Month: August 2021

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How Much Headstart To Retirement Do Radiology Residents Without Student Loans Get?

headstart

Due to my fascination with this topic and the bewildering debt of new residents, I wondered how much headstart you would get to accumulate five million dollars if you had no student loans vs. substantial student loans. So, I have decided to use the following numbers for student loan debt- 0 dollars (paid for by a rich Mom and Dad) or 500,000 (private schools, no help, or excessive spending). 

This time around, we will make the following assumptions: Either you will live in a relatively low-cost-of-living area and have a decent attending lifestyle or live in a relatively high-cost-of-living location with a proper attending lifestyle. I chose these assumptions because they are within reason for many residents. Of course, you can live with more or fewer expenses, but this will have a significant impact on the outcomes.

Also, we will have you save for college for two kids (twins), starting as an attending on day one. We are using the magical five million dollar amount because it is the amount that studies like Medscape’s annual net worth survey use for a reasonable retirement amount. We will calculate everything for inflation using that 3 percent inflation rate. Again, based on the survey, this will be a one-income family with an average radiologist salary of 413,000 dollars. Go directly to the end of the blog to check out the final numbers and conclusion!

Low Cost Of Living Area With Student Loans Of Five Hundred Thousand Dollars

Low cost of living areas with significant student debt

Additional numbers for this assumption:

  1. The house will cost 500,000 with a down payment of 100,000, saved over your first five years of working. (20,000 dollars saved per year)
  2. You will pay off student debt over ten years at an interest rate of 4 percent (5062 dollars per month*12 months)= 60744 per year.
  3. Practice puts away 30,000 dollars, including a match, into your 401k starting 1st year.
  4. Investment rate of return 8%
  5. Federal Income Taxes after deduction will be 76182 dollars per year based on an internet calculator.
  6. State Income Taxes are 0 dollars.
  7. You have twins beginning at the of your attending work and are putting away 556 dollars per month per kid to get to 250,000 dollars at age 18. (13,344 dollars per year)
  8. Rental of a three-bedroom house for five years at 2500 dollars per month

First five years

Total Salary 413000

Expenses

401k: 30,000 (383000 left)

Taxes: 76182 (Federal) + 0 (State) (306818 left)

Loan payments and house savings and children 529 plan: 60744 (student loans) + 20,000 (house down payment) + 13,344 (529 plan) (212730 left)

Rental/heating/electricity  30000  (182730 left)

Subtracting food for family 10000 (172730 left)

Transportation expenses for two cars/insurance 10000 (162370 left)

Vacations 10,000 dollars (152370 left)

Computers/Cellphones/Electronics/Cable Bill 3600  (148770 left)

Preschool/Day Care Expenses for two kids 24,000 (124770 left)

Clothes 5ooo dollars (119770 left)

Life and Disability Insurance  9600 (110170 left)

Dues and License and CME 5000 (105170 left)

Miscellaneous Entertainment  10,000 (95170 left)

Saved

Remaining available to save around 95170 per year (not including 401k)

30,000 dollars in 401k

Assuming an 8% rate of return on 125170 over five years- 734334 dollars in savings

Following five years (Own house)

Expenses

401k: 30,000 (383000 left)

Taxes: 76182 (Federal) + 0 (State) (306818 left)

Loan payments and house savings and children 529 plan: 60744 (student loans)  + 13,344 (529 plan) (232730 left)

Salary after mortgage payments and taxes (400,000 mortgage -30 year fixed at 3.5 percent 1796*12 (211178 left)

Salary after property taxes and insurance 12000 (199178 left)

Home maintenance= 5000 (194178 left)

Subtracting food for family 10000 (184178 left)

Transportation expenses two cars/insurance 10000 (174178 left)

Vacations 10,000 dollars (164178 left)

Computers/Cellphones/Electronics/Cable Bill 3600 (160578 left)

Education and Expenses for two kids 12,000 x2 (136578 left)

Clothes 5000 dollars  (131578 left)

Life and Disability Insurance 9600 dollars (121978 left)

Dues and License and CME 5000 dollars  (116978 left)

Miscellaneous Entertainment  10000 (106978 left)

Saved

Remaining available to save around 106978 per year (not including 401k)

30,000 dollars in 401k

Assuming an 8% rate of return on 136978  over five years +734334 in savings= 1882500 dollars

Following eight years (Student Loans Paid Off)

Savings After Expenses

Savings now 106978+60744 +30000 (401k)=197722 dollars per year

Assuming an 8% rate of return on 197722 over eight years +1882500 in savings= 5587000 dollars or 3428000 in today’s dollars

Next 5 Years (No More 529 plans)

Savings now 197722+13344= 211066 per year.

