Jan 22

Reader Mailbag: Should I Be a Radiologist?

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Every now and then readers send me emails with questions about nearly everything.  Usually they want advice on what to do about their personal situations. I love to help people, but I feel like detailed responses are an inefficient use of my time since only one person benefits. It dawned upon me that a better use of my time is to write these questions up in a post and share them with thousands of people.  Hopefully several will find the information useful and be able to apply it to their situation. It also forces me to put more thought into the answers, and will be of greater service to the original asker of the question.

 

So here is my first installment of Reader Mailbag: Happy Philosopher Style. I don’t know if I will keep that name, but it’s all I could think of first thing in the morning.

 

This series of questions is focused – all of them are about radiology. Since I’m a radiologist, and many of my readers are in the medical field, I get a fair amount of questions about it. I also know several radiologists read my blog regularly, so feel free to comment (you all know who you are).

 

 

 

Dear Happy Philosopher,

I’m a medical student considering radiology. I want help deciding if I’m equipped to withstand its pressures (and if I even understand what they are). I would love your thoughts on the matter.

 

Sincerely,

Medical student

 

 

 

This was a little vague, so I dug in a little further to what this student wanted to know and many questions emerged. Enjoy.

 


 

1) In what kind of setting and in what subspecialties have you worked? Anything you might do differently another time around?

I work both in a hospital and outpatient clinic setting. With picture archiving and communications systems (PACS) it doesn’t matter where you are physically sitting. You can read anything from anywhere. I do diagnostic radiology with a smattering of light interventional procedures (injections, biopsies, etc.). My workday is very different than that of an interventional radiologist. IR is much more procedure oriented. I made the best decisions about my career I could at the time and I don’t think I would change anything. I like the people I work with and where I live. After hearing about how some other groups operate I’m happy with the choices I’ve made.

 

 

 

2) What trends are you seeing now and into the future for radiology?  

I may not the best guy to ask this question because I don’t really pay attention to these things. The deeper I get into life, the more I realize not to worry or pay attention to things outside of my control. That said, I have observed a few general trends and huge changes over my almost 20 year career arc (residency fellowship and real job). In order to understand current trends and the future, I think we need to look back at the recent past.

  • Film was replaced with computer screens. This was the biggest change in radiology I have experienced. It happened while I was in residency, and then again when I got into the real world. Throw fellowship in there and I lived through 3 PACS transitions in a relatively short period of time. It was a good thing overall, but it changed the way other physicians used radiology. People stopped coming down to radiology to go over the images, and the interaction between radiologist and ordering doc changed. This lead to the next big trend…
  • Teleradiology: Anything could be read anywhere, so radiologists soon figured out they could cheaply outsource night work. This was a good thing for small groups where the volume was just large enough to torture someone on call, but not enough to justify an in house rad. Unfortunately hospitals realized that they could do the same thing because radiology was being turned into…
  • A commodity: Many administrators started looking at a radiology report as a commodity. It didn’t matter if it was read onsite or offsite, all that mattered was price. So a lot of small radiology groups got destroyed and hospitals contracted with larger groups. In some ways this was good because in very large groups you can have…
  • Specialization: When you are a 6 person group you are probably not going to have a pediatric neuroradiologist. When you are a 600 person group you probably have one always available for consultation. When I started in practice there were still general radiologists, but there are no general radiologists being trained any more. Subspecialty reads are slowly becoming the standard of care and I doubt you could get hired without subspecialty training fresh out of residency now.
  • Volume: There is a constant push to do more and become more efficient, and unfortunately there is a wide range of speed at which rads are able to comfortably perform. This frustrates the really fast people (they can’t understand why everyone else is so slow) and tortures the slow people (who end up working later than everyone else to catch up). It is extremely challenging trying to balance this and reward everyone for their strengths.
  • Small is the new big: The days of the 1 or 2 person group are numbered, but I suspect medium sized groups can thrive. I have found that although a radiology report has become a kind of a commodity, referring physicians don’t really want that. They want to know their rads and to have someone they can come to when there is a problem. Administrators want rads who will make their lives easier and keep their docs happy. A few years ago it was predicted that there would be no small groups left, that essentially all of radiology would be consolidated to a few mega groups of hundreds or thousands of radiologists. Maybe this will eventually happen, but the one thing that is constant is that the vast majority of predictions are flat out wrong. If I had a dollar for every wrong prediction about medicine made in the doctors’ lounge or those useless throw away journals I would be a billionaire right now swimming in gold coins like Scrooge McDuck.
  • The future is unknown: I don’t know what the future holds for radiology. Smart analytics tracking every mouse click and either making you a more efficient rad or giving your employer the data to fire and replace you? Machine learning AI that replaces you or augments your reads? Molecular imaging? Treatments that become so good that much imaging is not needed? A new imaging technology I haven’t even thought of yet?

