Will there be less IR independent programs in the next few years?

[Promised_Consort]

Coupled with the declining fellowship fill rates for IR and the increase in integrated spots, do you think independent programs will go away soon?

I’m an MS3 interested in IR but I’m wondering if the decrease in independent spots will make the ESIR -> IR pathway no longer feasible by the time I’m eligible to apply (~7 years from now).

I am also interested in neurorads and MSK rads, because both sound very procedural in nature, so I was wondering how difficult it would be to get a spot in those fellowship programs?

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[TXRads]

Current applicant in the independent pathway. A few programs have mentioned they are transitioning more spots from independent to integrated. Hard to say what it will look like in 7 years but I think options will definitely be less.

Can definitely scratch your procedural itch in MSK or neuro at least in academics, might be a bit harder in PP but not super knowledgeable about this. Not very competitive to get these spots, neuro probably slightly more comeptitive than MSK but overall you will match somewhere good.

I think if you can match integrated at a competitive place that still ensures solid DR training, i'd go with that assuming you plan on doing a good percentage of IR and are invested in building a practice or service line(s). If not, id just go to the best DR program I could get and go to a procedural fellowship.

Unfortunately reality is that if you aren't prepared to do the leg work to build up a practice you will be inundated with whatever bull**** the hospital produces without much "political" leverage in the hospital setting, where as if you establish yourself as a nice, capable IR and are a bit entreprenurial and are willing to see patients the sky is the limit.

 

[irwarrior]

Many programs are pivoting from independent slots to integrated spots directly from medical school. If you could see yourself doing procedural radiology such as MSK, neuro or body the DR route is better. The integrated VIR residency makes more senes if you are considering doing PAD, stroke, y90 , GAE, PAE, UAE etc. Lots of the nonvascular stuff can be done by any of the DR subspecialties without all the headache of VIR call dealing with bleeding and septic patients.

 

[SeisK]

Seems like a very shortsighted mistake. As DR pay continues to climb and they continue to be able to increasingly customize their work circumstances, integrated attrition I expect will rise with no independent option to recoup. DR programs will not stop taking transfers.

Med students do not know what they enjoy and do not. It takes longitudinal exposure to a discipline where the novelty of it has worn off and they understand the larger context of the discipline’s tasks in the healthcare system before someone gets whether they like the field or not, and that really only happens after a few months of rotations in residency. This does a disservice to both med students interested in the discipline and to programs recruiting them.

 

[irwarrior]

The challenge is the two fields are becoming more and more divergent. Interventional trainees are more and more surgical in nature and are recruited from medical school and DR is recruiting those who are ok or who want remote reading and are more lifestyle driven. Interventional continues to get busier and busier with broader scope and has a growing reliance on clinic. Most integrated VIR applicants do 3 or more sub internships in VIR as well as vascular surgery and other surgical subI 4th year so they have a better understanding of what VIR is. Most DR do 2 max 3 months Interventional during training and much of that is minor procedures biopsies, lines and drains.

The graduates of most ESiR don't have as much exposure or experience as some VIR students these days. Most VIR trainees also do a surgical internship gaining more manual dexterity and OR time and floor and icu experience. This separates the two groups even further. The Independent spots are not filling and have pretty poor percent fill rates and the applicant poor is also not as strong as years past. Thus more and more VIR program directors want to reduce independent slots and increase integrated and recruit more medical students into the spot.

Currently the attrition rate is high but as students see that VIR is a much busier and surgical field they will make the decision to apply DR and do a procedural field. Also the VIR integrated is doing more and more VIR /clinical rotations the early years so it will be harder and harder as time goes on for the integrated resident to pivot to DR without extending the training.

 

[SeisK]

Also the VIR integrated is doing more and more VIR /clinical rotations the early years so it will be harder and harder as time goes on for the integrated resident to pivot to DR without extending the training.

This is not a good thing. The play here is “if residents realize they don’t like IR, they’ll be less likely to drop out because of the years it’ll add to their training to switch?” Think about how that comes across for two seconds.

I think the rest of your points are mostly mistaken. It’s well known that practically a general surgery intern year affords you little procedural time as you’re mostly the admission, rounding, progress note, and order scut intern, your procedural time comes third to senior residents and categorial interns, and what little detritus / leftover procedural time it does give is largely unhelpful—watching a senior resident or attending perform a lap appy is of zero utility for anything other than port incision closures.

And finally, we were likely overtraining IR candidates as programs are more interested in having the scutwork that attendings don’t want to deal with covered, rather than focusing on the broader national need for IR physicians. It’s a problem that sunk radonc and interventional cardiology, it’s an easy pitfall to identify and avoid, and fortunately it’s one that having fewer matches in the independent position partially corrected. If the solution to this workaround is “let’s match med students who are too inexperienced to know whether they truly like the discipline, force them into it by making lateral transfer to DR painful when they realize they don’t like it as much as they thought they would, while prioritizing our lifestyles as attendings rather than their future in a marketable workforce,” then we as collective IRs are a pile of nutjobs.

 

[irwarrior]

There are stark differences in surgical preliminary program and have to chose one where you get more autonomy and time in the OR and time to do consults (more of an apprenticeship model). Usually the smaller programs give you more one on one time.

3 parts to surgical intern year (acuity/ technical skill set/ speed of charting and making decisions/ OR environment and mindset most reflects procedural fields IC/advanced endoscopy and VIR.

The surgical trainee is far more efficient than the average IM or TY trainee and are more practical as they understand surgical/ interventional issues. As an attending I work very closely with my surgeons and much less with the other services including IM.

Transferring a residency the eyes of ACGME is no different than a urology resident having to redo training to do diagnostic radiology. If it was a shift from neurorads to MSK rads that is a subspecialty.

The people going into the field and the training is becoming more and more different . Agree the number of well trained VIR is still quite limited as most are being trained to do biopsies, lines , drains and IO (TACE/TARE) and hepatobiliary which occurs mostly at transplant /academic centers. Few are getting trained adequately in PAD, stroke , spine interventions/pain , dialysis , varicose veins etc which are much more common in the private sector. Most don't do enough clinic to be comfortable when they graduate to get referrals from PCP or podiatry. Hopefully that will change with time.

 

[SeisK]

urology resident having to redo training to do diagnostic radiology

This is a self evidently ridiculous comparison to try to justify something also self evidently morally dubious. It would stand up to scrutiny if the entirety of the IR trainee’s time on DR was stripped of them and the 6 year training pathway was shortened to 3-4 years, but the comparison Urology : DR :: IR: DR is ridiculous. The majority of IRs are community docs who spend significant chunks of their time in the reading list, and while the academic IR occupies a disproportionate amount of the podium’s bandwidth at SIR and JVIR, their takes are out of touch for the rest of them.

The large majority of academic IR programs are affiliated with these poor procedural exposure gen surg prelim years. The good exposure prelim years are the nonacademic ones which, ironically, rarely have an IR training program in house. Functionally, I attest the typical intern year for an integrated IR residency functions profoundly little to improve an IR trainee’s longterm skill whatsoever.

 

[irwarrior]

The growing trend of independent VIR practices continues to grow. VIR involvement in obl/asc continues to expand. A solid surgical foundation is invaluable for VIR. Surgery is based on anatomy as is VIR.


There is a growing divergence in the personalities of those who apply VIR and DR especially after Covid and the rapid progression of remote radiology.