Assuming an 8% rate of return on 211066 over five years +5587000 in savings= 9447000 dollars or 4786000 in today’s dollars with 3 percent inflation

Following ten years (No More Kid Expenses)- if you were to go past 5,000,000 dollars

Saving now: 211066 +24000= 235066 dollars per year

Assuming an 8% rate of return on 235066 over ten years +9447000 in savings= 23802000 dollars or approximately 9.0 million in today’s dollars with 3 percent inflation

 

Changed Assumption: No Student Loans In Low Cost Of Living Area: How Much Headstart?

First five years:

Savings: 125170+60744 (headstart without loan)= 185914 per year

Assuming an 8% rate of return on 185914 over five years- 1090000 dollars in savings

Following five years (Own Home)

Savings: 136978+60744=197722

Assuming an 8% rate of return on 197722  over five years +1090000 in savings= 2762000 dollars

Next eight years

Savings= 197722

Assuming an 8% rate of return on 197722  over five years +1090000 in savings= 7215000 dollars or approximately 4.23 million in today’s dollars with 3 percent inflation

Next 5 Years (No More 529 plans)

Savings now 197722+13344= 211066 per year.

Assuming an 8% rate of return on 2110666  over five years +7215000 in savings= 11840000 dollars or approximately 5.99 million in today’s dollars with 3 percent inflation

Following ten years (No More Kid Expenses)- if you were to go past 5,000,000 dollars

Saving now: 211066 +24000= 235066 dollars per year

Assuming an 8% rate of return on 235066 over ten years +11840000 in savings= 28960000 dollars or approximately 11.9 million in today’s dollars with 3 percent inflation

 

High Cost Of Living Area With Student Debt Of Five Hundred Thousand Dollars

High cost of living areas with significant student debt (500,000)

Additional numbers for this assumption:

  1. The house will cost 1,000,000 with a down payment of 200,000, saved over your first five years of working. (40,000 dollars saved per year)
  2. Student debt will be paid off over ten years (4049 dollars per month* 12 months), or 48,588 per year.
  3. Practice puts away 30,000 dollars, including match, into your 401k starting 1st year.
  4. Investment rate of return 8%
  5. Federal Income Taxes after deduction will be 76182 dollars per year based on an internet calculator.
  6. State Income Taxes will be around 6 percent or (413,000*0.06)=24,780 dollars.
  7. You have twins beginning at the of your attending work and are putting away 556 dollars per month per kid to get to 250,000 dollars at age 18. (13,344 dollars per year)
  8. Rental of a three-bedroom house for five years at 4000 dollars per month

 

First five years

Total Salary 413000

Expenses

401k: 30,000 (383000 left)

Taxes: 76182 (Federal) + 20290 (State) (286528 left)

Loan payments and house savings and children 529 plan: 60744 (student loans) + 40,000 (house down payment) + 13,344 (529 plan) (172440 left)

Rental/heating/electricity  48,000  (124440 left)

Subtracting food for family 10000 (114440 left)

Transportation expenses for two cars/insurance 10000 (104440 left)

Vacations 10,000 dollars (94440 left)

Computers/Cellphones/Electronics/Cable Bill 3600  (90840 left)

Preschool/Day Care Expenses for two kids 24,000 (66840 left)

Clothes 5ooo dollars (61840 left)

Life and Disability Insurance  9600 (52240 left)

Dues and License and CME 5000 (47240 left)

Miscellaneous Entertainment  10,000 (37240 left)

Saved

Remaining available to save around 37240 per year (not including 401k)

30,000 dollars in 401k

Assuming an 8% rate of return on 67240 over five years- 394446 dollars in savings

Following five years (Own house)

Expenses

401k: 30,000 (383000 left)

Taxes: 76182 (Federal) + 20290 (State) (286528 left)

Loan payments and house savings and children 529 plan: 60744 (student loans)  + 13,344 (529 plan) (212440left)

Salary after mortgage payments and taxes (800,000 mortgage -30 year fixed at 3.5 percent 3592*12 (169336 left)

Salary after property taxes and insurance 14,400 (154936 left)

Home maintenance= 10000 (144936 left)

Subtracting food for family 10000 (134936 left)

Transportation expenses for two cars/insurance 10000 (124936 left)

Vacations 10,000 dollars (114936 left)

Computers/Cellphones/Electronics/Cable Bill 3600 (111336 left)

Education and Expenses for two kids 12,000 x2 (87336 left)

Clothes 5000 dollars  (82336 left)

Life and Disability Insurance 9600 dollars (72376 left)

Dues and License and CME (5000 dollars per year)= 67376 left

Miscellaneous Entertainment (10000 dollars per year)=57376 dollars

Saved

Remaining available to save around 57376 per year (not including 401k)

30,000 dollars in 401k

Assuming an 8% rate of return on 87376  over five years +394446 in savings= 1092000 dollars

Following eight years (Student Loans Paid Off)

Savings After Expenses

Savings now 57376+60744 +30000 (401k)=148120 per year

Assuming an 8% rate of return on 108480 over eight years +109200 in savings= 3596000 dollars

Next 5 Years (No More 529 plans)

Savings now 148120+13344= 159454 per year.

