The integrated IR residency design (3 years DR, 2 years IR) seems perfect if there were an abundance of 100% IR jobs. Outside of academia, 100% IR jobs appear to be scarce. I find it concerning that more DR months are not incorporated into the latter two years of the IR residency. Not only are the graduates of the new IR residency two years removed from most of their diagnostic responsibilities, they also have essentially 1 year less of DR training than those who trained in the historical model (DR residency + 1 year IR fellowship). So, when it comes time to find a PP job, and the group expects you to spend 30-60% of your time reading film, how prepared will these new graduates be? Or are they in for a harsh reality check?
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Reservations about the integrated IR residency
- Thread starter IRrads10
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The DR/IR folks have the same amount of required diagnostic training as everyone else. You need that amount to sit for the core and certification exams. However, that's the bare minimum. IR folks are not nearly as good with diagnostics as diagnosticians (how could they be?). The honest truth, in my opinion, is that the majority of diagnostic studies ordered don't need someone who is an expert in whatever section to read it. They need someone who is going to catch 80-90% of the findings and NEVER miss something big. The sub specialty training is nice when we get to tumor boards, super sub specialized reports, pontificating over specific brain tumor vs specific brain tumor based on the location/enhancement/T2 characteristics/advanced tumor imaging profile etc...Not for stroke CT imaging or run of the mill abdominal pain. Go to a good diagnostic program and you'll be able to handle the basic studies easily. Maybe do a few elective months of DR during PGY-5 rather than only IR.
With that said, I'm going to anger some people here. I'm currently a lowly, know-nothing PGY-5 who has matched into IR so I'm sure an attending is going to storm in with a counter argument to my next couple of paragraphs. Being someone who was 99.5% certain I wanted to do IR when I applied for residency, I think that only a fool would want to lock into something like DR/IR. In fact, I ranked UVA DR/IR as dead last on my rank list (the only one that I applied to during my cycle), and their DR program as number 2. Yes, it's currently the most competitive residency, but who cares? That's not why I chose the field. If you decide you don't want to do it, you have to find someone within your program to do a 1 for 1 swap to get out. As you get deeper into residency, there will be fewer people interested in it. Poor choice, IMO.
I also feel that the "clinical model" is an outright appeasement to clinicians. Our value should be to providing the imaging interpretation to the patient and the patient's current clinical status. I'm in the less vocal minority, but I feel this "clinical focus" is going to shift too far from what we're actually experts in, and make us even more of a commodity. Jack of all trades and master of none. We will never manage patients better than a full time midlevel provider, and if we lose our expertise in imaging, we'll have no ground to stand on. We shouldn't be prescribing medications that we're not intimately familiar with, either. So, unless you know all the nuances of who should and shouldn't get specific statins and why (I mean beyond which ones are the high intensity, the real in depth statin specific indications and side effect profiles), you should not be prescribing them.
For the record, don't get it twisted. I'm not saying we shouldn't have a clinical presence. We should absolutely see our sick patients before deciding on a consult (don't just look at the imaging and chart review), but we should not be managing anything.
That's a long winded answer/rant as to my impression on the whole DR/IR situation.
With that said, I'm going to anger some people here. I'm currently a lowly, know-nothing PGY-5 who has matched into IR so I'm sure an attending is going to storm in with a counter argument to my next couple of paragraphs. Being someone who was 99.5% certain I wanted to do IR when I applied for residency, I think that only a fool would want to lock into something like DR/IR. In fact, I ranked UVA DR/IR as dead last on my rank list (the only one that I applied to during my cycle), and their DR program as number 2. Yes, it's currently the most competitive residency, but who cares? That's not why I chose the field. If you decide you don't want to do it, you have to find someone within your program to do a 1 for 1 swap to get out. As you get deeper into residency, there will be fewer people interested in it. Poor choice, IMO.
I also feel that the "clinical model" is an outright appeasement to clinicians. Our value should be to providing the imaging interpretation to the patient and the patient's current clinical status. I'm in the less vocal minority, but I feel this "clinical focus" is going to shift too far from what we're actually experts in, and make us even more of a commodity. Jack of all trades and master of none. We will never manage patients better than a full time midlevel provider, and if we lose our expertise in imaging, we'll have no ground to stand on. We shouldn't be prescribing medications that we're not intimately familiar with, either. So, unless you know all the nuances of who should and shouldn't get specific statins and why (I mean beyond which ones are the high intensity, the real in depth statin specific indications and side effect profiles), you should not be prescribing them.
For the record, don't get it twisted. I'm not saying we shouldn't have a clinical presence. We should absolutely see our sick patients before deciding on a consult (don't just look at the imaging and chart review), but we should not be managing anything.
That's a long winded answer/rant as to my impression on the whole DR/IR situation.
