Matching into DR but potentially interested in IR -- options?

[randomerasquestion]

I am applying DR in part in order to keep my options open throughout residency. However I have always been interested in IR, I just have not had enough experience to definitively commit before residency, especially when I thought IR could still be an option through the 'traditional' pathway. That being said, it's hard to ignore the huge interest in IR on the interview trail this year, and two things worry me: 1) All my top programs also have either ESIR or IR match processes in place, and so those IR slots will already be filled; and 2) even if there are openings, the competition will likely be fierce given that there are so few IR residency slots and so many applicants dual applying into IR and DR (and if DR, likely with the intent of going the 'traditional' pathway into IR should they not match).

How valid are these concerns? By not applying IR direct, am I screwing over my chances of being able to one day do IR should I end up loving it during residency?

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[cowme]

Could go wrong either way. You could do direct IR and find that you despise IR, and need to switch into DR. I actually predict A LOT of this happening with the new system (I thought I was IR all the way until I rotated there--now it's the last thing in rads I'd consider). I anticipate a lot of openings for people like you going the DR to IR route and vice versa

 

[PL198]

I don't even understand the purpose of the new residency. If the first 3 years are the exact same, what is the purpose of committing now? I guess I just don't understand the point of both ESIR and the integrated residency existing. They lead to the exact same thing in the same amount of time, except one of them requires you to commit earlier than the other.

 

[Fab5Hill33]

90+% of IR graduates will be via the IR/DR residency. The ESIR pathway is just a backup option for DR residents who decide they want to switch to IR. It also serves the important function of helping with the transition period between IR fellowships and IR/DR residency.

 

[Fab5Hill33]

I suspect that you were like myself and didn't have IR exposure until residency. This is a very different era from when we trained.

I predict there will be very few IR residents switching into DR. IR/DR applicants nowadays are doing IR electives and IR sub-i's during their 4th year of med school. So they know what they are getting into.

Could go wrong either way. You could do direct IR and find that you despise IR, and need to switch into DR. I actually predict A LOT of this happening with the new system (I thought I was IR all the way until I rotated there--now it's the last thing in rads I'd consider). I anticipate a lot of openings for people like you going the DR to IR route and vice versa

 

[cowme]

I don't even understand the purpose of the new residency. If the first 3 years are the exact same, what is the purpose of committing now? I guess I just don't understand the point of both ESIR and the integrated residency existing. They lead to the exact same thing in the same amount of time, except one of them requires you to commit earlier than the other.

I completely agree, and actually think it's a detriment to training. In the current state, you can do a year long mini fellowship at your home program, and then goto another high powered institution and get a different skill set from different attendings and institutions. Your programs awesome at interventional oncology but has minimal arterial work? Before you could complement both sides. Now, you're kinda pigeonholed in whatever weaknesses your home program has, and they all have weaknesses.

To the poster above, yea I had a ton of 4th year ir exposure. I liked IR Just fine, but I LOVED diagnostic radiology, which I didn't anticipate. No way to know with either until you're the one doing it. I imagine I would have had to find a way to transfer had This system been in place years ago. There will be plenty of others like me

Just a dumb, dumb move all around. Let's hope it works out better than when Nuc Med tried to break off

 

[deleted379552]

The real advantage to an IR/DR integrated program is the opportunity to learn how to care for IR patients at an earlier stage in training. At Rochester, for example, the IR/DR residents will have their own IR clinic for 1 half day per week for all five years of training. Also, the assurance of knowing that your spot in IR is secured is invaluable. It's easier to switch out of IR, but much more difficult to switch into it.

If you're DR interested in IR, you face a potentially longer road with more competition. IR programs can only train so many residents at one time. Most programs I'm interviewing at have 2 IR/DR spots and 1 ESIR spot. So if you are a DR resident interested in ESIR, you'll be competing internally for that one ESIR spot. If you don't get it, you'll be forced to complete a 2-year independent IR fellowship (which isn't bad, but it just means you'll be delaying your attending status by 1 year). At the top programs like Mount Sinai, Penn, Hopkins, which send many of its DR residents into IR, the competition will potentially be much stiffer for that one ESIR spot. I would recommend paying close attention to how many ESIR spots are offered by your programs and how many residents they send into IR each year. That should give you a rough idea of what the competition will be.

 

[PL198]

90+% of IR graduates will be via the IR/DR residency. The ESIR pathway is just a backup option for DR residents who decide they want to switch to IR. It also serves the important function of helping with the transition period between IR fellowships and IR/DR residency.

ok but then what is the purpose of the new IR/DR then? I have to think most people going into 1 yr IR fellowships previously were doing a majority of IR in 4th year(residency), besides checking off requirements like mammo, so it just seems like a change in name only to me. if the first 3 years are truly the same, then the change seems effectively very small. and if the first 3 years are very different, then I wonder how the IR/DR residents DR knowledge/skills will be, as they will receive less and less DR specific training (if you insert ICU months, etc etc). I say this as both an IR and DR applicant.

a half day/ clinic per week sounds unique from my experiences at places. but would be beneficial. however you start doing half day/week clinic, then maybe some research or etc and you start losing a lot of training time which is already cramped from a DR perspective.

I feel like the common rationale in general for the changes is to become a more clinical specialty. however in doing so you are clearly going to be spending less time on diagnostic stuff. just seems like a natural trade-off to me.

What are you basing the 90 + % figures on? Not saying you're wrong, just curious. Seems like a very dynamic time so it seems hard to tell who will have independent spots.

 

[Fab5Hill33]

I'm basing that figure on discussions with friends in SIR and friends who are PDs. Maybe it will be lower like 80% rather than 90+%, but it will be the vast majority. My money is on the 90+% tho.

The IR/DR residency wasn't created just to create an alternate pathway. They've had the "DIRECT" pathway for over a decade. You can google that for more historical info. But it was an "alternate" pathway to IR that involved more clinical exposure. The IR/DR residency was created with the intention of eliminating fellowships and being the primary pathway to becoming an IR. This was a really big, game-changing decision that was really big news in the IR community.

