What, Exactly, Is an Interventional Radiologist?
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During my training as an interventional radiologist, my family, patients and colleagues in other specialties would ask me exactly what it was that I did. Only after training another six years after medical school, I’ve come to realize that the answer is far more complex than the question would imply.
In the simplest of terms, interventional radiologists use cutting-edge imaging equipment to perform minimally invasive procedures. We are part radiologist because we must interpret imaging studies like X-ray, computed tomography (CT) and ultrasound to diagnose abnormalities inside patients. But we are also part surgeon (or more aptly coined “interventionalists”), as we use this imaging to guide a combination of needles, wires and catheters to treat these abnormalities. While this explanation provides insight into how our specialty works, it still doesn’t answer what it is that we do... | ||||||||||||
How I Finally Decided on the Right Specialty for Me
Stephanie K. Nguyen
March 08, 2018
Stephanie K. Nguyen
March 08, 2018
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About this time last year, I wrote a piece about what to consider when choosing a specialty. Now that I've gone through most of the core clerkships, I have a better idea of what my interests are and the aspects of my future career that I want to prioritize. After many, many long hours of careful consideration, I've chosen interventional radiology.
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Women in IR
M. Victoria Marx, MD, FSIR
2018-2019 President, Society of Interventional Radiology
M. Victoria Marx, MD, FSIR
2018-2019 President, Society of Interventional Radiology
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FREQUENTLY ASKED QUESTIONS
Dr. Rakesh Navuluri
Dr. Rakesh Navuluri
INTERVENTIONAL RADIOLOGY
What is the typical day in IR?
Interventional radiologists usually arrive at the hospital between 7 and 8 am. They round on inpatients and review the day’s scheduled procedures before the first case. The workday primarily consists of performing procedures in an angiography suite using x-ray guidance. Some procedures are done with CT guidance or using ultrasound only. In private practice the average interventional radiologist will perform about a dozen cases in a day. The workday runs until 5 or 6 pm. In between cases interventional radiologists will dictate procedure (postop) notes, perform inpatient consultations, and sometimes also read diagnostic films (x-rays, CT scans, MRI scans, etc.).
Clinic schedules vary by practice. Most practices have 1 day of traditional clinic hours scheduled per week. Additionally, interventional radiologists sometimes have clinic visits scheduled in between procedures. Overall, the ratio of procedure or operating time to clinic time is greater in IR than in most surgical fields.
What do interventional radiologists see in clinic?
Just like surgeons, interventional radiologists see patients for pre-procedure consultations and post-procedure follow-ups. The spectrum of diseases treated by IR is extremely broad – everything from cancer to vascular malformations to peripheral arterial disease to women's health.
What is IR call like?
Call frequency is proportional to the size of your group. The more partners you work with, the fewer call nights you will take each month. Groups can range from just two physicians to over a dozen interventional radiologists. All interventional radiologists, including residents and fellows, take home call.
Interventional radiology plays a critical role in managing very sick patients on call. Urgent or emergent cases can include acute bleeding (gastrointestinal bleeding, hemoptysis, trauma), drain placement (acute cholecystitis, obstructed kidney, abscesses), and stroke therapy among many others.
Are there “turf battles” with other specialties?
In short, the answer is yes. But this is not unique to interventional radiology. There are turf battles between otolaryngologists, plastic surgeons, ophthalmologists (oculoplastics) and oral and maxillofacial surgeons when it comes to cosmetic surgery. Both neurosurgeons and orthopaedic surgeons compete for spine surgery cases. What is the common theme in all these examples? The procedures are interesting and lucrative.
Interventional radiologists occasionally have turf battles with vascular surgeons over the management of peripheral arterial disease. Once in a while you may even hear a cantankerous surgeon say: “You shouldn’t do endovascular interventions if you can’t perform open surgery.” I often counter that if this were the case, then there would be no interventional cardiology (cardiothoracic surgeons would be doing heart catheterizations), and gastroenterologists wouldn’t be performing endoscopy (colorectal surgeons would be doing all the colonoscopies). Besides… interventional radiology INVENTED these procedures!
