Is ESIR going to expand a lot?

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GoPelicans

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Only a few programs offer this pathway, and very few of the powerhouse programs do. Most of them do have a direct IR pathway, but I'm leaning towards IR late M3 so have no research. ESIR is very attractive to me for this reason. Is is risky applying to rads hoping ESIR will open up at a given institution in the next 2-3 years or is it a given most places will opt for this route? There is one city in particular I am interested in with several good hospitals but only one ESIR program right now.

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I think you're confused about the terminology. Doing an ESIR pathway doesn't make you an IR. It just means that when you apply for a 2-year independent IR residency (aka IR fellowship after your diagnostic radiology residency), you only have to do 1 year instead of 2 years.

Many programs have ESIR. I don't know the numbers, but I bet it's at least half if not more.

Few program have independent IR residencies... but more will come. How many is yet to be determined as they're just rolling it out.

Also the "direct pathway" is no longer. I think what you mean is the IR/DR residency.

The terminology is very confusing.
 
Are 1/2-year IR fellowships going to remain though? In 5/6/7 years will we still have the option to do IR fellowships? Or will fellowships dry out as more programs develop integrated IR residencies?
 
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also it's my understanding ESIR does not guarantee a 1 year IR residency.
 
Are 1/2-year IR fellowships going to remain though? In 5/6/7 years will we still have the option to do IR fellowships? Or will fellowships dry out as more programs develop integrated IR residencies?

Nobody knows how many independent spots there will be which is why the SIR has botched this whole transition. I would bet 1/4 to 1/2 of the students applying to the integrated residencies are just trying to cover their butts because they don't know if it will be possible to get into IR later.

SIR keeps saying "there will always be a pathway for you to get into IR". What they don't say is there might only be 10 independent spots and 250 applicants - who knows?
 
The current 1-year IR fellowship system will only exist for 2-3 more years. I think they all get axed (nationwide) in 2020.

If you are a current medical student and you are planning to do a diagnostic radiology residency, there is still an option to specialize in IR later on during your residency. That is called the "IR Independent Residency." It's basically the new terminology for a 2-year IR fellowship.

Are 1/2-year IR fellowships going to remain though? In 5/6/7 years will we still have the option to do IR fellowships? Or will fellowships dry out as more programs develop integrated IR residencies?
 
That would be a pretty risky way to cover your butt, because if you decide IR isn't for you, you don't get to just switch over to DR. Switching from IR/DR to DR is like switching into an entirely different residency. It would be sort of like switching from Ortho to ENT. It's doable, but you gotta hope that an ENT spot opens up somewhere. If all the ENT spots at your hospital are filled, they can't just make space for you out of the blue. You would have to find some equivalent (e.g., PGY-3) open spot somewhere in the country.

I would bet 1/4 to 1/2 of the students applying to the integrated residencies are just trying to cover their butts because they don't know if it will be possible to get into IR later.
 
That would be a pretty risky way to cover your butt, because if you decide IR isn't for you, you don't get to just switch over to DR. Switching from IR/DR to DR is like switching into an entirely different residency. It would be sort of like switching from Ortho to ENT. It's doable, but you gotta hope that an ENT spot opens up somewhere. If all the ENT spots at your hospital are filled, they can't just make space for you out of the blue. You would have to find some equivalent (e.g., PGY-3) open spot somewhere in the country.

True, but it will be much easier to go IR/DR -> DR than DR -> IR/DR. I bet one of the 200-300 applicants that didn't match IR/DR this year would love to switch with you if you decided IR wasn't for you.
 
True, but it will be much easier to go IR/DR -> DR than DR -> IR/DR. I bet one of the 200-300 applicants that didn't match IR/DR this year would love to switch with you if you decided IR wasn't for you.

Not so sure about that. A fair number of med students are gunning for IR because it's what hot right now. I've talked to a lot of DR residents who started out wanting IR but drifted toward another fellowship because they weren't cut out for it/didn't want the lifestyle after experiencing it on a day-to-day basis. No shade thrown on IR, it's an awesome and important specialty. I just don't think the situation is as lopsided as you describe.
 
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True, but it will be much easier to go IR/DR -> DR than DR -> IR/DR. I bet one of the 200-300 applicants that didn't match IR/DR this year would love to switch with you if you decided IR wasn't for you.

This is truly a medical student perspective because you see how many of your colleagues enjoy procedures, and, by extension, IR.

There are far more residents who go from, "IR is amazing and the only specialty for me," to, "Eh, I think I'll just do MSK and do some joint injections every now and then," than there are residents who do the converse. If you're DR/IR, you're stuck unless you can find someone WITHIN your program (likely your year) to switch with you.
 
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True, but it will be much easier to go IR/DR -> DR than DR -> IR/DR. I bet one of the 200-300 applicants that didn't match IR/DR this year would love to switch with you if you decided IR wasn't for you.

you guys are forgetting internal swaps. I'll be fortunate enough to go to a solid IR/DR program. There are definitely going to be DR residents in my class that would love to swap with me if for some reason I couldn't do IR anymore (given how much I love IR, i'd literally have to lose my hands or something lolol). From a PD perspective, this is a no brainer probably
 
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I don't know if I agree with this.

My feeling is that the die-hard IR types are going to be spread out among the IR/DR programs across the country. DR residencies are going to be filled with mostly people who have very little interest in DR. I.e., your average DR residency is going to have a smaller percentage of people who have any interest in IR. So internal swaps aren't going to be as easy as it might seem.

you guys are forgetting internal swaps. I'll be fortunate enough to go to a solid IR/DR program. There are definitely going to be DR residents in my class that would love to swap with me if for some reason I couldn't do IR anymore (given how much I love IR, i'd literally have to lose my hands or something lolol). From a PD perspective, this is a no brainer probably
 
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That would be a pretty risky way to cover your butt, because if you decide IR isn't for you, you don't get to just switch over to DR. Switching from IR/DR to DR is like switching into an entirely different residency. It would be sort of like switching from Ortho to ENT. It's doable, but you gotta hope that an ENT spot opens up somewhere. If all the ENT spots at your hospital are filled, they can't just make space for you out of the blue. You would have to find some equivalent (e.g., PGY-3) open spot somewhere in the country.

