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Hello, everyone. Welcome to our second talk on um applying to radiology. Um Today we have Doctor Dagger, er an ST one IR run through um trainee at Imperial College, London. Um He did his academic um foundation training at guys and Tommy's um spending his research block um at the School of Biomedical Engineering and Imaging Sciences at KCL. And his interests lie in vascular and nonvascular IR um is specifically oncological. Um IR so welcome, Doctor Dagger and please take the stage. Thank you. Thank you very much. Uh Hi everybody. It's um I guess nice to meet you is the way to say it. Um Basically, it might talk with a little bit about what IR is, what we do, what the different procedures and things that there are and then also a little bit of how you apply on doing it. So whether you wanna do the run through type of schemes or if you want to do the traditional pathway where you apply ST three ST four and I'll touch a little bit on it. Um Just so I can kind of keep it relevant. It'd be helpful to just to know what kind of level everyone is, are they medical students, foundation doctors, post foundation um, s or something else? Are you guys able to type in chart? I'm not, I'm not sure if they can, to be honest, I guess I'll just, uh assume. Oh, um, yeah, post foundation training foundation. Ok. Oh, wow. Ok. And I assume, um, you guys are applying for ST one entry, I assume there's no, uh, ST one plus, like already radiologists talking about um ST three level sub suspect I selection. Um At least that's what I assume. So I'll, I'll crack on, I'll talk a little bit about. OK. Fine. It looks like most people are post foundation doctors. So I'll start just by talking a little bit about what IR is. Um And what is it that we can do? I don't know how much experience you guys already have with it. Um Essentially anything that's a procedure under image guidance is, I guess Ir and it's not just treatment, you can also do it for diagnostic IR as well and I'll talk a bit about about what those different procedures are. So this pretty classic example um ed up all this mess and there's only one tiny puncture in the wrist of the groin and you do all types of angiograms, angioplasty, stenting, coiling, all types of things this way. And again, these can be just diagnostic procedures where you're just mapping out, seeing what the problems are. And this can be from the brain, neck, chest, abdo foot even. Um So you really have a big breadth of what you can do. Um These are ultrasound procedures. Uh Again, it could be a bit diagnostic like a lymph node biopsy or you could be doing ablations and I'll get onto the different types and stuff. Um This looks like a, a typical kind of ira consult another job reg in and then there's like the ST one in the back doing nothing. Um And then all types of other procedures. So the uncle where fellow might be asked to do things like chest drains, um where you go up to itu you do your bread and butter seldom gear technique, ultrasound guidance, pa patient's bedside and these can all come under. Ir depends on uh who does, what depends on where you are. But um that's kind of the general list of things. Um fine. So most people post foundation a few foundation level, but that's fine. So just talking a little bit about what different things there are in terms of procedures. Um bread, I think the main thing is to break it down by general and neuro in in the UK to do IR training. That's kind of the way you split in terms of um sub sex selection and training pathways. And I'll get on to that in a bit. But looking at general first, uh you can look at a vascular nonvascular. Sometimes there's overlap. You don't necessarily have to pick one most will just kind of have a specific area to focus on, but they'll do a bit of everything um to provide the on call cover. So there's a whole lot of aortic work. Um Sometimes they shared with vascular surgeons. Uh it depends on their trust, uh aortic repair, angiograms, everything. And I'll go into a few pictures on that peripheral angiograms, angioplasties. And you can do all types of things like fibroids, prostates, vus veins, uh which are generally quite low risk uh procedures, but they or they alleviate a lot of pain and suffering for the patients. So they're quite satisfying to do um the oncological stuff. That's the things that I'm a bit more interested in where you can do vascular directed treatment, um dropping of chemo beads right in the uh androgenesis of the extra vessels, feeding the tumors. You can do the same with radio embolization and then there's certain minor an as well. Um trauma is quite interesting. Um But it also depends on how much you like enjoying waking up at 2 a.m. because you'll have things like a burst spleen that you need to embolize. Um Similarly, you can have uh renal bleeds and things like that or a renal arteries. So there's all types of things and bleeds, um gi stuff as well. And then some interesting stuff though, some are kind of, some are not things like weight loss surgeries. Uh sorry, embolizations are quite interesting, um, kind of embolize the bit that leads to increased weather and release. So it's quite interesting how they hold it, anatomy and physiology of work its fire out and in some of the nonvascular stuff, um, PTC S, maybe you've heard of a cholecystostomies. If you've ever done a job, nephrostomy bread and butter of your on call, uh, vertebroplasties, ablations. And there's also a lot of gi stuff that kind of overlaps with endoscopist. So there's a big range of what you can do in ir. Um So starting off. So I just got a few pictures here to go through it. Um aorta, you can do these as elective cases when you have thoracic or abdominal aortic aneurysms and you want a stent that across to prevent the bleed, similarly trauma