Interventional radiologists usually arrive at the hospital between 7 and 8 am. They round on inpatients and review the day’s scheduled procedures before the first case. The workday primarily consists of performing procedures in an angiography suite using x-ray guidance. Some procedures are done with CT guidance or using ultrasound only. In private practice the average interventional radiologist will perform about a dozen cases in a day. The workday runs until 5 or 6 pm. In between cases interventional radiologists will dictate procedure (postop) notes, perform inpatient consultations, and sometimes also read diagnostic films (x-rays, CT scans, MRI scans, etc.).
Clinic schedules vary by practice. Most practices have 1 day of traditional clinic hours scheduled per week. Additionally, interventional radiologists sometimes have clinic visits scheduled in between procedures. Overall, the ratio of procedure or operating time to clinic time is greater in IR than in most surgical fields.
What do interventional radiologists see in clinic?
Just like surgeons, interventional radiologists see patients for pre-procedure consultations and post-procedure follow-ups. The spectrum of diseases treated by IR is extremely broad – everything from cancer to vascular malformations to peripheral arterial disease to women's health.
What is IR call like?
Call frequency is proportional to the size of your group. The more partners you work with, the fewer call nights you will take each month. Groups can range from just two physicians to over a dozen interventional radiologists. All interventional radiologists, including residents and fellows, take home call.
Interventional radiology plays a critical role in managing very sick patients on call. Urgent or emergent cases can include acute bleeding (gastrointestinal bleeding, hemoptysis, trauma), drain placement (acute cholecystitis, obstructed kidney, abscesses), and stroke therapy among many others.
Are there “turf battles” with other specialties?
In short, the answer is yes. But this is not unique to interventional radiology. There are turf battles between otolaryngologists, plastic surgeons, ophthalmologists (oculoplastics) and oral and maxillofacial surgeons when it comes to cosmetic surgery. Both neurosurgeons and orthopaedic surgeons compete for spine surgery cases. What is the common theme in all these examples? The procedures are interesting and lucrative.
Interventional radiologists occasionally have turf battles with vascular surgeons over the management of peripheral arterial disease. Once in a while you may even hear a cantankerous surgeon say: “You shouldn’t do endovascular interventions if you can’t perform open surgery.” I often counter that if this were the case, then there would be no interventional cardiology (cardiothoracic surgeons would be doing heart catheterizations), and gastroenterologists wouldn’t be performing endoscopy (colorectal surgeons would be doing all the colonoscopies). Besides… interventional radiology INVENTED these procedures!
DIAGNOSTIC RADIOLOGY
For students who are procedurally inclined, the idea of dedicating half your residency to mastering diagnostic radiology as part of an IR/DR residency can seem unappealing at first. There are a few common misconceptions that contribute to this:
“I don’t think I can work in a dark room all day”
There’s no denying that as a medical student, diagnostic radiology is not a particularly fun rotation. You sit in a dark room looking over the shoulder of someone who is scrolling through CT images at a mile a minute pace. It’s easy to imagine getting bored. But nothing could be further from the truth.
The analogy I like to give is that it’s not much fun to watch someone else play a video game - especially when you're not familiar with the objectives of the game. It is infinitely more fun to read a study and be in control of the mouse than to watch someone else do it. Once you train your eyes and mind to read a CT study, you simply see things that non-radiologists cannot, and the work becomes immensely fascinating.
And if you worry you may fall asleep working in the dark, just ask yourself how often you fall asleep waching a movie at a movie theater.
“I don’t think I can do without patient contact”
Diagnostic radiologists certainly don’t have the degree of patient interaction that a family practitioner does, but, at the same time, they aren’t in total isolation. For example, diagnostic radiologists interact with patients in mammography – counseling them and performing diagnostic procedures. Musculoskeletal radiologists perform arthrograms prior to interpreting MRI scans of the joints. And, of course, interventional radiologists have extensive patient contact just like any surgeon, cardiologist, etc.
Another oft-overlooked aspect of diagnostic radiology is that you are able to impact the care of more patients than most other clinicians. An emergency medicine physician may see 20 patients during a 10 hour shift. During that same period, a diagnostic radiologist will have read imaging studies on 80 different patients. They will have seen the same pathology and impacted the care of as many patients as four emergency medicine physicians combined!
