Radiology Residency: The Comprehensive Guide!

Radiology Residency - The Comprehensive Guide - BrettMollard.com
A comprehensive guide to radiology residency, including detailed descriptions of what the training is like.

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If you’re in medical school and deciding what you want to do with your life or have already made the smart decision to pursue radiology, this blog post is for you!

Here, I will share my experience as a former resident (and former chief resident) at the University of Michigan Health System and what, in general, you should expect when embarking on your journey to becoming a radiologist. The dim light at the end of the tunnel is finally going to brighten!

What is Radiology Residency?

 

Radiology residency is a postgraduate training program that provides radiology trainees with the means to learn diagnostic radiology and/or interventional radiology – it transforms a freshly minted doctor into a board-eligible (and eventually board-certified) radiologist.

Types of Radiology Residency

 

Radiology residency is a 5-year training program that includes an intern year and 4-5 years of radiology training, depending on whether it is a diagnostic radiology residency or an interventional radiology residency, which I’ll break down further.

Radiology residency underwent some pretty significant changes while I was a resident, converting into two separate pathways with both diagnostic radiology residency program and interventional radiology residency program options.

Radiology residency programs also come in two main flavors: academic programs and community programs. Regardless, all programs should be certified by the American College of Graduate Medical Education (ACGME). This isn’t the case for fellowship, but many fellowship programs are also ACGME accredited.

Diagnostic Radiology Residency Program

 

Diagnostic radiology residency programs account for the bulk of radiology programs as the vast majority of radiologists are considered “diagnostic radiologists.” This simply means that the primary focus for diagnostic radiology residents is on reading cases – the diagnosis aspect of radiology.

All diagnostic radiology residents will still be trained in basic interventional radiology procedures such as joint injections, paracentesis, lumbar puncture, chest port placement, biopsies, etc. and are exposed to more substantial interventional radiology procedures such as transjugular intrahepatic portosystemic shunt (TIPS) creation, angiogram/angioplasty, transarterial chemoembolization (TACE), etc.

Diagnostic radiology residency is a 5-year program with 1 year of internship and 4 years of radiology residency (the diagnostic radiology component is a four-year training program). Residents rotate through the various radiology subspecialties throughout their 4 years of training. The vast majority of diagnostic radiology residents pursue a fellowship in their area of interest such as breast imaging, pediatric imaging, abdominal imaging, etc.

Interventional Radiology Residency Program

 

Interventional radiology branched off within the past decade to allow for better specialization in interventional radiology and offer improved clinical training experiences to better prepare trainees for a successful career. Dedicated interventional radiology training programs are 6-year programs that offer early specialization in interventional radiology, include a more rigorous intern year, and are essentially inclusive of a fellowship.

Interventional radiology residents still receive diagnostic radiology training within their first 3 years of residency and take the radiology core exam in their third year. Following completion of their training, they take an IR/DR certifying exam.

Academic vs. Community Programs

 

There are two primary radiology residency training environments: academic programs and community programs. Every program will offer a slightly different training experience.

Not all programs have an affiliation with a pediatric hospital and may have away pediatric radiology rotations.

Academic Programs

 


Academic radiology residency programs are typically associated with a university hospital or medical school/ school of medicine (hence ‘academics’), which generally have access to more resources for research and education. Many academic programs are also considered ‘tertiary care’ and deliver higher specialized care, giving trainees access to a higher percentage of complex cases during their training. This may include certain types of cancers, organ transplants, interstitial lung disease, advanced surgeries, and more.

There is generally some expectation for residents to participate in research projects, educational exhibits, and conference attendance. This is perfect for residents interested in research and education.

Community Programs

 

Community programs typically have more emphasis on clinical practice and less opportunity for research projects. There is generally plenty of opportunities to create educational exhibits and present at conferences. Community programs offer very strong training in bread and butter radiology and give residents exposure to hybrid and private practice models.

Regardless of the training environment, all programs have the same program aims – to prepare you to pass your certifying exam and deliver excellent care to your patients.

