The Great Resignation and IR

  SFX Search  Buy Article Permissions and Reprints

I've been reading a lot lately about the Great Resignation. One can't help but read about it—it is all over the news, our professional journals, and in the hallways of our workplaces. There seem to be many theories on why this is occurring now, many of which have to do with COVID-19 and the effect it has had on all of us. But I am certain there are more reasons for this efflux from the workforce.

We have all seen the numbers, which are startling and bothersome at the same time. The number of physicians older than 55 years is impressive and growing. According to the AAMC, in 2019 nearly 45% of all physicians are senior (can't believe I just wrote that word—ouch); the number has increased from 38% in 2008.[1] Some specialties in particular are aging rapidly—91% of pulmonary disease physicians are older than 55 years. The good news is that as a specialty interventional radiology (IR) has relatively few older practitioners (21%), although diagnostic radiology is above the all-specialty mean (53%). It would be interesting to me to see the numbers of IR physicians per decade of life. I can't help but wonder if the more senior IRs still report themselves as a “radiologist” rather than specifically as an IR, meaning that perhaps our specialty isn't quite as skewed to younger practitioners as on first notice.

I am of the opinion, however, that there are some opportunities for IR in this uncertain environment. There will be voids that will need to be filled within the greater medicine sphere, and many of these holes directly affect us in IR. I'm thinking particularly of “minor procedures,” or IR-light, that others no longer know how to perform. Although some in our community would rather take a pass on these opportunities, I would suggest we look closely at those voids and decide whether or not it is in our best interests to fill them. I'm not talking about the sexy stuff—who doesn't want to do portal hypertension, vascular, and cancer work all day long? Rather, I'm talking about the stuff that pays the bills. Let me digress for a minute, particularly for the younger reader….

I graduated my fellowship in 1995. I had to literally beg for my first job out of training, and if the person who became my boss had hung up a couple of seconds before I would likely still be looking for that first job. The words I yelled into the phone right when he was hanging up? “Vascular access.” Yep—the stuff we complain about on a daily basis, the bane of our existence, the stuff that is below us, and our advanced skill set. Back in the day, as IR was maturing as a field, we had to fight for all of those procedures—thoras, paras, thyroids, vascular access, etc. I mention that to my current trainees, when they complain about fielding phone calls where they have to tell other referring clinicians, that they need to “call surgery for that type of procedure.” The conversation typically goes like this:

Ray: “Do you know how long it took us to get to the point where we are the service people think of when they have a problem. We WANT them to call us first!”?

Trainee: “No, sir, Dr. Ray—but please tell me about it because it sounds very interesting” (outside voice). “Oh, for God's sake—why do codgers always think we give a crap about the ‘bad old days’” (inside voice).

There is not one field of medicine that doesn't have a hemorrhoid clinic. Frankly, I'll take my mundane and dull over any other specialty; I'm even ready to tell you, dear reader, that I still enjoy putting in chest ports. There—I've said it. And, by the way, this stuff pays:

IR procedures

Relative value unit

Ultrasound-guided paracentesis

2.00

Image-guided thoracentesis

3.12

Non-tunneled central line

1.75

Tunneled central line

4.59

Tunneled line removal

3.10

Other specialty procedures

Image-guided selective nerve root block (anesthesia)

1.90

Right heart catheterization (cardiology)

2.47

Fecal disimpaction, manual[a] (not me)

3.19

a Yes, there is a code and yes, I did look it up. I'll do the line removal or thoracentesis, thank you very much.


I understand the argument people make that they don't want to clog up their angio suites with low-level stuff, but that argument only holds in three instances. First, you have other cases that you are bumping to do the trivial stuff. Second, you are also doing the boring stuff on off hours, which can detract from your availability to do the more meaningful and impactful cases. Finally, you would be using that time to build a service, understanding that as you do that you are doing un-reimbursable activities (or minimally reimbursed, such as longitudinal clinic).

I mentioned above the concept of “filling the void.” I think it is clear to all of us, but perhaps more so to those in academic centers who see what is happening to trainees outside of IR and radiology; trainees in other specialties are not being trained to do any procedures whatsoever. It used to be, for example, that all internal medicine residents would have to keep a case log with the number of paras, thoras, LPs, lines, etc., that they performed. The procedural requirement now to sit for the American Board of Internal Medicine (ABIM) exam? Peripheral IVs, arterial blood gases, and blood draws—five times each. That's it. And I'm not sure how well other specialties are preparing their trainees for invasive procedures—I'll never forget the first time I was asked to put a chest tube in a patient on the cardiothoracic surgery unit. I thought it was a joke (don't yell that into the phone, by the way—for some reason it's not appreciated).

