Month: April 2020

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Breast Imaging Versus MSK- What’s Better For Marketability And Lifestyle?

breast imaging versus MSK
Hi, Dr. Julius!
Been choosing between breast imaging versus MSK radiology fellowship, what do think is better in terms of marketability and lifestyle?
Yours truly,
Not quite sure
I find your choices of subspecialties of breast imaging versus MSK unusual because I almost consider them to be opposites in some senses. So, what are the particulars specifically about breast versus MSK radiology that you may find enticing or detract you from choosing them?

The Covid Crisis And Breast Imaging Versus MSK

Let’s start with current conditions. Many breast imagers that only perform breast imaging are currently out of jobs. Why? Because elective procedures have dried up entirely. So, you are subjecting yourself to a less diversified specialty in terms of outpatient versus inpatient imaging, that’s one negative for breast imaging. Today, MSK is more desirable in the Covid world because these subspecialists usually perform general radiology and inpatient imaging. But, times are atypical right now, and both specialties will likely return to a baseline (perhaps lower than before the pandemic- check out What’s In The Cards For The New Radiologist Job Market After Covid?).

The Traditional Job Market And Both Specialties

More traditionally, there have been fewer folks that have wanted to go into mammography for several reasons, such as more patient contact, lawsuits, and less diagnostic diversity. For these reasons,  the mammography job market has otherwise remained better than most subspecialties through other recessions. On the other hand, MSK is more conducive to practicing general radiology since it overlaps with other areas in radiology a bit more. So, you will find more cross-coverage, And, for this reason, this subspecialty tends to be more subject to the whims of the radiology job market in general.
In terms of lifestyle, both subspecialties tend to be primarily outpatient. And, both subspecialties can be procedural and usually non-emergent. Mammo folks do biopsies, and MSK folks perform facet injections and bone marrow biopsies/arthrograms. But that’s about where the overlap ends. Mammography is a specialty for those people that like patient interaction. MSK, on the other hand, in general, tends to be a more solitary subspecialty where you can work without having to see patients if you want. I find this to be the most substantial difference between the two subspecialties. You have to figure out if you are a people person or not to make this determination.
So, there you have it. Those are some of my thoughts about the comparison between the two subspecialties in a nutshell.
Thanks for the great question!
Barry Julius, MD
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What’s In The Cards For The New Radiologist Job Market After Covid?

radiology job market

In such a short time, a matter of weeks, the tenor of the radiologist job market has changed dramatically. Jobs in radiology were bountiful up until the beginning of March. Then, suddenly, elective procedures trickled down to almost nothing. And, practices began to fire their locum’s workers and furlough many part-time and full-time employees. But, this status will eventually end. And, the radiology job market will change and then establish a new baseline. But, what will that new baseline be? Can new graduates look forward to a booming job market once again? Well, let me give you a summary of what I think will happen as Covid-19 begins to wind down.

From Now To Three Months From Now

As we see a slight ramp up in elective studies, we will not yet see a brisk demand for radiologists. We will still have significantly fewer procedures, as many folks do not want to go to an imaging center for fear of contagion. However, many “elective” interventions, such as colon surgery for previously detected masses on colonoscopy, will need to begin again. But, don’t count on seeing many practices hiring just yet. Most practices will be more than adequately staffed during this time for the number of studies. Hiring freezes will remain.

Remember. You will continue to see advertisements for radiologists, but practices paid for these previous to the pandemic. These advertisements do not represent the current state of the job market!

Up To A Year From Now

Here, I will have to make a few more assumptions. But, I will postulate that a widely available vaccine is not yet available. And, I will conjecture that we have more widespread antibody testing (unlike now). Based on these premises, we will see more folks willing to come out to get their studies, especially those that tested positive for the antibody. However, fear will still prevent a lot of patients from getting the elective imaging that they want as not everyone will feel comfortable returning to hospitals and imaging centers. So, the patient load will not be back to the baseline. And, many practices will still be overstaffed based on the pre-Covid demand.  Therefore, new hires will have fewer job choices with lower salaries. Prospective new hires will face a tight job market.