Assuming an 8% rate of return on 121824 over five years +3596000 in savings= 6220000 dollars or 3155000 in today’s dollars with 3 percent inflation

Following ten years (No More Kid Expenses)

Saving now: 159454+24000= 183454 dollars per year

Assuming an 8% rate of return on 145824 over ten years +5428000 in savings= 16080000 dollars or approximately 6.06 million in today’s dollars with 3 percent inflation

 

Changed Assumption: No Student Loans In High Cost Of Living Are: How Much Headstart?

First five years:

Savings: 67240+60744 (headstart without loans)= 127984 per year

Assuming an 8% rate of return on 127984 over five years- 751000 dollars in savings

Following five years (Own Home)

Savings: 87376+60744=148120

Assuming an 8% rate of return on 148120  over five years +751000 in savings= 1971000 dollars

Next eight years

Savings= 148120

Assuming an 8% rate of return on 148120  over eight years +1971000 in savings= 5223000 dollars or approximately 3.07 million in today’s dollars with 3 percent inflation

Next 5 Years (No More 529 plans)

Savings now 148120+13344= 161464 per year.

Assuming an 8% rate of return on 161464  over five years +5.223 million in savings= 8.622 million dollars or approximately 4.37 million in today’s dollars with 3 percent inflation

Following ten years (No More Kid Expenses)- if you were to go past 5,000,000 dollars

Saving now: 161464 +24000= 185464 dollars per year

Assuming an 8% rate of return on 235066 over ten years +8.622 million dollars in savings= 21.3 million dollars or approximately 8.03 million in today’s dollars with 3 percent inflation

The Final Numbers (How Much Headstart Will You Get?):

Low Cost of Living Area and High Student Loans: After 23 years, you have saved 4.78 million dollars in today’s dollars. After 33 years: 9 million dollars in today’s dollars

Low Cost of Living Area and No Student Loans (Headstart): After 23 years, 5.99 million saved in today’s dollars. After 33 years: 11.9 million dollars in today’s dollars

High Cost of Living Area and Student Loans: After 23 years, you have saved 3.15 million dollars in today’s dollars. After 33 years: 5.42 million dollars in today’s dollars

High Cost of Living Area and No Student Loans (Headstart): After 23 years, you have saved 4.37 million in today’s dollars. After 33 years: 8.03 million dollars in today’s dollars

Does Student Debt Prevent A Reasonable Retirement?

In a high-cost-of-living area and with lots of student loans, you will need a long career, over 30-something years, to accumulate that mythical number of 5 million dollars. But, if you have no student loans and live the same way, you will have a headstart of less than ten years of working if you desire to retire earlier. On the other hand, those with high student loans and who live in a low-cost-of-living area can reach that mythical number of 5 million dollars around the twenty-something-year mark.

You may want to work for an entire thirty-something-year career. And, of course, you may not want to live to save money. Also, there are lots of factors that should go into where you should live. But, for those of you with lots of debt, the debt will significantly impact the number of years you will need to work to accumulate your desired nest egg. Without that student debt, you may have a headstart and more flexibility in your decisions. Just something to consider!

 

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Will I Be Able To Save Five Million Dollars As A Radiologist With Large Student Loans?

five million

There is something mythical about the number five million dollars. Medscape’s annual net worth survey for physicians uses that barrier as one of the leading wealth accumulation goalposts for their survey and has been doing so for years. The media has created a monicker that they love to use as well called pentamillionaire. And, it is a number that makes sense for those of you that eventually want to retire in today’s dollars.

Imagine. You can reasonably safely withdraw 4 percent of five million dollars per year and have an income of about two hundred thousand dollars while still allowing for capital appreciation. It may not be a king’s ransom in some parts of the country. (California, New York) But, it is undoubtedly a decent nest egg that can allow most folks the ability to live out their years comfortably. This five million dollar number most likely seems very large to those of you in residency that live frugally off of much smaller dollar amounts. But, believe it or not, it will all seem like a lot less when you live like an attending. 

Additionally, inflation will most likely eat into the principal of this dollar amount so that we will account for inflation on that five million dollars in today’s dollars. We will assume an inflation rate of 3 percent to be conservative.

Is It Even Possible To Achieve Five Million Dollars With High Debt Loads On One Radiologist Income?

