How To Rank an IR Program

The first quarter of 2024 has been busy as I’ve been very active clinically.  All good things come to an end, and starting in March I’ll be pivoting away from “locums” to several new projects, including Travelier (www.travelierir.com), which we have discussed previously on a BackTable Podcast, and two other projects to which I will dedicate a blog post in the upcoming weeks. Of course, topics that have been met with lots of fanfare, particularly the discussion of IR and DR splitting, have continued to gain steam into the new year with invitations to speak at the California Radiological Society two weeks ago and an upcoming talk at Western Interventional Next Generations Symposium (WINGS) in Southern California on March 2nd. These conversations will carry into SIR 2024 where I will dive deep into the world of “locums” and into OEIS in April. 

The discussion of independent IR and its relevance to the next generation has also been a hot topic, with multiple medical students and residents reaching out for advice. We had an excellent panel discussion regarding this topic at the virtual West Coast Vascular and Interventional Symposium last week. As challenging as things are for a specialty in transition, seeing so much engagement among trainees is encouraging. 

Keeping with the theme of trainees, part of my goal in doing my small part to push for the evolution of our specialty is to support the next generation. Previously, I wrote about how to find a good training program. While that advice still holds today, I have recently been asked to review some rank lists, so I’d dedicate a post to a timely topic and discuss some of the factors one should consider when making a final list. 

Is IR Independence Your End Goal?

Independence is often conflated with “private practice” or “OBLs,” but independence means practicing in a manner that is not dependent on diagnostic radiology. Independent IR practice is akin to 100% IR practice but takes it further by acknowledging that it is impossible without engaging in longitudinal clinical care. It’s a mission that the most passionate IRs, regardless of employment structure or location, should agree upon. It is the future of endovascular and image-guided surgery, a stand-alone medical specialty that deserves unique consideration among the American Board of Medical Specialties.

Independence matters because, as currently structured, most interventional radiologists scratch the surface of their potential impact by practicing predominantly within hospital-based settings and engaging in episodic care. Our most significant impact from a societal standpoint will only happen when we are free to structure our practices no differently than surgeons or medical subspecialists.

You need to assess what led you down the IR rabbit hole carefully. It comes down to this significant question:

 Are you a future procedural radiologist or image-guided surgeon?

There are two main phenotypes of “interventional radiologists” in practice—those who identify as radiologists and those who identify as surgeons. You must carefully assess which one you think you are because doing so will significantly affect your list.

My blog is biased towards helping surgically minded people interested in practicing IR in a longitudinal clinical fashion. Despite whatever noise I make via blog posts, podium talks, or podcasts, we still live in a world where interventional radiologists are viewed as radiologists who do procedures. We also live in a world where many students become attracted to IR through exposure to radiology departments.

If you’re the type of person, who is interested in diagnostic imaging and wants to perhaps take it a step further by doing procedures but may not necessarily be interested in some of the hard work you might remember from a surgery or medicine rotation, then admit to yourself that this is who you are and take solace in the fact that where you train, from an interventional standpoint, will not matter a whole lot. You are statistically destined to interpret imaging and collect trash. The good news is the road from the schoolyard to the dumpster truck is well-marked, and it’s not hard to get lost.

On the other hand, if you’re a future image-guided surgeon, your road is bumpy and laden with landmines. Your criteria for survival will look very different from your fellow classmates who chose the conventional path. Despite the challenges, you still have tremendous upside in having a fulfilling career. Reaching that potential is undoubtedly easier in surgical specialties, but if you cannot resist the magic of being able to operate on multiple organ systems in a minimally invasive fashion, then buckle up.

Knowing which type of path you are on will make this rank process very easy for you. First, consider some personal factors before moving on to more extensive details.

Personal Factors

1. Location, Location, Location.

No amount of good training or misperceptions of future opportunities is worth unhappiness being somewhere you don’t want to be. 

2. Financial Considerations

I don’t think financial factors should play as significant of a role in your decision-making unless you have a family to support on your resident salary. As someone who did not have a family to support while living in the highest cost of living market for 4 years as a trainee, the increased wage and moonlighting opportunities helped put me on a solid financial trajectory moving into attending-hood. I can’t say the same for co-residents with multiple hungry mouths to feed who may have benefited from a more cost-friendly environment.