Not entirely true, because IR/DRs are perfectly free to practice DR after residency, if they decide that IR isn't for them. Worst comes to worst, they spent two years doing IR when they could have spent that time chilling as R4s and doing another fellowship. Not exactly a total disaster.
 
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You're right. But would anyone really want to do that?

If your intent is to practice 100% DR and minimal-to-no IR, you're going to be at a disadvantage in diagnostic skill compared to the guy who did 2 more years of DR (R4 + fellowship in whatever diagnostic subspecialty). And I suspect you're also going to be miserable the last 2 years of residency doing IR and taking IR call when your intention is to practice 100% or near-100% DR.


Not entirely true, because IR/DRs are perfectly free to practice DR after residency, if they decide that IR isn't for them. Worst comes to worst, they spent two years doing IR when they could have spent that time chilling as R4s and doing another fellowship. Not exactly a total disaster.
 
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The fact is nobody knows what the future holds for IR/DR residents, how many will want to switch out, how many will want to switch in, and how many independent spots there are. That's my point. Nobody knows because there has been very little structure regarding this transition. Just, "oh, we'll see who gets approved!" and "Who knows how many independent spots there will be?" This uncertainty has pushed people interested in IR at all to throw in some applications because they don't know what the future holds or if there will even be enough independent residency spots to get in later.

Also, I think the IR/DR residency has attracted some applicants over from surgical specialties for better or for worse and many of them went unmatched (30% match rate or so). When these IR/DR applicants go unmatched they go into DR as their backup with the sole goal of going into IR down the road. I talked with a MS4 going into DR only who told me that he didn't like DR but "am going to get it over with so I can get into IR". Of course, he will be miserable and he made a terrible choice. He was choosing between IR and vascular surgery and it sounds like the new IR/DR residency won him over that way. What a nightmare.

It would be great if there was a residency where one could get exposure to IR on a month-long rotation each year then decide if IR was for you at that point...
 
1. You're right that nobody knows for sure. And I would agree on the point that the transition was flawed. I especially think they should have been more explicit in planning out how many independent spots there would be (or at least announced a projected number).

But I disagree that the uncertainty has pushed people into doing IR/DR residency. If you don't know you're 100% committed to IR, it makes no sense whatsoever to be applying for an IR/DR residency. It's no different than someone applying for Neurosurgery instead of General Surgery. Why would you apply to Neurosurgery if you're not 100% committed? I don't hear med students saying "I like surgery, but I don't know if neurosurgery is for me... but because neurosurgery is it's own residency I better apply just in case that's the type of surgery I really want to do"


2. There were a lot of med students in the past - and I'm one of them - who went into DR with the explicit intent of going into IR. I don't think this is a new phenomenon. FWIW - I thought I would hate DR, but ended up liking it a lot, but still not as much as I love IR.


3. There IS a residency where you can get exposure to IR and then decide if you want to do it. It's called diagnostic radiology! Just do DR, and then if you like IR, do ESIR and/or apply for a 2-year independent residency.

Going back to the Neurosurgery analogy. General Surgery residents don't have the option of applying for a neurosurgery fellowship. They have to decide as med students, but nobody complains about having to make that decision. Imagine if there was a pathway to go from gen surg to neurosurgery. And let's say that there were only a handful of spots in the country available to do that switch. I doubt anyone would complain. Yet, over and over, I'm hearing people complain that the option exists in IR. It makes no sense.


There are literally dozens of different medial residencies and you're asked to choose just one as an M4. You simply have to spend your time wisely and explore those specialties that sound like they might fit you and make a choice. Nobody gets to rotate in every specialty before they make their residency selection. IR is no different.



The fact is nobody knows what the future holds for IR/DR residents, how many will want to switch out, how many will want to switch in, and how many independent spots there are. That's my point. Nobody knows because there has been very little structure regarding this transition. Just, "oh, we'll see who gets approved!" and "Who knows how many independent spots there will be?" This uncertainty has pushed people interested in IR at all to throw in some applications because they don't know what the future holds or if there will even be enough independent residency spots to get in later.

Also, I think the IR/DR residency has attracted some applicants over from surgical specialties for better or for worse and many of them went unmatched (30% match rate or so). When these IR/DR applicants go unmatched they go into DR as their backup with the sole goal of going into IR down the road. I talked with a MS4 going into DR only who told me that he didn't like DR but "am going to get it over with so I can get into IR". Of course, he will be miserable and he made a terrible choice. He was choosing between IR and vascular surgery and it sounds like the new IR/DR residency won him over that way. What a nightmare.

It would be great if there was a residency where one could get exposure to IR on a month-long rotation each year then decide if IR was for you at that point...
 
1. You're right that nobody knows for sure. And I would agree on the point that the transition was flawed. I especially think they should have been more explicit in planning out how many independent spots there would be (or at least announced a projected number).

But I disagree that the uncertainty has pushed people into doing IR/DR residency. If you don't know you're 100% committed to IR, it makes no sense whatsoever to be applying for an IR/DR residency. It's no different than someone applying for Neurosurgery instead of General Surgery. Why would you apply to Neurosurgery if you're not 100% committed? I don't hear med students saying "I like surgery, but I don't know if neurosurgery is for me... but because neurosurgery is it's own residency I better apply just in case that's the type of surgery I really want to do"


2. There were a lot of med students in the past - and I'm one of them - who went into DR with the explicit intent of going into IR. I don't think this is a new phenomenon. FWIW - I thought I would hate DR, but ended up liking it a lot, but still not as much as I love IR.


