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Below is a summary of radiology fellowships and a summary of their day to day work.
There is a huge variation between some of these fellowships esp IR and mammo versus others.
Many medical students and even residents have a lot of misconceptions about how pp works. Most of their understanding is from their experience at a big academic center where Neuroradiologist reads head CT and chest radiologist reads HRCT. However, in pp there is a huge overlap between what you do. If you are a Neuroradiologist you still have to read CXR, MSK MR, body CT and even mammo. People have been talking about subspecialization for more than a decade, however it seems that pp can not afford exclusive reads by the subspecialist.

1- Neuroradiology: Is divided to Brain, Spine, Head and Neck and Pediatrics. Most MR heavy field. In most places spine is controlled by Neurorads. MRI spine, MRI brain, CT brain, CT head and neck and CTA are the major modalities. Can be very challenging and fun. Traditionally was the most popular fellowship, however recently it is very saturated. Has the potential to make the highest RVU. Procedure wise you may do some spine pain injections and diagnostic angiogram, but not very procedure heavy.

2- NeuroIR: Many think this will be controlled by Neurosurgeons in a few years. I doubt it, because the volume is not as high as you think. Neurosurgeons can have a better life style and yet make much more money by doing their field. It is really limited to big academic centers. Not a big player in pp. My guess is it will be split between radiology, NS and neurology in the future. Not popular among radiology residents.

3- MSK: Is bone and joint imaging and some spine imaging. In many places spine is done by Neuro or is a split service. Major modalities are MR and Xray. US and CT are also getting more, but are far from being popular. Many think MSK MR is the most difficult MR esp for a general radiologist. Also a lot of orthopods want their MR to be read by MSK radiologist. Has some procedures like arthrogram and pain injection, depending on practice setting. Like the rest of DR, not procedure heavy. Was very popular in early 2000s, not these days.

4- Body: is everything in the abdomen. Modalities include CT and US. MR is also other modality but not really high volume in pp. Body MR includes but not limited to liver , pancreas, prostate, Gync, MR enterography, .... Some places also include cardiac MR. Overall, may be a growing field, but the MR volume is low. Many radiologists think body MR is the easiest to read. Body procedures include biospsies, drains, ablations and in some palces percut nephrostomy and cholecytostomy. Overall, along with chest, is considered the least specialized field as many think it is just an extension of residency.

5- Chest: CXR, chest CT, cardiac CT and MR and HRCT. As described in body section, many consider it the least specialized part of radiology. Most general radiologists feel comfortable reading chest (including cardiac CT but excluding cardiac MR). Not a marketable fellowship for pp, but recently there are open spots in academics, more than MSK and Neuro.

6- Breast Imaging: Mammogram and US are the major modalities. Tomosynthesis and breast MR are low volume. Mammo and tomo has been out there for at least 2 decades. Procedures include US guided biopsies, Stereotactic biopsy, MR guided biopsy and wire localization for pre-op. Overall, the most difficult part is mammogram. Procedures are relatively easy to learn. MR is relatively easy to learn. These can be learned during residency. But mammo is difficult. Since mammo (screening and diagnostic) are 90% of what you do, many general radiologists do not feel comfortable doing breast imaging. Has the highest malpractice and lawsuit probability.

7- IR: Vascular and non-vascular procedures. Was very hot in early 90s, but after turf issues with cards and vasc surgery, went down. In early 2000s was an easy one to get (along with mammo). It is one of the most competitive (if not the most one) ones. New IR people have clinical mentality and admit their own patients, have clinic and consult patients similar to a surgical subspecialty.

8- Peds: Was hot 3-4 years ago. Is a different world. Different pathologies. X-ray and US are the major modalities. The field is more dependent on X-ray interpretation and US than adult. It is a low supply, low demand field. Most believe that only Peds radiologists can give high quality reads on many Peds case esp those in a children hospital. But the market is really small.

