Top 5 Criteria for Choosing a Neuroradiology Fellowship

Today we’re going to change gears a little bit, and I’m going to tell you a little bit of my perspective on making your fellowship rank list. I did medical school, residency, and fellowship at different institutions and I’ve been at my current institution for a while, so I’ve seen a lot of different training programs. This is just my perspective.

When choosing a neuroradiology fellowship, you might think it’s the same as radiology residency, which is somewhat true, but not exactly. A lot of the features are the same, but in a little bit of a different order.

We’re gonna do the top 5 things. We’ll do them in reverse.

#5 Reputation

Like in choosing a residency, the reputation does matter. Your fellowship is the last place you are doing your training, and when it comes to reputation this is probably the one thing people are most likely to remember. People are less likely to look back at where you did medical school, but since your fellowship is the last thing you did, it will always come up. Since you are entering the subspecialty, people that you work with and interview with in the future are more likely to know people you have worked with before. This can help significantly with networking when you are looking for a job.

However, one of the main reasons this is important is that the programs that have top reputations have all the other things that they need. Faculty, dedicated teaching and lecture time, supportive program directors. They tend to have the best fellows, who go on to get the best jobs, so you end up with the most connections. So, in some ways, it’s just a correlation that has nothing to do with the quality of the institution. It’s just a self-fulfilling prophecy.

Unlike residencies, there is definitely a difference between the top 10-15 places and a top 50 place. The top 15 places are likely to have high quality faculty, a strong reputation both in academics and the private job market, and the ability to make the connections that you want. A top 50 place will teach you everything you need to know to be a neuroradiologist though. Fortunately, fellowship are much larger relative to residency and it’s pretty easy to get a prestige spot if that’s what you want.

#4 Quality Faculty

Unlike residency, you rotate much less in your neuroradiology fellowship. This means that for the first time in your career you are working with the same faculty repeatedly over the year. In most fellowships, you’ll have anywhere from 5-15 faculty that you’ll spend most of your time with. You’ll actually get to know them, feel comfortable going to dinner with them, learn about their families, and really feel like you are part of the team. For that reason, there are two major considerations for quality:

Expertise and reputation. Of course, the easiest way to become the best is to learn from the best. The best fellowships have multiple high quality and probably nationally known faculty. They are the people that are giving lectures at the national conferences, helping develop standards at the national level, and writing papers on those topics. It’s great if a place has one or two really well known people, but what you really want is a couple of people who are great in each subsection. If you have a couple of real experts in brain, spine, AND head/neck, you’ll be really set and you are learning from the best at each topic.

Personality. This one is a little harder to assess and deal with, but to be honest, you are going to be sitting next to these people in a reading room for 50 hours a week for a year. You want people who are friendly, easy to work with, and who see you as a colleague. There is no reason to be at a place where they aren’t fun and interesting to be around. Ask around and see what kind of vibe you get in your interviews. Neuroradiologists are known for being weird, so try to find a place where the people are on the middle to better end of that spectrum.

Neuroradiologists are known for being weird, so try to find a place where the people are on the middle to better end of that spectrum.

#3 Case variety and exposure

For residency, you just need to see enough cases and a good amount of bread and butter cases. For neuroradiology, that means hemorrhage, stroke, trauma, multiple sclerosis, etc. For fellowship, since you are spending so much more time you want a greater exposure to cases of high complexity and rarity. To do this, you need to be at a tertiary referral center that has a large number of referrals and unusual diagnoses. If your institution has a neurosurgeon that is the world expert on unusual pituitary lesions, you’re going to see a lot of pituitary lesions. If they have a big H&N cancer service, same. Ideally, you want to see a lot of high end cases so you can at least be familiar with unusual diagnoses. This means brain tumors, spine tumors, CSF leaks, H&N tumors, unusual infections, weird metabolic conditions, and more. I still learn new things almost every day, but it’s a lot easier once you are out in practice if you’ve heard of a diagnosis before.

The corollary to this is to have an affiliation with different hospitals. You will get a better exposure to these high-end cases if you have rotations at dedicate pediatric hospitals, a high end otolaryngology service, and a trauma center. Do fellows participate in tumor boards and conferences? It’s good to be exposed to all of those different things.

A lot of programs now have overnight faculty. Depending on how it’s done, that can be fine. Most of the time you want to be working independently alongside the faculty, who may be at another location or at home. That way, you’re the one answer the questions. What you don’t want is a recreation of the daytime experience in the middle of the night. If you’re previewing a stack of cases and then you read them out with the faculty before dictating them, you might at as well be at home.

#2 Scut/Education Ratio

As you become a more educated and sophisticated radiologist, your work becomes more valuable to the hospital. Once you’ve finished a residency, you can be pretty independent. This can be a problem if an institution simply views you as low paid members of the workforce. So, how do you know if this is the case? Well, first of all, the faculty should be in the reading room working with you the majority of the day. They should be reading cases on their own, not just rolling in at 10 am to read you out before disappearing to read you out again at 4 pm. Ideally, the workflow should not depend on you as a fellow. If the wheels fall off when a fellow takes vacation, this is a big red flag. Most programs are not like this anymore as volumes have increased, but they are still out there (particularly more senior attendings at prestige places).

Do the fellows have some protected time for educational lectures and conferences? If they don’t, that’s gonna be a hard no for me dawg.

Ideally, you should have an on-call experience that helps you get more independent while at the same time having a safety net. It’s probably best if you don’t have to read the cases out in person after an overnight shift. I mean, we have electronic methods for giving feedback now. Evenings and weekends are going to be hard in terms of case volume, which is a GOOD thing, as you want to learn to manage your time and get better at reading a lot of cases in a short period of time.

If the wheels fall off when a fellow takes vacation, this is a big red flag.

So, you might ask how two year fellowships fit into this component? Well, they don’t, because for the vast majority of people the scut to education ratio is way too high for a second year. You are losing out on a year of very high salary to hang around and do a second year. Of course, you learn a ton during a second year, and you are much better prepared to take on a job. But you could have learned that during your first faculty year.

#1 Geography

There is a reason geography is the most important factor in a fellowship: you are most likely to stay in the region where you do your fellowship training when you get a job. Most of the former graduates from the program will be at practices in that region and can be the connection that you need to get a job in that region. You’re already settled in a region for and year and it’s easiest to stay. Who wants to be moving around the country every year? Vomit. Try to get a fellowship where you want to end up, and that will make it much easier.

Bonus: Do I need a 2-year fellowship to do academics?

Well, go back and read #2 above and tell me what you think. For most people, the answer is no, especially in a 2024 job market. The opportunity cost of a second year is REALLY high, as you are losing a year of full salary and a potential year of development. Institutions that have stuck to a 2 year only neuroradiology fellowship are stuck in the past and believe that they can pay you in prestige. Of course you are more prepared after that second year, but the cost is just too high. You’re just underpaid faculty.

Are there people who can benefit from a 2nd fellowship year? Yes. There are a couple of groups. First, people with an avid interest in research who can start developing research programs might benefit from that year. However, most programs are not set up to help them develop that. Second, people with a very specific interest who want to develop a specific niche (perhaps H&N imaging or functional MRI) might benefit from staying an extra year before moving to another place. Please note, this doesn’t apply to pediatric neuroradiology, which in almost every case requires an additional pediatric neuroradiology year.


So, what’s important?

  • Reputation
  • Quality faculty
  • Case variety and exposure
  • Scut/education ratio
  • Geography