Month: May 2020

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Will There Be A Mass Exodus Of Radiologists From The Cities?

mass exodus

Look through the newspapers, and you will most likely find articles espousing a mass exodus of urban residents moving to less crowded communities during the pandemic. And at first glance, it makes some sense. Local governments have banned bars, movies, exercise facilities, and more in the Covid era. Moreover, there are always close quarters, more prevalent in a city, which increase the risk of disease spread in the pandemic. So, why would anyone want to move to the city when finishing residency? It makes you think that new radiologists will permanently shun the cities.

But, are there other factors that may influence radiologists to choose a location to work over the coming years? Are they increasingly going to opt for a more simple life in rural America over the years to come? Let’s go through the motivations for young radiologists to stay or leave the urban landscape. Then, we will decide how it will all play out in the end.

Reasons For A Mass Exodus Of Radiologists From The Cities

Increased Fear of Close Interactions

Knowing that a highly infectious and potentially lethal disease can spread by respiratory droplets, definitely changes how you think about taking the subway, walking the streets, and assembling with groups of friends. But will it stick over the long run? We will see a slight shift in how we feel about living in the cities for years to come.

More Difficulties Raising A Family

All the challenges of living multiply in a large urban center when you have children as well. Imagine the issues that urban families face when they have to find day-care, nannies, and school with the added problems of a pandemic at hand. Of course, this factor will most certainly lessen the charms of living in a large city.

Culture Shifts

We learn many of our habits, wants, and “needs” from our colleagues and friends. The mere suggestion of your friends hinting that they no longer wish to live in a city to work can influence your choices of where you will want to settle down. So, new residents will more apt to move where their colleagues also want to go. This attitude can also persist over a long time.

Reasons For Radiologists To Stay

Pay

Typically, when you are on the side of an employer, the harder it becomes to find employees, the more you need to pay to get excellent workers. Theoretically, for this reason, you may begin to see better jobs and higher incomes in the city than before. Of course, with the massive student debt burdens, this can somewhat counteract the perceived threats of urban living in the Covid era.

Housing Costs

With a shift of young adults moving to the suburbs and the more rural areas, you will decrease rental and, eventually, housing prices. If you reduce one of the most significant expenses that young families have when they start, you make it more attractive to the new employees, such as radiologists. Cities may become more attractive in this sense.

The Wild Card

Historically speaking, people have a short term memory when it comes to disasters. Look at the population of Manhattan after the twin towers fell. It didn’t take long for the citizens of New York to want to return to urban living. Or, look at the population of Nagasaki in Japan. At the time of the nuclear bomb, the number of residents was 263,000. Yet, today it has almost doubled at over 513,000. Finally, take the populations of most cities before and after the 1918 pandemic. Most recovered. So, the temporary cultural shifts that have occurred with previous disasters do not necessarily cause long term population shifts.

So, Will There Be A Mass Exodus From The Cities?

Well, it is true. Young radiologists will present with unique challenges if they choose to stick around in the cities for the next year or two. Additionally, pay, and housing costs will take some time to catch up to the new marketplace. So, some new radiologists will opt to live in more rural areas than would have previously.

But, this attitude will not last forever. The economics will eventually catch up. And, the culture will shift, once a vaccine becomes widely available. Based on these factors and history, radiologists will soon forget about the hazards of city life. So, don’t expect to see the competition for rural jobs to increase that much. The long term trends do not favor a seismic shift in deciding where to work and live. Logic dictates that you need to take reactive newspaper articles exclaiming a permanent mass exodus from the cities with a grain of salt!

 

 

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The Best Radiology Subspecialties To Retire Early!

retire early

For some residents and radiologists, radiology is a calling. And, for those folks, retirement is the last thought on your mind. But, for others, it is just a job. And I get both points of view. But, regardless of which camp you are in, many of us have other hobbies and second careers that we would like to accomplish before it is too late. And, radiology has been an excellent medical specialty so that you can retire early.

So, let’s try to figure out from two different perspectives, early partial retirement or full retirement, which subspecialties within radiology are the best. Why? Although it is possible to partially or fully retire from any radiology subspecialty, certain ones lend themselves to early partial or full retirement more than others. And, many of you are trying to figure out which specialty to choose for your future career. So, after hours of deliberation, let me give you my clear winners in both departments. If you are on the fence, maybe, I can sway you in one direction or the other!

