Life as a trainee
How is radiology training structured?
Ok, so you've been offered a training post in clinical radiology, but what does that involve? How long does it take? When do you specialise? I hope we can give you an idea about what to expect so read on! Radiology training is 5 years in total (ST1-5). At the end of 5 years you will be awarded a Certificate of Completion of Training (CCT) and will be eligible to join the GMC specialist register as a Consultant Radiologist. A proportion of radiology trainees decide to sub-specialise in interventional radiology - in this case the training is extended by an extra year (so 6 years in total). The training is broadly split into two components:
- 3 years of core training (ST1-ST3)
- 2 years sub-specialty training (ST4-ST5) or 3 years if doing interventional radiology (ST4-ST6)
In general there are two main models of clinical radiology training in the UK and the model used will depend on the training scheme you apply to:
- The first is a more traditional, hospital-based apprenticeship where trainees learn on the job with live cases and consultant/senior supervision.
- The second is in a scheme with a radiology adacemy. These academy schemes tend to have more tutorials, simulations and skills-labs, with less focus (at least early on) with seeing live cases.
Both models have their relative advantages and disadvantages, and in reality most training schemes will use a mixture of both the apprentiship model and tutorials/simulations. At the end of the day it doesn't matter which training model is used as everyone should get a CCT in clinical radiology.
Core training (ST1-3)
The first three years of radiology training are spent learning the basics. This is the core radiology that all radiologists must know.
At the beginning much of the time is spent integrating into a new department that works quite differently to most others in a hospital. Transitioning from a ward-based job to radiology can be a culture shock for some, as you go from the chaos and lack of structure to relatively fixed and comprehensive timetable. This may seem a little daunting at first. Much of the time trainees feel supernumerary and are unable to practise independently without running their decisions past more senior trainees or consultants. This can be hard for more experienced trainees to deal with, especially if they have undertaken registrar training in other specialties before coming into radiology. They have to 'take a step back' and become students again!
After a few months trainees settle in and the first step is to pass the Fellowship of the Royal College of Radiologists (FRCR) First FRCR exam. This exam is taken in Spring of the first year and consists of a physics and an anatomy exam. During ST1 trainees will also be introduced to the different imaging modalities such as ultrasound, CT, MRI and fluoroscopy. Timetables are designed to encompass these topics whilst covering the Royal College of Radiologists curriculum.
Learning to operate the fluoroscopy machine
ST2 & ST3
The 2nd and 3rd years of radiology training are all about learning core radiology skills, such as CT and plain film interpretation, and basic interventional skills such as ultrasound guided drain insertion. Trainees will enter the on-call rota for evenings/nights and slowly gain experience and confidence. There is also the FRCR 2A exam to study for, which is taken during ST3. The FRCR 2A consists of two long papers sat on the same day with questions covering each radiology subspeciality (ie GI, MSK, GU etc). This is a difficult exam and many trainees underestimate the amount of time required and reading involved when revising for it.
As trainees approach the end of their third year (ST3) they must decide on what aspects of radiology they would like to specialise in. Some trainees choose to sub-speclise in a single area in detail e.g. neuroradiology or gastrointestinal radiology. Other trainees decide to specialise in a number of areas and gain a more broad skillset e.g. breast with abdominal radiology. It is also at this time that trainees must decide whether to continue with diagnostic radiology or change to the interventional radiology curriculum and add another year onto their training.
Having a little snack between CT reporting during a night shift as an ST3.
Sub-specialty training (ST4-5)
(+ST6 if undertaking interventional radiology training)
The last two years of radiology training are spent specialising in a particular area of radiology.
Most trainees spent two years training (finishing at the end of ST5), however a few trainees will have decided (at the end of ST3) to move to the interventional radiology curriculum and spend three years training (finishing at the end of ST6).
At the beginning of ST4 trainees take the Final FRCR 2B exam (hopefully their last exam ever!). This is a big exam made up of 3 parts: a rapid reporting session (rapids), a reporting session (long cases) and an hour long oral examination (viva). Once passed, trainees become Fellows of the Royal College of Radiologists and can use the letters FRCR after their name.
Towards the end of training they can apply for consultant posts, however some decide to gain more experience and go on to do a fellowship job (usually one year). Some trainees decide to take some ‘out of programme experience’, which is time outside of training, usually used to learn new skills at a different institution. There can be a lot of flexability so speak to your local radiologist team if you want to find out more.
Example of a 'typical' ST1 week
Training as an ST1 in clinical radiology has a pretty steep learning curve. There are a lot of new skills to learn, such as operating a fluoroscopy table, at the same time as understanding the radiological terminology, which is generally picked up by 'diffusion'. Weekly timetables vary however they should all cover the core competences required. A typical working week will consist of four days within the department and one day of FRCR part 1 teaching. Here is an example ST1 week:
Eight o’clock start for FRCR 2B x-ray teaching. Yes 2B, that’s not a typo. Teaching for and developing the correct exam technique for the final 2B begins from the first day. This typically lasts for an hour with all pre exam trainees taking turns to describe the image. The golden rule is to keep quiet unless you’re in the hot seat.
