318 radiology.rsna.org n Radiology: Volume 273: Number 2—November 2014

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The approval of the new certificate in interventional radiology (IR) and diagnostic radiology (DR) by

the American Board of Medical Spe-cialties (ABMS) was the culmination of more than 7 years of focused work and was just one incremental step in more than 2 decades of change in IR training (1). The approval was a notable event for two reasons: The basic training schematic in IR was changed from a 1-4-1 pattern (years of internship-years of DR-years of IR) to a 1-3-2 pattern, and IR was recognized as a primary specialty of the American Board of Ra-diology (ABR). Of critical importance and by careful design, IR remains a part of radiology, interventional radiologists remain radiologists, and the new pro-grams will reside within radiology de-partments and report to DR chairs. The new certificate signifies competence in both DR and IR. Nevertheless, this is a big change for radiology and engen-ders much passionate discussion among stakeholders (2).

A brief summary of the history of this change may be useful to the reader. The impetus for change in IR training has existed since the initial recognition of vascular and interventional radiology (VIR) as a subspecialty of radiology by the ABMS in 1994 (3). The major driver of this change has been the im-portance of nonprocedural patient care in IR, and therefore the need to provide this additional training. In addition, the practice of IR is now far more complex than in 1994, when a 1-year fellowship was adequate.

In 2000, the Society of Intervention-al Radiology (SIR) created the voluntary Clinical Pathway in IR, in which a res-ident has 16 months of training in pa-tient care specialties, 29 months of training in DR, 24 months of training in IR, and 3 months of research (4). The ABR agreed to examine graduates of this program because it was essentially

a modification of the existing Holman Pathway (a training pathway that allows 18–21 months of research [5]). How-ever, only a handful of programs imple-mented this Clinical Pathway.

In 2005, the ABR approved another voluntary alternate pathway called the DIRECT (Diagnostic and Interventional Radiology Enhanced Clinical Training) Pathway (6). This provisional pilot pathway was intended to provide ac-celerated training for residents inclined toward clinical care and intervention who were transferring from other spe-cialties. The ABR counts 2 years of clin-ical training toward fulfillment of the DR requirements, decreasing the over-all duration of training in DR and IR by 1 year. Thus, DIRECT residents have 24 months of training in patient care spe-cialties, 27 months of training in DR, and 21 months of training in VIR. The DIRECT Pathway has been successful in a few institutions, but, like the VIR Clinical Pathway, has not been widely adopted.

In 2006, the SIR commissioned a Primary Certificate Task Force to develop a proposal for a primary cer-tificate in IR. The justification for a primary certificate (and therefore rec-ognition as a specialty) was the unique combination of competencies that con-stitute IR: imaging, procedures, and nonprocedural patient care. The last of these three competencies is what distinguishes IR from a focused area of practice (or subspecialty) of DR. In 2007, the ABR agreed to support such a proposal, which was ultimately presented to the ABMS in 2009. The proposed training would have resulted in certification in IR alone. This was rejected by the ABMS based in part on details of the training that did not adequately address imaging compe-tency; however, permission was given for resubmission of a revised proposal. A 2-year process of reexamination of

1 From the Dotter Interventional Institute, Oregon Health and Sciences University Hospital, 3181 SW Sam Jackson Park Rd, Mail Code L-605, Portland, OR 97239. Received May 31, 2014; final version accepted June 20. Address correspon-dence to the author (e-mail: kaufmajo@ohsu.edu).

q RSNA, 2014

John A. Kaufman, MD, MS, Chair, SIR IR/DR Task Force

the interventional Radiology/diagnostic Radiology Certificate and interventional Radiology Residency1

Note: This copy is for your personal non-commercial use only. To order presentation-ready copies for distribution to your colleagues or clients, contact us at www.rsna.org/rsnarights.

