Please tell us more about yourself and your medical training in Germany?
I spent my childhood from kindergarten to medical school in Munich. In Germany, you go to school for up to 13 years and finish high school to be eligible to go to university. There’s no college system, which means when you are graduating from high school, which is usually when you are 18 or 19 years old, you have to immediately decide whether you want to go to medical school. I finished high school when I was 19 and decided to go to medical school. Admission to medical schools is different from state to state; some states have an admission test; others have an interview process. When I was applying in Bavaria in 2007 it was pretty straightforward and only based on one single number: the two-digit high school diploma grade average. In Germany, students are graded from 1 to 6 with a 1.0 being perfect, and anything past 4.0 is a fail. Given that my score was competitive, and I wanted to stay in my hometown of Munich I only applied there, and my application was successful.
Do you have any thoughts about your medical school experience in general?
I think overall my experience was excellent. International medical graduates are sometimes worried that they’re going to come to the US and be at a disadvantage from the knowledge standpoint. I think for many countries that is simply not true. I think that the level of medical education is actually excellent in a lot of countries. However, at the residency training level there is a huge difference between most of the world and the US.
When and how did you decide to continue your medical training in the US?
In Germany, medical school is about 6-7 years long, depending on how much research you do. Halfway through medical school, I decided to do some research in the US, so I went to Yale for about 10 months and worked on a neuroscience research project. At that time, I was in touch with US medical students and residents and started exploring residency in the US. Subsequently, I sought potential clinical electives in the US. I did an elective in head and neck surgery at the Massachusetts Eye and Ear Infirmary in Boston. Meanwhile, I took Step 1 while I was doing my research at Yale in early 2012. I returned to the US during my final year of medical school in 2014 and spent four months in the US doing hands-on electives in general IR and Neuro-IR at Cornell (two months) and Harvard (Brigham and Women’s Hospital and Beth Israel, one month each).
Can you please tell us more about your clinical rotations in the US?
I came up with a few US universities that offer electives for international students by Google search. I then applied for electives at Cornell, Harvard, and UCSD. I ended up going to Cornell for two months and then Harvard for two months. As this was organized through their elective offices it meant that I had to pay tuition. I was lucky because I was a scholar of the German National Academic Foundation, which supported me with a monthly stipend and covered tuition and some travel expenses for my international electives in the US (over $2000 US a month at Cornell and over $4000 US a month at Harvard). I could not have done these electives without the generous support of the German National Academic Foundation as tuition was just too expensive for my personal budget! To get into these electives, you have to be in your final year of medical school and unfortunately a lot of these programs are not available for someone who already graduated from medical school, even if it was recently. You will also need to show your vaccination records, pass the TOEFL exam and meet other requirements for most universities. The application process can be quite involved at times but there is an overlap in requirements so once you have sent one application the next one becomes easier.
How did your journey to IR start?
It was a pure coincidence! I didn’t really know anything about IR in medical school. Part of the research project I was doing at Yale related to Neuroradiology. Because of that, I got interested in Diagnostic Radiology, so I decided to do my electives in Radiology. I started the first month of my radiology elective at Cornell in late 2013, where I happened to be placed in an IR rotation. It took only a day for me to be completely amazed by this field. IR in my opinion was the coolest specialty and presented a perfect mix of Surgery and Radiology. I requested to stay in IR and Neuro-IR for the following month. When I went to Boston after I already requested beforehand to be placed in IR or Neuro-IR. Thankfully they were flexible and allowed me to do Neuro-IR for two months, which was really cool. I spent my entire final year of medical school abroad. I did four months of electives in Japan before I came to the US. Medicine in Japan, surgery in western Samoa, and IR in the US.
Were you interested in surgery before IR?
Yes, before I knew what IR was, I considered orthopedic surgery and did some research in Neurosurgery back in Germany.
Why did you decide to continue your training in the US?
