The Interventional Radiology/Diagnostic Radiology Certificate: Asking the Hard Questions
2014; Radiological Society of North America; Volume: 273; Issue: 2 Linguagem: Inglês
10.1148/radiol.14140002
ISSN1527-1315
AutoresDarel E. Heitkamp, Richard B. Gunderman,
Tópico(s)Radiation Dose and Imaging
ResumoHomeRadiologyVol. 273, No. 2 PreviousNext Reviews and CommentaryFree AccessControversiesThe Interventional Radiology/Diagnostic Radiology Certificate: Asking the Hard QuestionsDarel E. Heitkamp, Richard B. Gunderman Darel E. Heitkamp, Richard B. Gunderman Author AffiliationsFrom the Department of Radiology, Indiana University School of Medicine, 702 N Barnhill Dr, Room 1053, Indianapolis, IN 46202.Address correspondence to R.B.G. (e-mail: [email protected]).Darel E. HeitkampRichard B. Gunderman Published Online:Oct 23 2014https://doi.org/10.1148/radiol.14140002MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In AbstractIn September of 2012, the American Board of Medical Specialties (ABMS) approved a new field of residency training, the interventional radiology (IR) residency (1). The Accreditation Council of Graduate Medical Education (ACGME) added its approval in June of 2013. The result is a new pathway to becoming an interventional radiologist (2).The current paradigm of IR training typically involves 4 years of diagnostic radiology (DR) residency followed by an additional year of IR fellowship. Going forward, institutions will choose between two fundamental training formats, as described in the IR residency program requirements: the integrated format and the independent format. The integrated format describes a 5-year ACGME-accredited DR and IR program that begins with 3 years of dedicated core DR rotations and ends with 2 years of focused IR training. The training elements for the first 3 years are identical to those for a DR residency. The last 2 years must include experiences in the outpatient IR clinic, inpatient clinic and consultative care, and one rotation in critical care medicine or the equivalent. Also, up to four additional DR rotations are allowable as needed to comply with ACGME or DR program requirements, such as final rotations in breast imaging, nuclear medicine, night call, etc. All training in the integrated program is under the direct supervision of the IR residency program director.The independent format describes a 2-year IR residency program that residents will enter only after successful completion of a 4-year DR program accredited by the ACGME or the Royal College of Physicians and Surgeons of Canada. IR residency programs operating under the independent format will not be responsible for providing DR training requirements as outlined by the ACGME. As with the integrated program, the IR residency program director directly oversees all aspects of training in the independent program.The traditional IR fellowship will be phased out over 7–10 years. This key feature was in fact an addendum introduced after the plan’s initial approval by key DR societies, including the Association of Program Directors in Radiology. In effect, IR will become a subspecialty distinct from DR within radiology.The rationales offered for this change in IR training include the following: First, interventionalists regard their skill sets as highly distinctive from DR. Increasingly, IR involves nonimaging patient care, which has not been a traditional focus of DR training. Second, proponents argue that more focused training in IR will offer important benefits to patients. And third, the complexity of some types of cases in IR is increasing, requiring more intensive training to achieve proficiency (3).There are, however, some important caveats about this transition, many of which have not received sufficiently in-depth and comprehensive discussion throughout radiology. This article represents an effort to foster such discussion and to help current and future radiologists, program directors, and other radiology leaders better understand and respond to the challenges that lie ahead along this path. Ending the traditional IR fellowship may offer some advantages, but it is not without risks and costs, and only a thorough understanding of both will enable radiologists to make the best decisions going forward.First, why is the traditional path to becoming an interventionalist being phased out? The most common rationale is that failing to do so would create two classes of interventional radiologists—those who had had, on average, three or four rotations of IR during DR residency plus an additional year-long fellowship versus those who would receive approximately 2 years of IR training in the new IR residency. The ABMS has stated it would not accept two levels of certificates on an indefinite basis, acknowledging that IR cannot move forward simultaneously as both a specialty and a subspecialty. The goal of the ABMS and the ACGME seems to be to ensure that all radiologists who refer to themselves as “interventionalists” will, over time, have all received the