Special Ar ticles Original Research

Yablon et al.
Musculoskeletal Fellowship Training

Special Articles
Original Research

A Needs Assessment of
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Musculoskeletal Fellowship
Training: A Survey of Practicing
Musculoskeletal Radiologists
Corrie M. Yablon1 OBJECTIVE. The purpose of this study was to conduct a needs assessment of musculo-
Jim S. Wu2 skeletal radiologists regarding their musculoskeletal training experience and attitude toward
Lori R. Newman 3 a standardized musculoskeletal fellowship curriculum.
Brian K. Downie1 MATERIALS AND METHODS. An anonymous survey was sent to the Society of
Mary G. Hochman2 Skeletal Radiology membership querying musculoskeletal radiologists practice patterns, fel-
lowship program, curriculum, and modes of learning.
Ronald L. Eisenberg2
RESULTS. Of 216 respondents (26% response rate), 87% were musculoskeletal fellow-
Yablon CM, Wu JS, Newman LR, Downie BK, ship trained. The majority performed MRI, CT, and radiography (99%); arthrography (95%);
Hochman MG, Eisenberg RL spine MRI (77%); pediatric musculoskeletal imaging (75%); musculoskeletal ultrasound
(63%); and biopsies (62%). During fellowship, 72% read spine MRI; 74% pediatric musculo-
skeletal imaging, and 49% musculoskeletal ultrasound (49%); 33% received no spine proce-
dural training. Most felt comfortable performing arthrography, joint injections, and bone and
soft-tissue biopsies but not spine biopsies. Of the total, 33% received a curriculum and 67%
had no formal feedback and 56% did not evaluate their program. The highest rated program
features were teaching by attending physicians (69%), case variety (54%), and procedural
training (49%). The lowest rated features were lack of curriculum (57%), lack of structured
learning (48%), and lack of mentoring (24%). The favorite mode of learning was one-on-one
readout with attending physicians (90%), and 85% agreed that a standardized musculoskele-
tal fellowship curriculum would benefit musculoskeletal training.
CONCLUSION. Although musculoskeletal radiologists believe they were adequately
trained for practice, there are perceived deficiencies in spine MRI, pediatric musculoskeletal
imaging, and musculoskeletal ultrasound. A standardized musculoskeletal fellowship curric-
ulum would provide improved structure and a defined educational program. Clear expecta-
Keywords: fellowship education, musculoskeletal
tions, performance assessment, feedback, and programmatic evaluation should be core ele-
fellowship curriculum, musculoskeletal fellowship ments of the training of every musculoskeletal fellow.
education

DOI:10.2214/AJR.12.9105
Received April 20, 2012; accepted after revision
June13,2012.
1
Department of Radiology, University of Michigan, 1500 E
Medical Center Dr, Ann Arbor, MI. Address correspond-
ence to C. M. Yablon (cyablon@umich.edu).
2
Department of Radiology, Beth Israel Deaconess
Medical Center, Harvard Medical School, Boston, MA.
3
Shapiro Institute for Medical Education and Research at
Harvard Medical School and Beth Israel Deaconess
Medical Center, Boston, MA.
AJR 2013; 200:732740
0361803X/13/2004732
American Roentgen Ray Society
M
usculoskeletal fellowship training
has been characterized by a di-
versity of educational experienc-
es. Data obtained in 2012 from the
Society of Skeletal Radiology (SSR), the major
subspecialty society of musculoskeletal radi-
ology in the United States, listed 14 Accredita-
tion Council of Graduate Medical Education
(ACGME)-accredited programs and 64 non-
ACGME programs, offering a total of 184 posi-
tions [1]. Since 2010, there has been an increase
in non-ACGME positions from 123 to 163 [1, 2].
The challenge facing all non-ACGMEac-
credited fellowships, not only musculoskeletal
fellowships, is that there is no governing body to
provide uniform guidelines for call duties, work-
ing conditions, compensation, educational pro-
grams, and curricula, which now vary widely
[2]. Although the SSR has created a curriculum
structured around the ACGME core competen-
cies for musculoskeletal radiology residency
learning [1], there are no formal curricula at
the fellowship level. Even the guidelines for
ACGME-accredited fellowships only refer to lo-
gistics and not to a specific curriculum, which
is left to the individual programs to determine
[3]. Non-ACGMEaccredited fellowships are
not required to follow these guidelines; there-
fore, there are no didactic requirements, and
learning experiences are highly unstructured.
Most educational material is case based and de-
termined by the expertise of local attending phy-
sicians, referral patterns, and case volume, with
some fellowships similar to apprenticeships.
In light of the variability of musculoskele-
tal fellowship educational programming and

