Best radiology fellowship: IR, MSK, or Neuro?

[Tbus05]

I was just wondering what your opinions are for what the best and most interesting fellowship for radiology would be. So far, my top three choices that interest me the most are IR, MSK, and Neuro. If you had to choose out of the three, which would it be? Any other fellowships that you would choose other than these? Do you think its better to just stick with diagnostic? I'm not solely using anyone's answers to choose what I go into. I'm just trying to get an understanding of what other people think about it also. Thanks

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[shark2000]

I was just wondering what your opinions are for what the best and most interesting fellowship for radiology would be. So far, my top three choices that interest me the most are IR, MSK, and Neuro. If you had to choose out of the three, which would it be? Any other fellowships that you would choose other than these? Do you think its better to just stick with diagnostic? I'm not solely using anyone's answers to choose what I go into. I'm just trying to get an understanding of what other people think about it also. Thanks

There are a fraction of radiology residents who do radiology only for IR. Otherwise, most people think about multiple fellowship rather than one. It is hard to choose between two similar subspecialties. However, in pp everybody does many things. So if you are neuroradiologist, you will likely do at most 50% neuro and the rest will be other things.

I am personally not a great fan of IR. It looks great if you are in a large academic center. But generally speaking, in pp it is not as interesting. If you like it, it is the best choice for job market now.

MSK is my own subspecialty, so I am biased. IMO, MSK is one of the most specialized parts of DR and probably the most difficult one to master. You have the option to do interventions including pain management, injections, Kyphoplasty/vertebroplasty and ... If you like it, it is a good choice.

Neuro is also interesting. If you think about MSK, you are also probably interested in Neuro. The most MRI Heavy part of radiology. You also can do procedures like spine pain or may be able to learn kyphoplasty/vertebro from neuroIR people in your fellowship. It is also a good choice.

All of these are good choices. We don't have the best fellowship. Each of them can be the best if you like it.

 

[badasshairday]

Radiology is the best.

 

[tco]

I think it depends on your interests. I love procedures, so out of those listed, I like IR the best. That's not to say that the others aren't great, or aren't interesting. It's very individualized. There's something in radiology for everyone, I feel. Unless you enjoy rounding for 6 hours on 10 patients, then there's probably nothing here for you 😛

 

[fun8stuff]

I was just wondering what your opinions are for what the best and most interesting fellowship for radiology would be. So far, my top three choices that interest me the most are IR, MSK, and Neuro. If you had to choose out of the three, which would it be? Any other fellowships that you would choose other than these? Do you think its better to just stick with diagnostic? I'm not solely using anyone's answers to choose what I go into. I'm just trying to get an understanding of what other people think about it also. Thanks

There are different mind-sets. You can either do what is most in demand (IR and mammo), do what you like the most, or try and improve your knowledge by picking something difficult (neuro or MSK). I think a combination of the later 2 are the best options because market forces are bound to change. Might as well make the extra year of fellowship worth it and enjoy it at the same time.

I like quick procedures, but a lot of IR is tedious, long procedures.... and in private practice it's doing everything the rest of the hospital does not want to do. I would only do this if you really enjoyed it.... it is probably the most marketable subspecialty right now.

Mamms is also very marketable, but that is because nobody wants to do it... and you really should not need an extra fellowship to master it.

Ped's: don't do enough outside of academics/large childrens hospital to justify to the fellowship. Will be even more limited as to where you can live...

Body: you should get enough of this in residency to master it. People in private practice often feel like they can do it just fine (without the need to hire a new guy, as opposed to more challenging areas like neuro and MSK).

Nucs: Other than PET, it's a dying field. Not marketable at all. Nucs is very low volume in private practice.

I think MSK or neuro is the best bet as they are the most difficult/most breadth/most challenging. These are areas that you actually need more years of training to master. Unfortunately the market is pretty saturated right now, especially for neuro.

 

[TrainingMD]

From my experience, the best DR programs have "decent" IR programs. Likewise, the best IR programs have "decent" DR programs. I'm sure opinions will differ on this though... For this reason, it is probably good to figure out if you want to do DR or IR, but not absolutely necessary at this point.

