Jumping Ship to Rads

[RADRULES]

I've been in the Rad PP game a long time and while the Taurus dude seems like a douchebag he makes a couple salient points - the most important of which is the lack of efficiency gain by using mid-levels reading exams. It is simply much easier and faster for an experience boarded Rad to melt the stack than have some clown mid-level reading and having to double read all the exams. Very few Rads are going to take the infamous REDDY route and blind sign 70k studies a year for millions and end up someones bitch in jail.

There is - however - significant efficiency gain in having mid-levels do the low end garbage stuff that is needed in a Rads department but majorly reduces the efficiency of the Rad - such as slinging barium, Thora/para, PICC lines etc. That hasn't happened yet either but I could see that coming.

IMO - biggest threat to PP Rads is corporate infiltration. It is here and a growing trend. They skim 30-35% off the top and enslave Rads with onerous non-competes. I am sure you ER docs are familiar with all this.

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[Clean7795]

Man, this discussion took a strange turn. Thanks for all the advice.

I guess I like working but I want a job where I can keep working till I get old like 60. I don’t really care to retire early because I have enough hobbies but something about working is nice. Problem with ER is as I get older the shift switches seem harder. My gig and pay is good but if I did it past 50 I would kill myself. ER life just isn’t sustainable long term. I envy the old timers who do it into their 60s. What are they made of?

Would it make sense to put in 5-10 more years and then do a residency or not worth it at that point. This way money won’t be an issue as much as today. Part of me does get very burned out with what I do too so I guess it would be nice to sit in a room all day left alone reading picture. It’s not like in ER there is a fellowship that’s even remotely interesting.

I just want to comment on pathology; isn’t that field basically taken over by PhDs now instead of MDs hence the job shortages or am I misinformed?

Honestly if you've tried cutting down hours and you still hate your life every time you have to walk into the ER, then I think it is reasonable to try and find another specialty or even line of work.

Pathology (in terms of slide interpretation & billing) is still mainly done by MDs but many labs are now ran by PhDs instead of MDs is my understanding. Job prospects are generally poor, at least based on what it looks like in their forum.

Radiology is resistant to midlevel incursion for various reasons (though not immune). Definitely look into what it's like doing radiology before committing. In some ways it's like a conveyor belt of specialized physical examinations (minus the physical part, and patient part). It's interesting, but you have to be okay enjoying the "quiet satisfaction" of a good catch or interesting pathology. You aren't going to be resuscitating someone (personally anyway) doing diagnostic radiology.

 

[Mount Asclepius]

I've been in the Rad PP game a long time and while the Taurus dude seems like a douchebag he makes a couple salient points - the most important of which is the lack of efficiency gain by using mid-levels reading exams. It is simply much easier and faster for an experience boarded Rad to melt the stack than have some clown mid-level reading and having to double read all the exams.

Your point is understood. We’ve just seen this same phenomenon happen in EM. A board certified EP can see low acuity patients in significantly less time and more efficiently than a midlevel. Yet, they cost the entity where they work 3-4x as much. Corporate medicine has chosen to sacrifice quality and speed for profits. Many EPs are blindly forced to sign charts of patients they don’t see. It’s not out of the realm of possibility that corporate medicine will start employing radiology midlevels and then require a physician radiologist to sign off on their reads with or without looking at the imaging themselves. It may or may not happen, but it’s something not to completely ignore and dismiss out of hand. Maybe AI is the bigger threat, although I’m skeptical. As someone outside of the field looking in as an EP based on where I’ve seen our field go, I think corporate infiltration is the greatest threat to Radiology. I wouldn’t be surprised if it partially happens because of midlevel encroachment. I could certainly be wrong though.

 

[emergentmd]

I remember when our SDG hired our first PA. Many of the docs said, "I am not signing their charts, I never saw the pt". Newly minted docs grew up with APCs and didn't even batt an eye signing charts without seeing pts.

I would make a leap and say it is potentially more litigious to have a PA/NP see a pt without a doc even knowing they were in the department than a PA/NP reading plain films and having a doc mass sign it. Corporate could easily find radiologist to sign 10 PAs reads for 700K/yr for a cost of $2M/yr rather than hire 6 radiologist at a cost of 3-4M/yr.

 

[qwerty89]

While I don't completely agree with Taurus's optimism I also don't have the same pessimism as many of you EM folks have.

One advantage that rads, and even path, has is that the big bad honchos of the hospital such as Neurosurgery, Ortho, Cardiology, etc will not accept mid-level quality reports. Whether they are signed by the midlevel or given a cursory look and then signed off by a radiologist.

Increasingly even in community places these subspecialists want subspecialist radiology reads. A fellowship trained Otologist can probably read CT IAC/temporal bone better than many general radiologists.

