Expected Trainee Interpretive Volumes and Potential Threats to Neuroradiology Program Viability: A Survey of Neuroradiology Fellowship Program Directors

Abstract

BACKGROUND AND PURPOSE:

Nationally clinical volumes are rising, putting greater pressure on radiologists to read more and in turn jeopardizing the academic missions of many training programs. The purpose of this study was to survey neuroradiology fellowship program directors (PDs) to identify reasonable expected trainee and faculty interpretive volumes, common barriers to study interpretation, and threats to fellowship program viability.

MATERIALS AND METHODS:

This was an institutional review board–approved survey study disseminated to neuroradiology fellowship PDs through the American Society of Neuroradiology. This Web-based survey included basic program information regarding practice setting, faculty size, fellowship size, and multiple questions related to interpretative volumes, barriers to study interpretation, threats to program viability, etc. Summary statistics were computed for count and rank variables. For survey questions by using ranking, cumulative ranks across all institutions were computed with a statistical ranking procedure based on Savage scores.

RESULTS:

Forty-three of 85 PDs responded to the survey. Median daily interpretive expectations for fellows were 20 daily cases during the first 6 months of the year and 30 during the second 6 months. Median daily interpretive expectations for faculty working with fellows was 32 daily cases during the first 6 months of the year and 38.5 during the second 6 months. Telephone calls from technologists and referring clinicians and protocoling were identified as major barriers to interpreting studies. Perceived major threats to program viability included increasing case volumes, understaffing, and burnout.

CONCLUSIONS:

Reasonable interpretive volumes determined by fellowship directors ranged between 20–30 daily cases for fellows and 32–38.5 daily cases for faculty working with fellows. Common barriers to interpretation were related to phone call interruptions and protocoling. Perceived major program viability threats remain centered on increasing clinical volumes and burnout.

Utilization of neuroimaging studies has markedly increased over the past 10 years across inpatient/emergency and outpatient settings.^{1 -4} This increasing volume of cases has contributed to increased workloads for neuroradiologists and is a major contributor to increasing rates of burnout and fatigue among radiologists.^5,6 This increasing volume for neuroradiologists has been associated with increased rates of perceptual and interpretive errors and is directly associated with higher-volume shifts.^{6 -9} In a recent survey of neuroradiology division chiefs from 42 academic neuroradiology division chiefs, the median estimated number of studies reasonably expected to be interpreted by neuroradiology faculty during a single work shift was 32 cross-sectional studies when reading independently, 25 when reading with a junior trainee (first- or second-year resident), and 33 when reading with a senior trainee (third- or fourth-year resident or fellow).¹⁰ Regarding workload, 22% felt they were at capacity, 37% above capacity, and 41% well above capacity.¹⁰ No division felt that they were below capacity.

In addition to the detrimental effect on the quality of clinical reads and clinical service, increasing case volumes have also negatively impacted the time and energy faculty have to dedicate to teaching, mentoring, and supervision of radiology trainees.⁵ Program directors (PDs) for neuroradiology fellowships have had to balance the increasing demands of clinical volume with balancing the educational and mentoring needs of their trainees. Our aim was to survey neuroradiology fellowship PDs through the Fellowship Directors Committee within the American Society of Neuroradiology (ASNR) to identify specific threats to fellowship programs related to increased work-related demands and to determine reasonable daily interpretive case volume for neuroradiology fellows.

MATERIALS AND METHODS

This was an institutional review board–approved study utilizing a Web-based survey distributed to all academic neuroradiology fellowship PDs listed by the ASNR through the Fellowship Directors Committee. E-mail correspondences were sent to the listed neuroradiology fellowship program to describe the purpose of the survey and to encourage participation. The survey was opened on July 1, 2023 and was closed on December 31, 2023.

Neuroradiology fellowship PDs were asked basic demographic information about their department of radiology and division of neuroradiology including type of institution (eg, university-associated hospital, community hospital, private/hybrid practice, etc), number of full-time equivalent (FTE) faculty within the division of neuroradiology, number of Accreditation Council for Graduate Medical Education (ACGME) neuroradiology fellowship positions, and how many residents and fellows rotate through the neuroradiology division simultaneously. PDs were asked their opinion on reasonable and safe case volumes for neuroradiology fellowship trainees (during the ACGME-accredited fellowship year) and faculty members stratified by the first half compared with the latter half of the academic year. PDs were also asked to rank the level of impediment non-RVU generating activities have on trainee education and clinical productivity. Last, questions related to burnout and potential threats to program viability were also included. The distributed survey instrument can be found in the Supplemental Data.