732 AJR:200, April 2013

 Musculoskeletal Fellowship Training

80 Academic
40 05 years
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Private practice
610 years
70
35
1115 years
60
30 1620 years

Respondents (%)
Respondents (%)

50
25

40
20

15 30

10 20

5 10

0 0
05 610 1115 1620 020 2140 4160 6180 81100
Time (y) Time (y)

Fig. 1Chart shows percentage of respondents grouped by number of years past Fig. 2Graph shows musculoskeletal radiologists in private practice versus
training. academic practice grouped by percentage of practice time spent subspecializing
in musculoskeletal related activities.

the predominance of non-ACGMEaccredited
fellowships, we sought to assess the perceived
preparedness of musculoskeletal radiologists
and whether a standardized musculoskeletal
curriculum would be beneficial. We hypothe-
sized that although musculoskeletal fellowships
may provide sufficient preparation for practice,
there are knowledge, skill, and attitudinal de-
ficiencies that should be identified, addressed,
and incorporated into a standardized musculo-
skeletal fellowship curriculum.
Materials and Methods
The institutional review board of our hospi-
tal deemed our study exempt from further review.
We developed a 36-question survey that included
multiple choice, yes-or-no, and 5-point Likert scale
questions. Targeted to practicing musculoskeletal
radiologists, the survey queried radiologists cur-
rent practice patterns, fellowship training program
determine p values. Analyses were performed us-
ing SAS, version 9.2, statistical software.
Results
Respondent Characteristics
We sent the survey electronically to 844
SSR members and received 216 responses,
yielding a response rate of 26%. Of those re-
sponding, 87% were musculoskeletal fellow-
ship trained, 46% were in an academic prac-
tice, and 54% were in private practice. Of the
97 respondents in academics, 13% had not re-
ceived musculoskeletal fellowship training,
primarily due to the absence of formal muscu-
loskeletal fellowships before 1986 when mus-
culoskeletal training consisted of apprentice-
ship or mentorship models. Of the respondents
80
in private practice, 26% worked in small (1- to
10-person) practices, 30% worked in medium
sized (11- to 20-person) practices, and 44%
worked in larger sized (> 21-person) practic-
es. The respondents had a wide range of years
of practice experience (Fig. 1).
Most of the respondents considered them-
selves musculoskeletal subspecialists (87%),
and many (46%) spent 81100% of their total
practice in musculoskeletal imaging. Most mus-
culoskeletal radiologists in academics spent the
majority of their practice time subspecializing in
musculoskeletal imaging; whereas those radiol-
ogists in private practice spent varying degrees
of time in musculoskeletal imaging (Fig. 2).
Ninety-nine percent of respondents per-
formed extremity MRI, CT, and radiography
Private practice

and curriculum, views on preparedness after train- Academic

Fellowship
ing, and preferred modes of learning. The word
60
curriculum was defined as a directed course of
Respondents (%)

study or core educational content with stated learn- Fig. 3Chart shows
comparison of percentage
ing goals and objectives for a learner to master. of respondents who read 40
The survey was piloted before general testing and spine MRI, pediatric
then distributed electronically through the SSR to musculoskeletal imaging,
and musculoskeletal
its entire membership in April 2011 (Appendix 1). ultrasound in private 20
An accompanying cover letter notified potential re- practice versus academics,
spondents that the results were being collected for compared with the
percentage of respondents
research purposes and would be shared with the 0
who learned those
SSR and academic community. We used chi-square modalities in fellowship Spine Pediatric Musculoskeletal
training. MRI Musculoskeletal Ultrasound
tests and Fisher exact tests for statistical analysis to