The New Baseline Post- Covid Era Radiologist Job Market

The further you go out, of course, my predictions will become less accurate. And, we will assume that Covid infections go away from vaccinations and herd immunity. But, having seen other cycles, I believe that we will see several changes from the pre-Covid world. First of all, many patients will likely still be reluctant to return to imaging. Why? Unemployment will be much higher than what it once was before the pandemic.

Additionally, we will see a cultural shift of less imaging than before the crisis. Patients will more likely demand higher standards for cleanliness and sterilization. And, therefore, we may see fewer radiology procedures than in the pre-Covid world.

Also, many practices will have augmented their home teleradiology capabilities. So, reading efficiency will have increased dramatically.

Then, to add insult to injury, private equity firms and corporate radiology have become more significant players in the radiology space. These firms, formerly offering enticing salaries to new graduates, will now significantly lower the wages of new hires. Furthermore, we will see a decline in the salary of the contracts of the old hires since these firms renew these contracts on an annual basis. Why will this happen? Because profits rule their bottom line, and corporate radiology can cut with impunity. Corporate radiology will work radiologists to maximal efficiency, skimming any gains that they can from their radiologists. They will have no incentive to hire.

Finally, if we assume that the stock market remains lower than it was before March 2020, many prospective retirees will not retire. Why pack it in when your portfolio remains much less than what you planned at the time of retirement?

Between all these significant factors, the radiologist job market will not return to the pre-Covid era baseline. Instead, the market will most likely be more similar to the world five to ten years ago when good jobs were harder to come by.

What Are The Chances That I Am Wrong?

Of course, I can be wrong. However, I see the winds of change ahead based on what has happened in previous cycles. So, for those folks that are graduating soon, don’t expect the same radiology job market as the recent past. You will most likely have to work much harder to get the same position at a lower wage.

So my recommendations for you, as for years prior, take your training and residency seriously.  Be competitive. Step out of your comfort zone. Aggressively take charge of your education to become well versed in all areas of radiology. And, finally, expect to practice in locations and subspecialties that are not your primary area of interest. Although not for forever, we will see a return to a world more similar to the previous down cycle of the radiology job market. For those of you soon to find jobs, prepare accordingly!

 

tomatoes

 

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How To Mitigate The Next Pandemic: Encourage New Physicians To Get Business Training!

pandemic

Crises have a habit of magnifying gaps that we could not have imagined beforehand. And, this Covid pandemic reveals these large cracks in our healthcare system by the dozens. We have seen hospitals and imaging centers functioning without physicians receiving the appropriate personal protective equipment (PPE). We are witnessing a lack of ventilators for our sickest Covid patients. Moreover, we are beholding our healthcare system, reliant on lucrative elective procedures, go sour. Practices, hospitals, and imaging centers temporarily are almost empty (other than Covid patients) and dependent on our government to stay afloat. And, these issues are just the tip of the iceberg.

Did these misfires have to happen? Could leadership have prevented the dramatic shortfalls that we are experiencing now? How can we have known our future? Well, it’s a matter of ill-preparation.  And, this pandemic was not on the radar. But why? For years, many intelligent folks have been warning about preparations for pandemics. (check out this TED talk by Bill Gates) And, it is not just him. Other brilliant scientists and doctors have warned us about preparing for the next pandemic. No one listened.

Reason For Health Care’s Poor Preparation For The Current Pandemic

Why did hospitals and our healthcare system ignore prescient information sitting right in front of their noses? Well, it has to do with the model of healthcare that we follow in this country.  We have been treating healthcare as just a business for years.  And if you think about it only in these terms, the situation that we are in makes sense. Why would you prepare for calamity if it’s going to decrease your short-term and intermediate-term profits? Preparations reduce your bottom line.

But herein lies the crux of the problem. We can’t just think of healthcare as a business, but also as a way to protect and serve people. To accomplish this task, we have charged the wrong leaders with the responsibilities of running our healthcare system. Having only a JD or MBA, although helpful for understanding the business of medicine in the short term, is not enough. We need leaders in charge who have also been in the trenches and understand what our physicians and patients need in the long run. They need to understand the science and art of medicine. For these reasons, I would argue that we need more MDs and MD/MBA types in administrative leadership positions. With physicians in charge, hospitals could have prevented many of these issues.

