How does Neuroradiology work in Canada?

[fraservalley96]

I'm a Canadian who studied abroad and matched Diagnostic Radiology in the US (currently R1). At my program, the neuroradiologist will read everything related to the brain, neck, spine etc. and take shared evening and night call with the other subspecialized radiologists. I heard that in Canada, the neuroradiologist works separately from the other radiologists and have their own schedules and only read "complex cases." So that the other specialty radiologist will read stroke CT's and CTA's. Is this true all across Canada?

Also I want to do a fellowship in neuro, however in the US, I can do a one year fellowship and become certified by the ABR, whereas in Canada I would have to do a 2 year fellowship to be certified. Would I be at a disadvantage if I do a 1 year fellowship when looking for jobs in Canada (particularly BC). 

 

Thanks 

[rmorelan]

On 10/13/2021 at 6:47 AM, fraservalley96 said:

I'm a Canadian who studied abroad and matched Diagnostic Radiology in the US (currently R1). At my program, the neuroradiologist will read everything related to the brain, neck, spine etc. and take shared evening and night call with the other subspecialized radiologists. I heard that in Canada, the neuroradiologist works separately from the other radiologists and have their own schedules and only read "complex cases." So that the other specialty radiologist will read stroke CT's and CTA's. Is this true all across Canada?

Also I want to do a fellowship in neuro, however in the US, I can do a one year fellowship and become certified by the ABR, whereas in Canada I would have to do a 2 year fellowship to be certified. Would I be at a disadvantage if I do a 1 year fellowship when looking for jobs in Canada (particularly BC). 

 

Thanks 

Hey there - I can try to answer that. 

First point I guess is in Canada neuroradiology fellowship is not really a classic fellowship - it is actually another residency program. Thus you are actually still under the provincial union rules, and it has stricter rules etc. You will notice the royal college actually calls someone doing this a resident rather than a fellow. It is very similar to fellowships that internal medicine doctors can do post their initial core training. This is different than the US where it is a true fellowship. It also has just like the internal medicine fellowships an actual exam at the end you have to take at the royal college. You cannot call yourself a neuroradiologist in canada unless you have actually done that exam - similar to how you shouldn't call yourself a cardiologist if you haven't completed that examination as well. 

In terms of work flow any radiologist can read any study - just like again any general internist can also do any internal medicine well anything really to the limits of their abilities. It isn't just about complexity I should say as well - neuro rads because they do just the one thing tend to be not just better at it but also faster. You can think of this like a factory - the quickly you can produce a high quality product then the better it is for everyone - patients, hospital workflow, and well income. Doing fewer things better and faster is one way to do that. 

Neuroradiolgists are relatively rare - probably in part due to longer training and you can have some restrictions effectively on where you would be working - if you want complex neuro cases you need to be at a place that has complex neuro studies performed. Tends to create a bias for them to be at academic places, but of course they can and do also go into the community and at as generalists as well with probably a neuro bias (not everyone that does a fellowship in X actually gets to do X - that goes for anything really. We never have good match ups between jobs and training in anything in medicine). At those academic centres specifically they basically just do neuroradiology. The other divisions usually do their own thing as well but the call pool for neuro is usually neuro only, while the other diagnostic divisions do the other diagnostic call. That is in part as there is a lot of on call neuro relative to some of the other divisions - roughly 50% of all ER studies are neuro studies. We also cover other hospitals emergent stroke cases while we are on. That would emergent MRI. 

I am an ER radiologist. We cover the ER and inpatients roughly 2/3 of the time at my hospital. That means that my division reads more stroke cases than the neuro division - more emerg neuro studies in general including all the MRI. At my fellowship site in the US the ER division actually read ALL stroke/emergent cases 24/7 from the ER - the only way a neurorad would read a stroke case is if it happened to an inpatient ha.  At many academic centres as the call is split from neuro vs everything else diagnostic (IR has their own additional call pool as well) it is not usual for neuro to deal with all the emergent studies including stroke as a part of that call situation. 

The issue with a one year fellowship is that in Canada at least you wouldn't formally be a neuroradiologist , and you would be competing against people with a 2 year fellowship. There are ways around that - since any radiologist in canada can read anything you can still get hired to do neuro work. Still you have that overall disadvantage which at academic centres at least may come up. In the community I don't think people are going to care - since there general rads routinely read neuro cases anyway. 

You can use your one year of training in the US and combine it with a second year of neuroradiology training following their specific rules and also be allowed to write the neuro exam. If you did that you would end up equivalent to other 2 year people. This is effectively the royal college's way out for people that did do the one year training in the US. Some places would be ha more than happy to do that for you along a hiring pathway (they get to check you out, get a staff level person working who is motivated to do well, pay them far less ha, and you get to be exam ready. It isn't a bad deal for all players). 