Best Radiology Subspecialty For Early Partial Retirement

So, you are considering coming into work two to three days a week later on in your career. And, you still like practicing radiology. It might not be so bad to have four or five day weekends every week, right? Here is the specialty I chose that is most conducive to this path and why.

General Radiology/Body Imaging

I believe there is one clear winner for this category. If you had to pick one subspecialty that would most likely keep you in the game, even at an older age, it would have to be general radiology/body imaging. And, this choice may be in contrast to what others may tell you. But, radiologists that are general imagers tend to have the most extensive array of experiences and training. So, this training allows them to continue practicing radiology at a high level, even at a ripe old age. And, you are less likely to become an anachronism when you have many skills. If one imaging modality goes out of style(i.e., pnemocephalography!), you have many others to bank on.

Best Radiology Subspecialty for Early Full Retirement

In this pathway, the goal is to make as much money as quickly as possible. Then, you can pack it away so that you can do whatever else you want at a spry young age! Here is the subspecialty I believe is most favorable to this track.

Neurointerventional Radiology

Sure, this field can be a pressure cooker. And, it is not for the faint of heart. Clinicians will wake you up late at night to perform critical procedures on their patients. However, you are more likely to command top dollar for your services when you are actively practicing. And, while in practice, you will become difficult to replace. Of course, this will allow you to take that money and funnel it into retirement as soon as possible!

To Retire Early Isn’t Everything!

Now, most of you are going into radiology, not to retire early, but to have an exciting and fruitful career. However, it is nice to know that if you tire from the day-to-day work, and want something else out of life, you can. So, go into a particular subspecialty not to retire, but for what interests you the most. And, if you are not sure which subspecialty to pick, maybe these ideas will persuade you!

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How To Decrease Radiologist Hospital Presence Without Jeopardizing Care

jeopardizing care

For years, the mantra of quality radiology groups was to provide excellent service. And that would involve establishing a presence at all times. But, like many other former tenets of radiology practices, Covid has been turning over many assumptions about our work. Now that we have a situation where physical presence in the hospital can jeopardize radiologist safety, radiology groups have been decreasing their in-hospital staffing. However, potentially reducing staffing can increase patient barriers to quality care. So this begs the question, how are radiologists replacing physical presence in the radiology department without jeopardizing care? I am going to talk about how many groups are going about this process. Then, let’s discuss the reasons why some radiologists will always still need to remain on-site. Finally, we will use a crystal ball and decide where this is all heading.

Ways Radiologists Are Decreasing Physical Presence Without Jeopardizing Care

Less Physical Patient Facetime And More Apple Facetime!

Interventionalists and mammographers, if they haven’t already, will followup patients without an on-site visit. We see even more utilization of online communications via Zoom, Google Meet, Facetime, and whatever other technology rears its head. It also enables radiologists to maintain efficiency and have office hours between reading films at home.

Increased Ordering Of Hands-off Testing

We are noticing an increase in those tests that do not involve a radiologist presence. For instance, if a mammographer cannot be on the site to see patients, instead of a hands-on ultrasound for a positive mammographic finding, he may recommend a breast MRI. Or, radiologists will be more apt to followup findings when they may have suggested a physical procedure such as a biopsy in the past. All these changes are presently occurring below the surface, but they are happening.

Replacing In-Person Interaction With Referring Clinicians

Since the advent of PACS, most radiologists have already noticed a steady decline in direct physical interactions with their clinicians. Surgeons and internal medicine physicians come down much less frequently to review films than ever. And, today’s pandemic is further catalyzing this change. We are seeing even fewer of our colleagues and having more phone interactions than ever before. Even extracurricular activities with our fellow physicians are decreasing. Hospital meetings are becoming online.

More Tech Issues Resolved Remotely

Many radiologists are increasing the physical barriers between the technologist and the radiologist. In the past, radiologists would often ask a question from their technologist, and she would stop by. No longer. Radiologists are tackling these same issues with a phone call or a text. It has become less feasible to have that direct physical technologist interaction.

