Radiology!!!

[Guest Ian Wong]

Well, I figured I'd end my 1 month hiatus away from the forums by starting a thread about Radiology.

 

The internal medicine guys and anesthesiologists have their own threads already, so it's time to start one on Radiology.

 

So, why would anyone go into this specialty? Well, I can say that as a medical student, Radiology wasn't even on the radar screen. I still remember one of my classmates in Med 1 who just came back from a shadowing session with a radiologist saying that it "was the most boring experience of my life. You just sit there and dictate all day. And it's dark."

 

They are right about the dark. The boring part is only true when you are a med student. The trouble with Radiology is that it is entirely unlike most other specialties that you encounter as a med student. When you are on Internal Medicine, you round on patients, perform H&P's, write notes and orders in the chart, take call, and are an integral member of the team.

 

On a radiology elective, you sit in a chair behind 1-2 residents and the attending, and try not to fall asleep just in case it is the one time in the morning that someone actually asks you a question. There's just not much that a med student can contribute to a radiology department; unless you do IR and the IR guy is willing to let you try some minor procedures.

 

Still, when you are the one in the front chair, and are looking at the images trying to figure out what diseases could be the common ground between what you see, and the clinical history that you were provided, it's INCREDIBLY FUN! It's like solving puzzles all day long. Somewhere within the CT scan of the abdomen is the reason for the patient's severe, unremitting LLQ abdominal pain. It's your job to find it, or to exclude treatable causes of that pain.

 

The thing is that radiology is an incredibly diverse and complex specialty. You are the imaging expert, and imaging is currently the fastest growing area within medicine. Particularly in the US, imaging costs are growing faster than any other area of medicine, higher still than pharmaceutical medications and all their notoriety.

 

As the imaging expert, you need to be conversant with diseases that affect all ages, any organ system, and in both genders. Typically, the most interesting patients in the hospital will make multiple stops through your imaging department, and your interpretation will often determine the next step of treatment for your patient.

 

Your patients tend to be the most interesting ones in the hospital, because it is for that reason that the primary physicians are ordering the imaging studies, to try to confirm or exclude a tentative diagnosis. If they were sure about the diagnosis, they wouldn't be ordering the study!

 

As a general radiologist, you might interpret a head CT looking for a stroke, followed by a renal ultrasound for a patient with renal failure, followed by a knee MRI for a patient with physical findings suspicious for an ACL tear, following by a neonatal chest x-ray, and then perform a barium enema looking for colon cancer. There's an incredible variety of disease and imaging, and there are new techniques in development each day.

 

There are numerous fellowships in radiology, which may either focus on an organ system, or an imaging modality.

 

As a result, organ system fellowships include:

Neuroradiology

Musculoskeletal radiology

Chest/Cardiac radiology

GI/GU radiology

Mammography/Women's Imaging

 

Imaging modality fellowships include:

MRI

Nuclear Medicine

Ultrasound

 

Other fellowships include:

Pediatric radiology

Interventional radiology

Neurointerventional radiology

 

The workload and variety in these fellowships is extremely varied as well.

 

As an interventional radiologist, you are extremely hands-on, and see patients pre and post-procedure. Lifestyle is worse as there are many IR emergencies (GI bleeds, acute arterial occlusions, trauma with arterial bleeding requiring embolization, uncontrollable epistaxis, etc.).

 

As a musculoskeletal radiologist, you may lead a 9-5 lifestyle with no call reading MRI studies of knees and shoulders.

 

There is an emerging field known as teleradiology where you interpret images from multiple hospitals which arrive via the internet. This tends to be shiftwork, and has the advantage of being even more portable than traditional radiology. Wherever there is an internet connection, you can work!

 

This also raises the issue of outsourcing image interpretation to India, or other lower cost countries. The thing to remember here though, is that interpreting images is DIFFICULT.

 

Do you really want a surgeon taking your patient to the OR based on what a radiologist who didn't train in North America, nor complete a US/Canadian residency, and in fact, isn't even licensed to work in North America?

 

From the radiologist's standpoint, it is this medicolegal liability that makes it unlikely that imaging will ever be outsourced, except to radiologists who are US/Canadian board-certified. And it is difficult indeed to get this board-certification. The Canadian and US authorities aren't just handing out board-certification to just anyone, which is why many most foreign physicians need to redo residency (and possibly med school) in order to practice in North America.

 

Major pros of radiology include minimal overhead, near complete job portability (when you move, you don't need to sell your practice and re-establish a new own), diversity of patient population and disease, and shift-work.

 

I really think shift-work is one of the most powerful things you can get in medicine, simply because it's so rare. There are few specialties (others include Dermatology, Anesthesiology, Pathology, and Emergency Medicine), where you can always turn your pager off after leaving the office or hospital, and feel completely good about yourself. That shift-work principle also lends itself to scheduling your work-hours in advance, and that leads to a much more controllable lifestyle and hopefully the ability to take care of your non-medical priorities in life.

 

So, if you want to do something with your family or friends, just make sure that you aren't on shift that day. If you want to take a vacation, same deal. Physicians who see patients have a lot more difficult time doing this because it often means re-scheduling patients, and you really can't leave your practice for any really extended length of time unless you can find a long-term locum, which is very tough.

 

Income in radiology is very good at the present time, although we are also at the peak of the radiology job market, and it's likely to worsen in the future.

 

Probably the most important aspect of radiology is the patient care, or lack thereof. Radiologists can have minimal patient contact, but they have lots of people-contact. You interact constantly with other clinicians regarding imaging findings and recommendations, as well as the clerical staff and radiology techs within your department. On the other hand, in ultrasound, mammography, and interventional radiology, you can have a lot more patient contact if you want it.

