Dr. Tomashek is an Interventional Fellow at Methodist Hospital in Indianapolis, IN. He received his MD from the University of Wisconsin-Madison in 1996 and completed his residency at Methodist Hospital in 2001. He will join Wisconsin Radiology Specialists S.C. in Milwaukee, WI in July 2002.

Today's interventional radiologist is a clinically oriented specialist. The transitioning landscape to greater outpatient health care, increasingly competitive market forces, and advancements in interventional radiology (IR) procedures have led the interventional radiologist to continually refine his or her clinical skills and practice. As a result, the IR outpatient clinic is evolving as an integral part of IR practice. Clinical practice building will play a vital role in further establishing IR as a credible subspecialty and will help interventional radiologists assume a leadership role in the realm of minimally invasive image-guided therapies. The aim of this article is to discuss the merits and structure of an IR outpatient clinic, as well as highlight the typical obstacles encountered during development. A list of resources to aid in building a clinical practice in IR will also be provided.

Interventional radiology (IR) has always been a clinically oriented subspecialty of radiology. This is evident in Dotter and Judkins' original 1964 angioplasty article wherein patients received thorough preprocedural evaluation and close clinical follow-up. ¹ It is also apparent in Margulis' first description of IR when he states that the principle of the intervention entails "clinical judgment, technical skill, [and] responsibility to the patient before, during, and after the procedure." ²

The rapid expansion of the field, based largely on technical innovations, has shifted the focus from the patient to the procedure, however. Unfortunately, this has changed the perception of the interventional radiologist from a clinician to a technician. Despite this, the interventional radiologist has continually transcended the role of diagnostician to affect treatment for vascular and nonvascular diseases with not only angioplasty but with percutaneous stent placement, embolotherapy, tumor ablation, and myriad other equally advanced procedures. Coincident with the recent expansion of the specialty, interventional radiologists have found themselves immersed further in the role of clinicians, being more involved in the assessment and management of patients with problems ranging from uterine fibroids to spinal fractures. The future scope of IR seems endless, and practices across the country are expanding.

Yet, many in the field are uneasy about the future. Peripheral vascular surgeons, neurosurgeons, interventional nephrologists, and cardiologists--all experts in their respective clinical subspecialties--are each waging separate turf wars with the seemingly defenseless interventional radiologist, who often depends on referrals from these same clinicians. Peripheral vascular surgeons, sensing the expansion of IR as a threat to their livelihood, have endeavored to gain "endovascular surgical" skills and credentials. ^3,4 Organized cardiology has also attempted to make inroads in the field of peripheral intervention on the concept of "limited competency." ⁵ Levin et al ⁶ concluded that the perceived threat IR poses to the practice of peripheral vascular surgery is not serious in terms of reimbursement and workload, and that there is no conceivable threat posed to cardiology by interventional radiology. However, if peripheral vascular surgeons and cardiologists continue to expand into the field of peripheral vascular intervention, their threat to interventional radiologists is real.

U.S. Center for Medicare and Medicaid Services (CMS, formerly HCFA) 1999 statistics show a growth in peripheral vascular interventional services rendered by cardiologists and peripheral vascular surgeons and a decline in the number performed by interventional radiologists. In addition, a recent public awareness poll conducted by the Society of Cardiovascular & Interventional Radiology (SCVIR) revealed a major lack of public knowledge regarding interventional radiology. ⁷ Currently, interventional radiologists have no natural patient base and the public is unaware of the services an interventional radiologist can offer. Indeed, the public doesn't even know what an interventional radiologist is. The interventional radiologist will be dispensable if the doctors who control the patients acquire his skills and clinical judgment. Dotter predicted this situation in 1968 in an address to surgeons with this well-known quote: "If my fellow angiographers prove unwilling or unable to accept or secure for their patients the clinical responsibilities attendant on transluminal angioplasty, they will become high-priced plumbers facing forfeiture of territorial rights based solely on imaging equipment others can obtain and skill still others can learn."

The future viability of interventional radiologists will hinge on their ability to adapt to the changing practice environment. ^8-20 Continued innovation will be important to advance the field, but to survive, IR will need to evolve into a traditional clinical subspecialty complete with a busy outpatient clinic and the capability of providing independent evaluations, recommendations, and therapies. ^21-26 Interventional radiologists of the future will need to accept more patient-care responsibilities to remain competitive in the very field they created. In essence, getting back to the basics of patient care will help secure the future of interventional radiology.

