventional radiologists have a cadre of patients who are very loyal and appreciative of what we’ve done. So I don’t think it is a big leap to get to that widespread recognition.

We also need to speak to diagnostic radiology, not to make them do what we want, but to make them understand why we’re where we are, where we are going, and why it’s in everyone’s best interest to move in the same direction. We have strong ties to the ACR and the American Board of Radiology. We need to work with these groups to further compel our diagnostic imaging partners to act in their own best interest.

We also need to speak to payers and government. We all know that there are profound changes on the horizon. In a world where everyone looks at comparative effectiveness, we see that the benefits of the approach we use—being less invasive, offering shorter recovery time and less morbidity—as being critically important. We need to make sure that payers and government know who we are and the benefit that IR delivers to patients.

A last key group that we need to speak to is hospital administrators. Many administrators haven’t quite figured out what we are. Often, they think of us in the same way they think of a vascular surgeon or a cardiologist or any other office-based subspecialist who comes into the hospital, delivers care, and leaves. IR is different; IR is an anchor in most hospitals. Our support keeps many hospital services, such as trauma and transplant, going. Those services would find it difficult to operate without us. We shorten length of stay. We treat surgical complications. We provide these critically important services, but we haven’t done the job in terms of explaining that to hospitals. We’re making strides now, but administrators are a key audience for us moving forward.

RT: I’ve heard interventional radiologists mention that they are near the top of the list of doctors bringing patients into a hospital. You’d think that would get the administrators’ full attention. Is that because you don’t have a body part, per se? Is it because many of the things interventional radiologists do somebody else does, too? What is the key to getting that message to the hospital?
Stainken: We need to quantify our direct and indirect contributions. Then we need to educate hospital administrations. Among others, we've been working with SIR’s Advisory Board towards that end. We need to educate before the message is driven home when a hospital loses its IR presence. We've seen many cases across the country where that very thing has happened, and the hospital suddenly realizes how critical IR is to successful operations.

RT: That’s not really a good business plan for interventional radiologists.
Stainken: [laughs] That’s true. But moving forward, we’re gaining traction in educating hospitals about who we are and what we do. We see our relationship with hospitals as being unique—not better or worse than other specialties but different. We see our contribution as being unique, particularly with regard to the number of services we support. We support myriad clinical services while providing direct care and our own service line.

RT: We have a large audience of diagnostic radiologists. What would be your key message to them?
Stainken: Take a fresh look at IR. Look at it in the context of what your diagnostic group can do to solidify its position in the hospital and allow you both to prosper and grow. The group will see an improvement of its stature within the hospital and ultimately see downstream revenue to support the new model that we’re offering.

RT: And what would you say to the administrative side?
Stainken: That the model they use to look at other specialties—particularly off-site office-based specialties—is fundamentally different from the model for the care IR provides. We are not interchangeable. IR provides a unique service to hospitals—in many ways no different than the ICU and ED [emergency department]. We keep hospitals going. We solve problems in the hospital.

We fix the complications. We shorten length of stay. We enable key service lines. We are a dozen subspecialists rolled into one. No hospital these days can thrive without a strong IR presence.

When supported by progressive administrations, IR can also provide a significant, elective, high-contribution margin book of it's own. We have enjoyed historically loyal, strong relationships with hospitals. We need to leverage that.

RT: Looking ahead, what is the biggest challenge facing IR?
Stainken: We've survived a crisis of confidence and changed. I wouldn't go back to the old way for a million dollars. Our biggest challenge is to wake up our diagnostic imaging housemates. We want to stay in the “house of radiology,” but the residents of that house need to accept us as we are and support our practices. It's that simple.

RT: And what is the biggest opportunity?
Stainken: In a medical world where many solutions were never validated to begin with, it can be a huge challenge to push forward on many different fronts and try to change the conventional wisdom. The bar is set very high. We have a very strong and active research foundation arm. It is engaged in promoting and supporting the validating studies that should occur for both the solutions we offer as well as the old procedures that are part of the conventional medicine's wisdom. Many of those conventional or standard solutions, which were never before validated, should not survive.

We believe there is huge opportunity for IR as our government scrutinizes medicine, with an eye toward comparative effectiveness. IR delivered by interventional radiologists offers very precise care, significant reduction in recovery time, excellent patient satisfaction, and excellent outcomes. In the emerging debate on comparative effectiveness, we think our solutions will bubble up among the big winners.

What happens often in this field is that we discover a breakthrough disruptive solution, and we upset the conventional wisdom. We do that for good reason—and generally with good data behind us. That drives care forward. That’s what we’re all about—providing the kind of healthcare that everyone should expect in 10 years.