If you are on the fence between IR and DR and not 100 percent committed to IR and potentially pursuing a 100 percent IR practice, I would agree that perhaps applying to a radiology program with ESIR would be best as you have some time to consider your options. Many students come into radiology thinking that IR is for them but have limited exposure in medical school. The majority will see the great difference in lifestyles and many will decide that they would rather have the imaging lifestyle as opposed to a more surgical lifestyle. In these situations, I wonder if there will be some degree of attrition from the IR group similar to what happens in surgery. It is similar to the surgical mantra, if you can find anything else you would be happy doing you should pursue that and that includes IR vs DR. There are several radiology subspecialties that do procedures and have some patient contact without the emergencies that IR has (mammography, musculoskeletal procedure, abdominal imaging , neuroradiology et).
The IR call has become increasingly busy due to the numerous acute conditions we are asked to see from septic patients with cholecystitis or hydronephrosis to bleeding patients (epistaxis, hemoptysis, hematemesis, rectal bleeding, post biopsy, post surgical bleeding , stroke,PE, DVT, post partum bleeding, trauma). The frequency of call coverage can vary based on group and number of hospitals that you are asked to cover, but it can be as frequent as Q2 or Q3. Students who are considering interventional radiology should experience a busy IR rotation and take some night call to experience what the lifestyle is like. They should go to IR clinic, see inpatient consults , round on patients and perform procedures. If you are only in the OR environment as a passive observer, you will not get a true glimpse of what the IR lifestyle is becoming. If there is any doubt of what you want, it is better to go the radiology route with the potential to go ESIR.
Currently many of the radiology groups hire IR physicians primarily to fulfill the hospital contract and see IR physicians as a source of revenue loss as this is based on professional fees. The imagers can read at such break neck speeds that an IR physician doing procedures, doing consults and seeing patients in clinic could never compete. Clinics and consultative practices require significant overhead that is part of the cost of doing business, but radiology groups are not used to having much overhead. To develop a lucrative outpatient IR practice can take 3 to 5 years and often can be in the red for those years. Most radiology groups are not supportive of losing money as they historically have never had to wait for a return on investment.
I do think that pharmacotherapy is an important adjunct and that we as physicians (cardiologists, surgeons, interventional radiologists) involved in the care of certain patient populations should provide that care, otherwise they should consider not performing such procedures. For example a claudicant with Peripheral arterial disease should first go through an exercise regimen, potentially be on cilostazol and be put on a high intensity statin therapy (atorvastatin 40/80 mg) or rosuvastatin 20/40 mg and consideration for an ace-inhibitor 5/10 mg lisinopril and certainly counseled to stop smoking. I have seen too many patients referred to me by primary care or specialists for peripheral arterial disease who are under treated in terms of pharmacotherapy and there is clear evidence of the benefits of these medications and algorithms. So, I think it is our responsibility as health care providers to have an understanding of the conditions that we treat and offer that. Many of the older trials have showcased the under diagnosis of PAD (PARTNER) as well as the under treatment of PAD patients to reduce cardiovascular and cerebrovascular events.
The IR call has become increasingly busy due to the numerous acute conditions we are asked to see from septic patients with cholecystitis or hydronephrosis to bleeding patients (epistaxis, hemoptysis, hematemesis, rectal bleeding, post biopsy, post surgical bleeding , stroke,PE, DVT, post partum bleeding, trauma). The frequency of call coverage can vary based on group and number of hospitals that you are asked to cover, but it can be as frequent as Q2 or Q3. Students who are considering interventional radiology should experience a busy IR rotation and take some night call to experience what the lifestyle is like. They should go to IR clinic, see inpatient consults , round on patients and perform procedures. If you are only in the OR environment as a passive observer, you will not get a true glimpse of what the IR lifestyle is becoming. If there is any doubt of what you want, it is better to go the radiology route with the potential to go ESIR.
Currently many of the radiology groups hire IR physicians primarily to fulfill the hospital contract and see IR physicians as a source of revenue loss as this is based on professional fees. The imagers can read at such break neck speeds that an IR physician doing procedures, doing consults and seeing patients in clinic could never compete. Clinics and consultative practices require significant overhead that is part of the cost of doing business, but radiology groups are not used to having much overhead. To develop a lucrative outpatient IR practice can take 3 to 5 years and often can be in the red for those years. Most radiology groups are not supportive of losing money as they historically have never had to wait for a return on investment.
I do think that pharmacotherapy is an important adjunct and that we as physicians (cardiologists, surgeons, interventional radiologists) involved in the care of certain patient populations should provide that care, otherwise they should consider not performing such procedures. For example a claudicant with Peripheral arterial disease should first go through an exercise regimen, potentially be on cilostazol and be put on a high intensity statin therapy (atorvastatin 40/80 mg) or rosuvastatin 20/40 mg and consideration for an ace-inhibitor 5/10 mg lisinopril and certainly counseled to stop smoking. I have seen too many patients referred to me by primary care or specialists for peripheral arterial disease who are under treated in terms of pharmacotherapy and there is clear evidence of the benefits of these medications and algorithms. So, I think it is our responsibility as health care providers to have an understanding of the conditions that we treat and offer that. Many of the older trials have showcased the under diagnosis of PAD (PARTNER) as well as the under treatment of PAD patients to reduce cardiovascular and cerebrovascular events.
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