I am Dr. Justin McWilliams, an interventional radiologist at UCLA. Working through a hole smaller than a pencil, I can cure cancer, shrink prostates, save your life by controlling life-threatening bleeding, and make your legs look awesome. Ask me ...

Why is it that hospitals can have incredible hardware like electron microscopes, yet pagers are still being used?

Good question! I wonder this myself when I'm walking around the grocery store looking like a drug dealer. I think it is because we need a cheap device that doesn't lose contact in hospital basements and other locations lacking cell service. Sat phones are too expensive to give us, I guess. I do have all my pages go to my cell phone as well, though, so I don't have to carry that thing everywhere I go...

What is the most difficult procedure you have ever performed?

Wow tough question. One was a TIPS (which is basically a shunt placed through the liver under semi-blind X-ray guidance, used to relieve pressure in the portal system in patients with cirrhosis) that I was doing in a patient who was actively vomiting blood, bucking around on the table and generally trying to die. Another was a patient with a massive pulmonary pulmonary embolism who was 500 pounds and I was trying to navigate a catheter through the lung arteries to suck out the clot as their blood pressure was tanking and they were coughing blood and I had to decide whether to keep trying or call the surgeons to crack her chest. Both turned out OK, the TIPS patient survived and got a liver transplant a few days later, and the PE patient I was able to suck out enough clot to get them out of the woods, and the next day she was sitting up in the ICU eating french toast. Win.

Current med student who is very interested in a carrier in IR. What would you say would make a strong application for someone who is applying to an IR residency? Any suggestions about creating a strong application would be greatly appreciated.

Definitely start by not having any mis-spellings in your application or personal statement.

A strong application is the combination of a few things:

1) Good med school transcripts. Try to get some letters of distinction, or honors, or whatever your school offers. Work hard and be the first one there and last one to leave. It will be noticed.

2) High board scores. Especially step 1. It sucks to study for it but it is well worth it. A high score here can carry you a long way.

3) Good letters of recommendation. These get more important the farther along in training you get. If you are working hard and studying hard, and you aren't a total a-hole, then this should work itself out.

4) Research experience. Especially for academic institutions, they want to see one or more projects that you have carried through to the end. First author on a paper, or at least on a poster or conference presentation.

5) A really beautiful head-shot. Just kidding. Kind of.

Notice I didn't include a great personal statement. These all read basically the same to me, so I just skim them, looking for any signs that you are a mass murderer or serial rapist. Otherwise they don't make much difference, at least to me.

Hi Dr. McWilliams, just wanted to jump on with a very related question. I'm a current radiology resident planning to apply into IR prior to the switch in 2020, and I'm having a hard time gauging my competitiveness and how many programs/where to apply, since the more "objective" standards including grades and board scores are not as relevant to a fellowship application. I've heard great letters of recommendation and research become even more important (especially prior to the interview invitation), but wouldn't everyone have great letters and at least some research? How do you differentiate between candidates at that phase?

I guess from a practical standpoint that what I'm asking is, is there any way to gauge how competitive I am in order to figure out how broadly I should apply?

It takes some introspection. Look at the following things in yourself:

-How good is my board score? Yes we still look at that!

-Did I get AOA or lots of good grades in med school? We still look at that too!

-Is my radiology residency considered "top-tier"? That definitely helps your cause.

-Have I won any sort of awards or honors during residency?

-Did I do a lot of research, more than my peers?

-Has your own IR program told you you would be a shoo-in at their program?

If you have a lot of yeses to the questions above, you probably are sitting pretty, and applying to a dozen or so programs will do. If not, apply widely, since you can always turn down interviews after you are granted them.

During residency, be nice to nurses. You never know who they have the ear of.

This is 1000% true. Not just during residency, either. Nurses can make your life easy or very, very hard.

Current med student maybe interested in IR here. What were your work hours like in residency/fellowship and now as an attending?

Residency wasn't bad, in fact pretty sweet. Internship can be tough (like 60-80 hour weeks) but once you get into the diagnostic radiology years, the work hours are more like 50 hours a week, though you have to do a lot of reading and studying at home as well. During fellowship, you are limited to 80 hour work weeks by the ACGME, but I'd venture to say that some fellows work well over that at times (never at my program, in case ACGME is reading!), maybe up to 100 hours a week especially during busy call weeks.

Now as an attending, you have a lot of control over your life and your hours. Some of my friends work at the VA and work about 30 hours a week with 2 days off, some work in private practice where they work hard when they're on, but get 14 weeks of vacation a year, and then there are the truly mis-led like myself who take a job in academics because they like teaching and research and feel like it's a noble thing to do but then spend basically their entire waking life doing work-related things to the point where they are unable to have pets because they would die of neglect. That's pretty much where I'm at, but I am OK with it because I love my job and I get to help people every day. I'm probably between 60-70 hours/week most weeks but more if you count all the time I spend at home working on lectures, research, answering emails, etc.

Could you talk more about the private practice options that exist for interventional radiologists? I realize this is something you may have limited experience with but I was unaware how much interventional radiologists can really tailor their lifestyle.

