Best IR programs for training?

[piii]

In your opinion, what are the best 10 or 15 programs in the country for IR training?

I’m not looking for some silly “top ranked” list, but I thought a list of places that provide well rounded training, have a broad scope (transplant, PAD, aortas) etc would be beneficial to future applicants.

From interviews and speaking to attendings and fellows, the places with the most well rounded training seem to be (in no particular order):

UCSF
Kaiser
MD Anderson
Rush
Northwestern
MCW
Michigan
MIR
Miami Vascular
Penn
UVA
Mount Sinai
Brown
Beth Israel
Yale

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[NDcienporciento100]

In your opinion, what are the best 10 or 15 programs in the country for IR training?

I’m not looking for some silly “top ranked” list, but I thought a list of places that provide well rounded training, have a broad scope (transplant, PAD, aortas) etc would be beneficial to future applicants.

From interviews and speaking to attendings and fellows, the places with the most well rounded training seem to be (in no particular order):

UCSF
Kaiser
MD Anderson
Rush
Northwestern
MCW
Michigan
MIR
Miami Vascular
Penn
UVA
Mount Sinai
Brown
Beth Israel
Yale

Strong list, MD Anderson outside of IO not really sure what else they have going on. I have not heard about Israel might be good.

 

[Dave1980]

Beth Israel in NYC or Boston? The one in Boston is somewhat malignant I heard.

 

[piii]

Strong list, MD Anderson outside of IO not really sure what else they have going on. I have not heard about Israel might be good.

Beth Israel in NYC or Boston? The one in Boston is somewhat malignant I heard.

In Boston. good points. I was struggling with whether JHU and OHSU should make the list over those two programs. OHSU has well rounded case log with PAD, etc.

 

[NDcienporciento100]

In Boston. good points. I was struggling with whether JHU and OHSU should make the list over those two programs. OHSU has well rounded case log with PAD, etc.

See one do one teach one mentality is gone in many places that are academic heavy weights, the residents get very little hands on autonomy. Im not saying it’s bad but think about that and do your research accordingly when evaluating these programs.

 

[DJNYY]

See one do one teach one mentality is gone in many places that are academic heavy weights, the residents get very little hands on autonomy. Im not saying it’s bad but think about that and do your research accordingly when evaluating these programs.

As an IR resident at one of those "best" programs listed, I could not agree with you more. Compared to surgery, where there is an understanding that there is graduated responsibility and procedural autonomy from year to year, many IR programs still see training in black and white where residents are the ones on the brink of causing catastrophe with each movement and fellows are to be trusted with doing basically everything.

Had an attending of mine who told me that when they got to their fellowship year, they had not even done as much as place a PICC line. First case of their fellowship was a UFE, and the attending apparently said "let me know when you're in the internal iliac artery" and walked off.

 

[NDcienporciento100]

As an IR resident at one of those "best" programs listed, I could not agree with you more. Compared to surgery, where there is an understanding that there is graduated responsibility and procedural autonomy from year to year, many IR programs still see training in black and white where residents are the ones on the brink of causing catastrophe with each movement and fellows are to be trusted with doing basically everything.

Had an attending of mine who told me that when they got to their fellowship year, they had not even done as much as place a PICC line. First case of their fellowship was a UFE, and the attending apparently said "let me know when you're in the internal iliac artery" and walked off.

Lmao!

 

[NDcienporciento100]

As an IR resident at one of those "best" programs listed, I could not agree with you more. Compared to surgery, where there is an understanding that there is graduated responsibility and procedural autonomy from year to year, many IR programs still see training in black and white where residents are the ones on the brink of causing catastrophe with each movement and fellows are to be trusted with doing basically everything.

Had an attending of mine who told me that when they got to their fellowship year, they had not even done as much as place a PICC line. First case of their fellowship was a UFE, and the attending apparently said "let me know when you're in the internal iliac artery" and walked off.

All seriousness aside, that sucks if your attendings are freaking out every time your advanceing a wire but that said we have all seen attending’d like that and frankly it annoying.

 

[qxrt]

Residencies without IR fellowships typically give you much more hands-on experience with procedures. I was doing TACEs as primary operator by the end of my residency, with attending not even scrubbing in (granted, that's probably more than the average radiology resident does, but not that far off). Then I go to start IR fellowship at one of the big name academic centers, and the senior radiology resident who co-scrubbed with me near the beginning of my fellowship is impressed that I can put in an IVC filter on my own...kind of eye-opening.

