Month: November 2016

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The Struggling Radiology Resident

struggling

In any profession or career, some employees lag the performance of their peers. It turns out that radiology residency is no different from any other job in this respect. The key, however, is that the employer can identify the struggling worker or that the employee can recognize that he or she is struggling. It is only when this process happens that interventions can occur. Also, this process of identification needs to be early and effective. The radiology program’s goal is to help these residents along as soon as possible to allow rapid and more effective remediation. Early remediation can prevent a struggling resident’s further downward spiral that could lead to probation, suspension, or even worse, job loss. On occasion, there is no effective remediation for specific individuals, but that is instead the exception rather than the rule.

No matter how you slice it, the loss of a resident is devastating for both the radiology program and the radiology resident alike. So, my goal for today’s discussion is to help the individual struggling radiology resident and prevent him from going down this pathway. We will discuss how to identify oneself as struggling, what you can do to intervene before more severe repercussions, and how to deal with your attendings and colleagues when you are the “struggling resident.”

Self Identification

As is said, you cannot fix a problem unless you know a problem exists. So, self-identification of oneself as struggling becomes crucial. Some residents know from the very beginning that they are having difficulties and have good insight into their situation. Others may be having challenges but are not aware. Additionally, sometimes the feedback that residents get from attendings, technologists, nurses, and administrators can be different from the truth and outright misleading. Given that radiology residents tend to have limited responsibilities during their first year of residency, this issue is more likely to go unnoticed during this first formative year of residency. So, we will first talk briefly about some indicators that you are struggling during residency.

I will also classify the reasons for the struggling resident as either academic or professional, to simplify and organize the discussion. Let’s first start by discussing some of the indicators that a resident may be struggling in academics.

How to Know If You Are Struggling Academically

Noon Conference and Readouts

Noon conference can be an excellent time to discover your position relative to your colleagues. If you notice that you are unable to answer questions that your colleagues quickly answer consistently, that can be a red flag. If you have a hard time describing or making a finding on studies geared to the first-year resident, you may be struggling. Or, if different attendings become consistently frustrated with your answers while giving the noon conference, you may want to consider that you are having difficulties.

Readouts with your attending may help to determine whether you are struggling. Are you able to answer routine questions appropriately? Is an attending that typically accepts resident dictations re-dictating everything you write? Is your supervisor frustrated with you? Do your attendings provide you with some sense of independence during procedures similar to others in your program? These are some hints that all may not be quite right.

Call

Next, think about your experiences on “buddy call.” Do you feel comfortable going over films with your colleagues, attendings, and other clinicians? Is there a sense of frustration from these people with your reads? Are attendings not satisfied when they find out they are on call with you?

Feedback and Exams

How about feedback and evaluations? Is the feedback you receive from attendings routinely negative. Are milestone evaluations always below par? Do you receive comments from attendings that are uniformly negative?

You might think that the in-service exam or Radexam would also be a useful metric of resident performance. It turns out that as an associate program director, I put much less faith in academic evaluations based upon the in-service examination as a sole means of assessment. I have found a weak correlation with resident academic performance. So as a resident, I would put less stake in this form of self-assessment. However, in combination with the in-service exam, if you are underperforming in other residency-based quizzes or examinations, this can be an indicator of real academic issues.

How to Know If You Are Struggling Professionally

This area can be harder to recognize for a struggling resident. Many don’t realize they have a problem until it’s too late. But, we will go through some examples that you may be able to self-identify.

Absences

Absences, in its many forms, is a leading indicator of professionalism based struggles. Are you routinely late to conferences and readouts, and do you sense the frustration in others? Do your colleagues too often have to cover for you because you are not available? Have you been cited multiple times for missing conferences or required meetings?

Conflicts

Conflicts with classmates and colleagues can be an indicator of professionalism struggles. Are there routine yelling matches with your fellow residents? Do your colleagues not want to help you out with call coverage, studying, or other everyday residency issues? Are you routinely fighting with the secretaries, nurses, technologists, or even attendings?

Substance abuse

Substance abuse is all too common a cause for having a problematic residency. Take a serious look at your habits and if they may be genuinely affecting your performance. Are you routinely using alcohol or other illicit substances?

Organic causes

Chronic disease can be a cause of day to day residency struggles. Cancer, hepatitis, infectious diseases are all problems that can cause fatigue and difficulty with concentrating on a long shift.

And of course, there are psychological issues such as depression, anxiety, schizophrenia, and more. These issues are more likely to go unnoticed by the afflicted resident. But some residents, already diagnosed with these disorders, may have better insight. These residents need to take a hard look and see if these problems are affecting their residency performance.

Self-interventions

The next step in the process is to figure out how to remedy the situation before more significant repercussions. If you know your issues are academic or professional, you can certainly take measures to stem the riptide. We will go through several of these avenues.

You’ve decided that you are struggling academically. What do you do? The next step is taking a realistic assessment of why you are having difficulties. For some people, it may be the quantity, and for others, it may be the quality of their studies.

