Written by: Dylan Ropert
DO Candidate, Class of 2020
Western University of Health Sciences
COMP-Northwest

Interview with Hilary Swift

Hilary Swift graduated from Western University of Health Sciences COMP-NW in Lebanon Oregon in 2019. She was accepted to the Integrated IR residency program at the University of Michigan and is currently completing her surgical intern year.

What are some expectations of students on their audition rotation?

  • The obvious: show up on time, be professional and courteous, work hard
  • Be prepared to go into the angio-suite on Day 1. Look at the schedule and pick a few cases that sound interesting or stick with a particular attending. If you’re not sure, consult a resident/fellow and see what they think would be best to jump into. It can help to stick with one room during the day so the techs, nurses, attendings and fellows will get comfortable having you around.
  • Be prepared to self-scrub. Some places will do it for you, but be prepared and comfortable with self-scrubbing into cases.
  • Make yourself available to help set up rooms, transport patients, and cleaning up after cases.
  • Most importantly, be excited to learn from and interact with the techs and the nurses. They are crucial to cases running smoothly and they have a lot of guidance to offer.

What are some ways to impress on your audition?

One of the best things you could do is learning to run the instrument or “back” table. Learning how to anticipate the next step (catheter, wire, etc..). Some institutions the techs completely scrub out after setting up so you have the chance to function as a tech (as long as the techs are okay with it). On several of my rotations, I received compliments from attendings, fellows, residents and techs, on how well I was able to anticipate the next step, properly flush catheters, keep syringes filled, and stay organized. It’s a fun way to stay involved and help with the case if you find yourself wanting more action.

How do we navigate our interaction with the techs without interfering with their job, but also wanting to be very involved with the cases?

  • I had extremely positive interactions with techs over the course of my audition season. It’s always important to approach the situation cautiously because they see new students every month (at least) and want to protect their patients. Before the case starts, you should ask how you can help set-up and how to be useful during the case. Most are very happy to help teach you about their responsibilities and get you involved.
  • The worst thing you can do is show up with an attitude and think you are superior to them somehow. The techs can make or break your rotation. If a tech is scrubbed in during a case, it’s important to not be oblivious about where you’re standing. They move fast and have a system down so check with them to make sure you aren’t in their way. It may be helpful to address the situation before the case by asking, “where is the best place for me to stand for me to be involved, but not in the way.” This shows that you want to be involved, but are also aware of the fact they need to do their job efficiently for the best patient outcomes.
  • Remember that every place is different so don’t assume what you were doing in the angio-suite at your last rotation applies to the next one. Read the room and be flexible. You’re there to learn, not to take over. All of these interactions can take patience and finesse, but it’s well worth it in the end.

How should a student approach involvement in procedures (for example getting access)? Do you volunteer to get access or wait to be asked?

  • If you show interest in the case (ie. you know the patient, you’re scrubbed in and assisting with the case etc.) most attendings and fellows will recognize your desire to gain more experience and let you practice technical skills such as gaining access, maneuvering wires, and deploying stents or coils.
  • That being said, the time to address your desire to be involved in the procedure is NOT mid-case. Our patients are frequently awake and somewhat alert so it is best to discuss the possibility of more involvement prior to starting the case. Sit down with the fellow or attending and let them know you’ve been carefully observing and can verbalize your understanding. I found that one of the best ways to prove you understand the steps is to anticipate their next move. For example, if they’re about to get access, have the micropuncture kit ready on the table and pass them the wire and catheter.

What sort of compliments did you receive from your attendings/fellows/residents on your auditions?

  • A common compliment I received was my ability to work well in a team environment. I received feedback from several places that the techs, nurses, residents and fellows all enjoyed working with me. I would argue that this characteristic is the most crucial for a student interested in a procedural specialty.
  • Additionally, on several of my rotations I was complimented on my ability to run a back table. This skill takes a bit of time to master, but you’ll learn quicker if you help set up before the procedure and ask the techs questions about the sequence of events to expect in that particular case.
  • Most of the other compliments I received were along the lines of showing up on time, being engaged, caring about my patients and working hard.

After all is said and done, you’re most likely to stand out with characteristics that demonstrate you’re a normal human being who is eager to learn and functions well in a team setting.

What did it look like to work hard on your rotations?

Every place was different, but it’s always important to show an excess of interest in the beginning and whittle it down from there. Residents and fellows are usually the best resource for determining what is expected of you. I found that some places wanted students to pre-round, write notes and attend clinic. Others did not expect rounding or note writing.

A few things were the same across the board:

  • Always attend and be engaged in the morning conferences.
  • Know your patient. Know their name, past medical history, procedure (why are they getting it done?), and take a look at their imaging.
  • Always offer to help with setting up, moving patients, cleaning up, etc.
  • It can be useful to get an idea of the indications/contraindications/complications for the procedure. Whether it is an embolization or fistulogram, understand why you’re doing the procedure rather than just doing it for the sake of performing a procedure. This will get easier with time as you see more and more procedures, but this is where texts such Handbook of Interventional Radiology Procedures, Pocket Interventional Radiology and Pocketbook of Clinical IR can be really helpful.
  • Then, based on your institution’s expectations, write notes, round, attend clinic, run consults etc. as best you can.

What was the time-frame working on these rotations?

Again, this is obviously different from place to place and others may have different experiences than I do. But, typically we would start around 6:30-7:00am and go until 5:00-6:00pm, 5 days a week. Always offer/ask to work weekends, make yourself available, and be prepared to work. However, in my experience, I was often told by residents or fellows to take the weekend off and to explore the area a bit. Audition rotations are just as much a trial period for you as it is for the program. They’re going to encourage you to check out the area to see if it’s a good fit as a residency program. I would recommend trying to find things that you enjoy doing and seeing what is available in the area. It could be somewhere you live for six years…

What are some specific study areas I can prepare for as I get ready for my IR rotation?

  1. Vascular anatomy – I don’t have one good resource, but Netter’s is always great. A quick Google image search usually gets the job done too.
  2. Things I’ve been pimped on: anterior/posterior divisions of internal iliac, SMA branches, Celiac branches, hepatic segments and blood supply, portal venous system, venous drainage of the legs, aortic arch branches, relationship of vessels in the neck of central venous access. I typically look up cases for the next day and then review pertinent anatomy and basic procedural steps/considerations/indications/findings.
  3. Various classification systems like Child-Pugh status for liver function evaluation, kidney failure classifications, ABIs for arterial disease patients, endoleak types, aortic dissections/aneurysms, DVT prophylaxis and management, PE classification, portal hypertension pressures and goals.
  4. Always look at a patient’s name, brief clinical background, IMAGING, labs including creatinine, INR, platelets (these 3 typically dictate whether a case is going to happen or nor or if special considerations are needed), WBC, Hgb, and electrolytes.
  5. Seldinger technique is very important to know even on your first rotation. The different types of wires and catheters will come with experience.
  6. Take the time to scroll through images yourself and find an attending/resident/fellow to go through anything you may have questions about. They are usually very willing and helpful.

Any last words of advice:

Keep in mind that at the beginning of audition season (July, August, September), the fellows are new to IR at a lot of institutions. In just one year of training, they are responsible to learn how to be a full-fledged IR physician. What this means for you is that you may not get the hands-on experience you were hoping for right away, but be patient and realize you can learn so much from them.

Finally, audition and interview season is an incredibly wild ride. I can almost guarantee you will feel exhausted, frustrated and even foolish at times. The best thing you can do for yourself is be curious, be excited, and be adaptable. Feel free to reach out to me if you have any questions or concerns along the way. Good luck and have fun!