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I Am Caught In An Early Vicious Cycle: Help!

vicious cycle

Question:

Hello Dr. Julius,

I found your article about the struggling radiology resident and looked at your previous answer to a similar question. I am an R1. At the end of October, the program informed me that I was struggling and having problems with synthesizing information and communication issues. Since then, they told me I haven’t improved and am still behind my peers.

I know that you mentioned getting out of the vicious cycle will be difficult, but I feel that every time I’ve spoken with my PD or assoc PD, they think my problem is inherent and I can’t be a radiologist. I’ve seen a psychologist for help, and I accidentally got the GME involved in seeking information. I’ve been studying harder, but I have a shaken confidence. And I keep missing things and not improving. I am concerned that they will fire me. Where do I go from here? Do I start looking for another specialty or stick it out until they’ve had enough and will not renew my contract?

Name

Scared R1

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Answer:

Dear Scared R1,

Before anything else, you need to ask yourself if you have been putting in many hours of studying each day and have immersed yourself in radiology. If you are honest with yourself and have genuinely been putting everything you have into learning radiology, you shouldn’t be so hard on yourself. I am going to assume in your case that this is true.

So, what bothers me most about your situation is how you explain it. You said you just recently started as an R1. That would mean that you just began the second half of your first year. And yet, it seems that you assume that your PD and associate PD think that, inherently, you will not make it through your program.

It would be highly unusual for a PD to know that you can’t make it through your residency so early on. In my experience, I have had several residents who had a questionable first year, only to discover that they became more than proficient when they started on call. Typically, they can know only by seeing how you do on call. (assuming you passed a precall assessment) So, it seems they haven’t even given you a chance. From what you are saying, you may be in the midst of an early vicious cycle.

Remediation of the Vicious Cycle

Second, the ACGME requires the program director to allow you to remediate your situation. They can’t just indiscriminately fire a resident without due process. And, since you have barely started radiology, there is no way you could have had an adequate opportunity to remediate the situation. Again, this assumes that you have not done anything to endanger your patients or fellow staff that would require them to prevent you from working.

So, where does this leave you? Well, improvement is an incremental process with occasional setbacks along the way. You may feel like you are not improving, but you are. The key is to learn from your mistakes and not repeat them repeatedly so that the vicious cycle continues. It’s ok to have missed at this point. You certainly can’t expect a first-year not to make any mistakes.

All this being said, occasionally, some residents can’t cut it. But these residents are rare, and I certainly would not be ready to pack it in just yet.

At this point, you should view each mistake as a learning opportunity, not as something to get discouraged about. You need to stick it out with some grit and determination to get through this difficult time. Radiology residency can be very tough for first-year residents. Staff can be unforgiving.

Improvement is a gradual, almost imperceptible process in any small time frame. You may notice the changes from reading and studying in a more extended period. Continue to soldier on, and let me know how things go!

Sincerely,

Barry Julius, MD

 

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Question About Improving The Vicious Cycle:

Hello Dr. Julius,

Thank you for the encouraging reply. In your experience, what is the usual time frame for struggling residents to see improvement? I’ve finished four weeks on a must-cover, and my faculty state that I am not improving. I have another four weeks to go, but I am concerned that if I haven’t improved much in the first four weeks, what are my chances of improving in another?

Sincerely,

Scared R1

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Answer:

Scared R1,

Four weeks is a concise amount of time to assess for global changes/improvement. If we are talking about more specific goals you have set, that would be more appropriate. Based on what you are saying, it is hard to determine what improvements they are trying to assess. Global assessments don’t work too well. I am writing an article talking about that.

On the other hand, programs and residents can assess and create incremental specific goals. Hopefully, they are creating these for you, and you have made some for yourself. You can undoubtedly reach specific smaller goals within a 4-week block if these goals are appropriate.

Barry Julius, MD

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Nighthawk: A Viable Career Option For Radiologists?

nighthawk

When you think about the field of radiology, do you picture yourself working from dusk to dawn for years at a time? I suspect that most of you have not. More likely, you’ve probably dreamed of a 9-5 job with an occasional call on weekends and evenings. So, what do you lose out on by beginning a career as a nighthawk? And, are there any permanent advantages to working as a Nighthawk for years? Let’s delve into the main issues of working as a radiology Nighthawk.

Why Nighthawk Can Be So Difficult

Imagine yourself on the computer at night beginning at 10 pm and working until the wee hours of the morning at 7 am, reading films night after night. For most people, social and business activities occur during the daylight hours. So, when you create a schedule for yourself such as this, you essentially live the life of a loner. Sure, you may receive phone calls from attendings and medical professionals who need your assistance from time to time. But are those interactions you looked for when you decided to go into radiology? Probably not.

