Amanda Rigas, MD 
Clinical Associate Professor
Department of Radiology
Stanford University School of Medicine
Stanford, California
Interim Director of Interventional Radiology
Veterans Affairs Hospital, Palo Alto
Palo Alto, CA
drigas@stanford.edu
Disclosures: None

Shakthi Kumaran Ramasamy, MD
Research Associate 
Department of Interventional Radiology
Miami Cardiac and Vascular Institute
Baptist Health South Florida
shakthikumaran.ramasamy@baptisthealth.net
Disclosures: None.

Dr. Ramasamy:  Please share a bit about yourself, and what initially sparked your interest in medicine. How did your journey lead you to the exciting field of interventional radiology (IR)?

Dr. Rigas:  I grew up in Southern California, not too far from where I am now. My parents immigrated from Greece, and no one was in the medical field. I did not grow up with a doctor parent. For a long time, I’ve had a strong interest in just helping people. I know that sounds generic, but I found myself always drawn toward supporting other people. I also had a strong interest in science as a young child. Both of those things together had people around me encouraging me to seek a medical career. My parents were always pushing me and inspiring me to be the best that I could be—to be the strongest academically I could be. It was a longstanding interest from young childhood.

When I started medical school in 2007, I had no idea about IR and it was not on my radar at all. This was before the integrated IR residency, so there was no infrastructure to advertise IR to medical students. I entered school thinking maybe I’d do internal medicine or pediatrics—these were things that felt familiar to me from my own experiences as a patient. As I went through medical school, I realized that I really like doing procedures. I like working with my hands. We’ll talk later about my background playing piano as a child. I also did photography in college. I did DJing—a lot of things that combine a manual skill with capturing something in a specific moment in time.

So, I realized I want to do procedures, but that came in the middle of third year, so it was already a little bit late. But I was very lucky that someone happened to tell me about IR. It was total coincidence. So, I said, okay, I’ll check it out. I did, and the rest of the story was written from there. I rotated on IR, found it really fascinating, also rotated on diagnostic and thought, okay, this is pretty cool too. So, I ended up matching in a diagnostic residency, was fortunate to have amazing mentors in my residency who recognized and fueled that interest I had in IR, and then went ahead and did an IR fellowship, which led to where I am now.

Dr. Ramasamy:  In the past, you have compared the technical skills needed for IR to your time as a piano player. How has your background in music helped you with the practice and repetition needed to succeed in IR?

Dr. Rigas: I think there are two ways in which that background as a piano player really speaks to developing the skills for IR. One is manual dexterity—doing procedures and practicing those same skills over and over again, whether it’s ultrasound-guided access or handling wires and catheters or the microcatheter work—that improves with time.

The other is a mindset that it takes time to develop skills, and you need to be patient with yourself as you’re working toward those skills. In education, we talk about something called the zone of productive struggle. There’s a sweet spot of learning where things are a little bit hard to the point where you’re gaining skills. If things are very easy, that probably means you’re not learning that much. If things are too hard, then it can become very frustrating and it’s hard to learn. But that sweet spot in the middle, where you’re building skills and it’s challenging you some, is a good spot to be learning at. I think if you find that right amount of practice or struggle—like a song that’s hard in difficulty—then that is the point where you’re really learning. And that translates into a lot of what it takes to learn and build those technical skills for IR.

Dr. Ramasamy:  I think that offers a unique perspective on repetition and how musical instruments blend into medical education. A significant part of your early work focused on simulation training for things like contrast reactions and medical emergencies. How did these projects help you build the team-based training you lead today in the IR suite?

Dr. Rigas:  That’s a great question. When we think about simulation training for IR or other medical specialties, there are two different flavors. One is basic task training—such as practicing ultrasound-guided access—and that has its role for sure. Then there’s simulation toward more complex scenarios that can happen in the IR suite or elsewhere in the department, like contrast reactions. That more complex, team-based training has always been an interest of mine.

Even early on, I underestimated what that would involve. I was thinking I wanted to get the residents together to help give them more education about how to handle a contrast reaction. I had worked with the simulation team and built this whole scenario, and I had blocked off the scanner time, but I hadn’t thought about who else would be there in real life. It would also be the techs, the nurses. The day came, and I realized it wasn’t as realistic as it needs to be.

Those early forays helped me understand that I must think about how it would play out in real life and bring everyone to the table who would be involved. Other types of didactics and education that we have, regardless of the specialty, are often based on the physician (eg, resident didactics). One cool thing about this team-based training is that you have to include everyone on the team, and IR is a team-based endeavor.

