Advice For Medical Students Thinking About IR

I want to take a minute and focus on some content for medical students who are thinking about IR. Recently, I received dozens of emails and Twitter DMs from medical students thinking about IR. While I love the engagement and want to be as helpful as I can, I’ve beyond reached the point where I have the bandwidth to personally communicate with every single person who has reached out to me. At the height of this blog, probably in 2022, I took time to reach out to everyone who contacted me. It was a fantastic time, and I connected with hundreds of people in our specialty and adjacent specialties. From September 2021 through October 2023, I spent much of my time on the road in the upper midwest or Florida, working with several facilities and practices on an intermediate-term basis. I took over 32 weeks of call each year and pretty much did nothing but IR. My wife was in a vascular surgery fellowship in New York City, and I had more time on evenings and weekends to contemplate and think about IR, usually on call waiting for a case to start or on a plane en route to New York City, Sioux Falls, Duluth, Jacksonville, Tampa, Ft. Lauderdale or Raleigh-Durham. While I still have those big ideas and get fired up about IR, I’ve entered a new phase of life with many changes over the past year that have severely limited my bandwidth, which is for the better. I now live in Columbia, Missouri, and no longer live out of a suitcase. I’m intentionally focused on my life outside medicine because I have not had one in many years so I try to protect my time after hours as much as possible. I also opened an independent IR practice (www.igsmissouri.com) which has been a heavy lift as expected. I also spend some time as an adjunct faculty at the University of Missouri, where I take call about one weekend a month. While my outpatient practice is brand new, I still spend 1 week away a month away from home to help out on-site with a hospital contract in Western New York via our company, Travelier (www.travelierir.com), which helps out the organization and allows me to support my practice. I am also active in a company focused on consulting activities related to IR in addition to short-term staffing solutions with two IR friends (www.physicianstaffingsolutions.com). Between both companies, we have helped multiple healthcare institutions and dozens of IRs, and I couldn’t be prouder of my brilliant co-founders. 

I’ve also learned over the last couple of years that it is very easy to get burned out focusing attention on people who don’t share your values. And to be honest, most IRs do not share my values, so I simply don’t engage with many folks anymore. I have spent less time engaging in radiology professional societies and more time focused on changing what I can change, which are relevant career opportunities for IRs and my professional happiness with my practice. For me, this means fewer conference activities, fewer webinars, fewer Tweets, and less resident and medical student engagement which is unfortunate but better for my sanity. It is tough to fight the academic industrial complex of medicine. The level of brainwashing for future IRs is at an all-time high, and I simply do not have the time or resources to fight that power. The funny thing is, this blog seems to be thriving more than ever despite my lack of activity.

I recently received this question, which I felt deserved some serious attention. Please check it out with my response as follows:

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Dr. Devulapalli,

I’m currently an M3 at a large academic institution. I was initially on a path for Vascular Surgery, mainly because of the endovascular work I saw with PAD in my first few months of medical school – I saw a handful of cases, and I was hooked. I shadowed multiple times a month throughout my first two years of medical school and have always enjoyed the endovascular work. I recently finished a core surgery rotation in the Vascular Surgery service. While I wouldn’t say I’m no longer interested in Vascular Surgery at all, I’ve come to the harsh realization that the only cases I was legitimately interested in were endovascular cases. 

The 50th endovascular PAD was still something new, fresh, and exciting – each case was something different, whether we atherectomized or we didn’t, where the lesion was located, whether it was acute or chronic, what kind of wire we needed to use to cross, it was all still interesting, even just as an observer. The 10th fistula creation I saw was, well, just a fistula creation. Even the 10th cutdown and bypass I saw was, well, just a bypass. 

I’m starting to think, somewhat worryingly, that open surgery is not something I am interested in pursuing for a career. Talking to other students and residents, it feels as though the way they feel about open surgery and the sacrifices they are willing to make to pursue it – that’s basically how I feel about endovascular surgery. I don’t want to be at the hospital at 2 a.m., basically ever. But if I had to, I’d rather be sticking their femoral wearing lead rather than cutting their leg open. 

