VAMC Interventional Radiology Goals & Objectives Introduction: During the time allotted for the interventional radiology (IR) service, radiology residents can expect to become proficient in all major aspects of IR. During every training rotation, the resident will read the required literature and progressively and increasingly understand the management of patients and their disease process, including the indications, contraindications, risks and outcomes of common IR procedures. The resident will also become familiar with the workup and follow up of for specific interventions. The VAMC interventional radiology faculty will provide residents with graded supervision to develop technical expertise for minimally invasive, image-guided interventions using ACGME guidelines. Specific goals and objectives for each rotation are described in this document. Resident Daily Responsibilities: 1. The workday begins at 8:00AM and will be initiated by imaging rounds and case review with the IR team members including physicians, nurse practitioners, nurses and technologists. 2. The resident will be knowledgeable of the daily interventional procedure schedule. Prior to the start of the workday, the resident will prepare all relevant imaging for the patients who are on the current workday schedule. The resident will also review relevant medical records in the electronic medical record (EMR), including labs, medications, allergies and consent/npo status. 3. All interventional radiology patients who are currently being managed as an inpatient will be seen and examined with progress notes documented in the EMR prior to the start of the workday. Likewise, any patients expected to stay overnight will also be seen at the end of the workday. 4. The resident will regularly check the printer for requests and consultation and triage these cases for the possibility of adding them to the procedure or clinic schedule in consultation with the IR team. 5. Residents are expected to document the pre-procedure note, consent and post procedure note for each procedure in which they participate in a timely manner. 6. The resident will serve as a liaison with referring clinicians. They will evaluate requisitions for appropriateness, discuss relevant findings and interventions, and provide clear post-procedure instructions to the referring clinicians. 7. Consult supervising faculty when any questions arise beyond the scope of the resident s current level of training. 8. Residents will be familiar with the operation of all imaging equipment. 9. Residents will acquire knowledge of radiation protection and ways to reduce radiation exposure to both patients and hospital personnel. The resident will be supervised to assure that safe practices are followed. Supervising Faculty Responsibilities: 1. Supervising faculty will review the goals and objectives with the resident at the beginning of each rotation.
2. Supervising faculty will be available at all times for consultation by the resident. 3. Supervising faculty will provide the resident with constructive feedback on their performance during the rotation. 4. Supervising faculty will complete resident and all program evaluations in a timely professional manner. General Educational Goals and Objectives (All Years): Patient Care: 1. Competence with the CPRS EMR and radiology PACS system 2. Obtain a focused history and physical with appropriate documentation 3. Adequately explain each examination to the patient/representative and obtain an informed consent 4. Recognize monitoring abnormalities and physical signs/symptoms that need immediate attention during a procedure. 5. Demonstrate understanding and appropriate management of certain pharmacological considerations: a. Drug/Contrast Reactions b. Antibiotic Therapy c. Pain Management d. Anesthesia/Analgesia e. Anticoagulation f. Pharmacologic Treatment of Coagulopathy (FFP, Protamine, Factor VIIa) g. Alternative Contrast Agents (Gadolinium-based, Carbon Dioxide) 6. Recognize and treat complications during and after the procedure including but not limited to contrast/anaphylactic reaction, over sedation, pain, nausea/vomiting, arrhythmia, decreased oxygen saturation, sepsis, hypertensive urgency/emergency, low blood pressure, hyper-hypoglycemia or bleeding/hematoma. 7. Identify factors from patient history, physical and laboratory values that indicate potential risks for bleeding, renal damage, cardiovascular problems, breathing abnormalities or adverse drug interactions during or after the procedure. 8. Understand the importance of continuity of care by pre and post procedure assessments 9. Understand patient triage, patient selection, risks, indications, and contraindications for each procedure as well as the indications for and contraindications to use of intravenous radiographic contrast, and be able to monitor its administration Medical Knowledge: 1. Familiarity with the risks, benefits, and alternative methods of treatment for every procedure in which they participate 2. Familiarity with the relevant anatomy for every procedure in which they participate 3. Familiarity with all of the medications commonly administered during interventional radiology procedures 4. The resident should consult supervising faculty and appropriate reading material when unfamiliar with a disease or its management.