There are lots of private practice jobs in IR, in fact many more private practice than academic jobs out there. Usually this will be as part of a large radiology group. Radiology groups like to have IRs in their group, because it allows them to contract with hospitals who want IR coverage, and because IR procedures bring in a lot of imaging. Plus, IR doctors are also boarded in diagnostic radiology, so private practices put the IR docs to work in between their cases by having them read films. So, anyways, lots of job opportunities there.

There also are IR-only groups, which is kind of a newer thing, and semi-academic jobs like Kaiser, where you get to do some teaching and research but otherwise function much like private practice. There really are all kinds of options and you can tailor what you do, where you work, and how hard you work to a great extent (though you never want to be considered the lazy partner!)

In terms of IR's in a private practice setting, there are quite a few that open up varicose vein treatment offices. They close the diseased vein with minimally invasive techniques using thermal energy under ultrasound guidance. Doing just this procedure alone, many late-career IR's have become successful with these vein clinics.

Absolutely true. Not just IRs either, many MDs have found vein practices to be lucrative. The procedures are short and patients are happy. I personally am completely uninterested in doing varicose veins because I get much more satisfaction from treating diseases that can kill you, but maybe when I'm older...

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Yes, you're right. But the fellows actually push for working this hard. They have only one year to learn all the hundreds of procedures we do, and to accomplish that they want to do as many cases as possible. There are times when I have to strongarm fellows into going home after they have been up all night, because they want to stay and do more cases.

Interestingly, there are no work hour restrictions once you are done with training, so no governing body would come down on me if I started working 120 hour weeks every week. My girlfriend would definitely leave me, though.

What was your favorite class in college?

What is your favorite "ghetto gourmet" trick for dressing up cheap food?

How have things changed in the last 10 years in your field?

What do you consider to be the most exciting developments in cancer treatment in the last 5-10 years?

My stepmother has survived 5 years after a pancreatic cancer diagnosis, which would have been a death sentence not so long ago but for people like you, so thank you all for your hard work!

Any math class and logic. I actually got a perfect 100% for logic, for the whole semester. Didn't miss a point. I remind my girlfriend of this constantly.

I am king of ghetto gourmet. First, put blueberries on any cold cereal. Also, you can make pretty good quesadillas over the open flame of your gas range, just use tortillas and shredded cheese. And no one can convince me that there is a better mac and cheese than the classic Kraft box with the orange powder cheese. You can dress that up with hot dog slices, but I wouldn't say you need to.

The last 10 years in IR have seen an explosion of technologies. Our equipment keeps getting smaller, and new devices are coming out all the time, so the scope of what we can treat keeps getting bigger. Surgeons have seen the writing on the wall and have started to try to learn our techniques. It has created a competitive environment in health care, but overall patients are benefiting.

For cancer treatment, I'd say the advances of ablation technologies that allow us to cure (not just treat) small cancers have been big. Y90 radioembolization, which allows us to deliver massive doses of radiation through the blood vessels into very targeted locations, is very cool too. Also, the nascent field of personalized oncology, where biopsies are used to find what the cancer is susceptible to, and a custom cancer-fighting agent is personalized to the patient. As above, that one may be huge.

Thanks! Wish I could take credit for that one, but hopefully we keep getting better!!

Can you speak to the turf wars between IR and vascular surgery? Do radiologists make better interventionalists because of the dedicated rads experience?

It's a pretty open war in many ways- we pioneered the procedures, but they adopted them and have gotten quite good at them in many cases. I do still believe that the imaging skills are what separate us from the other doctors who try to do our procedures. There is a power in my ability to have a patient come in, interpret their MRI scan, treat them, and interpret their imaging results, allowing me to determine what the best follow-up treatments will be.

TL;DR - yes, we are way better.

It's just silly turf wars.

What's important is that you are dedicated to the field and good at what you do. If you have enough practice you can do everything well no matter what you are originally. Some specialties let you start a bit ahead of the curve from one side (rads with the pictures) others from the other side (vasc from the disease/clinical side). This applies to all the other 'common' grounds.

I think I overall agree with this view. There is some natural ability/cognition that comes into play as well, regardless of training. I sometimes think "you can't train logic". That is, I'll sometimes be supervising a resident or fellow, and we will be biopsying a lesion that is 2 cm deep, and suddenly he is advancing the needle 5 cm because he isn't visualizing the tip well with ultrasound... and I have to be like, man! Use your head! This, along with the ability to have a sense as to when you are over your head and when to ask for help, are things that are especially hard to train.

And no one can convince me that there is a better mac and cheese than the classic Kraft box with the orange powder cheese.

Spoken like a guy who may be pulling in big bucks now, but had to get through medical school once.

PS: a collective thanks to your profession for my varicocele embolization. Have 2 kids now, it worked great.

Did you have the kids before or after the embo?? Because that would not be the desired result... yikes

is your girlfriend also a Doctor, if so what kind?

