Congratulations to those MS4s who have now completed their Zoom interviews and are on the path to entering the wonderful world of interventional radiology. It’s a great field, certainly not without its challenges as I’ve described on this website. We honestly get to do some amazing work. Our future is bright, but only if you make it that way.
As a departure from my usual rant, I’m going to give you some practical advice when it comes to establishing a Rank List. How you rank programs is very much a personal decision. There are many factors that come into play and it isn’t as simple as 1. MCVI 2. Mt. Sinai 3. Northwestern, or whatever the order of the traditionally elite/top programs are today.
Looking back 11 years in the past when I was in your shoes, I realized how little I knew. And while hindsight is 20/20 and things have changed considerably in IR in the past decade, you first need to give yourself a break and eat some humble pie. You simply don’t know what you don’t know. Here are some great unknowns looking forward:
- Will reimbursements get significantly cut?
- Will IRs finally be viewed as clinical specialists?
- Will we all be employed or will private practice still exist?
- Will we be able to readily obtain hospital privileges?
Everytime I talk about the unknowns with medical students, they kind of look at me funny and are like ok boomer, just tell me what I need to know to get to the next step. One day you’ll look back at this and get it, but until then, I will acquiesce to your fleeting needs. Here’s what’s important, from my viewpoint:
- Seek Excellent Diagnostic Radiology Training
Yes, I sincerely mean that. While your future is IR, your future in IR practicing in the way that the new IR residency promotes may not be certain. At some point, there is a realistic likelihood that you will find yourself needing to do diagnostic radiology to either subsidize your current or future IR practice. If you’re going to learn a skill set, you need to go all in and be great at it so you can leverage your talents to the fullest extent possible. Hear me out, I’m not saying that you spend the rest of your life doing DR. You need a way to make money and if DR can get you on the path necessary to having a fulfilling clinical IR existence in any given market, then by all means take advantage of this commoditized skillset and run with it. It has certainly paid dividends for me.
The most important thing for diagnostic training: independent call. I’m talking about an incredibly uncomfortable, high volume diagnostic call in a trauma center. Get good and get fast at performing diagnostic radiology in the community setting and you will have tremendous job security. It’s harder to get this training these days with overnight attendings, but there are still good opportunities out there. For those of you committing to independent IR training, make sure your diagnostic call is at least as much as your DR counterparts. Ideally, you should probably take more call than them since you’ll have overall less DR exposure (for those of you entering the IR residency). This is a very unpopular opinion, but you need to make the most of the short time you have training in diagnostics.
- Outpatient Clinic Trumps Everything Else In Interventional Radiology
You are more or less entering this grand new experiment for IR where your mentors are being asked to devise some scheme to meet these requirements so you can graduate and their programs can continue to receive funding. A lot of them have no idea what it is to be clinically focused. And really, as easy as it is for me to be critical looking from the outside, I can’t blame them because this is not how they were trained. They are learning to adapt just like you are.
With that being said, a lot of them have no idea what the real world is like. But I do. Here’s the truth: without a robust outpatient clinic, you’re hosed. Those sweet PAD cases? Yea you’re not going to get them without a clinic. Prostate artery embolization? Same. UFE? Same. Gosh, even all those IO cases. You need to see those patients in the clinic. Clinic is where all the magic happens.
So what to look for? Vascular surgery clinic. Vascular Medicine clinic. Urology clinic. Gynecology clinic. Hematology clinic. Oncology clinic. GI clinic. Personally, I feel vascular is the most important because that reflects the largest base of patients in any given setting. You will get plenty of oncology exposure since you’re training in centers that do a disproportionate amount of this work. Gynecology and Urology are also incredibly important.
With respect to inpatient services like ICU, yes having those experiences are important. I still think they take a relative backseat to the clinic because it is an outpatient clinic which will be the primary driver of any given interventional practice.
Longitudinal IR clinic is also key. All in all, if you are spending more time in angio than you are in clinic, then you’re not doing enough clinic.
