Category: Resident Career

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How Not To Incriminate A Fellow Radiologist For His Mistakes

 

 

One major theme in many of my blogs is that radiology residents and radiologists do make mistakes. We see them all the time in prior reports. We hear them from our fellow radiologists and clinicians. It is just part of the normal ebb and trough of the radiology resident or attending. I still remember one of my attendings from residency sagely saying we slowly get less sensitive over time. Then, we miss a finding and become overly sensitive until we become less sensitive again. And, this process continues throughout our radiological lifetimes, hopefully, as we try to reach perfection. Bottom line. If you are not making mistakes, you have not read enough films and you are not getting better. We acknowledge that. It’s who we are.

More importantly, we as radiologists have to protect each other from our mistakes. It is important that we don’t throw our radiology colleagues “under the bus”. Politically and ethically, treating our fellow colleagues well is just as important as writing good reports. We all need to be team players in order to protect our practice of radiology. So, what are some general rules for protecting our colleagues from their own mistakes? Well, that is the theme for today. A mini-instructional, if you will.

Contact Your Colleague Immediately

Contacting your colleague is probably the most important step in reducing the issues that ensue from a miss. Often times, I will read a bone scan and find the corresponding metastatic lesion on CT scan that can be very hard to detect prospectively. Immediately, I contact the physician who recently dictated the CT scan, usually on the same day. As a courtesy, this step allows this radiologist to create an addendum if warranted and prevents any harm from coming to the patient due to an incorrect report as well as the possibility of a lawsuit.

Sometimes, however, you may detect a miss from a while back, maybe months or years. In this situation, the offending physician can contact the caring physician or patient and/or make an addendum to his/her report to right the mistake. It may not prevent a lawsuit, but it certainly prepares the physician for the possibility. And, it also happens to be good patient care.

Don’t Highlight Mistakes On Prior Reports

This may seem obvious, but radiologists commit this offense one too many times.  When your fellow radiologist misses a finding on a previous report, the last thing that you want to do in any way, shape, or form is to say explicitly that he/she missed the finding. If the patient catches wind of this miss, you will see dark clouds brew and lightning flicker through the air, about to target this unsuspecting radiologist and your practice too. You are asking for a lawsuit to strike down all those involved in the construction of the prior report!

Phone The Clinician Directly To Discuss The Case

Instead of adding the miss directly to the report, another good idea is to pick up the phone and call the clinician. The issues behind a radiologist miss can be better expressed sometimes by mouth than on paper. It allows you to guide the physician toward what he/she has to do next without having to state it officially on a report. Also, the less incrimination on paper, the less likely the radiologist with a miss will have to answer for his/her sins.

Use The Words New, Stable If Possible

Especially in mammography, the kiss of death for a radiologist with a miss on a prior report is to write that a mass has enlarged compared to his priors. In no uncertain terms, what you are really saying is that the radiologist missed the finding. Lawyers love this stuff! Not that you should lie, but many lesions cannot be seen prospectively because they are really too small to catch. So instead, if you can, use the word new. Or, just say a mass is present with a comparison date to the previous study. Even better, if the lesion was present and unchanged, you can safely say the lesion is stable without incriminating anybody. Stability is usually the radiologist’s friend!

Summary

A radiology practice is a team and if you don’t think like a team player, your team will break apart. Incriminating one’s colleagues for mistakes made (that we all make at times) is a selfish act and is one of the most unsporting behaviors out there. So, be a team player and think long and hard about what you will finally place in your report. It potentially can save your colleague from a lawsuit and allow you to earn respect from your practice as a team player!

 

 

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Twelve Red Flags At Your First Post Residency Radiology Job

red flags

 

Unfortunately, not all practices are equal out there. Some abuse the junior employees. Others require responsibilities of their employees that the employer does not outline in the contract. And, even others promise partnership with its employees and do not deliver. So how do you know that your first job is going to work out for you? Well, it can be exceedingly difficult to tell for sure. But, I have come up with twelve red flags while employed or interviewing that will enable you to figure out if you need to move on to a new job or interview elsewhere.

No One Tells You Anything

You show up to work one day and discover that the hospital owners changed the location of your reading area within the imaging center without warning. Or, the private practice partners have a partners’ meeting and are unwilling to divulge any information, even non-sensitive information such as compliance issues for the employees. If this pattern of poor communication continues over time, it is a sure sign that the partners either have poor communication skills or do not respect the employees’ work. Be very wary!!!

Constantly Changing Work Responsibilities

You may be a neuroradiologist, but the practice expects you to all of a sudden read mammograms that you have not read for many years. And, the next week, you are responsible for all the arthrograms, even though you have not done one since your residency. If this happens once or twice, it may be related to staffing or temporary issues. On the other hand, when it is a recurring theme, it may be the first signs of an inept management structure unable to either retain its employees or, perhaps, severe practice disorganization. Think twice about staying!!!

Severe Isolation Syndrome

When you come into work, you see all the offices with radiologists with the doors locked. Just like everyone else, you shut your door too. And, you don’t even hear a peep from another radiologist for days at a time. Is this a collaborative environment? Certainly not!!! It doesn’t bode well for a fruitful, enjoyable long career!!!

