Recommended fellowships for nighthawk?

[CallMeBigJeff]

What's up y'all. R1 here loving my rad training so far and really entertaining the idea doing a tele-nighthawk 7 on 14 off kind of deal. Other than a straight up ER fellowship (which it seems there are not that many), what fellowships usually best prepare one for nighthawk coverage? Neuro? Body? None at all? Happy to hear any and all input!

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[maxxor]

What's up y'all. R1 here loving my rad training so far and really entertaining the idea doing a tele-nighthawk 7 on 14 off kind of deal. Other than a straight up ER fellowship (which it seems there are not that many), what fellowships usually best prepare one for nighthawk coverage? Neuro? Body? None at all? Happy to hear any and all input!

Neuro.

 

[Rad2013]

Neuro.

 

[qxrt]

Neuro.

 

[RageQuitter34]

🧠

 

[sevo00]

Breast

 

[EPV213]

Body

 

[CallMeBigJeff]

Could someone expand on why Neuro? As opposed to body or no fellowship.

 

[EPV213]

In my experience, lots of variation with ED jobs. Neuro and body are usually the most sought after specialties. If you are covering a stroke center added neuro training is a plus. However, I would argue there is more variety with the types of body studies you encounter in a typical ED. Many different modalities CT US MRI. Bread and butter neuro in the ED is mostly CT and should be comfortably read by most graduating residents. Both fellowships should open the door to most ED jobs out there. I’m sure neuro folks might disagree, but some of the minuta is not as relevant in the ED setting.

 

[bobjonesbob]

Could someone expand on why Neuro? As opposed to body or no fellowship.

In the current job market you don't need a fellowship to get a generalist tele night job. Any decent residency should train you to be able to read ED cases by the time you graduate. However, most people don't find these jobs sustainable for a 20+ year career. Even if you tolerate nights ok now most people find it harder as they age. So with the idea that nights isn't a permanent job for most people, a fellowship would give you more flexibility to pivot into to something else later.

As far as neuro specifically, it has by far the highest volume of emergent MRI volume. In most body fellowships >50% of your time is spent reading outpatient MRI and doing procedures that have little utility to someone working nights. Same with MSK. Also if you have any desire to work nights for an academic department or any thrombectomy center, many of those jobs prefer or even require neuro fellowship.

 

[maxxor]

Could someone expand on why Neuro? As opposed to body or no fellowship.

Because no one cares what fellowship you did for a night tele ER coverage job.

Here’s the cases you will read:
CT CAP
CTA CAP
CT Head
CTA H&N
CT spine
Random CT MSK
US abd/renal/pelvic
US DVT
Uncommon MR brain and spine. Maybe an mrcp or a pregnant appy.
And a bunch of XR.

Which fellowship will make you fast at the neuro? Most residencies will make you competent at the rest.

I read all of those on call. I’m the slowest by far at CTA HN. I dread when one pops on the list because I know things will back up. If you do neuro, you will be comfortable and fast at those.

Abdominal/MSK fellowship’s value is in MR which is not happening in the ED

 

[Cognovi]

Could someone expand on why Neuro? As opposed to body or no fellowship.

A third of the emergency department misdiagnosis related malpractice claims are neuro (not necessarily radiology as the main target of the suit, but most cases will have had imaging). The more practice you get, the better you'll be. I've seen a lot of misses or misinterpretations from outside non-neuro-trained rads reading neuro ED studies. These include stuff you consider bread and butter - ischemic strokes and hemorrhages; they can be subtle but nonetheless lead to significant morbidity or mortality.

 

[Tiger100]

You need a pulse to get a nighthawk job.

 

[Tiger100]

A third of the emergency department misdiagnosis related malpractice claims are neuro (not necessarily radiology as the main target of the suit, but most cases will have had imaging). The more practice you get, the better you'll be. I've seen a lot of misses or misinterpretations from outside non-neuro-trained rads reading neuro ED studies. These include stuff you consider bread and butter - ischemic strokes and hemorrhages; they can be subtle but nonetheless lead to significant morbidity or mortality.