Consider the current state: As of right now, there are something like 60 IR/DR residencies that have been approved. There aren't any independent (2-year) IR residency programs approved yet. Why is that? SIR wanted all the new residencies in place first because that's the bread-and-butter future of IR. The 2-year independent program (1-year with ESIR credit) is an afterthought. It's essentially just the backup system.

Lastly, I'd point out that many residencies only allow a few months (not a full year) of IR in your 4th year of diagnostic radiology. So let's say your program let you do 4 months of IR as a "mini-fellow." You would do 16 months of IR before graduating. Now you're doing 24 months. I'd say that's a pretty big difference, and more than just a name change.

ok but then what is the purpose of the new IR/DR then? I have to think most people going into 1 yr IR fellowships previously were doing a majority of IR in 4th year(residency), besides checking off requirements like mammo, so it just seems like a change in name only to me. if the first 3 years are truly the same, then the change seems effectively very small. and if the first 3 years are very different, then I wonder how the IR/DR residents DR knowledge/skills will be, as they will receive less and less DR specific training (if you insert ICU months, etc etc). I say this as both an IR and DR applicant.

a half day/ clinic per week sounds unique from my experiences at places. but would be beneficial. however you start doing half day/week clinic, then maybe some research or etc and you start losing a lot of training time which is already cramped from a DR perspective.

I feel like the common rationale in general for the changes is to become a more clinical specialty. however in doing so you are clearly going to be spending less time on diagnostic stuff. just seems like a natural trade-off to me.

What are you basing the 90 + % figures on? Not saying you're wrong, just curious. Seems like a very dynamic time so it seems hard to tell who will have independent spots.

 

[Fab5Hill33]

With all due respect, it seems the only people who think this is a dumb move are diagnostic radiologists. I sense some bitterness about it, but I'm not sure why. A stronger IR division makes a stronger Radiology department.

IR is a lot different than nuclear medicine. Nuclear medicine residents don't get certification in diagnostic radiology. It's just an intern year and 2 years of nuclear medicine. Good luck finding a job where someone needs you to read nuclear medicine scans only. The IR/DR residency allows for dual board certification: IR and DR. I'd say that's going to be a lot more marketable than just having a NM certificate, or even just a DR certificate, alone.

Rest assured -- it will work out just fine.

Just a dumb, dumb move all around. Let's hope it works out better than when Nuc Med tried to break off

 

[PL198]

I'm basing that figure on discussions with friends in SIR and friends who are PDs. Maybe it will be lower like 80% rather than 90+%, but it will be the vast majority. My money is on the 90+% tho.

The IR/DR residency wasn't created just to create an alternate pathway. They've had the "DIRECT" pathway for over a decade. You can google that for more historical info. But it was an "alternate" pathway to IR that involved more clinical exposure. The IR/DR residency was created with the intention of eliminating fellowships and being the primary pathway to becoming an IR. This was a really big, game-changing decision that was really big news in the IR community.

Consider the current state: As of right now, there are something like 60 IR/DR residencies that have been approved. There aren't any independent (2-year) IR residency programs approved yet. Why is that? SIR wanted all the new residencies in place first because that's the bread-and-butter future of IR. The 2-year independent program (1-year with ESIR credit) is an afterthought. It's essentially just the backup system.

Lastly, I'd point out that many residencies only allow a few months (not a full year) of IR in your 4th year of diagnostic radiology. So let's say your program let you do 4 months of IR as a "mini-fellow." You would do 16 months of IR before graduating. Now you're doing 24 months. I'd say that's a pretty big difference, and more than just a name change.

Makes sense. I would just point out there are no independent programs yet because there is no one positioned to apply for them, right? Current residents are grandfathered into the 1 yr fellowships, as I understand it.

 

[cowme]

I have pretty clearly laid out my personal reasons for the "bitter" attitude about this move.

As others have alluded to, it just makes naive Med students make a decision before they are truly informed, and it doesn't really provide much of a benefit to trainees compared to the current system--if anything it may even be worse in some cases

and I think a lot of you are underestimating how hard it will really be to switch to a pure DR fellowship. Making it a separate residency with nrmp makes this a hell of a lot more complex. We'll see in 5 years though

 

[DrBowtie]

With all due respect, it seems the only people who think this is a dumb move are diagnostic radiologists. I sense some bitterness about it, but I'm not sure why. A stronger IR division makes a stronger Radiology department.

IR is a lot different than nuclear medicine. Nuclear medicine residents don't get certification in diagnostic radiology. It's just an intern year and 2 years of nuclear medicine. Good luck finding a job where someone needs you to read nuclear medicine scans only. The IR/DR residency allows for dual board certification: IR and DR. I'd say that's going to be a lot more marketable than just having a NM certificate, or even just a DR certificate, alone.

Rest assured -- it will work out just fine.

I don't think bitter is the right word. I see a small group of people saying we'll take our ball and go home. I think we're stronger together and this whole thing is just a rebranding/image thing not a real change in quality of IR training. How would you view Neuroradiologists creating their own residency? Many are already doing two year fellowships.

You bring up the Direct program which was basically the precursor to an IR residency. Why do you think it never caught on and now IR residencies are "hot"?

My concern is that is med students are naive. ~50% of interviewing med students and first year residents in my experience express interest in IR as their top choice fellowship. Only 15-25% actually end up applying and sometimes they weren't in the original 50%. This will be a logistical nightmare with the new setup if the trends hold true.

 

[Fab5Hill33]

Why do you see it as "taking our ball and going home?" That's what I don't get. IR as a specialty is still staying part of Radiology. There's no separate IR department being created. This sounds more like an older brother being jealous of a younger brother's success. We're all in the same family. You should be happy we're making progress and climbing out from your shadows.

There are politics with any profession, and medicine is no exception. As radiologists, our departments are politically stronger when we have a more clinical presence. The new residency training pathway accomplishes this. Secondly, IR has achieved "primary certificate" status with the new residency. That means IR is considered on the level of general surgery, medicine, and radiology instead of a subspecialty like oncology or pulmonology. This gives IR, and in turn, Radiology departments more clout when funding issues come up.

The DIRECT program basically asked for a 2 year internship in general surgery, and kept IR as 1 year. Adding a second year of surgery doesn't make you a better IR. It was a bad curriculum all around. Secondly, it was geared more towards surgery residents who wanted to bail out of their general surgery residency than medical students. The new IR/DR residency is geared only towards medical students.