If you are considering well any of the various route it would not hurt at all to reach out to various places, say in BC, even at this stage and ask about this in general terms. People are far too afraid of doing that I find that is weird. People want to help. If you don't yet know - and I truly didn't appreciate this on a real deeper level until my fellowship - medicine is a insanely small world really. There are roughly 2000 radiologists in all of Canada, and of those say roughly(?) 10% are neurorads, and not all at academic places (so 200 people). You have a long career and you all go to the same conferences etc for decades. Bottom line is you personally will know a huge fraction of all of them, and certainly the major players on a first name bases. My field is smaller, and I don't just know the players are but a fair bit about them as well. When your fellowship division head picks up a phone causally in a meeting and gets you job interviews in 10 mins (hey bob, how are the kids? .... look I got a guy for you, you need to check him out, his good....) you will understand how this works. Such a small world ha!

 

 

 

 

[fraservalley96]

16 hours ago, rmorelan said:

Hey there - I can try to answer that. 

First point I guess is in Canada neuroradiology fellowship is not really a classic fellowship - it is actually another residency program. Thus you are actually still under the provincial union rules, and it has stricter rules etc. You will notice the royal college actually calls someone doing this a resident rather than a fellow. It is very similar to fellowships that internal medicine doctors can do post their initial core training. This is different than the US where it is a true fellowship. It also has just like the internal medicine fellowships an actual exam at the end you have to take at the royal college. You cannot call yourself a neuroradiologist in canada unless you have actually done that exam - similar to how you shouldn't call yourself a cardiologist if you haven't completed that examination as well. 

In terms of work flow any radiologist can read any study - just like again any general internist can also do any internal medicine well anything really to the limits of their abilities. It isn't just about complexity I should say as well - neuro rads because they do just the one thing tend to be not just better at it but also faster. You can think of this like a factory - the quickly you can produce a high quality product then the better it is for everyone - patients, hospital workflow, and well income. Doing fewer things better and faster is one way to do that. 

Neuroradiolgists are relatively rare - probably in part due to longer training and you can have some restrictions effectively on where you would be working - if you want complex neuro cases you need to be at a place that has complex neuro studies performed. Tends to create a bias for them to be at academic places, but of course they can and do also go into the community and at as generalists as well with probably a neuro bias (not everyone that does a fellowship in X actually gets to do X - that goes for anything really. We never have good match ups between jobs and training in anything in medicine). At those academic centres specifically they basically just do neuroradiology. The other divisions usually do their own thing as well but the call pool for neuro is usually neuro only, while the other diagnostic divisions do the other diagnostic call. That is in part as there is a lot of on call neuro relative to some of the other divisions - roughly 50% of all ER studies are neuro studies. We also cover other hospitals emergent stroke cases while we are on. That would emergent MRI. 

I am an ER radiologist. We cover the ER and inpatients roughly 2/3 of the time at my hospital. That means that my division reads more stroke cases than the neuro division - more emerg neuro studies in general including all the MRI. At my fellowship site in the US the ER division actually read ALL stroke/emergent cases 24/7 from the ER - the only way a neurorad would read a stroke case is if it happened to an inpatient ha.  At many academic centres as the call is split from neuro vs everything else diagnostic (IR has their own additional call pool as well) it is not usual for neuro to deal with all the emergent studies including stroke as a part of that call situation. 

The issue with a one year fellowship is that in Canada at least you wouldn't formally be a neuroradiologist , and you would be competing against people with a 2 year fellowship. There are ways around that - since any radiologist in canada can read anything you can still get hired to do neuro work. Still you have that overall disadvantage which at academic centres at least may come up. In the community I don't think people are going to care - since there general rads routinely read neuro cases anyway. 

You can use your one year of training in the US and combine it with a second year of neuroradiology training following their specific rules and also be allowed to write the neuro exam. If you did that you would end up equivalent to other 2 year people. This is effectively the royal college's way out for people that did do the one year training in the US. Some places would be ha more than happy to do that for you along a hiring pathway (they get to check you out, get a staff level person working who is motivated to do well, pay them far less ha, and you get to be exam ready. It isn't a bad deal for all players). 

