Dr. Julius, I read the article you wrote last year on how to choose a fellowship. Have you any new insights since then? Also, could you help me narrow down my specialty?
What I am looking for: a very high salary, independence, being able to work from home would be a luxury, minimal patient contact, be a specialist.
My background: I finished two years of general surgery and switched to radiology. R1.
Thanks for starting this website,
Unsure Resident
Answer:
Hi,
I’m glad you have developed specific criteria for what you require in a fellowship. Often, that can be the hardest part. Of course, I wouldn’t tell the folks interviewing you that you would want minimal patient contact unless you know the interviewers well. Radiology 3.0 has become part of the vocabulary of most academic departments. And that implies some patient care — just a word of warning. But, between you and me (and the wall), we both know that not all subspecialties carry the same amount of patient interaction! So, which specialties have less contact? Most of the pure imaging subspecialties are without procedures. MSK or Neuro would be specialties more likely to have less patient contact.
High Salary Issue
Returning to the main question, which fellowship should you choose? Let’s start with the first criterion, a very high salary. Unfortunately, compensation is more tied to the number of reads and the location where you work than the type of fellowship you do. And, every year, the benefits of any given modality can change. For example, at one point, interventional radiology was the highest-paying specialty per procedure. Now, it generally pays less than most others. Currently, MRI probably reimburses better than most other studies. However, you would be chasing a moving target if I were to tell you that it would remain the same.
Independence Issue
Regarding independence, you ultimately rely on your referrers and patients, so you are never truly independent. But, if you want to become a group of 1, something like teleradiology would enable you to get your business paid with a 1099 form instead of a W-2. Also, teleradiology would allow you to interpret films as much or as little as you want. So, theoretically, you can “create” your desired high salary if you’re going to read like crazy! Additionally, teleradiology would naturally allow you to work from home.
Summary
So, there you have it. Based on your criteria, a possibility would be a teleradiologist specializing in MRIs such as MSK, body MRI, or neuro MRI. However, the two things that you failed to tell me were whether you wanted to work late hours or what procedures you enjoyed the most. You should probably consider that in this “equation” as well. Let me know what you think!
Radiology programs, radiology program directors, Early Specialization In Interventional Radiology (ESIR) directors, and residents interested in interventional radiology are dealing with a mini-crisis. For years, programs have allowed residents to make a choice to start an interventional fellowship several years into residency. Instead today, new residents face the crunch of having to make this decision to join up with ESIR programs right away. And, they should not take this decision lightly. Why? Well, that is exactly what we are going to discuss today!
So, What’s The Urgency, Huh?
Like anything else in the world, when you have limited supply and excess demand, you create bottlenecks. And, unfortunately, in many programs across the country, the number of ESIR spots available does not equal the number of residents interested in the program. Therefore, this problem exists in some programs, right here right now.
So, if a program has two residents interested in this program, but it only has one spot available, the program director needs to make the final decision by either one of two methods. First, the program can decide on a first come first serve policy. But, let’s say that you have two residents that decide they want to join a program at the same time. Well then, that leads us to the other way to decide. And, that would be a long drawn out application process to determine the most “qualified” applicant.
Either way, this puts pressure on the applicant and the program to make a decision pronto. As you now understand, the resident and program need to make rushed decisions together.
Why Can This Decision To Join ESIR Have Permanent Implications?
OK. First, I will mention the positive. ESIR programs allow residents throughout the country to decrease the number of years of a fellowship from two to one. And, these residents will be able to hit the proverbial ground running at their interventional fellowships from the very beginning. But, at what cost?
Problem 1
Here comes the tough part. ESIR programs need to allow residents to complete approximately one year of interventional related activities during radiology residency. So, where does the time come from? It has to come from somewhere, right? Well, here is the rub. Programs need to draw the time allotted to ESIR from the normal diagnostic radiology activities. So, residents that complete an ESIR program have less overall experience in the standard rotations like MRI, ultrasound, etc. And therefore, the training of an ESIR resident is not truly equivalent to a standard diagnostic radiology resident.
So, what are the implications of this? In the workforce still, most practices need radiologists that can perform interventional radiology (IR) but can also help out with some of the general work. Well, residents that start a typical IR job will not have the same experience and comfort level with general radiology practice. As you can see, this creates a serious problem for the ESIR graduate.