No she works in finance. I had dated doctors in the past, but sometimes it's nice to leave work at work and not "talk shop" all the time. I don't talk too much about my procedures and she doesn't tell me too much about her Excel spreadsheets, and instead we cuddle on the couch and watch Westworld

Are you concerned about the long term effects of radiation exposure from fluoroscopy?

I stand next to an X-ray beam almost every working day, so I am definitely concerned. Not so much about becoming sterile or anything, since that takes really high doses, but about small incremental risks of cancer, particularly leukemia or lymphoma. I'm hoping that instead, I will develop cool mutant powers like Spider Man, but I am told that is really really unlikely.

I wear a lead kilt and lead vest that make me look like a really slow Scottish warrior, and it protects from about 90% of the scatter radiation that I experience. I also wear a radiation badge that gets turned in every month, and radiation safety officers write me scary sounding emails about how many milliGray I was exposed to, but never really equate that to how much risk I'm exposed to. Fortunately I've done my own research, and it seems that the cancer risk from my occupational radiation exposure is fairly small in the grand scheme (cancer risk for the general population is 40%, but for me might be 40.5% or 41% after a lifetime of working in IR).

Interesting is that there are reports out there of cardiologists having tumors grow on the left side of their brain or face - this is more common because cardiologists typically stand with the radiation beam on their left side (same as me). I typically protect against this by hiring fat fellows (block a lot of X-rays) and standing behind them as much as possible.

What is your lifetime dose? As a commercial nuclear power worker, I'm up to about 9 REM over 20 years.

PS, thanks for all those guys you keep sending us all jacked up with Tc-99 and Cl-12, it's super fun guessing which one is knocking out every single radiation monitor we have at our checkpoint.

I have no idea what my lifetime dose is. Frankly, I'd be a little afraid to know.

Haha I don't do much nuc med but occasionally we do inject Tc-MAA or Y-90, so patients have to promise not to hug their child for a day or two...

I'm a Radiographer (technologist in USA I belive) in the UK, one of our consultants in the cath lab actually stopped growing leg hairs in his left leg as a result of the X-ray scatter..

They now wear lead shin pads, which; although is a definite increase in protection, makes them look like they play for a budget cricket team.

Leg hairs still intact. You mostly have to protect the hematopoetic marrow which is not so much in the distal parts of the extremities- so overall the hands and feet are fairly resistant to radiation compared to the more central body.

Med Rad tech here.

I've heard chatter about changes that would allow nurses to order, perform and report their own imaging work. What do you feel of this suggestion? I myself am very concerned about this as I completed years of schooling in order to take appropriate diagnostic images while you've undergone even further education to ensure those images are appropriately interpreted. I don't feel these jobs could be accurately done by an RN.

While it's probably less of a concern with high level IR procedures, what do you think about the possibility of rads and their image reading being replaced with computers? We already see this being done on a limited scale in mammography with CAD being used as a "second read", but it hasn't seen much penetration beyond that.

Beyond poor quality imaging (low quality images, sloppy pos'n), what is something that drives you nuts about us imaging techs?

Least favourite type of case to do/read? I've heard many complaints about the GI tract (swallows and enemas) from my doctors here. And then bitching about bone age studies.

I haven't heard this change myself, but I agree that it is a bad idea. There is a reason why we have to spend 14 years in training- there really is a lot to learn

Regarding CAD, this is definitely already here in some areas (like mammo), and for the rest of radiology, it is coming. I think it is a matter of time before you do a scan, and a computer auto-compares that to a library of millions of normal and abnormal scans, using pattern recognition. Then it spits out a report. Probably will still have a radiologist to double check it, but someday the humans will be the quality control rather than the other way around.

We have amazing techs at UCLA IR. The best thing a tech can do is anticipate what the doctor might want next. Sometimes you know the equipment so well you can suggest what tool might be right for the job. That's the sign of a great tech... along with staying in/near the room within shouting distance.

Least favorite case is definitely the dialysis graft de-clot. You spend an hour hugging the X-ray beam trying to pull and remove clot out of the graft, and when you finally do the angio run at the end to check your work, it is already clotted again. So discouraging sometimes.

What is the most disgusting case you've had? Funniest case?

I think I have been showered with every bodily fluid at some point, which has prompted me to come up with a definite ranking of bodily fluids, in terms of which ones I don't want splattered on me... in order from most to least disgusting: -Feces -Vomit -Saliva -Urine -Ascites -Blood

At this point I'd say the last 3 don't bother me at all. Urine for example is sterile and really is just filtered blood, so it doesn't seem disgusting to me at all any more.

But I digress. I did have a patient who was having heavy GI bleeding from the stomach. When that happens, the blood passes through the digestive tract and gets semi-digested into a nasty semi-solid blood/feces cocktail called "melena". The patient came down for me to stop the bleeding, and proceeded to "melena" all over my shoes as I was helping transfer the patient to the table... and I wasn't wearing shoe covers. This prompted a stat trip to Sports Authority for new sneakers.

