Tag: career

Posted on by

How I Made My Decision To Go Into Radiology

decision

This post is different from most. I am going to discuss my start in this field. By writing about my beginnings, I hope to either help you with your specialty decision or keep you going in your residency if you are still unsure once you have started.

Unlike what you might have thought by reading my blogs, I was not initially gung-ho about radiology from day one. In fact, like many medical students, when I first began, I had no clue. As a student, I planned on going into internal medicine after a stimulating rotation in medical school during my third year. I loved my instructors, the academic discussions, the grand rounds, and the camaraderie of it all. I like to say that if you associate with the right people, any task or job could be fun. And that was what happened during that third-year rotation. The stars aligned. Perhaps, I would complete a residency in internal medicine and become a cardiologist.

My Subinternship

And then, wham! I started my subinternship in medicine, a fourth-year rotation at my medical school. On day one, my resident micromanaged everything. And, attendings loved her because her notes were over three pages long. On the other hand, if you worked under her as an intern or fourth-year medical student, you entered an alternate reality. She could not decide what to do next on the simplest of matters. It could be the difference between Tylenol or generic acetaminophen in a healthy patient. No matter. She could not handle the small decisions. We left unnecessarily late every single day.

Moreover, if you did something on your own, exhibited any independence in a decision, she would stare at you with a frown on her face. And, later that same day, she would go to her attendings complaining about her underlings. So, you would hear about what you did wrong. Ahh, the pain.

But, if that was all, I noticed that I spent more time spending hours on the phone with insurance companies and burnt out attendings than any patient-related matters. Additionally, the patient matters that I did take care of were not intellectually challenging. Instead, I worked with the mundane issues of uncompliant patients or patients complaining about the same problems over and over again (obesity, diabetes) but not doing anything to improve their status. Between my team and the actual work, I realized I could not do this for the rest of my life.

Enter The Radiology Rotation

So, I completed my subinternship depressed that my initial career choice did not fit my requirements for what I wanted to do for the rest of my life. Luckily, I had the opportunity to begin my radiology rotation next early in my fourth year. No, there were no epiphanies/signs from above to let me know that radiology was right for me. (although you would never know that from my personal statement!) Instead, I mildly enjoyed my rotation. Looking at images and making interpretations seemed to be the better option than a life of hell in internal medicine. And, what else was there that I wanted to do at the time? So, I started with the ERAS process to create an application for a residency in radiology. A few months later, I matched at Beth Israel Medicine for preliminary medicine and Brown University for radiology. I was mildly enthusiastic.

Prelim Medicine Year- Second Thoughts

Like many of you out there, as I started my internship year in preliminary medicine, I began to question my original decision to go into the field of medicine in general. As the year progressed, I became even more disenchanted with medicine. My disenchantment eventually bled over to my initial thoughts about becoming a radiologist. Was I making the right decision?

Once again, in the dead of winter, I can remember being in a rotation in infectious disease with another crazed medical resident as my supervisor. This time, he was exceptionally aggressive and irritating. He had reported me to the program director for insubordination. Fortunately, that complaint did not go anywhere. But, it left a bad taste in my mouth. After that situation, I thought about interviewing for financial jobs and even completed one. However, I realized that with the excessive debt that I had from medical school, it would probably not end well. So, I stuck it out and made it through to my first year of radiology residency.

Radiology Residency- A Hellish First Year

Again, you would think that I started radiology, and everything became as smooth as a diamond. But, you would be entirely wrong. I began my residency reading a lot. But, it did not show during noon conferences. Nor did it manifest itself on rotation. As I like to say in some of my other posts, I committed the cardinal sin of reading as a first-year in radiology. I did not emphasize the pictures but instead read through mostly text without the images. So, when it came time to interpret pictures, I was somewhat clueless.

Also, I was not so “procedurally inclined.” One of my instructors (who shall remain nameless!) made sure to make that well-known. He would talk about me behind my back. Instead of helping me to become better, for the first time, I found out about this on an evaluation six months later. To this day, it left a bad taste in my mouth.

As the year progressed, I can remember the faculty’s pressures, not believing that I would be able to perform well on call. Should they even let me? Fortunately, I barely passed the precall quiz. And, my adventures in the second year would subsequently begin.

The Rest Of Radiology Residency- I Could Do This As A Career!

So, when did my outlook on radiology change? My new world order started once I began taking calls at the start of my second year. For the first time, I had some control over the environment. I could make my own decision, and it mattered. Every night, I found that I became more intellectually challenged. With each call, I discovered difficult cases. Even the attendings were unsure about them. And I would enjoy looking at the images and arriving at appropriate differential diagnoses. Finally, I gained the respect of my faculty as a decision-maker and a colleague. I felt part of the team. The rest was history.

So, What Was The Point Of Telling You How I Made My Decision?

