Radiology Residency: How It's Changing

May 5, 2017
Whitney L. Jackson

Today's radiology residency could differ vastly from what you remember.

It's not your radiology residency anymore. Today's residents and fellows are marching through a program that, in some ways, is vastly different from the ones you and your colleagues completed. Whether you've been out of school and in the field for decades or started practicing only a few years ago, radiology residency doesn't look the same. Some changes have already occurred, altering how and when residents receive training in various imaging specialties. Other alternations are still under consideration. The ultimate goal, said McKinley Glover, M.D., chair of the American College of Radiology's Resident & Fellow Committee, is to improve the overall quality of radiology residency programs nationwide. "We want residents to be more marketable for practice groups," he said. "The changes being made to residency programs strengthen their marketability, improves negotiations with payers, and bolsters their credibility and credentials with hospitals." Board Exam One of the most significant changes has touched the most important test you take as a resident -- the board certification exam. The oral exam you took during your fourth year of residency no longer exists. Instead, today's residents cram hard for a multiple-choice core exam at the end of their third year, said Glover, who is also a neuro-radiologist at Massachusetts General Hospital. Residents are shown cases and are given several diagnostic answers from which to choose.  Some in the industry feel the change has made the test easier, but many industry leaders still contend it makes the final two years of residency stronger.  "The exam is now a core exam that has redistributed how residency programs concentrate their training time," said Liva Andrejeva-Wright, M.D., associate radiology residency program director at the Yale University School of Medicine. Now, instead of spending their final year of training pouring over books and limiting the focus on patient care, residents devote extensive energy to studying and content mastery during the third year. That leaves the fourth year open for targeted, sub-specialty learning.  Mini-Fellowships By giving residents the option to choose sub-specialty training during their fourth year -- much like selecting electives in college -- residency programs are turning the final year into mini-fellowships, Glover said, making residents more attractive to potential employers. "This program change ties directly into the job market," he said. "Practices want people who come out of school with sub-specialty training to replace those who are retiring." Acceptable candidates must still be able to provide general radiology services, but the demand for higher skill sets is growing. For schools that have already adopted this format, fourth-year residents can select several sub-specialty areas on which to focus. Some choose to concentrate on the type of imaging they intend to practice, and others take the opportunity to improve their skills in sub-specialities where they haven't had as much success. Depending on the program, each mini-fellowship can last from one month to six months.  It's during these mini-fellowships, Andrejeva-Wright said, that fourth-year residents gain the greatest exposure to patient care. By spending extensive time focused on individual sub-specialty areas, residents not only increase their familiarity with particular types of imaging, but they also increase their reading speed, improving the level of care they're able to offer patients. Changing Curriculum To accommodate how the fourth year of residency has changed, many programs have also shifted the curriculum structure for the first through third years.  According to Andrejeva-Wright, some of the topics and material covered are the same, but the parameters of how residents work have changed. At Yale, first-year residents are exposed to the basic modalities they will encounter when they're on call, including bone films, body CT, body ultrasound, and nuclear medicine. She referred to these cases as "bread-and-butter" cases because they most commonly pop up. "We try to expose residents to everything in their first year so they have a chance to learn the basics," she said. "Many of these things they'll see when they're on emergency department call or when they start night call in their second year." Many program directors feel night call is no longer appropriate for first-year residents, she said, because they need more experience with complex modalities. And, once they do start call, students are surrounded by a greater number of senior residents and attending providers who can offer support and back-up services.  Instead, night call launches during the second year. Even then, many industry leaders have pushed for these residents to have greater attending supervision, as well. In fact, Glover said, many programs are starting to provide in-house, 24-7 attending coverage for residents. It also helps with turn-around time as residents learn -- patients and referring physicians routinely expect rapid reads. In these cases, residents provide the initial reads, and attending physicians double-check and sign off of the findings. Another big change has occurred in the third year for many residency programs, Andrejeva-Wright said. In an effort to properly prepare residents for the board certification exam, faculty expose residents to a wide variety of imaging modalities. For example, she said, at Yale third-year residents learn more about cardiac MRI, nuclear cardiac imaging, ultrasound, and body and bone MRI. They also take on more on-call responsibilities in hospital emergency departments. Third-year residents at Harvard are introduced to interventional radiology training, Glover said. All of these curriculum changes culminate in giving fourth-year residents the opportunity to choose their concentration areas. This final year is time for residents to develop a specialty, such as breast or musculoskeletal imaging, or to strengthen skills. With each rotation, they also improve their reading skills and their abilities to work with patients. Diagnostic-Interventional Radiology Programs This 2015 move pushed forward the conversation about merging the diagnostic and interventional radiology specialties. The merits of such a program have long been discussed, and now several programs, including Yale and Harvard, have introduced a dual track for interested residents. These five-year programs offer three years of diagnostic imaging training and two of interventional radiology instruction. When residents finish, they are certified to practice in both specialty areas. Such residency programs are still new, however, so the verdict is out on how many residents will be interested in this track and how many will complete the programs. Benefits & Challenges As with anything new, changes to residency programs come with positives and negatives. On the plus-side, re-structuring resident training gives students greater flexibility to learn more about the type of radiology they'd like to practice before putting a shingle out for patients. The mini-fellowship design also makes it easier for existing practices to determine which candidates have the skill sets they desire when filling open positions.  The biggest challenge, Glover said, is getting buy-in from program administrators that changing their programs is in the best interest not only of their residents, but of the radiology industry, as well. What Residents Want You To Know In addition to having the opportunity to get sub-specialty experience while still in residency, today's residents also differ from you in other ways, said fourth-year Yale chief resident Kaitlin Eng, M.D.Today's residency programs are tougher, she said, especially when compared to those from a decade or more ago. "It's pretty difficult because technology has advanced," she said. "We get images from everywhere." Often, she said, experienced radiologists relay stories about reading films and being responsible for roughly three chest CTs a day. Today, she said, residents can be responsible for handling 10 times that much.  Even though the pace of radiology residency is faster now, she said, that doesn't mean that residents come into the program ready to perform at a break-neck pace. "Some attending radiologists are so far out of residency that they forget how little residents know when we come into the program," she said. "It would be nice for them to keep that in mind as we work through our training."