Funniest case- I had a patient come in for treatment of varicocele, which is like a "bag of worms" in the scrotum composed of blood vessels due to incompetent venous valves in the abdomen. Usually patients come for treatment because the varicocele hurts, or is causing a decrease in sperm counts... but he wanted it treated because he didn't like how it looked on camera. Turned out he was a male porn star. I happily treated him (but never looked for my handiwork on the internet)

all to often DR and IR are viewed/discussed by surgery/medicine etc. as technicians to be consulted by other services. Do you think the profession needs to take more of a long term role in the management of patients? How can this be achieved?

Insightful question, as you are correct- IR has always been considered more of a "technician" than a "clinician". That is our own fault- back in the heyday of the 1980s, fee for service was king, there was no competition, and a bunch of radiologists made really good money by just sitting around waiting for procedures to get referred to them by everyone else. They would do the procedure, get paid, and send the patient back to whatever doctor they came from. Things changed in recent years. Other specialties (like cardiology and vascular surgery) started thinking, hey, these procedures are really cool, I bet we can do these ourselves! And so they gradually learned them and then trained their own doctors how to do them and stopped referring the patients to IR. IR initially responded by just expanding their scope by coming up with cool new procedures (like Y90 radioembolization, prostate embolization, HIFU, etc, etc) but the current generation has finally come to the realization that we have to really be clinicians and have patients consider us as their doctor, not just the guy who did a procedure on them. To that end, I run a full day of clinic every week, where I see every patient before their procedure and follow them after their procedure. Some of my patients think of me as their doctor more than their GP or their oncologist, so I think the approach is sound. IRs just have to realize that they have to run a clinic and they have to be responsive to patients and to referring physicians (Affable, Available, and Able, in that order... the saying goes)

I'm a Hospitalist and wanted to ask this very question. I'm grateful for the fantastic service IR provides, but sometimes lament the lack of communication between myself and the radiologist, and the lack of follow up for my patients, who are by definition hospitalized. I'm glad to hear hear about your clinic, and perhaps this thread will encourage me to reach out and communicate with IR more directly in the future.

Agreed. This is still an area where we need to improve. I am sometimes so busy that I can't follow up on every patient, even if I wanted to. I think having trainees who can act as the "hand of the king" helps, or having an inpatient NP who can bridge the gap and report to us how our patients are doing. But really, we just need to do a better job seeing all of our patients in follow-up, whether it be in-hospital or in our outpatient clinic. Not all IRs have jumped on board this new clinical paradigm, but they better do so soon, or else find their referrals drying up and their salaries drop.

How many years of training does it take to become an Interventional Radiologist?

4 years university + 4 years med school + 1 year internship + 4 years diagnostic radiology + 1 year IR = 14 years after high school. Sounds bad but to be honest those years were some of the best of my life, and the training and learning were really fun. Now that I'm out on my own I have real responsibility and spend a lot more of my time waking up at 4 am worrying about patients.

Have you ever had fluoro stop working midway through a procedure? What do you do in that situation?

Yea, a few times. Usually a re-boot gets it going again, just like my PC and iPhone. If it doesn't, I wish I could say I get out a scalpel and just dive in there the old-fashioned way, but in reality we just move the patient to another fluoro suite (we have 4 IR suites here at RRH).

Can you explain how the field of interventional oncology will grow? Like radonc will it also be put on the back burner to personalized onc chemo in the future?

In line with that do you think interventional radiology will be the big field of the future with its own residency?

IO is definitely growing. Cancer is really common (about 40% of us will be diagnosed with cancer during our lifetimes) and people are looking for minimally invasive treatments and cures, such as those that we offer in IR. So I expect that will really grow. I do agree that personalized onc chemo has great potential, but it has quite a ways to go... and maybe like flying cars, it may not reach the potential we expect as quickly as we hope it will.

Regarding IR residency, it's already a reality! Medical students can now apply directly to IR residency, which is a 5 year training program after internship. So 4 years med school, 1 year internship, and 5 years of diagnostic and interventional radiology (essentially 3 years diagnostic and 2 years interventional)

Have you ever had to call it quits during a procedure because it became too technically challenging? When should you think about punting to another day or service?

Almost never, it is kind of a pride thing. I tend to carry through almost to a fault, which sometimes means tough procedures last for hours and the back table looks like a garage sale with piles of catheters and wires. But if it truly looks like I can't do it, or if I run to more than 60 minutes of fluoro time, or if any point it is becoming unsafe to the patient, then I would definitely just stop and try again another day (or sometimes refer to surgery, if it can't be handled by minimally invasive means). Luckily I have really excellent IR colleagues, so I can always have them try as well- sometimes you just need a different set of eyes and a different pair of hands.

Hey, I recently had the misfortune of finding myself on one of your colleagues' fluoro tables, in desperate need of a percutaneous nephrostomy. It was 2:30 AM, the IR was irritated because he had to return for this procedure (ER didn't release me as they were supposed to, so...the IR team split, only to return an hour and change later). Dude used NO anaesthesia, just a couple of syringes of lidocaine. So....after the procedure, when they pried my fingers our of the ceiling tiles and brought me back down to the table, if I had ANY body fluids available to me....I'd have considered splashing them on Dr. Mengele. Please tell me this is NOT SOP.

