4th Year General Surgeon Path To Interventional Radiology

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SS 158: 4th Year General Surgeon Path To Interventional Radiology

Session 158

Dr. Deepak Sudheendra, also known as Dr. Sudi talks about his journey of switching from a 4th-year general surgery residency into an interventional radiology program. Dr. Sudi is a vascular and interventional radiologist and surgical critical care specialist.

Today, we talk about why he went down that path. We also go into a conversation about changing residences and a little known secret that he confirmed with me today. If you are interested in vascular and interventional radiology, check out the Society of Interventional Radiology.

For more podcast resources to help you along your journey to medical school and beyond, check out Meded Media.

Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:34] Interest in Interventional Radiology

Dr. Sudi just started his fourth year of general surgery residency as a categorical general surgery resident in Washington, D.C. at a major trauma center, which is part of Georgetown University. He initially wanted to do cardiothoracic surgery, wanting to follow the footsteps of his father being a cardiothoracic surgeon.

But as he was starting his fourth year, he started to see advancements in medicine, especially in cardiothoracic surgery and interventional cardiology. He saw that many patients were going for open-heart surgery but having an invasive procedure done.

His father was near towards the end of his cardiac surgery career and seeing him having some doubts, he advised him to look at what’s going to be big in his lifetime of medicine. And minimally invasive is where it’s at – whether it’s interventional cardiology, interventional radiology, or something endovascular

'Open surgery will always be needed. But the future is minimally invasive.'Click To Tweet

At that point, Dr. Sudi made the decision to leave general surgery. The entire hospital couldn’t believe he was leaving because he was going to be chief resident in a year. But he chose interventional radiology.

He was told that none of his four years of general surgery counted so he would have to start all over and be a medicine intern. But one of his friends who’s an interventional radiology attending physician told him about an accelerated pathway for surgeons to do IR. And so, that’s how he got into IR.

[05:31] Switching Specialties: What’s the Little Secret?

Dr. Sudi learned so much about the system and he doesn’t think we do a good job of educating medical students about picking a specialty. He admits that switching specialties was the hardest decision had to make. He loved being in the operating room. And being exposed to almost every specialty of medicine, he never thought he’d ever want to switch.

“Medicare pays for you to train for a certain number of years.” Click To Tweet

And he felt he was losing part of his identity by not being a surgeon. He also found it was very difficult to switch because part of him had this surgeon’s ego being a fourth-year surgery resident. So he thought switching into IR will be very easy to do.

At that time, in 2005, there were about 128 radiology programs in the country. Dr. Sudi applied to all 128.

And out of those 128 programs, he only got one interview, which was a courtesy interview from his, rather, our alma mater, New York Medical College.

Dr. Rachlin, the associate dean for Student Medical Affairs, was upfront with him to tell him that she didn’t think Dr. Sudi would get to radiology, or to any field of medicine for that matter. And she told him this little secret that not everybody knows: Medicare pays for you to train for a certain number of years.

“Medicare pays for you to train for a certain number of years.” Click To Tweet

Since Dr. Sudi has already effectively used up four years of Graduate Medical Education (GME) funding and with hospitals hurting for money, a fresh medical student has a better chance of getting a spot in any field over him. So he was advised to look at things outside of medicine since she didn’t see him practicing as a physician.

“If someone feels that they've chosen the wrong specialty, and it does happen, leave early.” Click To Tweet

Dr. Sudi recommends to students that if you think you’ve chosen the wrong specialty, then you have to leave early. There will be certainly times, or sometimes an entire year of a residency, where someone may not enjoy what they’re going through. In that case, talk to your attendings or counselors or friends and family. But that’s very different from saying you made a mistake and you do not want to do this specialty and you want to switch into something else.

[10:27] Leveraging Connections and Creating Opportunities

For Dr. Sudi, connections helped a lot as well as being very nice to people. He went to Johns Hopkins in Baltimore to get a research position but they didn’t have any. Then he went to NIH and spoke with their chief of IR.

At this time, he was three weeks from leaving his residency. He was in the ER and the ER physician called him to the emergency room to see a patient. And when asked if he was leaving the residency and what his plans were, Dr. Sudi told her he wanted to go into IR. And that he wasn’t sure what’s going to happen as he was looking for research positions. Then he told her about the NIH interview and when he mentioned who interviewed him, lo and behold, it was her busband! She actually went by her maiden name at work.

That evening, Dr. Sudi got a call from the interviewer and he told him they were going to find funding for him to come on board.

Dr. Sudi spent a year there doing the radiology application process. As abovementioned, there’s an accelerator program called the direct pathway for surgeons to go into IR. He would basically do two years of surgery an and two years of radiology and two years of IR. Then get boarded in radiology, diagnostic radiology, and IR. So he thought he’d do the program and there were only three program in the country. He interviewed at just one of them and they took their own surgery person.

His father who has always been his guiding force has always been aggressive and asked why the program started. He answered it got started due to the shortage of IR throughout the country. They wanted to attract more of a surgical mindset to the field as they were doing more and more complex cases. So his father encouraged him to look for opportunities if nothing is presented to him.