3. There IS a residency where you can get exposure to IR and then decide if you want to do it. It's called diagnostic radiology! Just do DR, and then if you like IR, do ESIR and/or apply for a 2-year independent residency.

Going back to the Neurosurgery analogy. General Surgery residents don't have the option of applying for a neurosurgery fellowship. They have to decide as med students, but nobody complains about having to make that decision. Imagine if there was a pathway to go from gen surg to neurosurgery. And let's say that there were only a handful of spots in the country available to do that switch. I doubt anyone would complain. Yet, over and over, I'm hearing people complain that the option exists in IR. It makes no sense.


There are literally dozens of different medial residencies and you're asked to choose just one as an M4. You simply have to spend your time wisely and explore those specialties that sound like they might fit you and make a choice. Nobody gets to rotate in every specialty before they make their residency selection. IR is no different.

1. I agree with you 100%. I was just communicating what I have seen (granted n=1)... people applying to IR/DR who do NOT want to do DR. I'm not saying this is a good thing but it is happening.

2. True. There are also a lot of residents who went into DR with the explicit intent of going into IR... and then changed their minds and did DR. Why lock in med students so early if a significant percentage will change their minds?

3. Exactly. I said that "if only there was a residency" line tongue-in-cheek. The new IR/DR residencies, IMO, do nothing but lock in a MS4 when they don't need to be locked in. With any of the IR pathways, you end up with DR and IR certification, they are 6 (maybe 7 if you don't do ESIR) years, etc. Instead, with the creation of the residencies, med students feel they need to get in to the IR pathway now because who knows if they can later. I don't see what was so wrong with the old pathway personally.

Also, your analogy doesn't quite hold up because neurosurgeons don't get certified in both general surgery and neurosurgery. It's a very distinctive choice between completely different organ systems, styles of surgery, so on. Also, neurosurgeons don't spend 3+ years doing general surgery before going to neurosurg like IR residents will in DR. A better analogy may be integrated vascular and integrated CT surgery compared to general surgery. There are many in the vascular/CT surgery community who think the integrated residencies were a bad idea but they did them to get stronger medical students going into those fields.

I think we will just have to agree to disagree. I see your points, I think they are valid, but I still stand by my point that IR/DR residency adds nothing
 
I agree with most of your points -- maybe even more than you think. I was perfectly fine with the old fellowship system. Heck, I even went through it myself.

I think the bottom line is that the new residency system is a calculated move to set up IR for the future. I completely agree that it will cause great confusion and annoyance in the short term. I didn't buy any of this at first, but after reading and learning about this over the last 3-4 years, I've actually come around on the long-term game plan for this new training system.

For those of you frustrated by the system, the best advice I can give is to really explore IR and DR as much as you can to decide if you're ready to commit to an IR/DR residency. If not, just do DR -- or even another specialty altogether that doesn't has as much uncertainty in the application process. If might be weird to hear an IR say this, but in the whole scheme of things, your specialty doesn't define your life or your contribution to the health and well-being of your patients. I say that as someone who was once a myopic med student myself.


1. I agree with you 100%. I was just communicating what I have seen (granted n=1)... people applying to IR/DR who do NOT want to do DR. I'm not saying this is a good thing but it is happening.

2. True. There are also a lot of residents who went into DR with the explicit intent of going into IR... and then changed their minds and did DR. Why lock in med students so early if a significant percentage will change their minds?

3. Exactly. I said that "if only there was a residency" line tongue-in-cheek. The new IR/DR residencies, IMO, do nothing but lock in a MS4 when they don't need to be locked in. With any of the IR pathways, you end up with DR and IR certification, they are 6 (maybe 7 if you don't do ESIR) years, etc. Instead, with the creation of the residencies, med students feel they need to get in to the IR pathway now because who knows if they can later. I don't see what was so wrong with the old pathway personally.

Also, your analogy doesn't quite hold up because neurosurgeons don't get certified in both general surgery and neurosurgery. It's a very distinctive choice between completely different organ systems, styles of surgery, so on. Also, neurosurgeons don't spend 3+ years doing general surgery before going to neurosurg like IR residents will in DR. A better analogy may be integrated vascular and integrated CT surgery compared to general surgery. There are many in the vascular/CT surgery community who think the integrated residencies were a bad idea but they did them to get stronger medical students going into those fields.

I think we will just have to agree to disagree. I see your points, I think they are valid, but I still stand by my point that IR/DR residency adds nothing
 
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I agree with most of your points -- maybe even more than you think. I was perfectly fine with the old fellowship system. Heck, I even went through it myself.

I think the bottom line is that the new residency system is a calculated move to set up IR for the future. I completely agree that it will cause great confusion and annoyance in the short term. I didn't buy any of this at first, but after reading and learning about this over the last 3-4 years, I've actually come around on the long-term game plan for this new training system.

For those of you frustrated by the system, the best advice I can give is to really explore IR and DR as much as you can to decide if you're ready to commit to an IR/DR residency. If not, just do DR -- or even another specialty altogether that doesn't has as much uncertainty in the application process. If might be weird to hear an IR say this, but in the whole scheme of things, your specialty doesn't define your life or your contribution to the health and well-being of your patients. I say that as someone who was once a myopic med student myself.

