What makes MSK fellowships so sought after?

[Medicineman1987]

I've seen a lot of discussion about how the reputation of certain residency programs (MGH, for example) can't be used to judge certain fellowships there in terms of competitiveness and desirability (IR, for example). Overall, I've seen a trend of people generally insisting that MSK training at quality institutions is the most competitive/desirable. If this is indeed true, what about MSK makes it so ideal? Is it better for PP vs. Academics or urban vs. rural etc. So far the only reason I've read is that certain specialties (ortho) might want a fellowship trained MSK rads to help them if needed, but in that case, I could see neurosurg needing neuroRads, etc. Is the quantity of referrals going to play a part in this? I can see lifestyle playing a part, maybe less "emergencies" and better lifestyle opportunities than say, IR. Any insight would be great.

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[shark2000]

Are you asking about MSK itself or MSK at certain institutions?

I answer both questions.

Take a look at all radiology fellowships. You can not compare IR to MSK. These are two completely different beasts.

After finishing residency, there are some areas that you feel very comfortable doing it and some areas that you don't. A lot of marketability goes to job market.

- IR: Most radiologists are not capable of doing high end IR. Most can do bread and butter IR but don't want. They prefer to do DR. Thus, IR is marketable and has always been. As a result, IR fellowships are sought after. Why not more than this? Because many rads don't like it.

- Mammo: Most radiologists don't feel comfortable doing it AND don't like doing it. Thus, it is marketable and mammo fellowships are relatively competitive. Why not more that this? Because most radiologists hate to do it.

These two were exceptional. Now let's take a look at other fields.

- Neuro: General radiologists feel comfortable doing 90% of it.

- Body and chest: Considered a given skill in pp for a general radiologist. Not marketable in pp. Most general rads feel very comfortable doing it.

- Nucs: Very low demand. Done mostly by general radiologists and they feel comfortable doing it. Only demand is in academics and cancer centers.

- Peds: Low demand. Most general radiologists DONOT feel comfortable doing it, but as I said very low demand.

- Eventually MSK: Still general radiologist feel comfortable doing it but about 60-70%, definitely less than Neuro, Body, chest and Nucs.


So as you see the marketability in pp is: IR > mammo >> MSK > Neuro > Body, chest and Nucs

For academics surprisingly, it is very different. In fact, chest may be more in demand than IR and mammo.

MSK traditionally has been the field that names mattered. I don't really know why, but probably some of it is because of the sports medicine part of it. If you want to get a contract to read MSK MRI for athletes, probably you need to put a big name up there. Not so much if you want to read spine MRI or mammo or do a TACE.

After working in pp for a few years, I can clearly tell you that in pp most people are general radiologists with one special skill. Real specialization is uncommon in pp. Everybody reads everything. That one special skill is what makes you different and as I mentioned before IR and mammo are considered top there and MSK is in the middle of the list. For some obvious reasons, not everybody wants to do IR or mammo. Most think between MSK, Neuro and body.

 

[colbgw02]

Nice summary, shark, but I think your logic about breast/women's imaging fellowships is backward. While it's true that most radiologists dislike mammo, that was also true 10-15 years ago, when these fellowships were going unfilled. That tells me that these fellowships only became competitive because of the job market, not because the fellowship confers some great new skill set (outside of MRI and MR-guided biopsies, which are not high volume). Groups like to be able to dump breast imaging on the dedicated, fellowship-trained breast guy, and the crappy job market lets them do that - not because the fellowship-trained guy is better at mammo. In fact, studies show that high volume mammo readers, even if they're not breast-trained or even very experienced, are more accurate.

 

[shark2000]

Nice summary, shark, but I think your logic about breast/women's imaging fellowships is backward. While it's true that most radiologists dislike mammo, that was also true 10-15 years ago, when these fellowships were going unfilled. That tells me that these fellowships only became competitive because of the job market, not because the fellowship confers some great new skill set (outside of MRI and MR-guided biopsies, which are not high volume). Groups like to be able to dump breast imaging on the dedicated, fellowship-trained breast guy, and the crappy job market lets them do that - not because the fellowship-trained guy is better at mammo. In fact, studies show that high volume mammo readers, even if they're not breast-trained or even very experienced, are more accurate.

