READY FIRE AIM: Don’t miss your best shot waiting for the perfect time
An interview by David Schmiege, president and CEO of Vein Specialists of America with Jeffrey H. Miller, MD
- Board-certified in Interventional Radiology and Venous and Lymphatic Medicine
- Diplomat of the National Board of Medical Examiners and American Board of Radiology
- Holds a certificate of Added Qualification (CAQ) in Interventional Radiology
Jeffrey H. Miller, MD, is the founder and CEO of Miller Vein, with six offices in Southeast Michigan. Dr. Miller has received numerous awards and honors in his field, including being named one of Detroit Magazine’s “Top Docs.” His multi-site company has received numerous awards including Coolest Place to Work by Crain’s Business Detroit, Novi Chamber of Commerce’s Customer Service Excellence Award, and several Corp! Michigan’s Economic Bright Spots Awards.
Schmiege Jeff, thanks for taking the time to sit down for this interview. Let’s start in the beginning. You have many interests, what influenced you to pursue a career in medicine? What was your path?
Miller Admittedly, I feel like my path has always found me instead of the other way around. I had a bit of an aptitude for science when I was young, so I was “pre-professional” when I started college. That covered any and all potential healthcare professions. Sounds corny, but when I was 18 years old, it was a beautiful fall day at MSU, and as I was walking between classes I decided I wanted to make a difference in the world, and that the best way to accomplish that would be a career in medicine. I proceeded to declare a major in physiology.
Schmiege How did your medical career lead you to focusing on venous disease.
Miller I was an interventional radiologist in a large hospital practice. Absolutely loved the profession! In 1999, we asked the hospital to purchase the first generation VNUS Closure device generator and to our surprise they bought it. Per the vendor, I was the first in Michigan to perform an endovenous thermal ablation. As time went on, I enjoyed performing these vein procedures while my interventional colleagues weren’t so keen on them. Thus, I became the go-to “vein guy” by default. It didn’t take long to realize these procedures didn’t belong in the hospital, as it wasn’t unusual for an emergent case to bump our elective ones. I tried to convince my group practice to build out a suite for us to perform vein procedures as well as see our IR patients outside of the hospital. Thankfully, I was unsuccessful at convincing them which eventually led me to go on my
Schmiege What made you initially decide to go into private practice?
Miller I loved the field of interventional radiology and enjoyed the variety of procedures in a large hospital setting. At the same time, I hated the bureaucracy and the lack of customer service in the institutional setting. Also, I had no work-life balance. With a wife and two small daughters at home, I wanted to be able to spend time with them. No more missing birthdays or other milestones.
I vividly remember walking the stairs of the hospital at 3 a.m. after getting called in to treat a gastrointestinal bleed knowing that I would need to report back to the hospital first thing in the morning. I was thinking that if I were in charge, I would require a physician who stayed up all night to be off the next morning. That kind of thinking was considered absurd.
I remember smiling in that stairwell when I thought of opening my own clinic. My wife encouraged me to quit my job even before I had any future plans. I had to give a 90-day notice. In that time, I was able to find a part-time radiology position and sublease space in that same location for our first vein clinic. The funny thing was that a competing vein practice was situated just down the hall in the same building! Let’s just say they weren’t thrilled with us. A few months later I was able to relocate to a larger space and become a full-time vein practitioner.
Schmiege What are some of the challenges of being a vein and lymphatic physician?
Miller Consumers see all kinds of advertising for vein care on a wide variety of marketing channels and to the average customer, they all look alike. Of course, nothing could be further from the truth. So, one challenge is fighting against the “sea of sameness.” I’m sure I’m not alone in this regard and I’d guess that most vein practitioners would agree.
Another major, and far more troubling challenge is the fight against unethical vein care. We have seen far too many patients get told by other clinics that they needed all kinds of medical treatment, when in fact they didn’t. It’s not unusual to see a patient that was told he/she has and abnormal ultrasound and needs four ablation procedures (four seems to be a magical number) and a variety of additional injections to help them. Upon a complete history, physical and ultrasound we often find they don’t even require medical care.