If you are considering well any of the various route it would not hurt at all to reach out to various places, say in BC, even at this stage and ask about this in general terms. People are far too afraid of doing that I find that is weird. People want to help. If you don't yet know - and I truly didn't appreciate this on a real deeper level until my fellowship - medicine is a insanely small world really. There are roughly 2000 radiologists in all of Canada, and of those say roughly(?) 10% are neurorads, and not all at academic places (so 200 people). You have a long career and you all go to the same conferences etc for decades. Bottom line is you personally will know a huge fraction of all of them, and certainly the major players on a first name bases. My field is smaller, and I don't just know the players are but a fair bit about them as well. When your fellowship division head picks up a phone causally in a meeting and gets you job interviews in 10 mins (hey bob, how are the kids? .... look I got a guy for you, you need to check him out, his good....) you will understand how this works. Such a small world ha!

Thanks for the detailed reply, it is vey helpful for someone who isn't accustomed to the Canadian radiology scene. 

I tried reaching out to a couple groups a few months ago to see what sort of subspecialty they would be looking to hire by the time I graduate, but neither group was certain about the future (which is understandable). Most of the jobs posted in BC are either general or something too specific such as cardiothoracic imaging. I guess I can reach out again before I apply for fellowship to see if they have any better insight.

I don't really mind doing a two year neuro fellowship, especially if I can match close to home (ubc). My main concern is that since I haven't really seen an opening for a neuroradiology specific job in BC over the course of the last 2 years, would it really be useful to do a 2 year fellowship and then work general rads. Also, considering most general rad jobs typically require you to do a lot of body IR procedures, would it be more useful to just do a body fellowship? At my program, IR does pretty much all the procedures, including thora, para etc, which isn't the case in Canada. 

Also, do the neurorads in Canada do all of the neuro interventional procedures as well, like angios and coiling? Again, at my program, the diagnostic rads only do reading since that has higher RVU. The Neuro IR is done by a neuro IR physician. 

Again thanks for the reply 

 

 

[rmorelan]

6 hours ago, fraservalley96 said:

Thanks for the detailed reply, it is vey helpful for someone who isn't accustomed to the Canadian radiology scene. 

I tried reaching out to a couple groups a few months ago to see what sort of subspecialty they would be looking to hire by the time I graduate, but neither group was certain about the future (which is understandable). Most of the jobs posted in BC are either general or something too specific such as cardiothoracic imaging. I guess I can reach out again before I apply for fellowship to see if they have any better insight.

I don't really mind doing a two year neuro fellowship, especially if I can match close to home (ubc). My main concern is that since I haven't really seen an opening for a neuroradiology specific job in BC over the course of the last 2 years, would it really be useful to do a 2 year fellowship and then work general rads. Also, considering most general rad jobs typically require you to do a lot of body IR procedures, would it be more useful to just do a body fellowship? At my program, IR does pretty much all the procedures, including thora, para etc, which isn't the case in Canada. 

Also, do the neurorads in Canada do all of the neuro interventional procedures as well, like angios and coiling? Again, at my program, the diagnostic rads only do reading since that has higher RVU. The Neuro IR is done by a neuro IR physician. 

Again thanks for the reply 

 

No one in anything will be able to tell you more than say 1.5 years in advance anything regarding their centre and the job situation. The current situation is a good example of why - surprises happen and it impacts staffing. Assuming steady volumes then someone has to retire for a new person to be brought on. It is not an advantage for someone to announce retirement years and years in advance  - they may decide to stay after all, and there is no upside to it. If you don't know who is leaving, you won't know who is coming on. On top of that volumes are not steady state, but can change making it more messy, and government changes the fee code schedule every once in awhile as well to mess things up. This is why almost all fellowships are a bit leap of faith. Some people can set up end jobs late 4th year and 5th but it is relatively rare and usually community places, and quite often after you have to select a fellowship anyway. What they can do those is give you insight to the overall state of the field, and be useful for what jobs do open up when the time comes. It never hurts to get insight and well just for them to know you exist.

For general rads yes a body fellowship is the default but I don't want you to think that any fellowship will prepare you for community rads perfectly. Ok so you did body but that means you didn't do chest, neuro, msk, breast..... I mean you can end up doing it all so everyone has a very step learning curve. Even if you do one of the cross sectional fellowships which basically scream community radiology their will be gaps. The learning never stops. Often community groups are looking for people to say 50% general rad but still have an area to work in as a focus. That way they can actually do all the cases and not have to ship people and business to another hospital. Plus if something weird shows up on a study you have someone in the group that knows probably what it is - you cannot unfortunately arrange it so just the "easy staff" shows up in the community   You get what comes in through the front door.

