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Reading mammo without fellowship
Im a fellow currently interviewing for jobs for next year. Theres a private practice partnership track position near me that checks off most of the boxes in terms of what Im looking for. My only major concern is that its a generalist job that would require me to read some low volume mammo a few days a week, including screening, diagnostic and some procedures. Im not doing a mammo fellowship and I dont feel like my mammo training in residency was particularly great, so this is making me nervous. Im curious to hear if other people were in a similar situation what theyre experience was with picking up mammo on the job? It is a skill that I would like to have under my belt, I just want to how doable it is before I agree to join. Thanks in advance!
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18 Replies
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This was me 10+ years back. Not a fun situation to be in if you don’t feel comfortable. Some recommendations include minifellowship or ACR mammo boot camp.
If you are comfortable with IR work, then mammo biopsies are not too hard. If not, I would highly advise doing a minifellowship because you don’t want to be put in a bad situation where you end up needing to hire a lawyer because of a missed breast cancer or poor biopsy leading to bad patient outcome.
My 2 cents.-
Mammo training in my residency sucked a## and I had to pick up screening and diagnostic skills during my first job in solo practice in a rural hospital. God bless the women who walked through our little hospital doors in those years. Later along the way, I was lucky that for a few years, I worked as the second radiologist in a breast center usually two days/week. I had a full time mammographer with me who did most of the biopsy work but was available to bounce cases of. That was the most satisfying way of doing mammo and in the end of that time I actually had good numbers. Fast forward a few decades, now I do all the routine mammo including procedures and I end up doing quite a lot of it.
Having done it the hard way as a result of circumstance, at this point I would advise someone coming out of training AGAINST going into a job where you have to do mammo without backup of an experienced mammographer. It’s really not the procedures that are the hard part to pick up. It’s learning which things to let go and which ones to jump on. Picking this up while doing a small volume and presumably working alone is going to be tough.-
In this market, simply refuse to do mammography.
Once you enter the mammography industrial complex, there is no exit.
I have done mammography for a decade. It is fine till it is not. Once you get the first lawsuit, the lawyer will use your lack a fellowship training as a tool against you…
Mammographers get much less WFH days.
You have to deal with patients, surgeons and oncologist which can be rewarding but also can be really annoying.My recommendation: Don’t do it esp if you’re in a highly litigious state. One major lawsuit can ruin your moral for a few years.
Why groups always look for a mammographers?
Because senior partners even the mammo fellowship trained ones always want to cut back on their share of mammo. Doesn’t happen with MSK, Neuro, Body, etc-
It is completely doable. I didnt do a mammo fellowship. If you are a confident reader and are in a group that is willing to help you along then it is a great skill. The work is satisfying and working with patients makes it rewarding. ACR is a great way to get your feet wet. See if the group will start you with a low volume at first. Everyone so worried about getting sued. If youre not sure at first just call it back! Youll learn from the diag workup. 3D makes it harder to miss things. In a couple years youll be a pro. If you like the job then go for it.
By the way I am in a group where the older partners WANT to do more mammo. Go figure.
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Mammo is smooth sailing until it’s not. As said above, cancer misses can be quite impactful to morale and mental health if it was obvious in retrospect, or you remember letting it go. Luckily, bad outcomes aren’t as common if patients continue with annual mammograms and clinical exams.
Becoming a good and confident breast imager requires great mentor(s) in residency or in fellowship. If you didn’t do much diagnostic work ups or procedures in residency, it will be tough in private practice.
Working alongside a skilled breast imager when starting would be the best. When I started, I worked alongside a very skilled breast imager which was great for my growth. You want to see them in action and run things by them. There were other breast imagers that were not so good and had been breast imagers for years. They convinced themselves that there were awesome, somewhat cringeworthy at times.
Breast Imaging – The Requisites is an awesome book. You should read this at the minimum. Great images, tables and breaks everything down. Rad Assistant, StatDx, Radiographics and AJR are also great resources. But it’s hard to build on this without some mentoring. I suppose you will eventually get there by trial and error, tumor boards, and follow ups. It will just be much less comfortable.
If you turn out to be good (enough) at breast imaging and your partners find out, you will be banished there. The partners you thought were breast imagers will give it up. Many rads aren’t trying to be on site these days, something usually required as a breast imager.-
As a fellowship trained breast imager, I say it is completey doable.
We often demand new hires to do diagnostic breast, e.g. even if they are neuro trained. Just not in this job market.
You just gotta work at it and have someone who is good that you can curbside and bounce cases off of in the beginning. Because our breast sections always have two diagnostic breast rads at each site any given time, our setup ensures there is always someone you can talk over a case with – or in a pinch – have them cover you for half an hour if you need to take off early to lunch to take a class or get a workout in.
Don’t feel pressured to give an answer on a tough or unusual diagnostic. Once in a while, after doing this for over a decade, I will tell a patient that I want to show the images to another breast radiologist or talk to their doc before giving an interpretation, and that someone will call in the next day or two with the results.
