Emerg vs Rads

[fellowshipskillzz]

Hello all, I'm currently in pre-clerkship and slowly starting to think about what I want to pursue as a speciality. Emerg and radiology have both peaked my interest the most. I enjoy ER a lot because of its fast pace, wide range of problems/diseases patients can present with, and the fact that its shift work. However, the fact that ER doctors have the highest rates of burnout worries me. As for radiology, again the I enjoy the breadth of knowledge required for this, the ability to mix patient interaction and alone work if you do biopsies or IR, and the opportunity to WFH. But for radiology, I'm worrying I'm idealizing this to be a lifestyle speciality when it may not be (depends on the practice I guess?).

I was wondering if anyone could give me more insight into these two specialities, especially regarding their work-life balance and lifestyle. Or if anyone has more comments to add on what I said above, it would be very appreciated! Thank you!!!

[anonymouspls]

Neither are particularly good work-life balance specialties. Maybe emerg a bit but shift work is not for everyone. 

Don't go into radiology with the expectation that you'll be able to wfh. This is a end-of career move, and it's hard to come back from it once you go into it. For the majority of radiologists wfh consists of working at night to finish up the list because you didn't finish your list in the hospital. I understand people think radiology = lifestyle because of the ROAD thing but that is very outdated at this point, radiology is comparable to many surgical specialties these days. 

Honestly if I was in your position and decided to do emerg, I would do family medicine + 1 in emerg. It allows you to the same type of work unless you are hell-bent on working in downtown Toronto, and gives you more flexibility with an ability to have something to fall back on other than emerg. 

[rmorelan]

Does depend on what you want to do - I mean in radiology if you wanted to work solely in clinic work then sure you can work from home for your career ( you will earn a bit less without access to CT/MRI imaging). 

I work from home roughly 1/2 time time. what otherwise would be for most people a living room is a complex office of multiple standing desks and work stations.  

The polishing off of cases from home that anonymouspls mentions is quite true - which is good as sometimes you just want dinner to recharge. 

[Arztin]

Take everyone's take with a grain of salt, including mine.

I do EM full time in a large urban setting. It's intense. Every shift is intense. You have to give it your 100% every single shift. 

Yes it's fun. It's fast paced. You see different pathologies. Most of the time, you diagnose or come close to diagnosing the problem. You need to think. You do procedures. You have to know a bit of everything. You deal with younglings, with the elderly, healthy patients, critically ill patients. You are overall a very ''well rounded'' clinician. You will constantly learn, and will be constantly challenged to improve. You will see all sorts of funky, or interesting cases. You work with a a great team, and usually the environment is very friendly between EM docs and ED nurses. 

Now, some of the downsides as you probably guessed:

- shifts are grueling, and extremely demanding. Doing a shift as an attending is no the same as a trainee. 

- shift work takes a toll. Talk to EM attendings who are starting, who are in their mid 30s, mid 40s, and 50+. They will all tell you how evenings are hard, and nights are even harder as they age. Some people only work nights. I could never. There's a reason many emerg docs stop after a couple of years.

- you will deal with really traumatic things. I've lost count of how many died a long time ago. I've seen patients who were victims of violent crimes reported on the news. I've seen dead children. 

- it's a great lifestyle when you are young, healthy, and have no dependants, not in an understaffed department (working a reasonable number of shifts), and are able to recover from these shifts. As you age, you will be annoyed by working so many weekeends, so many evenings. (BTW shift schedule is a recognized hazard for cancer)

- the health care system in Canada makes it that you will never have enough time nor ressources to do as much as you'd like for your patients. You will feel rushed by the endless waves of patients, trying to admit patients, discharge patients, not having enough time to do things as well as you'd like, while the hospital is bed blocked (same story basically all over the country). Talk to any ''old-timer'' emerg doc. They will all tell you that everything is much worse since they started.

I love what I do, at least for now, but don't expect me to still be in the ED by the time I'm 55-60.

 

For radiology, depending on where you work, calls can be absolutely brutal. I've seen radiologists reading non stop from 8 AM till 2 AM Saturday and Sunday in the community setting while on call (it was at another large urban hospital).

 

Hope it helps. My 2 cents.

[Ian Wong]

I am a full-time community (aka private practice) radiologist.  Have been practising full-time since finishing training.  There's been several changes over time, but I think the bigger picture remains similar.  Here's a few thoughts:

1)  I love my job.  If I was in med school again, and doing it all over, I'd still pick radiology.  This job and specialty fits me extremely well, and I can't think of any other specialty I'd rather do.  

2) Radiology is an extremely flexible specialty.  Here in the Lower Mainland, many/most of the radiology groups have a mixed practice, which includes both hospital and clinic work.  There are some radiologist practices which are solely hospital or solely clinic-based, and there are pros and cons to each.  With a hospital-based practice, you don't have the overhead requirements of running a clinic-based practice.  However, you lose the benefits of running your own practice.  You are not in charge of hiring/firing.  You can't expand or contract your services or hours of operation.  You also have to take call (this is the big one!).

Clinic-based practices typically have no call.  You set your own hours.  You have control over which staff you hire and promote.  However, you are fully responsible for clinic overhead, which is some of the highest in medicine, including maintenance and purchasing of radiology equipment and IT services.  

3) It is a shift-based speciality.  There aren't many in medicine; others include EM, pathology, anesthesiology, hospitalist, walk-in medicine.  I'm sure I've missed some.  Shift-based practice is amazing.  When you are off, you are truly off.  No paperwork to complete after-hours, consults to call/follow-up on, etc.

4)  Workload is increasing every year.  Every single year, the imaging volume increases.  This includes outpatients, inpatients, ER patients, ICU patients, oncology patients, whatever patients.  The worst from the lifestyle point of view is the ER.  As the primary care system buckles, and more people seek care through the ER, the ER needs a way to triage and dispo patients.  This often comes in the form of imaging.  As well, many specialists refuse to come to the ER to see patients unless a CT has been performed.  The volume of urgent, after-hour scans has never been higher, and shows no sign of stopping.  Most radiologists are fee-for-service, and are not on salary, so this extra workload means increased reimbursements, but it also leads to burnout. 

Our on call volumes have never been higher.  Most radiologists are already working at the upper limits of their comfort level due to the high volumes of work, and there's no slack remaining.  

As well, every year without fail, a clinical specialty comes out with a new ER triaging tool, that inevitably requires a CT scan to be done.  When I started practice, we often tried ultrasound to diagnose appendicitis in relatively young patients.  Many of them are now getting CT's.  All kidney stone patients get a CT KUB.  No more renal ultrasounds, even in young people.  CT chest to R/O PE is almost a joke at this point (if you think about a PE, you should rule it out...).  CT something for every elderly senior citizen who falls down.  The big one now is Neurology, where every patient with any symptoms needs an urgent CT angiogram of the head and neck to rule out everything.  We are picking up more and more incidental findings, many of which require continued CT follow-up.

Another trend is that as more primary care physicians turn to virtual appointments, and allied-health providers like NP's and PA's gain more practicing rights, we see a heavier reliance on imaging to diagnose and follow patients.

5) AI.  No idea how this is going to shake out.  We had CAD (computer-aided diagnosis) for mammography for many years.  I used it during residency, from 2005-2009.  It sucked then, and apparently still sucks now.  I suspect the medicolegal issue will be the hardest hurdle to overcome, which is the same reason radiologists haven't yet been replaced by cheap overseas radiologists, even though teleradiology has been widely available in the US since the 2000's.

If or when it rolls out, I suspect there will be many other specialties in medicine which will be affected, as well other allied health professions.

Ian