This section of our website is dedicated to students interested in interventional radiology and is overseen by our Medical Student Council.
Under the drop-down menu at the top of the screen labeled "Medical Students" you will find an introduction to the specialty as well as great resources on how to get involved, explore IR, and become a competitive applicant for residency.
Get involved by Joining the Society of Interventional Radiology. Membership is FREE to students. Also consider applying for a position on the Medical Student Reserves, a group of medical students who work on short-term projects throughout the year.
Physician Spotlight: Dr. Julius Chapiro
Can you give us a brief overview of your background and explain where your passion for IR began?
Originally from Berlin, Germany, I completed major portions of my post-graduate training in the United States. I first came here as a research student in 2009 and worked on my thesis within the Department of Rheumatology and Immunology at the Yale School of Medicine in New Haven. Back then, I had no idea IR even existed and focused on my degree in molecular cell biology, investigating mechanisms of proteasomal degradation of the hypoxia-inducible factor 1 alpha. Working on such basic concepts excited me, and I quickly developed profound interest in cancer biology. Almost by coincidence, I attended the CIRSE meeting in Munich in 2011 and quickly understood the potential of image-guided cancer therapy. It was love at first sight. After the completion of my degree and upon graduating from medical school back in Germany, I came to the Johns Hopkins Hospital in Baltimore towards the end of 2012 where I began a postdoctoral fellowship in Interventional Oncology. I had the unique opportunity to work on both basic science as well as on clinical and translational research projects. I learned how to handle the VX2 rabbit tumor model of liver cancer, I investigated the role of tumor metabolism in a mouse model of pancreatic cancer and in parallel delved deep into the role of image guidance and image analysis in locoregional therapies of liver cancer. I also learned a great deal about clinical trial design. I worked and published with unique and inspiring leaders in cancer research such as Prof. Bert Vogelstein who is the most frequently cited researcher of all time and Prof. Gregg Semenza, who was recently awarded the Nobel Prize in Physiology of Medicine. I then returned to the Charité University Hospital in Berlin to begin my radiology residency and was then recruited back to Yale Radiology in 2016 where I have been ever since.
What unique perspectives does being a physician-scientist provide, compared to solely research scientists, in the field? What are some additional rewards and challenges that come with that title?
Being a physician-scientist means having a unique ability to “speak both languages”, the language of science and the language of clinical patient care. I was initially surprised to find out how segregated those two fields can be in academic medicine and it’s really important to assume the role of a bridging element between the two. One has to be able to offer both clinical competency and a scientific record with original research and extramural grant funding to be fully accepted into this role. Once the relationships are established, sky truly is the limit. Being able to work with clinical physicians and basic scientists on shared projects is exciting and very rewarding. At times, this work almost feels like a mission to break down silos and interventional radiology as a relatively new specialty is far behind. As opposed to medicine and surgery, we have very few physician-scientists in our field and only very few laboratories around the country that are fully dedicated to original research in IR. Many medical school graduates unfortunately view research as a “CV bonus”, a must-have by convention, but once they match into a residency program only few want to fully commit to this at times very challenging and time consuming journey. However, the tides are clearly turning and most programs and especially our professional society has begun to understand that our future lies in innovation and scientific ownership of the problems and diseases that we treat clinically.
Please describe your typical work week- since you have the unique responsibility of balancing resident duties with running a fully funded, productive research lab in Interventional Oncology?
I will admit it was a challenging journey to wear the hats of a research faculty and IR trainee at the same time. Clearly, clinical training must play a central role and one should not settle for less than excellence in patient care. When involved in clinical patient care, one should ideally not be distracted with research-related issues and fully focus on delivering care with excellence. During a research block, clinical duties should be off limits and the focus must be solely on scientific productivity. I think the most important advice I can give to anyone who attempts to do both at the same time is to maintain a very structured life and daily routine. In reality, both identities overlap and some commitments will compete with one another. One should be prepared to make clear choices every day and understand the return of investment one is getting from each such decision. Clearly, good outcomes are only possible if the necessary effort and time is invested and there is no substitute for hard work and sacrifices along the way. There is frequently no such thing as a weekend off and rarely an evening off and understandably, this is not a lifestyle that most people would want to pursue. When leading a laboratory, one must be available for the research trainees and staff, always willing to communicate effectively and quickly and one definitely needs protected and structured time to do the actual research, write grants, correct papers and also to attend scientific meetings and remain active in our professional society. All these activities require protected research time away from patient care. And clinical duties will suffer if no such arrangement is in place.
Since you have successfully navigated this process before, can you give details on establishing/negotiating dedicated research time in residency? What to look for in a supportive program? And how budding physician-scientists can establish themselves in the field and go about thinking about starting labs of their own?
First and foremost, there is no such thing as negotiating dedicated research time. Noone will protect your time for research upfront unless and until you do it yourself by convincing the program and your department that you deserve it. This is best done by demonstrating clinical competency and scientific excellence. Nothing proves it better than a stipend or a resident/fellow research grant from one of our professional societies. If you are able to generate a hypothesis and propose a concrete pipeline of experiments that will investigate a problem in such a way that others are willing to fund it, I believe most programs will give you their complete support. An important thing to know about protected time during training is that all trainee salaries are funded by the CMS and you must be painstakingly cautious not to break ACGME rules and ensure that you are in compliance with all regulations. There are many pathways to achieve this goal, one such path is through the Holman Research Pathway, approved by the ABR. Ultimately, many roads lead to Rome.
Tell us more about the one-year fellowships introducing medical students from Europe to the radiology research world in the US through your lab? How has it been working with these students?
