I do not want to do a Fellowship

[redoitall]

So getting close to the time where I am going to apply for Fellowship. My first choice likely MSK, perhaps second would be breast. Now, I am sure this question was asked before, but things do change as you all know.
I am considering not doing a fellowship. I guess the brutality of my current program quenched any desire I had to continue training or to even contemplate academic medicine. As time goes by, I'd really like to avoid an extra year of training for many reasons
1- I am older than most (in my 40s). I seriously need to worry about retirement at this point. The contributions, savings and few stocks won't cut it for sure.
2- I am thinking of trying to get an ER rad job. I really don't mind the odd hours. I would also consider nighthawks down the road (like when I have 5-10 year left in me), or perhaps even now depending on circumstances.
3- I don't want to live in a big city. If it were up to me, I'd probably live in a cabin in the woods. The issue is that I have kids, and unfortunately these suckers have needs I cannot ignore (school, extracurricular etc...). That said, a small city should work I believe. I hate traffic and avoid crowds at any cost.
4- I am seeing the current job market which is doing quite well at the moment. The salaries are decent. Again, I understand this may change by the time I am done. However, I feel confident that given that I don't want to live in a big city and won't mind even working nights, hopefully, I should still be able to find a job.

It appears clear that not doing a fellowship would make me at a disadvantage. But I think I am willing to give up enough "perks" so as to remain somehow competitive. Overall my plan is not necessarily to make partner in a fancy place and make big bucks. Ultimately, the job I contemplate once I have enough saved, is to work 1 w on/2 off nights (even at a lower salary, and even telerad) and maybe even commute between the US another country to here (again, talking when my kids are gone and when I am 5 years away from retiring).

Any input of current radiologists or job applicant would be helpful. What have you seen / heard during your job interviews? As for current radiologists, what is the stance of your practice on the issue. Again, I full well understand that things do change. But where are we right now?

Thank you!

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[Chemdude]

The job market was doing well prior to COVID. The current graduating seniors have had a tough time landing jobs compared to years prior. Open up the ACR job board and you'll notice that the majority of the job openings listed are from private equity groups like radpartners. Nobody knows what is going to happen with the radiology job market, but there is a possibility that we are heading towards shrinking job opportunities as radiology volumes decrease. Not having a fellowship will place you at a severe disadvantage in a poor job market because 90%+ of other applicants will have a fellowship.

ER jobs typically prefer someone with neuro training. If you want an ER job, neuroradiology fellowship will make you the most marketable.

 

[redoitall]

I get your point. Although I believe that the majority of graduates tend to go for the same type of jobs, pays well, nice place, generally with good benefits. Again, things change fast, and now with COVID, cards will likely be redistributed sooner than later. Yet I do remain somehow confident as there will always be those jobs that no one really shoot for.
I guess I will monitor the situation and decide when the time comes, simulataneously applying for jobs and fellowship. We'll see.

Thanks for your input.

 

[808s&heartbreak]

FWIW, I personally know quite a few people including recent graduates who didn't do fellowships and are working in academia and in great desirable PPs. A few of my attendings are hired on as faculty after the minifellowships that they did during their R4 year.

Fellowships are the biggest scam. Most will have you take general call and final sign, but pay you pennies to assume all the liability. Ethically I find it very wrong.

 

[zero0]

OP you would have been in luck before COVID but if there was ever a time to be doing fellowship, it was after the 09 recession and right now.

 

[redoitall]

I do agree that the COVID pandemic is creating some serious issue there. But with 2 more years to go, I hope things will settle down. Surely, I will likely pursue a dual application and see.

 

[chudat]

Radiology fellowship such bogus. Anybody here that can share experiences about not having done a fellowship?

 

[GadRads]

20-40% of residents at Mayo don't do a fellowship, depending on the year. You might be able to get by without a fellowship.