Yes, if you do breast you will work less from home than other rads, except IR. This is real and can be a problem if your practice is located somewhere crappy and your commute is long. On the other hand, you are more marketable and “boots on the ground.” I also take general call in evenings and weekends, do fluoro, staff tumor boards, and I like that my practice is broader and my group can rely on me more in a pinch when people are sick out or on vacation. If they had to let people go or screw someone, I would be one of anchor people in the group.
Yes, breast can be more stressful for some. I and the other breast imagers in my group find breast easier than most other rotations.
Our group is hiring more breast imagers and our head of breast asked me and the other breast people, “who wants to do less breast and work from home more?” The majority of us want to have more breast work than less. A large part of that is that the breast work is scheduled/structured such that it is an easier day (last patient 3:30 or 4pm, able to take 90 min lunch most days) than most every other rotation in the group where you are nose to grindstone the whole time.-
Quote from Flounce
You just gotta work at it and have someone who is good that you can curbside and bounce cases off of in the beginning. Because our breast sections always have two diagnostic breast rads at each site any given time, our setup ensures there is always someone you can talk over a case with – or in a pinch – have them cover you for half an hour if you need to take off early to lunch to take a class or get a workout in.
To emphasize what I said further up. This is the way to do this if you are fresh out of training. Someone who can guide you when you are stumped or who can tell you that you are making things up 😉
Going out to ‘St Longwaytodrive’ one day a week, read 10 screeners and 2 diagnostics and having to make biopsy decisions is not the way to learn. Well, it is A way of learning it, it’s just very stressful and probably doesn’t ensure the best outcomes for your patients.-
Most mammograms in the US are read by general radiologists.
Attend the ACR Education Center Course.
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Quote from Flounce
As a fellowship trained breast imager, I say it is completey doable.
We often demand new hires to do diagnostic breast, e.g. even if they are neuro trained. Just not in this job market.
You just gotta work at it and have someone who is good that you can curbside and bounce cases off of in the beginning. Because our breast sections always have two diagnostic breast rads at each site any given time, our setup ensures there is always someone you can talk over a case with – or in a pinch – have them cover you for half an hour if you need to take off early to lunch to take a class or get a workout in.
Don’t feel pressured to give an answer on a tough or unusual diagnostic. Once in a while, after doing this for over a decade, I will tell a patient that I want to show the images to another breast radiologist or talk to their doc before giving an interpretation, and that someone will call in the next day or two with the results.
Yes, if you do breast you will work less from home than other rads, except IR. This is real and can be a problem if your practice is located somewhere crappy and your commute is long. On the other hand, you are more marketable and “boots on the ground.” I also take general call in evenings and weekends, do fluoro, staff tumor boards, and I like that my practice is broader and my group can rely on me more in a pinch when people are sick out or on vacation. If they had to let people go or screw someone, I would be one of anchor people in the group.
Yes, breast can be more stressful for some. I and the other breast imagers in my group find breast easier than most other rotations.
Our group is hiring more breast imagers and our head of breast asked me and the other breast people, “who wants to do less breast and work from home more?” The majority of us want to have more breast work than less. A large part of that is that the breast work is scheduled/structured such that it is an easier day (last patient 3:30 or 4pm, able to take 90 min lunch most days) than most every other rotation in the group where you are nose to grindstone the whole time.
I agree with Flounce, as usual.
what you really need is someone to go over each case with you, just like in residency. This is crucial in developing judgment, which is EVERYHING in mammo. You have to have enough confidence to blow off the slightly odd apperances, People who don’t do this have call back rates of 25 % at times. You can’t do that. SO, from this standpoint, a mini-fellowship, if you can manage it would be helpful.You also should set up a follow up systme, so when you call someone back, you get the results of the workup. If there is a biopsy, you get that, too.
You need some philosophical viewpoints. One that helped me is this: If you are on the fence, there is SOMEHTING about this that bothers you. Just the fact it is bothering you is enough to merit a biopsy. So I learned to quit debating with myself and just biopsy the damn thing. Of course this was after 15 years or so, and I learned to trust my gestalt.You also need some go-to things to say to patients to help them. When you are doing diagnostics, there are people you decide need to be biopsied. Here is what I tell them:
90% of the cases are not clearly cancer. so: “There is something there that doesn’t look right, and it COULD be a cancer. Most likely it is not, I would estimate (25%, 5%, whatever chance). However, it is small, and if it is a cancer, it is likely very early. THis is exactly why we do mammograms. To find these. If it is an early cancer, it is likely to require some surgery, and probably no radiation (I say this only when appropriate, of course)< and not mastectomy. This is the kind of cancer that is almost always cured. 5 years from now, when it is in the rear view mirror, you will have forgottne about it for the most part. But again, it is likely NOT cancer, and we will find that out for certtain in a few days and you can just forget about it. ”You can see the patients relaxing in front of your face when you tell them that. And, again, the large majority of the cases you decide to biopsy are not obvious cancers, so you can usually put their minds at ease with this.