Many students interested in IR also consider procedurally-oriented medicine subspecialties like cardiology or gastroenterology. If you find that you are fascinated by all of these specialties, consider asking yourself what skill sets you want to master:
“I don’t think I can work in a dark room all day”
There’s no denying that as a medical student, diagnostic radiology is not a particularly fun rotation. You sit in a dark room looking over the shoulder of someone who is scrolling through CT images at a mile a minute pace. It’s easy to imagine getting bored. But nothing could be further from the truth.
The analogy I like to give is that it’s not much fun to watch someone else play a video game - especially when you're not familiar with the objectives of the game. It is infinitely more fun to read a study and be in control of the mouse than to watch someone else do it. Once you train your eyes and mind to read a CT study, you simply see things that non-radiologists cannot, and the work becomes immensely fascinating.
And if you worry you may fall asleep working in the dark, just ask yourself how often you fall asleep waching a movie at a movie theater.
“I don’t think I can do without patient contact”
Diagnostic radiologists certainly don’t have the degree of patient interaction that a family practitioner does, but, at the same time, they aren’t in total isolation. For example, diagnostic radiologists interact with patients in mammography – counseling them and performing diagnostic procedures. Musculoskeletal radiologists perform arthrograms prior to interpreting MRI scans of the joints. And, of course, interventional radiologists have extensive patient contact just like any surgeon, cardiologist, etc.
Another oft-overlooked aspect of diagnostic radiology is that you are able to impact the care of more patients than most other clinicians. An emergency medicine physician may see 20 patients during a 10 hour shift. During that same period, a diagnostic radiologist will have read imaging studies on 80 different patients. They will have seen the same pathology and impacted the care of as many patients as four emergency medicine physicians combined!
Many students interested in IR also consider procedurally-oriented medicine subspecialties like cardiology or gastroenterology. If you find that you are fascinated by all of these specialties, consider asking yourself what skill sets you want to master:
Would you prefer to achieve mastery of primary care (internal medicine) en route to becoming a cardiologist or gastroenterologist?
OR
Would you rather achieve mastery of all imaging modalities (x-ray, CT, ultrasound, MRI, nuclear medicine) en route to becoming an interventional radiologist?
OR
Would you rather achieve mastery of all imaging modalities (x-ray, CT, ultrasound, MRI, nuclear medicine) en route to becoming an interventional radiologist?
IR/DR Residency
MIRMSS 2019
PROGRAM DIRECTOR Q & A
Dr. Geogy Vatakencherry (GV)
Dr. Rakesh Navuluri (RN)
What is an interview day like? How do you evaluate an applicant on an interview day?
GV: Our interview day is split into those accepted for VIR and DR interviews and those applying only for integrated VIR at our program. If for VIR only, we have 2 VIR attendings (VIR program director and VIR associate program director), the VIR chief resident and a DR attending (DR program director) who each do 15 minute interviews. For IR and DR days we have 2 VIR attendings and 2 DR attendings and the IR and DR chief residents all interviewing (15 minutes each). We have a tour of the facilities incorporated during the break time. During the VIR days we have a lecture talking about our program by the VIR program director . During the IR/DR interview days we have a lecture from the IR PD and the DR PD each. We usually have a resident meet and greet the night before the interview day. The interview day is usually a half day either am or pm.
RN: Our interview days are also split into morning and afternoon sessions. Each session begins with a 30-minute presentation providing details of the residency program. They are also given a tour of the hospital including IR facilities. There is a group lunch with our current IR/DR residents, in addition to a pre-interview dinner the night before. Candidates have one-on-one interviews with 3 faculty and 1 resident (20 minutes each). Evaluations are based on a number of factors including candidates’ ability to discuss items on their CV (research, personal statement, etc.). Interview day behavior, including etiquette and body language, is also very important.
It seems like there’s increasing specialization within IR. Should we look at programs that specifically have the fellowship we are interested in?
GV: I would look at the scope and breadth of diseases being treated and look for a program that offers a broad array of procedures and more importantly clinic time to evaluate patients with broad clinical conditions. Most places will train you well in interventional oncology and hepatobiliary conditions. Look for programs that have a sub focus in neurointerventional, stroke training, peripheral vascular disease, pain interventions, pediatrics, DVT/PE management and varicose veins, fibroid therapy and BPH treatments to name a few. Look at the case log of not only the PGY5 and 6 but as important the junior integrated residents PGY2 through 4. Look at the scope and breadth of their procedures and are they primary operator. I would not focus as much on procedural volume , but would focus more on procedural complexity and diversity.
