Extreme Subspecialization Builds Its Own Knowledge Base

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“The more you see, the better you are,” Javier Beltran, MD, FACR, says. “You’re exposed to so much pathology that you’ve seen it all, at the end of the day. It brings your expertise to another level.” Beltran is talking about what might be called extreme subspecialization. Beltran is a musculoskeletal radiologist. He estimates that he personally reads more than 10,000 musculoskeletal exams per year, with 95% of them being MRI studies. This is probably double the number that the typical subspecialist reads, and far more musculoskeletal exams than a general radiologist would read in a year, Beltran says.

On a particularly intense, up-until-midnight workday, Beltran says that he might interpret 100 exams. He’s exhausted after the effort, but such days have given him deep expertise in musculoskeletal-exam interpretation. He chairs the radiology department at a midsize hospital, yet he is a sought-after musculoskeletal lecturer around the world.

Javier Beltran, MD, FACR

It’s hard, however, to teach musculoskeletal interpretation without the appropriate studies to interpret. Even an extreme subspecialist can’t share knowledge with colleagues, residents, and fellows without a supply of cases to illustrate the various injury and disease states and how to spot them using the latest technology. This was the problem facing Beltran five years ago when, he says, he tumbled into his role with teleradiology provider Franklin & Seidelmann Subspecialty Radiology (F &S), Beachwood, Ohio. The tumble changed Beltran’s professional life. He put on another hat and joined F &S part time, as an interpreter and lecturer. In the bargain, he got access to the cases he needed to teach the residents and fellows at his hospital.

Eleven years ago, Beltran was named radiology chair at Maimonides Medical Center in Brooklyn, NY. He also became a clinical professor of radiology at the Mount Sinai School of Medicine, with which the Maimonides hospital is affiliated. Maimonides, which was founded in 1911, is licensed for about 700 beds; Beltran says that the radiology department has 20 radiologists on staff and 16 residents, plus two funded fellowships and occasional unfunded fellowships.

Before he joined F &S, Beltran says, it was difficult to find the musculoskeletal cases that he needed to teach and train his fellows and residents. Maimonides emphasized oncology and geriatrics (programs that met the needs of a somewhat elderly patient base), but the orthopedics department was somewhat weak, according to Beltran. There was a particular lack of sports-injury cases, but it was sports-medicine cases that the young musculoskeletal radiologists most wanted to see—and needed to see, in order to build practices later. With its much larger pool of cases from over 200 clients, F &S was able to supply the case studies that Beltran needed.

“I requested permission from the hospital to incorporate these cases into the daily review with the residents, and the hospital granted it,” Beltran says. He had enough cases then to offer an musculoskeletal fellowship at Maimonides, which he did.

Subspecialty Education and Training

Once onboard at F &S, Beltran found his expertise being tapped to broaden the training of the musculoskeletal experts interpreting for the company. F &S hires subspecialists, then continues to train them into extreme subspecialization. Beltran says that he helped initiate what F &S now calls its All-star Lecture Series. One of Beltran’s contributions, of course, was to offer lectures on his subspecialty.

“We select the best experts and we give a Webcast through the Internet,” he says. These Webcasts are seen by F &S physicians across the country. Beltran also lets his Maimonides residents and fellows participate. “It’s been working very well,” he says.

The lectures are held once per month on different areas of subspecialization. Beltran says that he’s given three or four lectures to date. While musculoskeletal and neurological cases make up about half of the topics, the lectures have included cardiac imaging and breast imaging: areas that will receive more focus in the future, Beltran says.

Beltran says that F &S radiologists are carefully vetted, licensed, and credentialed through a lengthy in-house process. They are already subspecialists when they join, but even so, the company routinely overreads for its newly hired physicians. Beltran says that the company also has a rigorous peer-review process. A component of this is random