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ABNM-ABR Pathway Completed: Do I Need A Breast Fellowship?

abnm-abr

Question About ABNM-ABR Pathway And Breast Fellowship

Hi,

I am a 4th-year radiology resident graduating from the ABR-ABNM 16-month dual certification pathway in June. I matched fellowship in breast imaging starting July. However, I am liking nucs and am considering bagging the breast fellowship and working in nucs.

Can you help me think through if this would be advisable?

Thanks,

Nucs Versus Breast

 


Answer

Dear Nucs Versus Breast,

 

If you are graduating from an excellent ABNM-ABR dual certification program, you have completed a “fellowship.” So, if you can find a job in nuclear medicine or nuclear radiology that you like, I don’t think it would be unreasonable to forgo the breast fellowship. Especially nowadays, the market for all sub-specialist radiologists is excellent (nucs included).

 

However, some breast fellowships rely on their fellows a lot. So, bailing out just before the start of the fellowship year may not be the best way to make strong connections in radiology. Of course, this is especially the case if you have already committed and signed on the dotted line. So, make sure to discuss the issue with the breast fellowship director if that is what you want to do. See if they can find another fellow easily and if it will be a hardship on the program if you decide to leave before starting. But before you do anything, make sure you have a job (with a contract in hand) before you talk to anyone about canceling the breast fellowship!

 

Also, just because you are not doing a breast fellowship doesn’t mean that you can’t practice breast imaging when you leave. I have been reading screening mammos and diagnostic mammos for some time now without a fellowship. And, you will likely have the opportunity to do interventional mammo as well if you want to go in that direction, with or without a fellowship. Completing a fellowship only implies having some additional expertise. It does not mean that other radiologists cannot be excellent breast imagers!

 

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How To Be Successful In Breast Imaging

successful in breast imaging

In the second part of the “how to be successful” series, we will walk you through the ins and outs of the breast imaging rotation. Breast imaging, in general, is much different than almost any other area in radiology. (except for some interventional radiology) Why? Because the whole subspecialty hinges on management instead of differential diagnosis. Differentials are usually relatively limited and easy to remember. The challenging part of becoming successful in breast imaging is deciding what to do next. (As long as you don’t miss the finding!)

Also, there are multiple shades of gray in this area of radiology about how to manage patients appropriately. And, it takes a whole heck of a lot of experience to get good at it.

In any event, just like last week, let’s run through what you should read, what and when you should study the appropriate topics, and then finally how you should tackle learning for each year that you are on the breast imaging rotation.

Reading

First of all, I would highly recommend that you check out the free material from the ACR BIRADS atlas on the web. Here, you will get the most up-to-date resource to understand how we dictate breast imaging cases. Additionally, you will learn the appropriate semantics for all sorts of calcifications, masses, etc. I would also advise you to look for a copy of the paid atlas to see each of the different descriptors and associated findings. (see if you can find one lying around in your residency program because they cost 250 dollars!) These sources are the best way to understand the mechanics of reporting breast imaging modalities.

Furthermore, you should also have a supplemental reading to understand the rest of the gritty details about breast imaging. My residents have recommended Breast Imaging, the Requisites (I am an affiliate of Amazon for purchases when you click on the link) to do just that. Although reading during this rotation is required, it is a little less critical to function as well than some of the other radiology areas because it is so “experience-based.”

When To Study Topics In Breast Imaging

First-year

During the first year of breast imaging, I would recommend that you stick to reading out mostly screening and diagnostic breast imaging cases while reading the above resources. Why? It would help if you got acquainted with the basics of breast imaging. The basics include positioning/views, artifacts, searching for findings, and breast imaging’s basic mechanics. Try to hold off on doing too much interventional breast procedures until you are well acquainted with the imaging. You can check out a few to get your feet wet. However, the interventions may not make as much sense because most radiologists make the initial screening and diagnostic imaging findings to get to the intervention point. And, you need to understand these modalities first. You will benefit a lot more from understanding all the interventions better later on.

Second-year

Toward the end of your first rotation or beginning of your second rotation, try to be the initial reader on diagnostic mammography cases. Be in the position of deciding on the additional views and then run it by your attending. In mammography, the only way to learn is to handle parts of the cases yourself. If you don’t take charge, you will miss a good portion of the key to breast imaging- management. Also, be sure to enter the ultrasound room for all the breast ultrasound cases possible. Scanning patients will help you learn how to find lesions and what to look for when you find a mammography lesion.

Final residency years

For your subsequent months of mammography, you should make sure to learn how to perform stereotactic breast biopsies, needle localizations, and ultrasound guide breast biopsies. Also, this is the appropriate time to learn the basics of breast MRI. Breast MRI has become an integral part of imaging in the breast imagers arsenal. You need to understand its place and the basics of how to read them. Again, check out the ACR-BIRADS book for the reporting of MRI findings.

Finally, during your last year of mammography, learn all the new “fancy-schmancy delancy” add-ons. Learn about breast MRI biopsies, PEM imaging, or other modalities that may be unique to your institution. At this point, you want to fill in the blanks. Also, make sure that you have a mammography rotation during your fourth year of residency because the mammograms you read count toward MQSA requirements when you start reading mammograms after a one-year fellowship.