Quantity of Learning

Having been through the residency process and supervising many residents over the years, I have learned that radiology is a reading-intensive specialty. Moreover, to increase one’s knowledge base, a resident needs to create a means to cover all the essential and relevant topics within the residency program. So, the first question is: on what do you base your study schedule? Some residents will use the curriculum guidelines from their residency program. Others will split the ABR core exam topics into bits of information that they can review. Even others may use STATDx/Radprimer to guide their studying. The bottom line is that you need to find some guidelines that will allow you to cover all the topics that you need to know.

The second question: have you created a schedule that allows you to cover the critical topics during residency. And what are some options for the resident? Many residents don’t realize the amount they need to learn to become a proficient radiologist. A schedule, therefore, becomes very important for the struggling resident. Plans can vary from one person to the next. Some people do better with studying for short blocks of time. Others prefer to slog it out for a long block at once. It doesn’t matter how you complete the necessary work, whether you take 2,3, or 4 topics per evening, but the work needs to get finished. A regimented schedule will allow you to get through the appropriate information for each rotation.

Quality of Learning

The next step is to assess if it is how you are studying, that is the problem. Some residents read for hours every night, only to find that their knowledge base is not to par. You would think that by the time one gets into the radiology specialty, they would have a method for studying well. But, that is indeed not the case for many residents. Studying and reading for the radiology resident is different from studying for medical school classes and the boards. Radiology emphasizes pictures. Medical schools emphasize words.

So, if you are genuinely studying for hours at nighttime without meaningful results, try learning differently. I would recommend emphasizing reading the pictures and captions within a book over the general text. Many residents do not realize they need to do this to be a more effective radiology student.

Pictures/Case Series

You may also want to explore case review series over general text reading. Again pictures are the center of the radiologist’s world. I find that a general text helps more when you have experienced a case firsthand during the daytime and want to find out more. On the other hand, a case image with text is more similar to the radiologist’s day-to-day work and will allow many residents to digest the information better.

Discovering Learning Disabilities

There is one last item that I want to bring to light. On occasion, a radiology residency may make a learning disability evident. Because radiology is different from other subspecialties and the methods for studying differ from other areas, some residents have problems with the transition. Some residents have issues looking at a picture and translating it into findings and conclusions. Radiologists do not usually test for this before beginning radiology. If you think that this may be your situation, it behooves these residents to consider psychological testing to find a more effective means of studying. Dollars spent to solve this issue now if you do have a learning disability may pay back itself in spades later on.

Fixing Professionalism

Professional issues and their solutions can vary widely. It may be as simple for the absentee resident as creating and sticking to a schedule to make sure you attend all the important events on time. If you are in constant conflict with your colleagues, you may need to learn to relate to others better, and that may involve sharing more or not taking everything to heart. On the other hand, maybe the conflicts are connected to other pressing issues such as substance abuse or health problems.

The critical thing to remember: there are many sources of help for the radiology resident. Whether it’s your colleagues, attendings, program directors, chairman, the Physician Assistance Program, a psychiatrist, or other individuals, there is someone at your program that can support you. It is crucial to talk to someone if there is a professionalism issue that you need to address. And, there is always help if the situation becomes unbearable.

How to Deal With Attendings and Colleagues If You Are Struggling

OK. So you have identified that you are struggling, and you have created the means to remedy the issues effectively. The next problem is that you may have created an environment where your colleagues’ expectations are so low that it may be challenging to defy their expectations. I like to describe this as the “vicious circle.” Your faculty will now scrutinize everything that you do, much more so than your colleagues. And, even though your performance may improve, they may not recognize the improvement. Unfortunately, they may still perceive you as below par. This “vicious circle” is probably the most challenging part of being an underperforming resident. So, what do you do at this point?

I would recommend continuing with the remediation program at hand. Healing a reputation takes not a few days or months. Instead, it can take years. Eventually, your effort will be recognized, but not without a lot of work and effort. You will have to suffer through some of your attendings and colleagues’ expectations until they realize you are a capable resident. This process takes grit and determination. You are going to have to ignore the expectations of others and create expectations for yourself. Eventually, you will notice a change in how they treat you, but remember, it will not happen overnight.

Summary

Radiology residency is a big transition for most residents, and some may struggle at the beginning academically or professionally. If you are struggling at this time in your life, don’t let these shortcomings define you. The measure of greatness is overcoming obstacles such as completing a radiology residency, a significant achievement. Struggling radiology residents often become radiology attendings with greater empathy for others’ struggles and can become the most successful radiologists!

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Ten Thousand Page Views- The Radsresident Experience

The Radsresident Idea

Sometimes the best ideas come about in the most mundane ways. I remember an uneventful Saturday in the middle of September when I sat down and began to surf the internet. I started to read about financial topics and happened upon a website called the Financial Samurai, a website dedicated to passive income. Most importantly, at the top of the page, there was an article called How To Start Your Own Blog. And so, it got me thinking… I haven’t really seen much organized accurate information on the web dedicated to the day to day issues of the radiology resident. Most sites were dedicated to medical students and board certified radiologists interested in radiology topics, but the radiology resident caught in the middle seemed to be skipped over. That being said, there were a few scattered helpful radiology residency related articles and forums on websites such as Aunt Minnie and Medscape, but it was a really a sparsely covered subject. And much of the information was not always reliable and accurate, not really personalized to the individual radiology resident, and was very technical and dry.