More Remote Teaching For Residents

And, finally, training is not immune to the Covid world. Already, online seminars have replaced in-house lectures at most training programs throughout the country.  And, I would not expect that to go back to the traditional in-person norm entirely. It becomes more accessible than ever before to teach from a remote site.

So, What’s Left For The Radiologist To Do At The Hospital?

Alright, even with all these factors allowing radiologists to practice off-site, some radiologists must remain as a physical presence in the hospital. Of course, some procedures will always involve a human being. Administration of radioactive treatments, interventional procedures, and emergency coverage for contrast injections will continue to require a radiologist on-site. But, compared to all the roles a radiologist can perform off-site, it is indeed limited. Don’t expect to see as many radiologists sticking around the treatment facilities as they did before. Many practices have reduced their on-site staffing by as much as 30-70% during this crisis.

How Will Radiologist’s Presence At The Hospital Ultimately Evolve?

Many changes are currently in motion, making it even easier to perform more activities outside the confines of a typical hospital or imaging center without jeopardizing care. And, facetime, ordering preference changes, and other remote capabilities are some ways that radiologists have been decreasing physical presence at primary sites. In time, we may begin to see some return of radiologists back to the hospital as the risks to radiologists dwindle. Nevertheless, don’t expect radiologists to return to the same complement on-site after the dust settles as the tools for remote patient care have developed. When culture changes, even temporarily, some of it always sticks. Radiologists are by no means immune!

 

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Colleague Recommendation: Can I Use It?

colleague's recommendations

Colleague Recommendation Question

 

Dear Dr. Julius,
Thank you for your tutelage via your blogs. Thank you for all that you do. It is truly inspiring and also hard work to maintain a (very current) blog despite your busy schedule!

I am a Canadian IMG (which counts as a foreign IMG), and I’d like to apply to Radiology in the States. I am currently M3 and doing my core rotations in the US. My step1 score was only 215, NOT stellar. My only redeeming quality is that I had worked in radiology for ten years before I entered medical school, and I was department head for three years. My question is: If I get a Letter of Rec. (LOR) from a Canadian radiologist with whom I’ve worked, would that be a faux-pas? Instead, I would much rather send out a LOR from a referee who has known me and seen me work for 4-5 years than a LOR from a 4-week elective rotation. Given ERAS takes up to 4 letters, do you recommend I include a Canadian letter from a Canadian radiologist who has known me well?

Oh, and if the score of 215 is too low, then forget all that I’ve asked above (haha), but I heard they are doing away with Step1 scores in 2022, and that is when I will be matching!
Thank you!

Answer:

I appreciate the kind words! But, in terms of your questions about which radiology recommendations to choose, I think that a colleague reference from someone who knows you well from work can be an effective letter of recommendation if she writes it well. Who better to see your work ethic than those with which you work?  There is no harm in doing so. You are in a much different situation than a medical student or resident who receives another reference from a colleague of the same level. In those instances, how could a fellow trainee honestly evaluate you? Usually, getting a recommendation like those would be a faux pas. (But that does not apply to you!)

Remember, all letters of recommendation have a bias. So, having one letter with a bias toward you from your former job makes sense. Also, as you mentioned, I would send this in addition to the letters that you would typically get for ERAS. It should not be your only stand-alone recommendation.

In terms of scores, make sure that you try to do well on Step II instead. They will be using this score for assessment of your test-taking skills instead of Step I when Step I board scores are no longer used in 2022.

Hope that helps,
Barry Julius, MD

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Considering An MBA: When Is The Right Time?

MBA

Recently, one of my residents asked an excellent question about both whether to pursue an MBA and the timing of getting one. And, I have a sneaking suspicion that many other radiology residents and radiologists have been taking an interest in starting MBAs with all that has been happening in healthcare lately. So, let’s talk about how and why an MBA can be useful. And, then we’ll talk a bit about the timing and the advantages/disadvantages of each.

Why Get An MBA?

First of all, how can an MBA help a radiologist’s career? Well, if you think about it, radiologists have so many years of training (counting college, we are talking typically 14 years of post-high school education)! But, in the entire 14 years of schooling, many radiologists have not had a lick of financial or management training whatsoever. Hell, I know of a few radiologists that can barely balance their budget! Additionally, many of these folks aspire to practice outside the typical clinical confines of radiology. Some may want to take up hospital or practice administration.

