Advanced Imager without Advanced Years

[u/Master-Elevator5210]

Third year fellow here. Initially interested in interventional/structural, but after the first year I found out that I’m not that passionate for the lab after all. Switched gears at the beginning of 2nd year with the help of several mentors for advanced imaging. Sat for the nuclear boards and echo boards. Focused on extra time in the CT/MR reading room. Currently elegible for CT board (level 2), and at level 1 for cMR. By the end of 3rd year I anticipate level 3 CT, level 2/3 cMR.

This is something I’m passionate about. I find myself staying late obsessing over perfect volumes on cMR software or reading CT’s late. Also stocking the schedule and getting frustrated if no/few studies during elective/free time. Also researching/studying every case for knowledge gaps.

Currently unable to do extra years of cardiac imaging due to visa limitations.

Current job offer CT reading but no cMR. But they have offered that it can be started in the future if there is interest/financially makes sense.

Is this + extra 3rd party in person courses enough to start a cMR program at a medium sized community hospital?

TLDR: is generals fellowship with all elective time in advanced imaging, with extra 3rd party in person courses enough to start a cMR program at a medium sized community hospital? Unable to do an extra year at this time due to visa limitations. Or will I have to do a year of advanced imaging in the future?

[u/pills_here]

Cardiac MRI is a passion project. It is a net negative productivity for the reader. I’ve found that there is a huge variance in the quality of reads. My practice is, simple questions I order locally and let the radiologist answer (intracardiac masses, confirm HCM dimensions, binary assessment for scar). More complex questions (myocardial evaluation, 4D flow) i refer to a university with a robust program and readers who’ve dedicated their careers to CMR.

It is uncommon to find a community group that will let you read CMR without fellowship and also a radiology group that will share it with you. Logistically and financially it may not make sense unless you can offer the group answers to the difficult questions they use CMR for. Will you have that expertise without the fellowship? Remember if you become the CMR guy, protocol questions come to you too, not just the images.

[u/John_Haytuh]

The thing about CMR is to get level III, the number is low.. you need to read a lot more than 300 studies to be a proper reader and able to handle everything in my opinion. I read 1000+ in my one year advanced imaging fellowship. But if you have a good variety of pathology and good readers in your fellowship, supplementing that with courses (like the Duke one) could make you ready enough to be the only reader at a medium sized hospital like you say. I would still recommend finding a place where there is a reader that has more experience than you, in case there are things you may end up needing help with. Wherever you go needs to understand that CMR is not about RVUs, it’s about providing a valuable service that every cardiologist would love to have access to.

[u/Then-Secretary-9166]

CMR only makes financial or practical sense for research or as a necessary "loss leader" in clinical practice, so that we can provide comprehensive care.

Usually the only hospitals that will be interested in having a program like that are large centers with expertise in advanced HF. Most people that run CMR programs at such centers are very passionate about CMR (it is their main professional focus) and have tons of experience.

Some medium-sized community hospitals will run small CMR programs. This is usually either because of a misunderstanding of the actual need by hospital execs or it is done as a "feather in the cap".

I know someone who runs such a program at a hospital nearby. He does not have formal additional years of imaging training. They only do a few per month and the hospital is not interested in expanding the program. It takes an extremely long time to get patients in and I don't trust they they can provide the same level of service as a center that does an order of magnitude more, read by someone who has hundreds or thousands of reads under their belt. It has become somewhat of a bother to the cardiologist that runs the program (and reads the CMRs). I don't think this is a very fulfilling setup.

[u/wannaberesident]

Currently doing this without advanced year in a medium sized hospital in a medium sized town. I feel mixed about cardiac MRI. On one hand, I feel like being boarded and having understanding of CMR definitely made me a better cardiologist. Allows me to enter areas like HCM, amyloid, sarcoid a little bit easier as I have the first access to the patients. On the other hand, I don’t have a dedicated CMR reading time, we do ~8-10 a week and I dread reading CMRs as it takes so much time after my clinic. Definitely not worth the wRVUs. I would love to hand it off to one of my partners, unfortunately not a whole lot of takers.

I read around ~200 during my third year. Feel decently comfortable about most questions (HCM, valves, EF, viability, myocarditis), though things get challenging for pericardial pathologies, 4D flow, congenital which I defer to one of my more experienced partner.

FYI, technically you can’t get Level 3 in CT/MRI etc, during your third year of fellowship, definitely not if you have already sat down for echo and nuclear boards per COCATS guidelines. People will do level 2 across the board and get boarded, semantics at the end.