Those early experiences made me realize you have to involve all these people. Now, a lot of the simulation that I do involves the techs and the nurses with regular sessions, and of course the physicians and any residents who are on service. It’s a really great opportunity to practice certain things, like a patient bleeding in the holding area; how do we all respond to that? A lot of the focus is on what I’d call pericode or near-code situations, because once something becomes a code, a lot of it is actually very prescribed. There’s a set of steps for how to run a code—we all learn that in advanced cardiovascular life support. But the near-code situation, where it’s almost a code and you have to decide what to do, that’s where I think it’s very interesting. There’s a lot of education that we can do in team-based settings to help us prepare for those types of scenarios and, hopefully, keep the patient safe.

Dr. Ramasamy:  Congratulations on being appointed as the IR Residency Program Director at Stanford University! What are the most important skills you think residents need to learn to succeed today?

Dr. Rigas:  Thank you so much for the congratulations. It’s an exciting time. It’s been a few months now, so I’m getting used to the new role. This is a great question, and I loved that you said skills instead of knowledge. I think the skills are really important. Of course, being a procedural-based specialty, we always focus on the procedural skills. But there are a lot of other skills that are important.

Being a great diagnostic radiologist is really important, both to diagnose and understand what’s going on, but also to help in procedure planning too. The other really important set of skills is around critical thinking. In IR, we’re often asked to help in these really nuanced scenarios—at least at Stanford, but I’m sure it’s true everywhere to some extent. There are a lot of complex scenarios where we could offer something, but so could other services. We’re often one of several options that a patient has. Being able to weigh the different options—like what the advantages are of IR doing something versus another service doing it—is crucial. Then being able to communicate the reasoning and the pros and cons to the other teams effectively, those are really crucial skills for IR.

From an attitude perspective, I think it’s important that residents are committed to lifelong learning, that they have a growth mindset and that they stay humble. Even as they gain skills, there’s always more to learn. I think those are important things as well.

Dr. Ramasamy:  Looking back at your early career, you were once told to start small, just do something, just do what you can. Do you think that advice still holds true today, especially for those trying to innovate in IR?

Dr. Rigas:  I think that sometimes people have their eye on a big goal or a big task, but often it can help to break that into small components. If an opportunity is presented that seems small, understanding that that’s still an opportunity to build a skill and to show that you’re able to handle that small task gives other people confidence in you so that they can trust you with bigger tasks. Even these small opportunities, especially early on as a junior faculty or as a trainee, can be really valuable in both building your skills and helping other people put trust into you.

Dr. Ramasamy:  That's a great point. As the IR Residency Program Director, mentoring is a major focus for you. How do you guide mentees, especially junior residents, through interventional radiology’s learning curve and early challenges?

Dr. Rigas:  Mentoring junior residents became a passion of mine because I felt like there was a gap there in our program with that transition from the old fellowship model. How do I guide them? Mostly, I try to make myself as available as possible and just listen to them. It’s really about meeting them where they’re at. A lot of times, the concerns that they bring are focused on their diagnostic training, which is a lot of what they’re doing when they’re junior residents. And when they bring concerns, I try to help them see another perspective, provide them with resources—whether it’s another faculty member or another resident who went through a similar scenario—and help them see things differently. These are all the kinds of things that I really try to do.

It’s really a privilege when people trust you with their concerns. Even voicing them to you is something important that I don’t take for granted. I always try to take all of those concerns and do the most that I can to help support people.

The Society of Interventional Radiology Resident, Fellow and Student section did a resident attrition survey. I found it interesting that > 70% of residents who were considering switching out listed lifestyle concerns as a big thing. They had identified that something that could be done to improve this issue was mentoring. It reaffirmed a lot of what I was instinctively doing.

When trainees have concerns about lifestyle issues in IR, it’s helpful just to talk to them and show them, there are so many different paths. There are so many different ways your IR life could look. A lot of trainees will see a really intense academic IR career at a place like Stanford and wonder, is this what I want my everyday to look like? Mentoring gives you the space to teach people that there are so many ways IR can look and to help remind them there’s a reason you picked this in the first place. You love the procedures, you love the patient care, which is different than diagnostic radiology. Helping them keep that insight as they go through their training, I think those are all important things that keep me motivated to continue the mentoring.

Dr. Ramasamy:  When it comes to newer procedures like prostatic artery embolization (PAE), what do you see as the biggest benefit of using a simulator? Is it the feel of the tools or learning the anatomy?

Dr. Rigas:  That’s a good question. Junior residents typically feel that the feel of the simulator is pretty true. I think it’s okay but not perfect. I think that learning the anatomy and the steps of the procedure on the simulator is of more value. Basically, here we’re gaining access at this site, we’re going to pick this catheter to go up and over, we’re going to form the catheter in this way, and then we’re going to select here, we’re going to do a run in these obliquities. I think those steps and for the trainee to decide those steps on their own and figure out which vessel they need to select on their own, instead of just watching an attending do it, especially as a junior resident is where the real value is, at least for a resident.

