Solo practitioner finds ongoing success in full-service menu

Any reputation for excellence that Roxborough Memorial Hospital in Philadelphia might have tends to be eclipsed by its larger academic neighbors. Dr. Robert Worthington-Kirsch, however, wouldn't trade the small-town flavor of Roxborough Memorial for the publish-or-perish world of academic centers. It helps that he doesn't need to, as he is one of a handful of successful solo interventional radiology practitioners in the nation.

Worthington-Kirsch built his practice, Image Guided Surgery Associates, on uterine artery embolization. Today, UAE accounts for half of his work, while superficial vein therapy including endovenous ablation and injection sclerotherapy occupy about 25% of his time. The rest of his schedule includes typical interventional procedures generated by the hospital: drainages, biopsies, PICC lines, dialysis catheter placements, and runoffs.

He adds new procedures to his menu as appropriate. He has just begun to perform vertebroplasty and has also added a nonsurgical birth control procedure that involves tubal implants. The implants, called Essure, were originally designed for placement under a hysteroscope, but Worthington-Kirsch says his approach, which is fluoroscopically guided, is at least as fast and convenient-and perhaps provides greater accuracy in positioning and placement.

The suite of procedures Worthington-Kirsch performs melds together nicely, he said. After he treats women in their 30s and 40s for fibroid disease, he discusses fertility issues. Recent studies have shown that full-term pregnancy is possible for women who have undergone UAE. Varicose vein disease is common in the same population of women as they get older. These patients will often refer their male partners for vein treatment as well. As this population continues to age, osteoporosis can take hold, resulting in vertebral fractures, treatable with vertebroplasty. Women may first arrive for varicose vein treatment but subsequently want to be evaluated for fibroids after reading about the disease in the office brochures. Either way, his patient population and his services complement each other.

For much of his career, Worthington-Kirsch worked in urban hospitals, performing procedures that confirm cancer or prolong lives that, at times, were of less than desirable quality. He did not achieve a high level of satisfaction with this work. But that has changed with his current focus on UAE and venous ablation. While people don't die from vein disease or fibroids, they often have severe limitations, from being housebound to shying away from normal social activities.

"I have many patients today who tell me that I've given them their life back," Worthington-Kirsch said. "It's very gratifying."

WHAT'S IN A NAME?

Interventional radiology has continually struggled with its identity. The Society of Interventional Radiology, after many surveys of patients and practitioners, deleted "cardiovascular" from its name several years ago. The organization hoped the move would raise IRs' public visibility, eradicate barriers that have slowed practice growth, and distinguish IRs from cardiologists. Since the name change, however, IRs have increasingly taken on more vascular work. During a recent SIR symposium on cardiac CT angiography, one audience member quipped that the SIR should put "cardiovascular" back into its name.

IRs also struggle within the world of diagnostic radiology. While the subspecialty has been around for decades, it wasn't until 2001 that the American College of Radiology formally recognized it as a separate class of radiology alongside diagnostic imaging, radiation oncology, and nuclear medicine. This move was supposed to help diagnostic radiologists recognize that interventionalists need to develop practices, including face time with patients, and should not be forced to read images in every spare moment.

Some larger academic groups with good supplies of labor might make time for clinical rounds, but it's a different story in private practice. Worthington-Kirsch said he occasionally gets calls from interventional colleagues complaining about their diagnostic brethren, who question money earmarked for an IR office and support staff. Diagnostic radiologists often don't understand the need to see patients, and say that E&M (evaluation and management) services don't make money. The common refrain is, "You should be reading film," he said.

"If an IR can't sit down and have a partners meeting and decide to make it work, whether that means hiring another radiologist or a PA to do the nonprocedural care, then the IR should leave the group," he said.

Worthington-Kirsch left his group in 2001, spurred by similar concerns. After a full day as an IR, he would find himself on the receiving end of a courier package containing 50 mammograms to be read because a colleague left early.

"That was intolerable, especially considering that more than half of the income stream I generated for my group was being used to support the rest of the group-to pay group overhead, to pay for other physicians' salaries, people who weren't doing procedures, who weren't generating as much money," he said. "I've got five kids; I can use that money more than my employer can."

His practice model is indistinguishable from that of a general surgeon. He sees patients, evaluates them, and works them up. Some patients have ongoing problems; others have only one intervention-related problem. He determines the proper course of treatment. He follows up afterwards. He is an interventional radiologist. Why, then, is his business called Image Guided Surgery? Part of it is marketing, he admits.