 

 

 

 

3) Have you ever found radiology socially isolating? Have you enjoyed your coworkers and senior attendings? Have you had difficulty in the field with finding kindred spirits and friends, as such an introspective and seemingly sensitive guy?

I guess I am quite introspective, but I’m not sure I’m any more sensitive than anyone else – I just openly admit my feeling and vulnerabilities (behind the curtain of semi anonymous blogging of course, hahaha).

Most of diagnostic radiology is isolating. You sit in front of a screen and endlessly dictate reports, but there are procedures, phone calls, interactions with radiology techs and other people. Outside of work it is only as isolating as any career, which is mainly a function of how much free time and energy you have at the end of the day.

I loved the vast majority of my co-residents, co-fellows and attending physicians I worked with. Every now and then someone was an asshole, but I learned from them as well and came to at least like most of them too. My current partners are great people, but I wouldn’t say I socialize a ton with them outside of work. This is because many of them are just in a different place in life, or we don’t have much in common other than radiology, or they are busy (most in my group are full time).

One thing I’ve noticed is people hit peak busyness in their late 20’s to 40’s. Between careers, spouse, kids and other obligations there is less time for friends. Making friends and being social is easy when you are in school; after this it gets more difficult, and I’ve noticed the relationships tend to be more superficial. Again, I think this is a function of available time and energy.

 

 

 

4) The biggest thing that concerns me about radiology practice is the immense amount of concentration and stressful multitasking every day on the job combined with a certain amount of monotony/repetitiveness. Do you think that the training and job has changed the way you use your brain and engage with the world outside of the reading room? Radiologists sometimes seem very aloof or pretty odd, and I don’t know if it’s a chicken/egg sort of situation.

Radiologists are weird AF, but then again so are most docs. Medical school and residency will change your wiring for better or worse, but then again so will any intense stressful experience. Medical training has a way of amplifying/unmasking/creating mental illness and dysfunctional coping mechanisms. Radiology can be tedious, stressful and boring all at the same time. It can also be rewarding and fun. Every medical specialty has its share of tedium. If the tedium of your specialty really gets to you, you will be miserable.

 

 

 

5) What do you think were the biggest factors that led to your burnout? Sometimes I get excited about all there is to learn in radiology and about their role in medicine. Other times I try and put myself in the shoes of a radiologist in private practice who needs to maintain laser-like focus all day long to not miss anything and kill someone, on 100-150 images in a shift, while dealing with interruptions, and I feel like that can’t possibly stay enjoyable for very long. I wonder at what point you felt like the intellectual stimulation, vacation time, etc, was no longer enough to keep you going full-time.

Burnout is an energy balance problem. When the good stuff no longer fulfills you enough to make up for the bad stuff, burnout is inevitable. For me, it was a combination of both. As the years wore on, the work became more tedious. The cases that were cool/fun when I started eventually became tedious after seeing them time and time again. As the job became more tedious there were external stressors which in retrospect I should have either ignored or dealt with, but didn’t have the tools or insight at the time. It is essential to either keep your job interesting and fun, or if it is boring and tedious to at least not let it become too stressful.