Well, I think it is critical that every one of you, whether in medical school, internship, or the start of residency, should realize that you will find a light at the end of the dark tunnel of medical training. Don’t expect that the long road will match your expectations along the way. Having doubts during the process of residency is OK. Nevertheless, try to give radiology a chance and stick it out for the long run. I think that most of you have probably made the right decision for your career. It was an excellent fit for me. And, I believe that if you can persevere, you will find that radiology as a career will reward you as well! Until next time…

 

 

Posted on by

Radiology Golden Niches: Do What Others Don’t Want To!

golden niches

What do the following jobs have in common? Garbage Workers, Oil Cleanup Crews, Sewage Treatment Workers, and Doggy Pickup Services. No, it’s not just that they all clean the environment and serve essential functions in our society. These are jobs that very few people want to perform. And therefore, those that do can charge high rates to complete the services. And, you know what? It is harder to find employees for these professions. I call these sorts of jobs: golden niches.

How is this relevant to radiology? It’s simple. Find an area (or even better, more than one!) that no one else in practice wants to do, and make it your life’s work. Then, you have a job for life (assuming that the business is not bought out or downsized!)

So, this brings me to the topic for today, the golden niches. What radiology specialties are ripe for a new radiologist to practice that can lead to this extraordinary situation and why? Well, we will go through several radiology procedures and modalities that can potentially qualify for one of the golden niches. However, not all practices are the same. And therefore, I must put in this qualifier, golden niches in one hospital or imaging center may not be so in another. You may find that you may have many MRI MSK readers in your practice, and in another, you may have a few. Or, some centers have little need for some of these golden niches. I will point you toward some modalities and procedures that you should think about reading and performing when you interview for your next job!

MRI Cardiac/Cardiac CTA

In our practice, we have limited numbers of radiologists that read these modalities. It is also costly and time-consuming to learn if you did not complete a fellowship. So, if you come aboard and have lots of cardiac work, you can be the hero!

Cardiac Nuclear Medicine

During residency, many residents do not get a chance to dictate these cases since the cardiologists perform them. And, at some centers, they require their radiologists to be nuclear trained. Therefore, fewer radiologists tend to read these studies, allowing you to take over!

MSK Musculoskeletal MRI and Ultrasound

Still, many radiology residencies throughout the country provide limited MSK MRI experience and even fewer MSK ultrasound. So, you may be one of a few in the practice that feels comfortable with these modalities!

Facet Injection For Pain Management

In some centers, practices farm out these cases to the anesthesiologists or the pain medicine physicians. However, in some hospitals, radiologists do the work. And you know what? Only a few MSK radiologists feel comfortable with this procedure.

Informatics

How many of you know the latest about pdfs, HLA, and more? I thought so. And, some practices need these radiologists to run the show!

Virtual Colonoscopies

Most residents are not trained well in this modality during residency. And, even fewer take courses when they finish up. So, you want to run a virtual colonoscopy program in an institution that has the demand. Here’s your niche!

Nuclear Medicine Therapies

Drug companies have developed loads of new nuclear medicine therapies like Xofigo. Moreover, many radiologists do not feel comfortable treating even the old standby of I-131. So, here is an opportunity for you to take charge!

MR Spectroscopy/Perfusion Studies/Neck CTAs

MR spectroscopy/perfusion/neck CTA studies tend to be more esoteric modalities reserved for the neuroradiologists. So, if you have trained as a neuroradiologist, make sure not to skip out on instruction in these areas. You can become instrumental!

Complicated Neck/Temporal Bone Work

Have you ever noticed the remaining cases at most imaging centers and hospitals? It tends not to be the head and body CTs. Instead, no one wants to pick up the CT soft tissue neck and temporal bone studies. So, don’t forget to learn about these topics during residency and fellowship!

Neurointerventional

To feel comfortable performing neurointerventional procedures, you generally need one year of diagnostic neuroradiology and two years of interventional radiology training. That limits the playing field for this work. Need I say more?

Breast MRI

Almost universally, non-breast imagers want nothing to do with these procedures. You have liability issues and inexperience that prevent many from wanting to read these cases. Time to step in!

The Golden Niches

Well, there you have it. Here were some undesirable (and therefore most desirable!) jobs you should consider performing when you start. And, I’m sure there are a few more that I forgot. In any case, it’s not about love. Instead, it’s about job security, my friends. So, go forward and find your golden niches. You won’t regret it!

 

 

Posted on by

Is Radiology Still A Career Or Just A Job? And What Does It Mean?

job

What exactly is a career? If you listen to the internet authority, Wikipedia, it is “an individual’s metaphorical “journey” through learning, work and other aspects of life.” And, what is the definition of a job? Again, if you listen to “all-knowing” Wikipedia, a job is an activity, often regular and often performed in exchange for payment (“for a living.”)

So, which definition does radiology meet today, a career or a mere job, a transaction made to make a simple living? Many long-standing radiologists and outsiders would say that radiology is a career. You spend countless years learning and practicing the art and science of radiology. Moreover, when you finish, you live and breathe the profession. You strive for professional excellence. More importantly, it becomes ingrained as part of your persona.

These everyday thoughts are an oversimplified answer to whether radiology is a career or a job. As such, the response has transformed itself over the past ten to 20 years.

Changes To The Equation of Job Versus Career For Radiologists

So, what has changed over the past decade or two that has morphed the answer to this question? First, the landscape of medicine has dramatically shifted. Students that formerly completed school with reasonable amounts of student loans are now graduating with hordes of debt. Additionally, external pressures from governmental bureaucracies have dramatically increased. The number of films radiologists need to read, and procedures they must perform have exponentially climbed. Some may say that the numbers have far surpassed what is safe for patients.

