Increase in integrated spots

[irwarrior]

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There was an increase this year of integrated interventional spots from 202 spots in 2025 to 238 spots in 2026. So 36 more spots opened up. This is likely due to more and more programs converting independent spots to integrated spots.

 

[SeisK]

36 / 3 =12. So on average this will result in 12 more lateral DR transfers per year. Academic departments are not paying any attention to the broader need for IRs, they’re reacting to being annoyed at how many lateral transfers out there are, how choosy independent applicants can be, and the most immediate way to get trainees to subsidize their lifestyle for them

I believe we’re also graduating too many IRs per year as it is.

 

[irwarrior]

Currently it is more like a 20 percent drop out ie would be about 8 spots transfer out (though majority are DR transfers some are to other fields). Are you seeing a 1/3 transfer rate? What do you think is the magic number for VIR graduates per year? In the current state with VIR integrated and IR independent it is nearly 300 graduates.

 

[SeisK]

Yes I’d seen 1/3.

I don’t know the number. I think very difficult to assess given the contraction of IR need as more types of cases are being relegated to midlevels. But I do know the job market right now is nowhere near as hot as for DR generally. And I know no efforts are made to assess the broader need for IRs before programs kneejerk expand their cadre.

 

[irwarrior]

There are lots of people trying to hire VIR at academic places (granted it is often not at the main campus) and as part of the OBL enterprises, but it is getting harder to harder to find them. More and more VIR are going the route of locums due to challenges in hiring locally. DR is a little easier, though global demand higher, they can do the work remotely.

 

[tomballunger]

Academic departments are not paying any attention to the broader need for IRs, they’re reacting to being annoyed at how many lateral transfers out there are, how choosy independent applicants can be, and the most immediate way to get trainees to subsidize their lifestyle for them

Being in an academic training program where our program is in shambles in terms of staffing (big exodus of faculty 2 years ago, now surviving barely on locums ) and very few fellows want to join, some attrition, and some of our fellow seats couldn't fill, this is so true

 

[SeisK]

granted it is often not at the main campus

This is a good representation of what I consider the selfish attitude problem of academic places. Rather than viewing their new hires as equal members of their team, sharing in the benefits and costs of keeping the division running smoothly, they simply want to cordon off the desirable corner they quarantined for themselves, and relegate the crappiest seats to the new hires, who are also paid less than them despite being locked to the boring scut, with the inability to build any type of referral pattern to match the others who didn’t even really build for themselves what they have.

No wonder these positions stay posted forever. Academic IR has a serious, serious attitude problem. Reliably the least professional people I’ve encountered

 

[irwarrior]

That is true to some extent. But, if you are given the dedicated clinic time and space it is up to new graduates to go out and hustle to get referrals. I agree if you are not given dedicated time and space to go out and build your own practice. Yes, it will be difficult to do y90 and IO as well as portal interventions outside of the main transplant center. However, you can build a pain division, PAD practice, fibroids, prostates, geniculars , spine etc at these affiliated practices. The challenge is most VIR training programs don't provide adequate clinical exposure or procedural competency outside of Y90, ablations and portal interventions for graduates to feel competent in those disease processes.

 

[tomballunger]

There is a huge lack of standardization in ir training compared to a legacy surg specialty like urology ent Ortho. ever since the exodus at my program we have a few new ones come in as faculty and each one has very different levels of understanding and varying years of experience in disease process such as pain , io, portal htn, and transplant work. But common theme is most of the new hires are stuck at our main center where yes averaged out 2 interesting cases come in daily from er and inpatient such as kypho, bleeds, ptc . But they are also stuck running understaffed at the main center staffing 25 other drain biopsy line tube consults with service line clinic in between and timing out these line tube biopsy rooms and oftentimes doing the case themselves as resident or fellow watches them (variable autonomy possible poor even) given how complex the main center pts are- more straightforward learning cases sent to our outpatient centers for the most senior fellows (heavily pgy6). And that is on top of the 2 interesting cases that take time and effort or at least some thought to do. Eventually in 6 months they burn out and a new hire comes in to take their place as they head to the outpt center, taking their clinic panel with them to do gae, kypho, pain , ablative work. the new hire gets dumped the 25 inpt consults , the 10 complex lines and tubes cases to do in return for the 1 or 2 interesting cases, and the cycle begins again and there's 0 continuity for fellow learning/teaching

 

[tomballunger]

