Imaging technologies such as Ultrasound, X-Rays and MRI are offering patients the option of non-surgical interventions by precisely identifying the disease whether it is a tumor or blocked artery or any other clinical problem, and formulating a treatment plan using minimally invasive procedures.

Dr Iranna Hittalamani, our next pathbreaker, Interventional Radiology Fellow at Dr. Rela Institute & Medical Centre, Chennai, consults with patients, identifies the clinical problem, and recommends different treatment options based on interventional procedures.

Iranna talks to Shyam Krishnamurthy from The Interview Portal about being drawn to the field of Interventional Radiology due to his love for computers and technology in general .

For students, there are vast opportunities in healthcare. Seek out areas with greater demand because that’s where you are going to make greater impact with the skills that you acquire !

Dr Iranna, can you take us through your background?

Growing up in a small town called Gokak, the northern part of Karnataka, I was always regarded as a bright kid and usually studied alongside one or two classes higher. I am not sure how many are aware of this culture, but yes it is quite common to teach a Xth std kid a XIIth std syllabus and test his acumen and interest. Looking at my interests in maths and physics, and how well I actually performed in those subjects, everyone (including myself) thought that I would become an “Engineer” since it was still considered to be the most rewarding career. Many times, my biology professors urged me and tried to motivate me, but I was always a stubborn and impulsive kid. But to my surprise, I was pushed into a Medical career since I had a good ranking! (For years that’s what I believed). Factually speaking, I was given the freedom to choose my career, though it is quite rare to expect Indian parents to give that freedom at that point of time. But, since I believed I was pushed into medicine, I really never had the passion for what I was doing. And there, I faced the biggest drawback in my career! An overachiever had flunked in one of the subjects of his first year MBBS. I was shattered and in fact, my whole family was shaken by this. But, my professors told me “Don’t worry, people who have failed in anatomy are eminent surgeons and radiologists” (by then radiology was the most lucrative career in medicine). And I was told that I would get to work with computers! I gathered some courage and decided to become a radiologist! But, little did I know how competitive and difficult it is to become one (there are only about 10,000 radiologists in India today!). Much rarer are the Interventional Radiologist species:-) I am only the 3rd and probably the youngest Interventional Radiologist in Belagavi District at 29 years!

What did you do for graduation/post graduation?

I am an MBBS graduate with a Postgraduate qualification (M.D.) in Radiology and have recently completed a Fellowship in Interventional Radiology.

How did you end up in such an offbeat, unconventional and unique career?

There were several key influencers that shaped my career journey.  

Richard Feynman: You really need to get to know this man and his amazing teaching techniques! I apply quantum physics, fluid dynamics, torque, stress, strain every single day!

Charles Dotter – The man who introduced the concept of Interventional Radiology to the world in the form of “Angioplasty”(a procedure to enlarge a diseased narrow artery). Yes, the Cardiologists (heart specialists) then pioneered it, but Radiologist Dr Dotter is the one who discovered it.  

Sven Ivar Seldinger – He showed the world that you can have access to any part of the body using needles, wires and catheters(small hollow tubes).

Antonio Egas Moniz – A revolutionary Neurologist known for his work on ‘Cerebral Angiography’ (Mapping the blood supply to the brain).

Apart from so many people who actually tutored me below are the real mentors in my life.

Mr. I C Sabarad – He was a family friend, and had a postgraduate degree in special mathematics. He recognised and nurtured my talent as a young kid. Without him, I would never have known the power of imagination and dreaming big. He eventually Introduced me to Prof.Arun Pujer.

Mr. Arun Pujer – The man who taught me Physics and Mathematics. He showed me why talent requires hard work, and he was definitely the first one to actually ‘Juice’ my talent. He should be credited with actually training most of the talent my city has ever seen! More importantly he still mentors me. Fun Fact: He once told me that Bill Gates was going to revolutionize education such that any student could learn from anywhere in the world – in 2008!!! Fast forward 2019, COVID has made this the new normal.

