How To Maximize Your IR Training

I’d like to take a break from your regularly scheduled programming of me lighting the IR world on fire and laughing from a distance to get back to some practical topics for trainees and students. Several of you have reached out to me privately to ask for some tips about how to make the most of your residency, particularly for those of you in the 6-year IR residency path. Perhaps it was my perspective regarding the sober reality of hospital-based IR, or the challenges of independent IR practice that makes you somewhat concerned for your future. I know my last two blog posts may have felt like a slap to your face. Some of you DM’d me fearing for your future. You will be fine. I’m going to give you a framework for approaching your training, but please note that this is from the perspective of a free-thinking independent IR comfortable in their own skin. Please get differing opinions from your academic mentors and others so you can make up your own mind. Though I guarantee you that if you spend a year or two in a typical community setting practicing IR, you will see exactly where I am coming from.

I remember being in training. Residency can be tough. I had the unique vantage of point of being at two very different institutions with two very different cultures: UCSF for residency and UNC for fellowship. In hindsight, I had very diverse training which gave me the confidence to practice independently. When I step back however and take a look at my trajectory, it is clear that the way I was trained is likely not going to be the way you will be trained. In the history of IR, we are in our infancy and things will change rapidly which is to be expected. I was in one of the last cohort of IR trainees to be brought up in the traditional 1+4+1 model with a 1 year IR fellowship. My training was perhaps a bit more progressive than typical as I did 6 months of IR in my fourth year of residency with one ICU rotation and I did have some IR clinic time. Here’s a framework for how to approach your training to maximize the cards which you have been dealt.

1. Have a goal for how you would like to practice as an attending.

Before you get to training, you need to have some idea of the end goal. This is perhaps the most challenging step because everyone’s crystal ball is cloudy and you really don’t know what you don’t know which is being an attending physician. Maybe you’ve had really good mentorship to this point and are confident that you want to be an academic IR. Maybe you jive with this blog and are confident you want to go down an OBL pathway. When I started residency, I came in thinking I wanted to do neuro IR. That quickly changed when I realized that I get to have a broad-based skillset in body IR and I don’t have to spend a million years training to do it. I also thought at that time I would end up in academics. I love research, I love writing and I enjoy public speaking. It turned out that I liked taking care of patients more than any of those other endeavors. I dislike playing the games required for academic promotion and I quickly learned that I was driven to build something, but I just didn’t know what exactly yet. So I decided to channel my energy towards private practice.

The point I’m trying to make is it’s hard to predict exactly how things are going to turn out, but if you dig deep and learn about your tendencies certain paths will begin to make sense for you and others will quickly seem like terrible ideas. In order to help facilitate you creating a vision for yourself, here is a simple and practical question you should ask yourself:

Do you want to be a radiologist, or do you not want to be a radiologist?

Perhaps this is overly simplistic, but I think creating your vision comes down to this question alone. If you want to be a radiologist, well congratulations then! You have a well-defined path to practicing a mix of IR and DR and becoming a hospital MVP (or trash collector) in many settings. I think unfortunately many of us in IR, particularly those who go down the IR residency pathway, really at heart do not want to be radiologists despite what we told the DR faculty interviewing us. I am this way. I was drawn to radiology as a means to be an image-guided surgeon. If you’re like me and this is the path you want to take, you have an uphill battle finding a meaningful IR job and you need an insurance policy in case you decide that you are going to build a job for yourself and others. That’s ok. You’ll prevail in your training, but it may hurt a bit because you will be forcing yourself to learn important skills that you may not necessarily enjoy deep down.

2. Establish your insurance policy.

If you enjoy radiology, then you will love learning to be a radiologist. If you don’t enjoy radiology really, you better learn it at the highest level possible because your dream of being an image-guided surgeon may not come to fruition the way you’d like it to. I know that sounds harsh, but to avoid another rant which may go “IR viral” just trust me on this one.

Diagnostic radiology is critical for what we do in interventional radiology. Without imaging we cannot intervene and do the cool things we can do. More practically, however, diagnostic radiology is important because it provides you with a tried and true skillset which can pay your bills and keep a roof over your head. Can you think of another medical profession where you can work from home and make at least $300,000 a year? Do not underestimate this skillset. So please don’t be one of those trainees who says “I don’t need to learn this! I’m going to get a 100% IR job.” It’s easy to act that way in residency. I definitely had my moments where I simply did not care about the cavum velum interpositum. I certainly had my moments where I thought to myself “why on God’s earth do I need to care about BI-RADS.” Well, to this day I still don’t care about BI-RADS, but the point remains.

To make the most of your diagnostic months, pick up as many studies as humanly possible. Clean the list like a boss. Do not be afraid to make mistakes. Ask tons of stupid questions.  Take as many cases as you can in conference. Focus your reading on cases you’ve seen. This work will pay dividends later. My radiology months were rough for me. It was like pulling teeth, even though I found the work intellectually satisfying the nature of the work was not compatible with me as a person. I suspect some of you will feel the same way. Grind it out and understand that you are establishing for yourself an essential asset which you can leverage in any way you wish. It also gets better with time. Most of you will feel like the most useless resident on Earth as a first-year radiology resident, but that feeling will tend to go away when you start taking call. The older I get, the more I actually enjoy practicing diagnostic radiology. No, I’m not at a point where I want to sit at a desk and crush volume for 10 hours a day, but in short bursts like the 2 hours I just did from the comfort of my home office, it’s nice knowing that I have a useful skillset which affords me the freedom to not worry about money ever again.