No Practice Socialization Events

Most practices have some sort of get-together for the members of the group or hospital, whether it be the attendings, technologists, nurses, or other staff. And, there is a good reason for that. It is essential to get to know your colleagues so that you can feel comfortable relying on them as people. If none of these events are available, it sure seems that a lack of trust may be in the cards. Do you want to be part of a practice where you don’t even know your colleagues?

Hallway Brawls

OK. Perhaps, once in a while, a colleague does not get along well with another. However, if you find this a regular occurrence, there is a good possibility that your colleagues have significant personality disorders. Are you willing to deal with this behavior for the rest of your working career?

No Rewards For Good Employees

Sometimes your employees go above and beyond what the employer expects of them. Practices that ignore good employees also tend to overlook each other. How do you reward someone who is adding value to an imaging business? Well, you give them a bonus, extra vacation, or at the very least essential verbal recognition of their excellent work. If your practice can’t see how good you are and are working hard to better the business, consider going elsewhere!!!

Always Being Told You Are Wrong

Perhaps, you are missing a lot of findings or do not communicate well with colleagues and physicians. But, if you find that you are within the bell curve and your employees are constantly criticizing your work, did you ever think that they might just not want you there? Start looking around!!!

Running Around Like A Chicken Without A Head

Living in constant stress with tons of studies and responsibilities without end is not sustainable over the long run. Some practices run continually by having radiologists read too many cases to be safe. They are just in the business to make money for the bottom line of the partners’ pockets. Can you work in this sort of situation for the rest of your working life? Think about finding someplace where you can work over a long, sustainable period!!!

Lack Of Hospital Involvement

You notice that none of your colleagues or future employers is on committees within the hospital staff. If you want to stay relevant to your place of practice, at least someone needs to be involved. Otherwise, if there is no connection to the practice facilities, the ax may fall when you least expect it, and all of you may be out of a job!!!

No QI Committees

Believe it or not, quality is a crucial element of good practice. How do you know how you are doing? Well, there is only one way. You need to have someone that monitors the quality of the practice. Does the imaging business have morbidity and mortality conferences or peer evaluations? If your future coworkers are embarrassed to have their work checked, you may be looking at a practice that doesn’t care how they are doing. Start thinking about finding a practice that cares about the quality of their work!!!

No One Cracks A Smile

I find it a relief to crack a joke or say something nice and get a good response. However, some practices take themselves way too seriously. Do you want to be in a practice where everyone is miserable?

The Almighty Buck Always Rules The Roost

If you have not learned it yet, you will undoubtedly learn it at some point. It is not always about the money. Employers need to value ethics, practicality, and hard work over money at many points to run a genuinely great practice. If there is never a time that your future employer factors these attributes above the almighty buck, consider your alternatives!!!

So There Are Red Flags. Now What?

Not all practices are perfect, and it doesn’t necessarily mean that they are dysfunctional. However, when you catch a pattern of multiple red flags again and again without correction, it may be time to rethink your employment strategy. Keep your eyes wide open and your ear to the ground!!!

 

 

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Expectations vs Reality Upon Graduating Radiology Residency (I Hate To Burst Your Bubble!)

expectations

During residency, most physician trainees are studying and working so hard that they vaguely realize what is in store for them when they finish their training and begin their first job. What they often expect differs dramatically from reality. So, I thought this would be the post to give you the lowdown on some expectations versus reality when you start as an attending. We will cover six employment topics: money, job performance expectations, the importance of the bottom line, teamwork, case sign-off, and feedback.

Money Issues

Scenario

You begin residency and see these large salaries that come across in your email from recruiters. And, you hear stories of friends doing well at their first job, making tons of money that they don’t even know what to do with.

The Reality:

Many residents consume themselves thinking about the relatively “large salaries” they will earn once they finish their residency. You may think, well, if I can do that for ten years, I will be out of debt and rich. However, every large salary comes with a price. Either you will be working like the proverbial “dog,” or you may be located in a place very far from your friends and family.

Other new attendings also do not realize the costs that accrue from debts, buying a house, and maintaining a luxury lifestyle. Often, these folks go into further debt, funding a lifestyle that they cannot afford. Don’t let that be you!

Job Performance Expectations

Scenario:

You have just graduated as a neuroradiologist, and you are ready to take your first job. The job post said you would be performing 50 percent neuroradiology and no mammography while on a partnership track. You are excited as can be not to have to read any mammography!!!

The Reality

As soon as you start, one of the partners asks you to help out reading mammography by taking a course and over reading one of the other radiologists’ mammograms. Since one of their mammographers left, they need the help until they can hire another.

This situation is commonplace in the world of private practice. Sometimes, undue circumstances arrive beyond the practice’s control, and your expectations for your work will not precisely align with reality. If you cannot be somewhat flexible, you may not become a partner in the practice!

Importance of the Bottom Line

Scenario:

Your academic nuclear medicine position at a high-powered center of excellence is about to begin in a few days. Since it is a large academic center, you figure you will have lots of administrative time to pursue your research interests. I can’t wait!