Schmiege What is it about Miller Vein that you believe sets it apart from your competitors? Why should a patient select Miller Vein for their treatment?
Miller It sounds cliché, but we are a company based on values. We hire and fire based on them. It’s embedded in our culture. And we see many patients who visit us after another vein clinic. They notice the difference… and they notice it immediately. We pride ourselves on humble service, integrity, specialization and kindness beyond vein treatment. Our front-line people feel empowered to make sure every need of our customer is addressed. I don’t want to brag, but we’ve won Crain’s Magazine’s Coolest Place to Work in Michigan multiple times for good reason. I believe engaged and happy employees translates to happy and healthy patients. Equally important, each of our physicians is truly a vein specialist. We all have experience running a hospital vein clinic prior to joining Miller Vein. As we have opened additional sites, I have been very patient when it comes to identifying, recruiting, and hiring doctors who are leaders and fit our practice culture.
Schmiege You are an Interventional Radiologist by training – Are there any parallels with IR and vein and lymphatic medicine? What do you see as the future for IR?
Miller The history of IR and the vein specialty are unique and almost 180 degrees opposite. IR’s origin is from radiology which started as angiography, the study of blood vessels. From a single medical profession, a new field IR was created and has continued to expand. However, little by little, other specialties have taken over areas that were once under the umbrella of radiology. I’m oversimplifying this, but the field of vein and lymphatic medicine vein started the other way around. Multiple medical fields coalesced into one. So, from their origins, IR and venous medicine have always had unique challenges. But one common question has always been there. Who should do what? Meaning which specialty is best suited to perform procedures?
I’ve been away from the field (IR) for over a decade. When I left the hospital setting, there were daily turf battles over who treated peripheral arterial disease. There were daily battles between IR, vascular surgery and interventional cardiology. For the most part, IR lost that war a while ago. I’m probably the wrong person to ask what the future of IR is, especially since I predicted that by now IR would be called something else or get divided into a variety of subspecialties. Although, this might still happen. For example, nephrologists that manage dialysis access are now “interventional nephrologists,” and vascular surgeons are often called “endovascular surgeons.”
I had guessed that by now, other specialties would’ve similarly moved into the interventional space. I’m also surprised that interventional radiology is still under the radiology umbrella. Over a decade ago, there was always a large divide between the imagers and the interventionalists. When I chat with my friends in the hospital, that rift still exists. I’m just surprised there hasn’t been a split. The next decade should be interesting. Maybe more IRs will decide to subspecialize in veins? Who knows?
While all this turmoil exists, it’s very interesting to note the direction interventional radiology training is taking. There is now an integrated IR residency which is five-years in length (a total of six years of post-graduate training with the required internship year). This IR training format is now available to medical students. After completing internship, the residency curriculum concentrates on diagnostic radiology in the first three years and interventional radiology in the last two years. From what I understand, this is now one of the most competitive residencies for medical students to get into.
Schmiege What do you think of the names “interventional radiology” or “phlebology”?
Miller From a marketing perspective, interventional radiology could not have a less compelling name. If you were to ask ten people on the street what is interventional radiology? you would likely get ten replies of “I don’t know.” Compare that to something like vascular surgery which intuitively makes sense. I’m guessing that this name will change one day. Or, there could become multiple names as there are so many facets of IR that there could be a variety of sub-sub-specialists. For example, interventional oncology has continued to expand and is still under the roof of IR. Interventional nephrology is a specialty where nephrologists (mostly) manage dialysis access This used to be a bread and butter type of procedure for IR.
Like interventional radiology, phlebology has always suffered from an identity perspective. Most laypeople believe a phlebologist draws blood. In my opinion, it was a great move to change the name American College of Phlebology to American Vein and Lymphatic Society. It makes so much more sense.