AJR:200, April 2013 733

 Yablon et al.

in their practices; 95% arthrography; 77%
spine MRI; 75% pediatric musculoskeletal
imaging; 63% musculoskeletal ultrasound;
62% imaging-guided biopsy of the extremi-
ties and pelvis; and 40% imaging-guided bi-
opsies of the spine.
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Only 74% of respondents received training in
pediatric musculoskeletal imaging; 72% of
respondents received training in spine MRI;
and 49% received training in musculoskeletal
ultrasound (Fig. 3).
station. Fellows were also required to teach
medical students at the workstation (44%)
and to give medical student lectures (37%).
When queried about the most outstand-
ing aspects of the fellowship, the top three
responses were teaching by attending phy-

Roughly half of the respondents did not per-
form spine procedures. In these cases, these
procedures were performed by several oth-
er providers, including neuroradiology (71%),
pain medicine (51%), anesthesia (39%), neuro-
surgery (32%), and physiatry or physical medi-
cine and rehabilitation (15%). Nine percent of
respondents replied that spine procedures were
not performed in their hospital.
Fellowship Training
The majority of the musculoskeletal fel-
lowships were small: 30% had only one fel-
low, 32% had two fellows, 25% had 3 or 4 fel-
lows, and 13% had five or more. The majority
of fellowships (54%) had four or fewer attend-
ing physicians. Twenty-eight percent had 5 or
6 attending physicians, 13% had 79, and 5%
had 10 or more attending physicians.
Spine procedural training was variable
across fellowships. Thirty-two percent of re-
spondents received no spine procedure training
at all. Of those receiving spine procedure train-
ing, 51% learned spine biopsies, 43% learned
epidural steroid injections, 54% learned to do
facet injections, 22% performed vertebroplas-
ty, and 12% performed kyphoplasty.
When asked if they received adequate
training to feel comfortable performing pro-
cedures in practice, the majority of respon-
dents replied that they felt adequately or even
better trained than colleagues in their prac-
tices to perform arthrography (99%); joint in-
jections (97%); and biopsies of bone (78%),
soft tissue (81%), and spine (49%). Regarding
cross-sectional studies (CT and MRI exami-
nations), 91% of respondents thought they had
read sufficient examinations to feel adequate-
ly prepared for practice; 89% thought they
had read a sufficient number of radiographs.
Evaluation of Fellows and the Fellowship Program
Procedural logs were maintained by only
36% of fellows. The majority of fellows (53%)
received informal feedback during their fel-
lowship; 33% of fellows received feedback
from fellowship directors at regular intervals,
27% of fellows received occasional informal
feedback, and 12% received no feedback (re-
spondents could provide more than one an-
swer). Only 44% of respondents were provid-
ed the opportunity to evaluate their program.
Faculty mentors were assigned to 40% of re-
spondents. Procedural skills were evaluated
by faculty in 78% of respondents. Interpreta-
tive skills were quantitatively evaluated (i.e.,
competency test, other grading scheme) in 7%
of respondents.
prisingly, online teaching modules were the
Curriculum
A curriculum, or learning goals and objec-
tives for the core educational content of the
fellowship program, were presented to 33%
of those responding. Of the remaining 67% of
respondents, 14% were given a list of muscu-
loskeletal topics they were expected to know
by completion of the fellowship. A structured
conference schedule was provided to 67% of
respondents. Conferences included orthope-
dic oncology or tumor board (77%), rheuma-
tology (67%), sports medicine (50%), journal
club (45%), didactics (43%), quality assurance
(34%), and follow-up conferences (28%).
Learning and Attitudes
When taught how to perform procedures,
31% practiced biopsies on a phantom be-
fore performing biopsies. Most respondents
(88%) were required to teach during fellow-
ship, with 73% required to give resident lec-
tures and 71% to teach residents at the work-
sicians (69%), variety of cases (54%), and
training in procedures (49%). When asked
about the three least-liked aspects of the fel-
lowship, respondents most often noted lack
of a curriculum (57%), lack of a structured
learning environment (48%), and lack of
help finding a job after fellowship (24%).
Respondents were asked to rank favored
modes of learning. One-on-one readout with
attending physicians was by far the most pre-
ferred mode of learning (90%); less popu-
lar modes were reading textbooks at home
(42%), interdisciplinary conferences (39%),
just-in-time learning (looking up items on-
line or in books as questions arose during
readout) (38%), journal and review articles
(37%), and didactic conferences (34%). Sur-
least-favored activity (only 3%).
Respondents wished they had received
more training during fellowship in the follow-
ing modalities: musculoskeletal ultrasound
(56%), pediatrics (43%), bone biopsies (32%),
spine MRI (26%), dual-energy x-ray absorp-
tiometry (23%), musculoskeletal MRI (21%),
and soft-tissue biopsies (21%). Respondents
were queried about their feelings of prepared-
ness to practice radiology after fellowship,
attitudes toward fellowship training, and a
standardized musculoskeletal fellowship cur-
riculum (Table 1). Overall, the majority of
respondents felt well-prepared for practice,
thought musculoskeletal fellowship training
was optimal for the practice of musculoskel-
etal radiology, and favored the creation of a
standardized musculoskeletal fellowship cur-
riculum. There was no statistical correlation
between respondents receiving a curriculum
and perceived preparedness for practice (p<
1.0)the reason being that all musculoskel-