Hospitals already have a hard time retaining these scarce specialists. If one hospital starts giving them this midlevel crap they will take their business elsewhere.

Doesn't mean that it won't happen but it is another barrier.

On a separate note, the downfall of EM wasn't just because of midlevels. It was still primarily decimated by the explosion in EM residencies, only some of which was driven by places like HCA.

If EM docs were scarce you would have more say in how midlevels were used in the ED. You would have leverage because you could go across the street to another hospital and the hospital you left would have its ER wait times skyrocket. Once you have a surplus you are screwed and lose all leverage because some poor bast**d will always take a crappier deal to stay employed. Great locums rates? Gone.

Rad Onc has had once of the most spectacular declines I've ever heard of. Previously a specialty for MD/PhD types with 250+ step 1 is now willing to take almost anyone with a pulse. Their decline had nothing to do with midlevels. It was mostly due to an explosion in residency positions (approximate doubling over 15 or so years) and partly due to less than expected increase in demand.

 

[TheComebacKid]

Let it sink in. Sleep on it. Once you accept it as fact, you will see how this is a beautiful, insurmountable moat that separates radiologist from midlevel.

I literally cringed when I read this. *Shudders*

I think it's extremely short sighted if you think of radiology as a fundamentally different specialty than the rest of medicine. While us sane, compassionate people can agree that a radiologist has a unique set of skills compared to say a primary care physician, we are all the same in the eyes of the administrator overlords. There is a dollar amount attached to your head. The goal is, and will always be, maximize profits and cut costs. NOT good patient care. In the eyes of a CEO, you are a very expensive janitor who works for the hospital. They don't know or care about your unique skills.

The people in this forum have nothing against radiologists. As ER docs, I would say we rely on you more than any other specialty. We understand your value added. You have nothing to prove.

There is absolutely ZERO downside to you being aggressive and protecting your turf. Radiology could be protected more so than the others, but I still fear that your vision of your "insurmountable moat" will ultimately lead to a degree of carelessness in your specialty that will leave you vulnerable to the same forces that took over EM. I know it must feel great to feel untouchable, but you are not only doing a disservice to yourself, you are doing a disservice to generations of future trainees/current residents who will potentially face the backlash of this in the future.

 

[thegenius]

I've been in the Rad PP game a long time and while the Taurus dude seems like a douchebag he makes a couple salient points - the most.

He has been quite reasonable to me. He's been more calm that some of my ER comrades.

Given that midlevels have encroached on so many areas of medicine (primary care, family practice, cardiology, orthopedics, ER, and many others), if it's true that there are few to any midlevels in Radiology then the Rads folks have done something right.

It appears that most other specialties allow midlevels to see and dispo patients. In ER we certainly do. We allow them to see low risk stuff and we never see the patient. We just sign the chart. If ER docs banded together and said "We must see all patients that midlevels do" then maybe there wouldn't be as many in our field.

Perhaps Rads is more group cohesive and they have banded together and said "we will never cosign midlevel imaging without reviewing it ourselves." I suppose hospitals can try to work around this, but it would be hard.

 

[Brigade4Radiant]

We have ortho’s and urology taking consult for patients in the emergency department. We also have cardiology nurse practitioners coming down for code stemi’s and such.

There is no such thing as big shot doctor because The hospital owns many primary care facilities so you can’t get any referrals without work in the hospital nor the big OR and Cath Lab costs and staff. I’ve seen it Ortho will advertise but they still depend heavily on Ortho

We mostly admit patients to the ICU PA at our hospital I haven’t talk to the intensivist in a long time.

The anesthesiologist said the same thing about CRNA.

Also radiology has been having a lot of it’s turf being reduced my other specialties. Cardiology taking echoes. Also allow the ultrasound techs can already tell you hey no DVT no ectopic. OB/GYN‘s can read the ultrasounds just as well as a radiologist.

All you have to do to create a mid-level is do a specialized education in radiology since it’s unlike most clinical medicine. 36 month program after college similar to PA. They are training would include basic x-rays and just looking at CT scans.

 

[SeekerOfTheTree]

If we can be trained to do it, a midlevel can be trained to do it. It can start off with small bites...like it did in ER. Limb X-rays get sent to mid-levels, then it would be X-rays in general, followed by US....I can see this. We aren't special because we went to medical school. Most of what we do we learned in residency. If we can learn it residency its not far fetched to say a mid-level can learn it with enough training. In all honesty, half our mid-levels in my ED could deal with 99.9 percent of the patients I see. I'm not stupid (I hope), they're just really damn good.

Isn't MARCA the start of this for radiologists if this passes?