- Procedural Volume, Breadth and Depth
Make sure you have a great procedural experience. You need to do a ton of bread and butter cases as unappealing as they become in due time. Make sure you have plenty of the other stuff, portal hypertension, IO, PAD etc. Chances are, you’ll get farmed out to vascular at some point for some of the PAD work. Not true for every center, but in many this will be the case. It is what it is. Not the end of the world. Read my post about PAD in academic settings for my take on the matter.
- Culture Matters
I have beef with a couple big name training programs in IRs. I’m not going to name them, but there are two places in particular which are highly sought after, but have a culture which I find not healthy. That culture is “if you’re not doing big cases, you don’t matter.” I will leave it to you to figure out which places these are, but anyone in IR will know exactly what I’m talking about.
Here’s my beef:
- Cases don’t matter. Patients matter.
I think there’s this incredible misconception that training is your time to do incredibly complex cases and get the best procedural training possible. This is true to some extent. You need to develop a baseline competency in performing cases, but the fact of the matter is when you get out in practice, there is a high likelihood that you will be asked to do cases you’ve never done before. There’s an even greater likelihood that you’re not as slick as you think you are and you’ll come to the realization that it takes about 5 years to hit a point of near excellence.
What matters more than doing cases is your ability to take care of patients. Can you develop meaningful relationships with patients? Can you handle the essential non-procedural elements involved in clinical IR practice that truly ads value to your patients and their referring physicians? We have trainees on Twitter making lists of the sweet cases they’ve done in the past week, but what really needs to be asked is how did you generate those referrals? That’s where you really learn. The cases are just icing on the cake.
- You don’t always win.
Everyone struggles. What we do is hard. This needs to be normalized. We need to share our wins and losses. You need to go into training knowing this. I sure hope your mentors acknowledge that sometimes “failure” is ok.
- Perpetuating the pipeline of traditional hospital based practices.
High-powered programs expect their trainees to enter high-powered jobs in either academic or advanced private practice settings. I’m personally of the opinion that our field will be better off in the long run when more talented trainees go out deeper into community settings to build new high-powered programs and practices. This is how we grow our field. Not by finding a “great practice in a great city where I have a 2 year path to partnership and they happen to only recruit from my program.” No offense to those who have taken those opportunities, but we need more entrepreneurs and fewer employees. As IRs, we have to be inherently entrepreneurial to practice clinical IR. Your future opportunity will likely be something you have to create! No level of elite training will prepare you for that.
- Do What Makes You Happy
I had the opportunity to train at an elite diagnostic residency (3 time zones apart from my significant other) and I had an opportunity to train at an excellent but “lower ranked” fellowship while being closer to my family and being able to live with my spouse. Was definitely much happier in fellowship than I was in residency. I do not regret passing up some historically amazing fellowship programs to do this.
Look, medicine is incredibly unforgiving and the truth of the matter is no one cares about you more than you. The moment you understand this and truly internalize it, you will be one step closer to achieving true happiness. At some point the constant hampster wheel of strategizing to get to the next step will come to an end and other things in life will become more important. Perhaps for some of you that moment is now. Roll with it. There is no pot of gold at the end. More money, more problems, more politics, more poop. That’s attending life for you. Find your happiness sooner rather than later.
- This Too Shall Pass
Keeping with my last point, you must realize that in the grand scheme of things where you train is far less important than you think. At the end of the day, no one cares where you trained. Your future employer wants you to be competent. Your patients want you to take care of them. They’re not going to ask for your resume or request to see your 24th Pubmed indexed paper that helped get some academic attending their promotion from assistant to associate professor. If you enter the world of private practice, especially OBL private practice, this matters even less.
What matters more is what you do when you get to training. Are you maximizing the opportunities presented to you? Are you networking with other residents and attendings both inside and outside of your institution? Are you going to conferences? Are you learning about job opportunities? Are you reading about personal finance and business matters? Are you creating a vision for your future beyond the walls of your current academic existence? You create your own future. Your diploma or the number of TIPS you did doesn’t mean anything other than provide an incredibly false sense of security.
So as you create this rank list, keep these thoughts in mind. They are just my opinions, but I suspect if you ask other private practice IRs, you may get similar answers. I still think these thoughts are quite valid for those keen on academic futures. Keep an open mind and wherever the chips may fall, make the most of them. There are many of us here to support you. Don’t hesitate to reach out if you need it.