Health Policy and Practice / Sant? e : politique et pratique m? edicale
Trends in Radiology Fellowship Training: A Canadian Review 2009-2011
John Ryan, MD*, Ashish Khandelwal, MD, Najla Fasih, MD
Abdominal Radiology, University of Ottawa, Ottawa, Canada
Purpose: To assess the percentage, type, and location of radiology fellowships chosen by graduating Canadian residents between 2009
Methods: A short e-mail questionnaire was sent to the radiology program directors at all 16 institutions in Canada that provide English or
French residency. The responses were collected between December 6, 2010, and May 20, 2011.
Results: A 75% response rate was observed for the survey: 76%e79% residents were enrolled in radiology fellowship training. In 2009e
2010, 72%e73% of residents remained in Canada. This dropped to 51% in 2011. In 2009e2010, 22%e23% of residents chose U.S.-based
radiology training. This rose to 49% in 2011. Europe was chosen by 0%e4% of residents: all of whom were French-speaking residents, and
all programs were in France. Relatively consistent percentages of radiology residents choose abdominal (19%e30%), cardiac (4%e7%),
musculoskeletal (12%e20%), and pediatrics (2%e5%) from year to year. Greater variability was noted in chest (2%e9%), women’s imaging
(0%e14%), intervention radiology (6%e18%), and neuroradiology (2%e18%). Radiology fellowships in split subspecialties, which were
available at a small number of institutions, were chosen by 8%e9% of the residents.
Conclusions: Nearly 4 of 5 residents choose radiology fellowship training. In 2011, there was a 2-fold increase in the number of residents
who chose training in the United States. This may be a 1-year outlier but should be observed. Awide range of fellowships were chosen, with
consistent numbers in some core fellowships and variability in others year to year. Limited exploration of the rationale for, or employability
value of, radiology fellowship choices has been done in Canada. Nearly 1 of 10 residents chose split radiology fellowships, an option limited
by availability at few centers. The value of expanding this option is worthy of investigation.
R? esum? e
Objet :?Evaluer le pourcentage de r? esidents canadiens en derni? ere ann? ee ayant choisi un programme de perfectionnement en radiologie de
2009 ? a 2001, de m^ eme que le type et le lieu des programmes s? electionn? es.
M? ethodes : Un court questionnaire a ? et? e envoy? e par courriel aux directeurs des programmes de radiologie des 16 ? etablissements canadiens
qui offrent un programme de r? esidence en anglais ou en franc ¸ais. Les r? eponses ont ? et? e recueillies du 6 d? ecembre 2010 au 20 mai 2011.
R? esultats : Le taux de r? eponse au sondage est de 75 %. De ce nombre, de 76 ? a 79 % des r? esidents ? etaient inscrits ? a un programme de
perfectionnement en radiologie. En 2009e2010, de 72 ? a 73 % des r? esidents sont rest? es au Canada. Ce pourcentage a chut? e ? a 51 % en 2011.
En 2009e2010, de 22 ? a 23 % des r? esidents ont choisi un programme de formation en radiologie offert aux?Etats-Unis. Ce pourcentage est
pass? e ? a 49 % en 2011. L’Europe est une destination s? electionn? ee par 0 ? a 4 % des r? esidents. Il ne s’agissait que de r? esidents francophones
ayant choisi d’? etudier en France. Au fil des ans, les pourcentages de r? esidents en radiologie ayant choisi les domaines suivants sont
demeur? es relativement constants : radiologie abdominale (de 19 ? a 30 %), cardiaque (de 4 ? a 7 %), musculosquelettique (de 12 ? a 20 %) et
p? ediatrique (de 2 ? a 5 %). Une variation sup? erieure a ? et? e observ? ee en radiologie thoracique (de 2 ? a 9 %), en imagerie gyn? ecologique (de 0 ? a
14 %), en radiologie interventionnelle (de 6 ? a 18 %) et en neuroradiologie (de 2 ? a 18 %). Offerts par tr? es peu d’? etablissements, les
programmes de perfectionnement englobant plusieurs sursp? ecialit? es radiologiques dans un m^ eme temps ont ? et? e choisis par 8 ? a 9 % des
Conclusions : Pr? es de 4 r? esidents sur 5 choisissent un programme de perfectionnement en radiologie. En 2011, le nombre de r? esidents ayant
choisi d’? etudier aux?Etats-Unis a doubl? e. Il pourrait s’agir d’un ? epiph? enom? ene propre ? a cette ann? ee pr? ecise, mais ce r? esultat ne doit quand
m^ eme pas ^ etre pass? e sous silence. Une vaste gamme de programmes de formation ont ? et? e choisis. D’une ann? ee ? a l’autre, le nombre de
r? esidents demeure constant dans certains domaines importants et varie dans d’autres domaines. Au Canada, les motifs justifiant les choix de
programmes de formation en radiologie ou les effets de ceux-ci sur l’offre d’emploi ont ? et? e peu ? etudi? es. Pr? es d’un r? esident sur dix a choisi un
* Address for correspondence: John Ryan, MD, Department of Diagnostic
Imaging, The Ottawa Hospital, 1053 Carling Avenue, Ottawa, Ontario K1Y
E-mail address: firstname.lastname@example.org (J. Ryan).