Our Yale Interventional Oncology Research lab maintains a unique exchange program with the Charité University Hospital in Berlin, allowing talented medical students from Germany with strong interest in interventional radiology to do full time research within our lab for a year. The exchange is funded by Prof. Rolf W Günther, who is Professor Emeritus for Interventional Radiology in Berlin and the inventor of the Günther Tulip IVC filter. Prof. Günther is a living legend and a great friend of ours, who understands the value of scientific research for our profession. Together with the team in Berlin, we have now mentored close to 20 medical students through very advanced research projects and many of them have meanwhile become radiology residents. The mission of our laboratory is not only to pursue interventional oncology research with the focus on liver cancer, but also to excite students of diverse backgrounds for research in general and to instill the spirit of team work into their professional DNA. Our international visitors work side by side with U.S. medical students and other career researchers and they all learn from one another. Together, we are a real Interventional Oncology research family.
Please share a turning point or defining moment in your work as a scientist? Budding researchers would take inspiration from this.
I think it’s probably hard to pin down my career to just one inspirational event or point in time. In fact, I would say I’m excited about the work we do every single day. Every accepted paper, every funded grant, every successful mentee reaching his or her goal of matching into their residency program of choice and also, increasingly observing how some of my former mentees become independent investigators on their own is truly what keeps me going. One should never wait for this one moment of inspiration. Instead, it is probably healthy to think of the journey as the reward on such a career path.
Please describe your field of research, what’s upcoming/can we get excited about?
My general research interest lies in developing new quantitative imaging biomarkers for the diagnosis, characterization, and therapeutic management of liver cancer. Our ongoing research projects focus on developing new tools to characterize the tumor microenvironment in the setting of loco-regional, image-guided therapies of liver cancer. We are specifically interested in better understanding the effects of loco-regional therapies on the immune system. We work on various animal models to establish molecular imaging tools that will help us better understand the immuno-metabolic crosstalk and resistance mechanisms in this setting. Creating innovative and clinically applicable imaging solutions for liver cancer with advanced molecular imaging, image post-processing and machine learning approaches and translating them to clinical practice has been my central mission for the past eight or so years. Thus, my second and complimentary research interest lies in the use of data-driven learning techniques aka artificial intelligence to improve diagnostic and therapeutic decision making in liver cancer care. Between those two overlapping trajectories of basic science and translational research, we made several exciting breakthroughs recently and published a series of papers on novel molecular imaging techniques in journals like Clinical Cancer Research, Theranostics and Radiology. At the same time, our team has tackled the full gamut of machine learning applications to liver cancer imaging and intervention. We have funding from various sources, including the NIH and the Society of Interventional Oncology as well as from our industry partners Guerbet and Boston Scientific to engage in more cutting edge research. I’m excited.
Do you have any advice for trainees seeking research projects in IR? Specifically, deciding on investigators, and topics of study?
I am biased when I say that interventional oncology is the most exciting field in IR. We have a very active scientific community with a small but growing number of rapidly expanding laboratories and young excited principal investigators in the field. Leaders like Terence Gade, Muneeb Achmed, Sam Mouli, Isabel Newton, Ron Gaba, Joe Erinjeri, Sarah White, Rony Avritscher and many others are inspiring pioneers that will reshape our field in the years to come. Regardless of topic and individual interest, it’s extremely important to find a mentor and build a professional relationship that is honest, mutually beneficial and cordial. It’s important to remember that no one is entitled to be mentored and one must deserve the trust and justify the investment your mentor is going to make. A mentor-mentee relationship is something that evolves over time. Remember also that you will have many mentors for different purposes at different stages of your career. Things to consider when picking a mentor are certainly his / her own track record in science, current activities, availability of funding and infrastructure and most importantly time. If the chosen one is too busy to respond to your emails or unable to meet with you, the relationship will likely not evolve no matter how great or accomplished the mentor appears on paper. Choose someone who has the time to meet with you and to guide you through the process and at the same time offer your own time as a resource to your mentor. It never hurts to ask but don’t waste your time if you don’t get a response.
What is your overarching end goal for your work as a researcher in the field?
I’m not sure I have an “end” goal. My hope is to be happy and satisfied with the research that we do as a team on a daily basis and at the same time to help repair the world, one piece at a time. Achieving my own childhood dreams with my humble contributions to science while helping others to achieve their dreams in research is so much fun. Ultimately, it’s important to me to be able to have a positive impact on patient care but as I said earlier, I’d like to see the journey as the true reward.
Interview by Rohil Malpani, Yale School of Medicine ‘21
Physician Spotlight: Dr. Elie Balesh
Can you give us an overview of your background?
I was born and raised in El Paso, Texas to Lebanese parents in a household where English, Arabic, French, and Spanish were spoken fluently. I graduated from Cathedral High School and completed my undergraduate degree in biochemistry at Harvard, where I spent three years performing research in stem cell biology and tissue engineering. I subsequently completed my MD at Yale, where our gross anatomy course was co-taught by the Department of Radiology, which introduced me to the field very early in my education.
My laboratory research focused on synthesizing pancreatic and hepatic “organoids” for transplantation, which had set me on my original path to become a surgeon. But I stumbled across interventional radiology during PubMed literature reviews, where I discovered the investigational use of image-guided, percutaneous transplantation of pancreatic islet cells into the portal venous system as a therapy for type 1 diabetes, with monitoring of cellular viability and function via MRI and nuclear molecular imaging. It wasn’t long before research groups around the world began investigating image-guided molecular/cellular therapy to investigate novel therapies for CAD/PAD, solid tumors, spinal cord injury, neurodegenerative diseases, and more. I immediately saw the potential of this new paradigm.
