be encouraged at all points in one’s career.”


Spreading the wealth Dr. Beall’s program presents a model for subspecialization through advanced training that, by virtue of its private- practice basis, does not compromise the training of IR residents. Academic fellowships can be similarly successful when the institution’s procedural scope and volume is enough to support a fellowship without overburdening the resident experience. One such program is the Advanced VIR Fellowship at Rush University Medical Center in Chicago, directed by Kumar Madassery, MD. Rush has robust practices in peripheral arterial disease and interventional oncology, which can benefit fellows.


“When it comes to patient care, primary referrals and being considered a primary treatment modality for patients, one of the main ways I see IR having a seat at the table is by being subspecialized in what we offer,” says Dr. Madassery. “By doing this, we open the door for our trainees to have better job potential as dedicated IRs.”


In addition to time in the angio suite, fellows have dedicated clinic and research time and function as junior faculty, teaching and mentoring residents while gaining exposure to complex vascular and oncologic interventions.


“As long as training programs continue to increase their case volumes, referrals and types of interventions, there can be enough cases to go around,” Dr. Madassery says.


Additional experience rotating in wound care, clinic and other environments like office-based labs and ambulatory surgical centers not routinely part of an academic center’s IR rotations can offer further clinical edification and offload a fellow from the primary services, ensuring adequate resident case exposure.


The value of a well-trained IR Beyond IR, most medical specialties are trending toward minimally invasive techniques. “The continued development of IR physicians with a unique set of skills in a particular organ system or along the lines of a traditional medical specialty will


help to produce physicians with next- level skill,” Dr. Beall says. The unique value of a well-trained IR lies in the uniquely broad approach to diagnosis, assessment and treatment imparted through training in both diagnostic imaging and interventional care.


“Practicing and maintaining general skills have always been a strength of the IR physician,” Dr. Beall says, “but developing subspecialization to whatever degree is necessary to provide the needed care is in our DNA.”


Dr. Madassery similarly advocates for a broad but solid clinical foundation which, in his opinion, is further enhanced by subspecialization. “Beating our chests and preaching how good we are at interventions is great, but it does little for increasing our patient volume and referrals,” he says. “By being more relevant in comprehensive disease management teams we can help focus on curative interventions, rather than often being contacted in a palliative situation.”


Parallels with general surgery The development of IR as a specialty has been compared to general surgery,1


be so overarchingly supervised as to never have to troubleshoot or to make prospective decisions for themselves,” Dr. Beall says.


As IR evolves and its subspecialties mature, competency could potentially decrease as a result of “shunting” procedures from residency to fellowship. The goal must remain for the IR Residency to produce fully functioning clinicians who can handle the general expectations of the communities they serve without requiring further training to become sufficiently competent. The role of IR subspecialty fellowships is likely to expand—but should not compromise—the overarching goal of producing highly competent general IRs capable of independent practice. Private- practice–based fellowships and focused fellowships in high-volume academic practices are potential avenues to push forward innovation and expand access to advanced minimally invasive procedures and comprehensive clinical care without jeopardizing this goal.


which


itself began as a solely technical trade and only later evolved to encompass clinical care, ultimately leading to modern surgical practice. The analogous thrust toward more comprehensive clinical care in IR has been prevalent in recent years, and the evolution of general surgery toward a more subspecialized field also merits consideration.


As surgical practice has advanced, truly “general” surgeons have become less common in many areas. A graduating general surgery resident might not, for example, be comfortable performing colorectal surgery without experience from a dedicated fellowship, whereas such a practice used to be fully within the domain of the general surgeon. Similarly, shifts in training paradigms have impacted trainee autonomy, raising concerns regarding the readiness of graduating surgery residents for independent practice.2


of course not limited to general surgery.


“One trend that must be avoided is that, with increasing supervisory responsibility, the trainee becomes sidelined only to observe the attending at work, or to


No better time than now Regardless of the shape that future IR subspecialization takes, the field will doubtlessly continue its trend of innovation and change. There is tremendous potential for IRs to mold the future of minimally invasive medicine through training the next generation and actively participating in the advancement of the specialty. “We are at the top of a logarithmic curve of the expansion of great minimally invasive techniques that can produce maximally beneficial outcomes,” says Dr. Beall. “There has never been a better time to be doing what we are than right now.”


References


1. Soares GM, Murphy TP. Clinical interventional radiology: Parallels with the evolution of general surgery. Semin Intervent Radiol. 2005 Mar;22(1):10-4.


Such concerns are


2. George BC, Bohnen JD, Williams RG, Meyerson SL, Schuller MC, Clark MJ, Meier AH, Torbeck L, Mandell SP, Mullen JT, Smink DS, Scully RE, Chipman JG, Auyang ED, Terhune KP, Wise PE, Choi JN, Foley EF, Dimick JB, Choti MA, Soper NJ, Lillemoe KD, Zwischenberger JB, Dunnington GL, DaRosa DA, Fryer JP; Procedural Learning and Safety Collaborative (PLSC). Readiness of US General Surgery residents for independent practice. Ann Surg. 2017 Oct;266(4):582-594.


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