 

Boredom + stress + tedium + poor coping mechanisms = BURNOUT

 

I burned out around 5 years into practice. This is earlier than most. I usually see it in others around 10-15 years. My story is here:

Happy Philosopher: The Backstory

 

 

 

6) How doable do you think your part-time job share situation is for the average radiologist?

Doing teleradiology or locums is probably an easier way to work part-time, but it depends on the job market and what groups are looking for. It’s probably easier to do this after you have been working in a group full time rather than coming into a new group as a job share. Most groups want full time rads, but part time is becoming more common. I think most people should work full time or near full time coming straight out of training, as the immersion is good for developing skills. Maybe the other rads can comment on this. I wrote this post a while ago.

A Physicians Guide to Working Part Time

 

 

 

7) How often in practice do you feel that you are working in unsafe conditions, i.e. being too rushed to catch most important findings?

Almost never. Sometimes call gets frantic, but a big part of being a good radiologist is learning to prioritize. Most of the studies can wait; a few need attention right now. In a world where everything is STAT, I’ve noticed only about 1-5% truly are.  All of the routine stuff can wait. After a while you develop a sense of how to manage workflow. If someone is really sick usually the ordering physician will call and ask you about the case. Many times the tech doing the study will call me if there is something critical so Ican put it to the top of my list.

 

 

 

8) What has been your experience with administration and practice owners? Sometimes I get the sense that attending radiologists are increasingly being treated unfairly and seen as commodities, in potentially abusive work environments.

I have only worked in 1 group, 1 hospital system, so my experience is limited. In general there are three types of groups: Businesses owned by the radiologists, companies owned by shareholders or venture capital that contract to hospitals, and hospital employees. I’ve only worked in the first type so I have no experience with the other two. In general you will have more control when you own your own practice. I’m skeptical that the VC groups are good for radiologists. Investors want a return on their investment, and it’s going to eventually come out of your bottom line.

In general I find most administrators to be pretty reasonable people, but there is a huge spectrum from heavily engaged and competent to people you wouldn’t hire to water your plants when you are out of town. But again my experience is limited.

 

 

 

9) How much would you say that continued learning and building of skills goes on after training? I’m someone who gets very bored if not trying and learning new things, which frankly is starting to seem like a huge strike against a medical career in general. A big plus for radiology is that it seems to have the greatest amount of intellectual material to master, but I’ve also heard a lot that in the private world things can get pretty monotonous.

I’m constantly looking stuff up and learning/relearning things, but I would agree with the statement that radiology can be pretty monotonous. Common things are common, and they will account for the vast majority of studies you interpret. The days will all pretty much start feeling the same.

 

Well, that’s a wrap for now. Hopefully this was helpful for some and not too boring for the rest of you. I will throw these in there now and then. Let me know what you think, and any radiologists (or other physicians) that want to chime in feel free to share your experiences in the comments.

12 comments

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    • VagabondMD on January 22, 2018 at 9:40 am
    • Reply

    Really excellent discussion, and even as a “recovering IR”, I would have answered many of the questions similarly.

    I have been asked, many times in various settings, if I would choose Radiology again if I had to do it over. My response is that I probably would do it again, with the information I had at the time and now, as even with the burnout and other professional bumps and bruises, it has been a mostly rewarding and satisfactory career.

    I would answer differently when asked if I would do it again today. That is, knowing how I have changed over time and also knowing how Radiology has changed over time, I would not choose to start a Radiology career today. That is not very useful for the next person, as Radiology (today) might be the perfect fit for him/her now and 20 years from now.

    The questions that are posed by the reader offer an interesting, insightful, and thoughtful perspective, with much more depth of understanding than what I had when I was choosing my career path. One thing that cannot be understood or predicted is how you are going to change over time. Sitting in front of a computer reading cases might be perfect for you now, but ten years in, it might be your version of Hell.