RN: While subspecialization and fellowships within IR could potentially develop in the future, I don’t believe it will be commonplace nor do I think it will have any impact on job placement. Choose programs that provide you with the best overall training experience. If you have a particular interest in an area of IR (aortic disease, oncology, etc.) it’s reasonable to seek out those programs that are relatively stronger in those areas.
How do PD’s look at clerkship grades?
GV: I personally look at your class rank as well as your 3rd year grades in internal medicine and surgery .
RN: Medicine and surgery clerkship grades and written evaluations are important to me. I don’t scrutinize the rest. Class rank is important to some of our faculty.
When it comes to matching into competitive specialties, research and publications are often seen as a priority. What is your take on research for IR?
GV: For our program it is not a deal breaker. But, if you have presented at SIR or another national IR conference it certainly does not hurt.
RN: Research that is relevant to radiology and/or interventional radiology demonstrates a genuine interest and commitment to the specialty. This is one of the first items I use to screen out applicants. Research that leads to peer-reviewed publications or presentations demonstrates that a candidate understands the scientific method, and has experience in compiling data and synthesizing it into a clinically meaningful conclusion.
Is there a “right” amount of IR and DR away rotations? Is there a specific strategy when planning DR and IR rotations?
GV: In my opinion you should do at least 2 if not 3 IR rotations before your interviews at busy IR programs. This gives me a gauge to your understanding of what you are getting yourself into. You should do at least 2 weeks to 4 weeks of DR. You should do 1 month of ICU and try to do a month of Vascular surgery. A surgical sub internship rotation will prepare you for a surgical internship.
RN: I expect any serious candidate to have done at least 2 IR rotations. I would advise that IR and DR rotations be done early in the M4 year. This will allow you to obtain letters of recommendation. Your experiences in IR and DR will also be helpful in navigating the interview day.
I am interested in IR and other DR fellowships. What are your opinions on 2-year independent residencies after DR and on ESIR programs?
GV: If you are not 100 percent you want to do IR, I would do DR and possibly ESIR and take your time to decide where your true interests are. Realize that there is no guarantee that you will get into an IR training program post DR residency and the number of available slots is in flux.
RN: If you’re not fully committed to IR as a medical student, independent residency/ESIR is the only way to go. Don’t assume that if you get into an IR/DR program you can back out later and join the DR program. For example, we have 2 IR/DR spots and 6 DR spots. If one of our IR/DR residents were to decide they no longer wanted to pursue IR, we could not accept them into the DR program as a 7th resident as we are only approved for 6 positions.
How is the pathway to IR evolving (IR/DR integrated, ESIR, IR independent)?
GV: This is the true unknown. My speculation is that more and more will convert spots to integrated IR spots as time goes on, but anyone’s guess is as good as mine.
RN: I believe IR/DR integrated residency will be the primary road to becoming an interventional radiologist. The IR independent residency is an alternate road. This road won’t ever close but I believe it will handle the minority of traffic.
How important is the personal statement?
GV: I personally read these and take into consideration if your passion for IR comes out. What has been your exposure and how committed are you to this specialty.
RN: A very well written personal statement can serve as a tiebreaker for granting someone an interview. I come across a handful these each year but it’s not too often that it comes into play.
How important is Step 2 relative to Step 1?
GV: Step 2 is very important if you did not do as well on Step 1 (for example, a Step 1 score <230). You want to showcase that you can do well on standardized exams. If you had over 250 on Step 1, the Step 2 score is not as important. But, most people tend to score higher on Step 2.
RN: I hate standardized tests, but they’re unfortunately necessary to wade through the hundreds of applications we receive. I generally look for Step 1 scores >235. If you scored less than that, I need to see a solid improvement on Step 2.
How is a letter of recommendation from an away rotation looked upon by a PD?
GV: If it is written by an IR that I know I will try to call them and see what they thought and I look highly on a strong IR letter.
RN: I look favorably on any good letter of recommendation from an interventional radiologist – whether it’s at your home institution or not. I don’t worry that you are only interested in the program you did an away rotation at.