Clinical Training

Most integrated training programs do a poor job regarding clinical training. Good clinical training will include longitudinal IR clinic with clinic time, even on diagnostic rotations. Too many IR trainees step into the dark room that is DR for 36 months and forget that they signed up for IR once they emerge from their caves. A handful of former mentees of mine have reversed course and are now happy as diagnostic radiologists.

The best clinical training programs will have longitudinal clinics and the opportunity to rotate through multiple services meaningfully. Going up to the ICU to be “the IR resident” on the ICU rotation, where you chime in on non-specific opacities, then retreating to IR for an afternoon of trash, is not a good use of your time. Being the senior resident on service and managing multiple patients the same way a medical resident of the ICU fellow would is a good use of your time. Spending significant time on off-service rotations being integrated into clinical operations is critical. Remember, most non-interventionalists still view IR as akin to “special procedures” where your expertise is imaging with the ability to put needles in random locations. They need to be reminded by the new generation that image-guided surgery is a new breed that practices medicine comprehensively. Most IR attendings will not pattern that behavior for you because most were indoctrinated in old-school training paradigms, so you’ll have to model that behavior for your peers.  

Ultimately, clinical training is crucial to future success as an independent IR.  Most of you will not have excellent clinical training because your future attendings don’t know how to structure their programs, or if they do, they will run into all sorts of political roadblocks from diagnostic radiologists. You must ask for certain things like clinic time and specific rotations.

How do you know if a program has good clinical training? Here are a few questions you should consider to make this assessment:

1. Do IR faculty compete for arterial work?

If there is no peripheral arterial or aortic work in an interventional radiology department, the longitudinal clinical training in that department could be better. Having trained in departments like that, I know I have former faculty reading this thinking I’m some ungrateful jerk. Still, I’d encourage them to look hard in the mirror and ask why they let that work go or perpetuate a culture where competition is not valued. Many dinosaurs have retired, and we have a new generation of young faculty interested in returning some of that work to a department. If a division chief has hired young faculty and supported them in building these areas, that is a good sign and suggests the stock will soon likely trade higher than it presently does.

2. What is IR Clinic?

You want to take the clinic and put it under a microscope. Many IRs, both in the private world and in academics, who claim they run a clinical service have IR clinics that are primarily pre and post-op clinics. You must carefully assess where referrals are coming from and what kind of legwork is done to evaluate patients. A clinic full of interventional oncology consults from tumor board decisions is hardly a clinic. Referrals for conditions like liver masses, back pain, and leg pain provide an opportunity to be a doctor; that type of training is invaluable since that is what the real world will look like as an image-guided surgeon. Some may argue with this point, claiming that I am against multi-disciplinary care by dismissing referrals from other subspecialists. I have written previously about the misconceptions regarding multidisciplinary care. At the end of the day, collaboration is great as long as IRs are on the same clinical playing field as our surgical and medical counterparts. Most are not. Every outpatient procedure should be done with a comprehensive clinic visit.

3. What Are Faculty Attitudes Towards Non-Procedural Work?

For surgeons, one’s ability to operate is simply the reward for the challenging non-procedural work it took to get that one patient to the OR. The culture of IR should be no different. You need to assess carefully how faculty and current residents perceive non-procedural work. While many surgeons don’t like rounding or going to the clinic, they understand it is necessary. It is simply the gas for their car. If IR faculty and residents don’t have the same attitude, then that department has not progressed to the 21^st century.

Understanding the Problem

When you look at the above considerations, it’s easy to become discouraged because one realizes that very few programs would meet the needs of the future endovascular and image-guided surgeon. There are probably less than 5 of these programs nationally. And it’s not like attending one of these programs will automatically translate into a meaningful job opportunity because the future I talk about does not exist in most communities. Many graduates from even the most progressive programs end up in situations that might seem less than ideal.  

The truth is that endovascular and image-guided surgery is not for everyone. The ideal person who would want to go down this magical path is one who was likely not really all that interested in radiology, to begin with. Some people may not know exactly what they are or aren’t interested in, despite having done many rotations. You may be a late bloomer to this concept of image-guided surgery. I certainly was one, and that’s ok. Just know that training in a traditional radiology-focused program, be it the integrated pathway or one of the alternative pathways that lead to combined IR/DR certification, is not necessarily a death sentence to practicing surgically. If that were the case, most people would be doomed. What instead will end up happening is that you will have to make significant strides in your life as an attending to learn essential clinical skills. Just know that it is slow and requires sacrifices that are probably not in your best financial interest, as the opportunity cost of practicing radiology is quite significant. Comprehensive disease state management is still something I struggle with despite being six years removed from training.