'If life doesn't present you with an opportunity, you have to create the opportunity yourself.'Click To Tweet

So Dr. Sudi wrote a letter to all 128 radiology programs in the country. He told them about the ACGME-approved direct pathway program and asked them if anyone would consider starting it and taking him as their first fellow. Nobody responded.

Several weeks went by, and he decided to send it again. This time, he sent it using his NIH account instead of his Gmail account. As a result, 30 institutions wrote back to him.

The University of Pittsburgh Medical Center wrote back and invited him so he could talk more about it. And so he went and gave them a little PowerPoint presentation on what the program was all about and how it will be funded by the ACGME.

Finally, Dr. Sudi matched at the institution. But a month before he was about to start the program, the director called up to tell him they’re closing their IR fellowship. So they won’t be able to offer him the accelerated direct pathway program.

But the match was a legally binding contract. So he was welcome to do four years of diagnostic radiology and then go elsewhere and do one year of interventional radiology fellowship. With his GME funding problem, he decided to take it. He did four years at University of Pittsburgh, and then came back to DC for his fellowship.

[17:07] The Biggest Myths or Misconceptions Around Interventional Radiology

The biggest myth is that they are just procedural and they know very little about medicine.

Dr. Sudi agrees with how people think that they’re like a car mechanic that does a procedure and doesn’t really follow up. But people have to understand how interventional radiology started. It was purely a diagnostic field. It was called diagnostic angiography or special procedures.

When it first began, they cannot treat anything in IR. They were the people who told the surgeons where the problem was but they can’t really do anything. But as surgery advanced, IR also advanced.

'IR developed as being the specialty that got the surgeons out of trouble.' Click To Tweet

When someone has a problem, they come to them. It’s not just surgery, but all fields now. They have to think outside of the box and be the doctor’s doctor in some ways. The advancement in IR has led to them to now seeing patients and setting up offices, just like any other specialty. It’s not 100% widespread but it is the future of the specialty.

A lot of specialists don’t know that IR specialists treat other conditions and that they’re not just the pickline service. 

Generally, IR does not do critical care medicine. But when he was doing his surgical residency, the surgical residents got an inordinate amount of training in surgical critical care. And when he left surgery, he didn’t want to lose his clinical skills during his four years of diagnostic radiology.

So he moonlighted six nights a week at two local hospitals as a surgical critical care moonlighter for cardiac surgery. Then he was hired as an attending for weekends. When he was in his third year of radiology residency while he was not operating, he was still doing a lot of bedside procedures and managing critically ill patients.

[20:49] Traits that Lead to Being a Good IR Doctor

Specific to IR, you have to know how to think outside the box. A lot of the things they do are trying to clear up problems many other specialties have not been able to fix. It’s common for other specialties to come to them and ask if there’s something else they could come up with.

'There's a lot of ingenuity and that's what has kept IR as a very progressive field.'Click To Tweet

Dr. Sudi always says that they are the most technologically advanced field in medicine. You have to enjoy coming up with new solutions to old problems. 

Patience is another critical thing to have. There’s a different mindset between a diagnostic radiologist and the interventional radiologist. As an interventional radiologist, you have to have a more surgical mindset than a diagnostic radiologist. 

[22:59] Types of Issues They’re Dealing With

Dr. Sudi describes their institution at University of Pennsylvania as having a very robust practice.

They do a lot of inpatient procedures. Most students would call them if they see on their rotations some vascular access, access drainage, feeding tubes, and nephrostomy tubes. Those are the things that help make a hospital run. You need someone to do those procedures and they do them in the morning. Basically, the patients will have to go to the operating room for GI bleeds, trauma, or embolizations. And then there’s also the whole outpatient world.

'One of the biggest things in interventional radiology right now is oncology.'Click To Tweet

Oncology is big. They have interventional oncology that treats liver tumors, hepatocellular carcinoma, metastatic cancer to the liver, lung cancer, etc. And they treat these with procedures known as ablation where they take a needle and they burn the tumor. They also do embolization or chemoembolization where they inject chemotherapy or radiation beads directly into tumors through the arteries.

They also take care of women’s health. Uterine fibroid embolization is very popular, and it really helps save a woman from having her uterus removed.

Peripheral vascular disease is an area where different specialties overlap such as vascular surgery and cardiology. But the procedure of angioplasty was actually invented by interventional radiology. And so, peripheral vascular neuro IR stroke comes within their realm as well as pulmonary embolism thrombolysis.

So they basically do a variety of procedures. Dr. Sudi’s area specifically is treating deep vein thrombosis and venous disease, and he has about a one-year waitlist of patients.

He sees about 25 patients a week in the office. They will ask how the procedure is done. And he explains to them how everything is done without making any incisions and only with just two or three little IV punctures.

[26:44] Typical Day

The days in an academic center are very different from days in private practice. Dr. Sudi’s practice is 100% IR so he doesn’t do any diagnostic radiology other than reading some vascular studies.