 

It is very true that even then, you won't develop many, if any longterm relationships with your patients (who tend to arrive for their imaging test, and then leave), but the information you provide their primary physician has a marked effect on that patient's treatment and outcome.

 

Your diagnosis of a pulmonary embolism on a chest CT automatically buys that patient heparin or lovenox anticoagulation followed by months on Coumadin.

 

Your diagnosis of lymphadenopathy or a pleural effusion could be the deciding point between whether or not a cancer is surgically resectable (and potentially curable).

 

As an interventional radiologist, your femoral artery angioplasty and stenting may be the difference between a patient losing their leg or not.

 

The 30 seconds you spend on diagnosing a patient with a new stroke on a head MRI or CT scan sets into motion many hours of work by other physicians for that patient. But, you've already moved on to the next interesting patient. The average physician is hard pressed to see 40 patients a day. The average radiologist could easily dictate 100-200 studies per day. That's a lot of decisions that significantly change that patient's diagnosis, prognosis, and treatment.

 

The benefit of losing patient contact is that you are also freed from all of the tasks that come along with being the point man for your patient.

 

It no longer becomes your job to hassle consultants to see your patient in a prompt manner, detangle the dysfunctional family dynamics that often accompany your patients, work with non-compliant patients who don't listen to your advice and recommendations (or worse yet, the drug-seeking patients that try to con opioid meds from you), or deal with all the potential headaches of trying to do the right thing for your patient (writing letters to get medications approved, filling out disability forms, calling pharmacies to renew prescriptions, adding on "urgent" patients despite the fact that you already have a full schedule that day, etc).

 

As a radiologist, you do a lot less paperwork than the average physician, and that's definitely a good thing. While dictating may not be the reason you went into medicine, it's infinitely better than writing stuff into a chart.

 

Anyway, there's my case for why Radiology is so awesome. We see the most interesting patients in the hospital, make all kinds of decisions that can dramatically affect their care, yet still have the ability to move immediately to the next patient. Scutwork is at a minimum. There's little to no overhead, and immense flexibility in choosing your hours due to the fact that radiology is mechanistically perfect for shiftwork. Incomes are very good right now (although that's likely to decrease, but we'll still do all right).

 

Radiology is the perfect specialty for people who like to think and enjoy anatomy and pathology. It even appeals to people who like to do procedures. These procedures are usually minimally invasive, so patients often show quick results, go home soon after, and therefore aren't in the hospital and don't need to be rounded on.

 

It's for these reasons that Radiology attracts folks who hail from both the Internal Medicine, as well as the Surgery mentality.

 

Ian

[Guest Lactic Folly]

Hey Ian,

Welcome back and thanks for the excellent and informative post. Could you comment on what distinguishes radiology from the other diagnostic specialty of pathology, seeing as they are appealing for several of the same reasons?

[Guest muchdutch]

Great post - lots of info to think about. I'm interested in both oncology and radiology. Is there such a thing? Or are you required to do a fellowship that specializes you as a chest oncological radiologist? Is there even enough of a specialty market for this, or would you be just a general chest radiologist for example who deals with both oncology and other conditions as well?

Also, because you don't see patients in the traditional manner, I can imagine there would be politics between specialites (as I'm sure there are between all specialties). Do you ever feel that your colleagues think you're not a 'real' doctor, as you are not in the traditional sense (rounds, patients, paperwork, etc.)?

Are you finished your residency? Do you work from 'home'? Is this a possibility or is it frowned upon?

If I remember correctly, you're in the states, no? What do you think would be the primary differences between practicing radiology in the States versus Canada?

 

Whew! This is only a few of the questions I have too!

[Guest Ian Wong]

I think that Pathology and Radiology are very, very, similar. For this reason, there are usually a few people each year who you'll see in the match for both specialties.

 

Mechanistically, your job is very similar. Each specialty serves as a consultant to the primary team. Neither specialty is the front-line physician who is managing the patient, auscultating for breath sounds, writing the orders, going to surgery, etc. In both specialties, you are visually analyzing a sample from a patient (whether that be some slides from a biopsy, or the images from the patient's chest x-ray), and rendering your best interpretation and diagnosis.

 

I think though, that Radiology is more closely affliated with the clinicians than Pathology. The reading room is a constant whirlwind of clinicians seeking input. In contrast, far fewer clinicians wander into the pathology department to review slides with the pathologists. Part of the reason for this is that radiology often deals with much more acute scenarios that cannot wait until the morning, or the next week.

 

While a Pap smear doesn't need to be interpreted immediately, the same cannot necessarily be said of radiology. There are innumerable radiology "emergencies", whether that be the pelvic or testicular ultrasound to rule out ectopic pregnacies or testicular torsion, to the head CT to evaluate for a stroke, to the chest CT or V/Q scan to look for a pulmonary embolus, or an abdomen/pelvis CT to look for appendicitis. All of these things carry a much higher urgency and delays in diagnosis can lead to increased patient morbidity and mortality.

 

As an example, I read a chest CT this morning that had been done late yesterday, but for whatever reason had been glitched in the PACS system, such that the images were not available for review until today. I found a spontaneous pneumothorax. The patient had noted increasing chest pain, and was tachypneic and recently post-op abdominal surgery, so this was for a suspected PE. Unfortunately, they had not ordered a chest x-ray, so this patient sat on the floor overnight without the diagnosis.

 

Now, had the patient's respiratory status deteriorated further, I'm sure the issue of the missing images would have been more vigorously pursued (or the patient would have gotten a chest-x-ray or a V/Q scan or another chest CT), but you can see that while nothing bad happened from this case, the opportunity is certainly there.

