To subspecialize or not to subspecialize? That’s a crucial question for radiology trainees who are finishing their residency but have yet to settle on a lifelong career path.
The dilemma is taken up by radiology researchers in an opinion piece published online July 12 in Radiology.
Corresponding author Haidara Almansour of Tübingen University Hospital in Germany, co-authors Aileen O'Shea of Mass General, Ryan England of Johns Hopkins and colleagues introduce their material by noting the slenderness of the line separating a generalist from a subspecialist in radiology.
“Arguably, all board-certified radiologists are generalists,” they write. “Once a generalist completes a certain number of examinations or undergoes fellowship training in a subspecialty, they can be considered a subspecialist. In many cases, a clear demarcation between generalist and subspecialist cannot be discerned, and sometimes this fine line shifts.” [1]
For working definitions of the two terms in the U.S., the authors cite a 2017 study by Rosenkrantz et al. classifying radiologists as subspecialists whenever more than half their billings reflected subspecialized reads. Analyzing data on more than 33,000 radiologists, the researchers found 55% practicing mainly as generalists yet spending 36% of their time on subspeciality cases [2].
Pointing out that post-residency training has largely shifted to ground radiology fellows in a subspecialty—even as generalists have remained “the backbone of the radiology workforce” in many countries—Almansour and co-authors encourage today’s residents to consider seven key components of sustainable job satisfaction.
1. Personal interest. Radiology residency being a singular experience in one’s life, allotting time to discern subspecialty likes and dislikes can serve trainees well throughout a career, the authors suggest:
Establishing meaningful connections to mentors who broaden subspecialty understanding, outline its advantages and drawbacks, or leverage their connections early in residency can be a critical component of career success. Indeed, solely focusing on a subspecialty early on might lead to decreased levels of dedication and engagement by residents for other ‘nonrelevant’ rotations. Inhomogeneous training leads to knowledge gaps that can have substantial ramifications, especially when staffing call shifts.”
2. Practice setting. Reporting daily to an academic medical center places a physician in a markedly different culture than working for a private practice, Almansour and co-authors remind. And that’s to say nothing about variables in geographic location and practice size:
[I]f a trainee envisions themselves working in a rural setting at a smaller practice, they may be best suited as a generalist, while another looking to join a larger urban practice may find they could provide significant value to the practice as a subspecialist.”
3. Financial considerations of extending training. Money matters for young doctors due largely to student debt. In the U.S., the authors remark, students graduate medical school owing an average of almost a quarter million dollars. This reality pushes more than a few to skip fellowship training and head straight to a steady job:
While salaries of residency graduates have been observed to be less than their fellowship-trained colleagues, this difference is offset by the fact that radiologists are in the top earning brackets among physicians ($413,000 vs $242,000 for primary care physicians and $344, 000 for specialists in the United States). … [P]ractice setting also plays a role; academic salaries have been reported to be lower than private practice salaries. However, due to a large variation in pay structures, costs and local market influences, it is hard to discern the discrepancy between academic and private practice salaries.”
4. Utility of acquired skills. Large academic centers offer state-of-the-art technologies and treat rare conditions that are often uniquely practice-specific, Almansour and colleagues state. More:
While a subspecialty radiologist is necessary for these interpretations, these skills may not be transferable, with notable examples including those required for complex congenital caseloads in pediatric neuroradiology or PET/MRI scan interpretation.”
5. Work-life balance. Work-life balance hangs in the balance when selecting a subspecialty simply because some of these are considerably more demanding of time and presence than others:
[T]he literature currently lacks specific comparisons of generalists with subspecialists and comparisons of different subspecialties. In general, procedure-heavy subspecialties (e.g., interventional radiology, neuroradiology) often require overnight and weekend on-call duties. Practice setting also plays a major role, as larger teams and staffing levels enable more scheduling flexibility and reduced impact on work-life balance.”
6. International mobility. Pursuing a fellowship abroad can have more benefits than the obvious rewards of expanding one’s intercultural literacy, language skills and appreciation of diversity, the authors suggest:
Mobility fosters international collaboration, which is especially crucial in the era of artificial intelligence, as expert teams at many centers are necessary to create high-quality datasets. … Most importantly, [an extended international experience can] underline good interpersonal communication, as radiologists increasingly focus on holistic patient care and betterment of the radiologist-patient relationship to advance our field.”
7. Social considerations. Social and family constraints such as a partner’s career, closeness to relatives and care of family members, “can impact the decision-making process at the time of fellowship applications and when considering future practice settings,” Almansour and co-authors write. More:
[T]he decision is especially complicated if one has children. Factors like children’s age, quality of available schools, preference of an urban or rural life, as well as possible commuting over the weekends are important factors to consider.”
Thanks to the certain uncertainty of the future, one could mull all the above pointers and still experience job-taker’s remorse, the authors acknowledge in so many words before closing on a note of upbeat exhortation.
“When the time comes to decide whether to subspecialize, every trainee will carve his or her own path according to previous experiences, current circumstances and aspirations,” Almansour et al. write.
“Since generalists remain the beating heart of the radiology workforce, trainees might strive to be chimeras: radiologists with excellent generalist skills trained in a subspecialty that offers personal satisfaction and benefits the community in which they serve.”
More Coverage of Radiology Subspecialists vs. Generalists:
How Will the Generalist Survive?
Dwindling number of generalists in radiology could have ‘far-reaching implications’
Radiology trainees' workload continues to focus more on noninvasive imaging services
Generalists still perform the majority of invasive procedures in radiology
What does the rise of radiology fellowships mean for general radiologists?
As subspeciality rates climb, the majority of American radiologists remain generalists
3 takeaways from a county-level exploration of the US radiologist workforce
References:
- Haidara Almansour, et al., “Fellowship Training: Navigating the Decision to Be a Generalist or a Subspecialist—Radiology In Training.” Radiology, July 12, 2022. DOI: https://doi.org/10.1148/radiol.220422
- Andrew Rosenkrantz et al., “Generalist versus Subspecialist Characteristics of the U.S. Radiologist Workforce.” Radiology, Nov. 27, 2017. DOI: https://doi.org/10.1148/radiol.2017171684
Dave P. has worked in journalism, marketing and public relations for more than 30 years, frequently concentrating on hospitals, healthcare technology and Catholic communications. He has also specialized in fundraising communications, ghostwriting for CEOs of local, national and global charities, nonprofits and foundations.