 

[Taurus]

Radiology, like any medical field, is not perfect and has it's own set of issues. Midlevels reading diagnostic imaging studies is not one of them. The biggest issue I think is consolidation by Wall Street firms. Sure, to a lesser extent, there are erosions at the margins because other fields want to do their own imaging. Cardiology took over much of cardiac imaging from radiology. OB started to read fetal US (although lots are still read by radiology including me unfortunately). ED has their FAST US exams. US machines are common in doctor offices or even handheld. However, the great thing about radiology is that it is innovative. What did radiology do to replace the significant loss of cardiac imaging? Better CT and US. MRI. Breast tomosynthesis. Virtual colonoscopy. CT lung screening. US elastrography. Theranostics. Etc. If radiology was like pathology, we would only be doing x-rays and slinging barium and our job market and incomes would reflect that. However, the constant pushing the boundaries and developing innovations mean that imaging has basically replaced the physical exam in this country (practically everyone gets some imaging when they go to the hospital). This has created lots of demand for radiologists. The current hot job market and high salaries are reflections of this. Plus, the increased use of clueless midlevels who use radiology as a crutch is driving up imaging demand. Personally, I don't care so much if other fields or even midlevels read their own imaging as long as my name is not attached to their reports. Nobody hides behind my license and most physicians feel this way.

I'm not sure why some folks insist that the "team" business model where many midlevels to one doc is inevitable in radiology. There are fundamental differences in the business models between diagnostic fields like radiology and pathology where the "buck stops here" and clinicians are looking for definitive answers versus clinical fields like primary care and ED. I and other posters have described many already. If the same business model could be imposed on radiology, don't you think it would have already happened? The fact that you very rarely see a midlevel reading diagnostic imaging studies with supervision except in some academic departments should tell you how well the model works in the real world. The only time you really see midlevels in radiology is they help with the scutwork and low-end procedures like para, thora, LP, PICC, etc. They're not doing embolizations, cryoablations, or TIPS independently. In my group, we don't even use a midlevel to sling barium. We use a tech who has been trained to sling barium but we dictate the reports.

For the sake of argument, let's play devil's advocate and say that you impose such a business model on radiology. What would happen? As some have suggested, you can't "triage" exams where you give the easy exams to the midlevels and the radiologist takes the hard ones. Each exam is a potential ticking legal timebomb. A new 3 mm grouping of pleomorphic calcifications or spiculated mass on a mammogram may be the only early sign of breast cancer. Here are two examples of "easy" exams that ended in multimillion dollar lawsuits.

Jury awards nearly $7M in malpractice lawsuit

A Charleston County jury has awarded a near $7 million verdict to a terminal breast cancer patient and her husband after a misdiagnosis from a doctor years earlier led the

www.postandcourier.com

$16.7 million award in cancer lawsuit - The Boston Globe

A jury has awarded $16.7 million to the daughter of a Boston woman who died of lung cancer after a Brigham and Women’s Hospital radiologist missed evidence of the cancer in a chest X-ray. The verdict is the largest this year in a medical malpractice case in Massachusetts.

www.bostonglobe.com

The first is a missed breast cancer on a screening mammogram. The second is a missed lung cancer on a chest x-ray. In both examples, the radiologists probably spent 1 minute or less on the exams and now they have this black mark of multimillion lawsuits on their records that they have to now report whenever they renew their privileges or licenses. These are typical lawsuits that I get called to be expert witness for.

On average, a radiologist in private practice reads 80-120 exams per day, depending on how busy that practice is. So a typical radiologist reads around 500 exams per week or 2000 per month. If as some have suggested that the radiologist only reviews 10-20% and then blindly signs the rest, that leaves more than a thousand exams per month that goes unreviewed by a radiologist. That’s just one radiologist. In my group with 100+ radiologists, more than 100k exams per month will only be read by a midlevel and will go unreviewed by a radiologist. How many misses will the midlevels make and the radiologists not catch because they didn't review the images? Inevitably, some of those misses will result in serious or permanent injury or even death. Those misses can easily be traced back to the original images and reports. Remember images do not change and can be kept forever. What will your defense in court be? "Your honor, my midlevel missed it not me. I didn't review the images myself even though my name is on the report." How silly will that sound in court? That's what the plaintiff lawyer will get you to admit at trial. The images are the smoking gun. Your miss will be magnified and projected on the big screen in court. After that court case, your next stop will be in front of the state medical board and you begging them to not revoke your license. How many radiologists would agree to work in such a group and risk their careers? It's not worth it.

The lack of significant midlevel penetration in radiology has nothing to do with specialty cohesiveness or collusion among radiologists. Like most people, individual radiologists are primarily looking out for themselves and how can they make the most money, work the least, and get the most vacation. Radiologists are not even looking out for each other. The lack of significant midlevel penetration in radiology is due to the business model, medicolegal landscape, market forces, etc. There would need to be significant structural changes to the business model and medicolegal regulations before you will start seeing midlevels putting out reports independently in diagnostic fields like radiology and pathology.