cases where you have transections or burst aneurysms. Uh You have to do this emergent as an emergency procedure, um which means less planning, less uh tailoring the stent to the patient. Uh But whereas if you've got a massive aneurysm, you see them in clinic, you, you can kind of really work it up. So all the limbs and all the abdominal aortic branches um are customized directly for this patient. I think it's like a 20 or 40,000 lb stent that you have to order from Australia and it takes weeks to get done and they make it specific in the patient's angiogram. But it's quite interesting. There's a big range of uh, doing that in the elective setting and then doing the trauma work where you have to do it ASAP. And you've only got, you know, maybe a few minutes or hours before the patient will bleed too much. Um, good example of, er, IR, uh, you know, just being a bit more mechanical, a bit more surgery, like, uh, starting on the left. There's a problem, you go into the vessel, there's a big bit of a missing, there's a bit of recanalization, I guess you could say. Um, but that's not good enough. And that's, that's, that's gonna mean that leg is not gonna do very well. So you can do many different things, passing wives through. It depends on what the problem is. If it's, um, uh, a thrombus, you can do a mechanical thrombectomy. If it's plaque, you can try and do some angioplasty stenting whatever he's done and then you cross it over like this and you get a very nice satisfying run afterwards and, you know, you've, what you've done is right or wrong because you'll, you'll get this result afterwards, which is, uh, quite a fun feeling. Um, this is quite interesting. I actually didn't know about it until I started ST one. a lot of ir and radiology in general really means that you have to, um, think about what the problem is and why it's occurred, uh, rather than just looking at pictures and plain spot the difference. Um, and this one. I don't think we have much interaction. So I'll just tell you uh what happens is in, in diabetic patients. Um You get all types of peripheral venous disease, um small vessel disease, small vessel changes, things like that. So your arteries sometimes get to a point where they're not really very usable. They don't really sort of function as much. They get quite um stenosed and you need to sort of think of the way of trying to solve that problem with things like angioplasty, stenting, things like that don't really seem to work. Um One interesting bit is that, that you've got a lot of veins in your leg that you don't necessarily need all the time. So what you can do is shunt one of the veins to arterial it. And it's called percutaneous venous ar a deep venous arterialization. And I'll show you a little diagram of how that works. This is the artery that you no longer does its job. Well, um you take a stent, pass it through the vein, go into the artery and the arterial flow will reverse the normal venous flow. And you just arterial that vein, there's enough veins in the lower limb that can uh still do the venous outflow. And it's just an interesting way of using the patient's anatomy and physiology to try and overcome a problem. Um Whereas I guess if you're doing it surgically, you wanna, you'd have to do something like a bypass which would be a massive cut down. So I thought it was quite interesting in terms of the actual technical success, I think I've heard mixed things but, um, it's, it's something that's interesting, that's an option that you can have. Um, yeah, this, er, sorry, I had to think about what that was again. Um, this is, um, there's a lot of, there's so many different things you can get involved with HPV transplant and all types of things. This is for transplant actually. Um rather than having those horrible. Um Well, I say horrible, maybe I'm being biased but quite extensive surgeries where they have to open up and make a fistula themselves. You can pass these two electrodes in through the artery and vein and you kind of just have an internal mechanism that uh forms a fistula endovascularly and you never have to open up the patient and I'm pretty sure the fistula is ready to use faster as well. Um And it just generally is um you know, an interesting way of going about it. Um I think the literature also says in terms of safety and efficacy, it works quite well as well. Uh This one, this is trauma. So uh you have a bleeding kidney and as you can see over here, there's a lot of blush in the lower pole. Um and that's not good. But as you know, your kidneys, uh when you go into your renal arteries, you have a different segments of them and you can just embolize a bit that's bleeding and that just means that that little wedge can get blocked off. Um, and you salvage the rest of the kidney without having to do a massive big operation. Um, that's fairly quick. Of course, if a senior person's doing it, uh, it's quite safe and I guess a way to think of it is the worst case outcome here is that it doesn't work and you have to do a nephrectomy. Uh, whereas if you did surgery r realistically, I mean, I guess you could do a partial, but realistically you're just gonna have to take the kidney out anyways, you're probably not gonna be able to get the best control of it because of where the bleed is. So, it's quite a, um, satisfying experience you can do when the thing goes for spleens and things like that. You can embolize bits and pieces of it and it saves you from having to remove the whole organ and doing a big massive laparotomy, um, which would take longer, recovery would be longer and it would be more dangerous. Um, now, of course, you know, this goes, this can't be done for every single case, but in a case it can, it works quite well. Uh This is another example. So, yeah, sometimes I think these ones are to demonstrate aneurysms. Um, yeah, it's