radiology questions

[StartsInGut]

radiology attendings and residents,
i am in between IM and radiology; have a few questions regarding radiology before i take the final leap of faith.
1) if i choose to practice teleradiology how isolating does it get? there is no relationship with the referring provider if am not mistaken and very little follow up or meaningful relationships with referring docs
2) after you become an attending do you feel like you are growing in the job as you progress through your attending cases, specially in private practice? for examples young gi or surgical attendings still call their fellowship attendings and run through a difficult case with them. every once in a while they come across a complex case that really gives them satisfaction of being able to do something where they were the difference for the patients. does this happen frequently in radiology as well?
radiologists come across more zebras probably in a day but due to the sheer volume is it even recognized at least by other radiologists or the referring doctor?
3) do radiologists feel more competent and skilled with age? what i mean is a surgeon with say 15 years experience will generally feel more competent due to the sheer no. of cases he/she has performed. Radiologists because of the wide variety of cases they see don't seem to have that big off a difference in skill gap between say a 35 year old radiologist and 50 year old radiologist ( say they got into med school at same time)

edit : modified question 3 to frame it better

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[Cognovi]

radiology attendings and residents,
i am in between IM and radiology; have a few questions regarding radiology before i take the final leap of faith.
1) if i choose to practice teleradiology how isolating does it get? there is no relationship with the referring provider if am not mistaken and very little follow up or meaningful relationships with referring docs
2) after you become an attending do you feel like you are growing in the job as you progress through your attending cases, specially in private practice? for examples young gi or surgical attendings still call their fellowship attendings and run through a difficult case with them. every once in a while they come across a complex case that really gives them satisfaction of being able to do something where they were the difference for the patients. does this happen frequently in radiology as well?
radiologists come across more zebras probably in a day but due to the sheer volume is it even recognized atleast by other radiologists or the referring doctor?
3)Is the radiology hierarchy more flat? what i mean is a surgeon with say 15 years experience will generally feel more competent due to the sheer no. of cases he/she has performed. Radiologists because of the wide variety of cases they see don't seem to have that big off a difference in skill gap between say a 35 year old radiologist and 50 year old radiologist ( say they got into med school at same time)

1-Depends on the arrangement, whether you are doing telerad for a bunch of different places all the time for general radiology, or are you doing more specialized radiology for a small number of places and you can call people up who will recognize your name after a while. There are now even academic teleradiologists who do tumor board, collaborate on research/QI/education, and all the trappings of an academic job that get you personal relationships with trainees and referring docs but while living in a different state. Nowadays with so few people visiting reading rooms in person, I feel like the only advantage I have being on site is interacting with radiology trainees, while my interactions with referrers are largely virtual or telephonic anyway (except for the rare in person lecture or social event involving that other specialty).

2a- This does happen often. A few of my friends who I trained with but are now in private practice like to text each other about difficult or zebra cases. There is so much breadth and depth of complexity in radiology.
2b- Do we recognize that we see zebras because we get them at high volume? I think radiologists take for granted and underappreciate how often we see zebras. The referrers are more excited about writing it up as a case report, making it their next CPC, etc. For the radiologists, they're just like oh that's a really cool case, thanks for showing it to me [adds it to my mental encyclopedia], next case. If you look at all the big and small clinical specialty journals, a bunch of them have these teaching images features - like a single figure and a few hundred words about a case that is uncommon and has interesting imaging. It's much more often the referrers that submit these articles than it is radiologists. These are way more common than in radiology journals, which have only recently started to do this in my observation. At my program we just recently started having an interesting cases of the day miniconference within the divison. There's really no shortage of cases if you just get radiologists to take the incremental mental effort to flag/save/present interesting cases.

3- Hierarchy is a term describing organizational politics and interpersonal dynamics. Your questions are different, about whether additional experience over a career after training leads to 1) feeling more competent, and 2) actually being more skilled, and whether the slope of that is different between radiology and other specialties. At the beginning of the career, I think radiologists have less steep of an early attending confidence curve and learning curve, because radiology training so closely simulates independent practice. Trainees write full preliminary reports and put your nickel down before the attending reviews. In contrast in surgical specialties, the decision making is much more closely dictated by the attending, often before the trainee has a chance to make a suggestion, and the critical portions of the procedure are done by the attending. My curve as a new attending lasted all of two weeks acclimating to a new practice environment, supervising trainees my own age, and having to final sign reports I could be sued for. I'm still learning of course, which makes the job fun, but I also enjoy that on occasion I will make calls that other senior attendings missed or misinterpreted. Being more experienced in radiology does give you more competence in my opinion but there is a big enough range of performance among different radiologists in practice that you won't feel that being junior necessarily means you are less skilled. There are also enough new things coming out in radiology that you will have to learn it on the job, and everyone is learning it at the same time. The older rads have more mental recognition of rare pathologies or clinical acumen about managing tricky scenarios but they're just an unfamiliar as you with the latest fancy sequence or AI program or new cancer immunotherapy complications.

