Traditional, DIRECT, and DR/IR

[DrMasochist]

So with these new changes in board exams, it seems that many programs are allowing up to 12 months of electives in your fourth year. Could one technically do 12 months of straight IR during this year?

After pursuing a fellowship, and supposing your program has 3 month of IR during your R1-R3 and ~12 months of 4th year electives, you could possibly have ~27 months of IR in your 6 years of residency and fellowship. To me, this sounds a heck of a lot better than the DIRECT path where they require 2 yrs Surg or IM and only guarantee 21 months of IR during your 6 years. What's the advantage of the DIRECT path then?

Also I know that the DR/IR dual certification was approved last November and is scheduled to take effect in 2015. I'm wondering if this dual certificate will only apply to certain programs or will be implemented more or less globally, i.e., if the programs have sufficient IR resources, attendings, etc. I suspect DIRECT programs (the few that remain) will become obsolete once this dual path takes effect. I know U Minnesota shut down their DIRECT program due to this new DR/IR tract.

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[CoopDoc]

I do not think that the goal of ones residency should be the accumulation of the maximum number of months of IR. The DIRECT program was instituted to address the need for more clinical acumen amongst the practitioners of IR. This is essential to our future at the table with other clinical specialties that view us as a service where we can be ordered to do whatever they deem necessary, and our opinion seldom (if ever) matters. We need to be able to discern subtle physical exam findings with the same skill as our vascular surgery colleagues. We need to know how to admit patients, how to run a clinic, how to arrange follow-up, and how to recognize the need for consultation. We need to recognize the skills of our colleagues in other specialties and use this knowledge to understand when to refer.

For this reason, I think the DIRECT pathway was a good initial step to address the shortcomings of prior IR training. I think that the Clinical Pathway (and the Dual Certificate coming down the pipes) is the ideal, however. These allow you to intermix clinical (non-IR) rotations with IR and with diagnostic radiology. Seriously, you can only see so much as a resident in the same IR lab with the same attendings before your level of return begins to plateau. Why not learn some skills which will make you a valuable clinician and interventionalist? Take a rotation in non-invasive vascular imaging. Spend a month or two in vascular surgery. Go rotate with the oncologists after you have had a few IR rotations and learn about how they treat their patients and at the same time, educate them regarding what IR has to offer.

Those are my opinions, but I think they are shared by the IR community at large - hence the push for the Dual Certificate.

To answer your question about the dual certificate, there are things that a program will have to have to qualify as a dual cert training facility, and yes, some of the existing DR programs currently do not meet the grade. These include an admitting service and an IR outpatient clinic, to name a few. We are pushing to educate programs that want to continue to train IR residents to make these changes sooner rather than later, because the accreditation of these programs will hinge on these features. Plus, why not give residents better education now.

DIRECT programs are on their way out. There will be only two radiology options in about 10 years - go into radiology, or go into interventional radiology. I think that probably the decision about whether or not to go into IR will be allowed to be made by some during their traditional DR residency - in which case they will switch into the dual certificate after they take their boards. But this is still being worked out.

Feel free to contact me if you have any more questions and hit me up at SIR if you are going to be there.

Cheers,

Kyle

 

[NZimm]

You are correct in that the Clinical pathway can offer more IR months during residency than the DIRECT pathway, however I agree with CoopDoc that training should not necessarily be about pure IR months but rather about becoming a well-rounded doctor and expanding your knowledge on how to treat a patient. Patients do not present merely with one complaint that can be treated by a simple IR procedure but instead come in with a PMH typically a mile long. We must be able to recognize their additional co-morbities, understand how they can influence our treatment, and be able to offer them the best medical advice possible. This comes with understanding the other specialties in medicine and surgery, not just IR.