Totally agree with you that mammo and to some extent IR became competitive because of bad job market. I personally hate doing mammo.

I didn't say it is a special skill. It is not about having the skills. It is more about feeling comfortable. I personally don't feel comfortable reading screening mammograms (and most radiologists don't). A 6 month or one year mammo fellowship, even if doesn't add any additional skills, at least gives more confidence and more experience.

My current knowledge in chest radiology is less than the time that I passed the oral boards, but I feel more comfortable now reading a CXR or HRCT. It is all about experience and I think the fellowship provides more experience.

 

[colbgw02]

I think we're in agreement. I thought you were saying women's imaging/mammo has become a competitive fellowship because graduating residents want to become comfortable with it, whereas I think we both agree that its competitiveness is all about the job market.

 

[shark2000]

My residency had a top notch mammo fellowship. When I was a first year, mammo could barely fill its spots. It was an open door fellowship for everybody. You just needed to apply. Recently, it seems that they receive 80+ applications for 3 spots and most of their spots are filled internally. Things have changed rapidly.

At least I am happy that there are enough well-trained people out there to do mammo, so I don't need to do it.

 

[choweee]

Additionally -- I don't know about pp MSK, but academic MSK seems pretty chill. MRs are mostly outpatient (except like, r/o osteo) and there are rarely urgent studies (compared to body or neuro). I've seen it referred to as the "dermatology of radiology" on forums. Part of the competitiveness also may come from it being a smaller field. If you look at the listings at hospitals, most places don't have as many MSK guys compared to body or neuro.

 

[shark2000]

Additionally -- I don't know about pp MSK, but academic MSK seems pretty chill. MRs are mostly outpatient (except like, r/o osteo) and there are rarely urgent studies (compared to body or neuro). I've seen it referred to as the "dermatology of radiology" on forums. Part of the competitiveness also may come from it being a smaller field. If you look at the listings at hospitals, most places don't have as many MSK guys compared to body or neuro.

The lifestyle does not apply to pp. In most groups, people take equal call. In academics, I don't think MSK, Body or Neuro lifestyles are very different. Most of nights are covered by residents or ER attendings.

There are more job opening for MSK per fellow. Overall, the job market of MSK seems somehow better than Neuro or body. Most groups look for a general radiologist with a broad spectrum of skills. The preference is IR>mammo>MSK>Neuro=body>>Nucs.

Private practice mentality of senior partners: "We need a general radiologist. Let's hire an IR guy. Even-though we don't have real IR business for him, he can do diagnostics and cover the IR call. Also he will save us from getting out of our chair to do a drain or a biopsy ". For a general radiology position, many groups prefer to hire MSK rather than Neuro or Body.

 

[FranzLO]

Why don't a lot of radiologists like mammo very much? I am a just a med student so I am pretty out of the loop but I was just wondering since I read it so often.

 

[colbgw02]

Why don't a lot of radiologists like mammo very much? I am a just a med student so I am pretty out of the loop but I was just wondering since I read it so often.

1) I think it's fair to say that breast cancer, more so than other cancers, is a highly publicized (seen any NFL games in October recently?) and emotionally-charged disease. It tends to "hit home", so to speak, more than getting a diagnosis of melanoma, for example.

2) Patients are also poorly educated about the sensitivity/specificity of screening mammography. In general, they believe that if their mammogram was clean then there's no way they could have cancer.

3) Somewhere around 20% of cancers had a finding on the previous year's mammogram seen only in retrospect. That's just the reality and limitations of the technology, but it's also a proverbial playground for plaintiffs attorneys.

4) Breast imagers tend to have a more clinically oriented job. They "see" patients, perform clinical breast exams, and do lots of biopsies. In some cases, radiologists are the ones who are informing the patient of their diagnosis. For radiologists who like a bit of clinical medicine, this can be a positive, but many radiologists got into this field to get away from seeing patients.