In my 2.5 years of medical school, the only thing that has consistently interested me has been endovascular surgery and catheter-based technologies. I currently see three pathways for me to pursue this: Vascular Surgery, Interventional Cardiology, and Interventional Radiology. It’s clear to me that there is currently no pathway that provides exclusively endovascular surgical training. I’ll have to be trained in something else to get to my goal, whether that be surgery (Vascular Surgery), medicine (Interventional Cardiology), or diagnostic radiology (Interventional Radiology). 

I stumbled onto your blog during a study break, and it was nice to hear a voice amplify some of the concerns I had heard about IR as a field. I think I could tolerate learning diagnostic radiology, but the honest truth of it is that I don’t think I want to be a diagnostic radiologist. I think I want to be an endovascular surgeon. In my ideal job, I have a robust clinic, similar to a vascular surgeon or interventional cardiologist, where I have longitudinal follow-up with patients and make clinical decisions as to whether a patient should receive an intervention or not. I also have operative days, where I’m performing the procedures that I decided were necessary for the patients I saw. In between, I’m managing my own patients that are admitted to my service. 

I guess my concern is that IR doesn’t provide a future for me to do that. I am worried that, after all my years of clinical training, I will be relegated to a “line-monkey.” And don’t get me wrong, at least in this point of my career, putting in a central line doesn’t sound so bad, and I recognize that it is an important service. But frankly, I don’t see that as a great payoff for 6-7 years of training, even with the salary and vacation.

I want to own my own patients, I want to have my own clinic, and I want to be treated more than just a highly-specialized proceduralist called in by other services to make their headaches go away. 

Ultimately, my question to you is – what would you recommend? Do you think that the future of IR has a place and a structure to allow me to practice medicine the way that I want? I have seen your many posts about the frustrations you’ve experienced with building this type of practice. The draw of Vascular Surgery and Interventional Cardiology is that they feel like a one-stop shop – they don’t have to rely on other services to give them procedures. They run their own clinics, they schedule their own procedures. The downside is that they spend a lot of time doing things that aren’t endovascular surgery. With IR, it seems like, in an ideal world, I could just be an endovascular surgeon. But I’m concerned that the current structure doesn’t allow for that to happen and also doesn’t provide suitable training for IR trainees to longitudinally take care of patients. And I’m concerned that other services will continue to take IR procedures. I got interested in endovascular surgery because I really, really enjoy PAD work – if I do IR, is there a good chance I won’t even be able to practice it? Will I never do an EVAR?

I would love to hear your thoughts, and I also wanted to say that I both enjoy and appreciate the blog posts.

Best,

An interested M3 student

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I singled out this inquiry of all the correspondence I received because this sounds like a far more insightful version of me from over 13 years ago. I chose IR because I believed that minimally invasive techniques are the future, and I loved the breath in terms of patients and disease states that IR engages with. I was turned off by the glorification of the rigorous surgical lifestyle and associated stereotypical narcissistic behavior. IR seemed like a great way to do extraordinary and meaningful work but avoid issues related to surgical specialties.

Fast forward over a decade later, I realized I was incredibly naive and misguided. If I had to do it over again, I would not do IR, knowing what I know now. That’s not to say I don’t enjoy IR or our impact on patients. If that were the case, I would not have invested significant time and money to open my practice. I have learned, though, that what is possible in our field is actively being fought with some of our worst enemies being our colleagues in interventional radiology who in my opinion falsely place diagnostic imaging on a pedestal. A clear pathway does not exist for an individual like this student to prosper in the future without significant effort, time, and monetary investment, and probable heartache, which will likely come at the expense of one’s well-being. 

