Interview by Rei Mitsuyama, MS2, MD Student, Brown University

Name: Dr. Jason Iannuccilli

 

How did you decide on a career in IR?
It was sweet serendipity. Like many other IRs, I entered medical school thinking that I wanted to be a surgeon. It was first exposed to IR during my 3rd year clinical rotation through Vascular Surgery. By that time I had realized that I preferred the ‘immediate gratification’ of surgical/procedural practice over the more traditional practice of medicine. The idea of being presented with a problem, analyzing it and using my hands to fix it seemed like a natural fit for me.

Although it really wasn’t that long ago, IR was still kind of a mysterious profession back then. Many physicians had little knowledge of the breadth or depth of services that IRs performed—the sign on the door to the angio suites actually read: ‘Special Procedures’ and it wasn’t until a couple of years later that it was officially changed to ‘Vascular Interventional Radiology’.

My initial exposure to IR was just enough to spark my interest. I remember thinking, “Wow. This is the surgery of the future.” I then signed up for a 4-week elective in VIR to become immersed in the environment of the profession, and that was all it took. Seeing a diverse array of complex, often life-saving interventions being performed in a minimally-invasive fashion through a small nick in the skin was truly amazing. It seemed like IRs were performing medical miracles every day. The message of ‘better, cheaper, and faster’ was engrained, and I knew that IR would always remain on the forefront of innovation and that’s where I wanted to be.

 

Please describe your typical work week.
IRs typically work at a very fast pace. On average, I spend 2-3 days working with residents and fellows in the IR suites at our main hospital performing scheduled elective procedures on my office/clinic patients in addition to any procedures scheduled for hospital-based patients. New inpatient consultations are seen ‘on the fly’ between cases, and the procedure schedule is often rearranged multiple times during the day to accommodate any urgent/emergent cases from the ER or inpatient units. These are usually busy days that run 10-12 hours.

Since my primary focus is in Interventional Oncology (IO), I also routinely spend 1 day per week on a dedicated IO rotation performing 2-3 scheduled tumor ablations before noon, then working in conjunction with our NPs seeing patients in the IO clinic.

The other 1-2 days are spent (variably) in office-based private-practice IR, on academic research, or on general administrative duty. Our robust outpatient IR practice has 3 offices dedicated to the comprehensive evaluation and minimally-invasive treatment of superficial venous insufficiency and varicose veins.

Like most IRs, we also provide coverage in emergencies for multiple hospitals on-call after hours. Call responsibilities are spliced into our typical work week at a frequency of 1 out of every 5-7 weekdays and 1 out of every 7 weekends.

 

How is your time balanced between clinical work and research?
Finding enough time to perform research and build an academic reputation can be difficult for many IRs that work in a busy clinical practice. Most academic IR jobs come with dedicated time to conduct clinical research and pursue academic duties. Private practice models usually do not support dedicated research time. We are a private-practice group that has an academic affiliation with the medical school, so we follow a hybrid practice model.

Hybrid practice models are somewhat complex. The physician group maintains its own private offices and revenue stream. Affiliation with a medical school means that the physicians hold faculty appointments and share in educational responsibilities such as training medical students, residents and fellows. The private-practice group doesn’t necessarily receive any financial compensation for its academic contributions to the medical school, but the relationship is usually mutually beneficial in some way.

To maintain affiliation with the medical school there are academic responsibilities (research, lectures, etc.) that the group physicians must fulfill. As a result of our group’s academic affiliation, I am allotted some dedicated time to perform research and other academic work in my practice. However like most hybrid groups with busy clinical schedules, I find that I comparatively spend much more time devoted to clinical patient care, developing IR service lines, building referral networks, and developing/implementing ideas to improve overall practice efficiency. Dedicated time for research can be hard to come by during times of practice growth or transition, and often I have to find my own time to do research during off-service hours.

Hybrid practice models usually offer the potential for greater income when compared to strictly academic positions, but also have greater potential for ‘physician burnout’. Finding an appropriate work-life balance is important, and choosing a career path that suits your own personal/family life is a critical factor in determining your own long-term professional success.

 

What are some of rewarding parts of working in your field? Challenges?
I was at a multi-disciplinary conference recently, and one of the talks was given by a gastroenterologist. He was discussing new endoscopic treatment options for patients who present emergently with GI bleeds. During the talk, he paused to acknowledge the critical role that IR plays in providing life-saving endovascular treatment to this patient population. His exact words were: “Although we have all of these tools at our fingertips, we’re still somewhat limited in our ability to treat these patients. We often call upon IR to perform emergent embolization when things get out of our control. We’re really just the infantry troops on the ground. The IR guys are the elite fighter pilots we call on when we need air support, and we’re so grateful that we have them up there for backup.” I thought that was one of the best endorsements of our profession that I’ve ever heard.

In IR we treat very complex patients under complex circumstances. In the middle of the night, if it’s infected, obstructed or bleeding we’ll probably be called upon emergently to fix it as a final line of defense when invasive surgery is deemed not an option. The positive impact that our interventions have under such dire circumstances makes for a very rewarding clinical career.

