An interview was held with interventional radiologists namely Dr Hameed Ninalowo and Dr Omodele Olowoyeye to throw more light on interventional radiology as a specialty and how aspiring doctors can hope to specialize in that field. The Inititive was brought about by @Ojayfemi with a view of helping and giving back to the medical community. The interview conducted by @Ojayfemi and @DamilolaMD. The Video would be available on the DamiMBBS youtube channel. A podcast to be available via @Ojayfemi soon. Click Here to watch the video. Read the interview below. Note; IR is designated as interventional radiology.
Dr
Femi:
Thank
you, Dr Ninalowo and Dr Olowoyeye, for obliging to do this, it is really
appreciated, thank you very much. The medical community that we link this with
would also appreciate this.
DamilolaMD:
I'm Dami, a medical officer, currently working in a private setting.
Dr
Femi:
I'm Femi, I have interest in acute medicine, internal medicine,geriatric medicine, and medical education with fellowship qualifications and a masters too.
DamilolaMD:
**Chips
in** And you're also the VC
Dr Hameed Ninalowo:
What
exactly does the VC
mean?
DamilolaMD:
He's
the head of a medical community, a virtual connection of medical professionals,
he counsels, drops lectures and medical advice from time to time and the name
VC just kind of got stuck. This initiative is one of the things he is doing for
us.
Dr
Modele:
I'm
Dr Omodele Olowoyeye, a radiologist, working in LUTH, I'm also trained as a
vascular technologist in the states and I have a PhD in medical science from the University of
Toronto. I also did a mini-fellowship in interventional radiology at the
University of Toronto.
Dr Hameed Ninalowo:
My
name is Hameed Ninalowo, I'm a vascular and interventional radiologist.
I
trained at the University of Maryland for diagnostic radiology, and then
trained at the university of Pennsylvania for vascular and interventional
radiology. I've been out of training since 2016. I started doing interventional
radiology in Nigeria 2.5 years ago, a practice I called IRdoc Nigeria, the
passion was also to bring it to Nigeria and I used to come to Nigeria every 6
weeks for one week at the time to give services and in September 2019 I
transitioned to spend more time in Nigeria until COVID-19 hit. Since
February last
year I have been full time in Nigeria.
For
me this is a specialty that is non existent in this environment and we
do have
people that are passionate about it and want to go into it especially
diagnostic radiology, but training is highly lacking.
DamilolaMD:
Thank
you very much. I will pose the first question to Dr Modele.
Why
radiology?
Dr
Modele:
Let
us say as a medical student, I was considering the different specialties and I
didn't find one that sort of got my interest until I did my radio-diagnosis
posting. That was when I realised that radiology touched on many aspects of
medicine and when I had one of the lectures, the lecturer then mentioned that
we are "consultants to consultants" . Radiologists provide consultatory
advice to other specialists on different patients so I found it interesting and
went into radiology as it gave me opportunity to keep abreast of what is
happening in different fields of medicine.
However,
going into radiology now, I have realised that since it is so vast, it makes
you a jack of all trades and master of none so now I am realizing the need for
subspecialisation so that the services a radiologist is giving to a clinician
is top notch.
DamilolaMD:
How
about you Dr Hameed?
Dr Hameed Ninalowo:
So,
for me radiology was a gateway to interventional radiology. As at the time I
went in the only way to get into IR was to go through diagnostic radiology
residency, so you would have to do your HJ which is the internal medicine/surgical
residency
For
one year and then go to radiology residency and then IR fellowship for one or
two years. But interestingly I actually fell in love with diagnostic radiology.
It's a specialty where you can offer not just
a report but also a consultancy. We also have a diagnostic radiology platform
which is called accurate radiology and interestingly Dr Modele also reads on
the platform. We focus on tele radiology with subspecialty readings, and we
constantly make sure there is quality control on the platform and we make sure
that people are getting proper consultancy services.
Dr
Femi:
Is
the Accurate radiology platform part of the IRdoc brand?
Dr Hameed Ninalowo:
No,
that is a completely different company. It's accurateradiology.com and right
now we actually service multiple hospitals in Lagos Abuja and port Harcourt.
DamilolaMD:
As
you have rightly said, a number of years ago interventional radiology wasn't
quite as popular as it now. And I want to know how has the experience
practicing in Nigeria been?