Very entertaining AMA. Thank you for all your good work!

Yea one thing that always amazes me is the difference in pain tolerance from person to person. For some people, a nephrostomy tube under local anesthetic is no big deal. For others, they absolutely can't do it unless it's under general anesthesia. I'm going on record by saying that old women are by far the toughest. The wimpiest are men, with their pain tolerance in inverse correlation to how many tattoos they have. Always blows my mind that they can get a 2 foot skull tattooed on their chest but my 25 gauge lido needle makes them nearly pass out from pain.

How did you decide on IR and what fields were you choosing between as a medical student?

I went into med school fully expecting to do ER or orthopedic surgery. But then I found that ER spends much of their time dealing with drug-seekers and deadbeats (not that they don't need help, but they are emotionally taxing!) and ortho spends much of their time mindlessly hammering and making sexist comments, only one of which I was good at. So I was kind of lost, but I liked the idea of being like an oracle that people came to for advice and answers to their problems, which is basically what a radiologist does- so I went into radiology. But then a few years in, I really missed the patient care aspect, and doing things with my hands, and discovered IR. The first day of IR fellowship I realized I had made the best decision of my life. Never looked back.

Hi Dr. McWilliams, with new applicants being corralled into the esir or integrated pathways and the vir fellowship disappearing what are your tips for evaluating all the new programs as an interviewee?

Tough time to be an applicant, since IR is a popular field right now- I think we had 220 applicants for our 3 integrated IR spots. But just realize you will be able to get into IR even if you "only" match diagnostic radiology. So look for DR programs that have a strong associated IR program (and offer ESIR) and also apply to integrated IR programs, which would be even better. As far as evaluating programs, it helps to talk to the current or past fellows, they will be brutally honest- or come shadow in the department or do away rotations to see for yourself. There are lots of good programs but you have to find one where you feel like you fit in. For example I thought of going to Miami Vascular for fellowship (which is an amazing place) but I was single at the time and the thought of being in beautiful South Beach and never doing anything fun because I was spending 18 hours a day at the hospital just crushed my soul too much. So I stayed at UCLA and never regretted it.

Corindus makes a robotic angioplasty system for interventional cardiologists that allows the physician to step away from the table and control stent placement from a computer, away from the radiation source. Has UCLA begun adopting a similar device for IR procedures and/or does a similar device for IR procedures exist?

Yes there is a similar robot system for IR, that allows remote control from the control room outside the angio suite, or even from across the world, theoretically. The technology though is still in its infancy. A lot of our procedures are performed by guiding shaped wires and catheters through the blood vessels or other parts of the body, and there is a certain "feel" - like a tactile feedback - that you get when you are holding/advancing/spinning the wire and catheter that can't really be replicated when you're just holding the controls of a robot. So as much as I like the idea of sitting on my sailboat in the Caribbean and curing cancer via robot, I think it is a ways off from reality. Plus I don't have a sailboat. And, I've never been to the Caribbean. Academic medicine doesn't pay that well...

PGY-1 here who's been accepted into a DR program with ESIR. I'm concerned that software will soon enable computers to interpret imaging in the near future, reducing the need for DR physicians, perhaps relegating them to just double-checking the computer's work. Is my fear justified?

Yea see above- it's a ways off though. In the same way, wouldn't you have some concern that an inpatient medicine doctor could be replaced by a robot that takes in all the lab values, vitals, X-ray reports, and synthesizes a diagnosis and best treatment based on its internal library of best practice literature? I've seen Terminator 2. I know what's going to happen. But overall I think robots are going to help us rather than replace us, at least for a long while.

In the event description, you mention using ice probes to eradicate cancer. How does that work? Never heard of that technique!

That refers to cryoablation. Liquid gases like CO2 or liquid nitrogen can be circulated from a tank into a specialized needle, where the cold energy is concentrated around the needle tip, producing a zone of freezing encompassing the targeted tumor. It's a cool (ha) treatment because it is almost painless in many cases, and can effectively kill tumor cells by causing the water-rich cells to crystallize and shatter their cell membranes. At the end of the procedure the cancer is dead and the patient just has a few needle-sized holes about the size of an IV that heal in a day or two. Patients don't need anesthesia and go home the same day.

What about tumor lysis syndrome? Or is the tumor mass being killed at the time of treatment too low for that?

Correct, not enough tumor being killed at one time for that. You can get "cryoshock", which sounds like a new PS4 game but is actually where you freeze too much tissue (like in the liver) and your cytokines go bananas and you end up in DIC and organ failure and overall a world of hurt. But it's super rare, never had it happen.

What's one thing you wish nurses knew regarding recovery of IR patients?

Call my fellow before you call me. Especially if it's after 9 pm.

BioMed engineering grad student. Just learned about CT and MRI this week, truly fascinating stuff. What future do you see for medical imaging in the world of big data? I would imagine that using a person's genetics, medical history, and scans of other patients with similar backgrounds could paint a better picture for treating various problems. How has big data affected your field?

Also I'm a USC alum. I hope you're prepared to get your butt kicked this weekend.

