Why I joined the VIR Dropout Club™

When I started my R1 year, I was surprised that a few of the integrated IR residents in the classes above me were transitioning into diagnostic radiology residency. "What gives?" I thought. "How could somebody give up a shot at the coolest specialty, which also had a very competitive match?" So, who would've guessed that as an R3, I would be making the same change? Well, it's sort of a complicated story. I don't think my path will apply directly to many people, but there are probably elements that will. I probably brought more internal anguish on myself than necessary throughout this process, and for what it's worth I did want to share my experience to hopefully provide some clarity to other residents or students. I could go on and on about certain facets of my experience all day, but nobody has time for that (even someone who takes the time to click a blog of an unimportant resident), so I tried to pare it down to the most crucially important elements. The bottom line is:

• You can't do everything

• Having a baby changes your perspective on time and opportunity cost

You can't do everything "Life's barely long enough to get good at one thing. So be careful what you get good at." - Rustin Cohle (Matthew McConaughey), True Detective Season 1 A few years ago, I was strongly considering doing IR and neuro IR. So, on top of IR residency (6 years), another 2-3 years! Was I insane? Nah, just enamored of being the person who "does it all." There is some benefit to that path. There are a few individuals like Venu Vadlamudi who have done it (and I owe Dr. Vadlamudi for his mentorship especially while I was considering that path), although I know very few who have done that full 9 year path. As I explored NIR a bit more, I found that what I was interested in was less cerebrovascular and more spine. I knew I wanted to do advanced spine and MSK interventions because many of them have such a tremendous and demonstrable benefit (with less risk of causing a fatal or seriously morbid complication, e.g. brain bleed). I also knew I was not going to get enough exposure at my program to become an expert, and so I pivoted. My plan was ESIR -> MSK fellowship -> IR fellowship. I had a tremendous amount of luck and got put in touch with Doug Beall, one of the world experts in MSK and spine interventional radiology, and landed a fellowship with him to start after ESIR. The fellowship entails mostly interventions and clinical care. I was (and am) stoked. The plan was still to do VIR fellowship after, and then do both VIR and MSK IR in practice. Sounds pretty badass, huh? That's what I thought, because I was still tied to this notion of being the one who "does it all." There are tradeoffs in every decision when it comes to specialization. For me, I ultimately came to the conclusion that I could not be an absolute expert in minimally invasive spine and MSK care if my focus was diluted by the entire gigantic specialty of IR. If I were to do ESIR, that's no electives in MSK or spine imaging to improve on that front. My fellowship with Dr. Beall will be mostly interventional, and so if I came in with good catheter skills but lousy knowledge of MSK MRI, that seemed like a tough tradeoff. The more I tried to come up with ways to cram this in (read MSK MRIs on my off days on night float?), the more I found it just wasn't possible to do it all. This is all to say nothing of the entire extra year of VIR fellowship (more on that later). Another factor is that my interest in all the amazing things coming out in the spine and pain world only increased, while my interest in vascular waned. Such is life. I was at a great endovascular conference a few weeks ago and while I really thought the cases were amazing and I admired the people doing them, I found myself thinking, "Do I really want to be the guy doing that?" The more I pushed myself on this issue, the more I found the answer was, "No." In fact, when I envisioned myself doing such a case, I created a bit of anxiety for myself, because I know how hard you have to want it to be a true vascular expert and compete in that realm. Do I really want to be competing with spine surgeons AND vascular surgeons? The defiant part of me says, "Hell yeah." The part that actually analyzes things more rationally says, "Doesn't seem like a formula for success in either realm." Meanwhile, it seemed like every other day I was seeing another amazing case from Dr. Beall or hearing about another spine or MSK treatment I hadn't even heard of. Most people hate reading spine MRIs. I love it because I'm constantly thinking, "How would I treat this?" Could I do both VIR and MSK IR? Yes, it's definitely feasible. But there are always trade-offs. I just described some of the professional ones (trading time you could use to become an expert in one area to spend time in a distinct area as well). I would argue that the personal factors are even more important. Having a baby changes your perspective on time and opportunity cost "After you kids came along, your mom, she said something to me I never quite understood. She said, 'Now, we're just here to be memories for our kids. ' I think now I understand what she meant. Once you're a parent, you're the ghost of your children's future." - Joseph Cooper (Matthew McConaughey), Interstellar If you haven't noticed, I'm a bit of a McConaughey fan. I can elaborate on that at