As with other subspecialties, the outpatient clinic is the cornerstone of the clinical practice. The tools needed to develop an IR clinic are conceptualized in Figure 1. This article will discuss the merits and organization of the IR outpatient clinic and outline the typical obstacles encountered during development. To aid the interventional radiologist in establishing a clinical practice, lists of practice-building resources are provided.

Benefits

A structured IR clinic provides innumerable benefits to the clinician; benefits that can be measured across the entire scope of the practice. ^21,24-27 For discussion, these have been divided into broad categories, including benefits relating to patient care, the "image" of interventional radiology, practice organization, and economic issues.

Patient care

The IR clinic helps to optimize patient care by providing the interventional radiologist with the opportunity to meet the patient prior to the procedure and to obtain a pertinent history and physical examination. In doing this, the radiologist can order the appropriate imaging studies, laboratory studies, or interventional radiology procedures. These can be explained to the patient in full and, ultimately, a discussion of treatment options and expectations can ensue. Time spent with patients in this setting is especially helpful with a primary care provider (PCP) referral, as work-ups may be less thorough than those received from a specialist. Needless to say, it is critical in the setting of patient self-referral, as a preconsultation work-up will be nonexistent. Addressing the need for preprocedural labs, radiographs, or referrals prior to any intervention reduces the chance of delay on the day of the procedure. Postprocedure follow-up (often an area in which IR receives criticism) can be coordinated through the clinic, which allows for the recording of more accurate outcomes.

Image

The presence of a clinic can enhance the image of IR in the eyes of the patient and referring physician. Meeting the patient prior to the procedure to answer questions, allay fears, and address concerns relating to a procedure or treatment (perhaps not accurately described by the referring physician) can improve patient satisfaction and increase patient confidence in the radiologist as a physician. It enhances the bond between the patient and physician and avoids the brief introduction to the interventional radiologist patients often receive while already on the table. This may have medicolegal ramifications as well.

The presence of a clinical practice elevates the perception the referring physician may have of the interventional radiologist from an able technician to an actual clinician. The clinic provides a vehicle for more efficient communication with the PCP. Keeping the PCP involved in patient management and apprised of patient progress shows that the IR is interested in participating as part of a patient-care team, and may bolster future referrals. ²⁸

Practice organization

Physician extenders and an office coordinator are integral to an efficient and financially profitable clinic. ^{21,25,26,29-31} Having clinic and procedural schedules coordinated by your own staff, not by the referring physician, is an obvious benefit. This same staff can provide pre-evaluation services, make follow-up phone calls, and address minor follow-up visits, all of which leads to fewer interruptions of the physician's schedule. Those involved in research may find that the clinic affords a convenient location for research coordinators and physicians to meet with patients and family. Having medical records in the clinic allows for easier and more accurate data compilation.

Financial

Time spent with patients and family during initial evaluations and follow-up visits adds a certain level of satisfaction to the practice of IR, but this time is also reimbursable. Accurate coding and billing for evaluation and management (E&M) services rendered by the physician and extenders is obviously important. ^32-35 The clinic also exposes the radiology department to physicians outside the hospital, which broadens the referral base. ²⁵ The financial gains of the IR clinic can also be felt outside the radiology group. The hospital may benefit, as clinic patients often become inpatients, the majority of whom are in the financially profitable short-stay category. The specialists servicing the hospital may also benefit as the clinic can act as a source of referrals to them. ^24,25 Incidentally, this can elevate the standing of the radiologist with the hospital administration and further enhance the reputation and rapport with medical staff.

Clinic structure

It is fortunate an IR clinic can take many forms, as no two practices are alike. Various practice models have enjoyed success. ^28,36-41 The choice of practice, whether it's an independent IR practice, one within a diagnostic radiology group or within a group of non-radiology physicians, or part of a multispecialty vascular center, will likely be determined by local political and economic factors. The size and scope of the IR practice will have a role in shaping the ultimate form of the outpatient clinic. To this end, the clinic should be custom-built to suit the needs of the individual group. There are two basic functions the outpatient clinic serves, regardless of the IR practice model. First, it acts as a portal through which the PCP and patient have access to the IR practice. Second, it provides a means to follow the patient and to communicate with the PCP.

The remainder of this section will include discussions of the consumers' (ie, patients' and referring physicians') expectations of the clinic, clinic personnel, and a brief description of the clinic at the author's training institution. An elaboration on clinic facilities will not be provided, but these facilities are outlined in Table 1.