Finally, different demographics have joined the profession. Today, many radiologists want to practice part-time to raise a family or pursue other interests. Years ago, this type of radiologist was much less common.

Individually, each of these factors plays a role in the change. In the following few paragraphs, we will go into more detail about the reason for each.

Reasons Radiology Has Become A Job For Many

Student Debt

Let’s start by talking about the noose of enormous student debt hanging around the shoulder of new radiologists. In the past, radiology residency graduates could afford to pick and choose where and what to practice based on the merits of the post-residency job alone. No longer is that the case. Now, it becomes more important to make sure you can afford the debt service payments and the day-to-day living expenses of the region of practice. For many, finding work is about desperately needing to make ends meet. So, radiology merely becomes a means to this end.

Increased Bureaucracy

We all feel the weight of increased paperwork and regulations we must follow. To that end, maintenance of certification has become more stringent (although, more recently, it has been slightly letting up). Requirements for accreditation have been increasing exponentially. Also, the maze of insurance requirements to complete a study keeps rising. Moreover, these factors are the tip of the iceberg. For many radiologists, many bureaucratic factors lead them to resign themselves to practice radiology as a job.

The Work Treadmill

Nowadays, many radiologists are hostage to the ever-increasing number of studies they need to read. Public expectations for the delivery of results promptly and efficiently have climbed. Also, time to transcription has become the holy grail of the hospital administration. In these conditions, how can some radiologists perceive their work as more than just a cog in the wheel to make ends meet?

Changing Demographics

Finally, we need to also talk about why different radiologists pursue radiology. No longer do all radiologists fit the same mold. For some, their role in raising a family has become more crucial than the position that they may play in running a radiology practice. So, these radiologists merely want to fund their lifestyle and not get involved in the professional aspects of radiology.

What Does This All Mean?

Well, to start with, we know that the most consummate professionals invest heavily in their careers and see their profession as a calling. These are the incredible clinicians, the movers, and the “shakers.” Moreover, they perform groundbreaking research, make improbable diagnoses, teach their residents, and create radiology systems and businesses to promote the profession.

However, based on the new pressures on individual radiologists, we cannot expect all radiologists to see their original “calling” as a “career.” Instead, many other factors play into the equation. Student debt burdens some radiologists. Alternatively, the chains of bureaucracy and increasing workloads prevent the pursuit of their interests and infringe upon the professional lifestyle of a radiologist.

Regardless, we should not talk badly about radiologists who need to work in the profession merely as a job. Many radiologists have excellent reasons for that. Instead, we should work to fix those factors that have changed to make radiology into a job so that we can improve the quality of our profession and return it to a career for all.

 

 

Posted on by

Top Ten Differences Between A Senior Resident And Radiology Attending

differences

You may be more than halfway through your residency program or about to graduate residency. And it may feel like you have been through the wringer. Not only have you made it through the call, but you have also studied all the minutia that you need to know to take the core exam. So, can life change that much more when you become an attending? I mean, it’s only a few years or less away. Well, for your education (and entertainment, of course!), we will go through the top ten differences between a senior resident and an attending. Let’s go from least to most noticeable!

Shallower Breadth And Increasing Depth Of Knowledge

Believe it or not, beginning a full-time job still changes what you know. Remember all that detailed information from the case review series and the survey books? And, of course, all that detail you learned from studying for the core examination? Where does it go? Let’s put it this way; your brain begins to trim out what you no longer use. So, that full breadth of knowledge you learned from studying for your core exam? Yes, gone! Instead, one of the biggest differences is that you remember the relevant information you need to know daily for your specific areas of expertise.

You’re Now The Expert

For the first time, you da’ man (or woman!). Regardless of your feelings, your colleagues see you as a guru in your specialty. A very different feel from your previous work as a resident or fellow in training!

Horses First, Then Zebras

As an attending, you know what you see because you have experienced it many times. The zebras only come out when you have exhausted all the horses first. Usually, not the case for residents!

Patients And Doctors Want To See You!

No longer are you an intermediary in the way of your attendings. Patients and doctors ultimately want to hear from the man or woman of final reckoning in the report. And that is you! Feels good to be desired. One of the biggest differences!

Need To Get A Move On!

No longer can you rest on your laurels as you did as a resident during the daytime. You have a job to do, and it must get done. If not you as an attending, then who? A hundred cases? If they do not get read by the end of the day, you hear and see a queue of angry clinicians and patients!

More Vacation But Perhaps Not At The Best Times!

You may notice that you took a vacation during residency, usually at the standard times- Christmas, spring break, or summer. And although the residency required some coverage from one or two of your fellow residents, most could still take off at those times. Well, alas, this is all about to change! And although you may receive more vacation in general, your practice will still need significant coverage during these favorite vacation slots. And who needs to work at these times? You!

Increased Liability

In the end, no longer can a senior cover for your mistakes. You are coming onto a shift in the morning and looking at the night resident’s dictations. Well, you own them. His and your mistakes are your problems! Miss cancer, your reputation, license, and nest egg are on the line!

Loans Come Due

You think all the money you earn as an attending is your own, right? Wrong! On day one, as you start your first job, the loan servicers ask for their due. Forbearance of your loans is no longer an option. Thousands of dollars per month only to service your student loan debt. Welcome to the real world.