Dr Deepashree T is the one who shaped my career as an interventional radiologist. I may not have had the international grade skills, but she made sure I am trained in the skills at par with interventional radiologists around the world. More importantly, she chose to give me a chance to work ‘with’ her. She always treated me more like a colleague and was always open to new ideas. I explored my uninhibited personality as a medical professional for the first time. I always joke around about my fellowship interview with her saying “Madam, I selected you to be my Boss”. And I strongly believe I am her Replica!

Dr S.Krishnamurthi – Son of India’s first woman doctor, Dr Muthulakshmi Reddy. Adyar Cancer Institute is a world renowned cancer research institute that is able to provide accessible healthcare to cancer patients for free / subsidised costs. He is also the man who introduced the concept of the oncology department in a government medical institute, in Chennai after returning from his training in Missouri, USA.

Sometimes you have to fall in a trench to fly high.

Though i won several awards and was an achiever in academics from a young age,

Winner of the Wrangler D.C. Pavate Mathematics Competition at District level (Won it in 4th std – conducted for std 4-6th)

Ranked 5th in the State level entrance examination of Sainik School Bijapur.

Ranked 1st to the JSS pre-university college, Gokak.

Won 1st prize for a science exhibition (Demo of Nuclear reactor) at district level in 1st Pre university level.

I also failed in Anatomy in 1st Year MBBS. If I had not failed in the 1st year in MBBS, I probably would have become so overconfident that I would have ruined my career and would not have gotten to where I am today. This failure taught me how to fight like a wounded lion!

This made me battlehard.

Also, from a young age, I was trained with students 2 years older than me, hence I never doubted my abilities. Since I was at least at par with the brightest of that lot, even at that time, I knew what exactly confidence is!

The Interventional Radiology Fellowship at Chennai, really made a difference to my character as a person. Everyone knows how hard it is to live in Chennai if you don’t know Tamil. I was depressed (I am usually never a person who is worried, stressed or depressed come what may in life) for the first few months! But, the amazing work environment and my passion for interventional radiology brought out the best in me. I even learnt to cook, and although I studied in a military school, I lacked discipline and consistency once I left the school. But my 2 years in Chennai made me rediscover myself, and of course made me a confident Interventional Radiologist.

How did you get to where you are today? Tell us about your career path

MBBS

When I planned to become an Interventional Radiologist, I was still in the final year of MBBS (It is a 5½ year course). I was already planning to become a Radiologist, being very fond of gadgets and computers. In my final year I attended coaching classes for the postgraduate entrance exam. I couldn’t secure a government seat through the national level examinations. 

Internship

Every medical graduate undergoes a compulsory rotatory internship training after they complete MBBS course. This is a crucial period where all the concepts learnt in the 5 ½ year of training are applied in practically taking care of patients under the guidance of senior doctors. You work in all the different specialties of the medical field like general medicine, surgery, dermatology (skin specialist) etc. I did all of this in a government medical college and was confident of the skills that I gained there. I was also the first ever intern in the history of my college to be working in a Computed Tomography (CT) scanner unit of the radiology department. 

Postgraduation

My family supported me a lot at this stage and we took an education loan to fund my postgraduate course in a private medical college. It has become very expensive now to become a Specialist Doctor in India. Medical students think that if they dont secure a free government college seat they are far inferior to others. But let me tell you this, once you are a Postgraduate Resident – you start from square one, again! Especially in a subject like Radiology, it’s a fresh start and you should kickstart your career like a boss. That is what I did. I worked very hard as a resident to become a good radiologist first. 