Rather than viewing their new hires as equal members of their team, sharing in the benefits and costs of keeping the division running smoothly, they simply want to cordon off the desirable corner they quarantined for themselves, and relegate the crappiest seats to the new hires, who are also paid less than them despite being locked to the boring scut, with the inability to build any type of referral

This is happening to new hires especially new grads at my center. Very siloed off and yes there is stated on paper the chance to build your referral pattern with the weekly pain conferences tumor boards/clinic/primary care networking but only after the new hire has more or less dealt with the inpatient/er side ( staff 25 lines tubes consults, rounds timeout/do 10 complex line tube biopsy cases, and then the 1 or 2 interesting inpt cases like ptc /bleed almost alone sometimes - and because it's inpt and poorly funded as a department the room turnaround is atrocious so stuck there from 7 am to 8 pm daily 5 days a week

Compare that to say, urology where I worked with them extensively as a subi and surgery intern, new hires even new grads had a better share and setup. Plug themselves into er urology call and huge numbers of stones, urinary retention bph stricture, gross hematuria renal mass/bladder cancer referrals start coming in and they're immediately busy with good cases within 1 month if they wish (otherwise small quick rvu generating small cases are available)

 

[SeisK]

That is true to some extent. But, if you are given the dedicated clinic time and space it is up to new graduates to go out and hustle to get referrals. I agree if you are not given dedicated time and space to go out and build your own practice. Yes, it will be difficult to do y90 and IO as well as portal interventions outside of the main transplant center. However, you can build a pain division, PAD practice, fibroids, prostates, geniculars , spine etc at these affiliated practices. The challenge is most VIR training programs don't provide adequate clinical exposure or procedural competency outside of Y90, ablations and portal interventions for graduates to feel competent in those disease processes.

Id say it’s more than “to some extent.” Much of the high end IR referral that ends up quarantined off at academic centers is stuff that ends up being default referred to IR anyway. Nobody built this referral pattern of portal and IO work. Some self-oriented disagreeables simply put a wall around a referral that was already there, and engage in internal political warfare when someone starts to build something in this regard for themselves. Oftentimes you can’t build something for yourself because if you do, you become a target for people in higher positions who get there from lateral transfer, being in the right place at the right time, or just being around long enough.

Who would want to be hired into a department of hostile, selfish, not-team-players? This is a problem that needs sniffing out generally, but is particularly concentrated in academic personalities which tends to discourage selflessness and comradely.

I do not want to do such things to new hires that come after me, and I do not want that done to me.

 

[irwarrior]

The key is to have the new graduates have dedicated clinic time (say 1 day a week ) that they have to fill and are responsible for trying to get their own referrals. They should also have dedicated block schedule that they can book their cases in. There should be a reasonable distribution of the inpatient consults and cases with a staggered shift . There should be some equity of the inpatient/call so that the new person is not stuck with just inpatient (IR hospitalist) cases only. If the clinic dose not get filled or their block does not get filled they should give it to. other physicians who have a backlog. This would be more comparable to a surgical subspecialty.

 

[tomballunger]

The above would be a good start to academic centers riddled with bad politics in improving when it comes to filling perpetual open faculty spots- many if not all academic programs are hurting for faculty and need locums help for a high price

 

[SeisK]

The above would be a good start to academic centers riddled with bad politics in improving when it comes to filling perpetual open faculty spots- many if not all academic programs are hurting for faculty and need locums help for a high price

Clearly not hurting enough

 

[irwarrior]

Yo

Clearly not hurting enough

Rather than hire physicians many academic sites have hired an army of extenders to fill in the gaps.

 

[tomballunger]

We did hire a lot of nps and pas to do the Paras thoras straightforward piccs and thyroid fnas in the past 2 years for outpatient satellites that we have a lot of. Other places have pa's for venous access like ports and tunneled lines. All commoditized procedures , many of which med schools taught the students how to do and intern years had interns so so many of, now belongs to ir
Also expanding the ir Dr integrated path fills in the coverage gaps for inpt call and these procedures when they end up inpatient.
Also hiring locums attendings for a high price 2-3x faculty pay fills the gaps

And thus our faculty complement has remained threadbare after the exodus , integrated fellow morale remains low

 

[irwarrior]

The key is to bring in and support new faculty to build a service line and there are so many that one can grow. Fibroid clinic, thyroid nodule /ablation, BPH/LUTS and PAE, knee pain (GAE); hemorrhoids, spine interventions,, pain (pumps/spinal cord stimulators); PAD; renal mass (ablation) etc. You need support from the section chief of interventional services and the chair of the department.