If you are in the IR residency pathway, you need to work extra hard on these diagnostic months because your time learning this skillset is limited. I would prioritize your work in body imaging and emergency radiology which will be most pertinent to the skills expected of you as an interventional radiologist if you choose to practice diagnostic in some capacity in the real-world. These DR skills will make you a better IR. In turn, practicing IR will further sharpen your DR skills and make you quite valuable for anyone looking for a good reader.

3. Establish clinical expertise

As part of the new residency pathway you will be spending time on various non-radiology services learning how to be a doctor. Or at least in theory this is what should be happening. The fact of the matter is you are part of a grand experiment with a completely unknown outcome.

If you want to practice interventional radiology as a physician who generates their own referrals as opposed to somebody who only services the needs of a hospital, then you need to learn clinical medicine. Since you are undoubtedly hospital based in your training program your training will naturally bias you towards inpatient oriented services and critical care. Make the most of these months, but understand that your highest yield for practical knowledge will be in the clinical disciplines related to outpatient practice: vascular surgery, vascular medicine, gynecology, urology and gastroenterology among others. The more time you can spend on these services in clinic learning about aortic disease, peripheral arterial disease, anticoagulation, chronic venous insufficiency, venous thromboembolic disease, pelvic pain and menorrhagia, benign prostatic hyperplasia, hemorrhoid disease and musculoskeletal pain the better set you will be for establishing a unique skillset in which you can function autonomously in the outpatient setting. Even if you chose to work in a hospital, the majority of your practice will be outpatient focused. Pay close attention to diagnostic work-up and evaluation of the patients making their way to these clinics. Learn the relevant algorithms and guidelines in the care of these patients. Develop a deep understanding of the medications used to treat patients before and after surgeries and interventions. There are other disciplines that are very important-transplant and oncology to name a few, but the IR workflow related to these fields tends to be more multidisciplinary/tumor-board centric. That doesn’t mean these disciplines are not important, but these are areas you’ll likely get plenty of exposure just by virtue of being in a large medical center with an IR department.

4. Develop your brain and trust that your hands will eventually follow.

I remember I got this same advice as a trainee, particularly in residency where historically the training has been less hands-on for residents compared to other places. I would always get frustrated because I felt like I was being deprived of useful opportunities to learn procedural skills. In fellowship, my experience was very different. My attendings had to beat out of me some of the extremely conservative tendencies taught to me in residency. I was soon let loose and told to call attendings if I ran into trouble. With my theoretical knowledge-base from residency coupled with much needed hands on training in fellowship, I ended up as a halfway decent IR. Looking back at my experience, I’ve concluded that our decision making in cases is actually more difficult than the hands-on skills necessary for case execution. Some may disagree with me here, but doing IR involves calling lots of audibles. You cannot reasonably call audibles unless you develop a deep understanding of the requisite playbook. Like a second string QB, there is a lot that can be gleaned from observing others do cases. Of course, you absolutely need to get your hands-on wires and catheters and ensure that you spend time as primary operator. Depending on the culture of your training institution, this may not happen until later in residency. Don’t let that or trainee Twitter bragging concern you. Keep in mind that no one institution will perform every type of case in IR and you will undoubtedly be forced to learn on the job as an attending. This is very much the rule and not the exception. It takes 5 years on average to develop true procedural comfort as an IR. I’m still working on that as I type this. Trust the process and remain humble.

5. Build your professional network and watch your back

The more I do this, the more I realize it’s an extremely small world. Like really small. Perhaps at times uncomfortably small. The way to use this to your advantage is to make friends, don’t piss people off and do not burn bridges. I’ve made a lot of friends, but I have pissed off two people in my career, and though not intentional ended up burning two bridges. Any long-time reader of this blog knows those bridges were with a senior IR partner in my first job who fundamentally disagreed with my idea of clinically oriented IR and my former cardiology partner in the OBL who truly is a special individual. I wish those bridges didn’t burn, but they did and sometimes they must to make your physical and mental escape from an unhealthy situation. What I never did though is burn any bridges in training. I’m pretty sure if you asked anyone I worked with in residency or fellowship they’d likely tell you I was a “quiet and conscientious trainee with a good fund of knowledge and strong work ethic.” Perhaps someone “they wish they knew better.” That’s what you want. Wait until you have multiple streams of income, then run your mouth if you must.

It was actually my sonographer in the OBL who sat me down and said “you need to know who you’re dealing with” when we were discussing some tensions which came up in the office relating to my former partner and how I was going to react to these issues. This former partner of mine is the kind of guy who can be very hot or very cold. Very much like I learned who I was dealing with in the OBL, you need to get good at reading the room quickly and learn to bite your tongue. Training is your time to listen and ask open-ended questions. Listen more than you talk.