TABLE 1: Respondents Views of Musculoskeletal Fellowship Training and Musculoskeletal Fellowship Curriculum
Survey Statement Response
Compared with other colleagues in your current practice, how Much more prepared (42) More prepared (29) Equally prepared (27) Less prepared (3)
well prepared for practice of musculoskeletal radiology did you
feel after completing your fellowship?
Musculoskeletal fellowship training is the optimal training for Strongly agree (65) Agree (32) Disagree (1) Strongly disagree (2)
pursuing musculoskeletal radiology in practice.
A standardized musculoskeletal fellowship curriculum would be Strongly agree (27) Agree (58) Disagree (11) Strongly disagree (4)
beneficial to musculoskeletal fellowship training.
NoteData in parentheses are percentages.

734 AJR:200, April 2013


etal-trained respondents except four felt pre-
pared for practiceor their perceived need
for a standardized curriculum (p< 0.4305).
There also was no relationship between years
after training and the desire for a standardized
curriculum (p= 0.3809).
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The top five factors influencing the deci-
sion to choose a job were the following: loca-
tion (75%), colleagues at the future location
(42%), income (25%), desire for an academic
practice (24%), and work hours (23%). Nei-
ther faculty mentors nor fellowship-related
clinical, educational, or research experiences
figured prominently in the decision to choose
a postition.
Discussion
Past studies of musculoskeletal fellowship
programs have focused on surveying the pro-
gram directors or fellows in training. A 1998
survey of fellowship program directors as-
sessed the status of the programs training and
supervision with a focus on ACGME accredi-
tation [4]. A subsequent 2003 study surveyed
program directors to compare the structure
of ACGME to non-ACGMEaccredited pro-
grams [5]. An unpublished 2010 abstract sur-
veyed fellows in the first few months of train-
ing regarding factors influencing their choice
of fellowship, their attitudes toward a fellow-
ship match, program logistics, and receptivity
toward a fellowship curriculum (Rao N et al.,
presented at the 2010 annual meeting of the
SSR). This is the first study to assess the opin-
ions of practicing radiologists regarding their
fellowship training and whether it adequately
prepared them for practice. By surveying radi-
ologists in practice, we had the opportunity to
query those who had gained perspective over
time as to the best educational methods to use
and whether a standard curriculum would ben-
efit fellowship training.
This survey revealed important findings
to help structure future fellowship programs.
For example, 77% of respondents continue
to read spine MRI both in academic and in
private practices, and 40% perform imaging-
guided biopsies of the spine. This indicates
that spine interpretation and procedures re-
main a significant and valuable aspect of
musculoskeletal imaging, and thus training
in this area should be an essential part of a
musculoskeletal fellowship.
Pediatric musculoskeletal studies are com-
monly interpreted in private practice and mus-
culoskeletal ultrasound use has grown both in
academic and private practices during the past
decade [6]. Seventy-five percent of our sam-
AJR:200, April 2013 735
Musculoskeletal Fellowship Training
ple read pediatric musculoskeletal imaging
studies, and a similar number received fellow-
ship training in this area; however, although
63% perform musculoskeletal ultrasound in
their practices, only 49% received training in
this area during fellowship. This suggests that
musculoskeletal fellowship training programs
should offer elective rotations in pediatric
musculoskeletal imaging and musculoskeletal
ultrasound if these areas are not already a part
of the standard curriculum.
Our study revealed room for improvement
regarding formal procedural and interpretive
skills assessment and feedback to fellows,
which can provide valuable teaching and in-
sight [7, 8]. Although the ACGME requires
quarterly feedback of residents and fellows
[3], only 33% of respondents received formal
feedback at regular intervals, with the remain-
der receiving only informal feedback. Feed-