Always ready for UCLA to lose. I gave up on expecting wins a long time ago. UCLA's MO is to beat lots of cupcake teams early in the season, just to get your hopes up, then crush your dreams with a string of late-season losses. So yes, I'm well prepared.

Glad you brought up big data. This is going to be absolutely huge in healthcare in general and in IR/radiology in particular. We capture a massive amount of data, but right now it is not meaningfully synthesized and summarized in a useful way. There are efforts underway to use standardized reporting (I run a SIR committee for this) so that all IR reports contain the same information in the same place- this would allow auto-exporting of data into huge registries. Once that can be combined with auto-pulling of outcomes data from the electronic medical record, we will be able to answer questions like "which treatment is better" or "what is the likelihood of this outcome" with great confidence due to the massive sample size.

This is just one example. Another would be the rad/path report, which is also being pioneered at UCLA. Why have the radiology report separate from the pathology report? They both are trying to establish the right diagnosis, and each has strengths and weaknesses, so the best approach would be to meld the two reports into a unified report that has the best accuracy in establishing diagnosis.

NASA guy here!

2 questions:

With the focus and new space race more directed towards Mars, how do you think we will be able to take care of our new colony on Mars after we inhabit that planet?

Do you think even simple diagnostic machines such as X-ray and ultrasound will be viable in that climate?

Oh man. All I know about Mars I know from Total Recall, the original Schwarzenegger one, not that crappy re-boot. I assume there will be lots of strippers with 3 boobs, which I would not be in favor of treating, but probably there will also be frostbite, radiation sickness, bone density problems from lower gravity, seasonal affective disorder, and all kinds of infectious disease coming from a concentration of people in a small station. Probably we won't need many interventional radiologists, but if they ask me, I'll definitely go.

I really doubt we would decide to put the X-ray or ultrasound machines outside on Mars, as that would be really really cold for patients, who already have to wear those embarrassing ass-less gowns. So since the machines will be inside in normal temperatures, I expect they will work fine.

Few things!

1) As a radiologist, what up and coming imaging technologies are you most excited about? I hear a lot about optogenetics making huge headway in the field of neuroscience, do you see something similar for hepatology?

2) With so much new research and publications printed daily and worldwide, how do you and your fellow radiologists keep up to date to give your patients the best care?

1) HIFU is one of the really cool new technologies- basically an ultrasound beam can be concentrated on a target, and the ultrasound energy causes vibration of the tissue resulting in heating. The targeted tissue can be heated enough to cause cell death. The whole thing can be done under direct MRI guidance and completely noninvasively- there are no needles needed. It is just starting to be used for prostate cancer, uterine fibroids, and soon will start seeing more use for liver and breast cancer, I think.

2) That's tough- there are way too many scientific journals out there. I go to a lot of conferences, where half the time I am playing words with friends on my phone, but the other half of the time I am listening to world experts summarize all the latest knowledge. Or sometimes I'm the one up there giving the presentation, which severely limits the amount of words with friends I can play simultaneously.

My Wife has cervical cancer. HERE'S THE CATCH! She has two of EVERYTHING. 2 uteri, 2 cervical canal and 2 vaginal canals. No one wants to give her a hysterectomy because it's to "risky" "strange" could a robotic surgery remove the tumors without having to get a hysterectomy? We're from Fl but are in NJ right now because he is the first gyno to give her a yes I'll take a look.

Hmm this one's out of my wheel-house. I'd recommend getting out of Florida and getting yourself to a state with a real academic medical center.

Just kidding, Florida. But really, get to a big tertiary care academic hospital with lots of specialists, they'll know what to do.

In private practice, what are the common procedures that the private guys love to see, ie fast and pays well? What has greatly increased or decreased in compensation for IR? There seems to be many companies peddling many versions of equipment that seems minutely different. What is your philosophy on trialing new equipment? What equipment in the next 5 years do you see greatly improving what you already do?

IVC filters used to be the best procedure out there. 15 minutes, pop the filter in, send the patient out, collect $1000 (or something like that). Then cardiologists and vascular surgeons started doing them too. But people didn't think, hey what happens to all those filters we put in? Meanwhile the filters were fracturing and embolizing and causing problems because they weren't being retrieved. Now you see lots of ads on TV for lawyers wanting to sue for IVC filter complications. Meanwhile, reimbursement for IVC filters dropped- which was a good thing, I think. Now the reimbursement is good for varicose veins and embolization procedures, so those are quite popular.

IR compensation depends on a lot of factors, some of which I don't really understand, but basically Medicare tries to equate a new IR procedure (like an ablation, for example) with something that takes a similar amount of effort, that it already has reimbursement data for (like a colon resection). Then it adjusts it over time.

True about lots of companies peddling similar equipment. I think we have 6 different companies selling us embolization coils, for example. This is the product of capitalism, and overall I'm in favor of it, because the competition drives innovation and lowers prices. So we trial new equipment all the time.

In the next 5 years I think controllable catheters and wires, and improved angio equipment allowing us to map out all the vessels in the organ of interest and direct us where we need to go, will make a big difference. Maybe robots too, but I hope not, cuz I'd like to keep my job.