 

[StartsInGut]

thank you for the detailed reply. i draw some satisfaction from being able to form a relationship with the referring provider as reporting and discussing cases with people i never see in my entire life is not something i am sure i can tolerate. To avoid this i can work tele in an academic setting or a boutique private tele with a few practices and must avoid big box tele companies right?

There are only drawback of radiology that i see and i may be wrong about this is satisfaction from work relationships with other radiology providers and that of going unrecognized at least by colleagues, all other aspects of the job i am fine with, like not much recognition from patients, the workflow, the feeling of being continuously on for the entire shift, small procedures split during the day. What drew me to radiology is i like the anatomical visualization of every pathology in the body and the ability to work at the intersection of medicine and tech. In the little exposure i have had i was blown by how much actual depth and breadth of medicine radiologists know. I don't particularly hate IM And am one of the rare people who doesn't mind the rounds and pimping and notes. my favorite part of the day during IM was probably the interaction between residents and attendings more than the patients. If i go IM i probably will end up doing a fellowship as i want to be more of a consult specialty than primary.
radiology seems to trump IM lifestyle and training by a MILE considering the amount of time spent on social work in IM

considering these points would you recommend radiology over IM for me? Is there something i have not thought about?

 

[Cognovi]

I am not sure why you seem set on tele practice even before you have chosen a specialty. Tele is a small part of radiology.

 

[qxrt]

thank you for the detailed reply. i draw some satisfaction from being able to form a relationship with the referring provider as reporting and discussing cases with people i never see in my entire life is not something i am sure i can tolerate. To avoid this i can work tele in an academic setting or a boutique private tele with a few practices and must avoid big box tele companies right?

There are only drawback of radiology that i see and i may be wrong about this is satisfaction from work relationships with other radiology providers and that of going unrecognized at least by colleagues, all other aspects of the job i am fine with, like not much recognition from patients, the workflow, the feeling of being continuously on for the entire shift, small procedures split during the day. What drew me to radiology is i like the anatomical visualization of every pathology in the body and the ability to work at the intersection of medicine and tech. In the little exposure i have had i was blown by how much actual depth and breadth of medicine radiologists know. I don't particularly hate IM And am one of the rare people who doesn't mind the rounds and pimping and notes. my favorite part of the day during IM was probably the interaction between residents and attendings more than the patients. If i go IM i probably will end up doing a fellowship as i want to be more of a consult specialty than primary.
radiology seems to trump IM lifestyle and training by a MILE considering the amount of time spent on social work in IM

considering these points would you recommend radiology over IM for me? Is there something i have not thought about?

Okay so I get the impression that the two things you like about radiology are the lifestyle (hence your focus on teleradiology specifically) and the idea of radiology (you use all the buzzwords like tech and visualization that fascinates all med students). But I don't get the sense that you actually think you will enjoy the day-to-day work of radiology. Have you spent a week shadowing someone in radiology? I get that it's boring to watch someone do radiology, but can you imagine yourself sitting in a dark room all day, with minimal human interaction other than occasional phone calls to people whose faces you've never seen? Can you live with other services reading your report, then forgetting that you exist?

I've personally always loved being the behind-the-scenes guy that isn't the center of attention, the one who actually makes the critical finding or doing the critical procedure that sets everything else in motion clinically. Even if you go into IR, it will never be like surgery where the hospitalist writes in their note "Dr. Urologist recommended nephrostomy, appreciate urology consult," it will be "nephrostomy placed by (nameless, faceless) IR, [statements of appreciation omitted]" If the idea of getting credit is as important to you as doing the actual work, then you won't find much of that in radiology. But for me, I get immense satisfaction from following the patient's chart and seeing that they are improving because the critical finding I made on the CT or the procedure I did changed the course of their hospitalization.