Problem 2
Unfortunately, the problems do not end here. Let’s say that you start the ESIR program. And then, you then apply for fellowship toward the end of residency. Due to the changes in allocated slots for interventionalists with new DR/IR programs, ESIR programs, and “independent fellowships”, fewer residents can easily drop out of interventional radiology during residency. So, fewer spaces become available for interventional programs throughout the country. And therefore, you, as an ESIR applicant to fellowship, may have a lower likelihood of gaining admission to an interventional radiology fellowship than residents applying in prior years.
So, who is to say for sure that you can obtain an interventional fellowship after residency as an ESIR applicant? In this case, theoretically, ESIR programs have now doubly screwed this resident. First, they completed a program for which they have a real chance of not completing the required CAQ certification. And second, they have less diagnostic radiology experience.
Problem 3
Many folks that want to do interventional radiology really do not know what they want to do until they have completed several IR rotations. So, what happens if the ESIR program resident decides that they do not like interventional radiology toward the middle or end of their residency? Well, they potentially have prevented another interested applicant from getting a spot. In addition, they have again decreased their own training in diagnostic radiology- a lose-lose situation. They will potentially graduate as a “second-rate” diagnostic radiologist.
Bottom Line For The Applicant To ESIR Programs
For those of you applying to ESIR and know for sure that you want to do interventional radiology, well then, go for it. But, I have a sneaking suspicion that many ESIR applicants are not in this category. So, if the program offers you a choice to apply for an ESIR program, make sure to think twice. The implications of joining this program can be far-reaching for the rest of your career!
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!
Question About Fellowship After Years In Private Practice:
I am an experienced radiologist and decided to join a fellowship after 12 years in private practice. Some people thought I was mad, and some thought I was going through a midlife crisis. I was sick of private practice work and wanted to do something new as I felt I was getting deskilled. So, I joined a fellowship in a tertiary hospital. Two weeks into the fellowship, I think I have become a bit slower and a little out of depth. I expected this change, and I thought it would take a few weeks for me to get up to speed. But now I feel I am very unwelcome because I am an outsider and there is a lot of politics.
I don’t know why I am writing to you, but I thought you might have seen a case like me and could provide some insight into my situation.
A Political Outsider
Response:
Dear Political Outsider,
I admire your tenacity to go back to fellowship. Sacrificing your current life for educating yourself after years in private practice to do something more speaks volumes about your determination and work ethic. Our most incredible residents are ones that have had prior experience. We have had one or two who completed former residencies in their own country before coming to our program.
Unfortunately, it sounds like you have entered a fellowship where education may sometimes take second priority to the whims of the folks who run the program. You have to decide if it is worth it to overlook the politics of your situation to receive the education that you wanted to get initially, Or do the politics of the place prevent you from accomplishing the goals that you had intended to get from the fellowship in the first place? It is often worthwhile to tough it out to get your education. A fellowship is for a relatively short period compared to years in private practice. So, if you can take the pain, it may be worth it. Especially if the tools you are learning will be essential to your future radiology practice.
Regards,
Barry Julius, MD
Question:
Hi Barry
Thank you so much for your feedback. Currently, I am doing the fellowship on my academic drive. It would have been nice if the department’s environment would have been additive.
I had joined the fellowship to gain more training. It appears all scans are done by consultants on weekends as they get paid extra by the department. So they have a vested interest in not letting us fellows report them.
The other day, I was in a meeting, and two radiology consultants mauled me in front of 30 doctors. They kept unsettling me while I was presenting and tried to humiliate me. I still have no clue what was their vested interest.
I want to thank you again for your encouragement.
Regards,
A Political Outsider
Response:
Dear Political Outsider,
Usually, those attendings/radiologists who exhibit bad behavior during a meeting do not reflect your competency. Instead, it measures the insecurity or mean-spiritedness of those who commit the inappropriate behavior. If these radiologists had an issue with you during the meeting, they should have taken you aside and spoken to you privately. Unfortunately, sometimes, in fellowship, you must keep a thick skin and try not to let these episodes derail your excellent work.