"Someone once said that being an internationally famous interventional radiologist means that somebody besides your mother knows what you do for a living," he said. "I call my practice Image Guided Surgery Associates because I think it gives lay people a better hint of what I actually do than the relatively cryptic term of interventional radiologist."

TIPS FOR SUCCESS

Within five months of leaving his group, Worthington-Kirsch opened his solo practice. It has been profitable from day one. Fortunately, his referral network followed him. He continues to attract business for elective procedures such as UAE, biopsies, and arteriography. But Worthington-Kirsch is no small business wizard. He made initial mistakes-such as advertising in the wrong publications and on the wrong radio stations. But what he did right overshadows what he did wrong. Hiring a team of advisors was the most important step he took.

"From the time I started thinking about going solo to notifying my employer and then actually opening my own doors, I built a team of business advisors, particularly an accountant and an attorney who specialize in medical practices," he said.

At the same time, he hired a practice manager and support staff for the office, who started work a month before the doors opened. A third tip to ensure a smooth operation is to contract with an experienced billing company. The extra cost up front is worth it, he said, because experts in this field can save money over the long term.

Another important factor is to maintain communication with referring physicians. After every patient visit, a letter is sent to the referring physician, explaining the nature and outcome of the meeting. Even though few practices send similar letters in return, this communication is key to his success. There are some referring physicians that Worthington-Kirsch has never met. One referrer in Baltimore has consistently sent patients for five years. A few other doctors in northern New Jersey refer a regular stream of patients.

"I've sent these doctors letters, I've spoken to them on the phone, but I wouldn't know them if I tripped over them," he said.

The competition for UAE has become fierce in recent years. A loyal patient and referral base goes a long way during potentially lean times. Many referring gynecologists practice at hospitals that offer UAE, but they send their patients to Worthington-Kirsch. When patients question the need to travel 40 minutes to see Worthington-Kirsch when another provider is available next door, referring physicians tell them he is worth the trip.

Dr. Patricia Hughes Jones, a solo practice gynecologist in Philadelphia, has sent patients to Worthington-Kirsch for 10 years. She also steers patients to the Hospital of the University of Pennsylvania but feels especially connected to Worthington-Kirsch.

"When I send patients to him, I know they will talk with him. I can prep them accordingly. It takes a lot of the guesswork out of the equation," Jones said.

Ten years ago, Worthington-Kirsch visited Jones' gynecology group practice at Penn. He presented a slide show explaining UAE. The group immediately began to send patients to him, she said. Worthington-Kirsch spends a good chunk of time marketing his services at conferences; to group practices; in brochures; on the Web, radio, and cable TV; and in newspapers and magazines. Recently, he's been marketing the fluoroscopically guided tubal implant procedure. Jones listened to his pitch and decided it was a good option for her patients who don't want surgery.

SMALL IS GOOD

If not for his family, Worthington-Kirsch admits he would be practicing somewhere other than Philadelphia, where reimbursement rates are "terrible" and living expenses high. But he would still seek out a small community hospital. He says he is the fifth largest admitter to Roxborough Memorial and probably the only radiologist who is anywhere near the top 20.

He likes the fact that many nurses and allied health staff live and work in the community, which imbues them with a sense of responsibility to one another. He has had patients on his table who attended high school with the nurses or technologists. He shares a good working relationship with the support staff.

"I know who to talk to if there is a problem. That allows me to control the interaction for the benefit of my patient," he said.

As for his relationship with the diagnostic radiologists at Roxborough Memorial, it can be summed up in a noncompete clause. He doesn't read CT scans, and they don't perform IR procedures. The vascular lab is the one place where the duties of the two overlap. Worthington-Kirsch is the lab's director and reads all vascular studies every other week. The alternate weeks are split between a vascular surgeon and the diagnostic radiology group.

As a faculty member of the Philadelphia College of Osteopathic Medicine, Worthington-Kirsch is sometimes accompanied by medical students on rotation. To some students, his work comes as a shock.

"They have no idea how involved I am and what kind of contribution I can make to patient care," he said.

That contribution is quantifiable. Dr. Pradeep Bhagat, chair of the pathology department, also serves as the medical staff president, a position that makes him privy to complaints and compliments from staff and patients. He said Worthington-Kirsch receives nothing but compliments and has a very loyal patient base. Bhagat's duties also include peer-reviewed staff activity. Compared with other interventional radiologists nationwide, Worthington-Kirsch has very few complications.

"Patients love him. He is extremely proficient. He is both confident and competent," Bhagat said.

Mr. Kaiser is news editor of Diagnostic Imaging.