Musculoskeletal Radiology Fellowship

The Musculoskeletal (MSK) Radiology Fellowship at the State University of New York at Stony Brook is a one year full-time closely supervised training program at a designated Level 1 Trauma Center.  This program is accredited by the Accreditation Council for Graduate Medical Education (ACGME). Currently, there is one fellow per year. The curriculum has been developed to build upon the knowledge and skills learned during residency.  The overall goal is for the fellow to become proficient in musculoskeletal radiology and procedures as well as adopt life long learning and self assessment skills.  The fellow is able to pursue future positions in either an academic or private practice setting.


During this time period, the fellow is exposed to imaging and procedures as they apply to the musculoskeletal system with expected graduated proficiency to the level of a subspecialist.  The rotations and curriculum have been instituted to include clinical, technical-hands on experience, didactic teaching, as well as scholarly activity/research. The six competencies set forth by the ACGME are addressed and incorporated into the rotational goals and objectives.

The rotations include:

  1. Plain radiography
  2. Cross sectional imaging-MRI/CT
  3. Procedures/interventional. This includes imaging guided joint aspirations, therapeutic injections, arthrography, MR/CT  arthrography, image guided biopsies, aspiration/drainage, kyphoplasty (utilizing either x-ray, fluoroscopy, CT, MRI, or Sonography). Some exposure to radiofrequency ablation techniques, as cases arise, is anticipated.
  4. Dedicated Musculoskeletal Ultrasound 
  5. Nuclear radiology (as it applies to the MSK system), DEXA
  6. Pathology - bone and soft tissue pathology
  7. MRI physics/applications - (includes physical  principles, hardware, applications, newer pulse sequences,     on- site   teaching with  hands on MR scanning experience)
  8. Scholarly activity/research, including a Quality Improvement Project

Active participation is expected in the following areas:

  1. Teaching of Fellow/ Fellow as teacher
  2. Journal Club
  3. Sarcoma Tumor Board/Orthopedic Tumor Board 
  4. Quality Improvement 
  5. Clinical Practice in the setting of Outpatient Imaging Centers
  6. Research and scholarly activity

Rotations are scheduled in half day and /or full day blocks.  Some rotations and cases are concurrent to assure adequate exposure and involvement in interesting or more infrequent cases. This method also more realistically simulates what is expected of a practicing radiologist after training. Most of the light Musculoskeletal interventional procedures (e.g. arthrogram, joint steroid injection, joint aspiration) are performed on an outpatient basis with the supervision of a Musculoskeletal Radiology Attending. Procedures that require more intensive periprocedural clinical care (such as kyphoplasty, CT guided bone biopsy, radiofrequency ablation of osteoid osteoma, to name but a few) and all procedures under sedation will be performed in the Interventional Radiology (IR) Department with dedicated IR nursing and technical staff, with supervision of an IR Attending.

Cases include:

  1. Emergency Department(ED)
  2. Inpatient studies (Stony Brook University Hospital, Southampton Hospital)
  3. Outpatient studies. Outpatient imaging studies are performed at both the University Hospital and Out-Patient Imaging Centers at the  Ambulatory Care Pavilion (ACP) and the Stony Brook Advanced Imaging Centers at Stony Brook Rd and Commack
  4. Adult and pediatric cases

The program has been structured and organized based on the ACGME Program requirements, specific objectives and the interpretation of the ACGME general competencies.                                 

Overall goals of the program are to facilitate fellow learning with demonstration of proficiency in Musculoskeletal (MSK) Radiology and to adopt life long learning and self assessment skills.  To this end the fellow will:

  1. Demonstrate mastery of the knowledge based curriculum;
  2. Demonstrate proficiency in the protocol of cases and interpretation of cross sectional imaging studies of MSK system;
  3. Demonstrate proficiency in the timely dictation of a concise accurate radiological report;
  4. Demonstrate proficiency in performing procedures including aspirations, joint/therapeutic injections, arthrography, bone and soft tissue biopsies;
  5. Communicate effectively with patients, families, peers, residents, and faculty, technical, nursing, and ancillary staff. Provide consultation with referring physicians and services;
  6. Apply knowledge learned to support and justify the appropriate clinical indications for ordering and  performing radiologic studies pertaining to both basic and advanced musculoskeletal imaging;
  7. Demonstrate proficiency in performing and interpreting MSK ultrasound examinations;
  8. Demonstrate a responsible professional work ethic;
  9. Demonstrate proficiency in the interpretations of plain radiographs;
  10. Formulate and master teaching skills and facilitate the teaching of medical students, radiology residents, rheumatology and orthopedic residents, as well as other professional;
  11. Demonstrate active participation in the Quality Improvement (QI) and monitoring process;
  12. Demonstrate confidence in the interpretation of Emergency Department (ED) emergent studies; 
  13. Perform critical analysis of journal articles as well as the process of research for discussion and for Journal Club. Includes effective electronic literature review to justify, validate, and critically appraise;
  14. Demonstrate mastery of the six competencies with knowledge of objective assessment methods as they apply to the program and its goals and objectives;
  15. Active participation and experience in MSK research including the IRB process, human subjects training.  Preparation of an abstract, manuscript, or case report for presentation at Grand Rounds, or submission at a national meeting, peer reviewed journal, interdepartmental, or at the Department’s Annual Research Day;
  16. Demonstrate proficiency in conference/lecture organization, PowerPoint preparation, and presentation;
  17. Incorporate the goals and objectives into critical self assessment and lifelong pursuit of knowledge;
  18. Develop tools and learning approaches to facilitate the continuous acquisition and use of knowledge.