CONTROVERSIES: The IR/DR Certificate and IR Residency Kaufman

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the concept, assessment of stakeholder needs, collaborative development with key radiology partners such as the Association of Program Directors in Radiology (APDR) and the Society of Chairs of Academic Radiology Depart-ments, compromise, and garnering of consensus and support from within DR followed (7). This approach resulted in a major change in the structure of the proposed training, which now consisted of 3 years of DR followed by 2 years of IR. In this proposal, two additional DR rotations (mammography and nuclear medicine) and one clinical rotation (in the intensive care unit [ICU]) were re-quired during the IR years. The grad-uate would be an individual certified in both DR and IR. At one point, the proposal was debated publicly by more than 400 delegates representing the gamut of DR at the 2011 American Col-lege of Radiology (ACR) Annual Meet-ing and Chapter Leadership Conference (8). The delegates voted unanimously to lend ACR support to the proposal as an additional training pathway. It is worth noting that the training proposed for the IR/DR certificate had more DR training (35 months) than either the earlier Clinical or DIRECT Pathways or the Holman Pathway.

The final proposal was structured to take advantage of the new DR curricu-lum, in that the R1–R3 years were iden-tical to and were meant to occur within a DR residency. In the new DR curric-ulum, the R4 year is intended to allow residents to focus training in areas of interest (9). In the IR/DR proposal, most of this year was applied toward IR training, while the entire R5 year was dedicated to IR.

The final proposal was also designed to allow a gradual introduction of this new program, as it was recognized that the seemingly small change from 4-1 to 3-2 was actually substantial. As the pro-posal was presented to the ABMS, both VIR fellowships and the new residencies leading to an IR/DR certificate would have coexisted, although the ABR was clear that this would not be continued indefinitely. However, the proposal did not provide any concrete end date for the VIR fellowships.

The proposal was submitted to the ABMS in the spring of 2012 and was approved in September of that year. During the approval process, the ABMS mandated that a timeline be developed for the transition from VIR fellowship to the new residency (7). The proposal then moved to the Accreditation Coun-cil for Graduate Medical Education (ACGME) and was approved first by the radiology Residency Review Committee (RRC) and then by the ACGME board of directors in February, 2013. The res-idency and the writing of the program requirements were assigned to the radiology RRC. A committee was as-sembled to compose the requirements under the careful guidance of Jeanne Laberge, MD. This committee included representation by key DR stakeholders, and each detail was carefully vetted in terms of overall feasibility, impact on DR residents and programs, fulfillment of training goals in DR, and fulfillment of training goals in IR. The program re-quirements were posted for public com-ment on May 19, 2014 (10). There are some differences between the original proposal and the actual program re-quirements, largely as a result of care-ful vetting of issues among DR stake-holders, but in principle it remains a 3-2 training program. The ACGME has named the training that leads to an IR/DR certificate the “IR residency.”

Concerns about this new IR/DR certificate can be grouped into four basic categories: the process of getting to the new certificate, the rationale for the change, programmatic challenges, and implications for further structural changes in radiology (2). The main process issue is the mandate by the ABMS to phase out VIR fellowships as the new training programs are phased in. As noted above, the proposal pre-sented to the ABMS, with wide en-dorsement by DR stakeholders, would have allowed the VIR fellowships and IR residencies to exist in parallel. The member boards of the ABMS would not permit this situation to exist indefinitely for two reasons: First, they believed that there should not be two different certificates offered by one board for a single discipline. This would confuse

the public. Second, and of overarching importance, all of the member boards of the ABMS viewed the changes in training leading to an IR/DR certificate to be in the best interest of patients, and therefore wanted a scheduled rather than an indefinite transition. The mandate to ultimately convert all VIR fellowships to IR residencies rep-resents the highest endorsement of this proposal by all of organized medicine.

This transition was never intended to be abrupt, nor could it be, as the lengths of training in DR and IR are changed for these residents. In addi-tion, each VIR fellowship that converts to an IR residency has to be formally accredited by the radiology RRC, a process that is anticipated to take 6 or 7 years at a minimum (7). During this time, the ABR will continue to exam-ine graduates of VIR fellowships, and it is designing processes for convert-ing VIR subspecialty certificates to IR/DR specialty certificates. DR and VIR programs will therefore have a con-siderable amount of time to plan and implement these changes. The SIR has constituted a task force and the APDR a committee to assist programs through this transition (11,12).

