Deciding IR ROL, interested in mix of academics and practice-building as an attending.

[Bildil99]

Hello! I'm really torn between these programs near the top of my ROL. Brown, Northwestern, Emory, Jefferson, and Mayo Rochester. I'm from New Jersey and Jefferson would be closer to home, but I'm wondering if the bigger name of some of the other places has any real advantage. Any advice as to which are better places to train? I'm willing to work as hard as needed to get to my goal!

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[irwarrior]

Which service lines do you feel each provide you that can enable you to go out and build it independently ? ie Neuro, PAD, varicose veins, pain, DVT, PE, fibroids, oncology, BPH , spine etc.

 

[SeisK]

The best programs are probably those with the most diverse procedure list, including a robust outpatient referral, with a good amount of dedicated clinic time. A half a day of clinic a week should be a goal, as the hard part of IR is not the procedure, it’s knowing when not to perform it, and what to do if you’re not performing it. Some academic IR programs let their residents view clinic as an afterthought.

Generally a program that was able to hold onto PAD, or better, aortas is golden. There are several such programs around the country. And they are not necessarily the namebrand ones. A lot of hidden IR gems.

 

[Bildil99]

Which service lines do you feel each provide you that can enable you to go out and build it independently ? ie Neuro, PAD, varicose veins, pain, DVT, PE, fibroids, oncology, BPH , spine etc.

Brown: Lots of neuro, some PAD are their strengths from what I've heard. Comparatively less oncology and portal htn due to transplant volume.
Mayo: All I have to go off of is word of mouth, but it seems they do a bit of everything.
Jefferson: Same as above.
Northwestern: Strong in oncology, venous disease and portal htn. Low PAD unless you manage to get a lot of VA.
Emory: Seems a bit of everything, with relatively low PAD but seems to be growing.

A number of smaller programs I applied at seem to due PAD and even some aorta, but not sure how strong their DR is. Not sure how important this is to consider.

 

[Bildil99]

The best programs are probably those with the most diverse procedure list, including a robust outpatient referral, with a good amount of dedicated clinic time. A half a day of clinic a week should be a goal, as the hard part of IR is not the procedure, it’s knowing when not to perform it, and what to do if you’re not performing it. Some academic IR programs let their residents view clinic as an afterthought.

Generally a program that was able to hold onto PAD, or better, aortas is golden. There are several such programs around the country. And they are not necessarily the namebrand ones. A lot of hidden IR gems.

Some programs have PAD and even aortas, but not sure how their diagnostic training is. Not sure how to prioritize this.

 

[SeisK]

Some programs have PAD and even aortas, but not sure how their diagnostic training is. Not sure how to prioritize this.

The busier your diagnostic call the better. The goal of a DR residency is to be a general radiologist, and general radiology needs to know how to cover CT head to toe, plain films head to toe, and adult ultrasounds. Pretty much any busy ED will get you this. Other “Gen rad” skills that are becoming less common are body and chest MRI (not cardiac), large joint MRI (shoulder, hips, knees), and degenerative spine MRI. Less common because most academic centers will be fellow heavy drinking this up. Experience in this is spottier and is often made up now in early attending years if you’re in private practice.

Though for the most part, these private practices which have broad generalists and practices with high end IR will not overlap.

I also want to flesh out my earlier thought a little: there are two IRs, both pathways valid—the traditional radiology pp IR who covers needed hospital procedures (lines, fluid drainages of all kinds, joint injections, diagnostic fluoro, emergent endovascular stuff) and the image-guided surgeon IR with a clinic. If you want to keep both options open, you want to go to a place that has a lot of the latter-minded IRs. These guys practice build and generate referral patterns from these built practices. The hard part about IR is getting referrals, and to get referrals you have to get your referrers to trust and like you. That’s why the programs that have a lot of clinic time built in are good. You learn how to medically manage your elective referrals, but more importantly, you learn what it takes to get people to trust / like you and refer to you if you ever decide to go out and build yourself. Generally, it’s also the case that places that have a lot of PAD and aortas are good. They were either savvy enough to build up some type of high-fidelity consulting infrastructure to maintain these referrals, or they were able to maintain a positive relationship with their referring physicians, or both.

It’s possible to have ivory tower names with poor clinical build-in, and lower-tier names with phenomenal clinic and referral patterns.

 

[irwarrior]

Agree with the fact that if you want to be able to build your own high end practice and practice 100 pct interventional you should go to a program with robust clinic that get referrals from all over and are aggressive about competing for referrals directly from primary care, ER, hospitals, extenders , wound care, podiatry etc. But, if you are thinking mixed practice and light IR, I would argue better to go DR route and consider MSK, Mammo, body, Peds with opportunity for procedures and a much easier lifestyle.

The average resident from any of the DR or IR programs will do quite well with their DR training. DR training is quite standardized and you are broadly tested. DR may vary in cardiac imaging, Vascular us, ob us . Most will send you to a peds place if they don't do enough .