 

The closest analogue that Path has to this sort of urgency is in surg path where the patient is having some kind of cancer surgically removed, and the patient is open on the table in the OR, and the surgeon is trying to figure out whether the resection margins for the tumour are clear, or whether he/she still needs to remove more tissue from around the cancer.

 

Those frozen sections are handled urgently since the longer the delay in interpretation, the longer the patient is languishing on the OR table. Still, while that can make for a hectic day in the lab, there are few elective cancer resection cases going on in the middle of the night!

 

Also, Pathology tends to be the definitive last stop for all sorts of histologic diagnoses (when a pathologist says it's a cancer, it pretty much goes without saying that it's cancer). If a radiologist says that it's cancer, the next step is often a biopsy to prove it.

 

Still, there are whole areas in medicine that Pathology isn't heavily involved in. A radiologist will be diagnosing all sorts of fractures, strokes, pulmonary embolus, the periventricular white matter lesions of multiple sclerosis, renal calculi, pneumonia, congestive heart failure, carotid artery stenosis, DVT's, etc, all without significant pathology input. There are an awful lot of diseases in the human body that don't require a biopsy for diagnosis. Pathology involvement in these diseases is rare unless they happen to be the cause of the patient's death...

 

Other differences between Radiology and Pathology would include the hours and income. Currently, radiologists work significantly longer hours and take more call (and the call is heavy when you are working), but in return, tend to be significantly higher up on the income scale.

 

Radiology has the potential to be much more procedural than Pathology. In path, many of your procedures (if done at all), include things like fine needle aspiration to obtain cytology. Radiologists also perform fine needle aspiration (usually under ultrasound or CT guidance), but general radiologists also do all sorts of other procedures, including LP's, thoracentesis, paracentesis, chest tubes, abdominal drains for abscesses, etc.

 

If you go into interventional radiology or neurointerventional radiology, you could be stenting arteries, coiling aneurysms and GI bleeders, ablating tumours with intra-arterial chemotherapy or embolization, placing G-tubes and central lines, stenting open biliary tracts, placing and retrieving IVC filters, etc.

 

I also think that Radiology is advancing much more rapidly than Pathology. Because the technology in Radiology is at an exponential point, each year brings huge new advances to the field. Radiology 20 years ago, or even 10 years ago, was a completely different entity than it is today. In the future, CT, MRI, and PET scans will be progressively more important in patient management, and there will be a whole new raft of imaging tests that we haven't even envisioned yet.

 

Increases in computing power brought us the CT scanner and MRI scanner. As these machines have become faster and more powerful, we can do more with them. New horizons for CT scans include things like cardiac CT, where we can visualize the coronary arteries to nearly the same accuracy as a diagnostic cardiac catheterization. While virtual CT colonoscopy isn't quite there yet, the results will only improve as the scanners get faster and more detailed.

 

MR spectroscopy hold the possibility of helping to render diagnoses on whether a particular lesion is likely to be cancerous based on it's molecular composition.

 

PET technology is evolving so that cardiac PET or neuro PET (wouldn't you want to be able to see which cells in your heart or brain were metabolically active, and when?) are on the horizon. Etc, etc, etc.

 

None of these things were even remotely possible 10-20 years ago. Who knows where we'll be in another 10-20 years?

 

To sum up, I think radiology holds a wider variety of procedures, and is very active in the management of all sorts of patients, not just those requiring pathologic diagnoses (such as cancers and biopsies). Radiologists tend to log more hours and take more call, but are paid significantly more as well. In the end though, I think the fields are more similar than they are different.

 

Ian

[Guest Ian Wong]

There is an entire field known as Radiation Oncology, which deals with the treatment of cancer using radiation. It's a totally separate 5 year residency.

 

The scope of Diagnostic Radiology, in contrast, is in diagnosing the cancer to begin with, and monitoring its progression. During your radiology residency, you'll be interpreting all sorts of images from patients with cancer. You will be comfortable diagnosing primary cancers and metastatic spread (to the limits of the technology), on CT, ultrasound, MRI, etc upon finishing your residency, without doing additional fellowships.

 

There is no separate oncology fellowship for radiologists, primarily because one isn't felt to be needed at this point. Having said this, a Nuclear Medicine fellowship often includes training in PET scans (particularly in the US, where there are far more PET scanners than in Canada). PET scans are uniquely good at imaging for cancers, because they home in on areas of the body that are highly metabolically active, such as tumour cells. If you wanted to get heavily involved in the diagnosis of cancers, doing a Nuclear Medicine fellowship will go a long way towards that.

 

If you are interested in treating cancers through minimally-invasive techniques (like intra-arterial chemotherapy/embolization, radio-frequency ablation, or cryoablation), then interventional radiology can get you there.

 

One of the most rapidly up and coming areas in interventional radiology lie within "interventional oncology", the percutaneous catheter-based treatment of cancer.

 

There are certainly clinicians out there that think we are not physicians since we do tasks that are quite different than what the stereotypical doctor does. We don't own stethoscopes, we don't generally write presciptions, and we don't have patients that we truly call our own.

 

In that same vein, many patients also have no idea that radiologists are physicians. That's fine by me. I don't derive my sense of worth from people thinking that I'm a physician, and most radiologists feel likewise.

 

If you want physicians to respect you, go into a surgical specialty and take all sorts of call and live in the hospital taking consults cleaning up other clinician's messes. If you want the public to respect you, likewise, go into ER, or surgery, or cardiology, or plastic surgery, or something equally glamorous.

