So you want to be an interventional radiologist, leaving the image reading in the dust in replace of hands-on operations. Well, not quite. This is the reality of interventional radiology.
Welcome to our next installment in So You Want to Be. In this series, we highlight various medical specialties to help you choose the best fit for you. You can find the other So You Want to Be guides here on the Med School Insiders website as well as our YouTube playlist.
What Is an Interventional Radiologist?
Radiology can be broken down into two distinct paths: diagnostic radiology and interventional radiology. The basic difference is that diagnostic radiology primarily deals with diagnosing disease, whereas interventional radiology primarily deals with treating disease.
Diagnostic radiologists do not usually take the images, but instead spend the majority of their time looking at the finished scans and providing interpretations of them for the clinical physician who ordered the scan.
Interventional radiology, on the other hand, involves using medical imaging technology to treat and sometimes diagnose conditions. Using imaging guidance—typically a kind of real-time x-ray called fluoroscopy—interventional radiologists often manipulate long thin wires called catheters to the site or organ of interest to then perform a procedure. Such procedures are known as minimally invasive, as traditional invasive surgeries require far more cutting than a needle stick or small incision.
Interventional radiologists operate all over the body, including putting in lines and tubes to drain abscesses or kidneys, lysing blood clots, embolizing bleeding, angioplasty and stenting, fixing aneurysms by filling them with wire coils, stenting the liver in cirrhotic patients, and removing clots causing stroke.
Interventional oncology includes treatments for liver and kidney cancer, such as freezing or microwaving tumors, dropping radioactive beads into tumors, and killing off blood supply to the cancer. This is a rapidly evolving field that’s given cancer patients more options.
Interventional Radiology vs Diagnostic Radiology
The first distinction we need to make clear is the difference between interventional radiology and diagnostic radiology.
DRs are experts in anatomy and pathophysiology throughout the body and have practical knowledge of medical physics. The basis of their work comes down to reading and interpreting images. IRs enjoy both imaging and operating. The basis of their work comes down to completing image-guided procedures. However, IRs are also certified in diagnostic imaging, as this is the foundation for their procedures.
Overall, the IR lifestyle is worse than DR, but it can still vary once you’re done with training. There are IR attendings who work close to general surgery hours and others who work closer to DR hours, and DR has one of the best lifestyles in medicine.
IR call is usually home call, meaning you can be called in from home at any hour and on weekends for urgent interventions. These happen often, meaning you may have to go in at 3 am or multiple times over the course of a weekend.
At a busy center or large hospital, scheduled IR cases can start between 7-8 am and run until 5-6 pm. This is in addition to call. Less busy centers will have fewer cases.
Community vs. Academic vs. Private Practice
The lifestyle, hours, call, and procedures depend on the practice type you are working in. For example, not all IRs operate every day. Academic IRs may only do procedures and have a day off for admin and research. In academic centers, where a number of high-end procedures are performed, IRs are usually quite busy.
In general, there are more interventional oncology and complex hepatobiliary procedures like TIPS done in academic settings, as these patients benefit from having a multidisciplinary care team that may also include oncologists or hepatologists.
Private practice IR physicians often do a combination of IR procedures and DR readings. Procedure-only jobs in private practice are normally the exception rather than the rule. This means that it can be difficult to maintain the case volume needed to maintain skills for more complex procedures, and that’s another reason there are more of those done in academics.
However, any IR-trained physician can perform whatever procedures they are comfortable with and have the staff for, and that’s why private practice IR settings vary widely depending on the specific group. One nice benefit of a private practice IR career is that it can generally be tailored to your desires.
On average, private practice IRs will make a bit more than academic IRs, as is the case for all specialties.
General IR vs. Specialized IR
There’s also a distinction between general IR and those who choose to specialize further.
More general IR involves lines and tubes and acute interventions like bleed embolization, percutaneous nephrostomies, and chole tubes.
More specialized IR tends to be done at larger and academic centers and includes complex vascular and hepatobiliary work, such as TIPS procedures, stenting the liver in cirrhotic patients.
Interventional oncology is also becoming a subfield that includes tumor ablation and embolization. Other niches include pediatric IR, which often deals with pediatric vascular anomalies, and neuro and vascular IR, which includes stroke thrombectomy or brain aneurysm coiling.
Common Misconceptions About Interventional Radiology
Let’s clear up some of the misconceptions about interventional radiology.
A common misconception is that IR is ideal for those who want to be surgeons. You might choose to become an interventional radiologist because you have an interest in surgery, but you must like imaging too. Diagnostic imaging still takes up a large portion of residency training, and you’ll need to have a deep understanding of it in order to become an IR.
If you’re passionate about surgery and dislike imaging, a surgical specialty will be a better fit.
Some have the misconception that neuroIR is becoming the domain of neurosurgery and there’s no longer a future for radiologists to do neurointerventional procedures. This is not accurate. While many radiologists aren’t interested in neuroIR, there are still plenty of opportunities for those who are. For radiologists interested in neuroIR, there are dedicated programs available for this career path.
