By Alok Bhatt, MD
Chair, SIR-RFS 

Radiology residency is an interesting experience for those that enter it wanting to pursue interventional radiology.  Without a doubt, a strong imaging foundation is critical to success as an interventional radiology attending.  However, practicing as a clinician interventional radiologist—one that has clinic, rounds on patients, and follows patients longitudinally—requires strong clinical skills that are not readily developed in a diagnostic radiology residency.  The last time most radiology residents manage hypertension, diabetes, and any number of other chronic conditions is at the end of internship. The problem arises when IRs-in-training attempt to care of patients with peripheral arterial disease or hepatocellular carcinoma where addressing the patient’s co-morbidities is as important to a good outcome as deciding which stent to place or how aggressively to ablate. Many radiology residents would struggle with this aspect of a patient’s care.  Lack of dedicated clinical education is a weakness in IR training and is something that has been acknowledged by the IR community at large. The new IR residency will fix this problem, but the question is, what about those of us in residency now? What about those that will start residency before the new training program is implemented?  If you are committed to interventional radiology, here are some steps you can take to sharpen your clinical skill set during internship and diagnostic radiology residency.

Internship:  
Internship is a critical first step to building your clinical acumen.  Do not waste this year on an easy program!  Completing a preliminary year in internal medicine or surgery is the only way to ensure you get a strong clinical foundation. There are virtues to both medicine and surgical internships.  I chose a rigorous medicine year because I wanted to learn how to manage every aspect of a patient’s care. At the end of my intern year, not only had I completed 1/3rd of a medicine residency, but I felt very comfortable in managing complicated medical patients with multiple co-morbidities. This is not to discount a surgical internship. Chad Burk, MD, an RFS member from Loma Linda completed a surgical internship and wrote about his experiences here.

As he said, his goal was to maximize his exposure to clinic, clinical decision making, and the operating room in a variety of surgical subspecialties.  By rotating through multiple surgical subspecialties, he longitudinally managed patients often intervened upon by interventional radiologists.

While arguments can be supporting both medicine and surgical internships, there has been a clear trend of IR program directors discouraging the pursuit of a transitional year.  True or not, transitional years are viewed as “cushy” and easy. Though they may provide a broad range of clinical experiences, many PDs say they view them as an extension of medical school without the same rigor found in a medicine or surgical year.  Kyle Cooper, MD, an RFS member who successfully matched into fellowship at Baptist Cardiac and Vascular Institute says “there are a lot of transitional years out there that are known as “fluff years”, so I would caution those planning to pursue IR that even going to a tough transitional year could get you lumped in with that group.”

Residency:
The IR residency is a reality and eventually, all programs will provide a standardized interventional radiology curriculum. However, until the IR residency has been implemented, each program will differ in the IR experience it provides its residence. Your experience will depend on whether your enter a traditional diagnostic radiology residency or a dedicated IR program like the Clinical or DIRECT pathway.

The Clinical pathway, which served as a model for the IR residency, offers excellent clinical and technical training.  You will be a disease expert, ready to compete successfully in the real world. Two programs that offer the Clinical pathway are the University of Virginia and University of Michigan. Those that are committed to pursuing IR should unequivocally learn more about these programs.

Dr. Saad, University of Michigan’s VIR fellowship program director, has shared his program’s curriculum:

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You can learn more about Michigan’s VIR pathway here.

While the Clinical pathway offers excellent training, there are only a few of them across the country. Fortunately, with the revised ABR board examination schedule, most traditional pathways can now offer significant elective time during the R4 year.  This time is invaluable because it will allow you to gain clinical experiences in ways that were not previously possible.  However, even though they are able to, not all programs will offer this flexibility depending on multiple program-specific factors.  It is critical to talk to the program director about how flexible that program is in accommodating your desire for additional clinical training.  This applies not only to medical students, but also to current residents. If you want more clinical training, actively pursuing it will yield positive results.

For example, two radiology residents at The Ohio State University developed a clinical curriculum that would not only increase their time on IR, but also allow rotations with other clinical specialties including oncology and surgical oncology.  A former OSU resident, Kavi Krishnasamy, MD noticed that their exposure to the longitudinal care of patients was limited and they were not  given much opportunity to practice their history-taking and physical exam skills beyond internship.  He designed a new curriculum based on the University of Virginia’s Clinical pathway which has since been refined. That curriculum was most recently completed by Kyle Cooper, who says:

“My experiences with medical oncology, surgical oncology and vascular surgery have been critical in preparing me for my future career.  The collaborating physicians have been extremely positive about having future IRs focused on strengthening their clinical skill set.  It is critical to understand the issues your referring colleagues deal with in their own practices and what their expectations are of IR when they refer a patient.  The rotations can give you an excellent insight on the limitations of each specialty (as well as our own), which can help you to form an effective, collaborative practice environment in the future.  The relationships I have built with the oncologists and surgeons have lasted far beyond the rotations and as such these specialties often call on us for advice and help, even when we are not on IR.”

In addition to rotating with other services, at Mt. Sinai Medical Center in Florida, Brandon Olivieri and his co-residents started a year-round IR rounding service staffed by residents interested in IR. At his program, three residents share responsibility, alternating week-long shifts. They arrive early and pre-round on a mostly vascular-based inpatient service, monitoring for post-procedural complications, performing a vascular exam (palpation and doppler), foot exam and the like. They then proceed to their regular DR rotations.  After work, residents go see and work up consults, allowing IR to function as a true consult service rather than a procedure service.

Moonlighting:
Moonlighting in radiology residency has traditionally come in the form of supervising contrast injections after hours or picking up extra diagnostic radiology shifts. However, clinical moonlighting opportunities can very useful to sharpen one’s clinical acumen.

After I completed my internal medicine internship, I did not want a lull in my clinical training so finding a clinical moonlighting opportunity was very important to me.  I contacted a private practice internal medicine group and contracted with them to cover their patients on weekends.  During this experience, I served as the attending physician independently evaluating and managing patients. I could not have found a better opportunity as each shift increased my clinical knowledge.  Similarly, several RFS members have pursued clinical moonlighting in community emergency departments, urgent care centers, and even prison clinics. If you are going to pursue IR, consider seeking out such clinical moonlighting opportunities to enhance your clinical training.  Your senior residents may help point you in the right direction, but cold calling can also be surprisingly effective. If you did a medicine or surgical internship, consider contacting those departments at your current institution to see if PGY-2 moonlighting opportunities are available.

For those that want to pursue intervention radiology, increasing your clinical acumen is crucial to be able to successfully care for your patients and have good outcomes. However, you do not have to wait until fellowship to get robust clinical training.  Even though it may not seem like it, the flexibility of a diagnostic radiology residency can aid in giving you time and opportunity to pursue rich clinical training experiences.

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University of Colorado, PGY-2