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, 2019Specialty
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 HistoryArticle published online:
31 August 2022
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