Expectations

Regardless of who answers the phone and where the examination takes place, the patient and referring physician have certain expectations of the outpatient clinic experience and of the traditional consultant. The patient expects: 1) to be able to schedule an appointment; 2) to meet with a healthcare provider for an evaluation, including appropriate laboratory and radiological tests; 3) to receive an opinion as to treatment options and recommendations; and 4) to obtain eventual treatment and needed follow-up, all in a timely manner. The experience should be made as pleasant as possible. The patient's reception should be timely and the environment comfortable. The time from arrival to first encountering a healthcare provider should be kept to a minimum.

The referring physician expects: 1) to receive a written evaluation regarding the patient's symptoms, history, and examination; 2) to receive a therapy plan, and 3) that the patient will receive eventual treatment of the problem for which the patient was referred, including appropriate follow-up, again in a timely manner. Regardless of whether the IR outpatient clinic is in a stand-alone facility owned by the group, in leased or shared clinic space, in the radiology department, in the interventional holding area, in a physician's office, or in a broom closet, the clinic should function so these expectations are met.

Personnel

The foundation of the clinic is the staff. The secretary or receptionist should be personable and able to communicate with physician offices and patients in a professional manner. He or she should have some basic knowledge of interventional procedures and of flow through registration and the department. This person will be responsible for obtaining patient demographic and insurance information, initiating the patient's office chart, and conducting office-to-office communications. In a smaller practice, radiology reception clerks or the physician extender may fulfill these duties.

The physician extenders should have detailed knowledge of indications, contraindications, risks, benefits, outcomes, and follow-up for the various procedures, as well as an understanding of the disease states for which the procedures are performed. They should be adept at performing physical examinations, determining clinical diagnosis, and facilitating hospital admissions. Nurse practitioners (NPs), physician assistants (PAs), and the relatively new radiology practitioner assistants (RPAs) are the usual options for these positions. They form the backbone of the clinic and spend most of their time involved in direct patient care and education. They perform most of the charting, coding, insurance pre-approval, and scheduling. They can also get involved with outreach programs in the community to increase the awareness of IR services. They can manage minor follow-up visits and can be trained to perform procedures, such as venous catheter placement and removal.

Nurse practitioners and PAs are clinically based practitioners who have received Master's-level degrees. They provide direct patient care incident to a supervising physician. They can perform histories, physical examinations, process admissions and discharges, and are usually required to hold medical staff privileges and state licensure. ⁴² They can prescribe medications and obtain their own DEA registration. Radiology practitioner assistants are radiology technologists who have received an additional baccalaureate degree. They are procedure-oriented and cannot prescribe medication or obtain staff privileges.

The number of office staff and physician extenders required will be determined by the individual practice. Even in a modest practice, a single full-time employee, such as an NP or PA, can easily fill a day with direct patient care and the various duties of PCP and patient communication, insurance pre-certification, medical record-keeping, and marketing efforts. Numerous reports have confirmed the returns on physician extenders exceed the overhead. ^25,26,29,31

Example-- At the author's training facility, the busy IR department (serviced by three peripheral and two neuro-
interventional radiologists) experi-mented with several different practice models. It became apparent that clinic space within the IR department was a necessity. Through discussions with radiology administration, existing space near the angiography laboratory was reallocated to IR and was used to construct office space for the three clinic staff (secretary, NP, RN), an examination room, and a consultation room (Figure 2). The patients are received in the main radiology reception area and are escorted back to the clinic, where they receive an initial evaluation from the NP or RN prior to being seen by the physician. The three-staff members handle all initial and follow-up phone calls, scheduling, coding for clinic and inpatient E&M services, insurance pre-approval, and record maintenance. History and physical examinations, consultation letters, and follow-up courtesy letters are dictated by the MD or NP and are transcribed on clinic letterhead by the secretary.

Obstacles

Establishing an outpatient clinic and practice requires a significant investment of time and resources. ^36,37 Efforts are needed on multiple fronts, and understanding the typical stumbling blocks will make implementation easier. A list of obstacles is shown in Table 2. A compilation of resources for building a clinical practice and dealing with these obstacles is listed in Table 3. The remaining discussion will focus on what many feel is the premier obstacle to establishing a clinical practice: the task of acculturation of diagnostic radiology partners and primary care providers. ^28,36,43

Radiology partners

Our diagnostic partners may be skeptical that increasing the "clinical presence" of the interventional section will lead to increased referrals and revenue. Furthermore, they may be reluctant to assume the costs of establishing a clinic that will pull the interventional radiologist into more time with patients and less time reading films.