 

[Kr#36]

This thread is interesting. I was in love with radiology so much so that I was almost to the point where I couldn't imagine choosing something else. However, Ive wavered on that recently after many have said a fellowship is mandatory in other threads because as a slightly older student myself I can't justify 6 years of training when I could make an equal check after 4 in gas or even more with a surgical route. While it isnt all about the benjamins, from the standpoint of supporting my family it is a little about the benjamins.

 

[gassedout2015]

This thread is interesting. I was in love with radiology so much so that I was almost to the point where I couldn't imagine choosing something else. However, Ive wavered on that recently after many have said a fellowship is mandatory in other threads because as a slightly older student myself I can't justify 6 years of training when I could make an equal check after 4 in gas or even more with a surgical route. While it isnt all about the benjamins, from the standpoint of supporting my family it is a little about the benjamins.

You can make alot in radiology if you dont mind working alot

 

[808s&heartbreak]

As a pgy1 hating prelim medicine and yearning for radiology residency to start, what made rads residency so brutal? I thought it would be more cushy

The knowledge needed to become a good radiologist, and the time it takes to gain those radiology knowledge. You would think that you learn on the job, but that simply isn't true. A great majority of residencies are work heavy but not teaching heavy, so you can get by your residency and still not know anything. This evident in the past years when the fail rate of the board exam gradually inch toward 20%. Although the core exam tests many obscure facts, in honestly it really isn't hard.

 

[changeofheart2016]

The knowledge needed to become a good radiologist, and the time it takes to gain those radiology knowledge. You would think that you learn on the job, but that simply isn't true. A great majority of residencies are work heavy but not teaching heavy, so you can get by your residency and still not know anything. This evident in the past years when the fail rate of the board exam gradually inch toward 20%. Although the core exam tests many obscure facts, in honestly it really isn't hard.

A popular theory for the rising percentage of failure rate is because a few years back, radiology was at an all time low in terms of competitiveness and accepted many unqualified applicants, who would never have matched radiology in any other year (low board scores etc).

These are the same people taking the core exam and thus the increasing failure rate.

 

[GadRads]

A popular theory for the rising percentage of failure rate is because a few years back, radiology was at an all time low in terms of competitiveness and accepted many unqualified applicants, who would never have matched radiology in any other year (low board scores etc).

These are the same people taking the core exam and thus the increasing failure rate.

Disagree with this assessment. Smart people have failed the core, including strong residents at top programs. The average step 1 has been ~240 for several years. I don't believe the testing pool has changed all that much to explain the rising failure rate. This is similar to the ABR Rad Onc boards when at one point, the exam had a 30% failure rate, and suddenly a <2% failure rate the subsequent year. I am not convinced the academic demographics of the testing pool changed that drastically.

The core exam is labeled a minimal competency exam by the ABR and which should be taken by residents without dedicated studying. However the exam is filled with tons of minutiae requiring a lot of time and effort to memorize. Many programs (including some strong academic programs) give their residents 3-4 months off clinical service to prepare. You should not need that much to prepare for a minimal competency exam.

Ben White comments here:
"the test includes too much material that a general radiologist would never use. Radiologists in practice would probably be more likely to fail than residents. That’s why MOC is so much easier than initial certification. Unlike the Core exam, the statement that no studying is required for MOC is actually true. Now, why isn’t the Core Exam more like MOC? That’s a question only the ABR can answer."

The 2019 ABR Core Exam Results, the Board Prep Arms Race, and Where It All Went Wrong | Ben White

On August 15, the ABR released the 2019 Core Exam results, which included the highest failure rate since the exam’s inception in 2013: 15.9%. (Side note: due to a “computer error,” the ABR decided to release the aggregate results before sharing individual results with trainees, resulting in...

www.benwhite.com

What The Core Exam Low Pass Rate Does Not Tell Us About This Year's Test Takers! - RadsResident

A low pass rate on the core exam tells us more about the test than the test takers. Here are some unfounded assumptions you should not make about them!

radsresident.com

 

[.Asterion]

Hard licensing exams are BETTER for radiologists. It prevents other specialties (e.g., cardiology) from stealing studies from radiology.