At nine, the working day begins with a fluoroscopy list, which consists of a range of cases from barium swallows to proctograms. After a few weeks of barium swallows, enemas and use of the fluoroscopy table it becomes second nature. In a typical session the cases would include a range of hiatus hernias, oesophageal pouches, webs and occasionally tumours.
X-ray reporting station
After lunch an x-ray reporting session is timetabled. This involves sitting in a dark room and working through a pack of x-rays and reporting them. Chest x-rays can be the easiest or most difficult modality to interpret. A good understanding of anatomy and pathology is essential. As a first year trainee reports are provisional and need to be checked by a consultant. Trainees are advised to keep a record of the provisional reports and compare it to final report. Generally as a first year the expectation is to identify any abnormality present. If something requires immediate attention such as misplaced nasogastric tube it is essential to find somebody to authorise the report. The day typically finishes at 5pm.
8:30 start, this time for MRI teaching. As a first year identification of MRI sequences and any grossly obvious pathology is expected. After teaching the morning session begins with a outpatient ultrasound list. This involves scanning anything from the neck down including the thyroid, ovaries, testes and kidneys. This is difficult because the image depends on the angle of the probe and it can be frustrating not being able to get a clear image, or any at all, whilst a senior can make a slight adjustment that makes everything look completely different.
In the afternoon a teaching x-ray reporting session is planned with a consultant who will review each image with you. At first this can be a case of 'Ctrl+A Delete' and rewrite the report, but as you gain experience you soon notice a big improvement and this happens much less often.
FRCR part 1 teaching day. This is normally split into physics and anatomy sessions. The sessions run up to the first sitting of the exam in March and are designed to cover the syllabus.
Back to work for a morning CT list. At the beginning of the day it is important to prioritise requests. This can be frustrating due to lack of clinical information, which often changes depending on which member of the clinical team is asked. An example being a CT request by an SHO for a patient with a focal neurological deficit which asks to rule out a CVA, however doesn’t mention the team are also concerned about abscesses. This is an important detail to include as we would give intravenous contrast if concerned about a possible abscess.
The CT scanner
After this, reporting of the CT scans that have been performed can begin. CT scans contain a lot of information and if you don’t know what you are looking for or where to look it is likely to be missed. As a first year it is useful to develop review areas.
X-ray teaching is scheduled during lunch, which again involves sitting in the hot seat and being questioned in a style similar to the exam. This is followed by an afternoon of plain radiograph reporting.
An ultrasound list mainly focusing on inpatients is timetabled in the morning. This is a good chance to scan patients with acute pathology such as cholecystitis, DVTs and pyelonephritis.
Operating the ultrasound machine
'Hot seat' is scheduled for the afternoon. This involves working with a more senior registrar and holding the 'on-call' phone. This is initially daunting because of the volume of phone calls and the fact you have relatively limited knowledge. The clinical teams claim their scans need to be done as soon as possible so part of the job is to negotiate what needs to be done ASAP or those that can wait. You should have the support from a more senior trainee/consultant to guide you with vetting scans, reporting plain radiographs and dealing with queries.
Obviously this is an example timetable and actual clinical and teaching sessions change between weeks, and are completely different between training schemes.
Workplace based assessments and R-ITI
Workplace based assessments
Just as you have workplace-based assessments (WPBA) during Foundation Training, you will also have assessments during Clinical Radiology training. These comprise of the following:
- Multisource Feedback (MSF)
- Teaching Observation
- Audit assessment
- Multi-disciplinary Team Working Assessment
- Procedure Based Assessment (PBA)
Radiology - Integrated Imaging Initiative (R-ITI)
The Radiology integrated training initiative (R-ITI), is an eLearning package created by the Royal College of Radiologists (RCR). R-ITI is designed to support trainees throughout training, especially core training (ST1-ST3). The package breaks the radiology syllabus into bite size sections (modules) including physics. The interactive sessions contain a series of reading material, images and self-assessment questions.
The Radiology Integrated Training Initiative (R-ITI) website
R-ITI is based entirely on the knowledge and experience of practising clinical radiologists, representing best practice in radiology and combines traditional teaching models with state of the art technology. It is free to access for NHS employees. Just register on the e-Learning for Healthcare (e-LfH) portal using your NHS email address. If you are from overseas, then please visit the R-ITI for overseas users page for information on how you can access the resource.
Each individuals learning styles differ, however R-ITI does provides an invaluable learning resource which is worth exploring. R-ITI modules are automatically imported onto ePortfolio and completed modules can be linked to the curriculum.