Not long before residency application season began, a close family friend invited me to shadow him for a week in IR. I was intrigued by the breadth and depth of clinical expertise that IRs applied across all sub-domains of medicine, especially in the acute setting. At Yale I was fortunate to meet Drs. Bob White and Hamid Mojibian who became amazing mentors. I felt an instant “cultural fit” with IR—I felt that surgery exalted its history and firmly established traditions, whereas IR celebrated its uncharted future as a burgeoning specialty that was redefining standards of care with disruptive maging and device technology. I am a futurist and a risk-taker at heart; I wanted to ride this new wave, not be engulfed by it.
I did my internship in internal medicine at MGH. I customized my schedule to be heavy in critical care, cardiology/vascular medicine, gastroenterology/hepatology, and oncology, understanding that these specialties overlap significantly with IR. It was an intense year, with the sheer volume of cases managed, the extreme autonomy bestowed upon house staff, and the relentless pursuit of evidence-based medicine which laid a solid foundation for my current clinical IR practice.
I stayed at MGH for my residency in diagnostic radiology. With some planning, I was able to satisfy the requirements for the ESIR curriculum (including a SICU rotation) and also complete a fellowship in cardiac imaging, earning Level III certification in both cardiac CT and MRI, in-demand diagnostic skills which have served me tremendously well in private practice.
Between residency and fellowship, I completed a one-year post-doctoral fellowship in biodesign innovation and digital health at the Texas Medical Center. Much more about this in the questions below.
When it came time to choose an IR fellowship, I wanted the most intense training program possible, where case volume, variety, and fellow autonomy would be maximized across all of the IR service lines. There’s a saying, “You can’t do the same fellowship twice,” and it’s absolutely true for IR, which is a relatively young and small specialty that is constantly evolving from forces within and around it, resulting in a very heterogeneous practice landscape. I completed my IR fellowship at the University of Texas Southwestern Medical Center, which was a phenomenal training experience spanning the full gamut of vascular, oncologic, GI/GU, hepatobiliary, trauma, pediatric, and neurologic interventions. The IR cases were definitely bigger in Texas.
Describe your current job responsibilities via private practice radiology and your medical innovations/consulting roles?
I joined a traditional physician-owned private practice that owns and operates outpatient imaging centers and contractually provides radiology services to a large hospital system. I am about 60% IR with a busy service providing the full spectrum of image-guided interventions, including PAD, DVT/PE, IO, TIPS/BRTO, UFE/PAE, etc. In my 40% DR time, I focus mainly on cardiovascular imaging, with a very high volume of cardiac CT (including FFR-CT and TAVR/TMVR/PVI examinations), cardiac MRI (adult and pediatric), peripheral vascular ultrasound/CTA/MRA, and (radiologist-interpreted) echocardiography and nuclear (SPECT/PET) stress tests.
My day-to-day clinical work allows me to identify unmet needs in both diagnostic and interventional radiology. For example, catching a missed diagnosis on prior imaging, encountering technical difficulty during a procedure, or managing a post-procedural complication, can inspire innovative digital and/or device-based solutions to prevent them in the future.
In terms of med tech roles which I pursue in my non-clinical time, I am the inventor/co-founder of two medical device companies and the medical officer for two digital health companies. NoviRad, Inc. (Houston, TX) has developed a novel percutaneous drainage catheter system. Azygos Vascular, Ltd. (Galway, Ireland) has developed a first-in-class structural heart intervention to treat HFpEF. Ferrum Health (San Francisco, CA) has developed an AI-powered quality and safety system which second-reads diagnostic radiology examinations for missed significant findings. POCUS Systems, Inc. (Los Angeles, CA) has developed an AI-powered handheld point-of-care ultrasound system optimized for use in interventional procedures.
In your experience, what do physicians who are interested in private practice in IR need to keep in mind when comparing it to academic practice?
The traditional differentiators between academic and private practice have blurred over time, and the landscape of private practice has also changed substantially. These days, both academic and private practices operate under the same financial boundary conditions of increasing operational costs and decreasing reimbursements, making RVU/FTE an emphasized physician performance metric in both settings. The need to produce clinically often comes at the zero-sum cost of protected time for research and teaching, duties which may be relegated to after-hours.
Today’s private practice landscape is best classified by entity ownership structure. 1) Traditional private practices are majority owned and operated by physician shareholders, with or without capital assets (e.g., brick and mortar offices, imaging equipment, etc.). 2) Direct employment by private or public (including governmental) integrated delivery networks (IDNs), which are large health systems that have grown over the last few decades from hospital mergers and acquisitions. 3) Corporate practice, which was catalyzed by the scalable deployment of teleradiology technology in the 2000s and which challenged the business model of on-site practice. In the last 10 years, private equity firms have consolidated approximately 5-10% of radiology private practices in the US into corporate mega-groups, a few of which have in turn gone public.
In my opinion, traditional private practice offers IRs the greatest autonomy and latitude for high-end clinical practice building and is definitely the most financially rewarding, especially when investment is made in an office-based lab (OBL) or ambulatory surgical center (ASC). In addition, for IRs interested in med tech, it is critical to understand the intellectual property and equity agreements delineated in an employment contract, which can be relatively unfavorable to the physician inventor if hired by an academic center or other large institution.
How did your year-long post-doctoral program in health tech innovation and entrepreneurship prepare you for a career in medical technology?
The lack of meaningful business education in medical school and residency/fellowship curricula is unfortunate, since it puts physicians at a disadvantage in the real world, where non-clinical administrators have taken control over so much of health care, from hospital governance to insurance companies to the biopharmaceutical and medtech industries. Understanding the language, principles, and metrics of business are no longer just nice-to-have qualities for modern physicians; I consider them must-have competencies, critical for anyone venturing into industry.