So, I ask: Is it even possible to save this much with all the student debt you have accumulated and salaries that may not keep up with inflation? Let’s do the calculations for two sorts of residents: Those of you who decide to live in high cost of living areas with significant student debt; those who choose to live in low cost of living areas with considerable student debt. You can skip to the bottom if you want to see the final results. Or, you can peruse all the nitty-gritty details if you are so inclined.

Assumptions For Accumulating Five Million Dollars

We will assume in all cases that you have higher than average debt (400,000 dollars) when you finish residency, that you have a family of four, with a spouse that is taking care of the kids and is not working. We will assume that you want to buy a decent size four-bedroom house in a nice area. Let’s also start with the assumption that you will male the mean income for a radiologist based on the 2021 Medscape compensation survey (413,000). Of course, you can make more or less depending on the practice. But, for simplicity’s sake, we will use this number.

Then we will assume that on average inflation rate is around 3 percent, with a worst-case scenario of radiology salaries that are relatively stagnant due to declining reimbursements. And, we will assume an interest rate on student loans of 4 percent. Finally, we will take that you will put aside a nice chunk of change for each of your kids to go to college (250,000 dollars). Of course, I want to make these circumstances as if you live like an attending instead of a resident. And, then we will go through how long it may take you to accumulate this amount of wealth given your circumstances as a radiologist.

High cost of living areas with significant student debt

Additional numbers for this assumption:

  1. House will cost 1,000,000 dollars with a down payment of 200,000 dollars, saved over your first 5 years of working. (40,000 dollars saved per year)
  2. Student debt will be paid off over 10 years (4049 dollars per month*12 months)= 48,588 per year
  3. Practice puts away 30,000 dollars including match into your 401k starting 1st year
  4. Investment rate of return 8%
  5. Federal Income Taxes after deduction will be 76182 dollars per year based on a calculator
  6. State Income Taxes will be around 6 percent or (413,000*0.06)=24,780 dollars
  7. You have twins beginning at the of your attending work and are putting away 556 dollars per month per kid to get to 250,000 dollars at age 18. (13,344 dollars per year)
  8. Rental of a 3 bedroom house for 5 years at 4000 dollars per month

First 5 years

Total Salary 413000

Expenses

401k: 30,000 (383000 left)

Taxes : 76182 (Federal) + 20290 (State) (286528 left)

Loan payments and house savings and children 529 plan: 48,588 (student loans) + 40,000 (house down payment) + 13,344 (529 plan) (184596 left)

Rental/heating/electricity  48,000  (136596 left)

Subtracting food for family 10000 (126596 left)

Transportation expenses 2 cars/insurance 10000 (116596 left)

Vacations 10,000 dollars (106596 left)

Computers/Cellphones/Electronics/Cable Bill 3600  (102996 left)

Preschool/Day Care Expenses for two kids 24,000 (78996 left)

Clothes 5ooo dollars (73996 left)

Life and Disability Insurance  9600 (64396 left)

Dues and License and CME 5000 (59396 left)

Miscellaneous Entertainment  10,000 (49396 or around 50000)

Saved

Remaining available to save around 50000 per year (not including 401k)

30,000 dollars in 401k

Assuming 8% rate of return on 80,000 over 5 years- 469000 dollars in savings

Next 5 years (Own house)

Expenses

401k: 30,000 (383000 left)

Taxes : 76182 (Federal) + 20290 (State) (286528 left)

Loan payments and house savings and children 529 plan: 48,588 (student loans) + 40,000 (house down payment) + 13,344 (529 plan) (184596 left)

Salary after mortgage payments and taxes (800,000 mortgage -30 year fixed at 3.5 percent 3592*12 (141492 left)

Salary after property taxes and insurance 14,400 (127092 left)

Home maintenance= 10000 (117092 left)

Subtracting food for family 10000 (107092 left)

Transportation expenses 2 cars/insurance 10000 (97092 left)

Vacations 10,000 dollars (87092 left)

Computers/Cellphones/Electronics/Cable Bill 3600 (83492 left)

Education and Expenses for two kids 12,000 x2 (59492 left)

Clothes 5000 dollars  (54492 left)

Life and Disability Insurance 9600 dollars 44892

Dues and License and CME (5000 dollars per year)= 39892

Miscellaneous Entertainment (10000 dollars per year)=29892 dollars

Saved

Remaining available to save around 29892 per year (not including 401k)

30,000 dollars in 401k

Assuming 8% rate of return on 59892  over 5 years +469000 in savings= 1040000 dollars

Next 8 years (Student Loans Paid Off)

Savings After Expenses

Savings now 29892+48588 +30000 (401k)=108480 per year

Assuming 8% rate of return on 108480 over 8 years +1040000 in savings= 3080000 dollars

