How to become an interventional radiologist?

[Reza Rajebi]

Hi,

After being on call for the whole weekend, I want to start a new thread. Here we go:

For many years there was only one pathway to become an Interventional Radiologist (IR): going through a Diagnostic Radiology residency and learn some basic skills and then applying for an IR fellowship for another year. This is called Traditional pathway.

You can find about available fellowships following this link: http://members.sirweb.org/members/APDIR/feldir/search.cfm or simply using FREIDA search engine from AMA.

Recently, as we know the new clinical model of IR practice was introduced and gained popularity. However, it was difficult to work around this concept with training IRs using Traditional pathway. As you can imagine most of those applicants had limited patient management experience after their internship and it was difficult for them to play this new role as clinicians and disease experts. Based on these facts the decision was made to create two new pathways for IR training:

1- DIRECT (Diagnostic and Interventional Radiology Enhanced Clinical Training) pathway: "The essential purpose of the pathway is to allow up to two years of clinical training to count toward the Diagnostic Radiology certificate and subspecialty VIR certificate." Training will take 6 years and you will be able to take the DR certification exam at the of your training and the IR certification exam 12 months after graduation.

You can get more information here: http://www.sirweb.org/fellows-residents-students/DIRECTpathway.shtml

For a list of programs offering DIRECT pathway visit: http://theabr.org/ic/ic_vir/ic_vir_direct.html

2- Clinical pathway: To increase the IR impact on patient management and train disease experts as well as research oriented IRs, this new pathway offers an in-depth clinical curriculum and seven months of designated research rotation. In addition to 32 months of DR education including 3 months of IR, there is a 9-month mini-IR fellowship.

This is an incomplete list of programs offering Clinical pathway: http://www.sirweb.org/fellows-residents-students/ClinicalPathwayInstitutions.shtml

Currently, we are contacting other radiology programs to provide a complete list.

Hope this helps,

Reza

Resources: www.sirweb.org and www.theabr.org

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[vicinihil]

if you do the DIRECT pathway, what can your first two years be? Can you do two years of Neurology or two years of pediatrics for example?

 

[Reza Rajebi]

Hi vicinihil,

SIR website says: Clinical training in an ACGME-approved program. Clinical training might include a transitional year plus another year in internal medicine, surgery, etc., or possibly in an integrated clinical year in Diagnostic Radiology.

So you need to have one year of transitional year internship then start another year based on the agreement between you and your program. Some of these programs might have a clinical year at the same institution to complete 2 years of clinical training.

RR

 

[werewethere]

Hi vicinihil,

SIR website says: Clinical training in an ACGME-approved program. Clinical training might include a transitional year plus another year in internal medicine, surgery, etc., or possibly in an integrated clinical year in Diagnostic Radiology.

So you need to have one year of transitional year internship then start another year based on the agreement between you and your program. Some of these programs might have a clinical year at the same institution to complete 2 years of clinical training.

RR

From having talked to a few people in DIRECT, it seems to be either two years of surgery, or one of surgery one of IM. I image other combinations may be possible

 

[werewethere]

if you do the DIRECT pathway, what can your first two years be? Can you do two years of Neurology or two years of pediatrics for example?

I'm wondering, based on your example, if you're thinking about working with kids or with neuro patients.

If that is the case, there are pathways for both. For peds IR, it would be intern year, diagnostic rads, and 2 year peds rad fellowship, one general, the following dedicated peds IR (total of 7 years).

For neuro IR, the radiology pathway is intern, diagnostic radiology, usually one year of neurodiagnostic and one to two years of neuro IR. (7-8 years). Neuro and NSGY can also obtain similar qualifications in the same time frame.

Note, however, that there are, depending on comfort level and experience, IRs that do some of the work in either of these fields, although the peds and neuro guys don't tend to do much if anything in other areas of IR.

Also note there within IR, there are many who subspecialize into IO, pain, PVD, Women's Health, non-vascular interventions, etc. At this point, they go through a standard IR pathway (DIRECT or through diagnostics most commonly) and find training and experiences to suit their needs.

