Ep. 90: Live where you want, work where you're needed

The following transcript was generated and edited using AI.

Narrator: In this episode of The Kinked Wire:

Ian J. Wilson, MD (episode clip): “I really have to give the rural setting its due, because it’s the place where you can have a quiet day of doing every day, bread-and-butter things, but at 4:30 you’ve got to do a really complex embolization for an acute GI bleed, because the GI specialist you know very well, who’s very talented, is asking you for help.”

Narrator: Dr. Dana Dunleavy explains why collaboration between primary care and specialists like interventional radiologists is so essential in rural communities, plus how he has made connections that result in patients getting the care they need.

J. Dana Dunleavy, MD: This is Dana Dunleavy, interventional radiologist in Buffalo, New York. I’m very excited to host a Kinked Wire episode with one of my fantastic mentors, Dr. Ian Wilson. Ian, welcome to the show.

Dr. Wilson: Thanks, Dana. Thanks for having me. Glad to be here. The “mentor” distinction makes me sound old.

Dr. Dunleavy: Yes, but as close as we are, it’s funny when you start at the early part of training. Those are the memories that never fade, right? Those early, impactful lessons learned, both technical and clinical, but also life lessons as well. So, lifelong. I appreciate it.

Dr. Wilson: Good to know. Good to be that.

Dr. Dunleavy: With that being said, can you start off by telling us a little bit about yourself, including where you did your residency and fellowship training?

Dr. Wilson: Sure. I’m a Brooklynite transplanted to Rochester, New York, in the mid-1990s. I attended the University of Rochester School of Medicine, graduated in 1999, and went back to New York City to do a transitional year at New York Hospital Queens in Flushing. I knew I was coming back up to Rochester, so I learned how to snowboard during the winter of my intern year. I started residency in 2000, served as junior, senior, and chief resident there, and did my fellowship there as well. I joined the faculty of the University of Rochester after my formal training and stayed for about 10 years. As much as I like to claim being a Brooklynite, I’m more of a naturalized Rochesterian than anything.

Dr. Dunleavy: Love it. Since we’ll discuss some of the advanced procedures, like prostate artery embolization (PAE), can you talk a little about what things were like at the time of your fellowship and your early academic practice, and then about how you built your own office-based lab (OBL)?

Dr. Wilson: Sure. When I finished my training, which began in 2004–2005 with my first year of fellowship, I then did a second-year, advanced fellowship. The emphasis at that time was on peripheral vascular and endovascular interventions. Interventional oncology really hadn’t taken on much of the volume of IR work, especially in academia. It was on the horizon, but it hadn’t developed into what it is now. So what we had was peripheral vascular disease and embolizations.

I took a particular interest in learning how to perform embolizations, chiefly uterine fibroid embolization. As I always tell folks in training, that’s one of those procedures that gives you a strong foundation for other embolizations, like prostate artery embolization, because it’s where you gain your microcatheter skills, develop respect for variant anatomy, and learn to negotiate very small vessels. It’s also very prevalent. I think I did the lion’s share of those when I was a fellow, along with the peripheral vascular work.

But that was the extent of what I learned about interventional radiology as a fellow in training. So much of what I practice now, I learned after formal training had stopped. Prostate artery embolization, for instance, didn’t exist at the time, at least not to my knowledge, in 2004–2005. We weren’t doing anything like that in my fellowship or at my academic center.

Nonetheless, in your professional life, you have opportunities to learn on the job. That’s what I did as a practicing interventional radiologist, along with some spine interventions, thanks to Dr. Dana Dunleavy. I’ve put those in my tool belt. There’s a lot you can learn after your formal training stops. Formal training gives you a good foundation and some ability to think through problems, and I think that’s what you can take into practice as an attending in whatever setting.

Dr. Dunleavy: A lot of great points there. One thing I think we all realize is that we come out of fellowship with a lot left to learn, and it’s great if you end up in a practice right afterward where you have good mentors. And like you said, many of us consider prostate artery embolization to be arguably the most technically challenging procedure we do. I think both you and I were a little reluctant at first, because we like to let things play out and make sure a procedure is efficacious and durable.

