How to Become a Radiologist: The Comprehensive Guide

How to Become a Radiologist - The Comprehensive Guide - BrettMollard.com
If you're looking to become a radiologist, look no further! This comprehensive guide will tell you everything you need to know to make that dream a reality.

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If you’re interested in how to become a radiologist, you’ve come to the right place! In this comprehensive guide, I will walk you through every step of the process (and yes, you’ll get your 10,000 steps in!). I’ll start by outlining the education requirements and how long it takes to become a radiologist. Then, I’ll discuss what steps you need to take to secure a job in this field, the best of all medical specialties (though I may be biased).

Radiology is an exciting and rewarding medical specialty, and I hope this guide helps you on your journey to becoming a radiologist!

What is a Radiologist?

Before we get started on how to become a radiologist, I want to make sure you have a good understanding of what a radiologist is and what skills are important for this career.

A radiologist is a medical doctor who specializes in diagnosing and treating diseases and disorders using medical imaging techniques such as x-rays, fluoroscopy, computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), and ultrasound. Radiologists come in two flavors: diagnostic radiologists and interventional radiologists.

Regardless of their specialization and sub-specialization, radiologists play a vital role in the healthcare team, primarily working as consultants to other specialists such as surgeons, oncologists, emergency medicine physicians, urologists, critical care providers, and internists.

Diagnostic Radiology


A diagnostic radiologist is a radiologist who focuses primarily on the interpretation of medical imaging exams (hence ‘diagnostic’) and may perform a range of medical procedures ranging from common fluoroscopy exams, such as esophagrams, to basic procedures including paracentesis, thoracentesis, lumbar puncture, hysterosalpingogram, joint arthrogram, and image-guided biopsy. The vast majority of diagnostic radiologists complete a fellowship and are subspecialized (e.g., abdominal imaging, musculoskeletal radiology, pediatric radiology, nuclear radiology, etc.).

Interventional Radiology


An interventional radiologist performs a wide range of minimally invasive interventional image-guided procedures that aid in both the diagnosis and treatment of various medical conditions. Interventional radiologists perform high-end interventional procedures such as angiograms (without or with angioplasty), image-guided biopsies, tumor ablation using techniques such as radiofrequency ablation, microwave ablation, and cryoablation, transcatheter arterial chemoembolization (TACE), transcatheter embolization in the setting of active hemorrhage, transjugular intrahepatic portosystemic shunt (TIPS), and more. They also perform basic procedures such as those listed under “Diagnostic Radiology” and typically interpret medical imaging exams in between procedural cases.

What is Important to Become a Radiologist?


Radiologists must enjoy problem-solving, have an eye for detail, and bring everything together in a succinct, easy-to-understand conclusion – a synthesis of the clinical importance of the relevant findings. Each case a radiologist reviews may have hundreds or even thousands of images, and it is their job to figure out what the most likely diagnosis is.

Radiologists must be masters of human anatomy. Practically everything a radiologist does revolves around a deep understanding of human anatomy and they must master both normal anatomy and a wide array of pathological processes affecting essentially every human organ system. They have to know a lot about a lot – a jack of all trades and master of one (sometimes two).

Radiologists must be excellent communicators. They often have to explain complex concepts to patients and their families, as well as to referring physicians and healthcare professionals. They must be able to clearly communicate the results of imaging studies and make recommendations for next steps or treatment.

Radiologists must be able to handle stress and work well under pressure as well. They often have to make quick decisions that can have a profound impact on a patient’s life. They must be able to remain calm in emergencies and deal with the emotional stress of seeing some horrific traumas and diagnosing, staging, and restaging patients’ cancers every day.

Moreover, radiology is a rapidly evolving medical field. New applications for medical imaging are continuously being developed, new promising PET radiotracers are being discovered in nuclear radiology, and there are constant advancements in post-processing techniques and algorithms. Imaging technology is constantly advancing and artificial intelligence is quickly integrating into radiology practices and augmenting workflows.