 

[NDcienporciento100]

Residencies without IR fellowships typically give you much more hands-on experience with procedures. I was doing TACEs as primary operator by the end of my residency, with attending not even scrubbing in (granted, that's probably more than the average radiology resident does, but not that far off). Then I go to start IR fellowship at one of the big name academic centers, and the senior radiology resident who co-scrubbed with me near the beginning of my fellowship is impressed that I can put in an IVC filter on my own...kind of eye-opening.

I think it’s all cultural, if your program has a “let the resident struggle or get his hands dirty” then it probably won’t matter whoever if your program has a culture of “see 100 before you do” then that’s how you will be treated.

 

[DJNYY]

Residencies without IR fellowships typically give you much more hands-on experience with procedures. I was doing TACEs as primary operator by the end of my residency, with attending not even scrubbing in (granted, that's probably more than the average radiology resident does, but not that far off). Then I go to start IR fellowship at one of the big name academic centers, and the senior radiology resident who co-scrubbed with me near the beginning of my fellowship is impressed that I can put in an IVC filter on my own...kind of eye-opening.

^This is so true from what I've seen as well. The problem with the new training paradigm of the integrated residency is that the integrated residency spots are concentrated at programs that are also fellowship heavy. I wish we still had the training pathway of prior years so I could have done my training at a place with fewer fellows "crowding me out" to get that better hands no experience before landing a "top tier" fellowship somewhere else.

I think the naked truth is going to be exposed at my program when they realize their own integrated residents are behind the outsiders who come in as independent residents for their final 1 year.

 

[NDcienporciento100]

^This is so true from what I've seen as well. The problem with the new training paradigm of the integrated residency is that the integrated residency spots are concentrated at programs that are also fellowship heavy. I wish we still had the training pathway of prior years so I could have done my training at a place with fewer fellows "crowding me out" to get that better hands no experience before landing a "top tier" fellowship somewhere else.

I think the naked truth is going to be exposed at my program when they realize their own integrated residents are behind the outsiders who come in as independent residents for their final 1 year.

One of the reasons why I think community programs are underrated. Also when you train at one of these places you mention most will give you no pad experience or stroke because vascular owns it or neuro IR owns it, and frankly the IR docs don’t care because there doing complex IO, AVMs, TIPS, Illeocaval reconstructions etc, and don’t really care there not not getting PAD.

 

[irwarrior]

Yes. Some good points. Students should look at what degree of autonomy is given to not only the PGY6 but equally as important or arguably more important I would look at the degree of autonomy given to the early years PGY2 through 4 for VIR integrated residents.

I would also look to see if the attendings are rounding and doing formal consults (not just the residents) similar to how a surgical service would.

Also, it is important to look to see if all service lines are being developed not just the ones that all have (interventional oncology, hepatobiliary , and venous). You want to see that they are going to compete for cases in the other arenas such as PAD ,neuro cases and even aneurysmal disease.


If they are doing over a 1000 cases but over 1/2 of those cases are lines and biopsies and drains, that is not a great spread. You want to have arterial experience throughout the body including the brain, legs, pelvis, arms, mesenteries, renal, intercostals etc. So you want to also have comfort in radial access as well as pedal access. You want to get very comfortable with not only super tortuous vessels of PAE but also difficult calcified vessels of PAD tibial /pedal CTOs.

If the program is not competing for these cases currently do they have a plan in place on how they are going to market and get those referrals? AT the least they should have you train with cardiology or vascular surgery to acquire those skills (but you should be the primary operator or assist just behind the attending). In many it is more like an observorship.

In the real world, if you do not have a clinic ( a place to see and follow patients), ability to admit patients and some clinical and technical ability in common disorders such as PAD, hemodialysis work, Fibroids, veins, pain interventions the likelihood of being successful drops. With current level of evidence and limited amount of HCC (ie most gets transferred to transplant centers) there is not enough interventional oncology to have a thriving VIR practice.

This information is not transparent as the programs (some are big names) that do not have quality volumes or training do not want to be disadvantaged in recruiting to programs that offer robust training.

 

[piii]

Yes. Some good points. Students should look at what degree of autonomy is given to not only the PGY6 but equally as important or arguably more important I would look at the degree of autonomy given to the early years PGY2 through 4 for VIR integrated residents.