 

Myself, I'm happy to leave that arena of "real" medicine in favour of a specialty that gives me lots of free time, the most interesting cases in the hospital, the most technologically-advanced and advancing equipment, a decent salary, and the feeling that by the end of the day I've truly made a difference to my "patients." Radiology is definitely not for everybody, but it's the closest thing to an ideal specialty for me personally.

 

Like many of the other senior moderators here, I'm a resident at the moment. Radiology, through teleradiology, can easily be designed to be practiced from home. This will only increase in the future. However, one problem with teleradiology is that the demand for it is greatest during the night-time hours in North America (when most radiologists are either on call, or are sleeping at home).

 

This is why many teleradiology companies have set up in places like Hawaii, Australia, or Europe, in order to take advantage of time zone differences, so that you can cover US night-time studies during the day-time at your teleradiology venue.

 

If you wanted to live in North America and do teleradiology from home, chances are good that you might need to work nights and sleep during the day. Most radiologists aren't interested in that, for family reasons.

 

Primary differences between radiology in Canada and the US lie in the much higher volume of tests and the higher prevalence of advanced imaging in the US. Ordering a CT scan or an MRI in the US is no big deal.

 

In Canada, often CT and MRI are reserved as a test of last resort, and are rationed accordingly. As a result, the imaging volume in the US is far higher than in Canada, and the proportion of those tests is heavily skewed towards the expensive stuff like CT, MRI, and PET, whereas in Canada, you are more likely to first try and work out the diagnosis using your history and physical and perhaps a plain film or an ultrasound.

 

It is not unusual in the US to write an order for a CT scan on a patient, and have it performed and formally interpreted in under 2 hours. Such a feat is rare in Canada.

 

As a result, more imaging means more income, as well as longer hours and more call responsibilities. I heard a joke from a general surgeon last year that MRI actually stood for "More Radiology Income."

 

Ian

[Guest noncestvrai]

Yet you mention a "trend" to decreased compensation for services. Can you elaborate on the matter?

 

As for "second nature CTs"...if I can Dx a condition with a plain abd XR or US, I'd be more that happy to spare the extra ionizing radiation...hehe, but who am I, I'm just a med student.

 

I dig radiology, anesthesia and ER...I know, broad, but I'm just a med II...there is so much to see, yet I've R/O quite a few.

 

I'll use this thread to ask a couple more questions.

 

What would be the ideal sequence of electives if I'm interested in these fields (however, if I had to choose right now, it would be something in neuroradiology)?

 

Do you think I should do say all 3-4 electives in a certain field or mix 'em up. For example, would the sequence rad/ICU/anes/ER be ok as a multipass?

 

Thanks, I've been doing some career planning while on break from USMLE "studying"...:hat

 

noncestvrai

[Guest Ian Wong]

Heya,

 

Sorry for the delay in replying. I've been out of town for the last little while.

 

As far as reimbursements go, I expect them to be on the decline in the future, at least in the US. In the US, real salaries have actually been decreasing for the last several years, in that radiologists have been working increasingly long hours and interpreting more studies, without an actual increase in overall income after adjusting for things like inflation.

 

What is happening is that while the total number of imaging studies increases, the reimbursement per study has decreased.

 

For a time, radiologists have been able to keep up their incomes by reading more and more studies, especially through the use of an efficient PACS machine, but there's still a finite limit to how many studies you can physically read each day.

 

It's incredibly fatiguing to blow through studies at a fast clip, and becomes increasingly stressful the faster you work, since there's always the nagging "what if?" thought in the back of your mind that you might be missing something.

 

Unfortunately, I think we've hit that point of diminishing returns, and that's a reason why radiologists are starting to hit burn-out. When you've maxed out on the volume of studies you can read, but reimbursement per study continues to drop, your income will decrease proportionally.

 

Still, I think that even if the reimbursement per study drops faster than radiologists can increase their numbers of studies, radiology incomes are still never going to be completely in the toilet. We are always developing new imaging tests and modalities, and that constant evolution will keep us at least reasonably reimbursed.

 

The situation in Canada might be a little different, although I'm not certain of that. At this time radiologists in Canada are not hurting for income.

 

The other marked benefit is the lack of overhead. Net income = gross income - overhead and taxes. Having minimal overhead means that you keep more of your earned income, and spend a lot less administrative time compared with if you were in an office-based specialty.

 

I think that a radiology elective is good to do so that you have a better mechanistic sense of what it is we're doing, and so you have a better ability to see whether it might be something you'd like doing. Unfortunately, as mentioned earlier, it's tough to jump into radiology as a med student, since your presence isn't really needed the same way it is on Internal Medicine or Surgery.

 

ICU is a phenomenal rotation to do as a med student irrespective of what you are going into. Anesthesia and Emerg also are reasonable electives. I think that doing all of your electives in Radiology is probably not a good idea, and that a mix of electives is probably better. A rotation in something like Respirology may also be good since you'll see a lot of chest pathology.

 

Ian

[tarzi]

Ian,

 

Amazing post and I really appreciate your contributions...you are a hero to me(since I believe you are also the founder of premed101 and these forums).

 

Got a question for you,

 

For the rads fellowships - what is the draw of specializing further in such narrow fields?

 

For example, if one does a fellowship in musculoskeletal radiology - does this mean that they are limited to this field, or would they still have the same broad scope of work as non-fellowship radiologists? Likewise, if someone does not do a fellowship in musculoskel rads, and they are just a regular radiologist, does this mean that they cannot interpret images of the musculoskeletal system?

