Key words interventional procedures - education - structured curriculum - neurointerventions
Introduction
Interventional radiology (IR) is a growing subspecialty of radiology based on the
increasing demand for minimally invasive procedures, the associated lower complication
rates, and ongoing technical developments that allow the replacement of invasive procedures
[1 ]
[2 ]
[3 ]
[4 ].
An excellent resident and postgraduate training program is a prerequisite for well-trained
colleagues providing optimal patient care with high job satisfaction. However, there
are several obstacles to deal with including workload issues, on-call service, demand
for part-time work, increasing desire for parental leave, economic pressure, competing
interests between departments, or increasing quality control demands, just to name
a few. These developments affect residents, fellows, and the senior physicians who
train them [5 ]
[6 ].
In addition to diagnostic radiology skills, radiation protection expertise, clinical
reasoning, and up-to-date knowledge of the current literature, interventional radiologists
have to possess excellent manual skills. Also, many radiologists consider the working
environment more stressful due to emergency situations, potential complications, and
the physical strain caused by long procedure times and wearing radiation protection
equipment. Therefore, developing the necessary resilience and the mentioned core competencies
places unique demands on residential and postgraduate training [7 ]
[8 ]. Repeated radiation exposure and the necessary work time flexibility due to participation
in interventional emergency care are further demanding factors, which may influence
subspecialization choice and potentially strain job satisfaction [9 ]
[10 ].
To understand the individual needs of young radiologists and thus improve residential
training in radiology, the Young Radiology Forum (Forum Junge Radiologie) and the
German Radiological Society (Deutsche Röntgengesellschaft, DRG), supported by the
German Society of Interventional Radiology and Minimally Invasive Therapy (Deutsche
Gesellschaft für Interventionelle Radiologie, DeGIR), conducted a survey of radiology
training conditions in Germany in 2018 [11 ]. While international radiological societies acknowledge the importance of dedicated
analyses of interventional radiology training [8 ]
[12 ]
[13 ]
[14 ], no such investigations exist so far in Germany.
The purpose of this survey was to investigate how residents and young radiology specialists
perceive interventional radiology training in Germany. We focused on identifying shortcomings
to propose specific improvement measures.
Materials and Methods
Development of the questionnaire and distribution
The survey was developed by members of the Young Radiology Forum and the German Society
of Interventional Radiology and minimally invasive Therapy. A dedicated software designed
to conduct online surveys (SurveyMonkey, SurveyMonkey Europe Sarl, Luxembourg) was
used to publish the questionnaire online from November 1 to November 30, 2020.
The addressees of the survey were resident physicians and board-certified radiologists
who were at least partially working in IR and younger than 40 years. To minimize selection
bias, the survey participants were recruited via the email distributors of the German
Roentgen Society (Deutsche Röntgengesellschaft, DRG), the German Association of Chairmen
in Academic Radiological (Konferenz der Lehrstuhlinhaber, KLR), the Chief Physician
Forum of the German Radiology Society (Chefarztforum der DRG, CAFRAD), the Heads of
the Institutions of the Professional Association of German Radiologists (Berufsverband
der Deutschen Radiologen e.V., BDR), and the Young Radiology Forum (Forum Junge Radiologie).
An email was sent at the beginning of the survey with reminders after two weeks and
three days before the survey was terminated. Duplicates were excluded by matching
the given answers’ IP addresses. Due to the anonymous nature of the survey, an ethics
committee approval was deemed not necessary.
Structure of the questionnaire
The questionnaire included 44 non-validated questions in total, which addressed the
six following topics: demographic and general working conditions (n = 11), personal
career preferences (n = 4), structure of the IR department (n = 5), women in IR (n = 2),
internal education and training in IR (n = 17), and congress attendance and external
training (n = 6). The survey mainly consisted of multiple-choice questions. In addition,
questions with multiple selections or complementary free-text options were presented.
The first set of questions included six questions focusing on demographic data (gender,
age, nationality, and number of children). Then, five additional questions queried
general characteristics of working conditions, including type of institution, working
hours, year of training of the survey participants, number of additional hours, and
satisfaction with the professional situation.
The second set focused on personal career preferences with four questions requesting
that participants identify their personal career preferences in general radiology
and interventional radiology in particular. In addition, reasons for a current interest
or lack of interest in interventional radiology were assessed.