What to Expect During Radiology Residency Training

Transitional / Internship Year (PGY-1)

 

Categorical residency programs have an intern year included and all 5 years of diagnostic radiology and 6 years of interventional radiology are included when you match into a categorical program.

Advanced programs do not contain an intern year. Medical students will choose an intern year separate from an advanced residency program and match into both programs. Intern year options include a preliminary year in internal medicine or general surgery or a transitional year program. Transitional year programs are generally a little easier with increased elective time and typically have rotations in internal medicine, emergency medicine, and possible family medicine or surgery.

This is referred to as your “Post-Graduate Year 1” year (PGY-1).

R1 Year (PGY-2)

 

If you thought you had to learn a lot in medical school, get ready to really start drinking from the fire hose! Radiology has a steep learning curve as you have to know a ridiculous amount of clinical medicine, the imaging appearance of innumerable disease entities, and more.

Fortunately, most faculty members have pretty low expectations for R1s, even in academic medicine. You will rotate through all of the core rotations, frequently in several week blocks, and some programs maybe even start call at the end of the R1 year, such as plain film call with more basic studies.

Your initial focus will be on bread and butter exams, radiographs, computed tomography (CT), ultrasound, and nuclear medicine exams. You may get some magnetic resonance imaging (MRI) exposure, but MRI is typically more of a focus in the remainder of residency. You will be given a description of your clinical responsibilities before each rotation to maximize your clinical experience.

You’ll participate in didactic lectures, most often in the morning or during lunchtime, where your attendings and fellow co-residents and fellows will spoon-feed you common, uncommon, and interesting cases.

Core Rotations

 
  • Abdominal imaging (GI/GU; sometimes referred to as “body imaging”)
  • Breast imaging/Mammography
  • Chest imaging (cardiac/thoracic imaging)
  • +/-Emergency radiology
  • Interventional radiology
  • Fluoroscopy (sometimes incorporated into abdominal imaging)
  • Musculoskeletal imaging
  • Neuroradiology
  • Nuclear medicine/Nuclear radiology
  • Pediatric radiology

R2 Year (PGY-3)

 

You’ll start off looking at the new R1s and realize how much you’ve learned in the past year! 🙂 Radiology faculty will begin to have higher expectations for your knowledge base and expect you to start picking up more complicated studies. Challenge yourself early and often! You want to see as much as possible while in training to best prepare you to be on your own.

R2 year revisits the core rotation and you further your knowledge within the core rotations. The early part of your R2 year generally doubles as call prep for more advanced call where you will be covering cross-sectional imaging (CT, MRI, ultrasound).

R3 Year (PGY-4)

 

Your third year of residency (fourth year of overall training) will be yet another rotation through the core rotations with more repetition and an even deeper dive into topics within each rotation. You will attend the American Institute for Radiologic Pathology (AIRP), and prepare for the radiology core exam that you’ll take toward the end of your R3 year. Call is frequently front-loaded to allow for dedicated time for core exam preparation. This is also when you will decide upon and apply for fellowship (prior to the core exam).

R4 Year (PGY-5)

 

Your R4 year is incredibly flexible, filled with multiple electives – you’re in your fourth and final year of your diagnostic radiology residency! Your call may be a bit back-loaded to help cover the R3s studying for their core exam (a faint memory for you by now).

Residents typically choose electives to strengthen any areas of weakness or they pursue a “mini-fellowship” in an area of interest. This is generally a very nice year – you feel confident, you’re rotating in areas by choice, and… you’re close to finishing residency!!!!

R5/Fellowship Year (PGY-6)

 

Over half a decade in… and counting. Interventional radiology residents will have their final year of training (essentially a fellowship), while their diagnostic radiology counterparts will have finished their diagnostic radiology residency and complete a fellowship either at the same medical center or a new medical center (whatever they decided on in their R3 year). Almost all fellowships are 1 year in duration aside from neuroradiology, which has both 1- and 2-year options.

Tests

 

In-Training Exams

 

Many programs have an annual in-training exam, which may be either a national exam or created by the residency program. From my experience, the national exam didn’t seem to have any real relevance. Aside from taking it and getting a score, it was never discussed and didn’t come up during fellowship applications or interviews.

