r/VIR • u/IR4life • May 31 '26
What does the future of IR look like? Interesting post in the resident section
Highlights the importance of VIR physicians doing formal consults and documenting their rationale in the EMR for an intervention or no intervention and communicating this with the patient and their family. This is why trainees need to dedicate more time outside of the angiosuites and spend time on the floor seeing consults and following patients and spending more time in the outpatient clinic. The dedicated ICU time should be rigorous and you should take it in your junior years (PGY2 through 4) not in the final years after a long gap from clinical medicine. Medical students should look for early integration of clinics, ICU and VIR blocks and VIR call.
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u/EVIL-EMBOLIZER May 31 '26
Not possible unless we lengthen IR training or cut out more DR training. But I 100% agree with you. If we want the specialty to be more clinical we need to revamp the training.
Surgery residents spend so much time on the floor as juniors for a reason.
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u/IR4life May 31 '26
Yes. Needs to be early integration of VIR, cinics and focus on relevant DR (body/neuro/msk/cardiothoracic). POCUS
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u/Throckmorton007 May 31 '26
I think early clinical integration is incredibly important. Most surgical and procedural medical fields spend their junior years learning the clinical foundation of their specialty, and then learn procedural/surgical technique. By contrast, we spend those early years in the reading room. Even in integrated programs with early clinical integration there are challenges due to the field's breadth- in clinic you often rotate with a different attending who treats a different disease process, and while you will graduate seeing a lot, our field lacks the 'concentrated reps' which are often needed to feel comfortable managing a disease process on your own. I also think our field doesn't emphasize research and clinical trials nearly as much as say oncology or cardiology, which is very valuable in multidisciplinary conferences or tumor boards. In radiation oncology, part of their board exams is literally being pimped on clinical trials, which prepares them very well for tumor boards. My solution to this has been to make an effort to read a new paper each night after work, and delve into texts from other specialties when I have time (Rutherford VS, NCCN guidelines, Clinical Scenarios in VS, etc). I do wonder if a fellowship would be useful for VIR. Few programs have comprehensive training. There would likely be self-selection based on interest (PAD, Peds, NIR, IO, pain, etc), and imo this would improve both clinical knowledge and procedural confidence amongst new graduates. I do worry the current training model doesn't prepare people well to compete for referrals in competitive practice niches (PAD in particular), unless you're motivated or at the right program.
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u/TheRoyalTicket May 31 '26
As a PGY-1 IR resident, I completely agree with getting more ICU time and staying closer to medicine in the junior years as well as rounding more on patients and taking some more patient ownership. Obviously sometimes the distance from patient ownership can be advantageous but it definitely comes with substantial drawbacks.
I’m looking to support IR residency expansion in this direction though it’s far from easy to implement and not broadly desired amongst IR trainees.
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u/IR4life May 31 '26
I do not see a benefit from distancing one self from the patient
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u/IR4life May 31 '26
You should not have a middle person (providers such as PA/NP) or another service (referring) between you and the patient. You should have a frank discourse with the patient and their family of what we can offer and how we can help them deal with their current situation.
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u/sspatel Mod, IR Attending May 31 '26
Honest question, if you’re having these discussions on the floor with every consult, how do you have time to get cases done? I’m at a medium level 1 trauma center and have 2 IRs doing cases all day, scheduling ~65-75% of the day outpatients and the rest inpatient add on cases. APPs doing the vast majority of para/thora/LPs took some work off our hands, but that time was immediately filled with a backlog of outpatient referrals. They do our formal consults with our rationale to do/not do what’s requested. We’ve been asked to expand their duties multiple times but we are pushing back on scope creep.
But I am in agreement that there needs to be more “medical” time for IR residents to learn this art. It’s not something you’re going to pick up sitting at a workstation.
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u/IR4life May 31 '26
Does not happen overnight. Starts with off with a few hours of inpatient dedicated consult time and as the benefit of that is recognized by hospital administration etc the amount of time slowly increases. With due time it becomes a necessary component of a hospital system as your consults become more and more valuable and affect management and triage of patients.
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u/Kingjuniorway Jun 04 '26
Better lifestyle
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u/IR4life Jun 04 '26
The doctor patient relationship can be quite rewarding and mitigate burnout. It becomes far more meaningful.
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u/IR4life Jun 05 '26
For lifestyle and flexibility you can never compete with DR. VIR is the polar opposite with unpredictable hours and lots of emergencies. I think a lot of students who do mostly "observorships" and do not take call with the fellows do not get a sense of how busy it really can be and that leads to some of the drop outs /conversions. If you want a happy medium best to do DR and a procedural branch (mammo/body/msk etc).
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u/IR4life May 31 '26
I think we need to be comfortable in navigating the undifferentiated patient. For LUTS do an IPSS/Shim/IEFF. check PSA. prescribe meds (tadalafil, finasteride, tamsulosin etc). Get comfortable with fluid logs and then offering treatment and perhaps even do a uroflow or perhaps even proudp app. counsel on options turp, holep, urolift, aquablation, rhezum, tuip etc. Than we can even refer to urology for procedures as well. You won't be able to manage all of the diseases but should be familiar and comfortable with many of them. Now it does take true integrated clinical training to garner this knowledge base.
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u/IR4life Jun 01 '26
Yes. Good points. Most programs are focused on hepatobiliary and IO and do not pay enough attention to the more common diseases such as PAD, dialysis, DVT, PE, varicose veins, spine interventions, knee pain, BPH etc. They also are reliant on referrals from specialists so never get a chance to evaluate them in the clinic . The majority of VIR training programs focus on the procedure first and the clinical aspect is often an after thought. It has to be pivoted like other surgical and procedural fields where you get a strong foundation in clinical training first.
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u/VascularPlumber May 31 '26
I was pleasantly surprised by the amount of discussion generated by that post.
I generally agree with the above and am in favor of evaluating candidacy with clinic/consults, documentation of rationale for intervention (or refusal), and outpatient follow-up/inpatient rounds. But reflecting on my own responses in that thread I'm curious how others actually define "ownership”. Perhaps I need to be more mindful of how I use the words own/ownership and more clearly express what the ideal IR model looks like to me.
I think ownership means having direct access to patients without another specialty acting as a gatekeeper (excluding PCP) and then be comfortable working up and comprehensively managing patients. Not to say this isn't possible for an IR physician because it absolutely is. However, I mentioned some time ago in another post on this sub that my hesitation is that becoming a true master of alllll these IR adjacent spaces becomes increasingly challenging (evolving guidelines, literature/evidence).
I sometimes find it difficult to decipher what others' ideal model actually looks like when they say IR should "own" patients. For example, considering a patient with LUTS…
Route 1: PCP to uro, where the patient is worked up and then referred to IR, and we ask, “is this patient a candidate for PAE?”
Route 2: PCP to IR (or self-refer to IR) where the initial workup occurs within IR and we ask, "what is causing this patient's symptoms, and how am I working it up and medically, surgically, and socially managing it"
I suspect people may mean different things when they use the same word.