But let's say the group is really unscrupulous and demands their radiologists blindly sign off on midlevel reports anyways without giving them the time to review images because the group really wants to make as much $$$ as possible. As I pointed out, this is fraud and people have gone to prison for this. I would be racing to be the first person in that group to file a whistleblower complaint with the federal government. This would be my ticket to an early and rich retirement! Whistleblowers have been awarded millions and tens of millions in these lawsuits, more than anything you can make in medicine.

How much are whistleblowers paid?

A whistleblower reward can be very significant. We have helped clients recover millions. Call us for a free and confidential consultation.

www.pagepate.com

"The amount of a whistleblower reward depends on how much money the government recovers as a result of the whistleblower lawsuit. A whistleblower who files a successful claim is paid a reward that equals between 15% and 25% of the amount recovered by the government if the government joined in the case prior to settlement or trial. If the government does not join in the case, and the whistleblower and his or her attorney pursue it on their own, the whistleblower can receive up to 30% of the total amount recovered."

 

[Brigade4Radiant]

Again lawsuits only matter to physicians. I don’t see any corporate mega groups nor did the hospital itself get sued. Corporate mega groups just take the money and leave the liability to the clinician or NP in this case it would still be the radiologist being sued after the NP does the reading. The examples that are pointed out change nothing.

Malpractice has not and will never stop mid level encroachment because the physician is the one who pays not the investors and not the administrators.

Corporate mega groups have been sued for massive fraud and guess what? All that happens is that they pay a fine and make all their clinicians do extra fraud training.

Emergency Physician Wins $26M in Wrongful Termination Suit

Raymond Brovont, MD, said he was fired for raising concerns about staffing issues

www.medpagetoday.com

HCA for example has defrauded the government more than any other single clinician or group of clinician and yet they are still chugging along without a care in the world.

Lawsuits stop medical professionals not corporate lol.

 

[VA Hopeful Dr]

I've been in the Rad PP game a long time and while the Taurus dude seems like a douchebag he makes a couple salient points - the most important of which is the lack of efficiency gain by using mid-levels reading exams. It is simply much easier and faster for an experience boarded Rad to melt the stack than have some clown mid-level reading and having to double read all the exams. Very few Rads are going to take the infamous REDDY route and blind sign 70k studies a year for millions and end up someones bitch in jail.

There is - however - significant efficiency gain in having mid-levels do the low end garbage stuff that is needed in a Rads department but majorly reduces the efficiency of the Rad - such as slinging barium, Thora/para, PICC lines etc. That hasn't happened yet either but I could see that coming.

IMO - biggest threat to PP Rads is corporate infiltration. It is here and a growing trend. They skim 30-35% off the top and enslave Rads with onerous non-competes. I am sure you ER docs are familiar with all this.

I just last week got a procedure note on a patient getting a paracentesis. Performed by an NP "under radiologist supervision".

 

[Franzd'Epinay]

Can some of the rads folks here comment on this idea that "radiologists are scarce and jobs are plentiful" while simultaneously "you MUST do a fellowship or otherwise you will be unemployed".

This is kind of the opposite of what we see in every other field of medicine: the smaller hospital will take the general orthopedist rather than hold out for the Shoulder/Elbow specialist, the rural community will take the FM doc rather than hold out for the Adolescent Medicine specialist, the low-volume hospital will take the cardiologist rather than hold out for the advanced heart failure specialist, etc.

Or is it that when people say that subspecializing is a necessity they really mean to work in big cities?

 

[qxrt]

The smaller hospital typically just needs a general orthopedist to take care of the bread and butter - if they get a complex elbow case, they can just ship the patient off to the regional tertiary care center. It is similar for most other specialties. Or, if they see a particular elbow pathology frequently in their patient population, they will learn to get good at that particular thing.

Radiology is different in that the smaller hospital feels capable of performing all manners of esoteric scans such as breast MR, cardiac CTA, MR wrist, etc. simply because they have the machine to do so, and expect the radiologist to be able to take care of it all in-house. Radiology is simply too vast and diverse for a radiologist to be familiar or comfortable with reading it all at an adequate standard. It is not realistic to expect a generalist radiologist to be able to read the MR brain for evidence of GBM recurrence, the MR ankle for ligamentous derangement, the MR prostate to evaluate for prostate cancer, the fetal MRI to evaluate for placenta increta/percreta, and then do the TIPS for the variceal bleeder. We do not have the privilege of being able to turf out complex cases like you do in the ED when you consult a specialist or transfer the patient to another hospital, or the specialist such as the cardiologist, oncologist, or surgeon turfs the complex patient to the tertiary medical center.

