The key to sustainability for VIR is to manage diseases comprehensively in an outpatient clinic with referrals from primary care and diet patient marketing, this often requires an OBL/ASC so that you can book your cases electively. The challenge with the hospital is that you often are inundated with fluid management (paracentesis/thoracentesis/lp/joint aspirations), drains (abscess, gallbladder, chest tubes, g tubes) , biopsies ( that historically all radiologists would perform), diagnostic minor procedures (arthrograms/myelograms/ sometimes even GI fluoro). There are so many add ons to the IR schedule that is hard to schedule your elective cases. Things that you can get in the inpatient side include stroke, PE/DVT/ GI bleedres/ trauma . Even in the hospital setting it is key to get dedicated time to build your practice and give talks to physicians and grow your elective referral practice (AV fistula creation and maintenance/ PAD/ fibroids/ prostate / knee osteoarthritis/spine interventions). This requires a considerable amount of clinic time , clinic volume and infrastructure. Most radiology groups and even hospitals will not readily give that to the budding vascular interventionalist. Convincing the powers that be DR groups and private equity that clinic is important is very challenging. If you are a hospital employee or part of a multi specialty group (vascular surgery/cardiology/nephrology/podiatry etc) they are much more inclined to provide this as it is part of their culture. Current VIR training is limited in how much clinic you do, often the clinical work is delegated to extenders and the trainees don't learn any of it and are only able to do procedures and so when they graduate they struggle with knowing who to treat or why to treat and what perioperative management and follow up entails.