5) To be good at breast imaging, you need to do it a lot. It's generally not a great idea to structure one's schedule such that you only cover mammo once or a few times a month. So, it's something that you have to like enough to be willing to do it a couple of times a week, ideally.

Combined, it adds up to a highly litigious work environment filled with emotionally-charged patients that don't understand how it's possible they have breast cancer when last year's mammogram was negative.

I still remember the first time I told a woman following a diagnostic work-up that her calcifications were not definitely benign (BIRADS 4B) and we were going to recommend a stereotactic biopsy. The pretest probably for cancer in this scenario is somewhere around 10%, and if it had been cancer, it would have an early-stage, amenable to breast conservation therapy with a very high survival rate. She started sobbing uncontrollably, as if I had just given her the diagnosis of a terminal cancer.

To put it in terms that non-radiologists might understand, imagine a CBC coming back with a high platelet count and saying you'd like to do a bone marrow biopsy, then having the patient burst into tears because all they heard is that they have CML.

 

[shark2000]

1) I think it's fair to say that breast cancer, more so than other cancers, is a highly publicized (seen any NFL games in October recently?) and emotionally-charged disease. It tends to "hit home", so to speak, more than getting a diagnosis of melanoma, for example.

2) Patients are also poorly educated about the sensitivity/specificity of screening mammography. In general, they believe that if their mammogram was clean then there's no way they could have cancer.

3) Somewhere around 20% of cancers had a finding on the previous year's mammogram seen only in retrospect. That's just the reality and limitations of the technology, but it's also a proverbial playground for plaintiffs attorneys.

4) Breast imagers tend to have a more clinically oriented job. They "see" patients, perform clinical breast exams, and do lots of biopsies. In some cases, radiologists are the ones who are informing the patient of their diagnosis. For radiologists who like a bit of clinical medicine, this can be a positive, but many radiologists got into this field to get away from seeing patients.

5) To be good at breast imaging, you need to do it a lot. It's generally not a great idea to structure one's schedule such that you only cover mammo once or a few times a month. So, it's something that you have to like enough to be willing to do it a couple of times a week, ideally.

Combined, it adds up to a highly litigious work environment filled with emotionally-charged patients that don't understand how it's possible they have breast cancer when last year's mammogram was negative.

I still remember the first time I told a woman following a diagnostic work-up that her calcifications were not definitely benign (BIRADS 4B) and we were going to recommend a stereotactic biopsy. The pretest probably for cancer in this scenario is somewhere around 10%, and if it had been cancer, it would have an early-stage, amenable to breast conservation therapy with a very high survival rate. She started sobbing uncontrollably, as if I had just given her the diagnosis of a terminal cancer.

To put it in terms that non-radiologists might understand, imagine a CBC coming back with a high platelet count and saying you'd like to do a bone marrow biopsy, then having the patient burst into tears because all they heard is that they have CML.

And talk about monotnous boring nature of the field. Cancer versus no cancer is what mammo is all about. You read 50-60 screens a day. It is zero or one. It is not "cancer versus no-cancer", it is "call back versus no call back". 90% are negative. 10% you call back. If negative, it gives you stress because as you stated above it does not necessarily mean no cancer. If positive, again it gives you stress, though it does not mean cancer. You have to call the patient back and do a diagnostic mammogram and probably go through the process of talking to patient about biopsy (can be stressful). Then only one third of your biopsies become cancer. If the result is cancer, it is another stress. If the result in negative, the patient becomes angry because she thinks you did a procedure that was not indicated.

One advantage of mammo is relatively lower pace of work compared to other parts of radiology. If you are supposed to finish at 6 PM, you are always guaranteed to leave at or before 6 PM, unlike other parts of radiology. Also job security is good now. Most jobs look for IR or mammo. Despite these positive aspects, still its disadvantages are much more than its advantages.