One burning question I have is - if procedures weren't taken by other specialities, would IR/DR ever have been proposed? It seems that, "IR needs to be more clinical" and "IR needs to admit its own patients" are more reactionary than essential. What's wrong with this model:

IR does interventional cath --> patient is admitted to cardiac ICU and cardiologists manages
IR does interventional neuro --> patient is admitted to neuro-ICU/neurology floor and neurologists manage.
IR does interventional pulm --> patient is admitted to MICU, and IM doc manages.

I feel that IR/radiology should have held a vice-like grip onto the practice of image-guided procedures. Only board-certified radiologists are legally able to interpret images, so why oh why aren't there similar guidelines requiring board-certified radiologists to do image-guided procedures?
 
One burning question I have is - if procedures weren't taken by other specialities, would IR/DR ever have been proposed? It seems that, "IR needs to be more clinical" and "IR needs to admit its own patients" are more reactionary than essential. What's wrong with this model:

IR does interventional cath --> patient is admitted to cardiac ICU and cardiologists manages
IR does interventional neuro --> patient is admitted to neuro-ICU/neurology floor and neurologists manage.
IR does interventional pulm --> patient is admitted to MICU, and IM doc manages.

I feel that IR/radiology should have held a vice-like grip onto the practice of image-guided procedures. Only board-certified radiologists are legally able to interpret images, so why oh why aren't there similar guidelines requiring board-certified radiologists to do image-guided procedures?

@Naijaba bringing the heat with yet another awesome post.

There is this pink elephant in the room notion that radiologist are, dare I say, push overs. Could it simply be that we have lost the turf war?
 
I agree with most of your points -- maybe even more than you think. I was perfectly fine with the old fellowship system. Heck, I even went through it myself.

I think the bottom line is that the new residency system is a calculated move to set up IR for the future. I completely agree that it will cause great confusion and annoyance in the short term. I didn't buy any of this at first, but after reading and learning about this over the last 3-4 years, I've actually come around on the long-term game plan for this new training system.

For those of you frustrated by the system, the best advice I can give is to really explore IR and DR as much as you can to decide if you're ready to commit to an IR/DR residency. If not, just do DR -- or even another specialty altogether that doesn't has as much uncertainty in the application process. If might be weird to hear an IR say this, but in the whole scheme of things, your specialty doesn't define your life or your contribution to the health and well-being of your patients. I say that as someone who was once a myopic med student myself.

That's very fair. I think I will end up applying DR-only because it is what's right for me right now but I have to admit the uncertainty of the IR independent pathway makes me hesitate as I am pretty sure that is what I want to do long-term. I guess that is my point.
 
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In a perfect world, naijabas theory would work. In the real world where money is king, cards/neuro/pulm wanted to get in on the gravy train and the fact that they admitted the patients was just leverage to do so. Who in their right mind would let IR rake the money on procedures that they are capable of learning/performing, and then volunteer to manage the crashes in the ICU. If the procedures didn't pay well, they would be referring them to IR like clockwork (they don't seem so eager to do lines & ports).

I think you're right that IR dropped the ball and it's trying to become clinical in a reactionary way, but I don't think it's to get those procedures back. I think the leaders see potential for IR to develop even more procedures in the future, and they hope that the new pathway and subsequent "control" of patients will prevent history from repeating itself.

As to earlier posts about IR being double-boarded, I don't think that's a completely fail-safe way to hedge your bets on blindly choosing IR. They've always been double-boarded, but as FabHill said earlier, it's not like the other subspecialty radiologists are twiddling their thumbs for two years while you're learning IR & taking call. In pp, everyone reads everything but they're gonna expect you to bring your fellowship to the table in some capacity. If you absolutely hate IR, which you spent 2 years learning while your colleagues are reading & learning more, what are you really offering? Places are probably different in the models they follow, but you can't deny that choosing wrong (IR vs. DR) is limiting oneself relative to someone who made the right choice for himself/herself early on.

I love IR but the thought of "omg you can lock up a spot now AND do two specialties for the price of 1 AND easily switch into DR if you hate it because everyone's gonna be begging you for your spot" doesn't sound entirely accurate.
 
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I feel that IR/radiology should have held a vice-like grip onto the practice of image-guided procedures. Only board-certified radiologists are legally able to interpret images, so why oh why aren't there similar guidelines requiring board-certified radiologists to do image-guided procedures?
Bolded is not true. Legally with a medical license I can do a craniotomy but no one is going to credential or insure me to do so without appropriate training.

Secondly, cardiologists are interpreting cardiac nucs, echo, cardiac CT/MR.
Vascular surgeons are interpreting vascular labs studies and US. ER docs are doing Ultrasound fellowships to do POC US.
 
Short answer: NO.

The only turf battle that was "lost" is cardiac caths. And I'm not even sure it was a battle to begin with. I feel comfortable speaking for my colleagues in saying that none of us wanted to deal with that. There are other ongoing turf battles including PAD and neuroIR. But in the whole scheme of IR, these are just small percentages of what we do. And many of my colleagues couldn't care less about those disease entities. There are far cooler, more exciting, and more lucrative procedures than stroke and PAD.

But I do agree that the new residency is in place to better protect our turf. And I strongly believe it will.


@Naijaba bringing the heat with yet another awesome post.

There is this pink elephant in the room notion that radiologist are, dare I say, push overs. Could it simply be that we have lost the turf war?
 
That's not true. PAD is one of the most highly reimbursing procedures in medicine. The new IR residency is nice but there still isn't enough clinical time to ward off the other sub specialists. IR will always be taken to task due to referral patterns. The strength of IR is also its weakness. IO is all the rage but that's only at tertiary hospitals. IR is being oversold to med students. There aren't enough 100 percent IR jobs. Some of these kids are going to have to do diagnostic work too and will be sorely disappointed.