The most variability in VIR is clinical training , which is a big deterrent from being able to go out on your own and build a practice. Your goal should be to do 50 pad cases , 50 oncology cases (tace/y90/deb), 20 ablations (liver, lung, kidney, bone), 20 spine interventions (kypho/vertebroplasty/spinejack etc); 20 varicose veins; 10 to 20 dvt cases and 10 to 20 pe cases. 10 to 20 fibroids/ 10 to 20 prostate embos / 10 to 20 genicular artery embodies; 20 tips; 10 BRTO/PARTO. The procedures are important but clinic is even more important so you can get an undifferentiated referral and recommend the proper treatment.

 

[SeisK]

Thanks guys! This is very insightful. If a program has lower volumes of PAD/aortas but excellent DR volume/an independent overnight shift (DR)/DR procedures (mammo, body, neuro) + high research output, is this worth the tradeoff? I'm unsure which geography I want to practice after training and would like to keep the options open, I also have family in the West Coast and Florida. Also, any thoughts on Rush and MCW? They seemed to do more arterial work than most.

I don’t want to provide any advice on specific programs. Any program that fits the above criteria is great.

With regards to your first question, the details depend on your preferences. There are no right / wrong answers. Ultimately you have to choose what reflects your values, and accept that your values will change as you get more experience in life.

 

[irwarrior]

If you are interested in potential mixed DR/IR practices than focus on imaging that way you are more marketable to private equity which wants high volume readers who can do light IR, and if you are considering building a 100 pct VIR practice from scratch consider Rush and MCW which will prepare you for that.

 

[NDcienporciento100]

I won’t beat around the bush. Overall Mayo is the best on the list. Overall. Some of the others are better in certain areas but overall Mayo is the best on the list.

 

[irwarrior]

I would ask for case logs and autonomy to determine what the trainees are really doing

 

[NDcienporciento100]

Graduated autonomy and clinical IR are the most important things. After that it’s about the procedure mix. Brown is known for being strong in Neuro, Northwestern for oncology. But they are both weak in other areas. Northwestern does not do PE work or PAD. Cardiologist and Vascular Surgeons are both extremely strong at Brown and own vascular and last I heard they split PE work. Emory is overall strong and is a close second. Mayo has IRs that are leaders in the field of peripheral vascular, liver transplant center so you get plenty of that. If you’re interested in Neuro they will allow you to do a fellowship there in neuro.

 

[SeisK]

I would ask for case logs and autonomy to determine what the trainees are really doing

asking for case logs is a weird ask because many fellows do this last minute before graduating. those that keep up with it for interviews probably don’t have it available to show people in interviews. and many weaker programs won’t want to because then they’ll have to show that half of the 1500 cases fellows graduate with are large volume paras and tube checks.

 

[irwarrior]

You can ask for the case log from those who just graduated from the program director or program coordinator. Most surgical disciplines offer this to their applicants.

 

[irwarrior]

Graduated autonomy and clinical IR are the most important things. After that it’s about the procedure mix. Brown is known for being strong in Neuro, Northwestern for oncology. But they are both weak in other areas. Northwestern does not do PE work or PAD. Cardiologist and Vascular Surgeons are both extremely strong at Brown and own vascular and last I heard they split PE work. Emory is overall strong and is a close second. Mayo has IRs that are leaders in the field of peripheral vascular, liver transplant center so you get plenty of that. If you’re interested in Neuro they will allow you to do a fellowship there in neuro.

Do you know the clinic volumes of these programs?

 

[NDcienporciento100]

Do you know the clinic volumes of these programs?

As you well know the SIR when things were still in the fellowship phase published such data. Now they don’t. Why is that?! So no I don’t have the most recent procedural logs for these places. I like you go off word of mouth and who is there. Frankly there are programs that are historically great programs that if they were to show their procedure logs would be shameful. Times change and there are shifts. Northwestern 10-15 years ago was by far the best program in Chicago and now in my opinion it’s Rush because they a more well rounded IR department. Sure NW may be better in certain areas but not overall.

 

[problematicfavorite]

Fellow IR applicant here who has interviewed at most of those programs as well. To add onto what has already been discussed, Emory has a lot of promise with Dave Prologo as the new division director with his pain and palliation work. Would consider that but also take into account that you'll be worked like a dog at Emory during the DR years just as much as the IR years. Jefferson is IMO what I perceived to be the strongest program on the list in the Northeast, with Brown overtaking Jefferson if you have an interest in NIR (at least if you want to take stroke call). I didn't apply to NW or Mayo so I can't speak to their strengths.

 

[Bildil99]

Thanks all for you advice, after much thought I think I'll rank for what appear to be clinically stronger programs. A few lesser-known small programs on the list seem to offer a lot of clinic time and a broad scope of procedures (including PAD) even if their DR is not well known. Would you recommend ranking a corresponding DR program right behind VIR on the rank list, or ranking my top VIR programs first? For example: IR,IR,IR,DR,DR,DR or IR,DR,IR,DR,IR,DR?

 

[irwarrior]

If you are interested in imaging would rank DR higher, if interested in 100 pct VIR would rank quality VIR higher.