Schmiege Arguably, one of the hottest topics in the vein space right now is about who is best qualified to do vein work. Who do you think is best qualified to do vein work and why?
Miller That’s a difficult question and one that I don’t think there’s a definitive answer to. I don’t mean to hedge here. Ultimately insurance carriers will decide who gets to continue to treat veins. On a procedural level, interventional radiologists have a significant advantage compared to other specialties when first treating veins in a clinic setting. After fellowship, an IR is adept at gaining access in any size vein as well with negotiating a catheter anywhere. Obviously, I’m biased in my opinion.
Having said that, with appropriate training, any physician can perform these procedures, and perform them well. It’s really all about training. Furthermore, these office-based procedures will continue to become technically easier to which diminishes the barrier to entry.
It saddens me that there are still plenty of “dabblers” out there who really have no business performing endovenous procedures. They never received appropriate or enough training. Patient care is definitely adversely affected.
Schmiege How would you describe the culture of Miller Vein?
Miller Two of my main philosophies I didn’t create. Years ago, I heard Tony Robbins introduce the term “CANAI” which stands for constant, and never-ending improvement. I’ve always loved that term and I believe that is a huge part of Miller Vein. We never want to be the company where an outsider would ask the front lines “why are you doing that?” and have the answer be “that’s the way we have always done things.”
My fear being that if there’s a better way, we always need to find it. So, we are always looking at ways to improve the company and most of the changes are driven by our frontline employees. Another part of our culture is based on a phrase I also learned years ago “Ready, Fire, Aim.” I first read that from one of Jack Canfield’s books. Too often, people wait until everything is perfect before they take action. If I had waited for everything to align prior to opening my first clinic, I might not be having this conversation with you today.
Reality is that it’s rare for everything to get perfectly planned. Sometimes pushing ahead is the best course. If you fail, you can then change course. I have absolutely done my share of failing! But each time I’ve failed, I’ve learned valuable lessons. To be clear, these philosophies apply to the business side of our practice. When it comes to procedures, “fire before aiming” does not apply.
I believe that meetings are where the magic happens. Too often, people hate attending meetings. If that’s the case, it’s because of bad meetings. We have built a solid meeting schedule that really keeps our company well organized and informed. We also try to separate tactical from strategic meetings at the leadership team level. Our strategic meetings are less frequent but longer and have a free-flowing vibe to them so we can get creative. I firmly believe that leaders are readers. Anyone in charge of running an organization, no matter how small, needs to continuously learn.
I would also add that community and philanthropy are a big part of Miller Vein. Our teammates are very enthusiastic about helping people in every way possible.
Schmiege Over the years, you have built relationships with many, many people in the vein space. What is something about you that would surprise your colleagues?
Miller I think people would be surprised at how many business mistakes I have made to get where I am today. I’ve bought the emperor’s clothing on more than one occasion – spent too much money on marketing while looking at the wrong metrics (but convinced by our marketing firms we were doing fantastic). With this in mind, I frequently tell people that all the tools to success are located in the treasure box known as failure. Just have to learn from mistakes. One big takeaway for me has been how successful we have been when we promote from within for leadership / management roles. We have failed more than I’d like to admit when we have hired from outside our company. People from the outside tend not to understand or appreciate our culture.
Schmiege If you could do anything else for a living, what would it be? Why?
Miller I would probably be a teacher. In fact, I see this as part of my retirement at some point. My father was a teacher and I believe it runs in my veins… no pun intended. Perhaps it’s why I enjoyed coaching girl’s-softball for seven years. This allowed me to spend more time with my daughters, but at the same time I loved coaching and teaching. My wife joked that coaching was actually my full-time job during that time.
I had the opportunity to guest-teach a health educational class at a local high school. It was an absolute blast! I can’t wait to get to do it again. In fact, I was scheduled to go back and host another class but COVID-19 hit and it got cancelled.