Furthermore, say you need to take care of some business at a bank or make returns to a store. These mundane activities turn into a real hassle. Instead of conveniently stopping by these places to take care of business, now you must reverse your entire schedule to get there. It can be hard enough sometimes to get out of work, even for me during the daytime! I can only imagine the difficulties for a nighthawk.

And then, of course, there are the health issues. Study after study has espoused the dangers of reversing one’s sleep schedule to counter normal nighttime sleep. Take a look at this article from the sleep foundation (1). They list many physical, mental, performance, and safety issues the night worker encounters. Believe it or not, it includes increased cancer risks, depression, and more. Do you want to take on these increased risks?

The Allure Of Nighthawk

Yet, wouldn’t it be nice to set up shop any place you want? Do you want to live on the west side of Manhattan? Or, maybe rent a home in Malibu on the beach? Well, it doesn’t matter if local jobs are unavailable when you are a Nighthawk. You can work from anywhere. But is it worth the sacrifice?

For some folks, Nighthawk positions allow radiologists to get their proverbial foot in the door. In some locations, getting into a practice can be exceedingly tricky. (although not as much in the current job market!) And sometimes, Nighthawk can be a solution. Because the hours are less desirable, radiologists are less likely to compete for these entry jobs. Now, you have a way in. But don’t think you can quickly work your way into a daytime position. Other radiologists in practice certainly will not chomp at the bit to take your place!

Then, working at an office or hospital with others may not sit well. Some people would instead go it alone, literally. Of course, Nighthawk from home can be a very solitary assignment. Maybe, this is what you want from life.

And finally, practices will often jack up the income stream to entice the new radiologist to take a Nighthawk position. The savings can be enormous for those of you with extreme debt (I mean greater than 500,000 dollars). Of course, it is not without sacrifice, however.

To Make The Ultimate Sacrifice- A Nighthawk Position

In the end, it is your decision. A Nighthawk position does have significant advantages, but not without substantial sacrifices. If you are willing to forego convenience, tempt fate, and live a loner’s life but live where you want and pay your debts off sooner, then maybe, just maybe, a Nighthawk position is for you!

 

(1) https://sleepfoundation.org/shift-work/content/living-coping-shift-work-disorder 

 

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Radiology Recruiters: The Good, The Bad, And The Ugly

radiology recruiters

Every once in a while, radiology residents and former radiology residents will ask if they should use radiology recruiters to search for jobs. And, if you glance at some forums (which will remain nameless!), radiology recruiters are labeled the epitome of evil. But, what is the real story behind radiology recruiters? Does it ever make sense to utilize their services? Or should you believe the hype online? Based on my own experience and the perceived experience of current and former radiology job seekers, I will give you the lowdown on the lowly radiology recruiter. By the time I finish, you will understand the good, the bad, and the ugly! (the Amazon affiliate link to the actual movie!)

The Good

Let’s start with the merits of a recruiter. For some with less job experience, recruiters can help improve the applicant’s overall package. What do I mean by that? They can provide services like interview practice, resume scrutinization, and general mentorship. For some, these services can be invaluable.

And then sometimes, these recruiters can provide insights to the applicant, such as contract negotiation tactics, legal help with contracts, and tips for the uninitiated. The recruiter can serve these individuals well if you don’t have the appropriate background to know some of the finer details of these job negotiation skills.

In some markets where the job seekers are scarce and applicants have lots of opportunities, some practices will utilize a recruiter to gain an edge. Rumor has it that those practices that use a recruiter are second-class. But, I don’t believe that is necessarily so. Sometimes, these practices may be smaller or do not have the connections with the local residency program as a feeder for positions. In these situations, recruiters can provide a valuable service to these lesser-known smaller practices, matching the appropriate applicant for the right job opportunity.

Finally, if the applicant is unfamiliar with an area or market, good recruiters can provide a good reference for the lay of the land. A good radiology recruiter will know a lot about the location and the market opportunities. Sometimes, searching for this information can be challenging to find on one’s own during the throes of residency or fellowship.

The Bad

The interests of the radiology recruiter and the applicant do not always align. What do I mean by that? A radiology recruiter can heavily advocate for an applicant to take a job that does not match his needs. If you think about who typically pays the recruiter (the practice), it almost always makes sense for the recruiter to push the job. Now, this can happen whether the job fits or not. To that end, an “honest” radiology recruiter may avoid this conflict of interest. But this is the real world, folks. And, not all recruiters follow the rules of nobility!