Why doesn't neuroradiology create their own residency? I think it's pretty obvious that while IR is founded in diagnostic imaging, it's a much different specialty to practice than neuro, msk, breast, etc. You're still primarily a diagnostic radiologist in all those other subspecialties. The day-to-day practice of an IR is much different than that of a diagnostic radiologist. There's a pretty good reason why IR needs it's own residency. You simply can't say the same about neuro... or nuclear medicine for that matter, which is why that residency didn't work out.

Sure, med students are naive. You can make the same argument about any number of specialties. How do you know you like Ophthalmology as a med student? Maybe it's actually ENT that fits you better. How do you know you like Urology? Maybe you're fascinated by the kidney but you realize you don't like operating as much as you thought and you'd prefer to be an IR who does PCNs and ablations, or maybe you prefer medical management of renal diseases more as a nephrologist. There are some students (and I was one back in my day), that went into radiology as "IR or bust." The number of those students is dramatically more now than there was in my day. Just look at the discussion threads on SDN for proof.

Having said all that, why are there still sour grapes? I say, just be happy for your brother.

I don't think bitter is the right word. I see a small group of people saying we'll take our ball and go home. I think we're stronger together and this whole thing is just a rebranding/image thing not a real change in quality of IR training. How would you view Neuroradiologists creating their own residency? Many are already doing two year fellowships.

You bring up the Direct program which was basically the precursor to an IR residency. Why do you think it never caught on and now IR residencies are "hot"?

My concern is that is med students are naive. ~50% of interviewing med students and first year residents in my experience express interest in IR as their top choice fellowship. Only 15-25% actually end up applying and sometimes they weren't in the original 50%. This will be a logistical nightmare with the new setup if the trends hold true.

 

[PL198]

An ENT isn't doing urology for half their clinical work though, they're separate fields with no overlap. Someone who wants to do IR anywhere besides ivory tower should probably like DR. The IR or bust people are in for a rude awakening IMO unless they stay in ivory tower. I don't think students realize how different community IR is from ivory tower IR. You mentioned a lot of high end work in community but that has not been my experience. I've personally seen a lot of low level stuff that is not nearly as flashy as the stuff students see on IR when they rotate at powerhouses.

 

[Fab5Hill33]

I'm an IR or bust person, and I haven't had any rude awakening. If there's any other IR's on here who have felt otherwise, feel free to chime in. And, by the way, I still practice some DR and I enjoy it. Nobody is saying they shouldn't like DR.

There's certainly going to be more high-end work at academic centers, but that doesn't mean there isn't any at community hospitals. What do you think happens in Urology or ENT? Those "high-end" cystectomy or head and neck cancer cases are similarly getting referred to tertiary and academic medical centers. It's the nature of every specialty. You don't see surgeons on SDN telling students that they're in for a rude awakening if they go into Urology or ENT.

Again, what's with the bitterness and curmudgeonly outlook? I don't get it. Why?

An ENT isn't doing urology for half their clinical work though, they're separate fields with no overlap. Someone who wants to do IR anywhere besides ivory tower should probably like DR. The IR or bust people are in for a rude awakening IMO unless they stay in ivory tower. I don't think students realize how different community IR is from ivory tower IR. You mentioned a lot of high end work in community but that has not been my experience. I've personally seen a lot of low level stuff that is not nearly as flashy as the stuff students see on IR when they rotate at powerhouses.

 

[PL198]

bitterness? I'm not bitter, I'm ranking IR residencies very highly. Everything is pros and cons. Just pointing out some cons I see. Obviously there pros or I wouldn't have applied

By IR or bust I meant someone who has no interest in DR. I've met multiple people who said they'd have no interest in DR if IR didn't exist. These are the people I think are in for rude awakening in any non-100 % IR job, as well as the first 3 years of residency where they are doing DR.

 

[Fab5Hill33]

Again, I'm an IR or bust guy. That doesn't mean you will hate a job that's less than 100% IR. It just means you want your focus to be on IR.

You will meet many people who have absolutely NO interest in internal medicine. They would rather gouge their eyes out than practice primary care. But they do internal medicine because they're "cardiology or bust" or "GI or bust" people. I would argue that this is no different. Those cardiologists aren't doing caths every hour of the day, nor are those gastroenterologists scoping people every day of the week. They still have to do clinic and mundane primary care-like work. Many of my interventional cardiology friends don't enjoy their clinic. They wish they were in the cath lab 24/7. But it is what it is. They haven't had any rude awakening. They just accept thats how any practice is. IR is no different.

 

[meister]

Bitter? Yeah, sure, because these IR/DR guys will only do three years of diagnostics and get the same certificate as me. I'm not bitter because of them, I'm bitter because it once again shows the craven power play by ABR to move boards to R3 and put R4s to work. What is the point of R4 for diagnostics?

Intern year and R4 year are largely wasted. Unless you're at a huge program that doesn't rely on resident labor so you can spend 6-12 months in a single service during R4 as a mini-fellow (most places aren't able to accommodate this).

I think people doing IR/DR are smart. DR should be a three year residency.

 

[cowme]

DR/IR get a DR certificate after 3 years? Assumed that's contingent on finishing the IR portion.


Otherwise that would be absolute bull****. you can just drop out your IR agreement at the last second, and scramble into a DR fellowship as a pgy5

 

[meister]

I'm certain they'll predicate it on completing the entire IR/DR program. But yes they get DR certificate.

 

[Fab5Hill33]

That is correct. You must complete the entire IR/DR residency in order to get the DR certificate.

I'm certain they'll predicate it on completing the entire IR/DR program. But yes they get DR certificate.

 

[DrBowtie]

Why do you see it as "taking our ball and going home?" That's what I don't get. IR as a specialty is still staying part of Radiology. There's no separate IR department being created. This sounds more like an older brother being jealous of a younger brother's success. We're all in the same family. You should be happy we're making progress and climbing out from your shadows.

You seem to be intent on ascribing feelings (bitterness, jealousy) to my thoughtful opposition. I just view the whole thing as unnecessary similar to the many opposition pieces presented in the literature and medical meetings outside of the echochambers of SIR.

