A Needs Assessment of Musculoskeletal Fellowship Training: A Survey of Practicing Musculoskeletal Radiologists

Special Articles Original Research Yablon et al. Musculoskeletal Fellowship Training Special Articles Original Research Corrie M. Yablon 1 Jim S. Wu 2 Lori R. Newman 3 Brian K. Downie 1 Mary G. Hochman 2 Ronald L. Eisenberg 2 Yablon CM, Wu JS, Newman LR, Downie BK, Hochman MG, Eisenberg RL Keywords: fellowship education, musculoskeletal fellowship curriculum, musculoskeletal fellowship education DOI:10.2214/AJR.12.9105 Received April 20, 2012; accepted after revision June 13, 2012. 1 Department of Radiology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI. Address correspondence 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; 200:732 740 0361 803X/13/2004 732 American Roentgen Ray Society A Needs Assessment of Musculoskeletal Fellowship Training: A Survey of Practicing Musculoskeletal Radiologists OBJECTIVE. The purpose of this study was to conduct a needs assessment of musculoskeletal radiologists regarding their musculoskeletal training experience and attitude toward a standardized musculoskeletal fellowship curriculum. MATERIALS AND METHODS. An anonymous survey was sent to the Society of Skeletal Radiology membership querying musculoskeletal radiologists practice patterns, fellowship program, curriculum, and modes of learning. RESULTS. Of 216 respondents (26% response rate), 87% were musculoskeletal fellowship trained. The majority performed MRI, CT, and radiography (99%); arthrography (95%); spine MRI (77%); pediatric musculoskeletal imaging (75%); musculoskeletal ultrasound (63%); and biopsies (62%). During fellowship, 72% read spine MRI; 74% pediatric musculoskeletal imaging, and 49% musculoskeletal ultrasound (49%); 33% received no spine procedural 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 musculoskeletal 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 curriculum would provide improved structure and a defined educational program. Clear expectations, performance assessment, feedback, and programmatic evaluation should be core elements of the training of every musculoskeletal fellow. M usculoskeletal fellowship training has been characterized by a diversity of educational experiences. Data obtained in 2012 from the Society of Skeletal Radiology (SSR), the major subspecialty society of musculoskeletal radiology in the United States, listed 14 Accreditation Council of Graduate Medical Education (ACGME)-accredited programs and 64 non- ACGME programs, offering a total of 184 positions [1]. Since 2010, there has been an increase in non-acgme positions from 123 to 163 [1, 2]. The challenge facing all non-acgme accredited fellowships, not only musculoskeletal fellowships, is that there is no governing body to provide uniform guidelines for call duties, working conditions, compensation, educational programs, and curricula, which now vary widely [2]. Although the SSR has created a curriculum structured around the ACGME core competencies 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 logistics and not to a specific curriculum, which is left to the individual programs to determine [3]. Non-ACGME accredited fellowships are not required to follow these guidelines; therefore, there are no didactic requirements, and learning experiences are highly unstructured. Most educational material is case based and determined by the expertise of local attending physicians, referral patterns, and case volume, with some fellowships similar to apprenticeships. In light of the variability of musculoskeletal fellowship educational programming and 732 AJR:200, April 2013

Musculoskeletal Fellowship Training Respondents (%) 40 35 30 25 20 15 10 5 0 0 5 6 10 11 15 16 20 Time (y) Fig. 1 Chart shows percentage of respondents grouped by number of years past training. the predominance of non-acgme accredited fellowships, we sought to assess the perceived preparedness of musculoskeletal radiologists and whether a standardized musculoskeletal curriculum would be beneficial. We hypothesized that although musculoskeletal fellowships may provide sufficient preparation for practice, there are knowledge, skill, and attitudinal deficiencies that should be identified, addressed, and incorporated into a standardized musculoskeletal fellowship curriculum. Materials and Methods The institutional review board of our hospital 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 current practice patterns, fellowship training program and curriculum, views on preparedness after training, and preferred modes of learning. The word curriculum was defined as a directed course of study or core educational content with stated learning goals and objectives for a learner to master. The survey was piloted before general testing and then distributed electronically through the SSR to its entire membership in April 2011 (Appendix 1). An accompanying cover letter notified potential respondents that the results were being collected for research purposes and would be shared with the SSR and academic community. We used chi-square tests and Fisher exact tests for statistical analysis to 0 5 years 6 10 years 11 15 years 16 20 years determine p values. Analyses were performed using 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 responding, 87% were