The third set of questions analyzed the structure of IR service with five questions
regarding the number and qualifications of interventional radiology staff as well
as the presence of interventional radiological consultation hours, a dedicated interventional
radiological inpatient service, and interventional radiological 24-hour emergency
care.
The fourth set of 20 questions was designed to obtain a comprehensive representation
of the current educational situation in interventional radiology within the department.
The items queries included the existence and length of a dedicated rotation in interventional
radiology. A particular focus was placed on the participation of residents in interventional
procedures, which were thematically divided into emergency interventions and DeGIR
modules [15 ]. In addition, the general satisfaction with training and workload were surveyed.
Four questions focused on satisfaction with training in interventional radiology as
well as hurdles faced by trainees in interventional radiology.
The fifth set of questions investigated the role of women in interventional radiology
with a focus on identifying possible hurdles to prevent adequate training in IR for
female residents. Moreover, statistical differences regarding general job satisfaction
and satisfaction with IR training between genders were investigated.
The final set of questions addressed resident training and post-graduate education
with questions covering congress attendance and external training.
Statistics
Statistical analyses were performed using SPSS (v25.0, IBM Corp., United States).
Descriptive statistics with respective percentages were used. Normal distribution
was investigated with the Shapiro-Wilk test. If applicable, standard deviations for
normally distributed data and median with [25 %; 75 % range] for non-normally distributed
data were given. Student’s t-test for two groups and ANOVA test for multiple groups
were employed to test for significant differences in parametric data. The Mann-Whitney
U-test (MWU) and Kruskal-Wallis test (with MWU tests for post-hoc analysis) were used
for non-parametric data. P < 0.05 was deemed statistically significant.
Correlation was investigated using the Spearman’s rank correlation coefficient. Results
are given with 95 % confidence intervals. A correlation of > 0.7 was considered strong,
> 0.5 moderate, and > 0.3 weak.
Results
Demographics, personal life, and general working conditions
A total of 330 participants completed the questionnaire with demographic characteristics
summarized in [Table 1 ]. There was no significant difference in job satisfaction between different institutional
types (P = 0.52), participants with or without children (P = 0.68), marital status,
and families with children.
Table 1
Demographic characteristics of survey participants.
Participants
total
330
Gender
[%]
male/female
56/44
Age
[years]
mean ± SD
35 ± 7
Nationality
[%]
German
88
Austrian
2
other
10
Children
[%]
yes/no
36/64
Year of training
[years]
mean ± SD
3.6 ± 1.5
[%]
1st –3rd
40
4th –5th
43
> 6th
16
Working hours
[%]
full time/part time
88/12
Type of hospital
[%]
university hospital
42
maximum care hospital
34
standard care hospital
20
private practice
3
General job
[%]
very satisfied
20
satisfaction
somewhat satisfied
52
undecided
17
somewhat unsatisfied
7
very unsatisfied
4
Personal career preferences
The majority of participants expressed a high interest in IR (47 % very interested,
30 % interested) regardless of the training year (P = 0.92). Overall, 47 % of the
respondents were able to imagine subspecializing in interventional radiology, which
was second only to diagnostic radiology (60 %). Neuroradiology, no specific specialization,
and pediatric radiology were favored by 27 %, 27 %, and 6 %, respectively.
The three main reasons for an increased interest in interventional radiology were
professional interest (82 %), manual work (80 %), and therapeutic focus (61 %). Additional
free-text answers included the promising future and broadness of the profession, scientific
interests, as well as the possibility of interdisciplinary interactions. The reasons
for a lack of interest were primarily a predominant interest in diagnostic radiology
(55 %), radiation exposure during interventions (43 %), and a potentially higher workload
(36 %). Free-text answers mentioned the long duration of training, high stress level,
elevated level of responsibility, lack of high-quality training opportunities, uncertain
future perspective, and the lack of autonomous work in residency ([Fig. 1 ]).
Fig. 1 Personal career preferences and interest in interventional radiology. IR = interventional
radiology, prof. interest = professional interest, therap. focus = therapeutic focus,
incomp. family/work = incompatibility of family and work, lack of training opp. = lack
of training opportunities.