same type of training (4).Of course, there are profound ironies here. For one thing, the IR residency will allow more residents to become board certified as fully qualified diagnostic radiologists while having completed less training in DR than residents who do not pursue the dual certification pathway. Among other things, they will receive approximately 1 fewer year of training in DR, and this will, in effect, create two classes of diagnostic radiologists. This is not inconsequential, because many interventionalists devote at least some portion of their practice to general diagnostic work, including on-call responsibilities.A second risk is the fact that most medical students entering DR residencies do not know for sure in which field of radiology they would like to practice. In our experience, the number of medical students who enter residency intending to pursue a career as an interventionalist outstrips the number who ultimately do IR fellowships by a factor of at least 2 to 1. Moreover, some medical students who evince no initial interest in IR discover that they enjoy it and successfully match into IR fellowships.Because IR and DR will be separate residencies, however, residents attempting to switch from one to the other will now be met with the same funding and administrative obstacles that DR program directors have dealt with for years regarding resident transfers from other subspecialties. Although provisions included in the IR residency program requirements allow for DR resident transfers from the same institution at the postgraduate year 3 through postgraduate year 5 levels, the typical rate-limiting factors in trainee movement between specialties are the receiving program’s ACGME accreditation limit and, more importantly, the program’s funded position limit. If an IR residency has met its quota of residents, either by funding or accreditation standards, any further net gain of trainees becomes exceedingly difficult to achieve.Another risk is likely to be a reduced level of dedication to training by residents and faculty outside their chosen field. For example, residents who know they are pursuing an IR residency may be less engaged while on their DR rotations, and the same may go for DR residents training in IR. Moreover, it is quite possible that the quality of training will decline for some residents, with DR residents (who may be seen as second-class citizens in IR) receiving poorer training on IR rotations. This could pose a serious problem in the education of these DR residents, particularly because a substantial percentage of image-guided procedures, such as biopsies and drainages, are likely to continue to be performed by noninterventionalists.A fourth risk will be a decline in the ability of some DR programs to recruit radiology applicants. For some radiology residency programs, the strength of their IR section is an important selling point to medical student applicants during interview season. With the elimination of the conventional IR fellowship, strong IR training programs will cease to play this important recruiting role for DR residencies. The consequences in terms of medical student recruitment could be highly problematic for some DR programs.And what happens when residents who thought as medical students that they were interested in IR decide to change to another field in radiology, such as neuroradiology or breast imaging? In the current structure of IR training this is not a problem because these trainees are recruited to radiology and can easily switch to another subspecialty area of their choice. In the future, however, these IR residents will hurt DR program recruitment up front and potentially cause administrative headaches on the back end.The independent IR residency program, while a viable interventional training pathway for institutions that cannot create or choose not to create an integrated residency, will likely never serve as a recruiting tool for DR residencies. The lure of finishing a year earlier in the integrated program is likely to outweigh the extra DR training that a full DR residency would provide prior to an independent IR residency. Third- and 4th-year medical students, often passive observers of IR who do not fully understand what is involved in the everyday practice of the field, are unfortunately asked to make difficult career decisions at a very early stage, at which overall length of training is likely to be an unduly influential factor.Another risk will be dealing with the jurisdictional frustrations that will arise when two types of residents sharing identical curricula report to different program directors. Among the scores of resident issues that the duplicated program directors, coordinators, and chief residents will need to deal with, most should be tracked and dealt with separately by the respective programs. But because the two residencies will be closely integrated during the 3 core DR years, there are many issues that will need to be scheduled and maintained by one office, such