Dr Hameed Ninalowo:
For
me it has been very rewarding, which is why I took the risk of staying here.
We're doing things that aren't readily available here, if we weren't here the
patient would die. I could think of a few cases during the COVID-19 period
where they were sick and the only thing that could do something for them was
IR. So, for me it was not easy making the choice to stay here but I had gotten
to a point where the choice was either here or America. If I had returned, I
would be abandoning my service and practice and they were a lot of people here
already depending on our services so it was an easy decision to stay here.
How
hard is it to practice here vs in America?
America
for example I go to work every day someone pays my salary, here it is completely
different, I'm running a business from top to down and even though I
collaborate with multiple hospitals I have to run my service and completely
take care of everything I need from A to Z including getting the supplies into
the country from the US, china and to make sure they are always available in
case of emergency situations to be able to take care of patients and they are
not cheap.
The
peculiarities are interesting where they send you patients from a hospital for
instance, I'm used to a doctor taking ownership of that patient telling me what
is going on etc and the patient is packaged to me saying "Hameed this is
what I want you to do for this patient" here its different where a patient
just shows up without referrals and now, I have to start from the bottom to get
to the top and to take ownership of the patients. Those are stressful and they
are things I am not used to. I'm used to working in a multidisciplinary
environment where there’s multiple teams managing a patient. There's a primary
owner of the patient and they bring me in as a consultant and after I hand them
back.
It
is still very satisfying knowing that a lot of things we do and the things that
we provide, it cannot be done in any other way.
DamilolaMD:
That's
very enlightening. Over to Dr Omodele, you have been practicing in Nigeria for
some time now. What are the challenges you have foreseen with IR from your
years of experience?
Dr Modele:
Well, how did I get into interventional radiology?
Let me start from there. There
is an NGO with which Hameed is one of the leaders called RADAID so they came to
Nigeria and they wanted to teach us how to do Uss and Ct guided procedures and
they kept coming yearly for like 2/3/4 years and that was what stimulated my
interest in interventional radiology. But the greatest challenge we have here
is similar to chat
Hameed said in terms of having a structure already laid down for example when
these people come to us because we are not used to such services, we spend a
lot of time running around trying to make things happen, make things work
unlike when you are practicing in an interventional radiology centre where
everything is already set up and things are in place, you have monitoring
equipment around etc.
For
practice here you have to think through everything because if you miss a step
it might be costly, to ensure you have resuscitative equipment
around and
so on.
I think the challenges so far have to do with setting up a proper interventional radiology practice. We're still in the early days at least here in LUTH so were just taking it one day at a time
Dr
Hameed Ninalowo:
Just
to add to what she said about the importance of having the right people around
you, the surgery back ups etc.
So,
I've always told folks that ask me about IR as a specialty, most of the
procedures I do I could teach people to do it within 6 months, but I can’t
teach them to get themselves out of trouble within that period.
An
Example, in my fellowship at PEN we do an average of 12 cases as fellows a day
and that period of time I saw an incredible number of complications, because we
have fellows everywhere being backed up by consultants, but when you have so
many trainees in an institution you see so many complications but, in that
environment, you learn what not to do and learn how not to get into trouble So those skills are
actually the most important to learn.
One
time I got a call from a professor of Urology at a Northern University who
wanted to learn how to do a prostate artery embolization in Lagos and he wanted
to bring 3 patients and learn so he can go back and practice it, and I found
that very offensive because this is something that has taken me years to do and
for someone to call me and say I want to bring some patients and start doing it
and by the way this is
probably the most difficult procedure that we do PAE but people just don't get
it.
What
if I do train that person and I say you can go start doing it, you know they
still carry my name and when they start hurting people, I have a responsibility
to that,
which is why I tell people if you're going to learn anything you have to just
make the sacrifice, go somewhere where you're going to learn it well and do it
well.
And
the other part of what she was saying (Having back up around you), as for that
I’ve been very particular in practicing in places where I have surgery
resources around me. An example is Euracare where there’s Neurosurgery, General
surgery, Bariatric surgery we have a cardiologist, we have multiple
specialists so I know if I get into this trouble, this is who I call. Thank God
we haven't gotten into a lot of trouble in the time I have been here but you
just have to have that back up.