    My only real advice to a med student considering a career in Radiology (or anything else, for that matter) would be to understand that your practice will change throughout your career, and though you will also change, these changes may not be congruent. Be prepared for this and recognize that that you and your career are likely to become out-of-sync at various points in time, especially in the mid-late 40’s. Sometimes, this manifests as “burnout” or perhaps other variations of maladapted behavior that needs to be readjusted. Be flexible, introspective, and kind to yourself, and these flash points can be overcome. (I wish someone had warned me of this.)

    1. Good observations VagabondMD. We can’t really know how we are going to change over time. All the more reason to create flexibility and freedom in our lives before we hit burnout.

    • HarjotSingh on January 22, 2018 at 9:59 am
    • Reply

    What a nice review of Radiology as it is out there! People do seek out rotations for it in Medical School, as it is a higher paying specialty but that doesn’t tell you about the life after training. I am going to use this post as a reference in the future. It’s like a mentor talking. With slight variation, it is true for most of Medicine, even life. Thank you for putting together this Q&A.
    I do Pediatric Tele-Psychiatry in a few settings, aside from organizational Burnout work. We are probably the least exposed Specialty in Medical school – I have to explain to fellow Physicians at times. It’s like that meme- what others think I do, what my family thinks I do, and what I actually do.
    The medical student sounds spooked, and inquisitive.
    Here’s my two cents- there is Residency in between medical school and being an attending. And things WILL change. Infantilization doesn’t last, except for people who don’t realize that. There is a huge learning curve in Residency – focus on that to be a good Physician first. Being a competent Physician involves making a lot of mistakes, and realizing that you will get paid to help and serve people. In Psychiatry, there used to be a folklore that it takes about 10 years after Residency to be a good Psychiatrist. I can vouch for that. After Residency, don’t immediately tie down yourself to one job or one location. “Live like a Resident,” for some time, as White Coat Investor says, and learn about life as you will live on your terms – like you are dating life for sometime. The work you see in academic settings is likely to be different from the work you may find out in the community or may be different in one place than another. Physicians have a lot of power to negotiate a lot of things, if they are willing to realize that power. You’ll have to shed the “pick me, pick me,” point of view that dominates when you are applying to Medical School or Residency programs. There is no shortage of good work out there – you have to go find it. Mind you, most of the good jobs in Medicine are never advertised. Do easy work- you don’t have to prove anything to anyone else anymore after training. William Bridges’ book – Transitions, may be of great help to have some framework in mind about all of this.

    1. Thanks for the comment. I am a proponent of using the early years of your career to create some financial freedom in your life, so when the burnout sets in you have options to pivot into a job that is fulfilling even if it is for less money. Feeling trapped is the worst part about job dissatisfaction. Maybe one never burns out, in which case they have both a satisfying job and a pile of money. Not a bad place to be.

    • Sean Garcia on January 22, 2018 at 7:26 pm
    • Reply

    I miss the days when we would actually go down to look at the films with the radiologist.

    1. No more film, but you can still look at a screen with the radiologist 🙂

    • Dr. Curious on January 22, 2018 at 9:08 pm
    • Reply

    Predicting the future of radiology, or medicine for that matter, is a fools game. Some trends will move more slowly than anticipated, others more quickly, and still others will fizzle out completely or arise out of nowhere.

    For example, our group took a reimbursement and salary hit in the my first few years of practice. But then the health system for its own reasons quickly and universally adopted tomosynthesis (3D mammography) for all screening mammograms, and our salaries jumped by about $100k from one year to the next. Eventually, the government will decide to reimburse less for this, and salaries will do down again.

    To be a radiologist in private practice, you have to accept that much of the work will be mundane and rote—with flashes of interesting cases or high pressure situations. You can’t care a lot about interacting with patients. I enjoy the short conversations I have during image-guided procedures, but I don’t miss the headaches and social issues that come with direct patient care.

    I’m still keeping my eye out for burnout, but so far so good 🙂

    1. 100k for tomo?!? That is crazy.