There are politics with any profession, and medicine is no exception. As radiologists, our departments are politically stronger when we have a more clinical presence. The new residency training pathway accomplishes this. Secondly, IR has achieved "primary certificate" status with the new residency. That means IR is considered on the level of general surgery, medicine, and radiology instead of a subspecialty like oncology or pulmonology. This gives IR, and in turn, Radiology departments more clout when funding issues come up.

We are stronger when we have strong leaders at the national, state and local hospital level. We have a radiologist on every important hospital committee and attend many multidisciplinary conferences. We are available 24/7/365.

I don't think having a primary certificate does anything other than attempt to change the negative optics related to IR being seen as proceduralists. Do you really think because IR will have this certificate that they are going have more clout than Onc or Pulm who do not? Do you think those subspecialties are less respected because they don't have this distinction?

The DIRECT program basically asked for a 2 year internship in general surgery, and kept IR as 1 year. Adding a second year of surgery doesn't make you a better IR. It was a bad curriculum all around. Secondly, it was geared more towards surgery residents who wanted to bail out of their general surgery residency than medical students. The new IR/DR residency is geared only towards medical students.

Why doesn't neuroradiology create their own residency? I think it's pretty obvious that while IR is founded in diagnostic imaging, it's a much different specialty to practice than neuro, msk, breast, etc. You're still primarily a diagnostic radiologist in all those other subspecialties. The day-to-day practice of an IR is much different than that of a diagnostic radiologist. There's a pretty good reason why IR needs it's own residency. You simply can't say the same about neuro... or nuclear medicine for that matter, which is why that residency didn't work out.

I disagree that IR is a distinct enough entity to warrant its own residency classification and that's where I suspect the root of our disagreement will be. The high ends of many of those subspecialties heavily overlap with IR. There are body sections doing ablations, drains, CCY tubes. There are neuro sections who do cerebral angiography and intervention. There are MSK and Neuro sections doing kypho/vertebroplasty. Yet none of these sections seem to think they warrant a residency. It's just part of their sections work.

Sure, med students are naive. You can make the same argument about any number of specialties. How do you know you like Ophthalmology as a med student? Maybe it's actually ENT that fits you better. How do you know you like Urology? Maybe you're fascinated by the kidney but you realize you don't like operating as much as you thought and you'd prefer to be an IR who does PCNs and ablations, or maybe you prefer medical management of renal diseases more as a nephrologist. There are some students (and I was one back in my day), that went into radiology as "IR or bust." The number of those students is dramatically more now than there was in my day. Just look at the discussion threads on SDN for proof.

Time will tell with med students and how much switching in and out we see.

Having said all that, why are there still sour grapes? I say, just be happy for your brother.

Again, I'm an IR or bust guy. That doesn't mean you will hate a job that's less than 100% IR. It just means you want your focus to be on IR.

You will meet many people who have absolutely NO interest in internal medicine. They would rather gouge their eyes out than practice primary care. But they do internal medicine because they're "cardiology or bust" or "GI or bust" people. I would argue that this is no different. Those cardiologists aren't doing caths every hour of the day, nor are those gastroenterologists scoping people every day of the week. They still have to do clinic and mundane primary care-like work. Many of my interventional cardiology friends don't enjoy their clinic. They wish they were in the cath lab 24/7. But it is what it is. They haven't had any rude awakening. They just accept thats how any practice is. IR is no different.

There is subtle difference for example in Interventional Cardiology and the new IR residency.
For IC you have at least two decision points to confirm your career path after getting experience. After experience in IM to match Cards and after experience in Cards to match IC. That's why I am in favor of the current system of IR fellowship with people making decisions after two years of real residency experience rather than two months of med school rotations. ESIR and the independent two year "residency" pathways also make much more sense.

Given the relative standardization of the first three years of IR/DR and DR, you can't convince me there is much to be added by forcing medical students to choose early.

See bolded above.

 

[Fab5Hill33]

There is subtle difference for example in Interventional Cardiology and the new IR residency.
For IC you have at least two decision points to confirm your career path after getting experience. After experience in IM to match Cards and after experience in Cards to match IC. That's why I am in favor of the current system of IR fellowship with people making decisions after two years of real residency experience rather than two months of med school rotations. ESIR and the independent two year "residency" pathways also make much more sense.

I concede that you have more decision points with IC, and with the current IR system. But I would argue the following:

1) You don't need those decision points. Many cardiology fellows will readily tell you that they were cards or bust going into their IM residency.

2) By your logic, specialties like Urology, ENT, Neurosurgery would be better off as simply subspecialty fellowships of general surgery. I think they're all doing better than average and they are attracting stronger caliber students than general surgery by having a separate residency program. I believe one explanation for this that there are high caliber med students who consider Cardiology or IR, but instead seek out ENT or Urology because they know they like procedures and they simply don't want the uncertainty and stress of having to re-apply for fellowships.

 

[Fab5Hill33]

You seem to be intent on ascribing feelings (bitterness, jealousy) to my thoughtful opposition. I just view the whole thing as unnecessary similar to the many opposition pieces presented in the literature and medical meetings outside of the echochambers of SIR.
Fair enough. I didn't mean to suggest your feelings aren't thoughtful. But I think the early evidence suggests that the IR/DR residency is a hit among students. Of course, only time will tell the truth of it all.

We are stronger when we have strong leaders at the national, state and local hospital level. We have a radiologist on every important hospital committee and attend many multidisciplinary conferences. We are available 24/7/365.
No argument here. I agree.

I don't think having a primary certificate does anything other than attempt to change the negative optics related to IR being seen as proceduralists. Do you really think because IR will have this certificate that they are going have more clout than Onc or Pulm who do not? Do you think those subspecialties are less respected because they don't have this distinction?
I agree that part of the benefit is optics. But I'm not referring to "clout" on your local hospital committee. Having a primary certificate is quite meaningful in terms of funding. Now I admit I'm not well versed in the details of funding of residency and fellowship positions, but I do know that residency programs are relatively immune to funding cuts relative to fellowships.

