A How-to Guide for Community Breast Imaging Centers: Starting a Breast Imaging Fellowship

Abstract

Opportunities exist to provide high-quality breast imaging fellowship training in the community setting. Various challenges exist, however, including obtaining funding for a fellowship position, creating an educational curriculum in a potentially nonacademic environment, and developing an overall competitive program that will attract radiology trainees. Here, we explore factors that contribute to the establishment of an academic breast imaging fellowship program in the community setting based on experience, including (1) providing guidance on how to secure funding for a breast imaging fellowship position; (2) developing a training curriculum based on established guidelines from the Accreditation Council for Graduate Medical Education, American College of Radiology, and Society of Breast Imaging; and (3) navigating the landscape of the recruitment process, from program branding to matching applicants.

Introduction

Increased demand for mammography services has contributed to a shortage of breast radiologists, who play a significant role in breast cancer monitoring and prevention.^1,2 While recruitment of radiology residents into breast imaging has been challenging historically, interest has substantially increased due in part to a burgeoning job market, greater patient contact, continued advances in breast imaging technology, and perceived greater work–life balance within the field.^3-6 While most breast imaging fellowships are located at major academic centers, there are opportunities to provide high-quality breast imaging training in the community setting. Numerous challenges exist, however, including obtaining funding for a fellowship position, creating an educational curriculum in a nonacademic or hybrid environment, and developing an overall competitive program that will attract potential candidates.

In this context, we explore factors involved in the establishment of an academic breast imaging fellowship program in the community setting based on experience, including (1) providing guidance on securing funding for a position; (2) developing a training curriculum based on established frameworks from the Accreditation Council for Graduate Medical Education (ACGME), American College of Radiology (ACR), and Society of Breast Imaging (SBI); and (3) navigating the complexities of branding and matching applicants (Figure 1).

Breast imaging training in the community setting

There are several benefits to providing breast imaging fellowship training in the community setting for both radiology departments and applicants interested in applying to such programs. For radiology departments, establishing a fellowship program can contribute to raising the profile of a department, improving operational efficiency, and educating future leaders in breast imaging. During training, fellows can assist with potentially time-consuming tasks, such as multidisciplinary tumor board and conference preparation and case presentation, patient communication, and report dictation. Once competence has been demonstrated, fellows can interpret studies and perform procedures independently, thereby increasing flexibility with scheduling and decreasing interpretation workload on individual radiologists. In addition, departments are provided a potential advantage in evaluating and recruiting experienced breast imaging radiologists who may choose to remain on staff after completion of training.^7,8

Applicants may consider numerous reasons to seek high-quality training at a community program. Considering the bulk of breast imaging exams are performed in community hospitals and outpatient centers, the community setting provides relevant exposure for trainees in an environment where radiologists are most likely to practice following training.^9,10 Additionally, training in this setting may provide unique exposure to business practices and patient considerations primarily seen in private practice. Lastly, consideration of community programs provides a greater selection of programs, offering increased geographic diversity for applicants who may be interested in specific locations outside of areas covered by major academic training sites.

Securing approval for a position

Non-ACGME fellowships are not funded by Centers for Medicare and Medicaid Services. Thus, a new breast imaging fellowship must obtain funding internally. For integrated systems, this usually means obtaining funding via the usual requisition process for adding providers. For systems with departmental budgets separate from a school or hospital system budget, funds may need to come from the same salary pool that covers salaries for departmental staff. For a private practice, the approval process is varied and can involve discussions with leaders in human resources and/or chief executive board members. Setting up initial meetings with leaders in these areas is the most efficient way to learn the necessary steps for confirming a position, which are institution specific.

It is critical to confirm both departmental commitment and readiness to establish a fellowship program before seeking approval. Clear breast imaging attending roles, standardized operational processes, established breast multidisciplinary conferences, and faculty commitment will aid in providing high-quality training while maintaining efficient workflow. With these measures in place, a faculty designee (program director) can be assigned to support personal and academic development of fellows outside of clinical training, utilizing either minimal academic time and/or free periods (informal lunch meetings) to perform periodic check-ins. Administrative needs are minimal and primarily aligned with tasks utilized to support other clinical staff; existing administrative staff and processes can thus be leveraged.