For some people, choosing a radiology fellowship is easy. They may have known they wanted to be an interventional radiologist or pediatric radiologist since they were two years old. But, for the majority of us, it is a more challenging decision. And it is a decision that you cannot take lightly. It has a direct effect on the type of practice (generalist or specialist), your lifestyle (academic vs. private practice), location (rural vs. urban), the types of people that you will see daily (direct patient care vs. indirect patient care), and more!
So, I have come up with some guidelines for making this agonizing choice. Consider basing this decision on your personality, what kind of lifestyle you want, the desire to make a little bit more money, the need to be in a particular location, application competitiveness, and gamesmanship/trends in the different subspecialties. I will divide the radiology fellowship decision tree into these six parts and describe how you should utilize each factor to choose your future subspecialty area. Let’s start with the first factor.
Personality:
You can’t deny who you are, and you can’t let others make that decision for you. If you hate working with your hands, interventional radiology will not be for you, regardless of your attendings’ opinion of your performance. It behooves you not to decide to enter the field because you will be doing what you hate. Likewise, if you don’t like patients, mammography is undoubtedly not an appropriate specialty, even if you are adept with people. When you consider your personality type, you’ve already significantly limited the playing field.
I will list several personality types and make a list of the appropriate possible specialties for you. Your personality type may differ from the ones listed below. If that is the case, you should think about your personality type and develop a different cluster of several fellowship options.
Gregarious and outgoing- General Radiology, Interventional Radiology, Mammography, Pediatric Radiology
Fiercely independent- General Radiology, Interventional Radiology, and Neuroradiology
Introvert- Body Imaging, MSK Radiology, MRI, Trauma and Emergency Radiology
Jack of all trades- Body Imaging, MRI, Nuclear Medicine
Likes working with hands/interventions- Body Fellowship, Interventional Radiology, Mammography/Women’s Imaging
Nurturing and friendly- Mammography/Women’s Imaging, Pediatric Radiology
Techie- Body MRI, Informatics, Interventional Radiology, Neuroradiology (Interventional and Nonintervention), Nuclear Medicine
And so on…
Lifestyle:
So, you’ve decided upon your personality type… The next issue is what kind of lifestyle do you want. When I mean lifestyle, I am thinking about the following factors. Do you want to be academic or non-academic? Are you interested in becoming the “go-to-guy” for your specialty because you know a specific subspecialty in-depth? Do you mind being on call late at night? Do you want to be in a small or large practice? So let’s go through each fellowship option and determine the lifestyle factors of each of these subspecialties. Add these factors to the personality factors to hone your choice of subspecialty further.
Body Imaging/MRI-
Most often practices general radiology without mastery of a single subspecialty area, Allows for academic and non-academic possibilities, Can practice in a very small or large practice.
Cardiothoracic Imaging-
Most often, practices in his/her subspecialty in an academic and large institution, Master of a single subspecialty.
Informatics-
Needs to work in a large or academic center, Allows for the increased possibility of entry into the business domain, Master of individual subspecialty
Interventional Radiology-
Allows for performing general radiology or mastery of individual subspecialty, Allows for small or large practice, Can be clinical or academic, Tendency for long call hours
Musculoskeletal Imaging-
Allows for the practice of general radiology or mastery of individual subspecialty, Allows for small or large practice, Can be clinical or academic
Neurointerventional Radiology-
Most often, practices in his/her subspecialty in an academic and large practice, Master of a single subspecialty, Tendency for long call hours.
Neuroradiology-
Can work in a large or small practice, Can be academic or non-academic, Master of individual subspecialty
Nuclear Medicine-
Tends to be situated in a larger practice. Can be academic or non-academic; most often is a generalist.
Pediatric Radiology-
More often, academic or related to a large practice. Maybe more predisposed to nighttime calls (i.e., intussusception reductions), Master of a subspecialty
Trauma/ER radiology-
Most often in a large or academic practice, most often a generalist, Tendency toward nighttime work.
Women’s Imaging/Mammography-
Has more options for part-time hours and fewer calls. Can be academic or clinical, Can be in a small or large practice, Master of individual subspecialty, and less likely to be a generalist.
Money:
Fortunately, you’ve entered the radiology world, and all of its subspecialties within the United States tend to be higher paying than most other specialties. And, the distribution of salaries (1) is relatively equal among all subspecialties. However, there is a slight discrepancy/increased income in the interventional-based subspecialties such as Interventional Radiology and Neurointerventional Radiology, mostly based on the amount of time working rather than bringing in more revenue. Money should, therefore, play a minor role in the decision tree.