Program Organization:

  1. Initial needs assessment based on fellow’s baseline knowledge and experience
  2. Rotational schedules
  3. Program goals
  4. Program objectives-based on rotational components
  5. Knowledge (cognitive) based curriculum
  6. Clinical, technical, and didactic elements.
  7. General requirements and responsibilities of fellow
  8. Instructional and teaching responsibilities of fellow (Fellow as teacher)
  9. Fellow Learning Portfolio and Case –Procedural Logs
  10. On-call requirements
  11. Faculty and 360 degree evaluations in addition to more task specific evaluations.
  12. Fellow evaluation of Program and faculty.
  13. Fellow self assessment
  14. Program Director-Fellow meetings
  15. Summative/Final Evaluation

Curriculum - Educational Goals and Objectives 

The MSK radiology fellowship program has integrated our goals and  objectives within the six competencies established by the ACGME:

1.    Patient Care
2.    Medical Knowledge
3.    Practice-Based Learning & Improvements
4.    Interpersonal & Communication Skills
5.    Professionalism
6.    System-Based Practice
 

Responsibilities:

a)    Protocoling, monitoring and interpreting CT and MR imaging studies under faculty supervision.
b)    Protocoling and performing patient procedures, including arthrography, therapeutic and diagnostic injections, ultrasound, and CT guided biopsies under faculty supervision.
c)    Performing diagnostic MSK ultrasound examinations and presenting the findings to the attending for review.
d)    Preparing interdisciplinary conferences.
e)    Consulting with referring physicians.
f)    Effectively communicating study results by timely signing of reports and appropriate direct communication. 

Core Competencies   

1.     Patient Care

Skills:
a)    Gather essential and accurate information about patient history for musculoskeletal imaging studies, including operative notes, comparison previous examinations (including outside studies),  pertinent labs, pathology reports and clinic notes, etc.
b)    Develop appropriate differential diagnoses and management recommendations that addresses the clinical questions and relevant clinical, labs, and prior imaging studies.
c)    Protocol and monitor imaging studies to ensure that exams are performed appropriately and safely.
d)    Plan and execute image-guided biopsies of bone and soft tissue masses using established orthopedic limb-sparing techniques.
e)    Perform appropriate diagnostic-quality US examinations.
f)     Obtain informed consent; explain procedure, risks and benefits to patient in lay terms, in a clear and concise fashion.
g)    Develop rapport, trust, and ethical relationships with patients and families.

Education:
a)    Prepare and present differential diagnosis and management plan for cases based on a synthesis of available clinical data, radiological findings and laboratory data to supervising faculty for  assessment and feedback.
b)    Observe and then execute informed consent.
c)    Observe and then perform diagnostic US examinations
d)    Actively participate in journal reviews to determine effectiveness of diagnostic imaging for specific diagnostic indications.
e)    Prepare and present radiological cases to other members of the healthcare team.

Assessment:
a)    Global faculty evaluation of performance regarding skills listed above.


2.    Medical Knowledge

Skills:
a)    Demonstrate knowledge of radiation physics, including the radiation doses of different musculoskeletal examinations and the ALARA principle (As Low As Reasonably Achievable) of minimizing lifetime patient radiation exposure.
b)    Demonstrate knowledge of the normal radiographic, CT, US and MRI anatomy of the musculoskeletal system.
c)     Appropriately protocol CT and MR imaging examinations recognizing the uses and limitations of the available imaging sequences and the necessary modifications requires for optimal  results in patients with indwelling orthopedic hardware.
d)    Recognize the potential complications of both CT and MR contrast agents, techniques to minimize these risks and alternative methods of imaging when contrast is contraindicated.
e)    Create a personalized, cost effective, imaging plan for the appropriate evaluation of patients with musculoskeletal disorders to include, as appropriate, radiographs, nuclear medicine studies  (including PET), CT, MR and/or ultrasound.
f)     Identify, describe, and classify (when appropriate) musculoskeletal disorders to include:

  •  Cellulitis, osteomyelitis, and septic arthritis
  •  Common fractures of the axial and appendicular skeleton  (including, mechanisms of injury and potential complications)
  •  Orthopedic appliances and hardware used to fixate these fractures, as well as their complications
  •  Bone and soft tissue tumors (using the WHO classification system), both for initial presentation and assessment of recurrent and metastatic disease
  •  Osteonecrosis
  •  Metabolic bone disease
  •  Arthropathies (degenerative, inflammatory and crystal)
  •  Systemic disorders to include hematopoietic and storage diseases
  •  Abnormalities of the knee, shoulder, foot, ankle, hand, wrist, hip and pelvis
  •  Disorders of the spine (including disc pathology using the ASNR nomenclature) 

Education:
a)    Complete a year-long didactic lecture series encompassing the topics listed in paragraph 2f.
b)    Participate in weekly educational conferences (i.e.: tumor board, interesting case conference,
c)    Participate in a weekly journal club.
d)    Prepare and present didactic lectures and case conferences for residents and/or staff.
e)    Use the attached list for supplemental reading (Addendum).

