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  • Look Ahead: Interventional Radiology: Changing How We Educate and Innovate

    Noted expert John A. Kaufman, MD, discusses the transformation underway in interventional radiology, including major changes in education. By John A. Kaufman, MD

    May 1, 2017

    Interventional Radiology (IR) is in the midst of many exciting but fundamental changes. Among these are new training pathways and new approaches to innovation. In some respects, this may be one of the most important periods in IR since the initial foundational decades of the 1970s and 1980s. What happens in the next few years will set the course for IR for the future.

    Education in IR is the most obvious and immediate major ongoing change. For over 20 years, IR education has been moving to increase emphasis on non-procedural patient care, and to increase the duration of training. In 2012, the American Board of Medical Specialties (ABMS) approved the creation of dedicated residencies in IR that would lead to a single certificate from the American Board of Radiology (ABR), the interventional radiology and diagnostic radiology (IR/DR) certificate. In essence, all of the member boards of the ABMS recognized the uniqueness of IR as a combination of imaging competency, procedural competency, and non-procedural patient care. The member boards also recognized the need for dedicated training to achieve these competencies, and that IR was a specialty of the ABR along with DR, radiation oncology, and medical physics.

    Changing Education to Embrace IR

    In 2015, the Accrediting Council of Graduate Medical Education (ACGME) approved the program requirements for residencies that will lead to certification in IR/DR, with a target date of full implementation (i.e., sunsetting of vascular and interventional radiology (VIR) fellowships) by 2020. The essential features of these residencies are that they will reside within departments of radiology, with two basic entry points and multiple opportunities for cross-over into straight DR residencies (and vice-versa).

    One new entry point is the integrated residency, which includes three years of DR and two years of IR, for a total of five years of training after internship. During the DR years, the residents seeking IR/DR certification and those seeking DR certification are in essentially the same program, taking the same required rotations, and taking the same ABR Core Examination. Starting in the R4 year the training begins to diverge, with the R5 year focused solely on IR or IR-related rotations. A key element of the R4 and R5 years will be training in outpatient and inpatient non-procedural patient-care skills. Residents seeking an IR/DR certificate will be interacting with patients more than their DR counterparts outside of the procedural suite, including clinic visits, inpatient rounds, arranging and providing consultations, and determining care plans. However, the common stem of training in DR permits great flexibility so that residents can change programs (internally only) should their interests change, and ensures that residents seeking the IR/DR certificate have DR competency.

    This year, approximately two-thirds of existing VIR fellowships had ICGME-approved integrated residencies with positions in the National Resident Matching Program. Medical students competed for the roughly 120 integrated residency positions with more than four applicants for each spot. Interest in IR at the medical student level appears strong.

    The second major entry point will be the independent residency. These programs are becoming approved now, but will not begin training residents until July of 2020. The independent residency will be open to residents who have successfully completed DR residency and are seeking additional training in IR. DR residents who complete an approved early specialization in IR (ESIR) curriculum during DR residency will need only complete one year of independent IR residency, while others will complete two years. The independent residencies will allow individuals who decide to enter IR after starting or completing DR training a pathway into the specialty. Equally important, the independent residency provides an excellent option for the resident who decides to train in a DR program that does not host an IR residency.

    Final certification in IR/DR will require both a computerized and an oral examination, a distinguishing feature from final certification in DR. Successful candidates will be issued one certificate that includes competency in both interventional and diagnostic radiology. The ABR considers the IR/DR certificate as satisfying the DR certification requirements for all DR subspecialty certificates (such as pediatric radiology and neuroradiology).

    New Approach Needed for Continued Innovation

    Another fundamental change in IR is how innovation in the specialty is occurring. Creativity, improvisation and innovation have long been hallmarks of IR. Innovation in IR was first directed by a lack of basic equipment for invasive diagnostic and interventional procedures, and later by difficult clinical challenges. In most cases, devices and procedures were conceived as replacements for more morbid open surgical procedures. For example, balloon angioplasty as an alternative to surgical bypass, or tumor ablation as an alternative to surgical resection. In almost every instance, IR focused on treating existing or established pathology by providing a structural solution to the problem — opening something that was closed, destroying tissue that was harmful. The result of this approach to innovation has been a diverse portfolio of procedures that have changed the care of entire categories of disease and patients and become a routine part of clinical care.

    This approach to innovation, however, is not sustainable. Devices that have additional capabilities, such as drug-eluting stents that both support the vessel wall and administer a therapeutic agent, are becoming more common. The selection of materials that can be employed for devices is expanding beyond the historically limited choices to a broad range of sophisticated materials that includes biologics, flexible printable sensors and new absorbables. In the future, smart devices that not only alter a structure but also sense physiologic parameters, administer controlled therapies in response to certain triggers, and access remote data collection will allow us to treat established disease more effectively, and perhaps prevent the development of pathology. Drug-eluting stents should only deliver a drug when needed, but allow us to monitor flow without imaging.

    Conception, prototyping, testing, validation and commercialization of these complex new devices and procedures will require a robust multidisciplinary collaborative approach. No individual can master all of the knowledge and skills needed to bring these new devices forward. Careful, thoughtful and purposeful identification of needs — focusing on earlier stages of disease than we currently treat — will be essential. Consideration of all aspects of a device or procedure has to happen at the outset, rather than late or at the end of the innovation process. In order to determine who will use a device and how it will be used, made, imaged, valued and followed, a multi-talented, multi-disciplinary team will be needed. The possibilities are staggering and the implications for IR are enormous in terms of the role of image-guided procedures in clinical care, but how we innovate has to change.

    IR is undergoing a transformation to a more robust specialty. Changes in education will produce individuals with expertise in imaging, image-guided procedures and patient care. A new approach to innovation may allow a shift from interventions that replace other procedures to those that fundamentally alter the course of a disease. The future is never certain, but for IR it will certainly be exciting.

    Dr. Kaufman is director and professor of interventional radiology and holds the Frederick S. Keller Endowed Chair of Interventional Radiology at the Dotter Interventional Institute, Oregon Health & Sciences University, Portland. An active clinician, researcher and educator, Dr. Kaufman has numerous publications and multiple grants. Dr. Kaufman is a past president of the Society of Interventional Radiology. He is a contributor to Radiology.

    Innovative approaches in interventional radiology have changed the care of entire categories of disease and patients and become a routine part of clinical care.