a renal optical aneurysm. It gets embolized, um, which is here in the top bit as you can see that it's blocked off. So you don't have that risk of bleeding and this can be done electively. Um I'm not sure again if you can put anything in the chat, but if anyone has any questions, you want me to slow down or anything like that, um Send me a message. I don't know how that works. This one, This is getting you into a bit more of um what I'm interested in. So this is a taste procedure of the liver. Um OK. Those are my other pictures. So you've got a cancer up at the top uh segment seven or eight. And sometimes what happens is they're too big to resect. If you had to go in and resect it, you'd have to take out a big chunk of liver, it'd be a lot more dangerous. Um And it's not quite exactly feasible. So what you can do is you go very selective, you go through the aorta um through your celiac into your proper a artery and then go directly into the segment that you need to get to and you go, you do enough angiograms to find the vessels that specifically feed that cancer and you just block those off. Now, there's different options. You can use radio um particles chemotherapy. There's also bland embolization that, that I think has fairly good technical success and there's different reasons for doing different things. But if you block it off enough. The tumors should start shrinking and being possibly amenable to this could be a curative treatment. Um They could then go to resect it depending on what the rest of the boer. If there's any Mets or anything else or just in general, it'll just improve the situation. So that's a little diagram of how it works. And these are your chemo embolic beats. Um So, yeah, that's a good an example on the top, you get the CT scans before uh before it's quite a large liver or quite a bit of retraction of the capsule and then they block it off. And the post um treatment CT scans show quite a bit of shrinkage of the tumor and these are the angio is a successive one. So you can see there's a lot of vessels that feed cancer and if you block it off, um it'll look a lot cleaner like a normal angio would for that liver tips. Fantastic emergency procedure. I haven't had a chance to see it myself yet, but um, uncontrolled virus or bleeding, you need to have a instant solution for the high pressure in the portal venous system, you can shunt it across with the tips. Um And it's, it's usually quite a lifesaver literally. Um This is quite interesting. Another thing where you can uh just be quite creative with ir so this patient has osteoarthritis. You can see there's quite bad osteoarthritis. Um If patients can't don't or you know, just don't want surgery. Another option is called genicular artery embolization. And I'm sure you remember you've got a better genicular artery, superior, medial lateral area and they form your joint capsule of your knee. Now, in arthritis, um what happens is you get a lot of um hypervascularization of this capsule of the Synovium. So one option is you can go in and embolize these arteries um and just leave what's needed. So the normal vascular plaque and that tends to help patients quite a lot with pain, with progression of the um inflammatory processes and things like that. So that's quite interesting. Um how I wouldn't really be able to say, but I think it's more for people who can't go along and have surgery. Just another option to have um PDC S. Uh Well, this is a nephrostomy but nephrograms as well. So, nephrostomy, uh all types of urgent situations where your urinary system is obstructed. You need to get access ASAP. It's fairly, fairly simple thing to do. It's quite interesting. This is kind of what it looks like. If you were to look at it in a diagram, you leave your pigtail catheter within the pelvis and you train reflecting system. Um Yes, hypoplasty vertebroplasties. Uh a bit of a debate on who does them, whether it's the surgeons or IR or something. I think that's OK, but you can do them for osteoporotic wedge fractures to prevent instability of the spine. So, um they're quite interesting and I've got some pictures. So this was made a conference that it's an American Iri. And um that's your example of your vertebral cross section. You stick your needles in, you have to be very careful. Um because of all the structures with the vascular supply to the core, the cord itself, the exiting and traversing nerve roots. But you keep using your floor guidance to check exactly where you are. Um Maybe a CT as well depends on how you're doing it, I guess. And you go through the pedicle into the vertebral body and you cement it. Um and you pull back slowly, check, pull back slowly and you have a cut off line on what's safe. Um m uh Any questions if you can put a message in the chat, no, I'll move on. This is a microwave ablation. That's another type of percutaneous ablation. So this is the liver. Um The actual physiology of how the different ablation techniques work is quite interesting. Um how they kill what needs to be killed and then um try and do the least damage of the healthy tissue around it. Um Just laser ablation. So you can see the laser beam shot up from the probes itself and this is pretty cool. This is cry ablation. It's the best for like renal cancers, how it works is um you put this probe into the real cancer, you turn on the there's freeze and Thaw cycles and it doesn't actually make the ice ball itself. You see, you stick the probe into the bucket of water. So, what it does is it just cools the temperature rapidly and the ice forms from the water already there. So, the same happens in your kidney with the cancer. What it's meant to do is freeze the water molecules within the cancer. It's not creating its own ice ball, it's freezing it within the cancer. And then you leave to Thaw and the free