another time, but the short version is I think he's a very authentic and multifaceted person who also happens to be a fantastic actor. When I rewatched Interstellar around my 30th birthday, it was just after Lindsay and I decided we wanted to have a baby. The fact that the scene above and multiple others in the movie made me sob heavily before I even had any kids probably could have predicted how my perspective would shift once Elliot arrived. When I was 3, my dad sold his successful wood-working business in Dallas and we moved to Colorado. My dad was retired for several years until he eventually started a new machinery automation business, and he's been doing that ever since. He sort of traded an earlier retirement from work for a temporary retirement to spend with his young kids. I didn't realize at the time how special it was to have both my parents at home when I was a kid. I think it had a major impact on me, but I didn't really realize how much until I had a kid of my own. When my son Elliot arrived just over 5 months ago, he instantly changed everything. Any parents will tell you that. Of course, the first months especially are very challenging and hectic (especially as a resident), but it's like wearing new prescription lenses when your old ones were woefully out of date. I saw very clearly what actually mattered to me and what did not. I had a much easier time saying "no" than ever before. I also saw how my perspective on time changed radically. When you are young and have no kids, your time is basically your own. You have family obligations, of course, but still a degree of freedom with how you could spend your time, even years of your life in residency or fellowship. As a med student with no kids, the difference between 6 years for residency and 7 years for an additional fellowship seems negligible, a no-brainer. "It's an investment in my career" or some variant was what I told myself again and again. I think that was true at that point in time. Now, I don't see it that way. That year does not just belong to me. It belongs to my son and my wife too. And if I'm living in another state for an entire extra year of my son's young life, or being stuck at the hospital until 2 AM embolizing bleeds and putting in nephrostomies, I better be damn sure the tradeoff is worth it. I have come to the conclusion that it is not. Medicine is a difficult career that demands much sacrifice. We sacrifice our time, family moments, physical and mental health, hobbies, our entire 20s and much of our 30s, to take care of patients. Some of it is unavoidable. But we have some say in what we will sacrifice. To make a sacrifice is to make something sacred. I found that the more I thought about it, I could not abide sacrificing memories with my family to be stopping GI bleeds or putting drainage catheters in septic patients. I couldn't see anything sacred in that path. I would become a miserable human, the kind who yells on the phone at an intern who calls to ask for help (something I absolutely despise). I didn't want to walk that path. I couldn't mortgage my son's early memories for some vague notion of identify---being the one who "does it all"---that was no longer personally motivating. So I decided I wouldn't. Okay… what now? Well, as of a few days ago I will no longer be pursuing ESIR or IR fellowship. Both my DR and IR PDs as well as a lot of my coresidents have been overwhelmingly supportive, which I appreciate tremendously. I will spend my last year of residency mostly in MSK imaging and neuroradiology rotations (with a lot of interventional procedures to go around) and focus on building up as strong a foundation as possible in those areas. I'll join Dr. Beall for a year to get as good as possible at what I want to do: all facets of minimally invasive spine and MSK care. What's beyond that? Who knows. There are several different possibilities and ultimately I want to find the one that best enables me to take care of patients and alleviate suffering. Suffice to say I'm a square peg, but I'm no longer trying to fit into a round hole. If I can find a suitable square hole, that might work. Or I might just have to make my own. There are a lot of unknowns. One of my mentors Reed Omary once gave me a fantastic piece of advice: "The more you can tolerate ambiguity, the better a leader you will be." It's a powerful notion. We often get too hung up on needing certainty when in reality almost nothing is certain. At the end of the day, we choose which kind of ambiguity we can tolerate. The unknowns of a career path are, for me, a tolerable kind of ambiguity. Wondering whether my son will know my face because I had to go on some Arthurian quest I signed myself up for years ago? That’s not an ambiguity I can tolerate. I do want to add that none of this should dissuade anybody from going into IR. There's never been a better time to get involved in this specialty and there's never been a greater need for compassionate and capable physicians to change it for the better. There are many things to love in IR. It's crucially important to know that the things you love professionally are worth it to you personally. I have too many family, friends, and mentors to thank all by name, but if you're reading this, there's a strong chance you're one of them. So, thank you for supporting me. Whatever happens next, it'll be interesting. Hopefully you'll stick around. Jacob