How You Should Learn Breast Imaging As A First Through Fourth Year Resident

More so than other specialties, breast imaging is not a “spectator sport” (a quote from my former chairman during my residency!). It involves being proactive in getting the experience that you need. Moreover, there have been a host of studies, specifically for mammography, that show you need to read tons of images to become an expert in breast imaging. So, you will have to be aggressive to get the numbers that you need to be successful in breast imaging. Not all residencies provide the same training in mammography, and some have significantly fewer cases than others. Therefore, this is a critical piece of the pie that you will need to become a consummate breast imager.

The Basics Of Being Successful In Breast Imaging 

To summarize, what are the critical factors in learning how to become an excellent breast imaging resident and future attending? Ensure that you read the BIRADS atlas and a supplemental book such as Breast imaging, the Requisites. Start with reading screenings, ultrasounds, and diagnostic mammography. Then, when you are ready, take charge of your cases independently. Perform and learn about interventional procedures a little later. Then finally, fill in the blanks during the final years. 

Also, I cannot repeat enough how important experience is for the breast imager. Writing down that you have seen “x” number of cases is not enough in the world of mammography. Make sure that you are looking carefully at each breast image. It is only with experience that you will feel competent enough to become a breast imager when you complete your residency. And, the best breast imagers have seen tens of thousands of cases!

 

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Breast Imaging Versus MSK- What’s Better For Marketability And Lifestyle?

breast imaging versus MSK
Hi, Dr. Julius!
Been choosing between breast imaging versus MSK radiology fellowship, what do think is better in terms of marketability and lifestyle?
Yours truly,
Not quite sure

I find your choices of subspecialties of breast imaging versus MSK unusual because I almost consider them to be opposites in some senses. So, what are the particulars specifically about breast versus MSK radiology that you may find enticing or detract you from choosing them?

The Covid Crisis And Breast Imaging Versus MSK

Let’s start with current conditions. Many breast imagers that only perform breast imaging are currently out of jobs. Why? Because elective procedures have dried up entirely. So, you are subjecting yourself to a less diversified specialty in terms of outpatient versus inpatient imaging, that’s one negative for breast imaging. Today, MSK is more desirable in the Covid world because these subspecialists usually perform general radiology and inpatient imaging. But, times are atypical right now, and both specialties will likely return to a baseline (perhaps lower than before the pandemic- check out What’s In The Cards For The New Radiologist Job Market After Covid?).

The Traditional Job Market And Both Specialties

More traditionally, there have been fewer folks that have wanted to go into mammography for several reasons, such as more patient contact, lawsuits, and less diagnostic diversity. For these reasons,  the mammography job market has otherwise remained better than most subspecialties through other recessions. On the other hand, MSK is more conducive to practicing general radiology since it overlaps with other areas in radiology a bit more. So, you will find more cross-coverage, And, for this reason, this subspecialty tends to be more subject to the whims of the radiology job market in general.
In terms of lifestyle, both subspecialties tend to be primarily outpatient. And, both subspecialties can be procedural and usually non-emergent. Mammo folks do biopsies, and MSK folks perform facet injections and bone marrow biopsies/arthrograms. But that’s about where the overlap ends. Mammography is a specialty for those people that like patient interaction. MSK, on the other hand, in general, tends to be a more solitary subspecialty where you can work without having to see patients if you want. I find this to be the most substantial difference between the two subspecialties. You have to figure out if you are a people person or not to make this determination.
So, there you have it. Those are some of my thoughts about the comparison between the two subspecialties in a nutshell.
Thanks for the great question!
Barry Julius, MD
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Brains Versus Breast: Which One To Choose?

brains versus breast

 

Question About Brains Versus Breast:

Dear Barry,

I hope you are doing well. I am PGY4/R3 radiology resident, hesitant between breast imaging and Neuroimaging. And, I have a concern about lifestyle and job market in the next couple of years. Which one do you think, will have a better job opportunity?


Answer To The Brains Versus Breast Question:

Both areas can make for an excellent career, but it all depends on what kind of environment, pressures, and lifestyle you want. To help you out I can give you a little summary of the critical factors about I would be thinking.
First of all, let’s start with the general pressure of work. In Neuroradiology, if you miss something in a film, it can be the difference between immediate life and death. On the other hand, if you miss cancer, the results are not as immediately devastating. However, the patient is more likely to sue you for your mistakes. So, I think that your choice in this department depends on what you feel you can handle. Moreover, you will be more procedure and patient-oriented if you pursue the mammography angle since you will be performing biopsies and seeing patients. As a non-interventional neuroradiologist, most see very few live patients and do fewer procedures.
Next, the lifestyles for both specialties can overlap. However, the mammographer can find more jobs that tend to be five days a week or part-time gigs without call. For the neuroradiologist, most do some inpatient hospital work, so it leads you to find a career with more weekends and nights. Indeed, this lifestyle does not apply to all neuroradiologists, however.
And finally, the job market for both specialties is relatively hot. Both neuroradiology and breast are the most needed radiologists out there. There is no lack of jobs at present. And, if I use my crystal ball, I don’t see any significant change coming through the market shortly. Of course, radiology job markets do change with the economy and macro-factors that I can’t predict. However, as long as the economy remains vigorous and radiologists continue to retire, you can expect a continued hot job market. If we look out to the more distant future, when that changes, so does radiologist job availability.
That’s my little summary for you!
Barry Julius, MD