as call trades and the scheduling of vacations, rotations, and daily conferences. Hundreds of resident-related issues arise over the course of an academic year. Constant communication between the two residency programs will be necessary to coordinate which issues are jointly tracked by one office and which are tracked separately by each residency program. While this might seem trivial at this stage in IR residency planning, in practice it may be a constant drain on the time and resources of the graduate medical education support staff.Moreover, IR residency directors will need to assume considerable responsibility for their residents on core DR rotations with which they may be quite unfamiliar. For integrated programs, the ACGME requirements are indeed lengthy and have evolved over many years. In the end, exactly how much responsibility will IR residency directors assume concerning the educational and curricular details related to their residents’ 3 core DR years? How much will end up being absorbed by the DR program director or, possibly, the DR assistant program director who gets assigned to both programs?Another risk will be ensuring that all programs have sufficient resources for adequate education of their trainees. Many programs already have difficulty ensuring that their residents complete sufficient numbers of specific radiology rotations, examinations, and image-guided procedures (5). When IR residents are added to the existing core curriculum, this task will become considerably more difficult, jeopardizing all residents’ resource needs. Both IR and DR residents will be vying for what will be finite resources in many programs: image-guided procedures, cross-sectional imaging examinations such as computed tomography and magnetic resonance imaging, one-on-one teaching time with faculty, and even basic accommodations such as workstations and physical space.Some programs may have ample rotations, faculty, and case workload to easily accommodate the additional IR residents without impacting the education of existing DR residents. Other departments, however, will not be so fortunate. Thus, many program directors—in both IR and DR alike—will need to be vigilant about monitoring the impact of other learners on their residents’ education, as these two groups of residents will be drawing on identical learning resources. Some DR program directors are already discussing the idea of reducing the number of DR residency positions in their own programs to accommodate future IR residents and at the same time avoid the anticipated resource strain in the core rotations. If this occurs in a widespread fashion, it may even eventually reduce the number of faculty members needed in a number of DR fields.Ironically, article III.D. of the ACGME Common Program Requirements states that, “The presence of other learners (including, but not limited to, residents from other specialties, subspeciality fellows, PhD students, and nurse practitioners) in the program must not interfere with the appointed residents’ education” (6). Directors of DR programs certainly might consider IR residents as being high on the list of learners who might potentially “interfere with their appointed residents’ education,” because they rotate on the same core rotations, vie for the same examinations and image-guided procedures, take care of the same patients, and participate in the same resident educational conferences. Some DR program directors may get the feeling that the very IR residents who, in effect, are being recruited away from their programs will be shoehorned back onto their own residents’ core DR rotations and then allowed to compete with them for valuable educational resources. In some cases, DR program directors or their assistants may even be asked to take on additional responsibilities and help guide these IR residents through the core curriculum of integrated programs.Another risk affects faculty members and program directors. If there is a question or problem with a particular resident, which program director should the faculty member contact? What exactly are the curricular differences between the IR and DR residency programs, and how is each evaluating its trainees? In many programs, it is already difficult to get faculty members to understand training and evaluation requirements for just one radiology program. As the number of programs increases arithmetically, some of the costs of coordinating the two may increase geometrically.A special task force recently finished writing the IR residency program requirements. These program requirements were presented to the Diagnostic Radiology Residency Review Committee in early 2014, followed by a 45-day public comment period (7). It is likely that the earliest IR residency programs will seek accreditation in July of 2015, so these changes are just around the corner.In the near term, program directors need to familiarize themselves with both the formal programmatic changes and also potential pitfalls, many of which have not been