Category: Resident Career

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Do Recommendations Come With An Expiration Date?

recommendations

Do letters of recommendation last forever? Obviously not! But, if someone provided you with a kind word once, shouldn’t it last? It all depends on the type of recommendation and what purpose it serves.  So, let me provide you with a basic outline of the staying power of different sorts of recommendations for radiology residents and radiologists (kind of like the shelf life for foods!)

To organize this into something useful that you can use as a resource that you can come back to many times, I will divide the recommendation categories into both timing and purpose. And, I will begin in the order of training and subdivide the recommendations into subtypes. Let’s start at the beginning, medical school, and end with recommendations for attending radiologists.

Medical Students Applying To Radiology Residency

General Recommendations

Of course, before you even start talking about expiration dates, we need to mention the sorts of recommendations that medical students should obtain. It is not fixed (and dilated!). Instead, it can be fluid. From my experience, I like to see one radiology related reference and a couple of non-radiology recommendations for our program. But, I’ve seen some impressive applications with credentials coming from all radiologists and also all non-radiologists. So, in general, it is essential that the referrer knows you, the applicant well.

Unexceptional Recommendations

Now that we got this general caveat out of the way, how old can the average recommendation be before it begins to get stale? For the average, unexceptional reference, I would say no more than two to three years. Usually, it is best to get these recommendations from physicians with whom you work in your medical school. These recommendations are a general evaluation of your work ethics during this time. So, it shouldn’t be much older than that.

Exceptional Recommendations

Instead, let’s talk about extraordinary recommendations. What do I mean by that? Let’s say you are a former olympian, and your coach gave you an incredible reference and testament to your grit and personality. Or, maybe the President of the United States knew you and wanted to put in a word (for some that may not be so great!). But, I think you get the idea. These sorts of residency recommendations can be used as an adjunct and have a longer shelf life, perhaps indefinite. You can probably afford to put one of these in your application to differentiate your application from the others. And, this recommendation has some staying power. More importantly, it can help the program director to remember your credentials at the time of interview selection and ranking.

Known Entities

And, then, finally, what about the recommendation from a known entity/physician within the radiology residency or someone that the program director knows directly? These recommendations also come with a longer shelf life. These sorts of recommendations last until the referrer is no longer known to the program/program director.  If you are talking about someone that a resident knows within the program, that shelf life only lasts until the resident leaves and no longer has much influence anymore.

Residents Applying To Fellowship

General/Unexceptional Recommendations

For your “Average Joe” recommendation for fellowship, generally, you should ask an attending from your institution to write you a reference. At the bare minimum, it shows that you can interact with your team and garner the appropriate support to apply for fellowships. These recommendations should be no older than the time you have already been within your residency. I would not request references from your former ERAS application for residency. That would show a bit of laziness as well.

Exceptional Recommendations

For Fellowships, the unique/unusual recommendation now has much less meaning. Most importantly, at this stage in your career, you want to show that you are capable of performing the work. Although it would be interesting to get a recommendation from the President, that will not help your program director to figure out if you can perform liver biopsies. Recommendations at this stage should be much more laser-focused on your future specialty. The role of this sort of reference wears off as you advance in your career.

Known Entities

These recommendations become more important than ever. Why? Well, that would be because the fellowship director wants to feel comfortable that he will be working with someone capable. And, for residency, there is no better way to accomplish that than to receive a recommendation from someone that you know. Therefore, the shelf life of one of these recommendations will last much longer. It may last as long as the person recommending you is actively involved with radiology!

Fellows Applying For Radiology Attending Jobs

General/Unexceptional Recommendations

These recommendations are a bare minimum requirement before beginning to look for your first job. Typically, most of these references are no longer actual letters. Instead, they come through direct phone conversations with the referrer. Practices will often place random phone calls to the referrers that you list on your application. So, these recommendations will only last as long as the person that recommends you is at your current institution. If that person leaves, the reference is no longer “kosher.”

Exceptional Recommendations

These sorts of recommendations no longer should play any role in your application for a job. Your future employer is only interested in two things, mostly. Can you function as an attending in your new job? And, can you get along with others. A recommendation from a President or other interesting source cannot tell you the answer to either of those questions.

Known Entities

At this point, these recommendations are the most critical. If the applicant receives a reference from someone that the practice knows, it is like proverbial “gold.” It is most likely a checkmark for you to get the job. Most partnerships take these recommendations the most seriously. Why? Because most other measures do not provide valuable information about the candidate. These recommendations will last as long as the referrer is in practice.

Bottom Line About Recommendations: Different Strokes For Different Folks

Depending on the stage of your training, recommendations do have different shelf lives and impact. Known entities usually have the most significant influence on chances of admission or getting a job, and they tend to have the most extended shelf life. On the other hand, “exceptional” recommendations play a smaller role as you go further in your career training. Additionally, in general, make sure that an average reference should not be older than your medical school or residency training time. Or, if you are trying to get your next job, these recommendations will last as long as your faculty are present and continue to remember you.