The Reality:

After a few days of working in your position, the institution issues rules regulating administrative time. If you cannot obtain a grant to support the institution, you will have very little administrative time.

Don’t assume that a large academic institution does not care about how much money it earns. It needs radiologists to financially support the institution by reading films just as a private practice needs to perform procedures and interpret enough films to stay solvent. An academic institution does not mean lots of free time!!!

Teamwork Expectations

Scenario

You are about to begin your first private practice job, and they told you that they treat all employees and partners equally. So, you are very excited to start a career with an equal footing to everyone else.

The Reality:

In your first week of work, a partner asks if you could help him out with reading some extra films because he and his wife want to go to a concert. You tell him that you had early dinner plans with your wife, but he continues to insist. You feel you have to stay to complete the work because he is an influential partner in the practice. Bottom line… Everyone is equal, but partners are often more equal than others!!!!

Case Sign-off

Scenario:

You are sick of waiting for your attending radiologist to sign off the reports you dictated a few hours ago. When you finish residency, now you will be able to complete your dictations whenever you are ready!

The Reality:

Now that you are the final reader and the buck stops with you, you become unsure of the findings and want to ask your colleagues before completing some of your more complex reports during your first days of work. Well, now you don’t have to wait for someone else to sign off your reports. Instead, you may need someone else to look at the cases for a second opinion before completing the study!!!

Feedback

Scenario:

The practice partners state that you will get immediate feedback about your progress after six months. Furthermore, they say that they can even tell who will be partnership material by the first year.

The Reality:

Six months roll around, and no one lets you know about your progress. You think you are doing well, but you are not sure. The patients and the clinicians seem to like you. After one year, no one lets you know if you will make a partnership after the three years they promised you. Unlike residency, feedback can be much more challenging to obtain since it is not designated. There is no guarantee!!!

Expectations For The New Attending!

Becoming a radiology attending is not like entering Shangri-La. There will be new challenges that you do not expect. Along with the added respect, you will have many additional responsibilities. So remember, as a radiology resident, try to prepare yourself for the reality of becoming a radiology attending. So, you will not be surprised about what to expect when you begin!!!

 

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Maintenance of Certification (MOC)- A Controversial Necessity?

MOC

A groundswell of controversy about maintenance of certification (MOC) has been building slowly for the past decade. In truth, no quality evidence-based study has shown a link between quality of care and MOC. Therefore, multiple entities in the United States are abuzz, attempting to create anti-MOC legislation to prevent boards from gaining a legal foothold in states requiring MOC for practicing medicine. Some of you may hear about these issues in the press. (1,2) These issues are not just unique to radiology.

But before we discuss the individual controversies, we need to delve into MOC a bit further, especially for those just starting. What exactly is the maintenance of certification once you complete your residency in the United States? What do you have to do to satisfy the requirements? Why do you need to meet the requirements for MOC? And when do the requirements for maintenance of certification begin? Some of the answers to these questions are not so obvious. So, these are some of the questions I hope to answer in this post.

What is MOC?

According to the “experts,” maintenance of certification is a way to show that you are continuing to keep up with the educational demands of your specialty. Theoretically, it should ensure continued minimal competency to practice medicine. The American Board of Radiology and your state of practice require specific essential documentation for diagnostic radiology. For instance, the ABR requires 25 hours of continuing education credits (CME) per year, passing a test every ten years or completing online email questions correctly to certify competency, verification of state licensure, and quality improvement projects or leadership roles.

Individual states also require their primary means of determining competency to maintain licensure. When I first obtained my license in New Jersey, I had to take a required orientation course. Every year, I need to submit 50 CME credits each year. In addition, the state requires me to satisfy an end-of-life care course requirement every three years. Each state can significantly differ in what is needed to keep a license. Go to the site called mycme.com for more information on your particular state.

How Do I Get CME Credits?

Typically, radiologists can get continuing medical education credits in one of many ways. First, many online radiology society websites, such as RSNA and ARRS, develop education portals for radiologists to complete either articles or lectures. The radiologist then takes a short quiz they must pass at the end of the episode to document that he has completed the task.

Second, you can attend conferences at many locations throughout the country and then collect the CME credits at the end of the course. Usually, the conference presents the physician with a certificate of completed CME at the end of the meeting.

And then, internally within your hospital or practice, you can participate in tumor boards, conferences, etc. Subsequently, you can obtain the CME credits after documenting what you have experienced as long as the creators of the conference have applied for CME.

What Happens If I Don’t Participate In MOC?

Unfortunately, for most radiologists, it is not an option to forgo MOC. Most hospitals require certification by the ABR and state licensure bodies to maintain staff privileges. And individual practices often stipulate that you need MOC to remain in practice.

But, you may hear about other specialty physicians in the news who have not renewed their certification. Many of these folks are leading political and internal movements to eliminate the MOC requirements. Individuals and organizations are suing certification boards who are teaming up with insurance companies and hospitals. Some of these boards aim to make MOC a requirement for radiologists to get reimbursed for the interpretation of images. Usually, the physicians not participating in MOC have been practicing for a while, so they have the clout to abandon the MOC process.

When Do I Need To Start With The MOC Process?