radicals that are then formed while it's thawing are, is what meant to actually kill the cancer itself. And you do your freeze thaw, freeze thaw cycles. So it's quite interesting and you use different ones of different cancers based on their physiology. So that's kind of why I'm so interested in. Ir there's a lot of anatomy and physiology and a lot of scientific thinking. But at the same time, you get that simple surgical relief when you fix something and you'll be able to charity, fix it. So, um fine. So that's all the body ir um I'll quickly go through neuro neuro is quite specific and to be honest. Um uh you know, it, there's only so much uh I guess that you would do so mostly it's diagnostic angiograms. So, spinal brain or spinal and an intervention is the aneurysm stroke, coiling, things like that. So these are angiograms, angiogram. Um Yeah, this is the uh basilar tip aneurysm that's been coiled off and you can see the coils within the aneurysm right over there. These are the different options. You can coil it, stent it, coil and stent it. Or if you're up for surgery, you clip the neck, but those are more dangerous. Typically depending on the aneurysm. Um, this cancer as well. Uh, this, this one is just a giant aneurysm, I believe. Giant, yeah, stent assisted embolization of a giant giant aneurysm. Um You can do some cancer work as well. Embolization of meningiomas, his middle meningeal ultra embolization as well. This is another one for tumors. Um And yeah, that's, that's just a bit, a bit of a whiz and neuro, it's a bit more nuanced. Uh And, and I think maybe a bit less of what some people might be interested in. So I just thought I'd give you a little example of what II is what we do and what a different pathway. Um Different procedures are to see if you're even interested. Um flex part. Uh I'll just talk a little bit about ir training pathways and I don't know if it's possible, but if they have any questions or if you make a poll, if they have any specific questions about applications uh or the job or how to get in or what's important, what they want to know. Um I'd be quite happy to answer it right now. OK. Happy to do that. Um So this is just a little overview. There's many different ways and normally it's medical school foundation and then you apply for radiology. Quite a few people who apply for radiology have some other experience and the ir budding people sometimes have done before surgery or years out. But you neces, you definitely don't have to have that. Um, I, for example, I've come straight from F two. So I've been an AF pa guys in Saint Thomas's, I've come to F two FF two. I've come to do my IR run through program at Imperial and that starts from ST one. Normally if you do diagnostics, it's ST 1 to 5. If you do ir it's uh ST 1 to 6, everyone does pretty much the same first three years. So ST 12 and three, everyone is doing your co radiology experience. Uh You'll do your F RCR one and two A and two B exams. You have to pass them. Uh I think two A is I think to clear A RC PST three, you need two A, you need to be done with two B which is your final exam. But I think ST four and you need to hit all your competencies for all the self specialties. So you'll do your diagnostic neuro head and neck gi all that. You need to be really good at it. All your on calls will probably be that as well. And then ST 456 will be your IR us. Um, the main benefit of doing the run through is at one, your subspecialty selection at ST four is guaranteed. Um And I'll get into that a bit more, but you don't have to reapply after ST 33 years, subs suspect and two is, um, it works a bit different in the different centers, but in my center, Imperial uh in your ST 12 and three, you'll get to do one ir session every week because you're on the IR pathway. And as you do them, you have to do more and more. You start by observing and you assist, you can do the biopsies yourself. Maybe they'll start to get you to do drains. You're assisting in things like uh the tunnel lined insertions and you'll slowly and slowly start doing more and more when it comes to like a nephrostomy and stuff like that as you get a bit more senior. Uh And then that way you hit the ground running an ST four, you've got the job already. Everything's set for you. Um On the traditional pathway. If you don't have a run through every single person at ST three will tell their TPD S or their supervisors, I'd like to do this self suspect, be it diagnostic head and neck breast ir or neuro whatever or I nr at this point as well. So, interventional neuroradiology is also you self suspect at ST four and you're doing just interventional neuro, not the body ir they're two separate arms. Um, and then what happens is, uh normally you used to be able to get it, but now I think IRS becoming a bit more competitive so more people want to do it and they're sometimes not all programs can accommodate you because the ST 60 is the additional year that you need to be funded for most people will still get it. You might have to move trust or Deanery. But um it's getting a bit more uh difficult in that way. So it's a bit beneficial if you just have the job at hand, but it's definitely not an end of the world. You, if you get the run through, you can definitely drop it off and um uh do diagnostic if you change your mind and vice versa. If you wanted to a diagnostic, if you change your mind, that's always the case. So I'll just take a pause. I've got a couple of questions. Um would getting an IR run through post six years and getting a standard clinical radiology program plus fellowship be equivalent. No. So um your standard clinical radiology program. So because IR is six years, it doesn't mean you do IR in just ST six, you're doing IR from ST +45 and six and there's a lot of curriculum on the RTR R website in ST four, you need to be