Increased Pay

Imagine rolling along for years at a time, garnering biweekly or monthly paychecks, and coming home with a few thousand dollars a pop. And, then suddenly, Whoosh! You notice that the direct deposit fills your account with something more substantial. Feels good, doesn’t it?

Expenses Rise

Now for the bad news. The more significant paycheck comes with more considerable account drainage from those expenses. Those larger paychecks suddenly drain rapidly from your bank account with new costs from a new house, car, loan payments, and child care. Where did all that increased pay go?

 

Final Thoughts About Differences Between A Senior Resident And A Radiology Attending

So, there you go. Perhaps, not what you thought? Or, maybe it was? Regardless, now you know what to expect to change once you graduate!

 

Posted on by

Should I Join A Practice With A High Buy-in?

buy-in

As of the end of 2020, the job market is beginning to improve post-covid. And, for those of you considering your first job nowadays, you may receive offers from multiple practices. And, some of those offers may seem enticing. Perhaps, you hear that the partners make 600,00o, 700,000, or 800,000 dollars or more. And when you interview, the President of the private practice tells you that you will have to pay a large sum of money into the business. This sum of cash called a buy-in can range from zero to as high as into the millions. So, here are the questions you need to answer. Is a high buy-in ever worth your while? In fact, should you even entertain the possibility of starting at one of these practices that come with an enormous buy-in? Well, I am here to help you to answer these questions today!

 

 

The Hope

OK, all things considered, paying into a practice a large sum of money doesn’t sound so bad if the practice guarantees that you will bring in gobs of money each year, right? If you are paying a million to own a radiology practice’s technical shares, you can potentially receive outsized benefits in return. For one, your salary can become much higher. That initial sum of money that you add to the practice equity can significantly increase in value if the practice does well. You can also diversify your income a bit by collecting the professional fees and the technical component. These hopes can all come true.

But Then…

OK. There is always more to the story. Practices can dash hopes in an instant. Let’s say you don’t receive a share of the partnership during your partnership track. Where does that leave you? A lot poorer!

Or, perhaps, the practice equity declines as you finally earn the golden ring of partnership. Can a practice’s equity decline that much? Sure, can! Assets can not only decline to zero but can become a debt burden as well. Think about it. Equipment depreciates. And physical properties can decrease in value. The money you put in can no longer exist after you put all that equity into the business. And some!

Besides, you may overpay for the practice more than it’s worth. Who is to say that you have paid a fair price to become a partner? The practice partners? How do you know if they know how to value the practice. Or, maybe, they are trying to defraud you. You never know.

Weighing The Risks Versus Benefits Of A Large Buy-in

So, let’s see. The potential for large rewards versus the possibility of paying into something that is not worth it. What should you do? As always, this comes back to a trust and numbers game. Only by vetting the practice’s balance sheet and getting detailed information about the practice owners can you make the decision. So, how do you go about making this weighty decision?

Of course, you need to assess the people that run the practice. But how? Track record becomes very important. Have they strung along with multiple employees on partnership track to never make them a partner in the business? Are these physicians respected members of the radiology community? Do your residency and fellowship directors know something about the practice?

To get at the matter of trust, you must research the practice well. Check for lawsuits and hiring indiscretions. These can all become red flags that the imaging business may not be what you think.

And then get to the bottom of the balance sheet. Be wary of any practice that does not let you know what the partners have made in the past. Think twice if the practice does not allow you to talk to the business manager about the finances and the assets the practice owns. I know of several radiologists who had been through an extended partnership track to find out that they became partners in only the professional component, not the technical component/equipment and real estate. They were sorely disappointed when the time came to make “partner.” So, make sure to find out what you are really “buying-into”!

Finally, you need to consider the current environment of the practice. Are private equity firms or large hospitals in the area taking control of practices? Is the area economically growing or contracting? These factors may influence the risk of entering a partnership track that you may not be able to complete.

A High Buy-in And Your Final Decision

Depending on the situation and the practice, a high buy-in may or may not be worth the risk. Take into account not just the great potential of the business. Instead, you also need to consider the risks you need to take to earn that potential outcome. It might turn out well, but it might not. So, maximize your probabilities of success. Do your due diligence!

Posted on by

Radiology Attending Day One: How To Get Started On The Right Foot

day one

Imagine: Your whole adult life consisted of schooling, including four years of college, four years of medical school, one year of internship, four years of residency, and perhaps one or two years of fellowship. And you will finish it all in a few days. This situation will be yours at some point. (If not at this moment!) Now, it’s day one, and you embark upon your new life as an attending.

For most, this transition is like moving from the confines of jail to the free world. No longer do you have someone to monitor you all the time. Now you become the arbiter of last resort. The buck stops with you. (All those hackneyed phrases are true!)

The transition to becoming an attending is enormous. And you want to make sure that you do it right. So, what are the most important tasks to accomplish on day one of your new job? What do you want to avoid? Assuming you have completed your administrative tasks before starting, we will go through some boxes you should check off on your first fateful work day.