Don’t stress over it and, unless you hear otherwise from more senior residents, it’s not something worth studying for. Just focus on your rotation at hand.

Qualifying (Core) Exam

 

The Quality (Core) Exam tests for minimally acceptable competence in radiology before you graduate residency and qualify for the Certifying Exam (not to brag, but I proved and have maintained my minimal competency ;)). Joking aside, this exam matters.

According to the American Board of Radiology (ABR): “The Qualifying (Core) Exam is designed to evaluate a candidate’s core fund of knowledge and clinical judgment across practice domains of diagnostic radiology and integrated interventional radiology/diagnostic radiology.”

The exam is an intensive three-day exam that covers all major topics in radiology, including physics, radiation safety, radioisotope safety, and non-interpretive skills. The ABR provides a study guide for the non-interpretative skills portion of the exam. This is actually one of the more difficult portions of the exam as you generally do not cover most or all of this document during residency. Memorize everything you can from the study guide – you’ll need it again for the Certifying Exam.

Most programs will give you protected time 1 or more months before the exam to prepare as well as dedicated “core review” (frequently incorrectly called “board review” – this is not a board exam, it simply qualifies you to take the board exam [technically certifying exam]) with didactic lectures. There are several review courses and review textbooks to help you prepare.

You are graded by section and will either “pass,” “condition,” or “fail” each section. If you condition a section, you didn’t score high enough to qualify for the certifying exam – yet. Luckily, they allow you to repeat any section you “conditioned” a few months later to give you a second shot at passing.

Certifying Exam

 

You’re at least in your early 30s now (kudos to any geniuses under 30 already at this stage) and FINALLY ready to take your certifying exam and become board-certified!

You won’t be able to officially take the certifying exam until 15 months after you finish residency. So by the time you actually take the exam, you’ll already have completed a fellowship (or 1 year of fellowship) and are already working as a radiologist in private practice, an academic medical center, or a teleradiology group.

The certifying exam, from my experience, is similar to the core exam in terms of difficulty. The certifying exam consists of 4 categories: 1 general radiology category and 3 categories of your choosing. You can choose more than one block within a category if you like, but any additional block within one category will be at a higher difficulty level. This is where you can take advantage of your fellowship and choose multiple categories related to your recently completed fellowship. Example: just finished a breast imaging fellowship? Choose 2-3 modules in breast imaging.

Non-interpretative skills are back and arguably the section you’ll have to prepare for the most (that was the case for me).

Conferences

 


Learning is always so much easier when you’re spoonfed all of the information! Diagnostic imaging is boundless with an endless amount of information for you to learn (and forget…and relearn…). This is where the quality of the residency program can make a difference.

While you will almost certainly get great training wherever you go (especially if you put in the extra hours), the higher-ranked programs typically have a bigger spoon to feed you with. The faculty at a university-affiliated medical center likely have dedicated time to create lectures, have access to a larger mix of rare cases, and may have access to other additional resources and tools.

Depending on where you train, trainees (residents and fellows alike) are also likely to give a few conferences, and giving conferences is a great way for residents to learn.

Regardless, you’re going to be exposed to a ton of lectures that will help prepare you for your exams and, more importantly, life as a radiologist.

American Institute for Radiologic Pathology (AIRP)

 

Unfortunately, I can only share second-hand information here as I had to forego AIRP to cram in enough nuclear medicine to qualify for my American Board of Nuclear Medicine (ABNM) board exam. That being said, I’ve heard nothing but positive reviews for AIRP – the ultimate in radiologic pathology correlation.

The AIRP is a 4-week review course, currently virtual, that covers an incredible amount of radiology with pathology correlation. Hopefully, AIRP will return to in-person following the COVID-19 pandemic as this is a fantastic opportunity to meet residents from other programs.

Call

 

In my opinion, call is one of the most important parts of residency, particularly if your program has independent call (i.e., you give preliminary reads on cases without staffing out). This, from my experience, is one of the best preparations for the real world. You’re forced to get comfortable making critical diagnoses that may send patients to the OR or require emergent consultations or procedures. We’re talking head bleeds, diffuse cerebral edema, aortic dissection or rupture, and even more basic things like acute appendicitis.