addressed in writing by the ABMS or ACGME. As radiology proceeds further down this path, it is likely that the separation between IR and DR will continue to increase, perhaps eventuating in increasingly distinctive curricula and independent residency review committees.At some point in the not too distant future, it is conceivable that the IR sections of radiology departments will travel further along the path of separation in training and seek formal separation from radiology as well. The more the message “IR is special” is reinforced, the greater this pressure is likely to become. Such separation might take the form of IR sections affiliating with other departments outside radiology, such as vascular or minimally invasive surgery, or perhaps forming completely new and independent departments. While small, the size of their faculties might approximate those of many independent departments of neurosurgery.While such pressures are low at the moment, it is also conceivable that other radiologic fields would follow suit. For example, breast imaging also differs in important respects from the rest of DR. Its diagnostic field of view is much narrower (cancer or no cancer?), it tends to be procedural, and it too involves a higher degree of direct patient contact and responsibility for patient care than many other radiologic fields. Perhaps breast imagers will soon be arguing that they too should have their own training pathway, devoting less time to low-relevance rotations such as neuroimaging and pediatric imaging and more to breast pathology, surgery, and oncology.In the final analysis, medicine has been on a path of differentiation and specialization for more than a century. Over time, it has split into specialties, and each of these specialties has then split into subspecialties. The ultimate criteria for the degree of differentiation should be the needs of patients for high-quality clinical care today and effective research and education to improve health care for the future. There does come a point, however, at which further differentiation undermines a field’s coherence and begins to generate costs of such high magnitude that they outweigh the benefits. We believe that the IR residency pathway poses substantial risks and costs that deserve wider discussion than they have received to date.References1. ABMS Announces New Dual Primary Certificate in Interventional Radiology and Diagnostic Radiology. ABMS Newsroom, Events, and Resources [Internet]. Chicago, Ill: American Board of Medical Specialties. http://www.abms.org/News_and_Events/Media_Newsroom/Releases/release_ABMSIRDRspecialty_12032012.aspx. Published December 5, 2012. Accessed January 18, 2014. Google Scholar2. Interventional Radiology/Diagnostic Radiology (IR/DR) – Latest Information [Internet]. Tucson, Ariz: American Board of Radiology. http://www.theabr.org/sites/all/themes/abr-media/pdf/ABR-IR-DR-FAQ.pdf. Published July 2013. Accessed January 18, 2014. Google Scholar3. Kaufman JA. IR/DR Dual Certificate Update. Presented at the 61st Annual Meeting of the Association of University Radiologists, Los Angeles, Calif, April 9, 2013. Google Scholar4. What Is the IR/DR Dual Certificate ... and How Does It Affect Me? Residents and Fellows Section [Internet]. Fairfax, Va: Society of Interventional Radiology. http://www.sirweb.org/rfs/interviews-with-IRs.shtml. Published 2013. Accessed January 18, 2014. Google Scholar5. Heitkamp DE, Gunderman RB. Transitioning to a new residency curriculum. Acad Radiol 2012;19(6):759–761. Crossref, Medline, Google Scholar6. ACGME Common Program Requirements [Internet]. Chicago, Ill: Accreditation Council for Graduate Medical Education. http://www.acgme.org/acgmeweb/tabid/429/ProgramandInstitutionalAccreditation/CommonProgramRequirements.aspx. Published July 1, 2007. Revised July 1, 2013. Accessed January 18, 2014. Google Scholar7. Vydareny K. IR-DR Certificate Update. Presented at the 99th Scientific Assembly and Annual Meeting of the Radiological Society of North America, Chicago, Ill, December 4, 2013. Google ScholarArticle HistoryReceived May 15, 2014; final version accepted June 18.Published online: Oct 23 2014Published in print: Nov 2014 FiguresReferencesRelatedDetailsCited ByFellowship Training: Navigating the Decision to Be a Generalist or a Subspecialist—Radiology In TrainingHaidara Almansour, Aileen O’Shea, Ryan W. England, Saif Afat, Konstantin Nikolaou, Ahmed E. Othman, 12 July 2022 | Radiology, Vol. 305, No. 2Abdominal radiology involvement in image-guided procedures: a perspective from the society of abdominal radiology Cross-Sectional Interventional Radiology Emerging Technology CommissionGhanehFananapazir, Meghan G.Lubner, Philip S.Cook, Olga R.Brook2022 | Abdominal Radiology, Vol. 47, No. 8Results of the 2019 Survey of the American Alliance of Academic Chief Residents in RadiologyDavid H.Ballard, DanielleSummers, Mark J.Hoegger, AmberSalter, Jennifer E.Gould2021 | Academic Radiology, Vol. 28, No. 7“What Program Directors Think” V: Results of the 