To this interested medical student, you need to understand that the world of interventional radiology chooses to be associated with radiology. We are simply tied to the hip of radiology. Even in our board certification, an integrated IR residency will ultimately yield you dual certification in both IR and DR. While many view this as a positive, it perpetuates a radiology-centric culture. Ultimately, we are viewed by hospital administrators, insurance companies, politicians, and the lay public as “radiologists.” Pseudo-exclusive contracts are primarily a function of this technicality. I’ve written about this extensively on this blog, and I encourage new and interested readers to digest the following articles carefully:

IR and DR: The Dirty Truth

Defining Our Culture

Interventional Radiology and Diagnostic Radiology: Know The Rules

Steps The SIR Can Take

Pseudoexclusive Radiology Contracts: Our Downfall

Even if one is an enterprising, passionate, and entrepreneurial IR who will go through creating one’s stand-alone practice or building a practice as an employee or contractor within a healthcare system, one will face significant hurdles that other specialties simply do not face. The opportunity cost required to create basic infrastructure to practice longitudinally is enormous. If the thought of doing some diagnostic radiology to make a living isn’t appealing to you, I would run, not walk, away from interventional radiology as fast as humanly possible.

The cruel truth is to excel in the fashion that you describe, being in charge of a patient’s care and managing them over time, requires a commitment to clinical excellence that requires an approach that is functionally no different from a surgical specialist focusing on disease states relevant to their specialty. It requires becoming not just an expert in the angiography suite but an expert in clinical management because, without the clinical management piece, you will never achieve the referrals necessary to support the practice you describe. You will either have to convince a hospital that trash pick-up services are enough to justify your payment, read diagnostic imaging as part of a radiology business model, or participate in some creative and questionably legal scheme to obtain in-house group practice referrals under the guise of collaboration. While many are making a living off of the former, claiming to practice “100% IR,” they will be in a rude awakening when advanced practice providers take over the IR hospitalist line of work because that day is coming faster than you would imagine. Most people work within a radiology context and a growing number of folks are participating in seemingly legal kickback schemes to support a living doing higher end endovascular work. Very few are creating organic practices which I describe on this blog because it’s really challenging.

When you pick a medical specialty, you not only have to pick something you will enjoy doing for decades, but you need to pick a base specialty that you can not only live with but can give you the political power necessary to care for and advocate for patients properly. While radiology is an intellectually stimulating and essential specialty with many knowledgeable and well-intentioned physicians, endovascular medicine is not best served on this team. Your mileage will go much further in a specialty rooted in direct clinical care. Without caring for patients directly and having recognition by the powers to be, government, insurance companies, and healthcare systems, as a distinct medical specialty with experience rooted in clinical conditions and not feats of technical excellence, you are facing an uphill battle with your biggest advocates being this random internet blogger and local physicians not in your specialty who see your value. 

I’ve learned this lesson the hard way, through seven very challenging years trying to create an honest living doing what I love. It has required personal sacrifice that I do not believe is realistic for most folks. Every day I get up and try to build a better future, it feels like an uphill struggle that my colleagues in other specialties simply do not face. My former business partner in my first OBL practice is an interventional cardiologist, and I’m married to a vascular surgeon, so you need to trust that I understand these other specialties better than most. I would not trust anything an academic thought leader has to say to the contrary, as most have never spent a day in their professional life off-salary fighting tooth and nail to make a living. I’d also be very suspicious of radiology private practice folks who feel they have the best of both worlds, but really are ok with the diagnostic portion of their work (or their partners’ work if they are “100% IR”) subsidizing their IR endeavors.

No medical specialty is without its challenges. Medicine is in a rough spot with the near extinction of private practice related to the corporatization and consolidation of healthcare. Most cardiologists and vascular surgeons are now employed by healthcare systems and have their own issues pertaining to reimbursement and turf. The difference between IR and these other specialties is that the other specialties focused on endovascular care have clear clinical roles and responsibilities recognized by many. Their professional societies play a vital role in advocating for their interests and protecting their turf the best they can. See RPVI certification as a means to control vascular imaging and take control of endovascular care. A growing number of surgeons and cardiologists are now taking on embolization work. IR continues to suffer turf, and our leading professional society, which happens to be over $300/year more expensive than either SCAI or SVS, continues to toe this line of pandering to the radiology majority while trying to push forward a more clinically centered agenda half-heartedly. 