I would also look to see if the attendings are rounding and doing formal consults (not just the residents) similar to how a surgical service would.

Also, it is important to look to see if all service lines are being developed not just the ones that all have (interventional oncology, hepatobiliary , and venous). You want to see that they are going to compete for cases in the other arenas such as PAD ,neuro cases and even aneurysmal disease.


If they are doing over a 1000 cases but over 1/2 of those cases are lines and biopsies and drains, that is not a great spread. You want to have arterial experience throughout the body including the brain, legs, pelvis, arms, mesenteries, renal, intercostals etc. So you want to also have comfort in radial access as well as pedal access. You want to get very comfortable with not only super tortuous vessels of PAE but also difficult calcified vessels of PAD tibial /pedal CTOs.

If the program is not competing for these cases currently do they have a plan in place on how they are going to market and get those referrals? AT the least they should have you train with cardiology or vascular surgery to acquire those skills (but you should be the primary operator or assist just behind the attending). In many it is more like an observorship.

In the real world, if you do not have a clinic ( a place to see and follow patients), ability to admit patients and some clinical and technical ability in common disorders such as PAD, hemodialysis work, Fibroids, veins, pain interventions the likelihood of being successful drops. With current level of evidence and limited amount of HCC (ie most gets transferred to transplant centers) there is not enough interventional oncology to have a thriving VIR practice.

This information is not transparent as the programs (some are big names) that do not have quality volumes or training do not want to be disadvantaged in recruiting to programs that offer robust training.

Very helpful info. Would you be willing to provide a list of programs that you think meet the standards of well rounded training, or critique my list in the OP?

 

[irwarrior]

all of the programs have their pros and cons.

All of the above listed programs listed do oncology

Miami Vascular with Barry Katzen was the original clinical VIR and developed a robust clinic and vascular practice (aorta's and pad) and is arguably the Mecca for clinical VIR.

 

[NDcienporciento100]

I would love to here from a current Miami Vascular Fellow, does it live up the hype of its gold age, are they really doing tons of PAD and Aorta work still?

 

[Kuratz]

To tack onto this with a somewhat different question: if one is ESIR how important is it to do your last year of training at a different institution than the previous 4 years? Integrated IR is all the same obviously but I’ve heard one should try to get more training variety instead of an additional year doing similar things. Thoughts?

 

[irwarrior]

It depends if you get all facets of VIR training. Also, when you go to a new place it takes some time for you to get accustomed to the EHR and the workflow and more importantly for the faculty to get used to you.

If you get into Miami Vascular or equivalent it is probably worth it, but if you are going from a high end VIR training program with a lot of clinical education and autonomy for complex procedures including stroke, IO, ablations, PAD, Prostates, fibroids, venous reconstructions, complex ivc filters, hemodialysis interventions etc than I would probably continue on. But, I do think it is wise to look outside of your organization to see what is out there as you quickly develop tunnel vision in 4 years of training.

 

[NDcienporciento100]

To tack onto this with a somewhat different question: if one is ESIR how important is it to do your last year of training at a different institution than the previous 4 years? Integrated IR is all the same obviously but I’ve heard one should try to get more training variety instead of an additional year doing similar things. Thoughts?

Integrated IR is not all the same! Go to Duke and you will never see an occluded SFA, no offense to Duke I’m sure you guys do crazy stuff like spend half a day taking out a IVC filter that has been in for 15 years etc, incredible cool and difficult cases but you are not being trained adequately in PAD, Aorta or Stroke work. And that goes for most big name institutions.

 

[piii]

Integrated IR is not all the same! Go to Duke and you will never see an occluded SFA, no offense to Duke I’m sure you guys do crazy stuff like spend half a day taking out a IVC filter that has been in for 15 years etc, incredible cool and difficult cases but you are not being trained adequately in PAD, Aorta or Stroke work. And that goes for most big name institutions.

what places are known for PAD, aortas, and stoke?

Ones I know of:

PAD: Michigan, MCW, Kaiser LA, Illinois Peoria, OHSU, Wake, rush

Aorta endoleak: MCW, Michigan Colorado, MGH, OHSU

Stroke: brown, Duke

 

[piii]

Do you guys think a requirement for solid IR integrated training is top DR training?

 

[NDcienporciento100]

what places are known for PAD, aortas, and stoke?