9- Nucs: Many general radiologists feel comfortable reading most of the Nucs studies. There are many studies not done in pp and even in academic centers are done once in a while. The major modalities are PET-CT for cancer staging, Bone scan, Cardiac stress test (done by cardiologists in many places but still radiologist do some of them), hepatobiliary and ... Overall, not very marketable. Many places combine it with body fellowship to make both of them more marketable. There is a separate residency as Nuclear medicine. It is neither marketable nor good enough to be competent at reading multi-modality studies. For example many of their graduates or even attendings have problem giving high quality read on PET-CT as they are not competent enough reading CT.

No matter what you do as a fellowship, you will read a diversity of cases in pp. One great advantage of radiology is the diversity of what you can do. There are people who have done IR for 10 years then got burnt and switched to DR. There are those who have done MSK for 10 years and then switched to mammo because wanted more patient interaction.

I hope this is helpful.
 
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Gadofosveset

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Nice summary. A few biased additions:

- Thoracic imaging is a very academic field... it's the ideal field for "splitters" (you know who you are). If the idea diagnosing overlapping lupus and Sjogren's lung interests you, or going to thoracic conference and discussing bronchogenic carcinoma variants with thoracic surgeons, then this is the field for you. Or if you like reading the voluminous literature on imaging for coronary artery disease. Good chest radiologists are uncommon, but someone who actually understands chest imaging is quite valuable in an academic setting. There's little to no MR, which means decreased $ potential. A chest fellowship is a hard/impossible sell as an advantage for pp, although most chest fellowships include cardiac imaging, which maybe can increase one's marketability for some groups (maybe). A chest fellowship is not for the vast majority of radiologists. It's for a special few.

- Neuro imaging and fellowship has its own distinct... culture. In addition, the "splitter" personality of thoracic imaging does well here. So many residents are interested in neuroradiology before they actually experience what it's like: Some quickly develop an interest elsewhere. Some fight the monsters long enough and become the monsters. A few make it through and remain normal.

- Body imaging (and neuro) is what residents tend to be exposed to most because of call. Most, if not all, residents graduate certain they have nothing left to learn in body or neuro. They are quite wrong. The sheer size of body imaging makes it tough to be decent in all areas. The technical variation in body MR makes it hard to read intelligently, although many can churn out some kind of report, right or wrong (for some MSK studies, you may not even know what you're looking at). I've noticed that graduating body fellows tend to be less confident about being masters of body imaging than graduating residents. The trick about body imaging is that you can read it at a low skill level with less consequence, which is different from MSK and neuro. If you suck, you'll miss or misunderstand a lot in body, but there's much more room for error and hedging.

- MSK really is a tough one to learn from the few rotations you have as a resident... especially since you will probably mostly be cranking through the bone plain film list. It's hard to learn on one's own and many places don't teach it especially well , either. So much MR ($)... MSK can be very academic as well, although from what I've seen, most fellows interested in it are using it to increase their pp marketability.

- Nucs: avoid a fellowship in this unless you have a very definite plan on how you are going to use it in the future.

I don't have enough experience in Peds or Mammo to comment. IR is kind of a different world, in some ways, and the experience is more heterogeneous than diagnostic imaging, so I won't comment on that either. It's true that NS isn't exactly in a rush to take NeuroIR.

The point Shark2000 made about valuing breadth is very valuable and very hard for residents to appreciate. You should try to be decent in everything with a strength in something. You never know what you are going to need in the future. If you love mammo, concentrate on learning how to get percutaneous access to a kidney. If you love IR, concentrate on how to be safe reading a mammogram.
 

Gadofosveset

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Also, when talking about which field is "valuable" for fellowship training, people are usually talking about three things

1) Which fields have higher reimbursement activities (MRI, procedures). This will almost automatically be what pp is looking to add.

2) If a field is relatively over- or undersaturated. Every radiology resident cannot go to a high reimbursement fellowship and most groups don't need all high-RVU specialists.