Non Neuro-trained rad missed hemorrhage and ischemic stroke? It has more to do with being tired and exhausted rather than their training and can happen to everyone.

Bread and butter Neuro is read by general rads in many practices and their miss rate is not different from Neurorads. If you talk about H&N cancer followups or Pediatrics Neuro, that's a different story.

 

[Cognovi]

Non Neuro-trained rad missed hemorrhage and ischemic stroke? It has more to do with being tired and exhausted rather than their training and can happen to everyone.

Bread and butter Neuro is read by general rads in many practices and their miss rate is not different from Neurorads. If you talk about H&N cancer followups or Pediatrics Neuro, that's a different story.

Are there any published data on error rate for CAQ vs. non-CAQ rads reading neuro? We just have conflicting anecdote.

 

[PhysMatMan]

Not necessarily what you wanted but relevant: Transfer patient imaging: discordances between community and subspecialist emergency radiologists - PubMed

 

[Tiger100]

Are there any published data on error rate for CAQ vs. non-CAQ rads reading neuro? We just have conflicting anecdote.

I am not aware of.

But in the last 20 years most Neuro studies in the community have been read by non-CAQ rads and it was not like that patient's died left and right.

In my opinion, in private practice and emergency setting, missing important findings has a lot to do with burning out, high volume of work, working evenings and nights and interruptions rather than radiologist's skill.

 

[Tiger100]

Not necessarily what you wanted but relevant: Transfer patient imaging: discordances between community and subspecialist emergency radiologists - PubMed

A big selection bias in the article.

Let's say we just switch the radiologists but keep the same setting. I bet similar results will come out.

 

[Cognovi]

A big selection bias in the article.

Let's say we just switch the radiologists but keep the same setting. I bet similar results will come out.

Agree with you, insofar as that article says nothing about training background and everything about setting. The tertiary center's emergency radiologists have diverse training backgrounds, as diverse as community radiologists.

It is interesting that the higher rate of discrepancy was in head/brain and neck exams (compared to body or extremity MSK).

 

[GadRads]

Agree with you, insofar as that article says nothing about training background and everything about setting. The tertiary center's emergency radiologists have diverse training backgrounds, as diverse as community radiologists.

It is interesting that the higher rate of discrepancy was in head/brain and neck exams (compared to body or extremity MSK).

I think it has to do with reading speed, volume and fatigue, and less likely training. Some non-neuro trained private practice rads read normal/routine head CTs in 1 min (max 2 mins). I read them in 3 mins (and up to 6 mins for more complicated/post-op cases) since I like to look at the ENT structures and subtle areas/blind spots. I have seen the routine 1 min reader miss a single small lytic lesion that returned as a plasmacytoma 2 months later. If this doc spent an extra 1-2 mins on the scan I doubt the lesion would have been missed. However these ER/inpatients shifts are extremely busy so they do what is needed to stay above water.

During training, I would see neuro CAQ attendings spend 5 mins or more reading a routine head CT, checking the chart, etc. Easy to do this since they have trainees and rarely have to answer the phone/deal with frequent interruptions. When on private practice ER/inpatient shifts at busy places, there is rarely any time to look at the chart and as such they read studies with indications like "stroke", "stat", "r/o patholigy"[sic], etc.

 

[guytakingboards]

I think it has to do with reading speed, volume and fatigue, and less likely training. Some non-neuro trained private practice rads read normal/routine head CTs in 1 min (max 2 mins). I read them in 3 mins (and up to 6 mins for more complicated/post-op cases) since I like to look at the ENT structures and subtle areas/blind spots. I have seen the routine 1 min reader miss a single small lytic lesion that returned as a plasmacytoma 2 months later. If this doc spent an extra 1-2 mins on the scan I doubt the lesion would have been missed. However these ER/inpatients shifts are extremely busy so they do what is needed to stay above water.

During training, I would see neuro CAQ attendings spend 5 mins or more reading a routine head CT, checking the chart, etc. Easy to do this since they have trainees and rarely have to answer the phone/deal with frequent interruptions. When on private practice ER/inpatient shifts at busy places, there is rarely any time to look at the chart and as such they read studies with indications like "stroke", "stat", "r/o patholigy"[sic], etc.