I think training here is exceptional and, in my opinion, the best in the world. The German healthcare system is overall very good, but if you look at the way training works in the hospital it’s not organized. There is no structure. The contracts are open-ended, and you don’t really know when you will graduate until you complete your logbook, which usually means you must be on good terms with your boss and are completely at their mercy. For example, if your boss starts working for a different hospital it could completely mess up your studies and you may even be forced to move with your boss in order not to disrupt your training. Overall, residency training in the US is very well structured. You know you will rotate in all sub-sections of radiology or whatever specialty you train in. Educators in the US place very high value on teaching and attendings take the time to explain and work one on one with trainees. In many other countries, including Germany, there is a lack of dedicated teaching happening on clinical services in the hospital.
What are the biggest challenges you faced as an IMG?
One of the biggest challenges are the expenses! I was fortunate because I had a scholarship, but for a lot of people, this can be a limiting factor. The second challenge is to excel in the USMLEs. Third, is to get the necessary letters etc. which you only can achieve if you get clinical rotations in the US and of course you need to pay for those, and then you will have to do an excellent job to get the letters. Basically, all these three things hinge mostly on the expenses ultimately. US medical students pay just the same, but I think subjectively there is a difference because in Germany and many other European countries people are not used to paying for education, which is considered a basic right. Therefore, people are not willing to take out money and take a risk and apply for US residency. Only people that are really determined to complete residency training in the US. Finally, there are organizational challenges of course. It requires a lot of correspondence and coordination. There is complex paperwork between your home medical school and US elective programs required to make sure electives, USMLE accreditation etc. work out and are approved. Indeed, it can really be a bureaucratic nightmare, but this is life and probably a good lesson for future challenges!
What about challenges during the application process?
I was set to graduate from medical school in Germany in November, so I didn’t even know if that was going to give me enough time to get my ECFMG paperwork lined up before the deadline. I applied in September when I was in my last year of medical school and only had my step 1 score ready. I didn’t even take other USMLE exams, which also put me at a disadvantage because a lot of programs filter IMGs based on ECFMG certification. I applied to about 25 radiology and 25 preliminary residency programs but only received a total of eight interviews. Fortunately, all of those were competitive programs where I knew someone or I completed a rotation including Harvard, Yale, Emory, and Cornell for Radiology, and preliminary year interviews at Mayo Clinic (Rochester), Beth Israel in Boston, Cornell, and Yale.
What is your advice for international medical students and graduates who pursue IR?
Do as many electives as you can in the US so that you have enough contacts and can get excellent letters of recommendation. Also, make sure you take your USMLE exams and get your ECFMG certificate before you apply. You need something to differentiate yourself from other candidates. Let’s say two applicants apply, one is from the US and one is from Germany with similar step scores and they both seem like reasonable people. Why would programs choose a German over an American applicant? With US graduates, there is no language barrier and there is no visa-related risk for the program. The only reason they will consider IMG’s is if the applicant brings something to the table, such as solid research experience. Of course the more research, the better! However, some very well published applicants don’t get into Radiology probably because of low USMLE scores, visa issues, or poor interview performance.
Doing research in the US is recommended. However, it’s not just about what you’ve published. It is more about connections, and therefore I would say clinical research can be just as valuable as basic science. As an IR applicant, clinical research related to IR is more relevant of course. It would be very difficult for radiologists to figure out the impact and quality of non-radiology journals and articles. Basically, a third author article in JVIR can have far more value than a first-author article published in the highest impact factor journal for orthopedic surgery. Additionally, If you’ve actually done research relevant to faculty who interview with you, you will have something in common to talk about. Just make sure to be well prepared for specific questions.
Do you recommend applying to DR or IR or both as an IMG?
If you want to go into IR, it’s better to have IR clinical research experience in your profile. Be honest when applying to DR/IR and mention that you are primarily interested in IR, and that doesn’t mean at all that you don’t care about DR. Be mindful that you might change your mind in residency. In summary, apply to both and be open to the people interviewing you about what your goals are.
What are your research interests?
IR training in Africa! How to bring IR education to resource-limit settings. I think that people really underestimate the potential for IR in low to middle-income countries. There is a misconception that people think IR can only be done in high-income countries. It is simply not true. It has been estimated that more than half of the world’s population doesn’t have proper access to IR! In Africa alone over 1 billion people right now have no access to even basic IR procedures like abscess drainage, biliary drainage, nephrostomy placement and many other life-saving procedures.