So, who will you be dealing with in training? For many of you, academic radiologists. I’ve met many wonderful academic radiologists and for the most part my experiences in training were very positive. Some are great friends to this day. Undoubtedly, you will meet attendings you simply do not care for.  Just keep your head down and work. It’s what they want you to do and what they expect you to do. Perhaps your personality is not conducive to that. Understand that this time in your life is temporary. What you do not want to have happen is be labeled as someone who is “not a team player” or basically be put on someone’s shit list.

I’ve had some good friends placed on shit lists. Let me tell you, it does not end well. They truly get cancelled.  Many times, I feel these are individuals who probably didn’t deserve to get cancelled, but it happens. And when it does the implications can be staggering. You may not get good letters of recommendations. You may have issues getting hospital privileges for reasons unrelated to pseudo-exclusive contracts! I’ve seen it with my own eyes. Academic radiologists control your immediate future. A fair number of them like the sound of their own voices. Some of them laugh at their own lame jokes. Particularly in IR, many academic attendings may not be “clinical” themselves because that is not how they were trained and frankly many of them have to play some insane non-clinical game to make it up the ladder whether they like it or not. A few of them may have incredibly thin skin.  Be kind, be compassionate, work hard, but above all, be careful and know who you are dealing with.

Keep in touch with people you train with and those attendings you work under. You never know when you need to reach out to someone. Along those lines attend different conferences. Make some private practice friends, please. We outnumber academic IRs at a 4:1 ratio. You should have more of us in your contact list than academic attendings. We know what the real world is like and can provide more honest feedback and mentorship than most academic physicians. There are many of us out here who truly care and are willing to help you simply for the love of the game. You don’t need to write some paper for me to help you.  In the IR world, everyone talks about the SIR Annual Meeting which is a great time generally speaking, but there are frankly better settings for trainees. Many of the smaller conferences can provide more meaningful opportunities to develop lasting relationships. Regional meetings such as WINGS, or SEAS in addition to multidisciplinary meetings like OEIS may provide for better trainee experiences.

6. Understand that there is an unwritten curriculum in IR

Part of this blog is to write this unwritten curriculum and give future trainees a roadmap to “success,” however you may define that (a topic for another day).  The unwritten curriculum in IR is that the way we are being trained is historically flawed, but is improving. The real world has yet to catch up unless a small minority of new practitioners with a clear vision for clinical practices build these practices to provide opportunities for new trainees who are seeking employment. Building a practice is truly difficult and is getting more difficult each year with healthcare consolidation, private equity acquisitions, a failure of our professional society to acknowledge the fundamental shortcomings with our relationship with diagnostic radiology and more. We do not know how this story is going to play out. That is truly up to you to decide.

Part of you deciding how you want this game to play out is by taking charge of your education and frankly your life. You need to understand that most of you will have IR program directors who really have no idea what they’re doing when it comes to your education and how it impacts your future. They’re just trying to check some boxes, but they aren’t really sure what the end product should look like. Why? Because many of them haven’t lived that life of true independent clinical practice. They have their own unique set of problems and circumstances. I know this sounds harsh, or maybe just mean, but it’s the truth no one wants to tell you. Some of them who have built incredible practices within their respective academic environments may beat their chest publicly and tell you that someone like me isn’t qualified to opine on this subject. I’d kindly invite them to live my last several years of private practice IR existence, then come back and tell me I’m wrong.

You must not passively sit by and let someone else tell you how you should be trained. Be entrepreneurial about your training. You need to create that vision for yourself and demand excellent clinical training. You need to go to clinic and advocate for yourself. If your end goal is being able to drive referrals to your practice, keep this in mind and do what’s necessary to get the requisite training. Please stay tuned for more information about the “unwritten curriculum.”

7. Find ways to enjoy your life.

Everyone’s personal situation is different and it’s hard to generalize, but you are about to start mile 1 of a marathon. This race will be running in the background for 6 to 7 years. While you want to make the most of this time, you do not want to neglect your life. Surgical residents and fellows tend to not use all their vacation. While we may want to be like surgeons, please use your vacation. Try to sleep as much as you can. Exercise as regularly as you can. Spend as much time as possible with your families. Make some good friends and have tons of fun outside of the hospital. I was fortunate to have an incredible group of friends in residency in addition to great residents and co-fellows in IR fellowship who I got to know really well and remain my good friends to this day. Career longevity is important. Part of this is making sure you do your best to strike some kind of balance in your life. This balance will look different for every individual IR. I work a lot and people think I’m nuts, but my balance is for me. Yours will be different.  Despite what others may say, I firmly believe that finding your balance begins in training. When you become an attending, things do not magically get better. Money is easier to come by, but everything else gets harder. You need to make your life outside of work a priority. Contrary to popular belief in medicine, doing so will make you a better physician.

These points here are rather general, and at least a few statements will be viewed as “controversial.” If you have any specific questions, please post them in the comment box for everyone to see so future readers can benefit. I will be writing more about these topics in future posts.