Next 5 Years (No More 529 plans)

Savings now 113480+13344= 121824 per year

Assuming 8% rate of return on 121824 over 5 years +3080000 in savings= 5240000 dollars or 2655000 in today’s dollars with 3 percent inflation

Next 10 years (No More Kid Expenses)

Saving now: 121824+24000= 145824 dollars per year

Assuming 8% rate of return on 145824 over 10 years +5428000 in savings= 13240000 dollars or approximately 5 million in today’s dollars with 3 percent inflation

 

Low cost of living areas with significant student debt

Additional numbers for this assumption:

  1. House will cost 500,000 dollars with a down payment of 100,000 dollars, saved over your first 5 years of working. (20,000 dollars saved per year)
  2. Student debt will be paid off over 10 years (4049 dollars per month*12 months)= 48,588 per year
  3. Practice puts away 30,000 dollars including match into your 401k starting 1st year
  4. Investment rate of return 8%
  5. Federal Income Taxes after deduction will be 76182 dollars per year based on a calculator
  6. State Income Taxes are 0 dollars
  7. You have twins beginning at the of your attending work and are putting away 556 dollars per month per kid to get to 250,000 dollars at age 18. (13,344 dollars per year)
  8. Rental of a 3 bedroom house for 5 years at 2500 dollars per month

First 5 years

Total Salary 413000

Expenses

401k: 30,000 (383000 left)

Taxes : 76182 (Federal) + 0 (State) (306818 left)

Loan payments and house savings and children 529 plan: 48,588 (student loans) + 20,000 (house down payment) + 13,344 (529 plan) (224886 left)

Rental/heating/electricity  30000  (194886 left)

Subtracting food for family 10000 (184886 left)

Transportation expenses 2 cars/insurance 10000 (174886 left)

Vacations 10,000 dollars (164886 left)

Computers/Cellphones/Electronics/Cable Bill 3600  (161286 left)

Preschool/Day Care Expenses for two kids 24,000 (137286 left)

Clothes 5ooo dollars (132286 left)

Life and Disability Insurance  9600 (122686 left)

Dues and License and CME 5000 (117686 left)

Miscellaneous Entertainment  10,000 (107686 left)

Saved

Remaining available to save around 107686 per year (not including 401k)

30,000 dollars in 401k

Assuming 8% rate of return on 137686 over 5 years- 807690 dollars in savings

Next 5 years (Own house)

Expenses

401k: 30,000 (383000 left)

Taxes : 76182 (Federal) + 0 (State) (306818 left)

Loan payments and house savings and children 529 plan: 48,588 (student loans)  + 13,344 (529 plan) (244886 left)

Salary after mortgage payments and taxes (400,000 mortgage -30 year fixed at 3.5 percent 1796*12 (223334 left)

Salary after property taxes and insurance 12000 (211334 left)

Home maintenance= 5000 (206334 left)

Subtracting food for family 10000 (196334 left)

Transportation expenses 2 cars/insurance 10000 (186334 left)

Vacations 10,000 dollars (176334 left)

Computers/Cellphones/Electronics/Cable Bill 3600 (172734 left)

Education and Expenses for two kids 12,000 x2 (148734 left)

Clothes 5000 dollars  (143734 left)

Life and Disability Insurance 9600 dollars (134134 left)

Dues and License and CME 5000 dollars  (129134 left)

Miscellaneous Entertainment  10000 (119134 left)

Saved

Remaining available to save around 119134 per year (not including 401k)

30,000 dollars in 401k

Assuming 8% rate of return on 149134  over 5 years +807690 in savings= 2061000 dollars

Next 8 years (Student Loans Paid Off)

Savings After Expenses

Savings now 119134+48588 +30000 (401k)=197722 dollars per year

Assuming 8% rate of return on 197722 over 8 years +2061000 in savings= 5918000 dollars or 3476201 in today’s dollars

Next 5 Years (No More 529 plans)

Savings now 197722+13344= 211066 per year

Assuming 8% rate of return on 211066 over 5 years +5918000 in savings= 9934000 dollars or 5033000 in today’s dollars with 3 percent inflation

Next 10 years (No More Kid Expenses)- if you were to go past 5,000,000 dollars

Saving now: 211066 +24000= 235066 dollars per year

Assuming 8% rate of return on 235066 over 10 years +9934000 in savings= 24854000 dollars or approximately 9.4 million in today’s dollars with 3 percent inflation

 

Can You Accumulate Five Million Dollars In A High or Low-Cost Area?