Examples Of Why Physician-Hospital Administrators Would Make Better Health Care Administrators/Leaders

Let’s take some of the examples I provided above. PPE and ventilators are examples of two expenses that make no sense for a hospital to buy if you are thinking only about the business of medicine. First of all, buying such equipment would attract patients with infectious diseases to your institution because you have the equipment to manage only the sickest of patients. These patients cost more to the hospital. Additionally, why buy ventilators or PPE if you don’t need them now?. For-profit and non-profit institutions lose money off of their balance sheets, thereby decreasing bonuses given to their leaders. We can no longer think in these terms.

Or, let’s think about elective procedures as a way for hospitals to make money. Does it make sense? No. In a pandemic, the profit centers of a hospital shut down, causing the government to have to bail them out. Instead, healthcare profits should be made based on treating patients for sickness and making them well. Who better than a physician with some business sense to change this system so that we begin to treat patients and not just increase short term hospital cash flow?

The Answer: Encourage More Physicians/Radiologists To Receive Business Training

I want to underscore that we do need folks with business minds in charge of our healthcare institutions. However, these folks should be the doctors as leaders who can understand both business and medicine. To know how to run a healthcare system, you need experience in the trenches, both in the corporate world and medicine.

So, we, as program directors, mentors, and faculty, should encourage our residents to learn more about hospital administration. Instead of dismissing those residents that are not following our clinical footsteps, we should guide these new physicians on how they can begin this new pathway. Business courses should not be just an afterthought or tack-on to the radiology curriculum.

We need to start thinking differently about what and how we teach about the business of medicine. Let’s start taking more seriously some of the excellent curricula that the ACR or other physician societies offer and create mandatory externships to learn more about healthcare administration. Or maybe, just like informatics or MSK, all specialties should have fellowships dedicated to hospital administration. Now is the time to create easy-to-follow health care administrative pathways for our residents. It’s more than just creating another silly specialty pathway; it’s the future and viability of the entire healthcare system at stake!

 

 

 

 

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Should Hospitals Force Radiology Residents To Work In The ICU During The Covid Crisis?

ICU

Radiology residents are working in the ICU or the wards to meet the increasing demands of an influx of Covid-19 patients, sometimes having little to do with their training. And, most residents have graciously accepted their new duties, in the name of helping a higher cause. But why must residents comply with these demands? Are hospitals treating these physicians fairly? Is it ethical for h0spitals to require residents to participate and forego training in their desired subspecialty? And, what must the hospital ethically provide in return? Let’s answer some of these burning questions as it reveals some underlying issues about residents and residencies themselves.

The Government Indirectly Hires Residents

Once you sign your residency contract on the dotted line (or solid line!), you are receiving a salary from not just the healthcare system that employs you, but also indirectly from a pool of money provided to the hospitals by Medicare. And, most residents receive these government funds in one way or another. Therefore, you are indirectly working as the Government’s servant. In this setting, residents must comply with the Government and the hospital to receive a salary. So, hospitals do have the right to set aside educational objectives for the moment (even though it may not be what you bargained for!)

Residency Has Service And Educational Obligations

It’s not all about take, take, take! There are two components to any residency, educational and service obligations. Not too long ago, in an attempt to get back Social Security taxes from the Federal Government, residents sued the IRS because they claimed that medical residents were students and not employees. (Check out this article) In the end, the Government returned taxes to residents because the Government never clarified the definition of a resident. However, nowadays, the definition of residency changed. Today, the Government/IRS considers residents to be employees, not just students. And, for that reason, all current residents pay Social Security taxes as well as need to comply with government/hospital demands for service. (That includes time in the ICU!)

What Do Hospitals/Government Need To Provide In Return?

Hospitals have a moral and ethical obligation to provide a safe environment for resident trainees. Any institution that does not offer such a setting violates the spirit of a resident’s contract with the institution. What does that mean? Well, hospitals should treat residents like any other employee. In the case of this epidemic, hospitals should provide residents with the protective equipment they need to stay safe. No resident should risk life and limb without the appropriate accommodations of the institution in return.

