Subspecialty Training: Needed for a Job But Not on the Job?

You need subspecialty training to find a job. But if you’re in private practice, you’ll likely spend more of your time on general radiology.

The reality of where radiologists focus their time was revealed in the 2015 ACR Commission on Human Resources Workforce Survey, the first time the American College of Radiology asked this question in the annual survey. What it showed was that only 39% of radiologists spend more than half of their time working in their subspecialty areas.

“Subspecialty is the future of radiology,” said Karen Johnson, MD, radiology residency program director and assistant professor of radiology at Duke University School of Medicine, but that doesn’t mean radiologists will only focus on that area. “[Employers] want to know you’re subspecialized in something. Most jobs want that, but they still want you willing to read general.”

The survey results didn’t come as a surprise to those who have been following employment trends, including subspecialization. And residents, if they’re paying attention, know this will be the case when seeking employment.

“A lot of residents like the idea of being subspecialized but keeping up their general skills,” Johnson said. Once a radiologist is subspecialized, they’re considered an expert in that field. “They’re using it. It’s not going to waste.”

The variety of radiology work keeps things interesting to many radiologists, said Richard Strax, MD, associate professor of radiology at Baylor College of Medicine in Houston. While he specializes in interventional radiology, he said that in his community hospital setting, he reads a lot of other study types aside from interventional work.

“There are some people who enjoy variety, and enjoy doing different kinds of imaging. It spices things up to do MSK part of the time, for example, and then do other kinds of body imaging or procedural areas you enjoy as well,” he said. Some radiologists do want to focus solely on their specific area, knowing it better than everyone else. It’s a personal preference, he said.

In the 2015 Workforce Survey, results differed depending on whether looking at overall radiology numbers, or those specific to the practice setting.

Overall the survey found that:

• 18% of radiologists spent more than 75% of the time in their subspecialty area

• 21% of radiologists spent 50%-75% of the time in their subspecialty area

• 35% of radiologists spent 26%-50% of their time in their subspecialty area

• 26% spent up to 25% of the time in their subspecialty area

Per practice setting:

• In academic medical centers, 75% of subspecialists focused more than 75% of the time in their subspecialty area

• In private practice, only 10% spent more than 75% doing subspecialty work

• In multispecialty clinics, 27% spent more than 75% of the time in subspecialty work

Subspecialists as a Resource
Those who want to use their subspecialty training to a higher degree should look for jobs in academic centers, said Edward Bluth, MD, chair of the ACR Commission on Human Resources, and chairman emeritus of the department of radiology at Ochsner Health System in New Orleans.

But for many radiologists, “it’s just the nature of radiology that, for efficiency purposes, a person needs to be able to handle a variety of different kinds of imaging, to interact with referring doctors in different specialties, to look at patients as a whole, and make recommendations as to what the diagnosis might be, and what further imaging and treatment might be needed,” Strax said.

Even if a musculoskeletal radiologist is only practicing in that area 25% of the time, that physician is still needed and used as a resource for group members who don’t have that background. “Many groups depend on that, having someone with that expertise to turn to when they need it,” Strax said.

A subspecialty can be more widely defined, as the designation is somewhat artificial, said Strax. “I was looking through the list of fellowships on RSNA, and there are multispecialty fellowships, combining MRI, CT, and breast in a fellowship,” he said. Body imagers can do ultrasound, CT, and MRI of the entire person below the neck, and cover a variety of different pathologies. Other subspecialties are more narrow, focusing only on cardiovascular reading, not chest as a whole.[[{"type":"media","view_mode":"media_crop","fid":"47915","attributes":{"alt":"Radiology subspecialty","class":"media-image media-image-right","id":"media_crop_118249123386","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5694","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 220px; width: 220px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"©Puwadol Jaturawutthichai/Shutterstock.com","typeof":"foaf:Image"}}]]

Residency Programs and Specialty Training
The American Board of Radiology changed the certifying exam structure a few years ago, so residents take the core certifying exam after their third year.

This prompted residency programs to change their program structures. The first three years in a residency program are prearranged, and the fourth year is more open.

“The training of radiology residents is changing,” said Johnson. “Since the ABR moved the exam, all programs are experimenting and trying to figure how best to have the residents ready for the workforce, being a subject expert and maintaining the specialized skills that employers are asking for,” Johnson said.

The greatest need for residency programs is to make sure their residents are capable of reading all components of radiology, since virtually all radiologists go on to fellowship where they get their subspecialized training, said Bluth. The survey results reinforced the understanding that many radiologists already have about workforce requirements, he said. However, “to some degree, it may have caught the attention of program directors, who have the responsibility to prepare their residents for the future,” he said.

Johnson said that Duke’s radiology residency program changed in 2001, unrelated to the later ABR exam change. Duke offers a 3/2 program, where the first three years are general radiology residency training. The fourth year is flexible, with elective time.

“It doesn’t necessarily have to be filled in with electives toward what their fellowships will be,” she said. Some use the time for research if they want academic careers, writing manuscripts, and presenting their work at meetings. Residents with a clinical focus can do a combination of things. “Some do a lot of general rotations before they spend their fifth year in fellowship. They do everything but what they’ll do in their fellowship.” Fellowship then focuses on one area.

Medical students looking into residency programs should consider what the program offers for its fourth year. Some offer one to two mini fellowships and some rotate through all areas of radiology. Some programs offer one larger fellowship during the fourth year. “[Medical students] need to think about what they’re going to do in that fourth year,” Bluth said. When considering a program, medical students should ask what type of radiologists they’re training, if the focus is on academic or private practice, and make sure the program’s goals line up with the student’s goals.

In his January 2016 JACR article, Bluth found that “the vast majority [of practices] wants to hire someone who had a fellowship with skills, but is capable of reading many areas, not just one or two.”

Residents who are certain they’re going into private practice should know they’ll be spending a lot of time reading many different types of studies. “If you only want to do a limited number of things, you should change what type of practice you want to go into, focus an academic career,” Bluth said.

The Future of Subspecialties
It’s possible that with health care consolidation, subspecialization will increase in the future, with more physicians practicing primarily in their area. “In the future, if groups become larger, they may become more subspecialized as a method of achieving a competitive advantage,” said Bluth. And then maybe more radiologists will be practicing more often in their subspecialty.

Johnson said that this is what most people think will happen, however most people also thought it would have already happened by now, “and it hasn’t quite gotten there.” With practices growing in size, there’s more opportunity for using subspecialization, which she said will increase the quality of care given. “I think that when you can have a subspecialist focus on what they’re specialized in, it only increases the quality,” Johnson said.