You are right IR in the US does a lot of that sort of thing - but again for smaller hospitals even in the US you won't have a dedicated IR person for that. They end up doing it often as well not because of the training so much as temperament I find - those procedures are not that hard and we all know how to do them, but you can fit them in between IR cases which reduces down time (do an angio and while the room is cleaned pop out and do a couple of US guided procedures etc. Doesn't work as well when you have less than 10 rads at a site (which is not at all unusual for community hospitals). Even if you have an IR person what happens when they are away? At academic centres as well procedures are definitely done within the various divisions - that way as well they can train others to do them. IR is really focused specifically on angio interventional work. 

In Canada the neuro IR stuff is done by either neuro interventional fellows - usually yet another fellowship post your neuro fellowship adding at least 1 more and usually 2 years. You can therefore do both interventional work and diagnostic work, which is actually important as no one does interventional 100% of the time - or at least shouldn't ha. You don't want your diagnostic skills to atrophy - for one thing you may not be able to do interventional work for ever. More and more that sort of work is also being done by the neuro surgery services in Canada which is also changing things. 

 

 

 

 

 

 

 

[fraservalley96]

3 hours ago, rmorelan said:

No one in anything will be able to tell you more than say 1.5 years in advance anything regarding their centre and the job situation. The current situation is a good example of why - surprises happen and it impacts staffing. Assuming steady volumes then someone has to retire for a new person to be brought on. It is not an advantage for someone to announce retirement years and years in advance  - they may decide to stay after all, and there is no upside to it. If you don't know who is leaving, you won't know who is coming on. On top of that volumes are not steady state, but can change making it more messy, and government changes the fee code schedule every once in awhile as well to mess things up. This is why almost all fellowships are a bit leap of faith. Some people can set up end jobs late 4th year and 5th but it is relatively rare and usually community places, and quite often after you have to select a fellowship anyway. What they can do those is give you insight to the overall state of the field, and be useful for what jobs do open up when the time comes. It never hurts to get insight and well just for them to know you exist.

For general rads yes a body fellowship is the default but I don't want you to think that any fellowship will prepare you for community rads perfectly. Ok so you did body but that means you didn't do chest, neuro, msk, breast..... I mean you can end up doing it all so everyone has a very step learning curve. Even if you do one of the cross sectional fellowships which basically scream community radiology their will be gaps. The learning never stops. Often community groups are looking for people to say 50% general rad but still have an area to work in as a focus. That way they can actually do all the cases and not have to ship people and business to another hospital. Plus if something weird shows up on a study you have someone in the group that knows probably what it is - you cannot unfortunately arrange it so just the "easy staff" shows up in the community   You get what comes in through the front door.

You are right IR in the US does a lot of that sort of thing - but again for smaller hospitals even in the US you won't have a dedicated IR person for that. They end up doing it often as well not because of the training so much as temperament I find - those procedures are not that hard and we all know how to do them, but you can fit them in between IR cases which reduces down time (do an angio and while the room is cleaned pop out and do a couple of US guided procedures etc. Doesn't work as well when you have less than 10 rads at a site (which is not at all unusual for community hospitals). Even if you have an IR person what happens when they are away? At academic centres as well procedures are definitely done within the various divisions - that way as well they can train others to do them. IR is really focused specifically on angio interventional work. 

In Canada the neuro IR stuff is done by either neuro interventional fellows - usually yet another fellowship post your neuro fellowship adding at least 1 more and usually 2 years. You can therefore do both interventional work and diagnostic work, which is actually important as no one does interventional 100% of the time - or at least shouldn't ha. You don't want your diagnostic skills to atrophy - for one thing you may not be able to do interventional work for ever. More and more that sort of work is also being done by the neuro surgery services in Canada which is also changing things. 

Okay I guess, it's always best to do a fellowship  in the subspecialty you prefer the most, and just hope that you find a specific job eventually.  General rads seems to be the most prevalent field in Canada.

Again thanks for all the info, I really appreciate it. 

[rmorelan]

13 minutes ago, fraservalley96 said:

Okay I guess, it's always best to do a fellowship  in the subspecialty you prefer the most, and just hope that you find a specific job eventually.  General rads seems to be the most prevalent field in Canada.

Again thanks for all the info, I really appreciate it. 

ha, general practise is - and body fellowship would probably be the most common fellowship. It is interesting that the fellowships that basically are general radiology - of which there are some great programs - are not as utilized as much as I think they should be. 

Yeah that is often the best approach - you can never get away from the luck aspect in this at all. Right or wrong just doing what you want to do was basically my approach. I was again lucky that worked out smoothly as it really easily could have blown up. In neuro rads in particular I have had some people really drift for a bit before they find a solid centre (particularly annoying as it is a 2 year fellowship - right out of the gate you are giving up a year's income to do it plus the delay in getting settled, so you would hope it would work out post).