Appropriate summary statistics were computed for count and rank variables. Nonparametric correlation (Spearman ρ) was assessed among count variables. For survey questions by using ranking, the cumulative ranks across all institutions were computed and used with a statistical ranking procedure based on Savage scores. All analyses were performed by using statistical software (SAS version 9.4, SAS Institute). Effects associated with P < .05 were considered statistically significant.

RESULTS

Program Demographics

PDs from 43 unique institutions responded to the survey, representing 49% of all 85 ACGME-accredited neuroradiology fellowship programs in the country. All except 1 institution responded as a university-associated hospital. In addition to the university-associated hospital setting, programs also identified as community (n = 4), rural (n = 1), city (n = 7), private/hybrid practice (n = 3), and Veterans Affairs (n = 3).

For all responding programs, the median number of full-time equivalent (FTE) faculty was 10.3 and the median number of ACGME-accredited fellowship slots was 4, however, a large variation in fellowship program size was seen ranging from 1–13. The number of FTE faculty, number of ACGME-accredited diagnostic neuroradiology fellowship positions (excluding neurointerventional positions) available, and the number of trainees simultaneously rotating through the section are summarized in Table 1.

Table 1:

Summary of faculty, residents, and fellows in diagnostic neuroradiology fellowship programs

	Median (IQR) [Range]
Number of FTE faculty	10.25 (8, 13.9) [5–25]
ACGME accredited fellowship positions available	4 (2.5, 7) [1–13]
Number of residents on rotation simultaneously	2 (1, 3) [1–7]
Number of fellows on rotation simultaneously	1 (1, 2.5) [1–15]

Note:—IQR indicates interquartile range, FTE, full-time equivalent; ACGME, Accreditation Council for Graduate Medical Education.

The number of FTE faculty was positively correlated with the number of available ACGME-accredited fellowship positions (ρ = 0.578, P < .0001). There was also a positive correlation between the number of residents and fellows on rotation simultaneously (ρ = 0.485, P = .001) with the larger programs having more trainees on rotation simultaneously.

PD Volume Expectations

Surveyed PDs had different expectations for a reasonable case-volume for fellows during the first 6 months of the year compared with a higher expectation during the latter 6 months of the year. For the first 6 months of the year the median daily interpretive expectation for fellows was 20 cases, increasing to 30 cases by the second 6 months of the year (Table 2). There was a wide variation in expected interpretive volumes for trainees as shown in Table 2.

Table 2:

Expected number of neuroradiology cases in the opinion of PDs

	Median (IQR) [Range]
Faculty member interpretations in rotation with a fellow during 1st half of the year	32 (28.75, 40) [15–50]
Faculty member interpretations in rotation with a fellow during 2nd half of the year	38.5 (30, 50) [15–60]
Interpretations by a fellow during 1st half of the year	20 (20, 25) [12–30]
Interpretations by a fellow during 2nd half of the year	30 (25, 36.25) [20–50]

For faculty working with fellows, a similar expected interpretive volume increase was noted between the first 6 months of the year compared with the latter 6 months of the year. For PDs, a reasonable expected daily read volume from faculty who are still able to provide teaching and support to the fellows is 32 cases during the first 6 months of the year and 38.5 cases during the latter 6 months of the year. There was also a large variation in the expected daily interpretive volumes for faculty as shown in Table 2.

Regarding expected number of interpretations, all 4 variables in Table 2 were positively correlated (P < .0457).

Barriers Limiting Trainees from Interpreting Studies

The fellowship PDs reported that the 2 greatest factors limiting trainees from interpreting studies come in the form of interruptions, such as responding to telephone calls and consult requests. The highest ranked limiting factor is trainees responding to telephone calls and messages from technologists for protocols and scan checks. This is followed by the trainees responding to telephone calls and messages from referring clinicians and staffing imaging consultations.

