There’s a lot more to radiology than choosing between diagnostic or interventional.
Let’s dig into the many fellowship options available to radiologists, including when additional training is necessary. Stay tuned until the end, when we discuss whether or not AI will replace radiologists in the near future.
Is a Radiology Subspecialty Worth It?
First, is additional fellowship training necessary, and how will it impact your career?
Strictly speaking, it is not necessary to pursue a fellowship in radiology. Given the current radiologist shortage and hot job market that looks unlikely to change in the near future, there are plenty of private practice groups that will hire newly minted general radiologists straight out of residency.
That said, there are plenty of reasons to pursue a fellowship, and the majority of residents today still elect to further subspecialize.
Let’s consider the pros and cons of pursuing a fellowship.
Number 1 is future-proofing. Although the job market is great right now and unlikely to change soon, no one knows what it will look like in 10, 20, or 30 years. Doing a fellowship was practically a necessity to be hired as a radiologist 10 to 15 years ago. If the market ever reverts back to that state, you’ll retain job security with a fellowship.
Many private practices are looking for a hole to fill, such as a clinic that needs a breast imaging expert, and there is no better qualification than having done a fellowship in said area.
Second, a fellowship will make you a better radiologist. You will get much more comfortable with reading certain studies that you may not have been exposed to as much during residency. Training for a year with global experts in your subspecialty will turn you into an expert as well. And there’s a lot of satisfaction that comes with having reached that level of expertise.
Third, a fellowship is beneficial for those who want to go into academics. While most radiologists end up in private practice, if you’re interested in academia, you’ll need to have completed a fellowship.
And lastly, your leadership abilities will improve. Many radiologists who are involved in some sort of leadership role at the local or national level have done a fellowship. It’s an ideal way to build connections.
But there are some downsides.
The major con of doing a fellowship is the opportunity cost. To pursue a fellowship, you will forgo a year or more of making potentially over $500K as an attending physician. You may also have to relocate to a different city or program, depending on the options and offerings at your home institution.
However, depending on your path and career goals, the opportunities a fellowship provides can offset the opportunity cost.
So, what are the subspecialties of radiology?
1 | Interventional Radiology
First up is the most commonly talked about subspecialization—interventional radiology.
While radiology is commonly broken down into diagnostic and interventional, interventional radiology is a fellowship option after a radiology residency. This can be either a 2-year fellowship or a 1-year fellowship as part of the Early Specialization in Interventional Radiology training pathway, also known as ESIR, during which much of the PGY-5 year is focused on IR.
IRs use imaging techniques to treat and sometimes diagnose diseases. Often, this involves manipulating long, thin wires called catheters to the site or organ of interest, then performing a procedure. Such procedures are minimally invasive and are often performed under a real time x-ray called fluoroscopy.
IRs operate all over the body. Common procedures include putting in lines and tubes, lysing or removing blood clots, embolizing active bleeds, angioplasty and/or stenting blood vessels, fixing aneurysms, and shrinking uterine fibroids or enlarged prostates.
The subfield of interventional oncology involves killing off blood supply and providing targeted chemotherapy to hepatic tumors and microwaving or freezing tumors of other organ systems.
In general, the IR lifestyle is worse than that of a DR. You will take call and sometimes have to go to the hospital during the middle of the night or on weekends to intervene in an emergency. However, in doing so, you will quite literally save lives.
The pay of IR is comparable to DR and will vary depending on the practice setting. Academic IRs do more high-end procedures and often spend their time doing 100% IR. In private practice groups, it is not uncommon for IRs to also read diagnostic imaging when they are not operating.
Learn about the differences between diagnostic and interventional radiology.
2 | Abdominal Imaging
Next we have abdominal or body imaging, which focuses on the organs in the abdomen and pelvis, including the liver, spleen, pancreas, kidneys, intestines, bladder, and reproductive structures. It includes looking for acute disease or post-traumatic injuries in an emergency setting, as well as evaluating chronic diseases like cancer.
Body imagers use a number of different advanced imaging techniques, including multiphase CT scans and various MRI sequences, to detect, characterize, and stage a large number of cancer types. They are also well-versed in chest radiology since many CT scans of the abdomen and pelvis also include the chest.
However, complicated pulmonary findings, such as interstitial lung disease, are more the domain of a fellowship-trained chest radiologist.
A body fellowship often includes additional training in barium fluoroscopy, which evaluates the throat, esophagus, and/or GI system in real time, as well as ultrasound-guided biopsies of both superficial structures, like the thyroid, and intra-abdominal organs, like the liver and kidneys.