 

I'm just wondering - if you specialize in such narrow fields, does this sort of limit the variability in the work that you do, or does it simply mean that in the event that there is something really weird going on that no one can figure out, and it falls within your subspecialty, you can take a crack at it while a general radiologist cannot?

 

Another good question is doing the MRI fellowship - what does this result in? Because I thought that all radiologists can interpret MRI images...

[Kirsteen]

For the rads fellowships - what is the draw of specializing further in such narrow fields?

 

For example, if one does a fellowship in musculoskeletal radiology - does this mean that they are limited to this field, or would they still have the same broad scope of work as non-fellowship radiologists? Likewise, if someone does not do a fellowship in musculoskel rads, and they are just a regular radiologist, does this mean that they cannot interpret images of the musculoskeletal system?

 

I'm just wondering - if you specialize in such narrow fields, does this sort of limit the variability in the work that you do, or does it simply mean that in the event that there is something really weird going on that no one can figure out, and it falls within your subspecialty, you can take a crack at it while a general radiologist cannot?

 

Another good question is doing the MRI fellowship - what does this result in? Because I thought that all radiologists can interpret MRI images...

Hi there,

 

Sorry, I'm obviously not Ian, but I might be able to help with some of these responses given some of my recent experiences.

 

I've interviewed at a number of Radiology programs this week and one Program Director mentioned that current graduates are tending towards entering the job market directly from residency as opposed to selecting the fellowship route. The prime reason for this is that the current job market is very rich for Radiologists. There are all sorts of positions and varied practice models available for Radiologists to choose from at the moment. This is salient given that this Program Director was from a program that is regarded for producing academic Radiologists, i.e., those who typically complete a fellowship prior to practice. That's not to say that these graduates who are now working cannot pursue a fellowship later on. They can.

 

As for practice models, they vary. You can complete a fellowship in a certain Radiological specialty and still enjoy a general practice. For example, I know a number of Radiologists who have been trained in Interventional Rads or Neuro Rads, but who also spend time in the reading room reading images from other areas. Again though, the practice models depend on the centre and whether you're practicing in a tertiary care centre or a centre that is less so.

 

Cheers,

Kirsteen

[tarzi]

Lol, much appreciated Kirsteen.

 

I have another question - how much physics is involved in radiology? What I mean is, I know that an understanding of physics is a big part of radiology, but is it such that, those who become radiologists could have become physicists as well?

 

I guess I'm trying to ask, do we need to be physics gurus in order to become radiologists?

[Kirsteen]

Lol, much appreciated Kirsteen.

 

I have another question - how much physics is involved in radiology? What I mean is, I know that an understanding of physics is a big part of radiology, but is it such that, those who become radiologists could have become physicists as well?

 

I guess I'm trying to ask, do we need to be physics gurus in order to become radiologists?

Hey again,

 

Physics is a very important part of Radiology--so much so that many programs offer weeks-long courses in the physical principles involved in Radiology. Also, in the US there is a physics exam that is a required part of the completion of residency. That being said, I don't think you need to be Albert Einstein to be a great Radiologist nor can you necessarily be a physicist if you are trained in Radiology. They are quite different occupations requiring different knowledge and skills.

 

Cheers,

Kirsteen

[tarzi]

Hey again,

 

Physics is a very important part of Radiology--so much so that many programs offer weeks-long courses in the physical principles involved in Radiology. Also, in the US there is a physics exam that is a required part of the completion of residency. That being said, I don't think you need to be Albert Einstein to be a great Radiologist nor can you necessarily be a physicist if you are trained in Radiology. They are quite different occupations requiring different knowledge and skills.

 

Cheers,

Kirsteen

 

Awesome, b/c I loved the physics that we learned in first year physics - well, not electromagnetism, but nuclear physics and waves, were my favorite and I had a pretty good grasp of the content - in fact, I would go so far as to say that I found physics to be the coolest and most interesting science in undergrad - and I would've aimed to become a physicist but I never felt smart enough to grasp it at the senior and espcially the graduate level...

 

The physical principles that you mention - it's what we would see in a first year physics course right?

[Kyleh]

Awesome, b/c I loved the physics that we learned in first year physics - well, not electromagnetism, but nuclear physics and waves, were my favorite and I had a pretty good grasp of the content - in fact, I would go so far as to say that I found physics to be the coolest and most interesting science in undergrad - and I would've aimed to become a physicist but I never felt smart enough to grasp it at the senior and espcially the graduate level...

 

The physical principles that you mention - it's what we would see in a first year physics course right?

Wow that's pretty intense. Me on the other hand strongly dislikes physics!

[Kuantum]

Awesome, b/c I loved the physics that we learned in first year physics - well, not electromagnetism, but nuclear physics and waves, were my favorite and I had a pretty good grasp of the content - in fact, I would go so far as to say that I found physics to be the coolest and most interesting science in undergrad - and I would've aimed to become a physicist but I never felt smart enough to grasp it at the senior and espcially the graduate level...

 

The physical principles that you mention - it's what we would see in a first year physics course right?

 

Probably not. I'm assumung its stuff you'd see in a Physical Chemistry course and beyond. So, probably a lot material into microscopic descriptions of matter and what is happening on the extremely small scale.

[paulos]

Hey Rads residents (Kirsteen, Ian?):

 

What is the down-low on doing teleradiology ?

 

Say, for example, if one trains in N.A., then goes to Asia (e.g., for missionary work).

 

Is it better to do one's residency in the US for this type of scenario, or is there also work for canadian-trained radiologists?

 

Thank you for your input.

[Ian Wong]

At this time, I believe most of the dedicated teleradiology is taking place in the US. There's a few different levels of teleradiology out there.