I disagree that IR is a distinct enough entity to warrant its own residency classification and that's where I suspect the root of our disagreement will be. The high ends of many of those subspecialties heavily overlap with IR. There are body sections doing ablations, drains, CCY tubes. There are neuro sections who do cerebral angiography and intervention. There are MSK and Neuro sections doing kypho/vertebroplasty. Yet none of these sections seem to think they warrant a residency. It's just part of their sections work.
We'll have to agree to disagree here. In my experience it's simply not the norm for body sections to do ablations, CCY tubes, etc and MSK sections doing kypho/vertebroplasty, etc. Medical students can see the practice pattern for themselves at their own institutions or talk to their local community radiologists if they're afraid of the academic bias.

 

[DrBowtie]

There is subtle difference for example in Interventional Cardiology and the new IR residency.
For IC you have at least two decision points to confirm your career path after getting experience. After experience in IM to match Cards and after experience in Cards to match IC. That's why I am in favor of the current system of IR fellowship with people making decisions after two years of real residency experience rather than two months of med school rotations. ESIR and the independent two year "residency" pathways also make much more sense.

I concede that you have more decision points with IC, and with the current IR system. But I would argue the following:

1) You don't need those decision points. Many cardiology fellows will readily tell you that they were cards or bust going into their IM residency.

2) By your logic, specialties like Urology, ENT, Neurosurgery would be better off as simply subspecialty fellowships of general surgery. I think they're all doing better than average and they are attracting stronger caliber students than general surgery by having a separate residency program. I believe one explanation for this that there are high caliber med students who consider Cardiology or IR, but instead seek out ENT or Urology because they know they like procedures and they simply don't want the uncertainty and stress of having to re-apply for fellowships.

The surg subspecialties are different than IR in that after doing some gen surg during intern year, you exclusively focus on your subspecialty. The same can't be said for IR/DR with the one year of internship, three year DR heavy curriculum followed by two years of exclusive IR focus. There is a reason you need to commit as a med student to the former since their exclusive training starts much earlier. The IR training much more mirrors that of a fellowship like IC rather than that of a surgical subspecialty.

 

[Fab5Hill33]

The surg subspecialties are different than IR in that after doing some gen surg during intern year, you exclusively focus on your subspecialty. The same can't be said for IR/DR with the one year of internship, three year DR heavy curriculum followed by two years of exclusive IR focus. There is a reason you need to commit as a med student to the former since their exclusive training starts much earlier.

I think that's a good point.

But why is the concept of committing to a career in IR as a medical student so different from committing to Urology or Otolaryngology? You may know you like operating as a medical student, but how do you know Urologic procedures or ENT is for you? Aren't you still taking the same leap of faith that a student is really committed to Urology and doesn't maybe become enamored by colorectal or cardiothoracic surgery during their intern year?

I see your concern that not every diagnostic radiology resident interested in IR ends up becoming an interventional radiologist. But I think if you establish that students must make the decision earlier, they will do their due diligence and investigate the specialty and commit. It's no different in deciding that someone wants to pursue Urology, ENT, Ophtho, Ortho, etc. Students do their due diligence with those specialties before applying and they will do the same for IR. ...And I believe this is happening. Nowadays there are many med students who are rotating in IR and they're figuring out if they like it or not.

 

[DrBowtie]

I think that's a good point.

But why is the concept of committing to a career in IR as a medical student so different from committing to Urology or Otolaryngology? You may know you like operating as a medical student, but how do you know Urologic procedures or ENT is for you? Aren't you still taking the same leap of faith that a student is really committed to Urology and doesn't maybe become enamored by colorectal or cardiothoracic surgery during their intern year?

I see your concern that not every diagnostic radiology resident interested in IR ends up becoming an interventional radiologist. But I think if you establish that students must make the decision earlier, they will do their due diligence and investigate the specialty and commit. It's no different in deciding that someone wants to pursue Urology, ENT, Ophtho, Ortho, etc. Students do their due diligence with those specialties before applying and they will do the same for IR. ...And I believe this is happening. Nowadays there are many med students who are rotating in IR and they're figuring out if they like it or not.

Well for one a medical student gets surgery exposure during their third year clerkships, some of which allow subspecialty rotations. Once you know you like surgery at all you can then explore subspecialties by fourth year rotations assuming an otherwise competitive application.

Outside of the rare medical school to offer a third year radiology clerkship, an IR aspirant would have no built in exposure until the fourth year. A month of IR and a month of DR (since that composes ~50% of the residency) gobbles up a lot of the prime decision making time. If you were considering 1-2 additional things, those ~3 months of audition time are largely used prior to applications. It puts immense pressure on a medical student that doesn't otherwise need to be.

I just fail to see how locking a medical student into a pathway that really doesn't diverge until 4 years later really helps anyone. Hell, look at the AM fellowship board and look how many unexpected fellowship openings happen with residents who committed less than a year prior.

Lastly describe what you think an IR month as a medical student should or does look like. I'm curious if that matches the real experience people are getting. I suspect it is a lot of watching. Similar to DR, watching and doing are different and those who think they will like DR or IR based upon watching, may find themselves surprised and preferring the other when doing.

 

[Fab5Hill33]

Well for one a medical student gets surgery exposure during their third year clerkships, some of which allow subspecialty rotations. Once you know you like surgery at all you can then explore subspecialties by fourth year rotations assuming an otherwise competitive application.
Outside of the rare medical school to offer a third year radiology clerkship, an IR aspirant would have no built in exposure until the fourth year. A month of IR and a month of DR (since that composes ~50% of the residency) gobbles up a lot of the prime decision making time. If you were considering 1-2 additional things, those ~3 months of audition time are largely used prior to applications. It puts immense pressure on a medical student that doesn't otherwise need to be.

OK, then what about specialties like Anesthesiology or Ophthalmology or Rad Onc? There are many specialties that students commit careers to based on a 4th year experience alone.


I just fail to see how locking a medical student into a pathway that really doesn't diverge until 4 years later really helps anyone. Hell, look at the AM fellowship board and look how many unexpected fellowship openings happen with residents who committed less than a year prior.

There's not a single IR fellowship opening on the AM board. There are a handful in other specialties though. But, even then, so what? There's people in every specialty who change their mind. I'm sure you knew of residents who switched into radiology from other specialties. I certainly saw first hand people from surgical subspecialties switch into my residency when I was a resident.