Some fellowships also include tumor ablation. For fellowships with more procedural training, look for the word “intervention” in the name. Note, however, that such procedures are usually only done by diagnostic radiologists in academic settings, as the interventional radiologists are busy with more complicated procedures involving cutting-edge tech. In private practice, IRs often do the majority of ultrasound-guided biopsies.
Abdominal imaging is a 1-year fellowship.
3 | Chest/Thoracic Imaging
Next is chest or thoracic imaging.
Chest radiologists are experts in imaging of the lungs, aorta, mediastinum, and often the heart. This includes evaluation and staging of lung and esophageal cancers, interstitial lung diseases, and aortopulmonary vascular pathologies, such as dissections, aneurysms, and congenital anomalies.
Many thoracic fellowships also include training in cardiac CT and MRI, which evaluates for coronary artery disease, cardiomyopathies, and other heart diseases. Some thoracic fellowships may also include procedural training for image-guided procedures, such as thoracenteses and lung and mediastinal biopsies. Chest radiologists may also sit on tumor boards and work closely with pulmonologists and cardiothoracic surgeons.
Chest radiology is a 1-year fellowship.
4 | Neuroradiology
Number four is neuroradiology.
Neuroradiologists focus on the brain, head, neck, and spine. In the acute setting, neuroradiologists use head CTs to look for brain bleeds, strokes, facial fractures, and other traumatic injuries. They also use a variety of advanced MRI techniques to evaluate brain tumors, infections, stroke, and other neurological diseases.
Neuroradiologists frequently sit on tumor boards and work with neurosurgeons, neurologists, and otorhinolaryngologists, which are head and neck surgeons.
Neuroradiology fellowships usually include training in procedures such as lumbar punctures, myelograms, and certain head and neck biopsies. Certain fellowships may also offer training in cerebral angiography, although in practice, this tends to be the domain of neurointerventional radiology.
A diagnostic neuroradiology fellowship is usually 1 year in length, although there are a handful of programs that offer 2-year fellowships. These longer fellowships are aimed at people who want to pursue academic careers and research.
For those interested in pediatric brain tumors and congenital anomalies, specialized pediatric neuroradiology fellowships are also available. These are 1 year in length and usually require the prior completion of either a standard neuroradiology or pediatric radiology fellowship. As you might expect, pediatric neuroradiologists usually work at children’s hospitals.
Finally, there are additional 2-year fellowships available in neurointerventional radiology. Neurointerventionalists perform stroke thrombectomies to remove clots from cerebral blood vessels and treat cerebral aneurysms, arteriovenous malformations, and other cerebrovascular disorders. This fellowship normally requires prior completion of 1 year of diagnostic neuroradiology and is also open to neurosurgeons and neurologists.
Neurointerventional radiology is a dynamic and rapidly evolving field, but it is not for the faint of heart. Since strokes can happen at any time of day and require immediate action, interventional neuroradiology has one of the worst lifestyles in all of medicine.
5 | Breast Imaging
Next is breast imaging.
Breast radiology is concerned with detecting and evaluating breast cancer and other diseases that affect the breasts. The core of this field is mammography, but ultrasound and MRI are also used as adjuncts for further evaluation. Some fellowships may also include additional training focused on imaging of the uterus and ovaries.
Unlike most other diagnostic subspecialties, breast radiologists have frequent patient contact, often discussing abnormal mammograms with patients in person. They also frequently perform breast biopsies, which can be ultrasound-guided, stereotactic, and occasionally MRI-guided.
Since there are no true breast emergencies, breast radiologists do not take call, making this one of the most lifestyle-friendly fellowships. However, some private practice groups may still expect their breast imagers to take general call, especially if they are on a partner track.
Note that breast imaging is a high-throughput field, and these physicians are quite busy during the day when they are at work.
Breast imaging is a 1-year fellowship and an excellent choice for someone who likes procedures and patient contact. For those who are interested in both breast and body imaging, there are also a few 1-year combined breast and body fellowships available.
6 | Musculoskeletal Imaging
Next up is musculoskeletal imaging, or MSK, which focuses on muscles, bones, joints, and the spine.
MSK radiologists are experts in anatomy and give detailed descriptions of fractures, muscular and ligamentous injuries, bone and soft tissue tumors, degenerative diseases, and arthritis. They are adept at reading x-rays and frequently use MRI to evaluate joint injuries, tumors, and infections. MSK radiologists may work with orthopedic surgeons and sports medicine doctors.