 

1) Local, in-house teleradiology:

 

This occurs WITHIN a radiology group, and means that the local group buys a PACS workstation for its members, so that they can interpret on call studies from home, rather than driving into the hospital. By doing this, the group saves on a lot of commute time, particularly if the on call radiologist is covering more than 1 hospital at a time. It allows a centralized "virtual reading room", where all the studies can be read.

 

2) National teleradiology:

 

In the US, there are a number of US teleradiology companies (at this time owned and operated by radiologists), which are based on US soil. The reason for this is that Medicare (the US government's health care coverage vehicle for Americans over the age of 65 years), will not pay for a radiologist interpretation if it was done outside of the US.

 

Since Medicare patients make up a large percentage of the hospital's patients (the elderly constitute a large percent of hospital patients), these companies choose to locate their radiologists in the US, enabling them to make "final reads", which include a signed, official report.

 

One example of such a company can be found here:

 

http://www.virtualrad.com/

 

The disadvantage for working for this company is that because of the requirement that you be based on US soil, you are not able to take advantage of time zones as much. One group has based itself in Hawaii, and reads overnight studies performed on the east coast. Right now, Hawaii is 6 hours behind New York, so a CT scan performed at 3 am in New York can be "read" at 9 pm in Hawaii. This means that you can cover the overnight studies from a hospital without needing to work an overnight shift yourself, which decreases the stress and burnout factor of living outside your normal circadian cycles.

 

If you were based anywhere in the US other than Hawaii however, you wouldn't have much of a time zone advantage, which means that you would be working a lot of overnight shifts. The alternate then would be to do teleradiology during the daytime, and the market is moving in this direction, starting with daytime coverage of small rural hospitals that are having a hard time recruiting for local radiologists.

 

3) International teleradiology:

This is the big one. The largest teleradiology company in the world fits into this category. It is known as Nighthawk Radiology Services.

 

http://www.nighthawkrad.net/

 

This company has two remote reading sites, one in Sydney Australia, and a second in Zurich Switzerland. As before, this company takes advantage of time zone shifts, so that their radiologists work in the daytime, and are interpreting overnight studies in the US. If you work for this company, you will most likely be living in either Sydney or Zurich, as it allows them to consolidate their resources into these two locations.

 

Being internationally located, they offer "preliminary reads". These are short, focussed interpretations that are designed to answer the clinician's question. A prelim read might say: "No appendicitis. Normal CT abdomen/pelvis." The local radiology group would then dictate a final and official report the next morning, which would also mention the 1 cm right renal cyst, or 4 mm left lung base nodule, etc.

 

In other words, the Nighthawk radiologists are looking to find or exclude those critical findings (like an SAH, or stroke, or appendicitis) which could potentially change management in the middle of the night. They are not taking the time to document those incidental findings that won't alter management decisisons. Because of this, they can blow through a VERY high volume of studies. Once again, the benefit to the local group is that they can literally take themselves off call for anything that doesn't require the radiologist to perform an in-house procedure (such as an emergent angiogram).

 

Now, if you are interested in working in Asia, I'm certain there's a teleradiology company out there that would be willing to set up a workstation there for you.

 

I'm sure that an enterprising company could even go one step further, and set up locations in several desirable Asian cities, and use that as a recruiting tool. That would be quite attractive actually, because then you could spend a month in Singapore, then move to Hong Kong, then jump to Shanghai, then jet off to Tokyo, all the while still covering for the same North American hospitals. It would be the ultimate in working vacations.

 

If no one has this setup going, they probably SHOULD!

 

At the current time, Canadian residency graduates are eligible to sit for the American Board of Radiology exams, and therefore become US-board certified. Therefore, I don't see an issue with either US or Canadian training, as I think both can lead to a career in teleradiology.

 

In fact, if you head to the Nighthawk website, and hover your mouse over Dr. George Knight, one of its radiologists, it states that he did his med school, residency, and fellowship all at Dalhousie University.

 

http://www.nighthawkrad.net/radiologists.htm

 

The bottom line is that there are a lot of teleradiology models out there, and it is currently the fastest-growing segment within the radiology job market. This leads to a lot of volatility, and it's likely that the job market will evolve significantly over the next several years. One particular possibility is that dedicated networks of subspecialized radiologists (ie. neuroradiologists, or pediatric radiologists, or MSK/orthopedic radiologists) could band together, thereby offering fellowship-trained quality reads on patients.

 

In smaller towns and cities that are currently staffed by general radiologists, this could represent a high level of competition to those general radiologists, since there's a perception that a fellowship-trained radiologist would be better capable to interpret those images. This is not dissimilar to having a fellowship-trained ENT surgeon putting in your cochlear implant versus a general ENT surgeon, or having a cardiologist manage your ST-elevation MI rather than a general internist.

 

Teleradiology could become a huge levelling tool that would allow fellowship-trained radiologists to enter into a rural job market (with its associated higher reimbursements per patient) without actually needing to be located in those areas.

 

Ian

[kali billi]

Hey guys,

 

Just wondering, as a staff (hospital or community-based) radiologist, is your work schedule more like 9-5 Mon-Fri (with or without the call) or are you doing shift work like a staff ER physician does?

Thanks!

[Kirsteen]

Hey guys,

 

Just wondering, as a staff (hospital or community-based) radiologist, is your work schedule more like 9-5 Mon-Fri (with or without the call) or are you doing shift work like a staff ER physician does?

Thanks!