In addition, I always wanted to create a website. And, with all the valuable information I have learned as associate residency director over the past 7 years or so, I thought I could really contribute to the body of knowledge of the unappreciated radiology resident. I would target the day-to-day information that radiology residents, students interested in radiology, and others involved in the radiology residency process need and want to know. So these were the humble origins of this blog/website.

From the beginning of the idea for the radsresident website, I thought it would take a very long time to get viewers to the website and was expecting a long slog. To my surprise, in a little over a month and a half, we have already reached 10000 page views! So, why not write an article about what I have learned about my initial experiences, what I think it means for my loyal viewers, and what are some of the exciting changes to happen in the upcoming months?

Continue reading Ten Thousand Page Views- The Radsresident Experience

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ESIR vs IR integrated

ESIR

 

Question:

Hello,

I am an M3 student, most likely applying to radiology next application cycle. I am interested in IR but do not have enough exposure to be dead set on an integrated IR residency. I was wondering about your opinions of applying to diagnostic radiology, specifically at programs with ESIR, and how feasible it is to knock a year off of the independent residency that we seem to be switching to through this option. Could you break down the ESIR pathway and how to transfer from DR to IR? Would this be the best option for someone not dead set on IR, or should I apply to integrated programs and pure diagnostic and rank them as I see fit when the match comes?

Thanks!

Director’s Response:

So, I am going to start by summarizing the three current pathways for interventional radiology at present:

  1. The “old-fashioned’ way involves a 4-year residency. But instead of needing a 1-year fellowship (as it was formerly), you now will require a 2-year fellowship. They call this the independent pathway.
  2. The ESIR pathway that you referred to. In this pathway, you must complete a full year of interventional-related rotations during your residency. At that point, you can then apply for a 1-year independent interventional fellowship.
  3. The DR/IR integrated pathway is an entirely separate five-year residency program.

The DR/IR program has three years of general radiology and two years of interventional-related rotations.

Specifically, regarding your situation, most residents who initially say that interventional radiology interests them usually find another subspecialty fellowship. So, if you aren’t entirely committed to interventional, chances are, you will do something else.

ESIR

If you apply to a program with ESIR, you must tell your residency director reasonably early that you are interested in the ESIR pathway. The reasons for this: A. Multiple residents may be interested in ESIR. B. The residency may only accommodate one or two people because of scheduling requirements. C. The conditions for ESIR can disrupt the schedule of other residents in your class because of the need for additional dedicated IR time and less time on different rotations.

However, the significant advantage of an ESIR program is two-fold. First, it enables the ESIR resident to take the one-year interventional fellowship instead of the two-year fellowship. And second, it makes the ESIR resident more competitive in the fellowship match because they have some experience under his belt. Also, programs have limited their two-year independent fellowships for those not following the ESIR pathway.

More About IR/DR

If you attend a program that has an IR/DR program or an ESIR program, it is possible to transfer in and out of one program or another. However, IR/DR programs give the resident less flexibility. Remember, the IR/DR program maintains independence from radiology residency with its own program director and scheduling. Its sole goal is to create interventional radiologists. (Although it does happen to share the core exam with the radiology program, however). So, it is possible that if you decide to transfer to the DR portion of the program, you may not have enough rotations available to meet the residency requirements. Although unlikely, you theoretically may need to find a residency slot elsewhere.

If you are not entirely sure that interventional radiology interests you, I recommend finding radiology residencies with an ESIR program rather than an IR/DR program. Why? , an IR/DR program commits to you the process of becoming an interventionalist. If you go to an ESIR program, you will more likely have a little more time to decide upon entering into interventional radiology later. (but you should still make a decision as soon as possible). And the ESIR program fits within the confines of the diagnostic program. This program allows more transfer flexibility.

Remember, if all else fails, you can still complete interventional radiology by attending a standard DR program without ESIR. However, you may have a much harder time getting into the fellowship. That may make more sense than applying to an IR/DR program to find out you don’t like it.

So, those are my two cents. I hope that clarifies things a bit. I wish you good luck in the radiology match process!!!

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Radiology Moonlighting: A Taboo?

moonlighting

Rarely do chairmen and radiology program directors in academia utter the word “moonlighting” to their radiology residents, fellows, and employed attendings. Yet, moonlighting is a mainstay for many neophyte and seasoned radiologists. Why is the subject so taboo? Academic stakeholders want to know that their residents and practicing physicians dedicate themselves entirely to their primary responsibilities as learners and their duties at their daily jobs. To these stakeholders, moonlighting implies that their workers work toward other endeavors that may “interfere” with their primary roles. Concerns such as duty hours and sleepiness during the day job can arise. Even worse, the stakeholders perceive these workers to be competing with their primary business.

