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. We talk about his career decisions, his work hours and lifestyle as an IR physician, what he does on a daily basis, the struggles and triumphs of his practice, and other interesting topics like exclusive hospital contracts and artificial intelligence replacing diagnostics.

Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:15] Choosing Interventional Radiology

Fayyaz realized he wanted to be an interventional radiologist one particular day during his third year of medical school. He had initially found interest in plastic surgery, vascular surgery, and orthopedics.

He had exposure to medicine growing up since both of his parents were physicians, but it was on his third-year surgical rotation that he remembers being chewed out after having observed a surgical procedure passively for so long. During that same day, he went to see a family friend who happened to be called in for a pulmonary arteriogram. Fayyaz was surprised at how quick the procedure was.

At that point, Fayyaz was considering orthopedics or radiology, with the full intention of going into interventional if he did the latter. What he likes about interventional radiology is the fact that you get to do various relatively short procedures that make a difference in patients’ lives.

What he likes about interventional radiology is the fact that you get to do various relatively short procedures that make a difference in patients' lives.Click To Tweet

[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 problem-solving. When things don’t go as planned in interventional radiology, you have to be able to improvise. You have to be able to figure out how to accomplish your goal using the tools you have.

When things don't go as planned in interventional radiology, you have to be able to improvise. Click To Tweet

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 IR physicians have a have in a whole bunch of different things. But problem-solving and thinking outside the box are the key traits to have for an interventional radiologist. And of course, you need to know your anatomy.

Problem-solving and thinking outside the box are the key traits to have for an interventional radiologist. And of course, you need to know your anatomy.Click To Tweet

[06:22] Types of Patients Seen By Interventional Radiologists

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

Interventional radiologists also treat older patients with spinal fractures for vertebroplasty or kyphoplasty. They treat a lot of oncologic patients, which can branch off into its whole own sub or super-subspecialty. They can treat hepatic tumors with radioembolization, chemoembolization, or radiofrequency or microwave ablation or cryoablation.

Hence, IR physicians see a full spectrum of patients, from younger, healthier ones to older and very, very sick ones.

IR physicians see a full spectrum of patients, from younger, healthier ones to older and very, very sick ones.Click To Tweet

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

Fayyaz’s current practice is less hardcore and interventional than he would like. Bread and butter for them is paracentesis, thoracentesis, chest port placement for chemo, various biopsies, and 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 myelograms. In between, he reads diagnostic imaging.

Interventional Radiologists Take on 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, or kyphoplasties. They’re also currently ramping up their oncologic work with the new group he’s in, doing ablations and radioembolizations that are starting to pick up now. They also do very heavy-duty cases like TIPS, which do not occur as often but can take longer.

In their group of 4 IR doctors, they split up the call, so once per quarter for a weekend and random days here and there depending on the hospital setup. Fayyaz says that 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 as an Interventional Radiologist

As reimbursements have fallen, IR does not generate as much income as it used to. 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 nontraditional options like outpatient vascular access centers, where they do dialysis interventions. Those have pretty regular hours. Then your work-life balance can be great.

As reimbursements have fallen, IR does not generate as much income as it used to.Click To Tweet

Fayyaz would describe his work-life balance as pretty good, starting work at 8 am and usually finishing 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 be getting called in the middle of the night for those cases. But if you’re doing bread and butter cases, work-life balance is fine.

[14:25] The Residency Path to IR

Back in the mid-’90s, there was a time when internship was not required, so you went right into radiology residency. That changed around 1995. Now the traditional pathway is a year of internship (can be in surgery. medicine, pathology, transitional, or pediatrics), then you do four years of diagnostic radiology residency, then a one-year interventional radiology fellowship So residency is six years total for interventional radiology.

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. As more and more programs go toward that, you will match into interventional radiology directly from medical school, which includes more clinical time, cutting down the diagnostic time a bit and increasing the interventional time. (The first set of programs following this model were just approved last year, so they’re just starting.)

The Changing Model for Interventional Radiology Practices

The new model for interventional radiologists is to set up your own practice just as a surgeon or cardiologist would. You see patients clinically and then bring them to a hospital for procedures.

In order to compete as an IR physician, you can’t rely on the old model of just sitting there waiting for procedures to come to you. You have to market yourself, and you have to evaluate patients and do consults, which not some of the older guys are not used to.

The new model for interventional radiologists is to set up your own practice just as a surgeon or cardiologist would.Click To Tweet

[18:14] Matching into Interventional Radiology

Competition for interventional radiology comes and goes in phases. More people have become interested in interventional radiology 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. If you say yes almost all the time, then when you do say no, 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.

To match into interventional radiology, you have to be a hard worker and have a mentality of saying yes almost all the time.Click To Tweet

Other things that can make you competitive are being innovative, being able to problem-solve, knowing imaging, being clinical, and being willing to constantly learn new things.