Hi there,

 

It depends on the practice. In one city I know, there are various combinations: 1) a hospital-based team where everyone rotates through the graveyard shift a few times a year but otherwise hours are generally 9-4; 2) a hospital-based team where the residents are largely responsible for call and the staff works 9-5 or so; 2) private practice where staff works 9-4 or so. I've also seen some contracts offered that are entirely graveyard shifts, i.e., midinight-8am, but the radiologist enjoys 26 weeks of vacation per year. Not bad if you're a night-hawk with no kids.

 

Given the job market and demand for radiologists these days, you can more easily find a job that best fits your needs, unlike jobs within some other specialties which can be a bit more difficult to come by.

 

Cheers,

Kirsteen

[rad86]

What do people think about the future of radiology? I'm not in med school yet but I have a strong interest in this specialty. However, having talked to many doctors (none of them a radiologist though), I find that most of them don't hold a very positive view for the prospect of radiology. Part of it, I guess, has to do with some jealousy, since it's almost unanimously agreed that radiologists get paid "too much" for doing "relatively little work".

 

They also did bring up a few valid points. For example, an orthopod said that for a patient with fracture who comes to ER on a friday, the radiologist often does not see the x-ray until the following week when the surgery is already done and the patient even discharged home. But a radiology report comes later anyways and the radiologist bills for it although the orthopod really didn't need it.

 

Another doctor said that when he did a radiology elective as a med student, the radiologist attending even dictated a report for a patient whose status showed as "deceased"!

 

Obviously these are not efficient use of the system funding and so many think that this should and will be corrected, which will significantly alter the practice volume and pattern of radiologists. It's scary how many doctors see radiologists as "enemies".

 

Another potential threat to the radiologists in North America is teleradiology as mentioned above, as loads of work may be transferred to places like China and India where people can do the same job for less than a quarter of the money, and with the difference in time zones there will not even be any delays through the nights since it'd be daytime for them. It seems like it's only a matter of when for the quality control part to be put in place to make these things become realities.

 

Finally, another person even mentioned that with the advance in computer and image recognition technology, maybe radiologists can be replaced by machines one day where films can be scanned and the results printed automatically...then diagnostic radiology will no longer exist.

 

I'd like to hear the views on this issue from the radiologist's side, especially from the residents who have recently chosen this specialty. When you chose radiology, what did you think about its future? Or are you planning to do mainly interventional stuff? What proportions of work are in diagnostics and interventional procedures for radiologists these days?

[rad86]

While we're on the topic, how much do radiologists really get paid? Everyone says they're paid very well, and I've seen that some radiologists who are on salary make about $350-400K/yr, while others can bill as much as $6000 a day. What's the avg value if working 50hrs/week? it's always been a mystery...

[Ian Wong]

What do people think about the future of radiology? ...it's almost unanimously agreed that radiologists get paid "too much" for doing "relatively little work".

I think that's a matter of perspective. We are constantly involved in the workups of the most complicated patients in the hospital. Routine sore throats and hypertension don't typically enter our department. However, if you are trying to stage a cancer, triage most severe trauma, identify a life-threatening pulmonary embolism, decide whether a clinical stroke may be amenable to thrombolytic therapy, or any of hundreds of other critical decision points in a complicated patient's care, then yes, you will encounter the radiology department and a radiologist will be weighing in on your care.

 

Literally, clinicians don't need us until things get complicated enough that they need us. Then they often need us, badly.

They also did bring up a few valid points. For example, an orthopod said that for a patient with fracture who comes to ER on a friday, the radiologist often does not see the x-ray until the following week when the surgery is already done and the patient even discharged home. But a radiology report comes later anyways and the radiologist bills for it although the orthopod really didn't need it.

The orthopod will also appreciate it when you point out the lung cancer on the corner of the shoulder study, that was missed by both the ER doc and surgeon. We take full responsibility for all areas of the study, including the quality control of the images themselves (do you think a surgeon knows how to protocol an MRI, or tweak a CT to optimize the imaging for a particular complaint?), comparison of that study to prior exams, and produce a written report. We also maintain objectivity with our interpretations, without the potential of being biased by the clinical history.

 

Another doctor said that when he did a radiology elective as a med student, the radiologist attending even dictated a report for a patient whose status showed as "deceased"!

This is a rare occasion in any medical setting. However, someone else clearly ordered that exam, and would have had a clinical indication for doing so. Post-mortem imaging can be helpful in selected clinical situations, such as the determination of non-accidental trauma in a pediatric fatality.

It's scary how many doctors see radiologists as "enemies".

Many of them are envious and jealous. Radiologists have the benefit of being involved with the most interesting and complex cases from all other medical and surgical specialties, without the tedium of rounding or clinics. We also have a lifestyle which, while not perfect, is significantly more controllable than most specialties, while being reimbursed higher than many other physicians.

 

Another potential threat to the radiologists in North America is teleradiology as mentioned above, as loads of work may be transferred to places like China and India where people can do the same job for less than a quarter of the money, and with the difference in time zones there will not even be any delays through the nights since it'd be daytime for them.

Interpreting images isn't something done in a clinical vaccuum, and the interpretations we make have a HUGE impact in clinical decision-making. The difference of a single 1.5 cm lymph node or a subtle obliteration of a fat plane by a cancer could be the difference between an attempted surgery for cure, or sending the patient home with an "unresectable" status and a trip home for that last fishing trip before the end.

 

Identifying that subtle pulmonary embolus buys that patient 6 months worth of anticoagulation, while failure to identify that lesion means that the patient unexpectedly drops dead 2 months later from a second, larger pulmonary embolus.

 

Even the lowly chest x-ray findings of pneumonia will engender a prescription for antibiotics, without which a patient could be at risk for developing an abscess, empyema, or even sepsis.

