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

[Promised_Consort]

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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?

 

[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.

 

[tomballunger]

I am about to graduate from my ESIR program and go to a stronger clinical IR program for a final fellowship year. We had a IR integrated in my class year transfer back to DR this year. Unfortunately majority of IR jobs out there are dumping ground procedures of lines tubes biopsy drains while reading the list that pay very well as a hospital employee, partner in a DR group, or like our locums hires, rivaling urology ent pay. Starting a high end IR clinical practice, unlike some of the surgical subs that experienced in my intern year like urology or ent, involves significant risks vs the legacy fields as linemonkey md blog puts it. In addition 95% of IR programs out there do not do well training graduates for these high end practices (they do great in training for the majority of ir jobs though reading DR and doing line tube biopsy dumps). Majority of IR DR integrated programs are out there to fiill with residents to do the scutwork rather than improve things, hence they go unfilled in the fellowship match- I didn't even apply to those as a fellow candidate who had plenty of options vs desperate med student needing to match somewhere will accept. I was in the position of a desperate med student needing a spot so I know too well.

Overall, based on what i saw during interviews for independent, yes IR indpendent slots will decrease to become converted to integrated which are easier to fill. But that will decrease the number of not so great programs in the fellowship spots that always go unfilled. Most DR residents nowadays do not choose ir as a fellowship, so it will still be easy to match a good IR fellowship

 

[hopefulraddaddypls]

I am about to graduate from my ESIR program and go to a stronger clinical IR program for a final fellowship year. We had a IR integrated in my class year transfer back to DR this year. Unfortunately majority of IR jobs out there are dumping ground procedures of lines tubes biopsy drains while reading the list that pay very well as a hospital employee, partner in a DR group, or like our locums hires, rivaling urology ent pay. Starting a high end IR clinical practice, unlike some of the surgical subs that experienced in my intern year like urology or ent, involves significant risks vs the legacy fields as linemonkey md blog puts it. In addition 95% of IR programs out there do not do well training graduates for these high end practices (they do great in training for the majority of ir jobs though reading DR and doing line tube biopsy dumps). Majority of IR DR integrated programs are out there to fiill with residents to do the scutwork rather than improve things, hence they go unfilled in the fellowship match- I didn't even apply to those as a fellow candidate who had plenty of options vs desperate med student needing to match somewhere will accept. I was in the position of a desperate med student needing a spot so I know too well.

Overall, based on what i saw during interviews for independent, yes IR indpendent slots will decrease to become converted to integrated which are easier to fill. But that will decrease the number of not so great programs in the fellowship spots that always go unfilled. Most DR residents nowadays do not choose ir as a fellowship, so it will still be easy to match a good IR fellowship

What are these good IR fellowships? Current DR resident interested in ESIR

 

[tomballunger]

UVA, MCW, UI Peoria, MDAnderson, OHSU, Mt SInai NYC, MCVI, Rush, Christiana are the top if you are looking to go into a practice with a strong outpatient component, no particular order. MDA is unique in that its got well rounded rotations in IO and PAD at partner hospitals and office labs. Northwestern Upenn Michigan Colorado Washu Brown Mayo Az and UW Seattle also excellent, but peripheral arterial disease will be more limited. Interview at all of the above and see where you fit in (location matters too, after factoring in the DR residency, you will have been in this for 6 maybe 7 years if independent or as more med students lost a year in research or gaps, and you are much older than when you started). Also figure out what you want to do, it is tough to master everything in 1 year and as some of my home program IR attendings have told me, it benefits to brand yourself in one thing like IO or PVD. (NW more for interventional onc than Christiana or Peoria, and vice versa for PVD)

Note how not all of the listed programs are traditional top household names- the more top traditional academic name the place, the more surgeons dumping lines and tubes and biopsys that unfortunately detract from your clinical time and you will be relegated to a proceduralist But then plenty of traditional IR jobs there paying a very high amount just asking for DR reads + lines tubes biopsys to be done. As linemonkey md says, growth or IR will not be in the hospital

 

[hopefulraddaddypls]

UVA, MCW, UI Peoria, MDAnderson, OHSU, Mt SInai NYC, MCVI, Rush, Christiana are the top if you are looking to go into a practice with a strong outpatient component, no particular order. MDA is unique in that its got well rounded rotations in IO and PAD at partner hospitals and office labs. Northwestern Upenn Michigan Colorado Washu Brown Mayo Az and UW Seattle also excellent, but peripheral arterial disease will be more limited. Interview at all of the above and see where you fit in (location matters too, after factoring in the DR residency, you will have been in this for 6 maybe 7 years if independent or as more med students lost a year in research or gaps, and you are much older than when you started). Also figure out what you want to do, it is tough to master everything in 1 year and as some of my home program IR attendings have told me, it benefits to brand yourself in one thing like IO or PVD. (NW more for interventional onc than Christiana or Peoria, and vice versa for PVD)

