This study gives a subjective indication of medical students' experiences and awareness of IR through their exposure to teaching, including students from 20 out of 23 different medical schools, and from all Australian states.
The results show that 50 students (61%) considered their level of understanding of IR to be “none” or “poor” (Fig. 1), noting that students will inherently compare this to their level of understanding of other specialties that they are familiar with. As a survey on student perception, the results suggest that IR understanding is far lower than what the authors would consider adequate and correlates with international literature (Ghatan et al. 2010; O’Malley and Atherya 2012; Hoffmann et al. 2018 Jan 1; Atiiga et al. 2017; Garg 2019; Xu et al. 2021; Agrawal et al. 2019; Foo et al. 2018 Dec). This is concordant with similar results in Fig. 2, where 72 students (88%) considered their perception of IR teaching to be “none” or “poor”, and this perception of teaching was significantly lower than the perception of teaching of diagnostic radiology (p < 0.001). 99% of students suggested IR teaching and education could be improved. It can be assumed that students are attending relevant teaching opportunities given their willingness to respond to the survey, and thus we believe that the results imply a relative deficiency in teaching of IR compared to DR, but also likely to be deficient compared to other well-known specialties.
There are likely to be a number of reasons for this disparity. First, in keeping with existing international surveys, IR remains an under-acknowledged specialty and has not made its way into mainstream medical teaching. This is likely compounded by a small number of IRs who are all busy clinicians, and it is unlikely that there is a large representation of IRs amongst clinical university trainers. As such, there is not only a lack of teaching but likely a lack of mentorship, and it is thus not surprising that only 11% of students surveyed would consider a career in IR.
What is concerning is that these results haven’t changed from previous studies including Foo et al. who suggested that only 7% of students they surveyed reporting adequate teaching of IR from 2 Victorian medical schools (Foo et al. 2018 Dec). A recent large study from Brien et al. presented the results of a wide survey of medical students from 11 countries across Europe. They showed that that only 10% of students had heard of IR, and two-thirds of students had no formal exposure to interventional radiology (Brien et al. 2021 Oct). What is most worrying is that there has also been no change to this trend dating back over 10 years from surveys across the world (Ghatan et al. 2010; O’Malley and Atherya 2012; Hoffmann et al. 2018 Jan 1; Atiiga et al. 2017; Garg 2019; Xu et al. 2021; Agrawal et al. 2019; Foo et al. 2018 Dec; Brien et al. 2021 Oct).
In assessing the technical side of IR, students did have knowledge of different procedures that IR does (including angioplasty, stenting, and embolisation). However, students also did not know that cardiac and open surgical procedures were not performed by IRs. This suggests either an acquiescence bias to the responses, and/or just a generally low understanding of what an IR can offer patients, similar to what has been reported in prior studies from the European Trainee Forum (ETF) (Brien et al. 2021 Oct). This further supports the low understanding of the duties of IR even though students at a median of 4th year would likely have had some exposure to surgical and cardiac procedures given they are relatively mainstream compared to IR procedures.
In assessing the clinical side of IR, students have a low understanding that IRs perform clinical duties including ward rounds, outpatient clinics, and admitting patients to their own bed card. They also incorrectly identified that IRs only perform procedures from other specialists, when in reality many general practitioners refer patients, and the range of care being offered by IRs extends beyond just procedures. This further supports a general lack of understanding of the specialty of IR including its scope and daily workflow.
In looking at student-reported ways to improve existing IR education, of the 99% of students who suggested ways to improve, they advised that a broad range of different potential measures could be employed including didactic, self-directed, clinical, and research learning techniques. This is similar to how different topics are integrated into a well-rounded and multi-modality teaching style, and these are all techniques that IR needs to harness. The ETF is a subcommittee of CIRSE which provides governance and advocacy for IR trainees including medical students and doctors in training. In their 2020 report on the status of IR training in Europe, they highlight the vital importance of teaching of IR in university faculties (Makris and (Editor). xxxx).
