Interventional radiology training and specialty status varies across the globe. In recent years, several countries have amended their training pathways, but there remains no uniform approach to education. In this article, we discuss the status of training efforts in the United Kingdom, Europe and the United States, to showcase the similarities and differences in how international IRs are educated.
Training in the United Kingdom
In the United Kingdom, interventional radiology has been a subspecialty under the Royal College of Radiology since 2011 with a structured training pathway that lasts 6 years (figure 1). Doctors can apply for radiology training in their second post-graduate (foundation) year, having spent time rotating through various non-radiology specialties. Radiology training is normally of 5 years duration for diagnostic trainees and 6 for IR trainees. Until very recently, 3 years of diagnostic training were required before one could apply for an IR fellowship and an additional 3 years of training; however, starting in 2022, trainees will be able to apply for an IR post from year one. This is seen as a major step in the right direction and will remove the previous uncertainty around securing an IR training post. IR trainees will still be required to complete 3 years of dedicated IR training, but their first 3 years will contain more IR and clinical training, so they may enter their dedicated coursework ready to perfect these skills.
The current intention is to maintain flexibility in the system to allow crossover, so that if trainees decide to change their path from IR or DR, they will have the ability to transfer. How this will work in practice remains to be seen and only time will tell. The IR curriculum will not change significantly since it was recently updated by the Royal college of Radiology with the support of the British Society of Interventional Radiology (BSIR) to ensure adequate coverage of vascular and non-vascular IR.1 All trainees, regardless of their final subspecialty intentions will still need to sit the final fellowship of the Royal College of Radiologists (FRCR) examination.
Training in Europe
Across Europe, there is wide variation in IR training. CIRSE’s European Trainee Forum (ETF) recently reviewed and mapped IR training in the various training systems via questionnaire, obtaining responses from the representatives of 24 European countries which confirmed this heterogeneity. IR has gained official subspecialty status in only 9 of 24 (37.5%) of the countries; however, structured IR training programs are available in 15 of 24 (62.5%). Great heterogeneity was reported in terms of duration of IR training, with 9 countries offering up to a 1 year, 10 countries offering up to 2 years and only 5 offering more than 2 years. In only 11 out of the 24 countries, was there an official IR certification examination post completion of training. Clinical training was only included as part of the IR curriculum in 7 countries, where it ranged from 2–6 months of vascular surgery or intensive care.2,3 In order to harmonize, support and certify training, CIRSE developed the European Board of Interventional Radiology examination (EBIR) in 2010 which has gradually evolved to become a highly professional and internationally recognized examination. This has been taken by candidates from within and without Europe (42 different countries) with > 850 holders at the time of writing.
A recent trainee survey performed by the BSIR trainee committee in collaboration with CIRSE’s ETF and SIR Residents showed that despite the heterogeneity of training, the vast majority of trainees in Europe are happy with the overall quality of training they receive as well as their quality of life. There remain issues of competition from other specialties and concerns around reciprocity of training, particularly for endovascular aortic and peripheral arterial work.3,4 This review showed that concerns around endovascular training are most acute in the United States and less frequent in Europe. In the UK, trainees reported a greater satisfaction with their exposure to vascular training. Heretofore, this has not been an issue for Irish trainees.
Training in Ireland
Radiology training in Ireland (overseen by the Faculty of Radiologists, Royal College of Surgeons in Ireland) is a 5-year residency consisting of 4 core years followed by a final year in the resident’s subspecialty of choice. Entrance to the training programme remains intensely competitive. All entrants will have completed a minimum of two years of clinical practice prior to commencing Radiology; however, most will have spent 3–4 years in Medical or Surgical practice before starting, resulting in a strong, clinical base. All radiology residents rotate through IR as part of their core 4 years, IR teaching and training (including vascular simulator-based training) being core components of the educational program which follows a common centrally-prescribed curriculum and incorporating central and local institutional-delivered components. At the end of fourth year, residents must pass a general Radiology exit examination (FFRRCSI—equivalent to the North American Board examinations). Those interested in pursuing IR will choose IR as their fifth year, following which they will complete an additional IR Fellowship in a non-Irish center, most commonly North America, the United Kingdom or the Antipodes. Those pursuing IR take the European Board of Interventional Radiology examination (CIRSE) at the end of their dedicated IR fifth year or first year of fellowship (adopted by the Faculty as the recognized exit exam in IR). Many Irish radiologists undergo two years of fellowship training to enhance their competitiveness in the job market. Scholarly pursuits leading to publications are expected and thus most will assume positions as attendings in major academic teaching hospitals.