2019 Spring Survey of the Association of Program Directors in Radiology (APDR)AnnaRozenshtein, Brent D.Griffith, Priscilla J.Slanetz, Carolynn M.DeBenedectis, Jennifer E.Gould, Jennifer R.Kohr, Tan-LucienMohammed, Angelisa M.Paladin, Paul J.Rochon, MonicaSheth, Ernest F.Wiggins III, Jonathan O.Swanson2021 | Academic Radiology, Vol. 28, No. 5A Citizen of Two Worlds: The IR/DR ResidencyDarylGoldman, Eric J.Keller2021 | Current Problems in Diagnostic Radiology, Vol. 50, No. 6Use of administrative health databases to estimate incidence and prevalence of acromegaly in Piedmont Region, ItalyM.Caputo, A.Ucciero, C.Mele, L.De Marchi, C.Magnani, T.Cena, P.Marzullo, F.Barone-Adesi, G.Aimaretti2019 | Journal of Endocrinological Investigation, Vol. 42, No. 4Generalist versus Subspecialist Workforce Characteristics of Invasive Procedures Performed by RadiologistsAndrew B. Rosenkrantz, Eric B. Friedberg, J. David Prologo, Catherine Everett, Richard Duszak, Jr, 31 July 2018 | Radiology, Vol. 289, No. 1The Benefits of Maintaining a Diagnostic and Interventional Co-sponsored Radiology Interest GroupMichael V.Friedman, Jennifer E.Gould, Gretchen M.Foltz2018 | Academic Radiology, Vol. 25, No. 2Evaluating current and recent fellows’ perceptions on the interventional radiology residency: Results of a United States surveyJ.C.Hoffmann, A.Singh, D.Szaflarski, J.F.B.Chick, N.Azimov, S.Mittal, J.Flug, P.J.Rochon2018 | Diagnostic and Interventional Imaging, Vol. 99, No. 1The 2017 Integrated IR Residency Match: Results of a National Survey of Applicants and Program DirectorsDaniel M.DePietro, Ryan M.Kiefer, Jonas W.Redmond, Jason C.Hoffmann, Scott O.Trerotola, Gregory J.Nadolski2018 | Journal of Vascular and Interventional Radiology, Vol. 29, No. 1Current Clinical Practice Patterns of Self-Identified Interventional RadiologistsPatriciaBalthazar, C. MatthewHawkins, ArvindVijayasarathi, Thomas W.Loehfelm, RichardDuszak2018 | American Journal of Roentgenology, Vol. 210, No. 3A practical description and student perspective of the integration of radiology into lower limb musculoskeletal anatomyS.Davy, G. W.O’Keeffe, N.Mahony, N.Phelan, D. S.Barry2017 | Irish Journal of Medical Science (1971 -), Vol. 186, No. 2Use of an Electromagnetic Navigation System on a Phantom as a Training Simulator for CT-Guided ProceduresYadielSánchez, Dmitry S.Trifanov, Taj M.Kattapuram, HaiyangTao, Anand M.Prabhakar, Ronald S.Arellano, Raul N.Uppot2017 | Journal of the American College of Radiology, Vol. 14, No. 6The new Interventional Radiology/Diagnostic Radiology dual certificate: “higher standards, better education”LucyDi Marco, Michael BretAnderson2016 | Insights into Imaging, Vol. 7, No. 1The New Interventional Radiology PathwaysMichaelRecht, J. MarkMcKinney, Anthony M.Alleman, Lisa H.Lowe, James B.Spies2016 | Academic Radiology, Vol. 23, No. 7Ready or Not: Are Medical Students Prepared to Decide between Diagnostic Radiology and IR?Jessica K.Stewart, Charles M.Maxfield, Mark L.Lessne2016 | Journal of Vascular and Interventional Radiology, Vol. 27, No. 2Incidence and Prevalence of Acromegaly in the United States: A Claims-Based AnalysisMichael S.Broder, EuniceChang, DashaCherepanov, Maureen P.Neary, William H.Ludlam2016 | Endocrine Practice, Vol. 22, No. 11The Time Is Now: Revisiting the Case for the 3-Year Radiology ResidencyTirath Y.Patel, McKinleyGlover2015 | Journal of the American College of Radiology, Vol. 12, No. 5A Guide to the Interventional Radiology Residency Program RequirementsJeanne M.LaBerge, James C.Anderson2015 | Journal of the American College of Radiology, Vol. 12, No. 8The Interventional Radiology/Diagnostic Radiology Certificate and Interventional Radiology ResidencyJohn A. Kaufman, 23 October 2014 | Radiology, Vol. 273, No. 2Recommended Articles The Importance of Left Atrial Function after Myocardial InfarctionRadiology2020Volume: 296Issue: 2pp. 310-311Myocardial Strain Evaluation with Cardiovascular MRI: Physics, Principles, and Clinical ApplicationsRadioGraphics2022Volume: 42Issue: 4pp. 968-990The Impact of COVID-19 on Radiology TraineesRadiology2020Volume: 296Issue: 2pp. 246-248Fully Automated Myocardial Strain Estimation from Cardiovascular MRI–tagged Images Using a Deep Learning Framework in the UK BiobankRadiology: Cardiothoracic Imaging2020Volume: 2Issue: 1Radiology Department Preparedness for COVID-19: Radiology Scientific Expert Review PanelRadiology2020Volume: 296Issue: 2pp. E106-E112See More RSNA Education Exhibits Feeling the Burn: Occupational Burnout in Interventional RadiologyDigital Posters2020Acquisition Techniques and Applications of Strain Imaging in Cardiac Magnetic Resonance (CMR)Digital Posters2020Principles and Applications of Magnetic Resonance Myocardial Feature TrackingDigital Posters2020 RSNA Case Collection Acute breast hematomaRSNA Case Collection2020Pulmonary Embolism with Right Heart StrainRSNA Case Collection2020Pulmonary embolism with right heart strain RSNA Case Collection2020 Vol. 273, No. 2 Metrics Altmetric Score PDF download
Referência(s)