Then, when you look you check out the literature on those hospitals that are most successful, you will find that physicians typically run these health care enterprises. So, an MBA may be of great benefit to those of you who want to take this pathway. Take a look at these links supporting these claims here:

https://www.kevinmd.com/blog/2018/08/5-reasons-you-should-put-physicians-in-charge-of-hospitals.html 
https://hbr.org/2016/12/why-the-best-hospitals-are-managed-by-doctors

So, if you want to run a tight ship and get into hospital administration, you, as a radiologist or radiologist-in-training, are well-positioned to be successful with the right financial/management education. And, for those of you in this boat, an MBA can make a lot of sense. Just make sure that you are doing it for the right reasons. At some point, the current pandemic will end, and we will return to a state of more normalcy. Don’t make your decision to choose an MBA only on the current poor radiologist job market!

MBA Before, During, Or After Fellowship?

So, all of this talk begs the question, when should you get an MBA? This part of the equation is a bit harder to answer, but I will give you my thoughts about the advantages/disadvantages of each.

Before Fellowship?

I like to consider this pathway, the path of least resistance. By far, logistically speaking, it is the easiest route to take. You are already training in medical school, and many programs offer MD/MBA pathways during their stay. What’s another year of education when you are already paying for your training, right?

However, I have witnessed many residents having pursued this extra degree before entering our program. And, a good chunk of these folks has no interest in utilizing their education toward the goal of healthcare management and practice finance. Although some may take a few nuggets from their MBA training with them into practice, the return on investment can be small.  Why? Because they never created an action plan on how to use this degree.  An MBA is only worth the time and money if you know what to do with it. And, herein lies the most significant disadvantage of completing an MBA early on in your training.

Instead Of A Fellowship

Out of all the ways you can complete an MBA, this pathway is the rarest. And I don’t know any radiologists in my program who have completed an MBA instead of a fellowship. For most of you, it is a difficult time to complete an MBA. First of all, your accumulated debt upon graduating residency often feels like a gazillion dollars. Then, of course, most of you are ready to embark on your career as a radiologist after all the training that you have completed.

In terms of timing, if you did not have to worry about money or the time it takes to complete while having to pay loans, it may make some sense. By this point, you have a better idea of your career goals. And, you can better focus on the goals that you want to achieve when you complete your MBA. However, many of you, by this time, still have not had the working experience to utilize your MBA teachings fully.

After Fellowship

Finally, in terms of convenience, completing an MBA while working is probably the most disruptive. Now, many of you have families and lifestyles that are less conducive to completing another degree. But there are courses and university programs that are willing to work within the confines of your life. These programs are often called executive MBAs and allow you to finish the degree while working. I know of several radiologists that have taken this pathway. Of course, you can also opt for a more traditional 2-year degree.

For those of you that complete an MBA after your fellowship, you most likely have a laser-focused reason for completing an MBA. Maybe, you know that the leadership of your practice may need a new change and wants someone with business experience. Or, perhaps you want to begin working for hospital administration at an available position. At this point, an MBA is usually the most meaningful since you most likely have a targeted application for the degree.

Considering A Business Degree? Taking It All Into Consideration

Well, for those of you mulling the MBA route, all this information is a lot to think about. But think of the MBA as a tool. If you utilize your degree for the right reasons, it can pay off “big-time.” It will allow you to pursue your selected area and have the knowledge to do so. On the other hand, a poorly thought out mission to complete this degree can lead to becoming cash poor with little to show for it. So, be careful choosing this pathway and when you decide to pursue this degree. And, don’t let the Covid pandemic be your only guide!

 

 

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Not A Good Test Taker! Can I Make It Through Radiology Residency?

test taker

Question:

Current radiology resident, just finishing up the intern year, with concerns whether I’m cut out for this. I was a miracle match: Low MCAT scores. Pretty much barely passed all shelf exams. I’m not a good test taker.

Am I smart enough to be doing this, or am I kidding myself? If I fail this crazy 80% pass rate core exam, will they fire me? And then what will I do?

Any advice, uplifting stories, anything would be appreciated. Should I transfer out now? Or, should I stick it out and see if I can pull out another miracle? I don’t want to ruin my life here.

Help!

