Addressing Diversity and Resident Attrition in Interventional Radiology: An Interview with Mina Makary, MD

In a recent interview with Diagnostic Imaging, Mina Makary, M.D., an interventional radiologist and asociate professor of radiology at Ohio State University, spoke about the challenges and possible strategies to improve diverse representation in the interventional radiology (IR) specialty and bolster the retention of residents in IR residency programs.

Q: What are some key challenges with respect to diversity and interventional radiology?

Mina Makary, M.D.: We’ve done a recent study on this, and we looked at interventional radiology (IR) recruitment and residency programs. Compared to other specialties, interventional radiology had the lowest level of diversity, gender diversity. We have underrepresentation of women, for example, race, etc.

I think there is a lot of factors that go into this. We looked at the phenomena. We did not study the actual causes. But in my opinion, one of the things that is maybe lacking is early mentorship. A lot of times to improve diversity, we have to have students or trainees from all backgrounds have role models that (one) can look up to (who have been) through a similar journey or have similar needs or similar challenges in their life, or their goals or whatnot. I think early mentorship is key, and it's probably lacking.

There's also less awareness of interventional radiology. I've done multiple other studies looking at this. As a specialty, we are not well understood by our patients, by our colleagues, by primary care physicians, by specialists. All these (studies) have been published in the last five years. … It also trickles down to medical school. There are some medical schools that don't even have an interventional radiology rotation, so students don't have the opportunity to learn about what IR is and what it is not, and all these factors contributed to the (lack of) diversity.

A Quick Primer on Pathways for Interventional Radiology Residencies

Q: Can you explain what is involved with an integrated IR residency program?

Dr. Makary: Absolutely. So historically, in the house of radiology, the primary training option was a diagnostic radiology residency. So medical students would match in a diagnostic radiology residency and then, during residency, they would pick the area that they want to specialize in, if they want to specialize, and whether it's musculoskeletal radiology, pediatric imaging, and one of those options was interventional radiology. So they would do a year of internship, four years of diagnostic radiology training, and then a year of fellowship in interventional radiology.

What happened was, in 2012, the American Board of Medical Specialties recognized interventional radiology as its own separate specialty, and the basis for that was the clinical emphasis of the training and the needs of the education and the way it's practiced with physicians having clinics, rounding on patients and prescribing medication, etc. As a result, that kind of pushed the development of the interventional radiology residency as a separate residency.

Interventional radiology training right now has three pathways. One of them is the integrated radiology residency that you mentioned, which is basically a year of internship after medical school, and then four years of integrated intervention radiology training. It still encompasses diagnostic radiology training. So the beginning of the residency is more diagnostic heavy and toward the end is more interventional radiology heavy, but it's integrated, so they learn everything at the same time, and that's the main pathway. There are other pathways, like the independent radiology residency, which is basically a diagnostic radiology residency, like the traditional pathway, and then two more years of a separate training, and it's called the independent radiology residency. Traditionally, fellowship was one year, but this would be two years.

Then there's a third pathway, which is a diagnostic radiology residency, and that has a track called ESIR or early specialization in IR. During their diagnostic radiology residency, they would take a few extra interventional radiology and related rotation. They would still have to do an independent radiology residency after those four years, but it'll be one year instead of two.

There are a lot of options, and it caters to the needs of the medical students out of their medical school, because if they find out their passion early for interventional radiology, they could apply directly for an integrated program. If during their diagnostic radiology residency there, they discover a passion for intervention radiology, they can, either join an ESR track and just do one extra year, or they can finish that and then do two more years after. So (those are) basically the three options, and the integrated one is the most common option out of those.

A Closer Look at Possible Contributing Factors with Attrition Rates in IR Residencies

Q: Now, in a recent study, you looked at attrition rates with integrated IR residency programs and noted this seemed to be a significant issue in the third year of residency. Why do you think that is the case?

Dr. Makary: That's a very complex issue. In our study, we found that of all the residencies, interventional radiology had one of the highest attrition rates. As you mentioned, the third year is the worst. We did not look into the factors. We looked into the trend. But you know, I hypothesized the third year is one of the most stressful years of training. It's the year where they take the core exam. It's the first part of the board exam.

