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Acknowledgement: Thanks to Drs. Sun Ho Ahn (Program Director, Brown), Alexander Kim (Program Director, Georgetown), and Erica Alexander (PGY2, University of Pennsylvania) for contributing to this article.
This fall will be the second year to directly apply into interventional radiology (IR) training through an integrated residency. Traditionally, IR was a 1-year fellowship after a 1-year preliminary year and 4-year diagnostic radiology (DR) residency. However, program directors across the country have recognized the increasing number of medical students who identified unwavering interest in pursuing IR. For these students, the 6-year integrated program allows them to commit to IR and receive greater depth and breadth of clinical training through 2-years of IR specific training instead of a 1-year fellowship. In addition to the integrated program is a more flexible option – Early Specialization in Interventional Radiology (ESIR). In short, ESIR allows DR residents to progressively integrated IR training into their DR residency with a heavy focus in the last two years of training. If accepted into the ESIR program, DR residents are able to obtain greater IR training throughout their DR residency to prepare them for IR fellowship.
More information regarding the logistics of the different pathways can be found here.
If you are interested in interventional radiology, but uncertain of whether the new integrated program is for you, ask yourself the next 5 questions.
Given the limited number of available residency spots for the integrated program, the application process will undoubtedly be competitive and the program directors will be identifying candidates who are ready to commit six years to a highly specialized residency. Dr. Erica Alexander (PGY2 DR resident at University of Pennsylvania) had a clear interest in pursuing IR since she was a medical student. She advises, “as a medical student, the best way to inform yourself is to spend several months doing IR electives (at your home institution and/or away), do IR research, and attend the national SIR meeting. I think if you’ve had enough exposure and have a decent understanding of the field then the commitment is reasonable.”
The commitment can sound daunting, but if you are most certain that IR is your career goal, then there are clear benefits for you to pursue the new residency track. Dr. Sun Ho Ahn (Program Director at the Warren Alpert Medical School of Brown University) said, “the benefit of IR integrated residency is that you are matching into a program with an established training program, which will provide comprehensive IR training compared to the current one year fellowship model.” With the specialty branching out to take an integral role in multidisciplinary patient care, Dr. Alexander Kim (Program Director at Georgetown University School of Medicine) believes the integrated program will provide greater exposure to the new paradigm in IR practice. “Having a second year of IR allows us to incorporate a lot more clinical education in terms of the breadth of the field encompassing treating peripheral arterial disease and treating cancer patients. You really have to have a lot more clinical expertise than say when IR started just as special procedures.”
If you are having some doubts about IR because you haven’t had enough exposures to other subspecialties in DR and don’t want to close those doors, the ESIR pathway may be the way for you. Dr. Kim advises, “for people who are not 100% sure they want to do IR, I would encourage them to go through a diagnostic residency and do an ESIR program. If there is even a small inkling that you would want to end up doing diagnostic radiology, doing the ESIR pathway makes a lot more sense because it will kind of allow you to have more options down the line.” Dr. Alexander agrees with Dr. Kim and emphasizes the commitment entailed in an integrated program. “I would strongly discourage applying to an integrated program if you have the slightest thought that you may not want to do IR. You are committing to completing residency and fellowship at the same location and you’re no longer a pluripotent stem cell within the field of DR ─ you’re committing to be very differentiated.” If ESIR will be on the horizon for you, Dr. Alexander recommends, “ask programs if the case exposure is high enough that you will meet the minimum ESIR requirements to fulfill an one year fellowship tract.” For many programs, ESIR is still in its infancy so it is important to confirm that the programs you’re interested in have a firm plan and timeline for their ESIR program.
Short answer: there will always be a way, but the spots may be just as limited as the integrated programs. If you solidify your decision to pursue IR during your DR residency, then you still have two options.
The first option is the already mentioned ESIR, which allows you to finish the first year of the new 2-year IR residency. The “Advanced Independent IR Residency” will be an added year after completing an ESIR program. Be aware that each program will be structured differently and training may be different from the integrated residency. Dr. Ahn emphasizes, “The ESIR program is not meant to compete with the IR residency. It is really designed to cater to those who may not decide to become an IR at the time of the 4th year medical school match. While ESIR allows you to complete your training in 6 years total, not many programs may be able to afford to accommodate all of the residents who wish to enroll in ESIR due to the DR work-flow demands of the DR residency.” Make sure to check with each residency program regarding curriculum, workflow, and DR requirements.
Second is the Independent IR fellowship/residency. By 2020, graduates of DR programs who later decide to pursue IR will apply to the 2-year Independent IR residency. The added year from the current 1-year fellowship was to fit the paradigm shift in IR practice by integrating residents into critical care services and outpatient clinic. The downside to Independent IR residency track is that it would take an extra year longer than integrated or ESIR track.
The above diagram compares ESIR and Independent Pathway.
Last year, there were approximately 150 applicants for about 15 integrated IR residency spots. While those numbers sound daunting, there will be approximately 61 additional programs participating in the integrated IR residency match this year. Despite the growth in the number of spots, both Drs. Ahn and Kim predicted increased competitiveness for candidates this year. It is a good idea for most to consider also applying to DR residency programs with the idea of potentially transitioning into ESIR or pursuing a 2-year independent IR residency upon completion of the DR residency.
Dr. Alexander emphasized that the majority of the programs with big training capacity are projected to fill only a fraction of their previous fellowship spots with integrated residents. “Don’t fret and give up your dream of pursuing IR if you don’t land an integrated spot. I do think that if you end up not matching to an IR spot and you still know you want to pursue IR, it behooves you to talk to the IR fellowship director early to establish your interest. You should also maximize the time you spend on your IR rotation to make a good impression. If you’re interested in research, then becoming involved in a project helps further establish your interest in IR and find mentors.”
While uncertainties are what medical students hate the most, we hope Dr. Kim’s words of advice will provide you with some comfort: “it shouldn’t be integrated residency or bust. ESIR is a very good option for a lot of people out there.”
Remember that IR stems from DR. The skill that differentiates an IR physician from other interventionalists is the confidence in reading and interpretating diagnostic imaging. A strong foundation in DR is crucial in IR or any other procedural subspecialties in radiology. Having a strong foundation in DR is a priority for both DR and IR residencies.
Dr. Kim recommends honesty is the best policy. “I appreciate when people are upfront with me and I think that most people do. A lot of people recognize that there is a lot of interest in IR residency and that this may be a side benefit for a lot of diagnostic radiology in that there are more people interested in the field of radiology overall. Attendings recognize that people will change their minds all the time during residency. No one is going to be unranked or ranked lower because they showed too much interest in IR. I think, and you know I probably thought this as a medical student too, but there isn’t that level of scrutiny about minor details when it comes to residency selection. We care about whether or not a candidate is going to be hardworking. Are they smart? Are they honest? It is less about whether or not they are going into my field of specialty. Ultimately, we want what’s best for the residents and students, so if you come in and decide that there is something that’s better for you we are going to support that.” As long as you show that, while IR is your ultimate career goal, you will value your DR training and you will be a studious, enthusiastic resident during the DR portion of your training, your strong interest in IR should not hurt your chances as a DR applicant.
The integrated program was not developed to self-select the most competitive candidates interested in radiology. Instead, it is supposed to provide an additional track for those who had early exposure to IR and are absolutely committed to subspecialization from the get-go. So take a deep breath and make the best decision that fits you.
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