 

[Trastuz]

Can someone elaborate further on why Peds is so unmarketable? Have heard this many times but don't quite understand. If no one feels comfortable reading Peds and many places presumably having a small but steady number of Peds studies, you'd think they'd want someone who could take them all. Maybe these groups don't care if the providers go elsewhere for the Peds reads cause they generate few RVU? Are Peds folks generally forced to work in academic (research forever) environments or are their non academic gigs?

Also, if someone knows the general region where they want to have a career, would it be more beneficial to complete fellowship in that region or go to the best fellowship? E.g. If you want to work in TX and are currently doing residency outside the region, is it better to do MSK at HSS or UTSW? Cincinnatti children's or Texas children's?

Would someone mind listing a few of the best/well known places for each fellowship? It's hard to get a feel of what places are good - most folks at my program just stay here.

Thanks Shark and Colb and everyone for the responses so far - this is a great thread.

 

[shark2000]

Can someone elaborate further on why Peds is so unmarketable? Have heard this many times but don't quite understand. If no one feels comfortable reading Peds and many places presumably having a small but steady number of Peds studies, you'd think they'd want someone who could take them all. Maybe these groups don't care if the providers go elsewhere for the Peds reads cause they generate few RVU? Are Peds folks generally forced to work in academic (research forever) environments or are their non academic gigs?

Also, if someone knows the general region where they want to have a career, would it be more beneficial to complete fellowship in that region or go to the best fellowship? E.g. If you want to work in TX and are currently doing residency outside the region, is it better to do MSK at HSS or UTSW? Cincinnatti children's or Texas children's?

Would someone mind listing a few of the best/well known places for each fellowship? It's hard to get a feel of what places are good - most folks at my program just stay here.

Thanks Shark and Colb and everyone for the responses so far - this is a great thread.

I have to correct my above post. Most general radiologists feel comfortable reading outpatient pediatrics radiology in community. The pathology is usually straightforward like pneumonia, mild trauma, mild urinary reflux/infection or ... On the other hand, complex diseases like congenital abnormalities are usually referred to children's hospitals. These studies NEED a pediatrics radiologist. Most of these complex diseases are fortunately rare.

If you want to practice high end pediatrics radiology, you have to go into academics/children's hospital which have very few job openings. On the other hand, there is not a lot of demand for pediatrics radiologist in community as most of the pediatrics studies can be read by a general radiologist.

Your second question is tough. It depends. The ideal situation is to do both RESIDENCY and FELLOWSHIP in the same area. If you are not there for residency, it is hard to make connections by doing one year of fellowship. Consider that you have to look for a job just 2 months after you start your fellowship. I really don't know the answer. But I think doing a fellowship in Texas helps more than doing a fellowship in a big name if you are looking for a private practice job. However, I personally choose the best fellowship that I can find. Because even if I don't get the job that I want, at least I get the best training. What if you choose UTSW over MGH, but still you don't get a job in Texas? Won't you regret it?

Well known fellowships are as below not in a special order:
MSK: Wisconsin, MGH, UCSD, HSS, U of Michigan, UVA, Stanford. Plenty of other good ones.

Pediatrics: Cincinnati, Boston, CHOP. Other programs are considered second to these ones.

If you want to stay in the area that you are doing your residency, probably doing fellowship in your program is a smart move. Most private groups have close connections to the local academic center and hire people from there. Most good jobs come through the word of mouth. Though MSK fellowship at MGH is better than UTSW, a UTSW graduate with good reputation has a first dibs on best MSK jobs in Dallas.

 

[shark2000]

Duplicate.

 

[colbgw02]

Yeah, high-end peds stuff is going to get shipped to the nearest children's hospital pretty quickly. And let's face it, kids just don't seek medical care with the frequency of adults, and when they do, their imaging tends to be of lower complexity (plain films, ultrasound) and performed less frequently (ALARA, etc.). That plays into the supply side as well, meaning pediatrics is the only "main" fellowship whose graduates have historically lower salaries than a general radiologist.

I would say that, between residency and fellowship, you probably need to do at least one in the region in which you intend to practice. And if you can only do one, then doing fellowship there is the more important of the two.