able to do this, this and this at this level of competency on your own five, this, this and this six, this this and this. So you're doing five years of diagnostic radiology and then doing a one year fellowship is, is you will not be considered an IR and you wouldn't get the GMT um subspecialty registration for IR either that, that, that exists if you do it through the full three years. Um Let me know if I've answered the question, if not ask me again. Um If you applied for IR run through but just Oh yeah, yeah. Yeah, as we just mentioned, so yeah, if you applied for run through and you change your mind, you can definitely um you can definitely change then. So moving on. So yeah, run through posts. There aren't that many, there's about 300 I think radiology posts, which I think are getting quite competitive now and then there's 10 to 14 of them, I think uh depends here on you about the dedicated IR numbers. Um You get the extra extra exposures. I have to do some extra work based assessments. So a few more mini cases and doc s but that's not difficult. I have to give you a logbook as well. But again, you don't have, it's not difficult requirements to it. You'll definitely get it and it's quite fun being able to go to these sessions every week, uh where, you know, no one's expecting you to be able to, you know, do the whole angioplasty yourself. They wouldn't even let you, it's just good for you to learn and you're supplementing your diagnostic knowledge. But it's really, really important that you are focusing 100% on your diagnostic competencies, making sure your partial exam is anatomy and physics exam that you have to do in the first year in March. Um And um you have a lot of numbers to hit you have on calls coming. We go on the full red rotor from C two in Imperial, which includes nights, weekends, everything and we're a major trauma center, neuro center transplant center, um GTD Referral Center. So there's a lot of diagnostic work and you have to feel like you're confident because, um you know, you will have some life and death decisions overnight where you'll get like strokes and er, they'll ask you if you want the thromb or not. And if you haven't spent your SD one focusing on gearing to be able to answer those questions, you know, the decision about thrombolysis is entirely in your hands. They'll, they'll rely completely on you. So it's, it's, it's very important that you do it um to a level that you're ready and you're always competent. Um And if you get on the IR run through and if you want to do interventional neuroradiology, you can definitely do it. Uh, the funding is already there for you. It's not a problem. This is the traditional route like we discussed. Um It's quite a competitive process in ST three, you have to apply, you have to show your um enthusiasm. This can be through your tasted blocks or just joining lists um during your first three years or uh projects, audits, getting to know people talking to them, getting supervisors involved. Um So it can be competitive. It depends on the, in London. If you don't get it in your own trust, they'll try and put you somewhere else in London and you usually will get it. It just, it's getting a bit more difficult. Nowadays, I think in, in our batch, we have about uh 10 people per year one and they can only accommodate two people for the ST six funded IR U out of the 10, which previously wasn't an issue. But then nowadays we're getting like five or six people pay per cohort that want to do it. So it's a bit difficult and then onto on calls um in ST four, this is how my trust and um I think guys and Tommy as well, you will still do on calls in diagnostic in ST four cos your ir you're not independent enough to do these procedures overnight by yourself. So you'll just do the regular diagnostic reg on call. But ST five and six you'll be doing um I on call. So typically 24 hour on calls that you're not resident for, you'll be answering phone calls from home. You don't necessarily need to come in, but you will probably get calls a lot of the night. Um, so just bear that in mind if that is something you're ok with. It's kind of like a surgical on call. Um, I think when I was in an Ortho sho the, the register did the same thing, they'd go home, they get called if they need to come in. Um, and you have a consultant obviously that you can, that can help you. Um, but that's a typical kind of on call structure and your day to day. Um From ST four was you're doing a lot of ir you're doing 70 to 80% ir you might have an MDT per week that you have to prepare for uh 22 30% diagnostic, which includes some of your survey provision like ultrasound lists on calls, things like that. Um What are your options if you want to do ir but don't get a post for, do you take a year out? Yeah, that's a good question. Um I mean, I gotta be honest, it's not really been much of an issue until recently. So I haven't heard of a lot of people that um what they did one option is, I guess if you were never 100% say you might decide just to do something else to make life easier. Realistically, what happens is you have to move trust, you might have to move Deanery. Um We get a few people from all that come to our trust cos um, I think Lon London Trust tend to have a lot more, um, like IR centers and provisions for having IR trainees. They want the 4 24 7 fellow Ir rotor, which as an ST five and six we on the fellow rotor. So it's a bit difficult. Um I'm afraid I don't have the exact answer but I think you have to reapply or move. Move is the most likely answer, which is a bit annoying at ST four. Um And there isn't a guarantee. There's another question if you apply for run through. Ir we do, we have less of a chance. No. So what happens is uh when you apply for ST one radiology um after you do your exam, your interview, whatever and you have to