By Audrey Magnowski (MS4, University of Colorado School of Medicine) & Rana Rabei (MS4, Rosalind Franklin University of Medicine and Science)
Acknowledgement: Special thanks to Dr. Paul Rochon (program director for the integrated interventional radiology residency at the University of Colorado), Dr. George Vatakencherry (program director for the Kaiser Permanente Southern California diagnostic radiology program in Los Angeles), Dr. David Maldow (PGY2 diagnostic radiology resident at the University of Rochester) and Dr. David Tabriz (interventional radiology resident at Rush Medical Center) for contributing to this article.
With so many training pathways available for medical students looking to enter interventional radiology, how does one decide where to apply, rank, and pursue a career in this field? We posed this question to our favorite SIR mentors, and we are excited to share their feedback with you as we enter this year’s residency application season.
Choosing the right pathway for you
For applicants in this year’s match, there are three main pathways to become a board licensed interventional radiologist: the six-year integrated IR residency, a five-year diagnostic radiology residency with the Early Specialization in IR (ESIR) track and a shortened one-year independent IR residency, or a diagnostic radiology residency and a full two-year independent IR residency. The current diagnostic radiology residency with IR fellowship route will cease to exist come 2020. For students who have no doubts about a career in IR, the integrated residency is the most streamlined way to get there. However, these positions are limited and their competitiveness means that many future interventional radiologists will need to take a different route.
How should students approach this scenario to optimize their chances of entering IR? Dr. Rochon recommends that students who want to find a pathway that leads to IR should strongly consider ESIR programs in addition to integrated programs, because training via ESIR will be similar to an integrated residency. For students looking to maximize their chances of matching, evaluate the available combinations that are available – does the program have an ESIR program and an independent IR residency? If so, pursuing this option (while requiring a separate application process for the independent IR residency) will allow trainees to complete their training in much the same way as the integrated residency. In fact, many programs are more eager to add ESIR positions for trainees because the resources needed to support each resident are already in place, making these spots easy for programs to add without having to allot additional financial resources.
While a pathway that includes the independent residency leaves students with the uncertainty of where they will complete their training, this also offers an opportunity that was previously seen with the IR fellowships. While there will be situations where residents can complete their training start to finish at the same institution, many students may find it valuable to do their independent residency year or years elsewhere. The diversity of IR naturally allows each practice to develop its own culture; this includes relationships with other medical and surgical specialties and relative proportions of different types of cases within the subfields of IR. Dr. Rochon’s take on this point is that trainees may find it beneficial to get a diverse experience at multiple institutions during residency to have a solid foundation in a variety of procedures, as well as to learn a variety of approaches and techniques from mentors in each location. For this reason, students should find out if programs are planning to have an independent residency program, and consider this when applying and ranking.
On the other hand, for students that are not certain about committing to IR, Dr. Vatakencherry recommends that students prioritize ESIR and diagnostic radiology programs and take full advantage of their early training years to explore other areas of radiology that have a procedural component. This will allow students time to consider other options as well as IR, yet still have the option of continue their training in IR down the road.
In short, institutions that offer multiple of the pathways into IR are high yield for application season as they provide availability and flexibility to maximize the applicant’s resources.
Location, location, location…
… is becoming less of a potential barrier to practice in the field of IR. Students used to emphasize the location of a residency thinking that it would impact the scope of their future practice. But, the current training structure de-emphasizes the local/regional mindset of trainees being “stuck” in the area where they trained. Practices and programs are becoming more familiar with the level of preparation that a resident would have received from another institution across the country due to the increased consistency of training and the emphasis on a structured curriculum for each of the training pathways. Future interventional radiologists are going to become more mobile, especially with the wide-reaching network of interventional radiologists across the country.
With this in mind, do residency programs take into consideration where a student is coming from when considering them for a position? How does a student demonstrate a meaningful connection to every place they apply? While the obvious ties still carry weight (family connections, places you have previously studied, etc), students can find authentic ways to demonstrate a potential link to a program. Are you passionate about training in a place that works with the underserved? Is there a faculty mentor involved in a research topic that you find fascinating? While the process of applying for residency can make students hypersensitive about potential rejection, keep in mind that programs likely feel the same way! Students have better chances of being favorably ranked by a residency that believes the student would be likely to come to their program.
Dr. Tabriz has the following to say about location: I regularly tell medical students, when applying to residency, to already have job considerations in mind. Do you want to settle down in a competitive geographic market? Then I would recommend ranking programs in those areas highly. Do you want to pursue a research-driven academic job? Then ranking research-heavy programs would take precedent.
Interventional Radiology as a Clinical Specialty
Interventional radiology is a unique clinical discipline that combines imaging expertise with extensive training in minimally invasive procedures. This duality offers image-guided targeted therapies for a wide range of medical conditions – from treatment of varicose veins to stabilizing a trauma patient with uncontrollable bleeding and everything in between. Compared to surgical alternatives, IR therapies are cheaper to perform and are associated with shorter hospital stays, faster recovery times, and lower rates of complications.
Interventional radiologists have been performing life and limb-saving procedures for many decades, but according to a national survey, only 6% of Americans referred to an interventional radiology department had previously heard of this specialty. One of the reasons for this, as Dr. Newton, the co-creator of Without a Scalpel puts it, is because interventionalists have traditionally been doing “good work in dark places”. The tools and techniques of our field are exceptional, but other providers can learn them. As a result, in order for our specialty to survive and thrive, and for our patients and the healthcare system to gain the full benefits of our unique discipline, we must strive to become visible, equal partners in patient care along with our medical and surgical colleagues.