Why You Should Consider Moonlighting

But I would like to argue against both of these notions. First, it is unusual that the worker moonlights more than she can handle. Of course, anything taken to an extreme can harm the practitioner. Too much sugar causes tooth decay. Too much water causes hyponatremia. And, too much moonlighting can theoretically distract from the day job or training. However, it turns out that this impression is a widely perceived misconception.

I harken back to my days as a radiology resident and fellow. As a resident, I remember reading CT scans in a quiet room in the evening next to the CT technologist’s workstation. I would preliminarily provide initial interpretations by fax to satisfy the demands of the ER physician and provide coverage that would otherwise would ordinarily not be available. Also, I would rapidly scan the plain films that attendings left from the afternoon shift. We made sure no impending disasters lurked in the morning as we searched for occult pneumothoraces, free air, pneumatosis, portal venous gas, and more.

Instead of interfering with my role as a radiology resident at the time, I found the experience to allow me to read more quickly and accurately. It supplemented my day job and, subsequently, my career. My moonlighting enhanced my performance during my daytime residency position. We can only achieve skills such as rapidly and accurately reading films by having had the experience to do so. Moonlighting experience easily fits the bill.

Second, you will perform most moonlighting gigs at a subsidiary of the primary institution or a local group. Usually, these opportunities may require temporary coverage due to staffing needs. It would be undoubtedly unusual for a moonlighter to “poach” cases from their primary residency program or day job.

Discordant Views Of Moonlighting- Academics Vs. Private Practice 

Even more interesting, practices consider moonlighting a badge of honor for the applicant to private practices, one he can display to his future employers. And, concordant with this view, the typical private practice employer considers moonlighting an asset. When interviewing for private practice jobs, the stakeholders would specifically ask if I had done any moonlighting. For these private practice stakeholders, moonlighting implies that the trainee has the experience and wherewithal to handle the daily pressures of a bustling private radiology practice. The typical skeptical chairmen and residency director’s impressions of moonlighting differ from this view.

Given the importance of moonlighting for a budding radiologist from both a training and future employment perspective, program directors should actively discuss the topic instead of suppressing the information. Therefore, for the rest of this discussion, I will discuss where to find exceptional moonlighting experiences, what to avoid, what you need to do before obtaining your first gigs.

Where Do I Find Moonlighting Opportunities?

First of all, if you are fortunate enough to have a moonlighting opportunity embedded in your residency or fellowship program that the institution supports, I would say this is the best situation. You don’t have to worry about “stepping on anyone’s toes.” And, your institution will likely already insure you for the task. These opportunities are the simplest and best for the trainee.

I am aware, however, that many programs do not have these opportunities on hand. So, I would recommend you ask either former or current residents and fellows about the options in the area. When you interview for your fellowship, make sure to get the phone number or email of the current fellows. Ask them if they moonlight and what exactly they do. Usually, the current trainees know the local environment for moonlighting the best.

Let’s say, however, the current residents or fellows are not moonlighting. What else could you do? You may want to call the local groups and find out if they have any temporary staffing needs. The local group may often need a warm body to “babysit” a magnet or give preliminary reads in the evening. This moonlighting experience would be your opportunity…

Lastly, if all else fails, you may want to either search employment websites or ask a locums company to help you to find moonlighting opportunities. I would reserve this option for last because the companies that use these agencies charge a fee that may lower your pay rate.

What Moonlighting Experiences Should I Avoid?

In the recent past, residents would finish their residency training, take and pass their oral boards. Subsequently, they would be board certified in radiology. No longer is this the case. This fact leads to some new technical issues with moonlighting as a fellow. In the past, I would have said, by all means, go ahead and give final reads as a moonlighting fellow. Instead, as a typical radiology resident or fellow, I would consider reserving final reads until after you have passed your boards. Find moonlighting opportunities to give preliminary reads or work for a senior attending that is ultimately responsible for the final readings.

Why do I feel this way? Well, if you miss a finding and it goes to court, legally, you may have a more challenging time defending your miss. If the plaintiff’s attorney asks you if you were board certified at the time of the reading of the study and you say no, they can theoretically question your judgment at the time of the interpretation.

It is also essential to check that your malpractice insurance for your residency or fellowship is compatible with the moonlighting site. If not, you should obtain the correct insurance, or the opportunity should be off-limits for the prospective candidate. If you provide final reads for a practice or don’t have an occurrence policy, you should consider tail insurance.

Also, make sure you do not commit too much time to the moonlighting job. As discussed before, you certainly don’t want your moonlighting to interfere with your day job.

What Do I Need To Do Before Moonlighting?

1. Months before the prospect of moonlighting, it would help if you started getting the prep work done. The first thing to consider, make sure you get all the necessary state licenses that you may need. It can take a lot longer than thought to get a state medical license. Have all that paperwork ready.

2. Keep your CPR and ACLS certifications up to date. Some opportunities require the applicant to have satisfied this requirement.