 

[MedManU]

I am interested in doing IR, but I think I would also like to do some DR. Maybe a 50/50 mix or something. If I ended up choosing to do this, would going to the DIRECT or clinical route still give me the opportunity to do this mix of IR and DR? Or does that more make it to where places are not as apt to allow you to do DR and make you do all IR? I hope this makes sense. Thanks.

 

[PistolPete]

I haven't really perused the above websites too closely, but can you match into the clinical pathway or direct pathway during your 4th year of medical school? Because if not, isn't not having a guarantee of matching into either pathway very problematic? Who would want to do two years of residency only to not match into the clinical or direct pathway and not end up with any residency at all? Or am I mistaken?

 

[werewethere]

I am interested in doing IR, but I think I would also like to do some DR. Maybe a 50/50 mix or something. If I ended up choosing to do this, would going to the DIRECT or clinical route still give me the opportunity to do this mix of IR and DR? Or does that more make it to where places are not as apt to allow you to do DR and make you do all IR? I hope this makes sense. Thanks.

Yes, graduates of DIRECT are board certified in both interventional radiology and diagnostic radiology and qualify to take the CAQ (certificate of added qualification) in IR. People who go via DR also can have the same qualifications after finishing a 1 year IR fellowship. The difference is the scope of your skills. The maximum a DR program can give you in IR is 12 months worth of training, and frankly, most programs don't even come close to that level of IR training. DIRECT people are essentially guaranteed a minimum of 24 months of IR at their home institution. Additionally, 24 months of clinical training is helpful if IR is the dominant part of your practice. Why? Because the clinical training prepares you to manage your patient's illness. For instance, say you want to be a peripheral vascular specialist working with people who have aneurysms or stenoses of the arteries. You want to know enough to manage them clinically (manage BP, cholesterol, etc) so that when you are ready for a procedure (EVAR, peripheral stenting, etc), you are there to do it. In the mean time your diagnostic imaging skills help you with the surveillance ultrasounds, CTAs and MRAs that the patient might need. And keep in mind, often these same patients will need tune ups, so it's not usually just one procedure, but actual longitudinal care of their given disease process. Let me underscore that this does not mean becoming their primary care doctor. It means becoming their specialist, akin to people who have cardiologists to manage their heart failure, neurologists for their Parkinson's, or endocrinologists for their thyroid/DM.

So DIRECT is one way to go currently. Three things you need to consider.
1) Are you absolutely sure that IR is the way to go for you.
2) Is the program that you apply to the place you want to be for six years (usually everything is done at the same place).
3) Even if you do IR, do you want to do all of your IR in the same place.

If all three of these are true, then DIRECT is the way to go.

However, keep in mind that the price you pay is less diagnostic training. You are trying to fit 4 years of training into essentially 2, which can be challenging. The good news is that there is a new boards format for diagnostic radiology, and it is probable that a few places will give you the opportunity to specialize during fourth year with mini fellowships. However, since the new board format doesn't start for another two years, the idea of mini fellowships during residency is still not a well developed idea.

Hope this helps.

 

[werewethere]

I haven't really perused the above websites too closely, but can you match into the clinical pathway or direct pathway during your 4th year of medical school? Because if not, isn't not having a guarantee of matching into either pathway very problematic? Who would want to do two years of residency only to not match into the clinical or direct pathway and not end up with any residency at all? Or am I mistaken?

Yes, DIRECT pathway is a match choice at select institutions. If you match DIRECT, I believe that many if not all of the places that offer it have the the entire process set up at their institution, so it's like matching categorical in DR, everything in one place. It is also possible to switch from another field, such as surgery or IM, into the last 4 years of a direct pathway program.

Keep in mind, however, it is by no means the only way to become an IR. If you get a flexible DR program, it is possible to get a great deal of what you need, so look around and ask when you are applying.

I mentioned in another post that in the future there will be mini fellowships in the fourth year of DR. However, other things are in the works as well. For instance, plans are in progress for a primary IR certificate which which would be a 5 year program for people planning to do IR only. This would be a reduced DR component (you would not be DR certified) while keeping the IR and clinical training essentially the same.

So for now, there are two broad choices, DR and IR fellowship, or DIRECT/Clinical at one place with more clinical and IR and DR crammed into 2-3 years. In the future, the options should be more plentiful.