Laziness can prevent you from getting into the residency, fellowship, or faculty position of your choice, especially when it comes to references.  Don’t rely on ancient endorsements. Instead, remember these guidelines the next time you ask for your recommendation. Don’t just leave the process on autopilot!

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What Is Your Work Limit? Find It Before You Get Your Next Job!

work limit

I’ve written before about RVUs and how much work is too much for a radiologist. But, let’s talk about how to figure your work limit before getting into RVU numbers. And that begins right where many of you are now, in radiology residency. Don’t just assume that you will start your first radiology job and you will comfortably work your tail off to make a gazillion dollars per year for the rest of your life. It’s not sustainable. Trust me. You will never be more miserable in your life.

So, how much can you do without going batty? Well, I am going to be a little bit formulaic and give you some ideas on how to figure that out now. Don’t make the wrong decision and work for that next burnout factory!

Do Some Thought Experiments To Determine Your Work Limit

Let’s Say You Could Do Your Favorite Specialty All The Time

Let’s begin by creating an ideal job for yourself where you could do just the right amount of work. For those of you who only want to practice within a specific subspecialty like mammography, this answer should be simple. How many of these studies can you realistically read in any given day without tiring yourself out? Is it twenty, forty, a hundred, or more? The number may not be entirely exact. But, it’s an excellent starting point when you begin to look.

Start thinking in this way because, for some lucky individuals, you can pick the number of studies you want to read in your desired subspecialty. Especially in this market, you can find many lifestyle jobs in the market. Who knows, maybe you can find one of them?

Let’s Say You Could Do Some of Your Favorite Specialty Some Of The Time

For many of you out there, you want to do some work within your area of expertise. But, you would also like to practice in other subspecialties as well. So, say you opt for 25% of the work in your area of fellowship training. And, maybe, the other 75 percent you will dedicate to outside your primary discipline. In this situation, think about which areas within radiology you would like to practice outside your subspecialty. And then, come up with a particular quantity of studies that you can comfortably read in a day.

Why is it more critical to figure out the number of studies you can read outside your primary area of expertise? Well, you want to figure out the most you can bear to do in specialties that you are the slowest. And, for most, that number relies on work they are willing to perform outside of their fellowship training.

In this thought experiment, I would recommend to base this number on your experience on call at nighttime or moonlighting. And then, take that number and apply it to your next job.

Imagine What It Would Be Like On A Day Of Your Worst Nightmares

And then finally, imagine what it would be like to have to practice on a day where your worst nightmares come true. Maybe, you hate reading triple-phase CT scans for pancreatic masses (probably one of my least favorite!) Well, pick a day where you have a ton of them. How much would it take to make you want to abandon ship? Well, you need to figure that number out. Why? Because Murphy’s Law says it will happen and likely more than once. Unless you make sure that you find a practice that will guarantee that you will not get a day like that, you will experience it.  So, figure out what this number would be.

Take A Test Drive Right Now- Apply The Ideal To Reality!

Now that you have some ideas about the numbers of studies that you would like to complete, you are now ready to confirm it all with real-world experience. How can you do that as a resident or fellow? Well, pick a day at your site. And then, go through the number of cases in your specialties of choice that you decided you can complete in any given day. Try it several times to confirm that this is a number that you can handle.

Of course, later on in your career, you will pick up speed and read more studies quicker. But, at least by giving it a trial run right now, it will provide you with a general idea of what your work limit might be. Well, how did it feel? Did it match with your thought experiments? If it doesn’t, and you feel like you should be reading more or less, rinse, wash, and repeat. Readjust the number depending on your experiences. There is no better time than the present to figure it all out!

Finding Your Work Limit The Right Way!

At this point, you have a realistic idea of the number of studies that you can handle. And you can apply it to your next job search. So, when you interview, ask questions about the numbers of cases that you are expected to read.  Does it match up with what you have calculated would work for you?  If it does, keep it in mind as a potential candidate for your next job.

Burnout is a hot topic these days with many job prospects expecting way too much from their applicants. If you want to prevent it from happening to you, be deliberate when you look for your next job. And, utilize these recommendations for helping you to vet the practices you seek. Being methodical and intentional about figuring how many cases you can comfortably and safely read now can be critical to your future career happiness and success!

 

 

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Radiology Fellowship Interviews: What’s The Difference?

radiology fellowship interviews

Question About Radiology Fellowship Interviews:

Hi Dr. Julius,

Thanks so much for the great piece about writing a fellowship personal statement. I recently went through the process myself and can appreciate the truth behind the points you stated.

As a follow-up, do you have any tips when preparing for the fellowship interview, after being shortlisted?