3. Before accepting any offer, make sure you feel comfortable with the requirements of the job. If they need someone to overread MSK MRI and do not have experience with this, it is probably not the best situation. Be thorough when you ask the employers about what they require.

4. Let your residency or fellowship program know that you are going to be moonlighting. The program needs to record your hours worked “off-campus” as part of the duty requirements of the ACGME. If the program catches you working too many hours, the ACGME can penalize the program. It’s probably not worth the risk of jeopardizing your residency or fellowship.

5. Once you have pinpointed the opportunity, you need to make sure your malpractice insurance covers the employment opportunity. Also, you must proceed rapidly with hospital credentialing as this process can be very time-consuming. Hospital credentialing also includes sending off the malpractice insurance information to the hospital medical staff office.

Summary

Moonlighting can be a fantastic experience that supplements your residency and fellowship education. It can enhance your prospects for future employment, can allow you to gain speed and confidence at your daytime job, and let you more rapidly pay down your student debts. I highly recommend moonlighting if the opportunity is available, you are so inclined, and it is allowed by your residency or fellowship program.

Good references/links to find out more about moonlighting

Moonlighting for Extra Money: Tempting, but Watch Out

Radiology resident moonlighting: A necessary evil?

 

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Staying Healthy for Residency (And Life)

“The only insurance of your health are the choices you make every day.” – Leonard Morneau, MD

Residency is arguably one of the most grueling times of a physician’s career/life. You’re working long hours (80 hour weeks can be the norm), usually don’t get enough sleep, and barely have time for yourself. At times residents can get so focused on the health of their patients that they forget about their own health and well-being. This is a very sad turn of events. Physicians are supposed to be leaders in healthcare and it’s my personal belief that the only way to lead is by example. Now you may be saying, but I don’t have time to be healthy! I barely get enough sleep, there’s no time for exercise! But the fact is that you can still be healthy even while working such strenuous hours. This is especially important for Radiologists that spend most of the day sitting in a chair. A previous post does a great job explaining the importance of exercise and the different types you can do to stay active, even with minimal time. The main focus of this post will be on other healthy lifestyle choices to make.

The MOST important thing, by far, is the choice of what food you put into your body. I’ll be honest; the cards are stacked against you here. It’s one of the main reasons we have the obesity epidemic and millions upon millions of people who suffer from completely preventable diseases. Our bodies have been engineered to desire sugar, fats and other bad food choices. Why? Thousands of years ago when food was scarce it was good to have fats to store energy for later use in case of famine or not being able to find food. So the human brain was trained to crave those sorts of foods. Fast forward a few thousand years and those impulses are still here, but food is plentiful (in most places).

In my personal opinion, most of the food choices we have today are very unhealthy. They’re packed with sugar, preservatives and other things that are simply not good for the human body. Yet this is the majority of food that’s produced, is heavily advertised and can be as addictive as a drug. Multiple studies have shown these addictive properties and that sugar specifically activates the same receptors in the brain as cocaine and heroin… 1, 2, 3 This is why “dieting” is so hard; it’s like trying to tell someone addicted to drugs that they need to stop. Easier said than done.

INSTEAD, what must be done is not to think of things in terms of this diet or that diet, but living a healthy LIFESTYLE. There is no magic pill. It is the choices you make every day. Now, here’s a list of some things you can do to start living healthier:

1) Water
I recommend only drinking water (preferably hydrogen enriched water).
Nearly all beverages are loaded with sugar, so ALWAYS check the nutrition facts. I’ve seen a “green juice” marketed to be healthy with “no sugar added” that contained almost 40g of sugar… And sugar is immediately converted to fat if it’s not utilized by the body (which is most of the time, unless you just finished a tough workout). This is one of the easiest things you can do that will drastically improve your health. A good starting point is ½ your body weight in ounces of water daily.

2) Eat More Greens
No one ever got obese by eating too many vegetables. Vegetables are nutrient dense foods (high in nutrients and low in calories) and they fill you up faster. For those of you complaining about them not tasting good enough for you, there’s a ton of different ways to prepare veggies that taste amazing. I do it every week in my meal prep. Also, growing more plants for food consumption would be better for the environment and help slow the pace of global warming as well.

3) Avoid The Aisles

When you go to the grocery store, the majority of your food should be purchased from the periphery of the store. Most of the food in the aisles of a typical grocery store is all processed, full of sugar and bad for you. Always check the nutrition facts before you buy something, you’ll be amazed at what you’re actually eating.

4) Prep For Success
Take one day a week to prepare most of your meals, at least lunch. This way you’ll have healthy meal choices ready during the week. I’ve been doing it for years and it is definitely one of the main reasons I’ve been able to stay so healthy.

5) Avoid Fast Food
Restaurants like McDonalds, Burger King, Wendy’s, etc… should be avoided like the plague. Compare eating fast food to using drugs like cocaine and heroin in your mind (after all they have a similar effect) and you’ll be less likely to eat them. (I haven’t been to one in nearly 4 years, so yes, it’s possible).