Ben White posts stuff like this from today, idk if I’d look to him as an expert on the ABR. He seems like a stream of consciousness guy sort of like trump.

 

[GadRads]

Hard licensing exams are BETTER for radiologists. It prevents other specialties (e.g., cardiology) from stealing studies from radiology.

Ben White posts stuff like this from today, idk if I’d look to him as an expert on the ABR. He seems like a stream of consciousness guy sort of like trump.

This is not a good rebuttal. You are overestimating the skills of non-radiologists and underestimating the skills of radiologists with respect to imaging. We have learned so much that some aspects of our daily practice now look routine, so much so that some of us fear that other clinical folks will take our work en masse. I do not have this worry.

Cardiologists with dedicated training already read cardiac studies for which they are trained; and these are cardiologists who have spent 1-3 years focusing on echocardiography, cardiac nucs, cardiac MRI and/or cardiac CT. The more cardiac modalities they read, the longer they train post-general cardiology, so it is not as if they are poaching cardiac imaging without some requisite/dedicated training. Even despite this training, they are not as good as radiologists when reviewing extra-cardiac findings. This has been my experience and that of others when co-reading studies with cardiologists interpreting cardiac MRI. They are, on average, inferior to fellowship-trained cardiovascular radiologists or radiologists with cardiovascular expertise. I am not convinced an imaging-focused cardiologist or non-imaging specialties (e.g. MFM OB-GYNs) will pass a watered down CORE exam.

I am just not a fan of several medical licensing boards who act as monopolies, are opaque, act in their own financial interests to the detriment of physicians, and are non-accountable to their constituents. As for Ben White, his political views do not detract from his comments on the ABR. I would treat those as mutually exclusive.

 

[Gadofosveset]

I think a lot depends on two questions:

(1) Is it right to have any “certifying” exams at all?

To me, I think the answer to this is yes. The intent would not be a gold star merit exam, but a minimal *standardized* qualification, set by the profession itself, really for the benefit of the public and the reputation of the specialty by performing minimal quality control. This benefits everyone eventually.

To anyone who’s been around a while, it becomes clear that just making it through any radiology residency is not an adequate surrogate for minimal quality. The uncommon instances of gross incompetence can easily fly below the radar. Programs have zero incentive to let a subcompetent resident go (except maybe to preserve a boards pass rate). But just taking an exam doesn’t make one a radiologist. A combination of residency + exam is a much safer option for quality control.


(2) what is “minimum competency”?

Is it a pass rate <1%, 2%, 5%, 10%, 20%? Each cut point has its own pros and cons.

“Minimum competency” is a philosophy and style rather than a fixed level. You have to contrast it with the “maximum competency” of the oral boards in which sometimes you would be pitched near impossible cases to see whether the examiner qualitatively likes the way you think on your feet and whether he likes the cut of your jib. A minimal competency style would pitch you many more questions, but which have been validated with a reasonable relatively high right answer rate... which is the current Core.

Oral boards has its pros and cons, MCQs have their pros and cons. One could imagine an exam at the workstation testing “real” radiology skills. It will have its pros and cons, too.

 

[Gadofosveset]

For the OP — fellowship is definitely an investment subject to a cost-benefit analysis. For many graduating residents it at least will pay them back over their career and they will probably end up net +, although the “loss” of a year (regardless of income) is hard.

“Fuzzy” nonfinancials also play a role, as you mention. In an extreme example, could I make more over the remainder of my career if I were to theoretically transfer right now from a radidology attending to plastics resident with a guaranteed job after graduation? Maybe? If I could, would it be “worth” it? Not for me. Career decisions are not only about choosing a larger NPV.

The particular CBA for fellowship depends on many factors which only you can weight. Give it some thought. There’s no one right answer.