Thanks once again for all the high-quality posts. 🙂

Yours sincerely,
A Concerned Fellowship Applicant

Answer:

 

Thanks for the excellent question. It turns out that I have never delved into the differences between residency and fellowship interviews. And, there are a few significant differences between the two that I should mention. So, I thought that in addition to answering your question, it would make an excellent post.

To begin with, I highly recommend that you take a look at my original posts on residency interviews called How Important Is The Interview, Really? and Ten Ways To Sabotage Your Radiology Residency Interview. These rules still apply. And, once you have gone through some of this essential advice, take a look at some of the other specifics below about what you should look out for on your fellowship interview trail.

Radiology Fellowship Interviews: What’s The Diffference?

First of all, you will notice that different from a residency interview, most fellowship interviews tend to be more intimate. Most of the time you will be the only candidate at the site at this time. So, you will get to know the few interviewers much better than on a typical residency interview day because you will no longer be just another one of ten candidates. In that sense, it will often be a bit less nerve-racking. However, the general rules for interviewing still apply!

Next, the interviewer will expect you to have a background and a specific interest in the fellowship field of choice. So, you cannot have makeshift answers to why you are choosing to train in the field of radiology in general. Instead, you need to get down to brass tacks and come up with specific reasons for choosing this area of specialty.

Moreover, you will need to know more about the individual program to which you are applying. It is not enough to say that this will be a well-rounded program for your radiology training. No. You need to say why this particular fellowship would be an excellent fit for you. So, you should verse yourself in the specific equipment and unique training that this program has.

Also, make sure that you can talk about specific areas of research that may interest you. Fellowships, more so than residencies, tend to expect that you will perform research. So, talk intelligently about some projects that might interest you in this specific facility.

Other than that, it comes down to the same rules for interviewing in general. Be enthusiastic, conversational, well-dressed and groomed, etc.

So there you have it: some additional rules of the road for the residency interview. Let me know how it all goes.

Regards,

Barry Julius, MD

 

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Job Market Is Booming: Are Fellowships Still A Necessity?

fellowships

Let me clear up the facts for all the radiology residents that are thinking about fellowships in this market:  Just like any other job market, the number of radiology attending positions available is subject to market forces. Moreover, this prolific job market will not last forever. To support these claims, in my medical career, I have seen two job cycles, trough to peak. And we are sure to see others. It’s just a matter of time.

So, how does the changing job market impact the topic for today’s blog, the necessity of fellowships? Well, I have a bit of explaining to do.

Back in the early 2000s, when I completed my residency at the last market peak, great jobs were everywhere. California, New York, and  Florida were no exceptions. The theme of the job market was: “Name your price!” And, I can distinctly remember the heated discussions in the reading room about whether fellowships are necessary.

Well, it’s happening again. All you need to do, go to the recent forums on Aunt Minnie on the topic. Or, you can stop by my residency program. You will hear a few passionate debates on the matter. (We had this discussion during noon conference a week or two ago!) Regardless, I think this is a prescient indicator of a market peak. Not that it means we will experience a sudden downturn. But, we are riding somewhere along the top of the curve.

So, what happened the last time around the market went from peak to trough? Well, if you took a poll of radiologists without a fellowship, I believe a higher percentage of these folks would have had more issues with their career than those with one. Therefore, I am going to throw a bit of proverbial cold water on those of you who are thinking about going down this non-fellowship path by telling you why.

More Likely To Have Work You Don’t Like

For better or for worse, those radiologists without a specialty tend to have less control over their domain of practice. Don’t like mammo and plain films? Well, you can’t say you are an expert in another area that you enjoy more when you are starting your career. So, guess where the practice will want to place you!

Severely Limited Job Market On The Coasts

If you want to have a better chance of securing a job in the more populated portions of the country, you will have a much better shot if you have a fellowship. I can certainly speak for my part of the country, New Jersey. It’s possible, but good luck finding a quality position without one!

Not Considered An Expert In Any Area

Now, this may or may not bother you. But, many radiologists like their colleagues and referrers to perceive them as experts in a particular area. Clinicians know individual radiologists and ask for them by name because of their fellowships. That will be less likely to be you!

Much Harder To Start A New Fellowship Once Established

Once you have already been working as a full-fledged radiologist for a while, it becomes much more traumatic to start anew as a fellow. You may have a family. Or, perhaps you have become accustomed to the lifestyle of a radiologist. It’s hard to go back and do a fellowship once you’ve started your career!

Yes, You Will Have Increased Chance Of Losing Your Job

And finally, you may not want to hear this, but as an employee of a practice, when the reimbursements turn down and the market becomes sour, who is the first to go? Well, it’s not likely to be that expert in neuroradiology who the neurosurgeons love. And, it’s not going to be the nuclear radiologist who performs complicated radiopharmaceutical treatments on the referring physician’s patients that the practice cannot replace so easily. Hmmm. Who can be ousted the most quickly without a significant impact on the business? That person is much more likely to be you!