6) Have A Cheat Day
With all the new changes to your diet, you’re likely to crave those old foods that you love. Try and save them for one day of the week only. This will make it easier to eat healthier during the week when you know you have a reward coming at the end of the week. The less you consume these food choices, the less you will crave them.

7) Track It
Many people find that they’re not aware of how much they’re eating until they make a note of it and calculate out how many calories they take in. Try using an app just one day a week to see how much you consume in a typical day. It may be the eye-opener you need to kick-start a new lifestyle.

8) Snack Healthy
Instead of going for that cookie or other sweet in the mid-morning or afternoon, try having a healthier option like a handful of almonds or nuts.

9) Keep A Balance
Think of health as a bank account. Every good health decision you make, like eating vegetables and exercising, is a deposit. Every time you eat unhealthy or make such decisions you are making a withdrawal. Keep a tally of your deposits and withdrawals like you would your bank account. Just like it takes time to build wealth, good health is only obtained from making these deposits every day. If you withdraw more than you deposit, you’ll go into debt and suffer the consequences. How does your account balance look?

It may seem difficult at first, but the habits you form today determine who you will be tomorrow. Keep the end goal in mind and you’ll be able to do more than you ever though imaginable.

Just as in airplane safety videos they always tell you to put your oxygen mask on before your children’s mask; why? Because you’re no good to that child if you’re dead. Similarly, we must make our own health our first priority because without it, we won’t be able to take care of others; which is the whole reason we got into this profession in the first place.

 

1. Spangler, Rudolph, Knut Wittkowski, and Noel Goddard. Opiate-like Effects of Sugar on Gene Expression in Reward Areas of the Rat Brain. N.p., 19 May 2004. Web. 14 Nov. 2016.
http://www.sciencedirect.com/science/article/pii/S0169328X04000890

2. Colantuoni, C., J. Chwenker, and J. McCarthy. “Excessive Sugar Intake Alters Binding to Dopamine and Mu-opiod receptors in the brain : NeuroReport.” LWW. N.p., 16 Nov. 2001. Web. 14 Nov. 2016.
http://journals.lww.com/neuroreport/Abstract/2001/11160/Excessive_sugar_intake_alters_binding_to_dopamine.35.aspx

3. Avena, Nicole, Pedro Rada, and Bartley Hoebel. Evidence for Sugar Addiction: Behavioral and Neurochemical Effects of Intermittent, Excessive Sugar Intake. Neuroscience & Biobehavioral Reviews, 2008. Web. 14 Nov. 2016.
http://www.sciencedirect.com/science/article/pii/S0149763407000589

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Physician Burn Out- Is An Inadequate Medical Education System The Fundamental Cause?

We read article after article about the complete dissatisfaction of physicians throughout the United States and how it affects patient care.  Since it makes a good story to cover the woes of physicians, the general press seems to covers this topic as dogma. But it is not just the general news. Even Medscape, one of my favorite radiology news/blog sites, has multiple articles and surveys on this topic.

Many different reasons are espoused for the cause of physician burnout. But, I believe there is one major factor that is not addressed. It all has to do with our medical school system and how the system is not made for the student/trainee but rather to support the folks running the schools.

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My First Real Radiology Job- Do I Want Partnership?

partnership

Every once in a while, a resident or fellow will ask me, “Should I take a partnership track versus an employed position?” Or, “What questions should I ask about partnership when I interview for a job?”. These can be somewhat tricky questions to answer since there are so many variables involved. I will tackle some of these issues here. I will also answer some common questions and clarify some misconceptions.

To make this post somewhat structured, I will first talk about the features of employed positions and ownership/partnership track positions. Then, I will determine whether it makes sense to be a permanent employee or on a partnership track. Finally, I will elaborate on the questions you should ask if you are fortunate (or unfortunate) to be placed on a partnership track. So, let’s begin…

To Be Or Not To Be– A Partner!!!

What are the initial differences between jobs that are permanent employee versus partnership tack positions? First of all, no hard and fast rules exist. Some employed roles have features of partnerships, and others have characteristics of employed positions. For the sake of simplicity, I will ignore these nuances and instead talk about the general features of each type of employment situation. You can further determine how the different components of your particular job offer apply to you.

Employed Positions

Basic Issues

Most practices pay employees a fixed salary that makes up the majority of their income. Some employees also may receive a production bonus of some sort, but it tends to be a small percentage of the salary. Starting salaries of employed positions tend to be higher than partnership track positions at the beginning. But, they remain more stable or gradually drift higher for many years to come. If the partnership or practice has a “banner” year, you will likely still get the same negotiated salary regardless of its profitability.

They also tend to be at the mercy of the employing body, whether a hospital system, partnership, or corporate entity. In general, employees have less control over their situation. Employers make the business decisions. If you don’t like the technologist, nurse, or administrator in your practice, you will still have to live with that person. You may not be able to change your PACS system or to set your protocols. Bottom line. You are at the whim of your employers.