Over time, the ABR requirements about when to start MOC have changed. The MOC process begins on day one since the ABR now considers MOC to be continuous. According to the ABR, you need 75 CME credits over three years of practice to maintain certification. That means you could theoretically begin CME on the first day of practice or wait a bit to start.

On the other hand, each state has different requirements for when to begin MOC. You should look up your state online to determine which rules are correct. Again, refer to the site called mycme.com, which outlines the specific requirements for each state. For the state of New Jersey (my state of practice), they give you a grace period of two years to begin CME after the first renewal of your state licensure.

Former Actions Against MOC

According to a Medscape article from 2017 (1), many state organizations have been banding together to prevent the overreach of MOC. This article documents many of the individual state medical society activities. I thought these activities were particularly fascinating.

To summarize some of the activities in this article, multiple state medical societies have attempted to pass anti-MOC bills in their states. Most of these attempts are in process or have been temporarily tabled. One state, Georgia, became the only state to pass a bill that prevents using MOC as a condition of licensure, employment, reimbursement, or malpractice insurance at certain hospitals.

At the time of the writing of the Medscape article, several states have initially failed in their attempts to pass MOC legislation. Three state medical societies (Arizona, Kentucky, and Michigan) created stipulations stating state medical boards “may not require a specialty certification or maintenance of a specialty certification as a condition of licensure.” However, legislatures did not pass the bills. Oklahoma became the first state to attempt to enact legislation to remove MOC as a requirement for physicians to obtain a license, get hired and paid, or secure hospital admitting privileges. However, at the last minute, the bill failed after significant lobbying by ABMS (American Board of Medical Specialties).

Other state medical associations are in the throes of creating anti-MOC bills. Both Tennessee and the Florida Medical Associations aimed to create bills to defeat efforts by the ABMS and FSMB to impose MOC as conditions for reimbursements and licensure. Finally, numerous other states, including Maryland, Missouri, North Carolina, Texas, Alaska, California, Maine, Massachusetts, New York, and Rhode Island, are trying to enact anti-MOC bills.

More Recent Defeat Against The Anti-MOC Movement

Most recently, in 2021, the federal court of appeals affirmed the dismissal of physicians’ claims against the American Board of Internal Medicine claims that challenged the MOC process. However, other litigation is still ongoing. 

Summary

Regardless of your stance on MOC, it is integral to most radiologists’ practice. It will be present in some form or another for a long time, perhaps in a more weakened state. Follow the current rules when starting, and you will get to practice radiology. Be a revolutionary against the system, and you may have difficulties. Either way, the final decision is up to you!!!

(1) Chesanow, N (6/21/2017) The War Over MOC Heats Up. Retrieved from http://www.medscape.com/viewarticle/881274

(2) Reese, N. (8/3/2016) MOC Exam: Take It Or Not? Retrieved from http://www.medscape.com/viewarticle/864922

 

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Should I Sell Out To The Legal Profession?

legal

Often radiologists deliberately take advantage of the opportunity to do legal consultation work for a fee. These services include expert witness work and legal brief consultations. Their colleagues deride some of these radiologists. Other physicians call this “selling out” to the lawyers. But is it? Today I will discuss why I think that radiologists who perform legal work provide some benefit not only to their financial well-being but also contribute to their own clinical and professional skills as a radiologist.

Better Understanding Of Radiology Malpractice

Nowadays, in the United States, radiologists encounter so many pitfalls that can potentially envelop them in a lawsuit. Sometimes the only way to avoid one is to observe others’ mistakes. Participating in legal work provides this window to see other radiologists’ errors and to understand how to prevent these hazards. We are only a hair’s width away from being involved in a lawsuit for our actions and vocabulary daily. Why not work to distance yourself from being the next lawsuit victim?

Improved Reports

Contrary to popular belief, involving oneself in legal work improves the readability of most radiologists’ reports instead of detracting from them. Those who do legal work are much less likely to leave grammar errors, typos, and other blunders in their reports. They tend to take the radiology report’s structure and final appearance much more seriously. Since they understand the ramifications of an unclear dictation, they are much less likely to confound their fellow clinicians with poor dictation.

Physicians participating in legal work are also more likely to know the jargon to not place in a report. Sometimes the wrong word choice can increase the chance of a lawsuit. Why not decrease the likelihood of it happening to you?

In addition, these radiologists tend to create differentials that consider the clinical situation because they know that subtleties can vastly change the outcomes of the patient’s management based on the malpractice outcomes of other radiologists. The final impression is more likely to consider these clinical issues, providing more benefit to the ordering clinicians.

More Thorough Documentation

Some radiologists do not take the documentation of conversations with clinicians seriously. Understanding the mechanics of malpractice increases the likelihood that a radiologist will document the critical findings and discussions with other doctors and patients. This information is vital not just for the attorneys but also crucial for the timeline of the medical record to allow for better treatment and an understanding of the events during a patient’s clinical stay.

Improved Communication With Fellow Physicians

Knowing what has happened in other malpractice situations also forces us to be more careful to communicate the results of a report on the phone or “in person” with other clinicians. Those that have completed malpractice work have a much lower threshold to trigger a phone call to their colleagues so that the report and the patient do not “slip through the cracks.” This understanding is only to the final benefit of patient care.