Another thing I had to come to grips with was the BR 3 mess. So, it looks worrisome enough to get sequentily 6 month imgges for 3 years (which is wht is recommended) but not worrisome enough to biopsy? If I were the patient, I would call BS on that.
First of all, as I followed up our BR 3 in my practice, NO one ever got 3 years follow up. Someone in the group would, after 2 o3 thrree follow ups, change it to a 1 or a 2, adn they remainder of the protocol would be ignored. And so far as I could find out, we had never missed a cancer this way. For that matter, I don’t think I ever saw a 3 that turned into a cancer.
And: Biopsies, are 1) an immediate answer to the issue 2) I never saw a false negative in 20 years. 3) basically a trivial procedure with no sequelae. So why not biopsy?So I came to the philosophical conclusoin that if it was worrisome enought to think about a 3, just biopsy the thing. 1) no one will criticize you for this 2) it is almost certainly benign anyway, and you will spare the poor woman a year or three of trying to sleep while worrying that she has a cancer growing. 3) It is likely cheaper to just biopsy it than to follow q 6 months x 3 years. So I almost never gave a BR 3. (I know this is not a universally shared opinon)
After all that, I would say that breast work, while rather dull, was something I found rewarding, as the patients really appreciated what you did for them, and it does put radiologists in the driver’s seat, where we belong.
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Mammo will be first to go with AI, screenings anyway.
We Rads need to control that tech, not the hospitals.
Doing a Mammo fellowship today is risky imo.
Current good situation for Mammos is not going to last longterm.
If I were a Mamma-donna, I’d keep my DR skills fresh.
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For now, it pays very well so we do a fair amount of Mammo work at my place.
I am good at it, despite no fellowship. It is not that hard especially with MRI
Less work from home is a big negative also to Mammo.
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It is a volume deal.
If you are going to get enough cases to feel comfortable and competent, with some of the caveats mentioned above, including good mentoring and backup; very doable. But you have to be motivated. It’s not complicated, but it does take experience.
Years of experience trumps fellowship, imo.
If they want to plug you in occasionally to make overall scheduling easier; it’s at your expense, and you will never be comfortable. Don’t get into that situation; good for them, bad for you, bad for patients.
Either do it right, or keep out of it.
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I def agree with boomer on that – all of our radiologists who do breast do it at least two days a week, almost every week of the year, that’s two full days of breast diagnostics, workups, localization, biopsy, stereo, etc. No one in the group only reads screeners without being fully committed to the diagnostics rotation. I wouldn’t want someone who only does breast twice a month unless they have a long history of doing a lot of it.
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Fellowship is unnecessary. None of our mammo readers have one and I think we do pretty good – I often see outside reports from mammographers and am kind of shocked by the lack of quality. I am sure most mammo fellowship trained are great but I feel it’s one of those fields that IRL experience and volume can put you at par.
I don’t enjoy mammo, but I don’t hate it. Our mammo center days are lighter, can go out and get lunch (more like 30 min, not 90 like Flounce) and yes, the day ends sooner. So we all want more mammo days — setup like that can incentivize doing mammo in a group or landscape where mammo is unliked.
Also, our mammo catchment area is less litigious. If I ever miss something in mammo, I don’t feel as bad as I would on a CT or MRI, because it’s inherently quite subjective and often a needle in a haystack. YMMV. -
Quote from ChuckI
Also, our mammo catchment area is less litigious. If I ever miss something in mammo, I don’t feel as bad as I would on a CT or MRI, because it’s inherently quite subjective and often a needle in a haystack. YMMV.
You don’t feel as bad until you go to court and see how misses on mammo are treated 10 times different than misses on CT or MRI. In the eye of court, If you miss something on CT, it is a medical mistake and you should compensate for that. But if you miss something on mammo, you are an a$$h.l. who has ruined a family by missing the DCIS of their mother, grandmother, wife, sister, daughter and friend.
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I think it’s very doable but takes some extra investment in the process compared to routine DR. The best thing one can do IMO is take the time to really understand BI RADS and stick to the nomenclature. That’s the best way to protect yourself in the medical legal realm. You will definitely be held accountable if you don’t use appropriate language in your reports.
I have found the UCSF Breast Imaging Update on HI to be valuable as a non fellowship trained breast imager.
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agree with the UCSF course comment, excellent.
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Quote from Chochom613
Im a fellow currently interviewing for jobs for next year. Theres a private practice partnership track position near me that checks off most of the boxes in terms of what Im looking for. My only major concern is that its a generalist job that would require me to read some low volume mammo a few days a week, including screening, diagnostic and some procedures. Im not doing a mammo fellowship and I dont feel like my mammo training in residency was particularly great, so this is making me nervous. Im curious to hear if other people were in a similar situation what theyre experience was with picking up mammo on the job? It is a skill that I would like to have under my belt, I just want to how doable it is before I agree to join. Thanks in advance!
This is a very common experience. I would be happy to help you with mammo. Feel free to PM me.