Defined Written Responsibilities

Also, in general, employed positions usually have particular sets of responsibilities written in the contract. If you perform a duty that lies outside the realm of your negotiated deal, the practice does not require you to accomplish that task unless your employer pays for it. Being an employee allows you to concentrate on radiology without dealing with the day to day issues of running a practice.

For instance, you don’t have to worry about hiring, firing, buying magnets, billing, capitalizing on radiology trends, attending hospital events, and more. A lot goes into the management of a practice that is not related to day to day radiology. And as an employee, you will likely be a lot less responsible for these activities. But everything comes with a price. You are selling your ability to control the entity for which you are working.

Risks of A Private Equity Buyout

And most importantly, for some, practices treat employees very differently when there are significant changes. In today’s rapidly changing practice environment, groups are merging; hospitals are buying out imaging centers; large corporations are taking over smaller entities. When a significant event such as this occurs, the employee usually does not benefit as the practice’s employer will. Typically, when a radiology practice is “bought out,” the partners or employers will get a large sum of money to pay for the accounts receivable, equipment, real estate, goodwill, and so on/so forth. On the other hand, the employee will typically get nothing. Or even worse, the employee will be the first to be fired if there is a business restructuring.

Partnership Track Positions

Partnership track positions usually pay a lower amount at the beginning than an employed position until you make a “partner.” A partnership track employee can make a substantially different income than a permanent employee. Many starting radiologists do not understand this concept, but it makes a lot of sense. You are paying for the equity/ownership of the partnership in two ways.

Sweat equity

First, there is a concept called “sweat equity.” “Sweat equity’ is essentially a time commitment. This process can last almost any time interval. Most practices have a partnership track period that can last anywhere from almost immediately (in the early 2000s, I knew one fellow offered immediate partnership before finishing fellowship!) to 10 years.

Time to partnership varies depending on multiple factors. First and foremost, these include location. The more desirable the area, the more competitive the partnership spots. And, the more years to partner the practice will charge the partnership track radiologist. Additionally, the time to partnership can be longer if you own equipment, real estate, and other assets. That makes sense because to pay for that share in the partnership, you need to put in more “sweat equity.” Finally, market conditions also affect time until a partnership. Suppose numerous radiologists are looking for partnership positions. In that case, the practice will charge a more extended period of “sweat equity” because of the high demand for a job and willingness of the partnership track position “to pay” for it.

Buy-ins

Second, many practices expect the partnership track employees to buy-in monetarily to the radiology business at the end of the partnership track term. This buy-in may be related to the accounts receivable and the owned assets of the practice. Furthermore, buy-ins can range from a nominal amount to over a million dollars, depending on the assets owned. It can be paid for directly, by a loan, or by increased “sweat equity.” The amount of buy-in can be a critical factor in selecting a partnership track position.

Practice building

Practices also expect partnership track employees to be involved in practice building. You will not just perform your daily duties as a radiologist, but you will be assisting and learning to accomplish other tasks outside of the normal radiologist purview. You may involve yourself with hospital committees, giving grand rounds, attending events outside regular business hours, and other important “non-radiologist” functions. These events are essential training for the partnership track radiologist to learn the business roles of the partner.

Partnership- Not An Obligation

The applicant needs to remember: Practice partners usually do not want to create a partnership position!!! Why? It’s pretty simple. It dilutes the preexisting partners’ equity (meaning that each partner will get a smaller share of the profits). There has to be a significant need to create a partner. These issues include lack of coverage in a particular subspecialty, need for more practice managers, etc. There is no such thing as an entitlement to a new partnership track position. Also, be prepared to work hard to gain a share of the partnership for that period.

What about the Partners?

Usually, practices pay partners a fixed salary. However, they earn a substantial portion of their income from the practice’s excess profits, usually a bonus. Usually, you expect the compensation of the partner to be higher than that of the employee. Why? Partners assume the risk of the practice and also manage practice issues. If reimbursement decreases, partners are affected first. If there is a loss of an employee, the partner needs to cover that position. Or, if there is a lawsuit against the practice, partners need to manage the subsequent issues.

However, the difference in salary between a partner and a non-partner can vary widely depending on the profitability of the practice. Therefore, it behooves the applicant radiologist to determine what the partners are making before joining the practice. You need to “check the books” or talk to the business manager. You certainly do not want to go through the process of “sweat equity” only to find out that your final income is not much different from your partnership track salary.

Does It Make Sense To Be On A Partnership Track?

Believe it or not, there is no quick answer to this question. It all depends on the individual situation and the job. There are also inherent risks to taking a partnership track position versus a permanently employed position. So, let’s evaluate each piece of this equation individually with different questions.

Are you the sort of person that likes running the show, or do you just want to do your work and go home?

A partnership track individual needs to be interested in business and practice building. There is no room for a partner who does not have any interest in building the practice outside regular business hours or is unwilling to perform different roles during the workday outside the normal radiology purview.

Is the job something temporary for you, or do you want this job to be permanent?