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1. Neither IO nor PAD is truly lucrative in terms of time invested to the return on investment. You know what is? Ports, varicose veins, etc. The ROI on those exceeds any cool procedure you can do. This is true of any specialty - ENT, Urology, etc. Ask any of them what makes them the most money, and it's the office-based minor procedures. Not the head and neck tumor, or the prostatectomy. I think you are misinformed about how lucrative PAD is. It's not chump change, but nobody is getting rich off PAD. You're not considering the patient population that has that disease, the time spent on the cases, etc... and what you could be doing instead.

1a. I think PAD is great and certainly a cornerstone of IR, but there seems to be some crazy rumor going around among med students that this is some holy grail procedure that you must do to be a half-way decent interventional radiologist. This is false. There are countless practices where there is so much more than PAD to do.

2. Are you -- a med student -- really going to lecture others on the job market in IR? And how "sorely disappointed" future IRs are going to be? I've been in practice for nearly a decade. I practice 80% IR and I enjoy reading films on my diagnostic days. I'm not disappointed at all.



That's not true. PAD is one of the most highly reimbursing procedures in medicine. The new IR residency is nice but there still isn't enough clinical time to ward off the other sub specialists. IR will always be taken to task due to referral patterns. The strength of IR is also its weakness. IO is all the rage but that's only at tertiary hospitals. IR is being oversold to med students. There aren't enough 100 percent IR jobs. Some of these kids are going to have to do diagnostic work too and will be sorely disappointed.


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Fab5 speaks the truth, anyone making a killing off PAD either has a rare population of wealthy vasculopaths or making ethical compromises and dropping in tons of stents and ballons in places that aren't really helping the patient. The work is long, tedious and has a fair amount of unwanted surprises/complications. I think its much more satisfying to place a couple ports or drains or do a couple biopsies in the same amount of time, and potentially more lucrative.
 
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1. Neither IO nor PAD is truly lucrative in terms of time invested to the return on investment. You know what is? Ports, varicose veins, etc. The ROI on those exceeds any cool procedure you can do. This is true of any specialty - ENT, Urology, etc. Ask any of them what makes them the most money, and it's the office-based minor procedures. Not the head and neck tumor, or the prostatectomy. I think you are misinformed about how lucrative PAD is. It's not chump change, but nobody is getting rich off PAD. You're not considering the patient population that has that disease, the time spent on the cases, etc... and what you could be doing instead.

1a. I think PAD is great and certainly a cornerstone of IR, but there seems to be some crazy rumor going around among med students that this is some holy grail procedure that you must do to be a half-way decent interventional radiologist. This is false. There are countless practices where there is so much more than PAD to do.

2. Are you -- a med student -- really going to lecture others on the job market in IR? And how "sorely disappointed" future IRs are going to be? I've been in practice for nearly a decade. I practice 80% IR and I enjoy reading films on my diagnostic days. I'm not disappointed at all.

Vascular surgeons and cardiologists have taken over PAD. If it wasn't worth the time, they wouldn't bother. Cardiologists have training in PAD now. I'm an intern. I matched Radiology last year. I was gung-ho IR and attended a medical school with an elite IR department. Even here, Vascular comes down to the IR suites to do procedures. IR rounds on patients but it is nowhere near to the same level as a surgical or medicine round. After doing my month long IR rotation in which I saw everything from BRTO to TEVAR, I realized the problem is that catheter-based procedures are easy to learn. IR is being oversold. The new residency still doesn't allow for enough clinical time to compete directly for referrals. Let's take UAE. For most patients its BETTER than hysterectomy. However, it will never be in vogue because OB-gyn doctors control the show. IR doesn't have training with menstrual bleeding. I talked to the five fellows and discussed their job prospects. Only 2/5 had 100% IR jobs. The other 3 it was around 50%. I also talked to the 2015 fellows as I shadowed during my third third year and for most of them it was a mix. So, not all of these individuals are going to get 100% IR jobs and they are only going to have three years of DR training. This pathway was poorly thought out. There will be a lot of buyers remorse when these IR only kids realize what their actual job will entail. These kids won't get better training and job offers than the fellows at my former medical school. It's laughable at the amount of hubris displayed by proponents of this new IR/DR residency. You marginally make them better clinicians and make them significantly weaker imagers. Finally, the fact that the intern year isn't built into it like integrated vascular is ridiculous. Maybe in the future it will work out, but right now it's a mess and to say otherwise is to deny reality.
 
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Vascular surgeons and cardiologists have taken over PAD. If it wasn't worth the time, they wouldn't bother. Cardiologists have training in PAD now. I'm an intern. I matched Radiology last year. I was gung-ho IR and attended a medical school with an elite IR department. Even here, Vascular comes down to the IR suites to do procedures. IR rounds on patients but it is nowhere near to the same level as a surgical or medicine round. After doing my month long IR rotation in which I saw everything from BRTO to TEVAR, I realized the problem is that catheter-based procedures are easy to learn. IR is being oversold. The new residency still doesn't allow for enough clinical time to compete directly for referrals. Let's take UAE. For most patients its BETTER than hysterectomy. However, it will never be in vogue because OB-gyn doctors control the show. IR doesn't have training with menstrual bleeding. I talked to the five fellows and discussed their job prospects. Only 2/5 had 100% IR jobs. The other 3 it was around 50%. I also talked to the 2015 fellows as I shadowed during my third third year and for most of them it was a mix. So, not all of these individuals are going to get 100% IR jobs and they are only going to have three years of DR training. This pathway was poorly thought out. There will be a lot of buyers remorse when these IR only kids realize what their actual job will entail. These kids won't get better training and job offers than the fellows at my former medical school. It's laughable at the amount of hubris displayed by proponents of this new IR/DR residency. You marginally make them better clinicians and make them significantly weaker imagers. Finally, the fact that the intern year isn't built into it like integrated vascular is ridiculous. Maybe in the future it will work out, but right now it's a mess and to say otherwise is to deny reality.