To stay relevant, radiologists must keep up-to-date on the latest technology to provide the best possible care for their patients. In addition, as more and more procedures are performed using image guidance, radiologists must be able to work closely with surgeons and other interventionalists.

What is the Average Salary of a Radiologist?


The average annual salary of a radiologist is $430,890 (ranging from $374,590 to $498,390) according to Salary.com (as of February 25, 2022). However, this varies depending on multiple factors such as location, job type (academics, private practice, hybrid, independent contractor), practice model (time-based or productivity-based), how much an individual radiologist works, etc.

How to Become a Radiologist?

What are the Education Requirements for a Radiologist?

Radiology, like all medical specialties, requires the same general pathway: undergraduate college (bachelor’s degree) followed by medical school (medical degree), radiology residency, and concludes with a fellowship (fellowships are the norm for radiologists, unlike most specialties).

How Long Does It Take to Become a Radiologist?

Becoming a radiologist takes about 10-11 years after undergraduate college. It includes four years of medical school, followed by a one-year internship, and a four-year residency in diagnostic radiology. Then most radiologists complete a one- to two-year fellowship to subspecialize.

What is the Cost of Education to Become a Radiologist?


As noted previously, there is a substantial time cost for becoming a radiologist; inclusive of undergraduate college, it takes upwards of 15 years to become a radiologist.

In terms of monetary costs, let’s break it down (brace yourself):

  • The average cost of undergraduate college is $35,331 per year* (attending an in-state public university is substantially less expensive than attending an out-of-state private university)
  • The average cost of medical school is $218,792* (similarly, attending an in-state public medical school is less expensive than attending an out-of-state private medical school)
  • Total cost = $35,331 x 4 + $218,792 = $360,116

These numbers do not consider the opportunity cost of earnings forgone while in school (for example, if you could have been working and earning $X per year instead of attending medical school) or the interest rate that accrues on student loans.

In short, the cost of becoming a radiologist is significant both in terms of time and money. However, the monetary returns are substantial as radiology is a highly-paid medical specialty. Delayed gratification, anyone?

What Training is Needed to Become a Radiologist?


There are many pathways to becoming a radiologist and I know many people who followed a non-traditional path. Below, however, I will discuss the shortest path from undergraduate college to medical school to internship to residency to fellowship.

Undergraduate College


Undergraduate college is your time to pursue any/all of your interests! I sincerely mean that. Medical schools like to have students with diverse backgrounds so you can obtain a bachelor’s degree in any field of your choice. However, you must complete all the prerequisite courses for medical school, including biology, chemistry, organic chemistry, physics, English, genetics, and calculus.

Medical schools are looking for well-rounded candidates who have excelled academically (GPA of at least 3.5), so make sure to focus on your studies. In addition to your academic coursework, most medical schools also value extracurricular activities, so get involved in your community and hone any leadership skills you may have!

The Medical College Admission Test (MCAT) is a standardized test that covers the material taught in your prerequisite courses and is a test that all medical schools require. Aim to take the MCAT no later than the summer before your senior year.

The average MCAT score for matriculants (people who have been accepted to medical school) in the 2020-2021 cycle was 511.9 (out of 528). It is important to note that you do not need a perfect score to get into medical school, but you do need a score that is competitive for the schools to which you are applying.

Medical School (MD/DO)


After completing your undergraduate degree, you will attend medical school for four years. During your first two years, you will complete coursework in the basic sciences such as anatomy, biochemistry, physiology, and microbiology.

You will then spend the last two years of medical school completing clinical rotations in various specialties such as surgery, pediatrics, internal medicine, psychiatry, and obstetrics/gynecology. Your fourth year of medical school is when you will have the opportunity to elect rotations (usually one month in duration) in fields that you are interested in, such as radiology. A radiology rotation will give you a taste of what a career in radiology entails and help you decide if it is the right fit for you.