go and rank, there'd be 300 posts, for example, last year um out of those 300 posts, 10 of them will say in the descript that they'll say this post is an interventional radiology run through. They're mostly in London. I think. So, we've got one in Imperial, one at Barts, one at guys in Tommy's, one at U not UCL Royal free, one of Kings and George's one has the most then one in like um Birmingham or one in um leeds. So uh to be honest, I wouldn't know the other ones, but you just put those posts higher when you're writing your oral preferences. Kind of like when you apply for foundation jobs. Um and uh everyone can do that. So even the diagnostic people can do that. Uh It's just one application or L1 interview process, nothing changes. The only thing is when you do your preferencing your jobs, you just put the ir them at tr at the top if that's what you want. Um And then you can mix and match, you can put, I put uh three of the ir the tracks cos I really wanted that, but then I also wanted only three specific trusts. So then I put those three specific trusts, diagnostic programs below those and then I put some more ir tracks. Um So it's entirely up to you and you don't have to put every single job. I can, I only put a few trusts. Um So you pick and choose as you want. Um After you use CCT, you can do fellowships. So there's niche interest. If you have an interest in peds, oncology, neuro, whatever or something more niche than that, if there is H PB or something, you can do an extra year or two years, three years. Um However long the fellowship is, there's ways where you can get the fellowship to be part of your se six year. So, you know, in theory, your se six year could be your fellowship year in a separate trust and in your yourself back, it's a lot harder to do. You have to still get your A RCP sign offs. And everything. And to be honest, there's not a lot of time to be a full ir there's a lot of procedures and independence. So most people will typically tend to do a post E CT fellowship afterwards in I it's quite common to do post fellowships. Um, there's research and stuff as well, but unlike other specialties, you don't have as many people going off to do phd and stuff like all, um, you know, the surgical specialties or cardiology or all of that. So, you know, the good thing is you can do research if you want, but you're not forced to do it just to get a consultant post. And speaking of consultant posts, there's a big, big shortage. Um you know, this is in the sense that everyone's trying to get a 24 7 IR provision, um Everyone wants it, it helps. There's a lot of, you know, money into showing that it's gonna save a lot of money for trusts, daycare services. Um things like that to be able to do ir get people in for IR day case units, ir inpatient beds, clinics, things like that. So it's a good career outlook. Um And I know a lot of people stress by getting into SD one radiology. But uh you know, once you get to the other end of it, you will have a job which you can't necessarily say for every single host where you finish a very difficult training program. Um black neurosurgery. Uh, it's no consideration so on call. Um, I, to be honest, think I would prefer the nonresident uncles. Once you get more senior, they won't be as difficult. The phone calls, you'll know which ones can wait till the daytime or till the week till eight hours and you just tell them no, relax, do this, do that. Um, we'll take care of it in hours. Whereas I think when I start off, when you first start doing nonresident, you'll be quite panicky about, you know, not seeing the patient yourself, not going in, not checking everything. Um But normally you'll have a workstation, I think um that they'll give you that you can access imaging from when you're not resident on site, take a look at it, see if it needs to be done in ASAP or if you can wait and if it can't, then if you have to go into the procedure, um your consultant will normally join you. If it's bad enough that you have to go in overnight to do it like a speed embolization, your consultant will help you. They'll do the procedure probably. Um So there's good pros and cons of that, which means that if you get, you know, as we're moving towards more fellow, full, fully staffed fellow rotors, it'll mean that um uh your fellows can be a bit difficult, but your consultant is uh will be a bit more relaxed because you only come in through the procedures that really need being done and you don't get bombarded with phone calls ideally. Um But yeah, you can cover multiple centers. So I think some consultants sometimes they'll be covering a tertiary center which is their main job, but they might also be covering like um the DJ issues surrounding them. So that can be quite stressful when to accept transfers, things like that, especially Turf four is quite annoying. Um but it is reality you, there's a lot of tier four for a to work with vascular surgeons. There's a lot of tier four for um, I think urologists think they can do the urology work. But II personally, I don't think um there's just too much bread of our procedures for an urologist. II don't know. Um But again, I think some places will do that. Um And then there'll be other, all types of other things so that there's t falls over like um I think the neurosurgeon or orthopedia surgeons want to be delivered through your class, which probably is a bit more fair. I don't know. Um But yeah, so it's a bit annoying in that way, you kind of have to carve out your own sub back area and your trust and say I'm going to do this and try and work with the other teams, but it's not that easy as like, you know, for example, the brain medication, you just know it, you, you know, you gonna have this service to provide. So, but I think it's changing a lot. So we'll see, um, positives. I hope some of the