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Radiology Vs Pathology


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Who would cover after 9 pm in your model then? Radiology is already 24/7 - imaging is an essential service in any hospital of a given size. The setup is variable and completely up to the specific group - could include teleradiology coverage, night float, or traditional overnight call +/- postcall day off (depends on how much you might get called overnight, and again is completely dependent on the setting).

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When people talk of radiology switching to a 24/7 service, what actual setup do you anticipate for staff? Will it be like the ER doc shift work model, where doctors work a 10-12 hour shift constantly rotating through days and nights? Would they still be taking off a 2 day "weekend" for about every 5 shifts worked? Exactly how much busier do you think they will be as a result, and how soon can we expect this to happen?

 

Correct me if I'm wrong, but from what I understand of how it currently works, radiologists largely still work mainly daytime hours, but do an extra evening shift until about 9 pm once every week or two, and cover an entire weekend every 6-8 weeks.

 

the models vary because the centres have different levels of staffing and call needs. 

 

in a community centre where it is busy the night can certainly go a lot later than 9pm for instance. That would meant that the ER for instance didn't need emerg imaging on anything from 9am until 8am - that would be very rare. The busiest places I have seen have the staff going well after midnight and of course are on call the ENTIRE night.  Many community radiology groups don't have those sorts of call needs though. 

 

One place I was at was a typical community hospital - roughly 150K population and had 6 radiologists. That means that basically with vacations/training time you are on call once a week at night, and once a month on call for the entire weekend. Community is a lot busier in many ways than academic with residents, and more staff. 

 

As for the 24/7 thing it is already happening. Toronto and Vancouver have switched. They are similar to the ER - three shifts a day, every day as I understand it. Our centre has staff a two staff shift system with one person going from 7-3pm, and another from 3-11pm with residents covering the gap time. Starts there and works its way down.

 

I am at a large academic centre with 60 rads so you may thing that means one week a year of call but that doesn't work - the older staff cannot always do CT for instance and some people are doing admin work instead, and some are actually part time. Actually we have 2 staff all weekend just doing plain films, and 2 more doing the call (one at each hospital). One top of that we have one neuro staff on call the entire weekend as well so 5 rads per weekend - plus any others doing back log work. Still that is pretty good none the less with roughly call every 6-8 weeks for a weekend. There are rumours of us going 24/7 soon, and already the neuro staff have now started an evening shift. Volumes are continuing to go up, and we are finding more and more things that require emerg imaging - most recently for use is the new CTA rules for TIAs which as increased the number of CTAs we do on call by a factor of roughly 4 I would say.

 

With the pressing need for stroke imaging, the emergence of CT cardiac imaging for MI, and the general increase in imaging for baseline standard of care now the need for radiology has literally never been higher. We sit in the vortex of almost all diagnostic decisions, and that is an exciting place to be. Of course with increased demand comes decreased lifestyle. 

 

Long term a question is whether we need a general night float system - right now we simulate that in many places. For instance Ottawa on call does a lot of the surrounding areas as well so those rads can sleep (and we get paid). It probably is not a good idea to have your staff woken up constantly overnight for their entire careers, when we can concentrate it perhaps and go from there.

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You'll see it in residency programs too. The radiology residents are by and large well put together. The pathology residents are mostly FMGs and very awkward, and very easily picked on. It reflects professionally.

 

Pathology is considered a weird, weak field, that's been gutted professionally by the government and for-profit lab corporations, ignored by the OMA, and self-sabotaged by the OAP. Students should know that before taking the plunge. You'll be on your own here. Crabs in a bucket.

I don't know what program you are at but at the programs in Canada that I've had personal experiences with, this is not true at all.

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the models vary because the centres have different levels of staffing and call needs. 

 

in a community centre where it is busy the night can certainly go a lot later than 9pm for instance. That would meant that the ER for instance didn't need emerg imaging on anything from 9am until 8am - that would be very rare. The busiest places I have seen have the staff going well after midnight and of course are on call the ENTIRE night.  Many community radiology groups don't have those sorts of call needs though. 

 

One place I was at was a typical community hospital - roughly 150K population and had 6 radiologists. That means that basically with vacations/training time you are on call once a week at night, and once a month on call for the entire weekend. Community is a lot busier in many ways than academic with residents, and more staff. 

 

As for the 24/7 thing it is already happening. Toronto and Vancouver have switched. They are similar to the ER - three shifts a day, every day as I understand it. Our centre has staff a two staff shift system with one person going from 7-3pm, and another from 3-11pm with residents covering the gap time. Starts there and works its way down.