Protocoling cases was ranked third of 9 possible factors limiting trainees from interpretating studies.

Moderate limiting factors to interpreting studies were managing the procedure service, managing contrast reactions, and time diverted to other learners, such as visiting observers and medical student or rotators from other clinical services.

Faculty independently reading cases from the queue was not deemed to be a substantial barrier to trainees interpreting studies. These findings are summarized in Table 3.

Table 3:

Rank order of responsibilities and factors that limit fellows from interpreting studies

Rank	Responsibilities and Factors	Median (IQR) [Range]
1	Answering telephone calls/pages/messages from technologists to check studies	1 (1, 2) [1–6]
2	Responding to consults from referrers/clinicians	3 (2, 4) [1–7]
3	Protocoling cases	3 (2, 4.25) [1–9]
4	Managing procedure service/performing procedures	5 (2.75, 6) [1–8]
5	Patient care issues managing contrast reactions	5 (4, 6) [1–9]
6	Responsibilities for teaching observers/other trainees in the reading room	5 (4, 6) [2–9]
7	Faculty independently reading cases, which decreases the number of available studies	7 (5, 8) [1–8]
8	Postprocessing images	7.5 (7, 8) [5–9]
9	Other factors	9 (9, 9) [1–9]

Challenges to Program Viability

Several factors were identified by PDs as being perceived threats to the viability of their neuroradiology fellowship program. The greatest risk was reported as increasing clinical workloads and volume negatively affecting the overall educational experience. Issues related to understaffing and burnout of faculty were nearly equally identified as subsequent substantial factors threatening programs. Despite the high risk of burnout among faculty threatening program viability, burnout among trainees was not felt to be a substantial threat. The challenges to program viability are summarized in rank order in Table 4. Summary statistics are also included.

Table 4:

Challenges to program viability

Rank	Factor	Median (IQR) [Range]
1	Workload volume	2 (1, 3.75) [1–6]
2	Understaffed faculty	3 (2, 4) [1–8]
3	Burnout in faculty	3 (2, 4.75) [1–7]
4	Competition with other fellowships	5 (2, 6) [1–7]
5	Funding	5 (3, 6) [1–8]
6	Not enough incoming residents for neuroradiology fellowships	5.5 (4, 7) [1–8]
7	Burnout in fellows	6 (4, 7) [1–7]
8	Other	8 (8, 8) [1–8]

Successful Interventions Used to Combat Neuroradiology Fellow Burnout

Open-ended responses by fellowship PDs were categorized and ranked according to frequency. The most common strategies used to combat neuroradiology fellow burnout were increasing wellness activities (14/43) including social activities, meals during conferences, and providing wellness programs/resources, and providing academic time for fellows (13/43).

These were followed by minimizing tasks with limited educational value either by incorporation of physician extenders, reading room assistants, and protocoling by technologists or by technologic resources to protocol and improve efficiency (n = 9/43); reducing call requirements (n = 9/43), limiting clinical diagnostic/procedural volume (n = 9/43); and flexible scheduling and extra days off (n = 7/43).

Less commonly listed strategies included frequent meetings between the PDs and fellows with more open communication (n = 3) and creating rotations that help decompress the worklist (n = 3). Additional strategies are listed in Table 5.

Table 5:

Successful strategies to limit burnout

Strategy	Frequency of Response
Wellness activities: Increase social activities, lunch or dinner with journal clubs, breakfast during conference, in person conference, wellness programs, increase awareness of mental health resources, regular breaks	14
Academic time	13
Minimize tasks with limited educational value (via extenders, reading room assistant, nurse practitioner, techs to protocol), autoprotocoling, technologic resources to improve efficiency, organize protocoling schedule)	9
Reduce call requirements (remove angio, remove evening/overnight, later start, decreasing length of coverage time, allowing for short preliminary reports on call, reduce frequency; moonlighting fellow to help weekend call fellow)	9
Limit case volume (including faculty reading examinations on own), reduce workday hours, reduce procedures	9
Flexible scheduling, extra day off (wellness day, pre/post call day off), advanced schedule made for whole year	7
Frequent PD meetings with fellows, open communication	3
Creating rotations that help decompress worklist (adding float rotation to help decompress other services, new short afternoon shift to decompress list)	3
Increase elective options	1
Larger fellowship class	1
Active mentorship	1
Increased number of faculty	1
Monthly faculty meetings to discuss work and fellowship issues	1