0846-5371/$ - see front matter ? 2013 Canadian Association of Radiologists. All rights reserved.
Canadian Association of Radiologists Journal 64 (2013) 176e179
programme de formation englobant diverses sursp? ecialit? es de la radiologie, une option offerte de fac ¸on tr? es limit? ee dans peu de centres. Il
vaudrait la peine d’effectuer des recherches suppl? ementaires sur les avantages du d? eveloppement de ce type de programme.
? 2013 Canadian Association of Radiologists. All rights reserved.
Key Words: Canadian; Fellowship training; Survey; Subspecialty
Multiple factors influence a resident’s career choices
[1,2]. Based on the current trend of the increase in high-
technology modalities and expanding applications, the need
for highly qualified radiologists in both academic and
nonacademic settings is clear [3,4]. The choice of radiology
fellowship training is often multifactorial and unique to
individual circumstances [1,2]. Many radiology residents opt
for advanced training to follow both personal interests and/or
to serve as niche specialty partners in a variety of clinical
settings. Some pioneering work has been done to assess for
subspecialties at risk for physician shortages in Canadian
academic radiology departments . There is no clear
information available to date on the actual radiology
fellowship choices of residents in Canada. The purpose of
this survey was to gather data on the radiology fellowship
choices made by Canadian trainees from the years 2009
This information is useful to understand the current trends
on a national scale and to identify areas of potential defi-
ciency or surplus in the Canadian Health Care system.
Understanding the trends in radiology fellowship choices and
whether training is obtained in Canada will help to guide or
model the structure of organized fellowships in Canadian
programs and alter the policy decisions that affect training
and education. It may also provide insight into other issues in
radiology fellowship organizations or serve as a launching
point to investigate such issues in the Canadian paradigm.
The program directors at all 16 universities in Canada that
provide residency training in radiology were contacted via
e-mail, and the survey was open for 5.5 months, from
December 6, 2010, to May 20, 2011, with invitations to
participate through e-mail questionnaire. A total of 3
reminders were send at regular intervals. The program direc-
tors were requested to provide the following information:
1. The number of postgraduate yeare5 residents who were
finishing training in each of the years 2009 (class of
2008e2009), 2010 (class of 2009e2010), and 2011
(class of 2010e2011).
2. The number of these residents in each of the years 2009,
2010, and 2011 who were planning for or had begun
fellowship training after residency.
3. The type of fellowship chosen.
4. The location of the fellowship chosen.
Analysis of the data was descriptive, with frequency
tables and graphs to highlight survey results.
A total of 12 of 16 program directors responded, which
represented a 75% response rate to the survey. Among these
programs, 9 (75%), 12 (100%), and 10 (83%) provided
information for year 2009, 2010, and 2011, respectively.
These data are depicted in detail in Table 1. A total of 76%e
79% of the residents were enrolled in fellowship training.
There was consistency in this ratio, with 44 of 58 (76%), 50
of 65 (77%), and 35 of 44 (79%) in years 2009, 2010, and
2011 respectively. These data are demonstrated graphically
in Figure 1.
A total of 72%e73% of residents remained in Canada in
2009e2010 for fellowship training. This figure dropped to
51% in 2011. In 2009e2010, 22%e23% of residents chose
training based in the United States, with a corresponding rise
to 49% in 2011. European training was chosen by 0%e4% of
residents, all of whom were French speaking, and all
fellowship programs chosen were located in France. These
data are shown in Table 2.