Booming Job Market: Still Need Fellowships!

I get it. You’ve been out working for so many years. And, you’ve become impatient. Maybe, you have a family and want to earn a real living. But, in the long run, it’s not worth the additional risks that you will take by not completing the additional training. So, think again before you choose to enter the job market without a fellowship now. You may regret your big decision later in life!

 

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New Radiologist Wanting Locum Work? Think Twice!

locum

Have you ever thought about living in different places for a little a bit at a time? Maybe you have always wanted to do some traveling before starting to work? Of course, it sounds exciting to go from Honolulu for six months and then onto Dayton for the next six. Indeed, I thought about the locum lifestyle when I first started.

But, are you missing out on by taking this route instead of the established full-time job career path? Potentially. As much as the ability to travel for your job may entice you, think twice before embarking down this infrequently traveled road as a new radiologist. Let me give you some good reasons for turning this opportunity down.

Pigeon Holed/Loss of Skills

Do you want your new practice to call you that temporary plain film reader gal? Unfortunately, this sort of attitude prevails among many groups. And, imaging groups tend to place you in a particular role based on the desperate needs of the practice. So, if you sign up for XYZ, the group may utilize you in Y capacity. Over the years, this is a surefire way to lose your skills in other areas that you trained for in residency.

Will The Good Times Last?

What do you think happens when the bottom drops out of the radiology job market? Perhaps, imaging reimbursements drop precipitously. Or, suddenly, the stock market crashes and older radiologists stay in the field. And, yes, unfavorable radiology job markets like this have happened in two separate cycles since I started medical school.

In these situations, what happens first? Well, the excess fat gets cut. And, what exactly is the excess fat? It tends to be the locums’ jobs! When you start, you certainly don’t want to be in that first wave of job cuts. It becomes challenging to recover.

Locums Looked Upon Unfavorably

At many practices, the question that arises when they consider a new locum radiologist is: WHY ARE YOU A LOCUM RADIOLOGIST? From my experience, many radiologists believe (rightfully or wrongfully so) that locums radiologists have a defect. Perhaps, they read to slow and cannot hold a job. Or, maybe, the individual cannot get along with others and drifts from job to job. So, if you have a track record of only holding locum work, you have painted a particular picture of yourself that may not be attractive if you ever want to find a longer-term career!

Never Quite Maximize Efficiency

When you drift from place to place, you never get to learn all the systems in place to maximize your output. PACs machines, paperwork, clinician demands, and technology continually change. And, they differ from one practice to another. By definition, you remain less efficient and slower just because you do not have the long-term knowledge you need to keep up with your colleagues at a job using the same technology for the past ten odd years!

Difficult To Establish Long Term Relationships

What do I value most from my current job? I treasure the relationships that I have made with my colleagues, residents, and fellow clinicians. How do you create and maintain these relationships as a locum? Well, it can become very challenging at the very least. You are new the kid on the block and will remain that way until your short term tenure as a locum radiologist ends.

Locum Work: A Dangerous Road To Travel

Now, locums can be an excellent opportunity for specific individuals. If you have a family and want to fill in some time with some extra hours, it can make some sense. Or, maybe you want to retire soon and desire some additional inconsistent or occasional work. Finally, perhaps, you are independently wealthy, and a full-time career does not matter for you. But, for the typical fresh graduate with a lot of debt and wanting to begin a new locum path, you will encounter many obstacles that can affect your future career and growth. So, think twice if you choose to become a locum radiologist when you start. It may become one of your biggest regrets!

 

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Why Standards Of Care Are Important To Fight For!

standards of care

I don’t know if you have noticed, but you have probably heard the term standard of care bandied about a bit during your residency program at some point.  But, first of all, what does the standard of care mean? Well, according to MedicineNet, it is “A diagnostic and treatment process that a clinician should follow for a certain type of patient, illness, or clinical circumstance.”

However, not all standards are the same. Some measures are national standards, and others are merely within one’s department or practice. But, why is it so important to all physicians, and more importantly, specifically for radiologists? And, what happens if we all don’t meet the “standard of care”? Well, the result may not be so beneficial for you or your practice. Consequently, standards of care are of critical relevance to our world. And, that’s the topic for today!

Legal Reasons To Follow National And State Standards Of Care

OK. Let’s first start with the bugaboo. If a practice or its members are not following the best national/state standards of care, they are prime candidates for a lawsuit. To that end, one of the three pillars of a successful malpractice lawsuit is not meeting the standard of care, So, that alone should make you quake in your pants if you do not abide by these norms.

Importance of Individual Practice Standards

Well, it’s not only about the legal issues when you do not follow national and state standards. Additional trouble can ensue if you do not apply standards within your group. What do I mean by that? Well, not all practices follow the same rules because norms throughout the country and state can differ widely. Let me give an example.