Financial and nonfinancial arguments can be utilized to justify the cost of a fellow (Figure 1). Nonfinancial arguments support how the fellowship would improve workplace culture, help foster a culture of scholarship, and help with recruitment efforts. Financial arguments can be supported by demonstrating that a non-ACGME fellow can generate revenue via (1) improving attending efficiency, which can be modeled based on institution-specific workflow and processes; (2) direct signing of breast imaging reports after demonstration of competence during fellowship; and/or (3) providing coverage of non–breast imaging areas, including diagnostic radiology call and contrast coverage at a fraction of the salary of a full-time radiologist, which can be based off the ACGME pay scale.

Developing an educational framework

Once funding for a fellowship position is approved, it is important to establish a framework for clinical and didactic training. There are several educational frameworks established for diagnostic radiology residency and breast imaging fellowship programs that can be utilized for this purpose. The ACGME lists 6 core competences for diagnostic radiology training programs to help guide development of curricula aimed at developing trainees into well-trained, competent, and compassionate radiologists (Table 1).¹⁰ These are systems-based practice, interpersonal and communication skills, patient care, medical knowledge, practice-based learning and improvement, and professionalism.

The ACR and SBI provide guidelines for breast imaging fellowship programs that can serve as the foundation for a comprehensive educational curriculum.^3,11 These guidelines define 4 skill sets that aim to produce a well-rounded breast imaging radiologist, including (1) clinical factors, (2) noninterpretative factors, (3) collaborative factors, and (4) scholarly factors. In the following discussion, we discuss key clinical skill sets identified by the ACR and SBI and their overlap with the ACGME 6 core competencies, which collectively should inform the educational framework for fellowship training.

Clinical factors

Clinical factors include the clinical day-to-day skills that contribute to proficiency in the interpretation of imaging, evaluation, and treatment. These factors center on the development of diagnostic reasoning and understanding of foundational knowledge in the field. Programs can meet this expectation by providing trainees instruction in a supportive environment with faculty who have extensive knowledge and experience in breast imaging. Trainees should receive comprehensive education in every aspect of breast imaging, including screening and diagnostic studies and image-guided interventions utilizing up-to-date technology. Additionally, establishing a regular schedule across different imaging modalities and procedural settings allows a fellow to see a wide range of cases, ensuring trainees are exposed to sufficient and diverse caseloads (Table 2). Much of the clinical feedback and education can be provided to fellows at the workstation as the day progresses by providing salient teaching points right after procedures and cases, which can be done in a few minutes. Programs during national conferences, such as the American Roentgen Ray Society Clinician Educator Development Program, can be utilized by the faculty of these programs to learn about efficient processes of balancing clinical workload and educational training of fellows.¹²

There should also be opportunities for personalized feedback and discussion at least once a month, which can be supported by 1-on-1 review with designated faculty, as permitted at the workstation during slow periods in the day, throughout academic time based on institutional processes for supporting administrative tasks, or during collegial lunch meetings. Feedback tools and methods should be obtained that can be accessed by trainees without need for faculty involvement to support self-directed, continuous growth (Figure 2).^5,9 Feedback can be supported by established feedback mechanisms, such as entrustable professional activity–based learning and assessment guides for breast imaging residents and fellows developed by a multi-institutional team of researchers to aid in trainee assessment and readiness to practice unsupervised.¹⁴ This is in addition to routine case conferences and educational lectures centered around clinical knowledge necessary for imaging method selection and interpretation, which can be supported by virtual, external curriculums such as the Breast Imaging Fellowship Consortium (BIFC).

Noninterpretive factors

Noninterpretive factors include the emotional and social intelligence skills utilized when interacting with patients, explaining diagnoses and treatments, and understanding quality control. These factors should be incorporated into the systems-based practice and interpersonal and communication skills of ACGME core competencies that focus on involvement in quality improvement initiatives, procedural safety, and patient-centered care. This skill set can be met with case conferences and educational lectures discussing clinical operations and patient communication. Communication with patients and other breast care team members is a critical skill in our field based on progressive decision-making established by prior exams and care coordination with other providers and team members. Therefore, fellows should also be provided ample opportunity to discuss findings with patients both in-person and over the phone and to interact with other staff members of the radiology department.