 

[bwmd]

Ben White posts stuff like this from today, idk if I’d look to him as an expert on the ABR. He seems like a stream of consciousness guy sort of like trump.

I don't know if I'm an expert in the ABR either, I'm just one of the few people willing to write about the topic online. But not sure that posting a quotation from a book I just read about the insidious and ubiquitous nature of American racism makes me anything like our current president. I was under the impression he doesn't read much.

As for the OP, I personally would keep an open mind about fellowship but consider trying to do one in a location that doesn't use fellows as general call fodder and has meaningful moonlighting, particularly if there is some external stuff available like at a local VA. It would make you more hirable for the long term while partially mitigating the financial hit. Some practices will hire incoming fellows to do some internal teleradiology prior to their official start, something else to consider if you can snag a position like that.

 

[redoitall]

As for the OP, I personally would keep an open mind about fellowship but consider trying to do one in a location that doesn't use fellows as general call fodder and has meaningful moonlighting, particularly if there is some external stuff available like at a local VA. It would make you more hirable for the long term while partially mitigating the financial hit. Some practices will hire incoming fellows to do some internal teleradiology prior to their official start, something else to consider if you can snag a position like that.

Eh Ben (that the other Ben here lol). Thanks for your input. Much appreciated. Yes we do have the local VA as you know. That's certainly a way to alleviate (partially) the financial loss associate with the extra year of training. I will also look at Telerad jobs, particularly if I can get a position that would consider allowing me to remote from close by countries (Canada/Mexico etc...)

Hope you are doing well!

 

[redoitall]

For the OP — fellowship is definitely an investment subject to a cost-benefit analysis. For many graduating residents it at least will pay them back over their career and they will probably end up net +, although the “loss” of a year (regardless of income) is hard.

“Fuzzy” nonfinancials also play a role, as you mention. In an extreme example, could I make more over the remainder of my career if I were to theoretically transfer right now from a radidology attending to plastics resident with a guaranteed job after graduation? Maybe? If I could, would it be “worth” it? Not for me. Career decisions are not only about choosing a larger NPV.

The particular CBA for fellowship depends on many factors which only you can weight. Give it some thought. There’s no one right answer.

Very thoughtful answer. Will certainly keep in mind your thoughts here!

 

[iatros]

I recommend the fellowship for a few reasons
1) In the post-2008 economic downturn and subsequent job market, the general rads had the hardest time changing jobs. Virtually no general rad took a new job out of residency w/o 1+ fellowship(s). Preserve your ability to pivot if needed in the future. Don’t lock yourself into a job you may end up hating if and when things change and your perfect gig suddenly becomes unbearable.
2) if You get your full license, you can do a lot of moonlighting during fellowship. As others said, in-house moonlighting during fellowship usually pays crap. I’d suggest getting plugged in with a local or regional group outside of the fellowship institution. Pick a non-stressful fellowship with good hours and do a lot of moonlighting on the side. I did something similar (although my fellowship didn’t exactly have “good hours”) and about doubled myfellowship salary. Plus, you may be entitled to a signing bonus when you accept a perm job. Makes the prospect of yet another year of PGYx pay a little more bearable.

 

[redoitall]

I recommend the fellowship for a few reasons
... Makes the prospect of yet another year of PGYx pay a little more bearable.

Iatros, thank you for your input. Your thoughts echo the consensus among the various radiologists I talked to. Sure it might work to not do one, but it can be risky and everyone I have talked recommended it. Ah... This is painful.

 

[fun8stuff]

In response to rads vs gas or surgery: wtf? In gas tire going to be working at 6 am and regularly taking call to give pregnant woman epidurals at 2 am. Surgery?!! You’re going to be working 100 hrs /week and won’t see your family. Rads beats these lifestyles hands down and usually pays out more $$/hr worked.

An extra year of fellowship is nothing in the grand scheme and is needed to gain mastery in a niche area. I don’t think i would ever hire someone without a fellowship.