The Ugly

So, think about it. How are recruiters paid? Typically, most recruiters receive payment from a practice (a retainer) when they have placed a candidate successfully. And now, who do you think would be the preferred candidate, all things being equal, if you have two folks with precisely the same credentials, one using a recruiter and the other going it alone? Well, it’s pretty simple. The applicant without the recruiter will get the job. Why? It’s free for the practice to acquire the resident without the recruiter! This problem leads to the ultimate paradox of recruiting!

The Real Truth Behind Radiology Recruiters

Radiology recruiters can be a godsend for those applying to noncompetitive locations who are unaware of job opportunities or do not have honed business skills. On the other hand, recruiters can put you at a distinct disadvantage for those interested in more competitive locales with a bit more experience and those who know the opportunities and most of the practices in the neighborhood. So in these cases, I recommend you try to network or cold-call first.

As you can see, based on your situation, a recruiter may or may not be suitable for the applicant. Here’s the bottom line. Do your homework before looking for a recruiter. Radiology recruiters can be the reason for obtaining or losing your next job!

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The 2018 Trump Tax Plan: How Will It Affect The Typical Radiology Resident?

It’s final. President Trump has signed a bill approved by the Congress to overhaul the U.S. tax system. And, it will take effect starting January 1, 2018. However, I am a bit irritated by the misinformation out there. Watching network TV would make it seem that the tax plan will increase everyone’s tax liability. But as usual, I delved a bit deeper into the facts behind the plan.

To find out what is really going on, I have compared the new and old tax brackets and the different deductions based on the new and old tax bills. We will go through these numbers and calculate what you would have paid through the old tax system versus the new tax plan. More specifically, we will look at a few scenarios. These include a single radiology resident making the median radiology resident salary with no kids; a married couple each making a median radiology resident salary; and a married couple each making a radiology resident salary with 2 kids.

Today, we are going to emphasize federal taxes alone since every state is different and most state taxes have not significantly changed. In addition, we will assume that most of you do not own a home (since that is the minority of residents!). And, we will say that you will pay off the maximum amount of deductible student loan debt. Finally, we will estimate that each resident makes the median salary of 54,378  dollars. (1) I bet you’re curious. So, let’s start with the calculations!

Single Resident, No Kids

For 2017, we used the turbo tax taxcaster software and the median radiology resident salary of $54,378. And, we are assuming that you are paying down the maximum student interest. With this information, your tax liability would be $6634 with a marginal tax rate of 25%.

For 2018, using the calcxml.com software and the median radiology residents salary, your tax liability would be $4,713 dollars with a marginal tax rate of 22%.

So, the truth would be a $1,921 decrease in federal taxes. Not too shabby!

Married Resident, No Kids

For 2017, we used the turbo tax taxcaster software and the median radiology resident salary of $54,378 for both spouses ($108,756). Again, we are paying down the maximum deductible student interest. This time your tax liability would be $13,372 with a marginal tax rate of 25%.

For 2018, using the calcxml.com software and the median radiology resident salary for both spouses, your federal tax liability would be $9,975 with a marginal tax bracket of 24%.

In this case, the decrease in taxes would amount to $3397, slightly less than double the amount for a single resident with no kids.

Married Resident, Two Young Kids

In this situation, we will assume that your children are getting childcare amounting to $5000 dollars per year. For 2017, the federal tax liability based on a median salary and maximum student deductible interest payments would be $8347. The marginal rate would be 25%.

For 2018, using the same software and the median radiology resident salaries, the total tax liability for the family would be $5975 with a marginal tax bracket of 24%.

For comparison, the decrease in taxes would total $2372. Also, much different than what the pundits will have you believe.

My Conclusions About Most Residents And The Tax Plan

For most residents out there, you will take home a small windfall, anywhere from $1921 to $3397, based on a typical radiology residency situation and assuming you maximize the student interest deduction. (To get the best tax deal you should take advantage of it!) Of course, a few radiology residents may not fare as well. For instance, if you own an expensive home or have a spouse that makes a lot of money, you may be in a special situation. But for the most part, you can ignore the pundits. You will do much better with Trump’s tax bill. Just another example showing that we all need to tune out biased media. It pays to check the facts and do the calculations on your own!