Residents have chosen among a wide range of available
subspecialty fellowship options. A relatively consistent
percentage of residents chose training in abdominal (19%e
30%), cardiac (4%e7%), musculoskeletal (12%e20%), and
pediatric (2%e5%) programs from year to year. Greater
variability was noted in chest (2%e9%), women’s imaging
(0%e14%), intervention radiology (6%e18%), and neuro-
radiology (2%e18%) fellowship choices. These data are
graphically shown in Figure 2. A small but consistent
number of residents chose to pursue breast, cross-sectional,
and magnetic resonance imaging fellowships (1%e3%).
These data are summarized in detail in Table 3.
Training in split subspecialty combinations fellowships
were chosen by 8%e9% of residents. These combinations
included 2 subspecialty trainings in a single year’s time. The
most common split fellowship components were cardiac,
women’s imaging/breast, and musculoskeletal, which vary
from training center to center. These fellowships are
Total program participation in the survey from 2009 to 2011
Total no. (%)
Total no. (%)
year for which
Actual % of
177 Radiology fellowship trends in Canada / Canadian Association of Radiologists Journal 64 (2013) 176e179
available at only a few training institutions. When consid-
ering the limited availability, this is an interestingly sizable
Fellowship training in radiology begin in 1959, with
speciality training in neuroradiology at Columbia university
. The judgement to pursue fellowship is multifaceted and
often an individual choice, but repercussions from this
decision have an obvious major influence on our speciality.
The factors that were thought to affect most in the previous
study by Ng et al  were interesting work (93.34%), job
availability (55.83%), and work hours and/or on call
schedule (55.83%). Ultimately however, fellowship training
affects the skill of medical service delivery, the employment
environment, research, and innovation in both general and
subspecialty practice environments. Most research to date in
this arena has been performed with American trainees .
There is a continuous increasing trend towards obtaining
fellowship certification. In the only study based on Canadian
institutions, quoted above by Ng et al , 65.83% graduates
intended to do a fellowship in year 2006 compared with an
average of 77.5% in the 3-year interval of 2009e2011 in our
study. The increase may be due to many factors but was
ultimately based on the perceptions of requisite and/or value,
and on the availability of training. Limited work has been
done to establish the value of fellowships or to tailor
fellowship training to observed need for skill development in
the Canadian Health Care system.
In our study, the most popular fellowships were abdominal
(19%e30%), neuroradiology (2%e18%), musculoskeletal
(12%e20%),and intervention(6%e18%). Thereis
considerably more variation in neuroradiology and interven-
tion radiology fellowships, and, to a lesser degree, women’s
imaging and chest imaging fellowship, as a choice from year
to year. Our results are confirmed with the previous Canadian
trend. In the study by Ng et al , of the 80 residents who
intended to pursue further training, abdominal and/or body
imaging was the most popular choice, with 12% of residents
selecting it. Interventional radiology, neuroradiology, and
musculoskeletal were opted by 10% each .
In another survey, conducted by Goodman et al  for the
class of 1999e2000 among third-year (n ¼ 395) and fourth-
year (n ¼ 402) residents, the body imaging fellowship (29%e
32%) and intervention fellowship (27%e28%) were the most
sought after fellowships. Although our figures for body and/or
abdominal imaging are comparable, they are different in
intervention radiology. This discrepancy in figures for inter-
ventional radiology also was highlighted in the survey con-
ducted by Canadian Interventional Radiology Association .
Figure 1. Exact number and percentage of residents choosing fellowships
Total number (%) of residents who chose different fellowship places
Fellowship2009 2010 2011
Figure 2. Different subspecialties chosen by resident years 2009-2011.
Exact number (%) of residents who chose the different fellowship
Speciality 20092010 2011
% Opting for fellowship
MRI ¼ magnetic resonance imaging; MSK ¼ musculoskeletal; Neuro ¼
178 J. Ryan et al. / Canadian Association of Radiologists Journal 64 (2013) 176e179
Although 51% of respondents in this survey were ‘‘moderate’’ Download full-text
or ‘‘very’’ interested in the field of intervention, only 13% re-
ported intention to do an intervention fellowship. The
researchers attributed this downhill trend in intervention to
lifestyle issues such as a greater call burden and work hours,
field, and the lack of intervention exposure to trainees.
A number of further issues are raised in this survey. There
was an increase in the number of Canadian resident who
pursued the fellowship training in United States, with data
showing that 72%e73% of residents chose Canada in 2009e
2010 vs 51% in 2011, which represents a doubling in the
number of residents who, in 2011, wanted to pursue training
based in the United States. This fact has never been brought
into notice in the past and should potentially alarm Canadian
academic radiology departments if a trend develops. Reasons
for this choice may also be investigated.