Successful Methods Used to Help Trainees Reach Appropriate Reading Volumes

Open-ended responses by fellowship PDs were categorized and ranked according to frequency. The most common successful methods used by PDs to help trainees reach appropriate reading volumes were to encourage and provide strategies to increase volume including providing brief structured reports (n = 13/43) and reviewing individual case numbers regularly with fellows (n = 11/43).

These were followed by the PDs providing volume guidelines to the fellows (n = 8/43) and decreasing distractions and responsibilities with lower educational value (n = 8/43). Seven PDs mentioned that fellows reaching appropriate volumes is not an issue given their high-volume practice. Additional strategies are included in Table 6.

Table 6:

Strategies used to help trainees reach target volumes

Strategy	Frequency of Response
Encourage and provide strategies to increase volume: emphasize balancing speed with accuracy, development of a search pattern, time management, encourage brief structured reports (3); start weekend call early to learn efficiency early on	13
Review numbers regularly	11
Give volume guidelines/minimum daily or weekly numbers	8
Decrease distractions and responsibilities with lower educational value, have others (faculty, residents, reading room assistants) take on “fellow” responsibilities, alternative shifts to minimize distractions	8
High volume practice not an issue	7
Assign cases	2
Not succeeded: some trainees do not seem to respond to feedback; some remain slow or unmotivated; unable to motivate fellows, burnt out, unable to address nonreading demands	2
Have fellows overread overnight cases and include conference cases and cases from external electives	1
Encourage faculty not to read cases independently	1
Reduce conference coverage	1
Focus on education early in year to increase fellow competence and confidence leads to higher volumes in 2nd half	1

Open-Ended Comments

Four of the 8 comments provided by fellowship directors specifically remarked on the negative effects of clinical volume on education with increasing faculty burnout and stress. One fellowship director mentioned that the difficulty teaching trainees has made it difficult to capture the interest of residents going into neuroradiology. A comment was also made on the increased nonradiologic obligations that cause frustration.

DISCUSSION

Approximately one-half of the ACGME-accredited neuroradiology fellowship programs in the United States responded to this survey sent to PDs through the ASNR Fellowship Directors Committee. Responses to specific questions related to expected faculty daily interpretive volumes demonstrated a concordant increase between daily expected interpretive volumes between the first 6 months of the year and second 6 months of the academic year of 32 and 38.5, respectively. These numbers were independently identified and are in line with those reported by the ASNR division head survey, performed within the year before this study, reporting an expectation of 32 daily cross-sectional studies when reading independently, and 33 when reading with a senior trainee (third- or fourth-year resident or fellow).¹⁰

Responses to specific questions related to expected fellow daily interpretive volumes demonstrated a concordant increase between daily expected interpretive volumes between the first 6 months of the year and second 6 months of the academic year of 20 and 30, respectively. This consensus opinion volume of the neuroradiology fellowship PDs is greater than the ACGME interpretive minimum requirement. The ACGME requires a minimum of 3000 CT and MRI cases need to be interpreted in a year by a neuroradiology fellow. Assuming 188 standard workdays per year, this would require an average of 16 cases per day, which is below the expectations of the neuroradiology fellowship PDs.¹¹ This highlights the discrepancy between expected interpretive volumes needed to achieve minimum clinical competency according to the ACGME requirements and neuroradiology fellowship PDs’ perception of the interpretive volumes needed to prepare fellows for the routinely higher clinical case volumes of any clinical practice.

Common barriers limiting the number of interpretations made by fellows were identified. Telephone calls and messages from technologists related to protocols and scan checks were identified as the most substantial barrier, followed by telephone calls and consults from referring clinicians, and protocoling studies. Open-ended responses by PDs to help trainees reach appropriate reading volumes included encouraging and providing strategies for fellows to increase their volume such as the use of brief structured reports and search pattern, regular quarterly review of fellow case numbers, and providing fellows with clinical daily volume guidelines. Additional strategies include decreasing distractions by minimizing noneducational activities and disruptions, such as disbursing these roles among multiple fellows, residents, faculty, and physician extenders.