 

 

 

(1) https://www.glassdoor.com/Salaries/diagnostic-radiology-resident-salary-SRCH_KO0,29.htm

 

 

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How Important Is My Radiology Interview Really?

radiology interview

Picture this: It’s more than halfway through radiology interview season. And you’ve already traveled through much of the United States to meet all sorts of radiologists. You’re a bit weary from all the work (Imagine how your interviewers feel!) So, with all that time and effort you have put into the radiology interview process, did the interviews make a significant difference? I mean, this is only radiology, right? A specialty that does not value human interactions as much as internal medicine let’s say? And what happens if some interviews went well and others stunk up the joint? Does it significantly change how the programs rank you on the rank list? Well, today, you are in for a treat. You are going to get an insider’s view of the process!

The Power Of The Radiology Interview

Even in radiology, if I were to say that the interview held no weight whatsoever, I would be lying! A radiology interviewee with good interviewing skills can potentially increase his chances of matching. On the other hand, the interviewee that fails miserably can detract from their application. So much so that occasionally the interviewer can give you the dreaded acronym DNR (Do Not Rank!). But let’s go into some more specifics here.

The Interviewing Maven

Are you one of those medical students who always sound intelligent to everyone you meet? Or, perhaps, your charisma infects the entire room? Let’s say your interviewers have a 10-point scale that considers all the information, including your Dean’s letter, recommendations, personal statement, research, experiences, and board scores. I have seen certain applicants bump themselves up to 3 points. So what does that mean? A lot! Most candidates drift around the middle of the rank list or in the 4-6 range. When you add three points to your application, that can place your application in a rarified atmosphere. It can almost ensure your acceptance to a program.

The Interviewing Wall-Flower

Are you shy or uncomfortable during interview situations? Or maybe, you always appear depressed and lethargic? Hmm… Perhaps, you have a bizarre schizoid appearance? How do these interviewer qualities affect your application? Let’s see. In my experience, an applicant that should be somewhere in the middle or top of the pack can go down to (drum roll please…), the land of nowhere. And where is that may you ask? DNR (Do Not Rank)!!!

On the other hand, the average poor interviewee who is not quite hitting the answers to questions well or making a few flubs usually gets detracted by a few points. However, that can still make an enormous difference in a competitive application process.

My Final Point

So, if you consider these calculations, which radiology interview has the power to change the status of your application the most, the good or the bad? It’s simple. A bad radiology interview trumps the potential positive effects of someone with a great one.

What is my final point of this exercise? Make sure to take the interview very seriously. Please, please, please. Practice before you come in. Tape yourself on your cell phone. Do whatever you must before arriving or showing up on Zoom. A radiology interview is critical. Your future livelihood is at stake!!!

 

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Texting- A Minefield For The Radiologist

texting

Formerly as a student, you could get away with texting anything you wanted on your smartphone or computer. Unless you bullied your colleagues or significantly abused the technology, the consequences remained minimal. On the other hand, an “insignificant” text from a medical professional, including a medical student, radiology trainee, or radiologist, can lead to dire results. Between the potential for HIPAA violations, unforeseen job losses, and discoverability of texts for evidence in legal cases, poorly thought out texting can severely damage your career. So today, we will delve into the dark side of an important technology that we all use, the unencrypted electronic text/message. And, you will see why radiologists need to use this particular communication tool so carefully. We will go through five different situations in more detail.

Patient Information Texting Taboos

Sending patient information over an unencrypted text message can lead to a disaster. HIPAA has its tentacles everywhere. God forbid… If a third party discovers this message containing sensitive private patient information without authorization, the federal government can severely fine and even incarcerate you! And, we are not just talking about a few hundred dollars. Millions can be on the line! (1) Not only that, but the patient can sue you for breaching their confidentiality. It is a lose-lose-lose situation!

Sending The Wrong Information To The Wrong Person

Have you ever texted a friend only to realize that two seconds after clicking send, it went to the wrong person or group? I suspect a majority of you, at one point or another, have encountered this problem. Usually, it is something benign. But occasionally, it can damage your reputation. Imagine sending a text to a friend saying, “I find Harry annoying.” And instead, it travels to the head of the department, and Harry is her fiance. These damaging texts happen all the time. But no longer may you lose just a friend. Instead, you may also lose your job or damage your reputation.

Poorly Communicated Intentions

Did you notice that most texts come off abruptly without context or emotion? We often misinterpret information that we intend to communicate by text as an offensive slight to colleagues or ourselves. A simple, seemingly insignificant text message to a technologist such as why didn’t you complete the study? can be interpreted in many different ways. Think about it. The technologist recipient may think that you blame him for never finishing his studies. Or perhaps, he can interpret this message as the radiologist believes that the technologist has a personal vendetta, which is why he thinks the technologist does not want to complete studies. On the other hand, it may just mean what it says: you need to complete the study and nothing more. Simple oral communication would have translated the initial intention more accurately with the appropriate accompanying facial expression and emotion.