back should be scheduled quarterly, discussed
in a private setting, and documented in writ-
ing. Fellows should also be given the opportu-
nity to evaluate the program, which is another
ACGME requirement [3]. In our experience,
these types of evaluation sessions have led to
positive change and training improvement.
There has been debate in the musculo-
skeletal community regarding the utility of
having a standardized musculoskeletal im-
aging fellowship curriculum. No formal cur-
riculum currently exists, and our survey in-
dicates that most programs devise their own
curricula, if any. This leads to a heterogene-
ous learning experience that is dependent on
the specific fellowship chosen. If there were
a standard curriculum, self-directed learners
could identify and fill programmatic gaps
or seek radiology experience not offered on
site. It is noteworthy that when queried about
the three things they liked least about their
fellowships, the two major complaints were
lack of a curriculum (57%) and lack of a
structured learning environment (48%).
It is not surprising that the respondents fa-
vored mode of learning was one-on-one read-
out with an attending physician. Despite ad-
vances in digital teaching methods, one-on-one
teaching during readouts remains the primary
method of teaching radiology and imparting the
subtleties of radiologic interpretation. One-on-
one interaction with a supportive instructor or
mentor is an immediate and gratifying way to
learn, in which years of the instructors expe-
rience can be distilled into focused teaching at
the workstation. Reading textbooks at home,
just-in-time learning, and reading journal arti-
cles ranked a distant second, third, and fourth,
respectively, as the favored learning method.
Web-based learning also did not score highly,
which is surprising given the digital nature of
radiology. This finding may be explained by the
heterogeneous quality of web-based offerings
for musculoskeletal imaging; the (often time-
consuming) need to search multiple sources to
find credible, referenced material; and the lack
of material directed at the fellowship level.
In retrospect, respondents wished they had
received more training in musculoskeletal ul-
trasound, pediatric musculoskeletal imaging,
bone biopsies, spine MRI, dual-energy x-ray
absorptiometry, musculoskeletal MRI, and
soft-tissue biopsies. These findings likely re-
flect the changing landscape of musculoskeletal
radiology. Both academic and private practic-
es are performing more musculoskeletal ultra-
sound. Pediatric musculoskeletal imaging is
ubiquitous in private practice and community
hospitals. Musculoskeletal interventions are in-
creasing, and requests for percutaneous biop-
sies of bone and soft-tissue masses of the ex-
tremities are commonplace in many practices.
Musculoskeletal specialists are well positioned
to partner with orthopedic surgeons to plan in-
terventions and perform posttreatment imaging.
Many orthopedic surgeons order spine MRI as
part of their practice, and musculoskeletal ra-
diologists can increase their consultative value
to their orthopedic colleagues by interpreting
these as well as extremity studies.
Most musculoskeletal radiologists surveyed
thought that musculoskeletal fellowships pre-
pared them well for practice, despite the dif-
ferences among fellowships. However, the
majority thought that a standardized musculo-
skeletal fellowship curriculum would provide
further benefit. Although fellows likely sup-
plement their own learning when modalities
or subjects are not covered in their programs,
the presence of a structured curriculum would
enhance the learning experience and provide
a guide for specific topics that should be cov-
ered during fellowship.
When the initial results of this survey were
shared with members of the SSR community
in late 2011 and early 2012, the SSR Education
Committee and others in the musculoskeletal
academic community agreed that the prelimi-
nary findings confirmed the need to draft fel-
lowship curricular guidelines or suggestions.
Limitations
Given the moderate (26%) response rate,
we likely encountered some selection bias. The
SSR is a self-selected group of musculoskele-
tal subspecialists who have a stated interest in
 Yablon et al.