Some of the best IR-heavy programs I came across for residency were Wake Forest, Emory, Northwestern, Baylor (which has 4 straight months of IR in R2 year). Anyway, the big academic centers will have people with connections in every subspeciality, so fellowships should not be too difficult to obtain if you work hard, get along with your attendings, etc.

 

[Zweihander]

There are different mind-sets. You can either do what is most in demand (IR and mammo), do what you like the most, or try and improve your knowledge by picking something difficult (neuro or MSK). I think a combination of the later 2 are the best options because market forces are bound to change. Might as well make the extra year of fellowship worth it and enjoy it at the same time.

I like quick procedures, but a lot of IR is tedious, long procedures.... and in private practice it's doing everything the rest of the hospital does not want to do. I would only do this if you really enjoyed it.... it is probably the most marketable subspecialty right now.

Mamms is also very marketable, but that is because nobody wants to do it... and you really should not need an extra fellowship to master it.

Ped's: don't do enough outside of academics/large childrens hospital to justify to the fellowship. Will be even more limited as to where you can live...

Body: you should get enough of this in residency to master it. People in private practice often feel like they can do it just fine (without the need to hire a new guy, as opposed to more challenging areas like neuro and MSK).

Nucs: Other than PET, it's a dying field. Not marketable at all. Nucs is very low volume in private practice.

I think MSK or neuro is the best bet as they are the most difficult/most breadth/most challenging. These are areas that you actually need more years of training to master. Unfortunately the market is pretty saturated right now, especially for neuro.

Have to disagree with your take on body here.

I went to a residency with a lot of body guys and where we did a lot of body CT/US. Came out thinking I was pretty good at body, and then did a body fellowship just because I liked it. I will tell you I learned way more than I thought I would, and no you definitely don't master body just by being a resident.

Your average resident doesn't get great at body MRI without a fellowship, which is okay as most people don't do that much anyways. That said, if you ARE really good at it, that can be a real asset to your group. Another thing you can get from body with the right fellowship is procedures: this is a great compromise for people that love doing procedures but don't want to go full IR and want to continue doing a lot of diagnostic work.

A lot of what you will get out of a fellowship will depend on the subspecialty interest you show as a resident and what the weaknesses of your residency or holes in your specific knowledge are.

I agree with the general sentiment above that you should do what you enjoy, and pinning down what is "hot" right now is kind of useless, especially for someone not in residency, because you are dealing with a moving target and ever-changing job landscape.

 

[Kablammo]

Agree with the sentiment defending body fellowships- there is always a lot more to learn, and no residency offers comprehensive body MR, pelvic MR, prostate MR, etc. Not to mention, doing ~50 liver bx etc over four years is not the same as 100's during a demanding fellowship. Like all the other fellowships, body MR has a lot to offer.

That being said, I've been told my a number of reliable mentors that residents over-think their fellowship choice, particularly these days when everyone is doing a fellowship and the market is tighter. The truth is that IR is the only real outlier, and most of us are serviceable at all of DR. Pick something you're interested in and use the fellow year to become an expert in that department (consult, protocols, safety, procedures, complications, finance, organization, etc.) and you'll be very valuable to any group.

 

[fun8stuff]

Agree with the sentiment defending body fellowships- there is always a lot more to learn, and no residency offers comprehensive body MR, pelvic MR, prostate MR, etc. Not to mention, doing ~50 liver bx etc over four years is not the same as 100's during a demanding fellowship. Like all the other fellowships, body MR has a lot to offer.

That being said, I've been told my a number of reliable mentors that residents over-think their fellowship choice, particularly these days when everyone is doing a fellowship and the market is tighter. The truth is that IR is the only real outlier, and most of us are serviceable at all of DR. Pick something you're interested in and use the fellow year to become an expert in that department (consult, protocols, safety, procedures, complications, finance, organization, etc.) and you'll be very valuable to any group.

I didn't mean to come off as saying that there is no value in doing a body fellowship, but that a lot of private practice rads do not realize the value added or feel it to not be as beneficial because nearly EVERYBODY in private practice feels comfortable (rightfuly so or not) reading CT/US.... and body MR is a lot lower volume compared to neuro and MSK MR. It is also my understanding that in PP, drains and biopsies are done by IR (with liver bx commonly done by GI). However, these things are not true with MSK and neuro (there will be commonly be people who read everything but neuro or MSK... or want to send the difficult cases to these guys).