But I’ve had the fortune of watching you do cases, whether it’s PAE, selecting the inferior vesical artery, or pulmonary thrombectomies and getting across from the right to the left. You make procedures look almost too easy, and elegant. I think that comes back to the foundation you mentioned, really understanding wire and catheter skills. Do you want to talk a little about where that foundation came from, and how you took it to PAE when it wasn’t part of any of your training?

Dr. Wilson: Sure. I was one of those IR nerds. When I was a resident, even if I wasn’t on the IR rotation, I would float to the IR section and ask if there were any cases. Because I was such a nerd, I was quite facile with tunneled central catheters as a resident, even before my fellowship. I would do a case and then continue on with my day or go home. But I had to touch a wire and a catheter. I was one of those residents who couldn’t get enough.

I think that strong desire to learn how to do IR procedures was coupled with an appreciation for some of the engineering that underlies it. One of my attendings when I was a resident was the nuclear medicine chief, Dr. Vasim Chingazi, who knew everything about nuclear medicine. You could not stump this guy. You could ask him any question related to the field, and he could answer it. It was impossible to throw him a question he couldn’t answer. So I wanted to be that for IR. I learned about catheters, braiding, tolerances, and different constructions of polyurethane. I mean, that sounds nerdy enough, so I’ll stop there.

But that’s where the foundation was: my strong desire to learn as much as I could about this really cool thing I had discovered, which became my career. The interest I had couldn’t be satisfied. I wanted to learn more and more and more about IR. And I’m glad I did, because I’m still that nerd to this day.

Dr. Dunleavy: That is awesome. And like you said, for me in the spine space, you can always take a procedure and modify it because of that foundation. For you, it’s always been the complex endovascular cases. I guess I have two questions. First, when we leave fellowship, most of us have a perception that all complex cases live in academia. Then I think we see that they can also exist in private practice if we’re committed to it. And the last thing we realize is that rural areas are actually one of the easiest places to advance a practice, because the need is so great and the collegiality is so strong that people really support innovation. Do you have any thoughts, since you’ve practiced in all sites and settings?

Dr. Wilson: Absolutely. You’re 100 percent right. When you finish your fellowship, usually in an academic setting, you have to make a choice. Do I continue in academia to do this really cool stuff I spent a year or two learning, or do I give it up for more bread-and-butter IR work, such as biopsies, drainages, and maybe venous access here and there? But embolizations, probably not. Peripheral vascular disease, definitely not.

Unless you are in a setting where, and this is where I really have to give the rural setting its due, you can have a quiet day of doing everyday, bread-and-butter things, but at 4:30 you’ve got to do a really complex embolization for an acute GI bleed, because the GI specialist you know very well, who’s very talented, is asking you for help. And it’s not a situation where you can look left or right and see another colleague. It’s you, and that’s it.

So I think the rural setting is where you get called on to do some really advanced things every now and then that you’re glad you had the training for. Even if you haven’t practiced it day in and day out, that stuff comes back. I don’t know where you pull it from, but whatever folder in your mind you click on, up comes your ability to rise to the occasion. Rural practice can surprise you. You can find some really tough cases in the middle of America, in places where travel to the next major center would be a great burden. This patient can’t travel. You’re it.

So the rural area is absolutely a place where you can practice some of those advanced things you learned in fellowship. It might not be every day, but the community is going to call on you to provide that care at some point.

Dr. Dunleavy: And like we said, you’ve been around quite a bit. We could talk about some of the underserved hospitals you’ve helped, from our home base in New York to Maine to those rectangular states in the middle of the country that you mentioned. Can you touch on [inaudible] General Hospital? They’ve brought on a new urologist who was trying to innovate care similar to what he had in his fellowship, and in my opinion, the reason he was able to do that is that you were there to support everything he needed on the IR side. I think there are quite a few things there, from nephrostomy tubes to nephroureteral stents to PAE, even cryoablation. Can you talk about some of those procedures you offer there and how you have helped him along the way?

Dr. Wilson: Absolutely. One of the great things about the rural setting is that you can often paint your own picture. It’s like a blank canvas. The community and the hospital have no reason to doubt that you can do what you say you can do. They see your credentials, and then you have an opportunity to paint some part of the picture. No one is telling you how to do it. You’re not being prescribed how to do something. There’s no boundary within which you have to practice.