Introduce Yourself To All The Staff

After the hospital orientations, ALS courses, and all that jazz has died down; you need to make a good impression on day one. The people you meet on that first may work with you for the next 30 years! So, make your introductions to all staff. That includes fellow attendings, technologists, nurses, secretaries, and janitors. By introducing yourself to everyone, you make yourself seem like a team player that is not “standoffish.” Who wants to work with someone who can’t talk to anyone in the department?

Dress The Part Of An Attending

You don’t want to stand out too much on that fateful day. So, make sure that your attire is appropriate to the department. I remember a few attendings at my prior residency that arrived at the department without a tie for the first time. The department chairman made these attendings return home and get a tie from their closet! You don’t want to start on the wrong foot in a department where you expect to work for many years.

Make Sure To Listen Carefully To Your New Colleagues

You will hear much on the first day of your new life. Sometimes, however, you will receive invaluable advice from your colleagues that you may never get again. So, pay attention. And, take notes if you don’t have a photographic memory. You are better off having the information you will need now than having to find someone to get the same information later on when you become really busy!

Stake Out The Joint

The first days are the time to explore your surroundings (Don’t break into the chairman’s office, though!) Discover the locations of the best bathrooms, cafeteria locations, local restaurants (if at an imaging center), physician and secretarial offices, reading rooms, interventional suites, and more. Become as familiar with the surroundings as you can. This is your new home!

Ask Lots Of Questions

OK. You don’t want to ask too many indiscriminate questions (It may seem like you don’t know anything!) But you do want to ask lots of important and relevant questions. Get to the practice’s expectations, pitfalls, and more. After the first day, your colleagues may become less attuned to answering these questions, as you will no longer be the new kid on the block. Get those questions in before it is too late!

Discover Your Boundaries

Especially on that first day, you do not want to step on anyone’s toes. Ask first if you want to help with a study that may not be in your daily expected routine. The last thing you want to do: is dictating a case only to find out that the clinical attending wanted a read from someone else. It does not look good for you or the practice. So, get to know and ask what you can and cannot do.

Get Dictation Standards

Different practices have specific requirements for all radiologists’ dictations. Some want structured reports, and others need the impression at the beginning. Make sure to ask your colleagues what exactly they expect before beginning your work. You certainly don’t want to rock the boat too much!

Learn The PACS and EHR

The PACS and Electronic Health Records systems have become crucial for relevant and quality reports. In addition, knowing these systems will significantly help your efficiency (You want to get out of work on time, don’t you?) Therefore, you need to spend your first day working to make sure that you get to know the PACS and EHR well. A little time now will save tons of time in the future. Think of it as an investment.

Work Slowly And Deliberately

As a fresh radiologist right out of fellowship, you don’t want to be known as the gal who does careless dictations. So, especially on that first day, slow down. Make sure everything you dictate is correct. You have years and years to pick up speed with your work. Now is not the time to rush, and newbies make more mistakes. Don’t add to the reputation!

Radiology Attending Day One- Final Thoughts

The first day as an attending is tough. You are transitioning to a new world, just like the many worlds you had transitioned to before. So, go forward and welcome the changes with open arms. Believe it or not, you will find your comfort zone one day. It just takes a bit of time!

 

 

 

Posted on by

What Really Goes On At A Radiology Practice Partners’ Meeting?

partners' meeting

I can remember back during my radiology residency many years ago. Every so often, the radiologists at my hospital would meet secretly outside the hospital for their partners’ meetings. As the radiology attendings rapidly left to abandon their shifts to get to this meeting, I thought perhaps the partnership was just like the secret societies such as the Freemasons or the Illuminati. Maybe, they had a secret handshake? Or could they be plotting the overthrow of the hospital or government? What was going on at the partners’ meeting?

Most likely, you also wonder what happens during the partners’ meeting since you have never experienced anything like it. Moreover, you are an outsider, not privy to private practice business. Yet, one day many of you will also become a partner in a radiology practice. So, today I will reveal the secrets behind what partners discuss at their business meetings. Therefore, pull up a chair, read this post, sit back, drink, relax, and enjoy. Now, you will learn the truth behind what the partners discuss at a partners’ meeting!

Finances

As you might expect, at most meetings, a business manager often discusses the current state of a practice’s finances. Are reimbursements declining? Do new potential sources of revenue exist? What imaging modalities are trending higher? Should the business renegotiate insurance contracts? For some of you, your eyes may glaze over when you hear about a practice’s finances. However, these discussions are essential for continuing business as usual. And, yes, radiology is not just about health care. It also needs to run positive income to pay the employees, the fixed costs, the partners’ salaries, that end-of-the-year Christmas party, and more. Most meetings involve financial discussions.

Long-Term Strategies- Mergers, Acquisitions, And Partnerships

Nowadays, practice size has trended upward. Many practices must evolve to create larger entities so that they can use economies of scale to reduce costs and maximize profits. What do I mean by that? Essentially, practices can distribute fixed costs among a larger group of employees, thus saving money for the business. Therefore, you probably hear a lot about practices merging or private equity firms buying out imaging companies to save on costs. Well, partner meetings are common private forums for discussing these issues. In addition, you can expect practices to talk about ways to maintain good relationships with the hospitals and clinical colleagues as a long-term strategy. This long-term strategizing all happens at some partners’ meetings.