As clinicians with a unique skill set, IRs also have the opportunity to develop strong relationships with our patients, often as long-term care providers. We are in a position to be viewed by some patients as the only one who could help them with their condition or illness. While this type of relationship can be very rewarding in practice (especially when outcomes are good), it also comes with all of the challenges of clinical patient care, such as managing patient expectations and dealing with difficult patient personalities.

 

What do you think medical students should know about IR (the field, the career, the technology, etc.)?
I’d be happy just to know that all medical students are aware that IR exists as a specialty and a potential career choice at a point in their medical training where early exposure may spark interest and the decision to pursue it. It seems that many students are exposed to the field late in the course of their training, when they may have already convinced themselves that they wanted to do something else.

Sun Ahn, one of my colleagues here at Brown has made it a point to expose our local and regional medical students to IR at an earlier stage in their training, and as a result we’ve seen a major spike in IR interest as a potential career choice. Establishing a student-run IR interest group, an IR-lecture series for pre-clinical students presented by IRs from our own practice, longitudinal clerkships for clinical students looking to explore their interests further, and a Northeast Regional collaborative IR symposium geared toward medical students are among the major changes he’s implemented to increase IR exposure at an earlier stage in medical training. This will become ever more important now as we transition to a separate IR/DR residency pathway.

 

Do you have any advice for medical students seeking research opportunities in IR?
The most fulfilling projects for an early investigator are those that are thought up and designed by you. My advice would be to pursue an opportunity that would allow you to clinically immerse yourself in a real-life IR practice environment so you can start thinking critically about some particular procedure or disease process that interests you. IR is such an innovative and dynamic field that there are plenty of clinical questions that still remain unanswered, especially with respect to some of the newer procedures that we perform. Doing a dedicated 3-4 week rotation or a sub-internship in IR is a great way to gain exposure and build some background knowledge about current controversial topics in IR-related patient care. There are plenty of IR physicians who are more than happy to mentor an ambitious and enthusiastic student through an investigative research project—it’s one of the most rewarding things we can do in academic practice. Alternatively, you can just take the initiative and ask to get involved. You may be able to buddy-up with a staff physician to help with an existing research project that hasn’t yet been started or that’s already underway.

 

What are some skills/assets that make for a good researcher (as a med student, resident etc.)? Stats? Comp sci?
Honestly, I think all that it takes is intellectual curiosity, organization and enthusiasm for the topic. Sure, understanding basic biostatistics is a good tool to have in your bag, but most academic training programs have a biostatistician on staff that is fully equipped to analyze a data set and crunch the numbers for you. The stats guy is able to handle confounding variables in ways that you’ve never even heard of, or would likely have overlooked as being relevant.

Having a biostatistician as a contributing author on your work helps establish its credibility and probably significantly increases its likelihood of acceptance for publication. Your role as a clinical investigator is to formulate the hypothesis and help the biostatistician understand the data set by providing the appropriate clinical context behind the variables you measured. A face-to-face meeting and discussion of the project with the biostatistician during the analysis phase directs the analysis and helps to identify any potentially confounding variables during the process. When the stats are complete, you the clinician must analyze the results to determine what the identified relationships in the data actually mean and how they might be used to improve clinical practice. A good clinical researcher shouldn’t get bogged down in the dry details of analysis. If you have a good clinical question, meet with a clinical mentor and a biostatistician first to design a good study that will uncover the answer.

 

What kind of attributes do you value in applicants for IR residency?/What advice do you have for medical students interested in IR?
To be a great IR physician it takes much more than dexterity and skill. You have to be able to manage patient expectations and relate to your patients on a personal level. You have to be willing to play a role in educating them about their disease process so that they understand their treatment options, choose wisely between them, and accept the consequences of their illness—especially when there may be no treatment options available to them at all. Your role as a physician is to help them understand their situation and put it all in perspective.

IR is becoming extremely popular as a potential career choice, largely because of its innovative nature and growing reputation as a frontier specialty in the minimally-invasive treatment of disease. As a result, IR residency selection will be a very competitive process and preliminary selection of applicants on paper will always be based on scholastic aptitude and academic merit, so studying hard and getting good grades is always important. If it were up to me though, once you pass the academic threshold for consideration then we would throw away the applications and establish an equal playing field for those applicants that remain. That being said, I think one of the most important tests of a potential candidate for IR residency is how well they carry themselves in the interview. Interpersonal skills are so important in this field because of the degree of clinical face-time that we spend with patients. Social/emotional IQ is probably the most important key to success in contemporary IR practice, or in any clinical practice for that matter. You’ll need to be able to relate and communicate effectively with a wide variety of patient personalities for them to trust in you as a physician. It’s easy to pick up on this in an interview. It’s an innate quality, and those that have it, by default, find some way to connect with each interviewer that they meet in the program. At the end of the day, all of the interviewers meet and unanimously say “I like that person.”

My advice: Trust your instincts. Any medical student who is interested in IR should sign up for a dedicated clinical elective rotation or sub-internship in IR to get full exposure. If it feels like the right fit for you then go ‘all in’.