Collaborative factors

Collaborative factors include skills utilized during interactions with other members of the multidisciplinary team when seeking to mentor or receive mentorship and in the reception of feedback from faculty. These factors may be achieved through participation in regular multidisciplinary tumor boards and radiology–pathology rounds, which are forums that bring together physicians from different specialties to discuss complex patient cases. Radiology fellows can eventually lead image reviews for such conferences, where they can discuss relevant findings with experts from other fields. Opportunities for fellows to rotate in other subspecialties with close ties to breast imaging, such as breast surgery or oncology, should be pursued to support collaborative multidisciplinary decision-making and patient care.^4,11

Scholarly factors

Scholarly factors include developing a skill set by teaching others, pursuing scholarly research projects, and attending and/or presenting research. There are similar principles underlying the professionalism core competency as described by the ACGME, which includes prioritizing patient needs over self-interest; maintaining emotional, physical, and mental health; and pursuing continual development, which contributes to personal and professional growth and quality control advancements. Opportunities for involvement in research and quality improvement projects can be provided through academic faculty or partnerships within or external to one’s institution. Additionally, fellows can develop skills in educating others on relevant topics in breast imaging. This can include participation in regular journal club or other seminars. Participating in local outreach activities aimed at expanding equitable care is another method for promoting professional growth and ethical practice.

Establishing an educational curriculum

The educational curriculum should support an educational framework that supports ACGME core competencies and ACR/SBI guidelines (Tables 2 and 3). Establishing an educational curriculum can represent a major barrier to developing a breast imaging fellowship program due to limited time and resources available to give lectures. Virtual resources, however, can be used to help overcome this potential obstacle, including utilization of the BIFC’s virtual didactic lecture series.⁷ This virtual format has several advantages, including exposure to multi-institutional speakers from different breast specialty fields. Only 1 hour of protected time each week of the academic year is required for fellows to participate in the comprehensive lecture series. Utilization of the online comprehensive curriculum series requires faculty from participating programs to provide a minimum number of lectures (at least 3 lectures) throughout the year, which can be distributed among those faculty members interested in lecturing.

The core curriculum covers major educational topics, including predominant breast imaging modalities, interventions, and symptom management. Multidisciplinary topics that involve fields with close associations to breast imaging, including surgical oncology and plastic surgery, are also covered. Additional topics beyond the core curriculum include providing culturally competent care to historically underserved groups, career development topics, and discussions on innovation.

Branding and growing a social media presence

The adoption of a digital landscape in residency and fellowship application processes has underscored the newfound importance of virtual recruitment endeavors.¹⁵ A program’s website is a major contributor toward program branding and plays a role when trainees decide on training programs.¹⁶ A dedicated breast imaging fellowship page should be created, including a description of clinical rotations, equipment, faculty, and contact information. In addition, the website should delineate educational experiences that support core competencies and other key objectives. This includes exhibiting clinical experiences, multidisciplinary conferences and rotation electives, and scholarly opportunities.⁴

Other important factors that contribute to branding training programs include the use of social media.⁴ A social media account run by passionate trainees or faculty members offers a new perspective into a program and allows applicants to learn more about their potential future colleagues. These digital opportunities may be in the form of resident and/or faculty spotlights that highlight program strengths or informal social interactions among team members. Ultimately, these forms of communication contribute to a dialogue that establishes a distinct voice and tone for a program, which has become important because many steps of the interview process have become virtual for training programs, particularly in a community program that may not be connected to a large academic medical center.

Coordinating the virtual interview process

Virtual interviews for breast imaging fellowship programs have been found to be cost effective and comparable to in-person interviews.^17,18 Benefits for this format include decreased cost for applicants and programs, associated potential for increased diversity and more equitable access, and reduced carbon footprint.^19,20 This removes barriers for candidates to interview for more programs, which is advantageous for smaller programs and community programs that can thereby gain direct exposure to more candidates during the interview process. Disadvantages of this format include a limited assessment of institutional culture and local geography for the applicant and limited exposure to how an applicant may interact with others.

Interviews can be completed in 4-hour blocks over 1 or 2 days in most cases and should include an overview of the program, a video virtual tour, individual interviews with breast imaging faculty and staff, and a wrap-up session with a faculty designee, minimizing the impact on a busy clinical schedule. On the interview day, the process can be supported by adapting the clinical schedule, designating an administrative contact for unforeseen issues, and securing information technology support during the interview period. Candidates with strong interest in a fellowship program should be encouraged to make coordinated, informal on-site visits.