I think the exception to this might be pediatrics, because there are the "big 3" that shark mentioned - MGH, Cincinnati, and CHOP. To take MSK as an example, there's probably enough regional bias that you could never get people from around the country to agree on who the top 5 programs are. So a practice on the east coast is just as likely to be impressed by the guy trained at Thomas Jefferson as the guy trained at UCSD. On the other hand, I think most people recognize those peds programs as the best, and may favor a graduate from them irrespective of geography. The exception to the exception might be if you intend to practice very close to a second-tier peds program. So, for example, if you wanted to work in Houston and trained at Texas Children's.

 

[Trastuz]

Got it.

What about well recognized places for the other fellowships? IR, mammo, neuro, body/chest?

 

[shark2000]

Got it.

What about well recognized places for the other fellowships? IR, mammo, neuro, body/chest?

IR: Miami vascular, UVA, Brown, Peoria, NW, Colorado, UCLA, . . . Many big name programs are not good for IR. IR is very tricky because top notch programs also have strong vascular surgery services (= more turf wars). Some community programs or mid size university programs in fact have very good or better IR departments.

Mammo: MGH, BWH, MSKCC on east coast. Stanford, UCSF and UCLA on east coast. Emory and NW are also good.

Neuro: UCSF and Stanford on west coast. MGH, BWH and Hopkins on east.

Body: MGH, Wisconsin and UCLA if you are into procedures. They do lots of procedures. Other big names are UCSF, Stanford, BWH, ...

 

[bashwell]

4) Breast imagers tend to have a more clinically oriented job. They "see" patients, perform clinical breast exams, and do lots of biopsies. In some cases, radiologists are the ones who are informing the patient of their diagnosis. For radiologists who like a bit of clinical medicine, this can be a positive, but many radiologists got into this field to get away from seeing patients.

Sorry if this is a dumb question! But I'm wondering, since breast imagers see patients (presumably mostly female patients), perform clinical breast exams, and do breast biopsies, are males breast imagers at more of a disadvantage than female breast imagers when it comes to getting a job in private practice? Fairly or unfairly, would private practices prefer to hire female breast imagers over male? Would patients prefer to see female breast imagers over male breast imagers, sort of like in OB/GYN? Or is all this really not too big of a deal? Thanks in advance.

 

[colbgw02]

Sorry if this is a dumb question! But I'm wondering, since breast imagers see patients (presumably mostly female patients), perform clinical breast exams, and do breast biopsies, are males breast imagers at more of a disadvantage than female breast imagers when it comes to getting a job in private practice? Fairly or unfairly, would private practices prefer to hire female breast imagers over male? Would patients prefer to see female breast imagers over male breast imagers, sort of like in OB/GYN? Or is all this really not too big of a deal? Thanks in advance.

I think there will always be a subset of patients who prefer one gender over the other, but in breast imaging I don't think that translates to the hiring process. Patients don't really choose their radiologist in the same way they choose their gynecologist. In the name of customer service, it's probably not the worst thing to have a female radiologist on board, but it's not obligatory. I don't think a group would hire an applicant just because she's female, but I could see it being the deciding factor between two otherwise nearly identical candidates, particularly if the group isn't already "diversified".

 

[MadRadLad]

With the creation of the IR residency, are they going to be phasing out fellowships? Or will the fellowship positions transition to residency positions? And is there any sort of projected competitiveness is that specialty expected to have?

 

[Over9000]

And talk about monotnous boring nature of the field. Cancer versus no cancer is what mammo is all about. You read 50-60 screens a day. It is zero or one. It is not "cancer versus no-cancer", it is "call back versus no call back". 90% are negative. 10% you call back. If negative, it gives you stress because as you stated above it does not necessarily mean no cancer. If positive, again it gives you stress, though it does not mean cancer. You have to call the patient back and do a diagnostic mammogram and probably go through the process of talking to patient about biopsy (can be stressful). Then only one third of your biopsies become cancer. If the result is cancer, it is another stress. If the result in negative, the patient becomes angry because she thinks you did a procedure that was not indicated.

This is pathology. Cancer vs no cancer. That's all there is to it.