As such, you need to have a diverse collection of radiologists who have the capability to read whatever the hospital throws at them. The scope of practice of a general radiologist who has done no fellowship and thus has little to add beyond what any fellowship-trained radiologist can also do is limited in any group that needs as wide a scope of practice as possible. You can see, this need has very little to do with the state of the job market itself.

 

[SirGecko]

He has been quite reasonable to me. He's been more calm that some of my ER comrades.

Given that midlevels have encroached on so many areas of medicine (primary care, family practice, cardiology, orthopedics, ER, and many others), if it's true that there are few to any midlevels in Radiology then the Rads folks have done something right.

It appears that most other specialties allow midlevels to see and dispo patients. In ER we certainly do. We allow them to see low risk stuff and we never see the patient. We just sign the chart. If ER docs banded together and said "We must see all patients that midlevels do" then maybe there wouldn't be as many in our field.

Perhaps Rads is more group cohesive and they have banded together and said "we will never cosign midlevel imaging without reviewing it ourselves." I suppose hospitals can try to work around this, but it would be hard.

I think the precedent of actually seeing every patient is something that helps prevent midlevel creep in radiology. (and like you said might help fight against it in other fields if people insisted on it)

The inability to 100% replicate a clinical appointment means that for nearly every specialty at some point in training you treat patients by yourself and the attending signing off your stuff may or may not see the patient and certainly doesn't repeat all of your work. This sets the precedent that it is possible to sign off a chart without actually having done all the things in the chart because you trust the resident to have done their work correctly. Midlevels when used as designed should be acting like a resident in this regard but then when they've been doing it a while they start to feel more competent and so you start getting advocacy for independent practice and midlevel creep etc.

Radiology training is different. (and it isn't because radiology is more difficult than other fields) There just is never a point where a trainee's work isn't repeated by the attending. As a culture radiology doesn't allow this and that is something that helps fight off midlevel encroachment. Obviously this won't be enough on its own (the economic drivers to try and add midlevel to every specialty are still there) but it is a big part. I do think that the statement that someone else prelim a report that you edit can do nothing but slow you down is a little bit overstated. A junior resident is likely going to slow you down but a good senior resident I feel actually can make you faster. But then again I'm not the fastest or most efficient radiologist out there so for those that are faster than me it might be true they are always going to be faster generating their own reports.

On another note I think one of the biggest factors protecting the field currently from encroachment is that most other specialties would not currently accept a read from a midlevel. Heck a lot of hospitals demand 24/7 attending level coverage currently. However if the rest of medicine starts being dominated by midlevel providers I could see this changing. While I don't think that neurosurgery is going to be ok with an RA read on a follow up for a brain cancer patient anytime soon a PA or a NP might be fine with a read from a RA.

On the original topic I don't think it would be crazy to switch from ER to radiology if you really think you would like the work better, but I would let that be the driver for whether you make the switch. I know I personally would hate to be an ER doc and that has nothing to do with compensation and more to do with my own personality and the types of things that stress me out. I also don't think you would have time to both be a good radiologist and keep up your skills to be an effective ER doc but maybe you are smarter than I am. Personally I think you should assume if you are jumping ship you are effectively quitting ER. (but again maybe you are superhuman and can do both, I just don't think that the average ER doc or radiologist could)

 

[thegenius]

Radiology, like any medical field, is not perfect and has it's own set of issues. Midlevels reading diagnostic imaging studies is not one of them. The biggest issue I think is consolidation by Wall Street firms. Sure, to a lesser extent, there are erosions at the margins because other fields want to do their own imaging. Cardiology took over much of cardiac imaging from radiology. OB started to read fetal US (although lots are still read by radiology including me unfortunately). ED has their FAST US exams. US machines are common in doctor offices or even handheld. However, the great thing about radiology is that it is innovative. What did radiology do to replace the significant loss of cardiac imaging? Better CT and US. MRI. Breast tomosynthesis. US elastrography. Theranostics. Etc. If radiology was like pathology, we would only be doing x-rays and slinging barium and our job market and incomes would reflect that. However, the constant pushing the boundaries and developing innovations mean that imaging has basically replaced the physical exam in this country (practically everyone gets some imaging when they go to the hospital). This has created lots of demand for radiologists. The current hot job market and high salaries are reflections of this. Plus, the increased use of clueless midlevels who use radiology as a crutch is driving up imaging demand. Personally, I don't care so much if other fields or even midlevels read their own imaging as long as my name is not attached to their reports. Nobody hides behind my license and most physicians feel this way.

I'm not sure why some folks insist that the "team" business model where many midlevels to one doc is inevitable in radiology. There are fundamental differences in the business models between diagnostic fields like radiology and pathology where the "buck stops here" and clinicians are looking for definitive answers versus clinical fields like primary care and ED. I and other posters have described many already. If the same business model could be imposed on radiology, don't you think it would have already happened? The fact that you very rarely see a midlevel reading diagnostic imaging studies with supervision except in some academic departments should tell you how well the model works in the real world. The only time you really see midlevels in radiology is they help with the scutwork and low-end procedures like para, thora, LP, PICC, etc. They're not doing embolizations, cryoablations, or TIPS independently. In my group, we don't even use a midlevel to sling barium. We use a tech who has been trained to sling barium but we dictate the reports.

