A Look into Vascular Interventional Radiology

Session 163

Dr. Mark Lessne gives an all-access pass into his field of Vascular Interventional Radiology and how it affects all other specialties from a procedure standpoint. Mark has been out of his training now for nine years and working in a community setting.

If this is a specialty you want to look into, check out Society of Interventional Radiology and the Journal of Vascular Interventional Radiology for more resources and information.

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.

[01:26] Interest in Vascular and Interventional Radiology

When Mark was in medical school, he had never heard of vascular interventional radiology before. But when he was in medical school, he was one of those people every rotation he did. And then he did a vascular rotation. And at that time, some of the procedures were done by both the interventional radiologist and the surgeon. That was his first exposure to interventional radiology.

Then he looked more into it and then realized that at that time, he had to go through diagnostic radiology to get into interventional radiology.

The first thing he liked about it was that the procedures were done by both radiology and a surgeon. And at the time, for some reason, the procedure was mostly done by an interventional radiologist. The surgeon just wasn’t familiar on how to accomplish the procedure. And that was the first time that he wanted to be the person that someone needs in order to do their work.

“A lot of what interventional radiology is allowing patient care to reach another level and in some cases, offering options and hope where previously there was hopelessness.”Click To Tweet

[03:12] The Biggest Traits of a Good Vascular Interventional Radiologist

They are tinkerers or the MacGyver’s as they are clearly very much hands-on people. So you’ve got to enjoy working with your hands and you’ve got to have problem solving skills. What attracted him to interventional radiology was, a lot of times, they have patients that someone comes down and consults them and says they have no idea what they’re supposed to do with this patient. And so they’d ask for help.

They will even sometimes invent things to do for people. Once every month or two, Mark would be doing a procedure that he has never done before, or some basic thing that he has never done before, or in some cases, that no one has ever done before.

“Having this willingness to think outside the box and try new things, and problem-solve when everyone else says there are no other options, is very important.”Click To Tweet

Communication is also crucial because they see a lot of patients every day. In the clinic, they talk to patients who have previously been told that there’s no options for them. Or they have to explain some complex procedure. And if you can’t do that effectively, it’s hard to get trust and it’s hard to build a relationship.

[04:38] Vascular Interventional Radiology vs. Interventional Radiology

“Vascular interventional radiology is the full name of interventional radiology.”Click To Tweet

The field was founded in 1964 by Charles Dotter. Compare that to other specialties which are hundreds of years old, interventional radiology is relatively a new specialty.

Interventional radiology was started by Charles Dotter who basically thought he could do a lot of work through small holes over wires and catheters. His first work was with vascular. He was able to treat a patient named Laura Shaw, who was going to lose her foot.

Instead of amputating her leg, he went in and opened up that blockage through a small hole. And that was the very first sort of angioplasty procedure.

What’s really been enjoyable to interventional radiology is the concept of working percutaneously through a small hole. It’s minimally invasive with a catheter and wire just exploded throughout the entire body.

Now, they treat everything from head to toe. They treat stroke, tumors, liver disease, and kidney disease. And so it started as a vascular specialty but actually, they say interventional radiology now because a lot of work they do is biliary, GYN, and kidney.

“It’s a broad field that interacts with every single organ system.”Click To Tweet

[06:40] The Turf War That’s Going On Between Specialties

The radiology part is both historical but also, they started because everything they did was image guidance. The reason they can do things through small holes is because they don’t need to cut someone open to visualize it directly. They can do it with X-ray, ultrasound, and CT and MRI.

Over the past 60 years, this has become its own specialty or residency separate from diagnostic radiology.

So even when Mark trained, which was only 10 to 15 years ago, they had to do a diagnostic radiology rotation residency. And then they did a fellowship in IR now.

“Interventional radiology is its own fellowship, and so it's sort of its own entity now.”Click To Tweet

In terms of other specialties, part of the success of interventional radiology is that they’ve shown they can do things safer, faster, and less invasive. So some other specialties certainly do some interventional radiology procedures. Some people from other specialties are great at it in the one area.

But for Mark, he is a minimally invasive expert doing things from all over the body. There are some surgeons out there that do a lot of the vascular work he does. But he also treats uterine fibroids, as well as kidney obstructions and biliary tumors.