Fellowship

By the time I became a radiologist, the buzz about Interventional Radiology started to increase among radiology residents. Being an Internet Kid, I started hunting for fellowships and DM seats (superspeciality). I shortlisted all the places and actually got the contacts of people already doing fellowships there. Being a very social person and being well connected to my seniors helped me a lot here. People from other specialties who worked in some of the corporate hospitals would get me in touch with the interventional radiology fellows and then I used to borrow their time and shower them with all my doubts about why they chose those fellowships over the others etc. Finally, I made the decision to join a particular fellowship. The fellowship is just like a surgical specialty with ‘Hands-on’ training which is very essential. So it is important to know how much hands-on training is being given in each programme. Fellowships are hard to get into; to give you a reality check, if you are applying for a fellowship at HCG hospital Bangalore, there will be at least 50 people who would be applying for a single position! Also, the duration varies for every fellowship. I can be contacted personally for Interventional Radiology fellowship enquiries. I will get you in the loop! There are 2 superspeciality courses –

DM (Interventional Radiology, Neurointerventional Radiology)

Now there are about 10 DM seats all over India and the level of competition is very fierce! This entry is through the NEET-SS (National Eligibility Entrance Test-Superspeciality) examination or INI-CET for some Institutes of national Importance like AIIMS.

DNB (Secondary DNB)-Diplomate National Board

This entry is through the DNB-SS examination. Usually this is much harder to get because the eligibility for the exam includes DM Neurology, MD Radiology & MCh Neurosurgery. So you are competing with much smarter people, so prepare accordingly. The future of this course is in doubt!

How did you get your first break? 

I think the fellowship that I was offered is my first break. Freshers are preferred in some programmes, but many will accept only candidates with at least 1 year of Senior Residency. Fortunately, the fellowship at Rela Hospital is offered to freshers too! It’s a quaternary care liver transplant hospital. I had literally zero experience working in a corporate hospital and this gave me a different perspective of healthcare in India. How I landed up here is quite magical for me. On the day that I came for the interview, only two others had come for the interview, because the hospital was new and most of the people applying for fellowships did not turn up because it’s a new hospital. Even though I was reluctant to travel to Chennai; when I was interviewed by Dr Deepshree T, I knew for sure she would be the boss I wanted to work with. Later I came to know that she had foreseen my ‘Fire in the belly’ attitude towards Interventional Radiology. And that is how a small town boy from North Karnataka bagged an Interventional Radiology Fellowship at a Quaternary Care International Medical Centre in Chennai!

What were some of the challenges you faced? How did you address them?

Challenge 1: Biggest Challenge was finding out how to become an interventional radiologist in India. There was no platform or network that had any information on the type of fellowships or training pathways. And even with the network of seniors and my teachers in medical school nobody knew how to guide me. All they told me was make it to MD radiology first, then apply for fellowships, like a generic answer. We as medical students are only taught to get into different specialties and super specialities by writing entrance examinations! I never knew alternative pathways existed. I searched for them, and also got myself involved in international societies like the Society of interventional radiology.

Challenge 2: Maybe I still haven’t addressed this completely. But unlike my international peers, I found it very difficult to find the right platform to have better training opportunities. This is due to the lack of awareness of this speciality within my own medical fraternity.

Challenge 3: Many of the specialist doctors feel threatened by the wonders that Interventional Radiology, as a specialty, can achieve. So they don’t prefer having an Interventional Radiologist around, except for building a brand image for corporate hospitals. We are merely colleagues wanting to improve patient care and let the patient know all the options they have. We as a community are speaking on different multidisciplinary forums where we educate other physicians to engage more with interventional radiologists and choose the best options for patient care.

Challenge 4: At present the medical devices that we use come at a very high cost. Most of the people cannot afford such treatments. With make in India initiatives, devices made in India would certainly be more affordable and super-specialty healthcare would reach the masses.

Challenge 5: The curriculum used in training future doctors in India is redundant. Most of what is taught is never practiced by our doctors because we don’t necessarily have the facilities. We were taught about the famous seldinger technique in my 3rd year MBBS, I practically performed or used that technique under proper guidance only after 7 years! Me and my mentor share a vision to make such redundant practices more practically applicable, and we are getting there!

Where do you work now? Tell us about your super-speciality as Interventional Radiologist

I currently work as a Fellow at Dr Rela Institute & Medical Centre, Chennai.