Note how not all of the listed programs are traditional top household names- the more top traditional academic name the place, the more surgeons dumping lines and tubes and biopsys that unfortunately detract from your clinical time and you will be relegated to a proceduralist But then plenty of traditional IR jobs there paying a very high amount just asking for DR reads + lines tubes biopsys to be done. As linemonkey md says, growth or IR will not be in the hospital

Im more interested in embolizations and spinal work rather than PAD, and would want an outpatient practice (I know takes work) plus DR locums. Id rather not do any lines or tubes as an attending lol

 

[tomballunger]

Sounds like mda mayo az mcw (mcw does a lot of y90 and msk spine) uw seattle USF would be top if you want embolic and msk work. Unc seems to do a lot of fibroid pae y90 and spine too. I have 0 interest in lines and tubes altho the ir locums and per diem telerads pay is extremely tempting plus the ready availability of these traditional jobs. Id still apply to all the above you'll get plenty of invites if your app doesn't have any red flags and interview day will show you what the programs do

 

[SeisK]

Lines and tubes are par for the course for new grads. To really get away from hospital work you need to be part of or own your ASC / OBL, and people hiring for those unvaryingly prefer experienced IRs who are far more efficient than new grads, and they are competitive seats. First few years in practice will always be hospital work for skill refinement. But it’s broader more varied and imho more interesting than pure angio stuff which when it’s all you do starts to lose its appeal also.

A few CT guided cases, a few US guided case, a few gastrostomies / nephrostomies, a few angios. Several small some big cases. The diversity makes it easy to appreciate and I think is understated. Doing nothing but thrombectomies and venous reconstructions, or nothing but legs or fistulas would get old.

The start pay is also usually better doing hospital work and you also have the availability to identify and build your own cases (presuming it’s not already saturated).

 

[tomballunger]

Yeah that's the reality I'm realizing as I go through the ir training (and what linemonkey puts it too) . The higher end jobs are few and go to those with a years of experience, and even then the lines tubes and biopsys are extremely high paying as a locums (many ir going locums). There are a few newer grads out there going into higher end ir groups, but again very limited number

Also being in a home program that is in a poor state of affairs doesn't help and maybe I spoke too soon against the lines and tubes

 

[hopefulraddaddypls]

Sounds like mda mayo az mcw (mcw does a lot of y90 and msk spine) uw seattle USF would be top if you want embolic and msk work. Unc seems to do a lot of fibroid pae y90 and spine too. I have 0 interest in lines and tubes altho the ir locums and per diem telerads pay is extremely tempting plus the ready availability of these traditional jobs. Id still apply to all the above you'll get plenty of invites if your app doesn't have any red flags and interview day will show you what the programs do

Awesome thanks for the info, ideally would like to focus on pain/easy quick elective procedures, so considering a pain fellowship as well as an add on, or to just do pain instead of IR. Not super interested in the arthrectomies or PAD, and I do enjoy DR lol. Have you interviewed at most places youve applied?

 

[tomballunger]

Awesome thanks for the info, ideally would like to focus on pain/easy quick elective procedures, so considering a pain fellowship as well as an add on, or to just do pain instead of IR. Not super interested in the arthrectomies or PAD, and I do enjoy DR lol. Have you interviewed at most places youve applied?

Yes I interviewed at most places I applied. 29 applications 22 invites, the 7 rejections mostly filled internally through their home program or local. You could do esir, skip the final ir year, and follow with a pain fellowship instead of ir fellowship but it'll be a very nontraditional path so you'll have to reach out to home institute or local pain fellowship directors since they tend to take from pmr and anesthesia. Imo, and I will probably get down voted, ir is a very long and disjointed training path to start with lack of a clear direction from leadership, from sir, to gme institutions, to Dr program directors, to ir program directors, to recruiting med students who will not be able to fully understand the challenges this field faces. The only thing guaranteed and straightforward is very high pay doing hospital based coverage doing the lines and tubes bx at odd hours and reading tele, with a top notch job market (these days it's easier for hospitals to find a urologist than an ir, and urologists are as rare as they come)