For the sake of argument, let's play devil's advocate and say that you impose such a business model on radiology. What would happen? As some have suggested, you can't "triage" exams where you give the easy exams to the midlevels and the radiologist takes the hard ones. Each exam is a potential ticking legal timebomb. A new 3 mm grouping of pleomorphic calcifications or spiculated mass on a mammogram may be the only early sign of breast cancer. Here are two examples of "easy" exams that ended in multimillion dollar lawsuits.

Jury awards nearly $7M in malpractice lawsuit

A Charleston County jury has awarded a near $7 million verdict to a terminal breast cancer patient and her husband after a misdiagnosis from a doctor years earlier led the

www.postandcourier.com

$16.7 million award in cancer lawsuit - The Boston Globe

A jury has awarded $16.7 million to the daughter of a Boston woman who died of lung cancer after a Brigham and Women’s Hospital radiologist missed evidence of the cancer in a chest X-ray. The verdict is the largest this year in a medical malpractice case in Massachusetts.

www.bostonglobe.com

The first is a missed breast cancer on a screening mammogram. The second is a missed lung cancer on a chest x-ray. In both examples, the radiologists probably spent 1 minute or less on the exams and now they have this black mark of multimillion lawsuits on their records that they have to now report whenever they renew their privileges or licenses. These are typical lawsuits that I get called to be expert witness for.

On average, a radiologist in private practice reads 80-120 exams per day, depending on how busy that practice is. So a typical radiologist reads around 500 exams per week or 2000 per month. If as some have suggested that the radiologist only reviews 10-20% and then blindly signs the rest, that leaves more than a thousand exams per month that the radiologist does not review. How many misses will the midlevel make and the radiologist not catch because they didn't review the images? Some of those misses will result in some patient permanently and severely being injured or even death. The miss can easily be traced back to the original images and report. Remember images do not change and can be kept forever. What will your defense in court be? "Your honor, my midlevel missed it not me. I didn't even review the images myself even though my name is on the report." Your miss will be magnified and projected on the big screen in court. After that court case, your next stop will be in front of the state medical board and you begging them to not revoke your license. How many radiologists would agree to work in such a group and risk their careers? It's not worth it.

The lack of significant midlevel penetration in radiology has nothing to do with specialty cohesiveness or collusion among radiologists. Like most people, radiologists are primarily looking out for themselves and how can they make the most money and work the least. Radiologists are not even looking out for each other. The lack of significant midlevel penetration in radiology is due to the business model, medicolegal landscape, market forces, etc. There would need to be significant structural changes to the business model and medicolegal regulations before you will start seeing midlevels putting out reports independently in diagnostic fields like radiology and pathology.

But let's say the group is really unscrupulous and demands their radiologists blindly sign off on midlevel reports anyways without giving them the time to review images because the group really wants to make as much $$$ as possible. As I pointed out, this is fraud and people have gone to prison for this. I would be racing to be the first person in that group to file a whistleblower complaint with the federal government. This would be my ticket to an early and rich retirement! Whistleblowers have been awarded millions and tens of millions in these lawsuits, more than anything you can make in medicine.

How much are whistleblowers paid?

A whistleblower reward can be very significant. We have helped clients recover millions. Call us for a free and confidential consultation.

www.pagepate.com

"The amount of a whistleblower reward depends on how much money the government recovers as a result of the whistleblower lawsuit. A whistleblower who files a successful claim is paid a reward that equals between 15% and 25% of the amount recovered by the government if the government joined in the case prior to settlement or trial. If the government does not join in the case, and the whistleblower and his or her attorney pursue it on their own, the whistleblower can receive up to 30% of the total amount recovered."

Makes sense. At the end of the day I really don't understand so many people are arguing with you. Whether you are right or wrong you have stated your case.

The only thing I'll say is that at one time ER docs said "we will never sign a midlevel chart without seeing the patient", much like you write "we will never sign a a midlevel radiology read without seeing the imaging". But over time, whether due to force or other things, that is what ER docs do now.

So I recommend that Rads folks continue to band together as a society and vow never to sign midlevel radiology reads, ever.

 

[Brigade4Radiant]

Also lawsuits and malpractice are state dependent so northern states have high malpractice payments while southern states do not.

 

[chudat]

What has changed? Last time I checked, everyone made 400k+ in radiology. In fact, I was under the impression that there were more radiologists making 500+ than ones making less than 400. Perhaps things dramatically changed since last time I looked.