Helping Out The Dark Side

Did you know that any text you send is potentially discoverable evidence for a lawsuit? You text your colleague, “I missed the pulmonary nodule on patient MR#123456”. Now that the text is in cyberspace and on your friend’s phone. The lawyers can recover that text from the cloud or your friend’s phone if the patient decides to sue you. All bets are off whether that text will incriminate you in a court of law!

Unintended Slip-Ups

And then, there is the essential unintended slip-up. Perhaps, the word correction software on your iPhone changed a word to something more sinister. Think about it. We see it happening all the time. I’ve seen the shift in expression from “see to sex” or “person to pee.” And unknowingly, you send the message out to the program director. (He may not be as forgiving as me!) In the wrong context, especially with the recent spout of sexual harassment charges, that message containing these words can be devastating!

Beware The Simple Text

In the modern era, avoiding texting our friends, colleagues, and loved ones is next to impossible. And, I am not saying that we should never text each other. However, based on these hazards, we should proceed cautiously and read over every text we create many times. An ounce of caution today can prevent a lifetime of work trying to recover from a poorly thought-out text!

(1) https://www.truevault.com/blog/what-is-the-penalty-for-a-hipaa-violation.html

 

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Worried About Dismissal Due To Bad Evaluations: My Dilemma: How Do I Keep My Radiology Residency Position?

dilemma

Hi Dr. Julius,

Big fan of your blog. I often come here for tips on being a better radiology resident. So I wanted your advice on a dilemma I’ve had.

The Dilemma!

The Evaluations

I am currently a third-year resident. Certain attendings have raised concerns about me since the beginning of the first year, specifically regarding my medical knowledge and procedural competency. The overwhelming majority of my evaluations have been primarily positive. However, the CCC has mainly picked on the negative assessments. I had some struggles with Fluoroscopy in my first year. At the end of that year, I was placed in a remediation program and assigned some radprimer modules, which I completed. I repeated the fluoro rotation in my second year and had positive reviews, with everyone saying I was at the level and receiving positive evaluations. One of my ER faculty felt that I had trouble synthesizing information. However, the others thought while I was not a superstar, I was appropriate for my level. 

At the end of last year, the CCC committee thought that in addition to GI/GU, I also needed help in Neuro. Still, given that I had scored over 30% in the in-training examination, I did not officially qualify for the program. However, I met with the assigned Neuro attending a couple of times. Due to the third year being busy with overnight calls, AIRP, and outside pediatric rotations, I haven’t had a chance to meet with her after the first month.

My Attempts To Remediate

Still, I have independently been working on the radprimer modules and doing them alone. Most recently, I completed an IR rotation (IR is something I am interested in, and I did receive two recommendation letters from 2 different IR attendings). At this rotation, the techs complained about my professional behavior (I have never had any issues with any other tech from any other modality). I was frustrated about being scutted out of procedures to get H&Ps and consents. In a rage, I had given extremely poor evaluations of the rotation techs and attendings. So, this time, the attendings have rated me poorly, with evaluations questioning my medical decision-making and procedure skills. I want to say that I busted my ass this time, kept my mouth shut, and did what the program told me, but that did not help me.

The CCC Meeting And Possible Dismissal

So, I am highly concerned about the CCC’s decision regarding my future. The CCC meets at the end of this month. I’ve been meeting my program director weekly to review things like him helping me remediate, etc. I am not officially on probation. At the last meeting, I heard through the grapevine that two vocal attendings were pushing for my dismissal/probation. Also, I wanted to mention that before the IR rotation, the GI/GU rotation attendings had given me positive evaluations, which made me appropriate for my skill.

So, I am sorry for the long-winded post; I am apprehensive about being dismissed by the CCC. What kinds of steps should I take to solve this dilemma? Should I meet with the GME committee or write the CCC a letter explaining my side of the events? My misses have been at par with other residents at my level. However, the perception is that I have missed a lot. Should I try to get the faculty who have written me positive evaluations to send to the PD?

I would very much appreciate your help!

I also should point out that two residents in my program failed last year, including the current chief. The education is not excellent, so they have even more reason to fire me as they think I will fail.

Sorry for using a pseudonym.

Name

Helpless Rad

Dear Helpless Rad With A Dilemma,

I’m sorry to hear about your dilemma over the past few years. Think of it this way. All these events have the potential to make you a much stronger radiologist.