Manpower Issues/ Human Resources

Almost every practice has its fair share of issues with employees. Perhaps, some physicians do not meet the requirements of the hospital. Or maybe, clinicians have been complaining about certain practice members. Partners meetings are the appropriate forums to discuss these practice problems. In addition, partners discuss hiring new employees to meet the demands of the practice. Partners will discuss these problems and attempt to devise solutions to match the workforce to the practice’s needs.

Scheduling

One thing that is constant in any practice is change! Whether it be new imaging modalities, increasing requirements of films to be read, or losing business to other clinicians, the scheduling demands must meet the appropriate workloads. Partnerships will broach better ways to schedule partners and employees to maintain maximal efficiency. In this same vein, practices will also debate vacation policy schedules and the appropriate workloads for daily and weekly rotations whose needs may differ over time. These items commonly enter into the typical partners’ meeting.

Beauracracy and Compliance Issues

Every year, governments develop new rules and regulations for practices to follow. A few years ago, it was ICD-10 codes. Now we have new quality improvement mandates set by Medicare. Whether for certification maintenance or hospital credentialing bylaws, these items constantly change and can be crucial for maintaining the practice and complying with the law. All partners need to keep aware of the newest compliance issues to run an imaging business successfully. What better forum than a partner’s meeting to discuss this?

Insurance And Benefits

In this category, I will include malpractice, health, life, and disability insurance, pension plans, and yearly bonuses. Partners must approve the renewal and disbandment of these annual benefits. These changes depend on the costs and overall contribution to the practice and partners. You wonder how they come up with these policies. Well, usually, this occurs at the partnership meeting!

Residency Issues

Lastly, although residency issues crop up, that can affect the practice. If you have an imaging company with a residency, the partners may or may not discuss it in a partnership meeting. But, they occasionally make it to the partners’ meeting agenda. The discussion could be about new residency requirements, a site visit from the ACGME that all partners need to plan for, a specific resident issue, a problem resident, and more.

The Secret Partners’ Meeting- Final Thoughts

A partners’ meeting is a necessary evil to maintain a practice. And, as you can see, a partners’ meeting agenda can fill up quickly. Depending on the time of year and the number of issues, meetings can take hours and hours. Yet, the partners’ meeting is an essential aspect of a quality partnership and business. So, the next time you see the partners disappearing to attend the partners’ meeting, you now have some faint idea of what happens. Although you may never learn the secret handshake (or the nitty-gritty financial details), you now know what to expect from that occult partners’ meeting. And no, it’s most likely not just about discussing you!

Posted on by

How To Add A New Modality To Your First Practice Fresh Out Of Fellowship

modality

The most significant controversies in private practice often stem from workload/relative value unit (RVU) or differences in “earnings” among physicians. Anytime one physician “works more” or earns less on a daily rotation, partners and employees interpret that difference as unfair. Even more so, radiologists heighten this perception when one physician performs this rotation more than others. So, imagine starting and attempting to introduce a new procedure or imaging modality to a radiology practice right after graduating from a fellowship. Often, this will tip the workflow balance for an entire radiology business. So, how do you incorporate this new work into a practice’s current workflow? And what might you need to do to sway your partners to change the workflow for this new procedure in your practice? Today, we will delve into what you need to know as a new radiologist fresh out of fellowship who wants to start a new program or modality.

Show That The New Modality Increases Practice Value

To begin the process, you need to demonstrate that the new procedure adds value to the practice. What do I mean by that? Well, your job (if you choose to do so) becomes to convince your partners that your procedure or modality will eventually increase or at least maintain business.

How do you go about this process? One of the easiest ways to accomplish this goal is to give a practice-wide presentation. To do so, you need to show that your new modality will provide revenue above and beyond what the practice brings in. If this is not the case, you should demonstrate how the new procedure may act as a loss leader or at least increase ties with the hospital for all to benefit.

Another option to increase the buy-in of the partners would be to perform the art of “politicking.” Talk to your partners individually to get them to understand what the new procedure/modality will bring to the practice. So, when it comes time to discuss adding your new procedure to the daily rotations, each radiologist will be on board.

And finally, you need to consider what the practice will need to add and the costs to start the new procedure or modality. Is this procedure going to take away from other businesses in the practice? Or, in the case of new high-tech equipment, are the costs prohibitively expensive? These items are crucial to think about before beginning the new procedure.

Make A New Schedule That Is Fair For Everyone

Next, you need to think about not just the procedure value but also you should develop ways to incorporate the new procedure into the schedule reasonably. The less onus on the partners to establish a new schedule, the more likely you will be able to add the new modality to the practice. So, come up with ideas about how to add the new procedure. Perhaps you want to first tack it on to a current rotation. Or maybe, it is worthwhile to go full-steam into a new daily or weekly rotation. You must consider working out these factors before “going live.” If you cannot accomplish this, the chances of creating a new addition to practice dramatically decrease.

Be Aware Of The Politics

Sometimes beginning a new venture can wreak havoc on a practice or hospital system. For instance, adding a new SPECT/CT to one site may take away business from another within the system. This new equipment and procedure may decrease the employment opportunities for technologists within the site that does not have the latest technology. And, you may get a lot of pushback when you try to add it to the site. Therefore, taking the politics of the practice and hospital before beginning the new procedure is crucial.