musculoskeletal fellowship trained, 46% were in an academic practice, and 54% were in private practice. Of the 97 respondents in academics, 13% had not received musculoskeletal fellowship training, primarily due to the absence of formal musculoskeletal fellowships before 1986 when musculoskeletal training consisted of apprenticeship or mentorship models. Of the respondents Fig. 3 Chart shows comparison of percentage of respondents who read spine MRI, pediatric musculoskeletal imaging, and musculoskeletal ultrasound in private practice versus academics, compared with the percentage of respondents who learned those modalities in fellowship training. Respondents (%) Fig. 2 Graph shows musculoskeletal radiologists in private practice versus academic practice grouped by percentage of practice time spent subspecializing in musculoskeletal related activities. Respondents (%) 80 70 60 50 40 30 20 10 0 80 60 40 20 0 Academic Private practice 0 20 21 40 41 60 Time (y) Spine MRI 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) practices. The respondents had a wide range of years of practice experience (Fig. 1). Most of the respondents considered themselves musculoskeletal subspecialists (87%), and many (46%) spent 81 100% of their total practice in musculoskeletal imaging. Most musculoskeletal radiologists in academics spent the majority of their practice time subspecializing in musculoskeletal imaging; whereas those radiologists in private practice spent varying degrees of time in musculoskeletal imaging (Fig. 2). Ninety-nine percent of respondents performed extremity MRI, CT, and radiography Pediatric Musculoskeletal 61 80 81 100 Private practice Academic Fellowship Musculoskeletal Ultrasound 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 extremities and pelvis; and 40% imaging-guided biopsies of the spine. Roughly half of the respondents did not perform spine procedures. In these cases, these procedures were performed by several other providers, including neuroradiology (71%), pain medicine (51%), anesthesia (39%), neurosurgery (32%), and physiatry or physical medicine and rehabilitation (15%). Nine percent of respondents replied that spine procedures were not performed in their hospital. Fellowship Training The majority of the musculoskeletal fellowships were small: 30% had only one fellow, 32% had two fellows, 25% had 3 or 4 fellows, and 13% had five or more. The majority of fellowships (54%) had four or fewer attending physicians. Twenty-eight percent had 5 or 6 attending physicians, 13% had 7 9, and 5% had 10 or more attending physicians. Spine procedural training was variable across fellowships. Thirty-two percent of respondents received no spine procedure training at all. Of those receiving spine procedure training, 51% learned spine biopsies, 43% learned epidural steroid injections, 54% learned to do facet injections, 22% performed vertebroplasty, and 12% performed kyphoplasty. When asked if they received adequate training to feel comfortable performing procedures in practice, the majority of respondents replied that they felt adequately or even better trained than colleagues in their practices to perform arthrography (99%); joint injections (97%); and biopsies of bone (78%), soft tissue (81%), and spine (49%). Regarding cross-sectional studies (CT and MRI examinations), 91% of respondents thought they had read sufficient examinations to feel adequately prepared for practice; 89% thought they had read a sufficient number of radiographs. 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). 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 fellowship; 33% of fellows received feedback from fellowship directors at regular intervals, 27% of fellows received occasional informal feedback, and 12% received no feedback (respondents could provide more than one answer). Only 44% of respondents were provided the opportunity to evaluate their program. Faculty mentors were assigned to 40% of respondents. Procedural skills were evaluated by faculty in 78% of respondents. Interpretative skills were quantitatively evaluated (i.e., competency test, other grading scheme) in 7% of respondents. Curriculum A curriculum, or learning goals and objectives 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 musculoskeletal topics they were expected to know by completion of the fellowship. A structured conference schedule was provided to 67% of respondents. Conferences included orthopedic oncology or tumor board (77%), rheumatology (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 before performing biopsies. Most respondents (88%) were required to teach during fellowship, with 73% required to give resident lectures and 71% to teach residents at the workstation. Fellows were also required to teach medical students at the workstation (44%) and to give medical student lectures (37%). When queried about the most outstanding aspects of the fellowship, the top three responses were teaching by attending physicians (69%), variety of cases (54%), and training in procedures (49%). When asked about the three least-liked aspects of the fellowship, 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 preferred mode of learning (90%); less popular modes were reading textbooks at home (42%), interdisciplinary conferences (39%), just-in-time learning (looking up