Based on your story, it seems like you have hit something called the vicious circle (the opposite of the virtuous circle) detailed in my previous blog called The Struggling Radiology Resident. Once a few attendings think that your performance is not up to par with your colleagues, these vocal attendings often spread the same sentiment to the other attendings. And poor evaluation and expectations from many attendings subsequently ensue. Usually, this happens regardless of your “true performance.” Unfortunately, the new evaluation milestone evaluation system (meant to prevent this dilemma with the global assessment) does not stop below-average recommendations from these staff members, even though you may exhibit improvement.

How To Repair The Dilemma

In any case, let’s get to how you can stop the vicious circle dilemma. (It’s not an easy or short process!) First thing, you need to take immediate action. Figure out why your attendings think that you have problems synthesizing information. Is it related to former errors you made during a call that you have already corrected since you are more senior? Was it a personality issue? Or is there a deeper-seated learning issue? 

Over the years, I have had a few residents with learning disability issues that only came to light when they started radiology since the learning skills are so different from other specialties and medical school. You need to figure out what the base issues are. If you are unsure, you may want to talk to your attendings to find out exactly what they think. Talk to both the attendings that favor you and those you believe do not. Then, set up your remediation plan based on your and your attending’s assessments. Afterward, give the plan to meet with the clinical competency committee so that they can see that you are trying to take action to improve. Finally, check to see that it matches their plans and expectations. That will go a long way toward showing you are proactive.

Keep It In The Department

By the way, I would try to avoid going through the GME. You want to ensure the issues stay within the department if possible. To that end, it sounds like you are not at the level of a GME issue such as probation. Going above the clinical competency committee status means this becomes a hospital-wide rather than a departmental dilemma. That can lead to further hard feelings between you and the department. Of course, in certain abusive situations, that may be necessary. But from what I think you are saying so far, it sounds like you can probably contain the damage to your department.

Basic Concepts To Live By

Also, it sounds like you committed one of the cardinal errors of someone with little workforce experience (unfortunately, many medical residents are in that category since their first job is in medicine!). You tried to avenge those who gave you inadequate evaluations by giving them bad ones. As you can see, that typically gets you into hot water. As a resident, you are at the bottom of the totem pole, which will continually worsen your situation. It just does not work! Always be careful what you put into writing, no matter what someone else says about you. It sounds like you will not make that mistake again!

Finally, you must understand that repairing the vicious circle will take a long time. Do not expect your faculty to change their thoughts about you for a while. You can sway them to your side only after many months or even a few years of hard work. It’s a long road to solve this dilemma, but your job is to ignore what they may think of you now. Just keep on plugging away and improving bit by bit. Eventually, you may get some of these attendings to understand that their former opinions of you were entirely unfounded.

I hope that helps. And let me know if there is anything else I can help you with,

Barry Julius, MD

 

 

 

 

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Phone Etiquette For The Radiologist

phone etiquette

Back in the day, I remember my former program director/chairman at Rhode Island Hospital, Dr. John Cronan, lecturing on the basics of the business of radiology. (if you’re reading this, I bet you’re impressed that I remember!) He mentioned the three A’s of maintaining a good radiology practice: affability, availability, and acumen. And, after all these years, I still take this to heart. Good phone etiquette also fits into the equation of the three A’s. It is one of the keys to maintaining a quality practice to entice repeat customers, fellow referring physicians, and patients.

And the rules apply not just for standing phones at your practice but also for cell phones too (We are not living in the 1980s, folks!) With the tens of thousands of phone calls, you will receive over your lifetime, the concepts behind good phone etiquette remain the same. So, let’s go through each of these threads to guide you on how to approach the phone.

Availability

Let’s address the most controversial area first. How can we be available by phone most of the time when I create a post such as Should Radiologists Ignore the Phone? Well, it creates a conflict of interest. We do need to make sure that we concentrate on our films first and avoid errors. On the other hand, it does not mean that we should ignore the phone. So, how do we solve this dichotomy? If you are not actively reading films, always pick up the phone. And, if you cannot pick up the phone now, at least you can promptly return messages that you may receive from the secretary or your voicemails.

If a clinician can never get through to you, you know where their business will go- down the street to the other guy! So, allowing your clinician to contact you is of the utmost importance.

Affability

Affability implies more than picking up the phone and being friendly. It also means an air of professionalism. What do I mean by that? If you are picking up a phone in a particular location, let your caller know they have reached that specific destination. So, if you are in CT scan, you may say Your Hospital, CT scan, Dr. X speaking.