Dr. Ramasamy:  That's a great point. You have implemented a unique wellness program for residents at Stanford. Could you please share more about this program’s structure and why prioritizing resident wellness is critical?

Dr. Rigas:  Thanks for including this question. It’s another passion area; you’ve picked all the things that I’m passionate about. 

Of course, we have a lot of the traditional things that people include now in wellness, like an annual retreat, but we started having monthly sessions that are confidential with a group of residents and a social worker at Stanford. It’s either the senior IR residents all together, or the junior IR residents have these sessions within their class cohort.
I got connected with our social worker somewhat randomly as I was looking into what other residency programs at Stanford were doing to support resident wellness. She had essentially developed this expertise of supporting resident wellness on her own. There’s no formal training in that, which is a gap for sure, but she had developed this passion on her own and was willing to lead these sessions.

The sessions are confidential. They’re led by this social worker. If the group wishes to amplify concerns to the educational program leadership, they’re able to do so through her, but otherwise it all stays confidential. There’s also an opportunity for one-on-one sessions with the social worker as well, whenever is convenient. The group sessions are held during protected didactic time.

There are a lot of things that are really great about this. It’s during protected time, we strongly encourage people to go, it’s a safe space for people to talk about whatever is going on. It may be good things; it may be difficult things. It may be procedural complications or other challenges that they’re facing at work. It could be personal as well. It’s really great for the trainees to see that their colleagues are going through something similar.

For the older generations of IRs, myself included to some extent, this was never really a part of our training. We probably don’t really show outwardly how we’re keeping ourselves well, and we’re probably doing it with varying degrees of success; some people better than others. For example, we don’t necessarily tell our trainees, “Oh, during the weekend I did this to help myself relax and recharge,” or “I had a bad procedural outcome, so I called my trusted friend about it and they helped me put it in perspective.” We’re not necessarily telling the trainees that, but we need to still be teaching them how to do that, because those are the things that keep people healthy and keep people going in the field.

To me, I think it’s critical from a moral and ethical perspective to be providing people those tools to keep themselves well as physicians, helping them build that perspective-taking and support network. From a practical perspective, there is attrition in IR. We talked about resident attrition. There’s attrition of attendings deciding to do other things, and I think part of it is just the challenges that come with doing these difficult procedures on very sick patients. Having tailored wellness programs that are really specific towards supporting people in our specialty goes a long way toward helping keep people practicing, and practicing in a way that keeps them happy.

Dr. Ramasamy:  There has been discussion lately about the possibility of loading a specific patient’s imaging into a simulator before surgery. How close are we to making this a normal part of preparing for complex cases?

Dr. Rigas:  I have heard about that as well. I know the simulation developer Mentice has talked about it, but the last I heard, they had it available as a one-off. If you had one particular case, you could ask them to specially load it for you.

I think it could become a more routine part of practice eventually, especially for more complex cases like complex aneurysm repairs, for example. But there are some prerequisites first. You need the simulator, which not every program has, and then the time and the preparedness to do all of that. I think it will be more useful for less experienced operators, which is true of simulation in general. How often we do it will probably depend on all those factors: availability, the technology, the experience and comfort of the operator. But I think it will be a very cool tool when it’s available.

When I was thinking about this question, I was also thinking about how cool it would be if eventually artificial intelligence could analyze the imaging and even predict for you. Because right now, what would happen is you would get the imaging loaded and then go practice on the case. You would try this catheter, say, “Oh, that didn’t really work,” and try another catheter. But what if at some point the program had enough information to predict for you: “Here’s a set of tools I think you should use to succeed in this procedure,” and then you went and did it? That is sort of another level. Maybe we’ll see that in a future state.

Dr. Ramasamy:  That's a great point. In fields like anesthesia, simulation is already part of the board exams to evaluate a doctor’s skills. Do you think IR should move toward using simulators for official board certification or credentialing in the future?

Dr. Rigas:  This is also another fascinating question to me. I think vascular surgery recently also started including simulation as part of their board exams. One of the vascular surgeons who really pushed it through, Dr. Jason Lee, is at Stanford. I’ve heard his perspective on how that happened. It was a multi-year-long effort by a few people who felt very strongly about it.

When I heard that, I thought we should absolutely do that. Now, I feel like I have a more cautious perspective on it, because I’ve seen what different fields have had to do to get to that point. To implement it, we would have to consider which procedures to test on, what is considered passing. Is it the amount of time it takes? Is it the amount of wire manipulations? And then programs have to prepare their trainees if we were to do that, so more programs would have to buy more simulators.

For vascular surgery, they picked one simulator—I think they do their board exams on the Angio Mentor (Surgical Science). For all the programs that have Mentice, is that good enough? Do we have to buy the one that they recommend? My understanding is that, at least for vascular surgery, I’m not sure if it was really driven by an interest from these particular physicians versus an actual issue that they were seeing with physicians out in practice.