If you decided to look up the requirements for how to determine which patients are appropriate candidates for a hysterosalpingogram (a test to check the anatomy of the uterus and fallopian tubes), the information is all over the map. At best, the data about how you should decide which patients should get the test is scattered and based on differing experiences. Some groups advise that you should perform the procedure between 6-10 days after a menstrual period without additional testing. Others recommend that patients should also have a urine B-HCG level before considering the patient for the test.

In either case, each practice standard is theoretically acceptable. However, if each member of radiology practice uses different criteria for deciding upon when to perform the procedure, what happens? The secretaries become confused about how and when to schedule the examination. And, the technologist or nurses can easily forget what each radiologist requires before the exam. It becomes a mess of confusion. So, practices need standards to prevent these inefficiencies.

Moreover, god forbid if somehow, a patient discovered that they were pregnant before the test, and one radiologist did not test the patient with a B-HCG level (unlike all the others in the practice), then that radiologist did not meet the standard of care for the practice. Theoretically, that could also open up the radiologist to additional legal actions.

Standards Of Care From The Patient Side

Finally, from the patient point of view, nowadays patients can look up information about best practices and procedures online before deciding to get a test. If your group does not meet these standards, and the patient becomes aware of a subsequent complication related to not meeting these norms, at best, the patient may never return. And, at worst, your practice becomes at increased risk of receiving legal action.

Fight For Group Standards Of Care!

As you can see, we all need to be on the same page in any radiology group. Changing practice standards to vary from national and state norms can lead to disaster for the group and the individual radiologist. Moreover, creating specific practice standards within a group can be critical to maintaining efficiency and reducing confusion among the staff. So, think twice if you decide to be OK with not meeting standards in your practice, it may be your future career at stake!

 

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You Want To Become A Radiology Program Director! Are You Nuts?

radiology program director

Did you ever wonder how your radiology program director started to run a radiology residency? Did she desire this calling from day one or did the residency bestow this honor upon her? Well, let me tell you a little about the world of residency  directors (my world!)

Typically, let me give you a picture of the process. It usually happens like this. The Chairman of the radiology department comments at a meeting, “Who wants to take on the role of the new residency director?” You hear a wall of silence. Then, the Chairman asks, “Who doesn’t want the role of radiology program director?” And, then everyone raises their hand except the one guy who is sleeping in the corner. So, who do you think gets this vaunted position?

All kidding aside (not really!), it does take a unique (better phrased “atypically crazy”) individual to relish the opportunity to become a program director. Today, I am going to go into the type of person that can succeed and can find this role rewarding. Moreover, I will talk about the most significant challenges and rewards of this position.

Radiology Program Director Personality

Not all personalities can handle the position of the radiology program director. If you have anger management issues or react before thinking, you are in for a lot of trouble. Optimally, you want to install a person who has a lot of patience, enjoys teaching residents, and can handle long hours of paperwork. But, unfortunately, many times, that is not the case. Hence, the enormous turnover in residency directors. The turnover in residency directors occurs over six years on average, more rapidly than most other residency programs. (check out this article from 2013 by Dr. Ruchman on AJR)

Most importantly, however, this individual needs to understand the dynamics of working with other people. My theory about why the turnover is so high for radiology program directors: I believe that departments select program directors based on academic credentials and technical skills, not upon the personality that will be running these programs (A big mistake!) You cannot expect to run a program well without excellent communication skills. Believe me. Nothing angers residents more than working with a program director that does not listen and talk to the residents within their program!

Challenges

When I started writing this paragraph, I could not even think about where to begin since the trials and tribulations have been so numerous. But, I will take a stab at some of the more significant ones.

As much as any program director would like to say he picks the perfect residents and never had any issues during their tenure, this is rarely the case. (This is also true at the most “prestigious” programs- but they will not let that on!) To this point, most program directors have incredible stories of resident hardships, horrifying incidents, and more. All you have to do is ask, and they will tell you a bizarre story or two! But, here are some of the most difficult of the challenges.

The Struggling Resident

The biggest challenge to the average program director is the struggling resident that cannot make it through the program. And, this may be for any number of reasons, but most commonly related to mental health, learning disability, or social/professionalism issues. Fortunately, these encounters are rare. And, most of the time, the residency team can solve them. But, every once in a while, they do crop up, and residency programs will have to let a resident go.

Trust me. It is heart-wrenching and terrible. However, in the end, each residency director has to attest to the following when they sign the graduation certificate, “This resident is competent to practice in the field of radiology.” And, if you cannot do that, then you cannot graduate the resident. We have a responsibility to the community to make sure that dangerous radiologists do not practice medicine. If you are working as a director long enough, it will happen in your program.