What qualities do you look for in an applicant on interview day?
GV: Are they enthusiastic, energetic, and passionate. Do they know something about the uniqueness of our practice. Are they engaged with the other applicants, residents and faculty.
RN: It’s important that candidates have a commitment to interventional radiology, and also fully understand what that commitment entails. I also look for eloquence and ease in answering questions. Finally, politeness and humility go a long way.
How do DR faculty/PDs look at IR residency applicants?
GV: This is a good question and a tricky one. A strong motivated passionate trainee will be liked by IR and DR alike. The trainee must showcase an interest and passion not only for IR but also for DR. The DR faculty are weary of someone who wants to just coast through the PGY2 to 4 years to get to IR. They want someone who is going to really bring it and do well on the DR rotations whether it is mammography or nuclear medicine.
RN: DR faculty and PDs know that IR residency applicants are outstanding; they always have positive impressions of them on interview day. But I think there is some reticence in accepting medical students into a DR residency who may pursue IR. There is concern among DR PDs that if they accept IR-bound students then the pipeline of residents who pursue diagnostic fellowships like MSK, neuro, etc. will dry up.
GV: Our interview day is split into those accepted for VIR and DR interviews and those applying only for integrated VIR at our program. If for VIR only, we have 2 VIR attendings (VIR program director and VIR associate program director), the VIR chief resident and a DR attending (DR program director) who each do 15 minute interviews. For IR and DR days we have 2 VIR attendings and 2 DR attendings and the IR and DR chief residents all interviewing (15 minutes each). We have a tour of the facilities incorporated during the break time. During the VIR days we have a lecture talking about our program by the VIR program director . During the IR/DR interview days we have a lecture from the IR PD and the DR PD each. We usually have a resident meet and greet the night before the interview day. The interview day is usually a half day either am or pm.
RN: Our interview days are also split into morning and afternoon sessions. Each session begins with a 30-minute presentation providing details of the residency program. They are also given a tour of the hospital including IR facilities. There is a group lunch with our current IR/DR residents, in addition to a pre-interview dinner the night before. Candidates have one-on-one interviews with 3 faculty and 1 resident (20 minutes each). Evaluations are based on a number of factors including candidates’ ability to discuss items on their CV (research, personal statement, etc.). Interview day behavior, including etiquette and body language, is also very important.
It seems like there’s increasing specialization within IR. Should we look at programs that specifically have the fellowship we are interested in?
GV: I would look at the scope and breadth of diseases being treated and look for a program that offers a broad array of procedures and more importantly clinic time to evaluate patients with broad clinical conditions. Most places will train you well in interventional oncology and hepatobiliary conditions. Look for programs that have a sub focus in neurointerventional, stroke training, peripheral vascular disease, pain interventions, pediatrics, DVT/PE management and varicose veins, fibroid therapy and BPH treatments to name a few. Look at the case log of not only the PGY5 and 6 but as important the junior integrated residents PGY2 through 4. Look at the scope and breadth of their procedures and are they primary operator. I would not focus as much on procedural volume , but would focus more on procedural complexity and diversity.
RN: While subspecialization and fellowships within IR could potentially develop in the future, I don’t believe it will be commonplace nor do I think it will have any impact on job placement. Choose programs that provide you with the best overall training experience. If you have a particular interest in an area of IR (aortic disease, oncology, etc.) it’s reasonable to seek out those programs that are relatively stronger in those areas.
How do PD’s look at clerkship grades?
GV: I personally look at your class rank as well as your 3rd year grades in internal medicine and surgery .
RN: Medicine and surgery clerkship grades and written evaluations are important to me. I don’t scrutinize the rest. Class rank is important to some of our faculty.
When it comes to matching into competitive specialties, research and publications are often seen as a priority. What is your take on research for IR?
GV: For our program it is not a deal breaker. But, if you have presented at SIR or another national IR conference it certainly does not hurt.
RN: Research that is relevant to radiology and/or interventional radiology demonstrates a genuine interest and commitment to the specialty. This is one of the first items I use to screen out applicants. Research that leads to peer-reviewed publications or presentations demonstrates that a candidate understands the scientific method, and has experience in compiling data and synthesizing it into a clinically meaningful conclusion.