You can gain a lot through cordial, collegial relationships with specialists, like the eager young urologist you’re mentioning, who is very active and very aggressive in performing lithotripsy. The access we gain is much appreciated. This is also someone who, because of that rural setting, is “it.” When they call on you, you’re it. Giant prostates are hard for anyone to manage no matter where you are in America, but especially in a rural setting, where you want to provide as much care as you can in that community to minimize the need for travel to a distant center of excellence. Now you can be that for this community. We were able to work together to provide endourologic support, if you want to call it that, for rather complex cases: some ileal loop anastomotic issues, PAE on giant prostates.

Playing that supportive role is where I think we can definitely make strides, especially if you see what you do as complementary to someone else’s work. It’s not necessarily for us to be front and center all the time. But if you have the personality and posture where you want to be helpful, you want to serve the community, and you want to help your fellow physician, great. You’ll find a lot of opportunities to do that. I have no need to be the center of attention. I just want to do a good job and know that I’ve given my best to that community. It’s about being collaborative. If you share the goal of patient care, there’s really no limit to what you can do.

Dr. Dunleavy: I know that you’ve received PAE referrals from the local urologists in Olean, but also from a urologist in Jamestown, which has its own rural hospital but doesn’t offer PAE. Can you address how you handle pre-op and post-op management? Most people perceive that IR physicians in rural settings don’t have a clinic.

Dr. Wilson: Right, exactly. As a specialty, it’s not widely known that IRs have a clinic of any kind, no matter where they are, but thankfully that’s becoming more the rule than the exception. What these doctors really appreciate in the community is when you send a patient to a clinic and you’re the one seeing them. You’re the one taking control of that patient’s workup, whether it’s urodynamic studies that you send to a urologist because the referral is coming from a family doctor, for instance. You’re helping that family doctor take care of his or her patient by taking ownership of that patient and the patient’s pre-procedural workup. They send you a patient with a problem, and that’s it. I’m not relying on anyone to order my tests. I’m not relying on anyone to manage my post-procedure care. We do that.

I remember years ago, when I was a student, one of the chief residents on my surgery rotation said, “Until IRs take care of patients, what they do is going to be done by other people.” Having a clinic, seeing your patients pre-procedure, and maintaining contact with them post-procedure keeps you front of mind with these referring doctors and your specialist colleagues. It gains you the respect of people who take care of patients day in and day out, who may not see us as also taking care of patients day in and day out, even though we do. Most of what we do is procedural, but there’s a patient involved. It’s like the saying goes: No one cares how much you know until they know how much you care. And you demonstrate that you care about these patients by managing them pre-, intra-, and post-procedure.

Dr. Dunleavy: That’s a great point. Since you built that clinic in Olean, I know you recently did an educational event for the emergency department and hospitalists about osteoporosis and vertebral compression fractures. Have you found that you’re getting referrals to your clinic from specific sites, or also from the emergency department?

Dr. Wilson: Oh my gosh, let me tell you, it’s like a shot in the arm to speak to the emergency room doctors and give them yet another disposition option for their patients. What do you do with the patient who doesn’t need to be admitted, who might take up a bed, and you’re just managing their pain? Now you can say, “Tell you what: you go to the interventional radiology clinic on X day, and Dr. So-and-so is going to manage your condition and take care of you from there.” It’s a great thing to be able to have.

Another reason you should have a clinic, especially in a rural setting, is that physicians have a place to send their patients. You need a place to see folks not immediately pre-procedure, but where you can be a resource to the emergency room for the patient with back pain who doesn’t need to be admitted but needs to be managed. Sometimes the ED doctor, depending on how aggressive they are, can get you some of your pre-procedure imaging. That’s the benefit of these dinners: when they hear how you think about these problems, they can preemptively take one or two steps in that direction on your behalf. Then, when you see the patient in the clinic, it’s just a matter of booking the case. But that comes from having face time with the community, with the emergency room doctors, and with the primary care physicians, letting them know, “All you need to do is send the patient with a problem, and we’ll figure it out.”