Joining the Match

Many breast imaging fellowship programs utilize the Breast Imaging Fellowship Match Program established by the SBI and managed by the National Resident Matching Program (NRMP) (Table 4). In 2024, the breast imaging matching program consisted of 95 programs for 162 positions. This matching service includes a universal application that requires a personal statement, letters of recommendation, and transcripts corresponding to medical school and standardized testing performance from applicants. The benefits of using this matching service for a training program include offering an even, unified playing field for applicants that follows standardized rules and deadlines. Programs are not allowed to extend early offers to candidates, thus removing additional pressure from participating institutions to quickly compete for the best candidates by extending such offers.

This process also produces an abundance of useful match outcome data that inform a program’s future candidate selection process. Application to the SBI Breast Imaging Fellowship Match requires submitting the Fellowship Match Agreement provided on the SBI website.²¹ This form collects information corresponding to an institution’s administrative faculty and contains requirement agreements corresponding to interview timeline, early offer restrictions, and NRMP policies.

Registering and preparing for the NRMP

Programs participating in the SBI’s Breast Imaging Fellowship Match Program must enroll in the NRMP Match, which requires fellowship programs to be accredited or affiliated with an ACGME program and agree to the timeframe established by the NRMP.²² The NRMP implements an “All In” policy that states any program participating in the Match must attempt to fill all available positions through the NRMP Match.

Institutions participating in the Match must complete institutional forms located on the NRMP website, which collects basic information about the institution and details about the type of position and number of positions to be filled in the Match. These forms will be used to create a record in the NRMP’s Registration, Ranking, and Results system wherein administrators are able to access and edit details regarding program position quota and contact information and allow institutions to search for applicants they wish to rank. A timeline for the Match process is provided on the NRMP website, and reminder emails are sent before important deadlines. After the Match, the NRMP assists in providing guidance and unmatched lists to assist programs that do not fill their position.

Once a candidate has matched, it is important to establish contact before their start date to establish an open line of communication, provide departmental updates, and initiate credentialing discussions. Additional aspects of onboarding that may need to be completed over this period include ordering white coats, arranging parking accommodations, and securing building access. Confirming availability of CME funds and sorting out scholarly activity options should be done over this period as well.

Breast imaging fellowship programs outside the Match

Not joining the Match is an option for programs interested in confirming candidates right away and for those programs without other affiliated ACGME training programs. Programs may choose to remain outside of the Match, which can be advantageous in confirming applicants interested in a particular program outside of designated Match deadlines. Institutions operating outside of the Match thus offer increased flexibility, which may be particularly attractive for nontraditional candidates who are off-cycle or for midcareer radiologists interested in breast imaging training. Applicants can be invited for personalized interviews in either a virtual or in-person format and accepted on a rolling basis. Because programs outside of the match are not a part of the readily accessible SBI database of breast imaging fellowships, robust recruitment efforts through word of mouth, online forums, and social media may be needed for promotion.

Conclusion

For community programs committed to starting a breast imaging fellowship, opportunities exist to improve operational efficiency, to advance institutional recruitment efforts of breast imaging radiologists, and to provide faculty with increased growth opportunities in their current role. While currently, 14% of all breast imaging fellowship positions went unfilled in 2024, unfilled positions have decreased by 10% over the past 3 years. This trend is likely to continue due to the increasing popularity of the field and increased demand for breast imaging radiologists.²³ Community programs offer candidates a greater selection of programs and geographic locations to choose from to match their specific needs. Following a strategic approach, there are opportunities for community programs to support high-quality training in breast imaging utilizing national educational guidelines, leveraging virtual resources, and providing a supportive work environment.

Funding

None declared.

Conflict of interest statement

None declared.

Author contributions

Randy C. Miles (Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing - original draft, Writing - review & editing), Antonio R. Lopez (Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Validation, Visualization, Writing - original draft, Writing - review & editing), Nhat-Tuan Tran (Resources, Software, Validation, Visualization, Writing - review & editing), Christopher Doyle (Formal analysis, Investigation, Methodology, Resources, Software, Validation, Visualization, Writing - review & editing), Charmi Vijapura (Resources, Software, Validation, Visualization, Writing - review & editing), Rifat A. Wahab (Resources, Supervision, Visualization, Writing - original draft, Writing - review & editing), and David M. Naeger (Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing - review & editing)

References