items online or in books as questions arose during readout) (38%), journal and review articles (37%), and didactic conferences (34%). Surprisingly, online teaching modules were the least-favored activity (only 3%). Respondents wished they had received more training during fellowship in the following modalities: musculoskeletal ultrasound (56%), pediatrics (43%), bone biopsies (32%), spine MRI (26%), dual-energy x-ray absorptiometry (23%), musculoskeletal MRI (21%), and soft-tissue biopsies (21%). Respondents were queried about their feelings of preparedness to practice radiology after fellowship, attitudes toward fellowship training, and a standardized musculoskeletal fellowship curriculum (Table 1). Overall, the majority of respondents felt well-prepared for practice, thought musculoskeletal fellowship training was optimal for the practice of musculoskeletal radiology, and favored the creation of a standardized musculoskeletal fellowship curriculum. 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 Compared with other colleagues in your current practice, how well prepared for practice of musculoskeletal radiology did you feel after completing your fellowship? Musculoskeletal fellowship training is the optimal training for pursuing musculoskeletal radiology in practice. A standardized musculoskeletal fellowship curriculum would be beneficial to musculoskeletal fellowship training. Note Data in parentheses are percentages. Response Much more prepared (42) More prepared (29) Equally prepared (27) Less prepared (3) Strongly agree (65) Agree (32) Disagree (1) Strongly disagree (2) Strongly agree (27) Agree (58) Disagree (11) Strongly disagree (4) 734 AJR:200, April 2013

Musculoskeletal Fellowship Training etal-trained respondents except four felt prepared for practice or 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). The top five factors influencing the decision to choose a job were the following: location (75%), colleagues at the future location (42%), income (25%), desire for an academic practice (24%), and work hours (23%). Neither 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 program directors or fellows in training. A 1998 survey of fellowship program directors assessed the status of the program s training and supervision with a focus on ACGME accreditation [4]. A subsequent 2003 study surveyed program directors to compare the structure of ACGME to non-acgme accredited programs [5]. An unpublished 2010 abstract surveyed fellows in the first few months of training regarding factors influencing their choice of fellowship, their attitudes toward a fellowship 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 opinions of practicing radiologists regarding their fellowship training and whether it adequately prepared them for practice. By surveying radiologists 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 benefit 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 imagingguided biopsies of the spine. This indicates that spine interpretation and procedures remain 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 commonly interpreted in private practice and musculoskeletal ultrasound use has grown both in academic and private practices during the past decade [6]. Seventy-five percent of our sample read pediatric musculoskeletal imaging studies, and a similar number received fellowship 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 insight [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 remainder receiving only informal feedback. Feedback should be scheduled quarterly, discussed in a private setting, and documented in writing. Fellows should also be given the opportunity 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 musculoskeletal community regarding the utility of having a standardized musculoskeletal imaging fellowship curriculum. No formal curriculum currently exists, and our survey indicates that most programs devise their own curricula, if any. This leads to a heterogeneous 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 favored mode of learning was one-on-one readout with an attending physician. Despite advances 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-onone interaction with a supportive instructor or mentor is an immediate and gratifying way to learn, in which years of the instructor s experience can be distilled into focused teaching at the workstation. Reading textbooks at home, just-in-time learning, and reading journal articles 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 timeconsuming) 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 ultrasound, pediatric musculoskeletal imaging, bone biopsies, spine MRI, dual-energy x-ray absorptiometry, musculoskeletal MRI, and soft-tissue biopsies. These findings likely reflect the changing landscape of musculoskeletal radiology. Both academic and private practices are performing more musculoskeletal ultrasound. Pediatric musculoskeletal imaging is ubiquitous in private practice and community hospitals. Musculoskeletal interventions are increasing, and requests for percutaneous biopsies of bone and soft-tissue masses of the extremities are commonplace in many practices. Musculoskeletal specialists are well positioned to partner with orthopedic surgeons to plan interventions and perform posttreatment imaging. Many orthopedic surgeons order spine MRI as part of their practice, and musculoskeletal radiologists 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 prepared them well for practice, despite the differences among fellowships. However, the majority thought that a standardized musculoskeletal fellowship curriculum would provide further benefit. Although fellows likely supplement 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 covered 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 preliminary findings confirmed the need to draft fellowship 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 musculoskeletal subspecialists who have a stated interest in AJR:200, April 2013 735