 

[Kr#36]

Was rads always like this(in regards to forcing ppl to get a fellowship to be hired) or is this just something that started when the job market crashed in 08 and now its become normal and self inflicted?

 

[zero0]

Was rads always like this(in regards to forcing ppl to get a fellowship to be hired) or is this just something that started when the job market crashed in 08 and now its become normal and self inflicted?

No it wasn't. It's partly a result of the 09 recession, current partners expecting more from the next generation despite never doing a fellowship themselves, and bloated rampant academic medicine which lives off cheap labor.

If rads training made any sense, it would be 4 years plus fellowship without the completely useless intern year I'm currently slogging through. There's really no reason to do this, just make all IR categorical and be done with it. Then maybe I'd consider fellowship, but as is 5 years is plenty for me. I won't be doing a fellowship if for no other reason than to push back against the training creep perpetuated by academic medicine.

 

[Dave1980]

No it wasn't. It's partly a result of the 09 recession, current partners expecting more from the next generation despite never doing a fellowship themselves, and bloated rampant academic medicine which lives off cheap labor.

If rads training made any sense, it would be 4 years plus fellowship without the completely useless intern year I'm currently slogging through. There's really no reason to do this, just make all IR categorical and be done with it. Then maybe I'd consider fellowship, but as is 5 years is plenty for me. I won't be doing a fellowship if for no other reason than to push back against the training creep perpetuated by academic medicine.

You likely wont have a choice unless you go telerad unfortunately. No desirable job is going to hire you. That's the sad reality of current job market.

 

[Neopolymath]

No it wasn't. It's partly a result of the 09 recession, current partners expecting more from the next generation despite never doing a fellowship themselves, and bloated rampant academic medicine which lives off cheap labor.

If rads training made any sense, it would be 4 years plus fellowship without the completely useless intern year I'm currently slogging through. There's really no reason to do this, just make all IR categorical and be done with it. Then maybe I'd consider fellowship, but as is 5 years is plenty for me. I won't be doing a fellowship if for no other reason than to push back against the training creep perpetuated by academic medicine.

I have not met a single radiologist in real life, even IR docs, that think that an intern year was anything other than a scam. I've only seen academic people online say that it was important in very vague terms. I will keep a good attitude and lean into the experience, but pessimistically, it's hard not to see it as a chance for a hospital to get some cheap notehoe to ward off pages for attendings.

 

[bobjonesbob]

I have not met a single radiologist in real life, even IR docs, that think that an intern year was anything other than a scam. I've only seen academic people online say that it was important in very vague terms. I will keep a good attitude and lean into the experience, but pessimistically, it's hard not to see it as a chance for a hospital to get some cheap notehoe to ward off pages for attendings.

Agreed. I'd like to see them go to fully integrated 4 year programs. Get rid of 6 months of PGY1 and 6 months of PGY5. Everyone can still do a one year fellowship but finish in 5 years. No way that makes any appreciable difference in the quality of training.

 

[zero0]

I have not met a single radiologist in real life, even IR docs, that think that an intern year was anything other than a scam. I've only seen academic people online say that it was important in very vague terms. I will keep a good attitude and lean into the experience, but pessimistically, it's hard not to see it as a chance for a hospital to get some cheap notehoe to ward off pages for attendings.

I can safely tell you based on what I've seen at my instution and others that it's just about putting more residents in the house/ICU call pool. 100%. Radiology training needs a thorough and rational reassessment.

 

[zero0]

You likely wont have a choice unless you go telerad unfortunately. No desirable job is going to hire you. That's the sad reality of current job market.

I would have believed you until recently but I am not convinced that is the case anymore. First of all, it was hard to even find mentoring apart from the "must do a fellowship" echochamber, but once I did I learned it was still very possible to get a decent pp job straight out of residency as long as you were geographically flexible. Granted all of this was before COVID when the job market was booming so who knows.