Dr
Femi:
If
I may just ask one quick question, if a fresh graduate is interested in
interventional radiology what are the steps they need to take and things they
need to do to get in? What are the things they need to put in place in Nigeria
and then Abroad?
Dr Modele:
One
of the things that is important is to have a feel of what the specialty is
like. For example, other specialties such as surgery, the lifestyle wasn't
suitable for me so I would say when choosing a specialty, you have to choose
something suitable for you. And you know this by paying special attention to
your rotations through those postings.
About
how to become a radiologist, in Nigeria basically you do your
housemanship, youth service, and primaries (NPMCN and WACS) then you start
training as general radiologists in the various teaching hospitals. The West
African college has started the training in interventional radiology, I don't
have to much detail, but a professor at the University of Maiduguri teaching
hospital has started training some people in IR, I also know that UCH Ibadan is
also trying to start a training programme in IR though it is still in its
formative period and here in Lagos we are trying to see what is possible but a
lot of it is in its formative period.
Dr
Femi:
Is
it safe to say that right now the IR in Nigeria is still very rudimentary, such
that it is very unlikely such that someone would finish and pick a form today
to get into radiology, train in Nigeria and expect to do IR? So, its not really
existing as we speak at this point in time, is it safe to say that?
Dr
Modele:
No,
I won't say that. In Maiduguri the training is going on. In the West African
college, the faculty of interventional radiology is now one of the
subspecialties the National post graduate college have also developed IR as a
subspecialty, so things are in process.
So, if someone is enrolling today the person would start with Diagnostic
radiology and before the person gets to the point of subspecialisation, I think
we would have made more progress and the structure would be better defined. So,
anyone who wants to do it can still start planning towards it.
Dr Hameed Ninalowo:
You
basically have to go through a diagnostic radiology residency and after that
you try to get into an IR fellowship programme and there are several ways to do
that.
Vascular
and IR is a very big specialty now, and this vastness does not exist currently
in any teaching hospital in Nigeria. After Diagnostic radiology there are a few
choices. Like getting a fellowship outside the country.
In
Tanzania there was a collaboration with yale, where a colleague, Fabián,
passionate about improving it in Africa, actually started with RadAid, left to
start the programme called Rotor IR and in the last 3 to 4 years they have
created a masters degree at a university in Tanzania where they are graduating
their first few fellows now and the programme holds for 2 weeks in a month
where a group of people come from the states to the University to teach and
work them through cases and that’s how they ran the masters programme.
The
lifestyle of interventional radiology is a bit different such that now there is
a separate residency in interventional radiology such that people that are
prepared to do the work just enter directly and continue with that lifestyle.
It has evolved to become a completely clinical specialty where interventional
radiologists run clinics for example, I was in clinic the other day, you have
to see patients, write clinical notes, follow patients longitudinally, be with
critical patients and hold your cool.
Dr Femi:
What if for example someone wants to get to the states or other African
countries for this programme what are the steps, they need to take to get
themselves in that spot.
Dr
Ninalowo:
I'll
talk about the states. For one you have to finish diagnostic radiology
residency here or you could do the housemanship here and then take the USMLEs.
However, if you're going through the USMLE pathway you have to be in the 99th
percentile as interventional radiology is the most competitive specialty to get
into in the match now, if you look at the data from 2017, looking at the ECFMGs
that applied from PGY1, 0% got in, PGY 2- 3% got in, so you see the odds are
stacked against the ECFMGs, especially getting interventional radiology as a
specialty, but if you go through diagnostic radiology then it's a little bit
easier. If you get into one that has an IR fellowship in it, and when you're in
the system, almost always someone drops out. You have a chance to pick up that
spot provided you show a lot of interest.
The
other way is that there are still a few spots for one- or two-year
interventional radiology fellowships that makes up about 5% of the slots such
that you can go through diagnostic radiology and apply for one of those slots
and complete with the citizens as by that time you are already in the system
and you're basically on the same battlefield.
I'll
let Dr. Omodele talk about Canada and how she came about getting the fellowship
in Canada.
Dr
Femi:
What
are the odds of getting into diagnostic radiology for an ECFMG candidate?
Dr
Ninalowo:
I
think its about 12 to 17% of candidates that apply that get in because it is
still quite competitive itself.