Are things changing in IR? Yes, they are, but that change is insanely slow to meaningfully impact your career, and the main issue is that clinically focused medical students are in for a day of reckoning when they realize the marketplace broadly does not support their primary motivations for entering this specialty and probably won’t for decades. That is why I have focused my efforts on Travelier and Physician Staffing Solutions on a national level and my practice, Image Guided Solutions of Missouri, on a local level. No professional society or academic leader will ever change this field. We need folks on the ground working to create marketplace solutions to move this field forward.

If you decide to go into this specialty, just know it is an uphill climb. You will need to work alongside those of us who are serious about change and are not just riding a wave to an academic promotion or private equity buy-out. The opportunity cost is quite significant because diagnostic work is so hot right now and likely will be for some time. The geographic flexibility with IR may not be what you had imagined. To consider this line of work, you need to think and train like a surgeon because, ultimately, superior clinical skills are your leverage in the marketplace. If you want to make over $500k and have 12 weeks off, stop reading this blog and do diagnostic radiology. 

If deciding between interventional cardiology, vascular surgery, and interventional radiology, I would strongly consider an integrated vascular surgery program. I think the future of that field is incredibly bright. The political leaders in vascular surgery know precisely what they are doing to push forward a future of endovascular care and they have for decades. There is a reason open surgical training has taken a backseat with the relatively new integrated training pathway. Without clinically focused interventional radiologists who can compete, they will continue to absorb endovascular market share in all aspects, including in areas once thought to be sacred, like embolization. These guys are eating our lunch with respect to turf, recruitment and diversity of their workforce and ability to organize politically. It’s absolutely embarrassing for us. We ought to be taking some notes, but as long as we continue to pander to organized radiology they’ll keep crushing us for the foreseeable future.

Concerning this idea of being bored by surgery, it’s probably not that different from being bored with diagnostic radiology. Surgery is probably much more fun to do than it is to watch. I remember feeling this way when I was a medical student watching IRs put in chest ports. Seeing the wire on the screen was cool, but seeing them make a port pocket and tunnel a catheter seemed dull and barbaric. I feel very differently about that than I did back when. So please keep an open mind and try to be as hands-on as possible during your surgery rotation. The best thing to do is be ready to anticipate next steps.

Interventional cardiology is also a great field, but it is very cardiology focused of course and the peripheral training isn’t excellent in most places. The training pathway is very long at 7 years. You have to love the heart as an organ, or it isn’t worth it. My former partner did multiple fellowships after the normal 7-year course to obtain peripheral expertise. He does very well for himself, doing largely genicular artery embolization, so I’ll leave it at that.

I hope this provides some clarification and helps guide others. I know I will get negative feedback for this honest take, probably in the form of angry text messages from folks who are afraid to voice their opinions publicly, but somebody has to say it because all the attendings reading this know the truth but are afraid to admit it. If you’re an attending who thinks I am wrong, put your name in the comments section and state your position. I don’t censor comments on this blog and am open to discussion. If anything, it would be great for the students reading this.

For other medical students, please do not contact me for advice unless you are deciding between IR and a surgical specialty. If you are interested in diagnostic radiology, you would be better off focusing on just diagnostic radiology. We don’t need more part-time IRs in this specialty. Most IRs are okay with that part-time life, and there are plenty of folks out there willing to support you if that’s the case. I’m not that guy.

If you are okay with significant uncertainty and the possibility of being more or less forced to do something you may not like in diagnostic radiology to maybe get to somewhere you want to be, buckle up and let me know how I can support you. I don’t think we need 400+ clinically focused IR trainees a year. We need 50 folks willing to crush it. A distinction has to be made between procedural radiology and Image Guided Surgery. The latter isn’t for most, but I think this field can be great for the right person willing to put in the work and take the risk. Unless you are eager to be entrepreneurial and creative, I believe there are better paths out there for clinically minded folks because IR is not quite where it needs to be to safely recommend to most medical students who seem to want some semblance of certainty to make their multi-six figure monetary and decade long time investment in their education seem palatable.