It is difficult to gain meaningful exposure to the med tech and venture capital industry on a part-time or avocational basis. To become a player in this space requires a dedicated immersion period to untangle its operations, network with relevant stakeholders, and discover opportunities. But full-time MBA programs are expensive, approaching 7 figures when accounting for opportunity costs, and executive programs feel that postgraduate medical education doesn’t count for real-world experience in their admissions decisions.
Biodesign fellowships fill these gaps in an excellent way. After a multi-step application process, I was selected as an innovation fellow at the Texas Medical Center, where I was teamed up with engineers and business consultants to develop novel device-based and digital solutions to unmet clinical needs. It was an intense year of formal didactics on venture formation and financing, intellectual property, prototyping, FDA regulation, and clinical investigation. It was a truly immersive learning experience in multidisciplinary team building, problem solving, and communication skills. I am often asked by trainees when the best time is to complete an innovation fellowship. I found that a year between DR residency and IR fellowship was perfect, as I was able to work as a tele-radiologist in the evenings to maintain strong diagnostic skills and income.
Where do you think bio-innovation in IR will push the future of the field?
Radiology is the Silicon Valley of medicine, and technology is its lifeblood. IRs pride themselves on being early adopters of new gadgets and techniques, and it’s what I absolutely love about the field. One thing I tell prospective trainees is that IR is still in the transition period between fledgling startup and established enterprise—what venture capitalists refer to as the “Valley of Death”—and as such is still subject to rapid boom-bust cycles. Turf wars, credentialing hurdles, reimbursement cuts, and competing technologies (e.g., endoscopic procedures, novel targeted drug therapies, etc.) are realities which our specialty will have to strategically contend with. As IRs grow in number and stature and become more visible on the clinical, research, and administrative playing fields, our future will become secure.
Innovation happens at the boundaries and intersections of different fields. Interventional oncology is currently at the center of IR research and will likely remain so for years to come. But the caliber of IO clinical trials is limited by funding, patient recruitment, and equipoise vis-à-vis competing anti-tumor therapies. If IO researchers can form collaborative relationships with medical, surgical, and radiation oncologists, as well as with biomedical engineers and basic scientists in molecular/cell biology and immunology, the future of IO could be very exciting.
Personally, I am very bullish on tumor ablation, where I foresee huge growth in procedural volume, indications, and positive long-term outcomes data. I am particularly excited about the ongoing investigation of ablation for breast cancer, ablation and cementoplasty for the palliative treatment of bone tumors and pathologic fractures, and the synergies being discovered between ablation and molecular/cellular immunotherapies. With the exception of ablative Y90 radiation segmentectomy, I am bearish on other trans-arterial liver tumor therapies, as they are likely to be outperformed by the development of targeted small molecule and/or antibody agents.
Compared to IO research, vascular IR research is much more mature, with a large amount of high quality evidence supporting an “endovascular first” approach to occlusive and aneurysmal arterial disease throughout the body, with major contributions from colleagues in interventional cardiology and vascular surgery. Clinical trial research on the endovascular treatment of stroke and DVT/PE with novel devices is following a similar exciting trajectory.
Could you shine more light on your experiences with healthcare policy and law?
Understanding healthcare policy and advocacy is critical to defending patient care and advancing our profession. My experience dates back to high school, when I competed in cross-examination policy debate tournaments at the city, state, and national levels, and also successfully managed a state-level judicial re-election campaign. During medical school, I co-founded the Yale chapter of the American Medical Association. In residency and fellowship, I participated in several ACR and SIR advocacy trips to Capitol Hill in Washington, D.C. to discuss imaging-related policy with Congressional leaders, and I continue to be involved with the Voices for IR Grassroots Program. In 2020, I was appointed by Governor Greg Abbott to serve on the Texas Council on Cardiovascular Disease and Stroke, where I formally advise executive and legislative public health policy.
What advice would you give medical students aspiring to become IRs, especially those interested in med tech?
Focus on being a great doctor first, a skilled radiologist second, and a successful innovator third. Always keep your diagnostic imaging skills sharp, for the best IRs are also excellent DRs.
There is no best training program or perfect job, only the right one for you. Learn the meaning of organizational culture, and make sure that your vision of excellence aligns with those around you. Good mentorship is invaluable but must be sought out. Leaders invite you to work with them, not for them. Know your value. Remember, institutions don’t love you back.
Patent first; publish later. Innovators don’t waste time on committees. Groupthink is deadly.
Always let best patient care be your North Star, and you will never be lost.