It actually kinda makes sense the non-neuro reader spends less time than the neuro reader regarding neuro studies. With regards to misses, a non-neuro reader is held to the generalist standard. A neuro-trained rad is held to the standard of a specialist. (Both from a legal perspective and from the clinician's POV).

 

[Tiger100]

It actually kinda makes sense the non-neuro reader spends less time than the neuro reader regarding neuro studies. With regards to misses, a non-neuro reader is held to the generalist standard. A neuro-trained rad is held to the standard of a specialist. (Both from a legal perspective and from the clinician's POV).

I am not aware of different legal standards based on fellowship training.

Sometimes the lawyers use "Not being fellowship trained" as a weapon against radiologists. But usually it does not go anywhere.

Also in my experience, people read their own fellowship studies faster. For example, Neurorads clear a stack of Brain MRIs much faster.
MSK rads clear a stack of MSK MRs faster and etc.

 

[guytakingboards]

I am not aware of different legal standards based on fellowship training.

Sometimes the lawyers use "Not being fellowship trained" as a weapon against radiologists. But usually it does not go anywhere.

Also in my experience, people read their own fellowship studies faster. For example, Neurorads clear a stack of Brain MRIs much faster.
MSK rads clear a stack of MSK MRs faster and etc.

There is certainly a difference between if a family med doc missed something on an x-ray vs a radiologist. I believe (but am not 100%) that subspec also entails a higher level of expectation.

I agree that generally, a subspecialist will reader specialty studies faster. the ol' CT heads are somewhat unique IMHO. I could probably do a similar job to a generalist reading a CT head in a shorter amount of time. My point was I tend to spend MORE time looking at the CT head as a subspecialist cuz I know all the subtle areas where misses are, know how subtle sulcal subarachnoid can be, intentionally clear the sella, mastoids, orbits, etc...

Some IR/generalists in my group will read a non-con brain MRI or non-con head CT in 1min, basically just clearing it for large stroke/bleed/mass/midline shift. But they're not looking for or calling dural venous sinus thrombosis, intracranial hypotension, or a myriad of other things.

 

[GadRads]

Some IR/generalists in my group will read a non-con brain MRI or non-con head CT in 1min, basically just clearing it for large stroke/bleed/mass/midline shift. But they're not looking for or calling dural venous sinus thrombosis, intracranial hypotension, or a myriad of other things.

I look for all these things (sella, isodense subdural, sinus thrombosis, PPF, etc), so I can never read a head CT in 1 min. The other day I picked up a very subtle MCA stroke in the subinsular region in association with subtle left MCA territory hypoattenuation. I’m sure this would have been missed by the IR/generalists who would have read this in 1 min. The CTA showed a proximal M2 occlusion. I don’t think you need to be a neuro CAQ to see the stroke, but just read a little slower and more intentionally. In my practice the fastest neuro docs read routine head CTs in 2-3 mins, slower than the general guys. The neuro guys read more complicated studies faster.

 

[Tiger100]

There is certainly a difference between if a family med doc missed something on an x-ray vs a radiologist. I believe (but am not 100%) that subspec also entails a higher level of expectation.

I agree that generally, a subspecialist will reader specialty studies faster. the ol' CT heads are somewhat unique IMHO. I could probably do a similar job to a generalist reading a CT head in a shorter amount of time. My point was I tend to spend MORE time looking at the CT head as a subspecialist cuz I know all the subtle areas where misses are, know how subtle sulcal subarachnoid can be, intentionally clear the sella, mastoids, orbits, etc...

Some IR/generalists in my group will read a non-con brain MRI or non-con head CT in 1min, basically just clearing it for large stroke/bleed/mass/midline shift. But they're not looking for or calling dural venous sinus thrombosis, intracranial hypotension, or a myriad of other things.

During my career I have come across a good number of narcissistic radiologists who believe that it takes some special skill and talent to read a brain MRI or to put in a central line or to do a breast Biopsy and you are one of them.