Here is the link to the SIR document regarding the clinical pathway.

www.sirweb.org/fellows-residents-students/IRresidency.doc

Hope this helps.

 

[MossPoh]

It seems that a lot of the programs listed on the SIR website don't really mention the DIRECT pathway for IR on their program website. I've gone to a few and they always mention the diagnostic radiology website, but nothing about DIRECT. Arre those things that you have to contact the program directly and ask about? I'm a long way off, but something I'm curious about.

 

[Gvataken]

Yes. This is a problem that I face when I am mentoring medical students who are interested in IR. Which programs offer DIRECT or CLINICAL pathways for IR. From talking to students, the only one listed on ERAS is the UVA Clinical pathway.

I know that UPenn, SUNY Brooklyn, Georgetown all have active IR pathways. I am not sure if you can apply to them straight out of medical school or not. I believe UPenn you can, not sure of the other 2. But, hopefully we can consolidate that information. This is something that a couple of the RFS members are working on .

If any of you out there know of DIRECT or CLINICAL pathways that are accepting applicants directly out of medical school. Please let me know or pm me.

V

 

[werewethere]

http://www.theabr.org/ic/ic_vir/ic_vir_direct.html

I know people who are doing DIRECT now, planned from med school, so they matched the entire program before starting any one part. It seems like planning is required to do it out of medical school and it is probably less common than people switching from other fields.

http://www.sirweb.org/fellows-residents-students/ClinicalPathwayInstitutions.shtml

Don't know anyone in this pathway, but this is what the SIR indicates as currently available programs.

 

[7summits]

I know that UPenn, SUNY Brooklyn, Georgetown all have active IR pathways. I am not sure if you can apply to them straight out of medical school or not. I believe UPenn you can, not sure of the other 2. But, hopefully we can consolidate that information. This is something that a couple of the RFS members are working on .

If any of you out there know of DIRECT or CLINICAL pathways that are accepting applicants directly out of medical school. Please let me know or pm me.

V

When I checked ERAS, I found the Clinical path offered by UVA, as well as 2 places that offered DIRECT pathways: UPenn and Christiana Care in Wilmington, DE.

Not sure if I missed any, but these were the ones I found when I compared the ABR list with the programs listed in ERAS.

 

[MossPoh]

I'm still not completely clear on how it works I think. There ARE scattered programs where you would select the DIRECT pathway to submit your application to BUT there are also programs that you don't? Does that mean you apply to their surgery, EM, IM or whatever clinical program at the same instition that has a DIRECT program, do two years and then apply or do you notify both the clinical program and the rads program that you intend on doing DIRECT beforehand and they have a heads up? If that is the case, do you try to get a little more of a radiology slant to the clinical education?

If there isn't some kind of communication between programs before matching in the clinical side, it seems kind of crappy to leave that program hanging to go bolting into interventional.

I know it is quite early to start thinking about this but I'd like to find research and start lining things up a bit 3rd year. I do have a bit more (a lot more really) exposure than the average medical student and regardless of what I'm intersted in, I just keep coming back to interventional stuff.

 

[IRmonkey]

My understanding is that the intention of this option was to make IR more attractive to intertested residents in other fields that are exposed late to IR or change their minds regarding training, rather than a planned intention apthway form the get go. I believe you would be correct in thinking that the residency that one began would not be to pleased if you entered their residnecy without intention to complete it. If you really do have interest in IR from the get go do the direct pathway.

The other line of thought is to do a traditional diagnostic residency even if you intend of doing IR to keep your options open incase you become unable to do IR for entire career.

 

[Gvataken]

This is the challenge. I am going to present these issues of training at APDIR meeting next week. Again I think that ther are multiple ways to get to IR. Which one is best , who is to say. My opinion is that as IR gets more and more clinical, the conventional pathway will not allow you to be prepare to face the day to day clinical issues that can arise in a modern day clinical IR's practice.

The problem is we need to have a good resource of which programs will accept you directly out of medical school (DIRECT or CLINICAL pathway). Now, part of the reason that the DIRECT pathway does not incorporate all 6 years and only the 4 years is because it is easier to fund 4 years rather than 6.