Interview by Rohil Malpani, Yale School of Medicine ‘21
Congratulations MSC Members: 2020 Match Results
|Hanzhou (Hanssen) Li||Emory Univ IR|
|Lynsey Maciolek||MD Anderson/Univ. of TX – Houston IR|
Biodesign & Innovation
|Yosef Frenkel||Montefiore Med Ctr IR|
|John Moon||Emory Univ IR|
|Neil Jain||Georgetown Univ IR|
Diversity & Inclusion
|Shannon Sullivan||CWRU/Univ Hospitals Cleveland Med Ctr DR|
|Ayalivis De La Rosa||Emory Univ IR|
|Belinda Asare||Johns Hopkins DR|
|Erik Hilborn||UMiami/Jackson Memorial IR|
|Rajath Rao||Mount Sinai Medical Center – Miami DR|
|Roger Kayaleh||UPMC IR|
|Nicole Law||Univ of Utah IR|
|Varun Singh||Massachusetts General Hospital IR|
|Josh Maclaughlan||Loma Linda Univ IR|
|Shelby Curren||Monmouth Med Ctr DR|
IR Interest Groups
|Lisa Liu||Univ of Colorado IR|
|Jordan Wells||Univ of Arkansas for Medical Sciences IR|
|Jared Cline||Univ of Southern California DR|
|Daniel Phadke||UVA IR|
|David Berezovsky||Rutgers RWJ IR|
|Mary Elizabeth McLaughlin||Cornell Univ IR|
|Jordan Taylor||UNC DR|
|Ansh Johri||Univ of Massachusetts IR|
Patient & Family Centered Care
|Sameer Singhal||Brigham & Women’s Hosp IR|
|Alain Nathan Sahin||Univ of Ottawa DR|
|J. Erik Winterholler||Univ of Wisconsin – Madison IR|
|Connie Liou||Columbia IR|
|Nathan Loudon||Univ of Michigan IR|
|Anisha Banda||Univ of Washington IR|
Public Relations & Communication
|Adam Swersky||Northwestern IR|
|Alex Sher||Mount Sinai IR|
|Albert Jiao||Brigham & Women’s Hosp DR|
|Kyle Maughan||Vanderbilt IR|
|Aesha Patel||Rush Univ Med Ctr IR|
|Dylan Ropert||Indiana Univ IR|
|Zhao Zhang||Mayo Clnic – Jacksonville DR|
|Gregg Khodorov||Thomas Jefferson Univ Hosp IR|
|Ricky Patel||Rush Univ Med Ctr IR|
|Scott Shuldiner||Kaiser Permanente Los Angeles IR|
|Monica Matsumoto||Upenn IR|
|Joseph Knox||UCSF DR|
Web & Technology
|Madhu Joshi||UCLA IR|
|Abin Sajan||New York Pres-Columbia IR|
|Sami Chau||University of Southern California IR|
Last updated 4/3/20
I Took an IR Research Year: Student Perspectives
As the career path to interventional radiology evolves, so too do the aspects of what may make a competitive candidacy. What was previously a decision about fellowship during the PGY3-4 years can now be a specialty choice made as an MS3 (or earlier). Like other competitive specialties, spending an extra year in the middle of medical school to fully immerse yourself and conduct IR research is an opportunity to strengthen your application and demonstrate to residencies how dedicated you are to the field. Read about the experiences of 3 medical students who are currently in the middle of an IR research year.
You may also find this article from the archives helpful!
Click below to navigate directly to each student’s testimonial:
Nikhil is taking a research year between his 2nd and 3rd year at George Washington University School of Medicine and Health Sciences in Washington, DC.
What is your research?
One year of clinical research at Children’s National Medical Center and George Washington University Hospital which includes work on:
• IGTFusion Trial: Ongoing study validating and setting up clinical trial for an image fusion utility for tumor biopsy and ablations
• May-Thurner’s Reading Study: Ongoing study on MRV reading accuracy
• PAD Outcomes Study: Retrospective quality assessment between IR and VS
How did you hear about your research?
I reached out to my mentor in the IR department at GWUH who connected me with my current mentor at Children’s National Medical Center, Dr. Karun Sharma.
How did you decide?
I explored the idea very last minute, just before the start of M3. I then read up on the idea of taking a research year on various forums and the current article on the SIR website. While I was interested and had prior interest in research, and was passionate about pursuing IR, I was not so sure about adding an additional year to my training. I was fortunate that my research was funded, which made my decision easier as I otherwise would have struggled to pay rent!
I weighed the following pros and cons:
• Wanted a research focused career
• Would help highlight my passion towards IR down the line
• Helps build connections and network for future opportunities/residency
• Making sure that IR was the right field for me
• Taking a little break from school
• No longer graduating with the friends I had made in the first two years of medical school
• Forgetting stuff learned in preclinicals
• Returning with my clinical skills a little rough around the edges
• Possibility of realizing IR wasn’t right for me and having committed to a year off (thankfully the opposite revelation happened)
Research experience in setting up a clinical trial (IRB proposals, review process, grant application process), paper writing skills, connecting with mentors at my home institution as well as at Children’s National. I will attend SIR 2020 and give an oral presentation.
As for publications, I had 4 before (non IR related), but will hopefully have at least 2 more that are IR related now.
Was this the right decision?
Yes! Children’s National is a refreshing experience and I am loving exploring the world of pediatric IR, something that I may not have gotten to learn more about otherwise. Additionally, I definitely realized that IR was the right field for me and hopefully set myself up on a good footing for residency applications.
Simone is taking a research year between her 2nd and 3rd year at the Chicago Medical School at Rosalind Franklin University of Medicine and Science in Chicago, IL.
What is your research?
One-year translational research at Northwestern University working with my mentor/PI Dr. Samdeep Mouli on two main projects:
• Assessing the safety and feasibility of using Y90 in the prostate (animal model)
• Figuring out the optimal time to give TACE or Y90 in combination with immunotherapy for HCC (animal model)
How did you hear about your research?
I attended the Midwest Interventional Radiology Medical Student Symposium (MIRMSS) last spring. Shortly after, an email was sent out to people who attended advertising for this opportunity.
What helped you decide?
I received the email in May and was scheduled to start rotations in June/July, so I had to make the decision quickly. I ultimately just wrote down the pros and cons:
• Research is in IR – good for my residency application
• Networking – build connections that will help with future opportunities/residency
• Opportunity to attend other conferences and learn more about the field
• Funded – it’s always nice to get paid!
• Hands-on skills – performing surgeries, cell suspension, antibody staining, flow cytometry, histology, etc.