Like us, clinicians run short on time, and we must respect their demands. They may arrive on your line through an operator, unsure of their destination. Taking the time to announce exactly where and who you will go a long way to establishing a rapport between you and the referrer.

In addition, treat your referring physicians on the phone as if they were a friend, not just another burden of the day. Even if it is 4:55 PM and you are about to leave the department, don’t be curt on the phone. Our referrers are the lifeblood of a radiology practice, so creating a relationship between the radiologist and the clinician is crucial. In the end, we need to develop friendships, or else why should the clinician refer patients to you instead of his friendly radiologist down the street? (We live in competitive times!)

Acumen

Finally, just as you treat any consult, on-phone or in-person, we need to ensure that we do our best to solve our referrers’ questions. Be direct. Make sure to answer any questions that you can answer correctly off-the-cuff. And, if you don’t know the answer at the moment, you can always look up the information and get back to the clinician. It is our responsibility to help our fellow doctors. That is just part of our job.

It is also awe-inspiring when you can give a source or a paper to your referring physician documenting why you think your recommendation is correct. It goes a long way to show that you keep up with all the literature. Additionally, it makes it more likely your referrer will return the next time.

Final Thoughts About Phone Etiquette

Many radiologists may dismiss phone etiquette as an extraneous part of our practice that is not worth their time. But, I beg to differ. Instead, it is an essential part of an excellent radiology practice. It is how we connect with our referrers, make friends with our fellow physicians, and direct our clinicians to the next step, whether ordering the appropriate test or solving a diagnostic dilemma. So, make sure to follow the rules of the phone!

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Can Introverts And Extroverts Thrive In The Field Of Radiology?

introvert

Students and physicians compartmentalize the different medical subspecialties into different personality types. And from what I hear, stereotypical radiologists tend to be introverts (formal definition- shy, reticent people). But, do most of us radiologists prefer to be alone? And, can extroverts thrive in the radiology specialty? I will try to answer these questions and give you my thoughts about the personality of the folks in my field.

Are Most Radiologists Introverts?

Well, I believe that, on the whole, radiologists lean toward the introverted portion of the personality spectrum. I mean… Can many extroverts stand to sit in front of a computer for hours at a time culling through images and dictating reports? You need to spend a bit of time on your own in between interruptions. On the other hand, you probably know a few radiologists that are not wall-flowers. Most of the more extroverted radiologists gravitate toward the field of interventional radiology or mammography, fields with more frequent patient interactions. Additionally, many of these extroverts enjoy performing additional highly social responsibilities such as heads of medical staff, chairs of departments, or hospital administration. All these roles benefit from an extroverted, gregarious sort. But, these folks tend to be the minority.

Why Do Some Introverts Thrive In Radiology?

OK. So, the field lends itself to a more introverted personality. But why is it that introverts have the potential to thrive in radiology? Some of the noted qualities of introverts, such as paying sharp attention to detail and processing large amounts of data, are personality traits that allow an introvert to succeed. And, no matter what your colleagues say, introverts have the potential to enjoy fewer personal interactions in radiology than in other fields such as medicine or surgery. These features of radiology allow the introvert to thrive in his profession.

Nevertheless, the typical introvert needs to learn some extrovert skills. For example, with the many phone calls we make and the numerous technologists and nurses we must manage, it is next to impossible to bury one’s head in the sand. And to run a group as a stakeholder, the introverted radiologist needs to learn leadership skills. Completely isolating oneself from others does not work well in our profession.

Why Do Some Extroverts Thrive In Radiology?

In baseball, we find the lefty pitcher more likely to succeed because he throws differently from most pitchers. Likewise, the extrovert is likelier to shine in a group of individuals dominated by introverts. Every group needs folks that can shmooze with the right people, interact well with the administration, and lead a group toward success. These folks tend to shy away from some of the more analytical independent areas of radiology. And many opportunities exist that require the skills of the extrovert in our field. The introvert cannot go it alone!

Introverts/Extroverts- Does It Matter?

In our field, no one size fits all. We both need introverted and extroverted radiologists for our profession to thrive. A group without an extrovert is a recipe for disaster, with poor communication skills leading to anarchy. And, a group without the analytical skills of an introvert will not last long. So, let us try to appreciate one another for who we are. In the end, the best groups are a combination of both.

 

 

 

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Private Equity Buyouts Of Radiology Practices – Who Gets Hurt?

privare equity

Why would anyone want to buy out a practice? Well, like all things economic, it’s simple: To make money. And that is what private equity companies do. They take over companies so the owners can collect a share of the profits. And who exactly are the private equity owners? These folks are private groups of investors that pool their money together to purchase companies. But, unlike publicly traded companies, the government does not regulate these companies as strictly.