Don’t Overwhelm The Decision Makers

These steps listed above are instrumental to creating something new in your practice. However, you have to tread very carefully. Frequently, your partners may be busy with lots of other practice requirements. So, try not to overwhelm them. What do I mean by that? Ensure the new procedure will not burden the partners and employees significantly. In the beginning, consider taking on much of the excess work yourself to get the new modality started within the schedule. Remember, you are the champion of this new procedure. So, it would help if you put in additional work to begin up front. If not you, then who else will do it?

Bottom Line For Starting A New Procedure Or Modality

Whenever you want to start something new within a practice, it is not enough to jump right in and begin. You need to put in much forethought and work before beginning. Starting something new not only affects the person initially responsible for developing the initiative. Instead, incorporating new procedures into the schedule affects the entire practice due to its effect on workflow. So, show that the modality increases practice value, demonstrate how to incorporate it into the schedule reasonably, be aware of the politics, and take on much of the initial grunt work yourself at the beginning. If you can accomplish these steps, you markedly increase the chances of starting a new procedure or modality within your practice for the benefit of all!

 

 

 

Posted on by — 2 Comments

When Do Radiologists Peak? (The Older The Better?)

peak

You can easily find all sorts of articles about when human intelligence in all of its forms peaks on the internet. For example, I particularly enjoyed one such article from science alert. As the piece states, different types of intelligence peak over different ages in one’s life. (1) We can always count on granny’s wisdom. Yet, we now know that many mathematicians write their seminal papers when they are young. But what about radiologists? Do we make the best radiologists when we first get out of fellowship and have just taken the boards? Or, do experienced radiologists make overall better radiologists? These are difficult questions to answer, but I shall attempt to come up with a logical conclusion.

Evidence For Increased Quality Of Younger Physicians

To start with, scientists have concluded that visual perception slows down with age. One article from the University of Arizona summarized that visual ambiguity increases with age because of brain inhibition defects. Over time, older people have a much harder time identifying unfamiliar shapes. Other studies have also shown losses in light sensitivity, motion, depth, and color perception. Although not specific to a radiologist’s work, presumably, these defects in processing could affect a radiologist’s reads over time. (2) Score one for youth!

Recently, another article based on an observational study in the BMJ stated that patients had lower mortality rates in hospitals when physicians under 40 cared for these patients. However, interestingly, there was a big caveat in this article. These outcomes only applied to doctors that did not see a large volume of patients. (3) So, I am not sure how well this data applies to radiologists since most of us see large volumes of studies. Furthermore, most of us do not directly care for our patients, as the physicians studied in this paper.

Evidence For Increased Quality Of Experienced Radiologists

On the other hand, a study in Radiology explored the quality of reads of mammographers over different ages. In this paper, they determined that experience counts. Notably, they found a significant increase in pickups and a decrease in false positives occurred during the first 1-3 years of community radiology experience. And even more importantly, the paper showed no significant drop off in quality as one aged. The false-positive rates had overall decreased over time. (4) Score one for experience!

Personal Experiences (Not Hard Evidence!)

Through my years as a radiologist from residency to the current day, I have certainly seen some fantastic radiologists over 70. Unfortunately, that statement does not apply to all the older radiologists that I have met. Some had passed their prime and likely had stayed in the field longer than they should have.

For comparison, many new radiologists fresh out of fellowship tend to overcall on imaging. The dictations of these radiologists often contain more unnecessary words and flowery language that clinicians do not want to read.

In the middle between these two extremes lies the middle age radiologist. Again, not all radiologists are created equal. And, some miss more than others. But overall, I have found these radiologists have the least problems with missing findings, irrelevant dictations, and overcalling diagnoses. They tend to know what to look for because they have been practicing radiology long enough. Yet, these radiologists do not suffer from significant perceptual issues.

My Take On The Peak Radiologist Based On All The Information

The article on mammography cements my suspicions that experience does count. Also, it says to me; individual radiologists may peak at a later date. On the other hand, even with “better perceptual abilities,” I have never met a newly graduated radiologist that I would have preferred to read my imaging studies over someone with more experience. Based on my encounters, I am biased toward favoring a quality peak multiple years after finishing residency and fellowship. Yet, based on scientific evidence, I believe that at some point, the decrease in perceptual abilities does affect the quality of work of senior radiologists. So, I would say that the final years of work most likely are somewhat past a radiologist’s peak.

My bottom line for the new radiologist: If you are finishing residency or fellowship, you should expect to continue to work hard and learn over your lifetime. Even though you have studied an extreme amount of information to pass the boards and get through your training, believe it or not, your best days are probably ahead of you!

(1) https://www.sciencealert.com/this-is-the-age-you-reach-peak-intelligence-according-to-science

(2) https://uanews.arizona.edu/story/research-shows-how-visual-perception-slows-age

(3) http://www.bmj.com/content/357/bmj.j1797

(4) http://pubs.rsna.org/doi/full/10.1148/radiol.2533090070

 

Posted on by

Contract Negotiations: What Do You Ask From Your Future Employer?

contract negotiations

When you are in the process of completing a residency or fellowship, looking for a radiology job becomes a daunting task. Not only are you trying to find a career that will last for years, but you are also left alone swimming through the complexities of contract negotiations, an area you probably have not experienced before. It’s a brave new world.