Ones I know of:

PAD: Michigan, MCW, Kaiser LA, Illinois Peoria, OHSU, Wake, rush

Aorta endoleak: MCW, Michigan Colorado, MGH, OHSU

Stroke: brown, Duke

Illinois Peoria does more PAD and Aortas then probably any program in the country, Mount Sinai New York does lots of endoleaks, USF Tampa does lots of endoleaks, UF Jacksonville does lots of stroke, Rush does lots of PAD, Michigan still does Aorta’s, UVA does Aortas, and PAD, have heard Mayo Arizona does PAD.

 

[Kuratz]

Integrated IR is not all the same! Go to Duke and you will never see an occluded SFA, no offense to Duke I’m sure you guys do crazy stuff like spend half a day taking out a IVC filter that has been in for 15 years etc, incredible cool and difficult cases but you are not being trained adequately in PAD, Aorta or Stroke work. And that goes for most big name institutions.

I meant an integrated IR resident is at the same institution for all of residency whereas an ESIR resident could train elsewhere during PGY-6.

The PAD, stroke, GU work etc is obviously extremely variable. The community program where I’m doing surgery prelim has private practice IR doing most of the thoracic/abdominal aortic work, plenty of PAD and some other oddball neuro cases in addition to the regular onc and bread and butter IR stuff. In contrast where I did med school (one of the above places listed) did almost zero arterial work. It’s surprising how variable the training can be.

 

[NDcienporciento100]

I meant an integrated IR resident is at the same institution for all of residency whereas an ESIR resident could train elsewhere during PGY-6.

The PAD, stroke, GU work etc is obviously extremely variable. The community program where I’m doing surgery prelim has private practice IR doing most of the thoracic/abdominal aortic work, plenty of PAD and some other oddball neuro cases in addition to the regular onc and bread and butter IR stuff. In contrast where I did med school (one of the above places listed) did almost zero arterial work. It’s surprising how variable the training can be.

And it’s not just IR, you go to these places for surgery, and there is the HIPEC, guys, the Thyroid guys, the abdominal wall reconstruction guys and they do almost nothing else.

 

[irwarrior]

The way I look at it is you need to have knowledge of the anatomy and pathology and get comfortable with the imaging using MRI, US, fluoroscopy, radiographs, CT and nuclear medicine of the entire body. This is through high volume and a great deal of self study.

The interventions can not (at least not yet) be learned without getting your hands dirty. You need to gain comfort in using an endobronchial forceps for IVC filter retrieval. Use the penumbra device to remove clot. Use the orbital atherectomy along with a nav6 filter. cross a CTO with wire escalation. Place a fenestrated aortic endograft after preclose technique. If you don't participate in these it will be harder to gain (not impossible) some of these skill sets. This can definitely be acquired even after training.

But, the hardest part is the clinical acumen and knowledge of seeing these patients in the office and making the decision of how to manage. What antibiotics for diverticulitis and for how long. When to scope that patient. What the diet is to reduce recurrence. When and if you should send to surgery etc. This takes years of seeing patient in the office and the clinic. This is why some trainees graduating from VIR may fail.

The clinical integration has to occur during the first 3 years of radiology. A 3 year clinical gap Is too much to maintain the hard earned clinical chops one has acquired from MS3/4 and PGY1 .

 

[piii]

The way I look at it is you need to have knowledge of the anatomy and pathology and get comfortable with the imaging using MRI, US, fluoroscopy, radiographs, CT and nuclear medicine of the entire body. This is through high volume and a great deal of self study.

The interventions can not (at least not yet) be learned without getting your hands dirty. You need to gain comfort in using an endobronchial forceps for IVC filter retrieval. Use the penumbra device to remove clot. Use the orbital atherectomy along with a nav6 filter. cross a CTO with wire escalation. Place a fenestrated aortic endograft after preclose technique. If you don't participate in these it will be harder to gain (not impossible) some of these skill sets. This can definitely be acquired even after training.

But, the hardest part is the clinical acumen and knowledge of seeing these patients in the office and making the decision of how to manage. What antibiotics for diverticulitis and for how long. When to scope that patient. What the diet is to reduce recurrence. When and if you should send to surgery etc. This takes years of seeing patient in the office and the clinic. This is why some trainees graduating from VIR may fail.

The clinical integration has to occur during the first 3 years of radiology. A 3 year clinical gap Is too much to maintain the hard earned clinical chops one has acquired from MS3/4 and PGY1 .

