Clinical radiology
BMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7194.S2-7194 (Published 15 May 1999) Cite this as: BMJ 1999;318:S2-7194
- Tom Sulkin, specialist registrar in clinical radiology
Tough exams include a back to basics approach to anatomy as well as knowledge of all the latest imaging techniques. Tom Sulkin reports.
The central role of a radiologist is interpreting images, whether they be plain x ray films, contrast studies, ultrasound scans, computed tomograms, or magnetic resonance images. It is essential to have a firm grasp of anatomy so as to decide what is normal and what is abnormal. Once an abnormality has been identified a radiologist must be able to draw up a list of differential diagnoses based on the imaging characteristics. A general practitioner or a hospital specialist may refer a patient, so it is important to have an understanding of the range of pathologies and the clinical problems encountered in different specialties. This diversity of caseload and the solving of diagnostic dilemmas are two of the main attractions of clinical radiology. Recent technological advances have benefited radiology enormously. New imaging techniques such as helical computed tomography and magnetic resonance imaging have been developed, while the scope of older techniques such as ultrasound scanning has widened. Working in this environment of rapid change is exciting and a continual challenge.
Radiologists are increasingly involved in invasive diagnostic and therapeutic procedures, which often allow a patient to avoid surgery. These range from image guided biopsy and drainage procedures to the insertion of vascular stents. Such techniques have become an integral part of the work of most subspecialties in radiology, so it is likely that any radiologist will be expected to have basic interventional skills. Those who choose to work in specialties such as vascular or hepatobiliary radiology require more advanced interventional training.
Why become a radiologist?
The good bits …
Well structured training schemes
Popular and expanding specialty with a high profile
Good career prospects
Diverse job with opportunities to work in many different fields and with a broad range of imaging modalities
Key role in solving diagnostic dilemmas
Combines intellectual and practical challenges
… outweigh the bad bits …
The FRCR exam
Retraining in a new specialty
No overall control of a patient's clinical care
A radiologist does not have overall clinical responsibility for a patient but carries out investigations that are requested by other doctors. Clinicians are often unfamiliar with the practicalities of an investigation or how different imaging techniques can be used to answer specific clinical questions. It is up to the radiologist to provide appropriate advice and guidance. Requests for imaging should adhere to locally agreed guidelines. These are based on recommendations from the Royal College of Radiologists (RCR)(1) and are aimed at avoiding inappropriate investigations and reducing unnecessary exposure to radiation. Clinical meetings between radiologists and other clinicians are an important forum for discussing complex cases. Consideration of a patient's full clinical history as well as the results of imaging often helps clarify the next step in patient management. It is also an educational process for both parties and helps foster a good relationship between the radiology department and the rest of the hospital.
Training
There are no senior house officer posts in radiology. The minimum requirement for appointment to a specialist registrar post is two years of postgraduate experience. In practice, however, many successful candidates have a postgraduate diploma such as MRCP or MRCS. This reflects the popularity of radiology. Radiology training programmes are based at central teaching hospitals. There are therefore a limited number of training centres in the United Kingdom, and a list of these is available from the Royal College of Radiologists. Interviews for specialist registrar posts tend to be held between January and March to start in August to October; this coincides with the preparation course for the first part of the FRCR examination. A few posts are advertised at other times of the year.
Radiology training programmes are highly structured and are divided into five academic years. It is essential to pass the FRCR examination during this time. The exam is divided into three parts - 1, 2A, and 2B. The first part examines radiological anatomy, physics, and techniques and can be attempted after a minimum of eight months of training. The syllabus for the second part is more clinically oriented and requires that a candidate shows “a sound knowledge of those common aspects of clinical radiology which compromise the routine general work in most hospitals”.(2) Part 2A consists of two papers of multiple choice questions and can be taken after a minimum of two and a half years of training. Part 2B may be taken six months later and is structured around image interpretation.
The first year of training is quite different from the others. There is very little service commitment, and it is not unusual for trainees to question their decision to become a radiologist. Before their appointment, most specialist registrars will have held a relatively senior position with considerable responsibility. After the initial euphoria generated by starting work in one's chosen specialty it can be difficult to adjust to being at the bottom of a hierarchical training scheme. Fortunately, once this transitional year is complete these doubts rapidly disappear. As well as studying for the FRCR part 1, the first year is spent gaining an overview of radiology with short attachments in specialist areas of imaging. It is important to become familiar with the full range of imaging techniques and to acquire the core skills that are central to radiology. There is no on call duty in the first year; this starts at different stages in different centres.
The aim of the second and third years of training is to acquire structured training in all the constituent specialties of clinical radiology.(3) This involves rotating through a large number of departments in a relatively short time and may include attachments in local district general hospitals. In the fourth and fifth years, as well as consolidating general training, specialist registrars are expected to develop a subject of special interest. With this in mind, some radiologists choose to do a fellowship as part of their post-FRCR training. These can either be in Britain or abroad and are strongly supported by the Royal College of Radiologists. Clinical research by trainees in radiology is usually integrated into the five year training programme. The royal college encourages full time research, but this does not necessarily attract training approval. At least four years must be spent in a full time clinical post.(4)
Flexible training is a mechanism by which doctors who are unable to train full time for personal reasons may train in their chosen specialist subject by working a reduced number of sessions a week. The sessional nature of radiology means it is more suited to flexible training than many other fields of medicine. Flexible trainees are appointed as specialist registrars in radiology by competitive interview with their full time colleagues. They must work a minimum of five sessions a week and take part in the on call rota on a pro rata basis.(4) It is difficult to progress in radiology without having passed the FRCR part 1. With this in mind, the college is guided by its regional advisers as to flexible trainees' suitability to sit the exam at the earliest opportunity (usually in the first year), even though they may not have completed a full eight months of training. The regulations regarding the two parts of the final examination are more strictly enforced, and a flexible trainee must satisfy the minimum entrance requirements.
A certificate of completion of specialist training (CCST) is awarded at the end of the fifth year, and it is then possible to apply for a consultant post. Such posts are either in general radiology (those that involve working across several subspecialties, with or without a major commitment to a particular one) or specialist radiology (those that involve a near full time commitment to a single subspecialty).(3)Subspecialist areas usually correspond to clinical counterparts such as paediatric radiology, neuroradiology, and mammography rather than a particular imaging modality.
Career prospects
Currently, the job prospects for an accredited radiologist are good. The popularity of particular posts varies, but overall there are insufficient suitable candidates to fill the consultant vacancies. The bottleneck in radiology is at the specialist registrar level, but the number of national training numbers has recently been increased and training schemes are being encouraged to expand. Though this may result in increased competition for consultant posts, the outlook for the specialty is promising. There is an ever increasing demand for imaging, and it has been estimated that each surgeon and each physician needs the support of a third of a radiologist.(5) Pressures therefore exist from other clinical specialties as well as from within clinical radiology for further expansion.
Finding out more
The Royal College of Radiologists (38 Portland Place, London W1N 4JQ, tel 0171 323 3100) is the regulatory body responsible for training, education, and professional standards in clinical radiology and oncology. General information about a career in clinical radiology is available from the college directly, and it may be useful to visit the website ( www.rcr.ac.uk/enquiries). More specific information about training in radiology and the FRCR examinations are available in the documents listed below. Guidance is also available from the head of training of a radiology training scheme. It does no harm to approach a radiologist for a personal view of the specialty.