The Relationship Between IR and Administration: The Importance of Alignment

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There has been a recent thread on SIR Connect of which I became involved that has revolved around the topic of the relationship between interventional radiologists and administration. The communication started over frustration with the amount of work deemed unnecessary by practicing IRs, and I think specifically started with annoyance over the need for checklists. I'm not sure the initial or subsequent comments were particularly against the idea of checklists, but simply the fact that much of the information exchanged during the checklist check is not applicable to the IR suite. I can't disagree with this sentiment, but I also am a believer in checklists so I can't entirely agree with it, either. I doubt checklists will ever be perfect for our environment, if for no other reason than we all expect or want different things from the exercise (including some who don't see the value added at all).

The SIR Connect chain, however, quickly took a turn into frustration and angst felt among the group toward administration and the fact that they don't respect our needs, wishes, and goals. It is actually “administration,” since included in that group were hospital as well as department administrators. The conversation quickly took on the tone of “us versus them,” which I found disconcerting.

The first way in which I was concerned by what I was reading is what I feel is a disconnect between what IRs expect of the health care system and what the health care system expects of IRs. Let me preface this in two ways. First, while (I don't even know if I used that correctly – but seriously, is there a better word we should learn to use when we speak or write American?) I proceed in this vein, recognize that I'll try to put on my department and hospital hats rather than my practicing IR hat. And second, this relationship between practicing IRs and suits (“them” in the us versus them) is highly variable and local – truly, when you've seen one you've seen one. But I do believe there are some general themes that would prove helpful when followed while (!) having conversations in the departmental chair's office or the C-suite.

First, whatever value IR adds to the enterprise will be measured in what it adds to the strategic aims of the health care system. It doesn't matter what the IR group wants to accomplish if they are going their own way. For example, if spinal care is an aim of the system, perhaps as a component of a larger orthopedics or neuroscience initiative, then IR could potentially add value by performing kyphoplasty. However, from an administrator's viewpoint, if there is already a service providing that procedure and periprocedural care of those patients, then the value added from IR doing it will be considered minimal. And IR offering this service while not aligned with the direction of the institution – starting the service line because it is what they want to do, not because it aligns with the greater institutional goals -is superfluous at best. While we might make the arguments that we can do it better, cheaper, and faster than other services, and then add into the equation the opportunity cost to the organization of tying up a neurointerventional suite or operating room for others to perform the procedure, at the end of the day that will still be considered nibbling at the edges. Interventional radiologists will have saved the institution minimally (time, money, definitely not frustration) and do this at the cost of upsetting another service. And the question of opportunity cost runs both ways – from an administrator's viewpoint, what will be lost by having IR tie up a room providing a duplicative procedure? Importantly, is there something else that IR can provide that contributes more to the strategic aims of the institution than providing a service already provided, even if IR can do the procedure “better”? Having two services arguing about the same procedure simply doesn't resonate with administration – frankly, there are bigger fish to fry. This segues to the second consideration….

While we as IRs can claim, often with good reason, that we are ignored and disrespected by administration, we need to admit the uncomfortable fact that we are in many ways small potatoes to “administration.” This is true at both the departmental level as well as the health care delivery system. A couple of years ago I had insight into this disconnect when I was part of a panel at a meeting of IR section chiefs discussing how to talk to radiology chairs who don't give the IR section the credit it feels it deserves; I think I was invited as a chair, not as an IR. My comments were not well received, particularly when I mentioned that the diagnostic radiologists often worked as hard or harder than interventional radiologists. I actually believe this – I would find a diagnostic day every bit as difficult as an IR day (if I did diagnostic). I don't mean physically draining, but mentally exhausting. I don't think our diagnostic colleagues are given the credit they deserve and the hassles they endure throughout their day, and if we feel that we as IRs don't have the ear of administration you should try garnering respect as a diagnostic radiologist. On a more practical note, I will say that many academic chairs and private practice group leaders alike look at the IRs in their groups as being the anchors rather than the chosen ones. IR now produces far fewer RVUs than many of our diagnostic colleagues, and that isn't just comparing to neuroradiology anymore. And we typically remain the highest paid within the department (at least in academia). That combination, along with a negative P&L statement, leads to ill-will between chairs who are diagnostic radiologists and their IR section. Here is the kicker – the arguments IR makes about bringing value to the department larger falls on deaf ears because we aren't making the appropriate arguments. It is up to the IR community to learn to speak the speak and walk the walk – there is a power differential, and the departmental and institutional leadership has the upper hand. Like it or not, we as IRs are asking for things when we go to the department, or institution, and walking in with a list of demands and claims of unfairness do not go very far. Frankly, oftentimes the messenger comes across as petulant; when asking (demanding?) for something, why do we feel that it's below us to say “please”?