Dr
Modele:
You
need to get into the system and people need to know you. One way you can do
that is by Observerships. If you want to for example do residency in IR in
Canada what you could do is to apply for an observerships and while you are
there, they have an opportunity to study and observe you to see if you're
someone they would like
to work with.
Another
way is by volunteering, however I'm not sure if there is any opportunity for
that specifically in IR. But it would help you get known in the hospital. If
you volunteer at a hospital there and you know someone there one could put in a
good word for you with the interventional radiology department and then you can
get an observerships and after you can indicate your interest in a fellowship
and you apply and that gives you a way to get in as a foreign trained
candidate.
If
you did residency in Canada it's probably easier.
Another
way to get into the system is to do some research work like an academic
pathway. For example, when I travelled to Canada I enrolled for PhD in Medical
science and my supervisor was a radiologist and I had a great time working with
him and I learnt a lot after we talked about career plans. When I came back to
Nigeria and I had been exposed to IR by the RADAID team I felt perhaps I should
learn more in a structured format in a proper training centre so that coming
back to Nigeria I can have some positive impact on those training in my
hospital. So,
I spoke with my supervisor and he asked me to speak to someone in charge of IR
in one of the hospitals and that gave some contact.
When
you take the exams, you should also be very good, I have a colleague who is
about finishing a residency in IR in Canada and when she was doing her exams
the likelihood looked very slim but she gave it her best shot and got very good
grades and at her interviews she was confident, she spoke like someone who knew
what she was doing and she got a spot she's almost done with residency. So be
good at what you do.
Dr
Femi:
Is
there a way for people who invested in IR to see you doing stuff, just to know
what it entails to do IR, maybe like a scheduled session for them to come have
a view? Is there opportunity for education like that?
Dr Ninalowo:
Absolutely. I brought RADAID to Nigeria and I'm very passionate about medical education so with the outfit we've gone to UCH many times, LUTH many times to teach interventional radiology techniques for example in UCH we taught them how to do biopsy and drains and that is a big deal for you to have those skills.
Now In my practice Dr Modele scrubs in with me, I have residents from all over also coming in to scrub in cases with me. This past week I had a medical student that contacted me on LinkedIn and he came to spend a week with us from OOUTH. He had the experience; he'd always been interested in interventional radiology and he did spend a week with us. And interestingly with him we actually put up a post on our Instagram.
I
asked him how his experience and about what he had learnt and interestingly
what he said was that he learnt proper consultation, where the patient comes in
and they understand completely what is wrong with them because you're drawing
diagrams and letting them know the anatomy, they understand what you're going
to do to them, they understand the post procedure care and everything so a lot
of people that are interested in IR they're kind of wowed by the procedures but
they don't understand the clinical management that goes on in the background
and how much work we put in before the patient gets to the table so it's a very
clinical practice.
One
other thing that I proposed to the Nigerian society of interventional radiology
that exists that contains all of the major radiology centres that they should
sponsor a resident to spend one or two years with me, pay their salaries for
those two years and let them have training because we know that there is no
advanced IR in these centres and it is going to take a while and we're doing it
in Lagos in a private centre so let them come to our practice here to learn and
train and go back to go serve their university.
So
far, we haven't been able to start that and I think that's something we may
start in the near future if they take up my offer.
Dr
Femi:
That’s
very impressive, thank you very much for doing that.
DamilolaMD:
Prior to this interview some people had sent in a few questions and through the discussions we had thrashed out most of them, apart from two. And the first one is this.
To
the medical student who is just finishing with hopes of IR what would you
suggest to the person as the best pathway?
Dr. Hameed Ninalowo:
If
the question is should I stay in Nigeria or get out of the country for training
I would say leave as soon as you can. It's just that simple. As we speak there
are no pathways to become a board-certified interventional radiologist. So, if
your goal is to be a full-fledged interventional radiologist and not just doing
biopsy or drains, you need to get out of the country. The question would be
what country? IR is very popular and advanced in most countries in Europe now,
also America, Canada but you do need to get somewhere where there is advanced
diagnostic and interventional radiology and see how you can get in that
specialty. And the easiest way would be to get into diagnostic radiology and
move on to interventional radiology if you can.