In supporting this forward-thinking approach, CIRSE has released a medical student curriculum (Cardiovascular and Interventional Radiological Society of Europe: Student Programme – Be InspIRed [internet]) which outlines an evidence-based document based on the scope of expert consensus, providing the roadmap for medical schools who wish to begin IR integration. CIRSE also advocates for IR training in further ways including the ETF, online training and advocacy, and dedicated webinar series (Cardiovascular and Interventional Society of Europe. ETF webinars [internet]. Accessed 30/11/22. Available from URL: https://www.cirse.org/trainees/etf-webinars/16. Australian Medical Students Association (AMSA) 2020). In addition, IRs including their college (Royal Australian and New Zealand College of Radiologists or RANZCR) and specialty societies (Interventional Radiology Society of Australasia or IRSA) should provide initiatives to incentivise students and promote training opportunities. This may be similar to the “Be inspIRed” program being offered by CIRSE (Cardiovascular and Interventional Radiological Society of Europe: Student Programme – Be InspIRed [internet]), or to support and work with AMSA. IRs should also actively seek involvement in training and education, including both clinical and research placement in partnership with their local universities.
At the 2021 RANZCR Annual Scientific Meeting, it was announced by the RANZCR President that the college would be applying to the Australian Medical Council with the aim of achieving separate specialty recognition for IR (RANZCR Inside News 2021; RANZCR). A successful application would mean IR and DR would be formally recognised as different specialties. Such a change may be a pivotal step in providing the foundation that IR needs for more formal medical school integration and will lead to a larger IR workforce which will allow staff to filter into universities similar to colleagues from physician and surgical specialties.
Muzumdar et al. suggests a lack of exposure is behind the lack of drive towards IR (Muzumdar et al. 2019) and as such, these initiatives are vital for patients and future doctors to understand the cost-effectiveness, short recovery times, and low complication rates that can be offered by IR. Shaikh et al. also showed that even something as simple as a short 10-h teaching curriculum can increase the knowledge and understanding of IR within medical students (Shaikh et al. 2016 Apr). The authors advocate for changes to begin with immediate effect in worldwide medical curricula, including Australia.
This study must be interpreted within its limitations. The overall response rate was low and likely to represent a number of factors. Firstly, as an online survey embedded within a newsletter there may be many students who did not read or see the survey. In addition, access to the Facebook page requires a specific account and the post may be lost within a range of other posts. There is certainly a significant response bias in that students don’t know much about IR and thus didn’t want to reply to something they didn’t fully understand, as shown in previous studies (Brien et al. 2021 Oct). Conversely, this low rate may actually reflect the survey conclusions, showing that people aren’t responding because their knowledge of IR is low and is supported by the 2020 report from CIRSE and the ETF (Makris (Editor)). Response rates may have been improved with incentives, but this introduces its own courtesy bias. In addition to the low rate, the authors also acknowledge existing studies in Australia on the topic (Clements 2022 Mar), however conversely this study presents a wider response from 20 different medical schools rather than 2, with a more national message being present in this manuscript. This study also assesses perception which is an indirect maker of measuring the curricula, and another method would be to assess medical schools themselves. We also acknowledge that the survey assessed predominantly vascular IR procedures and did not full address the scope of non-vascular IR, interventional neuroradiology, and interventional oncology procedures.
We also acknowledge that the responding medical students were predominantly from their senior years, similar to what has been reported in similar international surveys (Ghatan et al. 2010; O’Malley and Atherya 2012; Hoffmann et al. 2018 Jan 1; Atiiga et al. 2017; Garg 2019; Xu et al. 2021; Agrawal et al. 2019; Foo et al. 2018 Dec). This suggests that the exposure these students have had may not have come until their clinical time when they have made referrals to IR. Responses from junior medical students may be different, possibly even worse as the teaching is likely to be even less. There are several issues to consider with this. First, while this study assessed perception of teaching, it did not consider what type of teaching students had. There is likely to be a vast difference in the exposure students have depending on whether they are rotating to a large centre with advanced IR, a small centre with mainly basic procedures, or just receiving lectures with no practical exposure. While this is also a bias for all specialties based on the current model of rotating clinical teaching, IR teaching is arguably more vulnerable given the small workforce and large differences in work type and acuity between centres. This bias should be considered for the students who replied to the survey and their perception of IR duties (Figs. 3 and 4), but this also highlights why it is important to improve medical student teaching.