 

[shark2000]

Have to disagree with your take on body here.

I went to a residency with a lot of body guys and where we did a lot of body CT/US. Came out thinking I was pretty good at body, and then did a body fellowship just because I liked it. I will tell you I learned way more than I thought I would, and no you definitely don't master body just by being a resident.

Your average resident doesn't get great at body MRI without a fellowship, which is okay as most people don't do that much anyways. That said, if you ARE really good at it, that can be a real asset to your group. Another thing you can get from body with the right fellowship is procedures: this is a great compromise for people that love doing procedures but don't want to go full IR and want to continue doing a lot of diagnostic work.

A lot of what you will get out of a fellowship will depend on the subspecialty interest you show as a resident and what the weaknesses of your residency or holes in your specific knowledge are.

I agree with the general sentiment above that you should do what you enjoy, and pinning down what is "hot" right now is kind of useless, especially for someone not in residency, because you are dealing with a moving target and ever-changing job landscape.

I did almost a year of body fellowship during my fourth year. One of the body fellows left our program and I got 9 months of body mini-fellowship in a row and I was functioning as a fellow. Then later I did a year of MSK fellowship.

There are always new things to learn, but body fellowships are of less added value compared to other fellowships to a group for the following reasons:

1- In pp, 95% of body imaging is CT or US. MRI is not really a big modality in pp. I have seen big groups doing 2-3 body MR a day.

2- In you go to a good program, you should be able to handle 95% of body CT and US cases. And as you go through first years of your pp, you get better. Unless you work in a big cancer center, the pathology is simple; appendicitis, liver mets, .... This is not the case for MSK for example. Most general radiologist can't handle 95% of MSK MRIs.

3- Body procedures are done by IR in many practices. In an average community hospital, IR is not doing PAD work. They also don't do chemoembo or Y-90s. An IR in pp does mostly biopsies and drains and lines. Anyway, CT guided biopsies are not difficult. US guided biopsies need practice and is one of the added values of a body fellowship.

5- The most important reason: In pp most Orthopods, neurosurgeons and neurologists ask for MSK or Neuroradiologist to read their studies. Otherwise, they will refer their patients to other imaging centers. This is not the case for Body. GI doctors, surgeons, oncologists and internists don't care that much. One of the things that all radiology groups advertise for is subspecialty read on Neuro and MSK MRI. Recently our orthopods asked for MSK radiologist to read even their plain films. I have never seen similar situation for body at least in a large scale.

6- Body is very interesting and is the backbone of radiology. Right or wrong, in pp a body imager is considered a general radiologist who can handle tough cases (tough cases are uncommon in pp, believe me). You will be seen as an experienced general radiologist and not a specialist. My 2 cents.

 

[omarsaleh66]

I am an IR starting out at PP in a community hospital. Shark is right, we are only doing "light" IR procedures at the moment which can be done by most people as long as there is no complication (bleed after a kidney or liver biopsy). It takes alot of hard work to build up a practice and I think it applies for IR MSK or neuro. I think u really have to put yourself out there and advertise to people what u can do so they can start referring cases to you or coming to you for reads. I have been going to tumor board and have gotten 3 TACE referrals in just my first week so there is potential even in PP. Before these would go out to the near academic center

Personally, I find MSK the most challenging. I dread reading joint MRI and can get the basic findings but would not feel comfortable as I am reading neuro or body (just because u read more of these on call as a resident)

Any fellowship is good, just make sure u provide added value and that is done with alot of hard work and networking with your colleagues

 

[cowme]

2- In you go to a good program, you should be able to handle 95% of body CT and US cases. And as you go through first years of your pp, you get better. Unless you work in a big cancer center, the pathology is simple; appendicitis, liver mets, .... This is not the case for MSK for example. Most general radiologist can't handle 95% of MSK MRIs.

I don't think this is true anymore. Maybe 10 years ago, but it seems like any 4th year nowadays can comfortably handle any knee/shoulder/ankle MRI-- which probably comprises 90% of MRI volume in PP. Same goes for neuro--you see enough in residency that you can handle 90% of neuro cases you would come across.

