IR/DR Dual Certificate Question

[dakuzindabad]

Hey All,
So I've been thinking that since the IR/DR Dual certificate residency will be the only IR route in the future, do you think this will be a way to greatly improve the job market/pay of the profession? Perhaps SIR will limit the number of programs and/or residents allowed to be enrolled in such programs (much like ENT/Derm/Plastics/Optho)? Perhaps this may be an opportunity to control supply and always ensure that the field doesn't suffer the ups and downs (or at least mitigate these situations).

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[shark2000]

No. It does not help at all.

The only effective thing to do is to decrease the number of trainees in Radiology.

 

[nick_carraway]

Hey All,
So I've been thinking that since the IR/DR Dual certificate residency will be the only IR route in the future, do you think this will be a way to greatly improve the job market/pay of the profession? Perhaps SIR will limit the number of programs and/or residents allowed to be enrolled in such programs (much like ENT/Derm/Plastics/Optho)? Perhaps this may be an opportunity to control supply and always ensure that the field doesn't suffer the ups and downs (or at least mitigate these situations).

It should help because it creates a dedicated pathway that students will decide upon in medical school. There are talks about ways for radiology residents/IR residents to switch between the pathways at least at the beginning in case they change their mind, but I'd be surprised if this doesn't limit the number of interventionalists through rads over time. As you remind us, there are some years when too many people in the senior class want to go into IR and this will limit that event in the long-term. But then, you have to wonder if limiting your numbers is beneficial when competing against other specialties. In your example, ENT, derm, plastics, ophtho pursue aesthetics, but they all succeed only because they each self-regulate training slots.

 

[rule out normal]

No. It does not help at all.

The only effective thing to do is to decrease the number of trainees in Radiology.

There are too many hands in the cookie jar for that to happen easily. There are groups with a vested interest in churning out as many trainees as possible. When those residency spots decline in number, their good life starts to dry up. There's no oversight on this, because that oversight is comprised of the same type of people.

 

[shark2000]

It should help because it creates a dedicated pathway that students will decide upon in medical school. There are talks about ways for radiology residents/IR residents to switch between the pathways at least at the beginning in case they change their mind, but I'd be surprised if this doesn't limit the number of interventionalists through rads over time. As you remind us, there are some years when too many people in the senior class want to go into IR and this will limit that event in the long-term. But then, you have to wonder if limiting your numbers is beneficial when competing against other specialties. In your example, ENT, derm, plastics, ophtho pursue aesthetics, but they all succeed only because they each self-regulate training slots.

It does not limit the number of interventionalists. There are too much overlap between DR and IR work in the community. Most of what DR does can be done by an IR and 70% of what IR does can be done by DR. Most IR in community is not TACE or PAD, but is drains, Percut tubes, biopsies and lines.

The only way is to limit the total number of trainees DR+IR, no matter what pathway.

 

[DrBowtie]

It does not limit the number of interventionalists. There are too much overlap between DR and IR work in the community. Most of what DR does can be done by an IR and 70% of what IR does can be done by DR. Most IR in community is not TACE or PAD, but is drains, Percut tubes, biopsies and lines.

The only way is to limit the total number of trainees DR+IR, no matter what pathway.

Agree. Almost all of our graduating non IR fellows will have "light IR" duties.

 

[irwarrior]

The difference is that those who decide out of medical school that they want to pursue IR, will be the ones whose primary focus is to see patients and perform procedures. That was my goal going into residency and though I did start at a job that was "IR light" it has converted to a nearly 100 percent IR job. I have talked to a growing number of interventionalists who are either joining separate IR groups, building their IR practice from scratch or becoming directly employed by the hospital.

The more senior IR have not had adequate clinical training and so many are not as comfortable as more recent IR who have more comfort in this arena. The future IR trainee especially in the IR residency will feel right at home in a clinical environment and will feel uncomfortable any other way. So, I agree with the old model of IR training (ie just one year) where you have limited clinical acumen and are minimally trained in practice development, running an office and doing the more complex interventions such as pain, fibroids , veins and pad that there was not ample opportunity to do this. But, a motivated individual that is well trained should be more then capable of doing this in any reasonably sized hospital setting.

I don't think that IR/DR will necessarily result in higher pay or a limit in number of trainees. If anything I think it will have a more consistent supply of trainee see what is happening with some of the other similar types of residencies (combo of conventional and integrated). It will be able to potentially identify those who are truly interested in IR for IR and not because that is where the jobs are. As people have to decide earlier on whether they want to pursue IR or diagnostics , those who are committed to patient care and procedural medicine are more likely to go the IR route as it offers much more in terms of procedural medicine as well as patient care rotations then a conventional DR residency would.

