202b79f89cAuthor: Tom Folan, MD. 

Hyun S. “Kevin” Kim, MD, FSIR is the director of interventional radiology and image-guided medicine, Emory University School of Medicine, Atlanta, Ga

Members of the Society of Interventional Radiology’s Residents and Fellows Section (RFS) recently discussed the development and implementation of the dual certificate in interventional radiology and diagnostic radiology with Hyun S. “Kevin” Kim, MD, FSIR, and John A. Kaufman, MD, MS, FSIR, two of the leaders of this seminal event in interventional radiology.

On Sept. 11, 2012, the American Board of Medical Specialties (ABMS)-the organization that oversees the 24 medical specialty boards in medicine-voted to approve the American Board of Radiology’s (ABR’s) application for a new dual primary certificate in interventional radiology (IR) and diagnostic radiology (DR). The dual IR/DR certificate is now officially the fourth primary certificate for ABR and the 37th primary specialty certificate recognized by ABMS. A primary certificate confers specialty status, emphasizing the recognition by ABMS and its member boards that interventional radiology (IR) as a specialty offers an important and unique blend of expertise derived from competency in diagnostic imaging, image-guided procedures and periprocedural patient care.
Dr. Kim explains, “There were multiple reasons to develop and pursue the dual IR/DR certificate. For one thing, we felt that the training of future leaders in IR could be improved. By formalizing the role of the interventionalist as an expert in the clinical, procedural and interpretive setting, we felt we could ensure that patients receive the highest level of quality care going forward. For example, even though the two-year fellowship in IR I’d completed at Johns Hopkins was excellent [the standard IR fellowship is one year in duration], I felt that more extensive clinical training would have been valuable. The new dual certificate addresses that gap with plans for ICU training and local leeway integrated into the program. In addition, by identifying the role of the interventionalist as unique, we felt procedurally oriented medical students may view it as a viable but different pathway distinct from the diagnostic radiology pathway already available.”

IR/DR: An Integrated and Innovative Training Paradigm Is Born

The Society of Interventional Radiology (SIR) hailed the Sept. 11 decision by ABMS to approve the dual certificate. Now there comes a waiting period as the configuration of the new certificate is finalized. The American College of Graduate Medical Education (ACGME), the board charged with accrediting medical specialties, will likely spend the next 12 to 18 months developing an ACGME version of the dual certificate proposal.
Dr. Kaufman notes, “It will ultimately be very difficult to discuss any specifics until ACGME finalizes what the program will look like and determines what the accreditation process will be.” Furthermore, the transition from current fellowships to IR/DR residencies will be gradual and take many years. Dr. Kaufman added, “Diagnostic programs that do not currently have an IR fellowship available could very will link to other IR residencies in order to provide residents with the desired training. In the near term, some residents may complete all or three years of DR training in one program and go on to the IR portion of the residency in another to ultimately end up with an IR/DR certificate. We anticipate a lot of flexibility.”
Dr. Kaufman continued, “Now that the dual certificate is a reality, ACGME is very interested in understanding how it might impact current DR residencies and VIR fellowships. The issues that programs will face locally are especially important. This knowledge will help ACGME create a program that is relatively flexible and inclusive. We don’t want to exclude good DR programs that don’t have the possibility of an IR residency from producing people who will go on to IR. We want a lot of people in IR. We also encourage those with concerns to bring them forward.”
The proposed 3+2 model for IR residency will include three years of diagnostic radiology, followed by the core DR examination, and then two years in interventional training. The content of the three DR years will be identical to that of other DR programs. The same core examination will ensure diagnostic and physics competency for those in the new model. In order to prepare trainees for the future exam, some interventional radiology training is necessary during the first three years. The exact amount of IR training during those three years has yet to be determined.
At the completion of training, a resident will take both a written DR exam and an oral IR exam. A new oral examination will be developed for the new IR/DR certificate, as it is now a primary rather than subspecialty examination. Dr. Kaufman explains, “We felt very strongly that we would not give up the oral IR exam. There is really no other way the first time around to judge a candidate’s competency.”

Transition: Impact on Current and Future Trainees

As the current fellowship paradigm transitions to the new 3 + 2 IR residency format over the next five-plus years, there will be multiple pathways available to become an IR, including the IR/DR, clinical, traditional and DIRECT pathways. Drs. Kim and Kaufman noted that ABMS would not accept two levels of certificates on an indefinite basis, acknowledging that IR cannot be both a specialty and subspecialty simultaneously. At this point, the exact timing for phasing out fellowships is not clear; they have acknowledged, however, that it will likely take longer than initially anticipated, citing ACGME’s ability to accredit new IR/DR certificate programs and bring them online.
Ultimately, who will receive this primary certificate? According to Dr. Kaufman, “Everyone will end up with this certificate one way or the other.” During the transition period, those in traditional programs will be automatically converted to the new certificate by participating in and fulfilling maintenance of certification (MOC) requirements.
Recognizing that implementing the new 3 + 2 format will be more difficult in some programs, Dr. Kaufman adds, “The 4 +1 model was also approved for a limited time. In this model, individuals complete a regular DR residency with concentration in IR rotations during their fourth year, maintaining a procedure log. They can then apply one year toward the two years of IR in the IR/DR certificate. The additional year of IR training could be obtained in any accredited IR program.” He is quick to add that this option, as it currently stands, will only be available during the transition period despite the original intent to keep it permanently.
Drs. Kaufman and Kim note that availability of pathways offering the new IR/DR certificate depends entirely on ACGME, which will likely require more than a year to develop the certificate’s program requirements and accreditation process; programs will then be able to apply for accreditation and the first programs will become available. Both Dr. Kim and Kaufman cite an intent to maintain flexibility for different entry points into the training, adding that it is counterproductive to speculate too much at this point.

New Normal: The Clinician Interventionalist

On the subject of the need for inpatient and clinic care in the new IR/DR certificate program, Dr. Kaufman offers enthusiastically, “That is absolutely at the core. The three competencies that underlie recognition of IR as an independent specialty are competency in diagnostic imaging, image-guided procedures and periprocedural patient management. The latter includes outpatient clinics for pre- and post-procedural assessment and inpatient services often providing independent patient consultations on procedures.
“The current fellowship requirements strongly encourage clinic-based experience but do not require it. The new certificate does require experience in the clinical setting as well as an admitting service. So if you are at an institution where there is no admitting service and no formal clinic, that would be something individuals could start doing now to get ready for new certificate.”
Drs. Kaufman and Kim also said that all interested parties involved in formulating and developing the dual certificate wanted to keep the diagnostic component. They underscored the importance of keeping imaging competency and thus ensuring that future interventional radiologists will be best positioned to take advantage of the various diagnostic imaging modalities as they make their way into the IR suite.
Was a new certificate needed? What exactly were the proponents of the dual certificate trying to achieve? Dr. Kaufman concluded, “We believe that patients will truly benefit from individuals with competency in diagnostic imaging, image-guided interventions and patient care. IR has grown more complex and demanding. It was time to change training to produce the best IR practitioners possible.
He concluded, “In the long run, everyone will benefit. This is a big step for IR.”
Indeed it is!

The SIR RFS thanks both Hyun S. “Kevin” Kim, MD, FSIR (director of interventional radiology and image-guided medicine, Emory University School of Medicine, Atlanta, Ga.), and John A. Kaufman, MD, MS, FSIR (SIR past president; director, Dotter Institute, Portland, Ore.; and chair of the SIR/ABR task force that has been developing the certificate since 2005) for their contributions to this article.

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University of Colorado, PGY-2