You know, there's call duties as senior residents. With residents at that point, some of them are starting to think about jobs and long-term career prospects. It is a stressful year as a maturing resident kind of realizes the realities of call, the realities of clinical practice. They have more expected out of them, and they transition from more of the diagnostic rotations into more IR rotations, which add additional burdens. This is kind of my thought process that it’s because of all these factors. This is one of the most stressful years, and this could probably be contributing to burnout and attrition.

How to Address Recruitment and Retention Challenges

Q: From your perspective, what are some things that can be done to recruit and retain prospective IR residents?

Dr. Makary: I think we have to recruit from the proper pool. So I think from out of medical school, we have to recruit medical students by increasing awareness. Traditionally, IR was a fellowship after diagnostic radiology residency, a lot of the efforts or exposure to interventional radiology was during radiology residency. Now that students are applying directly out of medical school, we have to focus on improving our presence and our awareness of our specialty.

It's not always, you know, just to recruit, but also to make sure that they know what the field is. Going back to your previous question, some of the realities of attrition is maybe a false impression of what the specialty is during medical school. Then by the time they truly understand what IR is, they decide it's not the field for them. That's just another hypothesis I have. But I think to improve recruitment, (there needs to be) early exposure, a dedicated rotation and providing mentorship.

There are symposia that are being done in several areas in several parts of the country. There are good models for giving students the hands-on experience of IR and also engaging students in IR research opportunities.

We've actually have done a research study on the effectiveness of tools like the (Society of Interventional Radiology) symposium. We found that students find it helpful in increasing awareness, and it may influence their decision making to go into the specialty.

What are some things that can be done to retain IR residents in the residency program? That's an even more critical prospect here, which is not just recruitment, but retention. I think it all starts with helping them form an early identity of their specialty and being proud of their work, (and) helping residents understand that training is difficult. It's a journey but take pride in the practice, take pride in the knowledge they're gaining.

Also to retain residents, I think we also have to address issues like burnout and improving wellness. Now, luckily, in our specialty and in radiology, there's been a focus on wellness in recent years, which is fantastic. I think we should maintain that. And especially, like I said, if our previous research has shown a third year is the most critical year, we need to make sure that we provide the residents with the proper resources. Have support systems in place. Work on safe and fair call schedules and call duties and help them get to the finish line. Those are some of the things that I would do to improve retention.

Q: What about tactics that are working in recruitment for IR? What are some different approaches to IR recruitment that may have an impact?

Dr. Makary: So the biggest issue that has happened is that during the (COVID-19) pandemic, a lot of the recruitment efforts for residency, for example, (were) virtual because of the virus at the time, and some of these have been retained because it's easy when we give people options here: do you want to have a virtual visit or be in person?

They can interview at multiple places with virtual versus actually coming, but they lose a lot because they don't get a feel for the program. They don't meet the people. (They) may not really appreciate the city (and) the drawbacks or the benefits of it. I think to recruit people to a particular program, for example, more efforts on in-person visits, would be helpful, whether it's the primary interview experience or the second look experience if it's an option.

The other thing is that we have to do a better job highlighting (what) we offer in our specialty, in our programs, in terms of the level of education, the resources, the type of experiences the residents would have, research opportunities, funding, (and) the options to expand their training through unique experiences. Some programs have research tracks, leadership tracks (and) administrative tracks. Those are some of the features that we can highlight to improve recruitment.

In terms of overall diversity, I think we have to, again, going back to the first question, recruit from a diverse pool, which is really good for our specialty, because the more diverse we are, the more holistic ideas and more perspectives and abilities, and the stronger we all are as a group. (We need to start at) medical schools, start early on and give every student who's interested an opportunity to learn about our specialty and be good mentors and support them, whether IR is the path or not. We have to be there for our students help them succeed and give them the best chance to make the right decisions on their careers.

(Editor’s note: This interview is also available as a video at: https://www.diagnosticimaging.com/view/challenges-diversity-residency-attrition-rates-interventional-radiology .)