Yablon et al. musculoskeletal imaging and therefore affiliate with the organization. There are likely many more self-identified musculoskeletal-trained radiologists, unaffiliated with the SSR, who were unable to participate in this study because their identity and contact information were not readily available. For ease of distribution, we chose to send the survey through the SSR to provide a roughly equal mix of private practice and academic musculoskeletal radiologists. Moreover, we thought that musculoskeletal radiologists affiliated with the SSR most likely had a vested interest in the future of musculoskeletal education and were more likely to respond. Surveys on fellowship education may create recall bias in that the respondents tend to recall their training favorably as a reflection of good decision making on their part. In addition, respondents may not accurately recall the details of their fellowship training as the time of training grows more remote. Conclusion Practicing radiologists believe that musculoskeletal fellowship training has prepared them Appendix 1: Musculoskeletal Curriculum Survey well for practice. However, there are perceived educational deficiencies in spine MRI, pediatric musculoskeletal imaging, and musculoskeletal ultrasound as well as, less frequently, bone, soft-tissue, and spine biopsies. These deficiencies may be corrected by the creation of a standardized musculoskeletal fellowship curriculum that provides improved structure and a defined educational program. Didactics aimed at the fellowship level should be incorporated into the program. Clear expectations, performance assessment, feedback, and programmatic evaluation should be core elements of the training of every musculoskeletal fellow. References 1. Society of Skeletal Radiology website. MSK fellowships. skeletalrad.org/resources/fellowships. aspx. Published March 19, 2012. Accessed April 4, 2012 2. Baker SR, Luk L, Clarkin K. The trouble with fellowships. J Am Coll Radiol 2010; 7:446 451 3. Accreditation Council of Graduate Medical Education (ACGME) website. ACGME program requirements for graduate medical education in musculoskeletal 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 musculoskeletal radiology fellowships in the United States. Acad Radiol 1998; 5:509 512 5. Berquist TH, Bancroft LW, Kransdorf MJ, Anderson MR, Walters RM. Postgraduate musculoskeletal fellowship training in the United States: current trends and future direction. Skeletal Radiol 2003; 32:337 342 6. Sharpe RE, Nazarian LN, Parker L, Rao VM, Levin DC. Dramatically increased musculoskeletal ultrasound utilization from 2000 to 2009, especially by podiatrists in private offices. J Am Coll Radiol 2012; 9:141 146 7. Ende J. Feedback in clinical medical education. JAMA 1983; 250:777 781 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 emergency department. Acad Emerg Med 2011; 18:504 512 Part I: Tell us about yourself and your practice 1. Did you do a musculoskeletal imaging fellowship? 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. 0 2 years b. 3 5 years c. 6 10 years d. 11 15 years e. 16 or more years ago 4. Please select your current practice type: a. Small private practice (0 10) b. Medium private practice (11 20) 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. 0 20% b. 21 40% c. 41 60% d. 61 80% e. 81 100% (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 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? (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 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)?, 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)? 11. Are 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 program s core educational content? 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? 3. Did you have an assigned faculty mentor with whom you worked on a regular basis? 4. Were you taught how to perform procedures (e.g., practice a biopsy on a phantom) before working on a patient? 5. Were your procedural skills evaluated by faculty? (Appendix continues on next page) 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.) 7. Please rank, in order of importance, your top three preferred modes of learning during your fellowship. 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? 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 (Appendix continues on next page) AJR:200, April 2013 739

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 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 training 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. Spouse s 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