Think Beyond the Next Step

There is a lot of anxiety around seemingly life-altering decisions like rank list submissions. I see medical students getting so caught up in over-analyzing and over-emphasizing specific questions like:

·  Does where I train impact where I will get a job?

·  Do high-end IR jobs only go to graduates of high-end programs?

·  If I can’t get into a top integrated IR program, should I rank a higher-ranked DR program with plans for ESIR over an integrated program that isn’t as reputable?

·  Will the quality of my DR training impact my future IR practice?

Ultimately, none of these decisions will matter. You will get out of training what you put into it, regardless of that program’s reputation. Let’s dissect some of these questions.

Does where I train impact where I will get a job?

Not really. Yes, your attendings in a particular geographical location will tend to have stronger connections with colleagues in area practices than in other parts of the country, but counter this point with the simple fact that most new graduates eventually leave their first job. Also, couple this fact with the point that there are very few jobs out there that one would consider a job fit for an endovascular and image-guided surgeon. 

Do high-end IR jobs only go to graduates of high-end programs?

Not really. What is a high-end job to begin with? There are specific jobs that social media and the IR community will label as “high-end,” but when you dissect these practices carefully, you will realize that many of these jobs are fancy radiology jobs that benefit from long-standing relationships with large hospitals prone to all sorts of interesting pathology. This will result in some fantastic Twitter cases, but the outpatient portion of said practice may not be as impressive as it seems. Furthermore, many of these jobs have been controlled by private equity and now pay a fraction of what they used to.

Or how about that magical OBL job that promises you a market wage to do nothing but high-end embolizations? When you realize that the job was likely created by an IR Opportunist skilled at selling a pitch to a bunch of private equity-owned surgical groups to place a monkey to crank out cases in some closet you quickly realize that what would have otherwise been a LineMonkey for a radiology group has become an EmboMonkey for a surgical practice which is paying exorbitant management fees to an IR skilled at pimping out the next generation of talent to the highest bidder.

A distinction has to be made between simply doing high-end cases that don’t require much work to generate and creating a practice that requires time and dedication to primary disease state management. The latter is difficult to achieve and requires taking somewhat of a financial hit upfront relative to market wages for traditional IR/DR jobs or corporate OBL jobs. The pill may be so tough to swallow that even some of the best graduates suited for this work may opt for a market alternative. Trust me, there are plenty of trash collectors of varying academic pedigree.

Should I rank a higher-ranked DR program with plans for ESIR over an integrated program that isn’t as reputable?

If your goal is to practice endovascular and image-guided surgery, then no, do not rank that DR program higher. It serves you no purpose unless you are using it as a back door into an IR division that is quite reputable. Even then, you still need to ask the hard questions about clinical integration over the span of DR training and what opportunities you’ll have access to not being part of their integrated program. Go with the training route that affords you the best clinical training.

Will the quality of my DR training impact my future IR practice?

This response will surely upset many, but the answer is no. Imaging is an important tool to do our jobs, but it’s just one of several. Outside of biopsies, lines, and drains, no one refers patients to you just for your imaging interpretation prowess. Referring offices only care about your ability to solve that patient’s problem. Imaging is a big part of that, but it isn’t the only part. The ability to interpret plain films, ultrasounds, and specific advanced imaging like MRIs relevant to organ systems of interest and body CT becomes very helpful for what we do, but going to a world-renowned residency in imaging isn’t going to afford you magical skills that a community trained resident won’t have when it comes to developing comprehensive proficiency in the procedural and non-procedural care of patients we can treat as endovascular and image-guided surgeons. Going to a superb DR program will help you become an excellent diagnostic radiologist, but is that your goal?

Final Thoughts

I am not an authority on this subject, but I have the benefit of hindsight, being someone likely not meant to be a radiologist trying to make a living with a radiology board certification. Please take any advice as one data point and form your own opinions. You will hear advice opposite to what I say, but you must keep the context in mind. What is the end goal? The conventional path of getting excellent training and a job will require conventional decisions. My experience and perspective are anything but conventional.  If you want to be different and forge a new path forward, you need to talk to people several steps ahead of you. I hope this post gives you an alternative perspective to help you make the best decision.