The results are stark. Yes, you can accumulate 5 million dollars in a high cost of living area in today’s dollars with high student loan debt if you are willing to wait 33 years based on these numbers. On the other hand, if you decide to live in a low cost of living area, you can expect to accumulate 5 million dollars 10 years earlier. Now, money may not be everything. But, if you decide you want to change your lifestyle earlier than you expect, there will be many more doors accessible to you in your career if you choose to live in a lower-cost area. And, if you wanted to work a whole 33-year career, you would accumulate a large nest egg for your heirs. Something to think about!

 

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What To Do When A Hospital Performs Procedures Without Radiologist Consent!

consent

Have you ever encountered this situation? A hospital acquires a new piece of equipment and starts doing studies on it. Yet, the hospital administration never inquires if the radiologists consent to read them. Or, the radiologists working there never vetted the reporting systems or the software to interpret them. The studies sit on the worklist for days until the radiology group can determine the next step. I’m sure some of you have experienced something similar to this. Some radiology residents may have noticed as well. So, what do you do with these errant studies? How do you discuss this topic with the administration? And, what are the following steps to ensure that these studies do not sit on the worklist forever?

Bring The Topic Up For Discussion With Administration And Appropriate Parties

At this point, there is no time to beat around the bush. It would be best if you communicated rapidly and directly with the folks who decided to start the program. Delays can only lead to the ire of the ordering referrer, the patient, and the administration allowing the new study. Even though you may not be directly responsible for the situation, your group can still be in a bind.

So, find the administrator who allowed the study and tell them you need to discuss the issue further. Also, it is crucial to let the referrer and the patient know that the interpretation of the study will be delayed. Communication is the essential element here.

Create A Radiology Committee to Determine If Radiologists Should Consent To The Study

Next, you need to ensure that you abide by the Hippocratic oath to “do no harm.” Some studies can only lead to other studies and procedures that may not be best for patient care. If that is the case, a committee should decide to nix the procedure from the imaging arsenal. The practice should recommend at a high level with objective data that the hospital or imaging center refrain from completing more of these procedures. 

On the other hand, if the study has clinical utility, it behooves the radiologists to ensure enough staff can read them. There needs to be more than an adequate number of radiologists to make the schedule work. A committee within the radiology practice should also decide to look into these issues before the hospital completes more studies.

Make Sure That The Radiologists Have The Appropriate Training

Assuming the study is clinically valuable, a committee must also determine how to ensure that the radiologist will have adequate training and experience to read the study. This preparation may include courses, webinars, direct patient encounters, or supervised learning. The practice should determine the necessary prerequisites.

Interpret The Studies And Build The Program

Once the program has begun, radiologists must start doing the readings as determined by the committee. Moreover, as part of practice building, it may be worthwhile for these radiologists to talk to community physicians, referrers, or other administrators to ensure the program grows.

Radiologist Consent And New Studies

Sometimes, hospitals and imaging centers can be overly eager to begin a new program to create new sources of revenue. However, a lack of communication with the interpreting physicians can lead to its downfall. Radiologists’ reputations and licenses can be on the line if the hospital and the radiology practice do not take the appropriate steps. So before you consent to start interpreting any new procedure, you need to discuss it with the correct parties, validate it to make sure it is appropriate, train the radiologists, and ensure a process to build a great program. Rome was not built in a day. Hospitals should not rush through new procedures, either!

 

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How To Overcome Imposter Syndrome As A Radiologist!

imposter syndrome

It’s the beginning of the new academic year. Many of you have just started your journey in the radiology world. Others are beginning their first foray into fellowship or as an attending. In each of these situations, you will likely start to doubt yourself. In the case of a first-year resident, other physicians will ask you questions that you believe they know more about than you do. As a fellow, you are probably unfamiliar with all the subtleties in your “expertise.” And, as a new attending, it will be hard to believe that your name will go at the bottom of the report, possibly alone. How can you handle all this responsibility? Are you even worthy? In each of these situations, you are undergoing imposter syndrome. You feel like you don’t have the knowledge and confidence to play your role in the healthcare system. So, what do you do?

Solutions To Imposter Syndrome

Act The Role

Now, I don’t want you to get in trouble. Of course, don’t say things that can negatively affect patient care, especially if you don’t know a topic that can affect a patient’s morbidity or mortality. However, if a resident or attending stops by to look at a film, don’t hesitate to say yes. Go through the case. Look at the priors and the report. When you look at cases with other staff, you develop more confidence in your consulting role.

Additionally, make yourself available for all procedures. Each time you perform the subsequent barium study, PICC line, or paracentesis, your hands and brain become slightly more familiar with the technique. This process allows you to feel more comfortable in your skin. Eventually, you will feel like you know what you are doing!

Becoming good at a role involves becoming a good actor at first. Eventually, the acting job will turn into your career, assuming you put in the work. And you will feel like you know what you are doing!