 

[StartsInGut]

I am not sure why you seem set on tele practice even before you have chosen a specialty. Tele is a small part of radiology.

i am not set on tele practice. Its just that radiology seems to be moving more and more tele at least part time. i probably will never do tele if i have an option, but the way things are going i am not sure i will have that option. I see a lot of my friends who are applying this year who absolutely love that aspect, i just feel like the odd one out

 

[StartsInGut]

Okay so I get the impression that the two things you like about radiology are the lifestyle (hence your focus on teleradiology specifically) and the idea of radiology (you use all the buzzwords like tech and visualization that fascinates all med students). But I don't get the sense that you actually think you will enjoy the day-to-day work of radiology. Have you spent a week shadowing someone in radiology? I get that it's boring to watch someone do radiology, but can you imagine yourself sitting in a dark room all day, with minimal human interaction other than occasional phone calls to people whose faces you've never seen? Can you live with other services reading your report, then forgetting that you exist?

I've personally always loved being the behind-the-scenes guy that isn't the center of attention, the one who actually makes the critical finding or doing the critical procedure that sets everything else in motion clinically. Even if you go into IR, it will never be like surgery where the hospitalist writes in their note "Dr. Urologist recommended nephrostomy, appreciate urology consult," it will be "nephrostomy placed by (nameless, faceless) IR, [statements of appreciation omitted]" If the idea of getting credit is as important to you as doing the actual work, then you won't find much of that in radiology. But for me, I get immense satisfaction from following the patient's chart and seeing that they are improving because the critical finding I made on the CT or the procedure I did changed the course of their hospitalization.

yes you are partly right in that I don't know if i can be nameless, faceless to even the referring provider. I don't mind being nameless, faceless to the patients, i am perfectly ok with that. But i am not sure if i can live without ever seeing the people whose cases i read. I do get immense satisfaction in intrinsically knowing a finding i made changed the patient management and knowing they improved because of me. But i guess i do want the referring doctor to at least acknowledge that my contribution made a difference over say somebody doing locum cover at the practice or somebody doing tele for overnight. I don't know if i can live absolutely zero external validation. I enjoy when i am appreciated for doing the job well, doesn't matter who it is as long its someone. Am i being immature or are my fears justified?

 

[Cognovi]

It's a reasonable concern that resonates with me - I want to feel like I'm making a difference and having external validation helps. I get it. My job has been able to give it to me. I do academics so I share my good calls with my trainees and colleagues at conferences. I go to tumor board, where the radiologist is the center of attention. I message and know the faces of a handful of residents in a different specialty because I tell them about critical findings often or we collaborate in procedures or see them at the scanner. Even in the part of the practice I do tele for, a referrer has called me to talk not just about my read (feedback, clarification) but also shooting the **** because they too are lonely in private practice and want to make connections.

 

[guytakingboards]

radiology attendings and residents,
i am in between IM and radiology; have a few questions regarding radiology before i take the final leap of faith.
1) if i choose to practice teleradiology how isolating does it get? there is no relationship with the referring provider if am not mistaken and very little follow up or meaningful relationships with referring docs
2) after you become an attending do you feel like you are growing in the job as you progress through your attending cases, specially in private practice? for examples young gi or surgical attendings still call their fellowship attendings and run through a difficult case with them. every once in a while they come across a complex case that really gives them satisfaction of being able to do something where they were the difference for the patients. does this happen frequently in radiology as well?
radiologists come across more zebras probably in a day but due to the sheer volume is it even recognized at least by other radiologists or the referring doctor?
3) do radiologists feel more competent and skilled with age? what i mean is a surgeon with say 15 years experience will generally feel more competent due to the sheer no. of cases he/she has performed. Radiologists because of the wide variety of cases they see don't seem to have that big off a difference in skill gap between say a 35 year old radiologist and 50 year old radiologist ( say they got into med school at same time)

edit : modified question 3 to frame it better

1) Cognovi answered this well; it depends on the type of teleradiology.
2) Yes. If anything for me consulting partners was even moreso than what I'd expect for a clinician. When I was fresh out I might have run 10+ cases a day with my colleagues. Sometimes for a rare case, sometimes just to confirm a nothingburger was a nothingburger. Even now I still run a few cases by my partners/friends each day.
2/3) Scope of practice matters a lot in radiology as it does in any field. If you narrow your radiology field down to subspecialty, you may be able to master it earlier and not have much growth over the mid and late portions of your career. If you practice super generally (light IR procedures, nucs, multi-organ MR, mammo) then you may never reach expert level but damn you will be a highly desired rad after 10-15 years. Most rads fresh out of training are woefully under-prepared to practice a super general job.

 

[StartsInGut]

It's a reasonable concern that resonates with me - I want to feel like I'm making a difference and having external validation helps. I get it. My job has been able to give it to me. I do academics so I share my good calls with my trainees and colleagues at conferences. I go to tumor board, where the radiologist is the center of attention. I message and know the faces of a handful of residents in a different specialty because I tell them about critical findings often or we collaborate in procedures or see them at the scanner. Even in the part of the practice I do tele for, a referrer has called me to talk not just about my read (feedback, clarification) but also shooting the **** because they too are lonely in private practice and want to make connections.

