Do I Need to Do a Radiology Fellowship?

A few years ago, nearly every radiologist completed a fellowship. It wasn’t so long ago that the job market was so tight there was a real concern that doing two back-to-back fellowships was going to become the norm.

Oh, how times have changed.

Recently I’ve been asked by several readers if I thought that fellowships were still necessary given the current radiologist shortage and white-hot market. Are practices desperate enough to hire general radiologists fresh out of practice?

Well, the short answer is no, fellowships are not strictly necessary. Absolutely some practices are hiring straight out of residency. We had one of our residents go straight into practice a couple of years back even. There’s a real opportunity cost to training for another year, and we shouldn’t pretend there isn’t.

But here was my longer answer:

There are absolutely places/groups in the country that are willing to take non-fellowship-trained general radiologists, but I believe going without a fellowship will still significantly limit your options fresh from training. I don’t foresee a world where this changes regardless of the current shortage.

Want something more than just my opinion? Well, I did do a completely unscientific informal Twitter poll of practicing radiologists. I asked:

Radiologists, in the current job market, are your institutions/groups *currently* *generally* willing to hire candidates straight from residency without fellowship?

Yes (no fellowship): 44.9%
No (fellowship required): 55.1%

So can you go to work without a fellowship? Absolutely.

Are you closing doors if you skip one? Absolutely.

Anecdotally, fellowship is probably least needed for the job most in demand: ER work, especially swing shifts and deep nights.

* * *

I think the only hope for a more efficient future is if more subspecialties begin tracks within residency like nuclear medicine, allowing for a “complete fellowship” experience/equivalence during the normal residency term. Though as a practical matter it seems absurd to place so much value on a one-year process after longer training, ultimately there is a difference (pro and con) between doing something for the majority of a year and not bouncing from month to month like we do as residents.

Out in practice and in the context of a long career, ultimately, there is a substantial difference in performance between those who practice subspecialized radiology working a lot within their subspecialty and most generalists. There are a ton of general radiologists practicing general radiology–and the world absolutely does need a lot more general radiologists–but there is also a big demand for subspecialty reads. The ordering providers want it, and various “quality” entities and certifying bodies (e.g. Covera Health) are also looking for it. So a significant number of our workforce does need to have those robust skills, and most residents really don’t have the reps to do subspecialty level MR interpretation without some additional focus.

Yes, in the long term, how you practice will matter so much more than that 1-year fellowship, but in the short term, it’s still considered a meaningful proxy for your strongest area and the hole you can fill for a practice. (Also, yes: when that hole is general or ER radiology, one should even acknowledge that a fellowship without significant moonlighting could actually detract from your overall skillset. Nonetheless, it’s a stretch to suggest that therefore you shouldn’t do a fellowship).

The level of neuroradiology I practice–such that it is–is 100% from doing a ton of neuroradiology as an attending and not from what I learned in fellowship. But the outside world doesn’t really know that. The outside world likes labels.

In the world to come where AI, non-radiologist physicians, and midlevel providers may play an increasing role in imaging interpretation in the future, radiologists will also likely need to perform at that higher level to maintain their edge/prove their value. We could make residency training more efficient by allowing residents to specialize earlier and focus their training, but the potpourri approach we currently use–especially where many residents are spending a significant fraction of their final year doing mandatory breast imaging and some nuclear medicine– isn’t going to get us there.

* * *

But back to the current reality:

To give you an idea, a group like mine would love to hire more people (seriously, it really is a very tough job market). But we are a large subspecialized group and have not/would not compromise on fellowship training for a recent graduate.

So, yes, in the short term, sure, there is absolutely work out there. Especially for ED coverage and general radiology. It may even always be there. But–reasonable or not–not everywhere.


Bob Finegold / Robert B Finegold, M.D. 07.08.23 Reply

I had to chuckle because of the memory this evoked. A decade ago, my group of six radiologists provided our services to two competing community hospitals in Maine (and read MRIs via teleradiologyfor a third): Four of us were general radiologists. The other two a neuroradiologist and an interventionalist — both of whom, by the nature of a community hospital practice, performed as general radiologists half their work time if not more.

When our contract came up for renewal at the smaller of the two competing hospitals where my group had practiced for 50 years, the CEO informed me that he had decided to go with the 50+ radiology megagroup who serviced the largest medical center in our state who had promised him a whole gamut of radiology subspecialists.

Three weeks after the end of our contract, I received a frantic call from that CEO asking if my partners and I would be willing to resume our services to them.

The megagroup had kept its promise and rotated radiology subspecialists to his hospital: a neuroradiologist who did not read Body CTs, a Body imager who did not read Head CTs, none who could/would interpret Obstetrical or Vascular ultrasound or Nuclear Medicine studies or perform Breast biopsies, etc. — all studies and procedures and more, all ACR-accredited by my partners and I, that each of us performed as part of our daily community hospital practice.

A year or two of Fellowship is a marvelous asset, but it does not negate the value of the facile, experienced, general radiologist in the community hospital setting.

Well,at least at that time. :)

Ben 07.10.23 Reply

Absolutely. The practical reality is that until a hospital is big enough to require a whole cadre of subspecialists sitting around that if one on-site person is providing all care then they need to be comfortable providing all care. Now for better or worse it seems that an increasing number of hospitals are going with a combination of on-site and remote coverage.