Characterization of the IR service
Dedicated interventional radiology patient care existed at most of the respondentsʼ
institutions (95 %) and interventional 24 h radiology emergency care was provided
in 84 % of the institutions. Outpatient interventional radiology consultation was
established in 32 % of cases, and a dedicated interventional radiology ward was available
in 13 % ([Fig. 2 ]). On average, interventional radiology service was provided by one (0.8 ± 0.6) chief
radiologist, three (2.9 ± 1.7) senior radiologists, and two (1.9 ± 2.5) residents
in training for radiology.
Fig. 2 Spectrum and infrastructure of the interventional radiology department. IR = interventional
radiology.
Education and training in interventional radiology
More participants were satisfied than dissatisfied with their IR training situation
(very satisfied (16 %) and somewhat satisfied (29 %) vs. very dissatisfied (20 %)
and somewhat dissatisfied (19 %)). There was no significant difference in satisfaction
between different institutional types (P = 0.15) or participants with or without children
(P = 0.99).
63 % of the participants had a dedicated rotation in interventional radiology at their
institution, with a median duration of 6 [3 ]
[6 ] months. The definition of a dedicated rotation was a fixed, contiguous period of
work in interventional radiology lasting at least one month during which the participant
is actively involved in interventional work. The currently practiced length of IR
rotations in participants’ institutions was considered appropriate by 57 % of participants
([Fig. 3 ]). In the group with rotation durations of at least 12 months, more than 90 % of
all respondents were satisfied with their IR training. Appropriate periods of 2–18 months
were mentioned in free-text responses, with 6–12 months being favored (n = 25 vs.
n = 21). Few participants wished for an interest-based length of the training period
(n = 4) or emphasized the importance of the continuity of the training period (n = 3).
Most residents received feedback during their rotation, which was institutionalized
in 18 %, took place regularly but was not institutionalized in 25 %, or happened irregularly
in 33 % of cases. The number of extra hours per week in IR was not significantly different
from diagnostic radiology (both 3 [1 ]
[5 ] hours; P = 0.15).
Fig. 3 Presence and duration of dedicated rotations in interventional radiology. IR = interventional
radiology.
Based on the DeGIR/DGNR modules, residents participated in most of the interventions
themselves. In Module A (vascular opening and reconstructive procedures) and Module
C (diagnostic punctures, and drainages), the proportion of interventions performed
partially independently to completely independently was higher than the proportion
of interventions in which only assistance was provided ([Fig. 4 ] for a detailed overview).
Fig. 4 Involvement of residents and young radiologists in interventional procedures. The
procedures are grouped according to the DeGIR modules. [15 ]. IR = interventional radiology.
Moderate correlations with IR education satisfaction were found for an institutionalized
structured feedback interview and the duration of the IR rotation (both p < 0.001).
Weak but significant correlations for education satisfaction were obtained with respect
to performing interventions independently or partially independently (Modules A–D;
all p < 0.001; [Table 3 ]).
Table 3
Correlation of different parameters with interventional radiological education satisfaction.
Significant values are marked with *; p < 0.05 was considered statistically significant.
Correlation: satisfaction with IR training
r
95 % CI
P
Institutionalized IR rotation
0.38*
0.26–0.49
< 0.001
Duration of the IR rotation
0.51*
0.40–0.60
< 0.001
Institutionalized structured feedback
0.54*
0.44–0.63
< 0.001
Senior/resident ratio
0.07
-0.07–0.20
0.29
Autonomous work
Module A
0.37*
0.25–0.48
< 0.001
Module B
0.41*
0.30–0.52
< 0.001
Module C
0.31*
0.19–0.43
< 0.001
Module D
0.38*
0.26–0.48
< 0.001
Module E
0.13*
0.00–0.25
0.05
Module F
0.07
-0.06–0.20
0.25
Other
0.14*
-0.01–0.28
0.05
Congress visits
0.14*
0.01–0.27
0.03
Workshop visits outside of congresses
0.07
-0.06–0.20
0.26
IR = interventional radiology, 95 % CI = 95 % confidence interval.