If it didn't help anyone, the IR/DR residency wouldn't have been created. I personally think it will make our specialty even stronger for numerous reasons that I've explained already. And I suspect many other IRs felt the same because they went through the trouble of getting the residency approved. And let's not forget the diagnostic radiology community signed off on it.


Lastly describe what you think an IR month as a medical student should or does look like. I'm curious if that matches the real experience people are getting. I suspect it is a lot of watching. Similar to DR, watching and doing are different and those who think they will like DR or IR based upon watching, may find themselves surprised and preferring the other when doing.

I suspect it looks no different to what a student does on their, say, Orthopedics month. They round, help write h&p and progress notes, scrub into cases. Maybe instead of retracting, they're wiping wires. Maybe they get to put in a suture or work the insufflator during angioplasty.

It's much easier for a student to get a feel for IR than it is for them to figure out they enjoy diagnostic radiology.

 

[DrBowtie]

Well for one a medical student gets surgery exposure during their third year clerkships, some of which allow subspecialty rotations. Once you know you like surgery at all you can then explore subspecialties by fourth year rotations assuming an otherwise competitive application.
Outside of the rare medical school to offer a third year radiology clerkship, an IR aspirant would have no built in exposure until the fourth year. A month of IR and a month of DR (since that composes ~50% of the residency) gobbles up a lot of the prime decision making time. If you were considering 1-2 additional things, those ~3 months of audition time are largely used prior to applications. It puts immense pressure on a medical student that doesn't otherwise need to be.

OK, then what about specialties like Anesthesiology or Ophthalmology or Rad Onc? There are many specialties that students commit careers to based on a 4th year experience alone.


I just fail to see how locking a medical student into a pathway that really doesn't diverge until 4 years later really helps anyone. Hell, look at the AM fellowship board and look how many unexpected fellowship openings happen with residents who committed less than a year prior.

There's not a single IR fellowship opening on the AM board. There are a handful in other specialties though. But, even then, so what? There's people in every specialty who change their mind. I'm sure you knew of residents who switched into radiology from other specialties. I certainly saw first hand people from surgical subspecialties switch into my residency when I was a resident.

If it didn't help anyone, the IR/DR residency wouldn't have been created. I personally think it will make our specialty even stronger for numerous reasons that I've explained already. And I suspect many other IRs felt the same because they went through the trouble of getting the residency approved. And let's not forget the diagnostic radiology community signed off on it.


Lastly describe what you think an IR month as a medical student should or does look like. I'm curious if that matches the real experience people are getting. I suspect it is a lot of watching. Similar to DR, watching and doing are different and those who think they will like DR or IR based upon watching, may find themselves surprised and preferring the other when doing.

I suspect it looks no different to what a student does on their, say, Orthopedics month. They round, help write h&p and progress notes, scrub into cases. Maybe instead of retracting, they're wiping wires. Maybe they get to put in a suture or work the insufflator during angioplasty.

It's much easier for a student to get a feel for IR than it is for them to figure out they enjoy diagnostic radiology.

So I'll humor you one last time in regards to why other specialties do it the way they do. Gas and Ophtho you start your exclusive subspecialty training after one year of internship. They graduate residency completely before their IR residency classmate gets into the exclusively IR portion of the curriculum.

You're trying to create equivalency with other residency programs but you haven't laid out an argument of why IR needs to do it that way.

Why isn't there an opening on AM for IR? It's not because no one ever changes their mind about IR, it's because the NRMP requires you show up for at least 30 days to avoid being a match violator.

Plenty of programs were created that have harmed our profession (5th pathway).

Saying DR signed off sure, but that doesn't mean there weren't dissenters. This was extensively discussed in the literature. DR has to protect its IR access and exposure because some IR procedures are considered standard for a general radiologist. Hence my prior take my ball and go home comment.

 

[Fab5Hill33]

I feel as though you are selectively responding to parts of my posts and not reading the totality of them.

The benefits to the field are significant in my opinion and I've alluded to all of these in the above conversation... 1) Attract stronger caliber students 2) more stability and clout as a primary certificate 3) more exposure for the field (coming out from the shadows of diagnostic radiology) 4) More months in training dedicated to IR, particularly the clinical model.

Did it have to be done? I'm sure the field could have stayed the status quo. But is it good for us as interventionalists that we have our own pipeline of trainees. The change makes the field stronger.

Your only argument against it is that med students may switch out because they don't understand enough about IR to commit to it. And I've responded that other specialties require students to commit to the specialty as 4th year students with limited exposure to the field . Regardless if they start training in it 1 year later or 2 years later or 4 years later, those students have committed to that field. Likewise, it's very possible - and it's happening - that med students decide they want to pursue IR before they even get their M.D.

So I'll humor you one last time in regards to why other specialties do it the way they do. Gas and Ophtho you start your exclusive subspecialty training after one year of internship. They graduate residency completely before their IR residency classmate gets into the exclusively IR portion of the curriculum.

You're trying to create equivalency with other residency programs but you haven't laid out an argument of why IR needs to do it that way.

Why isn't there an opening on AM for IR? It's not because no one ever changes their mind about IR, it's because the NRMP requires you show up for at least 30 days to avoid being a match violator.

Plenty of programs were created that have harmed our profession (5th pathway).

Saying DR signed off sure, but that doesn't mean there weren't dissenters. This was extensively discussed in the literature. DR has to protect its IR access and exposure because some IR procedures are considered standard for a general radiologist. Hence my prior take my ball and go home comment.

 

[futureradres12345]

I feel as though you are selectively responding to parts of my posts and not reading the totality of them.

The benefits to the field are significant in my opinion and I've alluded to all of these in the above conversation... 1) Attract stronger caliber students 2) more stability and clout as a primary certificate 3) more exposure for the field (coming out from the shadows of diagnostic radiology) 4) More months in training dedicated to IR, particularly the clinical model.

Did it have to be done? I'm sure the field could have stayed the status quo. But is it good for us as interventionalists that we have our own pipeline of trainees. The change makes the field stronger.

Your only argument against it is that med students may switch out because they don't understand enough about IR to commit to it. And I've responded that other specialties require students to commit to the specialty as 4th year students with limited exposure to the field . Regardless if they start training in it 1 year later or 2 years later or 4 years later, those students have committed to that field. Likewise, it's very possible - and it's happening - that med students decide they want to pursue IR before they even get their M.D.