I agree to to the extent that, logically, specialists wouldn't bother taking over a procedure from another speciality if it weren't ultimately lucrative to do so. What's the sense in pushing/pulling against fellow docs if it ain't gonna fatten your pockets in your own practice? It ALWAYS comes down to money, often interchangeable with TIME.
 
Do you know why they've delved into PAD?
1) If you're a vascular surgeon, you have to just in order to stay in business. You can't live off of aortas. This is pretty self explanatory.
2) The cardiologists got into PAD because the gravy train for cardiac caths/stents dried up. They had to supplement their income and the next closest thing to their skill set was PAD.

What's truly ironic is your hubris in talking down IR as an intern... based on your experiences as a medical student.

Just another bitter (future) diagnostic radiologist. They're everywhere on SDN.


Vascular surgeons and cardiologists have taken over PAD. If it wasn't worth the time, they wouldn't bother. Cardiologists have training in PAD now. I'm an intern. I matched Radiology last year. I was gung-ho IR and attended a medical school with an elite IR department. Even here, Vascular comes down to the IR suites to do procedures. IR rounds on patients but it is nowhere near to the same level as a surgical or medicine round. After doing my month long IR rotation in which I saw everything from BRTO to TEVAR, I realized the problem is that catheter-based procedures are easy to learn. IR is being oversold. The new residency still doesn't allow for enough clinical time to compete directly for referrals. Let's take UAE. For most patients its BETTER than hysterectomy. However, it will never be in vogue because OB-gyn doctors control the show. IR doesn't have training with menstrual bleeding. I talked to the five fellows and discussed their job prospects. Only 2/5 had 100% IR jobs. The other 3 it was around 50%. I also talked to the 2015 fellows as I shadowed during my third third year and for most of them it was a mix. So, not all of these individuals are going to get 100% IR jobs and they are only going to have three years of DR training. This pathway was poorly thought out. There will be a lot of buyers remorse when these IR only kids realize what their actual job will entail. These kids won't get better training and job offers than the fellows at my former medical school. It's laughable at the amount of hubris displayed by proponents of this new IR/DR residency. You marginally make them better clinicians and make them significantly weaker imagers. Finally, the fact that the intern year isn't built into it like integrated vascular is ridiculous. Maybe in the future it will work out, but right now it's a mess and to say otherwise is to deny reality.
 
Do you know why they've delved into PAD?
1) If you're a vascular surgeon, you have to just in order to stay in business. You can't live off of aortas. This is pretty self explanatory.
2) The cardiologists got into PAD because the gravy train for cardiac caths/stents dried up. They had to supplement their income and the next closest thing to their skill set was PAD.

What's truly ironic is your hubris in talking down IR as an intern... based on your experiences as a medical student.

Just another bitter (future) diagnostic radiologist. They're everywhere on SDN.

Why is it so many come off as bitter?
 
Not sure.

But isn't it a common trend, that there's an honest discussion about IR -- in this case the ESIR pathway -- and some diagnostic radiologist has to chime in that IR is being "oversold" or that there's "no jobs" or some other BS like that?

Do you see non-anesthesiologists going on the SDN anesthesia forum and start posting negative comments about anesthesia? Yet somehow there's always a diagnostic radiologist who wants to throw a wet blanket on an IR discussion.

If it isn't bitterness, what is it? jealousy?
 
I'd add insecurity and anxiety regarding the field's likely volatile future causing many to act out.

I agree though, hardly any other forum has as much internal bickering as radiology.

Ultimately this only leads to a fragmented house, which proverbially never stands up in the long run.

Try something like that in surgery forum, for example, and you better get ready for a whippin.
 
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Many of the stand alone outpatient IR practices are based on varicose veins, PAD (atherectomy codes) and dialysis interventions. The global fees make many of these procedures quite lucrative. Ports and central venous access at more and more institutes are starting to be placed by physician extenders (NPs and Pas). I agree that many of the jobs out there are currently a mix, but there is a growing trend to more and more 100 percent or mostly IR practices..
 
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That's good to hear IRwarrior. I'm not bitter. I want IR to thrive. It's annoying when people like fab5 don't realize that IR has a lot of problems facing it. The new residency is a step but still leaves a lot to be desired. In addition, PAD is a huge moneymaker. As warrior said, atherectomies are highly reimbursed and worth the time. How many programs will even train their residents in PAD? That is a huge loss. The reason diagnostic guys aren't gung ho about the new residency are obvious. It weakens diagnostic training and doesn't really protect turf better. IR can't just give up on a huge piece of the pie like PAD and still be a major player. They have to fight for it but even at my past institution they are slowly ceding it to vascular and cards. The IO is cool but what's going to stop clinicians from doing that in the future? IR sees DR as the enemy. We need each other. IR keeps the contracts.

No I see hubris from people like fab5 who has shown on auntminnie he doesn't know how turf battles work. Cardiologists and vascular surgeons are doing veins and ivc filters. Your new residency won't stop encroachment which was the whole point. IR is jack of all trades. Embrace that and maintain great imaging and endovascular skills. The new residency fails at both and all DR people can see this. When we point it out we are labeled bitter. So be it. If they wanted to protect turf they should have made it 7 years. Include an intern year, three years of rads, then 3 years of IR and clinical months. Then you would be able to compete. But they didn't. They don't even make it categorical so some people do TY and others surgical. The training you get at UVA will be way different than northwestern because the latter is bereft of PAD. This is way more disparate than gen surg. Eventually this will get sorted. But I don't see how it's better than the old system.


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Every specialty has problems facing it. Every. Single. One. And that includes diagnostic radiology.