3) If you do everything, you can be great at a lot of things, but you can't be great at everything... and some areas are easier to muddle through on a day to day basis than others. Even if you are not actually any good at body and chest, it's lower risk to generate a low quality report. In body, nucs, and chest, even if you add little value -- even if your report is basically worthless -- you may not be in as much risk ('course you're not helping anyone either).
With neuro or IR, however, muddling through anything but the basic stuff is not a great long term strategy. It may not even be possible to muddle through some head and neck, temporal bone, and MSK MR imaging studies (e.g small joints, elbows) without sounding like a moron to a referring doc on the other end. So the value of a fellowship may not be in becoming "great" at something but in becoming capable of moving through a lot of it at lower risk.
 
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Cubsfan10

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As far as PP structure, I get the fact that high RVU (MRI, procedures) are great/valuable, but I was under the impression that typical PP rads groups split the money pretty equally among partners no matter their sub-specialty. I thought that the only real difference in how much Rads A makes from Rads B is whether he/she is a partner and how much call he/she takes. Is this not the case?
 
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As far as PP structure, I get the fact that high RVU (MRI, procedures) are great/valuable, but I was under the impression that typical PP rads groups split the money pretty equally among partners no matter their sub-specialty. I thought that the only real difference in how much Rads A makes from Rads B is whether he/she is a partner and how much call he/she takes. Is this not the case?
Yes, that is typical for private practice. Even more than that, in a typical private practice someone should take care of all the crap of going to hospital meetings, negotiating with hospital for new contract, admin work and ... Add to that tumor boards, consults, phones, improving protocols, supervising techs and ... which can be very time consuming. In a progressive successful business model, people may get some "admin days" to do these tasks which are THE MOST IMPORTANT things to keep the business going.

On the other hand, very few crappy groups are RVU based. As a result, their radiologists don't do admin stuff, don't go to the meetings, don't go to tumor board and don't try to strengthen the referral base. These groups will fail sooner than later.

The most valuable radiologist for private practice depends on the need of the group. If the group has enough admin-type people, then a fast reader is the best. If a group is full of mammographers, a neuroradiologist can be a great value. If the group gets referrals from a big oncology group, a body imager can be of the greatest value. It is case by case and group by group.
 
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PL198

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Yes, that is typical for private practice. Even more than that, in a typical private practice someone should take care of all the crap of going to hospital meetings, negotiating with hospital for new contract, admin work and ... Add to that tumor board, consults, phone, improving protocols, supervising techs and ... which can be very time consuming. In a progressive successful business model, people may get some "admin days" to do these task which are THE MOST IMPORTANT thing to keep the business going.

On the other hand, very few crappy groups are RVU based. As a result, their radiologists don't do admin stuff, don't go the meetings, don't go to tumor board and don't try to strengthen the referral base. These groups will fail sooner than later.

The most valuable radiologist for private practice depends on the need of the group. If the group has enough admin-type people, then a fast reader is the best. If a group is full of mammographers, a neuroradiologist can be a great value. If the group gets referrals from a big oncology group, a body imager can be of the greatest value. It is case by case and group by group.
this is one of the redeeming parts of AM, I like reading all the attendings talk about the structure of their groups and etc.
 

scootad.

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Very good post Shark.

I'll echo the notion that needs are totally variable depending the group. PPs vary tremendously in terms of size, structure, degree of specialization. The overall trend is more specialization however there are still many groups that need a jack of all trade. These are usually smaller 3-10 person groups and more often an hour or more outside large cities. For those it's probably best to pick a fellowship that round out your weaknesses. If you see yourself in a large group or academics then it's more important to pick an area and be the expert in it.
 

RadInterest

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Helpful post! Thanks for this :)
Quick question: Were there any significant changes for the fellowships since four years ago?

edit: four* not one
 
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Doctor D

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Helpful post! Thanks for this :)
Quick question: Were there any significant changes for the fellowships since four years ago?

edit: four* not one
Here are some points that I will add that I believe are accurate.