Graduated this past yr from fellowship.

Rads jobs are PLENTY and the pay I've been offered have all started in 400-450s for FTE and 600+ for partner.

 

[maxxor]

Graduated this past yr from fellowship.

Rads jobs are PLENTY and the pay I've been offered have all started in 400-450s for FTE and 600+ for partner.

400-450s wow. Good to hear.

In the southeast, partnership track is 300. Lockstep. All the groups in my large metro have colluded.

 

[collegestud2013]

Again lawsuits only matter to physicians. I don’t see any corporate mega groups nor did the hospital itself get sued. Corporate mega groups just take the money and leave the liability to the clinician or NP in this case it would still be the radiologist being sued after the NP does the reading. The examples that are pointed out change nothing.

Malpractice has not and will never stop mid level encroachment because the physician is the one who pays not the investors and not the administrators.

Corporate mega groups have been sued for massive fraud and guess what? All that happens is that they pay a fine and make all their clinicians do extra fraud training.

Emergency Physician Wins $26M in Wrongful Termination Suit

Raymond Brovont, MD, said he was fired for raising concerns about staffing issues

www.medpagetoday.com

HCA for example has defrauded the government more than any other single clinician or group of clinician and yet they are still chugging along without a care in the world.

Lawsuits stop medical professionals not corporate lol.

Actually, any malpractice lawsuit will always try to go after the hospital whenever a hospital is involved, and sometimes the CMG as well if they are involved. So unless the case exclusively occurred in a private practice office, just about any case that involving a hospital-based EM physician, radiologist, hospitalist, etc... will name the hospital in a lawsuit. After all, the hospital has much more money than an individual physician (and the limits of the malpractice insurance coverage) which basically makes itself a big target. And in today's age when profit margins for hospitals are razor thin, having to pay out an extra few million bucks a year can easily make the difference between profit vs loss.

Tort reform can partially solve a lot of these issues, or at least significantly reduce the risk of getting hit with frivolous lawsuit. I believe Colorado is the only state at the moment with an umbrella cap of $1million per case (both economic and non-economic damages) which probably deters many malpractice lawsuits who just want a quick payday. Hopefully more states will follow suits (since many states that have malpractice caps only cap non-economic damages).

 

[southerndoc]

Actually, any malpractice lawsuit will always try to go after the hospital whenever a hospital is involved, and sometimes the CMG as well if they are involved. So unless the case exclusively occurred in a private practice office, just about any case that involving a hospital-based EM physician, radiologist, hospitalist, etc... will name the hospital in a lawsuit. After all, the hospital has much more money than an individual physician (and the limits of the malpractice insurance coverage) which basically makes itself a big target. And in today's age when profit margins for hospitals are razor thin, having to pay out an extra few million bucks a year can easily make the difference between profit vs loss.

Tort reform can partially solve a lot of these issues, or at least significantly reduce the risk of getting hit with frivolous lawsuit. I believe Colorado is the only state at the moment with an umbrella cap of $1million per case (both economic and non-economic damages) which probably deters many malpractice lawsuits who just want a quick payday. Hopefully more states will follow suits (since many states that have malpractice caps only cap non-economic damages).

I was named in a lawsuit where only the physicians that touched the patient (in the ER) were named. The hospital or the admitting physicians/consultants were not named. Luckily I was dropped.

 

[Jabbed]

Man, this discussion took a strange turn. Thanks for all the advice.

I guess I like working but I want a job where I can keep working till I get old like 60. I don’t really care to retire early because I have enough hobbies but something about working is nice. Problem with ER is as I get older the shift switches seem harder. My gig and pay is good but if I did it past 50 I would kill myself. ER life just isn’t sustainable long term. I envy the old timers who do it into their 60s. What are they made of?

Would it make sense to put in 5-10 more years and then do a residency or not worth it at that point. This way money won’t be an issue as much as today. Part of me does get very burned out with what I do too so I guess it would be nice to sit in a room all day left alone reading picture. It’s not like in ER there is a fellowship that’s even remotely interesting.

I just want to comment on pathology; isn’t that field basically taken over by PhDs now instead of MDs hence the job shortages or am I misinformed?

Thread was massively derailed. Scale back to minimum full time hours and pay younger attendings cash to cover your nights. You'll be in a much better financial situation and can enjoy the good parts of EM while minimizing the negatives.

EM really is a good gig. We just work it too hard and too long to actually enjoy it.

 

[Ho0v-man]

The reason midlevels reading imaging won’t be a thing is that it’s harder to fake it than other fields. It’s not because rads is just so much harder than other areas of medicine.

