This month, at the request of the Society of Pediatric Radiology, the ABR announced the addition of pediatric radiology to the “do a fellowship during residency” pathway first pioneered by nuclear medicine several years ago. One surmises this new pathway is not being offered because pediatric radiology is easier or requires less training and expertise than any other type of radiology but merely reflects the reality that we need radiologists with skills in pediatric radiology just as we do in nuclear medicine.
Obviously, there are radiologists in the workforce, especially in academia, practicing nearly 100% nuclear medicine and 100% pediatric radiology, but we need more people with these skills than there are physicians willing to set aside a year of their life after training to do so—especially when those skills aren’t always as marketable as something currently in demand like breast imaging or even as reliably employable as body imaging or neuroradiology.
So while these intra-residency pathways are a reasonable measure to ensure the adequate supply of radiologists with desirable skills, they are also an inconsistency problem in that there is absolutely no reason why those two fields should be different from any other diagnostic radiology subspecialty other than the supply and demand issues within the broader radiology community (and perhaps especially those actively volunteering for the American Board of Radiology or having the ear of those who do).
My point:
If you can now subspecialize early during residency and sit for the pediatric subspeciality examination, then there is no justifiable reason why you shouldn’t be able to do the same thing for neuroradiology, which is the other diagnostic subspecialty that has a CAQ (Certificate of Added Qualification) exam. (Please leave aside for the moment the reality that these tests are not meaningful assessments and that there are plenty of terrible radiologists who manage to hold various ABR certificates.)
Frankly, this would be even more true for any non-ACGME fellowships like body or MSK, but those fellowships don’t actually have any associated tests that place barriers to qualification. As in, the ABR doles out only certain credentials that let you say things like, “Look at me! I’m a real neuroradiologist!” They don’t do that for, say, breast imaging. The ABR doesn’t have any power over deciding how much time it takes for you to be officially “breast-trained” or “body-trained” or anything else–that’s the market (because there is no such officiality). If we all wanted to agree that 9 months of breast imaging as a senior resident is good enough to be a mammo fellowship equivalent, we can do that. Various imaging societies would certainly have an opinion, but no one can stop us. That’s why some institutions already offer various hybrid combo fellowships. Starting right now residencies could start offering their own “Mammo Certificates” documenting a trainee has truly obtained specific breast skillsets and interpreted some even higher minimum number of exams if they so chose. Those certificates would carry whatever weight we as a field choose to ascribe to them. But the ABR subspecialties are in the hands of the ABR, and–I suspect–the ABR sets the tone for the whole field.
Now, perhaps we want to argue that opening up early subspecialization for other fields (e.g. A Neuro Pathway) would be counterproductive for the presumed purpose of encouraging people to dedicate more time during residency to pediatric imaging or nuclear medicine. That sort of early focus would instead just allow more people doing other subfields to forgo an extra year of fellowship instead of focusing on those two subspecialties (facilitating shorter training generally is presumably not the ABR’s goal, though ironically with the current radiologist shortage, many have advocated for just this type of streamlining).
I would argue that this is not an intellectually tenable position for the American Board of Radiology to take, in the sense that the ABR is not a central-planning puppeteer tweaking the strings to direct radiologists to where they are most needed. The ABR’s stated mission is “to certify that our diplomates demonstrate the requisite knowledge, skill, and understanding of their disciplines to the benefit of patients.” If a trainee can now sit for an ABR certification thanks to a given number of months of subspecialty exposure during residency, then it’s hard to understand how that should only be limited to the current two subspecialties. It’s hard to understand how these limitations can be explained by the ABR’s stated mission. The ABR is not the steward of the job market, and such certification changes probably shouldn’t depend on specific external requests from specific stakeholders. Why should the ABR wait for a request from the ASNR? None of these societies speak for radiology any more than the ABR itself does.
Now, to be clear, I’m not arguing here that fellowships aren’t important or that most mini-fellowships are as demanding and educational as most regular fellowships, or any actual real-world implications. Unfortunately, there is no canonical “fellowship” to compare to or any actual criteria we use to determine if training is adequate, let alone good. We have long in medicine just used training time and occasionally training volume combined with a multiple choice test or two to pretend that someone has real-world skills. It’s proxy turtles all the way down.
Residency and fellowship training composition and quality are highly variable, but the various argument permutations that immediately popped into your mind are actually irrelevant. You are absolutely free to think that these pathways shouldn’t exist, and you are equally free to believe that your subspecialty really does require a magical year after graduation.
These pathways already exist; I’m just here to point out the hypocrisy.
Once you say someone can specialize early mostly by completing their senior electives in a single field and then have that qualify as fellowship-equivalent subspecialty training, then logically that should be true regardless of diagnostic subspecialty choice.