M. Victoria (Vicki) Marx, MD, FSIR, is a professor of clinical radiology, the vice chair for education, and director of the radiology residency training program at the University of Southern California. The current SIR treasurer, she has been an active SIR volunteer for more than 25 years. Dr. Marx chairs a committee tasked with the development of IR material for the American Board of Radiology (ABR) Core Exam. This recent role, coupled with her background in education and current vantage point as director of a radiology residency program, places her in a unique position to consider the future of education in IR.
The opinions expressed by Dr. Marx in this interview are those of her alone, and should not be taken to imply that she is representing the perspective of the ABR or any other stakeholder in interventional radiology education.
COLLINS: What are the unique educational needs of IR trainees beyond what is offered in a traditional diagnostic radiology program?
MARX: The unique educational need that will be clearly addressed in the new IR Residency is patient care education—not just during the procedure, but specifically education in clinical decision-making before and after the procedure. The new IR Residency program requirements include clearly defined clinical components that address these issues.
COLLINS: How will the recently approved IR Residency strengthen IR education?
MARX: In addition to the clear patient care component, there will be added procedural education because the entire program is longer. There are also articulated opportunities for interdisciplinary education that current IR fellows could avail themselves of but that are rarely taken advantage of by many programs.
For example, it is indicated in the FAQs on the ACGME website that you can do interdisciplinary clinical interventional radiology-related rotations with hematology-oncology, hepatology, vascular surgery, etc.—any rotation that might be pertinent to IR education. With the clinical education in the IR Residency, there is clearly an expectation that IR residents will be exposed to in-patient, consult and out-patient experiences in the world of IR.
COLLINS: What unique skills will graduates of the IR Residency have to improve patient care beyond those acquired in the traditional pathway of a DR residency followed by an IR fellowship?
MARX: The close integration of imaging and procedures with longitudinal patient care. This defines the specialty of interventional radiology as unique from other specialties performing image-guided interventions.
COLLINS: In your opinion, how will the recognition of the IR/DR Certificate and dedicated residency pathway influence the public’s perception of interventional radiologists?
MARX: I think it’s a little soon to tell. That being said, a community of physicians who view themselves as a unique specialty, rather than a subspecialty, may develop a culture that can present itself in a more forward fashion to the public.
COLLINS: Now that medical students need to select the IR Residency, how can SIR and practicing IRs increase the visibility of our specialty to medical students?
MARX: The first way is to have a faculty member become an adviser for interventional radiology interest groups. The SIR resident and fellows section website has an interactive map that shows where these interest groups exist and materials on their website provide detailed support to develop an interest group at a medical school.
Second would be to quickly develop radiology electives or “selectives.” Medical schools now have a large number of elective options that can be two, three or four weeks in duration. Our medical school just started a month-long elective for senior students to do two weeks in subspecialties that they might not otherwise get any experience in. This has been classified a “career decision-making” elective. There are many options that need to be made available to medical students.
Third, someone in the IR division needs to work with the DR clerkship director to make sure that IR has a presence in the existing clerkship. In most schools, this is an elective, although in some it is a requirement. Finally, an IR faculty member must be willing to act as a medical student adviser. The need for a faculty adviser has already become apparent to me—yesterday, three third-year medical students met with me to discuss strategies for pursuing a career in IR.
COLLINS: Can you comment on the role of simulation in radiology education and IR education in particular?
MARX: Although I have limited simulation experience related to a pilot program at our institution, our culture is increasingly risk adverse and patients don’t expect to be anybody’s first case. Increasingly, simulators are present in many surgical training programs—we have a simulation lab at USC that the surgeons use. The surgeons also use cadavers for teaching in this lab.
We do use phantoms to credential our residents for paracentesis and thoracentesis procedures. The only procedures that radiology residents are allowed to do without direct supervision, according to the DR program requirements, are PICC insertion, paracentesis and thoracentesis. However, one must document that residents are competent before you can let them perform these procedures with indirect supervision.
So what we have done is develop a training program where a faculty member gives the residents a didactic conference, has them all go through simulated US-guided thoracentesis procedures using a phantom that has ribs and intercostal blood vessels that have to be identified and avoided. Subsequently, residents have to perform five thoracentesis procedures under direct supervision and get signed off; the goal is for all first-year residents to get signed off by the end of the PGY-2 year. This is the first year that we have implemented this program and we will have to see if all 10 of our residents will be deemed competent by the end of the pilot.
COLLINS: Can you comment on the advantages and disadvantages of computer-based testing to assess a trainee’s IR knowledge base compared to the traditional oral examination strategy?
MARX: A computer-based exam is absolutely fair. Everybody gets essentially the same exam. So from the standpoint of objectivity and fairness you can’t beat this approach. The problem with the computer-based exam where every question has to have one right answer is that there are a lot of scenarios in IR that, by the nature of clinical practice, have more than one right answer. And testing trainee judgment and response to the unexpected is, I would say, easier to do with the more subjective oral exam format.
COLLINS: How is the ABR trying to address this challenge?
MARX: To the extent that I am aware, I believe that the certification exam leading to the ABR certificate in diagnostic and interventional radiology will have a computer-based and oral exam component. The computerized component will cover DR with some interventional radiology material; the oral component will cover IR with material similar to what the vascular and interventional radiology CAQ covers, with the addition of a patient care focus.
COLLINS: Although I realize it is difficult to predict the future, do you foresee the ABR eventually replacing the oral examination in IR three months after completion of training with a computer-based exam?
MARX: I would say that I can’t predict the future. However, I would like the future to continue to have an oral-based exam component.
COLLINS: What do you think of the changes in IR education due to the new IR Residency?
MARX: I think that it is a huge change involving many people and that it is very, very exciting. Five years from now it will be great. A lot of us are doing a lot of work to get to that point.