I think that even the light "IR" such as drains and biopsies should be done in a more formal fashion with appropriate consultation, admissions as necessary and follow up. This way we provide more global comprehensive care to our patients that we deal with. We have started to approach these patients in a similar fashion to our more complex cases and we find that the patients, the referring and the hospital administration are all much happier.

 

[shark2000]

The difference is that those who decide out of medical school that they want to pursue IR, will be the ones whose primary focus is to see patients and perform procedures. That was my goal going into residency and though I did start at a job that was "IR light" it has converted to a nearly 100 percent IR job. I have talked to a growing number of interventionalists who are either joining separate IR groups, building their IR practice from scratch or becoming directly employed by the hospital.

The more senior IR have not had adequate clinical training and so many are not as comfortable as more recent IR who have more comfort in this arena. The future IR trainee especially in the IR residency will feel right at home in a clinical environment and will feel uncomfortable any other way. So, I agree with the old model of IR training (ie just one year) where you have limited clinical acumen and are minimally trained in practice development, running an office and doing the more complex interventions such as pain, fibroids , veins and pad that there was not ample opportunity to do this. But, a motivated individual that is well trained should be more then capable of doing this in any reasonably sized hospital setting.

I don't think that IR/DR will necessarily result in higher pay or a limit in number of trainees. If anything I think it will have a more consistent supply of trainee see what is happening with some of the other similar types of residencies (combo of conventional and integrated). It will be able to potentially identify those who are truly interested in IR for IR and not because that is where the jobs are. As people have to decide earlier on whether they want to pursue IR or diagnostics , those who are committed to patient care and procedural medicine are more likely to go the IR route as it offers much more in terms of procedural medicine as well as patient care rotations then a conventional DR residency would.

I think that even the light "IR" such as drains and biopsies should be done in a more formal fashion with appropriate consultation, admissions as necessary and follow up. This way we provide more global comprehensive care to our patients that we deal with. We have started to approach these patients in a similar fashion to our more complex cases and we find that the patients, the referring and the hospital administration are all much happier.

Though you want to picture here that doing 100% IR is doable, I don't think it is a viable option for most people in pp. There are about 200-250 IR trainees each year now. There is not enough business for all of them to do 100% IR. Like it or not, even if you talk forever about the clinical model and your great experience, most of these people will end up doing a lot of DR. Whether 3 years of doing DR is enough and how these people will compete in a market that a typical DR trainee does a fellowship and a mini-fellowship is not clear to me.

From practical perspective, there is a large overlap between what a DR and an IR can do. I am not talking here about your clinical model. I am talking purely business. As a result of this huge overlap, the job market for both field parallel each other and are fed by the same supply. Just imagine if in theory DR market gets tight and IR is good, all the DR people will start doing more biopsies, drains and tumor ablations.

Long story short, I think the number of trainees in both DR and IR should go down. We have 250 IR fellowship spots now. It is too many spots compared to vascular surgery of 100 and interventional cardiology of 250. And if you ask cardiologists, they all agree that they are training too many interventionists and most of them do 80% non procedure work. I deeply believe that there are not enough business for all these IR trainees. The only reason the market is OK now is that in the decade before 2010 only 1/3 of fellowship spots filled and we are facing a temporary shortage. And even with a decade of under-supply, there are very rare 100% or even 50% IR jobs out there. Most of these jobs are modified forms of DR job with some basic IR.

 

[irwarrior]

True, but the opportunity is great. I think that we should train less people as well, but train them well and I think that anyone who is doing invasive procedures should have a minimum competency and requirements of patient care. There is too much variability currently in the quality of IR training in fellowship and so what an IR is able to do coming out of fellowship varies. Only quality programs that can train an IR comprehensively should be able to train an IR physician. Then once out of fellowship, they should see the patient preoperatively and follow those patients longitudinally. This ensures quality and safe practice. This is currently not the norm in practice but as you establish this it can become the norm. It seems like you personally are doing a great job with pain interventions and seeing them preop and following them and I truly respect that. As time goes on if you so desire you could add rhizotomy, rfa /cryoblation, sacroplasty, cementoplasty, coblation, esi, facets all to your armamentarium. This is what is so exciting about our field.

I have talked to several motivated trainees coming out of IR fellowship who are in small community practices and they are quickly establishing such practices and they have built them faster then I was able to build my own practice. This tells me that if the individual is motivated and well trained, it can be done even in the smaller hospital settings in conventional radiology jobs. The bottlenecks are the other IR who are more senior and who do not embrace this clinical paradigm or the diagnostic colleagues who are more focused on getting the list done. But, the multitude of common diseases (very broad portfolio) showcases the truly untapped potential of clinical IR.