Dr. Dunleavy: That’s a great point. One of the many rewarding aspects of being in a rural hospital is that, following your events with the emergency department, they said, “We already have your phone number and your fax number, but can you give us a list of procedures and when we’re supposed to refer?” So, urinary retention: they can send those patients to you for PAE. Or compression fractures. They seemed very motivated to see how they could care for patients. It’s a different type of excitement, I think, in rural areas, where everybody knows that if they don’t provide the care, the patient is likely not to receive it.

Dr. Wilson: Right. One of the secondary gains is the community’s understanding of some of these conditions. I’m talking about the non-medical community, because now you’re treating a higher number of people who reside in the community with these conditions. It’s becoming, I guess you would call it, not necessarily literacy, but awareness. You’re increasing the community’s awareness of the options they have for care. So they may have a granddad or a dad or a mom who went to the emergency room because she fell and had excruciating back pain, and found she had a compression fracture, and these doctors put cement in the bone, and now the pain went away. Now they have that as a story. It becomes part of the family anecdote. It becomes part of the local knowledge that when you have certain conditions, the care is not that far away. So yes, I agree: there are definitely collateral benefits to that outreach.

Dr. Dunleavy: Just to draw back to earlier times, when do you think you first recognized the need for IR in rural areas?

Dr. Wilson: It goes back to an experience I had with a radiology group that provided a lot of diagnostic care in rural areas. There were some on-site interventional radiology services, but I never understood how large the need was until I went out into the North Country and the Southern Tier of New York, where hospitals are very far apart. You’re talking about 30 minutes, an hour, two hours to the next hospital. And you realize that your presence there has, in an instant, elevated what’s possible.

So it took some experience on the diagnostic side, seeing what was being done. You read studies and think, “Oh, this probably could use a drainage,” or “Oh, yep, there’s a PE, there’s some right heart strain.” You hope there’s somebody out there who can do something about this patient, especially if they’re leaking enzymes. But you realize that the need is greater than we think.

I think this is a tip-of-the-iceberg situation, where a lot of us doing teleradiology see the pathology that’s out there in rural America, but what’s lagging is the resources to treat what we find. It was actually through some diagnostic work, teleradiology work, that I realized how much pathology was out there. But the options to treat what was found were virtually nonexistent.

Dr. Dunleavy: It’s interesting, too. There’s all this talk now of whether AI is coming for your job, and nobody’s saying that about someone who’s actually there in person taking care of patients in rural settings. We find that we don’t even have many physician colleagues there anymore if people are able to do that work, like you said, as a form of teleradiology or in some other way. What I was getting at is that we haven’t seen underserved areas getting better. We’ve seen them getting worse. Do you believe that’s the case?

Dr. Wilson: I wholeheartedly believe that. Just to riff on what you mentioned about AI: we do more studies in a shorter period of time, so you find more pathology per unit of work. You find more disease. And then, by virtue of what you found, you create demand for interventions to address that pathology.

Dr. Dunleavy: Wholeheartedly agree. The more you scan, the more you find, and the more you find that’s actually legitimate. We’re not talking about incidental findings that could be biopsied to potentially guide some treatment. We’re talking about real issues that, if the patient were in any other location, would lead to treatment. But we find them in rural settings, and perhaps the management is purely medical, or care is prescribed but delayed by the distance to the physician who can provide it.

It’s just a growing problem. And honestly, until we as a specialty, or as organizations or companies, develop the means to address that need, the future could look very different for us. Not because of AI, but because other specialties and other medical professionals could fill the gaps that we don’t fill ourselves. So maybe that’s a motivation for some people. I know it is for us.

And I think you recognized it very early on. I’m also very thankful that SIR, through the Small and Rural Practice Committee, is creating awareness nationally and trying to support physicians who are interested in moving to these areas. You’ve talked in the past on other platforms about how working in underserved areas is arguably the most rewarding work we can do, and also that it feels like a calling for you. Can you address that?

Dr. Wilson: Absolutely. I was born and raised in Brooklyn, New York, and even a place like that has care deserts: places where the need is high and the compensation can be challenging, but where there is no question about the service to humanity that is required.

