Interventional Radiology Education

Between 1970 and 1990, vascular and interventional radiology (VIR) education consisted of diagnostic radiology residents rotating on the vascular and interventional radiology service for 3 to 5 months. For individuals wishing further training, a year fellowship was available in most academic radiology departments. However, during those two decades, there was neither a defined curriculum nor any formal requirements for the fellowship programs.

Beginning in 1990, this changed dramatically when the American Council on Graduate Medical Education (ACGME) began formally accrediting VIR fellowship programs. With accreditation came requirements involving the program director, faculty, interventional radiology space and equipment, patient population, and support services. The ACGME also defined requirements for clinical experience in all types of vascular and nonvascular interventions, graded responsibility, didactic instruction covering a defined curriculum, review of morbidity and mortality, and participation in research. Presently, there are 102 accredited VIR fellowships with 203 active fellows. (In comparison, vascular surgery has 88 accredited programs with 136 active fellows and cardiology 177 accredited programs with 2088 active fellows.)

In 1994, the first Certificates of Added Qualification (CAQs) in VIR were awarded. In order to sit for the CAQ in VIR, one must first be board certified in diagnostic radiology and have completed a 1-year fellowship in an accredited VIR program. In addition to fellowship, 1 year of clinical practice is required. Presently, approximately 2000 individuals have obtained a CAQ in VIR.

Despite these advances, many leaders in VIR feel that little has really changed over the years in terms of education and training. Our training has largely been limited to technical skills. We have been producing ``clones of ourselves'' who are superb catheter jockeys but who lack sufficient clinical skills to take care of patients and compete with other specialties that have become interested in performing procedures that have traditionally been within our purview. This is particularly evident in vascular interventions. In 1988 more than 85% of noncoronary transluminal angioplasty was performed by interventional radiologists. This number decreased to 75% in 1996, and in the year 2000 interventional radiologists performed less than 60% of these procedures. Thus, we are presently at a critical juncture-a fork in the road. We can continue the status quo and face a declining role with loss of more procedures, or we can make important changes to maintain interesting and stimulating practices for VIRs by keeping a viable role for them in minimally invasive and endovascular fields.

The new VIR training pathway approved recently by the American Board of Radiology (ABR) is an important step toward addressing this deficiency in clinical training of VIR fellows. This pathway is designed to provide a broader, more in-depth experience in clinical diagnosis and patient management and care. An additional or secondary goal of the new pathway is for the trainee to become familiar with and participate in VIR research. This 72-month pathway that includes the PGY 1 (post graduate year-year(s) of training after graduation from medical school) affords trainees the opportunity to spend 43 months in clinical and VIR rotations (including time on research) with 29 months devoted to traditional diagnostic radiology. Individuals completing this new pathway will have adequate clinical and diagnostic radiology experience during the 6-year training period to meet the requirements for both the American Board of Radiology Certificate in Diagnostic Radiology and the Certificate of Added Qualification in VIR.

Although this special pathway represents a significant step toward increasing the clinical experience of VIR trainees, the actual number of radiology residents who take advantage of it will be limited. Therefore, additional steps must be taken to establish and maintain an adequate supply of clinically proficient VIRs. Presently, the only pool from which VIR can select fellows is the diagnostic radiology training pool. Limiting the pool of potential VIR trainees to diagnostic radiology and requiring a complete residency and board certification in diagnostic radiology before VIR training is too restrictive. Accepting fellows from this single pool is a significant disadvantage because many residents enter diagnostic radiology precisely because they are enamored with the imaging aspects of radiology only and do not want patient contact.

Therefore, completion of a traditional diagnostic radiology residency should not be necessary for an individual wishing to become a VIR. Many rotations such as nuclear medicine and mammography can be completely eliminated, and others such as pediatric radiology and musculoskeletal radiology can be drastically reduced. We must be able to accept trainees from other disciplines such as surgery or medicine and provide them with basic experience in imaging-fluoroscopy, computed tomography, ultrasound, and magnetic resonance. These individuals from other clinical disciplines will already have the requisite clinical skills and the ``correct mind set'' to be clinicians as well as interventionalists. Once basic imaging experience in the preceding modalities is acquired, a 1- to 2-year fellowship in VIR will follow. This course of training will result in well-trained VIRs with increased patient management activity and skills who can compete effectively with other clinically oriented specialists and who will be well versed in acquiring direct access to patients.

This issue of Seminars in Interventional Radiology deals with interventional radiology education in many countries. In the United States, we have a single organization responsible for VIR program accreditation and similarly a single organization for certifying practitioners. We also have a single set of standards for performance of various VIR procedures. In comparison with CIRSE (Cardiovascular and Interventional Society of Europe), where the standards for accreditation, certification, and procedural performance are different for each of the 16 countries involved, we are indeed fortunate.

This issue of Seminars also details new and exciting educational methods such as live case transmissions using local or global methods. Since the September 11 terrorist attacks on New York City and Washington, DC, the publics' willingness for nonessential travel has decreased substantially. It is estimated that the attendance at the 2001 RSNA, a meeting that has grown every year, will be down by at least 10%. Not surprisingly, the number of video teleconferencing units sold since mid-September has increased dramatically.

For those who have not had the experience, it is truly exciting to witness or take part in a live multipoint televideo conference with panelists from multiple continents engaged in real-time discussions with the moderator. Electronic videoconferencing is no longer a dream for the future but a present reality. Simplification and improvement of its technology are inevitable. Soon it will be extremely easy and routine to organize ``virtual'' meetings accessed by computer with speakers, moderators, and attendees receiving maximal educational benefit and continuing medical educational credit without ever having to leave their offices or homes.