As the dual certificate progresses forward we can see more programs progressing towards the framework of the Clinical Pathway. It is unfortunate that schools are terminating their DIRECT pathways in the interim while the dual certificate is enacted. I don't think this reflects on any short-comings of the DIRECT pathway but instead indicates the need for a transitional pathway that programs can use while we wait for the dual certificate to be approved. This is currently being worked on by both the SIR and UVA so that current medical students interested in IR are not left with a short list of IR programs to apply to.

 

[TheRealDrDorian]

I do not think that the goal of ones residency should be the accumulation of the maximum number of months of IR. The DIRECT program was instituted to address the need for more clinical acumen amongst the practitioners of IR. This is essential to our future at the table with other clinical specialties that view us as a service where we can be ordered to do whatever they deem necessary, and our opinion seldom (if ever) matters. We need to be able to discern subtle physical exam findings with the same skill as our vascular surgery colleagues. We need to know how to admit patients, how to run a clinic, how to arrange follow-up, and how to recognize the need for consultation. We need to recognize the skills of our colleagues in other specialties and use this knowledge to understand when to refer.

Second this sentiment. As I'm "stuck" in a traditional pathway+ IR fellowship, one of my concerns is maintaining and adding to my clinical skills learned during internship on top of learning the small amount (joke) of knowledge required to be a proficient DR. I'm hoping to find some opportunities to moonlight on general medical/surgical floors and/or an ICU, but even visit a patient after hours for certain scans I read to compare imaging findings w/ bedside exams, and just talking w/ the primary services regarding workup and plan. I've found NEJM review articles on common clinical concerns are a great resource, as are ACP guidelines/resources (which at the begging of the year I thought 'I'm never going to use these').

Some thoughts for any current/near-future applicants that might also get "stuck" in a traditional pathway+fellowship. I'm finishing up my PGY-1 year at a small community preliminary medicine internship (very TY-esque) that only has 20 new residents a year (10 IM, 10 FM). The pathology has been pretty bread and butter with a few zebras here and there, but for typical patient issues, both surgical and medical (e.g. chest pain, CHF and COPD exacerbations, sepsis, Diabetes and DKA+HHS, ARF and ESRD patients, acute abdominal pain, wound care for diabetic ulcers/fresh BKAs, stroke vs. TIA vs. syncope, etc etc), I've been primarily handling these issues independently with attendings/consult services. I feel fairly comfortable managing both general floor and ICU patients (vent management, acid/base issues, etc) and HIGHLY recommend anyone planning on pursuing IR after a DR residency to find a similar-type program, and not look for a "cush" prelim program. Although I can't say with certainty, I presume that a high-level academic program simply has too many residents/residency programs and as a prelim, you will mostly be scutted out. Additionally, not having a general surgery residency at my program was a great asset for me. On my surgical elective, I was a primary operator on multiple cases, had ample suturing opportunities, and regularly put in CVCs. It was also interesting to work in a hospital that didn't have PACs yet (we do now) and still has paper charts.....I know some people are advocates for doing prelim surgery years over prelim med or TY, but I just can't justify the clinical knowledge you'll gain for bread-and-butter medicine issues. If doing a prelim med, I highly suggest doing a general surgery and/or urology elective.

I don't know how my DR program will handle electives, but if possible I think a vascular, surg onc (or at least liver transplant) are imperative; I do think MAYBE some clinic experience is important, but to me I think you can pick up a lot of outpatient skills on an inpatient setting, the thought being if you understand the outpatient followup one of your patients needs as they leave a hospital, then you'll already know what to expect and issues to address in clinic. Weekends off are nice though too...

For the IR skill set, I know the 1 year IR fellowship generally seems too short, and it probably is, but my mentality is so much of the technical qualities of IR are overlapping in procedures (e.g. vascular access, guidewire and (micro)catheter manipulation; Angioplasty +/- stent deployments; Needle insertion/guidance for biopsies/ablations/whatever), that I hope the bread and butter procedures that are ample during residency prepare me enough for my true fellowship.