In resource-challenged parts of the country, you can look at what you do professionally as having real value, and what you do has a multiplier effect. You help ensure that the family structure is maintained and that traditions get passed on. You can preserve the dynamic of a family by providing a service in an underserved area, be it rural or urban. Some of our urban centers are equally underserved. We may not think so. We think cities can take care of themselves, but they often don’t. They often concentrate resources in certain areas of the city, leaving other places underserved within city limits.

So if you look at the skills you have, whatever talent you bring to this field, and think about how you would make the most impact with what you’ve been given, I think looking at underserved areas is almost the only arena where you can have an outsized benefit to the community.

Dr. Dunleavy: That’s fantastic. As we near the end of this, I think of a wise man, Ian Wilson, who once said that we can live where we want and work where we’re needed. I think a lot of people, both in practice and coming out of training, are interested in what resources there are that may not necessarily go through recruiters. We think of Shamit, who has started PSS. And then there’s your work as the CEO of [company name unclear]. Some people call it “traveler,” some people call it “travel IR,” which gives a feeling of short-term contracts, which usually live with Shamit’s company, and long-term contracts, which usually live with yours, as you try to establish a stable response to this need. Can you tell us a little about it, and what you see as the opportunity both for people coming out of training and for people with years of experience?

Dr. Wilson: Absolutely. When we’re talking about doing the things you were trained to do in various settings, what we are doing is looking for areas of need and trying to solve those needs creatively through management services and organization, as well as the obvious staffing needs. I often say that the staffing part of our solution is almost a given. Yes, you need a well-trained interventional radiologist to do the work. Absolutely. But is there a way to provide a comprehensive suite of services that would keep the person fulfilling that staffing role stimulated as a professional? You’re not just doing what you’re being fed. You’re going out into the community, solving a need, and providing and actively promoting services, so that patients who wouldn’t otherwise make it to you passively come in and there is an influx of advanced cases.

I would challenge anyone who is near graduation, or who has graduated and may be doing some teleradiology now, as I do, to look at opportunities to provide these advanced services in rural communities.

What makes the adage you mentioned true, “live where you want, work where you’re needed,” is that you’re also working with a team of like-minded people who may carve out a week a month to work in some other part of the country, but to do so on a consistent basis, so that you can build relationships, be part of a community, and see the effects of what you do on a regular basis. I think there’s some comfort on both sides, the provider side and the community side, in “Oh yeah, Dr. So-and-so is in town. This is what’s happened since we saw you last.” Or, through telemedicine, you can meet people and talk to patients even when you’re not there, to tee things up. I used to do that: have a telemedicine call and then say, “Okay, see you Monday.” And when the patient sees you, the smile is so big, and the hugs. This morning I did a case, and the patient’s family said they wanted to at least give me a hug, because now we’re putting a face to the name.

So there are opportunities out there. Along with other entrepreneurial physicians, we are putting physicians back into the healthcare equation. I always talk about healthcare being… medicine is ancient. What we’re doing for other humans is very ancient. Healthcare is modern. So these companies we’re developing are being built within the healthcare ecosystem to address problems the way physicians know them and to create opportunities for the next generation.

Dr. Dunleavy: Really, really interesting. As you described, there’s sometimes the ability for a hospital to recruit a physician who is able to move to that rural area. But you also described another solution that provides longitudinal care and continuity to a rural hospital: a physician who goes consistently one week per month. They don’t have to uproot their family, but they can still provide those critical services to that area. I think you noted that there are two ends of the bell curve. There are the people who are new out of fellowship and very interested in this work. But I think a lot of people didn’t recognize that there are also many people with tremendous experience who might not want to work full force, full time, anymore. Working one or two weeks per month actually provides a new type of independence for them.

Dr. Wilson: Absolutely. I remember having a conversation in Tanzania. I’m also a faculty member for the Road to IR program, based out of Emory and Yale. During one visit, I think in 2023, I was talking with another faculty member who had traveled from the United States, someone who is maybe five years or so older than me, thinking about how to manage the next chapter. You’ve got someone with decades of experience who can do anything. I mean, these people are wizards, Jedi, who can do anything under the sun. And here’s a way to keep those skills fresh, to keep doing what you’ve done for tens of thousands of patients, one week or so a month.