“Part of deciding what you want to do as a specialty is figuring out what you like.”Click To Tweet

Moreover, part of interventional radiology that’s gotten so broad is they do subspecialize. So for example, Mark specializes in vascular disease. So he also gets to develop a depth of knowledge while maintaining some degree of breadth.

But at the end of the day a lot of the skills that he uses minimally invasive are applicable to multiple organ systems. And so it really concentrates on your expertise, as opposed to some people who are a little bit more of a hobbyist where they do a little bit of this, a little bit of that, and a little bit of whatever. Whereas they get to concentrate our expertise in one treatment paradigm and one sort of specialty.

[09:54] The Biggest Myths or Misconceptions About Interventional Radiology

The biggest myth is that they don’t even exist. Now that said, image guidance is a big part of their specialty. But they have a lot of patient interaction as well

“We're not the diagnostic radiologists who sort of sit in the dark rooms.”Click To Tweet

As interventional radiologists, they have an active clinic. He admits patients and he discharges patients and he rounds on patients and he does procedures. So there’s a gap between the word radiologist and interventional radiology specialty where they are at clinical specialty as opposed to something like pathology or radiology.

Most of the time, they have to fight the diagnostic radiology persona, because they’re clearly a different beast. But that said, he very much values his diagnostic radiology colleagues and his training in diagnostic radiology.

[12:11] Types of Patients

One of the two biggest areas of interest is the peripheral artery disease, specifically what’s called critical limb ischemia. There are patients with very severe circulation disorders, blockages in their arteries, to the point where they are actually at risk of losing their leg.

Unfortunately, there are a lot of patients who are just offered amputation. But critical limb ischemia specialists which interventional radiology is a big one, along with surgery and some cardiologists, they work really hard to prevent amputations and treat patients who again, other people have said there is nothing to offer.

His other area of interest is dialysis and venous disease. These are patients who have blockages in their chest, right above their heart, patients who have severe swelling and shortness of breath and can’t breathe because of these blockages or can’t get dialysis because there are blockages. So they’ll try to revascularize them and open them up in some way to improve blood flow to decrease their symptoms or to give them life-saving dialysis.

[13:19] Ratio of Diagnosis vs. Treatment

Mark went into radiology expecting to do interventional, but actually liked a lot of diagnostic radiology. Although he’s not a diagnostic radiologist anymore, he thinks that diagnostic radiologists are some of the smartest people in the hospital.

He remembers going to residency and he heard about diseases as a radiology resident that he had never even heard of. The diagnostic radiologist had to be the Sherlock Holmes and be the one who figured out not only to know about the disease, but what it looked like and what it would look like after treatment. They’d have to figure out what it looked like in its various stages.

As an interventional radiologist, a lot of times the diagnosis is already made and they’re there to fix it and treat it. But he likes having a diagnostic radiology background because he could speak and understand their language, so to speak.

[15:08] Typical Day and Taking Calls

Mark was on faculty at an academic center for many years. And he transitioned to a non academic environment in a tertiary care or coronary care hospital. So he sort of can give you a difference of day.

But in general, he thinks most interventionalists will agree that most of the time, their days are variable. Sometimes they start with a clinic, sometimes they have a procedure day.

Then he will do procedures which are often scheduled procedures for his outpatients that he had already seen. Sometimes it’s emergency procedures. He currently covers the largest transplant and trauma centers in the area. So clearly, emergency procedures come in quite a bit. And then often he’ll have a clinic in between or a dedicated clinic day.

“Interventional radiology is a relatively call-heavy specialty depending on where you practice, because we do treat patients with trauma and emergencies.”Click To Tweet

So if you absolutely hate calls, there are options for interventional radiology where you can avoid calls. But most interventional radiologists would have to take calls.

Mark admits that the older he’s getting, the harder it is. But that said, it makes it interesting. For example, if a patient is bleeding, they will have to actually go in and treat the bleeding at that time.

[17:44] The Decision to Transition From Academics to Community Setting

Mark enjoyed academics but it was more a personal geography move that made him decide to get into the community setting. And like many interventionalists, he is someone who wants to challenge himself. And so he did want to try a different practice environment and see if he could do something different.