cases I've talked about have inspired you. Um, you have to be able to adapt, you really have to know a lot of your anatomy and physiology and what your treatment options are, what's in your armory. Um You know, you have to be able to change your treatment approach, maybe mid procedure when things aren't working things, you have to maybe have a different backup two or three Plan Bs. So it's quite interesting the way people go about fixing problems. Um and also diagnosing problems because you again, you have to be a really good diagnostician to uh be able to use your imaging skills as well. And I think that's what we bring to the table when we, when we say we should be able to do the IR procedures rather than like, you know, for example, doing the stenting or whatever. So we can correlate the imaging a lot better. We, you know, this is what we're trained for. So that's that um it's an expanding specialty. I'm learning about new things every day, about procedures we offer. Um There's a lot of new kit, there's a lot of technology, there's a lot of industry um and it's only really getting better and better. So it's, it's quite innovative and you, I, one of the reasons I picked it is cos I thought I'd never be bored. There's so much that's coming out. Um, you can often have better option, uh, outcomes. Not always but, uh, your day cases and stuff. You can, some people at home and they feel a lot better. There's also a lot of life saving interventions. So, if you'd like the, you know, the cool big trauma surgery type of stuff, um, and you think that radiology might be too slow paced in ir, that's definitely not the case when you have people that are actively bleeding and they're dying to unable. Um, and you know, your embolization, you have to get in there within 30 minutes or sometimes you only have a matter of minutes and seconds before a certain part of the procedure has to go. Right. So, you know, it's dangerous sometimes but it's quite exciting in that way. Um, I don't know, every, my, even my consultants have different opinions on A I and what that means in the future. But if you're worried about A II IR is pretty well protected as protected as any surgical specialty would be. You can't just like in A, I try and, you know, embolize a big, big bleed or try and drink something that's really difficult to get to patient contact. I can kind of put it in both ways. I thought, you know, having a little bit of patient contact is nice, but I had a really chatty patient in an ultrasound today. So maybe, maybe not it's up to you what you wanna do and then D DH was a tertiary. So this is quite nice if you don't like the big horrible on call and you, you can choose to be ad GH IR where you do a 9 to 5 job, you don't provide that much out of hours cover. In fact, you know, your trust just might not have the provision for out of hours. So the out of hours stuff will go to the surgeons in your trust or to the IR in the region um Acceptance Center. So it's quite nice and that's quite good about IRS. You can really call out your own specialty, your own kind of work plan. Um cos it's so diverse in that way, but I think it's a bit down the road. So um main things are about the program about applying to it. The application for ST one is the exact same if you're applying AST four. So for subs spec it's a bit competitive, you have to be on it with your publications, your research projects, things like that. There's a question doctors who get CCT and IR um are they able to work as diagnostic radiologists or can they only take IR posts your CT er is is in what's called clinical radiology, everybody gets a CCT in clinical radiology, diagnostic and IRS. Um but on the GMT register, if you do the proper IR training pathway, you'll get something called subspecialty registration in interventional radiology and every single ir will have diagnostic work. So our consultants, the best IR consultants, they'll have like two or three hot rep acute CT reporting sessions where um they're checking our registrar reports for the, the vet. So the acute CT S or they'll have MDT S that they run like one of them runs a prostate MDT. Um they're reporting MRI CT S, some, one of them has an ultrasound list that she does. So you will definitely be doing diagnostic work and you can definitely work as a diagnostic radiologist. It's just if you, if you finish an IR and you haven't done any suspect diagnostic training, um you're not gonna be able to provide any suspect expertise. Um pretty much just the on call, you, some people will have a bit more interest so they'll go into it more. But you, you work as both as the short answer to your question. Um Any other questions, I guess Karen, what you were saying is that it opens more doors. It, it gives both options when, if you only do diagnostic, then you're, you're just stuck with diagnostic in a way. Yeah, I mean, you can always change but you have to retrain and stuff. Um So, II personally think, you know, if you're thinking about it, apply for the IR post and see what happened. Um So if someone so going back to like almost a question that was done, uh said earlier on if you did complete, if you did CCT in diagnostic radiology, how would you retrain to do? Um IR um mm I think if your CCT in diagnostic, so previously what usually happened is you could do add on fellowships in IR now you could probably still do that where you apply for fellowships and local training programs for IR but you in the UK, I don't know how you get subs recognition. You don't necessarily need it. I guess if you can kind of work at a job plan, like for example, UTC T and M SK Radiology Diagnostic where you do an IR type of fellowship where you're looking at things like um genicular artery, but maybe not genicular artery, but like, you know, injections, things like that. Um then you can maybe