Table Number and percentage of active physicians by age and specialty, 2019

Specialty

Total active physicians

Under age 55

Age 55 or older

Number

Percentage

Number

Percentage

All specialties

935,136

515,443

55.1

419,693

44.9

Allergy and immunology

4,900

2,377

48.5

2,523

51.5

Anatomic/clinical pathology

12,640

4,077

32.3

8,563

67.7

Anesthesiology

42,259

19,210

45.5

23,049

54.5

Cardiovascular disease

22,514

8,370

37.2

14,144

62.8

Child and adolescent psychiatry

9,786

5,459

55.8

4,327

44.2

Critical care medicine

13,093

10,378

79.3

2,715

20.7

Dermatology

12,505

6,970

55.7

5,535

44.3

Emergency medicine

45,134

29,397

65.1

15,737

34.9

Endocrinology, diabetes, and metabolism

7,993

4,717

59.0

3,276

41.0

Family medicine/general practice

117,955

62,554

53.0

55,401

47.0

Gastroenterology

15,467

7,815

50.5

7,652

49.5

General surgery

25,548

13,412

52.5

12,136

47.5

Geriatric medicine

5,973

3,909

65.4

2,064

34.6

Hematology and oncology

16,274

9,234

56.7

7,040

43.3

Infectious disease

9,685

5,707

58.9

3,978

41.1

Internal medicine

120,090

64,979

54.1

55,111

45.9

Internal medicine/pediatrics

5,508

4,832

87.7

676

12.3

Interventional cardiology

4,405

3,829

86.9

576

13.1

Neonatal–perinatal medicine

5,919

3,356

56.7

2,563

43.3

Nephrology

11,405

7,151

62.7

4,254

37.3

Neurological surgery

5,743

3,084

53.7

2,659

46.3

Neurology

14,140

6,237

44.1

7,903

55.9

Neuroradiology

4,089

3,134

76.6

955

23.4

Obstetrics and gynecology

42,687

23,313

54.6

19,374

45.4

Ophthalmology

19,306

9,436

48.9

9,870

51.1

Orthopedic surgery

19,058

8,168

42.9

10,890

57.1

Otolaryngology

9,775

5,053

51.7

4,722

48.3

Pain medicine and pain management

5,871

4,074

69.4

1,797

30.6

Pediatric anesthesiology (anesthesiology)

2,571

2,343

91.1

228

8.9

Pediatric cardiology

2,966

1,906

64.3

1,060

35.7

Pediatric critical care medicine

2,639

2,023

76.7

616

23.3

Pediatric hematology/oncology

3,079

2,124

69.0

955

31.0

Pediatrics

60,588

33,608

55.5

26,980

44.5

Physical medicine and rehabilitation

9,764

5,106

52.3

4,658

47.7

Plastic surgery

7,315

3,330

45.5

3,985

54.5

Preventive medicine

6,667

2,025

30.4

4,642

69.6

Psychiatry

38,778

15,019

38.7

23,759

61.3

Pulmonary disease

5,104

442

8.7

4,662

91.3

Radiation oncology

5,306

2,903

54.7

2,403

45.3

Radiology and diagnostic radiology

28,017

13,166

47.0

14,851

53.0

Rheumatology

6,264

3,430

54.8

2,834

45.2

Sports medicine

2,892

2,652

91.7

240

8.3

Sports medicine (orthopaedic surgery)

2,902

2,403

82.8

499

17.2

Thoracic surgery

4,478

1,785

39.9

2,693

60.1

Urology

10,199

5,047

49.5

5,152

50.5

Vascular and interventional radiology

3,875

3,061

79.0

814

21.0

Vascular surgery

3,941

2,275

57.7

1,666

42.3

Source: American Medical Association (AMA). AMA Physician Masterfile (December 2019).


Note: Excludes 3,844 active physicians whose age is unknown.


So I ask—if not us, then whom?

This stuff is not below us, and frankly it's good patient care to have most of these services provided by us. I get it, of course—we don't want to get to the point where this is all we do. And it isn't practicing at the upper limits of our license—but it is in the scope of our license. Everybody needs filler cases—I can think of worse ways to make a living than doing these minor procedures. Oh, and if we create a void by refusing to do the cases we might already do. How then can we really be surprised when others jump into the fray (read, advanced practice registered nurses and physician assistants) to take our cast-offs? If not surprised, how can we be irritated?

So, circling back around. Where will the Great Resignation leave us as a field? My predictions are the following. First, many medical fields will see early retirements from physicians who are sitting on the fence. It hasn't happened as much as people thought up to this point, but I do anticipate that as things continue to become more and more trying, more and more physicians my age will decide to hang it up. Second, we will have the opportunity to expand our practices in many different ways, giving us further latitude to grow things the way we want to grow them. This, however, will take an effort on our part, and that effort will start with saying “no” on occasion. As a field we seem to have a difficult time doing this, in part because other services typically look to us as the expert from whom they need help. We do, however, have to learn to set up boundaries so that we do what only we can do. As alluded to above, that skillset might grow, not because we are just learning to do the minor procedures like those listed above but expressly because other services aren't learning how to do them. Here there is the opportunity, but we need to have a measured approach. And finally, to compete for increasingly scarce resources, particularly workforce, we will have to make a conscious effort to keep IR interesting, welcoming, innovative, and exciting for those considering the field.

Publication History

Article published online:
31 August 2022

© 2022. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

留言 (0)

沒有登入
gif