I think this is exactly what I wondered. Thank you so much. So I guess if I go into radiology it would be academic radiology. I see a lot of attendings jump ship from academics to private practice now because of the pay difference, but this satisfaction probably cannot be gained there. Just out of curiosity cognovi do you ever intend to go into private practice or have any regrets so far? Your career trajectory is something I would like to know for sure coz it seems to fulfill exactly what I want. I am right now in between going the Im-cardio or Im-heme onc route vs radiology. I know different specialities but that is still a decision I can take later.
Top priorities for me include:
1) some sort of external and internal validation. I should feel my presence in the case made a difference. I probably also want a little external validation from time to time
2) good amount of intellectual stimulation but not surgery
3) ability to interact with familiar colleagues on a daily basis. It doesn't have to be the whole day. It can be as little as 30 min to an hour a day. It can even be three times a week but I don't know if I can stand weeks of not having stimulating professional discussion
4) i don't want to feel stagnant in my career, i don't intend to devote my life to any other side profession. My top priorities would be career growth and being there for my family
5) Good income ; anything above say> 400k without having to work an ungodly amount of odd hours. I don't really need 600/700k with no job satisfaction and hustling all the time. I think beyond a particular amount money doesn't make that much of a difference

 

[Cognovi]

Just out of curiosity cognovi do you ever intend to go into private practice or have any regrets so far? Your career trajectory is something I would like to know for sure coz it seems to fulfill exactly what I want.
...
5) Good income ; anything above say> 400k without having to work an ungodly amount of odd hours. I don't really need 600/700k with no job satisfaction and hustling all the time. I think beyond a particular amount money doesn't make that much of a difference

I'm not even six months into being an attending but I have no regrets or intention to do private practice so far. My job is varied, challenging, interactive, and prestigious. The main downside is I won't be hitting >400k despite hustling above average RVU.

 

[qxrt]

Don't necessarily need to choose between one or the other. There are hybrid academic/private practice groups out there, where you function as a private practice but also cover the major teaching hospital and are involved in the academic side of things including tumor boards, teaching residents/fellows, etc.

 

[GadRads]

I'm not even six months into being an attending but I have no regrets or intention to do private practice so far. My job is varied, challenging, interactive, and prestigious. The main downside is I won't be hitting >400k despite hustling above average RVU.

If you are hitting close to 400K in academics that’s pretty good. How many wRVUs per year?

 

[guytakingboards]

Don't necessarily need to choose between one or the other. There are hybrid academic/private practice groups out there, where you function as a private practice but also cover the major teaching hospital and are involved in the academic side of things including tumor boards, teaching residents/fellows, etc.

The total upside is a little bit lower than a true PP-only type group but plenty of people find the mix rewarding.

I work in a hybrid practice with a residency program and I teach our radiology residents, off-service residents, and medical students whenever I'm at the teaching hospitals. I do a fair amount of tumor boards and multi-disciplinary conferences. Other days I'll just sit at an imaging center and crush the OP list. It's an ideal mix at times.

 

[StartsInGut]

I'm not even six months into being an attending but I have no regrets or intention to do private practice so far. My job is varied, challenging, interactive, and prestigious. The main downside is I won't be hitting >400k despite hustling above average RVU.

this is good to hear

 

[StartsInGut]

Don't necessarily need to choose between one or the other. There are hybrid academic/private practice groups out there, where you function as a private practice but also cover the major teaching hospital and are involved in the academic side of things including tumor boards, teaching residents/fellows, etc.

i didn't know this existed. what is the salary range f this model. i know acade,ics tops out at 450k ish even in midwest universities for anyone below prof

 

[Cognovi]

If you are hitting close to 400K in academics that’s pretty good. How many wRVUs per year?

About 14-15k wRVU.

 

[qxrt]

i didn't know this existed. what is the salary range f this model. i know acade,ics tops out at 450k ish even in midwest universities for anyone below prof

Salary range is around that of private practice, since it is a private practice that just happens to cover a teaching hospital.

 

[GadRads]

About 14-15k wRVU.

I would have expected around 11-12K for academic neuro. You are probably at one of the underpaying academic institutions.

 

[Cognovi]

I would have expected around 11-12K for academic neuro. You are probably at one of the underpaying academic institutions.

You're right, and I'm extrapolating for the year so the final count once staffing has reached a steady state should hopefully be closer to 12k.