• Shadowing opportunities – scrub in on cases, attend resident/fellow lectures
• Ultimately determines if IR is the right field for me
• Reputation of the institution
• Nice break from school, especially having just taken Step 1
• Working with animals
• Delay graduation by 1 year and not graduating with my friends
What are your (ongoing) experiences?
Prior to this year, I had very little experience in research. Since then I have developed a wide variety of skills such as:
• Lab skills: I do a lot of tissue processing such as cell suspension and counting, and antibody staining
• Data analysis: Gathering histopathologic data and running the flow cytometry and analyzing the results.
• Annual Chicagoland Radiology Expo
• Radiological Society of North America (RSNA) Annual Meeting
• NYC Medical Student Interventional Radiology Symposium
• Society of Interventional Radiology (SIR) Annual Meeting
• Annual Medical Education Conference (AMEC) – upcoming
• American College of Radiology (ACR) Annual Meeting – upcoming
• New Cardiovascular Horizons (NCVH) Annual Conference – upcoming
Connections within the institution – I have gotten to know the residents, fellows, physicians, and PDs in both the diagnostic and interventional radiology programs at Northwestern.
Publications – Prior to this year I had no publications. At the end of this year I will come out with at least 6 papers from my two main projects, clinical projects, and assisted projects.
Abstracts/Presentations – I have submitted abstracts to upcoming conferences in which I will be able to present my work from this year.
Miscellaneous – Free time to enjoy life! I got to go on vacations, hang out with friends, and start back up on my hobbies again. I was able work on several projects and tasks for the RFS-MSC and get my sub-committee (Diversity Outreach – IRIG Committee) started on its projects for the year.
Was taking a research year the right decision?
ABSOLUTELY!! I came into this job with no prior experience and not a strong interest in research, but now I see it in a whole new light and hope to incorporate it into my future career. I have learned a substantial amount this year not only about IR as a field, but developing a large skill set in research that I previously did not have. This year allowed me to figure out if this is truly the right field for me – and the answer is yes. I have absolutely no regrets about my decision to take a research year. I strongly believe that I could not have created the same knowledge and experiences in IR and research had I not taken the leap. If you are thinking about taking a research but not sure if it is worth it, my advice is to write down the pros and cons and weigh them based on what is most important to you. However, I will say that taking a research year will definitely not hurt you when it comes to applying for residency!
Siddhant is taking a research year between his 5th and 6th year of the 6-year, integrated BA/MD program at the University University of Missouri – Kansas City School of Medicine in Kansas City, MO. His research is part of the TL1 Predoctoral Training Program at Washington University in St. Louis with Dr. Suresh Vedantham as his primary mentor.
One year of clinical research at Washington University in St. Louis which includes work on:
• ATTRACT (Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis) NIH sponsored, multicenter, randomized control trial – post-hoc analysis of completed clinical trial
• C-TRACT (Chronic Venous Thrombosis: Relief with Adjunctive Catheter-Directed Therapy) NIH sponsored, multicenter, randomized control trial – active engagement in on-going clinical trial
How did you hear about your research?
I first heard about the TL1/MSCI program at Washington University through a school wide email at my home institution (University of Missouri – Kansas City).
How did you decide?
This was a well thought out decision for me, but it wasn’t easy. There are a lot of factors that go into taking a research year. Nevertheless, I decided pretty early. Applications for my program were due Feb 20th so I reached out to my mentor around November.
• IR is an innovative field- research helps you be a part of that innovation
• Follow your research passions full time
• Get to learn new skills
• Expand your professional network
• Take a break from medical school
• Confirm you have chosen the right specialty
• Boost your resume
• Delay graduation by 1 year
• May or may not be compensated (NIH- funded programs such as TL1/MSCI are typically compensated though- thankfully)
• May need to relocate… then relocate back (if research is not at your home institution)
• Improve certain clinical skills but will definitely forget a lot of smaller details typically tested on board exams
What are your (ongoing) experiences?
Research – Full time research in a clinical science lab, interacting with professionals from diverse backgrounds (physicians, nurses, project managers, clinical trial coordinators, statisticians, residents, fellows). Also grant and paper writing.
Student – Full time student in the Master of Science in Clinical Research (MSCI) program. Example coursework includes: Analysis of Clinical Data, Designing Outcomes and Clinical Research, Introductory and Intermediate Statistics, Scientific Writing and Publishing, and Ethical Legal Issues in Clinical Research.
Certificate – An online curriculum in Entrepreneurship for Biomedicine Program (E4B) – nine nanocourses including Introduction to the World of Biomedical Innovation & Entrepreneurship, Survive and Thrive as an Innovator, Identifying Opportunities for Innovator, Building Effective Teams, Diversity and Inclusion in Innovation & Entrepreneur, Validating your Innovation, Fishing for Customers, Ethics in Biomedicine Innovation, Selling your Innovation
Conferences – Will attend 3 conferences throughout the year (American Venous Forum (AVF), Society of Interventional Radiology (SIR) Annual Meeting, Translational Science 2020)
Publications – I had 3 publications (2 basic science and 1 case report) prior to research year – none in interventional radiology. I will have at least 2 first author publications in IR after this year
Clinical Exposure – In addition to observing multiple IR procedures, I regularly attend IR clinic days with my mentor
Connections within the institution – During my year off, I made numerous meaningful connections with medical students, staff members, nurses, residents, fellows, and attendings at Wash U. The residents and fellow were extremely easy to converse with, and, in addition to helping me understand complex cases and procedures, frequently shared their insights about IR. Additionally, I was welcomed to the ORs anytime and, to the faculty’s great credit, I experienced first-hand how they always made time for teaching and engagement, despite how busy their day was. With IR being such a tight-knit community, I not only feel like I established an invaluable core mentor-mentee relationship to advance my career and knowledge of IR, but also created life long working relationships that I can turn to anytime in the future.