 

Answer:

First of all, you need to separate the following two issues, being a good radiologist and being a good test taker. I know of excellent radiologists who have had to take the core exam or the oral boards with multiple attempts to pass. So, don’t confuse taking tests with being “smart.” It is an entirely distinct skill from working as a radiologist. Moreover, don’t count yourself out. You may find that you are a better test taker than you think when you study material that is more relevant to your future career. You never know; maybe you’ll even pass on the first attempt.

 

Also, no program should fire you for failing a core examination if you are a good resident. Residencies should be looking at other characteristics other than the core exam and test-taking skills to assess their residents. If you do well in your residency, it should go noticed by your program directors and faculty regardless of your testing scores. No one test will ever be the judge of your abilities. And, if needed, you can retake the exam until you finally pass.

 

Finally, I don’t think you need another miracle. You have already accomplished a challenging feat, getting into a radiology residency program. It will just take a bit of hard work, grit, and determination over the next four years to do a good job and get to the next phase of your career!
Regards,
Barry Julius, MD
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No Longer Practicing Radiology During The Covid Crisis? How To Keep Up!

practicing radiology

Many hospitals and imaging centers throughout the country have recruited radiology residents to help out with the Covid crisis. But that leaves many of these residents in a bind. Some residents may feel that they may be losing some of their hard-learned skills. And many have not had time practicing radiology, the main point of completing their residency. So, I am going to outline some steps to make the next several months more relevant to your training. I will do this by going through each residency year and what you should do to keep up your skills. And, I will divide what residents should into First Years, Second and Third Years, and Fourth Years as each of these groups are in different boats.

First Years

For many first years, you are probably not getting the same case experience as you did before. However, for those of you lucky to have some extra time outside of an ICU rotation, I would go through essential books in each subspecialty section. You will find some ideas for books that you may want to read through in my books and links section of this website. (as recommended by my residents) Make sure to read through some of the recommended reading materials at home, now that you may have more time (or even if you don’t!) The key to a successful first year is reading as a basis for the rest of your residency. Don’t squander this opportunity.

Also, if you are interested in interventional radiology, I would recommend participating in some of the procedures that a clinical rotation like the ICU may offer. Volunteer for lumbar punctures, central venous lines, and paracenteses, if possible. These are some procedures that overlap with radiology and will help to maintain what you have learned.

Second And Third Years

Second and third years are years to practice and learn the art of Radiology. So, in addition to reading like the first years.  I would make sure to emphasize radiology cases over only reading raw reading materials/textbooks. So, make sure to go through the case series. Also, when you have the chance, go to the PACS systems and review older cases from the year in different subspecialties, now that some of the regular imaging volumes have dried up. For instance, pick up some of the earlier MSK MRI and make your interpretations and match them up with the final dictations. This action will help to keep your skills and search patterns fresh in your mind since many elective sorts of cases have probably dried up a bit.

Also, even though the ABR has delayed the core examination, it is likely at the forefront of your mind. Make sure to continue to review test questions from sources like RadPrimer and others. (Check out a great post called Up To Date Book Reviews For The Radiology Core Examination from a former resident for some ideas) You certainly want to reinforce this information when you do take the test. Rinse and repeat as much as you can.

Fourth Years

Finally, we need to talk about the fourth year separately. Fourth-year is the best time to learn practical radiology. So, during this time, you should be reviewing areas of practice that you may feel less comfortable with. Especially now, more than ever, I would recommend doing this since the job market will most likely be changing. (Check out my recent post What’s In The Cards For The New Radiologist Job Market After Covid?). So, make sure to read cases in your weaker subspecialties to keep up or learn new imaging skills. (PACS is a godsend!) You may be using some of these skills at your next job!

Keep Practicing Radiology Skills: You Have Worked Too Hard To Lose Them!

Just because some of your radiology training has been canceled does not mean that you should stop practicing radiology. Now, more than ever, you should be making a concerted effort to hone your skills. Whether you are just starting as a first-year radiology resident and need the basics, or if you need more practical training in your final year, allowing your reading and procedural abilities to slip away would be a shame. Reading books and reviewing cases on PACS now is vital. Even though you may be busy outside of radiology with Covid patients, make a concerted effort to stay in the game. Don’t lose your hard-earned skills!

 

 

 

 

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