Let’s be honest, they only have surface level knowledge of what’s going on most of the time. But they know their attendings do ABC in this situation, and XYZ in that one. You can’t just hang out in a dark room and learn what motions to go through so what you do will be good enough. You actually have to know what you’re talking about. There’s a reason they’re not reading EEGs, or echoes. We talk about ICU midlevels a lot on these boards. But I’ve yet to meet one that understands vent settings. I’m impressed when they interpret an ABG correctly tbh.

Midlevels are there to cosplay. That goes farther in some fields than others. It won’t go far in rads.

 

[Ho0v-man]

Also, not sure why this thread is so doom and gloom midlevels in the first place. The downfall of EM, Rad onc, and path have all been the same issue: too many residency spots.

 

[Febreeze]

Just here to say if you want to jump ship, I agree with doing it but to find a 1-2 year fellowship (Pain, Sports, Addiction, Occupational, Crit care, etc.) that you can do out of EM but allows you to actually work out of the ER. Or I would save up money and scale back to 8 shifts a month or so. I would not want to do another residency again.

 

[SeekerOfTheTree]

How long is a crit care fellowship and is it worth it?

I am working the bare minimum already.

 

[HowlPrenderghast]

You realize there are already a vast amount of pathology midlevels reading slides, right?

Administrators. Don’t. Care. About. Quality.

What? There are midlevels reading pathology slides? I'm gonna need receipts.

 

[TheComebacKid]

I don't get why people still bring up Critical Care as an EM exit strategy. Doesn't seem to make your life better from the standpoint of work life balance. Sure, you work less ED shifts, but ICU work is a different kind of exhausting. The goal is to not work less ED shifts so you can do something else that is equally if not more stressful.

 

[turkeyjerky]

I don't get why people still bring up Critical Care as an EM exit strategy. Doesn't seem to make your life better from the standpoint of work life balance. Sure, you work less ED shifts, but ICU work is a different kind of exhausting. The goal is to not work less ED shifts so you can do something else that is equally if not more stressful.

Some people still want to practice medicine…

 

[Dave1980]

Some people still want to practice medicine…

i feel attacked. rads isn't practicing medicine lol

i suppose youre right. when people ask me a non imaging medical question my response is always "i don't know, im a radiologist, not a doctor"

 

[Franzd'Epinay]

I don't get why people still bring up Critical Care as an EM exit strategy. Doesn't seem to make your life better from the standpoint of work life balance. Sure, you work less ED shifts, but ICU work is a different kind of exhausting. The goal is to not work less ED shifts so you can do something else that is equally if not more stressful.

The ICU gets rid of two huge aggravators from working in the ED: haphazard shift schedules and dealing with nonemergent patients. If these are some of the primary causes of one's burnout, then CC makes a lot of sense.

 

[sylvanthus]

Id say ICU is less overall work than EM. Course there are always crappy days, but, in general, I can sit down and eat, take naps on occassion, chill in the office for a bit, etc. I assume any ED shifts I pickup are gonna be running my ass off the whole time.

 

[Birdstrike]

Some people still want to practice medicine…

Highly overrated

 

[TheComebacKid]

The ICU gets rid of two huge aggravators from working in the ED: haphazard shift schedules and dealing with nonemergent patients. If these are some of the primary causes of one's burnout, then CC makes a lot of sense.

Not all non-emergent patients are aggravating. A lot of them are very straight forward: dental pain, ankle pain, anxiety, ingrown toe nail... discharge all of them very quickly and efficiently.

While we can act like every patient in the ICU is critically ill, the truth is, most intensivists roll their eyes at a ton of the admissions they get. Post arrest with ROSC awaiting declaration of brain death. Angioedema who is awake and talking but just there for monitoring. Awake head bleed patient who needs neuro checks. DKA patient with mild gap but needs a bit more time with the drip. Post op spine patient who is there because the surgeon demands it. These are not always super fulfilling cases.

Critical care requires an immense attention to detail, admissions, downgrading patients to floor status, goals of care discussions, family member discussions, endless rounding etc. Granted I am not an intensivist, I trained at a fairly ICU heavy residency program, and I found the work to be exhausting.

At least for me, I would be trading one type of stress for a different type of stress by doing CCM.

The answer, from my perspective, is to find ways to limit clinical time and patient care as much as possible. As much as we can say we love medicine because we love patients, I love spending a day doing administrative work alone in my office, teaching residents in a procedure lab, speaking at a national conference (especially when these activities are bought down by your department). All of those things would give me a better work/life balance than getting off an ED shift and prepping for a week in the ICU.

I'm also finding CCM to be open to the same pressures of CMG expansion, metrics, billing, documentation etc that we loathe in the ED, which doesn't really make it seem like that great of an alternative.

 

[Febreeze]

How long is a crit care fellowship and is it worth it?

I am working the bare minimum already.

Out of EM, critical care is 2 years long. "worth it" or not depends on what is important to you and how much you actually like ICU. I wouldn't want to do critical care though