But for some reason, a bitter med student or intern like yourself -- a future diagnostic radiologist -- takes pride in pointing out the flaws without having any perspective. Without having practiced a day of medicine in your life. Without having ever billed for a procedure - let alone an IR procedure. What does an intern know about how to battle encroachment? Or how turf battles work?

It's now clear you're more jealous than bitter. If you think the new IR pathway weakens DR, then you might as well change specialties before you get any further in your training. IR/DR isn't going anywhere. It's just getting started.

For the record, IR does not see DR as the enemy. I practice both IR and DR and I'm proud of it. And let's not forget it's an IR/DR residency. If DR was the enemy, they would have bagged DR and created an IR-only residency.

Somehow you're wiser than all the rest of us and have decided that we need 3 years of DR and 3 years of IR? Then we'll be able to compete? Thanks for the advice. Really. It's brilliant. And it's clear it's all coming from the goodness of your heart, and not some petty jealousy or bitterness. Sheesh.


That's good to hear IRwarrior. I'm not bitter. I want IR to thrive. It's annoying when people like fab5 don't realize that IR has a lot of problems facing it. The new residency is a step but still leaves a lot to be desired. In addition, PAD is a huge moneymaker. As warrior said, atherectomies are highly reimbursed and worth the time. How many programs will even train their residents in PAD? That is a huge loss. The reason diagnostic guys aren't gung ho about the new residency are obvious. It weakens diagnostic training and doesn't really protect turf better. IR can't just give up on a huge piece of the pie like PAD and still be a major player. They have to fight for it but even at my past institution they are slowly ceding it to vascular and cards. The IO is cool but what's going to stop clinicians from doing that in the future? IR sees DR as the enemy. We need each other. IR keeps the contracts.

No I see hubris from people like fab5 who has shown on auntminnie he doesn't know how turf battles work. Cardiologists and vascular surgeons are doing veins and ivc filters. Your new residency won't stop encroachment which was the whole point. IR is jack of all trades. Embrace that and maintain great imaging and endovascular skills. The new residency fails at both and all DR people can see this. When we point it out we are labeled bitter. So be it. If they wanted to protect turf they should have made it 7 years. Include an intern year, three years of rads, then 3 years of IR and clinical months. Then you would be able to compete. But they didn't. They don't even make it categorical so some people do TY and others surgical. The training you get at UVA will be way different than northwestern because the latter is bereft of PAD. This is way more disparate than gen surg. Eventually this will get sorted. But I don't see how it's better than the old system.


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Obviously I cannot comment on the accuracy of the comments in the thread, but there have been complaints.

Disagreements about the future or turf of IR and DR are not TOS violations. Arguments that become profane or delve into name calling or insults are.

So in that vein, please be kind, respectful and professional in your discussions with each other.
 
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I think the bitterness/jealousy problem is at a trainee level.

"Adult" DRs and IRs don't have a problem with each other (in general and in my opinion). They know each others' skill sets. They can both live in the same house.
...part of this understanding, though, was that they also trained in the same pathway. I think some of the hesitation with IR/DR is that separating the trainees will lead to a lack of ability for the two groups to understand each other, since they start pretty damn biased against the other. I optimistically think that it may not end up being such a problem since it may lead to even more reliance on each others' skill sets.
 
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I'm not bitter or jealous. I want IR to thrive. It's simply my opinion that the current format wasn't well thought out. If you bothered to read my post, I addressed this earlier. It will get better but right now it needs work. So why would you comment on it not going away? I know this nor do I want it to. However you have to start from somewhere. And keep calling me bitter if it makes you sleep at night. I love DR and will do light IR in the future. If you don't think some of these kids will have buyers remorse than you're misguided. One should like DR. You do. However, a lot of the IR applicants hate DR. Will they be happy with a 60/40 IR/DR respectively? This is why some of us DR people have concerns. But think what you want and resort to ad hominem attacks.


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Obviously I cannot comment on the accuracy of the comments in the thread, but there have been complaints.

Disagreements about the future or turf of IR and DR are not TOS violations. Arguments that become profane or delve into name calling or insults are.

So in that vein, please be kind, respectful and professional in your discussions with each other.

Hey there ;)
 
IR and DR are very different.

I don't particularly enjoy DR, but I don't hate it either. Often time I tolerate it and feel I am pretty darn good at it, but I garner little satisfaction from it. Sure occasional puzzling case or interesting pathology can make it slightly enjoyable. But the cataloging, pulmonary nodules, and non-stop reading can get tedious and I don't enjoy it.

I much prefer IR. I miss patient care while on diagnostics and find myself looking up patients I did consults on or procedures on to see how they are doing. I find professional satisfaction taking patients who are critically ill and performing procedures to help or provide them with recovery. I enjoy endovascular procedures and clinical management of vascular diseases. Basically in IR I feel like I am doing what I initially went into medicine for. My diagnostic colleagues do an important job, but the approach to patient care is totally different.
 
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Geez dude, thanks. This is exactly what we were trying to get away from: "I think my discipline is better than yours, really."

I derive much pleasure from creating accurate, tight typo-free report which encapsulates the patient's situation perfectly so that he or she will get a perfect plan from the clinical team. It's very hard to do this quickly and repeatedly and it takes a lot of practice and stamina. I also think on average DRs also care about doing right by their patients as much as the average patient-facing clinician does. I also follow up patients who I'm concerned about.

No value judgments here. IR is also a valuable discipline with its own set of rewards and challenges. Known some very smart and conscientious IRs. I probably could TACE something right now if you made me, but with little accuracy and zero elegance.
 
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Geez dude, thanks. This is exactly what we were trying to get away from: "I think my discipline is better than yours, really."