 

I am at a large academic centre with 60 rads so you may thing that means one week a year of call but that doesn't work - the older staff cannot always do CT for instance and some people are doing admin work instead, and some are actually part time. Actually we have 2 staff all weekend just doing plain films, and 2 more doing the call (one at each hospital). One top of that we have one neuro staff on call the entire weekend as well so 5 rads per weekend - plus any others doing back log work. Still that is pretty good none the less with roughly call every 6-8 weeks for a weekend. There are rumours of us going 24/7 soon, and already the neuro staff have now started an evening shift. Volumes are continuing to go up, and we are finding more and more things that require emerg imaging - most recently for use is the new CTA rules for TIAs which as increased the number of CTAs we do on call by a factor of roughly 4 I would say.

 

With the pressing need for stroke imaging, the emergence of CT cardiac imaging for MI, and the general increase in imaging for baseline standard of care now the need for radiology has literally never been higher. We sit in the vortex of almost all diagnostic decisions, and that is an exciting place to be. Of course with increased demand comes decreased lifestyle. 

 

Long term a question is whether we need a general night float system - right now we simulate that in many places. For instance Ottawa on call does a lot of the surrounding areas as well so those rads can sleep (and we get paid). It probably is not a good idea to have your staff woken up constantly overnight for their entire careers, when we can concentrate it perhaps and go from there.

 

The 2 shift system at your centre, is that in addition to doing occasional overnight call as most attendings currently do, or do only the residents cover past 11 pm?

 

So attendings in Toronto and Vancouver regularly do a 3rd overnight shift, rotating between all 3? Do they still get the equivalent of a 2 day weekend after about 5 shifts?

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The 2 shift system at your centre, is that in addition to doing occasional overnight call as most attendings currently do, or do only the residents cover past 11 pm?

 

So attendings in Toronto and Vancouver regularly do a 3rd overnight shift, rotating between all 3? Do they still get the equivalent of a 2 day weekend after about 5 shifts?

 

I will have to let someone from those centres speak to specifics :) They definitely have an overnight shift and there is some form of rotation. 

 

To be clear even at our academic centre you don't always get a 2 day weekend. For instance when you do a weekend on call you work mon-fri, do the weekend, and then do mon-fri again for I guess 12 days straight. That would be for both the neuro team and the general call team (including the plain film team) I don't think you usually get a weekend or equivalent in the community either if you are on a call rotation. There is a lot of variability of course so it is hard to speak in generalities.  There are some places where you work your ass off (those high paying rads you keep hearing about are working like crazy - nights, weekends, early days.....whatever.) Other places not so much. I guess a point to make is the trend - radiology over time is getting busier, and in a sense harder. It takes a lot longer to read a CT scan now than it used to (more images, thinner slices, more reformats, perfusion imaging, spec imaging........). 

 

at our centre from 11pm to 6:45 am the residents are alone with backup they can call in currently. Used to be we were alone from 5pm to 8am - which is what most of the staff trained under (the good old days).  

 

and to be clear when I say TO I mean the teaching hospital - there are a lot of hospitals in TO and they are not all academic centres. 

 

I did forget to mention - in addition to above there is also a separate neuro and angio interventional teams also on call. Of course those often are called in at night and have to work the following day as per normal. Think of those fields as basically a surgical discipline because they work like surgeons and are on call like surgeons. That would therefore be another 2 staff on call each night - those staff do not normally participant in the normal call system. So in total on any given weekend/holiday there would be 7 staff working.

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  • 2 weeks later...

For what it's worth I...

-Work in a path subspecialty.

-Had zero difficulty finding a job.

-Have 9 hour work day, Mon-Fri (though I take 6-7 weeks of home call a year)

-Feel respected and appreciated by my clinical colleagues (with whom I have a lot of contact)

-Am more than happy with my compensation.

-Sincerely love what I do.

 

I agree with Cain's assessment that the lack of control over work load and hiring is a problem with pathology. But... otherwise... I think we've had very different experiences :) 

 

Those curious about lab medicine should absolutely spend some time exploring the discipline, and see for themselves if it's a fit. Feel free to PM if you want to chat.

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For what it's worth I...

-Work in a path subspecialty.

-Had zero difficulty finding a job.

