On judging book covers.

I have always looked young for my age. The older I get, the less annoying this becomes but it still gets irritating sometimes. Like two nights ago, while buying groceries with my 6-year-old son, I was carded buying light beer (for about the thousandth time). Considering I could drink legally in 1984 (and drank illegally for several years before that), I have been dealing with this for over 20 years. Same thing happens at work. Every July, new interns or medical students who wander into our section ask me where they can find an interventional radiology (IR) fellow or attending. I can't count the number of times I've had would-be-savvy patients demand that the first-year resident perform the procedure because he or she looked older than me. My usual reply is, “Well, if that's what you really want—OK.” Incidentally, saying this usually makes me feel much better for some reason. As I write this editorial, it is interview season again. For the past several years, our fellowship program at the University of Chicago has been quite fortunate. We are accredited for three positions and have filled those slots during my tenure as section chief. Part of the reason is that we have a good training program; part of it is luck. Last year was particularly tough for many programs—there were far more positions than candidates and as a consequence, less than a dozen programs in the country filled all of their slots. Hopefully this year will be better. Predicting who will be a good fellow is more difficult than guessing age. Admittedly, I have no idea how to foretell who is likely to excel in IR, although I have learned a few things over the years. In general, academic success is nice but only a weak predictor of IR ability. In fact, overall, I'd say that intelligence is overrated. One of the best fellows we've ever had once pondered aloud to a filled reading room, “What's half of 3?” Conversely, we've had geniuses who may as well have baseball mitts on both hands. Age doesn't seem to be a good indicator either. We've trained fellows much older than I who could only be described as awful and others who were outstanding. Personality definitely has an impact on performance. Residents and fellows often fall into one of two categories. They are either too timid and need to be “tossed into the water” or are too aggressive and need to be “reeled back in.” The latter types are more common, more difficult to train, and more prone to morbidity and mortality. In general, clueless + fearless = dangerous. The majority of inexperienced interventionalists practice what I would describe as “cookbook IR”—they memorize a particular sequence of steps in a procedure but commonly have no idea why they are performing each step. I think I probably did this during training, although those memories are fading with every light beer. Good fellows are able to assimilate knowledge and techniques and apply them globally. The converse is also true. I've had fellows that were perfectly competent performing a case that they had been taught but had no ability whatsoever to extrapolate that knowledge to a similar procedure. I call these the “lather-rinse-repeat” group as I assume they are also the same ones who read the instructions on shampoo bottles. Judgment is one of the most important traits of any good interventional radiologist but impossible to assess prior to working with someone on a daily basis. Knowing when to push harder instead of backing off is largely a matter of experience. That being said, some fellows have an inherent ability to recognize their own limitations and therefore avoid disasters. This same group has the ability to minimize (or at least recognize) problems that arise. For whatever reason, others tend to attract calamity. Knowing when to ask for help is probably the single most desirable trait in a fellow. On the other hand, the single most frustrating trait in a trainee is unpredictability. I once had a fellow who could perform a transjugular intrahepatic portosystemic shunt procedure perfectly from start to finish then walk into a therapeutic paracentesis and have no idea what to do. This drove me insane. I guess overall, the most important attribute to IR (and probably life in general) is common sense. Unfortunately, this can't be taught. I know this because I've tried to teach it for years without much success. Some people have it and others simply don't. As I continue to interview prospective fellows, I wish I could predict who has this attribute. I'd take it over everything else.