Skill Sets Needed

To be a good Interventional Radiologist you must be a very good diagnostic radiologist first. Knowing how to use needles, wires, catheters to maneuver safely into literally any part of the body using imaging guidance is an essential part of the job. Imaging guidance means knowing how to use an Ultrasound, X-Rays and MRI to accurately place a needle at the problematic area due to the disease. So none of the procedures that I perform leave a scar more than an IV line. As a radiology resident, I had already taught myself a few of the basic procedures of Interventional radiology like using the ultrasound to take tissue samples from organs, and removing abnormal fluid that’s collected in a patient’s chest or abdomen. Apart from these, IR offers a host of other procedures that are performed under x-ray guidance in a cath lab, which is specially  designed to provide continuous visualization during procedures.  

Typical Day

Unlike the popular belief about Radiologists, an Interventional Radiologists will consult a patient in a clinic, identify the clinical problem, and provide them different treatment options to choose from. For example, we see a lot of patients who visit us for treatment of Liver cancer. So for liver cancer there are different treatment options that can be performed by interventional radiologists, like TACE (Transarterial chemoembolization), Thermal Ablation etc. It depends on whether we want to improve the quality of life of the patient or want to make them cancer free. And based on the size of cancer, one method will be better than the other. So, such issues are specifically discussed with patients and a tailored treatment plan is prepared. A scheduled procedure like TACE will include using x-ray guidance to reach the arteries of the cancer and administer chemotherapy medicine and these arteries will be blocked using appropriate blocking agents called embolic particles. Such elective therapies are performed during the day. Many times there are some emergencies that we handle such as an injured artery causing life threatening hemorrhage, with the help of x-ray guidance, a combination of needles, wires and tubes which reach the site of the bleeding and block it with appropriate blocking agents.

“I am a cancer sniper by day and human plumber by night”.  

I had developed an interest in Radiology since I just loved being in front of a computer. But in due course, as I eventually became an Interventional Radiologist, I started loving my job because of the ability to care for people and the way they express their gratitude to the thankless job we do on a daily basis.

How does your work benefit society? 

Interventional Radiology is the best kept secret of medicine. Although the specialty has been practiced for over 60 years in India, we have only a handful of Interventional Radiologists in the country. 

It breaks my heart even today that even after so many advancements in the field of medicine, people at my place are denied the right to live merely because an Interventionist is not available. Life threatening bleeding, stroke, cancer emergency, etc can just be controlled with a pin hole in either the wrist or groin! Why should the people of my land be denied modern healthcare? I dream of making this cutting-edge specialty accessible to all.

I am not going to give anyone a false sense of hope, but as of now, the salaries of Interventional Radiologists are not sky high, although they should be, because they generate the highest per capita income. So with increasing awareness this will improve.

Tell us an example of a specific memorable work you did that is very close to you!

Recently at 4am in the morning, I finally performed a procedure called angioembolization (procedure to stop bleeding) all alone, without being monitored by anyone or knowing that there is no one else to help at this hour. The patient reassured me saying “doctor you will be fine don’t worry.” There are countless such memories and faces that I can never forget.

Your advice to students based on your experience?

Have a clear mind and declutter randomness by speaking to your close ones (I believe the less is more here.). Mistakes are the only way to learn and become a better you, every second. Owning up to mistakes and not throwing someone else under the bus are also the core skills that an interventional radiologist needs within a cath lab. Some days are absolutely bad days, especially when you’re dealing with people’s lives, so move on as early as possible because that is going to affect more lives. 

“Trust your training” these were the only words that were ringing in my head when I was giving my fellowship exit exam (Hopefully the last exam 🙂 I am tired of these examinations now:-) )

Future Plans?

Learning never ends! I am going to embark on a new journey. As expected, I will return to my native region and start practicing interventional radiology and learn more about the skills required to steer my way into people’s brains. I intend to keep transferring my knowledge and techniques to the future generations, as well as indulge in making more medical students aware of this speciality and guide them in the right direction if they want to pursue it.