SIR-RFS – I have directly contributed to several projects for the RFS-MSC, and have been appointed Chair of MSC Reserves, helping interested medical students get involved with various RFS-MSC subcommittees: Education, Diversity and Innovation, IRIG, etc.
Was this the right decision?
YES! Clinical research requires its own unique skill set and level of understanding. When starting my research year, I knew very little about research methodology and how to design a good clinical trial or research study. While I obviously have a long way to go, this formal research experience, combined with structured coursework on the subject, has definitely provided me with a strong foundation from which I hope to continue to grow.
Perhaps the most valuable aspect of my research experience was being able to closely observe the day-to-day operations of an ongoing large, multicenter, NIH-funded clinical trial (C-TRACT) and the mentorship which came from the experience. Whenever I had any questions, I was able to address them directly with my mentor who gracefully shared his experiences and insight. Considering all that I have learned this year, I am unsure of any other avenues where a trainee could hope to gain such exposure.
Finally, soon after discovering the field of IR, I was hooked. What truly drew me to the field was its innovative spirit and diversity of cases. However, with innovation comes the irrefutable need to be informed and knowledgeable about the evidence backing that innovation. After this year, I feel much more confident in my abilities to distinguish between high-quality evidence and lower-quality evidence thereby, directly influencing the quality of care I hope to give my patients as a future Interventional Radiologist.
Previously updated on 4/9/20
The medical student guide to the updated SIR guidelines for managing thrombotic and bleeding risk in IR patients
Sanjog Singh MS4, University of New Mexico School of Medicine
Chris Gutjahr, Assistant Professor in Interventional Radiology, University of New Mexico School of Medicine
Even the newest of IR trainees quickly come to realize that the prevention and management of bleeding is an incredibly important consideration for any image-guided intervention. The SIR published its first consensus guidelines on management of thrombotic and bleeding risk in 2012 and updated them through two important papers published in JVIR earlier this year (links at the bottom of the page.) Part I is a relevant review of the physiology and pharmacology of hemostasis. Part II lays out the most updated recommendations. We will focus on 4 major takeaways from the updated recommendations, and we have structured them in the form of an algorithm that can be used to evaluate periprocedural bleeding and thrombosis for all IR patients:
1. Evaluate bleeding/thrombosis risk based on patient-specific factors.
2. Evaluate procedure-associated bleeding risk.
3. Evaluate periprocedural labs.
4. Use the recommended hold and re-initiation times for commonly used antithrombotics in the context of the overall clinical picture.
Of note, the data remains limited to retrospective studies due to minimal availability of high-quality, randomized, controlled data. Thus, the recommendations should be considered in the context of the patient’s overall clinical status, and a physician may deviate from them as necessitated by the individual patient, available resources, and established guidelines within the institution.
1. Evaluate bleeding/thrombosis risk based on patient-specific factors. Specific characteristics and comorbidities unique to a patient may increase their risk of bleeding or forming a clot and warrants pre-procedural evaluation. For instance, an underlying bleeding diathesis increases risk of periprocedural bleeding while an underlying malignancy may predispose a patient to periprocedural clot formation. There exist several scoring systems that can help evaluate an individual patient’s bleeding and thrombosis risk. The challenge is that these scoring systems refer to long-term risk, and therefore extrapolating from long-term risk to periprocedural risk is difficult and has not been validated. Nonetheless, when used as a component of the overall clinical picture, they are often used in clinical practice as a general guide to considering factors that may increase patient-specific bleeding/thrombosis risk. The two scoring systems highlighted in the JVIR article are the CHA2DS2-VASc score used to predict annual stroke risk in patients with nonvalvular atrial fibrillation and the HAS-BLED score in assessment of patient bleeding risk. Consider the components of these risk stratification systems when performing a pre-procedural bleeding/thrombosis risk assessment in all IR patients.
2. Evaluate procedure-associated bleeding risk. Periprocedural bleeding risk also depends on the procedure being performed. The risk of a major bleeding event is considerably lower for a nephrostomy tube exchange than for a TIPS, for example. The major update in the guidelines is in the categorization of procedure-related bleeding risk. Previous guidelines divided procedures into 3 tiers: low, moderate, and high bleeding risk. The new guidelines use a two-tier system: low risk and high risk. Low risk procedures are those that are expected to rarely have hemorrhagic complications or occur in areas where bleeding is easily identified and controlled, whereas high risk procedures or those in which hemorrhagic complications may be expected or involve locations where bleeding can have devastating consequences. In an attempt to define risk, high risk procedures can be categorized as having a > 1.5% risk of major bleeding or a 2-day risk of major bleeding of 2-4%. Low risk procedures have < 1.5% risk of major bleeding or a 2-day risk of major bleeding of 0-2%. In addition to considering the procedure-related bleeding risk, the guidelines recommend factoring in location and potential consequences of bleeding.