Tele is both simplifying and complicating the world of radiology.

Janet Reid 07.08.23 Reply

I work at a highly specialist academic center. I am vice chair of education. And I caution all of our trainees against ‘fellowship-itis’. The truth here is that encouraging more and more fellowships guarantees cheap labor. It makes sure our shifts are covered after hours. It does give the fellows a subspecialty hat to wear. But the greater advantage is to us in ensuring that we have perpetual trainees to cover the 24/7 slog. The real solution here is to create subspecialty opportunities during residency. And stop forcing our trainees to defer loan payments and family and life for the allure of job security. Training in medicine is logarithmically longer than any other job on earth. Let’s stop adding on obligations and start to get creative in how we prepare radiologists for the job market and for life. This is long overdue.

Ben 07.10.23 Reply

And we need those subspecialty opportunities to have credentials so they are viewed as meaningful. A 3 or 6-month “mini-fellowship” may be all you need as an R4, but it doesn’t give you the same hat.

No one should be doing an ER fellowship. What an academic overreach to get cheap labor!

Syed Hamid Husain, DO, MMM 07.08.23 Reply

Just great comments from the above 2 posts! Spot on. Fellowship or not (and I did one) in the community setting, we need radiologists that can wear multiple hats (at least three areas) each. After enough time, and with the volumes we are all seeing, most radiologists are very competent even out of their sub-specialized area.

Michael J Wolf 07.09.23 Reply

I find it interesting that during the discussion of “Fellowship or no Fellowship” the LACK of training in all other areas of Radiology is hardly ever brought up. It is a reality that, if you’ve neglected to read, say, a pelvic US over several months (or longer), your skills have eroded. Therefore, if you’re planning on just belonging to a group of 50+ Radiologists, where all you’re going to read is your subspecialty, then a Fellowship can be helpful. However, most practices (even large ones, as Dr. Finegold mentioned above), need general radiology skills. In these settings (which I would venture are the great majority of those who are hiring), a Fellowship could be as much of a hindrance as an advantage. As a result, I am not sure I agree with the comment that those who have done a Fellowship are any more prepared to go into practice than those straight out of Residency…new is new. Also, as a former Chair for our group, I know that hiring those straight out of a Fellowship means that they will be VERY slow at reading most everything but their subspecialty for at least a period of time, and some never recover their skills/speed in some areas outside their subspecialty.

I love the idea of more focused training in one area at the end of a Residency as opposed to spending one or more years reading/performing just one aspect of Radiology at the expense of everything else you worked so hard to learn.

Ben 07.10.23 Reply

It’s amazing how fast those skills atrophy. A fellow who wants to hit the ground running would be best served by doing general radiology moonlighting to keep things fresh.

Brian Manske 07.09.23 Reply

I started my first job in 1982 without a fellowship, the only resident among my group to do this. I just committed myself to keep up with new areas and learned how to read new areas, (MRI, ENT, PET, vascular US, CTA, hires chest CT, etc.) The current radiologists will have their new areas to learn now and into the future even if they had a fellowship. A fellowship gives you a head start in an area but does not guarantee excellence over the long term.

Ben 07.10.23 Reply

The fact that people even talk about fellowship decades into practice has always been sorta odd to me. What you’ve been doing all those years is clearly all that matters at that point.

Shawn Rayder MD 07.09.23 Reply

As someone who did a fellowship, and was CAQ’d in both Peds and IR (intense residency training) and taught at fellowship programs in both before going into private practice I contend the best practice outside of Academics is a group of fellowship trained General Radiologists. They possess the agility and ability to offer all specialty coverage and the broad based approach we need more of. By pigeon holing ourselves into specific specialties we actually decrease our value to the community we serve. Unfortunately our training programs now reflect the exact same loss of broad education in favor of the specialist approach. We can’t get that genie back in the bottle now and we’ll NEVER catch up to the needs (1500 jobs on the advertised boards) of our overall specialty of Diagnostic Radiology. As noted previously, the number one NEED on the job boards is ER coverage. What could be more up General Radiology’s alley???

Ben 07.10.23 Reply

The trainees have definitely picked up on this. A lot of residents narrow down their interest the minute they pick a subspecialty during R2 year and stop caring about more than what they need for the Core Exam and the bread-and-butter for call.

Ben 07.10.23 Reply

This post was picked up by Doximity, and someone posted a thoughtful comment on that thread that I want to share here. The thrust: 50/50 in a survey is misleading because groups looking for a fellowship-trained person are presumably looking for a specific fellowship, so not all slots are available to a person with any given fellowship. You’re not really closing doors on 50% because some of them aren’t even open.

I always see the job opportunity discussion brought up as general radiologist vs fellowship trained radiologist. For instance here they mention that over half of practices would not consider a general radiologist straight out of residency. All fellowships tend to be lumped together but this is not representative of actual job listings. You can be fellowship trained in MSK but that will not help you get a position with a group looking for a neuroradiologist or another non-MSK fellowship.

However if a little under half of the groups would be interested in a general radiologist, that means you could have your pick of nearly half of the groups out there. Additionally, many new grads only want to take a position that is focused on their fellowship so they haven’t added new positions to their available options, they have just switched the general radiology openings for openings in their fellowship of choice.

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