A radiologist is more than just a pretty face in a dark room. Radiologists play the role of both pilot and air traffic controller in the radiology department: they interpret X-rays, CT scans, MRIs, ultrasounds, and mammograms, and ensure the safety of patients as they are imaged. Before we delve into the daily work of the radiologist, join me as we witness the birth of a new radiologist into the world.
First, a radiologist is a doctor, with a degree of M.D. or D.O.. It is surprising to me that many people are unaware of this, or at least do not know exactly what the term “radiologist” means. It is perhaps understandable, given patients in years past seldom interacted with the radiologist, nestled in a dim office in the basement of the hospital, drinking coffee and eating Skittles. This stereotype of the “hidden radiologist” is thankfully less common today, but as a profession, we continue to work to become more visible and accessible to patients.
After obtaining an undergraduate degree—which can be in any discipline, providing prerequisite science classes are taken and appropriate tests passed—the budding radiologist digests loads of knowledge during four years of medical school (like a very hungry caterpillar.) Now he or she is no longer a very tiny caterpillar, but a great big caterpillar, knowledge-wise. (Can you tell I read a lot children’s books?)
School wouldn’t be school without those lovely rites of passage called tests, and medical school is no exception. Most important (read: scariest) are the U.S. Medical Licensing Exams, or USMLE. These obligatory exams are called Step 1, Step 2, and Step 3. Once passed, the unofficial “Step 4” involves a happy dance and a trip to the bar.
With medical school nearing an end, medical students prepare for The Match. Although it may sound like a reality TV show or dating website, The Match is an algorithm-based computer program that connects each medical student with a residency program. It culminates with the spectacle of medical students all around the country gathered in auditoriums with their classmates, tearing open envelopes which contain their future residencies —to their joy, horror, or indifference.
Radiology residency, where things get serious(er)
The next step is five years of residency training. You have undoubtedly seen the intimate lives of interns and residents depicted on countless medical dramas (medramas?) in the past few decades. Radiology residency is nowhere near this sexy, although it does occur primarily in rooms with dim lighting.
Following an intern year—a year of general medical or surgical training—the radiology resident spends four additional years steadily learning the craft, acquiring layer upon layer of skills and knowledge, like a mental ball of aluminum foil. There is much to learn, and the learning curve is steep. Over time, with hard work and experience, a radiologist the resident becomes.
Radiology residents are educated by senior “attending” radiologists, consummate masters of their field who impart the generalities and subtleties of radiology. Most of the learning takes place in the “reading room”, a large windowless chamber, stereotypically in the basement of the hospital. In the beginning, training is monkey see, monkey do; later, the resident has gained enough experience and confidence to work semi-independently. This takes years.
After residency, a radiologist must pass another test, THE BOARDS. I have capitalized THE BOARDS (technically called the Diagnostic Radiology Certifying Exam) because it looms so large over the life of each resident. In the recent past—including when the Neighborhood Radiologist took his boards—it was an oral examination. In June of each year, all radiology residents in the country converged and took their board exams in, strangely, Louisville, Kentucky, at the Executive West Hotel.
The experience was surreal, principally because this oral grilling took place not in some conference center, but in occupied hotel rooms. Not just any rooms, but the rooms in which the board examiners were living for the week. So, as residents answer questions which determine their future careers, they might, out of the corner of their eyes, catch a glimpse of undergarments lying on the nearby bed. Funny in retrospect, but distracting and horrifying at the time. Mercifully, the test ends in a few hours and, if you have held it together through tough questions and dirty underwear, you pass to become a “board-certified” radiologist.
As of 2014, the oral boards examination for radiology has been replaced by computerized tests—an overall simpler and fairer testing method, but with less opportunity for funny stories.
Interestingly, one need not necessarily pass the boards to practice radiology. One who has completed residency training but not yet passed the boards carries the strange title of “board eligible.” Quite a few radiologists (and other types of physicians) work this way for part or all of their careers—all perfectly legit. Many radiologists who fall into this category are older, and decided for whatever reason not to take the boards, a path more accepted in the past. Some board eligible radiologists have just graduated residency and are preparing to take their board exam in the near future.
The fact that a radiologist has passed the board certification exam indicates he or she has completed a rigorous radiology residency and was deemed by experts in the field—the board examiners—to possess the necessary qualities and skills to practice radiology. If you discover that a radiologist who read your study is not board certified, it may be worth further scrutiny on your part. My explanation is not a slight against the board eligible; rather, I seek to clear up this confusing terminology so that you, as a patient, can be better informed.
“Fellowship is an extra year or two of working for the man“—the cynical radiologist.
“Fellowship is an opportunity to further one’s knowledge and skill in a specific subspecialty in the greater field of radiology”—the optimist radiologist.
“Fellowship is what we make of it“—the philosopher radiologist.
There is truth in each of these statements, but the second is most informative and least snarky. Fellowship consists of 1-2 years of additional training in a subspecialty of radiology. It is optional, although greater than 90% of radiology residents continue on to fellowship for various reasons—primarily because most practices value the skills that fellowship-trained radiologists bring to the job.The most common fellowships are, in no particular order:
- Neuroradiology—brain, spine, and head/neck
- Body imaging—abdomen and pelvis
- Thoracic imaging—chest (sometimes combined with body imaging)
- Musculoskeletal imaging—bones and joints, spine
- Women’s imaging—primarily breast, sometimes female pelvis
- Pediatric imaging—all types of imaging in children. At large pediatric hospitals, there is often subspecialization within pediatric imaging (i.e. pediatric neuroradiology)
- Vascular/interventional radiology—image-guided procedures
Some fellowships—neuroradiology, vascular/interventional, and pediatric radiology—require another test (groan). But after that…
Well, not really. Although formal training is done, radiology, like many professions, requires lifelong learning—both formally as continuing medical education, and informally as questions arise on a daily basis. New technologies are developed, and research continually alters paradigms in the field. A steady flow of new insights and techniques are constantly integrated into daily practice, and help the radiologist operate at the cutting edge of medicine.