Now, that said, he still has his faculty appointment. And so he still does a lot of research, which is a nice option for interventional, although it’s no longer a part of a day-to-day training program. But he still gives talks and lectures and still has that education piece, which he enjoys.

[18:44] Work-Life Balance

The call is still fun. What’s not fun is getting interrupted during a dinner. But once you get over that, and realize you’re leaving to help someone who needs you, there is a huge satisfaction in that.

And so when he goes to a procedure, even if it’s a procedure he has done 1,000 times now, again,since they’re a relatively new field, there could be something new there. It could be something he has never encountered before. So he does a lot of thinking on his feet and trying to figure out how he’s going to treat it.

“It’s nice to get up at two in the morning and realize that you might be able to save someone's life.”Click To Tweet

The variations keep you on your toes. So you have to know all the anatomic variants that you could have only glossed over in medical school. You have to know it. There are anatomic variants and the patients are different so it keeps you on your toes and keeps it from being boring.

[21:55] The Training Path to Interventional Radiology

Mark interned for a year. And then they had to do four years of diagnostic radiology. And then they did a fellowship in interventional radiology, which was a year.

Because diagnostic radiology and interventional are so separate and so different, just doing a year to learn 1,000 procedures or more doesn’t make a lot of sense. So now, you actually match directly into interventional radiology from medical school.

“Interventional radiology is now its own specialty.”Click To Tweet

The training path is six years and diagnostic radiology is actually incorporated. So you will still get boarded in diagnostic radiology. But there’s a lot more integration of interventional radiology and interventional work early on. There’s also a mandate that you must learn how to do clinics. You have to learn how to manage oncology patients, vascular patients, and trauma patients. It’s now integrated into the residency which is still, in general, six years., which is a categorical program.

When the interventional radiology match first came out, which is a couple years now, it was the most competitive specialty in all of medicine. It beat out dermatology, neurosurgery, orthopedics, whatever it is. Now, recently, that competitiveness has decreased.

And there are some philosophies for that. Some people say, after about a year or two of it being the most ridiculously competitive specialty, people stopped applying as much. There are also some different pathways now. In other words, you can still get into interventional radiology, not through a categorical program. So although it’s decreasing competitiveness, it’s still a pretty competitive specialty.

[24:39] Message to DO Students

You’ve got to get yourself known and just have someone meet you and realize that you’re an awesome medical student. You have a lot to offer.

“You have to get your foot in the door.”Click To Tweet

Whether you’re DO or MD, you’ve got to figure out a way to distinguish yourself. At the end of the day, if you are passionate about something and you commit yourself and you do a great job, it’s pretty hard to argue that.

Obviously, if you’re a terrible allopathic medical student or a terrible osteopathic medical student, it’s going to hurt you. But if you work your butt off, you should get your voice heard and you have a chance to hear to tell people why you deserve a position in interventional radiology.

[26:47] Are There ACGME-Accredited Training Programs?

There’s no additional training with the exception of neuro-interventional. So if you want to become a neuro interventional to treat cerebral aneurysms at malformations, that is an extra fellowship.

But just with vascular interventional radiology residency, you can do whatever you want. And typically, you choose what you want to focus on because you’d like that or because you’re in a practice that needs it.

This will depend on your practice location. If you’re the only interventional radiologist in a 100-mile area, you’re probably going to be doing everything. But if you’re in an area where there are 14 interventionists, they’ve got interventional oncologists who just treat cancer patients, and pediatric and malformation specialists, and vascular specialists. So it sort depends on your practice location.

“All can be done with the residency itself without additional training with the exception of neuro interventional.”Click To Tweet

[28:13] Message to Primary Care Physicians

“If you are stuck with a patient, and you don't know what to do, run it by your interventional radiologists.”Click To Tweet

First, if you are stuck with a patient, and you don’t know what to do, run it by your interventional radiologists. A lot of times they can offer things, even things that don’t end up in a procedure. They can offer perspectives, or ideas or problem solving strategies that are very effective for patients.

Second, if you are having a patient that someone’s been told, nothing can be done, run it by the interventional radiologist. They can come up with solutions sometimes that no one else knows about.