A number of perceived threats to program viability were identified by the PDs. The largest threat was identified as increasing work volumes with the associated downstream effects. This is supported by numerous publications in the literature highlighting the deleterious effects that increasing case volumes are having in the clinical workforce. Also likely related to the increased volumes, issues of faculty understaffing and faculty burnout were identified as major perceived threats to program viability. The decreased ability to teach and maintain the academic mission due to increased clinical demands further compounds the feeling of burnout. Furthermore, it may decrease the ability to capture the interest of trainees to pursue academic neuroradiology, further contributing to understaffing. These results are not surprising and have been echoed throughout multiple other publications. However, despite increasing awareness of these issues, solutions to combat these threats have been limited.⁵

Despite the major threat of faculty burnout, most PDs felt that fellow burnout was not an issue; while this is from the PDs’ perspective and not directly that of the fellows, it likely highlights the contrast in the fellow experience from the faculty. In their open-ended responses, the PDs included a number of initiatives taken to reduce fellow burnout, likely done in response to ACGME requirements and ACGME and internal surveys, with active efforts to limit burnout and improve wellness. As a training program, there is a luxury in limiting the workload for the fellows not applicable to the faculty: limiting fellow case numbers and clinical day and call responsibilities usually necessitates increased independent reading and additional responsibilities for faculty, whereas limiting faculty numbers typically requires larger systemic and financial adjustments, such as hiring, provisions for moonlighting, and outsourcing.

While this effort to reduce clinical and call responsibilities is advantageous for fellows, it may ultimately further contribute to higher faculty burnout and its negative effects on training programs. Reducing call responsibilities and noneducational duties for fellows often shifts these tasks to the faculty. In addition, limiting the case volume and call responsibilities of fellows may leave them less prepared for the high case volumes common in current practices.

Implementing physician extenders such as reading room assistants to field telephone calls and contact referring physicians, nurse practitioners, and physician assistants to help manage procedures, and techs to protocol, can benefit both trainees and faculty by reducing distractions and disruptions. Additionally, with increasing roles for artificial intelligence (AI) and algorithmic approaches to the noninterpretative parts of clinical workflow, these solutions may be used to increase time dedicated to image interpretation and education. Utilizing autoprotocoling, AI tools for scan checks, increasing wellness activities including social events, conference meals, and wellness programs can also support both fellows and faculty in promoting work-life balance.^12,13 While many of these strategies may be temporizing solutions, addressing the root cause of the imbalance between staffing and workload may provide a more effective and lasting solution.

Last, advocacy, educational, and trainee resources may be leveraged through professional radiology organizations such as the ASNR, American College of Radiology, and the Radiological Society of North America. Through these efforts the creation of suggested guidelines and benchmarks for fellowship programs can be developed.

This study is not without limitations. This was a voluntary survey disseminated to neuroradiology fellowship PDs across the country through the ASNR. Approximately one-half of PDs responded to this survey. Potentially, PDs from the nonresponding programs may have different opinions that could affect the results. Additionally, because this was conducted as a survey of the PDs, these data reflect solely the opinions of the PDs. Neuroradiology fellows and division heads may have different opinions on volume expectations, perceived program threats, and barriers to study interpretations.

CONCLUSIONS

The results of this study demonstrate neuroradiology fellowship PD consensus on interpretive volume expectations for neuroradiology fellows from 20 daily cases in the first half of the academic year increasing to 30 in the second half, corresponding with increases in fellow proficiency. The interpretive volume expectations for neuroradiology faculty working with fellows was 32 in the first half of the academic year and 38.5 in the latter half; these expected interpretive volumes are in line with previously published survey data conducted among neuroradiology division heads. Increasing clinical volumes, understaffing, and faculty burnout were identified as major perceived threats to program viability.

ABBREVIATIONS:

ACGME

Accreditation Council for Graduate Medical Education

AI

artificial intelligence

ASNR

American Society of Neuroradiology

FTE

full time equivalent

PD

program director