Read A Lot

As you probably know, radiology involves much more reading than most other specialties. This burden is due to our overlap with many specialties and the core examination. If you are not reading, you sure will feel like an imposter. At a conference, everything sounds like mumbo jumbo chicken gumbo. With the clinicians, you will be at a loss. But that all changes once you start reading intently. I promise. Whether reading films or other complicated radiology tasks, you can answer questions and feel comfortable in your skin.

Get Involved Actively In Your Specialty

Those who know many others in their career will rarely feel like an imposter. If you know all the “muckity mucks” locally, regionally, or nationally; you will feel much more grounded and connected to the world of radiology. So consider heading out there and meeting and networking at the RSNA, AUR, ARRS, and more. (especially when the pandemic eventually subsides!) Or, get involved in your hospital administration by participating in conferences, GME, or other resident administrative roles. Each time you do so, you will feel more invested in radiology and less likely to catch imposter syndrome.

Imposter Syndrome And Radiology: You Can Overcome It!

Only a few simple steps can move you down the road from imposter to maven. Acting the role, reading, and actively getting involved in your specialty are simple ways to move in that direction. Most of us feel like an imposter from the get-go. We have never done anything quite like radiology before starting our radiology track. But you can leave that position quickly. It’s a bit of work to end imposter syndrome. So, get cracking!

 

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Disrespect From A Surgical Attending- How To Deal?

disrespect

Question About Disrespect From A Surgical Attending

The Situation

Hello, I am a radiology resident berated by a surgeon with disrespect in the reading room in front of my colleagues and attendings. An outpatient had imaging findings of small bowel obstruction. I sent a secure electronic message via EMR to the aforementioned surgical attending who ordered the CT scan, an unexpected result that could potentially affect management. I did it out of courtesy even though the hospital policy does not include this as a critical diagnosis that radiologists need to convey immediately. My radiology attending signed the report a couple of hours after I had sent the message. 

However, the surgery attending did not see the message/report until later that afternoon and started to ask me via chat if I had contacted the patient or another surgeon. As per my hospital policy, I did not do that because this is not a clinical diagnosis requiring immediate notification to the clinical team, such as a stroke or pulmonary embolism. The surgery attending took the time to come to the reading room soon after. First, he asked me if I was a resident or an attending; when I answered that I was a resident, the surgery attending started to yell at me for not reporting a critical finding directly. He made it sound like the patient was going to the OR urgently (at the conversation time).

Surgical Attending Disrespect, Exaggeration, And Bluster

Furthermore, he was threatening me that the patient could have died due to the delay in communication. Later, I found out that the surgery attending had already spoken with the patient on the phone. The patient felt perfectly fine/refused to go to the ER and would wait until Monday to go to the clinic (documented in the EMR). Even though we caused no harm to the patient, the surgery attending was very contentious. He made a public scene and stated that I did not do enough to communicate this finding in the middle of the reading room. 

Also, if I had not messaged, the surgery attending may not have found out about the SBO until after the weekend, as the patient felt perfectly normal. The surgery attending cared more about displaying her power over a resident. Her display of power was not for resident education. Is a new SBO on an outpatient a critical enough finding to call the patient directly or attempt to reach the inpatient surgical consult within minutes? What do you think is the best course of action to combat what I perceive as bullying and disrespect? Thank you for listening to my long story.

Answer

There are two main issues in your question. First, let’s first start with the facts about small bowel obstruction. Second, I will discuss the reasons for this public display of power and disrespect and the right course of action.

A Little Bit About Small Bowel Obstructions

Small bowel obstructions without other emergent ancillary findings such as portal venous gas, pneumatosis, free air, bowel wall thickening, SMA thrombus, free fluid, or focal fluid collections are typically managed clinically and are not “emergent.” As your hospital policy dictates, this reason is why radiologists do not usually have to make a phone call to the surgeon at your institution. And, you did more than required by sending the text message. 

Additionally, if you are talking about a plain film diagnosis, these findings are even less specific. I can’t tell you how often I have seen a plain film with dilated bowel loops and air-fluid levels. Then, we get a CT scan, only to see not much happening. A CT scan is a lot more specific for the diagnosis but is by no means perfect. 

Nevertheless, in a pure small bowel obstruction without complication, our role is less diagnostic than management-related. Usually, the surgeon wants to know if it is better, worse, or unchanged. This decision tree, along with the surgeon’s clinical assessment, should factor into the equation of whether they need to pursue the case/management further. The surgeon’s responsibility is to look at the plain film or CT scan with or without the radiologist and decide if further steps are necessary. This role is regardless of however the radiologist reads the study.