Is Legal Work Selling Out?

Based upon these tangible benefits of malpractice work, I think I make a case that participating in legal consultation is not “selling out.” Of course, some physicians abuse the legal system to make a quick buck and never learn from the mistakes of other radiologists. However, most radiologists that work with attorneys genuinely want to help their radiology colleagues and improve their clinical and professional skills as a radiologist. Maybe we should all consider doing some malpractice work at one time or another!

 

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Radiology Textbooks Vs. Case Review Books- A Death Match

textbooks

One question that often arises is: what material should I study since there is so much information to learn? But I think a more appropriate question may be: how can I get the most bang for my buck when there are so many reading materials out there? In this post, I will address this issue by talking about when you should be reading textbooks and when you should emphasize case reviews since both play a role in getting up to speed during radiology residency or learning about a new area of interest as an attending. (This is our death match!!!)

Why Textbooks?

Sometimes you lack any understanding of a modality when you begin a residency program, are starting a new rotation, or are attempting to learn a new modality such as MRI, perhaps not covered in your residency. For instance, when they begin, most radiology residents have no clue about ultrasound: how it works, and the images the technologist takes. Therefore, starting to read a case series on ultrasound may not be helpful when beginning.

Instead, a general introductory textbook such as Ultrasound: The Requisites makes more sense at this point to understand the basic principles of ultrasound and the key images that need to be taken and interpreted during a renal ultrasound, Ob/Gynecology ultrasound, etc. Another example would be reading CT scans of the chest. Most residents, when they start, do not have a search pattern for reading chest CT scans. Nor do they know their CT chest anatomy well. An introductory textbook on chest CT scans, such as Computed Tomography and Magnetic Resonance of the Thorax by Webb, would be appropriate before reading a case series.

In addition, good textbooks usually better outline the fundamental knowledge needed to interpret images better than a case review series can. Textbooks are better organized by topics, whereas case review series tend to be more haphazard. For example, it may be more direct and efficient to learn the fundamentals of determining whether an intracranial mass is intra-axial or extra-axial once in a textbook than reading 10 case series on the topic and trying to figure the same approach out.

How To Read Textbooks

When you read a textbook, you should emphasize the images, read the captions, and then read the text to get the most out. Reading in this manner reinforces the information that you need to know better than starting from the text first. This process differs vastly from reading a medical school general medicine textbook, where the text is usually more important than the images. You are now a radiology resident, so you have to think differently!

Why Case Review Series?

In our field, we solely exist because we are image interpreters. So, it makes sense to learn those images and what they mean. What better means to reinforce and understand radiology than with a case series? But, this assumes that the reader has some background knowledge on the topic and can understand the basic principles/fundamentals/meanings behind the images in the case review series.

In addition, case review series tend to have more of a “real word bent.” The images we read daily tend not to follow in an orderly manner by topic. Usually, an almost random distribution of cases comes through our departments. Going through a case review series is usually more similar to going through many images in no particular order.

How To Approach Case Review Series

It would help to start the case review series as soon as you have the fundamental knowledge to understand the modality, anatomy, and primary disease processes on imaging. On each initial rotation, you should aim to start reading at least one case review type of book after you have learned the fundamentals from lectures and textbooks. Do not wait too long to get started, however. Going through the case review series will be more helpful and applicable than most textbooks when you read out cases with attendings and when taking cases at noon conferences. But remember- it often does not summarize the fundamentals of a given subject as well as a textbook.

The Moral Of The Death Match

Both textbooks and case review series are at the beginning resident’s learning armamentarium. Be wary of someone that tells you that you can get through residency by just reading textbooks or case reviews by themselves. Each has its place, and you should use the correct one depending on your level and knowledge base. Now become great radiologists: go forth and read!!!

 

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Radiology Private Practice Versus Other Career Pathways- Is It Worth “The Extra Money”?

private practice

The herculean question up for debate: is a private practice career path worth the extra money? To answer this question, you have to know your career options. Suppose you are talking about standard career options for the radiologist (not the alternative career paths discussed in a prior post). In that case, you can divide it into three main choices: private practice, academic/government, and the hybrid model.

Lucky for you, if you are reading this article and you are now making this decision, you have come to the right place. I have worked in the world of academics as a fellow and dabbled in private practice at my first job out of training at Princeton Radiology. Now, I work at Saint Barnabas Medical Center, where we operate with a hybrid model (I was also formerly a resident at a program with a hybrid model-Brown University). Since I’ve been through it all, I am uniquely qualified to talk about how to decide between each option. So, I am going to do just that!!! (Don’t let other posers fool you!)

Are There Income Differences?

What is the difference in income for an academic practice radiologist versus a private practice radiologist? If you look at the Medscape Radiologist Compensation Report from 2016 (later surveys did not have this information!), the academic radiologist made around 262,000 dollars (in this category also is included the military and government physician). On the other hand, some of the other private practice type radiologists made significantly higher amounts: the office-based solo practitioner- 434,000 dollars; the office-based single-specialty group practitioner – 386,000 dollars; and the typical hospital compensated radiologist- 381,000 dollars. So, suppose you take these debatably inaccurate academic and private practice numbers into account. In that case, a pretty substantial difference exists between the income of private practice and academic radiologists (almost 100-150 thousand dollars per year).