Right now, it seems that program directors vouch for their trainees’ technical skills. Before moving forward, I would want to know is there an issue with the way we’re currently doing it. Is there really a problem and a need to be more objective about it? That’s the question I have. I think it’s a really cool idea, and I’m curious to learn—especially from vascular surgery—as they continue to move forward, do they feel like it’s really helping with their certification and with physicians’ practice beyond training?

Dr. Ramasamy:  What advice would you give to early-career professionals who want to follow a path like yours? Looking back, what is one thing you wish you had known when you were just starting out?

Dr. Rigas:  It’s good to get involved. I think it’s important, when considering different opportunities, to be thoughtful about whether this is something that’s giving you certain skills, or if it’s something that’s adding to your experience toward a certain goal. It’s good to have your own goal in mind. Maybe you don’t have one just yet, which is totally fine—in that case, it might be good to explore different things. But if you have a goal in mind, just consider how a certain opportunity is fitting into the experience that you need to move towards your goal. I think that’s really important.

I see a lot of people in their first few years of their career into mid-career who have a bunch of different things they’re doing and they’re trying to figure out what they want to focus on. If you have that focus early, that can be really helpful.

One thing I wish I knew when I was just starting out—and this is something else people tell you, but it can’t be emphasized enough—is that mentorship is really important, and having people advocate for you is really, really helpful. Making sure that you communicate with your mentors if you have a goal in mind, so that they can consider you for certain opportunities, is really important. You may have people who are supporting you generically but being honest with them about what you’re looking for, if you feel comfortable doing so, just means they can support you that much better.

Dr. Ramasamy:   Moving beyond your academic achievements, what really drives your passion for IR and finding new ways to innovate?

Dr. Rigas:  For me, IR is all about providing patients with choices and options. Often the only other options for a patient, if it wasn’t for IR, would be a big surgery with a long recovery time, which a lot of patients don’t want for various reasons, or just live with whatever the situation is, whether it’s pain from fibroids, whether it’s a vertebral fracture that’s just not healing and is causing someone to be in bed more of the day than they want to be, or whether it’s a cancer that can’t be surgically removed and they’re not a candidate for systemic therapies.

IR provides that other option for patients that can be attractive to them, that helps treat the condition and get them back to their regular life faster. That’s powerful for patients and really motivating to me to get that word out to patients that there’s another option. It’s really awesome to see patients after procedures. In the amount of time it would take them to recover from an IR procedure, they would still be in the hospital from their conventional surgery. It’s just so awesome to see patients recover and have their condition treated. It’s really amazing.

Dr. Ramasamy:  What hobbies and activities do you enjoy away from work? How do they help you stay balanced and keep things in perspective?

Dr. Rigas:  I like being active such as hiking and doing yoga. These things keep me grounded and help me take a step back from whatever the issues of the day or the week or the month are and help me realize there’s more than this issue that I’m currently dealing with. There’s so much to appreciate in the world.

I really love yoga because it's a relatively new thing that I'm learning. When I’m able to hold a pose for a longer period, it takes me back to that learner mindset. I’m incrementally getting better at something. Going back to that piano playing, I can see myself getting better at it and it’s something that helps me stay humble and helps me remember what it’s like to be that early learner.

I also like going to concerts. I have a 6-year-old, and I volunteer in his classroom. That’s super fun in terms of seeing things through the eyes of a child. There’s so much wonder in the world, and even how basic things work is amazing. It takes me outside of the field of IR and the hospital setting and helps me remember all of the other things out there.

Dr. Ramasamy:  What’s next for you in terms of your research and your role at Stanford? What are you most excited about contributing to next?

Dr. Rigas:  I was recently appointed as Program Director, so I’m focused on that, and I’m really motivated to make the program the best that it can be and help support the trainees as best as I can. 

I’m also interested in educational scholarship, which is something that the field of IR doesn’t really have much of going on. I think it’s another product or consequence of being a younger specialty. As the field matures, the specialty needs to think more about how we train physicians to be good teachers, to be good clinician educators. There’s really not much of that yet. There are some offerings through diagnostic radiology, but we’re a procedural field, so it’s going to look different for us. That’s something else I’m interested in helping develop in future years.

Dr. Ramasamy:  If you could describe the future of IR in just one word, what would it be?

Dr. Rigas: Awe-inspiring.

Dr. Ramasamy:  Would you like to add any other advice you want to give to trainees?

Dr. Rigas:  IR is a super exciting field, so any trainees who are interested in it know that you’re making a good decision to explore the field further. I have one trainee who decided to switch from diagnostic radiology into IR, and I was very excited for him and told him it was the best decision that he ever made. I do think it’s a very exciting field, and there are a lot of people who are very excited to support trainees. Reach out and find a mentor to advocate for you because that’s hugely important, and it will help you be successful.