musculoskeletal imaging and therefore affiliate
with the organization. There are likely many
more self-identified musculoskeletal-trained ra-
diologists, unaffiliated with the SSR, who were
unable to participate in this study because their
identity and contact information were not read-
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well for practice. However, there are perceived
educational deficiencies in spine MRI, pedi-
atric musculoskeletal imaging, and musculo-
skeletal ultrasound as well as, less frequently,
bone, soft-tissue, and spine biopsies. These de-
ficiencies may be corrected by the creation of
skeletal radiology. www.acgme.org/acgmeweb/
Portals/0/PFAssets/ProgramRequirements/426_
musculoskeletal_diag_rad_07012010_1-YR.pdf.
Published July 1, 2010. Accessed December 4,
2012
4. De Smet AA, Resnik CS. Current status of mus-

ily available. For ease of distribution, we chose
to send the survey through the SSR to provide a
roughly equal mix of private practice and aca-
demic musculoskeletal radiologists. Moreover,
we thought that musculoskeletal radiologists
affiliated with the SSR most likely had a vested
interest in the future of musculoskeletal educa-
tion and were more likely to respond.
Surveys on fellowship education may cre-
ate recall bias in that the respondents tend to
recall their training favorably as a reflection
of good decision making on their part. In ad-
dition, respondents may not accurately recall
the details of their fellowship training as the
time of training grows more remote.
Conclusion
Practicing radiologists believe that musculo-
skeletal fellowship training has prepared them
a standardized musculoskeletal fellowship cur-
riculum that provides improved structure and a
defined educational program. Didactics aimed
at the fellowship level should be incorporat-
ed into the program. Clear expectations, per-
formance assessment, feedback, and program-
matic evaluation should be core elements of the
training of every musculoskeletal fellow.
References
1. Society of Skeletal Radiology website. MSK fel-
lowships. skeletalrad.org/resources/fellowships.
aspx. Published March 19, 2012. Accessed April
4, 2012
2. Baker SR, Luk L, Clarkin K. The trouble with fel-
lowships. J Am Coll Radiol 2010; 7:446451
3. Accreditation Council of Graduate Medical Educa-
tion (ACGME) website. ACGME program require-
ments for graduate medical education in musculo-
culoskeletal radiology fellowships in the United
States. Acad Radiol 1998; 5:509512
5. Berquist TH, Bancroft LW, Kransdorf MJ, Ander-
son MR, Walters RM. Postgraduate musculoskel-
etal fellowship training in the United States: cur-
rent trends and future direction. Skeletal Radiol
2003; 32:337342
6. Sharpe RE, Nazarian LN, Parker L, Rao VM,
Levin DC. Dramatically increased musculoskele-
tal ultrasound utilization from 2000 to 2009, es-
pecially by podiatrists in private offices. J Am
Coll Radiol 2012; 9:141146
7. Ende J. Feedback in clinical medical education.
JAMA 1983; 250:777781
8. Yarris LM, Fu R, LaMantia J, et al. Effect of an
educational intervention on faculty and resident
satisfaction with real-time feedback in the emer-
gency department. Acad Emerg Med 2011;
18:504512