It’s Not Just About The Income Though!

But not so fast! In terms of numbers alone, the actual compensation may not account for other benefits like pension and health care. Employees that work for the government or large institution academic hospitals can sometimes receive substantial fringe benefits such as a pension of 70-80 percent of the final salary. Or, they can get incredible health care insurance that you cannot earn elsewhere. Finally, some have other perks, such as free tuition for children in college.

Moreover, the typical smaller radiology private practice will not give these perks. If you take the pension alone, that could amount to a guaranteed (0.8)(262000 dollars per year) or about 210,000 dollars for the rest of your life based on 2016 salary numbers. You would need to have 5.24 million dollars in the bank to have that kind of money guaranteed annually, assuming a 4 percent relatively risk-free return. So, the difference may not be as substantial as initially thought at first glance.

So, now that I have debunked some of the income-based differences (there are always exceptions to every rule!), let’s talk about the different models and decide which option is the right one for you. Let’s start!

The Academic/Government Model

In the purely academic or government model, the primary goal is not reading films and making money. Instead, you will need to publish, teach, or exist (if you are talking about a place like the VA hospital!). Prestige and promotion results from these activities. For comparison, the typical private practitioner couldn’t give a lick about these job requirements. The philosophy is often: publish or perish!

The typical academic sort writes a lot, obtains grants, and is responsible for his/her residents’ teaching and welfare. He/she typically reads fewer studies and sees fewer patients than a typical private practice radiologist. But, that may vary depending upon the institution for which you work. He/she gives many conferences, travels all over the country/world to give lectures, mingles with other academic sorts on all different types of committees, and plays a significant role in directing the future of radiology. Many of these radiologists have outside ventures and partnerships with various companies and academics centers since they do not only occupy themselves with the standard day-to-day role of reading films. Some of the associations may be based on their research or area of expertise.

The higher-up academic radiologists manage their staff as chairmen. These individuals may be responsible for budgeting, hiring, and firing depending upon the institution. Again, your mileage may vary depending upon the role that you have in the institution. The almighty dollar has less control over your day-to-day work. (Although many would say it still plays a nice-sized role!)

The Pure Private Practice Model

What about private practice? In general, private practice wants to maximize income and the number of patients that go through your system. Of course, excellent radiology businesses have an element of quality. But quality exists to increase profitability, and the almighty dollar tends to rule the day. And, of course, all roads lead back to the almighty dollar. Employees and owners grind out films daily, day in day out. The philosophy: if you do not work, you do not make money.

Now, of course, the private practitioner also accomplishes other activities in trying to make money. These folks may perform some or all of the following practice needs: advertising, buying and selling equipment, strategic partnerships, and mergers, maintaining relationships with hospitals, hiring and firing an army of numerous employees (possibly radiologists, technologists, janitors, nurses, physicists, and so on), maintaining and purchasing real estate, payroll, billing, legal issues, parking, and utilities. On the other hand, academic hospitals/ institutional facilities typically take care of most of these issues. Therefore, you need to enjoy playing many different hats and roles and being a self-motivated entrepreneur.

The Hybrid Private Practice/Academic Model

I currently work in this role. I like to think that I get the best of both the private practice and academic world. (Although some would like to say that is the worst!) The hybrid practitioner’s philosophy: A dabbler who enjoys elements of both private practice and academia, but not in such depth.

So, how does the hybrid model work? First of all, you have a few variations on a theme. In my situation, I am involved in a hospital-based private practice with a residency program and multiple covered hospitals and imaging centers. For another type of system, the hospital may employ you, but the hospital may tie you to the private practice world via output bonuses. In essence, the practice expects you to teach, do a little bit of research, and maximize your work output. Thereby, you create income by grinding through studies. Most of these practices are not involved in purely academic activities such as obtaining grants. And, you will probably not involve yourself in typical pure private practice issues. For instance, you will probably not need to maintain the building utilities.

The hybrid practitioner/dabbler likes to do a little bit of everything without delving into some hardcore academic and pure private practice issues. I was never interested in writing grants, but I certainly wanted to teach. I was not interested in dealing with some of the fundamental problems of private practice, such as hiring/firing technologists. Yet, I was interested in the mechanics of business and private practice. For the sort of person that likes to be a bit more generalist, the hybrid model can be a great career path.

How To Make The Final Choice?

I think the final choice becomes a personality-based thought process, not one based on the different income constructions of each career model. If you hate business in all forms, work for the government or academia. If you hate writing and teaching, a private practice may be for you. On the other hand, if you love doing a little bit of everything, think about the hybrid model. Bottom line: You need to be true to your self. Do what you like, not what others will think you will enjoy. If you follow these precepts, you will make a great choice and have a fantastic career!

Comments are welcome!!!

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Malpractice Insurance: What Physicians Need To Know

If you are just starting practice as an employee with a physician group, you may think you don’t really need to know that much about malpractice insurance. Few physicians have the resources available to defend against a malpractice claim when legal services can cost tens of thousands of dollars and damages or settlements can be hundreds of thousands of dollars. When deciding on a malpractice insurance policy, there are two types to take into consideration: a claims-made policy or an occurrence-based policy.

