Chest radiology: Not just an academic subspecialty

Like many other fellowship directors of non-ACGME programs, one of my pet peeves is how early the interviewing process begins. Why don’t we just start interviewing candidates when they are fourth-year medical students? They probably would have just as good an idea of what they want to do at that point.

However, an even greater source of irritation leading up to the process is the oft-repeated misconception that chest radiology is only for those who want to spend their careers in the ivory tower. In fact, I recently heard this canard stated by our residency program director, an otherwise nice guy whom I occasionally give a ride to work. My hope in writing this editorial is to set the record straight.

The mantra that one often hears from residency directors and, more important, community radiologists, is that “anyone can read chest imaging.” So, a radiologist trained in abdominal imaging or one with a background even farther afield may be tasked with reading chest radiographs and chest CT scans. It may be fair to argue that this approach can be sufficient when interpreting ICU films or chest CT scans for follow-up cancer imaging.

But it’s different when the CT indication is, for example, interstitial lung disease. This often sends a community radiologist into near-panic mode—typically reflected by the resulting interpretation. The impression generally states something about fibrosis – end of story. There is no indication as to what type of fibrosis, which has prognostic value and may alter treatment, or any consideration that this may not be standard idiopathic fibrosis and may represent a distinct condition such as parenchymal sarcoidosis or hypersensitivity pneumonitis. Consequently, a refrain that I frequently hear from community pulmonologists is that they would love to have a chest radiologist interpreting their patients’ studies.

To take the discussion a step further, what if the indication is for cardiac cross-sectional imaging? It is true that in some places this turf, particularly cardiac CT, has been ceded entirely to cardiologists. In many cases, however, there is considerable potential for community radiologists to share in cardiac CT imaging and interpretation or even to be the sole provider. Moreover, substantial opportunities often exist in cardiac MRI, which is more technically challenging but also often more rewarding. In this day and age, nearly all chest fellowships include comprehensive training in cardiac CT and MRI. Having this capability is a small but clearly quantifiable added value to a community practice.

It is also not the case that pursuit of a chest fellowship leads to atrophy of skills in other areas of radiology that are part and parcel of a community practice. Our chest fellows spend 15-20% of their working hours in various aspects of our general radiology section, which covers several community hospitals. In addition, there are multiple moonlighting opportunities that allow fellows to keep their general radiology skills sharp. To my knowledge, similar opportunities are available for most chest fellowships.

As a chest fellowship director for more than two decades, I would say that a sizeable minority of our fellows have taken jobs in a pure community practice or, in a few instances, a community practice that has a resident-training program. All have succeeded spectacularly and have become valued members of their practice for their overall contributions as well as for the incremental value provided by their capabilities in chest and cardiac imaging.

So, while I am certainly happy when our chest fellows choose academic radiology, I am no less happy when they select a community practice, because I know that the practice will be well served and our trainees will spread the word that chest radiology is not just an academic subspecialty.

As I write this editorial in the summer of 2017, our thoracic imaging section has just completed interviewing chest imaging fellows for the 2019-20 academic year. We are fortunate to have recruited three outstanding residents who come from excellent training programs and have impressive credentials.

And notwithstanding the above complaints, I am further delighted to have had such a successful fellowship interview season, and I enthusiastically anticipate the arrival of the new fellows in 2019.