Examples of lack of direction, ir and Dr pds are looking for call coverage to hold the ir pager do ir consults and Dr to clear the ever exploding lists in the er or outpt scanners, more than coming up with a clinic focused rotation. Faculty do clinic remote visits while timing out fellows to do cases and staffing inpt consults so the time is not protected even for faculty. Time Asking to go off service to other section clinics is near impossible because the above need for Dr and ir coverage, and the gme institute itself demands the Dr list be cleared and the ir calls to be covered and answered . And even then other residencies have their own residents and fellows covering clinic and won't really know how to integrate an off service fellow.

we still are under abr for our diagnostic cert so almost 7 months of our 6 years of training is mandatory mammo and nuclear medicine, and I've been told by faculty that those 3 disjointed months of mammo is not enough to put out any kind of safe read for screeners. Nucs is just all about clearing pet ct met workups list and feedback from even Dr residents is it's a pointless exercise. And this is just one semi academic programs experience. My next fellowship has dedicated clinic physical space and time for ir , not just entirely tele visits so hopefully things go better

 

[hopefulraddaddypls]

Yes I interviewed at most places I applied. 29 applications 22 invites, the 7 rejections mostly filled internally through their home program or local. You could do esir, skip the final ir year, and follow with a pain fellowship instead of ir fellowship but it'll be a very nontraditional path so you'll have to reach out to home institute or local pain fellowship directors since they tend to take from pmr and anesthesia. Imo, and I will probably get down voted, ir is a very long and disjointed training path to start with lack of a clear direction from leadership, from sir, to gme institutions, to Dr program directors, to ir program directors, to recruiting med students who will not be able to fully understand the challenges this field faces. The only thing guaranteed and straightforward is very high pay doing hospital based coverage doing the lines and tubes bx at odd hours and reading tele, with a top notch job market (these days it's easier for hospitals to find a urologist than an ir, and urologists are as rare as they come)

Examples of lack of direction, ir and Dr pds are looking for call coverage to hold the ir pager do ir consults and Dr to clear the ever exploding lists in the er or outpt scanners, more than coming up with a clinic focused rotation. Faculty do clinic remote visits while timing out fellows to do cases and staffing inpt consults so the time is not protected even for faculty. Time Asking to go off service to other section clinics is near impossible because the above need for Dr and ir coverage, and the gme institute itself demands the Dr list be cleared and the ir calls to be covered and answered . And even then other residencies have their own residents and fellows covering clinic and won't really know how to integrate an off service fellow.

we still are under abr for our diagnostic cert so almost 7 months of our 6 years of training is mandatory mammo and nuclear medicine, and I've been told by faculty that those 3 disjointed months of mammo is not enough to put out any kind of safe read for screeners. Nucs is just all about clearing pet ct met workups list and feedback from even Dr residents is it's a pointless exercise. And this is just one semi academic programs experience. My next fellowship has dedicated clinic physical space and time for ir , not just entirely tele visits so hopefully things go better

Totally agree, luckily my program lets us do as many screeners as we want during our rotation, and lets us wait until R4 to do our last, those are massive money makers, and I dont know how I would feel spending a year in fellowship (breast) essentially to do that. Maybe Im not a true IR guy, but I see a lot of utility with DR. Build up your OBL/outpatient gig, then have a DR gig to supplement your income. Good to hear that you had success this cycle though, do you have any idea what you want to focus on? And whats the going rates for IR locums that you alluded to earlier?

 

[SeisK]

Autonomy is understated and is not effectually assessed by the question “how is autonomy here.”

This may be a controversial take but you really should be graduating having done a solo independent or nearly independent TIPS at some point if it’s available at your program. If I were interviewing again this would be a question I would ask pointedly and explicitly in a way you get an explicit and unambiguous figure. There are programs that do this and programs that do not, and you can have the highest end case mix in the world but it means nothing if the faculty too jealously cling to the cases that you never get the opportunity for technical skill refinement.

This makes some of the programs tomballunger delineated above quite not so impressive

 

[tomballunger]

Autonomy is understated and is not effectually assessed by the question “how is autonomy here.”

This may be a controversial take but you really should be graduating having done a solo independent or nearly independent TIPS at some point if it’s available at your program. If I were interviewing again this would be a question I would ask pointedly and explicitly in a way you get an explicit and unambiguous figure. There are programs that do this and programs that do not, and you can have the highest end case mix in the world but it means nothing if the faculty too jealously cling to the cases that you never get the opportunity for technical skill refinement.