Speaking the speak to administrators means one thing, and one thing only. We must prove that we are aligned with the mission, goals, and direction of the department or greater system. The concept that we are being dismissed because we aren't aligned with the strategic direction or mission of the department plays out to the nth degree when the discussion turns to the relationship between the IR section and the hospital. In addition to the notion put forth above regarding providing value to the strategic plan of the institution rather than going our own way, other concepts must be realized. First, we are not actually the glue that holds an institution together. Do we provide vital services, many of which cannot be performed by other services? Absolutely, unequivocally YES! And the list grows – the answer to the question going through your mind right now, reader, is yes, it is true; internal medicine doctors are not taught to perform paracenteses, you are putting in chest tubes for thoracic surgeons, and percutaneous nephrostomy and cholecystostomy tubes now are definitive treatments. However, that irreplaceability of IR extends to every other service in the institution. We don't even have to look very far – in a mirror, in fact, at least in my case. Can it possibly be true that a board-certified diagnostic radiologist can't even read chest radiographs on his own patients (don't mock me)? The point is this – to a hospital administrator, EVERY service is vital or the doors to the institution close. Probably the most important service in the hospital is not IR. Probably the most important service in the hospital is not cardiology. Probably the most important service in the hospital is not surgery, or emergency medicine, or hospitalists. Probably the most important service in the hospital is housekeeping. The hospital administrator must juggle all these competing requests with only one thing in mind, and that is keeping the institution moving in the direction set forth by their strategic plan, vision, values, and mission.

I mentioned small potatoes before, to which I'm guessing many of you cringed. To those of you who did, I apologize but want to explain. To those of you who would prefer to just get your subscription money back, please contact Thieme directly. Or, our esteemed deputy editor Bob Lewandowski, who would be happy to field your complaints. At my institution, as an example, we have six full-time IRs. Not a large group, but not small either. Put in context however, we have 1400 providers and 800 faculty physicians in our medical group. We have fewer IRs than dermatologists in our physician plan. As an administrator, how would YOU look at that? Six divided by 1400 equals small potatoes. This imbalance as true for our training program, where we have eight trainees buried in a roster of over 1000 residents and fellows.

Please understand – and do so before the drawing and quartering begins – that I am not being dismissive of what we as IRs do, and the immense value we bring to the medical care of our patients. I challenge anybody to name for me one way (other than perhaps advanced imaging) in which medical care has been changed over the past couple of decades more than by the adoption of minimally invasive techniques. We have changed the face of medicine and the care of patients, we have improved access, we have made medicine safer and more effective, and we have set the tone for the next many years on what the delivery of medicine will look like. However, in one person's opinion we need to get out of our own way. Allying with, instead of arguing with, the decision makers of our respective organizations is the only way to push the envelope even further. Alignment with the greater organization and what it has to offer is essential, and if we as practitioners cannot align with the organization then perhaps it is time to switch organizations or at least switch direction.

I understand that every system is different, and there are at least as many relationships as there are IR sections, groups, and systems. And I as an individual can only speak to what I know and have experienced, which is only one of innumerable models of delivery. However, I do believe that regardless of the model, the power differential makes the concept as simple as this – if we dig in our heels and continue to claim what we feel is “ours,” we will be dismissed. If we fight, we will lose; if we align, we will be welcomed to the table or at least not excused from it.

Publication History

Article published online:
20 December 2022

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