by Neil M. Khilnani, M.D.

Venous insufficiency (VI) and its complications are among the most common medical problems affecting western societies. With a long history in diagnosing and treating venous diseases, Interventional Radiologists are one of the largest groups of physicians involved in caring for such patients in the United States. However, many perceived issues and real issues serve as impediments that discourage and hinder the majority of IRs from offering this care.

The contemporary care of venous insufficiency is primarily delivered in outpatient offices. The patients are seen at these sites for their original consultation and then return for minor procedures, duplex ultrasounds and follow-up care.

Until recently, almost all IRs had been organized into groups that focus their clinical activities in the hospital setting. IRs have traditionally been very procedure oriented with the majority of them having limited or no outpatient office space and minimally involved in outpatient pre-procedural and post-procedural care. The IRs have depended on procedural referrals primarily from acute care facility medical and surgical physicians.
IRs with thriving phlebology practices have adapted to this role in order to be able to accommodate outpatient care and its related demands. They have established an outpatient presence that facilitates a positive patient experience as well as provide the necessary financial benefit to make such health care delivery feasible.
The difficulties in developing an office practice have been the major obstacles cited by those IRs who want to expand their phlebological care but have not been able to do so. Several of the more commonly noted challenges with office development include:

• No time available away from the clinical demands of the hospital practice
• Limited experience for organizing, staffing and managing an office practice
• Capital expense to have the office and supplies
• Concerns about developing sufficient volume-to offset the practice costs
• No experience in patient marketing and assessing its results
• Opportunity costs associated with partners being away from the hospital

These challenges are not unique to IR as most office based procedural physicians have many of the same issues. In other clinical specialties generations of physicians have operated outpatient offices and subsequent generations have learned how to organize and manage these entities when they join. There are very few surgeons who spend all of their time performing procedures and not seeing patients in an office setting before and after treatment. In the IR profession there has been little experience in developing the model to do so and most will need to learn to do so themselves. IRs often have a difficult time convincing their general Radiology partners of the importance of having and staffing an office
practice. This challenge is not encountered by other physicians who
provide direct medicare care to patients.

It is quite clear that for IR to flourish, they will need to be more involved in managing their patients clinical problems rather than just being a provider of high quality procedural care. This is not unique to Phlebolgy but to other parts of an IRs practice. Such an approach will naturally lead to improving the patient experience and outcome as well as facilitating the IRs in branding themselves as clinicians with particular skills to attract physician and direct patient referrals.

There are several practice models for the IR to begin an outpatient clinical operation. Some choose to start the practice in the hospital-based environment. They do so "between cases" in facilities improvised for the role. Unfortunately this approach is flawed from the onset and rarely works well practically or financially beyond the infancy of a program. It is clear that a dedicated space and time away from the hospital based practice rigors is best for the physician and their patients.

Another incremental approach has been to physically incorporate a nascent IR practice into an outpatient radiology office. This concept has some advantages in up front capital expenses as well as the synergy it can utilize with regard to staffing and equipment.
In most cases, as the clinical practice grows, the IR will need to develop a separate IR office. Ultimately the branding of the IRs practice will be important for growth and having a separate identity and physical plant from the rest of Radiology will be important. This obviously will take commitment from the IR group as well as the Diagnostic Radiology partners.

Getting referrals for patients is easier than most IR expect. Ultimately, when you provide good service the word gets out. Making sure the IR is well trained in the disease entity and skilled in the treatment and diagnostic techniques is an essential. Interested IRs seeking to establish their Phlebology qualifications beyond their SIR CAQ can now do so by acquiring Board certification by the American Board of Phlebology.

It is just as important for the IR is to be prepared to provide the full spectrum of treatment options to the patient, including sclerotherapy and phlebectomy and not just limit their quiver to endovenous ablation and embolization. Societies like the American College of Phlebology and the Society of Interventional Radiology are offering much of the training needed to develop the additional skills. The American College of Phlebology Annual Congress in November includes a comprehensive review of the displine on its Pre-Congress day. It also provides cutting edge, refresher and practice management symposia over the remaining 3 days. The 2008 meeting is in Marco Island, FL November 6 through November 9.

Leveraging established medical referral patterns, especially utilizing colleagues in OB/GYN, family practice and internal medicine and making them aware of the IRs skills is an easy way to begin marketing. Wound care centers and emergency rooms are always looking for physicians to whom referrals for venous disease would be well received. Physician oriented informational newsletters, lectures and emails also are useful.
Direct patient advertising, patient information conferences and mailings can help bring patients attention to your skills. Nowadays, patients do a great deal of medical and physician research on the Internet and investing in an informative and attractive website will be essential.

However, for many IRs, the risk associated with such practice developing is often too foreign and frightening. Some IRs have found partnership arrangements with entrepreneurial groups for services which specialize in practice setup and management a more comfortable path. Organizations exist to set up all forms of medical practices and are available to help with creation of business plans, facility planning and selection, office set up, staffing, work flow management and marketing. These organizations include those that are purely consultative, those that will engage in joint capital ventures with the physician and those that make the entire capital investment and sublet office time to a physician. Some of these practice management companies are sub-specialized to serve the needs of IRs in developing outpatient practices and others are more disease specific including those dedicated to Phlebology. These companies often consult to help physicians make practice protocols, staff recruiting, creation of documents, inventory purchases and even contract negotiations with the parent Radiology group.

Setting up an outpatient office has been one of the major impediments for IRs wishing to expand their Phlebology practice. However, none of the obstacles are unique to IR and Surgeons, Dermatologists and other physicans encounter similar issues. The first step is to recognize that an outpatient office practice is essential to IRs, particularly those involved with Phlebology.