This makes some of the programs tomballunger delineated above quite not so impressive

Agree with the above there too. Not a good outlook either of you have a big list of hi end cases but didn't get to do much in the case besides holding the wire. it is very hard to gauge autonomy even with focused questions - fellows will often overstate what they are doing on interview day. I ranked and matched with the one that I felt the fellow was doing the most in the high end cases and the program got comments for great autonomy on the Google sheets we used to have (some programs are so big people questioned how likely will faculty get to know the fellow to give them autonomy). The ones I listed were more because they had a better variety/mix or focus in certain service lines and stable presence of faculty (I've seen and heard of examples where the program is so unstable that faculty are leaving en masse or resident flat out said it's a bad environment), but how much autonomy is again very tough to figure out- but once you're an r3 who's done enough ir you'll know how to ask that question better to figure it out

 

[irwarrior]

This is another reason interventional interviews should be in person. That way you can see what the autonomy is for various procedures. You can see the cases that are on the schedule for that week and the next week etc.

 

[tomballunger]

Med students are doing multiple ir away/subis these days and getting to see the program at work for a month each away/subi which is great. For fellow interviews in person would be ideal if local applicant like baptist or rush but given how expensive flights are and r3s are swamped with core study/covering understaffed rotations not practical if not local applicant

 

[NDcienporciento100]

UVA, MCW, UI Peoria, MDAnderson, OHSU, Mt SInai NYC, MCVI, Rush, Christiana are the top if you are looking to go into a practice with a strong outpatient component, no particular order. MDA is unique in that its got well rounded rotations in IO and PAD at partner hospitals and office labs. Northwestern Upenn Michigan Colorado Washu Brown Mayo Az and UW Seattle also excellent, but peripheral arterial disease will be more limited. Interview at all of the above and see where you fit in (location matters too, after factoring in the DR residency, you will have been in this for 6 maybe 7 years if independent or as more med students lost a year in research or gaps, and you are much older than when you started). Also figure out what you want to do, it is tough to master everything in 1 year and as some of my home program IR attendings have told me, it benefits to brand yourself in one thing like IO or PVD. (NW more for interventional onc than Christiana or Peoria, and vice versa for PVD)

Note how not all of the listed programs are traditional top household names- the more top traditional academic name the place, the more surgeons dumping lines and tubes and biopsys that unfortunately detract from your clinical time and you will be relegated to a proceduralist But then plenty of traditional IR jobs there paying a very high amount just asking for DR reads + lines tubes biopsys to be done. As linemonkey md says, growth or IR will not be in the hospital

I agree many power house names ie Cleveland Clinic are not good at IR.

 

[irwarrior]

Do you have objective data for which are the powerhouse programs in interventional? Ie those who run it like a surgical service and get their own referrals. Admit their own patients. Have a robust oupatient clinic. Do more than what every program runs ie lite IR (biopsy/drains/vascular access ) /IO and hepatobiliary? Do you know which programs offer high level stroke/ neuro training? Which programs offer PE training? Which programs offer PAD training? Which programs offer varicose vein training? Which programs do advanced pain (RFA of nerves/pain pumps/spinal cord stimulators/ kyphoplast/spinejack/ sacroplasty/ BVN/cryoneurolysis) ? Which programs offer advanced MSK interventions? ie pelvic fixations with screws/cannulas etc? Also which programs have their graduates go out and build 100 % independent practices, which is arguably the best test for the quality of the trainees and the VIR training. For example Miami vascular historically had a high percentage of their graduates obtain or build their own 100 % interventional practices.

 

[ZC9]

Agree with the above there too. Not a good outlook either of you have a big list of hi end cases but didn't get to do much in the case besides holding the wire. it is very hard to gauge autonomy even with focused questions - fellows will often overstate what they are doing on interview day. I ranked and matched with the one that I felt the fellow was doing the most in the high end cases and the program got comments for great autonomy on the Google sheets we used to have (some programs are so big people questioned how likely will faculty get to know the fellow to give them autonomy). The ones I listed were more because they had a better variety/mix or focus in certain service lines and stable presence of faculty (I've seen and heard of examples where the program is so unstable that faculty are leaving en masse or resident flat out said it's a bad environment), but how much autonomy is again very tough to figure out- but once you're an r3 who's done enough ir you'll know how to ask that question better to figure it out

Is there a good way to get autonomy in fellowship? Graduating from an ESIR program with poor autonomy, mostly did lines, tubes, some CT and US cases so really relying on IR independent year to get myself to where I want to be as an attending

 

[tomballunger]

Is there a good way to get autonomy in fellowship? Graduating from an ESIR program with poor autonomy, mostly did lines, tubes, some CT and US cases so really relying on IR independent year to get myself to where I want to be as an attending

depends more on the culture of where you match at. Maybe try to work with the attendings that give more autonomy and avoid the ones that don't in the final year but if the fellowship class is large they'll split it up to make it fair.