Fabhill and drbowtie, please take your cat fight private. You are both incredibly petty and the rest of us should not have to read your endless bickering.

 

[DrBowtie]

Fabhill and drbowtie, please take your cat fight private. You are both incredibly petty and the rest of us should not have to read your endless bickering.

No problem. Done

 

[redoitall]

Did it have to be done? I'm sure the field could have stayed the status quo. But is it good for us as interventionalists that we have our own pipeline of trainees. The change makes the field stronger.

I'd like to chime in as a Med Student going into DR. While I understand all the reasons you mention, I do personally feel that the status quo was not that bad after all. I do think that the specialties are too much alike to warrant the separation. If anything, it creates a lot of confusion. It also put a lot of pressure on the students. I was hesitant between RadOnc and Rads, so figuring this out in the 3 first months of 4th year was hard enough, and now that Rads splits in two fields, that made things simply worse. All I could do is about 2 weeks or so of IR 6 weeks or so of DR. At this point I feel that DR is for me, while being conscious that my decision is based on extremely limited exposure. I do find comfort however in the fact that IR is always a possibility later on (who knows).
There is definitely some upside in attracting "stronger students", but it is really hard to say if most of them know what they are getting into. When you hear someone say "I don't really like DR and want to do IR only", you can seriously question the judgment / understanding of said student. Similarly what would be the point of attracting a strong student who will change his/her mind down road. My understanding from the interview trail is that people change their mind quite often between DR/IR and this was mentioned at least ONCE at all of my interviews, i.e people originally wanting to do IR and then changing their mind, while some wanting to do DR and going into IR.

As for saying that field gets stronger with the change, in some aspect probably, but I want to see what the result of this change will be in 4 or 5 years from now. At this point, and given my limited knowledge of the field of radiology, I am far from convinced that there is a benefit in splitting radiology this way. I also feel that many PDs were not convinced this was wise, at least this is impression I got from the 10+ programs I visited. Sure they did it, because every other program did and no one wants to be last.

All in all I understand your reasoning. But my gut feeling remains that picking IR from the get go would be a mistake (even though I did interview to a few IR programs - another issue for the student, higher cost of application, more interviews and a lot of "diplomatic statements" - not to say BS- during interviews. ).

At a minimum, I would say these are very interesting times and I am quite excited to be part of the field and seeing how all of this unfolds.

 

[IR4thewin]

I also agree that the older pathway has a lot of benefits. It makes sense to do DR at the best possible place and then go to a powerhouse IR for that last year. There are many examples where these may be different institutions. If nothing else, its good to see techniques of multiple institutions so that you have more tricks up your sleeve when you get stuck on a case down the road.

That said, I think the issue behind all of this is that there is a growing split between IR and DR. I'll go on the record and say that IR will be split from DR in 10-15 years if not sooner. I don't mean that IR trainees won't get DR training, I think they will, but I think the relationship between the two specialty groups is ripe for a big change sometime soon. I subscribe to the SIR daily digest and every now and then you hear the rumblings of community IR docs who are breaking off and going rogue, forming relationships with hospitals and surgery centers to go around the diagnostic groups that hold the contracts. From my very limited perspective, I've only talked to a handful of IR about this, I think there is a lot more of this sentiment out there than many realize. Of course, lobbying power is better when the two are merged, and this would be a huge hit for IR if they left, but Diagnostic contracts are limiting IR docs in the community setting.

Heck, even the University of Miami has created a Department of Interventional Radiology. http://www.interventionaloncology36...ioneering-department-interventional-radiology

The split is coming, just a matter of time. My guess is that both IR and DR will be happier with a split (and some cross-training agreements), though I'm sure there will be tons of growing pains.

 

[tco]

Could go wrong either way. You could do direct IR and find that you despise IR, and need to switch into DR. I actually predict A LOT of this happening with the new system (I thought I was IR all the way until I rotated there--now it's the last thing in rads I'd consider). I anticipate a lot of openings for people like you going the DR to IR route and vice versa

Except you need to find someone within your program to switch with. Might be difficult.

 

[cowme]

Doesn't change the fact that most "potentially interested in IR" folk (such as OP) are going to end up DR.

Unless you're super super gung ho about IR procedures and truly don't care about the IR lifestyle, there's really no reason to commit to IR right now

 

[cowme]

Doesn't change the fact that most "potentially interested in IR" folk (such as OP) are going to end up DR.

Unless you're super super gung ho about IR procedures and truly don't care about the IR lifestyle, there's really no reason to commit to IR right now. The fellowship/residency option will be there down the line should you realize it's the only field you can tolerate.

 

[tco]

In this case, they might end up in DR, but they'll do it after their DR/IR residency.

 

[cowme]

There would be nothing more miserable than a 2 year ir residency/fellowship if you wanted to do diagnostics

 

[PL198]

Fabhill and drbowtie, please take your cat fight private. You are both incredibly petty and the rest of us should not have to read your endless bickering.

I don't think its endless bickering, I think its an interesting discussion

 

[deleted379552]

I don't think its endless bickering, I think its an interesting discussion

I agree. It was an interesting discussion.

 

[tco]

There would be nothing more miserable than a 2 year ir residency/fellowship if you wanted to do diagnostics

I agree with you, but if there is no one in the program willing to swap, that person is stuck. That's how the DR/IR is going to work. There's a set number of spots, and you can't transfer programs to enter the other program.

 

[cowme]

Which Is why this DR/IR a terrible idea if there is even a sliver of doubt with the IR vs DR debate

 

[cowme]

.

 

[tco]

Which Is why this DR/IR a terrible idea if there is even a sliver of doubt with the IR vs DR debate

I totally agree, but I have a fundamental hatred for our entire residency/fellowship structure that would be an entirely different argument.

 

[irwarrior]

The rationale for the IR/DR is to incorporate much more clinical integration into training for those that are IR bound. This includes outpatient clinic visits (initial and follow up), inpatient consults , admitting patients, and rounding on patients. The current IR trainee is inadequately trained to come out and build a practice. The IR group are trying to recruit more of a surgically minded student who is passionate about procedures and patient care and do not fear the long hours of a busy IR practice.