More About The Surgeon And What To Do

Based on your story, I suspect that the surgeon is at fault for negligence with the patient. And, I believe that the surgeon is transferring her inadequacies onto you. In my history of dealing with surgeons, the least confident ones unnecessarily tend to take their anger out on others. Unfortunately, you were a target because you are “lower” in the hospital hierarchy. This surgeon is trying to feel better about her faults by displaying her power over you.

If this bullying recurs or you feel that it was egregious, I would refer the case to your faculty in a situation like this. It is wholly unprofessional to berate and disrespect anyone in the middle of a public forum such as a reading room. I don’t care if it is a janitor, technologist, resident, or attending.

Also, it would help if you precisely documented what happened with any other witnesses. That way, it takes the situation to a faculty level with some objective facts. The attending staff can then can decide to talk to the surgeon based on the case. Unfortunately, as a resident, you are not in a position to reprimand or talk back to the surgeon.

On the other hand, your faculty can undoubtedly do so. This way, it should not happen again. And, maybe the institution can change this surgeon’s inappropriate behavior.

I would be very interested to know what you have decided to do,

Barry Julius, MD

 

 

 

 

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Why Artificial Intelligence (AI) Will Not Take Over Radiology!

AI

Artificial intelligence (AI) is still front and center for the layperson when discussing radiology. Family and friends always ask me why AI will not take over my day job. I had one of those “aha” moments in one of those discussions recently. We discussed how many factors will prevent AI from taking over our jobs anytime soon. These included legal, ethical/moral, and financial reasons. As I was droning on, I realized I could argue why AI could overcome these issues. However, one reason not related to these is why we won’t see a blank screen or a computer person from India, China, or any other country for that matter replacing our presence for a very long time. And that is that medicine is local, not universal. 

Medicine Is Local, Not Universal- AI Cannot Account For It!

“Standards”

Why would differing local “standards” be the most critical reason for keeping radiologists busy? Well, every country and every physician has their opinions about the best way to treat patients. Medicine is not universal. It is local. Yes, a few standards are omnipresent, like the Hippocratic Oath not to harm. But, other standards like lung nodule management vary widely among physicians, counties, states, and countries. The Fleishner criteria for managing pulmonary nodules are not standard. Some folks use that criterion; Others use LI-RADS.; And even others use ELCAP. 

I also know some clinicians that modify all these criteria to fit their patient populations. Therefore, it is only possible to standardize standards in an AI computer algorithm when your physician wants to use a different bar from the rest. One great way to lose the radiology business is to make recommendations that run counter to your referrers!

Management Differences Between Places

Different countries have different standards of care. For example, it would not be appropriate to recommend imaging a patient with an MRI of the shoulder in Canada due to lack of availability. Over there, physicians may be more apt to order a musculoskeletal ultrasound. Likewise, a radiologist in Canada may be more likely to recommend a musculoskeletal ultrasound for a possible rotator cuff tear. Yet, an MRI is part of a routine workup in the United States. Why? Because they have a much more significant backlog of patients waiting to get their studies done with fewer MRIs than we do in the United States.

In China, clinicians may regularly recommend “cupping” for different ailments. How can AI programs account for each cultural difference among countries, states, or counties based on availability, preferences, and cultural norms? These obstacles would be exceedingly difficult to overcome.

Differences Between Surgical And Medical Preferences

We work for other physicians. Our role is to make it easier for them to treat patients. And each clinician has specific needs for caring for their population. Oncologists look at assessment criteria differently from surgeons. Neurosurgeons have different interests than internal medicine doctors when they order a study. An AI program needs to consider all these factors when it summarizes findings and makes recommendations. AI is not ready to make different individualized reports for each subspecialist clinician. It would take massive programming power for which it’s not ready!

Differences Among Individual Patients

And finally, even among patients, culturally speaking, some patients want more aggressive workups, and others are more conservative. For instance, I may have a patient who can’t live with a small complex cyst in their breast and wants it drained. Meanwhile, another patient might be more willing to follow it. Some of these differences may be cultural or related to individual differences. How would an AI program account for that? AI is not ready to interpret every patient’s cultural and emotional status to make these decisions. Again, no supercomputer could make these individual recommendations for patients.

A Radiologists Job Is Still Way Too Complex For AI!

Whether it is differing standards, cultural differences, physician preferences, or individual patient preferences, radiology, in particular, is not a one-size-fits-all discipline. No program can consider all of these issues to replace a radiologist within the foreseeable future. The processing power required to figure this out for every clinician’s report would be enormous. Of course, 500 years later, a program may accomplish all these tasks and replace radiologists. But, by then, the same computer will replace every other job, and no trace of humans may exist as the singularity has come and gone! So, for those thinking about entering radiology, keep these issues from dissuading you. Over your career lifetime, you will still have a job!