An occurrence-based policy provides insurance against incidents that occurred during the term of the policy regardless of when the claim is made. A claims-made policy covers the insured for any incidents that occur during the policy period, as long as the claim for the incident is also filed during the policy term. Neither of the policies will provide coverage for incidents that occur before the inception date of the policy.

Tail insurance refers to a policy that the insured can purchase when he discontinues his claims-made policy. The tail allows the insured to report claims for incidents that occurred during the time the policy was active (from the retroactive date to the policy expiration date) even though the policy has been terminated. Tail insurance is generally a onetime payment.. If a physician decides to change employment, wants to continue practicing medicine, and requires a new malpractice policy, tail insurance will be required to continue coverage for all incidents that may have occurred under the old policy. Many claims-made policies offer “free” tail coverage for death, disability, or permanent retirement.

Based on this information alone, it would seem logical that an occurrence-based policy is the best option. However, the two types of policies vary greatly. Depending on how mature a policy is, and the specifics of the policy, the sum of all claims-made premiums along with the cost of tail insurance can approach the sum of all occurrence-based premiums over the same period. If it can be determined that a physician will be eligible for free tail coverage (i.e., he is covered by the same policy through retirement), claims-made insurance is usually the most cost effective. If a physician knows there is a high likelihood of changing employment and malpractice insurance, he may want to compare pricing of the two options including the cost of the tail coverage in his calculations. For example, a physician may want to consider an occurrence-based policy if he knows he is going to work at a location for a short amount of time and will not be able to take the coverage with him.

What To Look For In A Carrier:

While premium costs can’t be ignored, a company’s fiscal soundness, claims handling, and sensitivity to policy holders are also important considerations. Ask about the carrier’s A.M. Best rating. Given the current state of the medical malpractice climate, a rating of A minus is good. Your state insurance commissioner’s office can provide information about insurers licensed in your state and may also be permitted to give information about complaints that have been filed against the insurer.

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Teleradiology, A Risky Business?

It took years and years of hard work and dedication, long hours and sleepless nights, and the time has finally come.  You’ve got your home office set up, a couple of high resolution monitors, a few licenses and insurance in place.  You’re ready to take that leap of faith and get started in the world of teleradiology, right?

After all, entering the world of teleradiology seems like the dream choice for many radiologists.  Whether you’re working in a small practice by day, hospital at night, or trying to balance work and family, teleradiology can be the ideal choice for your primary income or to supplement your income.

Not so fast.  It’s 2017.  Just two decades ago, healthcare providers didn’t face significant penalties for improperly disclosing protected health information (PHI).  Since then, regulations surrounding the privacy and security of PHI have evolved to include strict requirements and corresponding steep financial penalties for non-compliance.

Where does this leave you? Is it far too risky to give it a try?

With security protocols and policies such as Information Security Risk Analysis, Information Security Risk Management Program, Information Security Audit Controls, System Activity Review Policy, Security Incident Response Policy, Data Backup and Storage Policy, Data Disposal Policy, Media Re-Use Policy, Workstation Policy, and Electronic PHI Movement Policy, is it best to stay out of the game?  You will also have to think about privacy policies such as PHI Uses and Disclosures, Patient Access, Accounting of Disclosures, Sanctions Policy, and Breach Policies and Procedures.  Don’t forget about the Regulations imposed by both federal and state authorities – there’s HIPAA, the Privacy Rule, Security Rule, HITRUST, The Omnibus Rule, Unique Identifiers Rule and the Enforcement Rule just to name a few.

Still ready?  Still have that home office, those high resolution monitors, various licenses and insurance in place?  Great!  Let’s do it!

But how?

My suggestion is, find a teleradiology company that has built a strong Data Security and Compliance Department.  A teleradiology company that has taken the necessary measures to secure Protected Health Information. One that is sought after by the larger urgent care centers, hospitals, and government entities because they have put these measures in place.  Urgent Care acquisitions are at an all time high.  These larger healthcare organizations are driving the teleradiology industry to be more security conscious.  If you want to be successful in this industry you will choose a teleradiology provider that is able to meet the expectations of these larger healthcare organizations.

This will be the teleradiology company that grows, and that contracts with the largest clients.

This will be the teleradiology company that safely and securely helps you realize the dream of becoming a teleradiologist.

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How To Combat A Difficult Radiology Job Market!

job market

Once again, like in many other economic cycles, the radiology job market has hit a bit of a pause. This time, it is due to Covid-19. Although the job market is not as bad as it was back around 2010, it certainly is not the same as it was at the beginning of this year. And, in many locales, the job market froze up entirely. Competition remains fierce in desirable practices on the east and west coasts. Even with some folks abandoning the cities for the more suburban and rural areas, you will likely find it very difficult to obtain a partnership position in San Fransisco or Manhattan!!!

How do you, as a graduating radiology resident or fellow, begin to approach finding a job in this competitive landscape? We are going to cover the essentials for finding a quality job in these problematic radiology markets. I will divide the essentials into the following sections: networking, diversification of skills, location, recommendations, and research/national organization involvement.