So, why is this important for the typical radiologist to understand? Within the past few years, consolidation has hit the radiology industry. Some of this consolidation has resulted from private equity companies buying out radiology practices throughout the United States. And, who knows? Private equity companies may buy out your current or future practice. So, here is a summary of what you can expect, who wins, and who loses.

What Happens To The Radiologists After A Buyout?

The radiologist’s destiny is the million-dollar question. (Literally and figuratively!) Soon after a buyout, you may notice that the radiology employees lose some of their ability to advocate for patients (1). The private practice partner radiologists no longer hold the purse strings to enact change. So, all radiology employees of the new private equity entity must follow the rules of the new owner/leader.

Next, contract negotiations ensue. Initially, former partners and employees will tend to get good benefits, similar to the old practice. Over time, however, the stakes can change dramatically. In lean times, salary cuts and layoffs can begin rapidly. Since former partners no longer control the salaries, these folks may have just to take what they get. During more flush times, the former partners no longer reap the potential outsized rewards.

Further, in the future, you may notice that capital expenditures decrease to save profits for the private equity owners. That new CT scanner will be challenging to justify in the budget unless it has the potential to bring in new revenues. Private equity-owned practices can no longer buy equipment with the motivation of improving care alone.

The Winners

The most apparent winners are the older radiologists in the practice who will soon retire anyway. These owners can now collect on a payday that may be as high as 10-12 times their yearly salary. (2) This added benefit, in addition to their savings from years of practice, can allow an early retirement or a more leisurely lifestyle while working fewer days per week.

Depending on the terms of the agreement, the private equity firm can also gain much from buying a practice. The private equity can skim the additional profits previously from its former partners. However, this is all variable and depends on the partnership’s deal.

Occasionally, inefficient practices may also win in these arrangements. For instance, sometimes practices spend too much or cannot take advantage of economies of scale to increase efficiencies. So, it may take an outside entity to improve profitability. Of course, this assumes that the private equity entity knows how to run a practice better than the original employer and delivers some of the added profits to the radiologists. (Many times, that is not true!)

The Losers

Unfortunately, the biggest losers are the former non-partner stakeholders. These include full-time employees and employees on a partnership track. A buyout can derail the best-laid plans for the future. No longer can partnership track radiologists collect upon the sweat equity they have already committed to their years of practice. Likewise, former employees can no longer count on a similar job structure and contract.

The former younger partners may also lose a bit in the deal. No longer can they rely on many years of good salary ahead. The private equity firm will determine its future. On the other hand, at least these former partners will get a portion of a nest egg to add to their future retirement savings in the buyout.

Unlike those practices that stand to gain from a private equity arrangement, other private equity practices may liquidate the assets of an imaging business to the bare bone and improve profitability on paper so that the private equity firm can eventually resell the company to another entity. These sorts of practices can destroy a radiology imaging center. Good employees leave. Morale declines. And ultimately, the radiology practice can cease to exist. It can certainly happen.

How Much Can You Stand To Gain Or Lose?

So, if you are on the winning side of the equation and make 400,000 dollars per year, you may collect over 4-5 million dollars depending on who formerly owned the equipment and resources. That number, combined with continued employment, may satisfy those winners in the deal.

In the losing lane, non-partners no longer have the chance to build equity in practice. If you think about it, you have already committed three years to a partnership track, and the business has not already made you a partner; you have already lost those dollars of sweat equity. So, if your salary was 300,000 and the practice partners made 500,000, you have lost out on the difference of 200,000 dollars per year for three years or 600,000 dollars. You have also missed out on the ability to collect the 500,000 dollars in perpetuity once you have become a partner. Now, you are subject to the whims of the private equity firm.

The Basics Of Private Equity Buyouts

Describing a private equity buyout is relatively simple. It merely follows the laws of economics. You win if you are on the right side of the equation (the senior and private equity partners). On the other hand, if the equation does not favor you (most employees and some junior partners), you lose. So, if you are fortunate enough to choose among multiple deals, ensure you are doing what is best for your practice. A private equity deal can enhance or destroy your radiologists’ livelihoods!

I would love to hear your comments. What do you think about private equity buyouts in the field of radiology? Any experiences with private equity firms?

 

(1) http://www.physicianspractice.com/blog/understanding-hospital-buyouts-physician-practices

(2) https://www.aao.org/senior-ophthalmologists/scope/article/private-equity-buyouts-of-ophthalmology-practices