1- Neuroradiology: Is divided to Brain, Spine, Head and Neck and Pediatrics. Most MR heavy field. In most places spine is controlled by Neurorads. MRI spine, MRI brain, CT brain, CT head and neck and CTA are the major modalities. Can be very challenging and fun. Traditionally was the most popular fellowship, however recently it is very saturated. Has the potential to make the highest RVU. Procedure wise you may do some spine pain injections and diagnostic angiogram, but not very procedure heavy.
*Diagnostic angiograms performed by neuroradiologists were common in the past, but this has become more rare unless you are a Neuro-IR. Many fellows trained in Neuro are recruited for night jobs as many ED studies are neuro related. With the job market improving fellows will likely have many more options. Not as competitive of a fellowship to enter compared to some others currently.


2- NeuroIR: Many think this will be controlled by Neurosurgeons in a few years. I doubt it, because the volume is not as high as you think. Neurosurgeons can have a better life style and yet make much more money by doing their field. It is really limited to big academic centers. Not a big player in pp. My guess is it will be split between radiology, NS and neurology in the future. Not popular among radiology residents.
*The demand for stroke work is increasing and will continue to increase as more data shows improved outcomes with intra-arterial thrombectomy. This will extend to more community hospitals outside of academic centers. I think that the field in general is leaning more to Neurosurgery; however I think there will be opportunities for Neuro-IR in the future.

3- MSK: Is bone and joint imaging and some spine imaging. In many places spine is done by Neuro or is a split service. Major modalities are MR and Xray. US and CT are also getting more, but are far from being popular. Many think MSK MR is the most difficult MR esp for a general radiologist. Also a lot of orthopods want their MR to be read by MSK radiologist. Has some procedures like arthrogram and pain injection, depending on practice setting. Like the rest of DR, not procedure heavy. Was very popular in early 2000s, not these days.
*Currently a hot job market for MSK and a popular fellowship. Some orthopedic surgeons are reading their own x-rays without radiology, but I don't think any of them are touching MRI or will be in the future.

4- Body: is everything in the abdomen. Modalities include CT and US. MR is also other modality but not really high volume in pp. Body MR includes but not limited to liver , pancreas, prostate, Gync, MR enterography, .... Some places also include cardiac MR. Overall, may be a growing field, but the MR volume is low. Many radiologists think body MR is the easiest to read. Body procedures include biospsies, drains, ablations and in some palces percut nephrostomy and cholecytostomy. Overall, along with chest, is considered the least specialized field as many think it is just an extension of residency.
*Body MR is becoming more common in PP, especially with prostates. The procedures performed by Body radiologists are variable depending on the group; however, I think the overall trend is for IR to perform these procedures. At many academic centers the traditional "Body procedures" are now done by the IR section.

5- Chest: CXR, chest CT, cardiac CT and MR and HRCT. As described in body section, many consider it the least specialized part of radiology. Most general radiologists feel comfortable reading chest (including cardiac CT but excluding cardiac MR). Not a marketable fellowship for pp, but recently there are open spots in academics, more than MSK and Neuro.
*Above remains accurate. Cardiology at some hospitals reads all cardiac imaging including CT and MRI.

6- Breast Imaging: Mammogram and US are the major modalities. Tomosynthesis and breast MR are low volume. Mammo and tomo has been out there for at least 2 decades. Procedures include US guided biopsies, Stereotactic biopsy, MR guided biopsy and wire localization for pre-op. Overall, the most difficult part is mammogram. Procedures are relatively easy to learn. MR is relatively easy to learn. These can be learned during residency. But mammo is difficult. Since mammo (screening and diagnostic) are 90% of what you do, many general radiologists do not feel comfortable doing breast imaging. Has the highest malpractice and lawsuit probability.
*Breast has always been in high demand in the job market. Some studies published in the past few years in prominent journals have questioned the benefit of mammography. The majority of people in radiology believe these studies were flawed and that mammo remains valuable.