-Have 9 hour work day, Mon-Fri (though I take 6-7 weeks of home call a year)

-Feel respected and appreciated by my clinical colleagues (with whom I have a lot of contact)

-Am more than happy with my compensation.

-Sincerely love what I do.

 

I agree with Cain's assessment that the lack of control over work load and hiring is a problem with pathology. But... otherwise... I think we've had very different experiences :)

 

Those curious about lab medicine should absolutely spend some time exploring the discipline, and see for themselves if it's a fit. Feel free to PM if you want to chat.

 A few caveats, just for the students out there:

- fellowships are basically required now and the demand for each specific fellowship tends to change year to year. this year heme is in demand. next year it might be derm. you can never tell. but you wont get a job in a decent city without a fellowship. so your residency is effectively six years, not five, and theres no telling where youll end up after.

- i know guys who have had difficulty finding work and had to move to remote undesirable locations

- youre not paid for that home call. thats the case for ontario no matter where you are. all other specialties get paid for home call. clearly path is marginalized.

- maybe youve not worked long enough to see the issues, maybe youre more tolerant of them in general, or maybe your institution is fair (though i doubt the latter). the staff paths ive talked to, minus a few imgs that seem insecure and dont want to rock any boats, say that youre expected to be a tech, not a doctor. how unfulfilling is that? a life of hard-won academic achievement, only to be told in the end to put your head down and be a tech.

- you shouldnt be happy with your home call lack of compensation. youre effectively working for free so hospitals can use money on other things like admin salaries. its not fair. nobody should tolerate that.

- i enjoy the practice of path but the politics of it are so offputting i regret having ranked it at all. i feel stupid.

 

- having zero control over your work and your hiring is a HUGE RED FLAG for a field. its not a small thing. the fact that pathologists accept this arrangement illustrates the type of personalities that go into path (this isn't directed at Liszt but at the general membership of pathology): insecure, weak-willed folk who wont stand up for something when they should, causing people to think that they actually may like being bullied.

 

i recommend students that think they might be interested in diagnostic medicine do radiology electives instead. strategically there will always be a pathology spot available somewhere so dont waste valuable elective time on it. path programs are under a lot of pressure from admin (see the pattern?) to fill residency rosters so they get the government funding that comes with it. That's why places like NFLD still fill with IMGs every year. rads is better than path in every professional way. there is no question about it. more jobs, more pay, fair compensation for call, more respect, stronger smarter colleagues who stand up for themselves.

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Most wouldn't support it. It reduces autonomy. In order to reap the benefits of the pension you become stuck at the institution despite better opportunities opening elsewhere. It reduces professional freedom.

 

I'm assuming that Sick Kids can salary their radiologists either because of the supposed prestige of working there, Toronto being a prime location, or maybe the billing codes or volumes for peds are lower and they're actually paying a premium to get peds radiologists there? I don't know. But what I can say is that pathologists get paid the same whether they do one case a year or 2000 (it's always closer to 2000, or more, and if it becomes 3000, well tough).

 

Pathology is the only field where you can't bill for your services solely because of the location where you provide them. If a pathologist diagnoses a GI biopsy in a hospital, he bills zero. If he does it at one of the two major lab companies, he bills about fifty bucks, which the lab corporations shave by 70 to 80%.

 

I cannot see how if someone does one thing somewhere it's worth ZERO while if they do it elsewhere it's worth X. I don't get that. I cannot see why OAP and OMA haven't been persistent in fighting this. OAP because it marginalizes pathologists, and OMA because it acts as a deprofessionalizing index case for other hospital based fields. If radiologists had not been so rightfully proud of themselves, they'd be in the same boat as pathology.

 

In that document I linked a while back, a few northern Ontario pathologists tried to fight it legally but coudn't  beat the government or the lab corps. The OAP did nothing. The OMA did nothing.

 

You'll see it in residency programs too. The radiology residents are by and large well put together. The pathology residents are mostly FMGs and very awkward, and very easily picked on. It reflects professionally.

 

Pathology is considered a weird, weak field, that's been gutted professionally by the government and for-profit lab corporations, ignored by the OMA, and self-sabotaged by the OAP. Students should know that before taking the plunge. You'll be on your own here. Crabs in a bucket.

 

missed this :) actually it is salaried because other wise people wouldn't do it. Not to go back to the money again but if you are looking for money you need CT and MRI. Pediatric radiology compared to basically every other branch just doesn't have that sort of volume of the cross sectional imaging. CTs are avoided due to the radidation, and MRI requires a general usually so you just don't due as many. What is left is x rays, fluro, and US - important but not where the money is, and you are even trying to avoid doing those studies often due to radiation often as well. 