Some programs I interviewed at actually had early integration of clinical rotations into R1-R3! For example, Michigan does 5 clinical rotations during the first three years in including vascular surgery, cardiovascular ICU, hepatology, and surgical ICU. That doesn’t include more clinical rotations in the IR years. With active and sustained IR clinic time, this is a step in the right direction for VIR residencies, like you are saying.

 

[irwarrior]

UVA had the original clinical pathway and that model was then subsequently taken to U of Michigan when a couple of those VIR physicians left UVA to go to Michigan. UVA and U of Michigan have done a great job in integrating and the rest of the country needs to follow suit. In this day and age, ICU is an invaluable skillset and ventilator management, pressors, mass transfusion for bleeding, cardiogenic shock (RV (PE) or LV dysfunction), septicemia etc should learn to be managed by the VIR physician.

 

[irwarrior]

Medical students are unaware of what is important (and are focused on name and facilities), until they go out and try to establish a practice, that is when you identify those who are well trained (clinically and technically) and can build a practice from scratch and are not afraid of competition as opposed to those depend on referrals from specialists and end up doing lines, drains and biopsies and forced into the diagnostic pool. The places that do only oncology and venous disease have not learned to compete for referrals (typically at transplant affiliated centers).

 

[irwarrior]

And it’s not just IR, you go to these places for surgery, and there is the HIPEC, guys, the Thyroid guys, the abdominal wall reconstruction guys and they do almost nothing else.

But, they have surgical specialists who cover the scope. The problem I have is when you don't have any body focused on building the PAD service line at a program. Even if their volumes are not great, they should establish a service line. After all Dotter started the whole specialty doing an SFA revascularization on a CLI patient.

 

[NDcienporciento100]

As someone that is currently out in training, working with attending physicians across multiple specialities I can attest that nothing gains respect like providing good patient care.

 

[irwarrior]

The other thing is to try to get the actual logs that the VIR resident does in a week or a month and throughout residency and how much are they doing of the case (primary/assist/observation).

Don't look at procedural volume (they can be skewed) ie depends on how they code. If it is the same patient for a TACE. (they may code 1) arterial access 2) SMA angiogram 3) celiac angiogram 4) micrcoatheter selection right hepatic artery 5) actual embolization and 6) closure ie 6 procedures for one patient's tace procedure.

Also, high volume places may be doing a lot of minor cases (ie intern level cases) paracentesis, thoracentesis, random liver biopsies etc. These are cases that are in general of lower procedural complexity.


I would look to see how many arterial cases that are being done (PAD, chemoemboliztion/Y90, fibroids, prostates, bleeding cases, neuro angiography, aortic interentions, avms). Also break down the various service lines (pain/neuro/peds/pad/venous/oncology/mens health/womens health etc) and the various arterial beds.

rough ballpark

50 PAD interventions (Aortoiliac/fempop/tibials/ pedal)
50 chemoembolizations of the liver
50 cerebral angiograms
10 fibroids
10 prostate artery treatment

etc

 

[IR2020]

would avoid Colorado -- distinct reputation for being malignant, particular misogynistic against women -- they lost their accreditation few yrs back due to negative complaints from trainees, also all PAD is lost to vasc surgery

 

[NDcienporciento100]

Don’t know anything about the misogynistic comment. If you want PAD UVA, Rush, Christiana,Oregon, UF Jax,University of Pennsylvania,Washington University, Mayo Arizona, Miami Vascular, and University of Illinois Peoria (does the most statistical fact). Those are the one I know. People that know of others should speak up.

 

[NDcienporciento100]

Keep In mind those are ones that will have and interventional radiologist teaching you PAD, you could go to Duke and double scrub with a Vascular Surgeon and watch his resident do everything and say you got PAD Training but there is a difference.

 

[IR2020]

PAD not being done by most IR’s in practice — unless you work at OBL, so I’m not understanding this huge emphasis on PAD in training. In real world - most PAD done by vascular surgery and Int Cards

 

[irwarrior]

PAD is quite common as far as disease process (10 million plus patients int he US) and it is harder to build an IO practice outside of a transplant or cancer center. Most of the evidence for IO is with HCC, which often gets referred to transplant sites.

PAD is also something that is done by more and more independent VIR groups, OBLs and in some of the practices that have partnered with podiatry. It is a valuable skill set to deal with calcified arteries, dissections, stent deployment, CTO management etc. If you want to set up an outpatient practice it is hard to be successful without doing PAD, ESRD, veins and pain.