Pathology is basically mammo.

 

[rads321]

Ir already is competitive with almost 20% of applicants not matching currently and on the upward projectory. I predict the split will drop radiology applications some because there is a subset of med students who only want to do IR. Fellowships will become residencies and will stay under the helm of the radiology department. The last 1 year fellowships will be in 2021 I believe.

 

[vm26]

This is pathology. Cancer vs no cancer. That's all there is to it.

Pathology is basically mammo.

It is however one of the few fields in radiology where your reads directly dictate patient care/work-up...I would imagine that many orthopods, neurosurgeons do not really pay much attention to our reports

 

[meister]

Patients have to actually get to those subspecialists in the first place.

 

[shark2000]

It is however one of the few fields in radiology where your reads directly dictate patient care/work-up...I would imagine that many orthopods, neurosurgeons do not really pay much attention to our reports

Yes and No.

Community setting is very different than academics. In a typical community setting even in an affluent area, the majority of care is provided by internists and ED doctors. The patient does not usually go directly to neurosurgery. They go to their PCP for headache or if they have a primary cancer, they go to their oncologist. If you call the brain MRI normal, even if there is a metastasis, the patient will not see a neurosurgeon. If you call it abnormal, then the patient is referred to neurosurgery. Unless it is a straightforward case and very abnormal, most neurosurgeons read the report. They are good in some areas but not other areas. For example, most neurosurgeons in community don't feel comfortable when it comes to base of skull, bones or soft tissues. A subdural hematoma or protruded disk; absolutely they are very good at it. Metastasis to the base of skull with extension to pre-potine cistern; most neurosurgeons want radiology input.

Don't forget something. Being a specialist and esp a surgeon is associated with a very high ego. Even if they read the report, still they claim that they don't need the report, they are the "guy to go" and they don't need any help. I have encountered this multiple times. "My PACS login doesn't work so I came to review the images here" or "My monitor is not as good as yours, so I came here to review the images on your monitor". Then after you are done with reviewing the case: "This is exactly what I thought".
When I was intern, on of the surgeons used to request medicine consult left and right. At the same time, he claimed that he is better than internists in managing MI or diabetes or PE but he does not have the time to do it.

On the other hand, I agree that in some parts of radiology the referring clinicians are much more dependent on what we say. Mammo is at the end of spectrum. Body and in general oncology imaging are the areas that the referring doctors depend on what we say a lot. Our oncologists read every line of the body of our reports esp on PET-CTs. Sometimes very surprising to me. Maybe less in some other parts of radiology.

In my experience, you never know who reads (and depends on) your reports even if they claim otherwise and you never know where the patient is in the complex referral chain. An oncologist will send the patient with headache home with pain medications without looking at the study because your report says no mets. Relatively common for a busy neurologist to just briefly look at the study and then manage the patient mostly based on your report. Thus, never take for granted any study even if it comes from someone who is very good at imaging. The same people who claim that they read their own studies will say different things when it comes into real life situation esp in the court.

 

[shark2000]

Ir already is competitive with almost 20% of applicants not matching currently and on the upward projectory. I predict the split will drop radiology applications some because there is a subset of med students who only want to do IR. Fellowships will become residencies and will stay under the helm of the radiology department. The last 1 year fellowships will be in 2021 I believe.

I thought with the new IR residency, the number of DR residency spots will also drop. It seems that the total number of IR + DR residents will be the same. It is hard to predict what will happen to the number of applicants. Some people start radiology to do IR but later they change their mind. Many people who apply to IR do it because of the tight job market. So a lot of competitiveness will depend on the job market and factors other than just applicants interests.

Splitting IR from DR is a wrong movement at best. It is based on the academics mentality that IR doctors do only IR and chest radiologist reads only chest studies. In private practice, there is not a clear line between IR, DR and DR subspecialties. Very common for an IR graduate to do 70% DR in private practice and relatively common for a DR graduate to do light procedures which are at least half of IR procedures in private practice. The last attempt to split IR from DR (Direct pathway) was a total failure. Interesting to see what happens in the future.