The new interventional radiology (IR) pathways have generated much discussion with articles and editorials pointing out perceived advantages and disadvantages compared to the current pathways. To briefly review, under the new system, there are three pathways to enter IR: the integrated (INT) IR residency, the independent (IND) IR residency, and the early specialization in interventional radiology (ESIR) program. The pathways have been designed to provide maximum flexibility to programs for implementation and to radiology residents for planning their subspecialty training. As a result, there are many potential permutations for these training programs, and understanding the variety of options can be a challenge at first. We offer three potential solutions, based on the different circumstances or requirements a department might face. The first two solutions involve integrated programs created through newly funded and converted diagnostic radiology slots, respectively. The third involves establishing ESIR and IND programs only. Hopefully, the examples provided will be useful for those currently planning for the future of their IR training programs.
In 2012, the American Board of Medical Specialties approved a new certificate in interventional radiology (IR) and diagnostic radiology (DR), recognizing IR as a primary specialty. This action was the result of many years of discussion and consultation, and was felt to be necessary because of the increasing importance and prevalence of nonprocedural care in IR, as well as the increasing complexity of the practice of IR . In response to this approval, the Accreditation Council for Graduate Medical Education (ACGME) approved new pathways for obtaining certification in IR in 2013. These new IR pathways have generated much discussion with articles and editorials pointing out perceived advantages and disadvantages compared to the current pathways. Although these discussions have been beneficial, they are no longer relevant as the decision to move ahead with the pathways has been made. The first class for the integrated IR residency will enter residency training in July 2017 and the traditional 1-year IR fellowships will end on June 30, 2020. Attention should now be focused on implementation strategies.
To briefly review, under the new system, there are three pathways to enter IR. The first is the integrated IR residency (INT). Medical students will apply directly for admission into this pathway consisting of a Post Graduate Year (PGY1) clinical year, followed by 3 years (PGY2–4) of a DR residency and 2 years (PGY5 and 6) of dedicated IR training. The second path to enter IR is the independent IR residency (IND), which is performed after completion of a 4-year DR residency. The IND residency, which comprised training years PGY6 and PGY7, can be performed at the same institution as the DR residency or at a different institution. The third pathway to enter IR is the early specialization in interventional radiology (ESIR) program. In the ESIR program, residents in a 4-year DR program need to complete 12 IR or IR-related training rotations and perform 500 IR procedures during their DR residency, the majority of which will occur in the PGY5 year. The ESIR pathway will allow residents to get credit for the first year of an IND residency, so that they may enter year 2 of an IND program at the same institution as their DR residency or at a different institution.
During a discussion on the new IR pathways at the 2015 Annual Meeting of the Society of Chairs of Academic Radiology Departments (SCARD) and in subsequent conversations among the members of the SCARD Taskforce on the New IR Pathways, several concerns were raised, and these are listed below:
1. The timing of the elimination of the current 1-year IR fellowship may result in a gap in trainees graduating in 2021. Under the current plan, the existing 1-year IR fellowship will end in June 2020, whereas the first INT trainees matching from medical school will not enter their PGY6 year (second year of dedicated IR training) until July 2021. This has led to worries that there will not be enough graduating IRs in 2021 and 2022 to meet practice needs. There is also concern that in the long term, the number of graduating IR trainees will decrease because the new pathways require 2 years of dedicated IR training compared to the current 1-year IR fellowships.
2. There may also be an insufficient number of candidates from DR or ESIR programs to fill positions for the independent residency in 2021 and 2022, when there is unlikely to be a full complement of IR candidates in the integrated pathway. This is because of the lead time necessary for many programs to complete their IR integrated residency applications and to receive accreditation.
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Option One: Creation of an INT Program Through Newly Funded Positions
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Table 1
Creation of an INT Program Through Newly Funded Positions
Year Residents in DR Training Residents in INT training PGY2 6 – PGY3 6 – PGY4 6 – PGY5 4 2 PGY6 – 2
DR, diagnostic radiology; INT, integrated IR; IR, interventional radiology.
The table illustrates a residency program with four DR residents and two INT residents per year. The number of residents in each program is listed by year. In this example, the program gains an additional six DR positions during PG years 2–4 from the additional INT positions.
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Option Two: Creation of an INT Program Through Conversion of Diagnostic Positions
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Table 2
Creation of an INT Program Through Conversion of Diagnostic Positions
Number of Positions DR INT ESIR IND PGY2 8 2 0 0 PGY3 8 2 0 0 PGY4 8 2 0 0 PGY5 4–8 2 0–4 0 PGY6 – 2 – 2
DR, diagnostic radiology; ESIR, early specialization in interventional radiology; IND, independent IR; INT, integrated IR; IR, interventional radiology.
The table illustrates a program that converts two DR positions to INT positions in a residency matriculating ten residents per year. This scenario allows a constant number of IR graduates annually while remaining budget-neutral. To allow residents the greatest flexibility in choosing to enter an IR pathway, the number of DR and ESIR residents in PGY5 can vary from year to year.
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Table 3
Creation of an INT Residency Through Conversion of Diagnostic Positions
2016 2017 2018 2019 2020 2021 2022 PGY2 10 DR 10 DR 8 DR, 2 IR 8 DR, 2 IR 8 DR, 2 IR 8 DR, 2 IR 8 DR, 2 IR PGY3 – 10 DR 10 DR 8 DR, 2 IR 8 DR, 2 IR 8 DR, 2 IR 8 DR, 2 IR PGY4 – – 10 DR 10 DR 8 DR, 2 IR 8 DR, 2 IR 8 DR, 2 IR PGY5 – – – 6–10 DR, 0–4 ESIR 6–10 DR, 0–4 ESIR 4–8 DR, 2 IR, 0–4 ESIR 4–8 DR, 2 IR, 0–4 ESIR PGY6 – – – – 4 IND 4 IND 2 IR, 2 IND
DR, diagnostic radiology; ESIR, early specialization in interventional radiology; IND, independent IR; INT, integrated IR; IR, interventional radiology.
The table illustrates the complement of residents in 2016 through 2022 assuming a program establishes an INT residency and participates in the 2017 National Resident Matching Program (NRMP) match, matriculating its first INT candidates in 2018 and accepts four ESIR residents for the second year of their IND program in 2020 and 2021 to continue to graduate four IR residents annually.
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Option Three: Creation of ESIR and Independent (IND) Programs Only
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Table 4
Creation of IND Residency and an ESIR Program Only
Number of Positions DR ESIR IND PGY2 6 – – PGY3 6 – – PGY4 6 – – PGY5 4–6 0–2 – PGY6 – – 2 PGY7 – – 0–2
DR, diagnostic radiology; ESIR, early specialization in interventional radiology; IND, independent IR; IR, interventional radiology.
The table illustrates a program with six DR positions per year that chooses to train two IND residents annually.
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Summary
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References
1. Kaufman J.A.: The interventional radiology/diagnostic radiology certificate and interventional radiology residency. Radiology 2014; 273: pp. 318-321.
2. Heitkamp D.E., Gunderman R.B.: The interventional radiology/diagnostic radiology certificate: asking the hard questions. Radiology 2014; 273: pp. 322-325.
3. Donating Unfilled Positions from One Program to Another : National Resident Matching Program. Available at: http://www.nrmp.org/wp-content/uploads/2015/08/Reversions-for-Programs.pdf Published September 15, 2015; Accessed March 22, 2016