USMLE


In addition to your medical school exams, you will complete the first two steps of the United States Medical Licensing Examination (USMLE) during medical school.

The USMLE Step I, which covers foundational sciences (e.g., anatomy, behavioral sciences, biochemistry, pathology, and physiology) and communication skills, is an eight-hour exam taken at the end of your second year of medical school. The USMLE Step II Clinical Knowledge (CK) is a nine-hour exam taken during your fourth year and tests your knowledge of clinical sciences essential for patient care including knowledge of organ systems, legal/ethical issues, and patient safety.

Radiology is a highly competitive field with an average USMLE Step 1 score of 241 and USMLE Step II CK score of 249 (each out of 280). Note, however, that USMLE Step 1 should be transitioning to Pass/Fail scoring in early 2022 if it hasn’t done so already.

The Match


U.S. medical school students participate in the National Resident Matching Program (NRMP), also known as The Match, to obtain their residency positions. The Match is a computer-based algorithm that pairs the preferences of medical students with the preferences of residency programs to fill all first-year (postgraduate year 1, PGY-I) positions available at U.S. teaching hospitals.

During Match Day in mid-March, U.S. medical students find out which residency program they will be attending. The overall match rate for diagnostic radiology is quite good at 96.3% (2021). It can be difficult to match into your first-choice program, however, especially if you want to go to a program in a competitive location like a big city. Be comforted knowing that if you perform well at whatever residency you attend, you can still end up with a great fellowship afterward and a successful career in radiology.

Intern or Transitional Year (PGY-I)


After completing medical school, you will spend one year as an intern (a first-year resident). Each residency program will either include an intern year (categorical programs) or require a separate preliminary or transitional year program. You should interview with at least a few preliminary or transitional year programs to ensure you match somewhere as you won’t be guaranteed a categorical residency position. Fortunately, most medical schools are understanding of this process and the need for extra interview days.

Transitional year programs are typically less stressful than preliminary year programs with more elective time. Preliminary years come in the internal medicine and surgery varieties. During your internship, your clinical rotations will typically include a month or more of surgery, emergency medicine, internal medicine, and/or family medicine. There’s wide variability between programs, so choose the best fit for you. Categorical interventional radiology programs generally include multiple surgical rotations to better prepare future interventional radiologists to manage and treat patients.

You will take the USMLE Step III during your internship year, which is a two-day examination consisting of both multiple-choice questions and computer-based case simulations that tests how well you can apply the medical knowledge you have acquired to actual patient care. Your USMLE Step III score doesn’t matter much – you just need to pass!

Diagnostic Radiology Residency (PGY-II to PGY-V or R-I to R-IV)


After completing your internship, you will begin either a diagnostic or interventional radiology residency. Diagnostic radiology programs are four years long and typically followed by a 1- to 2-year fellowship. Interventional radiology programs are 5 years long, though you can think of them as inclusive of an interventional radiology fellowship within those 5 years. Interventional radiology programs consist of 3 years of diagnostic radiology followed by 2 years of interventional radiology.

During your residency, you will rotate through various subspecialties in radiology such as abdominal imaging, breast imaging, cardiothoracic imaging, gastrointestinal imaging, musculoskeletal imaging, neuroradiology, nuclear radiology, pediatric radiology, ultrasound, and interventional radiology. Actual specific rotations will vary by residency program, but should all cover the same core curricula.

Regardless of what program you’re in, radiology residency is like drinking from a fire hose. While each resident is a medical doctor with a medical degree, most medical schools include minimal or no radiology within their curricula and, therefore, first-year residents are not expected to know much radiology on day 1. Medical imaging is an incredibly broad array of topics and pathologies and mastering general radiology takes countless hours of studying, reading cases, and performing procedures. There is an incredibly steep learning curve – you have to learn a lot about a lot and fast.