 

So many peds radiologist have some form of alternative funding model to help with the difference. Otherwise by the numbers they would earn less than most other 5 year specialties. 

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 A few caveats, just for the students out there:

- fellowships are basically required now and the demand for each specific fellowship tends to change year to year. this year heme is in demand. next year it might be derm. you can never tell. but you wont get a job in a decent city without a fellowship. so your residency is effectively six years, not five, and theres no telling where youll end up after.

- i know guys who have had difficulty finding work and had to move to remote undesirable locations

- youre not paid for that home call. thats the case for ontario no matter where you are. all other specialties get paid for home call. clearly path is marginalized.

- maybe youve not worked long enough to see the issues, maybe youre more tolerant of them in general, or maybe your institution is fair (though i doubt the latter). the staff paths ive talked to, minus a few imgs that seem insecure and dont want to rock any boats, say that youre expected to be a tech, not a doctor. how unfulfilling is that? a life of hard-won academic achievement, only to be told in the end to put your head down and be a tech.

- you shouldnt be happy with your home call lack of compensation. youre effectively working for free so hospitals can use money on other things like admin salaries. its not fair. nobody should tolerate that.

- i enjoy the practice of path but the politics of it are so offputting i regret having ranked it at all. i feel stupid.

 

 

To provide my experience for the students...

-My institution is different from Cain's, and I'm also in HP so that's going to affect my experience as well. My office is situated in/near the lab, but I'm at no risk of forgetting that I'm a laboratory physician. Lab management is a major part of my job (even as a new hire), and while I provide medical oversight on technical issues, my daily duties are very distinct from the technologists'. Outside of the lab, I consult a great deal with clinicians. Much of this comes from adult & peds hematologists, but I also have a lot of communication with intensivists, surgeons, internists, and anesthesiologists regarding both specific clinical cases, and larger issues requiring lab-clinic collaboration (for example, working on the design of order sets or institutional (or research) protocols where my role is guiding/advocating appropriate testing or blood product use).

-Agreed, fellowships are definitely becoming more common in all areas of path, but are still not always necessary (similar to almost all medical specialties). I know many who have gone on to work without fellowships, even in larger centres recently -- though this is becoming less common to rare in AP, depending on the institution.

-I am compensated for home call.

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- having zero control over your work and your hiring is a HUGE RED FLAG for a field. its not a small thing. the fact that pathologists accept this arrangement illustrates the type of personalities that go into path (this isn't directed at Liszt but at the general membership of pathology): insecure, weak-willed folk who wont stand up for something when they should, causing people to think that they actually may like being bullied.

 

i recommend students that think they might be interested in diagnostic medicine do radiology electives instead. strategically there will always be a pathology spot available somewhere so dont waste valuable elective time on it. path programs are under a lot of pressure from admin (see the pattern?) to fill residency rosters so they get the government funding that comes with it. That's why places like NFLD still fill with IMGs every year. rads is better than path in every professional way. there is no question about it. more jobs, more pay, fair compensation for call, more respect, stronger smarter colleagues who stand up for themselves.

 

I did not say "zero" control.

 

While I don't believe our workload/hiring situation is ideal, we do have some amount of control, through, for example, triage at the front end and workload assessments at the hiring end. The former can serve as a decent temporizing measure for workload, though you do need to organize your process to accomplish this, and be comfortable saying "no" and standing your ground, which is not a problem for any of the paths I work with (contrary to your perception of pathologists' personalities as a whole). My pathology residency was the best assertiveness training I could have asked for--as I med student, I would have never imagined I would be comfortable debating/opposing attending clinicians by the time I was R2. 

 

Workload measurement tools are probably the most effective means of controlling workload and hiring, but also require a process/system for tracking, and leadership and administration must then act (i.e., fund positions) based on the data. Pathology leadership in my parts has clearly been effective in their efforts because I know of significant number of positions created in the last year as a direct consequence of new workload measurement data. 

 

Students interested in pathology should explore it though electives... and optimally get a flavour for the culture at different programs. Some programs are filling in the first round, and all programs are looking for people who understand the discipline (its advantages and challenges), so that trainees don't end up unhappy and regret having ranked pathology.  Pathology isn't a good fit for everyone, and it shouldn't be. But for a lot of us it's an intellectually stimulating, fulfilling, and really fun career... zero regrets!

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