How to Become an Interventional Radiologist
Becoming an interventional radiologist takes 6-7 total years. There are three options to choose from for pursuing this career path.
1 | Integrated Pathway
First is the integrated pathway. Training for this path includes 1 intern year, 3 years of DR training, and 2 years of dedicated IR training.
The path begins with diagnostic radiology, since diagnostic skills form the basis for interventional procedures.
2 | ESIR (Early Specialization)
Next is Early Specialization in IR, also known as ESIR, which includes 1 intern year, 4 years of DR training, and 1 year of IR training.
This is generally for DR residents who realize early on that they want to do IR. They’ll do more IR rotations during their DR years than their DR counterparts. Their last year of DR training, year 5, will be mainly focused on IR rotations.
For this path, you need to know quite early on that you want to do IR in order to get the required 500 IR procedures during your DR years.
3 | Independent IR Residency
Last is the Independent IR residency, which takes the longest at 7 years. This training includes 1 intern year, 4 years of DR, and 2 years of a separate IR fellowship.
This path is usually taken by DR residents who realize late in residency that they want to do IR. Therefore, they need 2 years of fellowship training in order to complete the necessary IR procedure volume.
Subspecialties Within Medical Research
What about subspecialization?
Although interventional radiology is in many ways a subspecialization of diagnostic radiology already, there are paths to further specialize after becoming an IR.
Although you will gain experience with virtually all IR procedures during IR residency, some IRs develop a specific “niche” they become experts in, such as interventional oncology, pediatric IR, or ultrasound-guided biopsies. Additional fellowship years are available for pediatric IR, which often deals with pediatric vascular anomalies, and for neuroIR, which deals with strokes and cerebral vascular diseases. However, the majority of IRs do not pursue these extra fellowships.
What You’ll Love About Interventional Radiology
There’s a lot to love about working as an interventional radiologist.
IR is a rapidly evolving field with cutting-edge technology and new interventions being developed all the time. This means you can help forge a young field, find R&D opportunities, and make connections in the biomedical industry.
It’s a huge scope of practice that enables you to intervene all over the body. There’s a large variety of diseases, organ systems, patient acuity, and patient population, so there are many different niches you can establish yourself in.
IRs are also DR-certified, so depending on your interests, you can do part IR and part DR as an attending. There’s a great deal of flexibility in IR, so you’ll be able to focus on the areas that most interest you. There’s also minimal rounding and social work if those doctor duties sound unappealing to you.
You’ll also have job security, as midlevels won’t be doing complex IR work anytime soon, and you’ll earn a hefty paycheck. Interventional radiologists, like diagnostic radiologists, make about the same at over $480k a year, with specialists making even more. Your income is more determined by your practice type and niche rather than whether or not you are a diagnostic or interventional radiologist.
But best of all, you can instantly help people and literally save lives through acute interventions like bleed embolizations and thrombectomies.
What You Won’t Love About Interventional Radiology
While interventional radiology has a lot to offer, it isn’t for everyone.
First off, the lifestyle and being on call can be challenging. Due to the nature of the specialty, you will often have to come in on weekends and be woken in the night for emergencies.
Like many procedural specialties, residency won’t be a walk in the park either.
It depends on where your values lie— are you more interested in the money or your work-life balance and family life? There’s not a right or wrong answer here, but it’s important to understand this going in.
In some community practices, IR can become a “line and drain” service, doing all the procedures no one else wants to do. You’ll also spend many hours standing, and there is a danger of radiation exposure.
Turf battles can also exist with other specialties, depending on the institution. For example, you could come into conflict with vascular surgery for peripheral vascular interventions and neurosurgery for brain interventions.
It’s also not an easy path by any means. Interventional radiology is one of the top 10 most competitive specialties to match into based on our in-depth Specialty Competitiveness Index, linked in the description.
Should You Become an Interventional Radiologist?
So, should you become an interventional radiologist?
Those who thrive in radiology are intellectually curious and enjoy solving puzzles.
Interventional radiology is ideal for those who are interested in both procedural work and time spent with patients. As an IR, you’ll have more patient interaction and recognition but less work-life balance and more call work.
IR isn’t ideal for anyone who wants to become a surgeon. You will never be a surgeon without completing a surgical residency, so if you are truly interested in surgery, look to a surgical specialty or subspecialty.
Additionally, if you don’t like diagnostic imaging, IR likely isn’t for you. DR forms the basis for IR, and you will do a number of DR rotations during residency. You must have an expert understanding of DR in order to become an interventional radiologist.
Only students who are 100% certain they want to become an interventional radiologist and are truly passionate about it should apply for the integrated pathway. If you aren’t sure, applying to a DR program with ESIR spots gives you time to make a more informed decision once you have more experience with residency.
If you are considering interventional radiology, we strongly encourage you to complete a rotation in both DR and IR. They are unique fields that are impossible to appreciate without first-hand experience.
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Special thanks to Dr. Thomas Reith for helping us create this guide and video.
If you’re struggling to choose the best medical path for you, our So You Want to Be playlist is a great place to start.