Is there a “right” amount of IR and DR away rotations? Is there a specific strategy when planning DR and IR rotations?
GV: In my opinion you should do at least 2 if not 3 IR rotations before your interviews at busy IR programs. This gives me a gauge to your understanding of what you are getting yourself into. You should do at least 2 weeks to 4 weeks of DR. You should do 1 month of ICU and try to do a month of Vascular surgery. A surgical sub internship rotation will prepare you for a surgical internship.
RN: I expect any serious candidate to have done at least 2 IR rotations. I would advise that IR and DR rotations be done early in the M4 year. This will allow you to obtain letters of recommendation. Your experiences in IR and DR will also be helpful in navigating the interview day.
I am interested in IR and other DR fellowships. What are your opinions on 2-year independent residencies after DR and on ESIR programs?
GV: If you are not 100 percent you want to do IR, I would do DR and possibly ESIR and take your time to decide where your true interests are. Realize that there is no guarantee that you will get into an IR training program post DR residency and the number of available slots is in flux.
RN: If you’re not fully committed to IR as a medical student, independent residency/ESIR is the only way to go. Don’t assume that if you get into an IR/DR program you can back out later and join the DR program. For example, we have 2 IR/DR spots and 6 DR spots. If one of our IR/DR residents were to decide they no longer wanted to pursue IR, we could not accept them into the DR program as a 7th resident as we are only approved for 6 positions.
How is the pathway to IR evolving (IR/DR integrated, ESIR, IR independent)?
GV: This is the true unknown. My speculation is that more and more will convert spots to integrated IR spots as time goes on, but anyone’s guess is as good as mine.
RN: I believe IR/DR integrated residency will be the primary road to becoming an interventional radiologist. The IR independent residency is an alternate road. This road won’t ever close but I believe it will handle the minority of traffic.
How important is the personal statement?
GV: I personally read these and take into consideration if your passion for IR comes out. What has been your exposure and how committed are you to this specialty.
RN: A very well written personal statement can serve as a tiebreaker for granting someone an interview. I come across a handful these each year but it’s not too often that it comes into play.
How important is Step 2 relative to Step 1?
GV: Step 2 is very important if you did not do as well on Step 1 (for example, a Step 1 score <230). You want to showcase that you can do well on standardized exams. If you had over 250 on Step 1, the Step 2 score is not as important. But, most people tend to score higher on Step 2.
RN: I hate standardized tests, but they’re unfortunately necessary to wade through the hundreds of applications we receive. I generally look for Step 1 scores >235. If you scored less than that, I need to see a solid improvement on Step 2.
How is a letter of recommendation from an away rotation looked upon by a PD?
GV: If it is written by an IR that I know I will try to call them and see what they thought and I look highly on a strong IR letter.
RN: I look favorably on any good letter of recommendation from an interventional radiologist – whether it’s at your home institution or not. I don’t worry that you are only interested in the program you did an away rotation at.
What qualities do you look for in an applicant on interview day?
GV: Are they enthusiastic, energetic, and passionate. Do they know something about the uniqueness of our practice. Are they engaged with the other applicants, residents and faculty.
RN: It’s important that candidates have a commitment to interventional radiology, and also fully understand what that commitment entails. I also look for eloquence and ease in answering questions. Finally, politeness and humility go a long way.
How do DR faculty/PDs look at IR residency applicants?
GV: This is a good question and a tricky one. A strong motivated passionate trainee will be liked by IR and DR alike. The trainee must showcase an interest and passion not only for IR but also for DR. The DR faculty are weary of someone who wants to just coast through the PGY2 to 4 years to get to IR. They want someone who is going to really bring it and do well on the DR rotations whether it is mammography or nuclear medicine.
RN: DR faculty and PDs know that IR residency applicants are outstanding; they always have positive impressions of them on interview day. But I think there is some reticence in accepting medical students into a DR residency who may pursue IR. There is concern among DR PDs that if they accept IR-bound students then the pipeline of residents who pursue diagnostic fellowships like MSK, neuro, etc. will dry up.
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AMSER Guide to Applying for Radiology Residency
Version 8 - June 2017 |
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Bio-Design
Shakil Chowdhury, M4
Michigan State College of Human Medicine
Michigan State College of Human Medicine