Assessment:
a)    Global assessment by faculty during diagnostic interpretation.


3.    Interpersonal and Communication Skills

Skills:
a)    Create clear, concise and informative radiological reports.
b)    Provide clear, direct communication to referring physicians or clinic personnel when interpretation reveals an urgent or unexpected finding. Document this communication in the written report (time, date, method of contact, person to whom result communicated). Demonstrate compliance with urgent notifications departmental policy.
c)    Demonstrate timely and effective, respectful communication with physicians, nurses, technologists, and other members of the healthcare team.
d)    Demonstrate timely and respectful telephone skills.
e)    Demonstrate effective collaboration with interprofessional health care team.

Education:
a)    Participate as an active member of the radiology team by communicating in person or on the phone or by email with members of the health care team.
b)    Serve as a contact person for technologists with questions about protocols, stat reads, or image quality issues.
c)    Dictate radiological reports.
d)    Complete required departmental education.
e)    Coordinate interdisciplinary conferences.

Assessment:
a)    Review of trainee’s written radiological reports and direct feedback by faculty members.
b)    Direct observation of trainee’s verbal communication skills by faculty members.


4.    Professionalism

Skills:
a)    Demonstrate positive work habits, including punctuality and professional appearance.
b)    Perform responsibilities at the highest level.
c)    Demonstrate ability to perform self-assessment of knowledge and to pursue continuous active learning.
d)    Function as an effective team member, including identifying section needs and contributing help where needed (e.g. reading cases, interacting with patients and staff, preparing support  materials)  
e)    Demonstrate respectful behavior to peers, staff, patients, and technologists.
f)     Dictate cases and correct transcribed dictations in a timely and accurate fashion, including use of recommended report templates.
g)    Request permission in advance from section chief regarding requests for time away from the clinical work day.

Education:
a)    Completion of web-based self-directed learning and assessment program on human subject research guidelines.
b)    Discuss conflicts of interest and ethics of conducting research during section research meetings.

Assessment:
a)    Direct faculty observation of trainee in clinical setting.


5.     Practice-Based Learning and Improvement

Skills:
a)    Perform practice-based improvement in cognitive knowledge, observational skill, synthesis of clinical/laboratory/radiological data, and formulation of impression.
b)    Demonstrate a knowledge and application of principles of evidence-based medicine to daily practice.
c)    Use multiple sources, including, but not limited to, information technology, journal articles, etc., to support patient care decisions.
d)    Demonstrate an ability to assess the quality of various information sources, including peer reviewed journals, non-reviewed journals, web sources, etc.
e)    Participate in daily QA by identifying suboptimal images or studies.

Education:
a)    Participate in critical assessment of the literature through journal club, clinical conferences, and independent learning.
b)    Teach residents (case review in reading room, readout of wet reads, cross sectional review, case conferences), other health care professionals (through multidisciplinary conferences), with graduated supervision and feedback from supervising faculty.  
c)    Active participation in departmental quality assurance/ quality improvement program. 

Assessment:
a)    Global evaluation by musculoskeletal imaging faculty.
b)    Self-assessment using Case Review: Musculoskeletal Imaging textbook or ACR Learning File.


6.    Systems Based Practice

Skills:
a)    Demonstrate knowledge of appropriateness criteria for various musculoskeletal imaging studies.
b)    Demonstrate ability to design effective management plans based upon knowledge of best practices.

Education:
a)    Review the American College of Radiology Appropriateness Criteria to develop knowledge of the evidence-based indications for musculoskeletal imaging procedures.
b)    Attendance and active participation in departmental and multidisciplinary conferences where there is discussion of the imaging evaluation of, as well as the most appropriate and cost-effective methods for diagnosing, specific musculoskeletal disorders.

Assessment:
a)    Global evaluation by musculoskeletal imaging faculty.
b)    Multidisciplinary conference attendance.

 

There is exposure to Nuclear Radiology (to include DEXA) - 5 days and bone pathology via conferences and tumor board.

One half day per week is considered dedicated time for research and scholarly activity, based on individual Fellow's interest and needs. Five additional days may be allotted for elective time with the approval of the Program Director. These arrangements can be discussed with the Program Director at the beginning of the Fellowship. 

If interested , contact the Program Coordinator, Linda Erickson at 631-444-3580