That’s something I would honestly think about if I were at that chapter of my life. The time commitment is less than it was as faculty or as a member of a private practice group. One week a month, I travel somewhere and make a vacation out of it. “Okay, wow, there’s a lake nearby.” So I do my procedures, I spend my evenings on a lake, and I’m competitively compensated for that week a month. I think it’s a pretty decent deal, especially if someone is thinking about transitioning from full-time work, whether in academics or diagnostics, into something of a semi-retirement phase. I think this is a viable opportunity for folks in that cohort who have tremendous skill and knowledge, who can absolutely make an impact and do significant work in communities of need.

Dr. Dunleavy: To some degree you addressed it right there, but I know one of your commitments in this new phase has been not only satisfying the needs of rural and underserved hospitals, but also providing a means of independence for interventional radiologists. Can you touch on that?

Dr. Wilson: Absolutely. Again, we talk about things that didn’t exist when we were in training, and then we see a need that does exist in the world. Instead of waiting for a solution, we create the conditions for that solution to be implemented in the world. One of the things we’re able to do is create a viable path for someone to work as an independent physician. Lots of other specialties provide services on an independent-practitioner basis, but it’s not so prevalent in our community.

There’s a certain literacy that accompanies the status of independent interventional radiologist. People like us, who are independent and have been practicing independently for some time, know those things intuitively, and sometimes we learned lessons the hard way, because when I graduated fellowship, there was no such thing as an independent interventional radiologist. What does that even mean? Who do they work for? What hospital is it? You’re talking about a practitioner with a valuable skill set who’s working for themselves. That model didn’t really exist. If it did, there were only a handful of people in the country working that way, and they were usually part of some kind of group.

But now, in this day and age and in the future, you have the opportunity to be an independent interventional radiologist, contracting your services to organizations that have contracts with hospitals. Essentially, you’re a subcontractor, but you are your own business in that capacity. There are a lot of things that go along with that, as you become the entity that is the business itself. Like Jay-Z said, “I’m not a businessman, I’m a business, man.” So you’re the business. What do you know about business? What do you know about contracting? What do you know about accounting? What do you know about tax preparation as a business owner? Those are the things that people who have gone that way can help folks who are interested in this kind of work navigate.

Dr. Dunleavy: That’s very cool. As we round this out, do you have any closing remarks you’d like to make, whether about PAE, the clinic, or the opportunities in underserved communities?

Dr. Wilson: Absolutely. With any new procedure, PAE for instance, I think it’s important to spend as much time as you can with people who have done high volumes of PAE. There’s a lot of variant anatomy to learn, so there are didactics anyone should do if you want to take on PAE as a new tool in your utility belt. Again, it’s not something I learned as a fellow, but I did learn complex microcatheter work. Any time you have to do that, whether it’s in trauma or with fibroids, take advantage of the opportunity to practice your microcatheter skills. Spend time with people who have high volumes of PAE, or whatever procedure it is. It could be spine interventions. Spend time with people who have enough of a caseload that they can familiarize you with the nuances, some of the pitfalls, and some of the troubleshooting.

But also realize that when you add this procedure to your armamentarium, you may be called on to provide that service in an area that is underserved. What a benefit to that community you will be when you provide that PAE or spine intervention case in an area that has never had it, or that is very far geographically from anyone else who can do it.

Dr. Dunleavy: That’s awesome. And I think it’s probably good for people to know that, along with everything you just said, there have been many times you’ve provided support for people in rural centers, either remotely or by going to them, to help them get off the ground. A lot of people clearly want to do good for their community and region, and they want to make sure they’re doing the best possible job. So it’s nice that you’ve provided such great resources, and that those resources are more available than people think.

Dr. Wilson: Absolutely, they are. A lot of us who have taken on the challenge of being independent, and of creating services and practices in places where they didn’t exist before, have a lot to teach. There are a lot of lessons we’ve learned on the path to our present level of practice that can be immensely instructive and help folks avoid some of the pitfalls that exist. There are always challenges, but having the benefit of someone else’s experience can help you avoid potential hurdles that could otherwise derail a well-intentioned person from doing good.

Dr. Dunleavy: Ian Wilson, thank you for your time and your passion. This is Dana Dunleavy, signing out from The Kinked Wire.