Also, we need to develop more IR training in currently existing models of residency. At our program , the general radiology resident is allowed to do up to 16 month of IR in 4 years of radiology residency.

Hope that helps.

 

[MossPoh]

Thanks. It does clear stuff up a bit. I think I was crossing wires with different pathways. I am interested in DR as well, but part of me wants that extra clinical exposure too. With the ungodly amounts of information one has to learn during residency, it seems that it'd be all too easy to let the clinical issues in interventional fall to the wayside or rust.

I suspect if I'm still interested in it when the time comes, I will just apply to a ton of programs in both areas and see where it takes me. Being BC in DR is obviously a tremendous benefit in the long run career, but in the event of something happening 5, 10, 15 years down the road that keeps me from interventional, I'm not sure I'd feel too comfortable with my skills with the rapid evolution of radiology. Hell, during my dad's career CT, MRI, PET, etc. were all brand new for him. I remember him talking about how difficult it was simply to relearn the anatomy in a completely different plane he never thought of before.

 

[badasshairday]

Is the traditional pathway on it's way out? Or will it still be an option in the future? I know there is some talk about taking IR out of the house of radiology, like rad-onc.

 

[Chung B]

I strongly feel that the "traditional pathway" is a flawed training pathway. There is no way to justify spending 4 months doing nuclear medicine (the current requirement) when I could and should be learning about more important/pertinent clinical topics that will actually help me take care of my patients in the future. Don't get me wrong you have to have a firm understanding of imaging, some areas much more then others, to be a good Interventional Physician. However, the training pathway can and must adapt to the fact that IR is a clinical specialty that requires significantly greater clinical knowledge base then the "traditional pathway" can support.

 

[badasshairday]

I strongly feel that the "traditional pathway" is a flawed training pathway. There is no way to justify spending 4 months doing nuclear medicine (the current requirement) when I could and should be learning about more important/pertinent clinical topics that will actually help me take care of my patients in the future. Don't get me wrong you have to have a firm understanding of imaging, some areas much more then others, to be a good Interventional Physician. However, the training pathway can and must adapt to the fact that IR is a clinical specialty that requires significantly greater clinical knowledge base then the "traditional pathway" can support.

This may be true, but correct me if I am wrong, the most common way to became an IR is the traditional pathway. The DIRECT and clinical pathway are very new and only a handful of programs offer this.

I would see utility in being certified in DR as well as IR. Would the DIRECT program or clinical pathway provide board certification in both DR and IR as the traditional pathway allows?

 

[7summits]

I would see utility in being certified in DR as well as IR. Would the DIRECT program or clinical pathway provide board certification in both DR and IR as the traditional pathway allows?

This is my understanding:

For both clinical and DIRECT pathways, you take both the DR and VIR certification/subcertification exams and thus get certified in both. From what I've heard, the problems/difficulties with the DIRECT path may be in whether your DR skills are strong enough to make you marketable for whatever type of practice you want to enter. For example, if a practice is choosing between a DIRECT grad and someone who did the traditional path, they may give preference to the traditional candidate because their DR skills are stronger. Of course, this depends on the type of practice you want to enter, and what they're looking for.

Werewethere posted a really great link with info about the DIRECT path, which I'll repost here: http://www.theabr.org/ic/ic_vir/ic_vir_direct.html

Just my understanding- I'd love to hear any other thoughts on this.

 

[Gvataken]

I think for those who know they want to do IR, you should try to pursue an alternate training pathway. In my opinion, the new boards format is perfect to train the hybrid physician (imager, clinician, proceduralist). I would suggest doing an initial 12 months of clinical; during the 1rst 3 years of radiology do 2 months of IR each year (total of 6 months). The final year I would sugest doing 10 months of IR/clinical rotations . surgical oncology , cardiology, vascular surgery, medical oncology , hepatology , vascular medicine for examples. then after the 5 years of radiology training go for a clinical IR fellowship. This will give you a total of 40 months of clinical rotations and IR and 30 months of imaging. During this time you can pass your boards in diagnostic radiology with the core exam and then take the certifying exam (mostly IR) after fellowship and shortly after get a subspecialty certificate from ABMS in vascular and interventional radiology.