Residents typically rotate through the core rotations annually, though each program is a little different. Programs will prioritize preparing new residents to start taking call starting either at the end of your first year or early during your second year of residency. While call varies drastically between residency programs, it remains one of your best learning opportunities. You’ll see a lot of bread and butter cases (e.g. fractures, pneumonia) and a lot of cases where your read has an immediate clinical impact (e.g. stroke, bowel obstruction, appendicitis, acute hemorrhage in the setting of trauma, etc.). Putting out preliminary reports that can send patients to the operating room can be quite nerve-racking, but this is probably the area of residency that will best prepare you for a future in radiology.

No residency would be complete without exams and radiology is no exception. Most residency programs will have annual “in-training” exams, standardized radiology exams to give residents an idea of where they stand in their clinical knowledge relative to other residents throughout the country. This test is not terribly useful (in my opinion) so don’t feel bad if you don’t score well.

The test that matters most is the ABR Core Exam (see below), which you will take in your R-III year. Prior to this, most residents attend the ACR Institute for Radiologic Pathology (AIRP) course in Washington D.C. Residents learn a ton and, pre-COVID-19, actually got to meet residents from other programs!

The final year of residency includes a significant amount of elective time where you can finally choose rotations you are most interested in, areas of weakness, or rotations that will best prepare you for the job market. Many residents elect to complete “mini fellowships” lasting around 6 months. Several programs also offer a combined nuclear medicine/diagnostic radiology pathway where you forgo AIRP and certain rotations to meet the requirements to sit for the American Board of Nuclear Medicine (ABNM) Certifying Exam.

Lastly, during residency you will also have opportunities to participate in research projects, write articles, and present your findings at national conferences.

What is the American Board of Radiology (ABR)?


The ABR is the organization that administers board certification exams for radiologists in the United States. The traditional pathway to board certification requires successful completion of a one-year clinical training program (PGY-1 year), four years of accredited radiology residency training, and passing scores on the ABR Core and Certifying Exams.

What is the ABR Core Exam?


The ABR Core Exam is a computer-based exam covering 18 subspecialty and modality categories taken at the end of the PGY-IV (R-III) year. All radiologists must pass overall as well as pass each clinical competency, physics, and Radioisotope Safety Exam (RISE – required to achieve Authorized User Status). This test is designed to check for minimal competency and ensure you are safe to practice radiology.

The ABR Core Exam is a comprehensive exam that covers all facets of radiology, ranging from medical imaging techniques, physics of all imaging modalities including magnetic resonance imaging (just wait until you learn about k-space), radiation safety, normal human anatomy, and disease processes (all pathologies and disorders are fair game). The exam also includes Noninterpretive Skills (NIS), which covers statistics and various business principles (Lean, Six sigma, Pareto charts). Believe it or not, several of the business principles will actually come in handy once you’re involved in running and/or growing a radiology practice. You will be provided a NIS Study Guide by the ABR. Memorize as much as you can and you should be good.

What is the ABR Certifying Exam?


The ABR Certifying Exam is a computer-based exam covering 4 modules (3 modules covering clinical practice areas of the radiologist’s choosing and the last on the Essentials of Diagnostic Radiology) taken 15 months after residency. As the name implies, this is the exam you need to pass to achieve board certification. Noninterpretive Skills are again part of the exam and are often considered the most difficult part of the exam (since most of us instantly forgot everything we learned for the ABR Core Exam).

Once you’ve passed the ABR Certifying Exam, you’re officially a board-certified radiologist! Congratulations!!!

What is the Passing Rate for the exams?


The 2021 passing rate for first-time takers of the ABR Core Exam was >88%.

The 2021 passing rate for first-time takers of the ABR Certifying Exam was >87%.

Fellowship (PGY-VI or R-V)


After completing residency, most radiologists choose to pursue a fellowship as radiology has largely moved to subspecialization (and you can’t take the ABR Certifying Exam until 15 months after residency). Fellowships are one to two years long and provide training in subspecialties (e.g., abdominal (body) imaging, neuroradiology, nuclear medicine, breast imaging (mammography), pediatric radiology, musculoskeletal radiology).