A large proportion ultimately return to Ireland for most of their attending careers where the majority work in public academic teaching hospitals, some of whom also provide IR services to affiliated private hospitals. A minority of IRs work in sole private practice hospital settings; however, prohibitively high malpractice insurance is a disincentive.
IR is well regarded by other subspecialists and collaboration, rather than competition is the norm, albeit some turf battles are ongoing with vascular surgeons for PAD and aneurysm work in particular.
The Irish IR community is currently engaged in a lengthy process with the Medical Council to achieve subspecialty recognition, which is anticipated in the near future. Despite the current lack of such recognition, most Irish IRs have a clinical practice model, seeing patients referred from Family Practitioners and other Hospital-based attendings in clinic pre-and post-procedure or as in-house consults. Most IRs have day bed rights and a significant proportion have admitting rights; the latter usually reflecting individual IR’s motivation, requiring negotiations with hospital managers rather than an institutional ‘given’. IR residents and Fellows participate fully in this clinical practice.
Training in the United States
In the United States, IR was recognized as a primary medical specialty by the American Board of Medical Specialties in 2012, and in 2015 the integrated IR residency program was approved by the American College of Graduate Medical Education. With the new integrated IR model, trainees have three pathways to become an IR (Fig. 2). The most common pathway would allow medical students to match directly into a 6-year integrated IR residency program, consisting of the traditional intern year followed by 5 years of integrated IR/DR training. For medical students who are unsure about pursuing IR directly out of medical school, two additional pathways include:
The 5-year early-specialization (ESIR) program, which allows residents in diagnostic radiology to focus the last year of DR training on IR skills before matching into a one-year independent IR residency.
Completing a 2-year independent IR residency after finishing the 5-year DR residency.
Like the UK training model, these pathways allow for flexibility, as residents who match into DR residency still have the option to pursue IR if desired, while integrated IR residents can switch into the DR residency program should they decide that IR is not for them.
The creation of the integrated IR residency program was aimed to produce IR graduates who are strong both clinically and procedurally, being able to uphold the clinical practice model of IR going forward. Residents are expected to have regular IR rotations throughout residency that includes outpatient IR clinic to provide experience in longitudinal patient care, as well as inpatient rotations that stress comprehensive medical management and vascular medicine such as ICU and vascular surgery. After completion of IR/DR residency, trainees will need to pass both the written and the oral portions of the ABR certification exam to receive the IR/DR Certificate.
Conclusion
In each country, the curriculum is designed to prepare future IRs for clinical and procedural work, with many training programs allowing flexibility to choose between IR and DR. Given the close collaboration between international IRs, understanding the similarities and differences in training can increase the sharing of ideas, educational opportunities and progression of the specialty on a global front.
References
- Interventional radiology curriculum. The Royal College of Radiologists. rcr.ac.uk/clinical-radiology/specialty-training/curriculum/interventional-radiology-curriculum
- CIRSE European Trainee Forum Subcommittee. Status of vascular and interventional radiology training in Europe. Cardiovascular and Interventional Radiological Society of Europe. April 2020. cirse.org/wp-content/uploads/2020/05/ETF_survey_brochure_2020_web.pdf
- Makris G C, Burrows V, Lyall F, Moore A, Hamady M S. Vascular and interventional radiology training; International perspectives and challenges. Cardiovasc Intervent Radiol (2021)44:462–472
- CIRSE European Trainee Forum Subcommittee. Medical students’ perspectives on IR. March 2021.
- Career Pathway. irjuniors.com.
- SIR-RFS. Past, current, and future IR training models. rfs.sirweb.org