Appendix 1: Musculoskeletal Curriculum Survey

Part I: Tell us about yourself and your practice
1. Did you do a musculoskeletal imaging fellowship?
a. Yes
b. No
2. If you did not do a musculoskeletal fellowship, please describe any training after residency:
3. How many years ago did you complete your training after fellowship?
a. 02 years
b. 35 years
c. 610 years
d. 1115 years
e. 16 or more years ago
4. Please select your current practice type:
a. Small private practice (010)
b. Medium private practice (1120)
c. Large private practice (> 21)
d. Academics
e. I am not practicing radiology
f. Other (please specify)
5. What percentage of your total practice do you devote to musculoskeletal studies (includes extremity and spine, both diagnostic and therapeutic)?
a. 020%
b. 2140%
c. 4160%
d. 6180%
e. 81100%

(Appendix continues on next page)

736 AJR:200, April 2013

 Musculoskeletal Fellowship Training

Appendix 1: Musculoskeletal Curriculum Survey (continued)

6. Please indicate which of the following modalities you currently perform in your practice (please check all that apply):
a. Pediatric musculoskeletal
b. Musculoskeletal CT
c. Imaging-guided biopsies of the extremities and pelvis
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d. Extremity MRI
e. Spine MRI
f. Arthrography
g. Musculoskeletal radiography
h. Musculoskeletal ultrasound
i. Imaging-guided biopsies of the spine
7. If you do not perform spine procedures in your practice, who does perform them?
a. Neuroradiology
b. Neurosurgery
c. Anesthesia
d. Physiatry/Physical Medicine and Rehabilitation service
e. Pain Medicine
f. We do not perform these in our hospital
Part II. Your fellowship training program
1. If you did a musculoskeletal fellowship, how big was your program?
a. One fellow
b. Two fellows
c. Three or four fellows
d. Five or more fellows
2. How many musculoskeletal attending physicians were on staff in your program?
a. Four or fewer
b. Five or six
c. Seven to nine
d. 10 or more
3. Did you read or perform the following in your fellowship (please check all that apply)?
a. Spine MRI
b. Pediatric musculoskeletal studies
c. Musculoskeletal ultrasound
4. Were you offered the opportunity to do the following (check all that apply)?
a. Epidural injections
b. Facet injections
c. Spine biopsies
d. Vertebroplasty
e. Kyphoplasty
f. Other (please specify)
g. None of the above
5. Did you get adequate training to feel comfortable to perform the following procedures in practice:
Inadequate Adequate More than adequate
Arthrography
Joint injections
Bone biopsies
Soft-tissue biopsies
Spine biopsies
6. Were you required to keep a procedure log during your fellowship?
a. Yes
b. No

(Appendix continues on next page)

AJR:200, April 2013 737

 Yablon et al.

Appendix 1: Musculoskeletal Curriculum Survey (continued)

7. Please rank the top three things you found most outstanding about your musculoskeletal fellowship training (three is most outstanding)?
Mentorship in finding a job after fellowship
Curriculum
Wide variety of cases
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Supportive learning environment

Preparation for practice beyond fellowship
Training in procedures
Teaching by attending physicians
Appropriate volume of cases
Structured learning environment
Other (please specify)
8. Please rank the three things you found least desirable about your musculoskeletal fellowship training (one is least desirable).
Lack of help finding a job after fellowship
Lack of a curriculum
Lack of variety of cases
Lack of preparation for practice beyond fellowship
Lack of training in procedures
Not enough individualized attention
Not enough teaching
Too high volume of cases
Too low volume of cases
Lack of structured learning environment
Other (please specify)
9. Did you receive feedback on your performance during your fellowship (you may check more than one)?
a. Yes, by the fellowship director(s) at regular intervals
b. Yes, by the attending physicians in an informal manner
c. Yes, I received occasional feedback
d. No, I did not receive feedback
10. Were you given the opportunity to provide an evaluation of your program to your program director(s)?
a. Yes
b. No
11. A re there any other aspects of fellowship training that you would have liked to have received before entering practice? Please specify.
Part III: Curriculum/learning
A curriculum is defined as a directed course of study or core educational content with stated learning goals and objectives for a learner
to master.
1. At the beginning of your fellowship, were you presented with learning goals and objectives for the programs core educational content?
a. Yes
b. No
2. If you answered no to the previous question, were you given a list of topics in musculoskeletal radiology that you were expected to
know by the end of your fellowship?
a. Yes
b. No
3. Did you have an assigned faculty mentor with whom you worked on a regular basis?
a. Yes
b. No
4. Were you taught how to perform procedures (e.g., practice a biopsy on a phantom) before working on a patient?
a. Yes
b. No
5. Were your procedural skills evaluated by faculty?
a. Yes
b. No