An MSK fellowship will include training in procedures such as muscle and bone biopsies, joint injections, and arthrograms.
This is a 1-year fellowship and is a good choice for someone who particularly enjoys anatomy.
7 | Pediatric Imaging
Next is pediatric imaging, and as the name implies, it’s focused on children.
This field includes portions of most of the other diagnostic subspecialties, such as neuro, chest, body, and MSK. Pediatric radiologists have a deep knowledge of diseases unique to children, including congenital anomalies, syndromic conditions, and cancer. They also perform a variety of procedures, such as upper GI studies, barium enemas, and cystograms to evaluate GI and genitourinary diseases and congenital anomalies.
Pediatric imagers often work at children’s hospitals. On rare occasions, they may be called in during a night or weekend to perform a procedure to evaluate for a surgical emergency.
Pediatric imaging is a 1-year fellowship, and as previously mentioned, there are dedicated pediatric neuroradiology fellowships as well.
8 | Nuclear Medicine
Next up is nuclear medicine.
Nuclear medicine uses specialized radioactive molecular tracers to evaluate physiology and organ function in real time and treat certain types of cancer. The most well-known type of nuclear medicine scan is positron emission tomography, or PET, which detects cancer and other disease processes by measuring the metabolic activity of cells. However, a number of other tracers also exist.
Therapeutic applications of nuclear medicine include radioiodine and an increasing number of theranostic agents, which target and kill cancer cells via specific receptors. Nuclear cardiology is another application of the field.
A 1-year nuclear medicine fellowship is available after the completion of a 5-year residency. Board certification in nuclear medicine, which is equivalent to a fellowship, is also available to interested diagnostic radiology residents who complete 16 months of nuclear medicine training during their residency. Additionally, there are a few nuclear medicine residencies separate from diagnostic radiology that are 2 or 3 years in length.
These are often filled by international medical graduates due to the fact the job market for nuclear medicine residency alone is quite poor. There’s essentially only a handful of academic jobs, and no US medical graduate wants one. These roles get filled by IMGs who had trouble matching into other specialties or completed a radiology residency abroad and are trying to network into US radiology fellowships.
However, note that only the job market for someone who participates in an exclusively nuclear medicine residency is poor. The job prospects for a radiologist who chooses to further subspecialize with a nuclear medicine fellowship are excellent.
There is an increasing demand for radiologists who can read both PET and abdominal CTs and MRIs. The 16-month nuclear medicine pathway, alongside an abdominal fellowship, is a great combination for interested residents.
9 | Emergency Radiology
Next we have emergency radiology, which focuses on imaging for acute conditions from the emergency department. Although most residents get enough exposure to these conditions by taking call, there are a few 1-year emergency radiology fellowships out there. These are usually located at level 1 trauma centers.
Emergency radiology call is shift work by definition, as in you read all studies scanned from X to Y o’clock. The emergency radiology attendings are reading everything that passes through the ED for the hours they’re on call, and that’s essentially their entire job.
10 | Informatics
And lastly, there are a handful of imaging informatics fellowships available that focus on the intersection of imaging and information technology and how to manage imaging data systems. In most cases, these skills can be acquired without doing a dedicated fellowship, and they may not be the best return on investment.
The elephant in the room about the future of radiology is AI. Nearly all radiologists are currently in agreement that AI is not going to replace radiologists anytime soon. The people who say things like that aren’t radiologists and don’t fully understand the field and the intricacies of what they do.
While we cannot predict the future, by the time AI replaces radiology, it will have replaced a great deal of other industries first, which will result in major other societal shifts. So the so-called threat of AI shouldn’t deter anyone from considering entering the field.
At this time, AI helps radiologists be more efficient and is welcomed by physicians. But to actually replace a radiologist, you’d need an AI model capable of broad, generalized reasoning based on medical images, not just the few hyper-specialized areas currently in use. And we are very far from having anything like this.
If you’d like us to cover how AI is being utilized in radiology, as well as its limitations, in a future video or article, let us know in the comments.
Completing a fellowship after diagnostic radiology may not be necessary today but it’s still recommended by most attending radiologists. Keep in mind that unless you work in academia, you will likely read a combination of your subspecialty as well as more general imaging.
But before you can set your sights on fellowship training, you’ll first need to complete a 5-year radiology residency. Radiology ranks in the top 10 of the most competitive specialties to match into.