3. Evaluate periprocedural labs. Certain lab values are frequently used in IR to assess periprocedural bleeding risk. When interpreting these lab values, it is helpful to keep these 2 thoughts in mind: 1) Be aware of what a positive or negative lab value does and does not tell you. For instance, the prothrombin time (PT) test evaluates the coagulation cascade and may be used to assess bleeding risk before procedures. It was developed to identify the cause of bleeding in symptomatic patients; however, mild to moderate PT prolongation has not been shown to predict bleeding risk in a nonbleeding patient. 2) Always keep in mind the patient’s full clinical context. A useful example is a chronic liver disease (CLD) patient. These patients have nearly twice the thrombotic risk of the general population, yet many of them have an increased PT/INR. This paradox occurs because routine coagulation studies such as the PT/INR reflect a change only in the pro-coagulation factors and not the anti-coagulation factors. The liver produces the majority of both pro-coagulation and anti-coagulation factors used in hemostasis, and patients with CLD have rebalanced primary and secondary hemostasis due to relative decreases in both. Recall that whether excessive bleeding or clot formation occurs is a product of the relative balance between pro/anti-coagulation factors, and not necessarily the absolute value of the pro-coagulation factors. Therefore, a CLD patient with an INR of 3 may be incorrectly assumed to be anticoagulated when, in fact, they may be rebalanced or tipped towards pro-thrombosis, and the elevated INR is only taking into account the decrease in pro-coagulation factors.
With these two concepts in mind, the most commonly used periprocedural labs for evaluating bleeding risk are the PT/INR, platelet count, and hemoglobin. Keep in mind that there are no high-quality data to guide whether preprocedural lab testing reduces periprocedural bleeding risk. The panel did not recommend routine hemoglobin or platelet counts for procedures with low bleeding risks. However, they may be indicated if a patient inherently has a higher bleeding risk such as those with hematologic disorders and patients receiving certain chemotherapies. For procedures with high bleeding risk, the panel recommends routine preprocedural tests which may include hemoglobin, platelet count and PT/INR. PTT or anti-Xa can be considered for patients receiving heparin. The suggested laboratory thresholds are to transfuse platelets if <50 x 109/L and correct INR to 1.5-1.8. Although of low quality, available literature suggests low bleeding risk procedures can be safely performed at INR >1.5 or platelet count > 20 x 109/L. Thus, the recommendation for low bleeding risk procedures is to correct INR to within range of 2.0-3.0 and transfuse if platelets < 20 x 109/L. If arterial access is required for low risk procedures, the recommended INR threshold is < 1.8 for femoral access and <2.2 for radial access.
Low Risk Procedures
Expected to rarely have hemorrhagic complications
Occur in areas where bleeding is easily identified or controlled
-Catheter exchanges (gastrostomy, abscess, nephrostomy)
-Dialysis access interventions
-IVC filter placement
-PT/INR, hemoglobin, and platelet count not routinely recommended
–INR: correct to within range of 2.0–3.0‡
-Platelets: transfuse if < 20×109/L
< 1.5% risk of major bleeding
2-day risk of major bleeding of 0-2%
High Risk Procedures
Hemorrhagic complications may be expected
Involve locations where bleeding is difficult to identify or can have devastating consequences
-Solid organ ablations
– Portal vein interventions
– Solid organ biopsies
-Routine labs including PT/INR, hemoglobin, and platelet count recommended
–INR: correct to within range of 1.5–1.8
-Platelets: transfuse if < 50x109/L
> 1.5% risk of major bleeding
2-day risk of major bleeding of 2-4%
Additionally, PT/INR and PTT can be used to monitor the presence and level of specific anti-coagulants such as warfarin and heparin respectively. Tests such as thrombin time and Xa activity test can be used to measure the presence and level of direct oral anticoagulants such as apixaban. You may see thromboelastography (TEG) used at some point during your IR rotations. TEG works by assessing the viscoelastic properties of clot formation in whole blood from the start of primary hemostasis through clot lysis. In contrast to PT and PTT which only analyze a part of the clotting cascade, TEG measures the entire process of hemostasis including platelet function, clot formation, fibrin cross-linking, etc. The value of TEG in the preprocedural workup is unknown, and these tests have not been validated to assess bleeding risk in nonbleeding patients. Some authors have advocated that TEG has distinct benefits for patients with CLD in whom traditional coagulation studies are less accurate.
4. Use the recommended hold and re-initiation times for commonly used antithrombotics in the context of the overall clinical picture. Antithrombotic medications are among the most commonly prescribed medications in the US and consist of antiplatelets and anticoagulants. Antiplatelets work by inhibiting platelet activation and aggregation, while anticoagulants work by either blocking the synthesis or inhibiting the action of pro-thrombotic enzymes in the coagulation pathway. Part I of the consensus guidelines article goes into some detail and has some useful tables regarding each class of medication.
One of the most common questions IR physicians get from consulting providers is whether or not to hold anticoagulation and/or antiplatelets. Three factors must be considered when answering this question: 1) the overall patient status including thrombotic and bleeding risks 2) procedural bleeding risk 3) pharmacological factors of the medication being held. The goal, of course, is to minimize risk of medication-related bleeding during the procedure while avoiding thrombosis since the patient has some propensity to form clots.
Essentially, the decision must be made whether the procedure can be performed while the patient is on the anticoagulant. If not, then decisions on how long to hold the medication before the procedure, and when to resume the patient’s anticoagulant after the procedure must be made. Stepwise algorithms to assist in decision making are provided in the article (see algorithm.) Additionally, medication specific recommendations are included (see table). For some patients with a high thrombotic risk, ‘bridging’ with a different anticoagulant is required to minimize the periprocedural risk of a thrombotic event. Bridging is done with a parenteral agent that has a short half-life, typically heparin, giving the ability to minimize the amount of time a patient is not anticoagulated.
Take away points
· The clinical decision-making for periprocedural management of thrombotic and bleeding risk is complex and should be specific to each patient with variables including the provider, the practice, available resources, the patient’s specific risks, and comorbid conditions affecting the decision.
· The new consensus guidelines provide useful timetables and algorithms for management but should be used in the context of the previous point.