do a fellowship where you say to your supervisor, this is what I wanna learn. You sort of practice as an M SK radiologist, but you'll have two or three extra services you can offer as a consultant. Um But in terms of getting proper accreditation, um it's a bit more difficult. Yeah. No, that's great. Thank you. Um If someone asked um maybe about a joint make um about the previous question, what happens if you don't get a personal ira actually, for uh most of the time you'll try first in your trust. If they can't give it to you or trust in your training team, they can't give it to you in your deanery if you can accommodate, if they can't give it to you. Um They'll a national need to see if someone else can take you somewhere else. Um uh And then the next is, does one have to choose only one field of ir vascular? No, neuro, no, you have to choose between body and um neuro in the UK. Um in other countries. So back home in Singapore you, there's ways of practicing both if you qualified and both. Um in the UK, I'll just keep it simple for the purpose of our talk. Uh You know, you pick that a body or like general IR body ir is what it's called or near IR. And then neuro IR is a different training program. You have like, for example, in our trust, we have big neuro Center at Charing Cross. You have a diagnostic neuroradiology supervisor for you. You have an international neuro radiology supervisor. You have to be qualified in diagnostic and interventional neuro neuro is very specific in that way, it's very difficult as well. I'm always getting it wrong. So um that's why they kind of had their own training that way. So you have to choose between neuro and vascular uh sorry, your own body and then in body, it's your choice. You will learn a mix of vascular and nonvascular to be able to provide the on call service as a consultant. But um your subspecialty interests, what you do in your little niche that's up to you and you can usually make a mix of vascular and all that. Um Someone asked, did you express an interest in pursuing ir during the interview? Did that lead to the question in that direction? No, I got very lucky. My specialty um related question was on IR and I think I would have had like a little ear to ear grin because like I was really stressed in the interview and II could talk so much about Ir and I think the main thing is to show how passionate you are in the interview because they don't really care how much you know, um because regardless when you start SD one, they're gonna think, you know, nothing and teach you from the beginning. But if they see that you're really passionate, II was always passionate about Ir So um II got lucky. They asked me the question, but there's some other specialty related questions where you can kind of, if they don't ask you, you can try and um suggest that this is what you wanna do and link it to the question and demonstrate your passion. Um But it's not necessarily, they'll ask you, they usually have set questions, it's not like an open ended conversation. So um you might get asked about something else entirely. Like, I don't know, what do you think of A I and radiology or something? That could be your specialty specific question. So, yeah, jumping onto that. Karen. Did you actually do any research projects in um ir during your academic block or, you know, during your foundation years? Yeah. In the academic book, I did a mix. It was with a guy who was um he's a consultant at King's College Hospital, but he's also a um researcher at K CL um in, he's in diagnostic and interventional neuroradiologist. And I did one which was um a neuro which is, I guess a machine learning project on uh the rupture risk of intracranial aneurysms. And then I did one which is a bit more neuro oncology, I guess kind of nuclear medicine kind of project where we recruited patients for a THOS approach for treating glioblastoma. So we used to give them traces, we do a scan and we'd see where the uptake is and then we'd get biopsies and surgery to see how it correlates. So it's a bit of a clinical project. Um And it's a bit of a mix. And I think that kind of helped in my interview as well. Cos they asked me about um uh I think it was portfolio or teamwork or something. And I kind of led the question in that direction and I explained my projects and I've shown that I've got a breath, I haven't, I in your interview, if you say no, II only want to do one specific kind of neuro IR procedure. You probably wouldn't like they would be a bit put off because there's a long pathway to get there and you have to show you have an understanding and you want to do the breadth of radiology training you have to go through. But um yeah, that's great. Thank you any more questions. I'm happy to answer any questions generally about, I guess ST one training, radiology training. Um If anyone has a general question, feel free to drop it in and Karen, would you be happy for them to contact you if you have an email address that you'd be? Ok. Mhm Why don't you pop your email address on the group chat? Um If no one has any more questions, I'm happy to end this webinar. Um Thank you everyone for attending. Um It's been really interesting to hear about the breadth of IR and how, yeah, despite the fact that it's radiology and you think it's very much radiology, there's still the opportunity to do a lot of um a lot of trauma things, a lot of like emergency things, a lot of on call things, but a lot of out in hours as well. Um So lots of differences in lifestyle and different procedures in different parts of the body, which was really interesting and thank you for all the great pictures Karen um and your experience and expertise. Um As I said, thank you so much for uh attending next week. We have an ACF webinar. Um So please do join for that. Um and have a lovely evening. Thank you.