I derive much pleasure from creating accurate, tight typo-free report which encapsulates the patient's situation perfectly so that he or she will get a perfect plan from the clinical team. It's very hard to do this quickly and repeatedly and it takes a lot of practice and stamina. I also think on average DRs also care about doing right by their patients as much as the average patient-facing clinician does. I also follow up patients who I'm concerned about.

No value judgments here. IR is also a valuable discipline with its own set of rewards and challenges. Known some very smart and conscientious IRs. I probably could TACE something right now if you made me, but with little accuracy and zero elegance.

I'm not saying one is better than the other. I'm simply stating that the personalities differ tremendously. And because of that ESIR and the IR residency is a good thing. I'll give it about 10 years before IR goes completely rogue like Rad/Onc did a long time ago. Personally, this should have happened 20 years ago itself. Once it all pans out and the kinks are worked through there will be a lot more clinical components. I have seen the IR residency curriculum that my program is rolling out and these guys in the future are going to be way better than me.
 
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I have to agree that the future training model for IR is a significant improvement from the way I was trained as an IR. It will be a work in progress, but I do think they are making significant strides in the right direction.
 
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I'm not saying one is better than the other. I'm simply stating that the personalities differ tremendously. And because of that ESIR and the IR residency is a good thing. I'll give it about 10 years before IR goes completely rogue like Rad/Onc did a long time ago. Personally, this should have happened 20 years ago itself. Once it all pans out and the kinks are worked through there will be a lot more clinical components. I have seen the IR residency curriculum that my program is rolling out and these guys in the future are going to be way better than me.
The problem with a split is will there be enough 100% IR jobs for these residents? I don't know. If there will be this could make sense. If not, it would be foolish. I think keeping them under the same house is better for both. It will be interesting to see how this plays out.
 
I don't know. But the same was said about integrated vascular surgery just a decade ago. They seem to be doing fine. Prior to that a lot of vascular surgeons did general and vascular surgery. Many still do, but the intrgrated guys comeing out today don't have general skills and are doing all vascular.

The problem with a split is will there be enough 100% IR jobs for these residents? I don't know. If there will be this could make sense. If not, it would be foolish. I think keeping them under the same house is better for both. It will be interesting to see how this plays out.
 
My concern with the incoming manifestation of IR/DR training is that it's trying to have it both ways: Create physicians who are clinicians and who are also board-certified diagnostic radiologists. That in itself is not a bad thing, but I don't exactly have high hopes of it completely succeeding in either. Even with the current DR residency, I see many senior residents with questionable diagnostic skills who I certainly would not feel comfortable having them read scans for me or my family. And now this new training field is taking away diagnostic years yet still giving them the same certification to read those scans? That's like an anti-fellowship -- no, even worse, because now by taking away "just" a month of neuroradiology or MR body or whatever, you are effectively taking away a fourth or a third or possibly even half of that resident's experience in that particular subspecialty DR yet still expecting them to be competent in it by graduation. That's just crazy.
 
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Who said the goal was to create 100% IR jobs? It is an IR/DR residency after all. I think you have a underlying misunderstanding of the new residency.

The problem with a split is will there be enough 100% IR jobs for these residents? I don't know. If there will be this could make sense. If not, it would be foolish. I think keeping them under the same house is better for both. It will be interesting to see how this plays out.


The argument that IR's have questionable diagnostic skills due to their training curriculum is nonsense. How is it any different than a diagnostic radiology resident who does a mini-fellowship (say 6 months) in mammography and then a 1 year mammography fellowship. Is that person any better qualified to read neuro or msk? Would you feel more comfortable having them read a body CT or MR for your loved one with a liver mass? Speaking for my practice, I know I'm better qualified as an IR than the mammo guys/gals to read such a film.

My concern with the incoming manifestation of IR/DR training is that it's trying to have it both ways: Create physicians who are clinicians and who are also board-certified diagnostic radiologists. That in itself is not a bad thing, but I don't exactly have high hopes of it completely succeeding in either. Even with the current DR residency, I see many senior residents with questionable diagnostic skills who I certainly would not feel comfortable having them read scans for me or my family. And now this new training field is taking away diagnostic years yet still giving them the same certification to read those scans? That's like an anti-fellowship -- no, even worse, because now by taking away "just" a month of neuroradiology or MR body or whatever, you are effectively taking away a fourth or a third or possibly even half of that resident's experience in that particular subspecialty DR yet still expecting them to be competent in it by graduation. That's just crazy.


I still don't understand why people feel compelled to derail a thread that was designed to discuss the expansion of the ESIR pathway.
 
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@Naijaba bringing the heat with yet another awesome post.

There is this pink elephant in the room notion that radiologist are, dare I say, push overs. Could it simply be that we have lost the turf war?
This is a pretty obvious question. I'm sure IR would have loved to maintain that grip but they couldn't because other specialties will take their patients to the hospitals that would let them take those cases. The management of incidental findings is what allows DR to keep the hold over most diagnostic imaging. Those that don't have incidental non-primary organ findings (i.e. Echo, vascular US, POC US, cardiac CT/MR to a lesser extent don't have these, and surprise surprise, are often done by non-radiologists).
 
Short answer: NO.

The only turf battle that was "lost" is cardiac caths. And I'm not even sure it was a battle to begin with. I feel comfortable speaking for my colleagues in saying that none of us wanted to deal with that. There are other ongoing turf battles including PAD and neuroIR. But in the whole scheme of IR, these are just small percentages of what we do. And many of my colleagues couldn't care less about those disease entities. There are far cooler, more exciting, and more lucrative procedures than stroke and PAD.

But I do agree that the new residency is in place to better protect our turf. And I strongly believe it will.

There are more lucrative things than PAD for sure but it's pretty darn good. The newly minted vascular surgeons I know have job offers that are just unreal.
 
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