      I also enjoy the procedures. When you get good at them it is actually very satisfying. When I retire this is what I will miss the most, when a patient tells me it was much quicker and less painful of an experience than they expected.

      Side note: If you ever have a really great experience with a radiology procedure, drop the rad a quick note. It will take you 5 minutes, but you will make someones day. I remember every thank you note a patient sent me. If you are a referring doc and a patient compliments the rad, pass it on to them. Again it will make their day. It is these little things that make a big difference.

    • Steve on January 23, 2018 at 5:47 pm
    • Reply

    This is all very interesting to me as a practicing gastroenterologist who’s always seen radiologists as a very different species from physicians with more direct patient contact (other than the IR guys).

    I found this part of the last question very incisive in regards to physician burnout (at least mine):

    “How much would you say that continued learning and building of skills goes on after training? I’m someone who gets very bored if not trying and learning new things, which frankly is starting to seem like a huge strike against a medical career in general. A big plus for radiology is that it seems to have the greatest amount of intellectual material to master, but I’ve also heard a lot that in the private world things can get pretty monotonous.”

    I think this is extremely important. Expertise in a well-defined area leads to good patient care and better outcomes medically–but after becoming highly skilled and knowledgable, the routine of seeing patients and diagnosing/prescribing or, in the case of radiology, interpreting images or performing procedures loses its novelty and excitement. Those in specialties seeing patient directly, at least get some feedback, positive or negative. Those in specialties like radiology and pathology–not so much. Has a pathologist ever had a patient send them a card or cookies because of their reading of a biopsy? I doubt many radiologists do either other than, perhaps an IR guy.

    In any event, most physicians are very intelligent and curious individuals and medicine is a very wide field that is impossible (as a whole) to master. We can master circumscribed areas however and that makes us very effective and valuable to the medical establishment, but leaves me longing for the days when everything was new, exciting and cool in my training. The loss of that somewhat child-like wonder and excitement is a large part of my own semi-burnout.

    1. There is so little feedback in radiology, You only hear about your misses. It can be demoralizing at times. Thanks for the comment.

  1. I try to hammer home some of these points to my med students. Any field, no matter how exciting, will become routine once you have done it 1000 times. So don’t choose a field based on something being exciting to you. Eventually, it’ll feel like “just a job” no matter how fast it got your heart rate going when you are young.

    Do something that you can enjoy the good aspects of and deal with the negative.

    Good post and a helpful one for the students out there picking a field!

  2. Radiology is hands down the best specialty for me. But it will be different for anyone else, depending on their personality. I’m a very visual person and I like diagnosing things while leaving the treatment and management to others. Some people would hate to sit in a dark room all day and dictate a huge list of studies, but I’m an introvert and I love it. I’d hate talking to a different patient every 15-30 and listen to their woes.
    Radiology is such a wide field and you could never master it all. So I don’t ever feel bored or think there is nothing left to learn. Going to a rad conference always makes me feel totally inadequate. There are times when I feel my dictations just go into the void and my work doesn’t matter. I do go to tumor boards and multidisciplinary conferences so I feel like I’m part of the medical team and my input is valued.
    Would I go into rads again? That’s a tough question. I couldn’t see myself doing any other specialty- maybe GI or derm. Technology will change rads for sure, but I don’t know exactly how. There is talk that AI will replace rads but I don’t see that anytime soon. Maybe there will be a centaur model; half man half machine which will make us more efficient. Machines are being miniaturized to the point where one day, there may be handheld xray machines and portable CTs in every drugstore in America. The volume will be explosive and there would be no way human rads could handle it. So AI will screen everything and shunt abnormal cases to the rads. Who knows.
    Our group doesn’t hire part timers and a lot of groups don’t either. Most private groups are balls to the wall work hard, make money type. Lifestyle groups are out there but harder to find and get into.
    In any case, any medical specialty will have pros and cons. Doctors in general are losing autonomy and just becoming a cog in the wheel of the great medical industrial complex. I’m now just another “health care provider”.

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