And, hospitals should continue to pay their residents at their negotiated salary. Understandably, hospitals are struggling with the lack of revenue from canceled elective procedures. However, the amount that they receive for maintaining residency programs remains fixed by the Government. Therefore, it is only fair that residencies should continue to receive their salaries without furlough or pay cut. They are not the same as general employees whose wages can be subject to market forces.

A New World Order For Radiology Residents: Time In The ICU

No. ICU work is not what most residents signed up for when they began their radiology residencies. However, radiology trainees are still, first and foremost, physicians with service obligations. Part of these requirements is a duty to do no harm and help patients. Moreover, hospitals also have ethical and moral responsibilities toward their residents. Therefore, when both the resident and hospital meet these conditions, radiology residents can and should play a role in meeting the new needs of the healthcare system. Hey, when did you ever sign up for something that was as you exactly expected?

 

 

 

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Danger Of Using Case Studies To Dictate Imaging Policy: The Initial Covid-19 Study

case studies

Rumors abounded at the beginning of March 2020 about Covid-19. And, no one quite knew how Covid-19 would play out. All sorts of physicians were on edge to try to figure out what to do. But then a new case study about the role of CT scan arrived at the scene. And, clinicians began to read or hear about this “seminal paper” in Radiology that came out from China, called Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID-19) in China: A Report of 1014 Cases. This paper claimed a high sensitivity for the detection of the diagnosis coronavirus compared to PCR. Admitting physicians quoted it and demanded to get CT scans on their patients with presumed Covid-19. ER doctors were ordering Chest CT scans left and right.

What happened next? The throughput of patients slowed down to a crawl because the CT scanner needed special cleaning for potential Covid-19 contamination. Subsequently, this thorough cleaning delayed the treatment of patients. And, the CT scanner was out of commission for other patients that needed the CT scan for emergency workups.

Was it the right to use this paper to dictate the workup of patients? In hindsight, no. And, it brings up an all too common issue, the usage of case studies to dictate health care policy. So, what are the other factors that we need to evaluate before we decide to take a paper and apply it to patient care? Well, I will use this incident as a way to show you what you need to think about before using case studies to guide patient imaging. Let’s divide it into the following categories: practicality, throughput, exposure, and change in management.

Practicality- It’s Not All About Sensitivity Or Specificity

I don’t know about you. But, whenever I hear a test is highly sensitive or specific for a disease entity, I get excited. My first thought is usually, maybe we can use this exam to diagnosis patients? However, before arriving at that conclusion, we need to take a step back. Does the test make sense in the context of patients coming into the emergency department? Many clinicians did not think about these issues when they decided to utilize a CT scan to image presumptive Covid-19 patients. Just because you can make a diagnosis does not mean that you should complete a test.

Throughput is Important

A test is only useful when it can rapidly diagnose patients. In the case of CT scans for the diagnosis of Covid-19 patients, regardless of any other factor, our throughput for patient care significantly slowed down. And, this had a dramatic effect upon the patients that came into the Emergency Department for many other reasons. Always, physicians need to take this factor into account before jumping into ordering a test.

Exposure To Health Care Workers And Patients

We need to take care of all the folks that are providing services for the sick and infirm. If we do not perform this duty, we will have no health care workers to treat patients. In this situation, deep cleaning the CT scanner after each patient added undue risk to the technologists and nurses that completed these functions. Not to mention, you are also increasing the possibility of exposure to the next patient in the CT scanner. The upshot was a tremendous cost to the patients and employees.

Does It Change Management?

And, then finally, the most critical question that we need to ask ourselves is how does the test change management? In the case of Covid-19, a negative test did not preclude the possibility of the disease. So, regardless of the test outcome, the clinicians would need to use their clinical intuition to decide if they need to ventilate the patient or other invasive measures. Moreover, the treatment of the patient would remain the same, whether the CT was positive or negative. Why submit a patient to such a test?

Beware The Dangers of Using Small Case Studies To Dictate Policy!

We all need to take a step back when we hear the claims of physicians that we should be imaging a patient based on a paper. Instead, you should be answering the following questions: Is it practical? Will it prevent other patients from receiving appropriate testing? Will it endanger my staff and patients? And, does it change the management of the patient’s case? If the case studies can pass these tests, consider using it as a tool. If not, beware of imaging the patient based on a paper, the test may do more harm than good!