Thanks for being so generous with your time!

1. What's your favorite kind of procedure to do? What was the most rewarding time you did that? When did you first do it?
2. What's your least favorite part of your job? What gets in the way of your being productive? What could make those things better?
3. What kind of follow up do you do on patient outcomes? Do you get any feedback as to how well both a given procedure is working and how well you/your team are doing them?
4. How do you decide which procedures you'll do vs. the fellow vs. the resident?
5. What's the nicest thing a patient has done to thank you? What about someone you trained?
6. What's your favorite paper you've authored? What's your favorite paper you've read?

Thanks again!

1. I really love treating liver cancer. Most people are given the diagnosis as a death sentence, because most of them have cirrhosis and would go into liver failure if they underwent a curative surgical resection. So they get referred to me with little hope. Sometimes, the cancer is too advanced, and there is little I can do- but in most cases, I can stop or even cure the cancer using minimally invasive techniques. I also love the liver cancer population, they often have a history of harmful behaviors like alcohol or drug use, have reformed themselves, and are really appreciative that a doctor wants to help them. Just a great feeling to go into clinic after the procedure and tell the patient their tumor is cured. I will never get tired of that.

2. Meetings. I have so many meetings, where precious little usually gets done. I try to follow the 4 hour work-week advice: avoid all meetings, and if you have to go, show up 15 minutes late and leave 15 minutes early. That way all the small talk is already out of the way, you can get something out of it and get out of there before you waste your entire day looking at some admin's Powerpoint.

3. We do. A lot of our research consists of retrospective studies where we review patient outcomes and use that in reverse to figure out how we should best do procedures and who we should best do them on. It's a big part of what I do, and thankfully I have lots of good medical students and residents who are keen to jump through all the IRB hoops and spend lots of hours sifting through patient charts to collect this.

4. I'm always supervising, but I try to let the trainee do as much as they safely can. Exceptions would be really critically dying patients, really high-risk procedures, and the occasional time when I get bored watching and decide I just want to "show them how it's done". IR really is fun, but kind of like video games, it is more fun to play than to watch.

5. I had an absolutely adorable elderly patient who had kept a medical text from the 1800s- it had belonged to her grandmother. It was called "The Cottage Physician" and it had awesome chapters on how to make salves and ointments and potions for any ailment (this was well before antibiotics and the like). I had been treating her for cancer for a few years, and one clinic visit she brought it down and gave it to me. I took it to a professional book restorer who re-did the cover and it now sits on my shelf in my office at home. Gives me a smile every time I look at.

6. I can't say any of my papers have been New England Journal-worthy. I'm more of a clinician than a researcher, so although I do have a number of publications, I'm not going to say any were world-changers. Favorite paper I've read? There was a terrific paper on how to correlate hepatic arterial anatomy with angiograms, that I think about every time I do a chemoembolization procedure. Totally nerding out right now.

Are you the Sorcerer Supreme of our Universe?

I think Trump already took that title

I'm an M2 that is very interested in IR. How do you see the new IR residency working in terms of how prepared fresh attendings will be to perform procedures as compared to the current 1 year of fellowship? Also, since I'll be applying in the next years do you think competitiveness will be similar to DR? I'm hearing a lot of whispers that it may be very competitive with the number of available slots tightly controlled using Derm as a model.

I think the new IR residency will make better IR physicians. 1 year of fellowship just isn't enough any more. The extra time in IR, the ICU month, the clinic experience, all will produce IR doctors who are better equipped to treat patients rather than just do procedures.

Competitiveness seems higher than DR, significantly so, because the number of slots is quite low. This will expand in the next few years, but IR is a hot field right now (for good reason!)

Remember that there will be an independent residency (which is much like a fellowship, you apply for it during DR residency) so if you don't get into an IR integrated residency, you can still do the DR pathway and get into IR later. I don't think there is any secret meeting of the minds saying we want to limit slots, it is just a matter of funding and the fact it is a whole new training program.

What steps have you taken with your medical physicist to help reduce patient dose during your procedures?

They are very involved, but most of the dose reduction techniques are just common sense. We use low dose fluoro, whenever possible at 7.5 FPS rather than 15 or 30. We keep the patient to II distance as small as possible, cone down our images, and don't step on fluoro when we are moving the table or just to admire the patient's bone structure. I think this is one area where radiologists have a big leg up on other specialists, as we get a lot of specialized training on radiation physics and dose reduction during our residency.

Do you think cancer can be cured in the future?

Yea, I think so. Cancer really is just our own cells that have a few of the wrong switches switched, causing them to replicate uncontrollably. Once we can find and target the right switches, possibly using our own immune system, we can possibly reverse the process. We are seeing this work really well in some cancers like melanoma, but we have a long ways to go. What will be interesting is whether the fight against cancer will be tougher than the fight against infectious disease- both can mutate to evade treatment and are really tough opponents.

Schwannomas in difficult places like tied up in the cauda equina or under the sciatic nerve under the buttock/ back upper leg. Would these treatments you mention apply?