It would be best if you did not put “sweat equity” into a job where you think you will be leaving in several years to be closer to family or other needs. Generally, imaging centers will pay less for a partnership position. So, it’s just not worth it. Or maybe, you just need a position, but the practice job description is not exactly optimal, but it is the only thing available in your desired location. In this case, you may also decide a partnership track is not the correct decision. For example, you don’t want to be practicing women’s radiology when your only desire is to be an interventionist!

What is the current business environment in your location?

In some practice locations, hospitals are converting private practice jobs to employed positions due to mergers and acquisitions. You do not want to be stuck in a partnership track, only to find out that there is no partnership position at the end of the road. You may never make the “partnership” salary, or even worse, you may be out of a job. Remember, in a situation like this: employees are the first to go.

Have multiple recent retirees received buyouts?

First of all, what is a buyout? It is essentially the opposite of the buy-in. A partner that steps down expects to get the equity back that he put into the practice. Every once in a while, a practice may have many former partners retiring with enormous buyouts. Large buyouts can affect the partners’ salaries dramatically depending on the circumstances. It would help if you looked into all the specifics for yourself.

Is there a tiered partnership?

Some partnerships have separate buy-ins for the professional portion of the practice and the practice’s technical ownership. Others may give you only a small percentage of ownership compared to a “full partner.” You may become a partner one day. But, the partnership may not be what you thought it would be. Some practices are more equal than others!!! It is imperative to get all the facts correct before starting that partnership track.

Should Student Loans Affect The Decision To Be On A Partnership Track? 

I will try to tackle this question separately from all the others because it is becoming an important issue for residents/fellows before the partnership decision, given their enormous loan burdens. The difference between an employed position and a partnership track position can also seem substantial at the beginning. It may or may not be more financially savvy to take the initially lower-paying partnership track job. Here’s where it is vital to try to glean the specifics of your future career. And, this decision can be complicated. You have to plug in the numbers for yourself and make the calculations. To show you, we will take a specific circumstance under consideration. I will give you the example below.

Here are the inputs:
  1. You owe 500000 dollars on student loans.
  2. Student loan interest and long-term investment returns are both 6%
  3. The partnership track lasts three years.
  4. The difference between the salary of a partner and an employee is 150000 dollars.
  5. A permanent employee makes 100000 dollars more per year on average than the partnership track position during the partnership track term.
The calculation:

Theoretically, the salary difference can go to student loan payments if you are in a permanently employed position at the beginning. So, after taxes, you will have 66,000 dollars (100,000 dollars *0.66) per year or about 200,000 dollars (66,000 dollars x 3 years) more principal paid toward the student loans at the end of three years. Given that the loan’s interest rate and that the money you will make after you pay the loan is 6 percent, for a 30-year career, that same amount is equivalent to saving 200000 *1.06^30 or approximately 1.15 million dollars.

On the other hand, if you decide to take the partnership track, you lost out on the 1.15 million dollars you would have made if you were an employee. But, how much more, in the end, will you make to compensate for those years of “sweat equity”? So, let’s subtract the salary difference between a partner and a non-partner and take the taxes out every year. That number would be (150,000 dollars* 66 percent) or 100,000 dollars. Let’s take that 100000 dollars and multiply it by the number of years worked. That number would be 100,000 dollars *27 years (30 years of working minus three years of making less than an employee) or 2.7 million dollars. This number does not even include interest!! In this case, it would certainly make financial sense for the applicant to take a partnership track position.

The bottom line: you need to perform the calculations for yourself. It may make financial sense to take the partnership track position even though the initial salary is less than the permanent employee.

Bottom Line

The decision to become a partner vs. a permanent employee may not be simple due to the applicant’s personality, job-related factors, and monetary considerations. If you are thinking about the partnership route, make sure to know your role and get as much information/specifics as possible so you can leap. A partnership is a long-term decision, just like a marriage. Know what you are getting into!!!!

Please leave in comments below. I would love to hear from you!!!

 

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Investments vs. Savings- A Resident’s Guide- Part 2

As a reminder, last week we went through the difference between savings and investments and talked about why the difference is so important with examples of using savings as an investment and investments as savings as a resident. We also discussed many different ways to put money away for savings. This is all encompassed in the first part of the this series called Investments vs. Savings- A Resident’s Guide- Part 1. Please refer back to this article if you want to review these important concepts. Today, we are going to discuss what many residents are more excited about- what are the common options available for investing money as a resident? In particular, we will emphasize the usual individual types of investments available (stocks, bonds, mutual funds, and ETFs). This post is not going to include other sorts of alternative investments such as peer-peer lending, real estate, MLPs, etc.  Also, I am not going to discuss the  different overarching account types (IRAs, brokerage accounts, 401k, etc.). Both of these latter topics are grounds for another discussion as a full blown article at a later point!!!

To make it easier to follow, I will divide the investment types into the following categories: stocks and bonds. I will give examples of each and examine which places are good places to park your money as a radiology resident. Let’s start with the best place to put your money for most residents: stocks.

Continue reading Investments vs. Savings- A Resident’s Guide- Part 2