Most participants identified room for improvement particularly in the form of a structured
training curriculum (67 %) and in the form of the ability of residents to more actively
perform interventions (55 %; [Fig. 5 ]). Free-text answers included earlier exposure to interventional radiology rotations,
interest-based or longer rotations, the guarantee of a rotation during general radiological
training, an increased number of trainees, improvement of infrastructure-based strain
(increased staffing ratios, reduction of time pressure, decrease of overtime hours,
broader case ranges), an increase in training quality (better supervision, structured
training, elaborated feedback techniques, case reviews), a longer supervised learning
period, as well as stricter control mechanisms of official national bodies to ensure
training quality.
Fig. 5 Areas of potential improvement in IR training. IR = interventional radiology.
Free-text responses to the question “What hurdles prevent adequate training in IR?”
included the lack of a guaranteed rotation (n = 29), an inadequate amount of training
opportunities (n = 13), and the lack of reasonable selection criteria to receive mentoring
in IR during residency (n = 5). Furthermore, a general shortage of staff in radiology
departments leads to a transfer of trainees from training positions in IR to other
radiological modalities according to the participants (n = 22). The complete lack
or insufficient amount of (independent) practical work, the small number of completed
training cases, and the absence of an IR training curriculum during their rotation
were each mentioned by twelve participants.
Women in interventional radiology
The general job satisfaction of women was comparable to that of male colleagues (P = 0.39).
However, womenʼs satisfaction with IR training was lower than that of male participants,
albeit without reaching statistical significance (P = 0.06; [Table 2 ]). Free-text answers to the question “What hurdles prevent adequate training in IR
for female residents?” included the lack of encouragement for female residents (n = 12)
due to the possible risk of pregnancy, interest in starting a family, and physical
constitution. In addition, reasons concerning work-life balance, such as part-time
employment (n = 8), parental leave (n = 4), being a parent (n = 2), and incompatibility
of family and working place obligations (n = 4) were also considered.
Table 2
Satisfaction with IR training and general job satisfaction in relation to gender p < 0.05
was considered statistically significant.
Satisfaction with IR training [%]
P
General job satisfaction [%]
P
Female
Male
Female
Male
Very satisfied
16
16
0.06
17
23
0.39
Somewhat satisfied
22
35
54
50
Undecided
18
16
19
15
Somewhat unsatisfied
19
18
4
10
Very unsatisfied
25
16
6
2
IR = interventional radiology.
Congress attendance and external training + postgraduate training/courses
Many respondents attended congresses more often than once a year (32 %) or at least
once a year (48 %). The three most frequently attended congresses were the German
Roentgen Congress (Deutscher Röntgenkongress; 80 %), the European Congress of Radiology
(ECR, 25 %), and the Congress of the Cardiovascular and Interventional Radiological
Society of Europe (CIRSE; 17 %). The main reasons for congress participation included
interest in scientific education (62 %), professional education in congress sessions
(70 %), and workshops (60 %; [Fig. 6 ]). Apart from congresses, the majority of respondents have not attended workshops
yet (60 %), compared to 34 % who attend these workshops on average one time per year,
and 6 % who do so more often. Possible incentives for increased congress participation
included hospital coverage of registration costs (51 %) and the availability of different
kinds of workshops, e. g., tailored to different levels of expertise (29–51 %; [Fig. 6 ]).
Fig. 6 Congress participation and field of interests regarding congresses. Prof. edu. = professional
education.
Discussion
Interventional radiology (IR) is a growing subspecialty of radiology [1 ]
[2 ]
[3 ]
[4 ]. The presented survey investigated the training situation and general opinion of
residents and young radiologists in interventional radiology in Germany for the first
time. Furthermore, we aimed to identify potential issues to improve training in interventional
radiology to prepare the subspecialty for the future. We consider the discussion crucial
since care will be provided by those who are skilled and organized – regardless of
the discipline. If radiologists want to continue to offer minimally invasive interventional
procedures in this competitive healthcare system, we must ensure solid training. Furthermore,
we should draw the correct conclusions from criticism and be open to innovation.
Personal career preferences
The key message from this survey is that interest in interventional radiology among
young radiologists in Germany is very high regardless of their level of training.