Fayyaz doesn’t necessarily believe that Step scores tell the whole story when it comes to matching into IR. It’s one tool for weeding out applicants, but it shouldn’t be the only tool.

What Kind of Residency Program to Look For

Fayyaz went to a program where research was not a priority, but if you’re looking at research-heavy programs, you might want to pursue research. If your goal is academic research and publication, 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 residents. 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.

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. Click To Tweet

Turf Battles Over Procedures

A lot of procedures are pioneered by radiologists, but as they get more commonplace and more routine and more lucrative, other specialties start snipping away at it, so you’re going to be experiencing turf battles. For instance, a lot of different physicians might be fighting for cerebral angiograms, which can be done by interventional radiologists, vascular surgeons, neurologists, and neurosurgeons.

[24:47] Bias Against DOs in Interventional Radiology?

Fayyaz worked in a New York hospital that had a deep radiology residency DO program. They joked about how MDs couldn’t go into the DO programs, while DOs can go into MD programs. 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-Specializing in IR

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

The big thing right now is interventional oncology—that's what everybody wants to go into.Click To Tweet

But the big thing right now is interventional oncology—that’s what everybody wants to go into. It involves stuff like radioembolization, chemotherapies, and various regimens.

Other people do neuro-interventional, which typically requires a neuroradiology fellowship and then neuro IR. Some get involved in stroke intervention. You can also do a pediatric interventional fellowship.

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

Fayyaz is not sure if primary care physicians really understand exactly what IRs do, which has been a problem because they’re not aware of the services they offer. IRs do hundreds of chest ports, and they can even do it better than surgeons sometimes. They can do it faster and cheaper.

But IRs do more than just that; they do biopsies, spine interventions, peripheral arterial, biliary stuff—all of which people think of as surgical procedures. They also do fibroid embolization, venous disease, and gastrostomy, so all these things can be done.

If you're in primary care, learn about what IRs are doing because you might be surprised what the interventionalist can do for you.Click To Tweet

What feels frustrating is that interventional radiologists sometimes feel just like a backup, like they’re only sought out when no one else is available to do it. It would be nice to have a great relationship between the primary care physician and the IR. If you’re in primary care, learn about what IRs are doing because you might be surprised what the interventionalist can do for you.

Other specialties that interventional radiologists work closely with include oncology, orthopedics, and hospital/critical care.

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

Interestingly, there have been thoughts of merging diagnostic radiology and pathology into one specialty. The argument is that it’s a lot of pattern recognition on the diagnostic side, and those should be handled increasingly by computers, while 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. There is a lot of grey zone for now. If computers could just highlight findings of questionable significance and let a radiologist go through it, then that would be helpful in making their work faster and more effective.

[37:00] Opportunities for Interventional Radiologists Outside of IR

Radiologists have a lot of unique opportunities since they interact with a lot of other specialties. They can be very strong in administration. IRs are like anchors in the hospital because they provide a lot of coverage that can’t be easily outsourced.

Radiologists have a lot of unique opportunities since they interact with a lot of other specialties.Click To Tweet

Again, it’s important to not wait for things to come to you as an IR physician. You need to be out there somewhat marketing yourself, being available, and meeting people. This leads to more different kinds of opportunities. If you’re in academics, you can go into the consulting industry.

[42:33] The Best and the Worse Things About Interventional Radiology

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 he loves how quick the procedures can be and that people get to see results fast. He would love to expand his practice and get into the cosmetic side of IR or expand into oncology. Overall, seeing his patients get better is the most gratifying.

The most gratifying thing about being an interventional radiologist is seeing his patients get better.Click To Tweet

The thing he likes least 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. You can always find a niche as a radiologist depending on what you want to do.

The thing he likes least about being an interventional radiologist is getting dumped on with cases other specialties are not willing to take.Click To Tweet

If he were to choose another specialty again, Fayyaz doesn’t actually know what he would choose, considering his interest in plastic surgery. Although interventional radiology might still be on the top of his list, he can’t deny the difficulties and risks related to doing private practice.

Overall, he likes what he does, but some parts can be very frustrating, specifically the exclusive hospital contracts and being beholden to a hospital. But 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] Advice for Choosing Your Specialty

First: Do what you like. Don’t try to chase something because you think there will be a job afterward. If you don’t like it, don’t do it.

Second, try to spend time with somebody in the field you want to enter—or at least talk to them to see what their life is really like.

Third, see what life is like after residency 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 done in that specialty.

You’re going to have to weigh money, time off, location, and case mix, and you have to find the best mix for you. Try to adjust the dials to where you can live with something and say this is good. There is no perfect job ever. Don’t let people tell you that you can’t do it. If they say no, then find a way to do it and give it a shot.

Do what you like. Don't try to chase something because you think there will be a job afterward.Click To Tweet