 So, what do you do? As a typical resident, you find general information on the internet about the basics of contracts. And if you contact an attorney, he will probably give you generalities about how to approach contract negotiations. But, this post is different as it outlines what negotiation points a practice is more likely to give to the applicant.

To that end, today, you will get an insider’s view of what you are most likely to be able to negotiate and which benefits you may find difficult to change. You will also receive the perspective of someone who works as a private practice partner and advocates for his residents. Remember, I am not an attorney, so I am not providing legal advice. Instead, I am telling you what I think practices are more likely to leave on the table for negotiation and what items practices do not want to touch.

Depending on the desirability and location of the practice, however, you may be able to get a lot more, or you may have no wiggle room at all. That is something you will have to judge for yourself based on what you know about the practice. So, let’s go through some of the basics.

Benefits You Can Negotiate More Easily

Moving Expenses

Moving can cost a lot. Generally, you are talking about multiple thousands of dollars, especially if you move a substantial distance. However, many practices will usually be willing to include this benefit into the contract. Why? First, it is a tax-deductible expense for the business so that the practice will pay for it in pretax dollars. And then, it pays to create as many connections for you to the area as possible. What better way to accomplish this than to provide for moving expenses?

401k Plan Perks

Typically, practices tend to be more flexible with indirect expenses such as matching contributions to a 401k plan. Why? Again, it is a pretax benefit that the business can write off. Yet, it does not appear as an increase in income. Partners would prefer to negotiate a 401k plan than a salary because increasing a wage could lead to adding on additional income to other employees. It is much harder to calculate indirect perks!

Time Spent In Particular Departments

Maybe you hate mammography or can’t stand interventional procedures. In the beginning, discussing your expectations for where you want to work in the practice is entirely reasonable. For some applicants, this can make or break the quality of a job. And, for the imaging business, this can be a minor concession compared to other benefits!

Malpractice Tail Insurance

Malpractice tail insurance can cost an employee thousands of dollars when they leave a practice. So, this can potentially be a significant cost saving. And the practice can pay for coverage with pretax dollars. Like the 401k plan, it differs from the subheading of salary/income. For these reasons, the imaging business may be more willing to budge a little on a negotiated contract.

Restrictive Covenants

Nowadays, many practices place restrictive covenants within the contract to prevent the applicant from leaving and working for a local competitor. Each state enforces these covenants differently, and the time and distance restraints can vary widely. But, this can potentially lead to a problem if you want to continue living in the area and decide to quit your job. However, it is very unusual for a practice to enact the clause on a former employee legally. (although possible!) So, if you need to stay in the area, no matter how the job goes, this may be an item that you should consider entering into contract negotiations.

More Difficult Items For Contract Negotiations

Annual Income

Salaries are usually the most challenging item to negotiate. Why? Although typically not allowed, employees will often compare salaries, and tempers can flare if the employees perceive their salary as unfair. In addition, the partners usually compare the salaries of all their employees and themselves. It becomes hard to create a fair deal that does not impact others in practice. Some employees may have had more experience, and others bring particular skills to the practice. So, it can seem unfair among the partners as well. Unless you are in an enviable position of working at an undesirable location or you have a particular skill that the practice cannot find elsewhere, annual income is not as easily changed.

Years To Partnership

Years to partnership can also be a very touchy subject. Partners may have invested themselves in the business for years. And, you want to change the system to give you fewer years to partner? That typically does not fly as well as negotiating other benefits. In addition, large sums of money are at stake for each year removed from the track. So again, you will be hard-pressed to negotiate fewer years to partnership.

Buy-ins

Typically, a buy-in or sweat equity is an amount you pay to the practice for the privilege of becoming a partner. This number can vary from a nominal amount to millions of dollars. Again, emotions can flare when you decide to change the amount it costs to enter a partnership, as you may have to pay less than the other partners. In addition, some practices own equipment or real estate. It would be unfair for the practice to give away these assets. Depending on the business, this can be a challenging item to negotiate as well.

Loan Repayment

Unfortunately, residents bemoan student loans more than anything else. And the high debt burdens residents must face paying for the privilege of going to college and medical school can be overwhelming. To make things even worse, however, most practices will not make this an employee perk because the practice cannot deduct the money pretax. Perhaps even more important than that, the business has to trust that the employee will not skip town and leave the practice prematurely. As you can see, imaging businesses take a lot of risk by adding this benefit to sweeten the deal for the applicant. Therefore, a new employee getting loan repayment as a benefit is unusual unless the practice is in desperate need of the applicant.

Contract Negotiations: A Battle Or The Beginning Of A Great Friendship?

Finally, I have not mentioned the most critical point of contract negotiations. A contract is only as good as both of the parties’ word. A contract can be ironclad for the employer or employee. Regardless, the specifics outlined by a contract are rarely used if the employee likes the job, and the employer likes the employee’s work. Only when things don’t go as planned the contract becomes truly important. So, here’s the bottom line and the irony of it all. As crucial as contract negotiations can be, invest more time and effort in figuring out whether the job is right for you rather than worrying about the nitty-gritty details of the contract. Good luck!

Comments

Have any strong opinions about other items that should be negotiated in a contract? We would love to hear your thoughts by commenting below!