And then the third situation is just meet your interventional radiologist and see what office services and therapies and clinical work they can offer.

And because they interact with so many other specialties because again, they treat every organ system, there are a lot of patients that he sees and that he can refer to other specialties that can provide a better treatment plan. So they also have that perspective on other people’s specialties. And they often know what other people’s specialties can do.

In some ways, they can be a gatekeeper for other therapies, that maybe the primary care provider just doesn’t think about just because they don’t have as much exposure.

[30:29] Other Specialists They Work the Closest With

They work closely with oncologists. They do a lot of interventional oncology, with surgery, trauma, surgery, biliary surgery, transplant surgery, urology, etc.

[31:39] What He Knows Now That He Wished He Knew Going Into the Specialty

Mark says that he wishes he knew how much work there was to do in terms of getting their name out there. If you have schizophrenia, there is no question who you’re going to see, you’re going to see a psychiatrist. You’ve known that for the past 200 years.

But they don’t have that in interventional radiology. They have a fairly big problem with patient recognition. And so he has to work very hard to educate patients and refer doctors to what they can offer and how they can help save patients and treat patients.

This is a bit of extra work that he has to do but the good thing is that he loves doing it. And he loves giving talks and talking to people and communicating. But if you’re not into that, if you sort of just want patients and work to flood to you, then you have to think twice about interventional radiology. Because you’ve got to publicize and let people know what you can offer..

[32:58] The Most and Least Liked Things

Mark loves looking at a patient in the eye, who has been told that there is nothing else that can be offered to them. And that there is no solution to their problem to fix their life or save their life and being able to tell them that they can help.

As an interventionist, they always have to plan A through F, at least. So he likes being able to offer hope to the hopeless.

They typically see patients who have been recommended for amputation. And being able to say that he could try saving 80% to 90% success rate, that’s liberating.

On the flip side, what he likes the least is how frustrating it is to have to continually keep your foot on the gas. You do have some competition and have to prove yourself. Now that said it’s frustrating sometimes, but it keeps you good.

One of the misconceptions Mark had as a medical student was to go into whatever and then patients will just be handed to you. So you better figure out what your angle is.

“Get your name out there and brand yourself and show what you can do and continue helping more.”Click To Tweet

[37:01] Major Changes Coming Into the Field

The major change recently was obviously separating from diagnostic radiology in terms of residency training. That was the big one. There’s some talk about sub-specialization even more.

“The biggest difference is going to be the training paradigm, which is starting to change now.”Click To Tweet

The other thing is interventional radiology was always a hospital-based specialty. So they always were in the hospital to treat all these patients. And more and more interventionists are actually going into solo practice. And that is becoming a little bit of a paradigm shift where they’re opening their own office, and they are treating patients in their office, but then they have an operating angio suite. In some cases, that gets rid of calls, because it’s just nine to five and five days a week. Sometimes there’s a hybrid practice.

This change in practice models may be upcoming in the next couple years. But it’s also offering more flexibility. If you want to be the hospital-based coronary center, great. If you want to have your own practice and be your own boss, that’s great. So there’s everything in between.

[38:24] Would He Do This All Over Again?

Mark says he couldn’t think of anything else that he would want to be doing more other than interventional radiology. And this is coming from someone who literally loved every almost every specialty rotation.

“It just gets your hands into so many different disease processes and patient types.”Click To Tweet

[40:00] Can Manual Dexterity Be Learned?

If you have these minimal competencies, find a good teacher who can teach you how to handle wires and catheters and manipulate, and curves.

There’s always going to be the person who just literally can’t do it. So you have to know how to figure that out ahead of time. Probably start playing video games. In fact, some of his procedures, especially when he does a lot of radial access, where he goes through the wrist. He has a patient where their wrist is out, and he’s staring at the screen manipulating wires and catheters in their body. And someone who walks in would just think he’s just playing a video game.

[41:27] Final Words of Wisdom

Go find a vascular and interventional radiologist and spend some time with them. They’re not as well known as something like an internal medicine doctor or a pediatrician. So go figure out what it’s about, and see what they like about it and see if it’s right for you.

There’s a limit to what you can do by finding on the internet and googling. Go to an IR clinic and go to an IR procedure and ask them what their days are like and seek it out.