We assume a keen interest when 77 % of respondents are interested in interventional
radiology and 47 % can even envision a dedicated specialization in this field. These
figures are markedly higher than those previously reported by various international
studies ranging from 30 % among residents already working in IR to 20 %-35 % among
residents working in general radiology [8 ]
[9 ]
[11 ]
[12 ]
[16 ]. The reasons for interest or non-interest in interventional radiology are comparable
to the results of previous inquiries [8 ]
[9 ]
[11 ]
[12 ]
[16 ]. While diagnostic radiology faces its own uncertainties, e. g., implementation of
artificial intelligence, interventional procedures are undoubtedly an expanding field
in health care with a chance for radiology to be a part of that development. The aspect
of manual work and the chance to provide therapy are key arguments in favor of IR
in our study. Concerns that were mentioned are mainly radiation exposure and workload
issues. In line with those concerns, radiation protection during interventions is
constantly being improved and innovative software solutions can significantly reduce
the radiation dose by up to 35 % [17 ]
[18 ]. Furthermore, our survey shows that overall overtime hours in interventional radiology
were not higher than in diagnostic radiology. The reasons for the perception of a
higher workload are speculative, but could, for example, be due to individual, very
time-intensive interventions, so that the workload is markedly increased on certain
days and is less predictable.
Characterization of IR service
A prerequisite for successful training in interventional radiology is undoubtedly
the infrastructure provided by the institution. Most of the surveyed workplaces have
an interventional radiology department with a broad treatment spectrum and 24 h emergency
care available. Some even have dedicated radiology wards and consultation hours. There
appears to be a discrepancy between this data and the 37 % of residents who do not
receive an organized rotation in IR in their perception. One possible cause could
be that staffing of IR units is insufficient or that training in other modalities
is prioritized over IR. This coincides with the fact that several participants report
being regularly withdrawn from IR to compensate for staff shortages in other areas.
As the infrastructure to provide high-quality education in interventional radiology
seems readily available, organizational adjustments and an improvement in the staff
situation appear mandatory to ensure the basis for successful IR training. The survey
demonstrated keen interest in IR training on the part of the current generation of
residents based on their request for longer rotations in IR of up to 12 months. Such
a change would ensure the development of skills towards the independent execution
of procedures and full integration into IR service.
Education and training in interventional radiology
General job satisfaction (72 % satisfied) and satisfaction with IR training (45 %
satisfied) were higher compared to other disciplines like internal medicine (38 %),
urology (44 %), and ophthalmology (40 %) [19 ]
[20 ]
[21 ]. Nevertheless, satisfaction with IR training is lower than with training in general
radiology, which is similarly high (65 %) in a previous published survey by Oechtering
et al. in 2018 [11 ]. There is certainly room for improvement considering that 39 % of participants were
not satisfied with their IR training conditions.
The data from our survey suggest that the following areas are particularly relevant
to the quality and satisfaction of IR training: 1) the length of rotation in IR, and
2) the existence of a structured training curriculum with appropriate feedback from
trainers.
When participants were asked directly about areas of improvement, longer rotations
and more autonomy when performing interventions were frequently mentioned, which were
also confirmed by the significant correlations with training satisfaction. At most
institutions, the rotation time was six months, which was considered too short by
43 % of the respondents. On the one hand, in the group with rotation durations of
at least 12 months, more than 90 % of all respondents were satisfied, and none of
the respondents were dissatisfied with the IR training. On the other hand, a rotation
time of 6 months was mentioned as adequate by several participants. One possible conclusion
is that the appropriate rotation time depends on individual interest. This could be
asked for in the context of a structured training interview during further training.
Several free-text statements of the respondents indicated a possible reason for short
rotation times. The relatively low mandatory amount of conducted interventional radiological
procedures in official German training regulations, compared to cross-sectional imaging
examinations, is one reason why residents cannot spend more time in interventional
radiology. Otherwise, they run the risk of extending their training period until they
become a certified radiologist. Especially against the background of the high interest
among young radiologists and the growing clinical importance of interventional radiology,
this should be a reason to reconsider the weighting of interventional radiology in
training regulations. We recommend a rotation time of at least 6 months based on this
data since less time leads to low satisfaction among trainees.