 

[Dave1980]

I would have believed you until recently but I am not convinced that is the case anymore. First of all, it was hard to even find mentoring apart from the "must do a fellowship" echochamber, but once I did I learned it was still very possible to get a decent pp job straight out of residency as long as you were geographically flexible. Granted all of this was before COVID when the job market was booming so who knows.

Well I've actually been through the job search. Believe me or not that is the reality.

 

[GadRads]

Well I've actually been through the job search. Believe me or not that is the reality.

Look at the graduates from Mayo. 30-40% of them got jobs without doing a fellowship. This may be a regional peculiarity.

 

[jazzman84]

You may be able to find a decent job as a generalist but your future mobility will be severely limited. Like it or not, practices want to be able to advertise all subspecialty reads.

 

[speedyxx626]

Look at the graduates from Mayo. 30-40% of them got jobs without doing a fellowship. This may be a regional peculiarity.

You're way off there my friend. There's maybe one person per year that doesn't do a fellowship, and that's because they choose to go back to the dakotas, minnesota or montana where their families are from. You don't really need a fellowship if your plan has always been to go live in a small/rural town in the midwest. Besides that, pretty much everyone else does a fellowship.

 

[redoitall]

They choose to go back to the dakotas, minnesota or montana where their families are from. You don't really need a fellowship if your plan has always been to go live in a small/rural town in the midwest.

Well, well, well. That's kind of my plan here. Go in a small place and even work nights! My goal is certainly not the 1 million dollar a year job (if that's even a thing), but more flexibility (2 on 2 off) with decent income that will allow me to retire when the time comes since I am quite old already (in my 40s). As soon as I have enough savings, I will likely become a locum tenen contractor and work minimally to not tap into my savings... So I don't have much ambition, no plan to buy a castle or a Ferrari. Just pay off my debt, have time to enjoy and travel and leave in a 250K house if I can find one!
But the truth is also that I am eager to bust my ass at work, take on week-ends, holidays (Xmas, New years, Thxgiving, to allow some other partners to be off). But it seems fellowships are more important than most other considerations... So while I am planning of doing a fellowship bc that's the way things go and because we need to apply now, I would die for a decent shot at a real job. I mean how much do you need to give up to convince? And no one is going to sign a resident that far ahead of graduation. The more I talk to practicing docs, including the ones who didn't do fellowship, the consensus so far is near unanimous: do a fellowship! It seems you won't be giving too much away if you do.
I am lucking enough that I truly love radiology, and I enjoy MSK a lot. But training is killing me and I am really, really, really tired of it... It is what it is...

 

[Neopolymath]

Well, well, well. That's kind of my plan here. Go in a small place and even work nights! My goal is certainly not the 1 million dollar a year job (if that's even a thing), but more flexibility (2 on 2 off) with decent income that will allow me to retire when the time comes since I am quite old already (in my 40s). As soon as I have enough savings, I will likely become a locum tenen contractor and work minimally to not tap into my savings... So I don't have much ambition, no plan to buy a castle or a Ferrari. Just pay off my debt, have time to enjoy and travel and leave in a 250K house if I can find one!
But the truth is also that I am eager to bust my ass at work, take on week-ends, holidays (Xmas, New years, Thxgiving, to allow some other partners to be off). But it seems fellowships are more important than most other considerations... So while I am planning of doing a fellowship bc that's the way things go and because we need to apply now, I would die for a decent shot at a real job. I mean how much do you need to give up to convince? And no one is going to sign a resident that far ahead of graduation. The more I talk to practicing docs, including the ones who didn't do fellowship, the consensus so far is near unanimous: do a fellowship! It seems you won't be giving too much away if you do.
I am lucking enough that I truly love radiology, and I enjoy MSK a lot. But training is killing me and I am really, really, really tired of it... It is what it is...