If you want to dabble in procedures and do not want the lifestyle associated with a surgical field, the IR residency is not a good idea. It is this group who enjoys procedures but realize that getting up at 5 or 6 am routinely and getting called in for emergencies in the middle of night is not for them, are the ones that reconsider their decision and go into mammography, body, msk etc where there are some lighter procedure and far better and more predictable hours.

There will most likely be some dropout from IR residencies as the lifestyle of IR is not something that they were ready for.

Programs recruiting for IR should be looking for early commitment to IR, going to the SIR meeting, being involved in SIR , being heavily involved in their local IR interest groups, doing multiple IR rotations in 4th year as well as getting letters from IR physicians.

I do feel that the IR residency fails in a couple of areas as they only require 3 months of IR for the first 3 years of radiology residency. This is woefully inadequate as you are not maintaining true clinical integration. Also, a pgy 5 year of ICU is too little and too late. A good IR program has multiple ICU rotations which enable more clinical integration as well.

It is best if your IR training can incorporate stroke therapy, venous disease, arterial disease (PAD, carotidsand aortic disease) as well as all of the oncologic consults (pain,palliative, ablations and trans arterial therapy.)

 

[IR4thewin]

Programs recruiting for IR should be looking for early commitment to IR, going to the SIR meeting, being involved in SIR , being heavily involved in their local IR interest groups, doing multiple IR rotations in 4th year as well as getting letters from IR physicians.

I do feel that the IR residency fails in a couple of areas as they only require 3 months of IR for the first 3 years of radiology residency. This is woefully inadequate as you are not maintaining true clinical integration. Also, a pgy 5 year of ICU is too little and too late. A good IR program has multiple ICU rotations which enable more clinical integration as well.

It is best if your IR training can incorporate stroke therapy, venous disease, arterial disease (PAD, carotidsand aortic disease) as well as all of the oncologic consults (pain,palliative, ablations and trans arterial therapy.)

IRwarrior makes a lot of great points. I also know that several M2 and M3s will be reading this thread, and I want to just say that I have never gone to SIR (wish I did), did not have an early commitment to IR, have only been involved in SIR as a 'student member' which is a free sign up, and did not have an IR interest group at our school (decided on IR too late to start one myself). I did one rotation in IR in the 4th year. If you can do all that stuff, great. But if you are a good student and decide on to IR late, apply broadly and you still have a great shot. I've gotten a good amount of interviews, and I would never want someone not to go for it because they don't have all that stuff IRWarrior talked about.

As far as the rotation schedule of IR in the first 3 years of radiology residency, the main driver for rotation scheduling is the CORE exam that comes after R3. >90% of IR residencies have an identical schedule for the diagnostic and IR residents in years R1-R3. Very few places may differ by a month or two. You can't just spread out the clinical rotations over those 3 years in the current system without shortchanging the diagnostic education and the preparation to do well on the CORE. Hopefully in the future, there may be some other arrangement where the clinical rotations can be spread out easier.

 

[tco]

The rationale for the IR/DR is to incorporate much more clinical integration into training for those that are IR bound. This includes outpatient clinic visits (initial and follow up), inpatient consults , admitting patients, and rounding on patients. The current IR trainee is inadequately trained to come out and build a practice. The IR group are trying to recruit more of a surgically minded student who is passionate about procedures and patient care and do not fear the long hours of a busy IR practice.

If you want to dabble in procedures and do not want the lifestyle associated with a surgical field, the IR residency is not a good idea. It is this group who enjoys procedures but realize that getting up at 5 or 6 am routinely and getting called in for emergencies in the middle of night is not for them, are the ones that reconsider their decision and go into mammography, body, msk etc where there are some lighter procedure and far better and more predictable hours.

There will most likely be some dropout from IR residencies as the lifestyle of IR is not something that they were ready for.

Programs recruiting for IR should be looking for early commitment to IR, going to the SIR meeting, being involved in SIR , being heavily involved in their local IR interest groups, doing multiple IR rotations in 4th year as well as getting letters from IR physicians.

I do feel that the IR residency fails in a couple of areas as they only require 3 months of IR for the first 3 years of radiology residency. This is woefully inadequate as you are not maintaining true clinical integration. Also, a pgy 5 year of ICU is too little and too late. A good IR program has multiple ICU rotations which enable more clinical integration as well.

It is best if your IR training can incorporate stroke therapy, venous disease, arterial disease (PAD, carotidsand aortic disease) as well as all of the oncologic consults (pain,palliative, ablations and trans arterial therapy.)

It's great that you're drinking the Kool-Aid, but there is literally no difference in the current training pathway and doing DR with all electives plugged in with IR plus an ICU month (which most PDs are fine with you doing on your own) followed by a fellowship. Zero difference...Other than if you change your mind, you're screwed if no one wants to swap into being forced into such a program + fellowship.

Most programs that have DR/IR also will have ESIR. I'm failing to see the appeal of committing to IR so early, and this is from someone who still is considering IR midway through R2 year.

Your points about the rotations aren't lost on me, but there's that pesky issue of the CORE exam and being board eligible for over a year before you can be board certified. The time frames don't work if you plug in what should actually be done.

 

[Rippy087]

As far as the rotation schedule of IR in the first 3 years of radiology residency, the main driver for rotation scheduling is the CORE exam that comes after R3. >90% of IR residencies have an identical schedule for the diagnostic and IR residents in years R1-R3. Very few places may differ by a month or two. You can't just spread out the clinical rotations over those 3 years in the current system without shortchanging the diagnostic education and the preparation to do well on the CORE. Hopefully in the future, there may be some other arrangement where the clinical rotations can be spread out easier.

I agree that this is really the biggest problem with combined IR/DR. IR residents would be better served by having more IR rotations throughout the diagnostic years, and by taking the CORE in R4 or early R5. This wouldn't really hurt anyone, but it would make it more difficult to switch internally from IR to DR.

A few programs do a good job with this, but it really is a minority. I have seen a few programs where IR residents do a half-day IR continuity clinic throughout the entire residency. I think these will probably end up providing the best integration of DR and IR training in the long run.