The most important finding that emerges from this survey is that more than two-thirds of participants rated the quality of their MSK between “poor” and “average”, with limited time available for dedicated MSK training during the year. It has to be noted that survey results demonstrate considerable heterogeneity through all survey subsets, specifically regarding the structure of MSK training programs, which was evident even within single Countries. Nevertheless, as the survey includes a huge number of answers from young radiologists and trainees from several Countries, it represents an interesting snapshot of the current situation of MSK radiology training across European and Non-European Countries.
Response rates from residents were slightly higher than those of board-certified radiologists. The majority of young board-certified radiologists choose to work in academic institutions or large community hospitals (61%), which probably are better geared to accommodate research, academia and access to more advanced technology. This yet again varies from one country to the other depending on the set up of the national health care systems (see question #5).
Another important aspect that emerges is that relatively little time is dedicated to MSK training within most radiology training programmes. Dedicated MSK training rotations were included in just half of the residency programs (see question #6), and almost 20% of participants reported the absence of any MSK training program. Even when dedicated MSK rotations existed, those were allocated for less than six months in more than two-thirds of responders (see question #7). This paucity of education emerges also from the number of hours related to MSK teaching, which accounts for less than 20 h per year in more than half of participants (see question #10). Adequate MSK training is of paramount importance to general radiologists and those who choose to specialise in MSK, as showed by several studies reporting higher diagnostic accuracy of MSK-trained radiologists. Most plain radiographs (other than chest x-rays) performed for orthopaedic-related disorders, and more than 70% of MRI scans are for spinal or peripheral MSK problems [11]. Focused knowledge is important as MSK subspecialty second-opinion consultation has been proven to be more accurate than generalists reports in 82.0% of examinations; discrepancies were mainly observed in tumour cases [3]. Rozenberg et al. reported significantly higher performance of MSK radiologists when compared with non-MSK radiologists in interpreting orthopaedic oncology examinations, emphasising the importance of subspecialty training [12]. The importance of dedicated MSK training for residents has been recently presented by Nelson et al. by showing significant impact on their ability to report bone densitometry scans and initiate osteoporosis medications [13].
Senior consultants and fellows play a chief role in MSK training (question #11). This may relate to trainees’ preference to learn MSK radiology through daily clinical practice, supervised by experienced radiologists (question #13), a modality that was preferred over formal lecture-based teaching lesson by university professors.
According to the responses received for questions #8 and #9, trainees mostly rotated between different MSK modalities (71% of participants) instead of being assigned to a specific one, with only one-third of them having received dedicated MSK ultrasound sessions. With regards to interventional MSK training, 62% of participants were not expected to learn interventional MSK procedures (question #14); in two-thirds, the procedures were either not performed in their institution or the trainees were asked to be solely involved as observers (question #15). Indeed, the overall quality of MSK training was considered poor-to-average by more than half of participants (question #12), and the vast majority of young radiologists believe that MSK training should be enhanced (question #16), requesting improvements in ultrasound practice, image-guided interventional procedures and MRI interpretation and case discussion (question #17). The need for particular attention to ultrasound is corroborated by the fact that this examination is currently performed by several other specialities, who receive dedicated MSK US training [14]. Worrisome results have shown that that radiology residents in the USA receive far less training in MSK ultrasound than trainees of physical medicine and rehabilitation, sports medicine, and rheumatology [15]. Recent surveys have shown that ultrasound-guided MSK procedures are widely performed across Europe by various practitioners and that ultrasound is preferred as a guidance method over fluoroscopy and CT for joint injections [7, 16, 17]. In this regard, it should be highlighted that the ESSR undertook active measures to improve MSK ultrasound by organising several dedicated courses and publishing new guidelines to standardise clinical practice [18,19,20,21]. Both the ESR and ESSR have put efforts to improve the quality of MSK radiology training towards harmonising education across different Countries. In fact, several initiatives have been promoted, such as the European Diploma in Musculoskeletal Radiology (EDiMSK), which is an established qualification aimed at endorsing the skillset of MSK-trained radiologists [6]. Additionally, the European Training Curriculum for Radiology is a continuously updated template aimed to guide trainees in developing basic and in-depth knowledge required for subspecialist training [5]. Unfortunately, too many young ESR radiologists/residents are still not aware of these tools (questions #18 to #20), but when brought to their attention, most of them were highly interested and believe this may improve their recruitment chances in a competitive profession [22]. Our results are in line with those of a very recent survey by the ESSR, which reported the under-recognition of the EDiMSK as it is currently accepted as an official postgraduate qualification in 47% of European Countries [23].
Upon comparing the responses from the top five most represented Countries, we noted some relevant differences. First, while Italy, India, and Portugal had a dedicated rotation in MSK training in 41–50% of cases (concurring with the average in the survey), Spain and UK had dedicated rotations in 100% and 80% of cases, respectively. Spain and UK also had the highest rates of dedicated MSK ultrasound training, education on interventional procedures, hours per year of MSK-related teaching, and overall MSK training opportunities. Nevertheless, almost all participants believed that their MSK training should and could be improved in their residency programme, regardless of the country of residency. This confirms a trend already reported in a recent survey about musculoskeletal radiology training in the UK [24].
The comparison between different hospital settings showed few differences in the relative prevalence of answers, with few exceptions. The most relevant is probably the discrepancy in the prevalence of dedicated rotation on MSK subspecialties, which was higher for university and larger community hospitals. A possible explanation of this may be related to the more structured residency programs in the university departments, or the subdivision into more specialised branches often seen in larger hospitals even within radiology departments.
This survey has some limitations. Firstly, this was not an all-encompassing survey, since we could not consider a number of factors related to different health care systems and University programs (e.g., years of residency) of the different Countries that may have in turn affected the results [17]. Second, the methodology of this study based on a questionnaire introduces bias to the results through subjective evaluation of the problem. Nevertheless, in order to limit bias as much as possible we included only 2 questions (#12 and #16) that allowed a “subjective” answer. All the remaining questions were related to the objective structure of MSK training and therefore, cannot be influenced too much by the type of training experienced. In addition, the survey was sent to individual residents and radiologists and not to residency programs, thus may limit information about how many and which programs are represented. Our study design aimed to avoid stakeholders and conflict of interest bias for example if program directors or any of the decision makers would have been asked the same questions, this would have almost certainly influenced the results in the direction of overcompensating and not registering issues. Thus, it is essential to interview the person who is most involved in the outcome of the training as a stakeholder for personal future endeavours and everyday clinical work. Nevertheless, we chose to approach and collect individual experiences, to ensure anonymity of participants and to obtain unbiased results. Finally, the survey did not include questions about the level of residency training/number of training years, an information that may have further put the overall results into perspective by reflection; however, this would not have influenced the objective data collected. There are limitations inherent to the study design as we set out the ambitious task evaluating quite a complex scenario such as the global level of MSK training among young radiologists.
In conclusion, there are significant inconsistencies in the structure of MSK training offered by different Countries. Nonetheless, there is a unified need to improve MSK training in all residency programs, as advocated by the great majority of participants who demand a special attention to MSK ultrasound, MRI reporting, and image-guided interventional procedures. In recognition of MSK as a radiological subspecialty which is increasingly popular, both the ESR and ESSR have led initiatives to standardise and enhance MSK radiology training, promote standards of excellence and attract future generations to join our profession. The ESR and ESSR play a pivotal role in leading this strategic goal by opening continuous channels for education, quality assurance and support for radiologists who choose to train and work in MSK radiology.