What is your favorite IR procedure, and why?
Embolization for hemorrhage in the setting of trauma. I still find it fascinating that instead of doing a big open surgery you can go through a pinhole in the groin and save someone’s life by localizing and embolizing their bleed using coils, gelfoam, or other materials. These cases are very satisfying.
What is your favorite inspirational quote?
If there is a will, there is a way! (I have to say it’s my favorite quote as well) Don’t accept impossible as an answer, try a different approach, and success will follow.
WHY IR in Bullet points?
1. Minimally invasive with immediate impact
3. Delivers better results for patients
What do you think about the differences between European IMGs like yourself and others?
European medical schools, including Germany, are very flexible. This provides great opportunities for research and clinical electives. I was able to go abroad and do research and electives throughout medical school, which may not be possible in all other countries to my knowledge. I think exchange of knowledge and ideas between medical professionals from different continents is extremely important, now more than ever.
What is the success formula to match into IR residency (bullet point)?
1. Have a plan; don’t try to wing it! Take all USMLE exams on time.
2. Do as many elective clinical IR rotations or observerships in the US as possible. And if you can’t do that at least try to do relevant clinical IR research in the US.
3. Study hard for the USMLE exams because the score matters and can set you apart from other candidates.
4. Try to go to IR meetings, meet new people in IR, and build your network.
5. Apply to both IR and DR.
I would urge all IMGs to take the USMLE Step 1 before it becomes a pass/fail exam. I believe this could be a significant disadvantage for IMGs as many program directors don’t know most foreign medical schools very well, and no matter how accomplished you are and how excellent your medical school is, you will not have your step 1 score to set you apart.
If you could do it all over again, would you change anything?
I don’t think so. It worked out well for me. I was always pretty organized about my applications etc. which probably worked out to my advantage. I wouldn’t really change anything.
Where do you see yourself in five years?
I see myself doing academic interventional radiology and expanding on global IR training programs. I am open-minded, and I can see myself working pretty much anywhere including Asia, the Middle East, or the USA. Currently, there is a complete hiring freeze due to the coronavirus pandemic, so we will see. Hospitals are losing a lot of money from canceling elective procedures. I hope that by next year things will improve.
What do you feel most passionate about?
My contribution to the Global IR training program in Tanzania! I got involved with this when I was a second-year radiology resident. I first went to East Africa with Dr. Frank Minja, who is a neuroradiology attending at Yale. I went with him to check out whether it would be possible to do IR and to start the first IR training program in East Africa. In October 2018, we officially started the training program. Every two weeks an IR team travels from the US to Tanzania and provides training to local IR fellows. This Master of Science in Interventional Radiology program at Muhimbili University of Health and Allied Sciences in Dar es Salaam is, to my knowledge, the first accredited IR training program in sub-Saharan Africa. It’s a two-year fellowship program which Tanzanian radiologists can enter after completing a 3-year diagnostic radiology residency, corresponding to the IR residency system in the US.
This is fantastic! Can you tell me more about the progress and the future global IR program?
We published our initial paper in JVIR last year. I’m now writing up the second paper summarizing results of the first 16 months of the program. So far, we have performed over 350 IR procedures, anything ranging from biopsies to uterine and splenic artery embolization or embolization of pseudoaneurysms. If it wasn’t for the program, many of those patients would not have received any treatment because there are no surgical alternatives to some of these IR procedures. For example, in a septic patient with hydronephrosis or in a patient with biliary obstruction in advanced cholangiocarcinoma there is no real surgical alternative. I believe IR will have a great future in low-income countries, and the overall impact of IR in these countries will be very significant, maybe even more so than here. Surgical complication rates tend to be higher in low-income countries, which explains why offering minimally invasive alternatives makes such a big difference there.
IOC Interviewer: Amir Pirmoazen, MD
IOC/MSC Editors: Edna Wang; Yi Yang, MD, MPH; Andrew Moore, MD