Call is generally a gradual process where you start in a junior call pool, frequently overlapping or concurrently with another more senior resident. Many programs also have a “buddy” call system where junior residents shadow or work alongside a more senior resident prior to taking call independently.

There should always be a fellow or attending available as back-up for overly complex cases or when a final read is requested by a clinical service.

Research and Education

 

Research isn’t for everyone, but for those interested residents, there is plenty of opportunity for research in and around the field of radiology. This is also an excellent way to work closely with a faculty mentor (future letter of recommendation writer anyone?), gain a deeper understanding of a topic of personal interest, publish a research article within a peer-reviewed journal, add to your resume/CV, and even present in a conference somewhere across the country.

University residencies typically have more resources for education and research and make the research process much more streamlined and less stressful. It’s also nice to have an idea of what it takes to publish all of these journal articles that guide our everyday practice.

Education plays a momentous role in our training and there are two sides to this coin – learning and educating. And I’ve found that educating is actually one of the best ways to learn. You’ll have plenty of opportunities to give lectures, teach more junior residents, and even teach medical students.

The Important People

 

You’ll quickly get to know the program director and associate program director. The program director is essentially mom/dad for the duration of your radiology training. Your program director is the dedicated radiology faculty member that is in charge of the residency program and all of the residents. They are (or at least should be) your biggest advocate. The associate program director is the number 2. They typically serve as a backup role to the program director and their involvement/engagement may be somewhat variable.

Chief residents are your resident advocates and may consist of one resident or two residents at larger programs. They work with your program director and assist with any issues that may arise during the day. They frequently help with arranging coverage if a resident is out sick or can’t make a call shift and may help with creating schedules or other various administrative responsibilities. These are the residents that everyone, residents and attendings alike, will complain to 🙂

It’s good to have an idea who the section chairs are for each section, especially in subspecialties that you may be interested in for fellowship as you’ll likely want a letter of recommendation from them. It’s also good practice to know who the chair of your radiology department is, though chairs may have limited interaction with residents (- they’re generally quite busy with administrative duties). If your program has a vice chair, know who the vice chair is too.

There will be one or more program administrators (such as a graduate medical education [GME] Program Administrator) that will be incredibly helpful throughout residency.

Treat everyone with respect. This is just general life advice, nothing particular to residency 🙂

Salary, Benefits, and Vacation

 

If you’re used to living like a poor college student then good news! You get to keep doing it for another few years! (eye roll)

Resident salaries are not impressive and vary depending on location, program, and what PGY you are. Programs in cities generally pay a little more than in rural areas due to the cost of living and your salary will increase every year (e.g. a fourth year will make more than a third year, etc.).

While you are now physicians, you’re still in training and paid accordingly. At least you’re no longer paying to work as a medical student (another eye roll). You’ll start having to pay down student loans, pay for housing, and arrange child care if you have kids and a working spouse.

You may end up with what feels like a pretty decent salary in your final years, but my recommendation is to continue living like a college student for a few more years. Treat yourself occasionally and try to enjoy life while maintaining a budget.

Benefits will be dependent on whatever your program offers. Generally, you can expect pretty solid benefits such as health benefits (health, vision, dental) and you may have FSA and HSA options. If you have a 401k or 403b option, take advantage of it. If not, consider a Roth IRA.

Vacation typically ranges between 3-4 weeks/year. It may be possible to do a 2-week block (for weddings, big vacation/trip, etc.), but typically requires coordination with your program director.

Summary

 

While each radiology residency is unique in its own right, there are significant similarities across programs. Your primary goal when choosing a radiology residency should be to identify which program will best fit your style of learning and maximize your success. You can get excellent training in any residency you choose or match into.

This article has covered the basics of radiology residency and what I have felt are the key elements of a program. There are 212 programs (as of 2020) with 1,113 spots – find the program that will help you become the best radiologist you can be!

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