The most frequently stated suggestion for improvement was the implementation of a
structured training curriculum. This was also a commonly mentioned aspect in the study
by Oechtering and colleagues and has just recently been developed by the Young Radiology
Forum, the DeGIR, the DGNR, and the DRG. It will be interesting to see whether the
introduction of the curriculum impacts the structure of education within the departments
and leads to increased satisfaction in the future as anticipated by both study participants
and the literature [8 ]
[11 ]
[22 ]
[23 ]. The curriculum can also be used to promote the (partly) independent execution of
interventions by residents, which also correlated with satisfaction. While feedback
is provided in most institutions, it is rarely institutionalized. The authors strongly
advise structured and institutionalized feedback especially since it is relatively
easy to establish and the relationship with increased job satisfaction is supported
by the data of both this and a previous publication [11 ].
Women in interventional radiology
Although the data did not reach the significance level, female residents tended towards
lower satisfaction with the training conditions in interventional radiology. Systematic
investigation of the reasons for this was beyond the scope of this study and therefore
any conclusions remain speculative. However, free-text answers regarding specific
hurdles for young female radiologists indicate that it is difficult to reconcile family
obligations and the perception of a higher workload in interventional compared to
diagnostic radiology. As mentioned above, the number of extra hours in IR was not
significantly different from diagnostic radiology in our study. Although time-intensive
emergency interventions can occur in IR, this problem can certainly be partly mitigated
by suitable staffing and the obligatory establishment of 24-hour emergency service
in radiology departments. This would have two advantages: firstly, it would enable
highly qualified female radiologists to work in IR. Secondly, the radiologist would
also be perceived as a therapist in the clinical environment – strengthening the position
of radiology in relation to other disciplines. Moreover, preference for male residents
in male-dominated departments is also mentioned, although other respondents also indicated
no gender-specific hurdles. Overall, answers given by the study participants closely
coincide with concerns compiled in international publications on this topic [24 ]
[25 ]
[26 ]. The authors recommend a change in structure and support in the IR working environment
to attract more women to the subspecialty and encourage them to take on leadership
positions. However, further investigation focusing on female residents in IR seems
warranted.
Congress attendance and external training + postgraduate training/courses
In addition to training in the clinical environment, there is a very high level of
willingness to embrace education outside the daily training program. Educational activities
at congresses are one of the main drivers for young radiologists to attend such events.
A large proportion of participants would welcome a broader range of workshops, especially
at the most frequently attended congress, the German Roentgen Congress. Although this
congress is not explicitly focused on interventional radiology, more interventional
workshops could inspire many young radiologists to pursue interventional radiology
further. Interestingly, when asked, “What would prompt you to visit more congresses?”,
more than 35 % of participants mentioned more scholarships. Scholarships, however,
were the most negligible response when asked, “Why do you visit congresses?”. A possible
reason for this could be the insufficient quantity of scholarships or the lack of
awareness of the programs offered. A wide range of workshops targeting different levels
of expertise and scholarship programs, e. g., the “Flinke Finger” program for medical
students [27 ], are offered by different institutions and societies. An expansion of programs or
better advertisement could be helpful here.
Limitations
This survey has several limitations. Since the items were not validated in a standardized
manner, this may have distorted the results. The limited cohort size of 330 participants
possibly influenced the results. The representativeness of the study population for
the target population cannot be validated because essential demographics and other
characteristics such as place of residence were not collected for the target population
due to the anonymous nature of the study. Due to the focus on interventional radiology,
a particular preselection bias cannot be excluded. Furthermore, no differentiation
was made between neuroradiology and radiology departments, which introduces a possible
selection bias, especially considering complex neurointerventions and resident participation
in these interventions.
Conclusion
There is a high interest in interventional radiology among radiological residents
and young radiologists. The majority of German radiology departments provide the required
infrastructure with semi-structured interventional training. However, trainees in
interventional radiology describe only medium satisfaction with their training. This
discrepancy represents the potential for further improvement of IR training, e. g.,
including the presence and duration of an organized rotation in interventional radiology
and a structured curriculum with face-to-face feedback. Participants placed particular
emphasis on structured guidance by senior interventionists during procedures. Satisfaction
among women was somewhat lower than among male study participants. Further research
into the causes of this gender discrepancy and efforts to address these issues are
therefore desirable. We consider the improvement in IR training crucial and a chance
for radiology in general since there will be a demand for more minimally invasive
procedures provided by those who are skilled and organized in competitive health care
systems.