[Randomly, a project I did using this "recipe" as a cheap ultrasound guided needle procedure tissue phantom was a great learning opportunity; I've held some workshops using this and it always works well]

Hope this helps. PM if any questions. Great discussion.
Feel free to PM or ask any questions.

 

[badasshairday]

Second this sentiment. As I'm "stuck" in a traditional pathway+ IR fellowship, one of my concerns is maintaining and adding to my clinical skills learned during internship on top of learning the small amount (joke) of knowledge required to be a proficient DR. I'm hoping to find some opportunities to moonlight on general medical/surgical floors and/or an ICU, but even visit a patient after hours for certain scans I read to compare imaging findings w/ bedside exams, and just talking w/ the primary services regarding workup and plan. I've found NEJM review articles on common clinical concerns are a great resource, as are ACP guidelines/resources (which at the begging of the year I thought 'I'm never going to use these').

Some thoughts for any current/near-future applicants that might also get "stuck" in a traditional pathway+fellowship. I'm finishing up my PGY-1 year at a small community preliminary medicine internship (very TY-esque) that only has 20 new residents a year (10 IM, 10 FM). The pathology has been pretty bread and butter with a few zebras here and there, but for typical patient issues, both surgical and medical (e.g. chest pain, CHF and COPD exacerbations, sepsis, Diabetes and DKA+HHS, ARF and ESRD patients, acute abdominal pain, wound care for diabetic ulcers/fresh BKAs, stroke vs. TIA vs. syncope, etc etc), I've been primarily handling these issues independently with attendings/consult services. I feel fairly comfortable managing both general floor and ICU patients (vent management, acid/base issues, etc) and HIGHLY recommend anyone planning on pursuing IR after a DR residency to find a similar-type program, and not look for a "cush" prelim program. Although I can't say with certainty, I presume that a high-level academic program simply has too many residents/residency programs and as a prelim, you will mostly be scutted out. Additionally, not having a general surgery residency at my program was a great asset for me. On my surgical elective, I was a primary operator on multiple cases, had ample suturing opportunities, and regularly put in CVCs. It was also interesting to work in a hospital that didn't have PACs yet (we do now) and still has paper charts.....I know some people are advocates for doing prelim surgery years over prelim med or TY, but I just can't justify the clinical knowledge you'll gain for bread-and-butter medicine issues. If doing a prelim med, I highly suggest doing a general surgery and/or urology elective.

I don't know how my DR program will handle electives, but if possible I think a vascular, surg onc (or at least liver transplant) are imperative; I do think MAYBE some clinic experience is important, but to me I think you can pick up a lot of outpatient skills on an inpatient setting, the thought being if you understand the outpatient followup one of your patients needs as they leave a hospital, then you'll already know what to expect and issues to address in clinic. Weekends off are nice though too...

For the IR skill set, I know the 1 year IR fellowship generally seems too short, and it probably is, but my mentality is so much of the technical qualities of IR are overlapping in procedures (e.g. vascular access, guidewire and (micro)catheter manipulation; Angioplasty +/- stent deployments; Needle insertion/guidance for biopsies/ablations/whatever), that I hope the bread and butter procedures that are ample during residency prepare me enough for my true fellowship.

[Randomly, a project I did using this "recipe" as a cheap ultrasound guided needle procedure tissue phantom was a great learning opportunity; I've held some workshops using this and it always works well]

Hope this helps. PM if any questions. Great discussion.
Feel free to PM or ask any questions.

I'm with you brotha.

I feel fairly proficient (obviously with attending backup) at managing ICU patients, routine floor issues, arterial lines, central venous lines (IJ's only, haven't had a chance to do subclavian), codes, suturing, etc. I know this is all going to atrophy in my "traditional" pathway. It is tough. Will see what I can do during residency to keep things in high gear.

I'm at a community shop too. I definitely feel that I am learning a lot without wasting a ton of time being scutted out. There is practically no scut at my place.