Most fellowships are accredited by the Accreditation Council for Graduate Medical Education (ACGME). Neuroradiology, nuclear radiology, pediatric radiology, and interventional radiology (now integrated with residency) have board certification exams (i.e. you have to take a test). Abdominal radiology, clinical informatics, endovascular surgical neuroradiology (aka neuro IR), and musculoskeletal radiology are mostly accredited with documentation of completion from the fellowship program (no board exam). Breast, cardiothoracic, and women’s imaging fellowships are unaccredited (as of 2022), but you still get a fancy certificate from your fellowship program confirming completion of the fellowship.

What are the Best Radiology Residency Programs?


This is somewhat subjective and the bottom line is that there is no one “best” radiology residency program. The best program for you will depend on your individual preferences and goals and, ultimately, where you think you will be most likely to succeed. If being across the country from family is going to have a strong negative emotional impact on your psyche, you’ll want to take that into consideration.

That being said, people like to see lists and these are easily Googleable. The US News puts out an annual ranking list of residency programs and the Aunt Minnie community frequently discusses this topic.

Rank lists frequently put a lot of emphasis on the amount of research an institution does, which is debatable about how that correlates with the education you would receive. That being said, if you apply yourself, you can thrive in any program and become a stellar radiologist!

What are the Best Radiology Fellowship Programs?


Like residency programs, there is no one “best” radiology fellowship program. The best program for you will depend on your individual preferences and goals and help you land the job of your dreams. Program location and reputation are the main factors that will guide your decision and there are more fellowship positions than residency slots, so reach for the stars!

What are Steps You Need to Take to Secure a Job as a Radiologist?


You’re finally done with all of your education and training and ready to start working as a radiology attending. Congrats!

Here are the steps you need to take to secure a job:

  • Start by creating a list of the type of radiology jobs you’re interested in. Consider things like location, type of practice (academic vs. private vs. hybrid), and subspecialty focus.
  • Next, look over the ACR Jobs Board and start reaching out to any contacts you may have. The network effect can play a huge role in getting a great job.
  • If you’re having trouble finding a job through your contacts, consider using a professional placement service. These services can help match you with open positions that fit your qualifications.
  • Finally, once you’ve found a few potential jobs, it’s time to start applying. Make sure your CV and cover letter are up-to-date and tailored to each position.

With these steps, you should be well on your way to securing a job as a radiologist!

What is the Maintenance of Certification (MOC)?


You’re finally a board-certified radiologist and working as an attending but alas, you cannot forget about MOC! The MOC is a process that ensures radiologists stay up-to-date on the latest medical knowledge and technology. It consists of four components :

-Part I: Professionalism and Professional Standing

-Part II: Lifelong Learning and Self-Assessment

-Part III: Assessment of Knowledge, Judgment, and Skills

-Part IV: Improvement in Medical Practice

The MOC also consists of Online Longitudinal Assessment (OLA) questions (52 questions completed annually), 75 Category 1 Continuous Medical Education (CME) credits averaged over 3 years of which 25 must be Self-Assessment of Medical Knowledge (SA-CME; must pass a quiz to obtain credit), and completion of at least 1 Practice Quality Improvement (PQI) Project or Participatory Quality Improvement Activity (PQIA) every 3 years. This is required for all new radiologists to maintain their board certification.

Conclusion


There you have it! A comprehensive guide to how to become a radiologist. Yes, it may seem overwhelming and stressful but honestly, it’s completely doable. Just remember to take things one step at a time, stay organized, and ask for help when you need it. And before you know it, you’ll be a board-certified radiologist working in your dream job. You’ll also be quite a bit older…but also a lot wiser!

Now get out there and start your journey to becoming a board-certified radiologist. Good luck!

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