 

Radiologists read imaging at a much higher level than other physicians, and our knowledge base crosses multiple organ systems and imaging modalities. While the neurologist has a good working understanding of the brain on CT and perhaps MR, that individual will miss the temporal bone or middle ear lesion, or the bone metastasis to the clivus, because he/she is not versed on ENT radiology, or orthopedic radiology.

 

While the OB/GYN understands pelvic ultrasound, he/she has much less interpretative skill in correlating those ultrasound findings to those seen on CT or MRI.

 

Finally, another person even mentioned that with the advance in computer and image recognition technology, maybe radiologists can be replaced by machines one day where films can be scanned and the results printed automatically...then diagnostic radiology will no longer exist.

I have to make many judgement calls on literally every imaging study I interpret. I incorporate information from medical labs and available history into my differential diagnosis, and contact the referring clinicians when I feel I have insufficient history, or to relay what I feel are critical findings. I don't see the computer having the ability to make those subtle distinctions, with the confidence to satisfy the clinician or patient. Not any time soon, anyway. On my mammography rotations, I use one of the latest generation CAD software (Computer Aided Detection) packages to double-read my interpretations, and it sucks.

 

Mammography is one of the most brain-dead applications for CAD. There is no significant anatomy to speak of, and therefore no real anatomic variants to confuse the interpretation. The CAD program is only looking to see if there are microcalcifications or masses. Yes or no? Few things in medical imaging are entirely that binary, and CAD can't even manage to do that with any consistency. The CAD isn't even capable of evaluating for changes between old studies and the current study, due to the slight differences in patient positioning between the two studies (a difference of a few degrees in the angle of imaging can make a dramatic difference in the appearance of the images).

 

I think it will be a long time before we see computers being anything more than a potential adjunct to medical interpretation. If it did occur, I would hope to be the one that owned that computer, as someone skilled needs to be there to monitor and quality-control the computer. In which case the computer becomes an additional productivity tool for our radiology department.

 

I'd like to hear the views on this issue from the radiologist's side, especially from the residents who have recently chosen this specialty. When you chose radiology, what did you think about its future? Or are you planning to do mainly interventional stuff? What proportions of work are in diagnostics and interventional procedures for radiologists these days?

I think the future for radiology is exceptionally bright. Radiology is one of the most volatile specialties right now, as we are expanding the role of teleradiology and imaging modalities and percutaneous interventions supplant more traditional diagnostic tests and surgeries. However, I don't see the demand nor workload decreasing any time soon. We are at risk of reimbursement cuts, but that isn't a scenario unique to radiologists.

 

Ian

[El Matador de la Muerte]

Radiology looks like a very interesting speciality! I'm finishing my masters in Organic Chemistry were I have profusely used 1H, 13C NMR....

 

How does MRI works ? What sighal does it detects ? I mean basically, we get an NMR signal every time a nucleus has a non-nil magnetic spin.

 

What's responsible for the signal in NMR? Is there more of that compound in certain organ zones ?

[Kirsteen]

Radiology looks like a very interesting speciality! I'm finishing my masters in Organic Chemistry were I have profusely used 1H, 13C NMR....

 

How does MRI works ? What sighal does it detects ? I mean basically, we get an NMR signal every time a nucleus has a non-nil magnetic spin.

 

What's responsible for the signal in NMR? Is there more of that compound in certain organ zones ?

Hi there,

 

There's a decent Wikipedia article that covers the basics of MRI: http://en.wikipedia.org/wiki/Mri

 

Cheers,

Kirsteen

[tmc]

Hi guys,

 

I'm currently doing a radiology elective in Toronto and I'm stressing out about the job outcome/ future predictions for radiology. I've been working SO hard this year on a number of radiology projects (all of which have gone reasonably well) just to get into a program in the country. I've extremely disheartened by the fact that people keep hinting about radiologist being out of a job in the future. Just today, my radiology attending was joking about how he could train a his nephew to read his MSK films and that likely with more privatization, radiologists will be at the bottom of the medical ladder.

 

Anyhow, this wasn't exactly what I wanted to hear given that I'll be applying for CARMS in two short months and feel like maybe I've exhausted myself with all these projects for no real good purpose

 

Any reassurance/ comments would be appreciated.

[Kirsteen]

Hi guys,

 

I'm currently doing a radiology elective in Toronto and I'm stressing out about the job outcome/ future predictions for radiology. I've been working SO hard this year on a number of radiology projects (all of which have gone reasonably well) just to get into a program in the country. I've extremely disheartened by the fact that people keep hinting about radiologist being out of a job in the future. Just today, my radiology attending was joking about how he could train a his nephew to read his MSK films and that likely with more privatization, radiologists will be at the bottom of the medical ladder.

 

Anyhow, this wasn't exactly what I wanted to hear given that I'll be applying for CARMS in two short months and feel like maybe I've exhausted myself with all these projects for no real good purpose

 

Any reassurance/ comments would be appreciated.

Hi there,

 

It's true that there has been a slight slowing of the job market for radiologists in the past few years, however, that's a very relative term. Currently, if you train to be a radiologist, there are hundreds of jobs out there, and unlike some other specialties you can start a job immediately post-Royal College exams. To wit, I came upon a UofT medical jobs page in the past month and the majority of jobs that needed to be filled were not for surgeons or internists, but for radiologists. Also, it's still not unheard of for radiologists who wish to move to the US to receive significant ($50-100K) signing bonuses. Contrast this with jobs in many of the surgery fields which are relatively hard to come by and for which the physician needs one or even two fellowships in order to be considered competitive for the position.

 

At the moment, I think you have little to worry about.

 

Cheers,

Kirsteen