7- IR: Vascular and non-vascular procedures. Was very hot in early 90s, but after turf issues with cards and vasc surgery, went down. In early 2000s was an easy one to get (along with mammo). It is one of the most competitive (if not the most one) ones. New IR people have clinical mentality and admit their own patients, have clinic and consult patients similar to a surgical subspecialty.
*Now medical students must apply directly to IR as a separate specialty. The also is a way for DR resident to transfer into IR called ESIR. IR remains integrated with diagnostic radiology and graduates are certified in both IR and DR. IR continues to push for increased clinical responsibilities. New procedures being developed that will be available more broadly in the future include prostate embolization for BPH and left gastric embo for weight loss. Prostate artery embo in particular seems to have good data to back it up. The new mindset of IR docs is to compete aggressively for patient referrals for things such as PAD work instead of being a diagnostic radiologist who performs procedures when requested. Interventional oncology has seen much growth and continues to blossom.

8- Peds: Was hot 3-4 years ago. Is a different world. Different pathologies. X-ray and US are the major modalities. The field is more dependent on X-ray interpretation and US than adult. It is a low supply, low demand field. Most believe that only Peds radiologists can give high quality reads on many Peds case esp those in a children hospital. But the market is really small.
*Remains a niche field with most pediatric radiologists working in locations with childrens hospitals.

9- Nucs: Many general radiologists feel comfortable reading most of the Nucs studies. There are many studies not done in pp and even in academic centers are done once in a while. The major modalities are PET-CT for cancer staging, Bone scan, Cardiac stress test (done by cardiologists in many places but still radiologist do some of them), hepatobiliary and ... Overall, not very marketable. Many places combine it with body fellowship to make both of them more marketable. There is a separate residency as Nuclear medicine. It is neither marketable nor good enough to be competent at reading multi-modality studies. For example many of their graduates or even attendings have problem giving high quality read on PET-CT as they are not competent enough reading CT.
*Overall has not changed much, particularly for PP Nucs.
 
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RadInterest

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Here are some points that I will add that I believe are accurate.

1- Neuroradiology: Is divided to Brain, Spine, Head and Neck and Pediatrics. Most MR heavy field. In most places spine is controlled by Neurorads. MRI spine, MRI brain, CT brain, CT head and neck and CTA are the major modalities. Can be very challenging and fun. Traditionally was the most popular fellowship, however recently it is very saturated. Has the potential to make the highest RVU. Procedure wise you may do some spine pain injections and diagnostic angiogram, but not very procedure heavy.
*Diagnostic angiograms performed by neuroradiologists were common in the past, but this has become more rare unless you are a Neuro-IR. Many fellows trained in Neuro are recruited for night jobs as many ED studies are neuro related. With the job market improving fellows will likely have many more options. Not as competitive of a fellowship to enter compared to some others currently.


2- NeuroIR: Many think this will be controlled by Neurosurgeons in a few years. I doubt it, because the volume is not as high as you think. Neurosurgeons can have a better life style and yet make much more money by doing their field. It is really limited to big academic centers. Not a big player in pp. My guess is it will be split between radiology, NS and neurology in the future. Not popular among radiology residents.
*The demand for stroke work is increasing and will continue to increase as more data shows improved outcomes with intra-arterial thrombectomy. This will extend to more community hospitals outside of academic centers. I think that the field in general is leaning more to Neurosurgery; however I think there will be opportunities for Neuro-IR in the future.

3- MSK: Is bone and joint imaging and some spine imaging. In many places spine is done by Neuro or is a split service. Major modalities are MR and Xray. US and CT are also getting more, but are far from being popular. Many think MSK MR is the most difficult MR esp for a general radiologist. Also a lot of orthopods want their MR to be read by MSK radiologist. Has some procedures like arthrogram and pain injection, depending on practice setting. Like the rest of DR, not procedure heavy. Was very popular in early 2000s, not these days.
*Currently a hot job market for MSK and a popular fellowship. Some orthopedic surgeons are reading their own x-rays without radiology, but I don't think any of them are touching MRI or will be in the future.