 

[guytakingboards]

During my career I have come across a good number of narcissistic radiologists who believe that it takes some special skill and talent to read a brain MRI or to put in a central line or to do a breast Biopsy and you are one of them.

Lol. It's narcissistic to say a fellowship trained rad reads their subspecialty better than a general rad. Thanks for letting me know.

 

[Clean7795]

Neuroradiology or body imaging.

For ER nighthawk I feel that the above fellowship value is mainly added from being better with incidentals (more specific diagnoses & follow-up recommendations). It will also help you with the occasional day-time type case that bleeds over into the night for whatever reason.

 

[vm26]

What's up y'all. R1 here loving my rad training so far and really entertaining the idea doing a tele-nighthawk 7 on 14 off kind of deal. Other than a straight up ER fellowship (which it seems there are not that many), what fellowships usually best prepare one for nighthawk coverage? Neuro? Body? None at all? Happy to hear any and all input!

If you're training at a semi-busy level 1 trauma/stroke center you made not need a fellowship. With that said, who knows what the market will look like 4 years from now. When I graduated in 2013, CAQ neuro was more/less a requirement for overnights (given the cr*ppy job market back these jobs were 7-on/7-off)

 

[MrTaco92]

Any opinions on peds vs neuro/msk/body for the future generalist? Is it just that neuro/msk/body are more marketable in the private practice world? Peds fellows rotate through all non-mammo subspecialties during their year so they should be comfortable with doing a bit of everything. I'm not particularly drawn to peds but I'm also not a fan of the idea of pigeon-holing myself into a subspecialty for a year while my skills in reading everything else dwindle. Do people just keep their skills in general radiology afloat through moonlighting during fellowship or something?

 

[maxxor]

Any opinions on peds vs neuro/msk/body for the future generalist? Is it just that neuro/msk/body are more marketable in the private practice world? Peds fellows rotate through all non-mammo subspecialties during their year so they should be comfortable with doing a bit of everything. I'm not particularly drawn to peds but I'm also not a fan of the idea of pigeon-holing myself into a subspecialty for a year while my skills in reading everything else dwindle. Do people just keep their skills in general radiology afloat through moonlighting during fellowship or something?

Most radiology fellowships are not acgme. This allows fellows to moonlight.

I personally did a lot (possibly too much). But it kept my general skills up.

 

[guytakingboards]

Any opinions on peds vs neuro/msk/body for the future generalist? Is it just that neuro/msk/body are more marketable in the private practice world? Peds fellows rotate through all non-mammo subspecialties during their year so they should be comfortable with doing a bit of everything. I'm not particularly drawn to peds but I'm also not a fan of the idea of pigeon-holing myself into a subspecialty for a year while my skills in reading everything else dwindle. Do people just keep their skills in general radiology afloat through moonlighting during fellowship or something?

Peds is less marketable to most PP's because 1) the overwhelming majority of community imaging is done on adults 2) Most small to mid-sized groups don't service a peds hospital or have high volume/complexity peds worth having a fellowship trained rad.

That being said, plenty of groups could use a rad who wants to be the peds go-to person.

 

[Tiger100]

Any opinions on peds vs neuro/msk/body for the future generalist? Is it just that neuro/msk/body are more marketable in the private practice world? Peds fellows rotate through all non-mammo subspecialties during their year so they should be comfortable with doing a bit of everything. I'm not particularly drawn to peds but I'm also not a fan of the idea of pigeon-holing myself into a subspecialty for a year while my skills in reading everything else dwindle. Do people just keep their skills in general radiology afloat through moonlighting during fellowship or something?

Peds is less marketable. Low supply and low demand. But if you can land a good Peds job (Not just a job), it easily beats most other radiology jobs. Pay/Study is more for Peds radiology. So the pace is less compared to typical private practice. Radiologists who work at Children's hospitals have one of the best gigs in the realm of radiology. It is a hidden gem that most people are not aware of.

There is a significant difference between disease entities and pathologies between Adults and Kids. For example, Peds Neuro is a totally different world compared to Adult Neuro. The same for Body e.g Kidney masses and etc.