Networking, Networking, Networking!!!

Maintain Relationships At Home

Networking does not only begin when you start looking for a job. The search for the ideal job commences at home. What do I mean by that? The first and most important part of networking is maintaining good relationships with your colleagues and attendings.

Many attendings have their proverbial “ear to the ground.” More often than not, therefore, many can tell you about opportunities in the area. Moreover, they can guide you to those jobs. So, to get access to these high-quality jobs, you need to perform and be a good team player. The resident that has not been “playing nicely in the sandbox” during training will not receive those inside tips. More likely, the poorly behaved resident will need to fend for himself. On the other hand, residents who continuously strive for excellence and relate well to their colleagues will have first dibs on those desirable jobs with connections to your radiology attendings.

Keep In Touch

It also becomes more critical than ever to stay in contact with your colleagues and coworkers. When you are ready to leave your residency to go to your fellowship, keep in touch with your former colleagues, residents, and attendings. You never know when that next job lead is going to pop up. And, most former colleagues will happily give you a tip for a new contact. These connections will be the most likely to help with finding that next great job.

What about social media? Nowadays, professional-based social media groups such as LinkedIn can play a role in getting that next job. Besides, social media can keep you in contact with your former colleagues. And, social media allows you to let others stay aware of your current training and expertise. Therefore, residents should maintain at least one account. But be careful to keep the account relevant and correct. View it as a resume. If it is not updated and contains false information, it can be detrimental to finding that next great job. Otherwise, it can be a great way to contact your former colleagues as well as a way to obtain new leads.

Always Be Nice

Finally, even when you have started on that first job, whether it be a dream job or merely a stepping stone, make sure to be cordial and appropriate to your interviewees. I remember when I was interviewing, I met with a private practice attending who was touting the merits of his work to me. I subsequently found a job with a different practice. However, six months later, that same attending who interviewed me became an interviewee at my current practice. You never know what is going to happen!!!

Diversification of Skills

As a resident and fellow, try to do things in your field slightly out of your comfort zone. What do I mean by that? You never know what practices are going to want. Things change. Sometimes an imaging business may need a cardiothoracic radiologist but also require a radiologist that can also read mammograms. Other times, a practice may need an interventionist that feels comfortable with reading musculoskeletal MRI. To become the most competitive candidate in your class, you need to make sure that you feel comfortable in as many modalities as reasonable. Therefore, you should not just concentrate on your fellowship skills or areas of comfort, but also your weaker procedures/imaging areas.

As a fellow, it also becomes crucial to moonlight to maintain your skills in other general radiology areas, outside of fellowship. It can build your speed and accuracy. So, when you start your first job, you will be able to read studies at a reasonable pace. Moonlighting will allow you to have a higher likelihood of remaining at your first job after training!

Should Location Be The Sacrificial Lamb?

Sometimes the job market in some locations becomes so ultra-competitive that good jobs may not exist in your desired area. In that case, there are times when it makes sense to alter one’s expectations and apply to other locales outside of one’s original intentions. By switching locations, the applicant may significantly increase the job market choices that will allow her to practice her subspecialty or earn more income. However, an applicant should not take this decision lightly because personal or family issues sometimes can trump job selection. But, an applicant should consider all the alternatives before selecting a job.

Recommendations

As a radiology resident or fellow, obtaining a radiology job recommendation differs significantly from asking for one as a medical student. Instead of a formal letter, a radiology resident or fellow should let the attending know to expect a phone call from a radiologist at the practice where he had interviewed. Although informal, this practice gives more information to the radiology practice than a simple letter of recommendation. A radiologist can relay the real personality and information about a candidate on the phone more easily without legal repercussions. In this situation, no paper trail exists.

In the conversation, the caller may informally ask your supervising attending about your work ethic, whether you played well with your team, and more. Other times, a member of the practice may speak with a friend of theirs within your residency program to confirm that you would make a reasonable job candidate. Bottom line: it is good manners to let your attending and program know to expect a phone call!

Research/National Organizations

For those interested in academics, completing research projects can help to snag that first academic job. Although not as crucial for the private practitioner, it also can’t hurt to have completed research projects. As I’ve mentioned in a prior post on research, if practices have a choice between two equal candidates, they may sometimes choose the resident with more research experience. You never know…

Also, getting involved in national organizations, whether it be the ACR, RSNA, or AUR, can be a great way to learn about the politics of radiology as well to meet colleagues and practitioners. Residents should consider participation in these organizations.  It could be a stepping stone to find a great job or to become the next President!

Final Thoughts About The Job Market

If the job market is tight, all is not lost. Even in the most challenging markets, some practices will usually have a few jobs available. To increase your chances of getting one of these popular slots, you may need to work a bit more intelligently and focused so that you can become a desirable candidate. Networking, diversifying your skills, making sure to get great recommendations, finding the correct location, and participating in research and national organizations can help your cause. Ultimately, these practices will choose someone that fits the expected identity of an ideal candidate. If you follow these essentials, you have a much better chance that that person will be you. Good luck!!!