But the point of fellowship isn't the 90%. It's to master that last 10%. The zebras. The advanced imaging techniques.

Sure, you may not see many pelvic MRIs in private practice, but I also can't imagine you see that much perfusion MRI or bone tumor cases in private practice either. I don't understand why people scoff at body fellowships because they can read a body CT--head CTs and knee MRIs are easy too

 

[shark2000]

I don't think this is true anymore. Maybe 10 years ago, but it seems like any 4th year nowadays can comfortably handle any knee/shoulder/ankle MRI-- which probably comprises 90% of MRI volume in PP. Same goes for neuro--you see enough in residency that you can handle 90% of neuro cases you would come across.

But the point of fellowship isn't the 90%. It's to master that last 10%. The zebras. The advanced imaging techniques.

Sure, you may not see many pelvic MRIs in private practice, but I also can't imagine you see that much perfusion MRI or bone tumor cases in private practice either. I don't understand why people scoff at body fellowships because they can read a body CT--head CTs and knee MRIs are easy too

Because your assumption is incorrect. Body CT is easier to master than MSK MRI and Neck CT/MRI. I don't think that a 4th year can handle 90% of ankle or shoulder MRIs.

Anyway, though I disagree with your statement, I am not going to argue more.

Orthopods and Neuro people in most markets ask for MSK radiologist and Neuroradiologist . Period.

Ask yourself why this is the case? and why body referring services (oncologists, surgeons, urologists, hepatologists, GI, Gyn-oncs, Internists, colon surgeons, ... ) do not ask for subspecialty read the same as neurologists or orthopods?

 

[Zweihander]

I did almost a year of body fellowship during my fourth year. One of the body fellows left our program and I got 9 months of body mini-fellowship in a row and I was functioning as a fellow. Then later I did a year of MSK fellowship.

There are always new things to learn, but body fellowships are of less added value compared to other fellowships to a group for the following reasons:

1- In pp, 95% of body imaging is CT or US. MRI is not really a big modality in pp. I have seen big groups doing 2-3 body MR a day.

2- In you go to a good program, you should be able to handle 95% of body CT and US cases. And as you go through first years of your pp, you get better. Unless you work in a big cancer center, the pathology is simple; appendicitis, liver mets, .... This is not the case for MSK for example. Most general radiologist can't handle 95% of MSK MRIs.

3- Body procedures are done by IR in many practices. In an average community hospital, IR is not doing PAD work. They also don't do chemoembo or Y-90s. An IR in pp does mostly biopsies and drains and lines. Anyway, CT guided biopsies are not difficult. US guided biopsies need practice and is one of the added values of a body fellowship.

5- The most important reason: In pp most Orthopods, neurosurgeons and neurologists ask for MSK or Neuroradiologist to read their studies. Otherwise, they will refer their patients to other imaging centers. This is not the case for Body. GI doctors, surgeons, oncologists and internists don't care that much. One of the things that all radiology groups advertise for is subspecialty read on Neuro and MSK MRI. Recently our orthopods asked for MSK radiologist to read even their plain films. I have never seen similar situation for body at least in a large scale.

6- Body is very interesting and is the backbone of radiology. Right or wrong, in pp a body imager is considered a general radiologist who can handle tough cases (tough cases are uncommon in pp, believe me). You will be seen as an experienced general radiologist and not a specialist. My 2 cents.

I won't say you are wrong here because I assume your post is informed by your own experiences, but I can say for certain that the above has not been my own experience, even remotely.

I know some ortho guys want MSK readers, but I have seen my share of practices where this is simply not the case. As with anything, these sorts of details depend on practice environment. Ditto for procedures being done by IR - true in many places, but not a rule and not even rare for body to do them.

The bottom line is that you will find a fit with a practice that needs your skill set, and I do think it is wrong to say any fellowship in particular is unnecessary.

I will also reiterate that you can bring your skills with you to your practice if you go to the right environment, so it is not simply a matter of learning CTs and forgetting everything else.