Practice Based Learning and Improvement: 1. Demonstrate evidence of independent reading and learning through use of printed and electronic resources 2. Demonstrate appropriate follow up of interesting cases 3. Research interesting cases as directed by faculty 4. Identify, rectify, and learn from personal errors 5. Incorporate feedback into improved performance 6. Competent in using the EMR and PACS in the daily accomplishment of the workload 7. Define the role of common interventional procedures in the management of patients 8. Understand the role of interventional radiology in the diagnosis and treatment of patients Interpersonal and Communication Skills: 1. Communicate with the patient at all times before, during, and after the examination to ensure that patient and/or family remains comfortable 2. Communicate effectively with all members of the IR team (physicians, nurse practitioners, nurses, and technologists) 3. Communicate effectively the results of studies to referring clinicians whenever needed (for emergent studies, this will be accomplished in a timely manner) 4. Develop a working relationship with clinicians that refer patients 5. Interact with clinicians when reviewing cases involving radiographs and angiography imaging studies and show ability to provide preliminary readings, follow up with attending radiologists, formulate a plan of complex cases, and communicate any changes to referring clinicians Professionalism: 1. Demonstrate respect for patients, families and all members of the healthcare team (technologists, nurses, and other healthcare workers) 2. Respect patient confidentiality at all times 3. Develop skills for evaluating and following patients on the floor with attention to their needs 4. Present oneself as a professional in appearance and communication 5. Demonstrate a responsible work ethic in regard to work assignments 6. Explain the nature of the examination or findings in an examination to patients and their families when needed 7. Observe ethical principles when recommending further work-up 8. Promptness and availability at work are required of every resident 9. Dress appropriately for work including appropriate identification (PIV card)
Systems Based Practice: 1. Able and willing to participate in clinical conferences in which imaging studies are used to guide patient care/evaluations and be able to demonstrate understanding of how imaging relates to the clinical care of the patient 2. Demonstrate knowledge of ACR guidelines and technical standards for interventional procedures 3. Demonstrate knowledge of ACR appropriateness criteria and cost effective imaging evaluation of common disorders 4. Familiarity with departmental policies for procedures, contrast safety, and sedation required in the performance of examinations 5. Make suggestions to improve methods and systems utilized in radiology whenever appropriate 6. Develop an awareness of the devices used, their cost, and alternatives Educational Goals and Objectives (Second Year Resident): 1. Develop a thorough understanding of the arterial anatomy of the head, neck, chest, abdomen, pelvis and extremities 2. Develop an understanding of the devices available for long-term venous access 3. Develop a thorough understanding of the devices commonly used in the interventional suite while performing vascular procedures, including: needles, sheaths, diagnostic catheters, guide wires, snares, balloons, stents, arterial closure devices, thrombectomy catheters and embolic devices 4. Become knowledgeable about common vascular health problems treated by the interventional radiology service, including: a. Peripheral arterial disease b. Venous thromboembolic disease c. Acute and chronic renal failure d. Acute gastrointestinal bleeding e. Acute gastrointestinal hemorrhage f. Chronic venous insufficiency 5. Develop basic interventional radiology skills considered necessary in the practice of vascular interventional radiology, including: a. Ultrasound guided venous and arterial access b. Central and peripheral venous catheter placement c. Micropuncture technique, sheath placement d. AV dialysis graft / fistula access e. Arterial and venous catheter manipulation f. Microcatheter technique g. Use of arterial closure devices h. Catheter directed thrombolysis i. Use of mechanical thrombectomy devices j. IVC filter placement and retrieval k. Use of endovascular balloons and stents l. Use of embolic materials coils, particles, glue m. Use of snares for intravascular foreign body retrieval n. Endovascular vein ablation
Educational Goals and Objectives (Third Year Resident): 1. Develop a thorough understanding of hepatobiliary anatomy and genitourinary anatomy 2. Develop a thorough understanding of the devices commonly used in the interventional suite while performing hepatobiliary and genitourinary procedures, including: needles, sheaths, diagnostic catheters, guide wires, balloons, stents, and drainage catheters 3. Familiarity with common non-vascular health problems treated by the interventional radiology service, including: a. Chronic biliary obstruction b. Acute biliary ductal injury, bile leak c. Cholecystitis d. Nephroureteral calculus disease e. Renal obstruction non-calculus f. Ureteral injury urine leak g. Bladder outlet obstruction and incontinence h. Chronic malignant pleural effusion and ascites i. Uterine fibroids and pelvic congestion syndrome 4. The resident should continue to develop their basic radiology procedure skills and vascular interventional radiology skills. The resident should also work to develop additional interventional radiology skills considered necessary in the practice of nonvascular interventional radiology, including: a. Transhepatic cholangiogram b. Biliary drainage catheter placement c. Cholcystostomy tube placement d. Antegrade pyelogram e. Nephrostomy tube placement f. Ureteral stent / catheter placement g. Nephrolithotripsy access h. Use of balloons and stents non-vascular i. Tunneled pleural and pericardial drainage catheter placement j. Uterine fibroid and gonadal vein embolization Educational Goals and Objectives (Fourth Year Resident): 1. Develop a thorough understanding of the devices and materials used to perform hepatic chemoembolization, hepatic Y-90 radioembolization, transjugular liver biopsy and shunt creation, endovascular management of aortic aneurism, and treatment of vertebral compression fractures 2. Familiarity with common vascular and non-vascular health problems treated by the interventional radiology service, including: a. Hepatic metastatic disease b. Primary hepatocellular malignancy c. Portal hypertension, cirrhosis d. Abdominal aortic aneurism
e. Thoracic aortic aneurism f. Acute vertebral compression fracture 3. Develop their basic radiology procedure skills, vascular interventional radiology skills and non-vascular interventional radiology skills. The resident with special interest in interventional radiology should work to develop additional interventional radiology skills, including: a. Technique for hepatic chemoembolization b. Advanced mesenteric vascular evaluation and pretreatment protective embolization c. Technique for hepatic Y-90 radioembolization d. Transjugular liver biopsy e. TIPS creation f. Endovascular management of abdominal aortic aneurism g. Endovascular management of thoracic aneurism and penetrating ulceration h. Transpedicular needle placement; vertebroplasty, kyphoplasty, bone biopsy Recommended Texts: 1. The Practice of Interventional Radiology, Valji, K, 2012. 2. Vascular and Interventional Radiology: The Requisites, 2 nd ed, Kaufman, JA, Lee, MJ, 2013. 3. Abrams Angiography: Interventional Radiology, 3 rd ed, Geschwind J, Dake M 2013. 4. Handbook of Interventional Radiologic Procedures, 5 th ed, Kandarpa K, 2016 Resident Evaluation: Residents will be evaluated utilizing the new innovations online resident evaluation form.