One important element in the sustenance of Radiology as a vital specialty composed of physicians with special knowledge and expertise is the excellence of subspecialty training. It cannot be denied that the transformation of imaging as a discipline, which by dint of the incisiveness of newly introduced and continually improved imaging techniques, has transformed and increasingly dominated the diagnostic enterprise.

The fact that deployment and enhanced utilization of the core modalities of CT, MR, IR, and to a lesser extent ultrasonography has remained largely within the purview of Radiology is primarily because we have developed estimable fellowship programs to train our graduating residents so that they gain cognitive and procedural competence shared by no one else. But now our monopolies have come under challenge from other specialties who wish that imaging too, could be in their grasp. The benefits of imaging to patients and to their practice are too enticing to be entrusted to us automatically especially when they have the wherewithal financially, administratively and even politically to claim a piece of the pie. The strength of our resolution to be the dominant player in the future depends in large measure on the vitality, the relevance, the specific qualities of education and the overall affirmative recognition of our fellowship programs.

And yet, today, among all the forums in which radiology education takes place undergraduate, GME, Public Medical Education, and CME, fellowship is the least assessed, the most unregulated, the least subject to quality control, and the most diverse in curriculum even within a particular discipline. To wit, programs outside the surveillance of the ACGME, by my estimate, direct the training for more than half of current fifth year learners. These fellows are like orphans. And those within the reach of RRC inspection are like the proverbial step-child getting less attention and consideration than other siblings in the house. It is time then to look at the fellowship experience closely, noting deficiencies in order to search for ways to better organize and superintend the education received by young radiologists during this year of training and to bolster the credentials a graduating fellow can present to his or her next employer.

As a first step in this critique, it may be helpful to look back to the seminal stage of fellowship development in the 1970s and early 1980s.

Discipline-based fellowships as situated within a post-residency year of further training in many branches of Radiology was uncommon at the beginning of the modern era of Radiology, i.e., the time of the introduction of cross-sectional imaging modalities in the 1970s. And in comparison with Internal Medicine around 1980, the two specialties went their separate ways in their approach to subspecialty education beyond residency. Internal Medicine fixed the period of residency at 3 years allowing for the introduction of 2 and 3 year subsequent fellowships in the maturing subspecialties of cardiology, gastroenterology, etc. The most vigorous of these subspecialties have been those most procedurally oriented in part because reimbursement policy in the U.S. favors procedural over cognitive work.

Radiology leaders at that time realized also that the corpus of knowledge had grown so vast that a 3 year term of specialty training was not long enough, so in the late 1980s the residency term lengthened to 4 years. Nonetheless, it became apparent soon after that further training focused in one area was needed even beyond a 4 year residency. Thus, fellowships gained in importance and in number, even though in the 1990s and until very recently many questioned whether the additional seasoning occasioned by a fellowship was really necessary for those entering the private practice of Radiology. So the alternative of direct entry into practice positions was still an option some thought to be a valid and economically secure career move.