The Weird “One-Off” Incidents

Also, of course, there are the “one-off” incidents that most directors will encounter that can present real challenges as well. What do I mean by that? You have a resident that gets into trouble with the law for a DUI or a fist fight between a radiology resident and a surgeon in the middle of the night. I can tell you that each situation is unique and presents its own set of challenges on how to deal with them. We are always flying by the seat of our pants!

Mind-Numbing Paperwork

Lastly, we need to accept the responsibility of mind-numbing paperwork at times. In the past, with the old site visit system, we needed to create a gazillion essays about why our residency program should exist with terminology and mumbo-jumbo that you would not believe based on the musings of a few Ph.D. education types. But even today, with the newer site visit system, we still have enormous quantities of documentation to prepare.

Additionally, between the milestones, surveys, resident/faculty evaluations, meeting minutes, and more, you need an army of coordinators and personnel who are computer savvy to make sure your residency program can continue to survive. (That’s why small residency programs find it challenging to survive) However, many of these responsibilities often fall into the lap of the program director. And, these items are just the proverbial tip of the iceberg!

Rewards

Yes, with great responsibility comes great rewards. And, this time-honored cliche applies no differently to those running a radiology residency program. I can think of almost no better feeling than to see your residents succeed, becoming chairmen of other departments, writing inciteful academic papers, and becoming incredible clinicians once they graduate.

Also, getting your residents past the hardships they may encounter during their residency program can take an incredible amount of work, but there is no better reward than getting them over these obstacles and watching them take off in their careers. In the end, we are coaches and mentors. And, if you like these roles, you may enjoy becoming a program director (As long as you can accept all the other flaws that go with it!)

Becoming A Radiology Program Director- Are We Nuts?

Well, after all this discussion, the short answer is yes, we are nuts. We need to have unique nutty characteristics that enable us to succeed in our job. And, we take joy in the experience of teaching over all the other issues that come with the position. But, if that is nuts, so be it!

 

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Radiology Game of Thrones: University Vs. Corporate Vs. Private Practice- Who Will Win?

radiology game of thrones

Each of the three most prevalent practice models is vying for complete domination of the realm of radiology.  And, each of them wants to leave no survivors. They want to capture all the money, glory, and radiologists for themselves! Well, in honor of the up and coming last episode of the Game of Thrones, I figured I would narrate an all-out battle within the radiology Game of Thrones, which is happening right now as we speak.

So, first, who are the players and what are their armaments and defenses against the  “battle-hardened troops” of each group? And then, who will be the winners and losers in the battle to obtain the “Radiology Iron Throne”? We will discuss the conflict in detail!

University Radiology

Armaments

Out all of the weapons that the Universities can use to maintain control over radiology, they can manipulate the credentialing boards and legislative bodies such as the American Board Of Radiology (ABR), American College Of Radiology (ACR), and the Accreditation Council For Graduate Education (ACGME). In other words, they can stack these organizations with their members to get the radiologists they want. Want to make it harder to become a mammographer? Just make a new exam! Decide you need to work at a university hospital to provide services for a specific need. Well, let’s make the rules for that. They hold the majority of the political cards and are willing to use it pronto!

Also, who trains the radiologists? The academics, of course! These organizations can manipulate the minds and careers of new radiologists coming out to meet their own needs! Want to lengthen the time to credentialing? (Which they’ve done already by creating the credentialing exam!) Go ahead and have fellows for a few additional years to meet the requirements of these practices!

Defenses

These organizations tend to be large and have lots of money and politics backing them. It is challenging to uproot the Massachusetts Generals and the Columbia Presbyterians of the world. Plus, they have reputations that precede them. If you are planning to root them from the face of the earth, good luck!

Corporate Radiology

Armaments

These large entities can slice and dice the cash flow coming in so that they can create efficiencies that did not exist before. How do they do it? Of course, economies of scale. And they find willing radiologists to join their ranks. How? By offering younger radiologists higher salaries but never giving them a complete slice of the pie when they become more senior.

Plus, they have the backing of large private equity companies who have large amounts of money to throw at the situation to make their cause more viable. Need more equipment or bodies? They can raise more funds and gather up their needs. They have economies of scale in their favor.

Defenses

Many radiologists want to have a quality lifestyle and are willing to pay for it in any way they can. So, they can always recruit teleradiologists, part-timers, and early retirees to fill their ranks. What better defense than having the ability to maintain a constant supply of low paid troops to protect the organizations!

Private Practice Radiology

Armaments

Which organizations tend to be the most efficient and provide the highest long term cost effectiveness for imaging centers and hospitals alike? The private practices, of course. When you have incentives to work, you create these opportunities to save money for the system with good quality healthcare. So, this is their strong point and mantra.

Defenses

Although they do not have large swaths of capital at their back like the other entities, they can recruit new radiologists who want to form long-lasting relationships and are committed to entrepreneurship while taking control of a slice of the pie for themselves. Also, it is very challenging to find new general radiologists to replace the old guard since training programs emphasize subspecialization over private practice. Good luck finding academic subspecialists to read general work in rural areas to replace the current radiologists, especially when the job market now is so tight!