 

[Zweihander]

I don't think this is true anymore. Maybe 10 years ago, but it seems like any 4th year nowadays can comfortably handle any knee/shoulder/ankle MRI-- which probably comprises 90% of MRI volume in PP. Same goes for neuro--you see enough in residency that you can handle 90% of neuro cases you would come across.

But the point of fellowship isn't the 90%. It's to master that last 10%. The zebras. The advanced imaging techniques.

Sure, you may not see many pelvic MRIs in private practice, but I also can't imagine you see that much perfusion MRI or bone tumor cases in private practice either. I don't understand why people scoff at body fellowships because they can read a body CT--head CTs and knee MRIs are easy too

Exactly right.

 

[Kablammo]

Great discussion here folks, thanks for all the input. Clearly there is no right answer.

When I was first trying to decide on a fellowship, I was exposed to a number of different perspectives (we have something like 120 faculty, no shortage of opinions.) I had a neurorad attending tell me that it takes 2 years of fellowship to be really competent in neuro, and that MSK could be learned in a week-long CME event. I had an MSK faculty tell me that MSK MR was the most difficult modality encountered in pp, and that neurologists and neurosurgeons read their own advanced neuro imaging anyhow. I had a peds faculty tell me that their peds fellows had trouble finding jobs, but that peds was the last true general rads fellowship. I had a breast imaging faculty tell me that he loved his job, but that mammo fellows would saturate the market when the next round of USPTF recs tanked the volume. I also had a relatively famous IR faculty tell me that all of DR was doomed, and that I had better train with him in IR so that I would have a job.

In the end, no one has the right answer, so I think it is reasonable to try to do a fellowship in something that you love. Another method is to talk to groups that you would like to join and ask them what they might need. I did both, and ended up pursuing a body MR fellowship. This past year all of our fellows got great jobs, but one of the first to get a really good position was the chest fellow, who did a ton of cardiac MR, and joined a group looking to build that part of their practice. One of our MSK guys was still looking in late spring.

Regarding proficiency on difficult cases, we are tiptoeing on a really interesting question in all of rads, I think. That is, who should read what? Should all neuro cases go to the neuro gurus at Hopkins and UCSF? Surely their elite training and extensive experience would render them most able to sort out difficult cases AND pick up subtle important findings on non-con CT heads that general pp rads might miss. Should every group divide up the work based on which specialty we trained in fellowship? Is that financially practical? And another question- how much advanced training is necessary? If I do 6 months of MSK during my fourth year, is that enough? What about a resident who did 6 months at Duke MSK, is he as good as someone who did a year long fellowship at St-Elsewhere who perhaps did not have much advanced imaging at all during their residency?

Sorry for the long post.

 

[shark2000]

I won't say you are wrong here because I assume your post is informed by your own experiences, but I can say for certain that the above has not been my own experience, even remotely.

I know some ortho guys want MSK readers, but I have seen my share of practices where this is simply not the case. As with anything, these sorts of details depend on practice environment. Ditto for procedures being done by IR - true in many places, but not a rule and not even rare for body to do them.

The bottom line is that you will find a fit with a practice that needs your skill set, and I do think it is wrong to say any fellowship in particular is unnecessary.

I will also reiterate that you can bring your skills with you to your practice if you go to the right environment, so it is not simply a matter of learning CTs and forgetting everything else.

It is not my own experience. Many orthopods ask for MSK radiologist read. Many neurologists ask for neuroradiologist. There may be lots of them who also do not ask for subspecialty read.

I personally don't see a lot of skills added by doing a body fellowship. This is what you do most of your residency. Anyway, if you are happier doing body, go for it. Good Luck.

 

[cowme]

But a surgeon doesn't ask for a body imager reading a liver mri?

Please...

 

[Zweihander]

It is not my own experience. Many orthopods ask for MSK radiologist read. Many neurologists ask for neuroradiologist. There may be lots of them who also do not ask for subspecialty read.

That's my point - while there certainly are or orthos and neurosurgeons who want sub specialty reads, this isn't by any means universal and is not in and of itself a strict reason why one should go into those fields.

"Marketability" is more a function of whether a practice needs your skillset or not, and these fields aren't any less immune to saturation than any others.