Radiology department chairs’ survey indicated that all
subspecialty areas will experience manpower shortages if
current trends continue . The recommendations include
changes to the structure, content, and delivery of fellowship
training, with an emphasis on increased flexibility within
Our current fellowships are highly structured and often
designed with departmental service in mind. There may be
value or the need for more flexible fellowship options for
residents with specific career goals, such as work in commu-
nity or large general practice settings where areas of niche
expertise are valuable but at a lesser degree than in tertiary
work environments. Currently, 8%e9% of trainees opt for
combination fellowships, although most institutions do not
offer such programs. The statistics may be higher if greater
tailoring were available in fellowship design. Cardiac,
women’s imaging/breast, and musculoskeletal are the favored
subspecialty components of the combined fellowships.
A minority of residents (0%e5%) seek European
with all choosing France as the training location. All other
trainees chose fellowship programs in Canada or the United
States. Mammography (1%), cardiac (4%e7%), and pediatric
(2%e5%) radiology fellowships were the least opted choices
in the survey. Unfortunately, these are the subspecialty areas
predicted to be vulnerable to future shortages. Previously,
concern was raised for the increase in shortage in the area of
mammography and women’s imaging, with 22% of depart-
ment heads predicting shortages in the next 5 years, but this
numberincreases to 78% inthe next10 years . Ng et al 2
also previously made an observation that interventional radi-
ology, neuroradiology, mammography, cardiac imaging, and
pediatric radiology were the areas in which there will be
increasing workforce demand, and mammography, pediatric
radiology, and cardiac imaging were the areas in which there
will be a potential decrease in supply. If such deficiencies are
fellowship programs, as well as investigation as to why the
residents to provide adequate fulfilment of the need.
The results of this study are needed to be interpreted with
its limitations in mind. The data were acquired through
departmental record and recall, and could have been
improved with direct resident involvement with detail
interviews and questionnaires to assess their behavior.
Furthermore, we have collected data only pertaining to the
postgraduate yeare5 residents in a given year.
There is an increasing trend to do subspecialty fellow-
ships, with 76%e79% of Canadian trainees choosing to
undergo fellowship training. There is concern about the
recent trend in Canada to do fellowship training in the United
States, with only 50% remaining in Canada for training in
2011. Abdomen, cardiac, musculoskeletal, and pediatrics
were consistent in the number of residents choosing them as
fellowship choices. Mammography, cardiac, and pediatric
radiology were the least elected individual choices in the
survey and are identified as areas of potential deficiency in
training. Approximately 8%e9% of trainees chose split
fellowships. Although popular, this statistic is quite limited,
based on availability, with a highly limited number of centers
proving this option. Cardiac, women’s imaging, and
musculoskeletal are the favored subspecialty components of
these combination fellowships. This may require some
consideration in future fellowship development to allow
greater expertise development for radiologists who plan to
work in mixed or general radiology environments but which
have specialized interests or would like to develop niche
skills to be of greater service to nonsubspecialty groups.
We hope that the results will provide additional impetus to
and environments. Further surveys that incorporate factors that
influence fellowship training choices would add to our under-
standing of resident’s subspecialty choices in radiology.
 Feng L, Ruzal-Shapiro C. Factors that influence radiologists’ career
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 Ng KL, Yazer J, Abdolell M, et al. National survey to identify subspe-
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departments. Can Assoc Radiol J 2010;61:252e7.
 Bhargavan M, Sunshine JH. Utilization of radiology services in the
United States: levels and trends in modalities, regions, and populations.
 Soni K, Bhargavan M, Forman HP, et al. Who’s underworked and who’s
overworked now? An update on radiologist shortage and surplus. AJR
Am J Roentgenol 2010;194:697e703.
 Gay SB, Resnik CS, Harolds JA, et al. The radiology fellowship and
fellowship match: current status. Acad Radiol 2003;10:303e8.
 Goodman CJ, Lindsey JI, Whigham CJ, et al. Diagnostic radiology
residents in the classes of 1999 and 2000: fellowship and employment.
AJR Am J Roentgenol 2000;174:1211e3.
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179 Radiology fellowship trends in Canada / Canadian Association of Radiologists Journal 64 (2013) 176e179