One can't swing a dead cat without the topic of the relationship between interventional radiology (IR) and diagnostic radiology (DR) coming up, which raises this essential and existential question: What is the deal with the dead cat analogy anyway? Kind of disgusting, actually.

I am returning from a spring meeting at which everyone seemed to have an opinion about the “divorce from DR” topic. As with most debatable topics, there were some very vocal people on both sides. I have to say that while I have grown a little tired of the conversation, I actually believe that it is a healthy and necessary discussion. If nothing else, it has made us as a community bring to the forefront the very important question of who we really are, and how we want to represent ourselves both outwardly and inwardly. Importantly, has the evolution of our specialty from procedurally based to clinically based so separated us from our diagnostic colleagues that the divide is now too wide to bridge? Premal Trivedi, who is one of the most measured and reflective up-and-coming leaders in IR, recently co-wrote an exceptional editorial that accompanied a JACR issue dedicated to IR.[1] I would strongly suggest that one read it, along with the remainder of the editorials and articles. It outlined many of the philosophical differences between IR and DR that now exist.

It is evident to me that we (the IR community) are at a crossroads—but we have been at this intersection for some time. Talking about these philosophical differences and if/when would be the appropriate time to dissociate from our parent specialty has occurred over the last decade-plus. Perhaps it is time to consider what it would look like to operationalize this idea; at the end of the day we are data driven, after all, and it should be analyzed and vetted data that inform our decision. To my way of thinking, the following are challenging realities that should be acknowledged and, if possible, addressed before a parting of the ways.

First, IR must recognize the power in numbers. At my prior institution and I believe my current one as well, a separation from DR in the form of developing a new department would make the IR department the smallest clinical department in the institution. Dermatology and urology would be larger than IR, and like it or not pure numbers do indeed matter to both deans and hospital CEOs. And while an argument can be made that as (largely still) proceduralists we bring revenue into the hospital through facility charges, those returns pale in comparison to the radiology department as it exists now. Dollars and profit margins speak to administrators, whose job is to ensure quality clinical care to all patients served. To speak the speak of administrators is essential, and separating from radiology departments would likely undermine the argument.

Second, IR training in the form of the new IR residency requires 3 years of DR training. I cannot help but wonder if our DR residency program directors and chairs would be welcoming to residents from another completely separate department—never mind the politics about being a department that recently divorced from them—rotating with them for so many blocks. The answer to that may very well be yes, but it would behoove us to check that box before a split occurs, rather than make that assumption.

While we are at it, it might also behoove (love that word) us to confirm with the American Board of Radiology that we could still leverage their increasingly complex structure to administer the exam, or even to be allowed to have candidates be diplomats of the ABR upon successful completion of the exam. I don't know the history or circumstances of the separation of radiation oncology from the greater house of radiology, but making the assumption that like them we would be allowed to remain a part of “radiology” after separation without confirmation would be ill-advised.

Fourth, a little surprising to me at least was the result of a survey that upon their graduation went out to the first class of residents who matched into IR, in which well over 50% (I believe it was 75%) wanted a hybrid IR/DR position. It wasn't that those graduates accepted hybrid positions because that was all that was available, but rather that they intentionally pursued that type of first job. I have heard arguments that these graduates were making those claims because they understood that those were the only positions they could find, or that they were only making that assertion because they wouldn't be allowed to practice IR the way they wanted due to DR groups actively blocking their requests. Frankly, I find those arguments somewhat paternal/maternalistic at best, and arrogant at worst. While perhaps true in some instances, it is incumbent on us to dig a little deeper as to the real motivation of our graduates. Otherwise, we become just like those we accuse currently—forcing our graduates to practice medicine the way we, not they, see fit.

Finally—and this is the unfortunate truth that amazingly I still have trouble convincing those IRs with whom I have this discussion—for most radiology departments (both academic and private) IRs who perform procedures rather than reading imaging studies are a loss leader in the department. This is true at a time when we remain the highest-paid subspecialty (ignore the semantics here) in all of radiology. This is the reality before considering the increased opportunity costs of running a clinic, rounding on patients, and drumming up business at multidisciplinary clinics and tumor boards. People simply don't want to believe that we are just not bringing financial value to the department, but we need to get our heads out of our … the sand … and acknowledge the simple fact that a divorce from DR would with near certainty require a significant pay cut. Whether or not this gap might be bridged by increased funds flow from health care systems is completely local, but with increased funds flow come certain requirements; if we think that we are getting inundated with paras, bone marrow biopsies, and venous access now, see what happens when getting more from the health care system comes with a price tag of doing whatever we can to open beds. People may consider decreased pay the price of freedom and well worth the cost, but I am of the belief that that needs to be a personal, not a specialty, decision.

I started the conversation (Monologue? Diatribe? Rant?) by questioning whether there is a single correct answer to the question of secession. Perhaps a better question would be is there an incorrect answer. And how mandatory is it that we as a community come up with one model that needs to fit all? Perhaps we should be more welcoming of the idea that IR can mean a thousand different things to a thousand different people and allow (and support) those individuals and groups to make the decisions that are best for themselves.

Article published online:
19 August 2024

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