That being said, he does cases all day. He is generally at the hospital between 6am and 6:30am and their day starts at 7am. They will usually have a conference and then the cases start at 8am until 6pm. They’re doing cases, which are a mixture of inpatient and private. Dr. Sudi does cases four days a week.

Thursdays would be his clinic days where he sees around 25 patients in the office. These are new patients as well as patients that have done procedures and they’re coming in for follow-up. So they also have that long-term care of patients.

[28:19] The Training Pathway

Today, IR has become its own specialty. This means that you have to match from medical school. It’s called DR/IR (diagnostic radiology/interventional radiology) pathway. During your diagnostic radiology years, you will do several months of interventional radiology, as well as things such as critical care, oncology, transplant, etc.

The IR residency person is doing more clinical rotations in addition to their diagnostic radiology rotations. So it goes to show how the specialty is so competitive as it’s its own beast now.

To be a competitive applicant for this specialty, Dr. Sudi first advises to figure out whether you want to do procedures or not. And once you decide to do a procedural field, whether it’s surgical or IR, then check out all the different procedural fields to see what’s involved.

'Check out all the different procedural fields to see what's involved because we all make assumptions until you've done a rotation.'Click To Tweet

That being said, you can’t do a rotation in every single field of medicine. But you can just shadow. Even if you just spend one or two days with someone in IR, it can give you a flavor to consider doing an elective.

[32:06] Message to Osteopathic Medical Students

Dr. Sudi thinks that the bias against DO students is now more and more by the wayside. He has worked with some wonderful osteopathic physicians and they have osteopathic fellows in our program.

The main thing is that they want to see if you are aggressive, intelligent, hardworking, and resourceful – whether you’re a DO or and MD. And there may be certain parts of the country where it may be different but that generally hasn’t been a problem for them.

[33:03] Message to the Future Primary Care Doctors

Primary care physicians used to round in the hospital. And it was an opportunity for not only primary care specialties, but the specialists for everyone to co-mingle and interact whether at the cafeteria, the lounge, or whatever. And now, you don’t see that anymore. Everyone’s in their silos.

'The primary care specialists don't know how much IR has evolved over the past 20 years and what we are capable of doing.'Click To Tweet

So Dr. Sudi would wish for primary care physicians to reach out to two interventional radiologists. If they have patients where they’re not sure of what can be done, they can just call the local hospital to reach out to the interventional radiologist. And because IR specialist are interacting with so many other specialties, even if they can’t help, most of the time, they will know who can help them.

Secondly, Dr. Sudi believes IR needs to do a better job of trying to educate physicians and other disciplines as to what they do. Dr. Sudi is the director of the medical student elective at the University of Pennsylvania. And one of the things he tells students who are not interested in it is to do their elective. And he tells them that the goal over the time they’re there is not to learn the technical aspect, but learn what it is that they do.

'You can only treat what your mind knows. And you can only refer to a specialist if your mind has that knowledge.'Click To Tweet

If you’re an internist and you are seeing a patient with severe post thrombotic syndrome, after extensive deep vein thrombosis (DVT) and they are debilitated, they can barely walk. And say, you have now scrubbed with Dr. Sudi as a medical student, and you’ve seen what things he can do to fix that. Then now you know that IR may be able to treat someone with a chronic DVT and you’re going to refer your patient today. Hence, you’re providing better care for your patient.

[36:16] The Most and Least Liked Things

Dr. Sudi has now been practicing since 2011 and not a day goes by but he’s still amazed at what they can do without incisions. When he was doing surgery, he was doing a lot of laparoscopic surgery and he’d be amazed at what they did.

Now, they can do amazing things inside a patient’s body without an incision. That’s not only amazing, but it just shows how much medicine is advancing and continuing to advance.

On the flip side, what he likes the least is wearing 20 pounds of lead constantly. There’s radiation exposure, although he’s very good with all the shielding and everything.

But one thing that really bothers him is that there are so many patients that can benefit from their specialty but the medical community doesn’t even know what they do. And because they don’t know that, they won’t refer the patient and they will just tell them nothing can be done. And that’s not true.

'As a society, we need to do a much better job of reaching out to the medical community and educating so we can better serve the patients.'Click To Tweet

That being said, Dr. Sudi prides on the collaboration they have with a lot of specialties. At UPenn, they have a very good working relationship with their surgeons in a very collaborative environment. Coming together in that collaboration is really nice because you learn a lot from the other specialists as well.

[39:59] Final Words of Wisdom

For anyone considering a field in surgery or any procedural field, Dr. Sudi recommends checking out interventional radiology in your institution.

If your institution doesn’t have a robust radiology program, consider going elsewhere for additional elective to learn more about it because that’s really the future of IR.

Lastly, there is no other profession where you’re investing almost a quarter of a million dollars into an education. So you owe it to yourself to really investigate as many fields of medicine as you can before you graduate, even if it’s just for one day.

You want to be able to walk out of med school graduation, confident in the field you’ve chosen and not constantly wondering what if you’ve chosen another one.

“You owe it to yourself to really investigate as many fields of medicine as you can before you graduate, even if it’s just for one day.”Click To Tweet


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