Category: Resident Career

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The Informatics Fellowship- Bulletproof Your Radiological Future

Concerned about artificial intelligence taking over our jobs? Worried about the economic cyclicality of each of the radiological subspecialties? Do you fear the instability of your future radiology attending career due to corporate takeovers and mergers? Well, I have a solution for you (and no, I am not an infomercial!!!)… Welcome to the new fellowship called Informatics!!!

Why am I writing about the informatics fellowship and skipping all the other subspecialties? Well… the informatics fellowship warrants an independent post because it is truly the only radiology subspecialty that is in a permanent secular growth trend. It is also the only fellowship that has relatively little information published on the subject matter. In fact, once several of my residents and students heard about the existence of the fellowship program and understood its potential benefits, they began to salivate!!!

So, this article is dedicated to the topic of the informatics fellowship. Specifically, we will discuss the definition of informatics, what the fellowship entails, requirements for the fellowship, how to find where to complete the fellowship, and what job opportunities are available for graduates of these programs. I think once you understand the potential benefits of this fellowship program, you might consider it yourself!!!

Discussion of Definition and Importance of Informatics

So, what is the definition of informatics? According to Merriam Webster, it is as follows- “the collection, classification, storage, retrieval, and dissemination of recorded knowledge”. Prior to several years ago, I have to admit that I had never heard of the term or definition of informatics. In fact, I think I am probably not alone. It is only since the terms “the cloud” and “big data” have arrived into the mainstream, that I think the word informatics has been used more widely.

Why all of a sudden is this body of knowledge so important? In our age of electronic interconnectedness, large swaths of data are created and processed every day. Particularly in the radiology realm, there are numerous electronic/digital images and reams of clinical/health information. Someone has to both understand and manage all this information. Although computer engineers presently manage a lot of this information, they tend not to understand how to manage the data for physicians, administrators, and patients to understand. Herein lies the niche of the radiology informaticist, translating the imaging and clinical data from the computer engineer to the clinical realm.

What Do These Informatics Fellowships Teach?

Fortuitously, the same day that I started to write about informatics, I received a letter from the APDR explaining that there would be a new initiative to create a summary online 1 week course in informatics for residents. Some of the topics covered by the course as listed in the letter include Standards; Computers and Networking; PACS and Archives; Security; Life Cycle of a Radiology Exam, Data and Data Plumbing; Algorithms for Image and Nonimage Analytics; and the Business of Informatics. This course contained many of the topics that some informatics fellowship programs teach. But, the curricula of many of the informatics fellowships differed significantly from this course and were more expansive.

To add a bit more confusion, each individual fellowship program also covers differing topics from one another and varies the emphasis of each of these subjects.  Some of the topics that these fellowships include: RIS systems, Image Compression, Teleradiology, Quality Improvement, Operations, Clinical Engineering, HL7, Regulations, DICOM, Critical Results Reporting, Decision Support Systems, Radiation Dose Tracking, Mobile Health Applications, Image Segmentation, Imaging Room Ergonomics, 3D Printing, Natural Language Processing, Informatics Funding, Biostatistics, Health Policy, and Experimental Design. There was some overlap between the different programs. But coverage varied widely. I will also refer you to the ACGME formal program requirements in Clinical Informatics for a more formal explanation of all the areas of teaching required at all fellowships.

What are the Requirements To Become An Informatics Fellow?

The prerequisite requirements vary from program to program. Of the programs I visited on the web, most but not all, had a requirement to be board eligible in a specialty (not necessarily radiology), to be a graduate from an American Medical School, and to have an interest in the discipline of informatics. Most fellowships did not have a specific requirement for formal training in computer science. According to the ACGME, the program length was 1 or 2 years to graduate from a radiology program.

Where to Find the Fellowships?

I found several ways to find the informatics fellowships that are offered for diagnostic radiology program graduates. If you happen to be a member of the AMA, you can look up the fellowships on the FREIDA database. (It turns out I am not a member!) Alternatively, you can do a web search on informatics fellowships and many of the large institutions  describe their own programs. And finally, you can go to the ACGME website and look up informatics fellowships there.

Job Opportunities for the Informatics Fellowship Graduate

This is where things get really interesting… Job opportunities are endless. You want to be part of a large private practice or maybe a teleradiology practice?  Interested in becoming a practice leader?- It’s all yours! Not many employers can replace the only radiologist that can fix a PACS or RIS system and can also actually read films.

You want to become an entrepreneur and start your own company? You will have access to all the tools and methods to create a technological niche for yourself whether it be an app, a PACS addon, a new piece of software, or other countless unimaginable outlets.

You want to go into academics? The world is yours. Academics are desperate to have rads translate their IT department workings into something that is useful and efficient for clinicians. Think about the possibility of chairman or CIO.

You want to work for big business? Think Apple, Google, Cerner, and more! Large organizations are contstantly on the lookout for good talent that can translate the engineering esoteric data into clinical reality. You will be able to develop needed applications, improve health and radiology related products to get more clientele, and more:

Think about it… you will be at the forefront and crossroads of technology and clinical medicine- a job that only a few can currently fill. It will be very difficult to replace you.

Diagnostic readers can be outsourced to India. Robotics can replace human procedures. But humans will always be needed to rule the machines (unless our future is to be the same as The Terminator!)

Final Thoughts

Of course in the end, like anything else, you need to like what you are doing in order to be good at it. And, informatics is certainly not for everyone. But, if you have a remote interest in the intersection of computers and radiology, really consider this subspecialty. The possibilities are endless, job opportunities abound, and you have the ability to be in charge of your own destiny, potentially not subject to the whims of government or even private industry.  You can be your own captain!!!

 

 

 

 

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Radiology Moonlighting: A Taboo?

moonlighting

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

Why You Should Consider Moonlighting

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

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

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

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

Discordant Views Of Moonlighting- Academics Vs. Private Practice 

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

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

Where Do I Find Moonlighting Opportunities?

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

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

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

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

What Moonlighting Experiences Should I Avoid?

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

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

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

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

What Do I Need To Do Before Moonlighting?

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

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

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

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

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

Summary

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

Good references/links to find out more about moonlighting

Moonlighting for Extra Money: Tempting, but Watch Out

Radiology resident moonlighting: A necessary evil?

 

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My First Real Radiology Job- Do I Want Partnership?

partnership

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

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

To Be Or Not To Be– A Partner!!!

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

Employed Positions

Basic Issues

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

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

Defined Written Responsibilities

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

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

Risks of A Private Equity Buyout

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

Partnership Track Positions

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

Sweat equity

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

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

Buy-ins

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

Practice building

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

Partnership- Not An Obligation

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

What about the Partners?

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

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

Does It Make Sense To Be On A Partnership Track?

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

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

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

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

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

What is the current business environment in your location?

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

Have multiple recent retirees received buyouts?

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

Is there a tiered partnership?

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

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

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

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

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

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

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

Bottom Line

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

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