The Battle For The Radiology Game of Thrones: Who Will Win?

The Current State Of Affairs

Well, the fight for the radiology Game Of Thrones is raging on right now. And, the swords are swinging. So, what’s happening in the current market wars?

Private practices have been losing some ground. Why? New radiologists that come out are no longer as committed to the lifestyle of an individual practitioner. Many do not want to perform the sacrifices that need to be made to work for these organizations. Working on weekends and call, indeed, do not entice these new radiologists. Also, programs no longer emphasize training of general radiologists over subspecialization, causing some private practices to wither and die. So, private practice overall has been at the losing end.

On the other hand, the large corporate entities have been enticing new applicants with the promise of a quality lifestyle. They have been the big winners of late. And, these numbers bear out at each of the AUR meetings that I attend. Teleradiology and corporate radiology have been increasing their numbers.

And then, of course, academics have continued along their merry way. They are a steady presence since they control the politics, research, and numbers of residents they produce.

The Future: My Predictions

But, what about the next several years? I mean there are fewer radiologists per job. So, where will they go? Well, corporate radiology can always jack up the salaries of its members when times are good. Therefore, they will continue to recruit well. And, when the cycle reverses, they will continue to squeeze radiologists for every penny they have! But, lifestyle alternatives in corporate structures will continue to trump private practice organizations for most new radiologists.

And, what about the academic radiology world? Well, as long as they continue to maintain control of the politics and entry into radiology, they will be around for a long, long time. They can also promise a better lifestyle for new radiologists as they enter the field as well as have the financial backing to do so. And, for those residents I interested in research and teaching, they will always be an option.

Where will the private practice radiologists fit into the equation? Well, I see continued mergers and acquisitions until the smallest groups can finally compete with the other entities. Only by protecting themselves with increasing size can these private practices compete in the real world. Until then, the overall numbers of private practice radiologists will continue to shrink a bit.

So, there you have it, folks. As we wait for the last episode of the Game of Thrones, we will finally learn who the clear winners and losers are. Similarly, for us, only time will tell if my predictions for the radiology Game of Thrones will come true. For those of us that are fans of the show, enjoy tomorrow’s episode. You will never think of radiology and its different career pathways the same!

tomatoes

 

 

 

 

 

 

 

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The Radiology Job Market Cycle: Don’t Enter At The Bottom!

market cycle

Last month, one of my favorite fellow radiology bloggers, Eric Postal at Diagnostic Imaging, wrote a piece entitled Where Did You Enter The Job Market? In it, he described some of the issues of entering the job market at different points of the radiology job market cycle. And, he painted a relatively even-handed picture of the situation.

Now, I don’t want to be Negative Nancy or David Downer, but, unfortunately, I have to give a less rosy assessment of the situation. Sometimes, you have to describe it like it is: The residency graduate at the bottom of the job cycle sometimes may never completely recover.

Fortunately, for anyone who is entering the job market at this current “high point” of the cycle, you will not have to experience any of these issues if you find the right job at the outset. But, for those of you who entered the job market cycle at less desirable times, you will understand precisely what I am saying. So, let me tell give you a summary of the reasons why job applicants in the nadir of the cycle may permanently feel the pain.

It Takes Years To Recover From The Personal Financial Losses

Once again, the magic of compound interest only works when you can maximize the earnings of your earliest working years. Unfortunately, working at 20 vs. 25 years at maximal salary makes an enormous difference. And, if you find a barely adequate job when you first start, you will have lost out on that opportunity. You may have delayed partnership by three, four, five, or more years. Or maybe, you chose a second fellowship instead of going out into the job market. Either way, those lost years can become more significant than you might initially think. In the end, a loss of this amount of time can lead to millions of dollars of decreased savings as a radiologist!

You May Have To Root Up Your Family From A Locale

So, you don’t like the circumstances of your first job due to its location or circumstances. Well, it may not work out so well for you and your family. Perhaps, you have children in elementary or middle school. In this situation, you may have to pack up your bags and take your whole family with you to another town. Imagine the trauma of moving for your children to a new school in a different city. It is happening right now to many of you that entered the job market toward the negative end of the cycle!

Forced To Practice In A Specialty Area That You Don’t Like

OK. You did that fellowship in mammography because you thought that it would help with obtaining a job in a medium sized city, even though you did not enjoy it that much. Now, your skills have atrophied in other areas in radiology. What do you do, now that you want to switch jobs? Another fellowship? Well, at your stage in your life, it’s not so easy to pick up and start another training subspecialty again, once you’ve been out and working for several years, is it? Your decision may stick with you, forever!