The second category of concern is the rationale for this change. IR shares with DR competency in imaging and competency in image-guided procedures. However, the practice of IR requires cer-tain additional skills and activities that are distinct from those of DR. In many cases, the IR physician conducts a phys-ical examination and obtains a patient history separate from the performance of a procedure, independently formu-lates a plan of evaluation and treatment, performs that treatment, and provides follow-up care. The care of the patient requires assumption of longitudinal

Published online10.1148/radiol.14141263 Content codes:

Radiology 2014; 273:318–321

Conflicts of interest are listed at the end of this article.

See also the article by Heitkamp and Gunderman in this issue.

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inpatient and outpatient patient man-agement responsibilities by the IR phy-sician. Nonprocedural care provided by IR physicians is real. Between 1998 and 2008, the number of Evaluation and Management codes submitted by IR physicians for Medicare beneficiaries per year increased 1200% (from 4210 to 54 726) (13). This likely underestimates the actual nonprocedural clinical activ-ity, as younger patients, such as those with uterine fibroids and varicose veins, would not be captured in the Medicare claims data. One year of IR residency is no longer adequate training to provide this care.

The third set of concerns is related to the programmatic changes involved in implementing a new residency. These include the adequacy of training in DR, the ability of medical students to be able to commit to IR while in medical school (or for DR residents to opt in later in training), jurisdictional chal-lenges between DR and IR program directors, stress on the training re-sources, potential lack of commitment of IR residents to DR, and perhaps a negative impact on the overall number of DR faculty members needed to train residents. Most of these concerns are not new to the individuals who pre-pared the two ABMS proposals, nor to those who wrote the ACGME program requirements. In anticipation of these concerns, mechanisms to address them were devised and embedded in the pro-gram requirements. For example, the ACGME decided that two structures for the IR residencies—integrated or independent—were necessary. The in-tegrated program provides 5 years of training (3 years in DR and 2 years in IR) in a single institution, whereas the independent program provides only the final 2 years of IR training. In integrated programs, residents enter from medi-cal school or from a DR program in the same institution, while in independent programs, residents enter after com-pleting a DR residency. These programs can coexist, so a program may accept residents at multiple time points. The draft program requirements carefully state that integrated programs can ac-cept only transfers from within their

own institution; otherwise, completion of a DR residency is required. However, the program requirements allow for a resident who has finished 4 years of DR, during which he or she completes sufficient rotations in IR or IR-related disciplines, to be credited for 1 year of the IR portion of the IR residency. In other words, residents can complete a DR residency in one institution and then matriculate to another for either 1 or 2 years of IR training on the basis of how much IR or IR-related training they had during DR residency. This provides a flexible structure that is very similar to the current paradigm while enhanc-ing training in IR.

In challenging the adequacy of the DR training encompassed in integrated programs that lead to the IR/DR certif-icate, the implication is that all DR pro-grams consist of a uniformly defined and balanced program that leads to equal competence in all areas. The current DR training model requires conformity only during the R1–R3 years leading up to the core examination. The DR R4 year is highly variable, such that residents may focus on one or more subspecialty areas (9). In fact, IR/DR certification requires completion of the exact same training during R1–R3 and that residents pass the exact same ABR core examina-tion (10). Although the R4 year is then heavily weighted toward IR, up to four DR rotations are allowed in addition to the ICU rotation. Furthermore, every IR procedure requires image interpre-tation before, during, and after proce-dures, so the resident’s DR skill set will continue to grow. Finally, this particular concern does not apply to independent programs, which will require prior com-pletion of a DR residency.

Incorporated within the program requirements are specific tools to ad-dress jurisdictional issues, potential competition for resources, and other organizational challenges recognized by the writing group. These include, for in-tegrated programs, recommending ap-pointment of an associate or assistant program director from DR. This would effectively allow the DR program direc-tor to deploy the IR/DR candidates dur-ing R1–R3 as if they were DR residents,

thus maintaining adequate balance within the DR training program. The potential impact on DR training is fur-ther diminished if a department choos-es to implement an independent rather than an integrated training program. In this scenario, the DR residency is com-pleted in full before the IR residency is begun.