As interventional radiologists of the future, we must be equipped to educate our patients about their disease processes, counsel them on alternative therapies, and provide comprehensive longitudinal care both in and out of the hospital. Hence, when evaluating integrated residency programs, it is important to inquire about the extent of meaningful clinical training offered. With IR integrated residency programs still in their early phase, we cannot rely on AMA’s FREIDA and Doximity’s Residency Navigators to help us learn about and compare programs. The SIR Residency Directory can give us some insight about the procedural training at each institution, and the RFS IR Residency Training Committee is currently working to provide relevant program-specific information but until then, we must rely on words of advice to guide us. We asked our faculty and resident what to look for in order to make an educated assessment of IR residency programs’ culture and quality of clinical training. We have summarized their responses into the following three points:
1) Look for a vertical integration
Vertical integration in IR programs is defined as the level of clinical training offered throughout the full length of residency. While some programs offer no clinical rotations during the PGY2-4 years, others allow residents to rotate through several surgical subspecialties such as SICU, MICU, vascular surgery, surgical oncology, etc. Currently, Integrated IR programs have a minimum requirement to provide one month of ICU training during the entire length of integrated residency; but as stated previously, there is a wide disparity of exposure to the quantity and timing of non-IR clinical rotations offered at different institutions. When evaluating a program, it’s important to inquire about how many clinical rotations they offer, and how much of that clinical training is offered during the first four years of the program. As the curriculum for the residency programs become more standardized, the variability in both the number and variety of these rotations may decrease, but it will still be beneficial for students to consider the different clinical opportunities that will be available to them outside of the IR suite.
2) Look for a Robust IR Outpatient Clinic
The practice of IR has changed dramatically in the past several decades. Interventional radiologists are transitioning from being the option of last resort to becoming the first choice over surgical therapy. Many primary care providers routinely send patients to surgical colleagues instead of interventional radiologists because they don’t know about us! Building a robust outpatient practice is a key step to attracting patients and generating referrals from primary care providers. As future IR physicians, we must become comfortable with the outpatient management of our patients. Therefore, applicants should ask about the extent of faculty and resident involvement in the IR outpatient clinic. All integrated IR programs are required to have an outpatient IR clinic, but there are no rigid requirements about the extent and quality of time that residents spend in clinic. Currently, residents in some programs have assigned clinic days throughout the PGY2-6 years, but others only participate in the clinic in the PGY5-6 years of training.
Tip from an expert: When evaluating the quality of the IR clinic, ask about the clinic volume, what percentage of clinic visits are new consults or follow-ups, what percentage of new consults result in procedures, and inquire about the average length of follow-up for patients. A strong clinic is one where there are more follow-up visits than new consults, and not all consult lead to procedures. In a true clinical consultation, the physician utilizes their best clinical judgment to identify the most appropriate treatment modality for the patient’s specific concern. It is the clinical decision-making piece that distinguishes a consultation from pre-operative assessment, where a patient is being worked up for a treatment modality that a consulting provider determined to be the most appropriate course of action. In addition, the length of follow up (post op visit vs. lifelong) is also very telling of the of the attitudes of providers towards clinical practice and demonstrates if a provider take ownership of their patients.
3) Role of IR in patient management and relationship with other providers
The call for IR to become clinically oriented is nothing new. It was Dr. Charles Dotter, the father of our specialty, who famously said that if interventional radiologist are unwilling or unable to take full clinical responsibility for their patients, then they will become “high-priced plumbers”. However, it is important to recognize that there are many practicing interventionalists that have not adopted this style of practice. So when evaluating IR residencies, it is critical to assess the culture of IR when it comes to patient care at that institution. It’s not difficult to imagine that training at an institution where IR has admitting privileges, acts as the primary team managing the patient’s hospital course, and follows patients long-term in an outpatient clinic is a superior educational experience compared to training in an environment where IR serves primarily as a consult service, performing procedures and utilizing physician extenders to manage patients. As Dr. Vatakencherry puts it, “it’s not hard to manage a patient’s blood glucose or blood pressure, but if you haven’t done in a long time, it can be challenging.”
After going through the grueling surgical intern year recommended by many IR residency program directors, none of us wants to forget the basics of inpatient management due to lack of use and practice. But while it’s easy to ask a program how many ICU rotations they offer, it’s difficult to gauge the culture of an institution and their commitment to clinical patient care during the course of an interview. So what is the best way to find out? Dr. Maldow, a radiology resident at University of Rochester and Clinical Education Chair of RFS Governing Council, recommends asking attendings and residents about their daily routine; find out if the IR attendings see consults, round on patients, what inter-departmental meetings they participate in and where where they interface with other specialties. All of this can provide meaningful information about how engaged the IR service is in patient care and their relationship with other providers at their institution. Both Dr. Vatakencherry and Dr. Rochon also made a point to emphasize the importance of collaborative medicine to the future of IR – Advising students to inquire about multi-disciplinary conferences, clinics, and whether or not the interventional radiology practice performs hybrid procedures with other specialties.
Tip from an expert: Fellows are expected to keep an accurate log of their procedures during core training. When interviewing and rotating at an institution, ask to see the current fellows’ procedure logs!
As students about to apply to residency begin to narrow down their list of programs, it may be helpful to keep in mind some of the tips above to help seek out some of the distinguishing features between residencies. In a field where excellent training is the norm, many of the details that set programs apart from each other will be what helps students to find their best fit. While the integrated interventional radiology residencies are appealing for applicants committed to IR, the ESIR pathway and traditional pathways offer students the ability to further explore the specialty and diversify their training locations, which are all things for students to consider.