Location:
Location can be an essential factor in choosing a fellowship subspecialty because some fellowships may limit you to larger cities and academic centers. Take this into consideration if you need to be in a more rural locale for family reasons. Remember this issue if you want to practice in the more academic subspecialties of Cardiothoracic Imaging, Informatics, Interventional Neuroradiology, Nuclear Medicine, Pediatric Radiology, or Trauma/ER radiology. Location preferences can potentially whittle down your choice of subspecialty further.
Application Competitiveness:
Competitive subspecialties frequently cycle over the years. For example, when I was a resident considering a fellowship in 2002, you couldn’t find anyone to enter the interventional radiology subspecialty. Programs were desperate and would take anyone that graduated. Meanwhile, in 2014, the same specialty became an ultra-competitive fellowship, and our residents had to send out numerous applications for the same spot. Therefore, if you have not performed well during your residency program or come from a smaller program, you may have some difficulties entering a more competitive fellowship in some of the more competitive areas. Do not despair, though. Most of the time, you can get into one of these more competitive areas. You need to send out more applications and use your connections to your residency program.
Based on my recent experiences, some of the more competitive subspecialties in 2015 and 2016 include MSK Imaging and Interventional Radiology. But of course, that can change in any given year. You should still try to get into the more competitive specialties if that is what you desire. Just have a backup plan.
Trends/Countertrends:
So you’ve gone through the first five deciding factors, and you probably have whittled down your choice substantially, but you’re still not sure. There is still one more thing that you should probably consider before making your final decision for a radiology fellowship. There are currently two secular areas of significant growth within radiology: big data/data processing and increasing applications of MRI.
Then, consider this. You are probably better off picking an area of growth than one that may be more cyclical and subjected to the economic cycle’s vicissitudes. It is simple job security. Informatics and the MRI-based specialties certainly meet these criteria.
Also, I have found over the recent history of radiology, you are better off going against the grain, just like a contrarian investor in the stock market. You may consider in 1996, when Bill Clinton was talking about the socialization of health care and health care capitation, radiology became extremely unpopular. Those same residents that applied to radiology around that time had a fantastic choice of places to work. Also, they could command their salaries at the highest rate. And, most remarkably, they found work in the most desirable locations when they graduated in 2001-2003.
On the other hand, when radiology was extremely popular in the mid-2000s, many excellent radiology applicants applied. Those same residents graduated in 2009-2012 and were very limited in their job prospects. The same situation will likely hold for many of the less popular subspecialties at the current time. Take the contrarian view into consideration as well.
Summary About Choosing A Radiology Fellowship:
Using these criteria, you should certainly be able to narrow down your choice of subspecialties to one or two different possibilities at the most. Good luck with your final choice!
Concerned about artificial intelligence taking over our jobs? Worried about the economic cyclicality of each of the radiological subspecialties? Do you fear the instability of your future radiology attending career due to corporate takeovers and mergers? Well, I have a solution for you (and no, I am not an infomercial!!!)… Welcome to the new fellowship called Informatics!!!
Why am I writing about the informatics fellowship and skipping all the other subspecialties? Well… the informatics fellowship warrants an independent post because it is truly the only radiology subspecialty that is in a permanent secular growth trend. It is also the only fellowship that has relatively little information published on the subject matter. In fact, once several of my residents and students heard about the existence of the fellowship program and understood its potential benefits, they began to salivate!!!
So, this article is dedicated to the topic of the informatics fellowship. Specifically, we will discuss the definition of informatics, what the fellowship entails, requirements for the fellowship, how to find where to complete the fellowship, and what job opportunities are available for graduates of these programs. I think once you understand the potential benefits of this fellowship program, you might consider it yourself!!!
Discussion of Definition and Importance of Informatics
So, what is the definition of informatics? According to Merriam Webster, it is as follows- “the collection, classification, storage, retrieval, and dissemination of recorded knowledge”. Prior to several years ago, I have to admit that I had never heard of the term or definition of informatics. In fact, I think I am probably not alone. It is only since the terms “the cloud” and “big data” have arrived into the mainstream, that I think the word informatics has been used more widely.
