This article first appeared as a post by Dr Koshy Jacob on LinkedIn. We're sharing it here in full, in his own words.

When I was a trainee, I was genuinely undecided about which subspecialty to pursue. I was so confused by the choice that for a while I thought I would simply stay general and avoid the decision altogether. But everyone around me was choosing a subspecialty, and by my fourth year the pressure to pick one had become hard to ignore, so I settled on gastrointestinal radiology.

I do not want to upset any GI radiologists reading this, because I have enormous respect for the work, but the honest truth is that the thought of spending my career looking at CT colonographies and, in those days, performing barium enemas was simply not my cup of tea. It was only later, talking to a GI Radiologist recently, who absolutely loves GI radiology, that I came to appreciate just how different we all are. What feels like a calling to one radiologist feels like a chore to another, and there is nothing wrong with that. We are all built differently, and the profession needs that variety.

A nudge from a mentor

I carried on into my fifth year, working as a final year registrar in Weston-Super-Mare, and at the time I wanted to live near Bridgwater in Somerset. An MSK post came up in Taunton, and my consultant and mentor, Dr Gavin Stoddart, said to me, in his characteristically direct way, that I would be an idiot not to apply.

The funny thing is that MSK was one of my worst subjects. I had always felt relatively poor at anatomy, and MSK is essentially pure anatomy in action, so it was hardly the obvious choice for me. But I took Dr Stoddart's advice, decided to apply for the job, and resolved to get myself trained in MSK radiology somehow.

Of course, there were no real training slots waiting for me in Bristol, largely because I had not told anyone that this was the direction I wanted to take. So, I fell back on the kindness of friends. I contacted colleagues in Cardiff, where I had rotated for my first three years of radiology, and friends like Dr Sridhar Kamath generously agreed to let me come and learn some MSK. All I could realistically manage in the time I had was knees, shoulders and spines. Then, for my final six months at the Bristol Royal Infirmary, the legendary late Dr Charles Wakeley, one of the nicest consultants I had ever known, took me under his wing and did everything he could to turn me into some sort of MSK radiologist.

The fellowship I could not have

I did try to secure a proper fellowship, in Oxford and elsewhere, but I was not successful, and I cannot pretend it was unfair. There were better candidates than me, people who had shown far more sustained interest in MSK and had built up real experience. And the truth is I could not really have afforded to take the pay cut that a fellowship would have required, with a family to think about. In hindsight it was something of a blessing in disguise.

Did I get the job in Taunton? Absolutely not. In fact, they withdrew the post entirely, because no one else applied either. And honestly, I do not blame them in the slightest. I could not have stepped into that role as a genuine MSK radiologist without considerably more training than I had managed to scrape together. They were right to be cautious.

But the story did not end there. I had still learned a great deal, and as a junior consultant back in Weston-Super-Mare I did what I could with what I had. Over the years since, I have become genuinely good at the areas I report, and across my career I have now reported somewhere in the region of three hundred to three hundred and fifty thousand scans. The competence came, in the end. It just came slowly, and largely on my own.

What could have made me a good MSK radiologist?

All of this has got me thinking. What would it actually have taken to make me a good MSK radiologist more quickly and more reliably? Could I have done it on my own, without the disruption of a formal fellowship? And, the question that really stays with me, could there have been a database, a deep and well-organised library of cases, that I could simply have practised on until the patterns and the reasoning became second nature?

I did what was available at the time. I went to Dr Stoller's superb MSK courses twice, and I have attended a great many MSK conferences over the years, and bit by bit I learned. But it could have been so much easier, and so much faster, if I had been able to sit down with a large bank of real cases and practise, deliberately and repeatedly, against an expert standard.

That is precisely what we have now built at Revise Radiology. For musculoskeletal radiology alone, our database holds 6,568 cases. That is not a handful of teaching examples. It is a deep, working library of the kind I would have given a great deal to have had when I was trying to teach myself MSK between other people's goodwill and my own spare hours.

Why practice matters more than viewing

Here is the part I feel most strongly about, having lived it. Becoming competent in a subspecialty is not really about being shown images. It is about practice in the truest sense. Recognition, the ability to glance at a film and name the finding, is only the surface of what a subspecialist does. The real skill is in working a case up properly, deciding what matters and what does not, forming a sensible differential, knowing what you would recommend next, and then checking your reasoning against someone who has spent a career in that area.

A database of cases only helps if it lets you do that. The cases need to be reported, not merely viewed. You need to commit to an interpretation before you see the answer, because that act of commitment is what turns a case you looked at into a case you actually learned from. And you need a way to compare your work against an expert standard, so you can see exactly where your judgement diverges from theirs. That is how I eventually got good at the areas I report, except that I had to do it the slow way, one real reporting list at a time, with the occasional course and conference along the way.

Where this is going

This is the thinking behind the work we are now doing, and it connects directly to Practice Radiology, the programme David Savage and I built for consultants who want sustainable, self-directed careers. The freedom to deepen your expertise, or to add an entirely new area of competence, without taking a year out and a significant pay cut to do a traditional fellowship, is exactly the kind of choice I want radiologists to have. It is the choice I did not really have myself.

I swept our whole database recently to see where we have genuine subspecialist depth, and MSK, with its 6,568 cases, is one of the strongest areas we hold, alongside gastrointestinal and neuroradiology. The cases are there. The real work now is in building the right kind of practice around them, so that a radiologist who wants to become an MSK reporter, or to refresh a subspecialty they trained in long ago, can do it properly, on their own terms, and without the obstacles that nearly stopped me.

I would love to hear from other consultants on this. If you wanted to deepen your expertise in a subspecialty today, what would actually help you? I have my own answer, hard won over a career, but I would genuinely like to know yours.

Originally published by Dr Koshy Jacob on LinkedIn. Read and follow the original post here: View on LinkedIn