Swischuk ²⁸ and Smith ⁴⁴ each suggest the acculturation process may be initiated by starting small and making incremental commitments to the clinic over time. This will temper concerns about the financial commitment of the group. For instance, using available space in the department or office sharing, as opposed to leasing separate space, is a way to show that the interventional section is approaching this cautiously and economically. Informing partners that E&M services are reimbursable and can help offset expenses is important. Also, initially tailoring efforts to the type of patient you want to see in the clinic, so as not to outstrip resources, will help maintain focus on early needs and help one avoid appearing overwhelmed early in the endeavor. Indeed, building up a service or procedure that will have the best chance of success (ie, most needed by the referring physicians) will help garner enthusiasm within the group. Preferably this service will allow referral to the department for imaging, such as MRIs for uterine fibroid embolization or vertebroplasty, or noninvasive testing for vascular intervention.

Partners seeking evidence that investment of the interventionalist's time and the group's financial resources will result in growth and increased revenue should be directed to Swischuk's ²⁸ report of his group's experience. They have seen a 10% annual growth rate in arterial vascular procedures, despite 40% to 55% decreases in referrals from cardiology, cardiovascular surgery, and peripheral vascular surgery. Referrals of arterial vascular cases from PCPs increased 228%. An additional reference in support of enhancing the clinical practice is a study revisiting the admitting practices of university-based interventional departments. The original 1989 study by White ²⁴ reported that only 33% of these IR physicians admitted patients. In comparison, just 10 years later Wysoki et al ⁴⁵ reported that the number of patient-admitting IR physicians had risen to 78%. In addition, 52% of respondents to Wysoki's survey had a clinic and 71% used physician extenders.

Referring physicians

Acculturation of the referring physician presents a challenge as well. Convincing them that the interventional radiologist is a legitimate clinician who can evaluate and manage the patients they traditionally referred to a vascular surgeon or cardiologist will take considerable efforts. The attitude that radiologists in general are not "real doctors" is deeply entrenched. The PCP is not accustomed to referring patients directly to interventional radiology for an evaluation and recommendation for treatment.

To overcome these attitudes, Swischuk ⁴⁶ offers the following series of suggestions. First, communicate with the PCP. Use all vehicles at your disposal (phone calls, reading room discussions, grand rounds, hospital news letters, etc.) to inform them of the services you can provide to their patients, your level of knowledge of disease processes and patient evaluation, and your willingness to manage their patients' problems. Communicate with the patient as well. An informed and satisfied patient may prove to be your best disciple as he/she reports back to the PCP, family, and friends.

Second, being "user-friendly" will make the PCP's job easier. The less they have to "tee-up" the patient, the more they will see the interventional radiologist as a legitimate clinician who can work up and manage patients. Ultimately, all that would be asked of the physician is the patient's name, phone number, and permission to contact them to set up the evaluation. Third, don't forget your roots. Inform the PCP that, as a radiologist, you are the specialist best suited to tailor the imaging evaluation to the patient's needs and other medical conditions. Finally, the best business plan for courting the PCP is to take good care of their patients and involve them in the decision-making process.

Future expectations

The presence of a clinic will alter the daily practice of most interventional radiologists. They will need to dedicate more time and energy to direct patient care and maintaining clinical skills including physical diagnosis, clinical evaluation, health maintenance, and risk modification. They should encourage their support staff to attend continuing medical education (CME) activities and participate in professional societies. Referrals from cardiology and peripheral vascular surgery will decrease, as vascular intervention will likely be open to them. Interventional radiologists will need to gain referrals from PCPs and maintain a diverse practice.

Graduates from the new IR residencies will require a solid clinical foundation to compete. Formal training will be required in not only clinical evaluation of patients, but also in coding and billing, practice development and management, and vascular biology and medicine.

How competition is viewed will change. As a more credible, clinically oriented specialty, IR will be poised to "co-evolve" or "vertically integrate" with whichever specialty shows appropriate interest in the advancement of all image-guided therapies, with the goal of leading the field. ^8,12

Conclusion

Clinical practice building will play a key role in the ultimate survival of interventional radiology and in keeping radiologists involved in image-guided interventional procedures. In the current competitive market where the concept of IR turf and credentialing is no longer valid, the patient becomes the currency and the product is the ability to render a valuable service. The SCVIR leadership and numerous editorials in the radiology literature recognize the need for interventional radiologists to develop their own clinical practice, complete with a solid referral base of PCPs and patients they control, in order to compete in the current market. Medical economists and most clinicians already know that if you see patients in clinic, the procedures will follow. ⁴⁷ Establishing a clinically oriented specialty, credible in the eyes of the PCP, will help in branding the interventional radiologist as the leader in the robust future of image-guided therapies.