More Likely To Have Multiple Jobs

Anyone that starts a so-so job during a downturn will become more likely to leave their job when the market improves. Perhaps, you need to go because the practice has become so oppressive. But, who wants to pick up and start anew again? Moving can be such a drag. And, all those connections that you have made in the community, utterly lost!

Academic Career Rewards Delayed

Maybe, you have set your sights on an academic career, possibly becoming a chairman. But, wait. Since you entered at the bottom of the cycle, your department may not promote you as rapidly. Why? Because you have nowhere else to go. They can get away with it, of course!

Entering The Job Market At The Bottom Of The Cycle

No matter what other authors may say, there is no way around it. Nor, can I sugarcoat it. Entering the job market at the bottom of a cycle can become a permanent disadvantage to your career, finances, and future. But, I am glad to say these issues no longer apply for those starting after completing residency and fellowship now. Let’s continue to hope that for all of the future job applicants; the good times continue to roll!

 

 

 

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AUR Update 2019: What’s In Store For Your Radiology Residency?

For those of you that don’t know, the Association of University Radiologists (AUR) annual meeting is the main forum for all radiology residency programs throughout the country to discuss the most critical issues affecting radiology residency programs, GME education, and radiology medical student education. These include anything from the radiology residency match to the job market as well as the hardcore academic issues.  So, once again, I would like to keep you up to date with the AUR update 2019 on what is new in radiology education and the main factors that may impact your training.

Radiology Match/Competitiveness

As I had previously promised in a previous blog on the match, I will provide with a summary of the numbers compared to past years. Slightly different from my experience in the match, the numbers pointed to an overall similar year for radiology residency competition. Compared the previous year, 18 spots were left open (previously ten places). And, the percentage of foreign graduates were also similar (32% vs. 29%). However, the number of applications per resident had increased significantly, perhaps driving somewhat more competitive applicants into the interview spots.

Given the numbers, however, the facts show no significant change in competitiveness from year to year. Interestingly enough, in my experience, the overall quality of the applications was higher. (my experience can differ from the overall statistics!) So, I believe that some increased self-selection has been happening, not measured by the statistics. In terms of competitiveness, one of the hot topics lectures stated that radiology this year was similar in competitiveness to emergency medicine.

The Job Market

Like the previous year, the future has become rosy for new radiology residency graduates. Droves of retiring radiologists and a good economy are leading to the robust job markets for new radiology resident graduates. Also, similar to the last year, there are nearly two jobs available for each diagnostic radiology residency graduate. I would say that is not too shabby!

Furthermore, the needs of practices remain similar to the past. Body imaging, neuroradiology, and interventional are the most common available first jobs. And, the greatest need for radiology practices remains breast imaging, body imaging, and neuroradiology. Most jobs posted are again available in the South and the least in New England.

What I found particularly interesting: 8% of all graduates were able to find a job with no fellowship training. I’m not sure what the statistics were for the previous years (probably a lower percentage in past years), but I have a feeling these folks would still have a hard time finding a position on the populated coasts. However, these statistics bode well overall for all graduates trying to find a job.

Change In Board Pass Rate Minimums

From an associate residency director of a “smallish” program, ACGME board passing changes have the potential to make some issues for smaller radiology residency programs. No longer is the minimum requirement an 80% pass rate for residencies by the end of the residency.  Instead, each program needs either an 80% first-time core examination pass rate or be over the 5th percentile for all residencies (that makes up about seven programs) with a look-back of five years. If you happen to have a “freak” year or two of a lower pass rate as a smaller program, the ACGME can target your residency for a new site visit. And, that can wreak all sorts of havoc!!!

Radexam

Now that the monthly evaluation exam has matured a bit, we have more details on this evaluation system. You can expect the availability of a more sophisticated assessment of individual scores and more customizable examinations to different institutions. You will see new exams in fluoroscopy, GI, and GU. Even the AIRP plans to have a distinct test to confirm that residents have attended the conference!
Also, they have instituted a new overall R3 level assessment test for these residents before going into the core exam. The examination will be available until June 20 and may be a great way to assess the progress of the resident for the core. We will see!

Unconscious bias

The quality of the speakers at the meeting varies widely. But, this year the AUR meeting provided us with a treat. Straight from the NPR news station, Shankar Vedantam gave an excellent lecture on unconscious bias and how that can affect radiologists when it comes to issues like the selection of diverse radiology residency applicants. No, it did not provide us with a formula for maintaining diversity in our residencies. But, it did give a new perspective on how we make the decisions that we do. If not this year or next year, I would expect some future changes in the rules for the overall process of residency selection and evaluation to incorporate some of the principles from this talk.

AUR Update 2019 and Change

The one constant in all radiology residencies is “change.” And, this year with the AUR update 2019 is no exception. Between the match, the improving job market, changing pass rate standards, an evolving Radexam, and new perspectives on unconscious biases, I foresee that our program, as well as all programs across North America, will have to roll with the punches and continue to adjust!