 

[meister]

Is anyone concerned about the new pathway graduates actually being competent with DR?

 

[shark2000]

True, but the opportunity is great. I think that we should train less people as well, but train them well and I think that anyone who is doing invasive procedures should have a minimum competency and requirements of patient care. There is too much variability currently in the quality of IR training in fellowship and so what an IR is able to do coming out of fellowship varies. Only quality programs that can train an IR comprehensively should be able to train an IR physician. Then once out of fellowship, they should see the patient preoperatively and follow those patients longitudinally. This ensures quality and safe practice. This is currently not the norm in practice but as you establish this it can become the norm. It seems like you personally are doing a great job with pain interventions and seeing them preop and following them and I truly respect that. As time goes on if you so desire you could add rhizotomy, rfa /cryoblation, sacroplasty, cementoplasty, coblation, esi, facets all to your armamentarium. This is what is so exciting about our field.

I have talked to several motivated trainees coming out of IR fellowship who are in small community practices and they are quickly establishing such practices and they have built them faster then I was able to build my own practice. This tells me that if the individual is motivated and well trained, it can be done even in the smaller hospital settings in conventional radiology jobs. The bottlenecks are the other IR who are more senior and who do not embrace this clinical paradigm or the diagnostic colleagues who are more focused on getting the list done. But, the multitude of common diseases (very broad portfolio) showcases the truly untapped potential of clinical IR.

I was trained by great people, but nobody really showed me how to approach patients. I knew all the zebras of spine procedures and all the weird diseases of back pain, but never did a simple pre-procedure evaluation. You know what I mean. Then I met a person in my current practice who really showed me all the tricks. He is probably clinically better than most pain anesthesiologists in my area. Am I well trained now? I don't know but I think most patients and referring physicians are happy and the complications are rare.

So it is very very nice to have a training pathway where you can learn all of these aspects from the leaders in an academic environment. Something that unfortunately many people don't have the opportunity.

Agree that if you want to grow a business, it is doable. But on the other hand, having too many trainees is not good for the health of the field. I think at this point we are training too many DR and IR. This problem may self correct itself since many who are doing it to have a job may switch out of it later once the market becomes better. But if the market does not get better, then we will have a mixture of interested IR people and uninterested IR people who are doing it just to have a job which is bad for IR, DR, patients and everybody. The same for DR when a Neuroradiologist is doing 100% mammo just to have a job.

Good Luck.

 

[irwarrior]

Yes. I also worry that many who are now going into IR now many are perhaps doing it to get a job, but they are not truly interested in clinical IR and in fact sometimes take fellowship spots away from others who are passionate about clinical IR. This is unfortunate and hopefully IR residency will reduce these events. As, these individuals are likely to be happy with the status quo and will not enact the changes necessary for IR to blossom which includes a clinic, admitting privileges and rounding, marketing of what one can offer and longitudinal follow up. They are more likely to not want to grow the practice and satisfied with minor procedures which any non IR radiologist should be capable of. You have to enjoy patient care and patient interactions in order to really enjoy clinical IR and do it well, and that is one of the key elements.

Even though it seems like you may not have had the clinical training in residency or fellowship you were lucky enough to get it on the job and now with continued experience of seeing patients preoperatively and following them and listening to the stories and examining them and talking to them, reading about their conditions, you will likely be a very astute clinician when it comes to pain and pain related syndromes and procedural pain therapy.

As far as adequate imaging training . 3 years is a good chunk of time, especially if you study hard for the CORE exam and take out the scut rotations out of training. If they are all high yield rotations and you set some minimum numbers, it should be adequate. Especially if you take some diagnostic call your final year and you are also allowed up to 4 months of diagnostics your pgy 5 year on top of that.

 

[CoopDoc]

Is anyone concerned about the new pathway graduates actually being competent with DR?

Not in the least. The new IR residency will have an identical core set of rotations in PGY-2 to PGY-4, with only three months of IR, before taking the qualifying exam. ALL PGY-5 residents, whether in the Diagnostic or Interventional residencies, will then specialize in the PGY-5 year. Those planning to do private practice imaging or a specific imaging fellowship will do imaging rotations. Interventional residents will do IR and clinical rotations with a few imaging months.

Those of us that have spent time preparing and taking the new CORE exam will attest to the fact that the expectations to pass this test are more than were originally touted. An almost equal amount of preparation is needed by the end of PGY-4 to take this exam as was previously needed to prepare for the oral exams at the end of PGY-5.

Those that have gone through the DIRECT pathway will tell you that the diagnostic exposure was perhaps not enough in that system. But there is no difference between the diagnostic residency and new IR residency coming down the pipeline in the first three years.