Why all of a sudden is this body of knowledge so important? In our age of electronic interconnectedness, large swaths of data are created and processed every day. Particularly in the radiology realm, there are numerous electronic/digital images and reams of clinical/health information. Someone has to both understand and manage all this information. Although computer engineers presently manage a lot of this information, they tend not to understand how to manage the data for physicians, administrators, and patients to understand. Herein lies the niche of the radiology informaticist, translating the imaging and clinical data from the computer engineer to the clinical realm.
What Do These Informatics Fellowships Teach?
Fortuitously, the same day that I started to write about informatics, I received a letter from the APDR explaining that there would be a new initiative to create a summary online 1 week course in informatics for residents. Some of the topics covered by the course as listed in the letter include Standards; Computers and Networking; PACS and Archives; Security; Life Cycle of a Radiology Exam, Data and Data Plumbing; Algorithms for Image and Nonimage Analytics; and the Business of Informatics. This course contained many of the topics that some informatics fellowship programs teach. But, the curricula of many of the informatics fellowships differed significantly from this course and were more expansive.
To add a bit more confusion, each individual fellowship program also covers differing topics from one another and varies the emphasis of each of these subjects. Some of the topics that these fellowships include: RIS systems, Image Compression, Teleradiology, Quality Improvement, Operations, Clinical Engineering, HL7, Regulations, DICOM, Critical Results Reporting, Decision Support Systems, Radiation Dose Tracking, Mobile Health Applications, Image Segmentation, Imaging Room Ergonomics, 3D Printing, Natural Language Processing, Informatics Funding, Biostatistics, Health Policy, and Experimental Design. There was some overlap between the different programs. But coverage varied widely. I will also refer you to the ACGME formal program requirements in Clinical Informatics for a more formal explanation of all the areas of teaching required at all fellowships.
What are the Requirements To Become An Informatics Fellow?
The prerequisite requirements vary from program to program. Of the programs I visited on the web, most but not all, had a requirement to be board eligible in a specialty (not necessarily radiology), to be a graduate from an American Medical School, and to have an interest in the discipline of informatics. Most fellowships did not have a specific requirement for formal training in computer science. According to the ACGME, the program length was 1 or 2 years to graduate from a radiology program.
Where to Find the Fellowships?
I found several ways to find the informatics fellowships that are offered for diagnostic radiology program graduates. If you happen to be a member of the AMA, you can look up the fellowships on the FREIDA database. (It turns out I am not a member!) Alternatively, you can do a web search on informatics fellowships and many of the large institutions describe their own programs. And finally, you can go to the ACGME website and look up informatics fellowships there.
Job Opportunities for the Informatics Fellowship Graduate
This is where things get really interesting… Job opportunities are endless. You want to be part of a large private practice or maybe a teleradiology practice? Interested in becoming a practice leader?- It’s all yours! Not many employers can replace the only radiologist that can fix a PACS or RIS system and can also actually read films.
You want to become an entrepreneur and start your own company? You will have access to all the tools and methods to create a technological niche for yourself whether it be an app, a PACS addon, a new piece of software, or other countless unimaginable outlets.
You want to go into academics? The world is yours. Academics are desperate to have rads translate their IT department workings into something that is useful and efficient for clinicians. Think about the possibility of chairman or CIO.
You want to work for big business? Think Apple, Google, Cerner, and more! Large organizations are contstantly on the lookout for good talent that can translate the engineering esoteric data into clinical reality. You will be able to develop needed applications, improve health and radiology related products to get more clientele, and more:
Think about it… you will be at the forefront and crossroads of technology and clinical medicine- a job that only a few can currently fill. It will be very difficult to replace you.
Diagnostic readers can be outsourced to India. Robotics can replace human procedures. But humans will always be needed to rule the machines (unless our future is to be the same as The Terminator!)
Final Thoughts
Of course in the end, like anything else, you need to like what you are doing in order to be good at it. And, informatics is certainly not for everyone. But, if you have a remote interest in the intersection of computers and radiology, really consider this subspecialty. The possibilities are endless, job opportunities abound, and you have the ability to be in charge of your own destiny, potentially not subject to the whims of government or even private industry. You can be your own captain!!!
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