I personally don't see a lot of skills added by doing a body fellowship. This is what you do most of your residency. Anyway, if you are happier doing body, go for it. Good Luck.

I will have to say you are wrong here. There are plenty of things you learn in a good body fellowship you won't get good at in residency. Whether those things are useful to you or not outside of training depends on the nature of the practice you join and how aggressively you market your skill set. That said, you will still be much better at complex abdominal CT and US, not to mention assessment of abdominal masses, compared to your non-fellowship trained counterparts.

No hard feelings, you are certainly entitled to your opinion. But I think it is worthwhile to offer another opinion, for those who are still working their way through the process, and having recently gone through the process of looking for jobs/interviewing with practices I am pretty aware of the sorts of things people are looking for which you can't bring with you absent fellowship training.

 

[shark2000]

But a surgeon doesn't ask for a body imager reading a liver mri?

Please...

Most don't ask, believe it or not. The problem is logistic. Orthopods believe that they are better than a general radiologist in interpreting MRI, though some also think that they are better than MSK rads. Neurologists think they are better than general radiologist, though many of them respect neuroradiologists. This is not the case for GI doctors and oncologists. Surgeons may be a little more difficult to deal with.

As a person who is trained in both, reading a liver MRI is easier than Ankle MRI. The good or bad thing about MSK MRI is the precision required on interpretation. The anatomy is complex. I think every first year radiology resident can show all the structures on a liver MRI, however more than half of my partners in pp can not show all of the structures on an ankle MRI. It is not rocket science, but needs training.

The distribution of MRI in pp:

1- 30% Spine MRI. Most read by Neuro people, but some by MSK.

2- 25-30%% Neuro none spine

3- 25-30% MSK none spine

4- 10% other according to the practice setting. This includes Body, Breast and Cardiac. Some places may not do cardiac or breast at all. Some places may do a lot. Even if the surgeon asks for a body imager, one body imager is enough to handle all the body volume.

I don't have any beef with body imaging. Just saying that what you see in an Ivy tower program is different from pp. The same for IR. Its practice is totally different in pp and in a big academic center. For Neuro and MSK, though it is different, the difference is not as much.

My 2 cents.

 

[fun8stuff]

Most don't ask, believe it or not. The problem is logistic. Orthopods believe that they are better than a general radiologist in interpreting MRI, though some also think that they are better than MSK rads. Neurologists think they are better than general radiologist, though many of them respect neuroradiologists. This is not the case for GI doctors and oncologists. Surgeons may be a little more difficult to deal with.

As a person who is trained in both, reading a liver MRI is easier than Ankle MRI. The good or bad thing about MSK MRI is the precision required on interpretation. The anatomy is complex. I think every first year radiology resident can show all the structures on a liver MRI, however more than half of my partners in pp can not show all of the structures on an ankle MRI. It is not rocket science, but needs training.

The distribution of MRI in pp:

1- 30% Spine MRI. Most read by Neuro people, but some by MSK.

2- 25-30%% Neuro none spine

3- 25-30% MSK none spine

4- 10% other according to the practice setting. This includes Body, Breast and Cardiac. Some places may not do cardiac or breast at all. Some places may do a lot. Even if the surgeon asks for a body imager, one body imager is enough to handle all the body volume.

I don't have any beef with body imaging. Just saying that what you see in an Ivy tower program is different from pp. The same for IR. Its practice is totally different in pp and in a big academic center. For Neuro and MSK, though it is different, the difference is not as much.

My 2 cents.

I'm with Shark on this one. Private practice is a different world than academics. If you don't have exposure to PP, do a quick auntminnie search as this has been discussed many times with the same conclusions from private practice rads.

 

[colbgw02]

My experience jives with shark's as well. Not trying to universalize what I've seen and experienced...just adding anecdotal evidence.

I've always thought the difference between subspecialists was largely a function of the anatomy. To wit, skull base and small joint anatomy is just more complex than torso anatomy, so it takes more training to understand it.

I'm not saying that a body fellowship trained radiologist can't read a liver MRI better than a general radiologist can (they can), but in comparative terms, the neuro or MSK rads adds more value over baseline (i.e. the generalist) than many other subspecialists.