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The Society of Interventional Radiology survey in 2000 to 2001 reported what appeared to be favorable results. However, closer scrutiny provides more information. The Society of Interventional Radiology's strategic plan calls for 80% of interventional radiologists to be clinical practitioners by the year 2006. Recent American College of Radiology practice guidelines support this goal. Interventionalists need to decide whether they are going to provide clinical care and those who chose to take on the clinical practice model will most likely be successful.

It is clear that interventional radiology contributes substantially to the status of radiology departments in the hospital as well as in the community. Experience has shown that clinical management is the key to well-reimbursed procedure volume and increased referrals for those services. Additionally, it allows the opportunity for interventionalists to participate in technological changes that we can envision right now, which could have significant impact on the management of numerous diseases. If treatment is "clearly indicated," then the interventionalist has an obligation to present that opinion to the patient and to implement that care if the patient desires. Interventional radiologists have recognized that clinical care requires service to the patient first and foremost.

The business strategy for establishing a clinical office involves three key components: fundamental change from the traditional technical model in processes for accepting referrals; establishment of a high-quality clinical operation; and changing the perception of interventionalist radiology among the referring community and the public. The costs and revenues used to derive profit and loss statements will vary considerably across regions and practice set-ups. Some of the considerations are outlined in this article, but it will be up to interventionalists and their business managers to make these factors conform to their individual practices and locations.

The lack of clinical office space is the biggest Achilles' heel of interventional radiology and establishing an office eliminates that weakness immediately. Many interventionalists practice within a hospital setting; however, setting up a clinical office outside the hospital offers more flexibility. There are several reasons why interventionalists who set up clinical practices will succeed well into the future. Also, the American Board of Medical Specialties offers the fully trained interventional radiologist board certification in interventional disease management.

Once the clinical practice model is established, transitioning is fairly easy. Office staff such as schedulers and nurse practitioners should understand that all elective therapeutic interventions are to be booked only by interventional radiologists once the interventionalist has done a thorough diagnostic evaluation, including a history and physical in an office environment. To optimize the interventionalist's workload and efficiency, some triaging of patients in the clinical office is necessary. Also, noninvasive testing will need to be made available in the clinical office.

If interventionalists are able to set up clinical practices and promote themselves along service lines, especially peripheral arterial disease, it is likely that they will have some market share and that market share will grow as new devices and technologies become available. The key to success will be changing the impression of the referring community that interventional radiologists are technical specialists and don't see patients. Marketing experts tell us that several impressions are required for a concept to stick with the target audience. One of the most important points that an interventionalist can make to establish themselves as a clinical specialty is high-quality work and effective communications.

Parallels between the evolution of surgery into an accepted clinical specialty and changes in the practice of interventional radiology (IR) have been drawn. Technical advances have mandated a change in the role of interventional radiologists from diagnostic radiologist to that of the treating physician. The development of "modern" IR is an accelerated repetition of the evolution of "modern" clinical surgery. The resistance or delay of some to accept IR as a clinical specialty is a duplication of the resistance to accept surgery as a clinical specialty by medicine in general. It is clearly time to understand that the benefits the interventional radiologist brings to the patient far exceed his ability to synthesize imaging data with catheter skills. Those of us who have accepted this can take some comfort in the fact that we now tread a path already proven in its destination.

Within 10 years of Dr. Sven Seldinger's introduction of needle replacement of a catheter in 1953, Dr. Charles Dotter, at the University of Oregon Health Sciences, began to use catheters as surgical instruments. Dr. Dotter said, "The angiographer who enters into the treatment of arterial obstructive disease can now play a key role, if he is prepared and willing to serve as a true clinician, not just as a skilled catheter mechanic. He must accept the responsibility for the direct care of patients before and after the procedure; now see them as patients, not just as blocked arteries." On this prediction time has shown Dr. Dotter to be exactly right. We are on the verge of tremendous growth in peripheral vascular interventions, particularly in the arterial arena. There are several forces within and outside radiology that presaged this transition that will be explored in this issue. But it is clear that all of radiology, not just interventionalists, have finally heeded Dotter's message. In 2004, the American College of Radiology published a "white paper" on interventional radiology clinical practice. The white paper outlined the features and resource needs of interventional radiologists for providing patient care. In this issue we will explore the reasons why in 2004 there is no other way to practice interventional radiology than to practice as a clinical doctor.

By asking identical questions of several successful practitioners of clinical interventional radiology, a snapshot of the current and future status of interventional radiology as a clinical discipline is presented.

Interventional radiology was once considered "angiography," or in some hospitals, "special procedures." Angiographers usually did not perform evaluation and management services. In 1963, Dr. Charles T. Dotter recognized the potential of catheters to be used in performing intravascular surgery. By the mid-1980s a wide array of therapeutic interventions and devices had been developed. The emergence of interventional radiology as a dedicated specialty, where interventionalists practice solely interventional radiology, has been a tremendous boost to referrals for therapeutic interventions. However, the possibility for change depends on the practice environment in which interventionalists work. This may serve as a note of caution to young interventionalists just out of fellowship; they have the most to lose if a practice doesn't support interventional clinical practice over the long haul in terms of time and resources.

The American College of Radiology recently ratified a practice guideline on interventional clinical practice that includes very specific details about what constitutes a clinical practice for interventional radiology as well as interventional neuroradiology. Several "benchmarks" were developed. These "benchmarks" are felt to be important in the Society of Interventional Radiology strategic plan. Interventionalists need to establish themselves as disease process or organ system experts to succeed in obtaining clinical referrals. Interventionalists who don't take the initiative to obtain patients and populate their schedules with interesting, well-reimbursed procedures will be relegated to performing mundane services.

It is unfortunate that in the peripheral arena surgeons often get the first referral for patients with peripheral arterial disease. Interventionalists should present themselves as vascular specialists to the referring community. Peripheral vascular disease in the future will be primarily an interventional specialty. Endovascular interventions are safe for people with claudication and interventionalists should offer them. If interventionalists provide comprehensive care and thoughtfully enter a market with the will to compete, it is very likely that they will succeed.