The concern that residents slated for IR may not be as committed to their DR training is based on an interesting supposition: That there are two species of residents, those with a uniformly broad interest in DR and those who are more interested in IR. The reality is that residents are now encouraged to focus their training during R4 in areas of per-sonal interest and are allowed to select specific areas in which to be tested in their final certifying examination. Few residents will seek equal levels of exper-tise in all DR subject areas during the R4 year. By design, all DR residents will finish training with the same core but different advanced DR skill sets.

IR residents will highly value their DR training and competency. In prac-tice, IR physicians rely heavily on fluo-roscopy, ultrasonography, computed tomography, magnetic resonance imag-ing, and, increasingly, molecular imag-ing. All must make treatment decisions, often in dynamic situations, on the basis of their own interpretations of imaging data. The majority will likely enter practices that will include some component of DR responsibilities. Fur-thermore, over time, some may choose to focus more on DR than IR.

The suggestion that the IR/DR cer-tificate, and therefore the IR residency, will potentially lead to fewer DR faculty assumes two things: That potential DR residents will be siphoned off by a new competing training program and that this training will occur in isolation from DR programs. These assumptions are wrong. The training that leads to the IR/DR certificate has more overlap with DR, rather than less, and will almost uniformly be conducted within DR de-partments under the DR chair (10).

Many in DR have voiced the con-cern that allowing IR to become a spe-cialty and develop a unique training

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program will eventually lead to com-plete separation of IR from DR and to the dismantlement of DR as other subspecialties follow suit. This would be unwise for IR, as imaging competency is our single greatest asset for patients and will only grow in importance as more procedures are developed and im-aging becomes more complex. The SIR has clearly stated that the change in IR training is not intended as a first step in separating IR from DR, and it believes that IR should remain within the house of radiology (11). Patient care will be best when IR and DR work together, on the same team.

The concern that other DR sub-specialties will seek specialty status is best examined by reviewing the relevant ABMS definitions. A subspecialty is an area of knowledge, skill, and practice concentration that is generally regarded as within a larger general (primary) spe-cialty domain (14). Therefore, additional training is often required to achieve this higher level of focused competency. This definition comfortably accommodates nearly all DR subspecialties. Specialty recognition confers primacy, in that a unique combination of skills and knowl-edge requires dedicated training result-ing in competency that is substantially different from other spheres of practice (15). All specialties and subspecialties have regions of overlap, but within med-icine the three components of IR (com-petency in imaging, image-guided proce-dures, and periprocedural patient care) have been recognized as a unique and substantial combination by all member boards of the ABMS. The likelihood that proponents of another DR subspecialty will desire to seek distinction for it as a primary specialty of medicine or that

it will be recognized by other boards as such seems low.

The IR/DR certificate and the IR residency have been pursued for de-cades in the belief that these changes would result in better care for patients. This was the paramount criterion used by the ABR, the ABMS, and ultimately the ACGME when deciding to approve the IR/DR certificate. As we go forward, the importance of continued open and frank dialogue cannot be overstated. There will be many concerns and issues to address in this process, but there is also great opportunity for IR, for DR, and most of all, for our patients.

Disclosures of Conflicts of Interest: J.A.K. Ac-tivities related to the present article: disclosed no relevant relationships. Activities not related to the present article: has received grants for clinical research from W.L. Gore, Guerbet, and Cook Medical; is a consultant for Guerbet, Covidien, Crux Medical, Delcath, and Marrow-Stim; receives book and journal royalties from Elsevier; receives a section editor stipend from the American Roentgen Ray Society/American Journal of Roentgenology. Other relationships: disclosed no relevant relationships.

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13. Duszak R Jr, Borst RF. Clinical services by interventional radiologists: perspectives from Medicare claims over 15 years. J Am Coll Radiol 2010;7(12):931–936.

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