4- Body: is everything in the abdomen. Modalities include CT and US. MR is also other modality but not really high volume in pp. Body MR includes but not limited to liver , pancreas, prostate, Gync, MR enterography, .... Some places also include cardiac MR. Overall, may be a growing field, but the MR volume is low. Many radiologists think body MR is the easiest to read. Body procedures include biospsies, drains, ablations and in some palces percut nephrostomy and cholecytostomy. Overall, along with chest, is considered the least specialized field as many think it is just an extension of residency.
*Body MR is becoming more common in PP, especially with prostates. The procedures performed by Body radiologists are variable depending on the group; however, I think the overall trend is for IR to perform these procedures. At many academic centers the traditional "Body procedures" are now done by the IR section.

5- Chest: CXR, chest CT, cardiac CT and MR and HRCT. As described in body section, many consider it the least specialized part of radiology. Most general radiologists feel comfortable reading chest (including cardiac CT but excluding cardiac MR). Not a marketable fellowship for pp, but recently there are open spots in academics, more than MSK and Neuro.
*Above remains accurate. Cardiology at some hospitals reads all cardiac imaging including CT and MRI.

6- Breast Imaging: Mammogram and US are the major modalities. Tomosynthesis and breast MR are low volume. Mammo and tomo has been out there for at least 2 decades. Procedures include US guided biopsies, Stereotactic biopsy, MR guided biopsy and wire localization for pre-op. Overall, the most difficult part is mammogram. Procedures are relatively easy to learn. MR is relatively easy to learn. These can be learned during residency. But mammo is difficult. Since mammo (screening and diagnostic) are 90% of what you do, many general radiologists do not feel comfortable doing breast imaging. Has the highest malpractice and lawsuit probability.
*Breast has always been in high demand in the job market. Some studies published in the past few years in prominent journals have questioned the benefit of mammography. The majority of people in radiology believe these studies were flawed and that mammo remains valuable.

7- IR: Vascular and non-vascular procedures. Was very hot in early 90s, but after turf issues with cards and vasc surgery, went down. In early 2000s was an easy one to get (along with mammo). It is one of the most competitive (if not the most one) ones. New IR people have clinical mentality and admit their own patients, have clinic and consult patients similar to a surgical subspecialty.
*Now medical students must apply directly to IR as a separate specialty. The also is a way for DR resident to transfer into IR called ESIR. IR remains integrated with diagnostic radiology and graduates are certified in both IR and DR. IR continues to push for increased clinical responsibilities. New procedures being developed that will be available more broadly in the future include prostate embolization for BPH and left gastric embo for weight loss. Prostate artery embo in particular seems to have good data to back it up. The new mindset of IR docs is to compete aggressively for patient referrals for things such as PAD work instead of being a diagnostic radiologist who performs procedures when requested. Interventional oncology has seen much growth and continues to blossom.

8- Peds: Was hot 3-4 years ago. Is a different world. Different pathologies. X-ray and US are the major modalities. The field is more dependent on X-ray interpretation and US than adult. It is a low supply, low demand field. Most believe that only Peds radiologists can give high quality reads on many Peds case esp those in a children hospital. But the market is really small.
*Remains a niche field with most pediatric radiologists working in locations with childrens hospitals.

9- Nucs: Many general radiologists feel comfortable reading most of the Nucs studies. There are many studies not done in pp and even in academic centers are done once in a while. The major modalities are PET-CT for cancer staging, Bone scan, Cardiac stress test (done by cardiologists in many places but still radiologist do some of them), hepatobiliary and ... Overall, not very marketable. Many places combine it with body fellowship to make both of them more marketable. There is a separate residency as Nuclear medicine. It is neither marketable nor good enough to be competent at reading multi-modality studies. For example many of their graduates or even attendings have problem giving high quality read on PET-CT as they are not competent enough reading CT.
*Overall has not changed much, particularly for PP Nucs.
Excellent, thank you! The nature and demand/competitiveness of some fellowships changed within 4 years... interesting!