You said you are working incredibly hard at your program if I'm remembering correctly. I think you mentioned working several standard deviations harder even? While another year of getting paid peanuts is less than ideal, I think you will likely be in a better headspace when you leave your current situation and work better hours or less call. I don't know if rads fellowships are usually easier or harder than the residency but it seems like it can't be near as tough as your current environment. I think the sting of another year will be far less when you aren't getting owned every day like you are right now. I hope you find some relief.

 

[MadRadLad]

Some fellowships are very busy and others are relatively light. You don't want too chill of a fellowship or you will not get the optimal exposure to complex cases that you want as a subspecialist. You don't want to be burned out doing scutwork either. If you are at a very busy residency, you can probably find a middle ground fellowship which will seem somewhat relaxed in comparison and ideally you will primarily be reading in your area of interest. You mentioned MSK and that tends to be on the chiller sider due to relative lack of emergent studies relative to neuro or body. In many fellowships you may also have the opportunity to moonlight on the side and make some extra cash.

 

[redoitall]

You said you are working incredibly hard at your program if I'm remembering correctly. I think you mentioned working several standard deviations harder even?

My comment referred to the number of call hours in our program compared to ours. We certainly take way too much call. I am sure residents in every program work ward.

I think the sting of another year will be far less when you aren't getting owned every day like you are right now. I hope you find some relief.

Maybe you are right. It is hard to say for sure. A fellow makes 68k. Which is not much more than that last year resident. Now for sure, you can moonlight aggressively, but you probably won't turn that into 150K. Although I don't know for sure. The other issue is the mental aspect of again being a trainee for another year. I am frankly tired of putting up with the BS.

You mentioned MSK and that tends to be on the chiller sider due to relative lack of emergent studies relative to neuro or body. In many fellowships you may also have the opportunity to moonlight on the side and make some extra cash.

Yes, and lucky for me, at my institution our MSK fellowship is not bad at all. The attendings are very nice in that department for one, and MSK call is super chill as there are almost no stat MSK studies other than x-rays, which are handle by residents actually. However, because of the constant burn out of residents given the crazy amount of call we are taking, call is shifting slowly to fellows. It remains to be seen if by the time I am a fellow the call structure will change forcing fellows to take more call as years go by.
Now I could go somewhere else, but I just don't have the means to move my family on my fellow salary. My wife is the bread earner. So either I do a fellowship here, or I go find a real job.

 

[2brads]

I think you're asking for too much. You want lots of time off, working remotely, making "decent" money and no fellowship. Pick 1 or 2 of these wants and decide if you can sacrifice the others. Although, it's unclear to me if you want all of these things to start or are flexible. In any case, I would do a fellowship - despite what others may say, you will add to your knowledge fund and it will allow for more options in the future (I agree internship was a waste of time).

I did MSK, but if you are deciding between MSK and breast, do breast since it will allow you the greatest flexibility in the future (there are more rads willing to read MSK than breast). Believe it or not, there are dual MSK/breast fellowships out there (1 year total). I would also recommend doing your fellowship at a different institution from your residency. Chances are they will do things differently and you can add to your professional network. Most (>60%) people find a job within 100 miles of their fellowship so maybe make a list of places you would like to live and pick fellowships based on that.

Also, call as a fellow/attending is totally different than call as a resident. In my opinion, call during fellowship is a good thing. It will prepare you for the real world. Signing off that first final report is a doozy, but better to deal with those emotions in fellowship than early in your first job.

If you are willing to live anywhere, then you will find a job somewhere in the middle of nowhere. But if you have a specific "middle of nowhere" that you really want to live, then that is a much harder proposition because that tiny town you want to live in has a radiologist who clearly loves his job and you will need to enter the market just as that one guy leaves.

The market fell off a cliff after the pandemic hit. It has recovered somewhat but is nowhere near where it was in early 2020. ACR postings in January were about 1200, now 800 and many of those are corporate (bottom feeders). That being said, imaging volumes at my practice are now ABOVE where they were prior to the pandemic. The job market tends to trail the stock market, so keep a good eye on that as a predictor for where we will be in say 6 months.