Dr
Modele:
Well,
the first step is to start writing PLAB or USMLE. **laughs**. Start writing the
exams and try all the options available. Don't put all your eggs in one basket.
Whichever one works you go with.
DamilolaMD:
Well
at the very least we can all agree that it is not in the country **smiles**
Dr Hameed Ninalowo:
You
know we Nigerians we are very resourceful and resilient and you know if you're
looking for a group of people who can do something no matter how difficult it's
Nigerians.
As
you said, you write PLAB, USMLE, and you write and you see which one sticks.
DamilolaMD:
for
the last question which would end the session is this.
What
is that particular experience that you've had that made IR all that, for you?
Dr
Modele:
In
my department we have a good relationship with surgeons in the hospital and
they keep requesting for image guided procedures and at one point they had a
patient that came, had a nephrostomy done somewhere, and he was punctured three
times and he was leaking urine from three different places at that point I
already knew that percutaneous nephrostomy were done on IR departments so I
felt we should be able to offer image guided nephrostomy such that a patient
would not have to be poked three times and be dripping from the three different
orifices and I think that experience was what motivated me and made me feel I
needed to go learn this thing because you can't give what you don't have and
you cannot train others if you yourself have not been trained. And I think that
was the main procedure for me to go learn how to do the procedure properly.
Dr
Hameed Ninalowo
For
me I would go back to the peak of the COVID-19 period where I got called about
a 24-year-old male who had been having Upper GI bleeding for the last three
months and was at a tertiary hospital in Lagos getting a lot of transfusion,
vomiting blood, pooping out blood and they basically told the patient at that
point that you have to go for a liver transplant.
But
someone in radiology had diagnosed that patient of having an abnormal
connection between the hepatic artery and the portal vein, which was
responsible for the bleeding. The only thing that could solve that problem is
to block off that connection and its surgically impossible, making an
endovascular route better, going to the arteriovenous connection and block it
off and the only specialty that can do that is IR.
So,
for that boy he came to my clinic, his parents had spent a lot of money and
after the consultation the family understood what was wrong and I assured the
mom that this is something we would take care of and he should be able to go
home the next day, and she says “what does that mean? We've been in hospitals
multiple times over the last month so how could you tell be you'll take care of
this and he'll go home the next day?"
Anyways
we admit him, transfuse him, and that morning he gets up and basically pours a
lot of rectal blood and clots so we resuscitate him and rush him to the CATH
lab, I go into the liver to the artery and I shut off the connection and the
next day I told the mom he could go the next day. She said No she's not going
home and we wait till the next day and there was no more bleeding.
So, for them it was like "How is this possible?" As we took that boy from a death sentence, from being chronically ill-looking and being told they could only go to India at the peak of the COVID-19 procedure to doing a procedure where they did not see a cut on the boy’s body, and they don't even know where we went in.
I
saw him in clinic 6 months later and he's gained weight and has the happiest
person. For
me those are the experiences that really solidified it for me because we are
problem solvers. Even in foreign countries. When surgeons and physicians have
run out of options, they usually go find an IR specialist because those idiots
always find a way to do something. We almost never say no unless we know this
is just fatal. We're problem solvers.
DamilolaMD:
Thank
you very much, it seems IR does make all the difference. Thanks a lot for
honouring the invitation, it has been very enlightening and those who are going
to watch this are going to be very very invested in IR as a specialty.
Special
thanks to Dr Femi for putting this together and we hope to see many more.
Dr Hameed Ninalowo:
Thank
you very much Dr. Femi and as I said before if you're interested in IR you
could send us an email at info@irdocnigeria.org we entertain one week or
two-week rotation for medical students and residents.
Dr
Femi:
Thank
you for really honouring this and you took time put of your busy schedule so
it's really really appreciated.
Thanks
for the time and exposition and I'm sure there’s quite a lot of people
interested in the field and when they watch and read, you'll get a lot of
emails flying through your circuit and at least we know we've got IR doc for
cases now. We'll put out information for people to be aware of this service
such that if they have things like this done, they can, rather than pining and
wasting away they can consult you and if your service can be rendered and
hopefully if they can afford it.
Thank you very much.
Dr
Modele:
thank
you for the opportunity I really enjoyed the interview. Thankyou Dr Femi, thank
you Dr Dami.
Here is the video of the interview
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