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738 AJR:200, April 2013

 Musculoskeletal Fellowship Training

Appendix 1: Musculoskeletal Curriculum Survey (continued)

6. Were your interpretive skills evaluated quantitatively? (e.g., a competency test, MRI examinations to interpret for grading, etc.)
a. Yes
b. No
7. Please rank, in order of importance, your top three preferred modes of learning during your fellowship.
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a. Didactic conferences
b. Just-in-time learning, (e.g., looked up topics on Internet, in books, online teaching modules) as questions arose during readout
c. Online search/Google/Wikipedia, etc.
d. Read textbooks at home
e. Online teaching modules
f. One-on-one readout/teaching at the monitor with attending physician
g. Journal articles/review articles
h. Interdisciplinary conferences
i. Curriculum provided by the program
Part IV: Conferences
1. Did your fellowship have a structured conference schedule?
a. Yes
b. No
2. Did your program provide the following (check all that apply)?
a. Quality assurance
b. Orthopedic oncology/tumor board
c. Rheumatology conference
d. Sports medicine conference
e. Spine conference
f. Didactic conferences for fellows
g. Journal club
h. Follow-up conferences
i. None of the above
j. Other (please specify)
3. Were you required to teach others during your fellowship (check all that apply)?
a. Medical student lectures
b. Radiology resident lectures
c. Other resident lectures
d. Departmental CME course
e. Taught medical students at the PACS workstation
f. Taught residents at the PACS workstation
g. I was not required to teach

Part V: Reflections on your fellowship

1. Did you feel you read an adequate number of radiographs in fellowship to be prepared for practice after fellowship?
Strongly agree Agree Disagree Strongly disagree
2. In your opinion, did you read a sufficient number of musculoskeletal cross-sectional studies in your fellowship to prepare you for practice
after training?
Strongly agree Agree Disagree Strongly disagree
3. Please rate how comfortable you felt performing the following procedures on completing fellowship:
Very uncomfortable Uncomfortable Comfortable Very comfortable
Arthrography
Imaging-guided biopsy of the extremities
Imaging-guided biopsy of the spine

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 Yablon et al.

Appendix 1: Musculoskeletal Curriculum Survey (continued)

4. In which areas do you wish you had received more training? Check all that apply:
a. I felt perfectly trained in everything
b. Musculoskeletal MRI
c. Musculoskeletal CT
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d. Radiography
e. Arthrography
f. Bone biopsies
g. Soft-tissue biopsies
h. Spine MRI
i. Spine biopsies
j. Musculoskeletal ultrasound
k. Dual-energy x-ray absorptiometry
l. Pediatric musculoskeletal
5. Compared with other colleagues in your current practice, how well prepared for practice of musculoskeletal radiology did you feel after
completing your fellowship?
Much less prepared Less prepared Equally prepared More prepared Much more prepared
6. Please indicate your agreement or disagreement with the following statement: Completing a musculoskeletal fellowship is optimal train-
ing for the practice of musculoskeletal radiology.
Strongly agree Agree Disagree Strongly disagree
7. Please state your agreement or disagreement with the following statement: A standardized musculoskeletal fellowship curriculum would
be beneficial to fellowship training.
Strongly agree Agree Disagree Strongly disagree
Part VI: Life after training
1. Please rank, in order of importance, the top three factors that influenced your choice of job after fellowship:
a. Faculty mentor
b. Clinical experience during fellowship
c. Educational experience during fellowship
d. Research experience during fellowship
e. Income
f. Work hours
g. Spouses career/employment
h. Medical school debt
i. Location
j. Really wanted an academic job
k. Really wanted a private practice job
l. People at future job
m. Other (please specify)

740 AJR:200, April 2013