Not sure- I don't do nerve or CNS work- we have a whole department of Neurointerventional Radiology here at UCLA. I should have them do a Reddit!

If you ever hurt your hands, do you envision a second career as a magician?

The only other careers I could imagine liking more than this would be world-famous DJ or a sponsored tournament poker player. So I'd probably shoot for one of those... and probably fail miserably. But I have disability insurance, so I guess I could always just sit at home collecting checks and playing XBox with my feet.

Hi Dr. McWilliams. Care extender at Ronald Reagan MC here! There's a chance I might have seen you around. Thanks for taking the time to do this AMA.

I am currently in year 3 of undergrad planning to apply to med school the upcoming cycle. I got interested in IR ever since my grandfather's cancer metastasized to his liver, and he underwent TACE treatment. Could you explain the TACE procedure, and maybe why TACE would be better than other approaches in certain scenarios for treating liver cancer? Since my grandfather only stayed one night post-op, I am assuming that TACE's upsides are that its highly localized and minimally demanding on the patient. Other than that, my understanding of the hows and whys behind TACE is pretty limited.

Also could you expand on the differences between IR and vascular surgery? (interest in both!) Are there instances where IR docs will work closely with vascular surgeons, or do the two specialties tend to operate autonomously? They seem similar in certain regards, but I can imagine they are significantly different in terms of approaching treatment and practice.

Finally, what are your thoughts on AI in medicine, and its possible applications (or implications) for IR?

Just wanted to say that its doctors like you who have allowed me to spend more valuable time with my grandfather, so thank you for all that you do!

Just page or email me! Happy to talk more, running out of time here.

Why are doctors unable to do anything about IBS? GP and specialist both said "You have IBS, nothing we can do. Goodbye"

IBS has a bad rap among some doctors as being as much psychological as it is physical, and many doctors don't feel able to treat it. Remember that doctors are just like any other profession, in some ways... some are better than others, and some know more about certain diseases than others. So just because one can't or won't, doesn't mean you should stop there. Find another specialist.

My father is an interventional radiologist, and always says the specialty is a dying breed. The minimally invasive procedures performed by IR's are increasingly being taken over by other specialties in the hospital. Have you found this to be the case and do you see a future for the specialty?

They've been saying this for 30 years. Yet, we are training more IRs now than ever before, and they are getting good jobs. As discussed above, it has more to do with getting the right skills and putting yourself out there. Patients want minimally invasive treatments- can you believe that they used to cut you open to drain an abscess? I can drain that in 15 minutes with a tiny tube. There will continue to be a push for more and more of these treatments, and IR will continue to be at the forefront. I foresee growth of the field beyond the pace of other specialties.

What kind of variety in cases do you have? Do you ever wish you had more?

Also would you say that the new integrated residencies have a pretty big focus on research? Is a couple of posters and a case report or two generally good enough? Or is that totally program dependent?

Big variety. In a single day, I might do a chemoembolization for liver cancer, a prostate embolization for BPH, a transjugular liver biopsy, declot a dialysis graft, place a few tunneled catheters, and start a lysis procedure to melt away a clot in the leg. I love this part of the job, since my attention span sucks.

I'd say that research is a big component for the academic programs. A really strong research CV (like multiple first author papers) will get big time programs interested in you even if your board score is low or you went to a med school in Granada. A couple of posters and a case report are kind of the minimum we would expect, so it wouldn't really hurt or help you. Try to do at least that though, to show us that you have some ability to take on a project and finish it.

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Way better!! Too bad there are only like 5 pediatric IR jobs in the country...

What is the net amount of money you make per year? After taxes and insurances. Does being a faculty member at UCLA diminish the amount of money you could make? Why choose academics if you lose money?

After tax and insurance? Maybe $200k. Enough that I can buy a condo in LA, but not a house. If I moved to the Midwest, I could buy a nice house. And a boat. And the lake that the boat is on. Salaries are higher where there are fewer IRs, so LA and NYC tend to have lower salaries despite the cost of living being higher.

Yes, I could make more money in private practice. But it can also be a bit of a grind, there is always the feeling that you need to be doing cases or reading films because your partners are counting on you to be working hard all the time to keep the practice afloat. Plus, you don't get to teach, it's hard to do research on new technologies and new techniques, you don't get to do the coolest cases on the sickest patients, and you don't get all the fame that comes from being an Associate Professor at the Best Hospital In the West (that amount of fame is none, by the way)

How does your research interact with your clinical work? Are they directly related?

Being a bit greedy and going for a second question, but who do you interact with in your clinical work besides the patient? Are there radiology techs (not radiologists) you lead? Are there other doctors/surgeons who refer to you with for advice?

Very closely. I do clinical research not bench research, since the idea of pipetting or doing Western blots makes my soul cry. So, my research projects currently include doing a new type of MRI scan to detect AV malformations in HHT patients (I run a treatment center for HHT); using a new type of anti-reflux catheter for chemoembolization for liver cancer (another big part of my practice); doing prostate embolization for prostate enlargement and comparing it to outcomes of standard urologic surgeries like TURP, etc.